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Suggested Citation:"9 Female Infertility and COVID-19 Vaccines." National Academies of Sciences, Engineering, and Medicine. 2024. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press. doi: 10.17226/27746.
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Suggested Citation:"9 Female Infertility and COVID-19 Vaccines." National Academies of Sciences, Engineering, and Medicine. 2024. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press. doi: 10.17226/27746.
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Suggested Citation:"9 Female Infertility and COVID-19 Vaccines." National Academies of Sciences, Engineering, and Medicine. 2024. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press. doi: 10.17226/27746.
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Suggested Citation:"9 Female Infertility and COVID-19 Vaccines." National Academies of Sciences, Engineering, and Medicine. 2024. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press. doi: 10.17226/27746.
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Suggested Citation:"9 Female Infertility and COVID-19 Vaccines." National Academies of Sciences, Engineering, and Medicine. 2024. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press. doi: 10.17226/27746.
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Suggested Citation:"9 Female Infertility and COVID-19 Vaccines." National Academies of Sciences, Engineering, and Medicine. 2024. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press. doi: 10.17226/27746.
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Suggested Citation:"9 Female Infertility and COVID-19 Vaccines." National Academies of Sciences, Engineering, and Medicine. 2024. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press. doi: 10.17226/27746.
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Suggested Citation:"9 Female Infertility and COVID-19 Vaccines." National Academies of Sciences, Engineering, and Medicine. 2024. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press. doi: 10.17226/27746.
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Suggested Citation:"9 Female Infertility and COVID-19 Vaccines." National Academies of Sciences, Engineering, and Medicine. 2024. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press. doi: 10.17226/27746.
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Suggested Citation:"9 Female Infertility and COVID-19 Vaccines." National Academies of Sciences, Engineering, and Medicine. 2024. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press. doi: 10.17226/27746.
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Suggested Citation:"9 Female Infertility and COVID-19 Vaccines." National Academies of Sciences, Engineering, and Medicine. 2024. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press. doi: 10.17226/27746.
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Suggested Citation:"9 Female Infertility and COVID-19 Vaccines." National Academies of Sciences, Engineering, and Medicine. 2024. Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration. Washington, DC: The National Academies Press. doi: 10.17226/27746.
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9 Female Infertility and COVID-19 Vaccines This chapter describes the potential relationship between COVID-19 vaccines and female infertility (see Box 9-1 for conclusions). BOX 9-1 Conclusions for Female Infertility Conclusion 9-1: The evidence favors rejection of a causal relationship between the BNT162b2 vaccine and female infertility. Conclusion 9-2: The evidence favors rejection of a causal relationship between the mRNA-1273 vaccine and female infertility. Conclusion 9-3: The evidence is inadequate to accept or reject a causal relationship between the Ad26.COV2.S vaccine and