Welcome to your February issue of Connections, The American Fertility Association’s monthly e-newsletter. In this issue, you’ll find:

1. A Message from the Executive Director
2. Shared Egg Donation
3. Protecting our Reproductive Health and Fertility - Latest Findings on Environment Impacts
4. Adoption Option: Making the Choice between Domestic Agency and Private Placement Adoption
5. Support Services
   1. Free Teleconference Coaching Sessions
   2. West Coast Programs
6. Stay Connected

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Please contact Corey Whelan, Director of Development at 718-853-1411 or Corey@theafa.org

A Message from the Executive Director

Pamela Madsen

Dear Friend of The AFA, I know I’m a little tardy, but I’m finally making good on my “annual” New Year’s resolution to limit my pants size. This time, I really mean it. Every day I get on my elliptical glider and click on the tube to keep myself conscious. So the other morning I hop on the machine, flip on HBO On Demand and Rosie O’Donnell comes into focus. It’s her documentary about her first gay and lesbian family cruise. I think, “This’ll be fun.” Next thing I know I’m huffing, puffing and sobbing. I’m knocked out by the emotional wallop the film packs. As the portrait of these men and women in their pursuit of connection and family – basic human rights most of us take for granted –unfolds, the tears come faster and harder. Rosie captures couples marrying on board, others traveling with the multiple siblings they adopted out of foster care. Some talk about their aching desire for biological offspring, some describe their difficult negotiations with extended families. Teenagers reveal their experiences growing up with gay fathers and lesbian mothers. Everyone talks about how on this trip they feel “normal,” many for the first time; how safe it is to be who they are as couples, with their children and families. The film is searing in its honesty and moving in its compassionate portrayal of the universal of the quest for quest for love, community and acceptance. When these cruise mates walk off the ship—a floating Nirvana-- for the last time, their pain is palpable. It is a poignant moment because you know they’re leaving a haven to once more armor up to deal with a world full of judgment and adversity. I wanted to write to Rosie and her partner, Kelly, to cheer them on, to tell them what a wonderful thing they’re doing. I knew they’d never read my letter—who am I. So instead I’m urging everyone with HBO On Demand, a DVD or video player, to see the film. Once you see it, you’ll know why I’m so proud that The AFA is the first mainstream organization for families actively supporting the LGBT community’s rights to family. We’ve developed the first (RESOURE OR REFERRAL?) list for LGBT family building and published the first magazine dedicated to their legal, assisted reproduction, adoption and emotional issues. We’re working on fact sheets and other educational and outreach materials, too. There’s a lot of work to be done. Not just on LGBT matters but in all the areas that are at The AFA’s core. Take adoption, for instance. On February 20th at 8 pm EST, we’re hosting an important online chat about the radically changing face of Chinese adoption. Pamela Thomas of Homeland Adoption Services, which specializes in Chinese adoption, will help deconstruct the Chinese government’s stringent new rules defining who is a suitable foreign parent. I mean, the new guidelines cover everything from weight and psychological profile to lifestyle and income levels. We’ll look behind the policy shift to find out how China is attempting to mitigate a growing girl shortage, a legacy of female infanticide, abandonment and adoption. This subject is so compelling that no one will want to miss this. But anyone who’s considering this particular—whether you’re a single woman, an older couple, gay or lesbian -- or adoption option should jack in. Check our schedule for other chats in our Online Educational Series. This month they’ll cover endometriosis, acupuncture and improvement in IVF success rates. In this installment of Connections, you’ll find an update on the “womb transplant” controversy. There’s an overview of the pressing environmental concerns that affect reproductive health, according to a world class gathering of scientists, policy makers and advocates at the recent conference of the Collaborative on Health and the Environment. And one last thing…I want update you on a couple of significant changes within The AFA. The breadth and depth of talent that our staff and consultants bring to this organization gives it its unique character, flexibility and strength. Because we value what these smart, savvy men and women bring to us, The AFA is committed to accommodating their changing lives and imperatives. That, in some measure, accounts for the unusual professional longevity of the people who work with us. After a long, sometimes wild and always wonderful ride, Deputy Executive Director Lisa Rosenthal, an AFA leader since its founding, will move to a more part-time role in order to spend more time with her family. We’re lucky to hold on to her incredible institutional memory, knowledge of The AFA’s core fields, her unparalleled skills and generosity as she becomes senior development associate. At the same time, we are delighted that she’ll be handing over the reins of the deputy’s job to Anne Adams. As an editorial, media and policy consultant for The AFA for more than six years, Anne (What’s the style here? First names? Ms.?) brings the knowledge and expertise we need to move forward with our expansive strategic plans. With skills honed as a reporter and columnist for major publications (USA Today, The New York Daily News, The New York Post, New York Magazine and The New York Times among them), and as president of her own ditorial/communications consulting company, Anne’s unique brand of leadership and perspective is our perfect match. Well, that’s it for now. Stay warm and happy. Pamela Madsen Executive Director

