Welcome to your November 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. Implantation Failure
3. Adoption Option - The Ten Commandments of Private Adoption
4. Support Services
   1. New York City In-Person Couples Support Group Now Forming
   2. Westchester Women's Group
   3. Ovum Donation Seminar - Fall Series 2006
   4. AFA Adoption Series - Fall 2006
   5. West Coast Programs
5. Stay Connected

A Message from the Executive Director

Pamela Madsen

Dear Friend of The AFA, Halloween is come and gone. Thanksgiving is so close I can smell the giblet gravy. Almost. I can certainly smell the holiday season anxiety that starts simmering among our members right about now. It’s an annual eruption. After all, holidays usually mean extended exposure to extended family—parents, siblings, nieces, nephews, friends and their kids. Let’s face it, when you’re wrestling with reproductive difficulties, the whole Rockwell-ian festival that lasts from turkey day to New Year’s Eve can feel a bit Orwellian. Do not sweat it. You’re in good company. Indeed, there are so many holiday syndrome sufferers that The AFA produced a fact sheet devoted entirely too holiday-related stress. For a good read, jack into The AFA website and get some comfort and some tips for coping with grace. And while you’re at it, peruse the site and reacquaint yourself with the many different ways you can use www.theafa.org to find support and solid information any time of the day or night. This is one invaluable resource that’s at your disposal because you already have something priceless – a No Barriers membership in The AFA. For example, right now you could be getting the inside skinny on complementary medicine (and stress management) in the newest issue of inFocus magazine, the one with yoga guru, Desperate Housewives star and our national spokeswoman, Brenda Strong, on the cover. Or you could be lining up the moderated message boards that interest you. When you join in one of those sessions, you get the country’s top professionals--doctors, lawyers, psychologists, among others—answering your questions -- often the same day, almost in real time. What with November being National Adoption Month, this is an opportune time to log on to the adoption message board to investigate this remarkable family-building avenue. Even if you’re still pursuing ART, The AFA always encourages people to explore all the possible ways to have children and develop a comfortable knowledge base about the alternatives. Look inside this Connections issue to find the schedule for our weekly online educational meetings. These amazing sessions give you the chance to speak with an expert online every week in real time, get your questions answered and enjoy the group dynamics from the ease of your own home. The AFA website is rich with fact sheets, brochures, relevant news updates and announcements of special events. It’ll also give you the phone number for our helpline to assist you with any issues you’re confronting, whether it’s needing a second opinion, finding an ART center, or something quite personal. Don’t forget, too, that The AFA’s site provides a venue for peer support, one of the most important pillars of understanding and advice when you’re dealing with fertility matters. Our services don’t end there. If you do get pregnant or adopt, we want you to take advantage of the pregnancy and parenting message board. So stick around. Once you get familiar with www.theafa.org you’ll find we can keep you company down all the roads you travel to get to the family you want and deserve. Looking forward to connecting with you all. Happy Thanksgiving! Pamela Madsen Executive Director

Implantation Failure
By Michael A. Feinman, MD, FACOG

Michael A. Feinman, MD, FACOG

Implantation failure, in theory represents the major cause of infertility and treatment failure in many patients. For women with conditions like endometriosis or unexplained infertility, it is reasonable to believe that eggs are occasionally being fertilized in the tubes, but not implanting in the uterus. For women who require ovulation induction or undergo IVF without conceiving, implantation failure is more obvious.

Unfortunately, the science of understanding implantation failure has not kept up with the other advances in reproductive medicine. This is largely due to the lack of funding available to study the subject and the difficulty in obtaining material from patients. It is hard to study embryos or endometrial tissue in women undergoing treatment.

Breaking the problem down to its essential components, implantation failure can be due to problems with the eggs, the sperm, or the uterine environment. In contrast to the latter two problems, it is clear that many embryos are not competent due to chromosomal abnormalities that occur at the time of ovulation and fertilization. These errors increase with maternal age.

This article will briefly review what is known about sperm and the uterine environment.
Over the past decade, new research has illuminated the potential role of sperm in creating non-viable embryos. Similarly, some workers have developed tests that may identify women whose endometrial lining is the cause of implantation failure. Finally, the controversial role of the immune system will be discussed.

Before discussing these newer and controversial areas, it is important to remember that the simple things should be checked first. The most important of these is the shape of the uterus. Through the years, we have seen many women with repeat IVF failures or miscarriages who have a uterine septum that was either ignored or missed by her doctors. A septum can be diagnosed by hysterosalpingogram, hysteroscopy, and MRI. In the hands of a good observer, a septum can be detected on sonohysterogram too. The most common error in diagnosis is made with hysterosalpingogram. It is important to have your doctor view the actual films before accepting the diagnosis of a normal uterine cavity. When in doubt, a hysteroscopy is definitive. In our experience, repairing these abnormalities greatly improves IVF outcomes. Thus, the discussion below only applies to women with normal uterine cavities!

