Invited Lecture delivered by Dr Sujoy Dasgupta in the Annual Conference of ISAR (Indian Society of Assisted Reproduction) held at Kolkata in November, 2019
Invited Lecture delivered by Dr Sujoy Dasgupta in the Annual Conference of ISAR (Indian Society of Assisted Reproduction) held at Kolkata in November, 2019
Evidence for a significant effect in favor of progesterone for luteal phase support. Best result with synthe7c progesterone.
• Evidence that the addi7on of othe substances such as estrogen or hCG doe not improve outcomes.
• Evidence for equivalence of IM and vaginal routes of administra7on. Vaginal route is best tolerated by pa7ents.
• hCG, or hCG plus progesterone, was associated with a higher risk of OHSS. The use of hCG should therefore be avoided.
• Evidence showing a benefit from the addi7on of GnRH agonist to progesterone in luteal phase support
Ovarian reserve refers to the reproductive potential left within a woman's two ovaries based on number and quality of eggs. Diminished ovarian reserve is the loss of normal reproductive potential in the ovaries due to a lower count or quality of the remaining eggs
OVERVIEW
Aim
Definition
Prerequisites
Individualisation of patient.
Ohss free IUI. Clinic
{Strict cancellation of cycle if OHSS is suspected}
Newer trends
Sucess Rates in IUI with COH
PROGNOTIC FACTORS to increase Pregnancy Rates..& discussion
Invited Lecture delivered by Dr Sujoy Dasgupta in a CME, sponsored by Serum Institute of India Pvt Ltd in the Convocation Ceremony of Interns at Sagor Dutta Medical College
NEW USES OF LASER IN GYNECOLOGY
International Society for the Study of Vulvovaginal Disease (ISSVD)
International Continence Society (ICS)
2019 Guidelines
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
Invited lecture by Dr Sujoy dasgupta in the Annual Conference of the "Academy of Clinical Embryologists" (ACE) held in October 2021 in "Hybrid mode" (Kolkata and Webinar)
Evidence for a significant effect in favor of progesterone for luteal phase support. Best result with synthe7c progesterone.
• Evidence that the addi7on of othe substances such as estrogen or hCG doe not improve outcomes.
• Evidence for equivalence of IM and vaginal routes of administra7on. Vaginal route is best tolerated by pa7ents.
• hCG, or hCG plus progesterone, was associated with a higher risk of OHSS. The use of hCG should therefore be avoided.
• Evidence showing a benefit from the addi7on of GnRH agonist to progesterone in luteal phase support
Ovarian reserve refers to the reproductive potential left within a woman's two ovaries based on number and quality of eggs. Diminished ovarian reserve is the loss of normal reproductive potential in the ovaries due to a lower count or quality of the remaining eggs
OVERVIEW
Aim
Definition
Prerequisites
Individualisation of patient.
Ohss free IUI. Clinic
{Strict cancellation of cycle if OHSS is suspected}
Newer trends
Sucess Rates in IUI with COH
PROGNOTIC FACTORS to increase Pregnancy Rates..& discussion
Invited Lecture delivered by Dr Sujoy Dasgupta in a CME, sponsored by Serum Institute of India Pvt Ltd in the Convocation Ceremony of Interns at Sagor Dutta Medical College
NEW USES OF LASER IN GYNECOLOGY
International Society for the Study of Vulvovaginal Disease (ISSVD)
International Continence Society (ICS)
2019 Guidelines
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
Invited lecture by Dr Sujoy dasgupta in the Annual Conference of the "Academy of Clinical Embryologists" (ACE) held in October 2021 in "Hybrid mode" (Kolkata and Webinar)
Primary Endometrial Stromal Sarcoma arising from Cervixiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
In this presentation we will focus on aetiological factors that cause infirtility. Our focus is on US depiction of these aetiological factors to help physician in the management of infirtility.
We have nothing to do with direct radiological intervention in the management of infirtility in this presentation.
Adenomyosis, is a defined mass of cells within the uterine wall, is characterized as ectopic endometrial tissue within the myometrium in the uterus.
In adenomyosis, a series of immune responses is activated, including changes in both cellular and humoral immunity.
To know related details refer doctors answer --> https://www.icliniq.com/qa/adenomyosis/can-i-conceive-with-adenomyosis
Adenomyosis is a benign disease of the uterus characterized by ectopic endometrial glands and stroma within the myometrium.
It is associated with myometrial hypertrophy and may be either diffuse or focal.
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.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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
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.
2. Contents
• Background
• Diagnosis ; ultrasound- MRI-Hysteroscopy
• Adenomyosis and infertility.