female infertility. Conclusion 9-4: The evidence is inadequate to accept or reject a causal relationship between the NVX-CoV2373 vaccine and female infertility. BACKGROUND Infertility is defined as not being able to conceive after 1 year of unprotected sex in couples with opposite-sex gametes or donor insemination in those under the age of 35 years or within 6 months in those over 35 years (ACOG, 2019). In the United States, among married females aged 15 to 49 years with no prior births, about 1 in 5 (19 percent) are unable to get pregnant after 1 year of trying (CDC, 2023). Unassisted conception is complex. At minimum, it requires ovulation, sperm that is capable of fertilizing an oocyte, and functional female pelvic anatomy including patent fallopian tubes, and uterine endometrium that can support embryo implantation. Fertility may be impacted by a number of different biologic factors, in either the male or female reproductive systems. For females, there is an age-related decline in ovarian reserve (decrease in oocyte number) (Sharma et al., 2013). There is also an age-related decline in oocyte quality with an associated increase in aneuploidy. This decline can be exacerbated by exposure to things like cytotoxic chemotherapy, or alcohol or tobacco use. Metabolic (e.g. obesity) or lifestyle (e.g. alcohol or tobacco use) factors can also contribute to infertility (Sharma et al., 2013). In addition to issues related to the oocyte and ovulation, the fallopian tubes, uterus, and endometrium also need to be considered. PREPUBLICATION COPY—Uncorrected Proofs

246 VACCINE EVIDENCE REVIEW The study of biologic factors impacting natural reproduction is challenging given the complexity of the process. Investigating the cause of infertility is challenging given the latency to diagnose and its heterogeneous nature. Therefore, this review incorporates studies with measurable outcomes for specific elements of the reproductive process including ovarian reserve (expected female response to exogenous gonadotropins as measured by Anti-Müllerian hormone (AMH) levels, and/or antral follicle count (AFC), fertilization, and embryo implantation. MECHANISMS Syncytin-1, a crucial membrane glycoprotein, facilitates the fusion of trophoblasts into syncytiotrophoblasts, which are essential for the early development of the placenta during pregnancy (Gallagher, 2020; Lavillette et al., 2002). Initial theories posited that COVID-19 vaccines might trigger autoantibodies against Syncytin-1, potentially leading to female infertility due to its structural resemblance to the SARS-CoV-2 spike protein (Prasad et al., 2021). However, these concerns were primarily rooted in the interaction of the virus with the ACE2 receptor, which is expressed in reproductive tissues such as the testes, ovaries, and placenta. The paper by Segars et al. underscores the biological plausibility of SARS-CoV-2 affecting reproductive health, given its mode of cell entry through the S1 domain of the spike protein to receptors present in reproductive tissues, including angiotensin-converting enzyme-2 (ACE2), CD26, Ezrin, and cyclophilins. This connection is particularly concerning, as previous instances of coronaviruses, like SARS-CoV-1, have been associated with severe orchitis and the loss of germ cells in males, potentially affecting sperm quality for up to 90 days post-infection. Although ACE2 expression in human ovaries is dependent on gonadotropins, the exact impact of SARS-CoV-2 on female gametogenesis remains to be clarified. Contradicting the initial speculations about Syncytin-1 autoantibodies, subsequent investigations into the potential cross-reactivity between antibodies generated against the SARS- CoV-2 spike protein and Syncytin-1 revealed no detection of such autoantibodies in human plasma (Prasad et al., 