Perhaps you’ve never been pregnant, but try to imagine trying to conceive for more than a year and failing. Imagine then being referred to a fertility specialist for diagnostic evaluation and learning that you will need expensive, invasive, and time-consuming fertility treatments to even entertain the hope of becoming a parent. And then imagine reckoning with the nebulous but mounting threat of the Zika virus, and what it might mean for a desperately wanted child.
Now imagine that you’re the physician at the other end of the examination table, charged with making the ethical call about whether a patient in your care ought to pursue pregnancy under such a threat—with weighing the devastating risks against the deeply desired rewards.
With the news that Zika-carrying mosquitos have arrived in Miami-Dade, Broward, and Palm Beach counties, Florida—and the specter that they will eventually arrive in much of the southeastern United States—the question of what the virus means for both those struggling with infertility and their physicians is suddenly an urgent one. For many fertility patients, time is already working against them. Will doctors soon be forced to tell them to delay IVF, just to be safe?
If contracted by a pregnant woman at any point up to delivery, Zika can have life-altering effects on her child. The virus has been found to cause microcephaly in babies born to women who contracted the disease while pregnant, a lifelong condition wherein a child is born with an underdeveloped head and brain. And so, women in at-risk areas who hope to become pregnant are justifiably concerned about how to proceed during a time in which one mosquito bite could change the course of her future child’s entire life.
If you’re pregnant, have no symptoms, and haven’t been to an affected area, the Centers for Disease Control and Prevention do not recommend you be tested for Zika. “But patients, and rightfully so, are a little bit leary of this idea that the virus is merely confined to this one or two-square-mile red box in downtown Miami,” Christie said. “Why wouldn’t a mosquito be able to fly out of there and bite them in their own backyard? It’s an unsettling time right now.”
It’s been unsettling for some time now in South and Central America, where significant numbers of the population have become infected with Zika, resulting in the birth of babies with microcephaly. Exacerbating the issue, in these regions, contraception access and information limited are limited. Many women who contract the virus lack access to abortion, too, should they choose to terminate a pregnancy. Yet the World Health Organization and local health officials have advised that women living in many of these countries delay pregnancy, at least by a few months. El Salvador recommended delaying until 2018.
In the U.S., guidelines from the CDC and the American Society for Reproductive Medicine recommend that both men and women who have traveled to Zika-affected areas but do not think they have contracted the virus wait eight weeks after potential exposure to try to conceive or begin any kind of fertility treatment. And the organizations recommend that men who experience symptoms of Zika—which often presents like the flu with mild fever, red eyes, soreness and congestion—wait six months before attempting pregnancy, as the Zika virus can live for several months in semen.
Sexual transmission has already been documented in man-to-man, man-to-woman, and woman-to-man cases; the disease is also transmissible from mother to fetus at any point throughout pregnancy, and any point throughout delivery. Zika has also been detected in breast milk, but there is no documentation of this type of transmission. And while the virus has been shown to clear out of semen after several months, no substantive data exists on any potential long-term effects of the virus on female egg cells.
As southern Florida grapples with Zika-carrying mosquitos’ arrival, fertility specialists in other parts of the Southeast are beginning to brace for the same. After all, many experts believe the virus’ spread in this country isn’t a matter of if but when.
Earlier this summer, I spoke with Dr. James Nodler, a reproductive endocrinologist at Houston IVF, who is preparing for the virus’s arrival in his area. “Once summer kicks in, here in Houston there are just dregs of mosquitos and there is nothing you can do to make them go away. And the thought is that once the mosquitos come, the virus comes,” Nodler said.
Unlike in other countries, Nodler points out that modern conveniences like air conditioning, indoor sleeping and readily-available insect repellant could help curb Zika’s wrath. “But the big question is,” he said, “should we be telling people to delay fertility or not?”
Some fertility doctors fear the mental strain of infertility may blind a patient to the potential risks of Zika, should it continue to spread stateside. “The number one reason patients drop out of fertility treatment is stress,” Nodler said. “It’s a mental health issue. If you ask people, they would say it’s because of finances. But really, it’s the mental health part of it.”
Dr. Kathryn Calhoun, a reproductive endocrinologist at the Atlanta Center for Reproductive Medicine, told me that while some of her patients are truly freaked out, others seem to not realize the full scope and severity of the virus. “Patients should not take a cavalier approach to traveling to Zika-affected areas,” she said. “The threat to an unborn child is very real.”
Calhoun said she always initiates a conversation with her patients about Zika, asking them about any upcoming travel plans and any recent travels. Since the mosquitos carrying the virus have yet to arrive in Georgia, for now, she says she advises patients to not travel to Zika-infested areas, and to have good mosquito control on their own property. She also advises them to avoid excessive exposure to outdoor areas where you can’t control for mosquitoes—from wooded areas to outdoors seating in restaurants—as an added precaution.
But whether or not the patients are taking Zika seriously, she said, it’s the responsibility of the doctors to make the best recommendation for a healthy pregnancy and healthy baby.
If there is anything resembling a silver lining to Zika coming stateside, it might be the increased attention and awareness for the practice of egg freezing, according to some of the physicians I interviewed. For young women in particular, concern about the potential presence of the virus in the U.S. might serve as an impetus to preserve gametes today before facing the potential threat of Zika—or age-related limitations—in the future. While egg freezing does not guarantee a future pregnancy, said Calhoun, “it gives you more options.”
Christie also said that the spread of Zika has lead to a discussion among physicians about whether they should be encouraging all patients to freeze eggs, sperm, or embryos until the threat of the virus has passed or a vaccine is available. He adds, though, that the presence of the virus in the U.S. isn’t significant enough yet to make this kind of recommendation.
Indeed, all the physicians I spoke with agreed that even with the active transmissions documented in South Florida, they don’t yet have enough data to recommend that their patients delay fertility. At this moment in time, “if you’re already at an infertility clinic, you probably shouldn’t delay,” said Nodler. “A lot of our patients are already 37, 40—delaying for a year could be catastrophic.”
But if the threat of Zika grows, doctors may eventually have to advise patients along important but painful ethical lines. “We don’t go through the process of fertility treatment so people can get pregnant or have lots of embryos. The only thing that matters to us is healthy babies,” Nodler said. “There is no point in doing all of this if you don’t try for a healthy baby.”
And that’s where a physician’s training comes in. “I have a responsibility to be concerned about something that a patient can’t fully believe could happen,” Calhoun said. Which is why, should the situation with Zika escalate, fertility doctors are “going to have to be the ones to say, ‘we can’t transfer this embryo right now because there’s too much of a threat to the baby.’”
In emotionally trying times like these, she said, “staying true to your ethics is the hardest part of the job.” But, she added, “we took an ethical oath when we graduated and we have to honor it.”