• Impact of adenomyosis on infertility
• Treatment of adenomyosis in infertility
• Malignant potential of adenomyosis`
Osama Warda 2
3. Background
• Adenomyosis is defined by ectopic location of
endometrial and stromal tissue distal to the
endometrial-myometrial junction with associated
myometrial smooth muscle hypertrophy.
• Approximately 20% of cases of adenomyosis
involve women younger than 40 and 80% are
aged 40 to 50.
Osama Warda 3
García-Solares J et al 2018
4. Adenomyosis can be asymptomatic
or present with menorrhagia,
dysmenorrhea, and metrorrhagia
with these symptoms usually
occurring in patients aged 35 to
50.
Osama Warda 4
Background
5. Background
• The most accepted hypothesis for
the etiology of adenomyosis stems
from the invagination of the
endometrial basalis
layer into the
myometrium.
Osama Warda 5
García-Solares J et al 2018
6. Background
• Adenomyosis can have a diffuse
(haphazard distribution) or more focal
regions known as adenomyomas.
• Women with the condition, therefore,
present with enlarged, boggy uteri.
Osama Warda 6
7. DIAGNOSIS-TVS
• ULTASOUND: Criteria used to define adenomyosis
on ultrasound include:
1. Uterine enlargement with focal or diffuse
hyperechogeneity in absence of leiomyoma.
2. loss of a normal endo-myometrial interface
3. increased or decreased areas of echogenicity
4. cystic structures within myometrium with
increased color Doppler flow.
Osama Warda 7
Luciano DE et al 2013
9. DIAGNOSIS-TVS
Osama Warda 9
Sonographic image of a uterus with severe postetrior wall adenomyosis .
Dotted blue lines denote focal area of adenomyoma with classic
ultrasound features of adenomyosis; myometrial cysts & hyperechoic
areas
11. MRI
• Junctional zone (JZ) is a region representing the
inner myometrium and is a very important
imaging feature in pelvic MRI for interpretation of
various pathologies.
• In its intact state, it is usually visualized as a low
T2 signal layer beneath the endometrium.
• This low signal intensity is thought to be from
closely packed compact smooth muscle cells with
little extracellular matrix and water content.
Osama Warda 11
12. MRI-Juctional Zone
Osama Warda 12
Sagittal T2 weighted image of 35 –year-old woman in first part of her menatrual cycle
Shows zonal anatomy with endometrium (arrowhead) which is hyperdense; junctional zone
( short arrow) as hypodense band; and outer myometrium (long arrow) with intermediate
signal.
13. Significance of JZ : it is disturbed in following conditions:
• Uterine Adenomyosis: makes the junctional zone thicker
and hazy. JZ of <8 mm is considered unlikely to represent
adenomyosis . JZ of >12 mm very likely represents
adenomyosis . Other significance include;
1- A feature of myometrial invasion with endometrial cancer.
2- As a feature of myometrial invasion by an invasive mole in
the spectrum of gestational trophoblastic disease
3- Uterine lymphoma is not thought to disrupt the JZ.
4- Some research also emphasises the use of the JZ as a
predictor for implantation failure after in vitro fertilization .
Osama Warda 13
(Gordts et al 2018)
14. DIAGNOSIS-MRI
Magnetic Resonance (MRI):
Assessment of the thickness of the junctional
zone is the mainstay of diagnosis. The
consensus for diagnosis of adenomyosis is when
the junctional zone is greater than 12 mm but
the disorder can be suspected when the
thickness is between 8 and 12 mm.
Osama Warda 14
Novellas S et al 2011
15. 1. Focal or diffuse thickening of the JZ.
2. Low signal intensity uterine mass with ill-defined borders.
3. Junctional zone thickness > 12 mm
4. Poor defined JZ borders
5. Localized high signal foci in an area of low signal intensity
6. Linear striations of increased signals radiating out from
the endometrium into the myometrium.
7. Bright foci in the endometrium of similar intensity as the
myometrium (T1-weighted).
8. Ratio of JZ thickness to myometrium thickness (ratio max)
>40%.
Osama Warda 15
DIAGNOSIS-MRI
Novellas S et al 2011
18. Osama Warda 18
DIAGNOSIS-MRI
Pseudo-widening of the endometrium : sagittal T2 weighted images; thickened JZ with
striated high signal intensity areas radiating from the endometrium towards the
myometrium ( white arrow), an appearance that simulates invasion by endometrial
carcinoma.
20. MRI versus ULTRASOUND
• The advantage of MRI over TVS is that MRI has
a greater specificity and can differentiate
adenomyomata from leiomyoma.
• When noninvasive diagnosis with MRI and
TVS imaging became available, the role of
adenomyosis in infertility and early pregnancy
was better recognized.
