COVID-19 and the Future of Fertility as a Human Right: An Interview with Dr. Jennifer Kawwass

Interview by Jessie Liu

HHPR Senior Editor Jessie Liu interviewed Dr. Jennifer Kawwass, MD, FACOG, an Associate Professor and the Reproductive Endocrinology and Infertility Division Director and Emory Reproductive Center Medical Director. She is a native of Virginia Beach, VA, and a graduate of Davidson College and the University of Virginia Medical School. As a reproductive endocrinology and infertility fellow at Emory, Dr. Kawwass initiated a collaboration with the Assisted Reproductive Technology Team at the CDC, where she remains a Guest Researcher. During her tenure as the Medical Director of the Emory Reproductive Center, in vitro fertilization (IVF) outcomes have been consistently above the national average, IVF volume has steadily increased, and patient satisfaction has remained high.

Dr. Kawwass is actively involved in the field of reproductive medicine on a national level. She served as a Clinical Director of the Executive Council of the Society of Assisted Reproductive Technology (SART) and is currently serving as a member of the SART Research and Registry Committees. She is a member of the American Society of Reproductive Medicine (ASRM) Ethics Committee and the COVID-19 Task Force. She is also currently the Academic Director at Large of the Society of Reproductive Endocrinology and Infertility (SREI). She is among a handful of physicians chosen nationally by the American Society of Reproductive Medicine to participate in the CREST Scholars Program.

JL: Thank you so much for joining me today, Dr. Kawwass! I saw that you were involved in the Ethics Committee and COVID-19 Task Force at the American Society for Reproductive Medicine (ASRM). Could you tell me a little bit about what kind of work you do there and why you joined these initiatives?

JK: So just to give you a little background, I’m a reproductive endocrinologist (REI) at Emory University in Atlanta. To reach this point, after medical school, I completed 4 years of OBGYN training and an additional 3 years of reproductive endocrinology and infertility fellowship. My primary role is clinical—taking care of people that are trying to build families or preserve fertility. I also participate in research and teach medical students, residents, and fellows. In addition to these roles, I also participate in the field of REI (reproductive endocrinology and infertility) on a national level. These include roles on the ASRM Ethics Committee, the Board of SREI (the national educational REI organization), and on the ASRM COVID 19 Task Force. I particularly enjoy my role on the Ethics Committee. In medicine and especially in the world of fertility, reproductive health, and IVF, there are many ethical situations for which there are multiple perspectives that the ASRM’s Ethics Committee—a national source of guidance—takes an opinion on, whether it’s through practice bulletins or committee opinions.

The Ethics Committee is composed of lawyers, REIs, embryologists, urologists, general OBGYNs—a mix of people that interface with reproductive health. We meet twice a year to discuss topics that warrant a written bulletin, then draft and revise these opinions and put them out to all the REIs in the country for public comment. Those comments are incorporated into the documents as is appropriate, and then they are published.

As for the ASRM COVID-19 Task Force, as soon as we realized that the pandemic was a reality in March 2020, we began to meet every two weeks—again, with a multifaceted team that included urologists, embryologists, REIs, infectious disease specialists, mental health experts, and a few patients. Each meeting we discussed: “what are the current COVID related issues facing REI practices and patients? What data currently exists? How can we use that data to provide guidance?” We published regular updates in real-time throughout the peak of the pandemic.

JL: To that point, what would you say about claims such as those that suggest the COVID-19 vaccine impacts women's future fertility?

JK: One of the biggest hurdles in overcoming the pandemic has been vaccine hesitancy, and one of the main sources of that hesitancy has been fear of the vaccine’s impact on future fertility. I would say that there is no plausible scientific rationale for that claim; it was made based on someone’s suggestion that there is a common protein between the placenta and the vaccine, which is not actually true. Unfortunately, with disinformation, once something spreads it’s really hard to disprove it. So, one of our big aims in terms of advocacy has been to encourage vaccination in preconception, periconception, and pregnancy, as there has been more and more data to suggest that there is no such impact and that the vaccine is really our ticket out of this pandemic.

JL: That makes sense, and thank you for shedding light on a topic that not many people might know about. Zooming out from this, how has the COVID-19 pandemic impacted reproductive and fertility care? What disparities have you observed?

JK: Like with all facets of medicine, there was a six- to eight-week period of pause where we had to allocate resources to the sickest people and when we didn’t know the implications of the virus itself for early pregnancy and fertility. Obviously, this contributed to a state of limited access across healthcare and we are acutely aware of the health disparities and social determinants of health that have interacted with this trend. Some of it is a matter of physical access, like location of clinics; some of it is a matter of financial access, like having insurance coverage. In other ways, though, there’s a silver lining from the pandemic in that telehealth has become feasible, acceptable, and reimbursed by insurance, reducing the need for patients to drive long distances to see their doctors and improving access to care.

JL: What about the policy landscape surrounding insurance coverage? You made a compelling argument in Fertility and Sterility about fertility as a human right worthy of mandated insurance coverage. Can you elaborate on what you mean?

