14 December 2020
Progress Educational Trust’s one-day annual conference entitled “Fertility, Genomics and Covid-19” took place on Wednesday 9 December 2020. For the first time, it took place virtually with a varied panel of expert international speakers. It generated thought-provoking and wide-ranging debate about the impact of the Covid-19 pandemic on our health and the fertility sector, including: the changing role of the HFEA, challenges for fertility treatment delivery, ethical issues, effect on individual fertility and the fetus and the genetic resilience of women.
The impact of Covid-19 on the fertility sector
Sally Cheshire CBE, Chair of the Human Fertilisation and Embryology Authority (HFEA), delivered the opening session entitled “The HFEA at 30: Regulating During COVID-19 and Beyond”. She explained that the HFEA will celebrate its 30th anniversary next year (2021) and that for the first time in 30 years, UK fertility clinics were temporarily required to close on 15 April 2020 during the height of the first wave of the Covid-19 pandemic. She added that the HFEA had needed to react at pace to the rapidly evolving public health emergency caused by Covid-19, during what was a very worrying time for clinics and patients. She went on to explain that the decision to temporarily close UK fertility clinics had been the most challenging decision the HFEA had ever had to make during its 30 years of operation.
Ms Cheshire explained that lots of NHS fertility clinics had their staff and facilities redeployed to help support frontline NHS services, who were struggling to treat patients due to the scale of Covid-19 sickness. Private fertility clinics had capacity, but were unable to treat fertility patients; with staff placed on furlough or off sick. As a result, some fertility clinics struggled to communicate with patients, backlogs developed and longer waiting times built up. Furthermore, additional safety measures added further pressure to clinics as they started to re-open from 11 May 2020.
Ms Cheshire explained that UK fertility clinics had to carefully navigate a multitude of issues in resuming treatment services for patients. Many patients were worried and emotional, not knowing when they could proceed with treatment. Issues arose over whether treatment of patients should be determined by their age, need or by original chronological order. Communication between staff and patients was made harder due to remote working arrangements, staff shortages, unavailability of counselling and reduced emotional support for patients. There was also a lot of anger and frustration amongst patients as a result of the decision to temporarily suspend fertility treatment services, particularly amongst those rapidly reaching the cut-off age for treatment or the end of their 10 year gamete and embryo storage periods.
Ms Cheshire explained that after a great deal of work, NHS fertility clinics are currently operating at 90% of capacity, with the private sector operating at 110% of capacity through extended working hours. It has been a challenging year for the HFEA, clinics, patients and staff. As a result, the HFEA had adapted its practices, with more online regulation, regular communication with clinics and increased focus on updates to their website. Looking ahead, Ms Cheshire explained that the HFEA will continue to focus on patient information, ‘add-on’ treatments and the importance of further changes to update the Human Fertilisation and Embryology Act 1990.
This session was followed by Dr Jane Stewart, Chair of the British Fertility Society and Head of the Newcastle Fertility as a Consultant in Reproductive Medicine and Gynaecology, who gave an insightful view of fertility treatment from a UK fertility clinic perspective.
Professor Julian Savulescu (Uehiro Chair in Practical Ethics at the University of Oxford, Fellow of St Cross College, Oxford, Director of the Oxford Uehiro Centre for Practical Ethics, Co-Director of the Wellcome Centre for Ethics and Humanities) then delivered a session entitled “The Value of Liberty and Reproduction in the Pandemic”. He discussed a range of challenging issues that have impacted fertility treatment delivery during the Covid-10 pandemic. In particular, he highlighted issues around liberty versus well-being and rationing of limited medical resources (e.g. ventilators, vaccinations, staff and hospital treatment and IVF) as well as distributive justice. He also debated issues around the value of new life versus existing life and risk factors in treating fertility patients (e.g. age, co-morbidities such as diabetes and immunosuppression, BAME and low socio-economic status).
Can Covid-19 affect fertility and the fetus?
