SOPs for keeping Fertility Practice safe in Covid Era

1. Keeping Fertility Practice Safe In
The Covid Era
---------------------------------------
Dr Vaishali Chaudhary
M.D. , Ph.D.

2. We have gone through these stages
• 25 th jan
It won’t
hurt us
Let’s learn
to live
with it
We can control
it by strict
lockdown
• 25th May

3. When we are no longer be able to
change a situation
We need to change ourselves

4. We need to reopen
Delaying treatment may have permanent negative
consequences to:
• Treatment outcome (Poor Ovarian Reserve , Onco
Fertility , Increasing Age ,Severe Endometriosis,
Husband out on Duty abroad or in Army )
• Mental health (e.g. patient’s clinical depression, severe
anxiety)
• Access to care (e.g. loss of employment, loss of health
insurance)

5. Principles
• Safety of Patients
• Safety of the health
workers in the Fertility
Department

6. Code of Conduct
• For the Hospital
• For the Patients

7. Code of Conduct for patients
• Access video consultations
• Upload and share reports
• Decide and discuss plans before doing face to face
consultation
• Do not start IVF /IUI cycles if you have comorbidities like
Diabetes or Hypertension
• Undergo the Triage and complete questionnaire honestly
• Carry minimal things to the hospital
• Do not wear flowy clothes
• Confirm and Reach as per the time slots
• Maintain physical distance
• Cover Face with Masks and caps all the time
• Carry a small sanitiser bottle
• Self Isolate and avoid social interaction while on treatment

8. Responsibilities of Hospital -Triage
• All visitors - screened at the entry, temperature is
checked , asked to fill a questionnaire to screen any
potential high risk visitors
• All visitors made to wear masks .
• Ensure availability of facemasks at registration desk,
provide hand hygiene stations as well as bins with lids
at triage and specific areas where patients can discard
used paper tissues.
• Entry only after sanitiser application
• Entry alone or only with one relative
• Provide information about Covid and Pregnancy

9. The Triage Questionnaire
• Do you have fever (over 37,5°C)?
• Are you coughing at present?
• Do you have a sore throat?
• Have you lost your sense of smell or taste?
• Have you been in contact with somebody who has any of these
symptoms?
• Have you travelled to an area at high risk for COVID-19,
nationally or internationally?
• Do you work in a hospital/nursing home or healthcare facility?
• Have you been in contact with somebody who has COVID-19?

10. The Triage Questionnaire contd…
• Have you been sick in the last two weeks?
• Have you been you diagnosed with COVID-19?
• Do you live in a household with somebody who has
been diagnosed with COVID-19 infection or has
COVID-19 symptoms (fever, cough, loss of smell)?
• If you have been COVID-19 positive and recovered, do
you have certified medical evidence of clearance ?
• Do you have a severe medical condition like diabetes,
respiratory disease, chronic kidney disease, etc.?

11. Changes in OPD Facilities
Posters for
awareness
Video Consultations
Dedicated Staff for cleaning
surfaces , sofas chairs
examination beds
Physical Distancing
Widen the appointment intervals in order
to prevent crowding
Inform patients in Queue if there is a
delay

12. Patient Information Sheet

13. Training Staff for Donning and Doffing of
PPE

14. Doffing the PPE

15. PPE for Health Staff in OPD
• Hospital Scrubs
• Caps
• Masks (3 ply/N95)
• Goggles or Face shields
• Practice Hand Hygiene

16. PPE for embryologists
• Scrubs
• Sterile disposable Full Gown
• Cap and N95 masks
• Face shield or Goggles
• Non Powdered Gloves
• Shoe covers

17. The New Normal for Staff
• Triaging of all staff members every 5 days
• All staff members in the OPD to be in scrubs, caps ,
masks and face shields
• All staff members to maintain physical distance with
patients and each other . No shared Lunches
• No sharing of pens, slippers , water bottles
• Restricted Social Interactions of All staff members
• Concept of “Mini-teams” or “Back-up teams” to be kept
in mind for doctors, embryologists, nursing staff to avoid
unnecessary exposure and preparedness for trouble
shooting respectively.