JK: I’d love to. We’ve come a long way, but there’s still a long way to go. Thinking of infertility or the desire to grow a family even without a diagnosis of infertility, as one of the biological processes that are part of being human, and thinking of it as a disease and not something that is perceived as an elective treatment is an important part of reproductive health. In the big-picture landscape of taking care of all patients, fertility should be envisioned as one of the medical aspects of their well-being. Currently in the country, there are nineteen states that have mandated infertility coverage, which is more than zero but less than fifty; making forward progress in terms of improving access would ideally include having coverage for anyone that wants it, independent of their race, ethnicity, income, or other characteristics. Certainly, this taps into a larger healthcare problem in the U.S., but all that being said, even things that wouldn’t seem controversial are not covered by many insurance plans, for example fertility preservation: say someone who’s young gets cancer and will need treatment that will make them infertile, i.e., chemotherapy; they have the option to consider something like freezing eggs for their future fertility potential after chemotherapy. It’s really heartbreaking when you have a patient sitting in front of you that wants to do it and you have the tools to do it for them, but the limiting step is cost. In the scheme of medical care and cost, freezing eggs is significantly less expensive than many things that are covered routinely. Again, it’s just a matter of considering fertility treatment as something that’s not just “fluff” and understanding that part of being human is being able to reproduce if you want to.

JL: This is out of personal curiosity from a different project I've been working on, but what is your opinion on how fertility preservation fits into these conversations, given its "future" focus (and specifically ovarian tissue cryopreservation/OTC, which was only deemed nonexperimental in 2019)? Oncofertility—fertility for cancer patients—certainly comes to mind, but what about other populations seeking FP such as women seeking deferred reproduction, those with autoimmune or genetic disorders, and transgender adolescents?

JK: That’s a great question! It’s a part of the future of the field and something we see on a daily basis; we help people from a variety of family building, future family, and reproductive health standpoints. We see transgender men and women, boys and girls who want to freeze their eggs or sperm before transitioning; we see people who will have a medical or surgical treatment that will make them infertile who freeze eggs, sperm, or embryos prior to treatment; we see individuals who are approaching an age where their reproductive potential will decline significantly and they are still unpartnered and freeze eggs for future family planning reasons; of course, we see couples who are currently trying to conceive and having trouble; and we see those with genetic risk to their offspring who use IVF to minimize future risk to their children.

All of that is a balancing act in terms of counseling with a fertility specialist; you don’t want to scare everyone into thinking you need to freeze eggs when you’re fifteen, because that’s unnecessary and costly—basically using a technology that’s not warranted; rather, on a case-by-case basis you want to say “these are the pros and cons of moving forward, and this is the future potential of your eggs, sperm, and embryo if you choose to move forward.” It is incredibly important to be very transparent about the odds of future success after freezing eggs, sperm, or embryos as compared to alternative options.

JL: Considering all these clinical and policy issues, as well as everything in the context of the pandemic, how do you envision ethics intersecting with these conversations?

JK: The whole field of reproductive health is about options, counseling, transparency, informed consent, and patient autonomy. It’s my job to provide the science, data, and the options, and ultimately it’s the patient’s job to decide which options are right for them with my guidance. When we paused treatment at the height of the pandemic, that whole concept of whether fertility treatment is elective came to the surface. It’s certainly not elective in that people are not doing it by choice. The temporary pause reflected a need to balance the social good for the whole against the individual. However, once resources were less scarce, and we had better knowledge about how to prevent transmission and maintain patient and provider safety, we were able to resume care. Fertility treatment is, in fact, time-sensitive—you can’t stop the biologic clock, unfortunately.

JL: In your opinion, what are some of the most pressing and under-reported issues/barriers experienced by populations facing infertility today?

JK: Even though we’ve made progress, there’s still stigma, so people are hesitant to come see a fertility doctor or admit that they might be having trouble getting pregnant. There are different degrees of stigma in different cultures. Cost is undoubtedly a barrier for which there’s room for improvement. Additionally, lack of education is an additional barrier. I have some very well-educated patients who are surprised when they find out that it’s hard to get pregnant with their own eggs at forty-five. Those are my top three.

JL: Can you tell me a little bit about how existing attitudes and structures within medical education and the health professional/provider community have contributed to these problems? How has your own experience as Medical Director at Emory Reproductive Center shaped your views on these issues?

JK: I think that’s something, again, where we’re trying to make forward progress. Acceptance of medical professionals having children during training has increased dramatically during the last decade; the concept that to have a professional life, one puts their personal life on complete hold, is evolving a little bit. Some of it is also just education and exposure to the field of infertility; now, we have all the medical students at Emory spend a day with us. It’s not a lot, but at least it gets the issue on their radar. I also think the advent of egg freezing going from experimental to non-experimental in 2013 has given people the liberty to make fertility decisions as individuals. Before, you couldn’t really preserve fertility in a predictable way unless you were partnered or willing to fertilize the eggs with something, so in that sense it has opened up people’s options.

JL: Conversely, as a physician-advocate, how do you envision the medical field addressing these problems moving forward?

JK: Well, some of it is legislative advocacy: as we speak, we are trying to advocate for some legislation in Georgia to cover at the very least fertility preservation, and in an ideal world, all fertility coverage. Advocacy spans many levels: locally at your own institution, at the level of the state, and nationally even; ASRM has Advocacy Day and an entire group that’s committed to making these issues known to legislators.

JL: More generally, what might you say to aspiring reproductive endocrinologists who want to work in this field in the future?

JK: I can say that I absolutely love my job, and I probably cry for joy about once a week, which I don’t think many people can say. One of the things that drew me to this job was the intersection of ethics, advocacy, and reproductive health. When they asked me to be on the Ethics Committee, I was elated to have a seat at the table in thinking about these larger issues. It’s a fabulous job.