Shared Egg Donation

Michael Levy MD

Robert Stillman MD

By Michael Levy MD & Robert Stillman MD
Shady Grove Fertility Center
Washington D.C National Capital Area

INTRODUCTION
A very common cause of infertility is decreased ovarian function. This is usually, but not exclusively, seen in women over the age of 39. In this situation, the most effective treatment option is egg donation. The actual egg donation cycle involves synchronization of the donor’s and recipient’s cycles, retrieval of the eggs from the donor, fertilization with the recipient’s partners sperm in vitro and then transfer of the resulting embryo or embryos into the recipient’s uterus. In this way clinicians can optimize both egg quality and independently prepare the uterus to be most receptive.

OPTIONS FOR RECIPIENTS
Egg donation is a logistical and financially challenging undertaking. The medical aspects of the treatment cycle are relatively easy. The two greater challenges are finding a suitable egg donor and the cost of all aspects of the entire process. The costs include the donor fees, donor and recipient screening and treatment and the cost of medication for the donor’s stimulation cycle.

AVAILABILITY OF EGG DONORS
Egg donors need to be medically and psychologically healthy, are usually between the ages of 21 and 33 years, have good family medical histories and have favorable results of a wide battery of hormonal, genetic and infectious disease testing. There is a relatively small group of women who qualify to be egg donors and who are prepared to endure the intense medical treatment required during an egg donation cycle. The level of testing now required by the FDA and the complexity of treatment has significantly increased the medical cost of screening and the fees paid to egg donors.

SHARED EGG DONATION

In most egg donation cycles, a single egg donor is selected by a single recipient and all of the eggs obtained from that donor are fertilized with the sperm of the recipient’s partner (1:1). Excellent pregnancy rates are obtained, with very good experienced programs achieving delivery rates of about 50% per embryo transfer.
A recent published study from Argentina demonstrated very good success rates when sharing eggs between 3 recipients. (see table 1)

Table 1: Outcome of Argentinian egg sharing program ( 1)

When analyzing almost 1,000 donor egg cycles we noted that the average number of eggs retrieved in a single egg donation cycle is 18, with a rather wide range of 6-40 The pregnancy rates remain excellent even if only 5-8 eggs are available. Even a minimum of 4 mature eggs per recipient can produced good success rates.

Some years ago we began doing a number of shared egg donor cycles and found the delivery rates in the 90% of our cycles using a single recipient (1:1) was very similar to the 10% of our cycles where the eggs were shared between 2 recipients (1:2) (59% versus 55%) A number of centers in the US also provide the option of sharing the eggs between 2 recipients.

Experience suggests that in 60 % of donor’s egg retrievals there will be enough eggs for 3 recipients; and in 80% of cycles there would be enough eggs for 2 recipients to share. Since most cycles will have enough eggs to share, the idea of expanding the use of shared donors between not only 2 but to 3 recipients was raised and now can be performed by a number of IVF Centers.

