TOGETHER we can help fight hunger! 

Thanksgiving is approaching fast and the need for food is greater than ever.  For the month of November, please help by donating unexpired canned goods or non-perishable food items to the annual CARS food drive. Our goal as a Center is to collect 100 lbs. (Did you know that 100lbs can provide for 80 meals?)

Collection boxes are set up in the waiting room of each office. All items will be donated to Iglesia de Dios Pentecostal which one of our staff is a member of.

Examples of what you can donate:

–          Cheese or peanut butter crackers

–          Pudding

–          Granola Bars/power bars

–          Ramen noodles

–          Pasta/sauce

–          Trail mix/packaged nuts

–          Peanut Butter

–          Canned Vegetables and fruit (With pull top opening)

–          Soups (With pull top opening)

–          Mac and Cheese

–          Canned Tuna/chicken

–          Boxed drinks and juices

–          Pop Tarts

–          Packets of Oatmeal

–          Apple sauce

–          Bags of rice and beans

Thank you for all of your help!

Once again, the Center has distinguished itself at the American Society for Reproductive Medicine (ASRM) Virtual Congress through our commitment to academics and research. ASRM’s annual meeting is the premier education and research meeting for Reproductive Medicine. Our clinical team of MDs, fellows [past and present], residents, and lab staff worked tirelessly throughout the year to complete a variety of thoughtful and relevant research projects. Below is a list of all the oral and poster presentations that were accepted to ASRM.

Our research mentor of the year award goes to Dr. Lawrence Engmann. He is a wonderful teacher and has shepherded many of these projects to completion. His inspired ideas, knowledge of the literature, his gentle guidance, and knowledge of statistics have guided our residents and Fellows to make these presentations happen. Several manuscripts are in preparation for peer review journals. Dr. Engmann, thank you!

Truly outstanding work!

Oral Presentations

1)      THE EFFECT OF OBESITY ON EUPLOIDY RATES IN WOMEN UNDERGOING IN VITRO FERTILIZATION (IVF) WITH PREIMPLANTATION GENETIC TESTING (PGT) – Stephanie Hallisey, Reeva Makhijani, Jeffrey Thorne, Prachi Godiwala, John Nulsen, Claudio Benadiva, Daniel Grow, Lawrence Engmann

Oral Session Title: IVF Outcome Predictors 2

2)      BLACK RACE RESULTS IN LOWER LIVE BIRTH RATE (LBR) IN FROZEN-THAWED BLASTOCYST TRANSFER CYCLES (FET): AN ANALYSIS OF 7,002 SART FET CYCLES – Reeva B Makhijani, MD, Alicia Y Christy, MD, Prachi N Godiwala, MD, Kim L Thornton, MD, Daniel R Grow, MD and Lawrence Engmann, MD

Oral Session Title: Health Disparities

https://www.asrm.org/news-and-publications/news-and-research/press-releases-and-bulletins/black-women-experiencing-lower-birth-rates-in-fet-cycles

 

Poster Presentations

3)      OUTCOMES AFTER ADJUNCT GROWTH HORMONE TREATMENT WITH A LOW, INTERMEDIATE, OR HIGH DOSE PROTOCOL IN IVF CYCLES WITH POOR RESPONDERS – Reeva B Makhijani, MD, Stephanie M Hallisey, MD, Prachi Godiwala, MD, Chantal Bartels, MD, Daniel R Grow, MD, Lawrence Engmann, MD, John Nulsen, MD and Claudio A Benadiva, MD

4)      PREGNANCY OUTCOMES IN LETROZOLE OVULATION INDUCTION FROZEN-THAWED EMBRYO TRANSFER CYCLES AS COMPARED TO NATURAL AND PROGRAMMED CYCLES – Prachi Godiwala MD, Reeva Makhijani MD, Chantal Bartels MD, Alison Bartolucci PhD, Daniel Grow MD, John Nulsen MD, Claudio Benadiva MD, Lawrence Engmann MD

5)      EMBRYOLOGIC OUTCOMES IN INTRACYTOPLASMIC SPERM INJECTION (ICSI) CYCLES UTILIZING SPERM SELECTED VIA A MICROFLUIDICS DEVICE COMPARED TO STANDARD SELECTION – Prachi Godiwala MD, Jane Kwieraga BSc TS, Reeva Makhijani MD, Chantal Bartels MD, Alison Bartolucci PhD, Daniel Grow MD, John Nulsen MD, Claudio Benadiva MD, Lawrence Engmann MD

