Restart Fertility in Covid19

1
Resumption of ART Cycles Post COVID Taking the
threat seriously
2

• Dr Shivani Sachdev Gour
• MD DNB MRCOG (UK)
• Consultant Fertility Specialist Gynaecologist
• Director
• SCI IVF Centre New Delhi

• DR Nupur Garg
• MS, FNB Consultant Fertility
• Specialist Gynaecologist
• Director
• SCI IVF Centre Noida

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KEY RECOMMENDATIONS-ASRM March 13 2020

1. Suspend initiation of new treatment cycles,
   including ovulation induction, intrauterine
   inseminations (IUIs), in vitro fertilization
   (IVF) including retrievals and frozen embryo
   transfers, as well as non-urgent gamete
   cryopreservation.
2. Strongly consider cancellation of all embryo
   transfers whether fresh or frozen.
3. Continue to care for patients who are currently
   in-cycle or who require urgent stimulation and
   cryopreservation.
4. Suspend elective surgeries and non-urgent
   diagnostic procedures.
5. Minimize in-person interactions and increase
   utilization of telehealth.

4
ART and COVID-19 ESHRE 2/4/20
European Society of Human Reproduction and
Embryology

• ESHRE advises that ART should not be started at
  present for the following reasons
• To avoid complications from ART/ potential SARS-Co
  V-2 related
• complications during pregnancy
• To mitigate the unknown risk of vertical
  transmission in SARS-CoV-2 pt
• To support the necessary reallocation of
  healthcare resources
• To observe the current recommendations of social
  distancing.
• In cases of urgent fertility preservation in oncol
  ogy patients, the cryopreservation of gametes,
  embryos or tissue should still be considered.

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India
Denmark restart 20/4/20
Australia IVFclinics restarted 21 to 27 April
2020
Sweden some clinics stayed open
Canada Restart as per local jurisdiction
Germany restart as per ESHRE
USA clinics some stayed open/ restarted
UK Restart May 2020 as per HFEA
7

• Flu like illness is a serious problem every
  year, What is different now? How is corona
  different from flu or
• viruses like Ebola or HINI?

8
COVID-19 not like normal seasonal Flu

• The pathophysiology, epidemiology and
  transmission dynamics of COVID-19 are not fully
  understood.
• There are currently no specific medications
• for the treatment of COVID-19.
• COVID-19 is a novel infection and host immunity
  is assumed
• to be minimal.
• COVID-19 is more contagious than the flu.
• COVID-19 has a 10 to 15-fold greater mortality
  rate than the flu.
• Unclear whether the current proposed drug can be
  used safely in pregnant or breastfeeding women
• COVID-19 impacts the lungs differently than does
  the flu.

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Onder G JAMA 2020,Verity R Lancet Infec Dis 2020
9
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UNDERSTANDING BASICS

• Particles gt 5 to 10 micron called respiratory
  droplets
• lt 5 microns are called droplet nuclei/ aerosols
• SarsCov2 transmission is believed to be through
  droplets and direct contact
• feco oral transmission ?
• Recent Reports (MIT) Social distancing may need
  to be 27 feet?? (instead of 6 feet)

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Where do we stand in the epidemic curve?
12
Where do we stand in the epidemic curve?
13

• Growth rate lt5 or Growth factor lt1 indicate
  stabilisation and decline
• Indias R vale (4/5/20 as per news updates)1.36

14
Have we reached point of stabilisation?

• Many countries now reporting stabilisation of
  infection
• Australia
• Spain
• Italy
• China
• Germany

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• Should Infertility Treatment Be Considered Non
• Essential?

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• Should Infertility Treatment Be Considered Non
  Essential?
• Although infertility does not jeopardize the
  physical survival of infertile couples, it does
  jeopardize their future quality of life
• Treatment of infertility is medically necessary
• It is time sensitive and extremely important
  (such as IVF) but not
• a medical emergency.

