Today, I have a special guest on today who also happens to be my best friend who is a fertility doctor in Los Angeles, Dr. Catherine DeUgarte. Catherine is a reproductive endocrinology and infertility specialist, and the medical director at CMD Fertility. You can find Catherine at CMDfertility.com. She is also assistant clinical professor of ObGYN at UCLA.
We’re going to talk about preventing COVID-19 on the journey towards conception.
Dr. Aimee: Catherine, let’s get started. Tell us about COVID-19. What are the facts that people should know?
Dr. Catherine DeUgarte: Unfortunately, COVID-19 has affected all of our lives for the past year. Everybody has had an impact. More so the infertility patients that we deal with every day not only have the stress about their fertility journey, but now they have to figure out how to prevent getting this horrible disease and prevent their babies from getting it. So, it is something that is very important and I get asked questions about it every day.
Dr. Aimee: Who is at risk?
Dr. Catherine DeUgarte: Anybody can get COVID-19, especially if you’re not vaccinated. It’s a respiratory disease that is caused by the infection of the Coronavirus, also known as the SARS-COV-2 virus. It can be transmitted through respiratory droplets from person to person.
The good thing is right now there are many ways to test for it and there are ways to prevent it. A year ago, we had no vaccines, and now there are six vaccines available in the world and three in our country.
Dr. Aimee: What kind of symptoms should people look out for that might be a sign they might have it?
Dr. Catherine DeUgarte: The most common symptoms are fever, shortness of breath, and coughing. However, there are some specific symptoms, such as loss of smell. There are also GI symptoms that patients can present with. Symptoms can appear 2 to 14 days after exposure. The problem is that patients can be asymptomatic for 14 days before symptoms appear, but they can still transmit the disease during that time.
Dr. Aimee: What should pregnant women know? Are they at risk for more severe illness compared with nonpregnant women?
Dr. Catherine DeUgarte: A year ago when COVID first started, we were telling patients that we have no idea if COVID affects pregnancy, but now there have been many studies that have shown that pregnant women can have more severe disease. There have been studies that they have increased ICU admissions and need for ventilation. Unfortunately, they’re at a higher risk of death. They’re also at higher risk of pregnancy loss. There have been several studies that have shown that.
A recent study that actually came out last week in JAMA, which is a very important article, showed that in 2,000 women, 700 of which had COVID, from 18 countries that they studied last year from March to October and had COVID-positive confirmation on their labs and at least two symptoms of COVID, they had an increased risk of problems in pregnancy, such as preeclampsia, where they get high blood pressure in pregnancy, severe infections, ICU admissions, maternal mortality, and preterm birth. The babies also had increased risk of morbidity and mortality. This is the first time a study actually showed that in a clear fashion.
Dr. Aimee: What kind of things can someone do to prevent getting COVID?
Dr. Catherine DeUgarte: The most important thing we can do right now is social distance and wearing our masks, as well as whenever we can to get vaccinated.
We’re lucky that we are able to have three vaccines that are available in this country. There’s the Pfizer vaccine, the Moderna vaccine, and the Johnson & Johnson vaccine, which was initially paused for a few weeks but recently started again. As of yesterday, they met and they decided that the benefits outweigh the risks, and now it is back to be available to patients to get it as well.
Dr. Aimee: You mentioned the JAMA study and some of the things that it told us pregnant women could be at higher risk for. What are specifically the different diagnoses and what is the actual risk?
Dr. Catherine DeUgarte: The risks from the actual COVID-19 in pregnant women, they were admitted to the intensive care unit more, they had a higher chance of infections and preeclampsia, which is high blood pressure in pregnancy, preterm birth, and also their babies were at higher risk of dying, unfortunately, after delivery. They showed that with cesarean section you can have an increased risk of giving it to your baby, but not with breastfeeding, which I thought was interesting.
Dr. Aimee: Let’s just take one of those things, ICU admissions. How much higher is your risk if you’re pregnant versus not pregnant?
Dr. Catherine DeUgarte: In this study, the relative risk of ICU admission was five times higher for these patients, so definitely a much higher risk of ICU admission. Once you’re admitted to the ICU, then you get exposed to all of the other diseases, you could get pneumonia and other infections. Once you’re ventilated and intubated, then there’s less oxygen flow to the baby and can have preterm labor. Once patients are placed on the ventilator, there’s a much higher chance of dying as well.
Dr. Aimee: You mentioned in this country we have access to three different vaccines. Is there one that you recommend to your patients over another?