Sharing eggs with 1 or 2 other recipients provides an excellent solution to two of the major problems of egg donation, i.e. donor availability and the high cost of treatment. There are, however, some clinical disadvantages to sharing of donor eggs.

CLINICAL DISADVANTAGES OF THE SHARED DONOR PROGRAM

In a shared donor cycle each recipient will receive one half (1:2) or one third (1:3) of the eggs they would receive if they did not share the eggs with any other recipient (1:1). The decreased number of eggs available can result in a higher rate of cycle cancellation, lower pregnancy rates and lower chance of having extra embryos to freeze (as can be seen in Table 2).

Table 2

Comparison of Traditional (1:1) and Shared Donor Programs (1:2 and 1:3)

The delivery rate for the 1:1 program represents actual data for more than 1200 cycles performed over the last five years.
** The outcomes listed for the 1:2 and 1:3 programs are our best current estimate
* % of patients having embryos for cryopreservation

In the 1:3 program 60% of retrievals will produce enough eggs for all the recipients, 80% enough for 2 recipients by canceling the 3rd recipient and splitting the eggs between the remaining 2 and 100% for only 1 recipient. It is important to fairly manage which recipients are given 1st, 2nd and 3rd priority so that if the 2nd and/or 3rd recipient does not receive any eggs, she can repeat another cycle quickly and with a higher priority (still within the shared recipient program) and have a lower chance of cancellation the next time around.

The delivery rates may be lower with fewer eggs, they remain very good. (Tables 1 and 2) In 50% of cycles in the 1:1 program we have enough embryos to perform a transfer in the fresh cycle and freeze extra embryos. If the fresh cycle is unsuccessful then a frozen thaw cycle can be attempted without having to repeat an entire fresh donor cycle. If both the fresh and subsequent frozen cycles are successful the resulting babies will be full biologic siblings. While many recipients hope for this very favorable outcome it is relatively rare. In the last 5 years only 70 out of 720 (10%) of all donor egg cycle deliveries were from frozen cycles. About 35 of these deliveries were of full biologic siblings

FINANCIAL ADVANTAGES OF SHARED EGG DONATION

When the eggs from a donor are shared between 2 or 3 recipients, the major costs of treatment can also be shared. As can be seen in table 2 this significantly reduces the cost of treatment when treatment costs are financed by either fee-for-service or through a shared risk financial program.

Since 1992 the shared risk option has protected the patient in IVF and or donor egg cycles from the financial downside by refunding 100% of the fee if treatment does not result in the delivery of a baby. For recipients with normal uterine function we have introduced an expanded shared risk program to parallel our shared egg donor program. (To re-emphasize the definitions of the terms we are using: ‘shared risk’ and ‘expanded shared risk’ are options for financing IVF or donor egg therapy. whereas ‘shared egg donor’ is the clinical therapy option for sharing one donors eggs among 2 or 3 recipients). The expanded shared risk program includes not only the costs of medical treatment and cryopreservation, but also all the costs of screening the donor, all the donor fees, and the donors medication costs. Recipients can attempt up to 6 ‘fresh’ cycles and if they do not deliver a baby - or voluntarily drop out at any time - they receive a 100% refund of all of he payment.. In the 1:3 shared donor/expanded shared risk program this means that 6 cycles can be attempted (with a full refund if unsuccessful) for approximately the cost of a single fee for service / no refund 1:1 cycle!

CONCLUSION

There are now innovative new options available within the clinical therapy for donor egg and also for the means of financing this therapy. In choosing between receiving all the eggs from a single donor or sharing them with 1 or 2 other recipients, couples need to carefully consider the financial advantages versus the potential clinical disadvantages. There are some recipients for whom cost is not as much of an issue and the benefits of having all the eggs and the resultant higher pregnancy rates, lower cancellation rates and greater likelihood of having extra embryos to freeze is the best option.