18. Cleaning Protocols in The OPD Complex
• 0.1% Hypochlorite solution can be used for floors and
walls in outside area of OPD , Consulting rooms before
commencement and after the work is over
• 70% alcohol to clean the table tops and surfaces ,
computers screens , chairs ,sofas before starting the
work
• The USG machine to be cleaned with Oosafe or
Protexwipes ( as approved by the vendors )
• Sterile probe covers used and probes to be cleaned
periodically after every patient with the standard industry
approved wipes
• Maintain Log books of Daily Cleaning Procedures

19. Cleaning Protocols in The Lab
• All benches, Laminar flow cabinets and IVF
chamber ,Microscopes and ICSI rigs Computer
screens , keyboards should be cleaned with
Oosafe
• Deep Cleaning and Sanitisation of the theatre,
bed and trolleys with Oosafe post egg
collection.
• 0.1% Hypochlorite solution can be used in the
semen collection room if it is outside the lab
• Mobile phones to be covered and kept outside

20. Precautions in The USG Room
• Strictly By Appointment
• Well ventilated room for sonography . If AC is to used then with
open to outside Air with vent open
• Triaging to find any high risk case
• Cleaning Protocols of machine ,bed probes followed after every
patient.
• Each patient to wear masks and sanitise hands before entering the
opd and Consultant to wear PPE . Avoid talking to the patient while
doing sonography
• For Follicular monitoring of IUI cycles , limit the visits to 3 per cycle

21. Covid Consent before starting the IUI / IVF
Salient points
• I have approached the Fertility Clinic to undergo the procedure of IUI / IVF on
my own will
• I have been explained about the present knowledge and current information
available of the impact of Covid -19 on pregnancy and I have made the
decision of getting the treatment done out of my free will
• I understand that if I am an asymptomatic carrier, I may endanger the doctor
and the staff , so it is my responsibility to take appropriate precautions and
follow the protocols as well as the code of conduct to prevent getting myself
infected with the corona virus and transmitting the disease to others
• I promise to get myself tested for the viral infection ,as per the instructions of
the doctor
• contd……

22. Consent contd..
• I have been explained that my fertility treatment could be
discontinued at any stage if I develop Covid 19 during the
course of my treatment or the hospital has to be shut down
due to sanitation measures, if one of the healthcare staff
develops Covid 19
• I also know that I may get infected from the hospital or from
the doctor or the hospital staff and I will take every precaution
to prevent this from happening . I will not hold the hospital of
the doctor responsible if such infection happens to me or my
partner
• I have been explained the above in my vernacular language

24. ESHRE Guidelines before starting IVF Cycle

25. ISAR -IFS Guidelines
&
Proceed if
negative
Both partners undergo
triage and PCR testing
At the start of the cycle
Cancel if
positive
48 hours before hCG Proceed if
negative
Cancel if
positive
For IUI and IVF

26. The New Normal For IVF
• No reliable testing is available currently to predict disease because of the high
false negative rate. As a result, all patients should be treated as if they are
coronavirus positive.
• Individualise each patient’s protocol . Prefer Antagonist cycles to prevent
OHSS and decrease number of visits to the hospital. Do not use very high
doses
• Pre IVF detailed counselling about COVID 19 and its implications Take the
Covid Consent
• Avoid Batch IVF to prevent Crowding
• Reduce number of visits ( teach taking self injections or send nurse for
injections or train peripheral clinics staff)
• 5 visit IVF possible (Day 2, Day 6 , Day 9/10 , OPU and sos Transfer )
• Promote video consultations for minor ailments /queries
• Promote Home collections for semen ( with all adequate instructions )

