ASRM PAGES

Vaccination guidelines for

female infertility patients:
a committee opinion
The Practice Committee of the American Society for Reproductive Medicine
American Society for Reproductive Medicine, Birmingham, Alabama

Encounters for infertility care are opportunities to assess and update immunization status. Women of reproductive age are often un-
aware of their need for immunization, their own immunization status, and the potentially serious consequences of preventable disease
on pregnancy outcome. The purpose of this ASRM Practice Committee document is to summa-
rize current recommendations regarding vaccinations for women of reproductive age. This doc-
ument replaces the ASRM Practice Committee document of the same name last published in Use your smartphone
Fertil Steril 2008;90:S169–71. (Fertil SterilÒ 2013;99:337–9. Ó2013 by American Society for to scan this QR code
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VACCINATION BEFORE
E
ncounters for infertility care a vaccination. This fear persists de-
are opportunities to assess and INFERTILITY TREATMENT spite the fact that there are few vac-
update immunization status. AND DURING PREGNANCY cines that are contraindicated during
Women of reproductive age often are pregnancy (2). The contraindicated
Ideally, immunizations should be
unaware of their need for immuniza- vaccines include MMR, varicella,
completed before conception because
tion, their own immunization status, and herpes zoster. All others are
some recommended vaccinations can-
and the potentially serious conse- either fully recommended or recom-
not be administered during pregnancy
quences of preventable disease on preg- mended if some other risk factor is
(1–5). Vaccinations before or during
nancy outcome. In one study, fewer present. Vaccinations during preg-
pregnancy protect women from poten-
than 60% of surveyed obstetrician- nancy are indicated when benefits
tially serious illnesses, prevent vertical
gynecologists routinely obtained any clearly outweigh risks. Special circum-
transmission to the fetus, and confer
vaccination history, and only 10% stances that may influence the indica-
passive immunity to the newborn.
offered vaccines currently recommen- tion for vaccination include military
Transport of maternal immunoglobu-
ded for adults (1). National standards service, travel to high prevalence areas,
lin (IgG) antibodies to the fetus occurs
for vaccinations have been established hazardous occupations, immuno-
throughout gestation and increases
and last updated in February 2012 by compromise, and chronic illness.
markedly during the last 4 to 6 weeks
the Centers for Disease Control and Guidelines for vaccinations in individ-
of gestation (3–5).
Prevention (CDC) and are available for uals with such special indications are
Many physicians are reluctant to
review on the CDC website (2). The outlined in a committee opinion pub-
immunize pregnant women because
purpose of the present document is to lished by the Centers for Disease
of concerns that a spontaneous ab-
summarize current recommendations Control (2).
ortion or incidental congenital anom-
regarding vaccinations for female infer- Immunizations generally recom-
aly might be attributed wrongly to
tility patients. mended for women of reproductive
age are listed in Table 1, which
provides a condensed summary of the
Received August 13, 2012; accepted August 14, 2012; published online September 13, 2012. Recommended Adult Immunization
No reprints will be available. Schedule published by the CDC. Physi-
Correspondence: Practice Committee, American Society for Reproductive Medicine, 1209 Montgom-
ery Hwy., Birmingham, AL 35216 (E-mail: ASRM@asrm.org). cians are encouraged strongly to assess
the history of immunizations in wo-
Fertility and Sterility® Vol. 99, No. 2, February 2013 0015-0282/$36.00
Copyright ©2013 American Society for Reproductive Medicine, Published by Elsevier Inc.
men before beginning treatment for
http://dx.doi.org/10.1016/j.fertnstert.2012.08.027 infertility.

