In this issue, you'll find:

• Message from Pamela Madsen: World Infertility Month, June 2005
• Upcoming AFA Events:
  • Fertility Dream in Chicago, Danbury & Boston
  • Adoption Coaching Tele-Group
• This month's featured articles:
  • An Update on Polycystic Ovary Syndrome
  • Smoking & Infertility

Dear Friend,

Once again, this June we celebrate World Infertility Month (WIM). This month is our opportunity to raise our collective voices to speak out for those with reproductive difficulties.

World Infertility Month, created by The American Fertility Association, is a worldwide, international movement designed to increase public fertility awareness and education. Last year, patient and professional organizations in over 40 countries participated in WIM and shattered the silence with global media attention and international reach.

Each year, WIM has a unique theme that patient organizations can rally-around world wide. Our themes are reflective of the current trends in fertility and issues that we all face on a global scale. For 2005, our two-pronged theme is The Evolution of Language and Global Fertility Education. With small and daily changes around the world we can both reclaim our language and build fertility knowledge to get more people into treatment sooner.

It’s a long, slow process that varies dramatically from country to country, culture to culture, religion to religion.

The Evolution of Language

To reach the millions who are misinformed about and frightened by the pejorative connotations of the words in current usage, we must broaden our vision. We must find a way to make talking about the disease less scary and painful. We must open the door to knowledge, wipe away the misinformation and offer facts in a comprehensible and caring manner. To that end, we will continue to work toward neutral, objective terms that have the power to convey the nature of our situations. At the same time we press to de-stigmatize “infertility,” “subfertility” and “sterility,” we’re developing alternatives that liberate us from generations of bias and that are more precise.

Reproductive Difficulties – A Beginning
Right now, patient advocacy organizations in many countries are working synergistically to encourage the use of new, more objective and accurate terminology. Consensus is critical precisely because we are building a common language, a platform of reference on which we can all comfortably rest. For example, over the years, as we’ve consulted and worked with thousands of members, analyzed patient attitude research and talked with professionals in the field, The AFA finds that people are more responsive, less intimidated and more receptive to “reproductive difficulties” as a medical and social framework. It is encompassing, an umbrella term under which all diagnoses–from tubal obstruction and low or no sperm count to endometriosis and varicocele – can be easily accommodated. Reproductive difficulties is a straight–forward, descriptive phrase free of historical or cultural freight. That neutrality is so important as we try to reach the vast populations who we have not yet touched.

Global Fertility Education

The second part of our WIM theme this year is about ascertaining the level of fertility knowledge among our constituents and the general population. We need a baseline. Exactly what do people know about making babies? What do they know about the relationship of fertility to age, birth control and lifestyle? Do men know their fertility declines with the years, too?

Which brings us to the absolute necessity to cultivate a global awareness about the biology of conception and pregnancy as well as the conditions and diseases that inhibit biogenetic family building. Many of us take for granted that we know the nuts and bolts of reproduction and fertility preservation. The fact is most people don’t have a clue. An AFA on-line survey underscored the degree of ignorance. Of 12,000 respondents in the US, only one answered all 15 questions correctly.

We all agree that women should be forearmed with knowledge that as they grow older, their chances of biogenetic children diminish. No one should be blindsided by ignorance when we can shed light. That just isn’t fair. Knowing what we know, going through what we’ve all experienced, we have an obligation to make sure that preventable reproductive difficulties become an historical artifact. We have the power of knowledge. Let’s join together and use it.

We encourage you to talk with your spouse, partner, friends and family members to help close the gap on fertility awareness and knowledge this June – World Infertility Month 2005. Together, our collective voices can truly make our issues heard around the world.

Raising Our Collective Voices World Wide

The AFA will join the European Society of Human Reproduction and Embryology (ESHRE) at their annual meeting in Copenhagen, Denmark later this month. The world’s foremost fertility specialists and advocates will converge to perpetuate the organization’s 21-year history of bringing modern issues on reproductive biology and medicine into the public and professional eye and, moreover, the political spotlight. This year, The AFA will host a pre-conference reception to celebrate the outstanding accomplishments of Dr. Bruno Lunenfeld, professor emeritus of Israel’s Bar-Ilan University.

