Key points in fertility preservation treatment strategies during covid-19 pandemic. An update on pharmacological therapies

Abstract

The fertility preservation (FP) field has developed in the two decades and offers women the possibility to have genetic children at some point in life. Fertility preservation is urgent by definition, performed for social reasons or medical indications, such as impending gonadotoxic therapy or radical gynaecological surgery. One year after the pandemic was declared, the COVID-19 infection imposed several restrictions and limited access to health care for the infertile couple. Ovarian stimulation is a pharmacological treatment used to induce the development of ovarian follicles; FP guidelines provide different options for ovarian stimulation. We performed a systematic search on fertility preservation (FP) procedures during the COVID-19 pandemic using the keywords: FP, ovarian stimulation, assisted reproduction techniques (ART), and COVID-19. In order to update the different treatment strategies in ovarian stimulation on fertility preservation studied in the last ten years, we searched for randomized clinical trials (RCTs) focused on therapeutic agents used in current protocols, gonadotropins, gonadotropin releasing hormone (GnRH), clomiphene citrate (CC), letrozole, androgens, metformin, tamoxifen, glucocorticoids, aspirin, coenzyme Q10, and sildenafil. Fertility may be influenced by SARS-CoV-2 infection - especially in men; until more evidence confirms the effects on fertility, patients with COVID-19 positive should delay FP procedures if possible. Access to fertility conservation services decreased during the analysed period due to the medical services restrictions and the reorientation of medical resources on patients with COVID-19, without major changes in the current therapeutic protocols. In terms of pharmacotherapy in ovarian stimulation (OS) procedures, letrozole is first line therapy, superior to CC for OS. Similar ovulation and pregnancy rate can be obtained in letrozole - induced ovulation compared to gonadotropin protocol. Adjuvant therapies may be used for OS but lack proven efficacy. Further studies on adjuvant therapies and complementary support are needed, to ensure optimal condition in assisted reproductive interventions for fertility preservation, especially in gonadotoxic therapies.