This document discusses different methods for endometrial preparation in frozen embryo transfer (FET) cycles. It describes natural cycle FET, which can be done through a true natural cycle or modified natural cycle with an HCG trigger. It also outlines artificial/hormone replacement cycle FET, where estrogen and progesterone are administered without GnRH agonists in patients with remaining ovarian function. The key points are that the endometrium must be adequately prepared prior to embryo transfer, and the age of the embryos after thawing should correspond to the developmental age of the endometrium. The best method varies between patients and there is no clear consensus.
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.
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.
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 .
Invited Lecture delivered by Dr Sujoy Dasgupta in the Annual Conference of ISAR (Indian Society of Assisted Reproduction) held at Kolkata in November, 2019
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 .
Invited Lecture delivered by Dr Sujoy Dasgupta in the Annual Conference of ISAR (Indian Society of Assisted Reproduction) held at Kolkata in November, 2019
Live birth by fallopian tube sperm perfusion in hyperprolactinemic woman afte...lukeman Joseph Ade shittu
The case presented describes a live birth following treatment of a 35-year-old woman with fallopian tube sperm perfusion (FTSP) using donor sperm after three-repeated unsuccessful courses of In-vitro fertilization (IVF) with Percutaneous Epididymal Sperm Aspiration (PESA), Testicular Sperm Extraction (TESE), and donor sperm. The indication of FTSP is hereby explored and discussed.
Ovarian Hyperstimulation in Intrauterine InseminationElmar Breitbach
Intrauterine insemination is well established in the treatment of infertility. But which pretreatment leads to the best results? Do we have to trigger ovulation? What about luteal phase support? Whar patients do have the best chances? When do we have to switch to IVF?
Evidence based answers to these questions an a bit of experience based suggestions.
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!
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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
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
- 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
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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
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3. INTRODUCTION
1st successful pregnancy following FET:
1983 Trounson and Mohr
(Trounson, 1983).
Cryopreservation of embryos has become an
integral part of ART programs.
Increased dramatically
1.Ttrend towards transferring fewer embryos
after a fresh IVF cycle
2. Improved laboratory techniques
(Skovmand 1997; Diniz, 2002; Fineschi et al., 2005; Gordts et
al., 2005; Thompson, 2005; Le Lannou et al., 2006; JOINT
SOGC-CFAS, 2008; Min et al., 2010).
AboubakrElnashar
4. Success= keypoints in performing FET
1. Selecting proper embryos used for FET
•Cleavaged embryos with grade I or II, and present
≥6 blastomeres at D3 are the right kind.
•Embryos with 4 blastomere: continue in vitro
culture to reach the stage of 8 blastomere then
perform vitrification cryopreservation.
•Non-high quality embryos: continue to culture
them into blasocyst and select the valid blastocyst
for cryopreservation.
This step is important for settling the appropriate
time for ET
AboubakrElnashar
5. 2. Accurate synchronization of endometrium and
embyos is the key of performing FET.
Important for implantation
Age of the embryos after thawing corresponds to
age of the endometrium on the day of ET
3. Sufficient luteal support
AboubakrElnashar
6. Methods:
Regular ovulatory Irregular or unovulatory
I. Natural II. Artificial=Hormone
replacement
III. Ovulation induction
True Modified E and P Gna, E and P GnT Letrozole Nolvadex
Functioning ovaries:
Any method
Quiescent Ovaries (e.g. donor oocyte recepient
with ovarian failure)
Only HRT with E and P
Many infertility units use a mixture of protocols for
FET.
AboubakrElnashar
7. Best method:
Little agreement in ovulatory women
(Ghobara and Vandekerckhove, 2008;Weissman et al., 2009).
AboubakrElnashar
8. I. NATURAL CYCLE NC-FET
Indication
It is only feasible for women with regular cycles and
proven ovulation.
In normally ovulating women: protocol of choice
The simplest method
Endocrine preparation of the endometrium is
achieved by endogenous sex steroid production
from a developing follicle.