6)      EFFECT OF BODY MASS INDEX (BMI) ON PREGNANCY OUTCOMES IN FROZEN-THAWED BLASTOCYST TRANSFER (FET) CYCLES – Adrienne Schmidt MD, Prachi Godiwala MD, Reeva Makhijani MD, Chantal Bartels MD, John Nulsen MD, Claudio Benadiva MD, Daniel Grow MD, Lawrence Engmann MD

The Center for Advanced Reproductive Services [CARS] had been hoping the governor would get us to level 3 so we could begin to allow partners and spouses in the offices. We are not at level 3 however, current state guidelines are allowing for partners, spouses and close family members to visit in hospitals and nursing homes.

At this time, CARS has decided to relax our policy and allow partners and spouses into the practice on a limited basis. Partners and spouses will be subject to the same rigid health screening and temperature checks as patients. Currently, this would mostly include:

• Partners/spouses at pregnancy scans

• Partners/spouses at IUI

• Partner/spouses in PACU at transfers

• Partners/spouses or family members needed at other visits to provide translation services

Thank you to everyone who entered our Q2 2020 Fertility Massage Therapy Grant. This was a tough quarter of the year for everyone, with Covid causing uncertainty and obviously high levels of stress. We appreciate all of those who took the time to enter and have selected a patient from the Bristol area as this quarter’s winner whose story is below and who prefers to remain anonymous. She has, however, agreed to discuss her journey, including her losses, in the hopes they may help someone else in the process.

I really struggle with this question but I will give it a shot. I had a stillborn daughter in January 2006, and 2 more unsuccessful pregnancies by October 2008, and then in 2009 another miscarriage. Needless to say, those were really traumatizing years. All the losses were in the second trimester and after years of being treated, I finally had some answers. Testing showed it was all because of an incompetent cervix. So, fast forward a few years later and 2 more miscarriages and 2 failed cervical cerclages I found information about a TAC (Transabdominal Cerclage). I hoped this was going to be the answer to all my problems. In 2018 my ObGyn (my sweet angel) successfully placed an abdominal band (a few actually for security) on my abdomen and BAM!!! We hope that I can get pregnant. 

At this point, I was with a different partner and he went through the TAC surgery with me and we used protection because we weren’t ready for a baby. Around early 2019 he and I moved in together and started not to use protection and try to see if we could have a baby. Well, months and months went by, and nothing. I had an appointment with my ObGyn and asked to have my tubes checked and have my fiancées sperm tested and that’s how we ended up at the Center. After testing we learned his sperm isn’t very good and I probably have some other issues now too. Oh, and during my TAC surgery, they removed some pretty good-sized fibroids. Also during my fallopian tube and uterus check, they found some more fibroids. 

I wish I was more excited but I am very exhausted. This has also caused me to gain a little weight and the COVID probably has some play in that as well. I recently found a huge patch of loss hair and my ObGyn believes I didn’t ovulate this last month because my cycle is usually 29-33 days and it went 48 days this month. It scared me, especially because when I finally got my period today it was unusually heavy for almost 24 hours, out of control heavy, and just like that it is almost gone. Very weird. 

I think my body could use some relaxing because all of this has been stressing me out a bit. I’ve struggled with depression in the past and it has been difficult being quarantined but I am definitely more than ready to go through these procedures and see if I and my partner can have a live healthy pregnancy and baby (actually I’m terrified and nervous and totally freaking out but I have to speak my peace into existence so I have to work on that). I think this would help me mentally and physically get prepared and motivated for this journey we are getting ready to embark on in August. 

Sorry, I am so long-winded but I definitely gave you the super short version. Thank you for your time and I hope you choose me for a massage. I hope none of this makes you sad because I am ok. I refrain from sharing sometimes because of how people react but I truly am ok and I am glad to be in your care here at The Center. Thank you and God Bless.

Virtual Waiting Room

In order to maintain social distancing and control traffic thru the building, we are asking patients who are coming to the offices to remain in their car until we are ready for their visit to start. Once you arrive at the office parking lot, please text your name only to one of the numbers below. A member of the staff will call you to begin the check-in process and/or text when you may enter the building. Please have an insurance card and identification readily available.

