1. A new drug called Elonva (corifollitropin alfa) provides a patient-friendly approach to ovarian stimulation in ART by reducing the complexity and burden of treatment through shorter stimulation cycles and fewer injections compared to traditional gonadotropins.
2. Studies show Elonva individualizes treatment by optimizing ovarian response and risk of OHSS while maintaining or increasing pregnancy rates.
3. Starting gonadotropin stimulation on cycle day 4 reduces the total dose and duration of stimulation compared to day 2 with no difference in outcomes.
Elonva is a new drug for ovarian stimulation in IVF that has to be studied through randomised controlled trials. Moreover, Meta-analysis of RCTs would enable clinicians and researchers to identify potential benefits and risks
In ART, GnRH antagonists are effective in preventing a premature LH surge and induce a shorter and more cost-effective ovarian stimulation compared to the long agonist protocol.
Elonva is a new drug for ovarian stimulation in IVF that has to be studied through randomised controlled trials. Moreover, Meta-analysis of RCTs would enable clinicians and researchers to identify potential benefits and risks
In ART, GnRH antagonists are effective in preventing a premature LH surge and induce a shorter and more cost-effective ovarian stimulation compared to the long agonist protocol.
Ovarian reserve tests provide an indirect measure of the cohort of recruitable antral follicles present in the FSH window at the beginning of each menstrual cycle..Functional Ovarian Reserve
Role of progesterone in rpl by dr alka mukherjee dr apurva mukherjeealka mukherjee
It is well known that progesterone plays a major role in the maintenance of pregnancy, particularly during the early stages, as it is responsible for preparing the endometrium for implantation and maintenance of the gestational sac. The management of pregnant women at risk of a threatened or idiopathic recurrent miscarriage is complex and critical.
Early pregnancy loss, also known as miscarriage, generally occurs in the first trimester. For some women and their partners, miscarriages can happen several times, also known as recurrent miscarriages. While there are sometimes causes for miscarriages that are found, often no clear reasons can be found. The hormone called progesterone prepares the womb (uterus) to receive and support the newly fertilized egg during the early part of pregnancy. It has been suggested that some women who miscarry may not make enough progesterone in the early part of pregnancy. Supplementing these women with medications that act like progesterone (these are called progestogens) has been suggested as a possible way to prevent recurrent miscarriage.
Ovulation Stimulation Protocols for IUI - Dr Dhorepatil BharatiBharati Dhorepatil
What are important factors to be considered important
Ovarian reserve
Previous ovarian response
Basic hormone profile
Role of LH
Trigger
Luteal phase support
Pregnancy rate/cycle
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 tests provide an indirect measure of the cohort of recruitable antral follicles present in the FSH window at the beginning of each menstrual cycle..Functional Ovarian Reserve
Role of progesterone in rpl by dr alka mukherjee dr apurva mukherjeealka mukherjee
It is well known that progesterone plays a major role in the maintenance of pregnancy, particularly during the early stages, as it is responsible for preparing the endometrium for implantation and maintenance of the gestational sac. The management of pregnant women at risk of a threatened or idiopathic recurrent miscarriage is complex and critical.
Early pregnancy loss, also known as miscarriage, generally occurs in the first trimester. For some women and their partners, miscarriages can happen several times, also known as recurrent miscarriages. While there are sometimes causes for miscarriages that are found, often no clear reasons can be found. The hormone called progesterone prepares the womb (uterus) to receive and support the newly fertilized egg during the early part of pregnancy. It has been suggested that some women who miscarry may not make enough progesterone in the early part of pregnancy. Supplementing these women with medications that act like progesterone (these are called progestogens) has been suggested as a possible way to prevent recurrent miscarriage.
Ovulation Stimulation Protocols for IUI - Dr Dhorepatil BharatiBharati Dhorepatil
What are important factors to be considered important
Ovarian reserve
Previous ovarian response
Basic hormone profile
Role of LH
Trigger
Luteal phase support
Pregnancy rate/cycle
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
Workshop on Management of poor prognosis patientsMatheus Roque
In this presentation, it was discussed new concepts in stratification of low prognosis patients. It was also discussed the differences between LH and hCG, and how they can have an influence during COS.
Aflibercept in combination with fluorouracil, leucovorin, and irinotecan in t...Mary Ondinee Manalo Igot
Folfiri aflibercept poster for apcc 2015
Aflibercept in combination with fluorouracil, leucovorin, and irinotecan in the treatment of Asian patients with metastatic colorectal cancer
Role of adjuvants in poor ovarian responders , undergoing infertility treatment , in terms of Intra uterine inseminations ( IUI ) to In Vitro Fertilization ( IVF )
28-30 мая 2015 года в Одессе состоялся Х международный симпозиум Украинской ассоциации репродуктивной медицины «Теория и практика репродукции человека».
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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.
