fsa newsletter march 05 aim - fertilitysociety.com.au · keith harrison tel: (07) 3832 3279 e-mail:...

FSA Update

Working by the Code

Newsletter of the Fertility Society of Australia Volume 57 March 2005

Working by the Code

FSA Newsletter March 05 AIM 14/3/05 3:52 PM

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1

The FSA Newsletter is the

official publication of the

Fertility Society of Australia

FSA Secretariat

Waldron Smith Management

Danks Street,

Port Melbourne, Vic 3207

Telephone: (03) 9645 6311

Facsimile: (03) 9645 6322

e-mail: [email protected]

website: www.fsa.au.com

Secretary

Dr Gayle Jones

Monash Medical Centre

Institute of Reproductive

& Development

Level 5, 246 Clayton Road

Clayton, Victoria 3168

Treasurer

Roger Stables

Repromed Pty. Ltd.

180 Fullarton Rd,

Dulwich SA 5065

FSA Newsletter Co-Editors

Anne Jequier

Tel: (08) 9381 2067


Keith Harrison

Tel: (07) 3832 3279


Production

The Lighthouse Public Relations

Trevor Gill Tel: (08) 8298 6217

Advertising Inquiries

Lindy O’Connell

Tel: (08) 8231 5188

CONTENTS

President’s Report 2

Complying with international benchmarks 3

2006 deadline to implement new standards 5

Briefs from the FSA meeting in Adelaide 6-7

FSA supporting new research projects 8-9

Funding applications for 2006 10

Fertility NZ report 11

Comment: The quagmire of male fertility 13-14

Fertility Nurses Australasia update 15

Around the States and Territories 16

On The CoverThe Code of Practice for Assisted Reproductive Technology Units has beenreviewed and updated by the Reproductive Technology AccreditationCommittee (RTAC) of the Fertility Society of Australia.

RTAC accreditation based on the latest version of the code will begin thisyear. From 2006, all ART units will be required to comply fully with theRTAC Code of Practice.

See the story on Page 5.

DISCLAIMER:

Views expressed by contributors to the FSA Newsletter, and advertisementsappearing in the publication, are notnecessarily endorsed by the Fertility Society of Australia


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New RTAC Code of Practice central toplans for a busy and progressive yearPRESIDENT’S REPORT It is shaping up as a significant year for the

Fertility Society of Australia with theintroduction of the new RTAC Code ofPractice.

In recognition of changes in the code, aseminar has been prepared to assist units inunderstanding the changes. The firstpresentation occurred in Melbourne inDecember. In this edition, Doug Saundersand Ian Pike report on the code, plans to raiseawareness of it and the associatedquestionnaire, and obligations to conform.

FSA Meeting in Adelaide

Thanks to Dr Jeremy Thompson and the localorganising committee for an excellent annualmeeting in Adelaide.

The scientific program was of the higheststandard and I am sure all who attendedfound it worthwhile. Changes implementedas a result of the FSA members’ survey in2004 proved very beneficial. The mostpositive showcase of these changes was thewonderful attendance at our conferencedinner.

The presentation of prizes on the last morningof the conference proved far more successfulwith a large crowd in attendance to recognisethe contributions of our colleagues and thegenerosity of the sponsors.

I must also thank those good spirited membersSue Brown, Joi Ellis, Peter Illingworth, HaroldBourne, Richard Henshaw and Bert Stewartwho contributed to the President’s debate. Agreat deal of preparation went into this eventand it proved highly entertaining. I feel someof my colleague’s talents are wasted in ARTand perhaps successful careers inentertainment should be considered!

The awarding of FSA research grants was alsoa highlight of the meeting with two additionalprizes awarded in recognition of the highquality of proposed studies. The grants are asfollows:

• Analysis of perinatal outcomes for mothersand singleton babies after ART: A pilot studyto ascertain the feasibility and mechanismof selection of “sub-fertile” women. ChiefInvestigators - Professor David Healy andAssociate Professor Gordon Baker (MonashIVF and Melbourne IVF).

• Perinatal determinants of late-life humanprostate disease. Chief Investigator -Professor David Handelsman (ANZACResearch Institute, NSW)

• A prospective, randomised, double-blind,placebo-controlled trial on the effect of

metformin on in-vitro fertilisation outcomein women with polycystic ovary syndrome.Chief Investigators - Dr Michael Costelloand Dr Una Conway, University of NewSouth Wales. Co-investigators - ProfessorMichael Chapman, Dr Rob Lahoud, DrDavid Knight and Dr Frank Quinn.

• Maternal reports of the health, behaviour,temperament and development of infantsconceived with ART. Chief Investigator - DrJane Fisher, Key Centre for Women’s Healthin Society, University of Melbourne. Co-investigator - Karin Hammarberg.

Congratulations to the successful applicants.

Conference bidding

The FSA Board of Directors has beenapproached by members looking for theSociety’s support in bidding for internationalconferences. Support has been offered asthese bids often prove very beneficial to theSociety.

Target events include the HumanReproduction Meeting in September 2008(Melbourne) and the Congress of theInternational Society of Andrology 2009(Melbourne). If either of these bids provessuccessful, the FSA Annual Scientific Meetingwill be held at the same time.

Ethical guidelines on use of ART

The National Health and Medical ResearchCouncil (NHMRC) has released a revisedversion of the document entitled “Ethicalguidelines on the use of assisted reproductivetechnology in clinical practice and research”.

This replaces the previous “Ethical guidelineson assisted reproductive technology” (1996)and it reflects significant changes to ART. Theguidelines may be found on the NHMRCwebsite www.nhmrc.gov.au or telephone tollfree on 1800 020 103 (extension 9520).

Meanwhile, the New Zealand Governmenthas released the NZ Human AssistedReproductive Technology (HART) Act 2004. I recommend reviewing both of thesedocuments.

Remember to mark the FSA Annual ScientificMeeting for 2005 in your diary. The meetingis in Christchurch from 3 to 7 September,2005.

Dr Peter Benny is heading the localorganising committee, which promises anexcellent conference.

Adrianne Pope,President, FSA

Dr Adrianne Pope

Additional researchgrants awarded inrecognition of the

high quality ofproposed studies

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ESHRE WORKSHOP

How European IVF clinics must complywith latest international benchmarks

Standards for some of our reagents for

use with humantissues do not exist,

yet are required to be defined

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KEITH HARRISON attended the ESHRECampus Workshop at Birmingham in January. Here he reports on some key outcomes.

