Coronavirus (COVID-19): fertility services - winter 2020/2021 preparation plans

5 Mitigation steps for fertility services

All clinics have undertaken detailed risk assessments with policies and procedures put in place to reduce the risk of SARS-CoV-2 transmission (https://www.gov.scot/publications/covid-19-fertility-treatment-scotland-plans-restarting-treatment-framework/). Several service developments and altered working practices have been adopted, including:

• Increased use of remote consultations due to restrictions imposed by COVID-19. Patients are only attending clinics for procedures that cannot be done remotely e.g. egg collection, embryo transfer, ultrasound, blood tests, tubal patency check and semen analysis. For patients this is convenient, reduces travel time and cost in addition to reducing clinic footfall. This restructuring of service provision will continue after the COVID-19 pandemic due to the positive impact on patients as well as NHS service delivery
• All meetings are conducted via Microsoft Teams or WebEx, which will continue longer term. This has resulted insignificant cost and resourcing efficiencies along with improving communication
• Counsellors are providing support through remote consultations and this will continue. A recent NHS survey found that patients were positive about remote consultations (https://www.gov.scot/publications/public-clinician-views-video-consultation-executive-summary/ )
• Work to introduce an electronic consent system is progressing well with support from the Scottish Government. It is expected that electronic consents will be live later in 2020. This will significantly reduce staff time used in obtaining informed consent and reduce the risk of infection due to reduction in face to face clinic contact. This will also help in mitigating the effect of staff shortages

NHS staff have been advised that holidays that involve travel overseas will only be approved after prior discussion and agreement around self-isolation. https://www.sehd.scot.nhs.uk/dl/DL(2020)20.pdf

We will work on the following steps:

5.1 Flu vaccine:

In order to reduce the risk of developing flu, the vaccine will be recommended to all staff working in fertility clinics. The Flu vaccination will be accessed as per government guidance https://www.nhsinform.scot/healthy-living/immunisation/vaccines/flu-vaccine

5.2 Prioritisation

At the time of restarting, fertility services commenced with frozen embryo transfers. A full explanation for this decision is detailed within restart framework. Those in the older age group were subsequently prioritised at the time of restarting services in order to provide the best possible chance of a successful treatment outcome.

A contingency plan will be made by each clinic based on number of staff available in each discipline (medical, nursing, admin and laboratory). This plan will be used to prioritise clinic activity in the event of staff absence due to winter and COVID-19. Although the principles governing this process can be agreed nationally, the decision will need to be made by each clinic based on their local risk assessments, as each team will need to have critical number to run the service, especially scientists.

Further discussion and adaptation will be needed locally depending on the timing of a second and subsequent wave(s) and where individual clinics are in the restart plan when this occurs.

Table 1 shows an example of what a local plan may entail.

Table 1: An example of prioritisation

Staffing level	Continue	Reduce/Pause
100% staff	Full activity
75% staff	Continue those in treatment	Reduce clinics
50% staff	Fresh IVF ICSI treatments Frozen embryo transfer Donor inseminations Ovulation inductions	Pause non urgent fertility preservation Pause clinics
25% staff	Consider pausing Fresh IVF/ICSI treatments only* Donor inseminations Ovulation inductions	Pause Frozen embryo transfers*
10% staff	Urgent fertility preservation only	Pause all treatments

*whether fresh or frozen treatments are prioritised will depend on individual clinic staffing in each domain

As it was anticipated that winter pressures will hit services from November onwards, therefore tertiary clinics have utilised a window of opportunity (August to October) to prioritise those who will need face to face appointments, to mitigate against service disruption and treatment delay (for example):

• Those who need ovarian stimulation (fresh IVF treatments)
• Those requiring face to face appointments for diagnostics such as ultrasound/ Blood tests/ semen analysis

5.3 Patients with medical illness

During the initial peak of the pandemic, treatment of those with co-morbidities (e.g. well controlled diabetes, or those who were shielding) was postponed however, as shielding is no longer required, treatment for these patients has resumed. All clinics have systems in place to liaise with obstetric colleagues as and when required for those with medical illness and to ensure that an individualised plan is made.

5.4 Increasing capacity

In the restart framework fertility services previously discussed extending the working day and week. All clinics will continue to review the situation locally and jointly with other clinics, to increase capacity wherever possible with the aim to reach pre COVID-19 waiting times. However, this will need to be done in conjunction with local risk assessments and provision of safe services.

