Dr Sujoy Dasgupta moderated a Panel Discussion on "Difficult cases in IUI" in the Annual Conference of ISAR (Indian Society of Assisted Reproduction), Bengal held in December, 2022
Dr Sujoy Dasgupta moderated a Panel Discussion on "Difficult cases in IUI" in the Annual Conference of ISAR (Indian Society of Assisted Reproduction), Bengal held in December, 2022
IUI is a basic but effective form of fertiltiy treatment and can be a viable alternative to the expensive IVF / test tube baby treatment that is normally advised.
This presentation will be very useful for the practising gynecologists, IVF specialists and General practitioners who perform IUI.
Even patients on going through this presentation will be more educated about iui.
Please reach out to me on 9833032120 by whatsapp / Telegram or phone call or email on dalalsj@gmail.com for further details / treatment options.
Significant increase in live birth rate is found when IUI is done with stimulation compared with IUI in natural cycle in women with Unexplained Infertility .
Since the first formal description of LPD in 1949 as a possible cause of infertility and recurrent miscarriage by Jones. Innumerable investigations have been undertaken in an effort to verify its existence or to characterize its pathophysiology, diagnosis, and treatment. The consensus of the literature is that LPD does exist and that its cause is multifactorial like abnormal folliculogenesis, inadequate LH surge,inadequate secretion of progesterone by the corpus luteum, aberrant end-organ response by the endometrium.
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 a CME, sponsored by Serum Institute of India Pvt Ltd in the Convocation Ceremony of Interns at Sagor Dutta Medical College
IUI is a basic but effective form of fertiltiy treatment and can be a viable alternative to the expensive IVF / test tube baby treatment that is normally advised.
This presentation will be very useful for the practising gynecologists, IVF specialists and General practitioners who perform IUI.
Even patients on going through this presentation will be more educated about iui.
Please reach out to me on 9833032120 by whatsapp / Telegram or phone call or email on dalalsj@gmail.com for further details / treatment options.
Significant increase in live birth rate is found when IUI is done with stimulation compared with IUI in natural cycle in women with Unexplained Infertility .
Since the first formal description of LPD in 1949 as a possible cause of infertility and recurrent miscarriage by Jones. Innumerable investigations have been undertaken in an effort to verify its existence or to characterize its pathophysiology, diagnosis, and treatment. The consensus of the literature is that LPD does exist and that its cause is multifactorial like abnormal folliculogenesis, inadequate LH surge,inadequate secretion of progesterone by the corpus luteum, aberrant end-organ response by the endometrium.
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 a CME, sponsored by Serum Institute of India Pvt Ltd in the Convocation Ceremony of Interns at Sagor Dutta Medical College
As an intern doctor in Gyne department , this presentation outlines the steps of assessment of an infertile couple including history taking , examinations and relevant investigations and imagings .
Introduction
Natural conception
Epidemiologic figures
Factors affect the natural conception rate
Causes of subfertility
Female causes of subfertility
ovulation
Ovarian problems
Marker of ovarian reserve
Tubal blockage
Endometrial factors
Uterine factors
Cervical factors
History and PE
Investigations
Treatment
Male subfertility
Hypothalamic-pituitary disease
Obesity
Primary hypogonadism
Sperm transport disorders
Defective ejaculation
History and PE
Investigations
Surgical sperm retrieval
Cryopreservation of gametes
Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.”
By World Health Organization
This presentation covers the topic such as Male & Female Infertility Overview, approach & evaluation. Infertility is a condition in couples, failed to get a successful pregnancy after twelve months of timed unprotected intercourse or therapeutic donor insemination.
Eden fertility center serves as a unique fertility clinic with advanced facilities and state-of-the-art equipment to ensure excellent patient care. We deliver possibly the most advanced fertility treatments in Newport Beach & Fullerton CA
Eden Centers for Advanced Fertility offers patients the most advanced treatment solutions & also gives excellent quality patient care. We are a group of highly trained specialists who've innovative concepts for fertility treatment depending on three main principles: individualized personal care, excellent medical service & effective benefits.
Services We Offer -
Fertility Treatments
Third-Party Reproduction
Genetic Testing
Male Infertility
Egg Freezing - Oocyte Preservation
Fertility Preservation
medical management of infertility,think before surgery!!!!ShitalSavaliya1
Nowdays infertility is major issues world wide,It covers both male and female infertility causes,investigation and related treatments.it also includes recent options available at infertility centres.