Before 2001, there were no guidelines andstandards for tissue banking in the UnitedKingdom. In that year, the Department ofHealth established a code of practice but,because of the existence of the HFEA,gametes were excluded.

A Europe-wide EU Tissues and Cells Directivecomes into effect in April 2006 and differsfrom the code of practice in that itsapplication covers reproductive cells andtissues. The directive will have two technicalannexes defining practice and procedures.

The “competent body” to administer theDirective in the UK is likely to be a merger ofthe HFEA and another body being establishedcalled the Human Tissue Authority. Thismerged body, probably to be named theRegulatory Authority for Fertility and Tissues(RAFT), may commence function in 2008.

The inspectorate and its processes are likely tobe very different from the existing HFEA. ARTcentres presently not licensed by the HFEAwill have to comply with the directive by April7, 2006. Those currently licensed by the HFEAhave been given until April 7, 2007 to comply.

Annex 1, entitled The Technical Requirementsfor the Donation, Procurement and Testing ofHuman Tissues and Cells is available in draftform. Annex 2, the Technical Requirement forthe Coding, Processing, Storage andDistribution of Human Tissues and Cells, willdefine amongst other things the facilities andenvironment required to perform IVF.

The directive will cover all aspects of IVF,ICSI, IUI with washed semen, gamete andembryo storage, and reproductive donorprocedures. Each unit will require a “personresponsible” for its application.

It requires that a comprehensive clinic-widequality system be in place with fulldocumentation. It will define laboratorystandards, including air handling systems,clean rooms cryostorage facilities, andminimal standards for reagents.

These standards are likely to be based onGood Manufacturing Process (GMP)guidelines as currently employed in the tissuebanking code of practice.

Problems seen by those involved innegotiations for the development of the annexinclude:

• if “clean room” standards are required, asGMP could specify, could non-sterilespecimens, such as semen, be taken in tothe laboratory?;

• clean rooms define the frequency of airchanges, air locks, relative air pressures andmaximum personnel numbers. Mostlaboratories would have to be rebuilt tomeet this standard;

• clean rooms require a level of bodycovering greater than that required forsurgeons;

• all procedures, including ICSI, may have tobe done in a laminar flow unit as evenworking under oil is not considered aclosed system as required by GMP;

• could ICSI be done in a laminar flowcabinet due to the vibration and coolingeffects, and can laminar air flow beachieved around something as complex asan ICSI set-up?;

• standards for some of our reagents for usewith human tissues do not exist, yet arerequired to be defined;

• laboratories must have a designatedpurpose, and there must be separation ofclinical and research materials and activitiesunless research is done to the samestandard;

• all methods are required to be validated andanimal models would not be adequate, yetit is unethical to use human material forvalidation;

All procedures, including ICSI, may have to be done in a laminar flow unit

Cont. .

FSA Newsletter March 05 AIM 14/3/05 3:53 PM Page 5

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2006 deadline for implementation ofnew quality standards required in ART

RTAC GUIDELINES

• laboratory staff numbers would have toincrease as it would be very difficult for staffto move between laboratories;

• if staff have any form of an infectious illness,they are not permitted to work;

• most standard operating procedure manualsin their current form will not conform; and

• serum would have to be banked from alldonors and recipients, virtually indefinitely,to allow tests for infectious agents still to beperfected/discovered to be performed.

Hopefully, it will be recognised that manyGMP standards cannot be achieved in ARTlaboratories.

There is concern that the directive will allowsufficient flexibility since it applies to bone,cornea, skin, heart valves and haemopoieticstem cells as well.

Should the highest standards be applied, mostART laboratories would have to be rebuilt, andthe time frame for implementation is too shortto allow this to occur.

Having been involved in negotiations with theAustralian Therapeutic Goods Authority, I seesignificant parallels between the TGA’s stateddesires for the Australian ART industry and thestandards of the European Tissue Directive.

Australia is far better placed than the UK orEurope in that a majority of Australian ARTunits have some form of a quality systemalready in place as part of NATA or ISO9000accreditation, while laboratories there arestarting from scratch.

There was also some discussion on theappropriate standard for ART unit qualitysystem accreditation. ISO 17025/ISO 15189,as applied by NATA, was seen as morepreferable than ISO 9001 since it certifiescompetence as well.

We can only hope that our Europeancolleagues succeed in bringing commonsense to the application of the directive toART. There is also the need for the FertilitySociety of Australia to vigorously continue itsnegotiations with the TGA to maintain RTACas the accrediting body and arbiter ofstandards in Australia.

From Page 3

The Code of Practice for Assisted ReproductiveTechnology Units has been reviewed andupdated by the Reproductive TechnologyAccreditation Committee (RTAC) of theFertility Society of Australia.

The code sets and maintains minimumstandards for clinics and centres offeringassisted reproductive technology (ART) andencourages continuous improvement inquality of care offered to people accessingfertility treatment in Australia and NZ.

The code was first introduced in 1976 and itwas revised in 1992, 1997, 2001 and 2004. It is to be observed in units involved in thetreatment of patients with artificial insemination,surrogacy, in vitro fertilisation (IVF) andrelated techniques, and in all proceduresinvolving donated gametes or embryos.

RTAC Secretary, Dr Ian Pike, said theemphasis of the code had changed fromprescriptive instructions to allowing ART unitsto determine how best to access and managerisks in delivering the highest standards ofcare to patients undertaking fertility treatment.The code can therefore be used for regulatoryinspection and for self-audit.

Accreditation based on the latest version ofthe code will begin in 2005.

Dr Pike said that because of the change ofemphasis from previous versions, RTAC

accepted there would be a period of“reorientation” while quality managementsystems were developed.

“ART units undertaking accreditation in 2005will not be penalised if they have not fullyintroduced quality management systems atthe time of accreditation, but those units mustprovide evidence that they have begunintroduction,” Dr Pike said.

“From 2006, all ART units will be required tocomply fully with the RTAC Code ofPractice.”

A presentation outlining the new qualitymanagement elements of the code has beenheld in Melbourne in advance of inspectionsin April.

Another presentation may be held in Perthlater in the year. A special presentation hasalso been suggested for the FSA AnnualScientific Meeting in Christchurch inSeptember.

The questionnaire used for accreditation sitevisits has also been revised in line with theRTAC Code of Practice. Both of thesedocuments will be updated as comments arereceived during the implementation phase.

