IFS recommendations for COVID-19 Vaccination COVID-19 before ART

INTRODUCTION

The coronavirus pandemic has wreaked havoc on life and healthcare globally. According to WHO database as on 7^th June 2021, there have been 173 million confirmed covid19 cases worldwide and 3.7 million deaths. The World Health Organization declared the outbreak a Public Health Emergency of International Concern on 30 January 2020, and a pandemic on 11 March 2020. SARS-CoV-2 is a positive-sense single-stranded RNA virus that is contagious in humans. As described by the US National Institutes of Health, it is the successor to SARS-CoV-1, the virus that caused the 2002–2004 SARS outbreak

India is just recovering from the deadly second wave of the pandemic with more than 28 million confirmed cases and 3.49 lakh deaths.

In these trying times, as societies are gradually trying to return to a state of normalcy, it is also important to consider sexual and reproductive health of people.

Couples seeking conception are particularly distressed and need clear guidelines to help them make decisions about their treatment.

This document of the IFS has been prepared after taking inputs from all the chapter secretaries of the IFS and hence includes insights and common queries addressed by the healthcare providers across the country. It intends to provide both the providers and the patients an overview of covid vaccination in patients desiring fertility in order to help them make an informed choice regarding the vaccination.

THE VIRUS

COVID-19 disease is caused by the virus, SARS CoV2(Severe acute respiratory syndrome coronavirus 2) which is a beta coronavirus. Coronaviruses infect humans, other mammals, and avian species, including livestock and companion animals. Human coronaviruses are capable of causing illnesses ranging from the common cold to more severe diseases such as Middle East respiratory syndrome (MERS, fatality rate ∼34%). SARS-CoV-2 is the seventh known coronavirus to infect people, after 229E, NL63, OC43, HKU1, MERS-CoV, and the original SARS-CoV.

It bears 80% homology to SARS Cov and 50% to MERS.^[1]

Each SARS-CoV-2 virion is 50–200 nanometres in diameter.

It is an enveloped positive-sense single stranded RNA virus with four main structural proteins i.e. Spike (S) 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 attach to and fuse with the membrane of a host cell; specifically, its S1 subunit catalyzes attachment, 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] Initial spike protein priming by transmembrane protease, serine 2 (TMPRSS2) is essential for entry of SARS‑CoV‑2.] The host protein neuropilin 1 (NRP1) may aid the virus in host cell entry using ACE2. After a SARS‑CoV‑2 virion attaches to a target cell, the cell’s TMPRSS2 cuts open the spike protein of the virus, exposing a fusion peptide in the S2 subunit, and the host receptor ACE2. After fusion, an endosome forms around the virion, separating it from the rest of the host cell. The virion escapes when the pH of the endosome drops or when cathepsin, a host cysteine protease, cleaves it. The virion then releases RNA into the cell and forces the cell to produce and disseminate copies of the virus, which infect more cells.

SARS-CoV-2 produces at least three virulence factors that promote shedding of new virions from host cells and inhibit immune response.

An understanding of the structure of the virus has helped in developing preventive and treatment strategies against it.

Prevention of infection

Though risk mitigation measures like wearing a mask, maintaining hand hygiene and social distancing remain the best preventive strategy, availability of vaccines have provided a new hope of curtailing the virus and averting further waves of COVID-19.

So, couples are advised to continue with efforts at conception, follow all preventive measures and meanwhile seek vaccination at the earliest.^[11]

Generally, any vaccine which is available can be taken by those seeking pregnancy with the exception of live attenuated one to avoid harm in case of accidental pregnancy.

For patients who have already been infected with COVID, IFS advises to take the vaccination in order to enhance their immunity and dampen the effect of a re infection if it occurs.

The various covid vaccines are being developed using different platforms like nucleic acid based, viral vector based, protein and peptide subunit based, killed whole virus, nanoparticle and virus like particle based vaccines.

The COVID-19 vaccines approved in our country and the ones in the pipeline are shown in Tables 1 and 2

Table 1 Vaccines approved for use in India

Table 2 Vaccines under trial in India

Other international vaccines which may be available in near future in our country are

1. mRNA based vaccines- BioNTech/ Pfizer and Moderna. These do not contain the COVID-19 virus and so theoretically cannot lead to infection. In addition, they do not interact with the host’s DNA and so cannot cause genetic changes.

2. Viral vector vaccine − Jannsen (Johnson & Johnson) single dose vaccine, Oxford- Astrazaneca

3. Inactivated Virus vaccine: Coronavac, Sinopharm

4. Protein based- Novavax

Most vaccines have either no or minimal minor side effects like immediate pain, sweating and nausea after receiving the vaccine. There could be fever, fatigue, myalgia, arthralgia, lymphadenopathy, local pain, swelling, redness, rash and diarrhea in the first week after the vaccine. Most of these adverse effects can be alleviated by simple medications.^[12] Rarely there may be severe anaphylactic reactions, thromboembolic phenomena resulting in cardiopulmonary or cerebrovascular events, severe gastrointestinal disturbances, facial palsy and local infections like cellulitis.

RECOMMENDATION

IFS strongly recommends all preventive measures including vaccination to mitigate the possibility of infection to all those planning a pregnancy or contemplating ART treatment. Any of the available vaccines in the country may be taken.

There are many queries in the minds of the patients which need to be addressed. However, because of limited knowledge about the disease and the daily emerging evidence, it is recommended that the final decision to vaccinate should be left to the couple or the individual seeking advice.

Similarly, the advice to the person seeking opinion would be that although covid vaccines have been developed in a short time frame, they seem to be safe and efficacious. The final decision to accept or decline the vaccine by couples desiring conception and those who are pregnant should be in consultation with a healthcare professional after understanding the benefits and presumed risks as more evidence continues to evolve.

The present guidance attempts to provide answers to most of the queries raised.

FREQUENTLY ASKED QUESTIONS