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| Fertility Clinics Stay Open Despite Unclear Guidelines | Fertility Clinics Stay Open Despite Unclear Guidelines |
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| Since March, fertility clinics across the country have halted treatments for tens of thousands of people because of Covid-19, forcing patients to suspend their family planning. In recent days, some clinics have reopened, resuming services and procedures despite ongoing coronavirus concerns. | Since March, fertility clinics across the country have halted treatments for tens of thousands of people because of Covid-19, forcing patients to suspend their family planning. In recent days, some clinics have reopened, resuming services and procedures despite ongoing coronavirus concerns. |
| But shifting guidelines and minimal oversight have left clinics to decide for themselves when and how to resume in vitro fertilization, or I.V.F. At clinics where I.V.F. is ramping back up, or never slowed at all, some staff members are concerned about a lack of adequate protective equipment and safety policies. | But shifting guidelines and minimal oversight have left clinics to decide for themselves when and how to resume in vitro fertilization, or I.V.F. At clinics where I.V.F. is ramping back up, or never slowed at all, some staff members are concerned about a lack of adequate protective equipment and safety policies. |
| On April 24, the American Society for Reproductive Medicine issued recommendations for restarting operations, leaving it up to individual clinics to determine how to proceed. The professional society had previously advised fertility clinics to avoid starting new treatments, postpone nonemergency surgeries and shift to telemedicine. | On April 24, the American Society for Reproductive Medicine issued recommendations for restarting operations, leaving it up to individual clinics to determine how to proceed. The professional society had previously advised fertility clinics to avoid starting new treatments, postpone nonemergency surgeries and shift to telemedicine. |
| The shutdown generated a flurry of media attention and pushback from fertility doctors and patients. Most clinics paused starting new I.V.F. cycles, which are highly time-sensitive. But a few remained open, even operating at full capacity, causing the industry to debate when to resume care and what counts as medically urgent. | The shutdown generated a flurry of media attention and pushback from fertility doctors and patients. Most clinics paused starting new I.V.F. cycles, which are highly time-sensitive. But a few remained open, even operating at full capacity, causing the industry to debate when to resume care and what counts as medically urgent. |
| “Fertility treatment is by no means elective,” said Leyla Bilali, a nurse at a fertility clinic in New York City, referring to the consensus that infertility is a disease. “It’s just, right now, it’s not a matter of life or death.” | “Fertility treatment is by no means elective,” said Leyla Bilali, a nurse at a fertility clinic in New York City, referring to the consensus that infertility is a disease. “It’s just, right now, it’s not a matter of life or death.” |
| Clinics that stayed open scrambled to implement protocols compliant with the Centers for Disease Control and Prevention, such as temperature checks, masks and physical distancing. Still, people have gotten sick. At Reproductive Medicine Associates of New York, seven staff members have tested positive for Covid-19. At Vios Fertility Institute in Chicago, clinicians have reported flulike symptoms but have not been tested because of limited test availability. And several employees at Extend Fertility, an egg-freezing clinic in Midtown Manhattan, fell ill with possible cases of Covid-19. | Clinics that stayed open scrambled to implement protocols compliant with the Centers for Disease Control and Prevention, such as temperature checks, masks and physical distancing. Still, people have gotten sick. At Reproductive Medicine Associates of New York, seven staff members have tested positive for Covid-19. At Vios Fertility Institute in Chicago, clinicians have reported flulike symptoms but have not been tested because of limited test availability. And several employees at Extend Fertility, an egg-freezing clinic in Midtown Manhattan, fell ill with possible cases of Covid-19. |
| “We really didn’t feel it was appropriate to go out on a limb, outside major A.S.R.M. guidelines, and keep things open,” said Dr. Bat-Sheva Maslow, M.D., a reproductive endocrinologist at Extend Fertility who tested positive and recovered from the virus in March. “Covid-19 is almost impossible to control at this point. That weighed very heavily with us.” Extend Fertility has since closed its offices to virtually all patients. | “We really didn’t feel it was appropriate to go out on a limb, outside major A.S.R.M. guidelines, and keep things open,” said Dr. Bat-Sheva Maslow, M.D., a reproductive endocrinologist at Extend Fertility who tested positive and recovered from the virus in March. “Covid-19 is almost impossible to control at this point. That weighed very heavily with us.” Extend Fertility has since closed its offices to virtually all patients. |
| Amid the pandemic, clinics face a dizzying array of vague and, at times, conflicting instructions from states, cities and health agencies like the C.D.C. Doctors must interpret guidelines as they see fit — often the case in fertility services, which are largely paid out-of-pocket and where patient care and profit can be at odds. | Amid the pandemic, clinics face a dizzying array of vague and, at times, conflicting instructions from states, cities and health agencies like the C.D.C. Doctors must interpret guidelines as they see fit — often the case in fertility services, which are largely paid out-of-pocket and where patient care and profit can be at odds. |
