Every morning and evening for five days, Angie, 36, injected the flesh around her belly button with in vitro fertilization drugs to stimulate her ovaries to produce eggs. Her fertility doctor planned to harvest the eggs in a 15-minute surgical procedure about a week later.
On the morning of the sixth day, March 20, Angie, who asked that her last name not be used out of concern that her employer would retaliate if it found out she was trying to conceive, was working at her home in Vancouver, British Columbia, when she got a call from a nurse at her fertility clinic. Because of the coronavirus pandemic, the clinic was suspending all treatments and closing down.
"I was really angry," she said. "I burst into tears. I was shaking and sobbing uncontrollably."
Angie asked the nurse whether she could come in for an ultrasound to check the state of her ovaries, swollen from the drugs, and make sure she wasn't developing any cysts. The clinic refused.
"I had used $3,000 worth of medication," she said. "It was an emotional and financial loss."
Angie is one of thousands of women across North America whose in vitro fertilization treatments have been disrupted by the coronavirus pandemic, following guidance that the American Society for Reproductive Medicine issued March 17. The measures are designed to reduce the risk of spreading the virus to patients and staff during procedures the organization described as "elective" or "non-urgent."
It has left patients and their partners feeling extremely anxious at an already stressful time in their lives.
IVF is a treatment for infertility caused by a range of issues, including problems with ovulation, poor sperm or egg quality and endometriosis. It is highly time sensitive for two reasons: Fertility in both men and women declines with age, and the treatment requires carefully scheduled medications and regular appointments to check how the body is responding to them.
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If patients respond to the drugs, their ovaries produce more eggs than normal, which are removed via surgery and fertilized with a partner's or a donor's sperm. The resulting embryos are grown in a lab for a few days before being implanted in the uterus or frozen for a later transfer.
At each stage of the process, any hiccup has an indirect effect that delays possible pregnancy.
NBC News talked to 10 women and some of their partners about the impact the disruption has had on their mental states and their aspirations for growing families.
"It's like a death to many people," said Anne Malavé, a New York-based clinical psychologist and fertility counselor. "For many people, getting pregnant is the most important thing in their life, and they will experience the coronavirus as a threat to that goal more than a threat to their own personal health or loved ones."
In keeping with the American Society for Reproductive Medicine guidelines, most clinics, although not Angie's, said they would let patients who had already started the injections to stimulate their ovaries continue through to the egg retrieval.
Most of the women NBC News interviewed had their cycles canceled either before starting the injections or before the embryo transfer stage.
Ashley Carnes, 26, and her husband, Gene, 41, from Illinois, have been trying to conceive for more than two years. After months of preparations, including bloodwork and genetic testing, they were poised to start a round of IVF. They had the injectable medications stored, as directed, in the refrigerator and a large supply of needles, syringes and alcohol wipes.
"We were excited," Carnes said. "We have been praying for this for a long time."
On March 16, her Springfield-based clinic sent patients an email saying it was canceling new IVF cycles.
"I was numb," she said. "I am thankful they are looking out for our health and safety, but it's so hard to deal with the unknown of what's going to happen next. The next month is going to feel like a year."
Susan Nelson, 34, of Minneapolis went through a round of injections and egg retrieval in February and had planned to transfer an embryo shortly after. However, she developed internal bleeding after the procedure to collect the eggs, requiring a visit to the emergency room, and she needed more time to recover.
She was "devastated" when her doctor emailed to tell her the transfer was canceled.
"You lose a lot with infertility," Nelson said. "It always feels like something was stolen from you. You don't get to choose how many children you want or build the family in the way you dreamed. And sometimes you don't have the choice of any children at all. But now to not even have the privilege of trying to build a family is just adding insult to injury."
She said she respects the decision to cancel her treatment but finds it difficult to navigate the sense of loss, particularly at a time when most people are concerned about the pandemic.
"Everybody has their own hurt right now. It's hard for people to find space and appreciation for the unique ways we are being affected, because we are all dealing with our own wounds," Nelson said.
In some cases, patients canceled their own treatments before their clinics made the decisions because of concerns about their health or travel restrictions.
Halle Tecco, 36, lives in Charleston, South Carolina, but is a patient at a fertility clinic in New York. She had a baseline ultrasound to check the health of her ovaries and her injectable medications ready in the refrigerator, but she chose to cancel the round in early March because she has asthma, making her more susceptible to COVID-19, the disease caused by the coronavirus.
"I can't travel to New York," she said. "I am already medically fragile."
Working at home has exacerbated the anxiety for some patients.
"Everyone is home, and there are so many jokes about pandemic babies or how tired parents are of being around their kids," said Ashleigh Azzari, 36, of Santa Clara, California. "I have this constant battle not to tell people to appreciate what they have."
Azzari and her husband have been trying to conceive for almost three years. In that time, she's had five miscarriages and two ectopic pregnancies, potentially life-threatening events in which a fertilized egg implants outside the uterus. They had completed the paperwork for their next embryo transfer when their clinic told them it had been postponed indefinitely.
"My husband is from Italy. We are hyper-aware of the situation," Azzari said. "I don't want to put anyone's safety in jeopardy."
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Many clinics have allowed patients who were already halfway through their stimulation phases to complete their injections and go through with the egg retrieval operations. However, the clinics take extra precautions with these patients.
Anna Wang and her husband, Jeremy Tu, both 35, of Los Angeles, have been trying to conceive for seven years. They were halfway through the injection phase of their third round of IVF when they started hearing reports on social media of clinics' canceling cycles.
Wang called her clinic immediately and was told that she could complete the treatment, but she had to sign a waiver acknowledging that the cycle could be canceled at any moment and attend all her appointments — including blood draws and ultrasound scans to check that the eggs are growing correctly — on her own.
She must now wait in the car, rather than the reception area, until her room is ready. A nurse checks her temperature before she enters, and even reception staff members wear gloves before handling her credit card.
It's now a waiting game. "It's like when you are a kid and you are counting down the days to Christmas. Every day you pass is always a mini-celebration. One more day closer," Tu said, adding that the couple would be down by "$20,000 to $30,000" if the cycle is canceled.
Wang said: "Every time I get a call from the doctor's office, I am thinking, 'Is this the call? Is our cycle getting canceled because they found someone with the virus in the building?'"
The cancellations have been difficult for clinicians, too.
"Everybody wants to know when we can start back up. The hardest part is not having an answer," said Dr. Peter Klatsky, founder and CEO of Spring Fertility, a clinic in the San Francisco Bay Area.
Klatsky said that his clinic would comply with California's shelter-in-place order to be a "responsible member of the community and minimize infection" but that he hopes the American Society for Reproductive Medicine will release more nuanced guidelines to allow some patients to continue treatment.
"Then the lack of nuance based on geography and individual circumstance was disappointing," he said of the guidelines. "When you are 41 or 42, each month really does matter."
Angie had planned to take a couple of days off work last week to recover from her egg retrieval. After the procedure was canceled, she decided to use the days to try to process her loss and consider other options. "I need a Plan B, C, all the way up to Plan Z," she said, adding that she has started looking at adoption.
She doesn't know whether she can handle many more rounds of IVF.
"I am a ball of hormones and anxiety, and it has bled into every part of my life, and I want some of that life back," she said.