Letter to the Editor: The Coronavirus Disease 2019 Impact on Oncofertility Services in Malaysia

Dear Editor:

Coronavirus disease 2019 (COVID-19) was discovered as a possibly terminal infection starting in December 2019 in Wuhan, China, and it has been spreading worldwide. ¹ In Malaysia, our first COVID-19-positive cases were discovered on January 25, 2020, and subsequently, the number of cases rose, leading to the implementation of the Movement Restriction Order Act starting on March 18, 2020, aiming to flatten the infection curve. As of June 3, 2020, a total of 7970 confirmed cases with 6531 recoveries and 115 deaths were reported in Malaysia. ² During this pandemic, Universiti Kebangsaan Malaysia Medical Centre services were modified as hybrid-COVID-19 cluster hospital, and treating both confirmed COVID-19 cases and standard cases, thus overall significantly affected our health management, including our oncofertility services.

Newly diagnosed cancer with significant treatment-related gonadotoxic effects among children and the reproductive age group should receive fertility preservation (FP) treatment. The choices of the embryo, oocytes, sperm, and ovarian tissue cryopreservation (OTC) are offered to tailor to the patient profile. ³ However, assisted reproductive technique services are postponed due to the COVID-19 pandemic. ⁴ Although international bodies, mainly the European Society Medical Oncology and American Society Clinical Oncology, have highlighted that FP is considered urgent among cancer cases and should not be deferred, majority of oncology clinicians are not aware of this, and thus, few referrals were made during this period.^4,5

Among our oncofertility services, the additional cost of the COVID-19 screening for both members of the couple is added to the FP cost. However, the cancer treatment itself places a significant financial burden on the couple. From our current experiences, most of our patients developed complex emotional responses related to isolation or quarantine. They feared to contract the COVID-19, especially during the receiving of the FP treatment. Sadly, they willingly opted out of the FP treatment and barely followed the primary cancer treatment.

Otherwise, we need to modify the laparoscopic procedure to a mini-laparotomy for oophorectomy for OTC, as it is currently prohibited to reduce the risk of air droplets aerosolizing among the health workers. As most cases are prepubertal, we hardly receive any referrals for OTC, mostly due to the parents' anxiety at this time.

Nevertheless, our clinic's setting has also been affected. Previously, our clinic benefited from the presence of a psychologist who, together with the patients' family members, created a support system that ensured that a synchronized decision was made with a better FP outcome. However, this restriction led to ineffective consultations, thus, poor FP uptake. To overcome this, we implemented telemedicine (phone/video call) as a platform for the FP consultations. Despite that, the uptake is still low, as this is considered a new norm among patients and their relatives.

Although we do highlight that the oncofertility treatment should not be delayed due to the COVID-19 and that modifications of the services have been made, the uptake remains low. Therefore, we hope that the physicians dealing with cancer cases will be more proactive in referring suitable cases to the oncofertility center despite our battling the COVID-19 pandemic, as it will significantly impact their life in the future.