In this issue, you'll find:

• Message from Pamela Madsen
• Family Matters: The National Fertility and Adoption Conference
• NEW! The Patient Appointment Assistance Program
• This month's featured article: The key to defining PCOS

Dear Members,

If you’re trying to have a child, if you’re facing fertility challenges, or if you’d like to adopt, you believe – as The American Fertility Association does – that family matters. In fact, we believe it so much so that we have named our annual spring conference Family Matters: The National Fertility and Adoption Conference, the largest annual family-building event of its kind.

Please join us at on Sunday, April 17 at the Grand Hyatt New York Hotel, on Park Avenue and 42nd Street in New York City. Click here for more details and to register.

Thanks to the generosity of an anonymous donor, we can now offer 100 scholarships to those who need financial assistance to attend this conference. If you had hoped to attend this Sunday, April 17, but thought you couldn’t afford to, now you can! These scholarships are available on a first-come-first-serve basis, so please call today.

At our Family Matters conference, you’ll find a welcoming and supportive setting, where you can attend over 40 lectures and workshops and speak one-on-one with top doctors and other healthcare professionals, who will answer your questions and offer insights and perspectives on range of topics, such as in vitro fertilization (IVF), female and male factor infertility, PCOS, ovum donation, PGD, blastocyst transfer, international and domestic adoption, and so much more.

The AFA will also host an exhibit hall featuring fertility clinics, egg donor and surrogacy programs, urologists, alternative therapy programs, pharmacies and pharmaceutical companies, adoption agencies, and attorneys. You will have the opportunity to meet these professionals face to face, ask them your questions, and learn about their services.

The AFA has secured a block of hotel rooms at the Grand Hyatt New York. To reserve a room, please contact the hotel directly at 212-883-1234 and mention The American Fertility Association conference.

I look forward to seeing you on Sunday, April 17. For more information or to register, 24 hours a day, 7 days a week, call 888-917-4777 or click here.

NEW! The Patient Appointment Assistance Program

For every single one of us who seeks medical help to overcome the difficulties we have in conceiving, there are thousands more who do not. At The AFA, we want to see everyone who wants to have a child receive the information and medical assistance that they need. To help make getting to a specialist just a little bit easier we have developed a free nationwide program that I am pleased to announce to you today.

The NEW Patient Appointment Assistance Program is a free physician referral and appointment scheduling service that actually connects patients with fertility specialists.

As current and former fertility patients ourselves, the staff and volunteers of The AFA know all too well how difficult it can be to make that first call to a reproductive specialist even when no barriers exist such as financial concerns. So we set out to try to make it easier.

Here’s how the program works. Call our Support Line at 888-917-3777, an AFA Patient Advocate will help you find a physician if you need one, by giving you a list of providers in your area. Then, with you on the line, our Advocate will actually place the phone call to the provider you select, to help schedule your appointment – be it either a first appointment or a second opinion appointment. The AFA Advocate will stay on the line with you to help you ask the right questions to fully understand expectations for your appointment.

It’s like having a confident big sister who knows exactly what to do. One who says “take my hand we’re going to do this together.” When I went through my treatments, my sister had already been there and I relied on her strength and knowledge. Many patients are not as fortunate, so The AFA is going to step up and provide this support.

The Patient Appointment Assistance Program is offered free of charge and The AFA receives no financial reimbursement for referring patients. We hope you’ll take advantage of this new service, and call our Support Line at 888-917-3777 to get your family-building plans moving forward today.

All the Best,
Pamela Madsen

The key to defining PCOS
By Ricardo Azziz, M.D., M.P.H., M.B.A.

In 1935, Drs. Stein and Leventhal first described the association between amenorrhea and polycystic ovaries, which we now know as polycystic ovary syndrome (PCOS). In fact, PCOS appears to be one of the more common endocrine disorders, affecting approximately 6.5% of reproductive-aged women. This disorder is also associated with an increased risk of insulin resistance, type II diabetes mellitus, cardiovascular disease, and other health issues. Although there is no widely accepted definition of PCOS, useful criteria arose from a conference sponsored by the National Institute of Child Health and Human Development in April 1990. The conference participants were surveyed and most stated that the major criteria for PCOS “included hyperandrogenism and/or hyperandrogenemia, oligo-ovulation, and the exclusion of other known disorders. The presence of polycystic ovaries that appear on ultrasound was also noted as a possible inclusion criterion. Another conference was then convened in Rotterdam, The Netherlands, in May of 2003, and participating experts proposed that polycystic-appearing ovaries should be one of the potential features of PCOS. However, we should note that not all patients with PCOS would have polycystic ovaries. In general, most clinicians will agree that PCOS can be viewed as a diverse disorder in which ovarian, and possibly adrenal androgen excess is present, along with varying degrees of metabolic abnormalities. It should be noted that PCOS is a diagnosis of exclusion in which other causes of non-ovulation or hyperandrogenism are ruled out by an examining clinician.