AboubakrElnashar
9. A. True Natural cycle
Timing of ET is determined by detecting the
spontaneous LH surge
Method:
1. D10-12 (3-5 d prior to estimated ovulation day)
Serial US: E thickness, follicular development
and to time the commencement of testing for LH
LH (urine or blood) for detection of the LH surge ,
P levels
When a rise in serum LH levels is observed, it is assumed that ovulation will occur
36–40 h later (Andersen et al., 1995).
LH surges in urine lag up to 21 h behind the appearance of the surge in blood
(Hoff et al., 1983; Frydman et al., 1984; Miller and Soules 1996).
The day when LH exceeds 180% of baseline (calculated as the mean of the 3
previous morning samples) corresponds to a day prior to OPU/ovulation.
2. US for evidence of ovulation.
AboubakrElnashar
10. 3. FET
3–5 days after ovulation depending on the stage
of the embryo when frozen
The day of ovulation corresponds to the day of
egg retrieval.
If embryos were frozen at 72h, ovulation day+3 is
the right time to transfer.
(Nawroth and Ludwig, 2005; Paulson,2011).
4. LPS:
progesterone
AboubakrElnashar
12. Disadvantages:
1. Even in women having regular menstrual cycles,
ovulation may not always occur
2. Problem associated with the detection of
spontaneous LH surges
A. variation in timing of its occurrence between
cycles and between patients (Park et al., 2007).
B. In order to assess the LH levels correctly,
determination should be performed at least daily,
and preferably twice a day.
C. LH urine kits have a large variation in thresholds,
which involve the risk of up to 30% of false-
negative testing, and are often reported by
patients as being difficult to interpret
(Miller and Soules, 1996; Guermandi et al., 2001; O’Connor et al., 2006).
AboubakrElnashar
13. B. Modified natural cycle
To overcome the disadvantages of LH monitoring:
Administering hCG to initiate luteinization
Method:
1. Regular US:
2. HCG
5000 IU when dominant follicle (16 or 17or 18 mm):
ovulation 36–38 h later
(Andersen et al., 1995).
Combined with E2 levels of (450-550 pmol/L), 600-700 or 800-900 respectively
HCG administration correspond to the HCG
administration day of the source cycle
AboubakrElnashar
15. Advantages:
less US evaluation due to the hCG administration
compared with true NC-FET: less burden on
patients and doctors
(Weissman et al., 2011).
AboubakrElnashar
16. Risks
1. unexpected ovulation
: accurate planning of embryo thawing and transfer
is not possible: cycle cancellation (7–12%)
(Fatemi et al., 2010; Hill et al., 2010).
2. Difficulty in ensuring timely thawing and ET.
AboubakrElnashar
17. LPS in NC-FET.
Not required
(Kyrou et al, 2010)
similar result in patients receiving true NC-FET
(Lee et al., 2013).
{CL formation is not hampered by inadequate LH
secretion}
higher LBR in patients undergoing true NC-FET
with LPS.
(Bjuresten et al. 2011)
Too little evidence supporting a positive effect of
LPS in patients undergoing NC-FET
(Groenewoud et al, 2013, MA)
AboubakrElnashar
18. True NC-FET Vs modified NC-FET:
no difference in outcome
AboubakrElnashar
19. II. ARTIFICIAL (HORMONE
REPLACEMENT) CYCLE
In patients with irregular cycles HRT is best used.
Aims
To mimic the endocrine exposure of the
endometrium in the normal cycle.
AboubakrElnashar
20. Key points:
1.An endometrial thickness 6 and showing triple line is
favorable for ET
2.Endometrial development is unaffected by the length
of the follicular phase. No adverse effects of reduction
the duration of exposure to E to 6 days or an increase
up to 35 days. However receptivity is best preserved
when the follicular phase is kept between 12 and 19
days
3.The endometrium is affected by either incremental or
fixed E levels , even in supraphysiologic range
AboubakrElnashar
21. A. Estrogens and progesterones without
GnRHa.
used in women with remaining ovarian function
(Jaroudi 1991; Lelaidier 1992).