Flexibility provided with the increased use of remote consultations and using electronic systems will help in reducing waiting times for consultations but may lead to a surge in patients placed on the waiting lists for treatment. Centres will further explore the use of more electronic systems e.g. In HealthCare and Lensus Digital to increase the capacity for more consultations.

5.5 Cross working between clinics

In this speciality, like most tertiary specialities, there are a limited number of staff trained to perform procedures. With this in mind, staff absence can reach a critical level fairly quickly within smaller teams. Although IVF is a national programme, staff are employed by a local health board and are currently unable to travel to other clinics without lengthy Human Resources (HR) procedures. Experience to date has been that it can take months to process an honorary contract despite all staff being employed within NHS Scotland. It is anticipated that these HR procedures may result in cancellation of patient treatment due to staff shortages.

Ideally cross working between clinics would be possible with staff working between boards and with appropriate legal cover if an individual has a contract with any health board in Scotland. Cross working has also been recommended by the UK professional body, the British Fertility Society in their guidance.

Our current contingency plan already allows patients to be transferred between units for procedures. This has already happened during the pandemic between the Centres in Edinburgh and Dundee. However, in certain situations, it may not be possible for patients to travel.

5.6 Communication with Primary care

We have had feedback that primary care colleagues are sometimes unsure as to which services are running in secondary and tertiary care. While some referrals are been sent to secondary care, it is possible that others may be holding back referrals. This will impact on the pathway and eventual success rates for patients as age is the single most important factor affecting success rates.

We will continue to work on communication with primary care so that initial secondary care consultations continue. All modalities such as email, intranet/ website update and social media will be used.

5.7 Support for patients

Centres will work with Fertility Network UK to continue to support patients during these unprecedented and unpredictable times, aiming to provide updates to patients by regular webinars hosted by Fertility Network UK and delivered jointly by four tertiary clinics. The first one took place on 30^th June and a second on 25^th August. Clinics will continue to frequently update local websites as a method of ensuring patients are provided with up to date information. All clinics have already increased capacity to answer phone calls. All counsellors have been working throughout the pandemic and will continue to do so remotely. Cross clinic working of counsellors will be considered between the clinics as per existing contingency arrangements.

Fertility Network UK has worked tirelessly to provide patient support with an increased number of calls, and both SG and clinics are enormously grateful for the support they have given to patients and clinics during this period.

5.8 National and international guidance

We are developing national guidance in conjunction with emerging evidence from national (BFS) and international professional societies (ESHRE) as well as the advice from Scottish Government and Public Health Scotland.

5.9 Donor gametes

Recruitment of donor gametes was put in phase 5 of the restart framework road map. This was because recruitment campaigns need significant mobilisation of staff and requires donors to come to hospitals thereby putting them at risk of infection, when they themselves are healthy.

Donors will also increase the footfall which in turn may increase risk of transmission.

Given the concerns of winter as highlighted in section 3, it is unlikely that we will be able to start recruiting donors until spring 2021. This will have a major impact on the group of patients who require donor gametes.

In Scotland we have worked together with the National Infertility Group and Scottish National Blood Transfusion services (SNBTS) to have a centralised storage system for gametes and embryos (both for donation and fertility preservation). This will also create a central donor gamete bank. SNBTS have received approval by the regulatory authority, the HFEA, and this was to have its launch by the Minister for Public Heath, Sport and Wellbeing, on the 17^th of June 2020 but has been paused due to COVID-19.

Plans are in place to get all documentation and processes ready for recruitment for donors so that the campaign can be launched as soon as possible, when the risk of COVID-19 and concerns with winter are reduced. This will be prioritised as soon as it is safe to do so. Centres will look to share the donor gametes they currently have in storage at present, where possible.

5.10 Waiting for elective surgery

Those waiting for surgery prior to IVF will continue to have IVF treatment if they can safely do so. However, their embryos will be frozen rather than immediate transfer as without surgery chances of the implantation are less e.g. hydrosalpinx/ fibroid resections.

Those who need surgery even to facilitate IVF and are nearing the upper age limit to access funding, will be escalated through local health boards, if possible.

5.11 Self-funded patients

Self-funded patients will be treated in conjunction with local agreed policies and previous organisational structures. This will ensure appropriate budgetary management and avoid the unnecessary burden of organising specialised transport and legal documentation to enable gametes and embryos to be transferred to independent sector facilities.