As the COVID-19 pandemic is stabilizing, the return to normal daily life will also see the need to restart the provision of ART treatments. Once the risk of SARS-CoV-2/COVID-19 infection has been decreasing, all ART treatments are now restarted for any clinical indication, in line with local regulations.

Greece, due to the very early onset of lockdown measures to prevent the spread of the virus to the community compared to other countries and the strong compliance of the people to the scientific task force’s advice was able to flatten the curve of the virus transmission, thus holding the number of confirmed cases and deaths very low.

However, vigilance and measured steps must be still be taken for safe practice and in order to minimize the risks related to SARS-CoV-2/COVID-19-positive patients or staff during treatment.

Existing data on COVID-19 affecting pregnancy (although generally reassuring) are still considered limited and a possible adverse event cannot be ruled out. The same is valid for possible adverse effects on the embryo. Dealing with severe COVID-19 disease (pneumonia, admission to Intensive Care Unit, etc.) during pregnancy can have adverse effects on its outcome.

In ​​women at high risk groups with underlying conditions (eg respiratory, liver, heart or kidney disease, hypertension, diabetes, under immunosuppression or whoever has undergone transplantation) there is a strong recommendation to postpone fertility treatment reproduction for this time of period.

Triage questionnaire

ESHRE and the Greek National ART Regulatory Authority provide a triage questionnaire which must be used at all cases for the triage of both staff and ladies/couples and whoever enters the clinic.

The key principle in restarting activity in an ART center is that staff, ladies, couples and anyone attending the center is SARS-CoV-2/COVID-19 testing negative. From a patient perspective, it means that only SARS-CoV-2/COVID-19 testing negative are commencing and continuing treatments.

Procedure for patients in detail

1. All ladies and couples, (both partners), planning to start new IVF treatment or frozen embryo transfer cycle (FET) should have a triage questionnaire (paper or email) on the 1st day of their cycle or on their visit at the clinic.
2. Ladies/ couples suspected of infection after a triage –positive must get SARS-CoV-2 /COVID-19 testing.
3. The only SARS-CoV-2 /COVID-19 tests currently accepted by Serum are molecular assays for detection of SARS-CoV-2 viral RNA using polymerase chain reaction (PCR)-based techniques or nucleic acid hybridization-related strategies.
4. All ladies/ couples with a previous confirmed COVID-19 infection should present medical evidence of clearance in order to be eligible for treatment (Two SARS-CoV-2/COVID-19 negative tests with two weeks’ time distance). If patients have been on respiratory support during the COVID-19 infection episode, they should additionally provide evidence of assessment and a medical specialist report.
5. All ladies proceeding with IVF with their own eggs must have the molecular test for SARS-CoV-2/COVID-19 at the clinic the day before trigger shot administration.
6. Again ladies with a triage- negative that wish to proceed with a Frozen Embryo Transfer Cycle or transfer of donor embryos, SARS-CoV-2/COVID-19 testing should be performed while at Serum just before the start of progesterone administration.
7. Ladies/ couples with specific symptoms or positive SARS-CoV-2/COVID-19 testing at any step will be excluded /discontinued of treatment.
8. Ladies with specific symptoms or positive SARS-CoV-2/COVID-19 testing on the day of ovulation triggering will be cancelled and oocyte retrieval will not be performed. (with the exception of existence of a medical indication such us risk of OHSS etc. In such cases, the patient will proceed with an oocyte retrieval procedure at a National Referral Centre for SARS-CoV-2/ Atticon General Hospital)
9. Should a lady become suspect or positive for COVID-19 after oocyte retrieval and during embryo culture, a freeze-all policy will be adopted.
10. Ladies with specific symptoms or positive SARS-CoV-2/COVID-19 on the day of commencing progesterone for FET Cycles or transfer of donor embryos will be cancelled and embryo transfer will not be performed.
11. Ladies/ Couples with specific symptoms or positive SARS-CoV-2/COVID-19 after egg collection or embryo transfer within 14 days, must inform the clinic about this so to take the appropriate safety measurements.
12. Male partners with a triage- negative that visit the clinic for semen tests, SARS-CoV-2/COVID-19 testing is not necessary.
13. Male partners with a triage- negative that visit the clinic in order to provide sample for fertilization or freezing, need to be tested for SARS-CoV-2/COVID-19 first.

Modification of treatment

1. The use of personal facial protective equipment (PPE) like masks is mandatory for all patients. The use of gloves, antiseptic solutions and frequent washing of hands is encouraged.
2. Social distancing and avoidance of unnecessary human physical contact is advised.
3. Ladies/ Couples must agree that treatment can be discontinued if there is evidence of them encountering a high-risk situation.
4. Access for partners and accompanying persons will be restricted when it is unnecessary.
5. Μale partners should preferably provide sperm samples at home/hotel and bring to the unit whenever this is possible within one hour.
6. Appointments for scans and blood tests will be managed according to specific timetables.
7. The use of stairs instead of the elevator whenever this is possible is encouraged.

Post treatment

Ladies/ couples that will complete ART treatment at Serum and in compliance with the information provided on the consenting paragraph, are advised to continue social distancing measures, personal protection and a degree of self-quarantine as much as possible to avoid contracting the virus during pregnancy.

All ladies/ couples will be followed up by Serum staff at two weeks on their COVID-19 status as it required by the Greek ART Regulatory Authority.