2021). Moreover, studies by Lu-Culligan et al. (2022) in both animal models and humans confirmed that vaccination does not induce anti-Syncytin-1 antibodies, dispelling concerns over vaccine-related female infertility through this mechanism. Another hypothesized mechanism of female infertility is the effect of mRNA vaccines on AMH, a critical biomarker for assessing ovarian reserve, providing measurable insight into remaining egg count and, by extension, fertility potential. This hormone plays a vital role in evaluating ovarian health and predicting responses to fertility treatments like assisted reproductive technologies. The potential impact of mRNA vaccines on reproductive health, specifically whether the immune response they provoke could inadvertently affect ovarian tissues or hormonal balance, thus influencing AMH levels and fertility. In a longitudinal cohort study, AMH in participants pre- and post-administration of mRNA-based COVID-19 vaccines were quantified to assess its impact on ovarian reserve and fertility potential. The study accounted for established confounding variables that are known to affect AMH concentrations, including age, body mass index, and the phase of the menstrual cycle. There were no significant alterations in AMH levels post-vaccination, thus providing evidence against the hypothesis that mRNA COVID-19 vaccines compromise ovarian reserve (Chen et al., 2021). PREPUBLICATION COPY—Uncorrected Proofs

FEMALE INFERTILITY 247 CLINICAL AND EPIDEMIOLOGICAL EVIDENCE In evaluating the literature on whether COVID-19 vaccines impact female fertility, the committee considered three types of studies that included important biologic measures known to be associated with reproduction: ● Epidemiologic studies of populations that may or may have not included females with infertility ● Studies among oocyte donors ● Studies among females going through in vitro fertilization The last type of study does not provide direct evidence but is used to support clinical and epidemiological evidence. These studies evaluate treatment outcomes, not the development of female infertility. Female infertility was not an outcome studied in the clinical trials submitted for authorization or approval (FDA, 2021, 2023a, 2023b, 2023c). Table 9-1 presents eight studies that contributed to the causality assessment. PREPUBLICATION COPY—Uncorrected Proofs

248 VACCINE EVIDENCE REVIEW TABLE 9-1 Clinical and Epidemiological Studies in the Female Infertility Evidence Review Comparison Group/ Outcome Author N Vaccine Type Study Type Control Variable(s) Results Bosch et al. 115 oocyte mRNA Cohort with pre- Self-controlled Mean Pre-vaccination: 15.38 ± 7.0 (2023) donors (BNT162b2, and postexposure number of (95% CI: 14–17) mRNA-1273) oocytes Post-vaccination 16.62 ± 7.1 retrieved (95% CI: 15–18) Mean difference -1.24 ± 6.0 (95% CI 2.34–0.14) Mean Pre-vaccination 82.69% fertilization (95% CI: 79.23–86.15) rate Post-vaccination: 78.84% (95% CI: 75.21–82.47) Mean Pre-vaccination: 2.29 number of (95% CI: 1.85–2.73) high- Post-vaccination 2.32 quality (95% CI: 1.96–2.68) embryos (Grade A) Karavani et 224 women BNT162b2 Retrospective Unvaccinated Mean Pre-pandemic: 13.0 ± 8.2 al. (2022) Pre-pandemic: cohort (pre- and number of Intra-pandemic unvaccinated: 103 intrapandemic) oocytes 12.5 ± 7.4 Intra-pandemic retrieved Vaccinated: 12.6 ± 8.0 unvaccinated: 52 p = 0.892 Vaccinated: 69 Number of Pre-pandemic: mature 9.5 ± 6.4 oocytes Intra-pandemic unvaccinated: 10.1 ± 6.3 Vaccinated: 10.1 ± 6.9 p = 0.744 PREPUBLICATION COPY—Uncorrected Proofs