Farmington                           860 470 4679

Hartford & New London         860 704 9160

Branford                               860 704 9221

Resuming Operations

On behalf of The Center for Advanced Reproductive Services [CARS], we hope in the midst of these challenging times this letter finds you and your family safe and healthy.  As Connecticut is now experiencing a flattening in the number of new COVID-19 cases and a decrease in hospitalizations, we are writing to update you regarding the resumption of fertility treatments at CARS.

At each CARS office, policies & procedures have been implemented to optimize physical distancing and other mitigation strategies to minimize the risk of exposure for patients and staff. As of July 13, 2020:

• We are currently at 100% of normal volumes for IUI & IVF and continue to carefully track CT COVID -19 data, internal mitigation systems, and our inventory of PPE.
• Maintain strong social distancing standards for patients and staff.
• Have implemented strong personal protective equipment [PPE] and mitigation strategies to limit the risk of exposure for patients & staff.

Next Steps

• We are waiting for the governor to move us to level 3 to start allowing partners into the building.
• We are making daily/weekly changes to COVID – 19 policies based on the current tri-state travel bans.
• We are experiencing a major backlog of IVF treatment cycles and are doing our best to meet everyone’s scheduling needs.

Practicing medicine, especially fertility treatments, in a COVID – 19 world is going to look and feel very different than it did a month ago. There are a number of interventions we are implementing as part of our efforts to keep everyone safe.

Patient Visits

• All patients visiting CARS must be scheduled at a specific time. This includes morning ultrasound and blood monitoring, and Quest blood draws throughout the day. No more walk-ins of any kind.
• All new patient visits, IVF consultations [1B], and established subsequent office visits continue to be telehealth via Microsoft TEAMS.
• MD clinic visits on site will be limited to ultrasounds, procedures, emergencies, and clinical follow-up appointments for telehealth patients.
• Every attempt will be made for onsite visits to be as efficient as possible. There will be limited on-site counseling and instructions. Discussions can occur immediately following your visit with a call from your car or we can call you later when you’ve arrived home. Our doctors and nurses will have access to Microsoft TEAMS for video conferencing.
• Semen analysis appointments will be scheduled and patients asked to produce at home. Specimen collection kits will be provided to patients in advance via a repository by front doors at each office.
• Please stay in contact with us, and call your nurse or financial services representative [FSR] when you intend to start a cycle.  Your physician team will review your personal case and follow up with the next steps.
• All patients undergoing care once we go back up will be required to provide an active credit card on file so we can run co-pays, deductibles, etc so front desk and financial staff are protected from handling credit cards, money, checks, etc.

Health Screening

Staff and patients are asked about relevant exposure and health information upon entry into the offices daily and temperatures are being assessed. All staff and patients must wear a mask at all time when in our offices. If you have a mask at home [homemade cloth masks are fine] we ask that you use it or one will be provided.

COVID 19 Testing for IVF patients

This is a fluid situation due to the availability of tests and timely results. As of 5/19/20, we are requiring IVF patients have at least one COVID 19 negative test between Baseline and day of Retrieval. Our staff will provide you with testing site options [including at The Center] and instructions on the day of Baseline. Any patients testing COVID 19 positive during an IVF cycle will be managed on a case per case basis.

We will get through this together

Thank you for your continued patience and understanding during this time of uncertainty. The COVID-19 pandemic has changed many things including the way we practice fertility medicine, but one thing that has not changed is our commitment to helping our patients build families. We have been thinking about you during this difficult time and eagerly look forward to safely making your family building dreams come true. If you have any questions or concerns please contact Paul Verrastro, CARS CEO at 860.321.7082, EXT 8005.

Thank you.

Given the Covid-19 pandemic, we have been unable to hold our in-person RESOLVE of New England peer support groups. Instead, we are pleased to offer free, Center for Advanced Reproductive Services [the Center] sponsored virtual groups via Zoom Meeting. These will continue July through September.

What is a Peer Support Group?

Our peer support groups–open to women and men, individuals and couples–provide an opportunity for open discussion where you can come together and meet others who are facing similar challenges in a relaxed and confidential setting. Discussion at our general infertility groups may include talking about current treatment, dealing with friends and family, and coping strategies. Whether you’re newly diagnosed or have been in the trenches for years, attendees from all stages of the infertility journey will be warmly welcomed.

