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
Invited Lecture delivered by Dr Sujoy Dasgupta in the Annual Conference of ISAR (Indian Society of Assisted Reproduction) held at Kolkata in November, 2019
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)Sujoy Dasgupta
Dr Sujoy Dasgupta invited to deliver a lecture on "RPL- ESHRE Guideline" in the Annual Conference of RCOG (Royal College of Obstetricians and Gynaecologists) IRC (International Representative Committee) India East held on 20-21 May, 2023
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
Invited Lecture delivered by Dr Sujoy Dasgupta in the Annual Conference of ISAR (Indian Society of Assisted Reproduction) held at Kolkata in November, 2019
ESHRE Guideline on Recurrent Pregnancy Loss (RPL)Sujoy Dasgupta
Dr Sujoy Dasgupta invited to deliver a lecture on "RPL- ESHRE Guideline" in the Annual Conference of RCOG (Royal College of Obstetricians and Gynaecologists) IRC (International Representative Committee) India East held on 20-21 May, 2023
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
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.
Hysteroscopic procedures are getting refined and with the advent of miniature scopes , doing these procedures in he office is getting better and more comfortable.
Ovarian Hyperstimulation Syndrome(OHSS), is a Rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy where a patient's ovaries become swollen and fluid builds up around her abdomen
Endometriosis and fertility how and when to treatDr Aditya Keya
Endometriosis can influence fertility in several ways: distorted anatomy of the pelvis, adhesions, scarred fallopian tubes, inflammation of the pelvic structures, altered immune system functioning, changes in the hormonal environment of the eggs, impaired implantation of a pregnancy, and altered egg quality.
Optimization of ovarian stimulation to improve success rate in ‘ART’Apollo Hospitals
ART is defined as the technique used where there is a need for in-vitro preparation or manipulation of gametes. The commonest ARTs are intrauterine insemination (IUI) and in-vitro fertilization (IVF). Ovarian stimulation is required with these procedures to increase the pregnancy rate as ART with natural cycle has a very low pregnancy rate. Optimizing pregnancy rates per cycle is the real basis for ovarian stimulation protocols in ART.
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
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.
Hysteroscopic procedures are getting refined and with the advent of miniature scopes , doing these procedures in he office is getting better and more comfortable.
Ovarian Hyperstimulation Syndrome(OHSS), is a Rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy where a patient's ovaries become swollen and fluid builds up around her abdomen
Endometriosis and fertility how and when to treatDr Aditya Keya
Endometriosis can influence fertility in several ways: distorted anatomy of the pelvis, adhesions, scarred fallopian tubes, inflammation of the pelvic structures, altered immune system functioning, changes in the hormonal environment of the eggs, impaired implantation of a pregnancy, and altered egg quality.
Optimization of ovarian stimulation to improve success rate in ‘ART’Apollo Hospitals
ART is defined as the technique used where there is a need for in-vitro preparation or manipulation of gametes. The commonest ARTs are intrauterine insemination (IUI) and in-vitro fertilization (IVF). Ovarian stimulation is required with these procedures to increase the pregnancy rate as ART with natural cycle has a very low pregnancy rate. Optimizing pregnancy rates per cycle is the real basis for ovarian stimulation protocols in ART.
The Newer Concepts forReduced Surgery to preserve fertility in Endometrios...Lifecare Centre
The Newer Concepts forReduced Surgery to preserve fertility in Endometriosis
ENDOMETRIOSIS IS ENIGMA
DIAGNOSTIC DILEMMA
DEBILITATING DISEASE QOL
PROGRESSIVE DISEASE
RECURRENCE IS BIG PROBLEM
NO FINAL VERDICT ON CAUSE
NO PERMANENT CURE
The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women
Endometriosis and Subfertility, Primium non nocereSujoy Dasgupta
Dr Sujoy dasgupta and Dr Arun Madhab Barua were invited to moderate a panel discussion on "Endometriosis and Subfertility, Primium non nocere" in the International Congress on Endometriosis (ICE) on 10 December 2023 at Dhana Dhanya Auditorium, Kolkata
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS RELATED INFERTILITY (EVIDENCE BASED)
MODERATOR
DR SHARDA JAIN
DR JYOTI AGARWAL
DR ILA GUPTA
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
Panel Discussion on Post Menopausal Bleeding Lifecare Centre
Panel Discussion on Post Menopausal Bleeding
Moderator
Dr Jyoti Agarwal
Dr Meenakshi Sharma
Panelists
Dr Uma Rai
Dr Raj Bokaria
Dr Ila Gupta
Dr Vandana Gupta
Dr Renu Chawla
Dr Manju Barik
Dr Krishna Gopa
Dr Sharda Jain
AGAINST the Motion- “Surgery is the ONLY treatment of Endometriosis with Infe...Sujoy Dasgupta
Dr Sujoy Dasgupta participated in an invited debate through a webinar organized by Dr B. N. Chakraborty School of Fertility Management and research, held in July, 2020
Endometriosis and Subfertility - What to do?Sujoy Dasgupta
Lecture delivered by Dr Sujoy Dasgupta in IPCON 2823, the Mid term conference of ISOPARB (Indian Society of Perinatology and Reproductive Biology) held at Kolkata on 10 September