Dr. Catherine DeUgarte: Personally, I tell them that whenever they can get the vaccine, the sooner the better, especially before getting pregnant. From my personal experience, from having had many of my patients, I would say at this point about 80% of my patients have been vaccinated. I always ask them how they felt afterward, any side effects.
What I’ve seen personally, and again just from my own experience, is that with the Pfizer vaccine they’ve had the least amount of symptoms. With the Moderna vaccine, more people have gotten flu-like symptoms and severe pain at the injection site. But they’re both very effective. They are equally effective in terms of preventing COVID-19.
With the Johnson & Johnson vaccine, they did have seven patients that developed blood clots. That’s basically our patient population, it’s women 18 to 49. Really, we see patients over 40, but it’s really the women over 18 that showed the blood clots.
If they have a preference, if they have a choice, I would say Pfizer and Moderna over the Johnson & Johnson. But if you think about it, seven patients developed blood clots out of 7,000,000, so many people prevented COVID by taking the Johnson & Johnson vaccine, preventing death from that reason, so in a way it saved lives. Benefits outweigh the risks.
Dr. Aimee: We have all these societies out there, like American College of OBGYN. What are the recommendations that ACOG is making when it comes to COVID vaccines and pregnancy?
Dr. Catherine DeUgarte: There are recent recommendations from ACOG that says that vaccines should not be withheld from pregnant women and they should be offered to lactating individuals, with the hope that the babies build antibodies.
Also, they’re now tested in pregnant women. However, the pregnant women were not included in the original studies. There are unfounded claims linking infertility to the COVID vaccines. I don’t know about you, but I get a lot of patients who tell me, “I’ve heard that the vaccine causes infertility.” I don’t believe in that. There are no studies on that. ACOG doesn’t believe in that. ASRM doesn’t support that. So, I think there are, unfortunately, a lot of theories out there about that. I don’t believe in that.
Dr. Aimee: I’ll call those myths. I would say there are myths out there, definitely.
Can you break down the mRNA vaccines, both Pfizer and Moderna? What is messenger RNA and how does it use our own body’s cells to fight COVID-19?
Dr. Catherine DeUgarte: Absolutely. mRNA vaccines are new to us. The technology has been around for a while, but it hasn’t been used in a vaccine. This vaccine was developed quite rapidly because of the prior research that was done.
Messenger RNA is basically encapsulated by a lipid nano particle. This lipid particles help deliver this mRNA into our cells, into host cells. Then they utilize our own body’s cells to generate the Coronavirus spike protein, which is the protein that then stimulates the immune cells to create antibodies. It kind of fools our body into thinking that we have COVID so that it makes antibodies against COVID.
What’s important to know is that these vaccines are not a live virus, so you can’t get COVID from the vaccine. They don’t enter the nucleus. They don’t change our DNA. Again, there are no studies on pregnant women because they weren’t in the initial studies, but since then they’re being followed. There are many pregnant women that have received the vaccine.
In terms of the mRNA vaccine, the efficacy for the Pfizer one has been shown to be 95%. For the Moderna, about 94%. They’ve been also been studied in diverse sex, age, race, and ethnic categories, as well as for those with underlying health conditions.
The Johnson & Johnson (or the Jansen) vaccine is an adenovirus vector vaccine, it’s a monovalent vaccine. It has a recombinant replication of the human adenovirus vector, and that also makes the spike protein, just like the mRNA, however it doesn’t have the special particles to get in. For patients with allergies, since it doesn’t contain preservatives, it may be better. It’s also not a live vaccine and it doesn’t replicate in our cells.
Dr. Aimee: How effective are the vaccines in preventing, let’s say, moderate to severe COVID symptoms or illness and preventing hospitalizations?
Dr. Catherine DeUgarte: In the initial outcome studies for the Pfizer and Moderna, they looked at overall effectiveness against COVID, which were around 94% and 95%. With the Johnson & Johnson vaccine, they looked at specific categories. For example, it ended up being 67% effective at preventing moderate or severe COVID disease and 77% effective at preventing severe COVID illness. What’s most important is that it was 93% effective for preventing hospitalizations, even two weeks after the vaccine.