The Center’s virtual groups will be managed and facilitated by Ami Chokshi, Certified Health coach. Ami is an experienced live group facilitator having facilitated the RESOLVE of New England live peer support group at the Center for many years. She is also a former fertility patient.

The Center is committed to providing in-person and/or peer support and is proud to have been hosting RESOLVE and RESOLVE of New England peer support groups for nearly 30 years.

Pre-registration is required. Kindly register at least 12 hours in advance of the group to ensure that your registration is received. Registration can be found here.

Also, please look out for posts on our Facebook page from RESOLVE of New England to join one of their virtual peer supports groups or visit their web site for more information https://www.resolvenewengland.org/support/#virtual

We are offering free yoga classes especially for women who are trying to conceive and their partners. No yoga experience is required. In order to accommodate safe COVID – 19 practices, these classes will be held offsite, outdoors, and participants must bring their own yoga mats and supplies.

Dates:  July 11, July 25, Aug 8, Aug 22, Sept 12, Sept 26 AND Saturdays (2nd and 4th of the month)

Time:   8:30am to 9:45am

Location:  the West Hartford area; directions will be provided on registration

Registration: To register for yoga classes please go to:

https://Carissaschedule.as.me/FertilityYogaOutdoors

About the Class:

This in-person outdoors class is full of support and nourishment for your body, your mind, and your emotions.

* Participants must bring own mat & supplies

* Share Circle to Introduce Ourselves and Build Support

* Readings/Poetry/Meditation to support our path

* Visualizations and tools for stress reduction and manifestation

* Gentle, all levels class- no experience needed

* This class is safe for any phase of fertility or treatment

* Partners of all stripes are more than welcome to attend

* Open and affirming class for anyone on a fertility journey

* Fertility Tip given at the end of every class

**If weather doesn’t allow us to meet an email with zoom link will be sent for class

Taught by a registered yoga teacher and former fertility patient, Carissa Spada, the classes require no previous yoga experience and all levels of yoga are included for everybody.

Shoreline
Shoreline yoga classes in Branford continue to be on hold. Stay tuned!

In order to be compliant with the Tri-state travel ban that went  into effect Wednesday, June 24 at midnight the following will apply to patients at CARS:

•If a non-cycling patient, or member of the patient’s household, has traveled to any state on the ban list after Wednesday, June 24 at midnight that will trigger a 14-day quarantine before the patient can resume treatment at CARS.

•If a patient who is about to start a cycle or a member of a patient’s household has traveled to a banned state prior to Wednesday, June 24 at midnight, a negative COVID test will be required prior to cycle start [baseline] and then again mid/end-cycle per current protocol.

•If a patient who is currently cycling, or a member of the patient’s household, has traveled to a banned state prior to Wednesday, June 24 at midnight an immediate COVID 19 test will be ordered and then again mid/end-cycle per current protocol.

Currently, the states include Alabama, Arkansas, Arizona, Florida, North Carolina, South Carolina, Washington, Utah, and Texas. Our policy will stay in place so long as there is a travel ban and change based upon additions/deletions the state makes to this list.

By Stanton Honig, MD

June is Men’s Health Month and we want to heighten awareness of preventable health problems and encourage early detection and treatment of disease among men and boys. We are highlighting men’s infertility.

Male factor infertility accounts for approximately 50% of all infertility. For this reason, the evaluation and treatment of the male are critical to a comprehensive program for the infertile couple. Because there are many treatable, reversible, and preventable causes of male factor infertility, early evaluation and treatment are very important.  While in-office visits are returning, we have developed a telehealth program for patients who are not ready to come to the office for a consultation. 

In 1994, Drs. Honig, Jarow, and Lipshultz reported the incidence of significant medical conditions associated with the evaluation and treatment of male factor infertility. In 1% of patients, a significant medical condition, sometimes life-threatening (such as a cancer of the testis, brain, or spinal cord tumor) caused male infertility. Subsequent studies have shown a significantly higher incidence of testis cancer in infertile men despite variable semen quality. Early intervention was crucial to treat the life-threatening condition and improve the couple’s overall chance of conceiving.

Early evaluation of the male should include a semen analysis. If this is abnormal, an early consultation with a urologist well-trained in male infertility disorders should follow. This should occur before or in conjunction with assisted reproductive technologies.

What can be done as “preventive medicine” for male factor infertility?   