VOL. 99 NO. 2 / FEBRUARY 2013 337

ASRM PAGES

TABLE 1

Recommended Adult Immunization Schedule modified from the Centers for Disease Control and Prevention (2).
Age group
Vaccine 19–21 y 22–26 y 27–49 y 50–59 y 60–64 y R65 y
Influenza* 1 dose annuallyy
Tetanus, diphtheria, pertussis (Td/ Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yy Td/Tdapyy
Tdap)*
Varicella 2 dosesy
Human Papilloma virus (HPV),* 3 dosesy No recommendation
female
Human Papilloma virus (HPV),* male 3 doses (y19–21;z22–26) No recommendation
Measles, mumps, rubella (MMR)* 1 or 2 dosesy 1 dosez
z
Pneumococcal (polysaccharide) 1 or 2 doses 1 dosey
Meningococcal* 1 or more dosesz
Hepatitis A* 2 dosesz
Hepatitis B* 3 dosesz
* Covered by the Vaccine Injury Compensation Program.
y
For all persons in this category who meet the age requirements and who lack documentation of vaccination or have no evidence of previous infection.
z
Recommended if some other risk factor is present (e.g., based on medical, occupational, lifestyle, or other indications).
yy
Tdap recommended for R65 if contact with <12 month old child. Either Td or Tdap can be used if no infant contact.
Practice Committee. Vaccination guidelines and infertility. Fertil Steril 2013.

ROUTINE VACCINATIONS ber and November because the flu season occurs during Janu-
Measles, Mumps, and Rubella (MMR) ary through March. Injectable influenza vaccines, trivalent
inactive vaccine (TIV), contain inactivated virus and therefore
MMR vaccine is recommended for all women without
may be administered at any time during pregnancy. In con-
confirmed immunity to rubella. MMR vaccine contains live
trast, intranasal influenza vaccines contain live attenuated vi-
attenuated virus. Vaccination therefore should be
rus and should not be administered during pregnancy.
administered before pregnancy to avoid the possibility of in-
Concerns had previously been raised about administering
trauterine infection, and pregnancy should be avoided for 1
thimerosol-containing influenza vaccine to pregnant women.
month after vaccination. However, there is no confirmed in-
Thimerosol is a mercury-based preservative used in vaccines
stance where MMR vaccine has been linked to congenital
that was thought to be associated with adverse effects. However,
malformation or significant intrauterine infection (6).
no scientific evidence has correlated ill effects in the children
Consequently, inadvertent MMR administration during preg-
born to women who have taken vaccines containing thimerosol
nancy is not an indication for pregnancy termination.
(7). Therefore, the TIV influenza vaccines can be given to preg-
nant women whether they contain thimerosol or not.
Varicella
Varicella vaccine contains live attenuated virus. Prior to preg- Tetanus-Diphtheria-Pertussis (Tdap) and Tetanus-
nancy, all adults without evidence of immunity should Diphtheria (Td)
receive 2 doses of single-antigen varicella vaccine adminis-
A tetanus toxoid, reduced diphtheria toxoid, and acellular
tered 1 month apart or a second dose if they have previously
pertussis vaccine (Tdap) was approved by the Advisory Com-
received only 1 dose. Pregnancy should be avoided for
mittee on Immunization Practices (ACIP) in 2011 and was rec-
1 month after vaccination. If exposed to varicella prior to
ommended for adults (19 to 64 years of age) who have or who
pregnancy, the vaccine should be administered within 96
anticipate having close contact with an infant less than 12
hours of exposure and pregnancy avoided. Pregnant women
months of age (8). Due to the recent increase in pertussis out-
should be assessed for evidence of varicella immunity. Preg-
breaks, healthcare providers should vaccinate women who are
nant women who do not show signs of immunity should
pregnant or might become pregnant and have not previously
receive the first dose of varicella vaccine upon completion
received Tdap. If they are currently pregnant, Tdap preferably
or termination of pregnancy and before discharge from the
should be administered during the third trimester or late sec-
hospital. Cases of congenital varicella after immunization
ond trimester (i.e., after 20 weeks' gestation). If not given dur-
have been reported.
ing pregnancy, it should be administered immediately
postpartum to ensure pertussis immunity and to reduce trans-
Influenza
mission to the newborn.
Annual influenza vaccination is recommended for all individ-
uals 6 months of age and older. Women who are pregnant or
contemplating pregnancy should be immunized because influ-
NON-ROUTINE VACCINATIONS
enza infection may increase the risk for medical complications, Pneumococcus
as heart rate, stroke volume, and oxygen consumption are in- Pneumococcus vaccine is recommended for any person at in-
creased and lung capacity is decreased during pregnancy. The creased risk for pneumococcal infection. Individuals at high
optimal interval for immunization spans the months of Octo- risk include those with asplenia, sickle cell anemia, chronic