It’s given as one dose, so you don’t have to have a second dose, which is one of the big advantages of the Johnson & Johnson. Again, the problem is the blood clots, which we talked about. Just so people know, I’ve had several patients that have gotten the vaccine. What I’ve told them is, since the pause happened from the FDA, to look out for symptoms such as headaches, chills, fever, back pain, trouble breathing. Now they’ve released it back into the market, women under 50 who have gotten this vaccine are now a given a handout that shows it can increase a rare blood clotting disorder which cannot be treated with heparin because it’s also associated with lower platelets.
Dr. Aimee: How many people have gotten these vaccines total in the US?
Dr. Catherine DeUgarte: At this point, I would say that the Pfizer vaccine it’s more than 10,000,000 doses, the Moderna it’s more than 7,500,000 doses, the Johnson & Johnson, because it was released later than the others, I’m not aware of how many total have been given, but it’s approximately 7,000,000 reported right before the pause.
Dr. Aimee: I want to go through some vaccine myths.
Myth number one: The vaccine was rushed, and it isn’t safe.
What is the vaccine fact here?
Dr. Catherine DeUgarte: That was one of the most common reasons why my patients have declined the vaccine, they say it was done really fast. Again, the technology has been around for a long time. It was actually a woman who first discovered the mRNA technology many years ago, but nobody believed her. When this happened, there was some work a few years ago with Ebola and trying to work on those vaccines, and now they had the technology already, they just basically tried it. They enrolled patients really quickly and they were able to get the information to the FDA rather quickly.
Again, they didn’t take any shortcuts. So far, the studies that are out there show that the vaccine is safe.
Dr. Aimee: Another myth: It can give you COVID-19.
I’ve had patients say, “I’m about to have my egg retrieval and I just got the vaccine. I’m worried I’m going to be positive.”
Dr. Catherine DeUgarte: The vaccine can’t give you COVID-19. However, if you get the vaccine today, and if you happen to be exposed to somebody who has COVID tomorrow, you could get COVID. That person might think the vaccine gave them COVID, where in fact they got it from the person the next day but they didn’t have antibodies yet to prevent it.
Dr. Aimee: Another myth: If I’m allergic to eggs, I can’t get the vaccine.
Is that true?
Dr. Catherine DeUgarte: That’s a good question, because with the flu vaccine, as we all know, you can’t take the flu vaccine if you have an egg allergy. You can take a version of it, but not the one that everybody else takes. This vaccine does not have any egg proteins, so it can be given to those with egg allergies.
Dr. Aimee: I want to talk about some vaccine considerations. A lot of these things are questions that a lot of my patients are asking me, so I’m super curious and I’m glad you’re here to answer these questions.
Should women who experience fever following vaccination be counseled to take Tylenol?
Dr. Catherine DeUgarte: Absolutely. It is very safe for women to take Tylenol in pregnancy, and it does not impact the antibody response to COVID-19. But I would advise them not to take Motrin.
Dr. Aimee: Should someone who finds out they’re pregnant after their first shot, if they got Pfizer or Moderna, still get their second shot in pregnancy?
Dr. Catherine DeUgarte: It is recommended by ACOG that women should continue and complete their two-dose series even if they are pregnant. However, if possible, to get both vaccines before attempting pregnancy would be ideal.
Dr. Aimee: There are other vaccines that are recommended in pregnancy, like TDAP and the flu shot. How should you time your COVID vaccine to the other vaccines that are recommended in pregnancy?
Dr. Catherine DeUgarte: ACOG recommends that if you are giving other vaccines, such as TDAP or the flu shot, you should wait 14 days after giving the COVID vaccine.
Dr. Aimee: For women who are Rh-negative and need RhoGAM in pregnancy, is there any special consideration for them when it comes to timing the COVID vaccine?
Dr. Catherine DeUgarte: That’s a great question. With RhoGAM, you don’t need to wait the 14 days, so you should give it as needed. To patients who, for example, have had miscarriages or if they’re 28-weeks, you should not delay that, because you don’t want to have a problem with the baby.
Dr. Aimee: Then I want to know one more time, and I want to hear you say it. Does the COVID vaccine cause infertility?
Dr. Catherine DeUgarte: At this point, there are obviously no studies showing that the vaccine causes infertility. Obviously, long term studies are not there yet. From what I’ve seen with my patients, I’ve had many patients who have gotten the vaccine and have gone through procedures and have gotten pregnant.
Dr. Aimee: ASRM has given out a fact sheet about vaccine considerations as well around reproductive care procedures like egg retrieval and transfer. Can you talk a little bit about that?
