Pacific Fertility Center is now participating in an important program that helps protect the fertility of cancer patients undergoing chemotherapy and radiation. Fertile Hope, an advocacy organization that raises awareness about fertility issues for cancer patients, is partnering with carefully selected clinics throughout the US in a program called Sharing Hope. The program will be open to those who have been diagnosed with cancer, want to preserve their fertility and have limited financial means. Sharing Hope offers qualifying cancer patients significant discounts for fertility-preservation treatments, such as embryo freezing and egg freezing before undergoing chemotherapy, radiation and/or surgery.

Cancer treatments can affect fertility in both men and women. In some cases infertility will be temporary, but in others it will be permanent. Currently, options are limited for cancer patients wishing to preserve their fertility. Men may freeze their sperm prior to cancer treatments to be used for artificial insemination or IVF. This is quite successful and in most cases at least 50% of a man’s sperm will survive freezing and thawing. The best option for women is to freeze embryos (via IVF). Yet this offers a viable solution only to women with partners or those willing to use donor sperm. What is the single woman diagnosed with cancer to do? She has not yet found Mr. Right, or even Mr. Perfect Sperm Donor, but knows she wants to have a child in the future. The bright spot may be egg freezing. Still considered experimental, egg freezing is a relatively new procedure and has much lower success rates than embryo freezing. Some say the numbers for egg freezing are around 1 live birth for every 100 eggs frozen, yet there are clinics around the world claiming to have 1 live birth for every 10 eggs frozen. The success of egg freezing will continue to improve as technology and scientific knowledge develop. PFC will offer egg freezing in the near future.

For some people, the idea of losing their fertility is as devastating as the diagnosis of cancer. Often, cancer patients have little time or opportunity to gather funds for the high cost of cancer treatment, let alone fertility preserving treatments. At PFC we hope to extend a helping hand to cancer patients unable to afford these costly treatments and to provide them with the hope of building a family.

You may find out more about Sharing Hope at Fertile Hope’s website

Law Tries to Keep Up with ART: A spate of judicial decisions here in California has family law attorneys paying close attention to a handful of unique conflicts, or “gray zones” made in some way possible by Assisted Reproductive Technologies (ART). As the definition of “family” expands more broadly, thanks to ART, new laws are actually being forged. Couples that don’t fit the rubric of a traditional family (heterosexual man + woman = marriage) are being asked to make sure they have all of their legal ducks in a row.

A few California cases are summarized here, including at least one that may reach the state Supreme Court.

Lesbian Parents and Child Support: This complex case involves two lesbian partners, not registered as domestic partners, who jointly agreed to have children using the same sperm donor. Both women conceived, one year apart, and one of the infants was born with Down syndrome, prompting one of the women to remain at home as the care-giver. Two years later, the two women separated and the primary caregiver began receiving monthly child support payments from the woman who worked. When the child support provider halted payments after 18 months, county social workers attempted to tap her wages, a standard to which a biological father would have been held.

Although a Superior court judge agreed with the county that child support payments should continue because the woman showed initial “intent” to raise the children, this past May the Court of Appeal in Sacramento reversed that decision to the dismay of gay rights legal activists. This decision is particularly disturbing, asserts Deborah Wald, a San Francisco attorney who specializes in non-traditional family law. “Children of same-sex couples do not have the same rights compared to children that have two parents of opposite sex; this is a shocking ruling and one that we are confident that the state Supreme Court will overturn,” she said. Posthumous Conception: Many are anxiously watching a case that is pending final decision by the Los Angeles federal court. A wife had medical personnel extract her husband’s sperm for freezing after his unexpected death. This was not contested. Four years later, after she conceived a daughter with his sperm, the mother sought Social Security survivor benefits. Although she didn’t seek inheritance or life insurance claims, the outcome of this case is expected to have implications in these other areas.

The Social Security Administration denied the benefits, insisting that the deceased dad is not recognized as the father under California law. The SSA follows specific state guidelines in resolving such issues, and has granted posthumous benefits in other states. But California has no laws governing children conceived after the death of a parent. This case has simultaneously prompted the state Legislature to craft AB 1910, which is enjoying broad support. This bill establishes that a posthumously conceived child is entitled to inheritance rights and other benefits under the Uniform Parentage Act if the decedent intended his or her genetic material to be used for posthumous conception of the child and expressed it in writing. It is expected to be signed by the Governor in September. Copies can be found at www.assembly.ca.gov .

