16 – 17 JULY 2020 PRAGATI MAIDAN - DELHI INDIAN FERTILITY SOCIETY IFS RECOMMENDATIONS FOR COVID 19 VACCINATION BEFORE ART IFS SECRETARIAT +91 11 40018184 +91 9899308083 indianferlitysociety [email protected] www.indianferlitysociety.org indianferlitysociety 302, 3rd Floor, Kailash Building, ifsdelhi 26, Kasturba Gandhi Marg, C.P. New Delhi - 110001 Cosmo Tech is the Most Important Trade show for the Suppliers to EXPAND Strengthen Increase Multiply Profits New Markets Pan New Market Customer Base India & World Customer Soaring Boost Network Brand Sales Brand Recall Value with the Industry Visibility ORGANIZED BY CALL EMAIL +91 9971811937 [email protected] +91 9999302797 [email protected] +91 9811141938 [email protected] W W W .C O SMO TEC HEXPO IND IA .C O M Dr. Sudha Prasad Dr. Neena Malhotra President Secretary General Indian Fertility Society Indian Fertility Society Director, Matritava Advanced IVF & Professor, ART Centre, Department of Training Cenre, Vasant Vihar, New Delhi Obstetrics and Gynaecology, AIIMS, New Delhi Dr. Sonia Malik Dr. Kuldeep Jain Past President Indian Fertility Society, Past President Indian Fertility Society, Director & Nova Southend Fertility & Director, KJIVF New Delhi IVF Delhi NCR Dr. KU Kunjumoideen Dr. A K Pandey Joint Secretary Indian Fertility Society, Dean Academics &. Co Ordinator Director ARMC IVF Calicut. Molecular Lab. ESI Medical college Faridabad Dr. Charu Jandial Dr. Sumita Aggarwal Member IFS, Consultant, Member IFS, Fellow, Nova Southend Fertility & IVF Delhi NCR Nova Southend Fertility & IVF Delhi NCR Introduction The coronavirus pandemic has wreaked havoc on life In these trying mes, as sociees are gradually trying to and healthcare globally. According to WHO database as return to a state of normalcy, it is also important to on 7th June 2021, there have been 173 million consider sexual and reproducve health of people. confirmed covid19 cases worldwide and 3.7 million Couples seeking concepon are parcularly distressed deaths. The World Health Organizaon declared the and need clear guidelines to help them make decisions outbreak a Public Health Emergency of Internaonal about their treatment. Concern on 30 January 2020, and a pandemic on 11 March 2020. SARS CoV 2 is a posive-sense single- This document of the IFS has been prepared aer taking stranded RNA virus that is contagious in humans. As inputs from all the chapter secretaries of the IFS and described by the US Naonal Instutes of Health, it is the hence includes insights and common queries addressed successor to SARS-CoV-1, the virus that caused the by the healthcare providers across the country. It 2002–2004 SARS outbreak intends to provide both the providers and the paents an overview of covid vaccinaon in paents desiring India is just recovering from the deadly second wave of ferlity in order to help them make an informed choice the pandemic with more than 28 million confirmed regarding the vaccinaon. cases and 3.49 lakh deaths. The virus Covid 19 disease is caused by the virus, SARS CoV2( entry using ACE2. Aer a SARS CoV 2 virion aaches to a Severe acute respiratory syndrome coronavirus 2) which target cell, the cell's TMPRSS2 cuts open the spike is a beta coronavirus. Coronaviruses infect humans, protein of the virus, exposing a fusion pepde in the S2 other mammals, and avian species, including livestock subunit, and the host receptor ACE2. Aer fusion, an and companion animals. Human coronaviruses are endosome forms around the virion, separang it from capable of causing illnesses ranging from the common the rest of the host cell. The virion escapes when the pH cold to more severe diseases such as Middle East of the endosome drops or when cathepsin, a host respiratory syndrome (MERS, fatality rate ~34%). SARS- cysteine protease, cleaves it.The virion then releases CoV-2 is the seventh known coronavirus to infect RNA into the cell and forces the cell to produce and people, aer 229E, NL63, OC43, HKU1, MERS-CoV, and disseminate copies of the virus, which infect more cells. the original SARS-CoV. SARS CoV 2 produces at least three virulence factors that It bears 80% homology to SARS Cov and 50% to MERS(1) promote shedding of new virions from host cells and .Each SARS-CoV-2 virion is 50–200 nanometres in inhibit immune response. diameter. An understanding of the structure of the virus has It is an enveloped posive-sense single stranded RNA helped in developing prevenve and treatment virus with four main structural proteins i.e. Spike (S) strategies against it. protein, Membrane (M) protein, Nucleocapsid (N) protein and envelope (E) protein(2). In SARS-CoV-2, the spike protein, which has been imaged at the atomic level using cryogenic electron microscopy, is the protein responsible for allowing the virus to aach to and fuse with the membrane of a host cell; specifically, its S1 subunit catalyzes aachment, the S2 subunit fusion. It binds to angiotensin receptor conversion enzyme 2 (ACE2) on host cells for viral entry and with the help of Transmembrane serine proteases 2 (TMPRSS2) is incorporated in host cell wall(3).Inial spike protein priming by transmembrane protease, serine 2 (TMPRSS2) is essenal for entry of SARS CoV 2.] The host protein neuropilin 1 (NRP1) may aid the virus in host cell The Need of Vaccination Impact on Reproduction: Covid 19 may influence both male and female steroidogenesis, germ cells and reproducve health.