Polycystic ovarian syndrome (PCOS) is a condition
of unexplained hyperandrogenic chronic anovulation
that most likely represents a heterogenous disorder.
About 10% of women in the reproductive age group
suffer from this disorder.
Allison Taylor, MD, with the Center for Women's Health in Wichita, KS, presented about perimenopause and hormone therapy during a Women's Connection July 9, 2013, at Corporate Caterers. The event is sponsored by Via Christi Health.
Polycystic ovarian syndrome (PCOS) is a condition
of unexplained hyperandrogenic chronic anovulation
that most likely represents a heterogenous disorder.
About 10% of women in the reproductive age group
suffer from this disorder.
Allison Taylor, MD, with the Center for Women's Health in Wichita, KS, presented about perimenopause and hormone therapy during a Women's Connection July 9, 2013, at Corporate Caterers. The event is sponsored by Via Christi Health.
This presentation briefly discuss the polycystic ovary syndrome in terms of pathogenesis, features and management. Then, It moves on to discuss the various guidelines laid down by Endocrine Society in 2013 for the management of patients with polycystic ovary syndrome.
International Guidelines 2018 PCOD Dr Sharda Jain , Dr Jyoti Agarwal Lifecare Centre
International Guidelines 2018 PCOD DIAGNOSTIC ASSESSMENT TOOLS + What we have learnt in last 50 years
OVERVIEW of PCOD
HISTORY
PREVALENCE
ETIOPATHOGENESIS as we understand it.
SYMTOMS & SIGNS
2018 GUIDELINES DIAGNOSTIC criteria, assessment, investigations , monitoring &
short / long term impact of untreated PCOD
PANEL DISCUSSION
MANAGEMENT OF PCOS - WOMB to TOMB
MODERATOR : Sharda Jain
PANELISTS : Dr.Chitra setia
Dr Puneet Arora
Dr. Ila Gupta
Dr. Rupam Arora
Dr. Archana Sharma
Dr. Sangeeta Gupta
Dermatologists
Dr. V.K. Upadhyay
Dr. S. Kandhari
Treatment of Polycystic Ovary Syndrom (PCOS)Dr JP Singh
An Invented technique to treat the PCOS, Introduced by Dr JP Singh. PCOS is a leading cause of women infertility. Near about 50% women at the age group of 15-30 in Kolkata, (India) are suffering from PCOS. Polycystic ovary syndrome is a Gynecological problem that can affect woman's: Menstrual cycle, Difficulty to be pregnant, Hormonal imbalances, Skin and hair problems. It may be treated through this technique. More details logon: www.brainstup.com
What is the status of surgical interventions for infertility in patients of p...Apollo Hospitals
Anovulation is a very important component of polycystic ovarian syndrome and it is this that majorly contributes to
infertility in these women. Besides lifestyle changes and medical methods for ovulation induction, one still fails to achieve an ideal scenario at times and that is a single, good quality follicle. Because of high costs of IVF which uses gonadotropins, and also multifetal pregnancies, it may be advisable to widen the net and use minor surgical methods like ovarian diathermy.
This presentation briefly discuss the polycystic ovary syndrome in terms of pathogenesis, features and management. Then, It moves on to discuss the various guidelines laid down by Endocrine Society in 2013 for the management of patients with polycystic ovary syndrome.
International Guidelines 2018 PCOD Dr Sharda Jain , Dr Jyoti Agarwal Lifecare Centre
International Guidelines 2018 PCOD DIAGNOSTIC ASSESSMENT TOOLS + What we have learnt in last 50 years
OVERVIEW of PCOD
HISTORY
PREVALENCE
ETIOPATHOGENESIS as we understand it.