Lesbian Parents and Custody: A woman who provided the donor eggs for her female partner, enabling the partner to conceive twins, signed away her parental rights per a standard egg donor contract used by a Bay Area infertility clinic seven years ago. Nevertheless, the two women spent the next six years living together and raising the children. As the egg donor started pressuring the gestational mother about being identified as a legal co-parent, their relationship fell apart, and the gestational mother moved across country with the twins, eventually cutting off all contact between the children and the egg donor.

A California Court of Appeals ruling affirmed the gestational mother’s hold on primary custody, saying its decision is based on the “intent” contract signed by the egg donor, which absolved her of all parental rights and future claims. The biological mother has appealed, the case has received a flurry of press, and the case may end up at the First District Court of Appeal in 2005.

Couples who are at risk of passing on an inherited disease are probably familiar with genetic counselors. However, those who have decided to undergo IVF with Preimplantation Genetic Diagnosis (PGD) will need to see a genetic counselor who is specialized in the procedure of PGD itself. It is important to make sure that the mutation in question can be diagnosed by PGD since not all heritable diseases have DNA probes. And sometimes there are other means of using PGD to determine mutation likelihood.

In cases where there is concern about chromosomal abnormalities rather than single gene defects, Preimplantation Genetic Screening (PGS) is another option that requires a genetic counseling session. The genetic counselor can help patients understand the basics of chromosomes, how they affect the health of embryos and what this testing conveys about the embryos.

Some of the common reasons why patients undergo PGS include:
1. Age (eggs of women >35 years old have a higher risk for chromosome abnormalities),
2. Unexplained recurrent pregnancy loss,
3. Gender selection for genetic disease,
4. History of unexplained unsuccessful IVF cycles.

Who Are Genetic Counselors?
Genetic counselors are health care professionals with graduate degree training in genetics and counseling, and certified by the American Board of Genetic Counseling. Genetic counselors practice in several subspecialty areas of genetics including assisted reproduction technologies, infertility genetics, and prenatal diagnosis. Because your genetic counselor can see you to discuss PGD or PGS, as well as prenatal testing options once you are pregnant, you will receive continuity of care. He/she will help you understand the complex information involved in your PGS cycle, and encourage your own decision making according to your needs. He/she will also serve as a liaison between you, your fertility doctors, and the PGD/PGS laboratory.

What Happens During A Genetic Counseling Visit?
There are two main objectives:
1. Family History Review: Your genetic counselor will take a three generation family tree (pedigree) to identify any additional genetic risks. This process ensures that the type of screening being offered is correct, and to identify any additional testing needed. Medical records may be requested for review.
2. Informed Consent: Informed consent includes an in depth discussion of the PGD/PGS process, from beginning to end, and a review of the information in the consent form, which is designed to inform and protect patients. Important information contained in the consent form includes risks and limitations of PGD/PGS, as well as the purpose of the procedure and the diagnostic technique. Your genetic counselor is available to answer questions regarding its content and to help you thoroughly understand it before signing. For those who have already gone through IVF, the beginning of the IVF with PGD/PGS cycle will be familiar. However, as complex as IVF is, embryo testing adds yet another layer of complexity. Additional steps include biopsy procedures, screening of a single cell for specific chromosome abnormalities or DNA mutations, and reviewing the results prior to embryo transfer. Only a genetic counselor is especially trained to mentally guide you through this process before you are actually in cycle so that, hopefully, there are no unanticipated outcomes.

How Can I Find Out More?
Please contact the Certified Genetic Counselor working with Pacific Fertility Center: Lauri Black at (415) 600-6371.

– Carolyn Givens, MD and Lauri Black, MS, CGC contributed to this article

The marketplace offers a dizzying selection of devices to help women predict ovulation to increase their odds of conceiving. Collectively, these products are called ovulation predictor kits (OPKs) or fertility monitoring devices.

They are broadly grouped into two main types: those that gauge a woman’s Luteinizing hormone (LH) surge and those that monitor one’s estrogen level. The LH surge is tracked with urine testing strips, which are then discarded. Estrogen can be tracked with longer-use fertility monitoring devices that check saliva or other bodily fluids.

When under-going artificial insemination (AI) and intrauterine insemination (IUI), women need a very precise measurement of ovulation. Single-use OPKs that require urine testing first thing in the morning or after 2-4 hours of “holding it” are ideal for this. They react when a woman’s pituitary gland sends out an LH surge, directing the egg to leave the ovary in 24-36 hours, like clockwork. The egg then spends the next 6-12 hours sliding down the fallopian tube where it must be fertilized before implanting into the uterus. This critical window requires sperm to be on the spot, ready to fertilize.

For LH testing, PFC recommends ClearPlan/ClearBlue Easy and Ovu-Kit One-Step because, in our experience, they tend to give the most unambiguous results. The kits that are not as highly recommended are Answer, First Response and generics; they appear to be more prone to false negative results.

