I know we are all feeling it this year. Tension, uncertainty, caution, maybe even a little hopelessness. This year has been (and continues to be) one of immense disruption. Perhaps it is serendipitous that the theme of this year’s ASRM conference was “Dynamic Collaboration,” something medicine has always required, but which has rapidly been pushed to the forefront in 2020.
Helping couples and individuals build their families requires participation from an array of disciplines: physicians, embryologists, andrologists, psychologists, financial counselors, patient navigators, nurses, genetic counselors, and, occasionally, attorneys. All these disciplines and more are represented in the ASRM community. Family building in individuals or couples experiencing infertility, whether medical or social, or for those hoping to preserve their fertility has always required dynamic collaboration. But ASRM’s organizers had no idea just how important the concept of “dynamic collaboration” would become when they started planning this meeting two years ago.
The importance of this collaborative framework increased exponentially with the arrival of COVID-19. Within weeks of the virus’ arrival on our shores, public health officials were scrambling to craft strategies and responses to address this onslaught, and fertility treatments got caught squarely in the middle. Out of the blue, in many parts of our country, helping people build their families was deemed “elective.”
We can agree that in terms of severity, infertility may fall lower on the scale than some other disease states. But that does not make it elective. No one chooses to be infertile. Not surprisingly, as presented at the ASRM annual meeting, 85% of patients at a New York fertility clinic who were required to cancel their IVF cycles because of COVID-19 found it to be a moderately to extremely upsetting experience, and 22% said it was the equivalent to the loss of a child. Ultimately, as the health care system reached some measure of stasis, authorities relaxed restrictions and patients returned for treatment. Indeed, another study presented at the conference demonstrated that the majority of patients whose IVF treatment was delayed with the COVID-19 pandemic shut down desired to resume treatment immediately when able.
COVID-19 not only underscored the disparate views on the medical necessity of fertility care, it further highlighted what we already know. Minorities and marginalized communities are disproportionately impacted by the inequitable distribution of essential resources, including access to affordable and effective health care. Among these impacts is the significant disparity in access to and efficacy of fertility treatments for patients of color.
One study presented at ASRM this year that investigated access to care found that Black women are often older and wait longer periods of time prior to seeking treatment. Many of these delays can be related to knowledge of infertility risk factors and treatment options. It was also suggested that many Black women may have unmet psychological needs related to stigmata around of race and fertility status. Another study found that living in a disadvantaged area may impact ovarian reserve, and this impact may be more pronounced in overweight women, suggesting a role for diet. The researchers recommend that the application of Area Deprivation Index, which is a helpful measure of socioeconomic disadvantage, can be expanded to fertility medicine. Future studies are needed to explore the relationship between socioeconomic status and ovarian reserve, and to clarify the impact of obesity and diet.
Another study presented at ASRM demonstrated that Black women experienced lower live birth rates in Frozen Embryo Transplant cycles than white women. While the study did not elucidate a physiologic cause for this disparity, it is hard to ignore the possibility that there is some connection between these outcomes and the environmental and societal factors that impact communities of color.
Under the best of circumstances, effectively addressing these and related issues is a significant challenge. Layer on top of that the need to collaborate virtually and the tasks become nothing short of daunting. In “normal” times, conferences like ASRM organically facilitate collaboration. And while technology has allowed us to keep working, it is no substitute for the dynamic that exists when thousands of the best minds on the planet come together in the same physical place to solve problems.
Those who know me well would never accuse me of being the eternal optimist. I prefer to think of myself as the pragmatic stoic. However, I do see a silver lining in the very dark cloud that currently hangs over us all. COVID-19 has ripped the scab off the festering wounds of systematic bias and discrimination in almost every aspect of our society, including in the delivery of health care in general, and fertility care in particular. We are not only infertility specialists, we are caregivers. It has become incumbent on us to embrace the challenges laid bare by COVID-19.
I am confident we will find effective ways to address these challenges. Why? Because as a specialty, we are extremely adept at collaborating, and not just among the clinicians and scientists, but across the wide array of disciplines mentioned above. Then, when we throw into the mix the vast number of patient advocacy resources with which we collaborate on a regular basis, I begin to see hope.
The hope here lies in awareness. The hope lies in knowing each patient we treat is an individual person, not a number. Patients who are struggling with infertility, whether social or medical, as well as those hoping to preserve their fertility as they face cancer treatment, gender affirming treatment, or diminishing ovarian reserve, should be encouraged to seek treatment and help. We collaborate with one another not just as doctors, but as people in this world working together towards the goals of equality, fairness, and family inclusion for all.