SYMTOMS & SIGNS
2018 GUIDELINES DIAGNOSTIC criteria, assessment, investigations , monitoring &
short / long term impact of untreated PCOD
PANEL DISCUSSION
MANAGEMENT OF PCOS - WOMB to TOMB
MODERATOR : Sharda Jain
PANELISTS : Dr.Chitra setia
Dr Puneet Arora
Dr. Ila Gupta
Dr. Rupam Arora
Dr. Archana Sharma
Dr. Sangeeta Gupta
Dermatologists
Dr. V.K. Upadhyay
Dr. S. Kandhari
Treatment of Polycystic Ovary Syndrom (PCOS)Dr JP Singh
An Invented technique to treat the PCOS, Introduced by Dr JP Singh. PCOS is a leading cause of women infertility. Near about 50% women at the age group of 15-30 in Kolkata, (India) are suffering from PCOS. Polycystic ovary syndrome is a Gynecological problem that can affect woman's: Menstrual cycle, Difficulty to be pregnant, Hormonal imbalances, Skin and hair problems. It may be treated through this technique. More details logon: www.brainstup.com
What is the status of surgical interventions for infertility in patients of p...Apollo Hospitals
Anovulation is a very important component of polycystic ovarian syndrome and it is this that majorly contributes to
infertility in these women. Besides lifestyle changes and medical methods for ovulation induction, one still fails to achieve an ideal scenario at times and that is a single, good quality follicle. Because of high costs of IVF which uses gonadotropins, and also multifetal pregnancies, it may be advisable to widen the net and use minor surgical methods like ovarian diathermy.
Adjuvant therapy, also known as adjunct therapy or add-on therapy, is therapy given in addition to the primary or initial therapy to maximize its effectiveness.
Add-ons have become ubiquitous with the process of assisted reproduction (ART) which is markedly more complex than it was at its inception.
PCOD,How are they different ??Difficulties & Solutions made Easy , Dr. Sharda...Lifecare Centre
Tremendous advances and extensive human studies have uncovered the complexity and management of PCOD
Global prevalence -2.2% to 26% Roughly 1 in 15 women worldwide, (Lancet, 2007)
Explore the intricacies of ovulation induction in intrauterine insemination (IUI) with Dr Laxmi Shrikhande's informative slide share presentation. From understanding the hormonal mechanisms to the latest techniques, this presentation offers insights into optimizing fertility through IUI. Whether you're a clinician seeking to enhance patient outcomes or an individual navigating fertility treatments, this resource provides valuable knowledge for your journey towards conception.
Do Women With Polycystic Morphology Without Any Other Features of PCOS Benefi...Alex Swanton
Women with ovaries of polycystic morphology (PCO), without any other features of polycystic ovary syndrome(PCOS), respond similarly to women with PCOS when stimulated with exogenous gonadotrophins, and both groups share various endocrinological disturbances underlying their pathology.
The clinical approach to ovulation induction requires an
understanding of the causes of anovulation. Check my detailed presentation to get detailed understanding.
Patient selection and work-up
Ovarian stimulation
Monitoring of follicular growth and endometrial development
Timing of insemination
Number of inseminations
Semen preparation
Insemination procedure
Luteal support
Similar to Evidence -based Management of PCOS (20)
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
4. Evidence-based guideline for the
assessment and management of
polycystic ovary syndrome
Developed 2011
Updated August 2015 - Section 7.4 Aromatase
inhibitors
Further update scheduled 2016/2017
5. An Overviewof the Magnitudeof The
Problemof PCOS
Prevalence
~ 20%
Complex
Pathophy-
siology
Diagnosis
2003
Women’s Health
Aspects
2011
Treatment &
Outcome
2007
Three ESHRE/ASRM PCOS
Consensus Workshops
Approximately 75% of PCOS women suffer from infertility due to anovulation.
6. EVIDENCE-BASEDMANAGEMENT OFPCOS
Surgical
• Laparoscopic Ovarian Drilling
• Bariatric Surgery
Pharmacological
• Clomiphene Citrate
• Metformin
• Aromatase inhibitors
• Gonadotropins
Non Pharmacological
Life style modification
7. Lifestyle intervention (to optimise preconception
health, fertility and long-term complications)
Lifestyle interventions include diet, exercise, behavioral
management techniques for modifying diet or exercise,
or a combination of these.