338 VOL. 99 NO. 2 / FEBRUARY 2013

 Fertility and Sterility®

cardiovascular/pulmonary disease, diabetes, or immunocom- CONCLUSIONS

promise as may result from human immunodeficiency virus Prior to, during, or after pregnancy, it is important to be aware
(HIV) infection, systemic illness, or malignancy. Ideally, of a patient's immunization history and to update her vaccine
high-risk women should be immunized before pregnancy. status when appropriate.

Hepatitis A (HA) Acknowledgments: This report was developed under the

direction of the Practice Committee of the American Society
HA vaccine is recommended for any women at high risk, in-
for Reproductive Medicine as a service to its members and
cluding those receiving clotting factor concentrates, those
other practicing clinicians. Although this document reflects
with chronic liver disease, women working with HA virus or
appropriate management of a problem encountered in the
HA-infected laboratory animals, women traveling to coun-
practice of reproductive medicine, it is not intended to be
tries with a high prevalence of HA infection, and intravenous
the only approved standard of practice or to dictate an exclu-
drug users. The vaccine contains inactivated virus and poses
sive course of treatment. Other plans of management may be
no known risk to the fetus.
appropriate, taking into account the needs of the individual
patient, available resources, and institutional or clinical prac-
Hepatitis B (HB) tice limitations. The Practice Committee and the Board of Di-
HB vaccine is approved for any woman at high risk, including rectors of the American Society for Reproductive Medicine
those receiving hemodialysis or clotting factor concentrates, have approved this report.
healthcare workers exposed to blood and blood products, in- The following members of the ASRM Practice Committee
travenous drug users, women having a sexually transmitted participated in the development of this document. All Com-
infection or multiple sexual partners, those traveling to coun- mittee members disclosed commercial and financial relation-
tries with a high prevalence of hepatitis B infection, and ships with manufacturers or distributors of goods or services
women living in the same household with a known infected used to treat patients. Members of the Committee who were
individual. The vaccine contains noninfectious DNA particles, found to have conflicts of interest based on the relationships
can be administered during pregnancy if needed, and poses no disclosed did not participate in the discussion or development
known risk to the fetus. of this document.
Samantha Pfeifer, M.D.; Jeffrey Goldberg, M.D.; R. Dale
Meningococcus McClure, M.D.; Roger Lobo, M.D.; Michael Thomas, M.D.;
Eric Widra, M.D.; Mark Licht, M.D.; John Collins, M.D.; Mar-
Meningococcus vaccine should be administered to any person celle Cedars, M.D.; Catherine Racowsky, Ph.D.; Michael Ver-
who is at increased risk for meningococcal infection. For non, Ph.D.; Owen Davis, M.D.; Clarisa Gracia, M.D.,
pregnant women, its use should be limited to those at high M.S.C.E.; William Catherino, M.D., Ph.D.; Kim Thornton,
risk who have not been inoculated previously. Individuals M.D.; Robert Rebar, M.D.; Andrew La Barbera, Ph.D.
at high risk include those who live in high endemic areas,
such as sub-Saharan Africa, parts of the Middle East, and col-
lege dormitories. Preferably, such high-risk women should be
vaccinated before pregnancy, because experience with the REFERENCES
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infection prevention practices among obstetrician-gynecologists. Obstet
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SUMMARY 2. Centers for Disease Control and Prevention. Recommended adult immuniza-
tion schedule—United States 2012. Atlanta, GA: CDC, 2012. Available at
 Vaccination in women of reproductive age before or during
http://www.cdc.gov/vaccines/schedules/downloads/adult/mmwr-adult-schedule.
pregnancy confers resistance to intrauterine infections and pdf. Last accessed August 2012.
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