For many recipients the ability to substantially decrease the cost of treatment and, particularly with the shared risk option, afford multiple attempts (with a refund if they are unsuccessful) makes the shared donor program more attractive.

It is expected that, with persistence, the ultimate success rate in the 1:1, 1:2 and 1:3 programs will be very similar. Those in the shared donor egg programs may need to have more emotional and physical stamina to tolerate a higher cancellation rate and the possible need for more attempts.

The shared donor (especially in conjunction with the expanded shared risk program) offers an important new cost effective options for couples pursuing donor egg to consider Many couples who may not have been able to consider therapy because of costs may now be able to pursue donor egg as a means to complete their family.

REFERENCES
1. Glujovsky D, Fiszbajn G et al. Practice of sharing donated oocytes among several recipients. Fertil Steril 2006;86:1786-87.

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Protecting our Reproductive Health and Fertility - Latest Findings on Environment Impacts

Michael Lerner, PhD, President, Commonweal Institute; Co-Founder, Collaborative on Health and the Environment, Bolinas, CA

Audience at Environmental conference

In the US today, there is increasing concern about the potential impacts of environmental contaminants on the reproductive health and fertility of women, men and families. In particular, there are worrisome health trends amongst the US public. For example:

In women

• At least 12% of the reproductive age population reports difficulty in conceiving and maintaining pregnancy. This appears to be a rising trend, most markedly in women under 25 years old.
• Other fertility-related diseases, like endometriosis and polycystic ovarian syndrome (PCOS), are diagnosed more frequently now, which may result from an increase in prevalence, better detection, or both.

In men

• Hypospadias (deformities of the penis in infants), cryptorchidism (undescended testicles in babies) and testicular cancer are increasing while sperm count and testosterone levels are declining in certain areas and populations. Animal studies find prenatal exposures to phthalates associated with this suite of male reproductive health problems.

Data from US Government tests give insight.
Chemicals like phthalates, bisphenol A, perfluorinated compounds, and cadmium are found in numerous consumer products such as baby bottles, children's toys, plastic food containers, cosmetics, dental fillings and wrinkle-free pants. Data from the US Center for Disease Control shows that exposures to chemicals are common and almost every person has detectable contaminants in their bodies- some even at levels near or above those shown in scientific studies to cause adverse effects.

There is a link between Environmental Contaminants and Reproductive Health
A recent reproductive health conference brought together 500 scientists, researchers, clinicians, health-effect groups, and community activists to discuss the current science and how to move forward to protect the health of our families and the future health of our nation. On Jan 28-30, 2007 a Summit on Environmental Challenges to Reproductive Health and Fertility, organized by the UCSF Department of Obstetrics, Gynecology & Reproductive Sciences and the Collaborative on Health and the Environment, was held at the University of California, San Francisco.

In the US, we have made great strides to improve our understanding of the link between environmental exposures and health, such as air pollution on cardiovascular health, and lead and mercury on our neurological development. One of the goals of this summit was to start making those same gains in revealing the impacts of key pollutants on reproductive health. The people who participated- from researchers to clinicians to community advocates- seek to better understand how recent science relates to clinical care, to improve communication between clinicians, patients and the public, and to ultimately improve the policies that can protect us from exposure to environmental contaminants.

Startling Findings from Research Presented at Summit
Exposure to chemical contaminants that occur during pregnancy or during infancy are particularly powerful and are referred to as “windows of vulnerability”.

• During this time, exposures to bisphenol A can cause permanent changes and increased risks of reproductive health problems later in life (infertility, miscarriage, breast cancer, prostate cancer).
• Prenatal exposure to phthalates has been linked to reproductive effects in males like reduced testosterone, reduced sperm count and fertility.

Cadmium is a metal which is found in cigarette smoke and in the air and thus we are exposed to it often.

• It is considered an endocrine disrupting chemical which can interfere with our hormones and where and how they act in our bodies- pathways important to fertility and reproduction.
• Recent research shows that cadmium in women is related to gynecological disorders, such as endometriosis.