- 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
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- 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
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the 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 lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
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. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Light House Retreats: Plant Medicine Retreat Europe
Elonva: A new patient friendly approach in ART
1. 1
Elonva: A new
patient friendly
approach in ART
Daniel S. Seidman, MD
Department of Ob/Gyn,
Sheba Medical Center,
Sackler School of Medicine,
Tel-Aviv University
6. 6
6%
6%
8%
8%
9%
11%
25%
28%
0 5 10 15 20 25 30
Physical or Psychological Treatment Burden
is a Primary Reason for Dropout
Physical or psychological burden of treatment
Unknown
Relational problems/divorce
Ethical objections to ICSI treatment after failed
IVF treatment
Adoption
Poor embryo quality
Poor response/signs of ovarian aging
Other
Among 384 couples undergoing IVF treatment, 65 (17%) dropped out
Reason for Dropout
Percentage
Adapted from Verberg et al. Hum Reprod. 2008;23:2050.
7. 7
Reasons couples discontinued
treatments before achieving two live
children at each stage:
Ceased ART for 1st
child (25)
Did not return for
2nd child (13)
Ceased ART for 2nd
child (13)
Stage treatment
discontinued (n)
9 (36%)5 (38.5%)4 (30.8%)Psychological
burden
9 (36%)04 (30.8%)Lost hope of success
4 (16%)01 (7.7%)Medical staff advice
1 (4%)02 (15.4%)Bureaucratic
difficulties
2 (8%)3 (23.1%)1 (7.7%)Divorce
01 (7.7%)1 (7.7%)Major illness
04 (30.8%)0Not ready yet for 2nd
child
12 (48%)8 (61.5%)4 (30.8%)Eventually returned
/ plan to return for
treatments
Lande et al., 2014
8. 8
Reasons couples chose to cease ART
treatments before completing all
subsidized cycles
Brandes et al.Olivius et al.Smeenk et al.Lande et al.
15.3%21%20.5%34.3%*Drop-out rate
1-21-21.55.2**Number of
cycles
49%32.3%38.5%39.1%Psychological
burden
33%31%30.8%10.9%Physician
recommendation
9%18.1%08.7%Divorce /
relational
problem
18%1.9%04.3%Health problem
0021.8%8.7%Postpone
treatment
7%0028.3%Lost hope
9. 9
1 2 3 4 5 6
ECPR = expected cumulative pregnancy rate; RCPR = real cumulative pregnancy rate.
Schroder et al. RBM Online. 2004;8:600.
Difference between
expected and real
pregnancy rates is caused
by the diminishing size of
the cohort due to dropout
frequency
Dropouts Negatively Impact Real
Cumulative Pregnancy Rates
Data from 4102 IVF cycles in 2130 women
Cycles
0
10
20
30
40
50
60
70
Percent
Dropout rate ECPR RCPR
(n=2130) (n=1087) (n=518) (n=222) (n=74) (n=36)
10. 10
Patient-Centered Approach in
IVF
Increase cumulative live birth rates
Optimize risk/benefit ratio
–Individualization of management
strategies
– Reduce OHSS and cycle
cancellation
Reduce complexity and patient
burden
–Shorter treatment cycles
–Fewer overall injections
12. 12
The objective of the individualization
of the treatment strategy
To increase the
percentage of patients
with an appropriate
number of retrieved
oocytes, while reducing
the number of women at
high risk of cycle
cancellation due to poor
response or ovarian
hyperstimulation
syndrome (OHSS).
21. 21
Study Question:
Is the ovarian response to
controlled ovarian stimulation
(COS) related to the ongoing
pregnancy rate when taking into
account the main covariates
affecting the probabilities of
pregnancy following fresh embryo
transfer?
27. 27
Summary answer:
In patients treated with
corifollitropin alfa or daily
recombinant FSH (rFSH) in a
GnRH-antagonist protocol:
– A high ovarian response did NOT
compromise ongoing pregnancy
rates
– Increased cumulative pregnancy
rates following fresh and frozen-
thawed embryo transfer.
30. 30
Comparative incidence of OHSS
following ovarian stimulation with
corifollitropin alfa or recombinant
FSH
Overall, 1705 patients received
corifollitropin alfa and 5.6%
experienced mild, moderate or severe
OHSS.
In the randomized controlled trials,
Engage and Ensure, the pooled
incidence of OHSS with corifollitropin
alfa was 6.9% (71/1023 patients)
compared with 6.0% (53/880 patients) in
31. 31
Comparative incidence of OHSS
following ovarian stimulation with
corifollitropin alfa or recombinant
FSH
Adjusted for trial, the odds ratio for
OHSS was 1.18 (95% CI 0.81–1.71)
indicating that the risk of OHSS for
corifollitropin alfa was similar to that
for rFSH.