Prevention starts with avoiding lifestyle issues that may be detrimental to sperm quality. Acquired causes of male infertility include exposure to substances that can be toxic to sperm such as illicit drugs (marijuana, cocaine, anabolic steroids), heavy alcohol use, cigarette smoking, medications, and excessive heat to the scrotal area.  

It is becoming increasingly clear that recreational drugs can have an adverse effect on the testes and sperm quality. Chronic marijuana use may lower testosterone levels and affect sperm quality. This has become more of a problem since laws requiring marijuana use have loosened. Cocaine has been shown to have direct effects on the testis and may affect sperm concentration, motility, and DNA of the sperm. Anabolic steroids used for bodybuilding clearly have direct effects on the testis by lowering the body’s ability to make its own testosterone. It also decreases spermatogenesis and may cause temporarily no sperm in the ejaculate, which is sometimes irreversible. Education of high school and college students regarding the negative impact of anabolic steroids and other recreational drugs is critical to prevent male fertility problems down the road.  

Cigarette smoking and heavy alcohol use have been shown in clinical and research studies to affect hormone levels, as well as direct toxic effects on the testicle. Basic science data has shown increased testicular injury when exposed to environmental toxins. 

Many medications used for the treatment of unrelated medical conditions may have negative effects on sperm quality, as well. It is the job of the reproductive specialist to educate physicians and the public on these effects. Some medications that may affect sperm quality are testosterone, calcium channel blockers for high blood pressure, sulfasalazine (Crohn’s disease-bowel disease), cyclosporine (organ transplants), and chemotherapy for cancers or rheumatologic disease and anti-virals utilized for severe COVID disease.

Many of these medications can be interchanged with similar drugs that have less toxic side effects. For example, we have seen a MAJOR increase in the use of testosterone in men of reproductive age. This has been driven by the sense that testosterone will bring “the fountain of youth”. Unfortunately, this “overuse” in men has resulted in the lowering of sperm counts, in some cases to zero. Luckily, most of the time, this is reversible. In addition, there are other medications that can increase testosterone via the hypothalamic pituitary axis that can be utilized instead to improve libido, sexual function, energy level, etc. With high blood pressure, it appears that calcium channel blocker medication may directly affect the sperm’s ability to bind to egg receptors. Switching to a different medication may remove this risk. In irritable bowel disease, mesalazone may be substituted for sulfasalazine having less reproductive side effects with similarly good disease control results.  

Chemotherapy for cancer and other chronic diseases (like rheumatoid arthritis, renal disease, autoimmune illnesses) can also affect sperm quality. Important considerations include freezing sperm prior to starting any toxic drug regimens and using the least toxic chemotherapy regime with equal survival results. Younger males with prostate cancer should be asked about future fertility interests prior to definitive therapy. Radical prostatectomy, radiation therapy, and hormone deprivation therapy have specific deleterious effects on sperm and/or sperm transport.

Occupational exposure to toxins may also affect sperm quality. Agents like pesticides, cadmium, lead, and manganese may interfere with male reproduction, so checking and removing work exposures is important.  

Direct heat to the testis can be a major cause of diminished sperm quality and male infertility. Varicoceles are one of the most common, treatable, and reversible causes of male factor infertility. Although the exact mechanism of how varicoceles affect sperm quality is not known, it is believed that this is usually through an increased heat effect. Multiple studies have shown that scrotal temperature is increased in patients with varicoceles. Varicocele repair has been shown to improve sperm concentration, motility, morphology, and the DNA of sperm. Minimally invasive ligation of varicoceles can significantly improve the chances of pregnancy as compared to natural intercourse. In varicocele-associated infertility, multiple studies have shown that it is more cost-effective to perform varicocele repair as compared to going directly to IVF/ICSI in moderate male factor infertility cases. In addition, varicocele repair may upgrade semen quality to allow couples to proceed with less invasive/less costly hyperstimulation/IUI as opposed to going directly to IVF/ICSI. 

External heat effects on the testis may affect semen quality as well. We recommend abstinence from hot tub use or lowering the temperature to 97 degrees (same as scrotal temperature). It is unclear if the illness-related effects of COVID-19 will have a temporary or permanent effect of sperm but one study did show a drop in sperm quality in patients with severe effects of COVID-19.  On a lighter note, wear whatever underwear you want. Conventional lay information regarding types of underwear is vastly overplayed. Scientific studies have shown that there is no difference in sperm quality between boxer shorts and briefs.