The AFA is proud to acknowledge Dr. Lunenfeld’s dedication to our community and his wherewithal to transcend modern medical research and practice. His achievements to date are truly outstanding, and it is our pleasure to honor him with our prestigious World Infertility Award.

Patient advocates from around the globe will join us in our honoring of Dr. Lunenfeld, and we will join together behind the WIM 2005 theme of Evolution of Language and Global Fertility awareness.

Warm Regards,
Pamela

Upcoming Events

This summer and early fall, you will have the opportunity to join reproductive health patients, their families and supporters at three different Fertility Dream 5K races

Chicago, IL August 7, 2005
Danbury, CT September 11, 2005
Boston, MA September 18, 2005

Anyone can take part in the Fertility Dream: fitness enthusiasts, elite runners, and most importantly, those who’ve never participated in a race before. A 5K (kilometer) race is 3.1 miles, which can be a leisurely hour-long walk or a fast-paced 18-minute run. The AFA will help interested members find the pace that’s right for them. But most of all, we want you to join us, as a participant or sponsor, to help us raise awareness for fertility in communities nationwide, and to say “We’re serious about preserving health and getting fit!”

All the information you need to get started is available here, just clicks away. You can register to run, receive a training program customized to your fitness level, become a sponsor, make a donation, or tell friends and family members. All profits from the Fertility Dream will benefit The AFA’s patient education outreach.

Click here for more information.

GET PERSONAL SUPPORT FROM THE PRIVACY OF YOUR OWN HOME

Please join The AFA for our free one-hour Adoption Coaching Tele-Group. This introductory group is for individuals and couples who are exploring alternative family building via adoption. The group will focus on the "how-to's" of adopting a child and on individual concerns that naturally arise during the adoption process. The group will be led by Sara Barris, (psychologist and adoptive parent) and Bob Bamman (psychotherapist and adoptive parent).

When: Wednesday, July 12, 2005
Time: 8:30 - 9:30 PM EST

For information and to register please contact: Sara Barris at 718-544-0932 or sarabarris@aol.com.

This month's featured articles:

• An Update on Polycystic Ovary Syndrome
• Smoking & Infertility

AN UPDATE ON POLYCYSTIC OVARY SYNDROME (PCOS)

Peter G. McGovern, M.D. Academic Title: Assistant Professor, Department of Obstetrics, Gynecology and Women’s Health Director, Division of Reproductive Endocrinology and Infertility UMDNJ-New Jersey Medical School 185 South Orange Avenue, MSB-E506 Newark, New Jersey 07103 973-972-2235 Clinical Practice: University Reproductive Associates, P.C. 214 Terrace Avenue Hasbrouck Heights, New Jersey 07604 201-288-6330

The last several years have been exciting ones for health care providers, researchers and scientists interested in PCOS. In the last few years, we have learned more about this disorder than in the decades since the original description by Drs. Stein and Leventhal. They originally described a group of women who came to them with three common complaints: obesity, hirsutism (unwanted excess hair growth, especially facial hair) and oligomenorrhea (infrequent or irregular menstrual cycles). Since that time, we have come to understand that the irregular menstrual cycles are caused by chronic anovulation. This explains why many PCOS patients also reported infertility. “Chronic anovulation” means that women with PCOS fail to ovulate (release an egg from the ovary) on a regular basis, although they may do so from time to time. (Many women with PCOS have mothers who have had the same symptoms all their lives, and yet managed to have children before medical treatments were available.)