Similar to Basic infertility inves,Prof.S.Roshdy (20)
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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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!
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
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.
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 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
2. Objectives
know definitions of primary and secondary
infertility
• understand the causes of infertility
• know the initial investigations of the
infertile couple
Investigate male factor
• Test for ovulation
• Test for tubal patency
• Investigation role of laparoscopy and
hysteroscopy
3. INTRODUCTION
Infertility is a common condition with
important psychologic, economic,
demographic, and medical
implications.
Infertility is a unique medical condition
because it involves a couple, rather
than a single individual.
4. DEFINITIONS
It is defined as inability of a couple to
conceive after 12 months of regular
intercourse without use of contraception in
women less than 35 years of age; and
after six months in women 35 years
and older.
Some clinicians use the term subfertility
to describe this failure to conceive unless
the couple has been proven to be sterile.
5. Primary infertility
is the term used to describe
a couple that has never
been able to conceive ,after
at least 1 year of
unprotected intercourse.
7. NORMAL FERTILITY
A study examined the number of months to
conception in 5574 normal women who had
unprotected intercourse and who became
pregnant . Eighty-five percent of the women
conceived within 12 months.
Five to 15 percent of apparently normal couples
will conceive in the second 12 months of
attempted conception so that after 24 months ,
95 percent of couples will have conceived.
9. PREVALENCE Of INFERTILITY
ranges from 12 to 18 %.
women 15 to 34 years (7.3 to
9.1 percent)
35 to 39 years (25 percent)
40 to 44 years (30 percent).
11. The World Health Organization (WHO) task
force on Diagnosis and Treatment of Infertility
performed a study of 8500 infertile couples and
utilized standard diagnostic criteria to determine
the medical conditions contributing to infertility.
female factor : 38 %
Male factor : 20%
Both : 27%
UI : 15%
12. Male factor
1-Endocrine and systemic disorders
(hypogonadotropic hypogonadism)2-5%
A-Congenital disorders
B- Acquired disorders
C-Systemic disorders:
13. 2-Primary testicular defects in
spermatogenesis(65 to 80 %)
A-Congenital disorders;
B-Acquired disorders
C-Systemic illness
D-Genetic causes of dysspermatogenesis
3-Sperm transport disorders(5%)
4-Sexual dysfunction:
5-Idiopathic male infertility(10-20%)
17. W H O classification of
anovulation
LHRH
FSHLH
Hypothalamo-
pituitary
WHO Type 1:
Hypogonadotropic
hypogonadal anovulation
(hypothalamic
amenorrhea):
Anovulation WHO Type 2:
Normogonadotropic
normoestrogenic
anovulation
Ovarian failure WHO Type 3:
Hypergonadotropic
hypoestrogenic
anovulation:
18. The Clues
Hot flushes
Irregular/absent periods
Short cycle
Amenorrhoea
Weight loss/Exercise/Stress
Drug-induced
Other disease
LHRH
FSHLH
Irregular menses
Weight gain
PCOS signs/symptoms
19. NIH Criteria 1990:
Menstrual irregularity due to
anovulation or oligo-ovulation
Evidence of clinical or biochemical
hyperandrogenism
Hirsutism, acne, male pattern baldness
High serum androgen levels
Exclusion of other causes (CAH,
tumors, hyperprolactinemia)
PCOS
20. Rotterdam Criteria (2 out of 3)2003:
Menstrual irregularity due to
anovulation oligo-ovulation
Evidence of clinical or biochemical
hyperandrogenism
Polycystic ovaries by US
presence of 12 or more follicles in each ovary
measuring 2 to 9 mm in diameter and/or increased
ovarian volume.
* In addition, other etiologies (congenital adrenal
hyperplasias, androgen-secreting tumors, Cushing's
syndrome) must be excluded.
21. AES criteria 2006:
Presence of three features
Androgen excess (clinical and/or
biochemical hyperandrogenism)
Ovarian dysfunction (oligo-anovulation
and/or polycystic ovarian morphology)
Exclusion of other androgen excess or
ovulatory disorders
24. 2-FALLOPIAN TUBE
ABNORMALITIES/PELVIC ADHESIONS
Tubal disease and pelvic adhesions
prevent normal transport of the oocyte and
sperm through the fallopian tube.