Insulin Resistance and PCOS
Insulin is a hormone produced by the pancreas that is responsible for processing the sugars (i.e. carbohydrates) that we ingest in our diets. Insulin resistance is a condition in which the tissues of the body do not respond appropriately to normal levels of insulin which then forces the pancreas to produce increasing amounts of insulin to process the same amount of sugars. Various investigators have observed that IR affects between 25% and 60% of PCOS women studied, depending on body weight. Insulin resistance in PCOS is made worse by being overweight or obese. However, although many women with PCOS are overweight, about one-third are actually of normal weight. In fact, just because a woman is not obese does not mean that she cannot have PCOS. And IR can also be observed in PCOS who are of relatively normal weight.

The excess levels of insulin in blood (hyperinsulinemia) that are the result of our bodies attempts at keeping blood sugar levels normal also make the ovary overproduce male hormones. As the IR of PCOS becomes worse, with increasing overweightness or age, the pancreas is forced to produce ever-increasing amounts of insulin. Eventually the pancreas is not able to produce enough insulin to meet the body's needs and the patient develops type 2 diabetes mellitus (DM).

The exact cause of IR in women with PCOS is not yet clear. A great deal of research is being directed at discovering more about the mechanisms underlying IR, why it occurs, and how best to treat it. However, what is known is that weight reduction in overweight women with PCOS will greatly improve IR. In addition to improving insulin resistance, weight reduction can also improve many of the other signs and symptoms of PCOS. For example, overweight women with PCOS and insulin resistance who lose weight may regain normal ovulation, normal menstrual periods, and normal fertility. Thus, although scientists are still in the process of understanding the association between obesity, IR and PCOS, what is clear is that there appears to be some common link that ties all these factors together.

Excess male hormone levels and effects in PCOS
Women affected by PCOS commonly report bothersome excess hair growth, acne, and scalp hair loss or thinning, also called androgenic alopecia. Hirsutism refers to the excess growth of coarse, often long and dark hair, in a male-like pattern over the face, chest, abdomen, back, arms and legs. Hirsutism, acne or androgenic alopecia are generally the result of the increased production of male hormones (androgen excess) in women with PCOS. Androgen excess refers to the presence of excessively high male hormone (androgen) levels or effects. Male hormones include testosterone, androstenedione; the adrenal androgen byproduct DHEAS can also be measured. The ovaries, and frequently the adrenals, of women with PCOS overproduce androgens.

Excess male hormones circulate in the blood and act on hair follicles in the skin to stimulate the growth of long, coarse, and commonly dark hairs. They also cause hairs in the scalp to stop growing, resulting in balding. Excess androgens also result in the overproduction of sebum, the skin oil, which results in clogged pores and the development of acne. In addition to being considered a significant cosmetic problem, for many women hirsutism, acne, or androgenic alopecia may indicate an underlying hormonal problem of significant concern - elevated androgen levels. There is also evidence to suggest that long-standing elevations in androgens in women with PCOS can lead to problems with cholesterol and other lipid levels, which are risk factors for heart disease.

In fact, while recent press announcements and research publications have suggested that most patients with PCOS have IR and secondary hyperinsulinemia, we should note that the most common abnormality in PCOS is androgen excess. It is androgen excess, and not IR, that is directly responsible for the signs and symptoms we have come to recognize as PCOS, including hirsutism, acne, alopecia, and ovulatory problems. However, we should also note that high male hormone levels cannot be detected in all patients with PCOS, and that signs of excess male hormones (e.g. hirsutism) may be all that is observed. Furthermore, it is important to note that not all women with hirsutism, acne or alopecia have PCOS. Also, not all women with hirsutism will be found to have elevated androgen levels. Conversely, not all women with PCOS will have hirsutism.

Androgen Excess - key factor in diagnosing PCOS
Although many women with PCOS have IR and high insulin levels androgen excess is the immediate culprit that determines the symptoms of PCOS, including the woman’s degree of irregular ovulation, hirsutism, acne, or alopecia. Androgen suppression continues to be the mainstay of treatment for PCOS patients who do not desire immediate fertility. However, for those women who are actively pursuing pregnancy, your doctor can provide you with medications that can help you ovulate, a process called ovulation induction. Insulin sensitizers can also be used to improve ovulation. If ovulation induction alone is not successful in producing a normal pregnancy, then the use of the assisted reproductive technologies (ART) - such as in vitro fertilization- can be attempted.

While a diagnosis of PCOS suggests that you are more likely to have some difficulty becoming pregnant, with help from you doctor pregnancy should be an option for almost everyone with PCOS. The key factor is the early diagnosis of PCOS for which androgen excess can be the best detector.

Dr. Azziz is currently the Endowed Helping Hand of Los Angeles Chair in Obstetrics and Gynecology at Cedars-Sinai Medical Center in Los Angeles, CA. He is also Vice-Chair and Professor, Dept. of Obstetrics and Gynecology, and Professor, Dept. of Medicine at UCLA. Dr. Azziz is Board Certified in Obstetrics and Gynecology, and Reproductive Endocrinology/Infertility; and is a Fellow of both The American College of Surgeons and The American College of Obstetricians and Gynecologists. He is former Chair of the Advisory Committee on Reproductive Health Drugs, of the U.S. Food and Drug Administration; and a current member of the Reproductive Endocrinology Study Section of the National Institutes of Health.