Welcome to the November issue of Connections. In this issue you will find:

• Message from Pamela Madsen
• Ovum Donation Seminar
• Adoption Seminar
• "An Evening with Leading Infertility Experts" - an AFA patient seminar
• Golf "Fore" Kids Invitational
• Footprints: The IVF Children's Health Study
• Featured Article: Ultrasound and Infertility: Diagnostic and Therapeutic Uses

Dear Friend:

Fall has been a busy season for the AFA. We have introduced our new name to our members and the industry, we have held our annual fundraiser, the Kokopelli Ball, honoring the professionals that help us to achieve our family building dreams, and we have attended the American Society of Reproductive Medicine (ASRM) conference to further reach-out to professionals in the field. And that's not all. Read on to learn about seminars on Ovum Donation and Adoption in New York City, an informational session in New Jersey on Pathways to Pregnancy with Reproductive Medicine Associates, as well as our first annual Golf "Fore" Kids Invitational in Palm Beach, Florida.

You will also find in this information-packed Connections, details on our ground-breaking relationship with the RAND Corporation to study the health of IVF Children.

I hope you will read on for details on all of these exciting and informational programs and services provided by The AFA.

And, if you haven't been to our new Web site, please visit us at www.TheAFA.org to see all the new information available including new message boards, fact sheets and much, much more.

Stay well,
Pam

Ovum Donation Seminar (Click here for more information)

The American Fertility Association is sponsoring an Ovum Donation Seminar Series beginning Monday, October 25, 2004 for six consecutive weeks. Each of the six weekly seminars will discuss in detail a different aspect of the ovum donor process enabling individuals to get a clear understanding of the medical, psychological, and practical choices that are part of this family building option.

Adoption Seminar (Click here for more information)

When you choose to adopt you are making a lifetime decision. Find out whether adoption is the way to build your family by exploring the options, gathering the facts, and empowering yourself to make the choice that is right for you.

A new fact sheet on adoption is also now available on our Web site at www.TheAFA.org.

"An Evening with Leading Infertility Experts" - an AFA patient seminar

The American Fertility Association (AFA) presents a very special educational event on infertility in collaboration with Reproductive Medicine Associates (RMA), one of the most successful fertility clinics nation-wide.

RMA infertility experts Dr. Brad Miller and Dr. Doreen Hock will discuss how to choose and evaluate a fertility specialist or clinic.

Beth Harley, RN, will explain counseling options and educational seminars for patients, the emotional and physical stress infertility can create, and how emotional support can have a positive impact on treatment.

Drs. Miller and Hock and Ms. Harley will all be available to answer patients' questions.

Please contact The AFA's Lori Masi at 888-917-4777 to register. This patient seminar is free and parking is available. Refreshments will be served.

Sponsored by Reproductive Medicine Associates and Schraft's, A Specialty Pharmacy.

Golf "Fore" Kids Invitational (Click here for more information)

It's not too late to register for the first annual American Fertility Association Golf "Fore" Kids Invitational to be held in warm and welcoming Palm Beach, Florida on December 5, 2004.

Kokopelli Ball 2004 Co-hosts, Olympic Gold Medal swimmer Dara Torres and News Channel 4-NBC Medical Correspondent Dr. Max Gomez, joined by special guest Brooke Shields, helped to make the 2004 Kokopelli Ball one to remember!

Brooke Shields, Dr. Max Gomez, and Dara Torres, Masters of Ceremony at the 2004 Kokopelli Ball

Footprints: The IVF Children's Health Study

The AFA announces "Footprints: The IVF Children's Health Study," the first longitudinal, prospective, and scientifically objective study that chronicles the health and welfare of children conceived through IVF.

There are at least 250,000 IVF children born in the U.S. to date. "Footprints" will deliver facts - not hypotheses - about the physical, emotional and intellectual development of this significant and growing population.

"Footprints" is a partnership between The AFA and the RAND Corporation, a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world.

