Welcome to your March 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. Womb Transplants: Do the Benefits outweigh the Risks?
3. The HPV Vaccine: Cost and Controversy
4. Adoption Option: You don't have to be “Traditional” to Adopt!
5. Support Services
   1. New York City Women's In-Person Mind/Body Support Group Forming Now
   2. West Coast Programs
6. Stay Connected

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A Message from the Executive Director

Pamela Madsen

Dear Friend of The AFA, There I was in my hotel room in Orlando getting ready for the inaugural session of one of the world’s preeminent conferences on women’s sexual health. I was looking forward to all the mind-blowing insights into what women want and need. The ingredients were all there: Disney World, the moist Florida heat and top-flight sex-perts from around the globe. Yeah, well. Wrong! Let’s just say the conference was so cerebral and academic, it was medicinal. Make no mistake, it’s beyond great that there’s serious scientific, medical and psychological research dedicated to sexual wellness. We desperately need to understand function and dysfunction, gender identification, physiology, the effects of pregnancy, motherhood and age. Sexuality, after all, is fundamental to us as a species and to our happiness as individuals. It’s whyThe AFA is expanding its mission to encompass sexual health, in all it’s aspects--from safe sex, to sexual wellness and it’s bearing on reproductive health, to the mind-body link and individual identity. But frankly, lecture after lecture managed to wring all the juice out of the subject. And then came Esther Perel. Perel, a licensed marriage and family therapist, held her audience spellbound with an unflinching, layperson-friendly analysis of the impact of parenthood on sexuality. (Check out her out at www.estherperel.com for a synopsis of her incredible book, “Mating in Captivity, Reconciling the Erotic & The Domestic.”) How did she put it? Oh right. Nesting, domesticity, familial intimacy and stability--all the things children need to feel safe --are libido assassins. Perel looked straight at us and said that what really excited us is danger. She insisted that our relentless pursuit of equality, togetherness and candor in our partner relationship kills passion. Passion, she observed, is “politically incorrect,” excitement thrives on “powerplays,” and the unexpected. It needs playfulness and enough emotional oxygen to let a warm ember burst into flame. Perel told the cautionary tale of one couple savvy enough to hire a babysitter so they could have an adults-only date. They returned all fired up to cap the night with a bit of triple-X rated foolery. But first she had to debrief the sitter. That was the death knell of desire. By the time she’d heard the litany of the baby’s BMs, bottles consumed and crying jags, she’d turned back into a mother instead of a playmate. Classic, snorted Perel. Instead of unleashing mommy, perhaps the husband should have had the conversation with the sitter, allowing the wife to keep building a head of steam with a scented hot bath. Anything sensual, sexual, maybe a bit naughty. The point is, whatever it takes to make room for the spark, we need to do it. Not extinguish it. It becomes even more urgent when couples are dealing with the rough hand of infertility, which has the nasty effect of reducing sex to its most functional and least romantic aspects. As pressed as they are for time and sometimes good will, couples have got to set aside time for each other and break some rules. Now I know this isn’t rocket science. A lot of it is common sense. But hearing Perel lay it out brought home how important, healing and strengthening the intimate connection of sex is, how it keeps us happy, calm and close. How it can help reinforce the most important relationship edifice in our lives – the one we inhabit with our partner. You know, it’s funny. Once we’re kid-focused, constructing that nest for our kids – the ones we’re planning for or those that are here, we lose sight of each other, of the things that brought a couple together in the first place. There’s no point in denying sex is part of it. If we’re going to survive trials like reproductive difficulties we’ve got to find ways to buttress each other as well as our own selves. One of The AFA’s goals is to raise awareness about the interconnection of sexual health and fertility preservation. That came up during the conference, too, but in a most unexpected way. A Dutch physician was discussing his groundbreaking work that with transgender adolescents transitioned them nonsurgically at age 16. His findings are encouraging: helping them to look more like their chosen like their chosen sex at a younger age make their lives measurably better. I got up and asked if they counseled these kids on freezing eggs and sperm. He said that these kids weren’t thinking about that and so neither was he. I was so disappointed. Precisely because kids can’t anticipate a future desire for family, someone needs to be looking out for their options, helping them and their parents understand the importance of preserving the possibility of having a family later on. It brought be back full circle to how much work we have ahead of us. And we’re moving right along. In this issue of “Connections” we’ve got articles on two hot topics that are stirring hope and controversy. In the first, Dian Harrison, CEO of Planned Parenthood Golden Gate in San Francisco, takes on HPV and the Great Vaccine Debate. The second, by lawyer-bioethicist and AFA board member Nanette Elster, looks at womb transplants, the promise, problems and perils. Liz Schuman dispels some of the big myths around adoption that nag a non-traditional signles or couples in a lively Q&A with Carolyn Berger, The AFA’s resident adoption expert and veteran board member. Jump in. There’s all sorts of good stuff waiting for you. And there’ll be more next month. See you then. Warmly Pamela Madsen Executive Director

Womb Transplants: Do the Benefits outweigh the Risks?

