My name is Albert Hsu, and I a reproductive endocrinologist in mid-Missouri.  I am an Ob/Gyn that cares for patients with infertility, endometriosis, PCOS, fibroids, and hormone replacement therapy questions.  Since late January, I’ve been encouraging travel restrictions and contact precautions for all couples in my office (“seriously, don’t visit China right now!”), but now that a pandemic has been declared, I’ve changed my tune, to try to allay some of the fear and panic that I see in everyone’s eyes.

I first tell my patients that they are young and (usually) healthy, and that they are unlikely to die of COVID-19.  I show them the most recent data from Italy and China, emphasizing that there is significant mortality for the elderly (3% for 60 year-olds, 8% for 70 year-olds, 15% for 80 year olds), but zero deaths in the pediatric population, and rare morbidity in individuals under 35 years of age.  I then contrast Italy and Taiwan:

Italy is a wonderful, warm country.  They also have a high life expectancy (over 80 years, with the fifth-highest median age in the world = 46 years old).  Apparently, they also did not deploy social distancing until too late.  They now have reportedly had more deaths than China from COVID-19, possibly due to what looks like an increased virulence of the Italian mutations of COVID-19.

Taiwan is an island nation of 23 million citizens, with 5% of their population living or working in China.  Partly because of their proximity to China (just 80 miles away), they were economically devastated by the 2003 SARS epidemic (346 cases, and 73 deaths, for a 20% fatality rate).  In response to reports of the Wuhan coronavirus earlier this year, they sent a team to China to collect information.  Through aggressive travel restrictions, school and work policies, case finding, public communication, and resource assessments of hospitals, they have kept their virus numbers and death rates surprisingly low; in fact, they managed to keep their cases under 100 until a few days ago, and they have still only had one death due to COVID-19.

I then show the epidemic curve of COVID-19 cases inside China, explaining that Surgeon General Jerome Adams and other national leaders want to “flatten the curve” of affected and critically ill people.  Many or even most of us will be affected eventually, and some will certainly die, but let’s try to have less death, and also spread out the cases over time, so as to not overwhelm our healthcare system.
So, I urge our patients to view all these cancellations of sports events, closures of schools/bars/restaurants, and public health recommendations to cancel/postpone events with more than 10 people, as appropriate measures to “let’s try and protect our elderly population,” and *not* “run for the hills and save yourselves, we’re all going to die of this Black Plague / Spanish Flu apocalypse.”  Cancelling the NBA wasn’t about protecting LeBron, it was about protecting the workers in those arenas, and also the general public.  Hopefully, we have instituted social distancing just when it mattered the most.

Regarding pregnancy, my specialty society (the American Society for Reproductive Medicine) has new recommendations (3/17/20) regarding COVID-19.  With a stated goal “to provide practices with recommendations that guard the health and safety of our patients and staff, and recognize our social responsibility to comply with national public health recommendations,” they recommend suspending new fertility treatments, completing current treatments and urgent treatments (such as fertility preservation for cancer patients), suspending elective surgeries, increasing utilization of telehealth, and minimizing in-person interactions.”

The question then becomes, is it safe to conceive?  Should our fertility patients use contraception?  There is no evidence of vertical transmission, and the data on COVID-19 (and also the related coronaviruses, SARS and MERS) are quite limited.  I ask all my patients about their health status, and I encourage patients with significant comorbidities (uncontrolled hypertension or diabetes, BMI > 40, significant cardiac or pulmonary dysfunction) to use effective contraception for the near term.  For everyone else, I ask about their tolerance for the risk of an unforeseen pregnancy complication (such as preterm labor, or eclamptic seizures) that could land them in the hospital for an extended period of time, and thus increase their risk of exposure and (possible) sequelae associated with COVID-19.  If they accept those risks, it would be reasonable to try to conceive on their own; otherwise, I would again recommend effective contraception.

In summary, I encourage everyone to donate blood, comply with good hygiene and social distancing, stockpile 2 weeks’ worth of food and sundries (in case you need to self-quarantine) but *not* hoard 6 months’ supply of necessities.  Please also refrain from hoarding personal protective equipment, as we need it for our front-line healthcare workers, first-responders, and long-term care facilities.  It is also important to go outside and get some fresh air, reconnect with friends and family, and have us all take care of ourselves and each other.

Most of us will probably get COVID-19 (or COVID-20, or -21) over the coming months and years.  The virus is mutating, and there are some signs that the Wuhan coronavirus was more deadly than some of the other mutations.  Our goal should not be to stay forever disease-free, but rather to “flatten the curve” of affected and critical ill people.  Many of our front-line staff will likely get ill, but if other countries are any indication, 80% will likely have mild disease, 14% may have moderate disease requiring oxygen, 4-6% may get severely ill, and perhaps 2% will die.  Over time, we will need those healthcare workers who get sick and recover, to take care of the rest of us.

In the meantime, this will be a time of great societal change.  We need to fight fear, panic, social isolation, and #CoronavirusCabinFever, while also remembering to take care of ourselves and each other.  My hope is that this pandemic (and our response) will increase our sense of community and togetherness.  Our state and national leaders are right:  this is a war, and we need to band together, so that we don’t get overwhelmed.  And in the meantime, I am quite happy to be living and working in a Flyover State with a robust public health response.

Stay safe and panic-free,

– Albert Hsu, MD  President-elect, Boone County Medical Society

  Please visit <https://health.mo.gov/> and <msma.org> and <ama-assn.org> for more information.  All opinions expressed here, are strictly my own.