AGAINST the Motion- “Surgery is the ONLY treatment of Endometriosis with Infe...Sujoy Dasgupta
Dr Sujoy Dasgupta participated in the invited debate on “Surgery is the ONLY treatment of Endometriosis with Infertility” in the Webinar organized by the AICC RCOG (All India Coordinating Committee) East Zone held in February, 2022
The Newer Concepts In Endometriosis Management : Dr Sharda JainLifecare Centre
The Newer Concepts In
Endometriosis Management
ENDOMETRIOSIS IS ENIGMA
DIAGNOSTIC DELEMMA
DEBILITATING DISEASE QOL
PROGRESSIVE DISEASE
RECURRENCE IS BIG PROBLEM
NO FINAL VERDICT ON CAUSE
NO PERMANENT CURE
The exact prevalence of endometriosis is unknown, but estimates 10% in the general female population in India but up to 50% in infertile women
Anemia Free India Gynaecologist to focuss on *12gm Haemoglobin at Delivery I...Lifecare Centre
Important Highlights
Prophylactic Iron and Folic Acid Supplementation in all six target age groups.
Intensified year-round Behaviour Change Communication (BCC) Campaign for:(a) improving compliance to IFA and deworming, (b) enhancing appropriate infant and young child feeding practices, (c) encouraging increase in intake of iron-rich food through diet and/or fortified foods (d) ensuring delayed cord clamping .
Testing and treatment of anaemia, using digital methods and point of care treatment, with special focus on pregnant women and school-going adolescents.
Addressing non-nutritional causes of anaemia
in endemic pockets with special focus on malaria, hemoglobinopathies and fluorosis
Strategies for Improving Success Rates in ART PARTLifecare Centre
Strategies for Improving Success Rates in ART
Part - 2
Strategies for Improving Success Rates in ART
Tailoring Controlled Ovarian Stimulation
Strategies for Luteal Phase in ART cycles
Endometrial Receptivity Array
How to optimize success rates in ART? : Dr Sharda JainLifecare Centre
How to optimize success rates in ART? : Dr Sharda Jain
How to improve success rates in ART?
The big debate कार्य में आनंद
Evolution of In-vitro Fertilization (IVF)
Factors Influencing IVF Success Ist Part
Strategies for Improving Success Rates in ART Second Part
Innovations & Breakthroughs in IVF Part Three
OPEN DEBATE
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda JainLifecare Centre
SOCIALEGG FREEZING : Dr Poorva Bhargav and Dr Sharda Jain
Introduction
Social egg freezing (oocyte cryopreservation for non-medical reasons) has evolved as a proactive option for women looking to extend their reproductive possibilities past their peak childbearing years
It is the process of saving or protecting eggs, or reproductive tissues so that a person can use them to have biological children in future
CMV UPDATE Few solid facts about cytomegalovirus (CMV) Infection & New devel...Lifecare Centre
CMV UPDATE Few solid facts about cytomegalovirus (CMV) Infection & New development from France for Indian Gynaecologists & public to know :Dr Sharda Jain
CMV is a common herpesvirus that can infect people of all ages, including pregnant women.
CMV is not the same as HSV (herpes simplex virus), although they belong to the same viral family.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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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.
- 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
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
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.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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
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.
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.
5. Important Facts
• 25-50% of infertile
women have
endometriosis
• Infertile women are
6-8 times more likely
to have E
• South india : 73%
INCIDENCE 10%
11. The stages of Endometriosis
Stage – 1 • Mild / moderate endometriosis
• Isolated implants
• No significant adhesions
• Superficial implant <5mm
Stage – 2 • Moderate endometriosis
• Multiple implants both superficial and deep >5mm ,peritubal +
para – ovarian adhesions
• <4 cm endometrioma
Stage 3 • Severe endometriosis
• Multiple superficial & deep implant
• Large ovarian endometrioma > 4 cm
• Flimsy + dense adhesions
Stage 4 • Advanced
• Recto-vaginal Infiltrates
• Frozen Pelvis
12. Recommendations for the diagnosis of Endometriosis
Category Recommendation Grade Quality of
Evidence
CPP Consider endometriosis in the
presence of : dysmenorrhea non
cyclical pelvic pain , deep dyspareunia
, infertility & fatigue in the presence
of any of the above
- -
CPP In women of reproductive age with
non – gynacological cyclical symptoms
( dyschezia , dysuria, hematuria, ractal
bleeding , shoulder pain)
- -
CPP Perform a thorough clinical examination
including per abdominal/ per vaginal , per
rectal & rectovaginal examination in women
with suspected endometriosis
- -
13. Recommendations for the diagnosis of Endometriosis
Category Recommendation Grade Quality of
Evidence
CCR Suggest diagnosis of deep endometriosis in
patients with deep pelvic pain and findings of
nodules & / or induration of the rectovaginal
wall
c -
CCR Suspect endometrioma if examination
shows adnexal mass
c -
CCR Absence of clinical evidence during
examination & USD does not rule out
the disease.