| Because of unclear guidance, in most states it is difficult to tell whether remaining open during the pandemic is legal or if fertility procedures are considered an essential service. New York is an exception: On April 7, the state’s health department issued an advisory deeming infertility treatment an essential service, thus exempt from closure. New Jersey’s governor, in an executive order responding to the coronavirus crisis, made a similar but less specific exemption, referring to general family planning services but not directly to infertility. | Because of unclear guidance, in most states it is difficult to tell whether remaining open during the pandemic is legal or if fertility procedures are considered an essential service. New York is an exception: On April 7, the state’s health department issued an advisory deeming infertility treatment an essential service, thus exempt from closure. New Jersey’s governor, in an executive order responding to the coronavirus crisis, made a similar but less specific exemption, referring to general family planning services but not directly to infertility. |
| The majority of fertility clinics nationwide halted treatments — particularly those related to immediately getting pregnant, like I.V.F. and embryo transfers. But Reproductive Medicine Associates Network, part of the world’s largest network of fertility practices, announced in April that its clinics would remain fully operational through the Covid-19 pandemic. | The majority of fertility clinics nationwide halted treatments — particularly those related to immediately getting pregnant, like I.V.F. and embryo transfers. But Reproductive Medicine Associates Network, part of the world’s largest network of fertility practices, announced in April that its clinics would remain fully operational through the Covid-19 pandemic. |
| “We were appalled and shocked we were staying open,” said Frances Boamah, 29, a full-time nurse at a network clinic in New Jersey. | “We were appalled and shocked we were staying open,” said Frances Boamah, 29, a full-time nurse at a network clinic in New Jersey. |
| As a post-anesthesia care unit nurse, Boamah and her colleagues interact closely with patients, providing up-close, face-to-face care. | As a post-anesthesia care unit nurse, Boamah and her colleagues interact closely with patients, providing up-close, face-to-face care. |
| “There’s no way for nurses to properly clean our hands,” said Erika Colindres, another nurse at Reproductive Medicine Associates in New Jersey. “We’re rationing hand sanitizers. I can’t even wipe down surfaces properly. My manager says she’s trying to get us more supplies but that her hands are tied.” | “There’s no way for nurses to properly clean our hands,” said Erika Colindres, another nurse at Reproductive Medicine Associates in New Jersey. “We’re rationing hand sanitizers. I can’t even wipe down surfaces properly. My manager says she’s trying to get us more supplies but that her hands are tied.” |
| The New York Times spoke to numerous employees about operations at Reproductive Medicine Associates Network, which has 19 clinics nationwide. Many spoke on condition of anonymity because they were concerned about retaliation from management. | The New York Times spoke to numerous employees about operations at Reproductive Medicine Associates Network, which has 19 clinics nationwide. Many spoke on condition of anonymity because they were concerned about retaliation from management. |
| One senior staff member, who brings her own cleaning supplies from home to disinfect her work space, said it’s difficult to keep working when you don’t feel supported by your organization and almost all of your competitors are closed. | One senior staff member, who brings her own cleaning supplies from home to disinfect her work space, said it’s difficult to keep working when you don’t feel supported by your organization and almost all of your competitors are closed. |
| Employees spoke of feeling unsafe at work because of a lack of sufficient protective gear, physical distancing and other safety measures. Several expressed frustration about being short-staffed and lacking clear communication from corporate leaders about when their colleagues and patients have tested positive for Covid-19. | Employees spoke of feeling unsafe at work because of a lack of sufficient protective gear, physical distancing and other safety measures. Several expressed frustration about being short-staffed and lacking clear communication from corporate leaders about when their colleagues and patients have tested positive for Covid-19. |
| “Staff morale is so low,” Boamah said. “But I don’t want to let my co-workers down, or the patients that are still coming in. I’d feel like I was abandoning them.” | “Staff morale is so low,” Boamah said. “But I don’t want to let my co-workers down, or the patients that are still coming in. I’d feel like I was abandoning them.” |
| Clinicians told The Times they were devoted to their patients but also wanted to support health care workers on the front lines of the pandemic by being available to work at hospitals and conserving critically needed medical supplies. They also worried about how Covid-19 might impact their patients’ pregnancies. | Clinicians told The Times they were devoted to their patients but also wanted to support health care workers on the front lines of the pandemic by being available to work at hospitals and conserving critically needed medical supplies. They also worried about how Covid-19 might impact their patients’ pregnancies. |