Any questions regarding RTAC and therevised Code of Practice should be directedto the Secretariat at [email protected]

Dr Ian Pike

Notice of ASRMmeeting in MontrealMembers of the FertilitySociety of Australia may haveexperienced troubleregistering for the last ASRMMeeting. This was caused by postal delays.

The next meeting is inMontreal from October 15 to 19, 2005. Registrationdocuments will be availableto download from the ASRMwebsite from about threemonths prior to the meeting.Please alert us to anyproblems you experience.

In addition, all submissions toFertility and Sterility are nowmade on-line via the website.

Doug SaundersFSA Representative at ASRM


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FSA meeting advances the benefits

FSA MEETING BRIEFS The Fertility Society of Australia annualmeeting in Adelaide in October addressed thetheme: “A Healthy Start: Good Things InModeration”.

The primary aim of the meeting was to sharegood news about improved understanding ofproducing healthy babies for our patients.

The local Organising Committee worked hardto ensure a balanced program for the interestof all groups within the Fertility Society. Thismeant assembling a diverse array ofinternational speakers on subjects such as:

• selecting the healthiest embryo;

• characteristics of a healthy placenta;

• a healthy diet for conception and pregnancy(we could all do with a healthier diet!);

• a healthy mind; and

• the benefits of single embryo transfer.

Our first plenary was presented by the IanJohnstone Lecturer, Professor Marilyn Renfreefrom the University of Melbourne. ProfessorRenfree showed us that dogma about sexdetermination in mammals should bereviewed based on her team’s results onmarsupial sex determination.

Dr David Gardner, Scientific Director of theColorado Centre for Reproductive Medicine,spoke on achieving single embryo transferwith little impact on overall pregnancy rates.

In our clinics, we tend to forget aboutimplantation processes and the importance ofearly placental development. To help addressthis issue, we heard from Dr FranciscoDominguez of Spain about the functionalgenomics of early placental development andDr Graham Burton of Cambridge about thephysiology of foetal nutrient supply.

Professor Jeannette Milgrom of the Universityof Melbourne spoke about lifestyle issuesduring pregnancy and Dr Peter Clifton of theCSIRO discussed the importance of dietduring pre-conception. This generated somecontroversy due to Dr Clifton’srecommendation to avoid a high protein dietduring pre-conception.

Finally, Dr Henry Leese from York brought usup-to-date with work in quantifying embryoquality and the influence of morphologicaland biochemical assessment.

A number of workshops and symposia wereconducted covering a wide-range of subjectsfrom surgical techniques to ethics andembryos. I thank the convenors of theseworkshops for their commitment.

The meeting was well supported by anexcellent array of free presentations, both as

oral and posters. This, I think, was perhapsthe most pleasing aspect of the meeting inthat the quality of presentation from ourmembership balanced well against theplenary sessions.

Overall, feedback from the meeting has beentremendously positive.

Many thanks for the support of our sponsors.The meeting was well serviced by WaldronSmith Management. Finally, my personalthanks go to the creative and hard-workingteam on the Organising Committee. It was apleasure to work with you.

I am looking forward to New Zealand.

Jeremy ThompsonChair, Local Organising Committee 2004

Following are briefs from the FSA meeting inAdelaide.

Call for mandatorysingle embryo transfer

A world leader in human reproductivetechnology called for government regulationto ensure couples undergoing IVF for the firsttime have only a single embryo transferred toavoid the possibility of twin or triplet births.

Professor David Gardner, Scientific Director ofthe Colorado Centre for ReproductiveMedicine in the United States, said mandatingsingle embryo transfer would preventsignificant health risks associated withmultiple births.

At the FSA meeting in Adelaide, ProfessorGardner said international experienceindicated couples undergoing IVF treatment toachieve parenthood were advised of the risksof multiple gestation.

“However, many decide to accept the risksbecause of their overwhelming desire to havea successful pregnancy,” he said.

“While Australian IVF units encourage onlysingle embryo transfer, I believe there is aneed to mandate this for couples under 35having their first cycle of IVF.

“It would be an effective measure inprotecting people from their own decisionssimilar to laws that prevent under age peoplefrom buying cigarettes or rules that compelpeople to wear seatbelts when driving.”

Risks associated with multiple gestationinclude high rates of pre-term delivery andlow birth weights.

Excess embryos are‘part of their family’The majority of couples whohave undergone successfulIVF treatment to have ababy, and have excessembryos in storage, maychoose not to donate themto other couple becausethey consider it likerelinquishing a child foradoption.

The FSA meeting inAdelaide was told ofresearch indicating suchcouples often looked upontheir excess embryos as“part of their family.”

Dr Sheryl De Lacey, aclinical researcher with theResearch Centre forReproductive Health at theUniversity of Adelaide, saidcouples in many casesintended to donate theexcess embryos.

“But ultimately most of themdecide to discard them,” shesaid. “They have beensuccessful in having one ofthe embryos implanted andhave generated a child, andthey feel the remainingembryos in storage arevirtual twins of their offspring.

“Our research shows thatfactors influencing theminclude the thought that they are relinquishing achild for adoption orreleasing from their familyan embryo that will growinto a child with the samelook, personality and soul of their offspring who wasborn from IVF.

“In some cases they haveconcerns about the welfareof children born fromdonated embryos.”


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of good things in moderation

“In spite of improved antenatal care for twinsor triplets, the perinatal mortality is ten foldhigher than that of singleton gestations,”Professor Gardner said.

“Furthermore, the incidence of cerebral palsyis seven fold higher in twins and twenty foldhigher in triplets than in singletonpregnancies.

“These statistics apply to naturally conceivedmultiple gestations, just as they do to thoseresulting from assisted reproductivetechnology.”

Disclosure to donorconception childen“When I grow up I want to share my eggswith another lady so that she can have a baby.”

That was the reaction of a three-year-old girlwho had been told by her parents she wasborn as a result of a donor egg.

The parents of a four-year-old boy born fromsimilar circumstances found it easy to talk tohim about his special conception by sharingwith him a children’s book called “SometimesIt Takes Three To Make A Baby.”

Much to their delight, the boy slept with thebook for a week and took it to kindergarten toshare it with his friends.

These happy stories from the homes ofAustralian families were presented at the FSAmeeting in Adelaide to illustrate the growingtrend of early disclosure to children born fromdonor egg conception.

Melbourne IVF counsellor Kate Bourne toldthe meeting there was a significant change inattitudes among parents of children born fromdonor eggs.