c -
16. Recommendations for the diagnosis of Endometriosis
Category Recommendation Grade Quality of
Evidence
EBR
Laparoscopy remains the
gold standard for
diagnosis of
endometriosis –but
discouraged just for
diagnosis
A II
19. Stage I (Minimal) Stage II (Mild)
Stage III (Moderate) Stage IV (Severe)
Classification of Endometriosis R
A
F
S
S
C
O
R
E
R
E
V
I
S
E
D
A
F
S
S
C
O
R
E
20. Recommendations for the diagnosis of Endometriosis
Category Recommendation Grade Quality of
Evidence
CCR CA - 125 is poorly sensitive for
diagnosis . however , it has a role in
treatment follow – up
A -
CPP One should assess ureter , bladder and bowel
involvement by additional imaging
techniques
- -
22. Question 1
Are hormonal therapies effective
for infertility associated with
endometriosis ??
23. Hormonal therapy and infertility
Suppression of ovarian function by means of
hormonal contraceptives , progestagens
GnRH analogues or danazol to improve
fertility in patients with minimal or mild
endometriosis is NOT effective and hence
should not be offered
Evidence does not comment on more severe disease
(Hughes et al., 2007). ,recommendation 21,22
A
25. Infertile women with Stage I/II endometriosis
Evidence recommends that clinicians
should not perform operative
laparoscopy readily .
Diagnostic laparoscopy To diagnose
ENDOM….OUT
.
27. Recommendations for the management of infertility in
women with endometriosis
Category Recommendation Grad
e
Quality of
Evidence
EBR IN INFERTILITY WOMEN WITH
ENDOMETRIOMA < THAN 3 CM THERE
IS NO EVIDENCE THAT CYSTECTOMY
PRIOR TO TREATMENT WITH ART TO
IMPROVE PR
A II
28. Recommendations for the management of infertility in
women with endometriosis
Category Recommendation Grade Quality of
Evidence
CPP ENDOMETRIOMA LARGER THAN 3 CM
CLINICIANS SHOULD CONSIDER
CYSTECTOMY PRIOR TO ART ONLY
TO IMPROVE ENDOMETRIOSIS –
ASSOCIATED PAIN OR THE
ACCESSIBILITY OF FOLLICLES
- -
29. Recommendations for the management of infertility in
women with endometriosis
Category Recommendation Grade Quality of
Evidence
EBR
IN STAGE III/IV OPERATIVE
LAPAROSCOPY INSTEAD OF
EXPECTANT MANAGEMENT
INCREASES CHANCES OF
SPONTANEOUS PREGNACY
A III
30. Women with Stage III/IV Endometriosis
So far no RCT,s comparing the reproductive
outcome after surgery and after expectant
management is available but
4 cohort studies have shown
better pregnancy rate after surgery so
Clinicians can consider operative
laparoscopy, instead of expectant
management ,& senf for IVF to increase
spontaneous pregnancy B
32. Effectiveness of Surgical techniques
Guidelines recommend that in infertile
patients with chocolate cyst clinicians
should perform excision of the
endometriric cyst, instead of drainage
and electrocoagulation to increase
spontaneous pregnancy rates .
(Hart et al., 2008) ,Guidelines 21
A
33. why excision ?
Cystectomy
provides greater improvement pain
–Spontaneous pregnancy rates
–Decreases Recurrence and repeat surgery
ASRM Practice Guidelines 2013
Possibility of occult malignancy to be kept in mind
34. MOST IMPORTANT !!!!
surgery must be complete &
performed by a best qualified gynae
surgeon with experience in dealing
with endometriosis.
35. Counselling ….. Two concerns
Ovarian Reserve Recurrence
Decision to proceed with surgery should
be considered very carefully ,especially if the
women has had previous ovarian surgery
36. AMH
AMH should be done pre –operatively & 3
months post Operatively to determine
the effect of surgery on the Ovarian
reserve
39. • In infertile women with endometriosis, clinicians
should not prescribe adjunctive hormonal
treatment before or after surgery to improve
spontaneous pregnancy rates (Furness et al., 2004).
