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
Vasundhara Hospital Jaipur is a premier specialty hospital for infertile couples, complete women care, high risk pregnancy management, located in heart of Jaipur.
Click to more info :- https://www.vasundharafertility.com/jaipur
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
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
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 .
Update on LETROZOLE Current Guidelines for Ovulation Induction Dr. Sharda Jain Lifecare Centre
Update on LETROZOLE Current Guidelines for Ovulation Induction
LET NOT FORGET
WHY
??
LETROZOLE was withdrawn from
Indian market (2012)
“SAFETY ISSUES”
“Could Be Teratogenic In Human”?
Invited Lecture delivered by Dr Sujoy Dasgupta in the Annual Conference of ISAR (Indian Society of Assisted Reproduction) held at Kolkata in November, 2019
Vasundhara Hospital Jaipur is a premier specialty hospital for infertile couples, complete women care, high risk pregnancy management, located in heart of Jaipur.
Click to more info :- https://www.vasundharafertility.com/jaipur
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
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
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 .
Update on LETROZOLE Current Guidelines for Ovulation Induction Dr. Sharda Jain Lifecare Centre
Update on LETROZOLE Current Guidelines for Ovulation Induction
LET NOT FORGET
WHY
??
LETROZOLE was withdrawn from
Indian market (2012)
“SAFETY ISSUES”
“Could Be Teratogenic In Human”?
Ovarian reserve refers to the reproductive potential left within a woman's two ovaries based on number and quality of eggs. Diminished ovarian reserve is the loss of normal reproductive potential in the ovaries due to a lower count or quality of the remaining eggs
Luteal phase insufficiency is one of the most important aspect of fertility treatment . But due to lack of proper understanding many unwanted medications are prescribed . This ppt will give an idea on the best evidence based luteal phase support for an ivf cycle.
It describes the Progesterone physiology. It describes the latest evidence as regards progesterone formulations, use of progesterone as Luteal phase support. It scrutinizes the value of serum progesterone in monitoring luteal phase
Explore the intricacies of ovulation induction in intrauterine insemination (IUI) with Dr Laxmi Shrikhande's informative slide share presentation. From understanding the hormonal mechanisms to the latest techniques, this presentation offers insights into optimizing fertility through IUI. Whether you're a clinician seeking to enhance patient outcomes or an individual navigating fertility treatments, this resource provides valuable knowledge for your journey towards conception.
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.
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Uterine Fibroids: Symptoms, Causes, Risk Factors & Treatment uterine fibroids aren't associated with an increased risk of uterine cancer and almost never develop into cancer
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You can get the awareness that you were looking for Non Specific Musculoskeletal Pain details
Non-Specific Musculoskeletal Pain presented by Dr.Laxmi Shrikhande Consultant –Shrikhande Hospital & Research Centre Pvt Ltd
Nagpur. The leading hospital in Nagpur
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Contraception where have we been and where are we going is a presentation made by Dr.Laxmi Shrikhande who is a Fertility Specialist, Laparoscopic Surgeon & no scar Hysterectomy Specialist and a leading Gynaecologist from Nagpur
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Can prevent two generations from developing diabetes in the future.
Anti-Müllerian Hormone (AMH) is critical for physiologic involution of the Mullerian ducts during sexual differentiation in the male foetus.
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Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
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Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
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Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
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DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
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FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
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VERIFICATION AND VALIDATION TOOLKIT Determining Performance Characteristics o...
Luteal phase support in IUI and ART | Dr. Laxmi Shrikhande | ShrikhandeIVF
1. Dr. Laxmi Shrikhande MD; FICOG; FICMCH;FICMU
▪ Director-Shrikhande Fertility Centre, Nagpur
▪ Senior Vice President FOGSI 2012
▪ Associate member RCOG, London
▪ Member of European Society of Human Reproduction
▪ Received Bharat excellence Award for contribution to women’s health
▪ Chairperson HIV Committee FOGSI 2009-12
▪ Received best FOGSI committee award
▪ National Editor-The Journal of OB / GY of India
▪ Vice Chairperson Elect Indian College of OB/GY
▪ Publications-Thirteen National & seven International
▪ Editor-FOGSI Focus on HIV in women
▪ Editor-FOGSI Focus on SUI- Myths & Facts
▪ Presented Papers at FIGO,SAFOG,AOFOG, IFFS
2. Luteal phase support in IUI
and ART
Dr Laxmi Shrikhande
Director-Shrikhande Hospital &
Research Centre, INDIA
3. “When a thing ceases to be a subject of
controversy, it ceases to be a subject
of interest.”