Dr. Catherine DeUgarte: Sure. That was actually a recent guideline by the ASRM. It basically stated that patients who are undergoing fertility treatments and pregnant patients should be encouraged to receive the vaccination based on their eligibility criteria, and that they don’t need to delay pregnancy because of the vaccination or defer treatment until the second dose. They also state that there is no evidence that the vaccine can lead to the loss of fertility.
This is the important one that I’ve gotten a lot of questions about, is when to do the vaccine while they’re undergoing an IVF cycle. What ASRM recommends is that you should wait three days either before or after. If you have your retrieval scheduled for Saturday and today is Monday, that’s a great time to get the vaccine.
So, at least three days should go between the day of the retrieval and the day of the vaccine. Not because the vaccine is going to cause a problem with your eggs or anything. It’s just that you can get a fever from the vaccine, so if you get a fever from the vaccine and it’s happening the same day as the retrieval, you don’t know if the fever is an infection from the retrieval, so you have no idea how to treat that. You don’t want to mask an underlying infection.
Dr. Aimee: What about the ERA test, do you think that the vaccine would impact ERA results? What do you tell your patients?
Dr. Catherine DeUgarte: I don’t think it makes a difference. Again, I think just because of the fever issue, just because it can cause pain when you do the ERA procedure, I would say I would wait three days before any procedures just to be on the safe side.
Dr. Aimee: What about mammograms? We recommend mammograms for people in certain age groups, but especially reproductive-age women who are, let’s say 40 and planning a cycle, a lot of times people recommend a mammogram before they start IVF. What should women do when it comes to the vaccine and their mammograms?
Dr. Catherine DeUgarte: In fact, I recently had my mammogram and that was one of the questions that they asked me, “Have you had a recent vaccine?” I asked them why before I actually looked it up myself, and I read that there is a recent guideline that showed to avoid mammograms four to six weeks after the vaccine because it can increase the size of your lymph nodes. Since the vaccine is given in the arm, the lymph nodes that are getting enlarged are the ones near the breast area, so it would appear like you have an enlarged lymph node, which could be a concern for possible cancer, so it would go down this pathway of freaking people out. So, I think it’s best to avoid four to six weeks afterward.
Dr. Aimee: What about for folks who have already had COVID? I have patients who have been exposed to COVID, they’re positive, and I’m still recommending the vaccine. Is that something that you’re doing as well?
Dr. Catherine DeUgarte: I still recommend the vaccine, especially if they’re trying to get pregnant, because the immunity is thought to wean after three to six months. I don’t recommend getting the vaccine very soon after getting the diagnosis of COVID, but they are recommending about three months afterward.
Dr. Aimee: Do you think that we’re going to need a booster shot? If we do, when do you think that’s going to be needed?
Dr. Catherine DeUgarte: Some folks from the CDC are saying that because there are so many new strains out there and it seems like the virus is changing course, there are new strains from Europe, Africa, and Brazil, so some of the initial studies tested a few of those strains, but not all of them, so the thought is that we may need a booster. Just like we get annual flu shots, we may need to get an annual COVID vaccine, or we all may need a third booster shot in the next 12 months.
Dr. Aimee: What are you doing at CMD Fertility, in your own clinic?
Dr. Catherine DeUgarte: What we do is we don’t make all of our staff get vaccinated, but I was lucky that they all volunteered to get vaccinated. That makes us all feel better, and our patients are safer because we’re not going to spread the disease. We’re all wearing masks.
We’re not allowing at this point partners, unfortunately. That’s really heartbreaking, especially when they have their first heartbeat ultrasound. We’re trying to not allow them to come in unless they have to provide a sample.
Also, we are giving them questionnaires before they come in. We check everybody’s temperature. We do extra cleaning. We have air purifiers. We do check everybody for COVID who has not been vaccinated within five days of their procedures. We’re also spacing patients out and not allowing anybody to wait in the waiting room, so that decreases their chance of getting it.
Dr. Aimee: Did you ever think that you and I would do a ‘COVID and fertility’ talk together?
Dr. Catherine DeUgarte: Never. My grandfather was a virologist. I wonder if he’s up there smiling. I always wondered why he became a virologist. He said, “It’s such a small particle, but it’s very powerful and it can affect the whole world.” Now I realize that he was right all along.
Dr. Aimee: Thank you, Catherine, for shedding light on such an important topic for us today. I wish you all the best and best of luck. I hope all of your patients’ eggs and sperms and embryos sparkle.
Dr. Catherine DeUgarte: And let’s all stay healthy and get through all of this together.
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