1st Line Non Pharmacological management for
Infertility
8. Lifestyle change
4 RCTs, (20, 21, 46 and 343 PCOS Obese/over weight
womens) intervension groups VS lifestyle
Metformin only, CC only, Metformin + CC ( 24 – 28 weeks) VS
( diet only, diet + exercise, and diet + exercise + behavioral).
No significant different between Lifestyle VS pharmaceutical
in term of menstrual fuction, pregnancy rate
Pasquali,143 obesePCOS women,RCTs
metformin+diet VSplacebo+diet
Menstrualimprovement : 4.3vs3.2(p= 0,017)
Nodiff.inpregnancyrate
9. Secara singkat, bukti2 RCT tidak mendukung pengobatan
dengan induksi ovulasi seperti CC/metformin yang
mendahului treatment gaya hidup atau memulai
treatment gaya hidup yang dikombinasi dengan
pengobatan induksi ovulasi dibandingkan dengan tretmen
gaya hidup saja pada wanita obes infertil anovulatoar
dengan PCOS
10. Balen Adam H. et.al. 2005 Polycystic ovary syndrome a guide to clinical management.
Lifestyle change is the first line treatment for women
with PCOS who are over weight or obese, with as little
as 5-10 % weight loss improving psycological outcome,
reproductive features and metabolic features.
Amplification of sign and symtoms of PCOS with
Increasing obesity and insulin resistance
11. ClomipheneCitrate
• 1967
• as anti estrogenic and estrogenic
• competitive binding ER
• Studies with clomiphene citrate show
ovulation rates of 60%–85% and
pregnancy rates of 30%–50% after six
ovulatory cycles.
• The rates of twin 5%-7% and triplet
pregnancy 0.3%, respectively.
• The incidence of OHSS less than 1%
- Usadi, R, Fritz, M, Glob. libr. women's med., (ISSN: 1756-
2228) 2008; DOI 10.3843/GLOWM.10337
- Teede et al, Med J Australia 2011
12. Clomifene citrate
If ovulation cannot be achieved with clomifene citrate,
then the patient is said to have clomifene citrate
resistance. If pregnancy cannot be achieved after six
ovulatory cycles with clomifene citrate, then the patient is
described as having clomifene citrate failure.
Systematic review and meta-analysis 3 RCTs comparing
CC VS placebo, 3 trials 133 patients CC improves ovulation
rate and pregnancy rate, but no publish CC VS placebo/ no
treatment examining live- birth as outcome.
13. 1st line Pharmacologicalmanagement for
Infertility
Teede et al, Med J Australia 2011
Evidence based recommendation:
CC should be fisrt line pharmacological therapy to improve
fertility No other infertility factor. CC is selective estrogen
receptor modulator with both estrogenic and anti estrogenic
properties.
Clinical practice point:
The risk of multiple pregnancy is increased with CC use and
therefore monitoring is recommended.
14. METFORMIN
Biguanide
Rationale as ISA to retore ovulation
1994 as tretment for PCOS
Adnistration metformin for PCOS many protocol : 1500 –
2550 mg.
The most adverse reaction gastrointestinal symtoms
15. Metformin
o Metformin alone has been shown to improve ovulation and
clinical pregnancy rate but not live- birth rate.
o Metformin combined with clomifene citrate has a higher
ovulation, pregnancy and live-birth rate compared with
clomifene citrate alone only in clomifene citrate-resistant
(CCR) PCOS.
17. Metformin
o Fertility outcomes are improved with the addition of
clomifene citrate to metformin compared with
metformin alone in obese PCOS women (BMI >= 30
kg/m2).
o There is no improvement in fertility outcomes when
metformin is combined with laparoscopic ovarian
drilling, gonadotropin ovulation induction with timed
intercourse, or IVF. However, metformin
coadministration with IVF results in a 70 –80% lower risk
of OHSS
18. Metformin
Clinical question. In women with PCOS, is metformin effective for improving fertility
outcomes?