(4) The reproducve system in both sexes has abundant ACE2 receptors and are suscepble to SARS CoV 2 infecon. Studies have suggested that downregulaon of ACE 2 may cause alteraon in follicular development and oocyte maturaon affecng their quality and subsequently affecng embryo development. Also increased oxidave stress may have detrimental pro inflammatory effect. Endometrial recepvity may also be altered leading to unfavourable outcomes.(5) Hajizadeh Malekiand Tarbian conducted a prospecve, longitudinal cohort study of 84men with confirmed COVID 19, and 105 men without the disease in Iran. The researchers analyzed changes in angiotensin-converng enzyme 2 (ACE2) acvity, markers of inflammaon and oxidave stress, apoptoc variables and semen quality, all of which were evaluated at 10-day intervals for up to 60 days. They also had higher levels of reacve oxygen species and lower superoxide dismutase acvity compared with healthy controls. The markers of inflammaon and oxidave stress in sperm cells of men with COVID-19 were increased by more than 100% compared with controls, according to the researchers. Sperm concentraon was reduced by 516%, mobility by 209% and sperm cell shape was altered by 400%.Although these effects were reported to improve over me — represenng “a transient state of male subferlity like those with oligoasthenoteratozoospermia” — the researchers wrote they remained “significantly and abnormally higher in the COVID-19 paents, and the magnitude of these changes were also related to disease severity.” Basigin (BSG) is also one of the most crucial receptors for COVID-19 that mediates its entry to host cells. BSG is expressed not only in the uterus but also in the stroma and granulosa cells of the ovary. BSG may play a role during follicle development, corpus luteum formaon and embryo implantaon. In men viral orchis may develop and impair semen parameters albeit transiently. The long term effects sll need to be evaluated.(6) Covid 19 infecon in pregnant women is more severe than their nonpregnant counterparts with increased morbidity and mortality and adverse perinatal outcome in the form of preterm birth, growth restricon, sll birth and increased caesarean delivery(7)(8). Also vercal transmission though not proven is sll a possibility.(9) The psychological effects of stress due to fear of the disease, social restricons and financial implicaons may also disturb the HPO axis. Drugs used in the treatment of Covid 19 infecon and sanizaon agents in the environment may also result in changes at the molecular level and have a bearing on the ferlity potenal of a couple. (4) RECOMMENDATION Even though the evidence is scant, it is important to (a) scarcity or non-availability of vaccine in some prevent this infecon as well as augment immunity states, against this infecon prior to commencing ferlity (b) medical condions like ferlity preservaon for treatment. cancer, advanced age, poor ovarian reserve etc. IFS therefore recommends vaccinaon before In these circumstances, the paent may be advised to iniang ferlity treatment. However, certain iniate treatment but the final decision may be le to circumstances may warrant iniaon of treatment the paent aer explaining all pros and cons and an before taking the vaccine, for instance, informed consent taken before starng treatment. The vaccine can be taken as and when it becomes available. Prevention of infection Though risk migaon measures like wearing a mask, maintaining hand hygiene and social distancing remain the best prevenve strategy, availability of vaccines have provided a new hope of curtailing the virus and averng further waves of Covid 19. Generally, any vaccine which is available can be taken by those seeking pregnancy with the excepon of live aenuated one to avoid harm in case of accidental pregnancy. For paents who have already been infected with COVID, IFS advises to take the vaccinaon in order to enhance their immunity and dampen the effect of a re infecon if it occurs. The various covid vaccines are being developed using different plaorms like nucleic acid based, viral vector based, protein