Coital factors are extremely important in achieving pregnancy. Although timing intercourse with ovulation may be tedious, it is critical with male factor patients. Timing with basal body temperature or ovulation predictor kits is extremely useful. Intercourse every 24-48 hours around the time of ovulation is critical to achieving pregnancy naturally. Some patients maintain good semen parameters despite frequent ejaculation, and in these patients, intercourse every 24 hours or so may be beneficial. In addition, avoidance of spermatoxic lubricants such as K-Y jelly, surgilube and lubrifax, is important. A natural lubricant, such as “Replens” or “Pre-seed”, may be substituted and is not sperm toxic.  

Are vitamins and supplements helpful? The answer is… sometimes.

Scientific data is quite mixed. Some supplements used for other reasons (depression, memory loss, “prostate health”) may affect semen quality in a negative way, while others have been studied to determine if they’ll improve semen quality in patients with male infertility. Below are vitamins and supplements that are recommended:

Vitamin C   500-1000 mg/daily

Carnitine and/or L-acetyl carnitine         3gms/daily 

Vitamin E  400 -800 iu/daily

There is a large amount of literature evaluating the effects of antioxidant vitamins (C and E) on sperm. These studies have been performed on patients taking these vitamins by mouth as well as mixing them with semen. It appears clear that some male factor patients have an increase in “reactive oxygen species” or oxidants in their semen. Reactive oxygen species may have effects both directly on the sperm and indirectly on the sperm environment. Vitamins C and E are antioxidants and may serve to lower the level of reactive oxygen species and, therefore, negate its negative effects. 

Carnitine appears to play an important role in both the function of the epididymis and possibly in sperm energy/motility. Some studies from Italy have suggested some benefit in using this supplement (mostly with improvement in sperm motility), with no significant side effects. We recommend 3gms of carnitine and L-acetyl carnitine. Be careful with supplements that claim they are “Male Fertility Supplements”, as they may contain only tiny amounts of the recommended supplements.

Most other supplements (such as zinc, selenium, folate, coenzyme Q-10) are not necessary if a balanced diet is maintained since most are present in healthy foods. Not all nutritional supplements are good for sperm. Saw palmetto may have a negative effect on sperm production and ejaculate volume. It is thought that saw palmetto lowers levels of dihydrotestosterone (DHT), which is thought to be important for sperm production and ejaculation. Studies on the effects of 1 mg of finasteride (Propecia-for male pattern baldness) showed no negative effects on sperm quality. Saw palmetto may work similarly to a higher dose of this drug used for benign prostate enlargement. It would be my recommendation that any patient trying to achieve a pregnancy stop using saw palmetto until further studies show that there are no deleterious effects.   

Summary

Preventive medicine has an important role in male factor infertility. A thorough evaluation and physical examination by a physician familiar with male infertility are important to identify treatable, reversible, and potentially life-threatening conditions. In addition, modification of behaviors, and avoiding toxic recreational drugs such as anabolic steroids may improve the chances of pregnancy. Avoiding supplements that may negatively affect male infertility and using other vitamins and supplements that may positively impact male fertility-related disorders are important to consider, as well.

Patients should ask their physicians and seek out organizations like RESOLVE, the American Society for Reproductive Medicine (www.asrm.org), The Society for the Study of Male Reproduction (www.ssmr.org), American Urological Association (www.urologyhealth.org/urologic-conditions/male-infertility).

In Vitro Fertilization Cycle Starts
We resumed IVF starts May 11 on a limited basis to test the system relative to CT State COVID 19 data, personal protective equipment [PPE] supplies and new operational systems designed to keep patients and staff safe. The plan is to re-evaluate the situation in a month [around June 15]. Our hope is provided all things continue to move in a positive direction, we will be able to resume normal IVF volumes sometime in June/July.

COVID 19 Testing for IVF patients
This is a fluid situation due to the availability of tests and timely results. As of 5/19/20, we are requiring IVF patients have at least one COVID 19 negative test between Baseline and day of Retrieval. Our staff will provide you with testing site options and instructions on the day of Baseline. As testing options improve we hope to move to testing day of Baseline and then again within 48 hours of Retrieval. Any patients testing COVID 19 positive during an IVF cycle will be managed on a case per case basis.