Deferral of fertility treatment for patients who are not fully vaccinated against COVID-19
Letter issued 7 January 2022.
Following clinical concerns raised by the lead Clinicians in the NHS Assisted Conception Units (ACUs) in Scotland, consideration of the evidence of increased levels of morbidity and risk of severe illness amongst unvaccinated pregnant women, which I discuss further below, and taking account of ongoing uncertainty around the impact of the Omicron variant on pregnant women, I recommend a temporary deferral of fertility treatment for patients who are not fully vaccinated against COVID-19 as set out later in this letter.
As you will be aware my letter to Chief Executives of 16 December (SGHD/CMO(2021) 39) (attached), highlighted recent updates to JCVI advice on vaccinating pregnant women, namely that pregnant women should now be considered as a clinical risk group and part of priority group 6 within the vaccination programme.
The latest evidence from the UK Obstetric Surveillance System (UKOSS) and the Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) showed that unvaccinated pregnant women and their babies have died after admission to hospital with COVID-19 and 98% of pregnant women in ICU with COVID-19 were unvaccinated. According to recent data reported by Public Health Scotland, pregnant women with COVID-19 have a higher risk of severe disease requiring admission to critical care than non-pregnant women of a similar age.
With the arrival of the Delta variant increased numbers of pregnant women have been admitted to hospital with moderate to severe COVID-19 symptoms requiring critical care. The Scottish Intensive Care Society Report (SICSAG) Report, published on 13 October, highlighted that of the 89 COVID-19 positive pregnant women who were admitted to critical care between December 2020 and end September 2021, 88 were unvaccinated, 1 was partially vaccinated, and none was fully vaccinated.
As advised by the JCVI, COVID-19 continues to pose a significant risk to unvaccinated pregnant women and their babies, therefore I recommend that fertility treatment should be deferred for patients who are not fully vaccinated against COVID-19. This applies to NHS services providing any fertility treatment (with the exception of Fertility Preservation) aimed at creating a pregnancy.
To summarise, this recommendation takes account of: the JCVI advice that pregnant women should be considered as a clinical risk group within the COVID-19 vaccination programme due to growing evidence that they are at increased risk of serious consequences from COVID-19; data from UKOSS and MBRRACE-UK revealing that clinical outcomes following COVID-19 in pregnant women have worsened over the course of the pandemic, with the UKOSS study and SICSAG report both finding that the vast majority of pregnant women who were admitted to hospital with COVID-19 were unvaccinated; and of course the concerns raised with me directly by the lead Clinicians in the NHS Assisted Conception Units.
We are now seeing an exponential rise in cases of Omicron, with increased transmissibility. As there is still uncertainty around the impact of this variant on pregnant women, and whilst the Delta variant continues to account for a significant number of cases in the UK, a more cautious approach to fertility treatment in unvaccinated women is now recommended. This overall approach is a protective one and based on the robust published evidence.
I recommend that women who have had their first and second COVID-19 vaccinations and who have had or (in the event that it is less than 3 months since their second dose) who are waiting for their booster dose should continue their treatment as normal, in line with advice. It should be noted that access to boosters will be delayed in the event of a positive PCR test. Clinicians can get further guidance in the Green Book on this type of post infection scenario COVID-19: the green book, chapter 14a.
The COVID-19 vaccines are safe and effective and NHS Scotland strongly recommends people get the vaccine when offered. There is no evidence to suggest that the COVID-19 vaccines will affect fertility in women or men. More information is available on this at NHS Inform Pregnancy, breastfeeding and the coronavirus vaccine | The coronavirus (COVID-19) vaccine.
There will be a small number of women for whom vaccination may be clinically contraindicated – guidance on this is also set out in the Green Book Chapter 14a COVID-19 greenbook chapter 14a. Treatment for those women should be risk assessed on a case by case basis by treating clinicians who can take further advice, including from their local immunisation coordinator, as well as Green Book chapter 14a.
All patients having treatment temporarily deferred should have the deferral time added back on to their treatment journey to ensure that no patient loses out on treatment, for example by reason of age.
This recommendation will be kept under review. It will be reviewed alongside emerging evidence of risk as well as the prevailing levels of COVID-19 during January and February 2022 to ascertain whether treatment of unvaccinated women should recommence, or whether a further deferral is necessary. I shall of course keep you updated.
Thank you for your continuing support and valued input.
Professor Sir Gregor Smith
Chief Medical Officer