Over the past decade, a number of tests have been developed that evaluate the stability of sperm DNA under harsh conditions. The most well-known version of these tests is the Sperm Chromatin Structure Assay (SCSA). These tests have been shown to be more predictive of fertility than the routine semen analysis. Men with poor test results are less likely to fertilize eggs (even with ICSI), resulting embryos are less likely to implant, and pregnancies are more likely to miscarry. Some evidence is mounting to suggest that the presence of a significant varicocele in the male may be the source of an abnormal test. Thus, in couples with longstanding unexplained infertility or repeated treatment failures, a SCSA or similar test may be indicated. If the test is poor, an examination for a varicocele can be considered. If there are no correctable explanations for the poor test result, allowing embryos to develop to the blastocyst stage and transferring more than the usual number may be a reasonable option.

As with the male factor, tests have been designed to assess the endometrium’s role in implantation failure. These tests measure so-called “implantation markers” in the uterus. At least two tests have been reported in the literature with good predictive value of outcomes and are clinically available. These are the beta-integrin test and the endometrial function test. Both tests are performed on an endometrial biopsy taken on specific days of a natural or hormone replacement (“mock”) cycle. Abnormal results have been shown to predict lower success rates with IVF. Possible causes of abnormal results are the presence of hydrosalpinges, endometriosis, either extreme of the weight range, and stress. The originators of these tests have individual patient stories showing that women conceived after correcting the biopsy result. It is important to remember that no test is perfect. Despite abnormal results, some women still conceive, and this fact is well-reported in the literature.

Finally, a great deal of attention has been paid to the possibility that the immune system may play a role in implantation failure. A myriad of tests have been developed to look at the possibility that the woman rejects her own tissue (autoimmunity) or her husband’s genetically foreign body (alloimmunity). Few people doubt that these phenomena may occur. The problem is that there are very few clinical trials that prove the predictive value of these tests, or the effectiveness of suggested treatments. Some of the recommended treatments can be expensive or potentially dangerous. For example, one of the treatments known as leukocyte injection therapy (LIT) was banned by the FDA. While there may be a role for this evaluation and treatment in a small number of women, it is clear from the above discussion that embryo and endometrial factors account for the majority of implantation failures.

In the face of longstanding infertility or repeat treatment failures, a thorough review of the history and previous tests is the appropriate first step. We have seen many women with undiagnosed or untreated uterine septums in this setting. If everything checks out, tests like the SCSA and the endometrial biopsy for implantation markers should be considered. If all the above prove normal, tests for immune factors may be appropriate for these few cases.

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Adoption Option

THE TEN COMMANDMENTS OF PRIVATE ADOPTION
By Robin A. Fleischner, Attorney at Law

Robin A. Fleischner

Over the course of twenty years as an adoption attorney, I have found myself repeating the following ten principles of advice for achieving a successful private adoption.

I. You and the birth parents deserve to be treated with respect and compassion.

As a result of the very emotional nature of the adoption process, you and the birth parents are extremely vulnerable. Since you all want to act ethically and humanely, you should treat each other with respect and compassion. It is equally important to demand that attorneys, doctors, agencies, and social workers involved in your adoption treat you with respect and compassion as well.

II. Come out of the closet and broadcast your decision to adopt.

Once you decide to adopt, make the adoption your central focus, and be proactive. Tell and write to as many people as possible about your desire to adopt – friends, family, acquaintances, business associates, doctors, dentists, teachers, clergy, congregants, nurses, social workers, counselors, college roommates. And ask anyone you contact to spread the word of your adoption crusade. In addition, you should advertise in newspapers and on the Internet.

III. Keep it safe. Keep it legal.

Almost all of the practical aspects of your adoption have legal importance. Before you take any action, choose an experienced adoption attorney so that you will be able to finalize your adoption safely and legally in your state pf residence. Excellent resources for locating an attorney are: support groups, such as the American Fertility Association (888-917-3777 or www.theafa.org); The Child Information Gateway (www.childwelfare.gov/nad/), and the American Academy of Adoption Attorneys (www.adoptionattorneys.org).