Nanette Elster, JD, MPH

Nanette Elster, JD, MPH
Spence & Elster, PC
Chicago and Lincolnshire, IL

It seems as if nearly every day there is a new development in human reproduction, many greeted at first with trepidation but eventually accepted, if not embraced. In vitro fertilization is a case in point. At first IVF conjured images reminiscent of Huxley’s Brave New World, but we have come quite far since 1978, with Louise Brown now married and a mother herself not to mention over 35,000 births in 2004 in the US as a result of IVF. The latest controversial development in human reproduction is transplanting of a uterus. Will this come to be the next widely accepted procedure or are the risks still too great?

A uterine transplant may enable women without a uterus to carry and give birth to a child, but do the benefits outweigh the risks not only to the woman but to the child and society as well? For many women who have either been born without a uterus or lost a uterus due to injury or disease, the idea of being able to gestate a child may be a dream come true, but this ray of hope is not without some serious risks not to mention ethical dilemmas. Womb transplants raise a host of ethical and practical concerns including concerns about allocation of scarce resources, harm to the woman, and harm to the fetus and/or resultant child.

In a recent proposal by a New York City physician, the first uterine transplant in the United States may be on the horizon. The uterus to be transplanted would be donated with consent from a deceased woman who has previously agreed to be an organ donor. The recipient would then undergo in vitro fertilization to create and freeze embryos to later be transferred to the transplanted uterus. The transplant would then occur. The recipient would be placed on anti-rejection drugs and once she has had time to heal, the previously stored embryos will be transferred to her. The pregnancy would be treated as a “high-risk” pregnancy. The child would be delivered by cesarean section at which time the uterus would be removed so that the anti-rejection drugs could be stopped. While one transplant has occurred in humans in 2002, the uterus failed after three months -- before a pregnancy had been achieved and sustained. To date, no pregnancies have been followed in primates to even gauge how a pregnancy might proceed. This is one of the concerns of the procedure – it has not been attempted non-human primates before being attempted with a woman.

Another concern with the procedure is that unlike most other transplants, a uterine transplant is not life saving, yet it entails the same risks of anti-rejection and the same, if not higher costs than a kidney transplant or a heart transplant, running an estimated $500,000 per attempt. Given the experimental nature of the procedure, insurance is not likely to foot the bill and few will be able to afford it otherwise. If such a procedure is subsidized, this then begs the question of how this can be supported while many go without basic health care.

Current options, including surrogacy and adoption would cost only about 1/10th of the uterine transplant and not carry the same potential medical risks to both woman and child. Granted these may not be options for every woman without a uterus seeking to build a family due to religious or cultural beliefs, however, given burgeoning health care costs, would society be remiss if these less costly, more reliable alternatives were not explored further? Another consideration is that this type of transplant is intended to be temporary, which again necessitates a weighing of the costs and benefits.

The social and emotional value of carrying and giving birth to a child, however, may not have a price for the woman aching to carry a child, and therefore, the autonomy of the recipient cannot be overlooked when considering all of the risks and benefits of this novel treatment. It is precisely the emotional aspect of this scientific breakthrough, though, that requires us to take pause and assess whether the recipient alone should be the one to weigh the risks and benefits. Respecting autonomy and avoiding paternalism requires a very delicate balance. Some questions that must be explored, though, would include: Might it be more difficult, physically and emotionally, for the woman to achieve a long awaited pregnancy only to miscarry if the uterus is rejected mid-pregnancy? What about the unknown toll the anti-rejection drugs might have on the woman’s health and the child’s development in utero and after birth? Most scientific promise does not come without its peril, but as with most decisions the adage “look before you leap” rings true, especially when something as private and significant as reproduction is at issue.

Little, if anything can replace the experience of pregnancy, but if the ultimate goal of a pregnancy is a healthy child and a mother well enough to experience such fought for parenthood, then the time may not be yet be right for this procedure. The issue, though, is not whether it is right or wrong, as this is very much an issue of individual autonomy, but safety for mother and child should be paramount.

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The HPV Vaccine: Cost and Controversy
by Dian Harrison

Dian Harrison, President & CEO, Planned Parenthood Golden Gate

Last year, Merck & Co.'s Human Papilloma Virus (HPV) vaccine, Gardasil, was approved by the FDA for girls and women ages 9 to 26. Finally, after a decade of development, we have a break-through vaccine that can contain the second-leading cause of cancer among women world-wide. “Great,” you say, “Where do I sign up? Where do I sign my daughter up? Are we giving this away in the streets to make sure we protect as many people as possible?”