“In the past, there was a reluctance to disclosebecause of fears about rejection from thechild along with concerns about stigma andprivacy issues,” she said. “But now there isgrowing recognition of the benefits of tellingchildren sooner rather than later, and this isbeing supported by the adult offspring ofdonor insemination.”

Ms Bourne said the question of “whether totell” was now being replaced by “how to tell.”

“Infertility clinicians and counsellorsencourage disclosure among parents ofchildren born from donor eggs, but ultimatelythe choice belongs with the couple.”

Ms Bourne said she discovered there was awealth of resources to assist parents in telling

their child about natural conception, but littleto help parents who had conceived their childusing donor eggs.

After extensive consultation with parents,other infertility counsellors, sex educators andthe Donor Conception Support Group, shewrote the book entitled “Sometimes It TakesThree To Make A Baby.”

Information barriers on male infertility

Males experiencing infertility are confrontedwith a range of information, social andprofessional barriers in the quest tounderstand and treat the condition.

The FSA meeting in Adelaide was told theneeds of men diagnosed with infertility werenot being met.

Male infertility is a factor in an estimated 40per cent of cases where couples havedifficulty in achieving parenthood.

However, according to Dr Carol Holden ofAndrology Australia, based at the MonashInstitute of Reproduction and Development inMelbourne, IVF promotion and treatment isdirected predominantly towards the femalepartner.

Dr Holden presented the results of researchshowing that men are unable to locateinformation about male infertility for reasonsincluding:

• feminisation of the IVF experience;

• negative community attitudes towards malereproductive health issues;

• traditional masculine attitudes;

• insufficient training of general practitionersin men’s health issues; and

• little community education on maleinfertility.

Research involved focus group meetings andinterviews with men experiencing infertility, acomprehensive literature review andcommunity education survey.

“There have been significant improvements inthe treatment of male infertility through theuse of IVF and intra cycle sperm injection,”Dr Holden said.

“However, the message is not reaching thevery large number of men who, with theirpartner, are having difficulty in achieving apregnancy.”

FSA MEETING BRIEFS

Psychological aspectsof older motherhood

A study of expectant mothersin various age groupssuggests that older womenmay have variouspsychological buffers thatsmooth the transition intoparenthood.

Macquarie Universitypsychologist Dr CatherineMcMahon said the researchshowed that in many casesolder women were betterprepared for motherhoodbecause of their maturity andperceived stronger resilience.

"They have more lifeexperience and are likely tobe financially better off thanyoung expectant mothers,"she said. "However, olderwomen expecting their firstchild face particularpsychological challengesbecause they often do nothave the family or peersupport structures of youngerexpectant mothers.

The collaborative study ofwomen aged less than 35years and over 38 yearsinvolved the MacquarieUniversity and IVF Australiain Sydney. Latest figures from the National PerinatalStatistics Unit show theaverage age of womenundergoing assistedreproductive technology isnow 35.2 years.

The collaborative study of 51mothers focussed onbiological, psychological andsocial issues surroundingpregnancy and parenthood.

Professor Saunders, Chair ofthe Research andDevelopment Committee ofIVF Australia, said the studysought to understand thedeeper implications ofdelayed parenthood amongwomen and their partners.


Society supporting research for

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Adding to knowledgeabout maternalfunction and the

health, temperament,behaviour and

development ofinfants conceived

through ART

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RESEARCH GRANTS

Maternal reports of the health,behaviour, temperament anddevelopment of infants conceivedwith ARTDr Jane Fisher, Senior Lecturer, Key Centre forWomen’s Health in Society, School ofPopulation Health University of Melbourne.Consultant Clinical Psychologist, MasadaPrivate Hospital Mother Baby Unit

Karin Hammarberg, RN, PhD candidate, KeyCentre for Women’s Health in Society, Schoolof Population Health University of Melbourne

We have found in two previous investigationsthat women who conceive through assistedreproductive technology (ART) are at anapparent elevated risk of early parentingdifficulties requiring hospital treatment in aspecialist mother-baby unit.

In order to understand the particular perinatalmental health needs of women who haveconceived with ART, we are conducting alarge prospective longitudinal study of theirexperiences of pregnancy, birth and earlymothering.

A consecutively recruited cohort of 172women who conceived with ART havecompleted repeated assessments in early andlate pregnancy and at three, eight andeighteen months postpartum.

The sample includes women who have twins,are multiparous, or have used donor gametes.They have been excluded from previousstudies.

Assessments include brief telephoneinterviews and comprehensive self-reportpostal questionnaires relating to maternalhealth, mood and social functioning.

Infant health, behaviour and developmenthave been assessed through maternal reportsand standardised measures of infanttemperament at each postpartum review.

At each assessment, women have beeninvited to provide written descriptions of any

relevant matters they believe have not beencaptured in the self-report questionnaires.

This opportunity has been used almostuniversally and we now have detailedaccounts from participants about theirexperiences of mothering and their infant’shealth, behaviour and development.

The aim of this sub-study is to analysequalitative data and relate it to thequantitative data. Analysis of this unique dataset will add significantly to current knowledgeabout maternal functioning and the health,temperament, behaviour and development ofinfants conceived with ART.

It will also provide a unique opportunity tounderstand the relationship between infantfactors and maternal mood after assistedconception.

The 2005 Fertility Society of Australiaresearch grants were announced at theFSA Annual Scientific Meeting inAdelaide. Following are outlines of theresearch projects to be undertaken.

ART and reported early parenting difficulties

Better IVF outcomes inwomen with PCOS

A prospective, randomised, doubleblind, placebo-controlled trial on theeffect of metformin on in-vitrofertilisation outcome in women withpolycystic ovary syndrome.Dr Michael Costello and Dr Una Conway,University of New South Wales. Co-investigators – Professor Michael Chapman,Dr Rob Lahoud, Dr David Knight and DrFrank Quinn.

This prospective, randomised, double blind,placebo-controlled clinical trial, to beperformed at IVF Australia in Sydney, primarily aims to determine if metformintherapy during ovarian stimulation and thefirst twelve weeks of pregnancy improves IVF outcomes in women with polycysticovary syndrome (PCOS).

The secondary aim is to study the mechanismof action of metformin in the treatment ofwomen with PCOS by searching for changesin a known protein of carbohydratemetabolism, or the expression of a novelprotein of carbohydrate metabolism in thefollicular fluid and serum.