For couples timing pregnancy to the LH surge, natural intercourse is recommended both on the day that the kit changes, and the next day. If a couple is going through IUI with fresh sperm, the insemination will be timed the day after the kit shows ovulation. If frozen sperm is being used, many times two inseminations take place: one on the day of change and another the following day.

The longer-use ovulation monitors that use saliva to measure estrogen levels typically identify a 72 hour peak “zone” of fertility. Tracking estrogen levels can be a fascinating process, although patients may need additional time to train their eye to spot the critical pattern that appears in saliva with elevated estrogen. Curiously, the salt content in body fluids increases with a rise in estrogen. Once dried in a magnified setting, the saliva reveals a distinct crystallization, or “ferning” from the salt level (see illustration on left), similar to ice patterns on a frosty window.

Some name brands include Fertile Focus, the Donna and Lady-Q. These devices are useful if couples can have frequent intercourse during their 3-6 day zone of fertility.

A brand new product that also tracks ovulation via estrogen levels uses a wrist watch-like calculator that must be worn every night. This device makes direct contact with one’s skin, and uses a sensor that contains a non-allergenic gel released to detect one’s estrogen from the moisture released off the wrist.

Since PFC has not reviewed the estrogen-monitoring products and their efficacy, patients are strongly advised to do their own research.

*Reproduced with permission: www.maybeit.com

Following Halloween, the holiday season suddenly looms. Excited children, crowded stores, decorations, and holiday parties are all set to descend on us. Yet because the winter holidays tend to celebrate families and children, these usually joyous occasions can bring up painful feelings when you are struggling to create and celebrate with a family of your own. In order to feel as good as possible during the holidays, you will need to develop some good holiday coping skills. Coping is “developing the ability to manage in a difficult situation.” Here are a few suggestions. Use whichever of these suggestions seems helpful to you. Do what feels right for you.

DO: Give up any and all feelings of guilt for how you are feeling. There is no right or wrong way to experience infertility. Your feelings may run the gamut from indifference to intense anger and despair and everywhere in between.
DO: Reach out to childfree friends. Their parties will be adult-focused.
DO: Choose the gatherings you attend carefully. If you are upset by being around children or babies gracefully decline invitations to events where they are likely to be present. Know your limits and stick with them.
DO: Think of non-child centered holiday rituals. Take a vacation. Eat at a fancy restaurant.
DO: Continue to get moderate amounts of exercise. Eat healthy and get plenty of rest. You will feel better if you treat your body with care.
DO: Shop for the holidays online or from catalogs. You will avoid mall madness.
DO: Attend religious services at the time when there will be the least number of children. Or attend on a university campus, as those services tend to be more adult focused.
DO: Volunteer at a nursing home or homeless shelter. It may help to help others having a difficult time at the holidays.
DO: Plan for how you will answer uninvited questions about when you’re going to have children. Remember, you are not required to tell them your entire “story!”
DO: Meet and talk with others who are experiencing similar feelings. Finding that you are not alone helps. DO: Communicate with your partner to let him/her know of your feelings. If you are single, call a friend with whom you feel safe to share your feelings.

Alcohol and pregnancy don’t mix.

This article includes contributions from Isabelle Ryan, MD and Beth Schriock, MD

Studies have tied alcohol consumption during pregnancy to increased risk for stillbirth and first trimester miscarriage. Indeed – alcohol abuse by women who are expecting is the number one cause of birth defects, premature births, low birth weight and mental retardation. A shocking 12,000 babies each year are born with Fetal Alcohol Syndrome (FAS) and at least twice that many with the milder Fetal Alcohol Effects (FAE) associated with learning disabilities and lower alcohol intakes.

While the tragedy of FAS is well established, less certain is whether casual consumption of alcohol while trying to conceive either hinders or helps a woman’s chances. Past published studies have been mixed as to whether there is an association between moderate alcohol consumption and waiting time to pregnancy. One study did show decreased probability of conception in women imbibing 1-5 drinks per week. Another study saw no effect of 7 or more drinks per week in younger woman but women over 30 were more likely to be infertile. None of these studies have stratified the data to see if any type of alcohol might benefit or hinder. Yet a recent study drew a mildly positive correlation between moderate wine drinking and pregnancy.

The study, published in the September Journal of Human Reproduction was conducted at the Danish Epidemiology Science Center in Copenhagen by Mette Juhl, who had already researched the impact of moderate alcohol consumption on conception. Her past survey work concluded that moderate consumption of alcohol (up to 7 glasses per week) does not reduce a woman’s chances of purposefully getting pregnant.