Unfortunately, it’s not quite that simple. Fundamentalist politics and high costs have combined to slow the distribution of this life-saving vaccine.

With more than one third of American women infected by the time they are twenty-four years old, HPV is the most common sexually transmitted disease. There are more than 100 types of HPV, and most have no visible symptoms. Some types produce common hand warts. Others produce genital warts, and certain strains, if left untreated can result in cervical cancer. Vaginal and anal intercourse spread genital HPV infections. In some cases, other kinds of skin-to-skin contact, such as body rubbing and oral sex, may also transmit HPV.

In clinical trials involving over 20,000 women worldwide, Gardasil has been shown to be 100 percent effective in preventing infection with HPV strains 6, 11, 16, and 18. Strains 16 and 18, together, cause about 70 percent of cervical cancer cases. The vaccine has been extensively tested to ensure safety. Typical side effects are minimal and may include soreness and/or swelling the injection site.

Cervical cancer is the second most common form of cancer among women worldwide.
Each year about 10,000 women in the U.S. are diagnosed with cervical cancer and nearly 4,000 die. The HPV vaccine has the potential to radically reduce this deadly cancer.

The vaccine is approved for girls as young as 9 because it is most effective before the onset of sexual activity. Parents can't predict when offspring will become sexually active and, tragically, sexual assault remains a reality. Parents can help protect their daughters by getting them vaccinated as young as possible.

Strangely, this great news for women’s health hasn’t been greeted with enthusiasm by all.

Before the vaccine even hit the market, a small but vocal right-wing contingent argued against FDA approval, on the absurd premise that the vaccine could lead to promiscuity. These tend to be the same folks who believe comprehensive sex education leads to sexual activity, despite all evidence to the contrary. A vaccine to end cervical cancer will not cause promiscuity any more than a seat belt will cause reckless driving. Needless to say, they had a hard time convincing politicians to take a stand against cancer prevention. Now they are up in arms again at suggestions to make the vaccine mandatory even though opt out clauses for parents are standard.

Cost is yet another, and even more potent, barrier to thousands of women and girls who could benefit from the vaccine. 37 million people live in poverty in the United States. Nearly 10 million more (46.6 million) are uninsured. At a cost of around $450 to procure and administer the three-shot series, the breakthrough vaccine is well beyond the means of many families.

Poor women and those without insurance need this vaccine the most. Without access to cancer screening, they run the highest risk of contracting cervical cancer. But without funding to help community clinics provide the vaccine, they will also be the least likely to receive it.

Access to the vaccine is especially important for minority women who are disproportionately affected by cervical cancer. For example, in the San Francisco Bay Area where Planned Parenthood Golden Gate operates, Latinas have the highest rates of cervical cancer in the Bay Area and also lack insurance in greater numbers than other ethnic groups.

In a positive first step toward making the vaccine more accessible, Merck is helping to fund the vaccine for low-income women and girls. Unfortunately, their funding structure places a heavy burden on community health centers, which must pay for the vaccine up front and have to cover the associated administrative and medical personnel costs. This will limit distribution of the vaccine to low-income women and girls who need it most.

The most successful immunization programs, such as those for polio are those that require immunization for school entry. For this reason, Governors and legislators in various states including California, Texas and Kentucky are considering making the vaccine mandatory.

Unfortunately, they are facing opposition from the same groups that have opposed the vaccine from the beginning. Planned Parenthood, on the other hand, supports required immunization up to grade 7 as long as adequate funding is made available to remove the financial burden from families. Any school entry requirements should reflect the guidelines from the U.S. Centers for Disease Control and the Advisory Committee on Immunization Practices.

Mandatory vaccination could be an efficient way to direct funding for younger age groups and encourage widespread immunization. But it still won’t solve all the distribution complexities tied to the vaccine. States will still have to work out the funding issues and women aged 19-26 could be left out of the mix if funding is largely channeled through vaccines for children programs.

The HPV vaccine presents a wonderful opportunity for women’s health, but it won’t reach its true life-saving potential unless we commit to making it available for all members of our community, regardless of ability to pay. If you have a daughter, make it a priority to get her vaccinated as early as possible. And don’t forget to do your part to help bring the vaccine to all daughters. Educate your friends. Lobby your state legislature. Show your support for using public funds to help end cervical cancer. Together, we can protect our daughters.

Dian Harrison is the President and CEO of Planned Parenthood Golden Gate. For more information on the HPV vaccine and reproductive health care, visit www.ppgg.org

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Adoption Option: You don't have to be “Traditional” to Adopt!