William Hazlitt (1778–1830), English essayist
4. • 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.
Jones GES: Some newer aspects of management of infertility. JAMA 141:1123, 1949
5. The consensus of the literature is that LPD does exist
and that its cause is multifactorial-
• abnormal folliculogenesis,
• inadequate LH surge,
• inadequate secretion of progesterone by the
corpus luteum,
• aberrant end-organ response by the
endometrium
6. Scope
• Is there any need for support in natural cycle /
IUI / IVF cycles ?
• What to give ?
• When to give ?
• What dose?
• When to stop ?
7. Luteal phase in a natural cycle
• Between ovulation and either
pregnancy / menses
• LH as the hormone to
support corpus luteum and
stimulate progesterone
production
• In ovulatory women, 92% of
cycles show normal luteal
function, and luteal support is
unnecessary (Rosenberg et al.,
1980).
8. Natural cycle IUI
• Donor Inseminations
• Cervical factor infertility
• Mild/Moderate male factor infertility
Luteal Phase support will unnecessarily increase the cost
of the cycle without increasing the pregnancy rate.Thus
not recommended
9. What happens to Luteal phase in stimulated
cycles
▪ Multiple follicles of different size might ovulate at different
times, expanding the fertilization window.
▪ Thus, both oestradiol and progesterone, after multiple
ovulation is expected to be significantly higher
(Macklon and Fauser, 2000).
▪ These high concentrations may not only influence the
receptivity of the endometrium, but may also cause luteal
insufficiency and early luteolysis
(Erdem et al., 2008).
10. CC - Stimulated Cycles
Some authors reported luteal phase
inadequacy in up to 50% of clomiphene citrate
induced cycles in anovulatory women
[Cook et al.,1984,Keenan et al.,1989]
11. CC - Stimulated Cycles
▪ 400 women analysed
▪ No difference observed in ongoing pregnancy between
patients who did, or did not, receive vaginal
progesterone as luteal support [8.7% (17/196) versus
9.3% (19/204)
▪ Thus routine supplementation of the luteal phase with
vaginal progesterone does not seem to improve
pregnancy rates in normo-ovulatory women stimulated
with clomiphene citrate for IUI
Paul devroy, Human reproduction, vol 25, issue 10. pg 2501-2506
12. Studies favoring the luteal phase support in IUI
• Montville et al -Fertil Steril. 2010
• Erdem et al – Fertil Steril. 2009
• Cohlen review - Reprod Biomed Online.
2009
13. Studies not favoring luteal phase support in IUI
• Ebrahimy M.- 12th International Congress of
Gynecology and Obstetrics 2010.
• Kyrou D - Hum Reprod. 2010
• Bibi Shahnaz Aali, Iran J Reprod Med. Apr 2013
• Romero Nieto MI , Gynecol Endocrinol.2014
14. Luteal phase support after IUI
Conclusion
➢ Progesterone luteal phase support may be of benefit to
patients undergoing ovulation induction with gonadotropins
in IUIcycles.
➢ Progesterone support did not benefit patients undergoing
ovulation induction with CC, suggesting a potential
difference in endogenous luteal phase function depending
on the method of ovulation induction.
Hill MJ Fertil Steril. 2013- a systematic review and meta-analysis.
15. LPS in IUI cycles
• Shortened luteal phase in 20% of stimulated cycles for
ovulation induction using FSH (Olson et al., 1983).
• In a recent meta-analysis (Hill et al., FS, 2013) of 5 trials
involving 1,938 cycles in 1,298 patients, LPS with P
improves success.
• Improvement seen in FSH cycles only but not in CC-
induced cycles.