Method:
1. Oestrogen
Effect:
proliferation of the endometrium, while suppressing the
development of the dominant follicle
Form and dose
Oral E2 (progynova or Trisequence (Blue tab) or Cycloprogenova (White tab))
4-6 mg/d or 2 mg/d with an increasing doses
Transdermal patches (estrofem/estrace)
subcutaneous implants
vaginal rings or tablets.
AboubakrElnashar
22. When:
D1 of cycle: prevents follicular recruitment by
suppressing FSH: spontaneous ovulation is
avoided.
D3
before D4.
AboubakrElnashar
23. 2. Progesterone
Aim:
initiate secretory changes
Form
oral tablets
IM 40-60 mg in oil
vaginal suppositories, gel or rings (Devroey 1998).
When
Once the lining endometrium: 7–9 mm on US
Not duration of E2 supplementation but the
endometrium thickness should be the leading factor
in determining the start of progesterone
(Nawroth and Ludwig, 2005; El-Toukhy et al., 2008).
AboubakrElnashar
24. Route:
No difference in PR between vaginal and IM
progesterone.
(Glujovsky et al., 2010, SR)
based on patient and doctor preference.
AboubakrElnashar
25. Timing of embryo thawing and ET:
Planned according to the moment of progesterone
supplementation.
The day P is started is considered ovulation/opu
day, and the time of thaw/transfer is determined
accordingly.
AboubakrElnashar
26. 1. E2
From D2 or 3 of cycle:
3 or 4 tab (acc to wt of pt) (for 7 or 8 days)
2. US:
When endometrial thickness 9 mm
3. Prontogest 400 mg twice daily or
duphaston 10 mg tds
4. ET
If you are freezing
Blastocyst: transfer on 6th or 7th day of progesterone
D3 or Morula: transfer on day 4 of progesterone
(some say D 5 for all, no difference)
4. LPS
Estrogen and progesterone
AboubakrElnashar
27. Cases of amenorrhea (after induction by lutone
or lutofolon or cycloprognova or pills)
1. E2
1 Tab x 3 day from D3 of the cycle
2 Tab x 3 day
3 Tab x (2 – 5 day )
2. TVS monitoring
till endometrial lining is 9 – 10 mm.
3. Uterogestan1 tab of utrogestan/d
E2: 2 Tab/d till pregnancy test
4. ET
5. LPS:
if preg test positive: utrogestan 2X3
AboubakrElnashar
28. 1. Oral E2
2 mg/d from cycle day 1-4
4 mg/d from day 5-8
6 mg/d from day 9-12.
2. TVS: assess endometrial-thickness and ovulation
from D13 and E2 dosage was adjusted based on
the endometrial-thickness.
3. P: 40 mg IM when the endometrium reached a
thickness of 8 mm or maximum.
60 mg, 80 mg, and 80 mg progesterone were used
respectively in the following 3 days.
4. ET after 4 days of progesterone administration.
AboubakrElnashar
29. 1. Oral E2: 2 mg three times daily.
2. TVS: After 11, 12 or 13 days
A. If no leading follicle is present and the endometrial thickness is
≥ 8 mm: micronized progesterone (utrogestan) is added and
thawing and transferring is commenced 4 or 5 days later
according to the stage of cryopreservation
B. If the endometrial thickness is less than 8 mm: progynova
dose is raised to 2 mg 4 times daily for 7 days.
After a week the endometrium is checked once again.
When the endometrium thickness is >8 mm and no dominant follicle (≥
14 mm) is present: utrogestan can be added and thawing and
transferring is performed according to local protocols.
If a follicle is visible during ultrasound: LH and P levels are determined.