Osama Warda 20
Devlieger R et al, 2003
21. Diagnosis: Hysteroscopy
Osama Warda 21
Adenomyotic hysteroscopic images become pathognomic
after sub-endometrial exploration: (Gordts et al 2018)
(A) visible endometrial defects on uterine septum;
(B) after incision different cystic structures become visible;
(C) incision of lateral wall of T-uterus reveals the presence of
adenomyotic cyst;
22. (D) formation of cyst, still small opening is
present; and
(E) opening of this defect shows the inner sight
of the cyst.
Osama Warda 22
Diagnosis: Hysteroscopy
Gordts et al 2018
23. Osama Warda 23
Hysteroscopy in adenomyosis
Adenomyosis (sub-endometrial cystic structures): [Gordts et al 2018]
(A). by lowering intra-uterine pressure abnormal vascularization and
cystic bulging hiding adenomyotic cyst can clearly be identified;
(B) .opening cyst with scissors with outflow of chocolate content;
(C). insight view of adenomyotic cyst;
24. Adenomyosis (sub-endometrial cystic structures): [Gordts et al 2018]
(D) progressive dissection of cyst with scissors;
(E) view of dissected cyst, arrow showing the opening of initial access
with scissors; and
(F) postoperative control after 12 weeks (defect is still visible).
Osama Warda 24
Hysteroscopy in adenomyosis
25. ADENOMYOSIS IN INFERTILITY
• There is a significant association between
pelvic endometriosis and adenomyosis, with
estimates indicating that it occurs in 54% to
90% of cases.
• Because endometriosis is well-known to
cause infertility, there is concern that findings
of infertility were due to concurrent
endometriosis rather than adenomyosis.
Osama Warda 25
Kunz G et al 2005
26. ADENOMYOSIS IN INFERTILITY
• However, a study in baboons showed a strong
association between histological adenomyosis
and lifelong infertility (20-fold increased odds)
even in cases where coexisting endometriosis
was excluded.
• In a study of women who received embryos
created through oocyte donation , rates of
miscarriage were significantly higher in those
who had adenomyosis alone versus those with
co-existing endometriosis or controls.
Osama Warda 26
Tomassetti C et al 2013
27. ADENOMYOSIS IN INFERTILITY
• A recent meta-analysis [Younes G, Tulandi T
2017] concluded that adenomyosis has a
detrimental effect on clinical outcomes of in
vitro fertilization (IVF). In women undergoing
IVF, rates of implantation, clinical pregnancy
per cycle, clinical pregnancy per embryo
transfer, ongoing pregnancy, and live birth
among women with adenomyosis were
significantly lower than in those without
adenomyosis.
Osama Warda 27
28. ADENOMYOSIS IN INFERTILITY
• The miscarriage rate in women with
adenomyosis was also higher than in those
without adenomyosis. One of the confounding
variables in this study was age, given that
women with adenomyosis were older;
however, even after controlling for these
confounders using regression analysis, the
significant difference still existed.
Osama Warda 28
Younes G, Tulandi T 2017
29. IMPACT OF ADENOMYOSIS ON INFERTILITY
• Proposed mechanisms of infertility in patients
with adenomyosis focus on derangements of
three putative pathways:
1- Utero-tubal transport,
2- Endometrial receptivity, and
3-Implantation
Osama Warda 29
Harada T et al 2016
30. Utero-tubal transport is impaired due to:
1. intrauterine anatomical distortion that blocks
the tubal ostia and potentially blocks sperm
migration and embryo transport.
2. Uterine hyperperistalsis has been seen on
ultrasound in patients with adenomyosis due to
destruction of normal myometrial architecture.
These abnormal myometrial contraction waves
lead to abnormal sperm transport through the
uterine cavity and may also lead to increased
intrauterine pressure.
IMPACT OF ADENOMYOSIS ON INFERTILITY
Osama Warda 30
Kissler S et al 2006
31. Endometrial receptivity and function becomes
altered via:
1. increased production of estrogens from
aromatization of androgens and altered
estrogen receptor/progesterone receptor
expression.
2. The inflammatory response in women with
adenomyosis has also been shown to be
increased.
IMPACT OF ADENOMYOSIS ON INFERTILITY
Osama Warda 31
Tremellen KP , et al 2012
32. Failed implantation in women with severe
adenomyosis may be attributed to:
1. Higher density of macrophages. This increased
macrophage density subsequently increases
intrauterine inflammatory response and release of
reactive oxygen species that are thought to be
embryotoxic.
2. impaired implantation results from a lack of
adequate expression of adhesion molecules, reduced
expression of implantation markers, and altered
function of the gene for embryonic development
(HOXA10).
IMPACT OF ADENOMYOSIS ON INFERTILITY
Osama Warda 32
Fischer CP , et al 2011
33. ADENOMYOSIS & OOCYTE FUNCTION
• In contrast to women with endometriosis,
adenomyosis has not yet been shown to have an
adverse influence on oocyte function or
folliculogenesis.
