Windows of Opportunity Lost and Found
The year 2020 will be forever etched in human history as a period of profound transformation. As the COVID-19 pandemic swept across the globe, it disrupted every aspect of our lives, including the deeply personal journey of family building. Reproductive medicine faced unprecedented challenges—clinics shuttered, treatments postponed, and patients left in heartbreaking limbo. Yet, within this crisis emerged unexpected opportunities for innovation, reflection, and growth.
"You can't go back and change the beginning, but you can start where you are and change the ending."
The pandemic served as a crucible, testing the resilience of healthcare systems and exposing both weaknesses and opportunities in reproductive care.
In March 2020, as COVID-19 cases surged worldwide, reproductive medicine faced an existential crisis. National and international societies, including the American Society for Reproductive Medicine (ASRM) and the European Society of Human Reproduction and Embryology (ESHRE), issued guidance recommending the suspension of non-urgent fertility treatments 6 . This decision affected hundreds of thousands of patients globally, creating what many described as a "biological clock emergency."
The sudden halt to treatments revealed troubling disparities in how different countries and healthcare systems categorized reproductive care. While some nations recognized infertility as an essential medical condition, others relegated it to elective status, leaving patients in emotional distress 6 .
Amidst the widespread treatment suspensions, one group received special consideration: cancer patients requiring fertility preservation. Before gonadotoxic therapies that could permanently destroy their reproductive potential, these patients were granted exceptions to continue treatment 2 . This distinction highlighted the urgent nature of fertility preservation versus other reproductive care, though it also raised ethical questions about whose fertility deserved priority during a global health crisis.
This differential approach revealed underlying societal values regarding reproduction—preserving future potential was deemed more urgent than addressing existing infertility 6 .
The reproductive research community rapidly pivoted to address critical questions about SARS-CoV-2's potential impact on reproduction. Studies investigated whether the virus could infect reproductive tissues or be transmitted through gametes and embryos 2 .
Amidst the pandemic gloom, a bright spot emerged in reproductive genetics: the 2020 Nobel Prize in Chemistry was awarded to Emmanuelle Charpentier and Jennifer Doudna for their development of CRISPR-Cas9 gene editing technology 1 .
One of the most significant concerns was whether SARS-CoV-2 could be present in reproductive fluids and tissues. Early studies produced conflicting results, with some detecting viral RNA in semen and others finding no evidence 2 . This uncertainty prompted conservative approaches to treatment involving gametes from infected individuals.
With in-person consultations limited by safety concerns, reproductive medicine experienced an accelerated adoption of telemedicine. Virtual consultations became the new norm, offering unexpected benefits including increased accessibility for patients in remote areas and reduced time away from work 6 .
Behind closed clinic doors, laboratory staff implemented innovative safety protocols. Concerns about potential viral contamination in liquid nitrogen storage prompted revised cryopreservation strategies 2 .
| Adaptation | Pre-COVID Practice | COVID-Era Innovation | Potential Legacy |
|---|---|---|---|
| Consultations | Primarily in-person | Widespread telemedicine adoption | Hybrid care models |
| Cycle Monitoring | Clinic-based ultrasounds and blood tests | Reduced frequency + home monitoring | More patient-centric approaches |
| Laboratory Safety | Standard infection control | Enhanced PPE and cryostorage protocols | Permanent safety upgrades |
| Patient Education | In-person sessions | Virtual platforms and digital resources | Improved accessibility |
The pandemic exacerbated existing disparities in reproductive care, particularly for women of color and those with lower socioeconomic status 7 . Studies revealed that minority women were less likely to receive referrals to fertility specialists even before the pandemic, a gap that widened during COVID-19 3 .
One study at a single academic institution found that only 14.6% of reproductive-age women with newly diagnosed gynecologic cancers were referred to fertility specialists, with significant disparities based on race, marital status, and even the gender of the oncologist 3 .
Female oncologists were nearly four times more likely to refer patients to fertility preservation services than their male counterparts 3 .