FEMALE INFERTILITY 249 TABLE 9-1 Continued Comparison Group/ Outcome Author N Vaccine Type Study Type Control Variable(s) Results Kolatorova et 25 healthy fertile BNT162b2 Cohort Self-controlled LH, FSH, LH: al. (2022) women before mRNA-1273 SHBG, Before dose 3: 6.36 IU/L and after 3rd AMH, After dose 3: 6.11 IU/L vaccination AFC p = 0.424 FSH: Before dose 3: 6.2 IU/L After dose 3: 6.49 IU/L p = 0.424 SHBG: Before dose 3: 67.4 nmol/L After dose 3: 70.17 nmol/L p = 0.75 AMH: Before dose 3: 3.25 ng/mL After dose 3: 3.03 ng/mL p = 0.689 AFC: Before dose 3: 23 After dose 3: 24 p = 0.19 PREPUBLICATION COPY—Uncorrected Proofs

250 VACCINE EVIDENCE REVIEW TABLE 9-1 Continued Comparison Group/ Outcome Author N Vaccine Type Study Type Control Variable(s) Results Mohr-Sasson 129 without BNT162b2 Self-controlled Self-controlled Mean Pre-vaccination: 5.3 ± 4.2 µg/L et al. (2022) known infertility AMH Post vaccination: 5.2 ± 4.5 µg/L levels p = 0.11 Soysal and 30 vaccinated BNT162b2 Prospective cross Unvaccinated AMH Control group: 4.14 ± 2.79 Yilmaz and 30 sectional women and Pre-vaccine group: 4.17 ± 1.87 (2022) unvaccinated pre- and Post-vaccine study group: 4.13 ± 1.94 with no history postvaccination p >0.05, between control group and of infertility among the post-vaccine group, and pre- and post- same vaccine group vaccinated people (self- controlled) 2,126 women BNT162b2 Cohort Unvaccinated Per cycle First dose for any vaccine, compared Wesselink et aged 21–45 mRNA-1273 fecundity with unvaccinated: al. (2022) vaccinated: 1,229 Ad26.COV2.S rate FR 1.09 (95% CI: 0.92–1.30) unvaccinated: 897 BNT162b2: FR 1.06 (95% CI: 0.92–1.22) mRNA-1273: FR 1.11 (95% CI: 0.95–1.29) Ad26.COV2.S: FR 1.06 (95% CI: 0.78–1.43) PREPUBLICATION COPY—Uncorrected Proofs

FEMALE INFERTILITY 251 TABLE 9-1 Continued Comparison Group/ Outcome Author N Vaccine Type Study Type Control Variable(s) Results Yang et al. 836 patients BNT162b2, Retrospective Self-controlled Mean Mean AMH (2023) prevaccination, mRNA-1273, cohort pre-vaccination AMH, Pre-vaccination: 3.83 ± 4.56 ng/mL 138 patients Ad26.COV2.S median Post-vaccination: 3.86 ± 4.31 ng/mL postvaccination AFC (95% CI: 0.491–0.566) Median AFC Pre-vaccination: 18 (IQR, 11–28) Post-vaccination: 20 (IQR, 12–29) Yildiz et al. 104 women: 74 mRNA Prospective case unvaccinated Mean Vaccinated group: (2023) vaccinated and (BNT162b2, control AMH Baseline: 3.37 ± 2.23 μg/L 30 unvaccinated mRNA-1273) levels After 6 months: 3.40 ± 2.26 μg/L p = .127 Unvaccinated group: Baseline: 3.17 ± 2.17 μg/L After 6 months: 3.32 ± 2.13 μg/L p = .166 NOTES: BNT162b2 refers to the COVID-19 vaccine manufactured by Pfizer-BioNTech under the name Comirnaty®. mRNA-1273 refers to the COVID-19 vaccine manufactured by Moderna under the name Spikevax®. Ad26.COV2.S refers to the COVID-19 vaccine manufactured by Janssen. AFC: antral follicle count; AMH: anti-Müllerian hormone; CI: confidence interval; FR: fecundability ratio; FSH: follicle-stimulating hormone; IQR: interquartile ratio; IU/L: international units per liter; LH: luteinizing hormone; mRNA: messenger ribonucleic acid; ng/mL: nanograms per mililiter; SD: standard deviation; SHBG: sex hormone binding globulin; μg/L: microgram per liter. SOURCES: Bosch et al., 2023; Karavani et al., 2022; Kolatorova et al., 2022; Mohr-Sasson et al., 2022; Soysal and Yılmaz, 2022; Wesselink et al., 2022; Yang et al., 2023; Yildiz et al., 2023. PREPUBLICATION COPY—Uncorrected Proofs

252 VACCINE EVIDENCE REVIEW Although all oocyte donors do not have proven fertility, they are screened for a number of infertility factors. Because oocyte donors are young, they do not have age-related infertility. Donor oocyte studies provide the strongest available evidence about the absence of a relationship between COVID-19 vaccines and female infertility. Oocyte donors are healthy females, usually 18–33 years old, who have undergone intensive medical, psychological, and genetic testing. Potential oocyte donors are screened for expected ovarian response to stimulation to exogeneous gonadotropin via AMH and/or AFC. They undergo ovarian