PFCs (perfluorinated chemicals) are common in consumer products and have been found in almost everyone in the US.

• Prenatal exposures to PFCs can cause irreversible damage in offspring.

Health effects are starting to show up in the children of exposed mothers, fathers and grandparents.

• Some exposures can make permanent changes that are being passed from one generation to the next.

Studies in animals and humans show the impacts of many of these environmental contaminants on reproductive health - but we are missing data for most chemicals and understanding the whole picture is difficult because studies evaluate chemicals one at a time, and we are exposed to multiple chemicals on a daily basis.

Signs in Nature that things are going awry:
The impact of environmental contaminants on reproductive health and fertility is not only seen in scientific data. A wide range of wildlife populations have been shown to be adversely affected by exposure to endocrine-disrupting contaminants.

• Impacts among birds, fish, shellfish, mammals and reptiles include decreased fertility and increased reproductive tract abnormalities; feminization and demasculinization in the males; and masculinization and defeminization in the females.

There have been some recent Governmental and Policy Changes to protect the public.
Under public pressure, some governments and manufacturers are taking action to protect people from the potential dangers lurking in household products. Recently, San Francisco, CA passed a ban on the production and sale of toys containing certain levels of phthalates and any level of bisphenol A, a chemical compound found in a variety of products such as food containers and dental fillings. Additionally, the European Union recently passed landmark legislation which will regulate and restrict 30,000 chemicals; over 1,100 of these are found in personal care products. In addition, the European Union has banned phthalates from toys.

This is promising progress, but there is much more to be done. It’s true that our society is increasingly chemical-dependant and exposure to some toxicants is virtually unavoidable. Regardless, there should still be more information about and options for safer alternatives. Though consumers can take precautions, the onus should really be on manufacturers and governmental regulatory agencies to protect the public. It is surprising that the US does not regulate chemicals before they are allowed on the market, as we do pharmaceuticals or pesticides. Without this information consumers can’t take action or make informed decisions.

What can be done next to protect the future health of women, men and families?
At the recent summit in San Francisco, participants identified top priorities for protecting our reproductive health: enhanced research on environmental impacts, better testing and information on chemicals in products, and policies for reducing exposures to chemicals.
The Summit organizers will be using the energy and information from the discussions to create a comprehensive plan for environmental reproductive health through research, education, health care and policy.

In the US, we need more science to better understand how these environmental contaminants impact our reproductive health life course, including decreases in fertility, adverse pregnancy outcomes, fetal origins of adult reproductive disease, changes in puberty, and later in life reproductive diseases. As our knowledge expands, we can improve communication between clinicians, patients and the public. Likewise, science can be used to enhance policies that protect our reproductive health and the future health of our nation.

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Adoption Option: Making the Choice between Domestic Agency and Private Placement Adoption

Denise Seidelman

Nina E. Rumbold

WHY SOME PEOPLE CHOOSE PRIVATE PLACEMENT ADOPTION

• It tends to be less expensive (no agency fee is required)
• The process of becoming qualified as an adoptive parent can be more quickly and easily accomplished
• Adoptive placements tend to occur more quickly because the adoptive parents have more control over the process of seeking out and identifying a potential adoptive child
• The adoptive parents, with the guidance of their attorney, have more control in directing the various aspects of the adoption process
• The adoptive parents look forward to the opportunity to have direct communication with the potential birth parents in the hope that this positive relationship will extend past the adoptive placement.