PID
Severe endometriosis
Previous surgery or non-tubal infection
(eg, appendicitis, inflammatory bowel
disease),
Pelvic TB
25. Hydrosalpinx:
Women with distal tubal obstruction may
develop hydrosalpinges, which decrease
the success rate of (IVF). In addition to
obstruction to sperm migration,
hydrosalpinges appear to reduce fertility
by
retrograde flow of tubal contents into the
endometrial cavity, which creates a hostile
environment to implantation of an embryo.
26. Hydrosalpinx:
Treatment of hydrosalpinx before IVF
Negative effect on PR, IR, early pregnancy
loss & LBR. LBR are reduced by 50%
WHY?
The fluid of hydrosalpinx:
1.Mechanical barrier to implantation: embryo to
float
2.Deficient to support the developing embryo
3.Toxic to the developing embryo
27. Hydrosalpinx:
There is good evidence for
recommending :
laparoscopic salpingectomy or
proximal tubal occlusion
28. Classification of Tubal disease
British Fertility Society
Minor
Proximal occlusion without tubal fibrosis
Distal occlusion without tubal distension
Healthy mucosal appearance at HSG,
salpingoscopy
Flimsy peritubal/ovarian adhesions.
29. Intermediate
Unilateral severe tubal damage
Limited dense adhesions of tubes & ovaries
Severe
Bilateral severe tubal damage
Extensive tubal fibrosis
Tubal distension >1.5 cm
Abnormal mucosal appearance
Bipolar occlusion
Extensive dense adhesion
30. 3-UTERUS
Impaired implantation, either mechanical or due
to reduced endometrial receptivity, are the basis
of uterine causes of infertility
Uterine leiomyomata:A meta-analysis showed
that only leiomyomata with a submucosal or
intracavitary component were associated with
lower pregnancy and implantation rates.
The likely mechanism is inhibition to normal
implantation.
31. Uterine anomalies; Uterine abnormalities are
thought to cause infertility by interfering with
normal implantation. Müllerian anomalies are a
significant cause of (RPL), with the septate
uterus associated with the poorest reproductive
outcome .
Other structural abnormalities associated with
infertility include endometrial polyps, and
synechiae from prior pregnancyrelated
curettage.
32. ENDOMETRIOSIS
Mechanisms which decrease fertility in women
with endometriosis include
Anatomic distortion from pelvic adhesions,
damage to ovarian tissue by endometrioma
formation and surgical resection,
and the production of substances such as
cytokines and growth factors which impair the
normal processes of ovulation, fertilization, and
implantation.
33. 4-CERVICAL FACTORS
Normal midcycle cervical mucus
facilitates the transport of sperm.
Congenital malformations and trauma
to the cervix (including surgery) may
result in stenosis and inability of the
cervix to produce normal mucus,
thereby impairing fertility.
34. 5-UNEXPLAINED
Unexplained infertility is the
diagnosis given to couples after a
thorough evaluation has not revealed
a cause.
Many cases of unexplained infertility
may be due to small contributions
from multiple factors.
35. When To start Workup
( investigations)?
An infertility evaluation is usually initiated after
one year of regular unprotected intercourse in
women under age 35 years and after six months
of unprotected intercourse in women age 35
years and older.
However, the evaluation may be initiated sooner
in women with
irregular menstrual cycles or endometriosis,
a history of PID,
or reproductive tract malformations.
38. History-General
Both couples should be present
Age
Previous pregnancies by each partner
Duration of infertility
Sexual history
Frequency and timing of intercourse
Use of lubricants
Impotence, dyspareunia
Contraceptive history
39. History-Female
Previous female pelvic surgery
PID
Appendicitis
IUD use
Ectopic pregnancy history
Endometriosis
Leiomyoma
40. History-Female
Irregular menses, amenorrhea, detailed
menstrual history
Molimina
Vasomotor symptoms
Changes of hair growth.breast discharge
Stress
Weight changes
Exercise-drug –radiation -chemotherapy
Cervical and uterine surgery
42. Very long list of tests, have been
advocated to assist in
determining the cause of the
infertility in the diagnostic
evaluation of infertile couple.