stimulation therapy, to develop multiple oocytes, followed by oocyte retrieval. The oocytes are fertilized by sperm in the laboratory, and, after several days, the best resulting embryo(s) is (are) placed in the uterus of the recipient, whose uterine lining has been appropriately prepared. Studies of in vitro fertilization provide an opportunity to study measurable outcomes in specific steps of the reproductive process including markers of ovarian reserve (AMH, AFC, oocyte count), fertilization, embryo development, and embryo implantation. Bosch et al. (2023) conducted a self-controlled study on a number of factors related to fertility pre- and postvaccination with a messenger ribonucleic acid (mRNA) vaccine (BNT162b2, 1 mRNA-1273 2), among 115 oocyte donors serving as their own controls. More oocytes were retrieved postvaccination (16.62 ± 7.1, 95% CI: 15–18) versus prevaccination, (15.38 ± 7.0, 95% CI: 14–17) ,with no difference in the mean fertilization rate comparing pre- to postvaccination (82.69 percent vs. 78.84 percent, respectively), or high-quality embryos (2.29 vs. 2.32, respectively) (Bosch et al., 2023). Although the sample was small, the findings support the absence of a causal relationship between mRNA vaccines and female infertility. In a study of women undergoing elective oocyte cryopreservation, Karavani et al. (2022) 224 women aged 30–39 or older from before (January 2019 to February 2020) or during (December 2020 to January 2022) the pandemic who were unvaccinated with those vaccinated with BNT162b2. They found that the vaccinated group had comparable mean numbers of retrieved and mature oocytes compared with the two unvaccinated groups (12.6 ± 8.0 versus 13.0 ± 8.2 and 12.5 ± 7.4 retrieved and 10.1 ± 6.9 versus 9.5 ± 6.4 and 10.1 ± 6.3 mature oocytes, respectively; not significant for both) (Karavani et al., 2022). They included women who had been screened to identify and exclude pre-existing infertility factors. To assess whether COVID-19 vaccine had an effect on the levels of AMH, Mohr-Sasson et al. (2022) conducted a self-controlled study among 129 reproductive-age women (18–42) who were evaluated for infertility before vaccination with BNT162b2. They found no difference between mean AMH levels (µg/L) pre- and postvaccination (5.3 ± 4.2 versus 5.2 ± 4.5, respectively). Yildiz et al. (2023) conducted a prospective case-control study of 104 women (74 vaccinated with an mRNA vaccine, and 30 unvaccinated) without known infertility who presented for routine follow-up. Their mean AMH levels (μg/L) were assessed as an indirect measure of ovarian reserve before two doses of mRNA vaccines, with no difference pre- and postvaccination (vaccinated group baseline versus 6 months postvaccination: 3.37 ± 2.23 versus 3.40 ± 2.26, unvaccinated group baseline versus 6 months post vaccination: 3.17 ± 2.17 versus 3.32 ± 2.13). One retrospective cohort study evaluated the impact of mRNA vaccines (BNT162b2 and mRNA-1273) and Ad26.COV2.S 3 on ovarian function, measured by mean AMH (ng/mL), and 1 Refers to the COVID-19 vaccine manufactured by Pfizer-BioNTech under the name Comirnaty®. 2 The COVID-19 vaccine manufactured by Moderna under the name Spikevax®. 3 Refers to the COVID-19 vaccine manufactured by Janssen. PREPUBLICATION COPY—Uncorrected Proofs

