To continue or not to continue fertility treatments?
That was the question faced by Amanda* and her husband. The Puerto Rico-based couple had been undergoing fertility treatments for over a year when Zika transmission was reported on their island. They knew that some international health officials, including Puerto Rico's secretary of health, had advised women to consider delaying pregnancy in an effort to avoid serious birth defects, but they also knew that pushing back treatment would reduce their chances of conceiving.
For couples who have been trying to conceive, the existence of a birth defect-causing virus has added a layer of fear and uncertainty. The safest option may well be to wait until more is known, or until a vaccine is available—but that's not a realistic option for many people.
"Many of these couples have been struggling with infertility for many years, and time is not on their side," says Juan Correa Perez, Ph.D., an embryologist in Texas who works closely with infertility clinics in his birthplace of Puerto Rico. That's why infertility experts are being inundated with questions from concerned patients.
"At this point in time, because we don't have all the answers, the best we can probably do is [focus on] prevention and making [patients] aware of the situation, what the symptoms are, and where to look for more information," Dr. Perez says. "I think if you make them aware, they can make intelligent decision."
Kaylen Silverberg, M.D., medical director of the Texas Fertility Center and Ovation Fertility, says he gets Zika-related questions about "every day." Questions he's fielded include, Is it safe to get pregnant? What if my husband travels to a country with Zika and I don't? Should he bank sperm before he travels? Should I freeze my eggs?
Here's what you need to know to make informed decisions:
Zika infection during pregnancy does not guarantee that the child will be born with birth defects. But it's wise to take precautions. No one knows exactly how great the risk of serious birth defects is. In fact, researchers are still learning a lot about virus infection and transmission. But that uncertainty—and potential for extremely serious health problems—is exactly why couples struggling with infertility may want to be extra cautious.
"A woman who gets infected and is pregnant will wind up being monitored for her entire pregnancy. If the baby looks affected, she is then facing delivering a child who will likely be extremely mentally handicapped and face a very short life span, or she will be facing terminating a pregnancy fairly late in the course of gestation," says Nanette Santoro, M.D., professor of reproductive endocrinology at the University of Colorado. "For a woman who is not struggling with infertility, this is awful. For a woman who has conceived after struggling with infertility, it would be unimaginable stress and pain."
Think about delaying fertility treatments if you've traveled to (or are planning travel to) an area with Zika transmission. If you're planning on using your own sperm and eggs for fertility treatments, you might want to stay put for a while. The American Society for Reproductive Medicine recommends waiting eight weeks before attempting conception after possible exposure but not showing symptoms of Zika infection. Women who have Zika symptoms, however, should wait at least eight weeks after symptoms appear, and men with symptoms should wait six months after symptoms appear, before TTC. And given that there's no easy way to determine whether or not you've been exposed—an estimated 80 percent of people who have been infected don't show any symptoms, and virus-detecting blood tests aren't recommended unless you already have symptoms—it's safest to wait.
Consider banking sperm. If the male partner must travel to a high-risk area, sperm-banking before departure could be wise. Because the virus can be spread through sexual contact, the CDC says that men who develop symptoms after travel should abstain from unprotected sex—and, therefore, trying to conceive naturally or with fertility treatments—for at least six months after symptoms first develop. Men who travel to affected areas but don't develop symptoms are advised to abstain from sex or use condoms (i.e. no TTC) for at least eight weeks.
Time is precious to couples who have already waited for years to get pregnant. Banking sperm ahead of time allows a couple to "go full speed ahead" with fertility treatments, Dr. Silverberg says.
Donor eggs and sperm should be safe, provided certain precautions are taken. There are no commercially available tests for Zika, so clinics can't screen eggs or sperm for the virus. But in early 2016, the FDA issued recommendations instructing clinics to screen potential donors. Donors who live in or have traveled to areas with active transmission can't donate until six months have passed—plenty of time, it is believed, to clear the virus.
If you're using a gestational carrier, talk about any travel plans. Babies seem to be at the greatest risk if the mother is infected while she's pregnant. So if you're using—or considering using—a gestational carrier, it's a good idea to put a nix on travel to countries under a travel advisory for the duration of the pregnancy. (See the CDC's list of travel advisories.)
"One of my couples was planning to transfer their embryos inside the uterus of a gestational carrier. She was planning on traveling to the Caribbean and they became quite concerned. They met with her and told her that if she didn't postpone her trip, they'd get someone else," says David Diaz, M.D., a reproductive endocrinologist at Orange Coast Memorial Medical Center in California. "The carrier agreed it was probably not in her best interest or the interest of the parents to go, so she postponed her trip."
Egg freezing is not the answer. Egg freezing may be a way for women to prolong their fertility, but if you're dealing with infertility right now, egg freezing won't help you decrease your risk of birth defects, because the greatest risk seems to be infection during pregnancy, Dr. Silverberg says.
After much reflection and discussion, Amanda and her husband decided to continue fertility treatments. "I put it in God's hands," says Amanda, who is also relying on bug spray and long-sleeved clothing to protect her from mosquito bites. "If He wants this to happen, then it will happen."
*Last name withheld for privacy.