WHY SOME PEOPLE PURSUE AN AGENCY ADOPTION

• Once the agency qualification requirements have been completed the adoptive parents look forward to being able to emotionally distance themselves from the process until the time a child is actually identified
• The Adoptive Parents personal schedules do not afford them the opportunity to direct the adoptive process or receive calls from potential birth parents
• The adoptive parents are uncomfortable speaking directly with potential birth parents either because they feel they wouldn’t know what to say or because the process of receiving the phone calls would be too emotionally draining
• The adoptive parents feel that the agency’s expertise and its established policies and procedures will make the process more secure
• The adoptive parents do not have the confidence that they will successfully identify a potential adoptive child themselves

Practicing as Rumbold & Seidelman since 1996, Denise Seidelman and Nina E. Rumbold concentrate their practice almost exclusively in the areas of adoption and reproductive law. They are licensed to practice in both New York and New Jersey. Nina and Denise are experienced in all aspects of adoption law and have handled the full panoply of adoptions, including domestic private-placement adoptions, domestic agency adoptions (including adoptions of children in foster care), international agency adoption, and step-parent adoptions. They also focus their practice in the evolving field of reproductive law and have counseled Intended Parents, Egg, Sperm, Embryo Donors and Gestational Carriers in collaborative reproduction arrangements. They are both members of the American Academy of Adoption Attorneys and the American Society for Reproductive Medicine. In addition to their law practice, Nina and Denise are trained mediators and serve as mediators in the fields of Child Permanency and Parent Child Mediation.

Nina was admitted to the New York State Bar in 1979 and Denise was admitted in 1980. Both Nina and Denise started their legal careers working as criminal defense attorneys for the New York City Legal Aid Society, where they each tried numerous criminal cases to verdict and Nina also handled criminal appeals. Nina has two sons, ages 21 and 18 and a daughter aged 16. Denise has two sons, aged 21 and 17 and a daughter aged 18.

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Support Services

FREE TELECONFERENCE COACHING SESSIONS

Phone based tele-coaching groups provide a convenient way for you to take part in a supportive and educational group experience from the comfort of your home or work place. These groups meet for one hour via a phone bridgeline. A bridgeline allows all participants to hear and speak with each other via the telephone. No special phone is required. All groups are led by licensed mental health professionals with an expertise and often personal experience in infertility treatment and/or adoption.

TOPIC: New Year—New Ideas

It's a New Year; here's a chance to hear some new thoughts in coping with INFERTILITY. Join us for an opportunity to learn and share successful strategies in dealing with our spouses, families, friends, and co-workers during this challenging time. Together we will also exchange information and experiences on current medical procedures (IVF, PGD +) as well as alternative treatments (Acupuncture, Guided Imagery, Herbal remedies +)
Receiving feedback from group participants around the country will be helpful in understanding we're not alone while moving forward exploring viable options.

WHEN:	Wednesday, February 28th
TIME:	9:00 to 10:00 pm EST
FACILITATED BY:	Emily Laitmon, LCSW

For further information and to register, please e-mail laitmon@aol.com
or call 212 988 2054 or 914 633 4224

Emily Laitmon LCSW is a psychotherapist in NYC and Westchester. She is a facilitator for AFA support groups and mother of a daughter through IVF.

West Coast Programs

Four Seminars Offered

• EGG DONATION: WORKING WITH A THIRD PARTY
• CHOOSING SINGLE PARENTING
• CREATING A SUCCESSFUL SURROGATE ARRANGEMENT
• GAY AND LESBIAN PARENTING

The American Fertility Association is sponsoring separate discussion groups for patients considering alternative family building options. The emotional, medical and practical aspects of each of these arrangements will be explored, such that prospective parents can make an informed decision about whether these plans are the “right” choice for them.

Elaine R. Gordon, Ph.D. is a licensed clinical psychologist with a specialty in reproductive medicine. She has worked in the field for twenty years helping individuals and couples build families through non-traditional options. She is the author of “Mommy, Did I Grow in Your Tummy? Where some Babies Come From”.

Ellen Speyer, M.A., M.S., MFT. is a psychotherapist with twenty years with working with assisted reproduction, pregnancy loss, surrogacy, and adoption. She is a retired Chair of the Education Committee for the Mental Health Professional Group of the American Society for Reproductive Medicine.

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Online Education Session Schedule—February - March 2007