FEMALE INFERTILITY 253 median AFC (Yang et al., 2023). Results were aggregated. Baseline AMH levels were 3.83 ± 4.56 pre-vaccination compared to 3.86 ± 4.31 post vaccination (95% CI: 0.491–0.566), and median AFC were 18 (IQR, 11–28) pre-vaccination compared to 20 (IQR, 12–29) post- vaccination. The investigators found no difference in ovarian function pre- and postvaccination; however, this study was carried out among women who may have had pre-existing infertility (Yang et al., 2023). In a self-controlled study of women without known infertility, no difference appeared in ovarian function as measured by luteinizing hormone (LH), follicle-stimulating hormone (FSH), sex hormone binding globulin (SHBG), AMH, and antral follicle count before and after the third mRNA vaccine (Kolatorova et al., 2022). Soysal and Yılmaz (2022) also evaluated the effect of the BNT162b2 vaccine on ovarian reserve by comparing AMH levels pre- and post-COVID-19 vaccination in 30 young women 60– 90 days after vaccination and comparing levels between vaccinated and unvaccinated women. The study excluded women with a history of infertility. The 30 women showed no difference in the mean AMH before and after vaccination (4.17 vs. 4.13; p = 0.785). The authors also found no difference in the mean AMH comparing vaccinated with unvaccinated women (4.13 vs. 4.14; p = 1.0) (Soysal and Yılmaz, 2022). A cohort study of 2,126 women found no decreased fecundability in either partner after BNT162b2 (fecundity rate (FR) 1.06, 95% CI: 0.92–1.22), mRNA-1273 (FR 1.11, 95% CI: 0.95–1.29), or Ad26.COV2.S (FR 1.06, 95% CI: 0.78–1.43) (Wesselink et al., 2022); it was one of very few studies to include Ad26.COV2.S. The study was limited by self-report of both exposure and outcomes. The authors also noted that approximately 11 percent of the participants had a prior history of female infertility (Wesselink et al., 2022). None of the studies reported an adverse effect on fertility after vaccination. Most studies that examined whether COVID-19 vaccines affect the treatment outcomes of female infertility found no association. These studies have been summarized in few systematic reviews. Although they were not the focus of this review, they provided reassurance and context that COVID-19 vaccines do not affect fertility. All systematic reviews focused on whether COVID-19 vaccines affected female infertility (Chamani et al., 2022; Huang et al., 2023; Zaçe et al., 2022; Zhang et al., 2023). None of these studies reported that COVID-19 vaccines negatively affected IVF treatment outcomes. FROM EVIDENCE TO CONCLUSIONS The studies reviewed reported no effect of COVID-19 vaccines on fertility. The donor oocyte studies provide the strongest clinical evidence, although the sample sizes were small (Bosch et al., 2023; Karavani et al., 2022). The lack of an adverse impact on ovarian function further suggests no effect on fertility. This conclusion was further supported by animal and human data that disprove a hypothesized mechanism (Lu-Culligan et al., 2022; Prasad et al., 2021). Conclusion 9-1: The evidence favors rejection of a causal relationship between the BNT162b2 vaccine and female infertility. Conclusion 9-2: The evidence favors rejection of a causal relationship between the mRNA-1273 vaccine and female infertility. PREPUBLICATION COPY—Uncorrected Proofs

254 VACCINE EVIDENCE REVIEW Very few studies examined Ad26.COV2.S and female infertility; the only epidemiological study that did so did not find an association. The study was limited by the inclusion of people with known infertility and because measures of infertility and exposure to vaccines were both self-reported (Wesselink et al., 2022). No studies examined NVX-CoV2373 4 and female infertility. Conclusion 9-3: The evidence is inadequate to accept or reject a causal relationship between the Ad26.COV2.S vaccine and female infertility. Conclusion 9-4: The evidence is inadequate to accept or reject a causal relationship between the NVX-CoV2373 vaccine and female infertility. 4 The COVID-19 vaccine manufactured by Novavax. PREPUBLICATION COPY—Uncorrected Proofs