Professor of Andrology and Head of Oncology and Metabolism Allan Pacey, University of Sheffield, discussed whether Covid-19 can affect male fertility. He explained that concerns about male reproductive health might be justified amongst groups of men suffering with Long Covid or men who had been ventilated as a result of Covid-19. However, he went on to explain that initial data does not seem to support the hypothesis that male reproductive hormones or semen quality are affected by Covid-19 amongst other male cohorts although it is still early days and more research is needed.
Emeritus Professor of Reproductive Immunology Ashley Moffett, University of Cambridge, explained that there is no evidence that pregnant women are more seriously at risk of death from Covid-19. She went on to explain that 5% of infants of infected mothers tested positive for Covid-19, caused by transmission across the placenta, during childbirth or postnatally in saliva and breastmilk. However, she explained that some of these test results were false positives. She also explained that it is still very difficult to ascertain whether a number of confounding factors arising from the pandemic affected fertility (e.g. lifestyle, stress, economic disparities).
What can genetics tell us about the severity of Covid-19 infection?
Dr Sharon Moalem, a physician, scientist and expert in the fields of rare diseases, sex differentiation, neurogenetics and biotechnology, gave a fascinating insight into the genetic superiority of women and their greater resilience to Covid-19. He explained the Law of Homogameity and how women benefited from having a pair of XX sex chromosomes compared with men who possess a pair of XY chromosomes.
Dr Moalem explained that many x-linked conditions are more common in men, including: Fragile X Syndrome, Duchenne Muscular Dystrophy (DMD), red and blue colour blindness and Hunter Syndrome. He went on to explain that female cell populations exhibit cooperative behaviours using both X chromosomes and this gives women better survival chances. He said this helped to explain why despite the fact that more males are born, more females reach their first birthday, 80 percent of centenarians and 95 percent of supercentenarians are female. He added that behaviours are also a factor with more men in higher risk occupations, men tending to take greater risks in life and a higher prevalence of drinking and smoking amongst males.
Dr Moalem also explained that more males are born premature and more males are discharged from intensive care with chronic lung disease and have a higher risk of adverse neurological outcomes. He went on to say that males have a 10 percent greater risk of stillbirth, more males develop and die from cancer and have a higher level of congenital abnormalities, including: cleft lip/palate, cleft foot and clinodactyly (e.g. crooked little finger). Furthermore, males have a higher risk of intellectual disabilities including autism and ADHD.
Dr Moalem explained that whilst three quarters of the healthcare workforce are female, approximately three quarters of the healthcare worker mortality rate from Covid-19 around the world were male. He added that XX female individuals have more genetic diversity, with more than 1,000 additional genes compared with XY male individuals. As a result, XX females have many more immune related genes (i.e. TLR7) and their oestrogens generally prime the immune response, creating wider T cell responses and better antibody responses in B cells. In contrast, testosterone is typically immunosuppressive.
Dr Moalem concluded that as a result of these genetic differences between males and females, there needed to be more basic research conducted on female/male basis. This needed to translate into clinical research too, with separate drug approval processes for males and females. There also needed to be greater consideration of how the female survival advantage could be applied to help males.
Dr Qian Zhang, Research Associate at The Rockefeller University gave an in-depth presentation explaining the correlation between defective Type I IFN immunity in patients with life-threatening disease such as influenza, Covid-19 and other viral infections. She explained that individuals with genetic mutations in Type I IFNs are at greater risk of severe Covid-19 due to a severe cytokine (inflammation) response and that 95 percent of these are males. As such, she explained that Type 1 IFN immunity is an important factor in combatting Covid-19 and that people with such defective immunity needed to take greater care to shield themselves from SARS Covid-2 and other viral infections. She went on to say that in future, early identification of this genetic mutation in people might help inform the management of their health and treatment protocols to combat viral infections.
The final session of the day resulted in lively debate about the lessons that could be learned from the resumption of fertility treatment across Europe. Overall, the conference generated thought-provoking and wide-ranging debate about the impact of the Covid-19 pandemic on our health and the fertility sector. It also highlighted the need for more high quality medical research and more data and understanding about the longer term effects and outcomes of Covid-19.
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