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As we approach this more-than-usually momentous New Year, we continue our look ahead, as parenting experts tell us what changes and developments they foresee in their fields in the upcoming 50 years. We can feel the future! HAPPY NEW YEAR!

INFERTILITY More and more 'future babies'

According to Zev Rosenwaks, M.D., internationally renowned infertility specialist and director of The Center for Reproductive Medicine and Infertility at New York Presbyterian Hospital-Weill Medical College of Cornell University, the outlook for the millions of American couples affected by infertility is much less bleak today than it used to be, and promises to be even more encouraging as we move into the new millennium - due to continuing advances in Assisted Reproductive Technology (ART). "Twenty-five years ago we could help 60-65 percent of infertile couples; today that figure is somewhere between 90 and 95 percent," he reports.

The era of assisted reproduction in humans began with attempts at in-vitro fertilization by teams in England and Australia, culminating in the successful birth of the first "test-tube baby" in 1978. Since then, there has been a surge of new advances: problems with ovarian stimulation have been reduced, egg retrieval has been simplified by the development of ultrasound-guided follicle aspiration, assisted hatching has significantly increased the success rate, embryo freezing has allowed for additional pregnancy without the risk or cost of another stimulation and egg retrieval, and several procedures have revolutionized the treatment of male factor infertility.

The most common ARTs now used include:

* IVF (InVitro Fertilization) where egg and sperm are combined in a laboratory and incubated, with the resulting embryos transferred into the woman's uterus.

* GIFT (Gamete IntraFallopian Transfer), where eggs and sperm are transferred into the fallopian tube during a laparoscopy, allowing fertilization to occur in the normal location.

* ZIFT (Zygote IntraFallopian Transfer), a combination of IVF and GIFT, where fertilization occurs in-vitro (outside the body) but fertilized eggs (zygotes) are placed into the fallopian tube.

* ICSI (IntraCytoplasmic Sperm Injection), in which fertilization is achieved by the direct injection of a single sperm into the egg.

* AH (Assisted Hatching), a variation of IVF in which a small hole is made in the shell surrounding the embryo to facilitate implantation.

What does the future hold? Dr. Rosenwaks, who served as the first director of the country's first IVF clinic, says current research is focusing on several areas. One is the development of new techniques to help stimulate the maturation of immature eggs from women undergoing IVF. Others are the micro-manipulation of eggs and embryos, and the identification and isolation of young sperm cells from men with testicular failure and azoospermia (complete absence of sperm in the ejaculate). The refinement of techniques of pre-implantation genetic diagnosis (testing for chromosomal abnormalities in an embryo before it is implanted into the woman's body) can potentially decrease the births of infants with disorders such as sickle cell anemia or Tay Sachs.

Other anticipated advances, continues Dr. Rosenwaks, are finding ways to create new eggs from regular cells in a woman's body, creating new sperm or repopulating sperm in men whose sperm quality is poor, and using a variety of culture media in the laboratory to grow embryos until they can be safely implanted in the woman's body. Dr. Rosenwaks also hopes we will increase our knowledge of markers of embryo viability (survival), leading to fewer eggs implanted during in-vitro fertilization.

In addition, new treatment techniques for women with Polycystic Ovarian Syndrome are expected to reduce infertility problems often associated with this disorder. The recent FDA approval of Antagon, a drug which delays the surge of leutenizing hormone, will reduce the amount of medication needed to treat certain types of infertility. And advances in non-surgical aspiration of sperm present effective alternatives to vasectomy reversal.

As we move forward, the future for people yearning to experience the joys of parenthood is bright indeed.

PEDIATRICS New vaccines, gene therapy, stemming serious disease

The 20th century has seen enormous progress in the diagnosis and treatment of childhood illnesses. Advances in pediatric clinical medicine, improved access to prenatal and health care, improved nutrition, environmental interventions, the development of immunizations against common childhood illness, and the discovery of anti-microbial agents such as penicillin and the sulfonamides have all contributed to a substantial decrease in infant mortality and more effective treatments for numerous childhood conditions. Since the development of the oral polio vaccine in 1963, for example, the incidence of poliomyelitis has decreased to less than 10 cases per year; and the Hib vaccine, first developed in 1987, protects against Haemophilus influenza B infections and has greatly reduced the incidence of meningitis and other serious childhood illnesses caused by this bacteria.