FEMALE INFERTILITY 255 REFERENCES ACOG (American College of Obstetricians and Gynecologists). 2019. Committee opinion: infertility workup for the women’s health specialist. Paper read at Committee on Gynecologic Practice, American Society for Reproductive Medicine, May 23, 2019. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/06/infertility- workup-for-the-womens-health-specialist. Bosch, A., S. Albero, J. C. Castillo, J. Ten, J. Guerrero, J. A. Ortiz, A. Bernabeu, and R. Bernabeu. 2023. Does mRNA COVID-19 vaccination in oocyte donors impact ovarian stimulation parameters or IVF outcomes for recipients? Reproductive Biomedicine Online 46(4):697–704. https://doi.org/10.1016/j.rbmo.2023.01.002. CDC (Centers for Disease Control and Prevention). 2023. Infertility. https://www.cdc.gov/reproductivehealth/infertility/index.htm (accessed December 18, 2023). Chamani, I. J., L. McKenzie, F. Licciardi, and D. H. McCulloh. 2022. COVID-19 vaccination and assisted reproduction outcomes: A literature review and meta-analysis. Fertility and Sterility 118(4):e82. https://doi.org/10.1016/j.fertnstert.2022.08.249. Chen, F., S. Zhu, Z. Dai, L. Hao, C. Luan, Q. Guo, C. Meng, and Y. Zhang. 2021. Effects of COVID-19 and mRNA vaccines on human fertility. Human Reproduction 37(1):5–13. https://doi.org/10.1093/humrep/deab238. FDA (Food and Drug Administration). 2021. Emergency use authorization (EUA) amendment for an unapproved product review memorandum. Food and Drug Administration. https://www.fda.gov/media/153439/download (accessed May 3, 2023). FDA. 2023a. BLA clinical review memorandum - COMIRNATY. Food and Drug Administration. https://www.fda.gov/media/172333/download?attachment (accessed December 5, 2023). FDA. 2023b. BLA clinical review memorandum - SPIKEVAX. Food and Drug Administration. https://www.fda.gov/media/172357/download?attachment (accessed December 5, 2023). FDA. 2023c. Emergency use authorization (EUA) for an unapproved product review memorandum. Food and Drug Administration. https://www.fda.gov/media/168233/download?attachment (accessed December 5, 2023). Gallagher, B. 2020. Response to nCoV-2019 against backdrop of endogenous retroviruses. https://virological.org/t/response-to-ncov2019-against-backdrop-of-endogenous-retroviruses/396 (accessed December 12, 2023). Huang, J., Z. Fang, Y. Liu, C. Xing, L. Huang, J. Mao, H. Chen, Z. Huang, L. Xia, L. Tang, Z. Zhang, B. Liu, H. Huang, L. Tian, X. Ai, and Q. Wu. 2023. Effect of female coronavirus disease 2019 vaccination on assisted reproductive outcomes: A systematic review and meta-analysis. Fertility and Sterility 119(5):772–783. https://doi.org/10.1016/j.fertnstert.2023.01.024. Jung, A. M., S. A. Missmer, D. W. Cramer, E. S. Ginsburg, K. L. Terry, A. F. Vitonis, and L. V. Farland. 2021. Self-reported infertility diagnoses and treatment history approximately 20 years after fertility treatment initiation. Fertility Research and Practice 7:7. https://doi.org/10.1186/s40738- 021-00099-2. Karavani, G., H. H. Chill, A. Dick, C. Meirman, E. Gutman-Ido, S. Herzberg, A. Ben-Meir, and T. Imbar. 2022. Pfizer SARS-CoV-2 BNT162b2 mRNA vaccination (BNT162b2) has no adverse effect on elective oocyte cryopreservation outcomes. Reproductive Biomedicine Online 45(5):987–994. https://doi.org/10.1016/j.rbmo.2022.06.001. Kolatorova, L., K. Adamcova, J. Vitku, L. Horackova, M. Simkova, M. Hornova, M. Vosatkova, V. Vaisova, A. Parizek, and M. Duskova. 2022. COVID-19, vaccination, and female fertility in the Czech Republic. International Journal of Molecular Sciences 23(18). https://doi.org/10.3390/ijms231810909. PREPUBLICATION COPY—Uncorrected Proofs