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Tell us about the Best practice guidelines for
reintroduction of routine fertility treatments
during the COVID-19 pandemic by ARCS and BFS
Date of publication 6th May 2020
19
It states that ARCS and the BFS published
initial guidance on 16th March, which was
updated and expanded on the 18th March
2020, Recommended that ART centres cease all
elective treatment activity asap to reduce the
potential burden on the NHS from treatment
complications, ensure social distancing, reduce
risk of viral infection for patients and free up
essential resources to aid in the fight against
the pandemic. Then on 23rd March 20 HFEA
published General Direction 14 It which limited
treatments to fertility preservation in patients
who were, in the written opinion of a registered
medical practitioner, likely to become
prematurely infertile.
20
Guidelines updated 6/5/20

• The following 5 principles underpin the approach
  taken in developing this guidance
• Resumption of fertility services must take place
  in a manner that minimises the chances of spread
  of COVID-19 infection to patients and fertility
  clinic staff.
• Centres should ensure a fair and transparent
  approach to any prioritisation policy.

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Five Key Principles

1. Resumption should not result in an undue burden
   on the NHS.
2. Patients should be fully informed about the
   effect of the ongoing pandemic on their
   treatment and give informed consent to having
   fertility treatment at this time.
3. The fertility sector should adopt sustainable
   changes in working practices that help to build
   resilience against any future increases in the
   spread of COVID-19 in the community.

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ESHRE updated statement on restarting ART
23
ESHRE Released statement
23 April 2020 As the COVID-19 pandemic is
stabilising, the return to normal daily life will
also see the need to restart the provison of ART
treatments. Infertility is a disease and once
the risk of SARS-CoV-2/COVID-19 infection is
decreasing, all ART treatments can be restarted
for any clinical indication, in line with local
regulations.
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Resumption of ART

• 6 pillars of good medical practice
• Discussion, agreement and consent to the start of
  treatment
• Staff and patient triage
• Access to advice and treatment
• Adaptation of ART services
• Treatment cycle planning
• Code of Conduct for staff and patients

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HOW TO ENSURE PATIENT SAFETY
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Ensuring patient safety
a.Information and consent Patients are likely to
be anxious about coronavirus and its potential
effects on pregnancy. Patients should be made
aware that the present experience is limited and
does not indicate that the severity of infection
is any worse in pregnancy, there is no evidence
of an increased risk of fetal anomalies
(RCOG) Patients should be carefully counselled, ta
king into account their individual clinical
situation and risk profile, and the likely
persistence of the virus in the local
community This counselling and the patient's decis
ion whether or not to proceed with fertility treat
ment should be documented in the medical record.
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Patient education

• Tutorials on the use of personal protective
  equipment (PPE)
• Advice on continuation of social distancing and
  avoidance of unnecessary human physical contact.
• Information about symptoms of SARS-CoV-2/COVID-19
  infection
• or exposure occurrence
• Agreement that treatment can be discontinued if
  the patient encounters a high-risk situation

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HOW TO PRIORITISE PATIENTS
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Prioritisation
Fertility preservation for patients facing cancer
chemotherapy In addition, it is reasonable to
prioritise patients in whom delay is most likely
to significantly affect the outcome of
treatment. those with a low ovarian reserve,
advanced age and those facing extirpative pelvic
surgery (for instance due to severe endometriosis
or bilateral ovarian cysts). The above list is
not exhaustive
30
ANY SPECIAL CAUTIONS for particular group of
patients
31
Particular caution
In patients whose co-morbidity places them at a
higher risk of complications in the event of
contracting coronavirus infection.e,g obesity,
hypertension, diabetes and those receiving
immunosuppressive medication. Such patients may
delay conception until epidemiological evidence
shows a sustained reduction in the community
spread of the infection.
32

• High-risk patients (e.g. diabetes, hypertension,
  using immunosuppressant therapy, past transplant
  patients, lung, liver or renal disease) should
  not start ART treatment until it is deemed safe
  to do so .
• All patients should be offered a choice to
  proceed with or postpone their ART treatment
• In both cases patient preference should be
  clearly documented.
• Patients must be comprehensively informed, the
  risks related to COVID-19 disease and the
  increased risks in case of infection during
  pregnancy.
• Patients must also be informed on how to reduce
  the risk of infection in general.
• Patients must sign and adhere to the Code of
  Conduct.

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TELL US ABOUT TRAIGING SCREENING BEFORE STARTING
TREATMENT
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Triaging, Screening and Testing

• Before starting treatment
• A screening questionnaire
• Antigen test (if available)
• Patients and donors with a diagnosis of COVID-19
  infection should not start treatment until they
  have recovered and are not considered infectious.
  National guidelines should be followed in this
  regard. Centres should consider whether they
  advise patients and potential donors to
  self-isolate, if possible, from the start of
  ovarian stimulation treatment until egg
  collection.