• If these are raised, (serum LH ≥ 13 E/l or progesterone ≥ 15
nmol/l) luteinization of the follicle is considered to have taken place
and because of the associated diminished pregnancy rates,
thawing and transferring will not be performed.
• If serum levels are below the above mentioned levels thawing and
transferring can be performed according to local protocol
AboubakrElnashar
31. Advantages
1. Greater control and flexibility in the timing of
transfer. cycles are easier to plan: popular
among many patients and their doctors.
2. The length of the follicular phase can be varied
without detriment to IR or PR
(Leeton 1991; Navot 1989)
3. Cycle cancellation rate is low.
AboubakrElnashar
32. 4. Higher IR and PR than patients with natural
cycles
IR and PR was higher in patients without ovulation
than ovulatory patients
ovulation in HRT cycle has a detrimental effect on
pregnancy.
HRT should be used in FET cycles, and ovulation of
patients should be evaluated during the treatment.
Zheng et al, 2014
AboubakrElnashar
33. Risks:
1. The administration of E and P does not guarantee
complete pituitary suppression: a dominant follicle
may occur. luteinization may occur in 5%
(El Toukhy et al., 2004).
2. Should the follicle undergo spontaneous
luteinization: endometrium may be exposed to
progesterone earlier: incorrect timing of thawing and
transferring.
From a cost-efficiency perspective, this aspect is of
great importance and should be taken into account
GnRHa co-treatment may be used to down-
regulate the pituitary and prevent follicular growth
(AC-FET with GnRH-FET). AboubakrElnashar
34. 3. Both of these AC-FET approaches require
medication and are therefore less ‘physiological’
AboubakrElnashar
36. LPS:
If a pregnancy occurs, E and P must be continued
until placental autonomy is established to replace
the absent corpus luteum.
No difference in PR between different methods of
LPS in patients undergoing ‘fresh’ IVF or ICSI
(Chocrane SR, van der Linden et al., 2011).
The use of synthetic progesterone in patients
undergoing IVF or ICSI did lead to higher PR
compared with natural progesterone.
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37. B. Estrogens and progesterones with
GnRHa.
Indication:
In women with remaining ovarian function
Aim:
GnRHa is used to suppress temporarily ovarian function and
render the patient functionally agonadal prior to inducing an
artificial cycle with E and P.
Method:
1. GnRHa (Decapeptyl CR, 3.75 mg)
in regularly menstruating it is given on D21 of the cycle
in oligomenorrhic from D1 of the cycle.
2. After 14 days:
E2 is determined
E2 is started as before
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39. Disadvantages:
1. More expensive
2. GnRHa can have side effects
3. Delay the resumption of spontaneous ovulation
if FET fails.
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40. AC-FET Vs AC-FET with GnRH
Cost is less
Cancellation due to luteinization occurs in 5% is
more
No significant difference in PR
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42. NC-FET Vs AC-FET with GnRHa:
No significant difference in PR or LBR.
(Ghobara and Vandekerckhove,2008)
Significantly higher cancellation rates in
NC-FET (17.4%) Vs AC-FET with GnRH (4.5%)
{preventive effect of down-regulation with regard to
luteinization and ovulation}.
(Hill et al., 2010).
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43. III. OVULATION INDUCTION
Ovary is functional but anovulatory and irregular
cycles, ovulation may be induced by CC, Nolvadex,
letrozole or hMG or or a combination
(Van der Auwera;1994).
For synchronization the day of HCG administration
should correspond to the day HCG administration of
the source cycle in which the embryos were retrieved
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44. A. Letrozole, GNT
In patients with irregular cycles Letrozole is 1st
choice for endometrium preparation for FET
1. Letrozole:
2.5-5mg on cycle D3 to 7, in order to promote monofollicular development
2. TVS:
if follicles growth is not ideal: mild stimulation (HMG 150 IU)
3. HCG:
10000: when the follicles reach the criteria of mature
4. ET
Embryos were frozen at 72h: ETAfter 4 or 5 days
Blastocyst transfer is performed after 7 days.