256 VACCINE EVIDENCE REVIEW Lavillette, D., M. Marin, A. Ruggieri, F. Mallet, F. L. Cosset, and D. Kabat. 2002. The envelope glycoprotein of human endogenous retrovirus type W uses a divergent family of amino acid transporters/cell surface receptors. Journal of Virology 76(13):6442–6452. https://doi.org/10.1128/jvi.76.13.6442-6452.2002. Lu-Culligan, A., A. Tabachnikova, E. Pérez-Then, M. Tokuyama, H. J. Lee, C. Lucas, V. Silva Monteiro, M. Miric, V. Brache, L. Cochon, M. C. Muenker, S. Mohanty, J. Huang, I. Kang, C. Dela Cruz, S. Farhadian, M. Campbell, I. Yildirim, A. C. Shaw, S. Ma, S. H. Vermund, A. I. Ko, S. B. Omer, and A. Iwasaki. 2022. No evidence of fetal defects or anti-syncytin-1 antibody induction following COVID-19 mRNA vaccination. PLoS Biology 20(5):e3001506. https://doi.org/10.1371/journal.pbio.3001506. Mohr-Sasson, A., J. Haas, S. Abuhasira, M. Sivan, H. Doitch Amdurski, T. Dadon, S. Blumenfeld, E. Derazne, R. Hemi, R. Orvieto, A. Afek, and J. Rabinovici. 2022. The effect of COVID-19 mRNA vaccine on serum anti-Müllerian hormone levels. Human Reproduction 37(3):534–541. https://doi.org/10.1093/humrep/deab282. Prasad, M., J. L. Lin, Y. Gu, R. Gupta, P. Macary, and H. Schwarz. 2021. No crossreactivity of anti- SARS-CoV-2 spike protein antibodies with syncytin-1. Cellular & Molecular Immunology 18(11):2566–2568. https://doi.org/10.1038/s41423-021-00773-x. Sharma, R., K. R. Biedenharn, J. M. Fedor, and A. Agarwal. 2013. Lifestyle factors and reproductive health: Taking control of your fertility. Reproductive Biology and Endocrinology 11:66. https://doi.org/10.1186/1477-7827-11-66. Soysal, Ç., and E. Yılmaz. 2022. The effect of COVID-19 vaccine on ovarian reserve. Saudi Medical Journal 43(5):486–490. https://doi.org/10.15537/smj.2022.43.5.20220007. Wesselink, A. K., E. E. Hatch, K. J. Rothman, T. R. Wang, M. D. Willis, J. Yland, H. M. Crowe, R. J. Geller, S. K. Willis, R. B. Perkins, A. K. Regan, J. Levinson, E. M. Mikkelsen, and L. A. Wise. 2022. A prospective cohort study of COVID-19 vaccination, SARS-CoV-2 infection, and fertility. American Journal of Epidemiology 191(8):1383–1395. https://doi.org/10.1093/aje/kwac011. Yang, L., S. Neal, T. Lee, A. Chou, A. K. Schutt, and W. Gibbons. 2023. Comparison of female ovarian reserve before vs. after COVID-19 vaccination. JAMA Network Open 6(6):e2318804. https://doi.org/10.1001/jamanetworkopen.2023.18804. Yildiz, E., B. Timur, G. Guney, and H. Timur. 2023. Does the SARS-CoV-2 mRNA vaccine damage the ovarian reserve? Medicine 102(20):e33824. https://doi.org/10.1097/md.0000000000033824. Zaçe, D., E. La Gatta, L. Petrella, and M. L. Di Pietro. 2022. The impact of COVID-19 vaccines on fertility—a systematic review and meta-analysis. Vaccine 40(42):6023–6034. https://doi.org/10.1016/j.vaccine.2022.09.019. Zhang, L., X. Sun, R. Wang, and F. Ma. 2023. Effect of COVID-19 vaccination on the outcome of in vitro fertilization: A systematic review and meta-analysis. Frontiers in Public Health 11. https://doi.org/10.3389/fpubh.2023.1151999. PREPUBLICATION COPY—Uncorrected Proofs

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 Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration
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Vaccines are a public health success story, as they have prevented or lessened the effects of many infectious diseases. To address concerns around potential vaccine injuries, the Health Resources and Services Administration (HRSA) administers the Vaccine Injury Compensation Program (VICP) and the Countermeasures Injury Compensation Program (CICP), which provide compensation to those who assert that they were injured by routine vaccines or medical countermeasures, respectively. The National Academies of Sciences, Engineering, and Medicine have contributed to the scientific basis for VICP compensation decisions for decades.

HRSA asked the National Academies to convene an expert committee to review the epidemiological, clinical, and biological evidence about the relationship between COVID-19 vaccines and specific adverse events, as well as intramuscular administration of vaccines and shoulder injuries. This report outlines the committee findings and conclusions.

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