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Triaging Questionnaire for Covid-19

• Have YOU or YOUR PARTNER or ANY MEMBER OF YOUR
  HOUSEHOLD been diagnosed with Covid19?
• Have YOU or YOUR PARTNER or ANY MEMBER OF YOUR
  HOUSEHOLD had any of the following symptoms in
  the last 2 weeks
• Fever (feeling hot or temp gt37.5)
• 2. Persistent cough
• 3. Loss of the sense of smell
• 4. Loss of the sense of taste
• 5. Sore throat
• Have YOU been in contact with anyone in the last
  2 weeks who has any of these symptoms or has
  been diagnosed with Covid-19?

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Any difference between this and Eshre guidelines
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Patients

• All patients planning to start treatment to
  undergo triage questionnaire (paper, email or
  phone)
• two weeks before commencing treatment.
• Triage of both partners two weeks before starting
  the ART treatment.
• A further triage of both partners during ovarian
  stimulation.
• Medical evidence of clearance from all patients
  with a previous confirmed COVID-19 infection
• If patients have been on respiratory support
  during the COVID-19 infection episode, additional
  evidence of fitness assessment and a medical
  specialist report.

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TRAIGING SCREENING DURING TREATMENT AND WHAT IF
TEST FOR COVID19 IS POSITIVE
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Triaging, Screening and Testing
During treatment A coronavirus screening
questionnaire should be administered prior to
every clinic visit. Patients and donors with a
negative coronvirus antigen test at the start and
who remain negative on questionnaire throughout
should be allowed to complete treatment. Consider
ation should be given to performing a further
antigen test as close as reasonably possible to
any surgical procedure depending upon local
guidelines and availability of testing.
42
Action in the event of suspected COVID-19
If a patient or donor develops symptoms / or
screens positive on the questionnaire (RTPCR )
antigen screen should be arranged treatment
should not proceed unless the patient screens
negative . If patient or donor presents with
suspected or confirmed Covid-19 after the
ovulatory trigger, a multidisciplinary
individual risk assessment should take place to
balance the risks of refraining from oocyte
retrieval against those of proceeding. Patients
who become symptomatic after oocyte retrieval but
prior to embryo transfer should be advised to
freeze all their embryos for future use.
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HOW TO REDUCE FACE TO FACE INTERACTION
Dr Poornima Durga
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Reducing face-to-face interactions
Frequency and duration of visits required may be
reduced. Use Telephone and video consultations -
ensure that any software used meets the
requirements of data protection. Clinicians may
require training in the performance of virtual
consultations, including the need for
confidentiality, accurate patient identification
and provision of sufficient time for patients to
assimilate information and ask questions. Recordi
ng and Consent for fertility treatment may be
taken remotely, provided the clinician is
satisfied that the patient thoroughly understands
the implications of consenting. Software
packages exist to aid this process.
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Reducing face-to-face interactions
Use of videos and podcasts that can be accessed
from home, avoiding the need for patients to
congregate in large numbers. Online counselling
options Reduce the number of visits required for
monitoring ovarian stimulation, particularly in
women with a normal ovarian reserve. Minimise
the number of accompanying persons. Virtual
consultations, including those where an
interpreter is needed, offer a way of managing
care safely without the need for multiple
attendees in person
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HOW TO MINIMISE CLINICAL RISK
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Minimising clinical risk
Clinical protocols to minimise the risk of
OHSS GnRH-Antagonist protocol and GnRH-agonist
trigger in appropriate cases. Minimise the risk
of hospital admission for patients Operative and
infective complications following oocyte
retrieval are rare, and preventative measures
such as prophylactic antibiotics should be
considered to reduce risk where appropriate.
The use of empirical immunosuppressive
treatments should be avoided.
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Tell us about precautions for the staff will you
advise staff to do Covid19 test will you advise
staff to take HCQ prophylaxis?
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Staff

• Triage information should start at least two
  weeks before the beginning of clinical
  activities at the centre.
• Staff should be subdivided in mini-teams with
  minimum interactions among them.
• Teams should work according to a rotating
  schedule, similar to the one adopted for weekend
  work

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Adaptation of ART services

• Sanitation
• Staff and centre adaptation
• Access procedures

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• SANITATION/ DISINFECTION REARRANGEMENT OF
• CLINIC

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Sanitation

• Routine sanitation of all areas should be
  performed according to local protocols.
• Specific COVID-19 sanitation procedures should be
  implemented in case of COVID-19 positive
  patients or staff members.