The necessity and cost effectiveness
of performing many of these tests and
correcting the abnormalities found by
them have not been demonstrated.
43. 1-Investigations of Male Factor
Conventional semen analysis
Computer- assisted sperm analysis (CASA)
A variety of sperm function tests
- The acrosome reaction test
- Hypo-osmotic swelling test
- Measurement of generation of Reactive oxygen species
- Sperm capacitation assays
- Hemizona-binding assay
- Hamster penetration test
- Human sperm-zona penetration assay
A variety of imaging techniques for detection of
varicocele
44. Semen Analysis
Semen analysis is the key laboratory
assessment of the male partner of an infertile
couple.
The standard semen analysis consists of the
following:
Semen volume and pH
● Microscopy for
• Sperm concentration, count, motility, and
morphology • Debris and agglutination
• Leukocyte count• Immature germ cells
45. Semen Analysis
The semen sample should be collected
after two to seven days ejaculatory
abstinence.
If possible, the patient should collect the
sample by masturbation at the doctor's
office. If not possible, then the sample may
be
collected at home and delivered to the
laboratory within an hour of collection.
46.
47.
48. 2-Assessment of ovulation
Basal body temperature
Urine LH kits
Mid luteal serum progesterone
Routine hormonal profile: FSH, LH, Prolactin,TSH
Endometrial biopsy
Serial pelvic Ultrasonography.
A variety of tests for assessment of ovarian reserve
such as D3 FSH & E2, Inhibin B, Clomid challenge test,
TVS for ovarian volume, antral follicle count and
Stromal blood flow.
49. Evidence of ovulation:
1. Menstrual history of regular cycles.
2. Serum progesterone in the mid-luteal
phase of their cycle (day 21 of a 28-day
cycle) even if they have regular menstrual
cycles.
3. Serum gonadotrophins ( FSH & LH) on
Day2-3 especially in irregular periods.
(N.B.: No role for basal body temperature
charts)
50. Further investigations
Ovarian reserve
-More important in >35 years old, suspected
ovarian failure and to detect response to
ovulation induction.
1. Total antral follicle count.
2. AMH of less than or equal to 5.4 pmol/l for a
low response and greater than or equal to 25.0
pmol/l for a high response
3. FSH greater than 8.9 IU/l for a low response
and less than 4 IU/l for a high response.
51. D 3 FSH
Both the day 3 FSH level and the CCCT,
which is a provocative test for
measurement of FSH, are widely used for
screening ovarian reserve.
The CCCT involves oral administration of
100 mg clomiphene citrate on cycle days 5
through 9 with measurement of day 3 and
day 10 FSH levels and day 3 estradiol
level.
A value less than 10 mIU/mL suggestive of
adequate ovarian reserve.
52. Antral follicle count (AFC)
Ultrasound examination can be used to
determine the number of antral follicles (defined
as follicles measuring 2 to 10 mm in diameter).
On transvaginal ultrasound,
The ovaries are visualized in their transverse
and longitudinal planes and the antral follicles
are counted and measured; the size of the
follicle is the mean of two perpendicular
diameters, one of which should be the largest
dimension of each follicle
53. AFC
A low AFC ranging from <4 to 10 antral
follicles between days two and four of a
regular menstrual cycle suggests poor
ovarian reserve.
Although AFC is a good predictor of
ovarian reserve and response,
It is less predictive of oocyte quality,the
ability to conceive with IVF, and pregnancy
outcome.
54.
55. Antimüllerian hormone (AMH)
is expressed by the small (<8 mm) preantral and
early antral follicles. The AMH level reflects the size
of the primordial follicle pool, and may be the best
biochemical marker of ovarian function across an
array of clinical situations.
The AMH level appears to be an early, reliable, direct
indicator of declining ovarian function.
AMH level correlates with the number of oocytes
retrieved after stimulation, and is the best biomarker
for predicting poor and excessive ovarian response.
56. AMH
Unlike the day 3 FSH, AMH can be
measured anytime during the menstrual
cycle.
AMH <0.5 ng/mL predicts reduced ovarian
reserve with less than three follicles in an
IVF cycle
● AMH <1.0 ng/mL predicts baseline
ovarian reserve with a likelihood of limited
eggs at retrieval.