For this study, the researcher set out to take a closer look at specific types of alcohol consumed by the 29,844 pregnant women who had participated in the first survey. Researchers discovered that wine drinkers had a nearly 30 percent greater chance than nondrinkers of getting pregnant within one year of trying. Woman who exclusively drank wine became pregnant sooner than those that drank only beer or hard liquor (spirits). Interestingly, drinking all three types of alcohol was associated with the shortest time to pregnancy.

Again, the study confirmed that heavy drinking of spirits actually decreases conception chances. Women who drank more than seven shots per week were 240 percent less likely to conceive. However, it is important to note that many of these women also had other risk factors for subfertility (smoking, greater incidence of pelvic infections or abdominal surgeries).

Ms. Juhl is cautious to point out that it may not be wine consumption per se, causing the increase or decrease in pregnancy success, but rather other lifestyle influences that may go along with wine drinking. For instance, some oenophiles enjoy healthier food than nondrinkers and beer or liquor drinkers. They also are more likely to be of average weight, and practice healthier lifestyle habits. The wine drinkers were less likely to smoke; smoking has been shown to prolong time to conception. Other confounding factors such as caffeine consumption, partner’s age and frequency of intercourse were not evaluated. She cautioned against drinking alcohol specifically to try to conceive, since this benefit was quite mild.

As little as one drink per day in pregnant women has been linked to decreased cognitive performance in their infants. Alcohol can have detrimental effects on the fetus as early as three weeks gestation – before a woman even knows she is pregnant. The “safe” amount of alcohol intake for pregnant women has not been established. Given that wine drinking could just be a proxy for a healthier lifestyle and the known negative effects of alcohol on the fetus, it is premature to encourage the consumption of wine to enhance conception.

For now we at PFC endorse the positions of the Centers of Disease Control (www.cdc.gov/ncbddd) and the American Academy of Pediatrics (www.AAP.org) advising that women attempting pregnancy should abstain from alcohol.

References:

American Academy of Pediatrics: Preventing Fetal Alcohol Syndrome. www.aap.org/advocacy/chm98pre.htm

CDC: Alcohol Use and Pregnancy. www.cdc.gov/ncbddd

National Institute on Alcohol Abuse and Alcoholism: Fetal Alcohol Exposure and the Brain. www.niaaa.nih.gov/publications/aa50.htm

Barefoot JC, Gronbaek M, Feaganes JR, McPherson RS, Williams RB, Siegler IC. Alcoholic beverage preference, diet, and health habits in the UNC Alumni Heart Study. American J of Clinical Nutrition 2002;76 (2): 466-472.

Bolumar F, Olsen J, Boldsen J. Smoking reduces fecundity: a European multicenter study on infertility and subfecundity. The European Study Group on Infertility and Subfecundity. Am J Epidemiol. 1996; 143 (6): 578-87.

Bolumar F, Olsen J, Rebagliato M, Bisanti L. Caffeine intake and delayed conception: a European multicenter study on infertility and subfecundity. The European Study Group on Infertility and Subfecundity. Am J Epidemiol. 1997; 145 (4): 324-34.

Jacobson JL, Jacobson SW, Sokol RJ, Martier SS, Ager JW, Kaplan-Estrin MG. Teratogenic effects of alcohol on infant development. Alcohol Clin Exp Res. 1993; 17 (1): 174-83.

Jensen TK, Hjollund NH, Henriksen TB, Scheike T, Kolstad H, Giwercman A, Ernst E, Bonde JP, Skakkebaek NE, Olsen J. Does moderate alcohol consumption affect fertility? Follow up study among couples planning first pregnancy. BMJ. 1998; 317: 505-510.

Juhl M, Andersen AM, Gronbaek M, Olsen J. Moderate alcohol consumption and waiting time to pregnancy. Human Reproduction. 2001; 16 ( 12) 2705-2709.

Juhl M, Olsen J, Andersen AM, Gronbaek M. Intake of wine, beer, and spirits and waiting time to pregnancy. Human Reproduction. 2003; 19 (9): 1967-1971.

Kesmodel U, Wisborg K, Olsen SF, Henriksen TB, Secher NJ. Moderate alcohol intake during pregnancy and the risk of stillbirth and death in the first year of life. Am J Epidemiol. 2002; 155 (4): 305-12.

Kesmodel U, Wisborg K, Olsen SF, Henriksen TB, Secher NJ. Moderate alcohol intake in pregnancy and the risk of spontaneous abortion. Alcohol Alcohol. 2002; 37 (1): 87-92.

Rosenberg A. Brain Damage Caused by Prenatal Alcohol Exposure. Scientific American. July/August 1996; 42-51