When blood tests to measure hormone levels became available clinically, it became widely recognized that most women with PCOS had higher than normal levels of androgens (male hormones, such as testosterone, androstenedione, and DHEA). These androgens lead to facial hair growth in women, just as they do in men after puberty. Because many women with PCOS were also overweight, most theories which tried to explain what was going wrong in PCOS revolved around the role of extra adipose tissue (fat). In general, these theories went something like this: Fat produces extra estrogen (female hormone). Estrogen suppresses the normal process of egg production (just the way a birth control pill prevents ovulation). Without a developing egg, the ovary cannot make estrogen and instead makes mostly androgens. These extra male hormones cause unwanted hair growth, and also work to stop the process of egg production.

Although most women with PCOS had noticed symptoms since their teenage years, many had also been overweight since they were teens. It was noticed that some women of normal weight had regular cycles, then gained weight and developed symptoms of PCOS. Many times these women were able to reverse the process by losing weight, in which case their PCOS usually was cured. This observation helped support these theories, and led to the general impression that PCOS was a preventable problem, and that women could solve it themselves if they would just eat less, exercise and lose weight.

However, these theories didn’t explain everything. It was observed that sometimes women of normal weight (or even some very slender women) could develop PCOS. It was also noticed that some overweight women who did lose weight still had their PCOS.

Several years ago, as our understanding of the way the body controls glucose (blood sugar) improved, researchers discovered that most women with PCOS have a condition called “insulin resistance”. Insulin is the hormonal messenger made in the pancreas which lowers blood glucose. After you eat a meal, you absorb nutrients and your glucose rises. The pancreas then releases more insulin into your bloodstream, which helps keep your blood sugar in the normal range, and also helps your liver, muscle and fat store energy (some as glucose, but most as fat). When you are in between meals, your pancreas releases less insulin, you shift from storing to releasing energy, and fat and stored glucose are released to increase your blood glucose back into the normal range. People with insulin resistance have normal blood glucose levels, but they are less sensitive to insulin and therefore their bodies need much more insulin around to keep their blood sugar in control.

The problem is that extra insulin causes more fat to be deposited, and interferes with the normal process of developing eggs. Put simply, excess insulin can cause someone to be overweight and not ovulate. It can also increase male hormone production by the ovary. In short, insulin resistance can produce all of the symptoms of PCOS: obesity, anovulation, hirsutism, and infertility!

Studies have tried to determine whether insulin resistance is the “chicken or the egg” in PCOS. When you shut down ovarian function (with drugs such as Lupron®), patients still have insulin resistance. But when you correct insulin resistance with diet, exercise or insulin-sensitizing drugs (such as metformin), normal ovarian function usually returns. This evidence strongly suggests that the primary problem is insulin resistance, and that PCOS develops later as a side effect.

This opens up new avenues of treatment for women with PCOS. Now in addition to the anti-estrogen clomiphene citrate (Clomid®, Serophene®), we have insulin-sensitizing drugs such as metformin (Glucophage®). Both medications have been suggested as first-line therapies for women with PCOS attempting pregnancy. They have different side effects: clomiphene can cause low estrogen symptoms (such as hot flushes or headaches) and carries a small but not insignificant risk of multiple births (5-10% in most studies), whereas metformin causes mainly GI side effects (upset stomach, increased gas) but has a multiple birth risk similar to the general population (about 1-2% twins). Clinicians and patients alike are now faced with a dilemma: which drug is better to try first, or would the combination have some additional benefit over either drug individually?

In order to answer this question, the National Institute of Child Health and Human Development (NICHD), a branch of the National Institutes of Health (NIH) is sponsoring a clinical trial at 13 sites around the country. Named the “Pregnancy in Polycystic Ovary Syndrome” (or PPCOS) study, a group of PCOS women who desire pregnancy are now being recruited. Eligible subjects will receive one of three treatments: clomiphene citrate alone, metformin alone, or the combination in a randomized fashion (like flipping a coin). The study pays for necessary tests, and provides free medications and free office visits to monitor progress during the 30 week study. Of course, since these two drugs are standard medications, any physician may also prescribe them.

Women interested in the PPCOS Study may go to the Website (rmn.dcri.duke.edu) for more information, a map of participating centers across the country, and a list of names and phone numbers of people to contact about the study.