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Disinfection

• For surface cleaning and disinfection, agents
  that are useful are alcohol or chlorine based.
• Alcohol based agents should contain 70 isopropyl
  alcohol.
• Chlorine based solutions are prepared by diluting
  liquid chlorine (1000 mg/L strength) or freshly
  prepared 1 sodium hypochlorite solution.
• The appropriate concentration of sodium
  hypochlorite for disinfecting general liquid
  biological waste is
• approximately 1.
• Household bleach is 5 - 6 sodium hypochlorite
  therefore a 15 (v/v) dilution of bleach to
  liquid biological waste is appropriate.
• The contact time of these solutions should be at
  least 30 minutes.

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VENUE SANITATION AND REARANGEMENT

• Waiting Room
• Distance seating
• Mask for symptomatic
• All indoor areas, waiting chairs should be should
  be mopped with a 1 sodium hypochlorite solution
  or phenolic disinfectants
• The frequency of mopping will depend on the
  footfall. At 23 patients an hour, 2 h mopping
  is recommended.
• Hand sanitisation at entry

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Checking Desk Physical barriers, such as glass or
plastic windows panels, should be used or
distance of 6 feet to be kept High contact
surfaces telephones, printers/ scanners cleaned
twice daily by mopping with a linen/absorbable
cloth soaked in 1 sodium hypochlorite Frequently
touched areas like table tops, chairs, chair
handles, pens, office files, registers,
keyboards, mouse, mouse pad, tea/coffee
dispensing machines etc. should specially be
cleaned with 1 sodium hypochlorite or a
sanitiser that contains at least 6070
alcohol. Hand sanitising stations at clinic
registration counters Gloves for reception
registrar Patient Room Bed,chair,door
handle,computer wiped down with sanitising wipes
or spray after each patient visit
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TELL US MORE ABOUT STAFF AND CENTRE ADAPTATION
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Staff and centre adaptation

• COVID-19-specific training
• COVID-19-specific standard operating procedures
• Adjusted work shifts
• Emergency agreements between ART centres to
  guarantee continuity of treatment provision

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Access procedures

• Limitation of the number of persons
  simultaneously present in the centre
• Provision of protective screens for
  administrative staff
• Provision of personal protective equipment and
  sanitation devices for patients and staff
• Restriction of access for partners and
  accompanying persons
• Redesign of waiting rooms and working spaces to
  guarantee appropriate distancing
• Management of appointments according to specific
  timetables, also for scans and blood tests

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• Subdivision of staff into mini-teams to reduce
  unnecessary exposure of patients and staff
  members
• Follow-up of patients three weeks after oocyte
  retrieval and/or embryo transfer, in order to
  identify potential COVID-19 positive patients
  and implement necessary measures (i.e. contact
  tracing and sanitation

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• PLEASE TELL US ABOUT PRECAUTIONS and
  SANITISATION DURING SCANS

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Precautions while doing Scans

• Patient examination tables sheets and pillow
  covers must be changed after each patient.

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• Mattresses and table edges must be sanitised
  using a sanitiser containing 6070 alcohol or a
  1 sodium hypochlorite solution.

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Equipment Sanitation

• Excess ultrasound gel on the transducer should be
  wiped off after each examination
• Transducer surfaces and cords should be wiped
  with low level disinfectant (LLD) include 70
  Alcohol, 10 Bleach, Clorox, standard dilute
  Cidex, Protex wipes, SaniCloth, PI Spray, Oxivir
  wipes, Mikrobac, Microzid, Lonza, Klercide70,
  Descocept wipes
• Equipment desktop, edges, keyboard, transducer
  resting stands and especially the
• side in close proximity to the patient should be
  wiped with an LLD.
• Cloths may be laundered with standard
  machine-washing.
• Transvaginal probes are classified as
  semi-critical items that should be high-level
  disinfected between patients.

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TELL US ABOUT EGG COLLECTION AND ET PROCEDURE IN
COVID19 ERA
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TVS PROBE

• FDA has approved ortho-phthaladehyde (OPA),
  hydrogen peroxide, glutaraldehyde, and peracetic
  acid with hydrogen peroxide as high-level
  disinfectants.
• Place transvaginal probe into Cidex OPA solution
  and clip cord to the holder to ensure the top of
  the probe does not hit the bottom of the Cidex
  container.
• Soak probe for 12 minutes in Cidex OPA
• Remove from Cidex, rinse under water for one
  minute, wipe dry.