The primary outcome measure is the ongoingpregnancy rate at twelve weeks’ gestation.


improved patient outcomes

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RESEARCH GRANTSKey issues of malereproductive healthPerinatal Determinants of Late-LifeHuman Prostate DiseaseProfessor D. J. Handelsman

A key issue in male reproductive health is theslowly progressive sub-clinical development ofprostate disease during mid-life leading toovert prostate disease in late life.

This research project is based on the postulatethat influences acting before and around birthmay be an unrecognised, but importantdeterminant of late-life prostate diseases,including prostate cancer and benign prostatichyperplasia.

This may occur through the perinatalandrogen surge, a period of months aroundand after birth when the testis secretestestosterone to maintain adult male bloodtestosterone concentrations, and to imprintlong-term hormone sensitivity in androgensensitive tissues, including the prostate.

Prostate cancer is now the second mostfrequent fatal cancer of men.

Nearly all men who live out their full lifeexpectancy will develop nodular prostatehyperplasia, the second most frequent

operation performed on older men generatingmajor national hospital health expenditures.

Although the prolonged latency of disease,the existence of pre-morbid states and thehormonal dependence should provide anexcellent basis for effective interventions inthe natural history of prostate disease, toolittle is known of the determinants of late-lifeprostate disease to develop effectiveprevention or screening programs for prostatedisease.

This is unlike the major hormone-dependentcancers of women.

This project aims to identify perinatal factorsinfluencing the development of late-lifeprostate disease by utilising Barker’s originalHertfordshire cohort, in which fetalprogramming of adult cardiovascular diseasewas described.

With Professor D. Phillips of the MRCEnvironmental Epidemiology Unit atSouthampton, we recently identified thatweight at birth, and especially at one year ofage, strongly predicts bothersome prostatic(lower urinary tract) symptoms and prostatesurgery.

This proposal will support performing assaysfor markers of prostate disease to examinewhether variation in birth and/or infantweight do influence long-term androgensensitivity and size of the prostate.

Comparing outcomes of ART and natural pregnancies

Analysis of perinatal outcomes formothers and singleton babies afterassisted reproductive technology (ART)The chief investigators are David Healy, JaneHalliday, James King, Gordon Baker and theassociate investigators are Lyndon Hale, MacTalbot, Gab Kovacs, Luk Rombauts, SueBreheny, Debbi Rushford and Penny Smithers.

This project is to compare the outcomes ofpregnancies conceived by ART with thoseconceived naturally in women who registeredwith ART clinics in Victoria.

Several studies suggest maternal complicationsof pregnancy are increased in womenpregnant by ART, particularly antepartumhaemorrhage, placenta praevia, and pre-termand caesarean delivery.

However, it is unknown whether the increasein the rates of these complications is the resultof the ART procedures or to other factors, suchas the woman’s health. Similarly the increase

in low birth weight seen generally in ARTsingletons may be due to the IVF proceduresor factors associated with the infertility.

There is also an apparent increase inreportable congenital malformations in babiesfrom ART. A minority of these arise by knownmechanisms, such as inherited unbalancedchromosomal translocations and possibly,increased aneuploidy in sperm from men withsevere primary seminiferous tubule disorders,or imprinting disorders resulting from ovarianstimulation or embryo culture in vitro.

However, there is no clear indication of thecauses of the majority of the defects. Thereremains a possibility that the finding of highermalformation rates with ART is a result ofbiased reporting from ART children beingmore carefully examined and reported tochild health registers than naturally conceivedchildren in the general community.

The research projectaims to identifyperinatal factors

influencing the development

of late-life prostate disease

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Cont. Page 10.


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The Fertility Society of Australia is seekingresearch grant applications from financialmembers for financial support in 2006.

The FSA Board of Directors has made$60,000 available for research in the comingyear with a particular focus on evaluation ofnew technology in reproduction.

It is intended to encourage development ofresearch plans to evaluate an aspect of recenttechnological advance with application, orpotential application, in human reproduction.This could include a health outcome, thesocial impact, or a scientific effect of thetechnological advance under evaluation.

FSA research grants are intended to providefinancial assistance to initiate new researchor complete existing research by professionalsor students working in the field of humanreproduction and fertility.

Funding focus for projects evaluatingnew technologies in reproduction

The grants are intended as start-up funding tothe value of $5,000 to $30,000.

The applications should be of sufficient detailto allow critical appraisal by a panel ofexperts. The grants will be judged on:

• innovation and scientific soundness;

• relevance to the nominated researchpriorities identified by the FSA Board; and

• track record of past research as judged bythe list of publications

The FSA Research Advisory Committee willassess applications. The final decision ongrants to be funded, and the level of funding,will be made by the FSA Board.

Fo more information on grant applicationscontact the FSA Secretariat, Waldron SmithManagement, 61 Danks Street, SouthMelbourne, Victoria 3207. Submissions closeon Monday 9 May, 2005.

RESEARCH GRANTAPPLICATIONS 2006

Evaluating healthoutcomes, social

impacts or scientific effects

of advances in technology

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The Key Centre for Women’s Health in Society

The University of Melbourne

THE SOCIAL DETERMINANTS OF HEALTH

Monday 6 to Friday 10 June 2005 - Cost $2200 GST incl.

Social epidemiology: concept, methods, and application

Come learn from world experts about social epidemiology, a discipline that focuses on understanding how the social and economic circumstances in which individuals and communities live influence health. The course will be taught by Professor Ichiro Kawachi, from the Harvard School of Public Health and one of the world's most eminent social epidemiologists. Participants will also have the option of participating in one of two methodological workshops in the afternoons with A/Prof SV Subramanian from the Harvard School of Public Health and Dr Milicia Markovic from the University of Melbourne. A/Prof Subramanian will teach about multilevel methods and Dr Markovic on qualitative methods in public health.

For further details and registration please check http://www.kcwh.unimelb.edu.au/ Telephone: +61 -3 8344 4333 Facsimile: +61 3 9347 9824

Email: [email protected]

The overall aim is to determine if singletonpregnancies arising from IVF and ICSI freshor thawed cryopreserved embryo transfershave a higher frequency of maternalcomplications and baby complications,particularly low birth weight and birth defects,than singleton pregnancies conceived byGIFT, naturally by sub-fertile women and byfertile women in the general community.