Long term health issues are also important. PCOS patients are known to be at higher risk (compared to the general population) for developing heart disease, elevated cholesterol and other blood lipid levels, further weight gain, and diabetes and/or high blood pressure as they age. Proper diet, weight loss and exercise are proven methods to decrease all of these risks. Studies are starting now to find out whether insulin-sensitizing drugs (such as metformin) will also help to prevent these long-term consequences of PCOS, but they will take years to give us a definitive answer. At least in terms of diabetes prevention, a well-done study has already shown that, although insulin-sensitizing drugs were of some benefit, they did not work as well as lifestyle modification (diet and exercise). Since exercise and weight loss each independently improve insulin resistance and lower insulin levels, women who exercise regularly experience health benefits (meaning more regular menstrual cycles, better general health and a lower risk of cardiovascular disease) - even when they fail to lose weight. Yet more evidence that we need to exercise – whether we like it or not!

SMOKING AND INFERTILITY

Robert J. Stillman, M.D. Medical Director Shady Grove Fertility Center

C.Everette Koop, M.D., the former U.S. Surgeon General, has appropriately labeled smoking "the chief single avoidable cause of death in our society and the single most important health issue of our time.” (1) Specifically addressing the adverse effects of smoking on reproductive health in the introduction to an issue of Seminars in Reproductive Medicine devoted to a review of the this subject (2), Dr. Koop summarized the available data in stark terms:

"Women who smoke have decreased fertility.
The risk of spontaneous abortion is higher for pregnant women who smoke...
Babies born to smokers weigh, on average, 200 grams less than babies born to comparable women who do not smoke, with low birth weight being an important predictor of infant mortality"

A number of comprehensive reviews of the literature have been published (2,3,4,5,6.,7,8) summarizing the cumulative data supporting a strong association between cigarette smoking and diminished female fertility. It seems that the adverse effects are dose related, i.e. greater damage is seen the greater the number of cigarettes smoked per day and over time (referred to as the total ‘pack-years’. For example, 1 pack per day for 4 years equals 4 pack-years).

The impact of cigarette smoking on early spontaneous abortion has been an important addition to these reviews on fertility. The increase in pregnancy loss and ectopic pregnancies attributable to smoking all add to the overall adverse reproductive impact of this habit (2). The damaging effect of cigarette smoking on oocytes is emphasized by clear data indicating an earlier age of menopause correlating to the number of cigarettes smoked.

Based on a major analysis of many articles about smoking’s effect on fertility (a meta-analysis), Augood estimated that, in Great Britain, up to 13% of female infertility is caused by cigarette smoking (7).

The negative effects of side stream and passive smoking (that is smoke that may be inhaled from the smoke of others, especially in the home or in the workplace), are also notable. Hull (9) concluded that the percentage of women experiencing conception delay for over 12 months was 54% higher for smokers compared to non-smokers. Exposure to passive smoke further increased the odds against a woman conceiving within 6 months. Smoking by the mother, the father, or other exposure to tobacco smoke were all associated with a longer time to conception. (9). Newer data emphasizes the effect of side stream smoke on embryo quality and IVF success.

To these data should be added the adverse effects of cigarette smoking by males on their own sperm counts and fertility (2,4,5,12,13) beyond the effect on their partners through passive and side stream smoke (14).

Smoking is also clearly associated with an increase in spontaneous miscarriage (6); with bacterial vaginosis (which can be associated with late pregnancy miscarriage); with preterm labor (4,5); risk from multiple pregnancy (10); and with delivery of low birth weight infants who are at added risk of neonatal morbidity and mortality (11,4,).

One piece of good news: while some of the damage to eggs may be irreversible, stopping smoking seems to help fertility since ex-smokers have fertility similar to that of women who have never smoked, often when they quit within a year of starting to try to conceive (8). And getting males to stop is also imperative as smoking may affect their fertility and/or affect that of the female through side stream or passive smoke. Some fertility clinics, like our own at Shady Grove Fertiltiy, require that partners stop smoking for at least three months before embarking on fertility therapies as a means to improve success rates for them. We offer smoking cessation as an integral part of our clinic, often through hypno-smoking cessation techniques.