27. Anaesthesia - The New Normal
• Prefer Spinal or Local Anaesthesia Over GA to prevent
aerosol generation
• If GA, can use plastic aerosol container boxes with suction
• Place two high quality HMEFs ( Heat and Moisture
Exchange Filters ) between tracheal tube and breathing
circuit and second between expiratory limb and
anaesthesia machine
• Scavenging can be done by applying the corrugated tubing
to the scavenging port and that can be dipped in a bucket
with 1 % hypochlorite solution

28. Precautions in the OT
• Minimum Number of people should be present in the OT . Make two
mini teams who work in rotation
• There should be 90 mins delay between 2 cases to allow cleaning
• PPE Kit to be worn by all the people present in the OT
• All cables , monitors, anaesthetist work station to be covered with
transparent plastic sheets which should be disinfected after every
procedure
• The patient should also be wearing cap and surgical mask and
hands should be sanitised just before taking in OT
• Avoid repeated movements and transit in and out of the OT

29. To Make OT Covid Ready
• Negative pressure OTs would be ideal to minimize
infection risk However, OTs are normally designed to
have positive pressure air circulation. A high air exchange
cycle rate (≥ 25 cycles/h) contributes to effectively reduce
the viral load within OTs
• Blocking Off the return air vents in the OT
• Hepa filters with no leaks to be present in exhaust ducts
• Treatment of the exhaust air with Hypochlorite 1%
Covid Operation Theatre Advisory Statement : ISA National : volume 64
Indian Journal of Anaesthesia

30. Precautions in The IVF LAB
Ensure adequate supply of disposables and consummables,
liquid Nitrogen in advance
Cleaning -The laboratory is cleaned at shut down and at opening
up with Oosafe . All benches, Laminar flow cabinets, microscope
ICSI Machines and IVF chamber should be disinfected
• Pipette holders , computer screens , keyboards should be disinfected by
wiping with oosafe in between operators and in between procedures
• Diligently disinfect the outside of the shipments received with non-
embryo-toxic disinfectants

31. Precautions in IVF Lab
• Evidence to date suggests that the respiratory virus responsible for
COVID 19 is not present in follicular fluid or seminal plasma, nor
associated with gametes or embryos.
Semen freezing to be advised only in indicated cases and not as
a regular back up for all OPU. Wipe exterior of container with
suitable disinfectant when the sample is received before it is
brought to the andrology laboratory
• Prefer Density Gradient method for sperm preparation
• Follicular fluid and semen should be diluted down with water (to
reduce the bio burden) prior to discarding in a clinical waste bin.
Containers should be tightly capped and disposed off.
• UV light for overnight use Precautions are necessary as UVC
sanitizers can damage your eyes and skin.

32. Precautions in the IVF Lab
• Waste bags - double bagged and disposed off
• To prefer closed system for cryopreserving embryos /oocytes
• Separate Cans for freezing gametes and embryos
• Newer Filter system - The Photocatalytic systems which can
decrease the viral load
• AHU settings to Have frequency of air changes 25 /min

33. What To Do If……..
• Health Staff member turns positive
• In case any member found positive for COVID-19,
only those in direct contact (face to face with less
than a meter /having unprotected direct contact with
infectious secretions or excretions of the person
with confirmed COVID-19) shall be tested and
quarantined.

34. Will the centre need to be shut down ?
In case there is a COVID-19 positive individual
(staff/patient/husband) at the clinic,
then complete sanitization to be done after informing the
local authority.
Closure of the facility will be required as per the regional
guidelines for 24-48 hours.
In such an eventuality the clinic will have to shift patients
with ongoing cycles to a back-up facility with a close liaison
as informed to patients before the start. This has to be
consented from every patient before start of the cycle.

35. • If husband test positive for COVID any time
between start of cycle and day of OPU- go ahead
with OPU as wife negative and freeze all eggs (prior
consenting in place).
• If either patient or husband has a direct contact
(face to face, within < 1 mt) with a COVID-19
positive case then both need to go for quarantine
justifying cancellation of cycle

36. Triaging
Disinfectin
g
Physical
distancing
Consent
Follow
SOPs in
USG room ,
OT
And Lab