The AFA and RAND Health have begun to work closely on the data collection strategies for this innovative research endeavor. This forward-looking study will track multiple gestations, birth weight, birth defects, surgical procedures, physical health, and developmental milestones for IVF children.

Serono, Inc. has provided The AFA with an unrestricted educational grant for "Footprints," which will serve as initial funding to assist with the development of the study design and the collection of pilot data from a cross-section of U.S. IVF centers. The AFA and the RAND Corporation will seek federal funding for "Footprints," enabling it to become an expanded national study.

Click here for further information on Footprints: The IVF Children's Health Study.

ULTRASOUND AND INFERTILITY:
DIAGNOSTIC AND THERAPEUTIC USES
by Michael P. Zahalsky, M.D.and Harris M. Nagler, M.D., F.A.C.S

Ultrasonography has become widely utilized as a diagnostic technique in medicine. It allows the visualization of structures within the body by transmitting sound waves through the skin. These high frequency sound waves are then reflected off the surfaces of internal structures. The same instrument that transmitted the sound waves then receives the reflected sound waves. Computers process the signals and an image (picture) is created. This is technology similar to that utilized by ships to visualize the bottom of the ocean or fisherman to identify schools of fish. This article will describe ultrasonography in greater detail and discuss its application to the infertile male.

Ultrasound has become essential in the diagnosis of the infertile male. It allows visualization of the male reproductive organs and the male reproductive tract. The two primary types of ultrasonography used by urologists to evaluate men are scrotal and transrectal ultrasonography.
Scrotal ultrasonography provides a detailed examination of the testicles, indicates the presence or absence of varicoceles, and can identify other abnormalities. Transrectal ultrasonography can visualize the male reproductive tract including the ejaculatory ducts, seminal vesicles, and vas deferens. These ultrasonographic techniques have provided the urologist with non-or minimally-invasive techniques with which to evaluate the infertile male.

Current estimates indicate that infertility affects approximately 15% of all couples attempting their first pregnancy. In infertile relationships, male infertility has been found responsible for approximately 30-40% of all cases of infertility.

Semen analysis is the bedrock of laboratory testing in dealing with male infertility. However, it is not highly predictive of fertility, which is couple-related phenomenon and can only be determined by initiation of pregnancy. Semen analysis examines the quantity and quality of sperm present in a specimen.

ULTRASONOGRAPHY: TECHNICAL CONSIDERATIONS
Ultrasonography is used both scrotally and transrectally in the evaluation of male infertility in order to identify structural abnormalities which may be the cause of abnormalities detected by the semen analysis or abnormal findings on physical examination. The ultrasound wave is initiated by a transducer. The transmitted sound waves are directed to the area of interest and interact with tissues of various densities, reflective and absorptive characteristics and are converted into computer generated images. The frequency of the ultrasound wave determines the structure that can be visualized.

Ultrasound imaging techniques include real-time ultrasound, Doppler ultrasound, and color flow Doppler imaging. The real-time ultrasound images are produced when high-speed ultrasonic beams create independent images at high rates. For superficial examination of the scrotum and penis, a high-frequency probe is optimal because it provides greater resolution of the superficial areas of interest. A slightly lower frequency probe allowing deeper penetration is used for transrectal ultrasonography (TRUS). Transrectal ultrasonography is utilized to identify abnormalities in the prostate, the seminal vesicles and ejaculatory ducts.

Doppler ultrasonography provides the physician with the ability to measure directional blood flow. A pulsed Doppler system measures flow velocity by the transmission at regular intervals of short bursts of ultrasound waves that are reflected from a moving target. Duplex ultrasound combines the pulsed Doppler system with real-time imaging. This technique is extremely valuable in the imaging of small vessels. This is the technique that is commonly employed in the diagnosis of varicoceles.