IV. It ain’t over ‘til it’s over, but once it’s over, it’s over.

One of the most pressing concerns for adoptive parents is ending birth parents’ rights once the adoptive parents have custody of a child. Your attorney or agency will provide for quick, informed ending of birth parents’ rights. Generally in a private adoption, adoptive parents connect with a pregnant woman and make an adoption plan with her during the pregnancy. However, birth parents’ rights are not terminated until after the baby is born. You should proceed with optimism, but with a realistic understanding that the birth mother may choose not to place the baby for adoption. Continuing to explore all leads is always helpful until a child is placed for adoption with you. Once the birth parents rights are ended (generally between 72 hours and three months after the baby’s birth), they cannot come back to reclaim the child.

V. The first healthy baby is the best baby for you.

Don’t second guess yourself. If you have the opportunity to adopt a healthy baby, act immediately and do not pass up the chance for an adoption because you have heard about another situation that might appear more attractive.

VI. You have to connect the dots.

Remember connect-the-dots coloring books from childhood? As you began connecting the numbered dots, the picture emerged, but you usually recognized what the image would be even before you were finished. To spot an adoption scam, you need to connect the dots, the clues that let you know whether a birth parent, attorney or agency is legitimate. Support groups for adoptive parents offered by the AFA are invaluable in helping you obtain reliable referrals. The homestudy process is another way to obtain reliable adoption referrals from the social workers who visit with you. Once you retain an experienced adoption attorney in your state, he or she will help you screen birth parents. Listen to your attorney’s advice.

VII. Expenses are a legal issue.

The goal is that you succeed in your adoption with a minimum of risk, both financial and emotional. You should never give money to a birth mother. Your attorney will approve and monitor all expenses, which will be paid through an attorney trust account. Although you can pay for the birth mother's medical expenses, many birth mothers qualify for Medicaid and some have medical insurance. Your medical insurance will cover the baby from birth, but not the birth mother. In addition, you can pay for the birth mother’s counseling, reasonable living expenses during the pregnancy and recovery, and legal expenses.

VIII. Objective information is key.

Your attorney will help you evaluate whether a potential birth mother is pregnant and committed to an adoption by speaking with her and sending her a social and medical history questionnaire and an authorization for release of her prenatal medical records. Once your attorney receives the completed questionnaire and signed medical release, he or she will obtain the birth mother’s prenatal medical records and forward them to you with the social and medical history. You will have your doctor will review the medical information and advise you about the baby’s health.

IX. Establish a relationship with the birth mother.

The best way to ensure that a birth mother is committed to the adoption plan is to establish a caring relationship with her. Adoptive parents usually set up a weekly phone call with the birth mother during the pregnancy and meet with her (without revealing their identities if they wish) before placing the child for adoption. Connecting with the birth mother is the best way to obtain background information for your child. After the baby is placed for adoption, the adoptive parents and birth parents can correspond. Adoptive parents can exchange letters and photos with birth parents without disclosing their identity by opening a confidential post office box for the correspondence.

X. Never give up hope.

Do not allow yourself to be discouraged by setbacks. Remember that you are one lucky phone call or contact away from your dream. Everyone who continues to work toward an adoption will succeed.

Robin Fleischner is an adoptive parent and an attorney with offices in New Jersey and New York, whose practice is dedicated to helping adoptive parents form families through adoption. She is a member of the American Academy of Adoption Attorneys, the American Fertility Association, and the Family Law Sections of the New York and New Jersey Bar Associations. Ms. Fleischner lectures and writes frequently about adoption. You can reach her at (212) 362-6945 or via email at robin@adoptionlawyer.com

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Support Services

In New York City:

New York City In-Person Couples Support Group Now Forming

This group will focus on how during fertility treatments couples are often at "different places" on what paths they are ready to pursue during their decision making process. The participatatnts will learn techniques in helping them resolve their differences, even when partners are in disagreement in how they desire to pursue parenthood.

Facilitated by Joan Winograd, LCSW, and AFA Support Group Leader. Space is limited.

Contact Joan at 212-362-4003 or e-mail at Joanwino@aol.com with your contact information.

Westchester Women's Group

A support group for women with infertility is commencing In Larchmont/ New Rochelle. Here's an opportunity to share emotions and concerns while acquiring information on current procedures and alternative treatments. A confidential and safe environment contributes to your ability to explore options and know you're not alone in your quest for a successful pregnancy.

5 Wednesday evenings beginning Dec. 5th

OVUM DONATION SEMINAR
FALL SERIES 2006

The American Fertility Association is sponsoring a six week Ovum Donation Seminar Series beginning Tuesday November 7th and continuing weekly on Mondays for a total of six consecutive weeks. Topics that will be discussed by our distinguished faculty will include:

AFA ADOPTION SERIES
FALL 2006

The American Fertility Association is presenting a 5-week series of workshops designed for people who are considering adoption and want to learn about their options.

Topics to be discussed by adoption experts include:

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—November-December 2006