The economic devastation of the pandemic further limited access to fertility care, which is rarely covered by insurance in the United States. With a single IVF cycle costing approximately $19,200—representing about 50% of an average person's annual disposable income—many prospective parents found their dreams pushed further out of reach 7 .
| Factor | Impact on Referral Rate | Statistical Significance |
|---|---|---|
| Age < 35 years | Increased referral | p < 0.001 |
| No living children | Increased referral (OR=11.46) | Significant |
| Female oncologist | Increased referral (OR=3.8) | Significant |
| BMI > 30 | Decreased referral | p = 0.012 |
| Type 2 diabetes | Decreased referral | p = 0.031 |
| Married status | Increased referral | p = 0.019 |
For cancer patients requiring fertility preservation, the pandemic created agonizing choices between prioritizing cancer treatment versus preserving reproductive potential 6 . While guidelines consistently recommended that fertility preservation should remain available for these patients, logistical challenges often created delays.
The typical narrow window between cancer diagnosis and treatment initiation—median time of 18.5 days in one study 3 —became even more compressed due to pandemic-related care delays.
The oncofertility community responded with creative approaches, including emergency protocols for ovarian stimulation that minimized clinic visits and coordinated care between oncologists and reproductive specialists 6 .
The treatment interruptions of 2020 sparked increased interest in restorative reproductive medicine (RRM)—approaches that seek to identify and treat underlying causes of infertility rather than bypassing them through assisted reproductive technologies 4 .
The pandemic highlighted longstanding issues in diagnosing reproductive conditions like endometriosis, which typically takes 8-12 years to diagnose despite affecting more than six million American women 4 .
With clinic access limited, many couples turned to fertility awareness methods to optimize their chances of conception 5 . These methods help identify the fertile window—the 6-day interval ending on the day of ovulation when conception is most likely 5 .
Technological advances supported this trend, with numerous smartphone applications and home ovulation tests becoming increasingly sophisticated. However, research revealed significant limitations in some calendar-based apps, which showed only 21% accuracy in predicting ovulation day compared to urinary luteinizing hormone testing 5 .
Research confirmed that timing intercourse during the fertile window significantly improves conception probability, with the highest likelihood occurring when intercourse takes place 1-2 days before ovulation 5 . Contrary to popular myths, studies found that daily intercourse during the fertile window did not adversely affect sperm parameters in men with normal semen quality, and may even improve them in men with oligozoospermia 5 .
| Day Relative to Ovulation | Probability of Clinical Pregnancy |
|---|---|
| -5 to -3 days | 8-9% |
| -2 to -1 days | 21-34% |
| Day of ovulation | 8-10% |
| +1 day after ovulation | 0-3% |
Advancements in reproductive medicine rely on specialized reagents and technologies. Here are some essential components of the modern reproductive scientist's toolkit:
Revolutionary technology allowing precise modification of genetic material, with profound implications for understanding genetic causes of infertility and potentially preventing heritable diseases 1 .
Advanced transcriptomic analysis tools that have revealed surprising heterogeneity in cellular responses within reproductive tissues 1 .
Critical components for understanding SARS-CoV-2 potential impact on reproduction, as these receptors serve as entry points for the virus 2 .
Essential for fertility preservation through gamete and embryo cryopreservation, though requiring enhanced safety protocols during the pandemic 2 .
Critical for monitoring menstrual cycle dynamics and optimizing timing for fertility treatments or natural conception attempts 5 .
Including urinary luteinizing hormone tests, basal body temperature tracking, and cervical mucus monitoring systems that help identify the fertile window 5 .
The year 2020 presented reproductive medicine with numerous challenges that initially appeared as closed windows of opportunity. However, many of these challenges ultimately led to innovations and reflections that may improve care in the long term. The accelerated adoption of telemedicine, heightened awareness of healthcare disparities, renewed interest in restorative approaches, and improved patient engagement through home-based monitoring all represent potential silver linings from a difficult period.
The reflection on 2020 reminds us that while beginnings cannot be changed, we retain the power to change endings.
As the field moves forward, integrating these lessons will be crucial for building a more resilient, equitable, and effective reproductive healthcare system. The pandemic forced a reevaluation of priorities and practices that might otherwise have taken decades to accomplish. In this sense, the crises of 2020 created unexpected windows of opportunity—ones that the field would do well to keep open as it advances toward a future where building families remains possible even in the face of global challenges.