57. AMH
● AMH >1.0 ng/mL but <3.5 ng/mL
suggests a good response to stimulation
AMH >3.5 ng/mL predicts a vigorous
response to ovarian stimulation and
caution should be exercised in order to
avoid ovarian hyperstimulation syndrome.
58.
59. No evidence for:
- ovarian volume
- ovarian blood flow
- inhibin B
-estradiol (E2)
61. Assessment of the uterine cavity
Modalities to assess the uterine cavity
include :
Saline Infusion Sono-
hysterography (SIS)
Three dimensional sonography
Hysterosalpingography (HSG)
Hysteroscopy
62. Laparoscopy as a diagnostic tool in
infertility has diminished markedly
Today, we rarely perform diagnostic laparoscopy in
infertile women. (Tulandi, 2017)
1.The benefit of diagnostic laparoscopy with no risk
factors for intra-abdominal adhesions: small.
2.Treatment of stage I or II endometriosis: small
increase in PR.
3.Alternative treatments of infertility are available
Superovulationwith IUI
IVF.
63. Indications
1.Abnormal HSG or US
2.Young women with history or symptoms
suggestive of pelvic disease. Even if HSG
indicates patency in one or both tubes
.A history of PID,
.Ectopic pregnancy.
.Pelvic surgery.
.Chronic pelvic pain
. Current dysmenorrhea, pelvic pain, or deep
dyspareunia; previous complicated appendicitis
64. Indications
3. Three cycles of super ovulation with IUI are
unsuccessful.
4. After failed IVF
-Laparoscopy after failed IVF:(Littman et al.,
2005).
Pathology in 50%
endometriosis or adhesions
No RCTs have confirmed this rate.
65. TESTS OF LIMITED CLINICAL
UTILITY
PCT for assessment of the cervical factor.
Chlamydia trachomatis antibodies .
Endometrial biopsy
Basal body temperature records
Zonafree hamster oocyte penetration test
Mycoplasma cultures
Testing for antibodies; antiphospholipid, antisperm,
antinuclear, and antithyroid antibodies.
Karyotype
66. Controversies
Lack of agreement exists among
trained infertility specialists with regard
to prognostic utility as well as criteria of
normality of many of these tests?
There is no consensus on which tests
are essential before reaching the exact
diagnosis ?
67. Investigations of infertile couple
Evidence Medicine Based Era
National Evidence-Based Clinical Guidelines
“Assessment and treatment for people with fertility problems
developed by the National Collaborating Centre for
Women and Children's Health on behalf of
the National Institutefor Clinical Excellence (NICE)”
February 2004
68. Grading – Evidence Based Recommendations
A
recommendation
I evidence
B
recommendation
II evidence
C
recommendation
III evidence
D
recommendation
IV evidence
I a- meta-analysis
of RCTs trials,
I b- at least one
RCT.
II a - at least one
controlled study
without
randomization
II b - at least one
other type of
quasi-
experimental
study
non-experimental
descriptive
studies, such as
comparative
studies,
correlation
studies and case
control studies
from expert
committee reports
or opinions and/or
clinical experience
of respected
authorities
• GPP Good practice point : The view of the Guideline Development Group
•The design of a quasi-experiment relates to a particular type of experiment or other study in which one has little or no control over the
allocation of the treatments or other factors being studied.
69. 1-Semen analysis
• CASA is not superior to conventional
semen analysis (Grade A)
• Screening for antisperm antibodies
should not be offered because there is
no evidence of effective treatment to
improve fertility. (GPP)
70. What To Do if Semen analysis Is
Abnormal?
Repeat confirmatory test ( 3 months after
the initial analysis & ttt). (Grade B).
If azoospermia or severe oligozoospermia ,
repeat test as soon as possible. (GPP)
71. Where & When Testicular Biopsy
(TB) be done In Azoospermia?
TB should be performed only in a
tertiary service where there are
facilities for
Sperm recovery ,
Cryopreservation and
ART( C )
72. 2-Assessment of Ovulation
Women with regular monthly menstrual
cycles are likely to be ovulating. (Grade
B)
The use of basal body temperature
charts to confirm ovulation does not
reliably predict ovulation and is not
recommended. (Grade B)
73. Assessment of Ovulation
Women with regular menstrual cycles and
more than 1 year’s infertility are offered a
blood test to measure serum progesterone
in the mid-luteal phase of their cycle (day
21 of a 28-day cycle) to confirm ovulation.