Lisa Schuman, LCSW

Q: I have heard that it is nearly impossible to adopt if you are single, older, gay, lesbian or have health issues? Is this true?

A: No, this is definitely not true! There are a lot of misconceptions about adoption, and there are no objective websites that will give you the hard facts. Most of the information out there is based on anecdotal evidence, rumor, or PR from a particular adoption agency—none of which tells the whole story. Unfortunately, people often take these pieces of information as fact and resign themselves to ideas that are simply untrue. I have worked with countless “non-traditional” couples and singles over the years, and they all have children or are on their way to becoming parents right now.

Q: Okay, let me focus on singles then. How does the adoption process work for them?

A: The way a single person adopts is a matter of choice. Domestic adoption through an agency or with an adoption attorney are both possible. In each of these options the birthmother chooses the adoptive parent(s) for her child. She may have been raised in a single-parent household herself, and thus feel comfortable about placing her child with a single parent. ( In either type of domestic adoption the individual needs to determine whether independent or agency adoption works best for her, based on all the pros and cons.) In international adoption singles have fewer choices, both in their choice of country and the age of the child. Each country has its own criteria. Is it possible to adopt internationally as a single? Yes, it is—just more difficult. There are many organizations out there that can provide single people with information and support as they set out to adopt a child.

Q: How do gays and lesbians fare as they go through the adoption process?

A: Gays and lesbians have more choices than they may believe. Although it is a shrinking option right now, international adoption is still possible. But, again, domestic adoption is the most popular choice with these clients because it is the birthmother, not the agency or adoption lawyer, who chooses the adoptive parents of her child. Often, these pre-adoptive parents are less judgmental with birthmoms, and as a result these birthmoms feel cared for and accepted. In the end, a birthmother’s feeling accepted and cared for is the most important factor in her choice of who will parent her child. Since the gay baby boom has peaked, there has been a surge of information opportunities for gays interested in adoption. There are gay and lesbian centers in most areas, and websites like Family Pride which provide support and education to these individuals.

Q: Can you tell me what an older single or couple can expect when they try to adopt?

A: Once again, the choices are limited internationally, but domestic adoption is open to everyone since it’s the birthmother, not the country or agency, who decides who will be the right parent(s) for a child. I have clients who are first-time parents at ages 52 and 54. They met later in life: He had been married before and she had not. After some time they felt that their lives were not complete without a child and they chose to pursue independent domestic adoption. In the beginning they had some difficulty accepting birthparents who were not “ perfect,: but in the end they adopted a very healthy little girl and are very happy. Another couple I worked with already had teenage children. They were motivated to adopt because of their desire to live through the early childhood years again, and they finally adopted from China. They are enjoying their second chance at parenting and feel that their age and experience are allowing them to bring more to their youngest child, now 5, than they were able to bring to their older children.

Q: Can you tell me how health issues such as a past history of cancer or depression will affect my ability to adopt?

A: This is really a question for the person who does your homestudy, and the agency, if you are using one, to answer. I have seen people adopt with all sorts of emotional and physical challenges, and usually these issues can be worked with. It is helpful to get counseling if there is a question, and keep in mind that the way you present an issue will have an impact as well.

Q: Is there any other critical piece of advice you would give to non-traditional pre- adoptive parents?

A: Yes, the two most important things to remember are: First, make sure you are well-educated about your choices, and second, since there is no “better” or “right” way to adopt, each individual or couple should choose the path that feels right to them.

Lisa Schuman, LCSW, is a psychotherapist specializing in adoption and infertility. She is the founding Director of Adoption Cooperative Consultants and is a psychotherapist for Reproductive Medicine Associates of New York. She is a former Board member of The American Fertility Association and has a private practice in New York City. She can be reached at Adoption Cooperative Consultants: 212-308-5660; her private practice: 212-874-1318; and RMA of NY: 212-756-5777.

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Support Services

NEW YORK CITY WOMEN'S IN-PERSON MIND/BODY SUPPORT GROUP FORMING NOW

Facing Fertility Challenges?

Come join us and discover the power and benefits of mutual support.

Build resilience and feel more centered as you learn and use valuable MIND/BODY TECHNIQUES to ease stress and gain a greater sense of control over your life.

Fee is $30 per session, some of which may be reimbursable by insurance. It can also be considered a tax-deductible, medically-related expense.

Facilitated by Izetta Siegal Stern, LCSW, Board Certified Diplomate and American Fertility Association Support Group Leader.

Space is Limited. You may contact Izetta at 212-691-1266 or e-mail ISiegalStern@aol.com

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—March - April 2007