• In patients with endometriosis, levels of activated
macrophages, prostaglandins, interleukin (IL)-1β,
tumor necrosis factor (TNF)α, and proteases were
increased in peritoneal fluid and their high
concentrations may adversely affect oocyte function.
• As of yet, there no association has been found
between adenomyosis and oocyte quality or function.
Osama Warda 33
Sanchez AM et al 2017
34. • Treatment with gonadotrophin-releasing hormone
agonist (GnRH-a) serves to down-regulate the pituitary,
exert an anti-proliferative effect, promote apoptosis,
and reduce the anti-inflammatory and angiogenesis
effect.
• Multiple case reports show conception and live birth in
women with infertility and adenomyosis after
pretreatment with GnRH-a for 3 to 5 months.
• In other retrospective studies, pretreatment with
GnRH-a prior to fresh- or frozen-embryo transfer
appears to increase pregnancy rates.
Treatments for Adenomyosis in Infertility
Osama Warda 34
Khan, K.N , et al 2010
35. • multiple methods of fertility-sparing surgery
for adenomyosis have been performed, with
subsequent pregnancies. These techniques
include
1-classical adenomyomectomy,
2-H-incision,
3-triple-flap method, and
4-laparoscopic cytoreductive surgery.
Treatments for Adenomyosis in Infertility
Osama Warda 35
Osada H , et al 2011
38. • Surgical management of adenomyomas and adenomyosis
can present an operative challenge, especially compared
with myomectomy.
• Adenomyomas are less distinct given absence of well-
defined borders and given protrusion into the myometrium.
• During dissection, the plane is identified mainly by
recognizing healthy myometrium rather than simple
enucleation as in myomectomies.
• This can lead to increased risk of intraoperative bleeding
and weakening of the myometrium, which can increase risk
of uterine rupture or abnormal placentation in future.
Treatment for adenomyosis in infertility
Osama Warda 38
39. • Uterine-preserving surgeries have shown benefit
for women who have previously experienced IVF
treatment failures, especially patients ≤ 39 years
old.
• In retrospective studies, conservative surgery or
combination surgery with GnRH-a has shown to
be more effective in controlling symptoms and
also in increasing pregnancy and live birth rates
when compared with GnRH-a alone in patients
with extensive adenomyosis.
Treatments for Adenomyosis in Infertility
Osama Warda 39
Osada H et al 2011
40. • HIFU: High-intensity focused ultrasound ablation
(HIFU) has been used for leiomyoma and is now
being used for patients with adenomyosis who
want fertility.
• HIFU is a noninvasive thermal ablation technique
in which high-intensity ultrasound energy is
focused on a small focal region to increase tissue
temperature sufficient to cause irreparable cell
damage in the target at a certain depth within the
body.
Treatments for Adenomyosis in Infertility
Osama Warda 40
Kishi Y. et al 2014
41. • Selection criteria for using HIFU ablation for
adenomyosis vary depending on the center, but very
strict selection criteria are required to improve efficacy
and decrease risk of thermal injury.
- Patients typically must be age 18 or older,
- premenopausal, have no history of pelvic inflammatory
disease or severe pelvic endometriosis,
- symptomatic adenomyosis with junctional zone
thickness > 3 cm for diffuse adenomyosis or a lesion
diameter between 3 and 10 cm for focal adenomyosis.
Treatments for Adenomyosis in Infertility
Osama Warda 41
Xiong Y . Et al 2015
42. • A recent retrospective study showed high
rates of conception and live birth in HIFU-
treated patients with adenomyosis, suggesting
that it is a promising noninvasive fertility-
sparing treatment option.
• In another study, pregnancies after HIFU
resulted in 2 miscarriages and delivery of 4
healthy babies. One delivery was complicated
by a major placenta previa and hemorrhage.
Treatments for Adenomyosis in Infertility
Osama Warda 42
Zhou M . Et al 2011
43. Malignant transformation of adenomyosis
• The malignant transformation of
adenomyosis is thought to be due to its
endometrial epithelium transition to
monolayer tumor cells before malignant
transformation, which eventually develops
to varying degrees of cancer. However, the
specific molecular mechanism of
adenomyosis is not yet clear.
• . Osama Warda 43
Yuan H & Zhang S 2019
44. • Because of its low incidence of malignant
transformation, lack of large-sample,
multi-center clinical trials, and large
heterogeneity of the existing research,
the evidence based on the high-risk
factors of malignant transformation of
adenomyosis is weak.
Osama Warda 44
Malignant transformation of adenomyosis
Yuan H & Zhang S 2019