(Grade B)
74. Assessment of Ovulation
Ovulation is most easily documented by a
midluteal phase serum progesterone level,
which should be obtained approximately one
week before the expected menses.
For a typical 28day cycle, the test would be
obtained on day 21. A progesterone level >3
ng/mL is evidence of recent ovulation.
75. Assessment of Ovulation
Women with irregular menstrual cycles
should be offered a blood test to measure
serum FSH & LH (GPP).
Blood test for prolactin should only be
offered to women who have an ovulatory
disorder, galactorrhoea or a pituitary
tumor. (Grade C)
76. Assessment of Ovulation
Tests of ovarian reserve currently have limited
sensitivity and specificity in predicting fertility.
However, women who have high levels of
gonadotrophins should be informed that they
are likely to have reduced fertility. (Grade C)
The value of assessing ovarian reserve using
Inhibin B is uncertain and is therefore not
recommended. (Grade C)
77. Assessment of Ovulation
Women with possible fertility problems are no
more likely than the general population to have
thyroid disease and the routine measurement of
thyroid function should not be offered.
Estimation of thyroid function should be
confined to women with symptoms of thyroid
disease. (Grade C).
78. Assessment of Ovulation
Women should not be offered an
endometrial biopsy to evaluate the luteal
phase as part of the investigation of
fertility problems because there is no
evidence that medical treatment of luteal
phase defect improves pregnancy rates
(Grade B).
79. 3-Assessment of tubal factor
Women who are not known to have co-
morbidities should be offered HSG to
screen for tubal occlusion because this
is a reliable test for ruling out tubal
occlusion, and it is less invasive and
makes more efficient use of resources
than laparoscopy.
(Grade B).
80. Assessment of tubal factor
Where appropriate expertise is available,
screening for tubal occlusion using
hysterosalpingo-contrast-ultrasonography
should be considered because it is an
effective alternative to HSG for women
who are not known to have co-morbidities
(Grade A)
81. Assessment of tubal factor
Women who are thought to
have co-morbidities should be
offered laparoscopy and dye so
that tubal and other pelvic
pathology can be assessed at
the same time. (Grade B)
82. 4-Assessing uterine abnormalities
Women should not be offered
hysteroscopy on its own as part of the
initial investigation unless clinically
indicated, because the effectiveness of
surgical treatment of uterine abnormalities
on improving pregnancy rates has not
been established. (Grade B)
83. Unnecessary laparoscopy!!!
It is not cost effective to do
diagnostic laparoscopy as part of
the initial infertility evaluation
when:
History, and physical examination,
TVS, HSG, and Midluteal progesterone
are all normal (Grade B)
84.
85. When To Do Laparoscopy For tubal
evaluation?
When associated pelvic co
morbidities (PID, previous Ectopic,
endometriosis ..etc) :evaluation of
the pelvis is required.
(Grade B)
88. Indications of Hysteroscopy as workup of
infertility?
Abnormal HSG
When Laparoscopy is indicated as in
Unexplained infertility ?
Before IVF in cases of
unexplained infertility ?!!!!
After Failed IVF ?
89. No Role for...
1. Postcoital test.
2. Endometrial biopsy
3. Antisperm antibodies
4. Routine cervical cultures
5. Thyroid function ( in absence of symptoms
suggestive of of thyroid disease)
6.Prolactin (in absence of galactorrhoea and
…)
90. The basic infertility evaluation of
all couples consists of:
Semen analysis
Assessment of ovulatory function
Determination of tubal patency and presence or absence
of abnormalities of the uterine cavity,usually by HSG.
Diagnostic laparoscopy is indicated for women with
suspected endometriosis or pelvic adhesions.
Ovarian reserve is assessed with day 3 (FSH) and
estradiol levels in women over 35 years of age and in
younger women with risk factors for premature ovarian
failure.
Editor's Notes
Figure 3 Flowchart summary of algorithm for diagnosis of male infertility. As detailed in section PICO 2 (Is it necessary for all infertile men to undergo a thorough evaluation?) the first line investigations should include Physical Examination, History and Semen Analysis. Abnormalities in these lead to further investigations. YCMD, Y chromosome microdeletion; CFTR, CF transmembrane conductance regulator.