OR (95% CI)
Clinincal pregnancy 1.47 (1.15-1.98)
Live birth 2.11 (1.21-3.67)
16. Luteal phase defect in IVF
Reasons
1.Supra-physiological steroid concentrations
secreted by multiple corpora lutea directly inhibit
LH release (Fauser and Devroey, 2003)
2.HCG for the final oocyte maturation suppresses
LH production (Miyake et al., 1979)
17. Luteal phase defect in IVF
3. GnRH agonist or antagonist for downregulation
prevents LH rise in the luteal phase
4. Removal of large quantities of granulosa cells
during oocyte retrieval
18. • hCG or progesterone improved pregnancy rates IVF
cycles using GnRH agonist
• OHSS in 5% of cycles with hCG
• Conclusion: Routine use of luteal phase support in
IVF cycles using GnRH agonist
Meta-analysis of 18 trials
19. • 385 women were randomized into 3 groups
hCG TUGOR ET (D3)
No. of patients 130 128 127
Ongoing
pregnancy rate
20.8% 22.7% 23.6%
21. LPS in ART
1. Human chorionic gonadotrophin (hCG)
2. Progesterone: oral, intramuscular, vaginal
3. Progesterone and oestradiol
4. hCG and progesterone
5. Progesterone and GnRH agonist
22. hCG Vs Progesterone
• No significant difference found between P and
hCG or between P and P plus hCG in terms of
pregnancy or miscarriage rates
• Risk of OHSS significantly higher with treatments
involving hCG than with P alone
23. Progesterone Vs HCG
• Consensus opinion in favor of
Progesterone
❖Once pregnancy is established
– Supplemental hCG is not beneficial
25. Oral progesterone
• Reduced implantation rates when compared with
hCG, IM and vaginal progesterone
▪ Poor bioavailability due to rapid hepatic metabolism
(Maxson et al., 1984)
▪ Failure to induce uniform secretory changes in
endometrium (Devroey et al., 1989; Critchley et al., 1990)
• Metabolites induce significant sedative and hypnotic
effects (Arafat et al., 1988)
26. Vaginal progesterone
• Easy to administer
• Avoids liver first-pass metabolism
• No systemic side-effects
• Higher endometrial tissue level despite low serum
level due to ‘first uterine pass effect’
• Similar pregnancy rate as intramuscular
progesterone
27. Vaginal progesterone
• Associated with vaginal discharge and perineal
irritation
▪ tablets: 6%
▪ gelatin capsules: 0-14%
▪ suppositories: 25-30%
▪ bioadhesive gel: 17%
• Affect patients’ comfort and compliance during
the IVF treatment
28. Intramuscular progesterone
• Uncomfortable daily injections
• Trained medical personnel
• Allergic reactions to the oil vehicle and marked
inflammation at the injection site, resulting in
redness, pain and even sterile abscess formation
29. Dydrogesterone
• It is structurally and pharmacologically
similar to natural progesterone, has
good oral bioavailability
• has a good safety and tolerability profile
• has no androgenic effects on the fetus,
30. • 1,373 infertile women undergoing IVF randomized
into micronized P gel (Crinone 90mg daily), P capsule
(Utrogestan 200mg tds), and oral dydrogesterone
(Duphason 10mg bd)
• Comparable PR and miscarriage rates
Oral Vaginal gel Vaginal capsule
Clinical PR
at 7 weeks
121/422 (28.7%) 138/482 (28.6%) 104/459 (22.7%)
Miscarriage
rate
14/121 (11.6%) 18/138 (13.0%) 19/104 (18.3%)
31. Dydrogesterone / vaginal progesterone
Comparison of oral dydrogesterone with suppository
vaginal progesterone for luteal-phase support in in
vitro fertilization (IVF): A randomized clinical trial.
Salehpour S, Iran J Reprod Med. 2013
Conclusion - Oral dydrogesterone is as effective as
vaginal progesterone for luteal-phase support in
women undergoing IVF.
32. GnRH agonist in luteal phase -IUI
▪ GnRH agonist was recently suggested as a novel luteal-
phase support that may act at different levels, including
the pituitary gonadotrophs, the endometrium and the
embryo itself
▪ Regimens for IUI :
▪ single dose triptorelin 0.1 mg 6 days after ovulation
▪ Three doses of lupride 1 mg sc 6 days after ovualation
33. GnRH agonist in luteal phase-IVF
Evaluation of the impact of gonadotropin-releasing
hormone agonist as an adjuvant in luteal-phase support
on IVF outcome.
Conclusion - Three 1 mg doses of Lupride administration 6
days after oocyte retrieval in the long protocol cycles does not
result in an increase in ongoing pregnancy rates.