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45. 1. Letrozole
2.5mg,once daily from D3 to D7 of cycle
2. TVS
D10 of cycle: IM Gnt 37.5~75 IU/d until there is
LH surge or ovulation
3. HCG
On the day appearing LH surge: IM HCG10000
IU.
If there is sill no LH surge when the follicle is 20-
24mm: ovulation is induced by HCG.
4. ET
3 days after ovulation is observed.
4. LPS:
HCG 2000-2500 IU/3d.
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46. B. Letrozole or nolvadex, E2
1. Letrozole:
1x1 x 5 or
Nolvadex
1x3x5 from D3 of the period
2. E2
1x2x3 from D 8 - 9th day of period (follicle 12-14mm)
1x3x3
3. TVS:
from D10-11 till endometrial lining 9-11 mm
4. HCG
4. ET
after 3.5 Days for the 2 days frozen embryo or after 4.5 Days for the 3 days
frozen embryo
5. LPS:
E2: 1x2x12 w of pregnancy.
Cyclogest 200mg 2 days before E.T
Then Cyclogest 400mg after E.T. till 12w
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47. C. CC, E2
1.CC
Start D 3 to 5 of menstruation or withdrawal for 5
days
2. E2
2mg/d until D of HCG administration to overcome
detrimental effect of CC on endometrium.
3. HCG
Repeated testing of P with US
P within follicular levels
adequate follicular size (20-24 mm) and
E thickness ≥8mm: HCG 10000
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48. D. Chronic low dose GnT
Anovulatory patients resistant to CC:
1.FSH
37.5 -75 U /d for up to 14 days
2. TVS
if no dominant F is recruited , the dose is increased
at increments 37.5 U every week to a maximum
225 U/d
When single dominant F of 10-12 mm the dose is
maintained
3. Monitor by US and E2 and P
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49. CONCLUSION
It is not possible, to recommend one endometrial
preparation method in FET over another
Future RCTs should not only address PR but also
consider convenience and cost efficiency.
No significant advantage of one specific approach
to prepare the endometrium for FET in terms of PR
or LBR.
(Ghobara and Vandekerckhove, 2008; Groenewoud et al, 2013, MA)
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50. Choice for either NC or AC should be made based
upon other factors:
1. number of canceled cycles
2. number of hospital visits to plan FET
3. possible serious adverse events and side-effects
4. hospital and IVF laboratory logistics
5. patient or doctor preference.
No publications that address these factors
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52. For the patients with thin endometrium or multiple
ET failures, HRT
1. Oral E2
(ethinyloestradiol) is given 75ug/day for 14-28 days.
Once the lining is greater than 8
mm, Femonston (estace and dydrogesterone)
8mg/d can be started.
1. The day femonston is started is considered
ovulation/opu day, and the time of thaw/transfer is
determined accordingly.
2. If oral E2 is not sufficient, E2 can also be given
through vaginal routes. Femonston (estrace)
1mg/d by vaginal route has good effects for the
patients with thin endometrium.
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53. For the patients with menstrual cycle more than 40
days: dose of letrozole is 5mg qd for 5 days.
for the patients with cycle 35-40 days, the dose of
letrozole commonly use 5mg for 3 days.
for the patients with cycle less than 28 days, the
dose of letrozole is recommended 2.5mg for 3-5
days.
For purpose of synchronization day of HCG
administration correspond to the HCG administration
day of the source cycle in which the Embryos were
retrived
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54. For the patients can not build the lining with the
above methods
1. office hysterscopy before FET.
2. if the endometrium is present pale mucous and
insufficiency bloold flow, docotors will scissor
endometrium gently.
3. Intrauterine scar tissue canbe removed with hyste
roscopy, intrauterine device will be placed for a
few months to prevent further adhesion formation
when necessary.
(Yanping Kuang)
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