Teede et al, Med J Australia 2011
Evidence-based recommendations
Metformin should be combined with clomiphene citrate to improve fertility outcomes
rather than persisting with further treatment with clomiphene citrate alone in women
with PCOS who are clomiphene citrate resistant, anovulatory and infertile with no
other infertility factors.
19. Gonadotrophins
Gonadotrophins are often used as second-line therapy in
anovulatory PCOS women with CCR (Clomiphene Citrate
Resistance) and CCF (Clomiphene Citrate Failure).
Recent randomized evidence suggests that gonadotropin
therapy may be more effective than clomifene citrate in therapy-
naive PCOS women. Low dose Gonadotropin 70%
monofollicular, PR per ovulatory 15-20%, cumulatif PR 55-70%.
Increased risk of multiple pregnancy and OHSS 1% A low-
dose “step up” protocol
The duration gonadotropin therapy should not exceed 6 ovulatory
cycles
Teede et al, Med J Australia 2011
20. Gonadotrophins
Cohcrane systemic review rFSH and uFSH no different,
in OR, PR, MP and MCR in treatment CCR women with
PCOS
2 RCTs FSH induction ovulation VS CC in treatment 76
women with PCOS Improvement in pregnancy rate,
no different in live birth, no different in OR, and no Diff
in MP.
The second RCT low dose step up of FSH VS CC in 255
women PCOS FSH higher PR and LBR
But > cost and inconvinient
SECOND LINE TREATMENT
21. Aromatase inhibitors were proposed as ovulation-inducing
agents in 2001.
Letrozole and anastrozole are the most commeonly in IO
Aromatase Inhibitors
Aromase Inhibitor === biosyntesa estogen (interfering H/P)
increasing FSH
Growing Follicle
The effectiveness of letrozole is not better than CC
There is conflicting published data on the potential teratogenic
effect of letrozole when used as an ovulation induction agent.
D
22. LAPAROSCOPI OVARIAN DRILLING
Laparoscopic ovarian “driling” was first
described in
1984
Mechanisms underpinning hormonal
changes
and resumption of ovulation remain
poorly
understood.
Result 6 month : OR 54-76%, PR 28-
76%,
12 month: OR: 33-88%, PR: 54-
70%
Laparoscopic ovarian drilling in PCOS is
23. LOD When Recommended?
Second line Tx. CC resistence
in PCOS Patients, alternative
gonadotropin equal in efficacy
but lower of MP and Cost
Hypersecretion LH
Who need laparoscopy?
Who live too far from
hospital intensive
monitoring during
gonadotropin tx
24. Bariatric Surgery
• Bariatric/ Weight surgery result in aproximally 15-30% weight
loss
• A Cohrane review -> conventional Tx in obesity reduce DM,
Hypertension based on 3 RCTs, did not assess fertility
outcome
• There not any published RCTs assesing the effectiveness of
bariatric surgery specifically in PCOS women.
• Another systemic review based in reproductive outcome
improve fertility and reduction obstetric complication ( DM in
pregnancy, macrosomia, hypertension disorder), but IUGR
increase.
• A recent study reported that bariatric surgeryis a potential
future tratment option for obese PCOS women, the criteria
still large debateble and more scientific research is required
25. 2ndlinepharmacological/surgicalmanagement
3st line management could be other approriate intervension
1st line Non Pharmacological
management for Infertility
Don’t use Aromates
inhibitor as First Tx. (B)
LOD (B)
Under caution
CC+Met (A)
Management of Infertility in women with PCOS
Gonadotropin (B)
Metformin, if BMI <=35
(B)
Bariatric surgery (CR)
Arom Inhibit (D)
Only women CC rest,
anovulatoar, infertil with no
other fertility factor
Lifestyle intervension
(C)
1st Line Pharmacological
managent for Infertility
Clomiphen C (A)
Only for adult who are anovulatory and
have a BMI >= 35 kr/m2 and who remain
infertile despiter undertaking an intensive
structured lifestyle management program
for minimum of 6 months