An important control group is the sub-fertilewomen who conceive without ART as they

From Page 9

Comparing outcomes of ART and natural pregnancieswill provide information on the effect ofinfertility on the adverse outcomes. The pilotfeasibility study is needed to ensure that thisgroup can be traced among patientsregistered with the three ART clinics, whoconceived naturally. It will be necessary todevelop methods of cross-linking the databases to ensure that the pregnancies were notconceived by ART at another clinic.

The patient databases of Monash IVF,Melbourne IVF and the Mercy AssistedConception Centre will be used to ascertainthe patients and data on pregnancies andtheir outcomes obtained from the PerinatalData Collection Unit and Birth DefectsRegister managed by the Department ofHuman Services and the Public HealthGenetics Unit at the Murdoch Children’sResearch Institute, Royal Children’s Hospital.

After successful completion of the pilot study,a larger record linkage study forapproximately 8000 ART singletonpregnancies will be undertaken. This samplesize, and the expertise in perinatalepidemiology and record-linkage, combinedwith the reproductive medicine data, shouldallow examination of a number of thecontentious issues and the contributions ofthe ART procedures to the various adverseoutcomes to be separated from those causedby patient factors, such as age and the causesof the infertility.

People interested may contact Assoc. Prof.Jane Halliday ([email protected]).


11

Generating greater awareness of issuesbeing confronted by our NZ colleagues

The past year has been challenging andrewarding for Fertility NZ. Our tenacity toensure the consumer voice is heard, and therights of individuals facing fertility issues areunderstood, has paid off. This has generatedrenewed energy to face future challenges.

Fertility NZ continues to grow in numbers andstrength. The structure of the organisation andexecutive team allows Fertility NZ to deliver aservice in a professional and compassionatemanner.

Our executive is a group of hard-workingindividuals made up of consumers and healthprofessionals who provide a high level ofsupport and advice. The organisation providesinformation and support to consumers offertility treatment via an interactive website,an 0800 line, an annual national conferenceand a quarterly magazine.

Regional branches throughout New Zealandalso provide contact groups, coffee morningsand seminars on a regular basis supported bynational office.

Recent achievements and highlights

Fertility NZ plays a vital role in advocatingconsumer views to health system policymakers and those making funding decisions.This is one of our most important roles.

Most recently, the culmination of strong andsustained lobbying of the government resultedin the introduction of a second publicly-funded cycle of fertility treatment for NewZealanders meeting the criteria. This is a hugeachievement for Fertility NZ and it will makea big difference for many New Zealandershoping to create a family.

This would not have happened without thededicated work and support from Fertility NZmembers and our extended network.

However, the work on equitable andaccessible public funding is not yet over. Theachievement of a second-funded IVF cyclecompletes only stage one of our steppedapproach to increase the availability ofpublicly-funded fertility treatment.

In 2003 Fertility NZ presented a paper to theMinister and Ministry of Healthrecommending a four step process:

• firstly, the introduction of a second cycle;

• a lowering of the criteria to 63;

• an increase to three cycles; and

• a further reduction in the criteria to 55points.

The next stage of our advocacy, to lower thecriteria to 63, will be developed andimplemented over the next year.

A robust and comprehensive submission wasmade to the Health Select Committee during2003 on the Human Assisted ReproductiveTechnology (HART) Bill, which was passed inparliament in November 2004.

It is balanced and sensible legislation andFertility NZ is pleased to note that ourrecommendation of the addition of aconsumer perspective on the MinisterialAdvisory Committee for assisted reproductivetechnology was included.

A voluntary donor register requirement hasalso been included, which was stronglylobbied for by the Donor ConceptionNetwork, a branch of Fertility NZ.

Consumer representation

Successful lobbying by Fertility NZ hasresulted in consumer representation on anumber of committees that make decisionsabout assisted reproductive technology.

We have for the past few years had aconsumer voice on the National EthicsCommittee for Assisted Human Reproduction(NECAHR).

More recently, Fertility NZ was asked tonominate a representative to the advisorygroup on Assisted Reproductive TechnologyHealth Risks. Fertility NZ also providesconsumer representation on the RTACCommittee, which accredits fertility clinics inAustralia and New Zealand

Information service

The information service we provide toconsumers and health professionals improvedsignificantly over the past year. A Fact Sheetseries has been expanded to 21 titles and anew partnership with MDS Diagnostics wasforged in recognition of its generoussponsorship for production of thepublications.

Sponsorship from MDS Diagnostics meansthe Fact Sheets can be printed in bulk anddistributed to a wider audience around NewZealand. We are extremely grateful to MDSDiagnostics for its support with this resource,along with the health professionals aroundthe country who have assisted in writing theFact Sheets. The Fact Sheet series is one ofthe most popular and valuable resourcesprovided by Fertility NZ.

By Sue Domanski Executive Director, Fertility NZ

Cont. Page 12.

NZ UPDATE

2005 FSA meetingin ChristchurchThe 2005 FSA AnnualScientific Meeting will beheld at the ChristchurchConvention Centre from 3 to 7 September, 2005.

Chairman, Dr Peter Benny,said the theme of themeeting would be “Today’sChoices, Tomorrow’sConsequences.”

Dr Benny said the meetingwould attract high calibreinternational speakers witha strong academic streamand a focus on fun andexcitement.

The accompanying SeronoSymposium will be entitled“Pursuit of the Perfect Egg.”

“September is a beautifultime in Christchurch withdaffodils in bloom andsnow still on themountains,” Dr Benny said.

For more details on the meeting in Christchurch go to the websitewww.waldronsmith.com.au/fsa2005


12

NZ UPDATE

Helping in theimplementation of

a support group for families with

children born fromdonor gametes

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The Fetal Matrix:Evolution, Development and DiseasePeter Gluckman (University of Auckland) and Mark Hanson (University of Southampton)

New discoveries reveal how crucial interactions which determine our destiny occur before birth, whenour genes interact with their environment as the embryo and fetus develop. These processes – in thematrix of the womb – are evolutionary echoes of mechanisms which allowed our hunter-gathererancestors to survive. These exciting insights into predictive adaptive responses suggest new ways ofprotecting the health of the fetus, infant and adult. If inappropriate they can trigger obesity, diabetesand heart disease, formerly thought to result solely from adult lifestyle. The new concepts in this bookare crucial to understanding the daunting public health burden in societies undergoing rapid transitionfrom poverty to affluence. They add an important new dimension to evolutionary theory. Synthesisingdevelopmental biology, evolutionary history, medical science, public health and social policy, this is aground-breaking and fascinating account by two of the world’s leading pioneers in this importantemerging field.• Combines evolutionary history, medical science, clinical medicine and public health• Explains the evolutionary background and biological basis of the emerging burden of diseases of affluence• Written by two of the world’s leading experts and pioneers in this rapidly emerging fieldFebruary 2005 272pp 15 line diagrams 3 half-tones Isbn 0 521 54235 9 PB $75.00

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477 Willamstown Road, Port Melbourne VIC 3207Phone (03) 8671 1411 Fax (03) 9676 9955

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International patient leaders conference

Fertility NZ was also fortunate in receivingsponsorship for representation at theInternational Consumer Support for Infertility(iCSi) Patient Leaders Conference in Berlin.