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Oocyte retrieval

• Scenario I Follow standard procedures unless
  changes occur between ovulation trigger
• and oocyte retrieval
• Scenario II If positive re-triage, consider
  SARS-CoV-2 IgM/IgG and/or RT-PCR testing for
  COVID-19. Based on the result, decide whether to
  continue the treatment or to postpone it.
• Scenario III If the patient tests positive for
  SARS-CoV-2/COVID-19, before ovulation trigger or
  embryo thawing, postpone treatment, refer and
  isolate.
• ExceptionPatients at risk of OHSS and fertility
  preservation

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ART in COVID positive

• FFP2/3 masks according to clinical duty
  requirements
• Gowning
• Disinfection of operating theatre, transfer room
  and IVF laboratory after the procedure
• The procedure should be cancelled for newly
  diagnosed COVID-
• 19 positive patients.

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Embryo transfer

• Limit the number of staff members in the transfer
  room
• Restrict access for accompanying person(s)
• Perform transfer only in cases of low
  risk/asymptomatic patients and partners
• Apply a freeze-all policy for all patients and/or
  partners who became symptomatic after the oocyte
  retrieval.

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• Can Virus be transmitted through gametes?

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• SARS-CoV-2 cannot enter cells that do not carry
  ACE2 on the surface
• ACE 2 receptors were not found on mature human
  spermatozoa and oocytes
• But ACE2 receptors were reportedly detected in
  Leydig and Sertoli cells and spermatogonia of the
• human testis (Wang and Xu, 2020) as well as in
  theca and granulosa cells of the human ovary
  (Reis et
• al., 2011).
• Currently no evidence of transmission of virus in
  reproductive cells
• La Marca Fert Stert 2020, Schwartz and
  Graham,Viruses 2020,Jan Tesarik RBM 2020

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• ABOUT CRYOPRESERVATION

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Cryopreservation

• High security straws and/or vapour phase storage
  tanks should be used for cryopreservation of
  samples from COVID-19 positive
• patients

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• PLEASE TELL US ABOUT LABORATORY ASPECTS
  including the Air Handling Unit

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Laboratory

• Routine good laboratory practice should be
  followed and laboratory staff should wear masks
  and gloves.
• Staff should be organised in mini-teams.
• Extra care should be taken to reduce exposure to
  native follicular fluid and sperm by dilution and
  safe disposal of fluids in individual closed
  containers, as quickly as possible.
• Guidelines and good laboratory practice
  principles should be followed at all times
• Should a patient become suspect or positive for
  COVID-19 during embryo culture, a freeze-all
  policy should be adopted.
• Any laboratory spaces, biosafety cabinets, or
  incubators used for handling specimens from
  infected individuals should be thoroughly
  decontaminated with a disinfectant approved for
  use against corona virus

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LABORATORY

• Intensive washing of gametes and embryos is
  mandatory at all steps.
• Written protocols on maintenance of cryo-stored
  gametes and embryos, including liquid nitrogen
• levels.
• For any ongoing cycles follow strict screening
  protocols
• Lab intensive disinfection in case urgent cycles
  to be done
• Cryopreserved specimen should be in separate tank
  during this period.
• No transfer of embryos/gametes between clinics to
  be done in this period

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AC/ AHU/ Fans operation gudelines ICMR
The following process is recommended at start-up
Open all the doors and windows of the space.
Ensure that all cleaning protocols
are complete Run the fresh air system at the
maximum intake of air setting. Start and run the
exhaust systems if available. Start the AC
system in fan mode, without filters for minimum
of 2-4 hours with doors open and exhaust system
operational. Install the clean sanitized
filters Start the AC in normal mode and run for 2
hours with doors open and then close the doors
and windows. The fresh air and ventilation system
should be kept on throughout the off cycle and on
the weekend and holidays in air circulation mode.
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Code of Conduct for staff and patients

• All staff members and patients will be instructed
  to avoid unnecessary exposure (both at work and
  in private).
• Each service will prepare compulsory instructions
  for staff
• Attendance at work will be tied to respecting the
  signed Code of Conduct
• Activities that are not allowed will be clearly
  detailed (Expose yourself less principle)

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• Restricted social life and interactions
• Patients should sign regularly that they are
  well and have respected the Code.
• Staff members should sign regularly that they are
  well and have respected the Code or inform the
  centre's Person Responsible of any infringements
  of the Code of Conduct previously signed.