| “We don’t know how the virus affects a fetus,” said Colindres, who has worked for Reproductive Medicine Associates since 2014. “So I don’t really feel comfortable helping with embryo transfers and getting women pregnant during this time.” | “We don’t know how the virus affects a fetus,” said Colindres, who has worked for Reproductive Medicine Associates since 2014. “So I don’t really feel comfortable helping with embryo transfers and getting women pregnant during this time.” |
| Her company rebutted these characterizations. In an internal letter to staff, the network’s New Jersey physicians and management team emphasized the company’s mission to help patients build families, as well as its conviction that completely shutting down its practice would not benefit the public good or patients. The letter also cited limited but reassuring data indicating that coronavirus is not transmitted by a mother to the fetus. | Her company rebutted these characterizations. In an internal letter to staff, the network’s New Jersey physicians and management team emphasized the company’s mission to help patients build families, as well as its conviction that completely shutting down its practice would not benefit the public good or patients. The letter also cited limited but reassuring data indicating that coronavirus is not transmitted by a mother to the fetus. |
| “We’re complying with all regulatory guidelines,” said Dr. Richard Scott, M.D., founding partner of the network and chief executive officer of its parent company, IVI-RMA Global. “We take everyone’s temperature every day. We maintain strict social distancing. Everyone wears masks and gloves and we disinfect everything virtually constantly.” | “We’re complying with all regulatory guidelines,” said Dr. Richard Scott, M.D., founding partner of the network and chief executive officer of its parent company, IVI-RMA Global. “We take everyone’s temperature every day. We maintain strict social distancing. Everyone wears masks and gloves and we disinfect everything virtually constantly.” |
| Company employees contacted for this story said temperature checks have been inconsistent and that masks and gloves are in short supply. | Company employees contacted for this story said temperature checks have been inconsistent and that masks and gloves are in short supply. |
| Dr. Scott said that in mid-March, as fertility clinics began to shutter, his network conducted a survey asking staff members how they felt about keeping their clinics open. Additionally, he said that managers talked to every single employee. “We would’ve paid them to stay home,” he said, noting that employees had the option of staying home through July 1 with full pay. | Dr. Scott said that in mid-March, as fertility clinics began to shutter, his network conducted a survey asking staff members how they felt about keeping their clinics open. Additionally, he said that managers talked to every single employee. “We would’ve paid them to stay home,” he said, noting that employees had the option of staying home through July 1 with full pay. |
| Dr. Scott has mentioned the survey to other media outlets but none of the staff members contacted for this story had heard of it or the option to stay at home with full pay. Reproductive Medicine Associates declined to offer evidence of their claims. | Dr. Scott has mentioned the survey to other media outlets but none of the staff members contacted for this story had heard of it or the option to stay at home with full pay. Reproductive Medicine Associates declined to offer evidence of their claims. |
| Dr. Scott said he felt the American Society for Reproductive Medicine recommendations were misguided. He added that employees who chose not to come to work during the pandemic would not lose vacation days or be required to use paid time off. In at least one case, however, an employee was forced to resign while sheltering-in-place and not given a reason. | Dr. Scott said he felt the American Society for Reproductive Medicine recommendations were misguided. He added that employees who chose not to come to work during the pandemic would not lose vacation days or be required to use paid time off. In at least one case, however, an employee was forced to resign while sheltering-in-place and not given a reason. |
| Updated July 22, 2020 | |
| “I was shocked,” the staff member said, who received an email from Reproductive Medicine Associates stating that staying home counted as sick days. “It was so sudden. Obviously, I wasn’t trying to leave. But I didn’t want to argue with them. I didn’t want to burn bridges.” A company representative declined to comment whether any staff were terminated during the pandemic. | “I was shocked,” the staff member said, who received an email from Reproductive Medicine Associates stating that staying home counted as sick days. “It was so sudden. Obviously, I wasn’t trying to leave. But I didn’t want to argue with them. I didn’t want to burn bridges.” A company representative declined to comment whether any staff were terminated during the pandemic. |
| In recent years, investment firms have acquired a sweeping number of fertility practices, prompting concerns that clinics face increased pressure to generate revenue. Demand is high and competition between clinics is fierce. One cycle of I.V.F. can cost 10 times as much as giving birth in a hospital. | In recent years, investment firms have acquired a sweeping number of fertility practices, prompting concerns that clinics face increased pressure to generate revenue. Demand is high and competition between clinics is fierce. One cycle of I.V.F. can cost 10 times as much as giving birth in a hospital. |