Inamdar and A Majumdar.J Hum Reprod Sci. 2012.
35. • GnRH-a can collaborate in the corpus luteum
function, acting directly on the endometrium via local
receptors, a direct effect on the embryos or
combination.
• GnRH-a administration can improve clinical outcomes
after ICSI.
• Premature to recommend the use of GnRH-a in the
luteal phase because of heterogeneity among trials
36. Role of oestrogen in IUI for luteal support
• The role of oestrogen along with
progesterone in the luteal phase appears to
be only in those cases where GnRH agonist
was used instead of hCG to trigger ovulation
37. Estradiol as luteal phase support-IVF
1. The use of estradiol for luteal phase support in IVF /
ICSI cycles: a systematic review and meta-analysis.
Gelbaya TA, Fertil Steril. 2008
conclusion - The addition of E(2) to P4 for luteal phase support in
IVF/ICSI cycles has no beneficial effect on pregnancy rates
2. Luteal phase support with estrogen in addition to
progesterone increases pregnancy rates in IVF cycles with
poor response to gonadotropins.Kutlusoy F , Gynecol
Endocrinol. 2014
38. LPS in natural cycle FET
• Controversial
1. Retrospective study: no effect on pregnancy rate
following vaginal P in hCG-induced natural FET
cycles (Kyrou et al., 2010)
2. RCT: significantly higher live birth rate when vaginal
P was given in natural FET cycles (30% Vs 20%); no
difference in clinical PR and miscarriage rate
(Bjuresten et al., 2011)
39. • Before 1st July 2009, 2 doses of 1500 IU hCG given on
the day of FET and 6 days after the transfer.
• Such practice was stopped after 1st July 2009.
With hCG Without hCG
Clinical PR 53/205 (25.9%) 59/203 (21.1%)
Miscarriage rate 12/66 (18.2%) 12/75 (16.0%)
41. 600 mg of progesterone starting on the day
of ET for 14 days after ET
150 women did NOT receive P
for another 3 weeks (Study
group)
150 women received P for another 3
weeks (Control group)
Delivery rate
+ve hCG
42. • Prolongation of P in the early pregnancy (up to 7
weeks of gestation) has no effect on the
miscarriage and delivery rates.
• P can be safely withdrawn after a positive hCG test
Study Group Control group
Ongoing preg. 133 (88.7) 139 (90.8)
Delivery 118 (78.7) 126 (82.4)
Biochemical 10 (6.7) 7 (4.0)
Abortion 22 (14.6) 18 (11.8)
43. F&S, 2010
No difference in ongoing pregnancy and miscarriage
rates on early P cessation
F&S, 2012
F&S, 2010
44. Duration of LPS in IVF
Authors Protocol Study Gp Control Gp
Andersen 2002 Vaginal P
Livebirth
LPS till 7 wks
78.7%
LPS till PT+ve (4 wks)
82.4%
Aboulghar 2008 Vaginal or IM P
Miscarriage
LPS till 10 wks
4.6%
LPS till USS (7 wks)
4.8%
Goudge 2010 IM P
Livebirth
LPS till 8 wks
52.0%
LPS till PT+ve (4 wks)
49.0%
Kyrou 2011 Vaginal P
Ongoing
LPS till 7 wks
82.0%
LPS till PT+ve (4 wks)
73.0%
Kohls 2012 Vaginal P
Ongoing
LPS till 8 wks
73.0%
LPS till USS (5 wks)
75.0%
45. Conclusion
• Prevalence of a luteal phase defect in natural
cycles is about 8.1% (Rosenberg et al., 1980).
• In these cases LPS is controversial
• CC stimulated cycles do not disturb the
luteal phase, however there is an urgent need
for prospective randomised trials.
• HMG/rec-FSH with GnRH agonist and
antagonist cycles must be supplemented.
46. Conclusion
• IVF
✓vaginal P alone for about 2 weeks from day of
hCG, TUGOR or ET
• FET in natural cycles
✓Controversial
• IUI
✓Vaginal progesterone for 2 weeks
48. 'Spiritual blossoming' simply means
blossoming in life in all dimensions.
Being happy, at ease with yourself
and with everybody around you.
Sri Sri Ravi Shankar
The Art of Living