SCROTAL ULTRASONOGRAPHY
Scrotal contents can be accurately assessed with ultrasonography. Testicular abnormalities, which may be identified by ultrasonography, include: testicular tumors both benign and malignant, testicular cysts, and testicular calcifications (microlithiasis). Additionally, abnormalities in the scrotal contents including adnexal abnormalities can be observed. The adnexa are the structures within the scrotum, which are responsible for the maturation and delivery of sperm. Spermatoceles (cysts containing sperm) and hydroceles (fluid accumulation around the testicle) can be visualized with scrotal ultrasonography eliminating the need for diagnostic surgical procedures. Ultrasonography may also be used to calculate testicular volume and texture.
Testicular tumors are, unfortunately found more frequently in infertile men than the normal population. The rate of testicular tumors found in an infertile group of men was 1 in 200, which is significantly higher than the 1 in 20,000 that is reported for the general population. Although, ultrasonography is useful in the diagnosis of testicular masses, it is not utilized to screen all infertile men. Most testicular tumors are appreciated by routine physical examination or because of patient symptoms.

Recently, it has become apparent that patients with testicular microlithiasis have an increased risk of developing testicular tumors. Therefore, patients identified as having calcifications within the testicle often undergo routine and periodic scrotal ultrasonography. This entity - microlithiasis, abnormal calcifications of the testicle - was not diagnosed until the initiation of scrotal ultrasonography.

Testicular torsion is an acute event associated with severe testicular pain and swelling due to the abrupt twisting of the testicle blocking the blood flow to the testicle. This can be accurately diagnosed when no blood flow to the testicle is demonstrated by color flow Doppler (CFD) ultrasonography. Patients with testicular torsion appear to have decreased fertility. The ability to rapidly and accurately diagnose testicular torsion results in preservation of the testicle and, hopefully, reduced infertility

Although each of the above conditions may affect male fertility, scrotal ultrasonography plays its major role in the evaluation of the infertile male by the detection or confirmation of a varicocele, an abnormal dilatation of the testicular venous system thought to be the leading cause of male infertility. Real-time ultrasonography provides a visual image of the scrotal contents and has also been used to diagnose varicoceles13. Most urologists believe that ultrasonography should be utilized to confirm physical findings or resolve controversy regarding physical findings. Scrotal ultrasonography should not be utilized to search for varicoceles that cannot be appreciated by physical examination. Studies have demonstrated that subclinical varicoceles are not a cause of male factor infertility.

TRANSRECTAL ULTRASONOGRAPHY - EVALUATION OF THE SPERM DELIVERY SYSTEM:
While vasography is the foremost tool in evaluating the normalcy of the vas deferens and the ejaculatory duct, transrectal ultrasonography (TRUS) has recently emerged as a significant diagnostic tool in the evaluation of abnormalities of the ejaculatory duct apparatus7. Initially used solely to evaluate the prostate, TRUS has recently gained much attention in the evaluation of male infertility. Recent improvements in transrectal ultrasound, with the use of higher frequency multiplanar transducers, have enabled the ejaculatory ducts to be visualized14. Ejaculatory duct obstruction is currently recognized more frequently than in the past due to its ability to be diagnosed by TRUS15,16. Infertility patients presenting with a low ejaculate volume, zero or a decreased number of sperm in the ejaculate, or significant sperm motility abnormalities are all appropriate candidates for TRUS. Any patient with a prior history of prostate infections, prostatitis, and evidence of diminished seminal volume warrants TRUS. In patients suspected of having ejaculatory duct obstruction (EDO), TRUS, being virtually risk-free, has nearly supplanted vasography. Detection of ejaculatory duct obstruction is important because it is a specifically treatable, correctable cause of male factor infertility.

CONCLUSION
Recent developments have resulted in dramatic advancement in the diagnostic evaluation of the infertile male. By developing highly specific imaging procedures, it has enabled more precise targeting of the abnormalities responsible for the previously ill-defined causes of male infertility and identifying potentially significant medical conditions. While the standard semen analysis maintains its position as the initial study of choice, more advanced imaging studies can be used to pinpoint specific abnormalities of physiologic or anatomic significance. The rapid progress in therapeutic options for infertile couples combined with improvements in the diagnostic arena will allow physicians to more aggressively, more accurately, and more successfully treat the infertile male.