Our Co-President, Sian Harcourt, representedFertility NZ and found it to be one of themost important events she has ever attended.Representatives from 35 countries attendedseminars and workshops focussing onlegislation, patient support and fertilitytechnology.

Sian said one of the clear messages from theconference was that people experiencinginfertility all over the world face discrimination.

“The work an organisation such as FertilityNZ does to change this really matters, and itis so very important,” she said. “We verymuch hope to be able to attend the 2005conference, to bring back initiatives to assist

New Zealanders, and support the work ofFertility NZ.”

Funding

Over the past year, we have receivedsignificant funding from the NZ LotteriesGrants Board and the Lion Foundation, as wellas our loyal corporate benefactors andsupporters including Fertility Associates,Serono, MDS Diagnostics, the Fertility CentreChristchurch, Organon and the IVF DirectorsGroup. We are very grateful to the trusts, ourbenefactors and sponsors.

Future challenges and initiatives

In the next year, Fertility NZ aims to:

• undertake a research project and a nationalpublic health initiative to promote betterpublic understanding of fertility andimpressions of assisted reproductivetechnology; and

• assist in the implementation of a supportgroup for families with children born fromdonor gametes.

From Page 11

One of the most important objectives isto create better impressions of ART


13

When I came to Australia in 1975, it wascommon practice for male fertility to beassessed simply by means of a single semensample. It was usually a case of determiningwhether there were any sperms present, ifthey were moving, and the number of themper millilitre of ejaculate.

We have come a long way since then, and itmight seem just as well. Sperm count isprobably one of the least significantparameters to use in the assessment of malefertility.

Today, other characteristics of semen are alsoassessed, including qualitative andquantitative measures of sperm motility, theincidence of morphologically abnormalsperms, and sometimes an assessment of thepercentage of live and dead sperms, as wellas the physical quality of ejaculates.

In addition, a thorough medical history andphysical examination of male patients isusually undertaken in an attempt to obtain amore rounded picture.

However, the difficulty in assessing humanmale fertility lies in our lack of understandingabout what may be considered normal orabnormal as far as semen characteristics areconcerned.

The tests that we use are based on thoseoriginally worked out for bull semen, andassessment in the two species is notcomparable. Bulls in breeding centres arebred for high fertility. If a bovine semensample is shown to have 20 per cent deadsperms, or 40 per cent of abnormal forms, theanimal in question would immediately betaken out of the system, and probably culled.Yet such features are commonplace in humansemen.

Compared with most domesticated mammals,man has a less controlled evolutionaryhistory. As a result, assessing human malefertility is rather like assessing fertility in awild animal.

We have had no serious predator beyond themicrobe for a long time. Consequently, wehave had the luxury of being rather lazybreeders. Unlike a prey animal, there has notbeen the need for high quality semen.

The spectrum in variation in semen quality inman can be expected to be much wider thanthat of bulls. It night indeed be so wide thatlaying down boundaries of normality isvirtually impossible.

By Emeritus ProfessorTimothy D. Glover*

COMMENT

The FSA welcomescontributions to the newsletter from units aroundAustralia. We want news and photographs from yourregions to keep membersinformed on issues ofimportance in infertilityresearch and the outcomes of clinical treatments.Contributions should be e-mailed to the co-editorsAnne Jequier [email protected] or Keith Harrison [email protected]

We need to move the goal posts because ahuge variation in human semen quality couldwell be a simple reflection of a biologicalnorm. We all produce poor “stuff” comparedwith bulls, yet a man with very poor qualitysemen, as judged by conventional methods,might be quite capable of fathering a child.

I have often put in a plea for improved sementests. More recently, estimations of the levelof DNA damage among sperm populationshave been undertaken. On the face of it, thisseems much the most useful parameter tomeasure.

Assays, such as the single-cell gel electrophoresis(Comet) assay, do not help us with the causeof damaged DNA. Such tests also suffer fromthe same disadvantage as all others unless weare able to determine a level of normality.

I submit that we are probably not going to beable to do this. The nearest we can get is toset our own man-made arbitrary limits.

I used to say to my research students: “If youput to nature a silly question, you are likely toget a silly answer”. I think, therefore, there ismerit in at least asking whether the measureswe use in semen analysis are providing uswith information that is really useful.

What is the point of employing a host oftechnical staff to produce carefully standardiseddata, if it provides no more valuable informationthan an entirely qualitative assessment?

The need for quality control andstandardisation of laboratory methods isobvious. The World Health Organisation hastried to help as far as semen analysis isconcerned. But, what are these tests reallytelling us?

We urgently need to answer this question incase we are all barking up the wrong tree.

We have tended to use semen analysisprimarily for diagnosis of spermatogenicdysfunction and sperm count. It has been auseful hook on which a frustrated cliniciancan hang his keys.

How often do we hear men say: “They tell methat I have a low sperm count”. One couldlegitimately answer: “So what?”

It looks, therefore, that we have come a fullcircle and are little nearer to judging a man’sfertility potential than we were in 1975. I suggest, having examined semen samples forfifty years, that this is because human malefertility, except in extreme cases such asazoospermia, is an immeasurable entity.

Cont. Page 14.

Male infertility: Contemplating how tonavigate through the ‘quagmire’


COMMENT

14

We hear much these days of declining malefertility. If it were true, it would be enticingfor scientists to try to search out the cause.There is, however, no evidence of a declinein male fertility for the simple reason that wecannot measure it.

We can only obtain vague indications ... andthe rest we have to guess.

Episodicity is common in biologicalphenomena, so a change in male fertility atany particular time might only be “par to thecourse” of history. Young men smoke lessthan in the past. Generally, they have abetter diet, and are subjected to lessatmospheric pollution.

If they are less fertile, it is probablygenetically based and could well rectify itselfspontaneously. I doubt, therefore, that weneed to pay much attention to it. I think thehuman race will survive for a little longer yet!