Dr. Philip Lanzkowsky, M.D., FRCP, DCH, Sc.D., vice president of the Children's Health Network of North Shore Long Island Jewish Health System, chairman of the department of pediatrics and chief of staff at Schneider Children's Hospital, believes that the new millennium will bring many exciting advances in pediatric medicine. He is particularly optimistic about the development of new immunizations, including one for rotavirus, the most common cause of severe gastroenteritis and diarrhea in infants and young children. Although the Rotashield vaccine was recently withdrawn from the market due to concerns about its link to a painful and potentially fatal bowel obstruction, the National Institute of Allergy and Infectious Diseases reports that eight other vaccines to fight rotavirus are in various stages of development, and Dr. Lanzkowsky is hopeful that a safe and effective one will be available in the not-too-distant future. He also expects that within the next few years we will see the development of vaccines which can prevent pneumococcal illnesses, middle ear infections and other common childhood diseases, as well as the emergence of medications to treat other disorders.

Dr. Lanzkowsky, an expert in childhood leukemia and other pediatric malignancies, anticipates breakthroughs in the treatment of childhood cancers - such as the development of powerful new chemotherapeutic agents. He points out that when he started practicing medicine about 40 years ago, childhood leukemia was 100 percent fatal, while today there is a 70 percent cure rate, and many of the remaining 30 percent do well with continued treatment. The cure rates for other childhood cancers, such as Wilms tumor and Hodgkin's disease, have also greatly improved.

Dr. Lanzkowsky is excited by new possibilities for the use of gene therapy, believing "it holds great promise for the future." The National Cancer Institute concurs, pointing out that "gene therapy could redefine the practice of medicine in the next century." Potential applications include replacing missing genes which are responsible for genetic disorders such as cystic fibrosis, or injecting genes into target cancer cells to either kill the cells directly or make them more receptive to anti-cancer drugs. Dr. Lanzkowsky, who also expects great strides in the area of organ transplantation, believes that "research will help us to overcome immunological barriers to the use of animal organs," and also predicts we will be able to use mechanical hearts and other technologically-sophisticated devices to sustain life until an organ is available for transplant.

One cause for concern is the antibiotic dilemma. While new ones will be developed, according to Dr. George Post, chief scientific officer of SmithKline Beecham, the British pharmaceutical giant, "As more and more bugs become resistant to more and more antibiotics, we will have a definite window of vulnerability before new antibiotics begin to be introduced to overcome the (super)bugs which are resistant to today's antibiotics... We're not going to see those new antibiotics until at least 2007 in any significant numbers."

Recently, the American Health Foundation announced the formation of its Pediatric Task Force, an advisory group of experts which will examine in depth the health status of our nation's children. According to chairperson Myron Winick, M.D., New York City pediatric specialist in nutrition, "As we embark on the 21st century, pediatrics is about to introduce a new concept - the concept that many of the most serious diseases in adulthood may begin in early childhood or even before (in utero) and that with proper management early in life, some of the leading causes of death in adults (i.e., cardiovascular disease, diabetes, and obesity) may be prevented or at least delayed...

 "A very important new dimension is entering into the care of children. No longer is it sufficient to treat them only when they are sick. No longer is it sufficient to prevent the usual diseases of childhood. Now a healthy childhood must also encompass maximal protection against many diseases that will become overt 30, 40 or even 50 years later. Thus, anyone concerned with child health in the 21st century will be concerned with recognizing and eliminating 'pediatric antecedents of adult disease.'"

A healthy childhood and a long, healthy adulthood. As we prepare to don our party hats and celebrate the beginning of a brave new century, this is certainly a wonderful wish for the children of America. 

- Barbra Williams Cosentino RN, LCSW is a writer in Queens, NY

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