Despite a higher ovarian response with
corifollitropin alfa compared with rFSH
for the first 7 days of ovarian
stimulation, the incidence of OHSS was
43. 43
Objective:
To identify whether women with
poor ovarian response may benefit
from treatment with corifollitropin
alfa in a GnRH antagonist protocol.
Design: Retrospective pilot study.
Intervention: Corifollitropin alfa
(150 mg) followed by 300 IU rFSH
in a GnRH antagonist protocol.
Polyzos et al. Fertil Steril 2013
45. 45
Conclusions:
Treatment of poor ovarian
responders, as described by the
Bologna criteria, with
corifollitropin alfa in a GnRH
antagonist protocol results in low
pregnancy rates, similarly to
conventional stimulation with a
short agonist protocol.
Polyzos et al. Fertil Steril 2013
47. 47
Study Question:
Will sequential administration of
highly purified (hp)-HMG after
corifollitropin alfa in a GnRH
antagonist protocol benefit women
with poor ovarian response
according to the Bologna criteria?
50. 50
Endocrine profiles during the follicular phase
in women who are poor ovarian responders,
according to age
E2, estradiol. *P . 0.05 for all comparisons between age groups
at Days 2, 7, 9 and day of hCG triggering.
51. 51
Summary Answer:
Corifollitropin alfa followed by hp-
HMG in a GnRH antagonist
protocol results in very promising
pregnancy rates, albeit only in
young (<40 years old) poor ovarian
responders fulfilling the Bologna
criteria.
56. 56
Objective:
To identify predictors of ovarian
response in women undergoing
ovarian stimulation with
corifollitropin alfa in a GnRH
antagonist protocol and determine
specific thresholds for the
prediction of low and excessive
responders.
59. 59
Conclusions:
AMH and AFC are the best
predictors for low and excessive
response in women treated with
corifollitropin alfa in an antagonist
protocol.
Using AMH and AFC to select
suitable candidates for treatment
with corifollitropin alfa may result
in a safe and convenient
64. 64
Day When hCG Criterion Was Met
0
5
10
15
20
25
30
35
40
5 6 7 8 9 10 11 12 13 14 15 16 17 18
Stimulation day
%ofpatients
Corifollitropin alfa 150 µg
rFSH 200 IU/d
One-third of the patients did not require any rFSH
Engage
Adapted with permission from Fauser BC et al. Reprod Biomed Online. 2010;21:593‒601.
66. 66
Conclusions
Early responders receiving HCG prior
to or on stimulation day 8 have
advanced follicular development but
the final number and size of
preovulatory follicles is comparable to
those of normal responders.
A short follicular phase of stimulation
did not affect the number of oocytes
retrieved, the number of good-quality
embryos obtained or the ongoing
pregnancy rates.
71. 71
Study Conclusions
No significant differences were found
in any analysed parameters between
treatments.
However, when donors who had
undergone both treatments chose
which treatment they preferred, the
results clearly showed a positive trend
towards choosing corifollitropin a,
confirming that this protocol may
reduce treatment burden and increase
donor compliance.
72. 72
Overall Conclusions
Corifollitropin alfa offers an attractive
new option for ovarian stimulation.
Proper patient selection avoids over
response.
OHSS totally preventable by triggering
with GnRH agonist.
Corifollitropin alfa may offer an
advantage to young poor response
patients
Corifollitropin alfa use is associated
75. 75
Conclusions
Treatment flexibility of ovarian stimulation does not
substantially affect the clinical outcome in patients’
treatment following initiation of ovarian stimulation
with either corifollitropin alfa or with daily rFSH in a
gonadotropin-releasing hormone antagonist
89. 89
1.Usage of estradiol pretreatment for planning cycles
2. Elevated levels of progesterone at the start of
stimulation, approaches to manage it
3. When (which day) to start gonadotropins (particularly
ELONVA)?
4. Does hCG delay for 1-2 day influence on the chance
of pregnancy?
5. How “quickly” the ovaries will respond to Elonva
stimulation?
6. Trigger agonist
7. Which extra dose of rFSH required on the 8th day, if
not met the criteria for the hCG?
93. 93
Results
The total dose of rFSH at the end of the follicular
phase was significantly reduced in the CD4 group
compared with the CD2.
A significant reduction of total duration of rFSH
stimulation in the CD4 group was also observed.
The number of cumulus-oocyte-complexes was
comparable in both treatment groups
Ongoing pregnancy rates of 48% in the CD2 group
and 41% in the CD4 group were achieved.
Final oocyte maturation was triggered with GnRH
agonist instead of hCG in two patients in the CD2
group and in eight patients in the CD4 group,
because of an increased risk of ovarian
94. 94
Conclusion
If the approach of starting ovarian
stimulation on Day4 of the cycle
could be implemented in a large
population of infertile patients, it
would result in a significant
reduction of gonadotrophin
consumption.