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PLEASE TELL US ABOUT TRAINING AND RECIPROCAL
AGREEMENTS
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TRAINING
Many centres are involved in training whether
through formal training programmes or local
skills training COVID-19 work patterns should
not be a barrier to continuing to support
training in all areas of practice. Physical
distancing rules apply Since changes in practice
are likely to exist for some time this is an
important training period for both new and
existing practitioners and indeed, they may
bring useful ideas and insights from experience
elsewhere.
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RECIPROCAL AGREEMENTS

• Contingencies should be in place to allow for
  unexpected staff reduction and centres should
  investigate the feasibility of sharing staff
  across facilities.
• the breadth and scope of reciprocal arrangements
  between centres should be reviewed, to
  incorporate staffing, consumable provision and
  general support, where applicable and where
  possible.
• A caveat to increasing public freedoms is the
  risk of a second wave of infection.
• Since the incidence of asymptomatic infection and
  population immunity can only be estimated, the
  severity of a second wave and the effect on
  workplaces where staff have previously been
  relatively protected should be considered.
• In a staged resumption of treatments, centres
  need to take into account the potential for a
  number of staff being sick or isolating at any
  one time. The volume and complexity of work
  undertaken should be matched by an appropriate
  number of staff with the appropriate skill mix.

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What about PGT A test? Are you going to take a
COVID19 specific consent along with ICMR consents
86

• One publication which was a conversation on ASRM
  website stated the PGT A cannot be done as they
• cannot ensure enough precautions social
  distancing with staff

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During the current shutdown how to maintain your
Lab
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DURING SHUTDOWN

• SUPPLIES Place consumables
• and media orders on hold
• Perform inventory on stock to determine the
  extent of capable operations with the amount in
  hand in case of shortage of supplies

• MEDICAL GASES AND LIQUID NITROGEN Maintain
  regular supplies
• Incubators and Other Lab Equipments If shut
  down ensure it is clean and ready to restart as
  required, can be left on to minimise temp and
  gas drift in this case ensure regular check on
  gas reserves and systems

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Concluding Remarks
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SOMETIMES OUR LIVES HAVE TO BE COMPLETELY SHAKEN
UP CHANGED AND REARRANGED TO RELOCATE US TO THE
PLACE
WE ARE MEANT TO BE
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Resuming services

• Maintain contact with patients whose treatment
  has been disrupted or deferred
• Prioritisation when services are able to
  recommence.
• Ideally commencement when peak of of the
  Epidemic subsides

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CONCLUDING REMARKS

• Management of potential staffing and supply
  shortages
• Unintended exposure of staff members
• Additional cost burden
• Emergency plans and SOP to restart shd be made
• Informed consents
• SECOND WAVE risk of reopening too quickly
• Indias R0 1.36 (as of May 4 2020 - news source)

La Marca Fert Stert 2020
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• If we add costs of covid19 tests twice for both
  husband and wife its approx 4500 x 4 thats 18k
  per case along with extra expenses for the PPE
  so cost is
• a big factor
• The PPE could release VOC which could have an
• effect on gametes
• Testing is not freely available in all areas

96

• Health being State subject no doubt the local
  Guidelines and our National
• Association guidelines have to be followed
• Tell all patients before coming to clinic for
  first appointment to look up Courses on WHO /
  Diksha app for Infection prevention control it
  only take an hour or so to do
• these courses and get a certificate
• All doctors and staff members should also do it
• Rotate staff in shifts with one week off and on
  or 2 weeks off an on as quarantine is 2 weeks if
  positive remember. (dont extend the day and make
  staff come on
• same day at different timings or do alternate
  days)
• Prepare a document for your own clinic with SOPs
• 15 minute gap between 2 appointments and 90
  minute gap between ET and Egg collection
  recommended as per HFEA Guidelines

97

• Prioritise Fertility preservation
• then
• Poseidon Group 4 and then group2/3
• Then
• Frozen transfers

98
Posieden criteria(Patient-OrientedStrategies
Encompassing Individualized Oocyte Number)
99

• THANK YOU