| “It’s a lack of regulation that’s driving this and making it the Wild West,” said Emilia Simeonova, Ph.D., a health economist and associate professor at Johns Hopkins Carey Business School. “The more competition, the more likely people will engage in risk-taking behavior.” | “It’s a lack of regulation that’s driving this and making it the Wild West,” said Emilia Simeonova, Ph.D., a health economist and associate professor at Johns Hopkins Carey Business School. “The more competition, the more likely people will engage in risk-taking behavior.” |
| “I don’t know at what point it became less about the patients and less about fertility, and so much more about money,” Boamah said. | “I don’t know at what point it became less about the patients and less about fertility, and so much more about money,” Boamah said. |
| Many clinicians, like Dr. Scott, say the original guidelines from the American Society for Reproductive Medicine advising postponing infertility treatment went too far, but it’s not clear what alternative would balance the needs of patients and staff. Europe and Canada created similar guidelines, though the U.S. recommendations made exceptions for patients who were mid-treatment when the guidelines were announced, as well as for people with cancer who wanted to freeze eggs or sperm before starting chemotherapy. | Many clinicians, like Dr. Scott, say the original guidelines from the American Society for Reproductive Medicine advising postponing infertility treatment went too far, but it’s not clear what alternative would balance the needs of patients and staff. Europe and Canada created similar guidelines, though the U.S. recommendations made exceptions for patients who were mid-treatment when the guidelines were announced, as well as for people with cancer who wanted to freeze eggs or sperm before starting chemotherapy. |
| Many fertility patients do not have time to wait. On March 19, Olivia Smith dressed carefully for the day. Makeup, hair, a determined smile; pink sneakers and her favorite pink purse. Then the 25-year-old drove to get her biopsy results. | Many fertility patients do not have time to wait. On March 19, Olivia Smith dressed carefully for the day. Makeup, hair, a determined smile; pink sneakers and her favorite pink purse. Then the 25-year-old drove to get her biopsy results. |
| “I thought, ‘I’m not going to get a cancer diagnosis looking classy like this,’” Smith said, speaking from her family’s home in Hillsborough, N.C. | “I thought, ‘I’m not going to get a cancer diagnosis looking classy like this,’” Smith said, speaking from her family’s home in Hillsborough, N.C. |
| She was diagnosed with breast cancer later that day. Her specific cancer treatment requires medication that puts her in menopause for five to 10 years. Her doctors urged her to freeze her eggs. | She was diagnosed with breast cancer later that day. Her specific cancer treatment requires medication that puts her in menopause for five to 10 years. Her doctors urged her to freeze her eggs. |
| “It was do or die,” said Smith, a freelance music teacher who works part-time at Starbucks for health insurance. “We needed to get my ovaries turned off five days before I started chemo.” | “It was do or die,” said Smith, a freelance music teacher who works part-time at Starbucks for health insurance. “We needed to get my ovaries turned off five days before I started chemo.” |
| Smith ultimately couldn’t freeze her eggs, but was able to freeze two embryos fertilized with her boyfriend’s sperm. | Smith ultimately couldn’t freeze her eggs, but was able to freeze two embryos fertilized with her boyfriend’s sperm. |
| For cancer patients like Smith, time is especially critical. Still, the fertility community remains deeply divided about when and how to resume regular operations. Several clinicians told The Times they worry they might create new Covid-19 cases and overwhelm the health care system. Patients, too, are wary; many have canceled their appointments until the crisis has passed. Most clinics hope to fully reopen sometime this month, with risk mitigation strategies in place. | For cancer patients like Smith, time is especially critical. Still, the fertility community remains deeply divided about when and how to resume regular operations. Several clinicians told The Times they worry they might create new Covid-19 cases and overwhelm the health care system. Patients, too, are wary; many have canceled their appointments until the crisis has passed. Most clinics hope to fully reopen sometime this month, with risk mitigation strategies in place. |
| “It’s definitely not business as usual,” said Dr. Anate Brauer, M.D., director of I.V.F. at Shady Grove Fertility New York. “We’re going to have to live with this pandemic.” | “It’s definitely not business as usual,” said Dr. Anate Brauer, M.D., director of I.V.F. at Shady Grove Fertility New York. “We’re going to have to live with this pandemic.” |
| To restart care safely in an environment where Covid-19 exists, the American Society for Reproductive Medicine recommends fertility clinics strictly follow policies to decrease coronavirus transmission, test for immunity and maintain adequate protective equipment. | To restart care safely in an environment where Covid-19 exists, the American Society for Reproductive Medicine recommends fertility clinics strictly follow policies to decrease coronavirus transmission, test for immunity and maintain adequate protective equipment. |
| “If you can’t employ those measures, then don’t open, because you’re going to be putting people at risk,” Dr. Brauer said. “And we’re going to be right back where we started.” | “If you can’t employ those measures, then don’t open, because you’re going to be putting people at risk,” Dr. Brauer said. “And we’re going to be right back where we started.” |
| Natalie Lampert is a journalist based in Boulder, Colo., who is currently working on a book about the future of fertility. | Natalie Lampert is a journalist based in Boulder, Colo., who is currently working on a book about the future of fertility. |