In the future, I think we need to examinemale patients in terms of their general health.

If their semen proves inadequate for thefathering of a child, we can focus on surgicalrepair or technology.

It is my belief that, at the moment, scientistsshould concentrate more on the sperm.

Assessments of the quality of sperm chromatinusing techniques such as the TUNEL assaycould become essential if ICSI is to beemployed safely. Moreover, more detailedwork on spermatogenesis at the molecularlevel may guide us to the cause of damagedsperms and tell us more about the frequencyof mutation.

Why, for example, should bulls yield bettersemen than man? The answer, undoubtedly,lies in the spermatogenic process. So howdoes it differ in the two species? There is asecret locked in there somewhere and wehave tools today to explore it.

This is where scientists can be of real help!

* Tim Glover was President of the FertilitySociety of Australia in 1986 and is anHonorary Life Member of the Society.

From Page 13

There is a secretlocked in there

somewhere and wehave the tools todayto explore it ... this is where scientists can be of real help

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No evidence of a decline in malefertility because we cannot measure it

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15

FERTILITY NURSES

AUSTRALASIAFertility Nurses Australasia is celebrating 15wonderful years of nurse education promotionwithin our specialty. How we have evolvedover the years!

It is a credit to all who have been involvedfrom the inception in Perth in 1990 to wherewe are now with more than 150 membersthroughout Australia and New Zealand.

The FNA executive met in Adelaide in Octoberand Donna Close was voted Chair Elect.Louise Younger from Queensland was electedTreasurer. Thank you Donna and Louise foraccepting such important and busy roles.

At the executive meeting, it was clear themain issue of concern to general memberswas the issuing or dispensing of drugs bynurses. It would be ideal if we could achievea national standard on this practice, but thismay not be possible.

If you want further information, or indeed ifyou can contribute helpful information orexperience regarding this issue, please contactyour State representative/s. We shall keep youposted with any developments.

It is also important for nurses to berepresented and have significant input on thenewly-established Fertility Protection sub-group of the FSA, headed by Professor IanFraser. A few of us attended the inauguralmeeting in Adelaide and Kerry Hampton fromVictoria has volunteered to join this groupwith a view to increasing communityawareness of fertility issues.

The committee has supported my request torepresent FNA at the pre-ESHRE congressparamedical workshop as well as attendingthe conference itself in Copenhagen. I havebeen in contact with my counterparts inBritain and the United States with a view tomeeting them in Copenhagen and organisinga united Global Nurses in ReproductiveMedicine Group. Hopefully we can meetwith other interested nurses from specialinterest groups around Europe to work outhow to instigate this group.

I recently attended the FSA Council meetingand updated members on FNA activities andplans for 2005. It is wonderful to have thisopportunity and we appreciate FSA’scontinued interest and support.

We decided that it was vital to continue therelationship begun with RCNA accreditingand allocating CNE points to our workshopsas it offers external recognition of the value ofthese educational sessions while promotingour group to the broader nursing community.

As such, Sandra Kennedy was nominated andfunded by FNA to attend the RCNA AuthorisedProvider of Endorsed Courses Workshop.

A great deal of our time has been spentupdating and re-formatting the nursingcomponent of the RTAC Code of Practice.

A variety of State Representative positions willbecome vacant later this year and I encouragemembers with a possible interest in assistingFNA to consider nominating. I alsoencourage members to be active in suggestingto the executive ideas for workshops,meetings, book purchases or relevant ideasyou may have to ensure FNA deliversmembership needs.

Finally, thank you to Serono and Organon forour continued gold sponsorship, and also toBayer Healthcare (formerly Roche) for itsbronze sponsorship with book supplies. Thesupport of these companies is very muchappreciated in assisting the continueddevelopment of nurse education andnetworking.

I look forward to seeing many of you on theGold Coast in May and to sharing somebirthday cake with you in Christchurch!Please contact me with any comments orsuggestions. We are always thrilled to haveinput from the general membership.

Victoria Breidahl

ANZICA continues to offer professionaldevelopment opportunities to its members.

To this end, the Victorian ANZICA group ishosting a workshop in Melbourne on Friday20 May.

The topic is Access to ART Treatment.Speakers from various States will present withcase discussion to illustrate issues anddilemmas. From this process, best practicestandards will be derived.

This workshop will also provide anopportunity for the Executive Committee tohold a face-to-face meeting.

Planning is underway for the ANZICAworkshop that will be held in conjunctionwith the FSA conference in Christchurch inSeptember 2005.

One of the intended topics for this event isEmbryo Donation.

Anne Graham. ANZICA President

May 20 workshopANZICA


16

AROUND THE STATESAND TERRITORIES

Keeping FSA members and interestgroups informed on key issues

WESTERN AUSTRALIA

Over the past year, there have been somewelcome changes to legislation in relation toassisted reproductive technology in WA.

The law has been amended to allow us to useIVF in the treatment of single sex couples,and more recently to permit pre-implantationgenetic diagnosis.

It is now mandatory that all gamete donors,whether egg or sperm donors, agree to beidentified by the offspring of that donationwhen children reach the age of 16 years.

To our surprise, quite a few of these donorshave agreed to this identification. This makessperm and egg donation less of a problemthan we had envisaged. However, there aregoing to be some restrictions in relation togenetic disorders that will concern IVFclinicians and geneticists. Hopefully matterswill be resolved in the near future

Four clinics now offer IVF in Perth, yet thedemand continues to rise.

Anne Jequier

VICTORIA

In November 2001, Melbourne hosted theInternational Federation of Fertility Societies(IFFS) 17th meeting.

The South African Society of ReproductiveScience and Surgery is proud that South Africahas been chosen to host the 19th IFFSCongress on Fertility and Sterility WorldCongress in Durban from 1 April to 5 May 2007.

Professor David Healy, the FSA representativeson the IFFS Executive Committee, is calling fora strong Australian contingent to attend themeeting in Durban. He said the meetingwould feature the highest quality science in anexciting part of the world with wonderfulopportunities to explore Africa.

“South Africa is relatively close in world termsand, in a sense, we have an obligation to oursouthern hemisphere neighbour to contributeto the success of IFFS 2007,” Professor Healyadded.

For more details, visit www.iffs.2007.org.za

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fsa newsletter march 05 aim - fertilitysociety.com.au · keith harrison tel: (07) 3832 3279 e-mail:...

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