One of the most sobering parts of all this data and information is the lack of knowledge about infertility, miscarriage, ectopic pregnancy and early menopause not only by patients but even by health care professionals. An abstract by Roth (15) detailed the results of a questionnaire given to health care workers about their knowledge of the effects of cigarette smoking. Here are the sobering results comparing the known risks of smoking to the percent of health care workers knowledgeable about the risk:

Clearly, this article reflects our desire to provide information and to educate health care professionals and you, our patients, about the reproductive health risks caused by cigarette smoking as one cause of preventable infertility.

Bottom line: if you and or your partner smoke and you are trying to conceive, or are worried about conceiving, and / or are worried about the outcome of a pregnancy conceived - you should stop smoking NOW.

References
1. U.S. Department of Health and Human Services: The health consequences of smoking: a report of the Surgeon General. Washington, D.C., U.S. Government Printing Office, 1984
2. Seminars in Reproductive Endocrinology: Smoking and Reproductive Health: Robert J. Stillman, M.D. Editor, Thieme Medical Publishers, Inc., New York, November 1989
3. Weisberg, E. Smoking and reproductive health. Clin. Reprod. Feril., 1985; 3, 175-186
4. Stillman, R.J., Rosenberg, M.J. and Sachs, B.P. Smoking and reproduction. Fertil. Steril., 1986; 46, 545-566
5. Fredricsson, B. and Gilljam, H. Smoking and reproduction. Short and long term effects and benefits of smoking cessation. Acta Obstet Gynecol. Scand., 1992; 71, 580-592
6. Edward Hughes, M.B., Ch.B., Barbara G. Brennan, M.D., Ph.D. Does cigarette smoking impair natural or assisted fecundity? Fertil. Steril. 1996; 66, 679-89
7. C. Augood, K. Duckitt, A.A. Templeton Smoking and female infertility: a systematic review and meta-analysis. Hum. Reprod.
8. Curtis, K.M., Savitz, D.A. and Arbuckle, T.E. Effects of cigarette smoking, caffeine consumption and alcohol intake on fecundability. Am. J. Epidemiol., 1997; 146, 32-41
9. Hull, M., North K., Taylor, H., Farrow, A., Ford, W.C., et al., Delayed conception and active/passive smoking. Fert Steril 2000; 74,724 - 732.
10. Parazzini, F., Chatenoud, L., Benzi, G. et al. Coffee and alcohol intake, smoking and risk of multiple pregnancy. Hum. Reprod. 1996; 11, 2306-2309
11. Llahi-Camp, J.M., Rai, R., Ison, C. et al. Association of bacterial vaginosis with a history of second trimester miscarriage. Hum. Reprod. 1996; 11, 1575-1578
12. Vine M.F., Smoking and male reproduction: a review. Int. J. Androl. 1996 Dec/, 19(6):323-37
13. K.A. Joesbury, W.R. Edirisinghe, M.R. Phillips, and J.L. Yovich Evidence that male smoking affects the likelihood of a pregnancy following IVF treatment: application of the modified cumulative embryo score. Hum. Reprod. 1998; 15, 1506-1513
14. Zenzes MT, Krishnan S., Krishnan B., Zhang H., Casper R.F., Cadmium accumulation in follicular fluid of women in in vitro fertilization-embryo transfer is higher in smokers. Fertil. Steril. 1995; 64, 599-603
15. Roth, L., Taylor, H.S., Yale University School of Medicine, New Haven, CT., USA. Smoking Risks to Reproductive Health: Assessment of Women’s Knowledge. P 235 Conjoint Annual Meeting of the American Society for Reproductive Medicine and the Canadian Fertility and Andrology Society. September 25-30, 1999 Toronto, Ontario, Canada