A
But clinicians should not withhold hormonal
treatment for pain in symptomatic women in the
waiting period before undergoing surgery or
medically assisted reproduction .
GPP
40. Endometriosis:Take Home Tips
Medical
In minimal or mild
endometriosis it
does not enhance
fertility and hence
should not be offered
Surgical
is not offered in
minimal or mild
But helps in
moderate to
severe
endometriosis
Medical treatment is not effective
Rather delays fertility restoration
41. Is ART needed in
women with
Endometriosis
???
Question 5
BIG YES
43. Objective is the baby
Dictum is to send the patient for ART
earlier than late
44. IUI in endometriosis stage 1,2
Live Birth Rate is 5.6 times higher in
couples with minimal to mild endometriosis
after COS with oral ovulogens or
gonadotrophins and IUI as compared to
couples after expectant management .
45. Recommendations for ART
IVF is the treatment of choice if
Tubal function is compromised
There is male factor infertility
Other treatments have failed
Stage 3 -4 endometriosis
46. Recommendations for A..R.T. in women with
endometriosis
Category Recommendation Grade Quality of
Evidence
CPP ART should be recommended on
presence of tubal dysfunction or in
presence of male factor or if other
management options fail
B
-
CPP Recurrence rate of endometriosis is
not increased with controlled ovarian
stimulation
-B -
52. Women with stage 3- 4 endometriosis
Women with chocolate cyst
< than 3 cm there is NO evidence that
cystectomy prior to treatment with
ART improves pregnancy rates . ( A )
Consider cystectomy prior to ART
ONLY to improve
• endometriosis-associated pain or
• difficulty in oocyte retrival (GPP)
53. Take home Messages
• Consider female age ,duration of infertility and
stage of endometriosis for formulating the
management plan
• Benefits of laparoscopy for diagnosis in minimal &
mild endometriosis in not reported however , if
surgery performed , ablation or excision should be
done
• Consider expectant management or super ovulation
& intrauterine insemination as first – line therapy
in younger women (<35years) with stage i/ii
endometriosis – associated infertility
54. Take home Messages
• Consider more aggressive treatment , such as Super
ovulation+ IVF for women more than 37 years of
age or older
• Remember Conservative surgical therapy with
laparoscopy or possible laparotomy followed by
ART is beneficial in women with stage III/IV
endometriosis – associated infertility
55. Tips ……
• Surgery should be given
backseat
• Do not cauterize excessively.
• Adhesions preventing barriers
have a role.
• Medical management: improves pain, not fertility
Success depends upon the residual
disease left behind
57. CASE 1 - Large Endometriotic Cyst
32 year old female married for 4 years; keen to
conceive in the last 2 years; came with complaint of
severe dysmenorrhea for 3 months.
• Investigations-
Semen Analysis: within normal limits.
USG suggestive of 6 x 4.5 x 3.6 cms left ovarian
endometriotic cyst.
• Management: given Dienogest outside .No decrease
in size
58. CASE 1 - Large Endometriotic Cyst
.
• Management:
Laparoscopic left ovarian cystectomy done along
with chromopertubation with methylene blue to
check for tubal patency.
Ovulation induction with low dose gonadotropins
done in the next cycle followed by IUI.
Patient conceived in second IUI cycle
59. CASE 2 - Surgery Post GnRH agonist depot given
twice
• Patient Details-
30 years old patient,3 years infertility, referred by a
Gynaecologist after giving GnRH agonist 3.75 mg
depot twice as her dysmenorrhoea was+++
She was referred for surgery+ chromotubation
60. CASE 2 - Surgery Post GnRH agonist
depot given twice
MANAGEMENT
Upper abdomen normal
• stage 2 ,Post depot surgical planes were well
defined and even though there was little
obliteration of Pouch of Douglas.
61. CASE 2 - Surgery Post GnRH agonist
depot given twice
At Laparoscopy endometriotic spots were
fulgurated. No cysts in ovaries
Both the tubes were patent and anatomy was
restored.
She conceived with ovulation induction with
letrozole along with low dose gonadotropins
followed by IUI.
62. CASE 3 - Frozen Pelvis with Deep Infiltrating Endometriosis
• Patient details
29 year old patient present primary infertility
3years; came with complaint of severe
dyspareunia associated with dysmenorrhea
and dyschezia since 4 months.
• Investigations-
USG and MRI pelvis suggestive of B/L
ENDOMETRIOMA + frozen pelvis with dense
adhesions and rectovaginal involvement.
63. CASE 3 - Frozen Pelvis with Deep Infiltrating Endometriosis
Management:
Extensive Adhesiolysis with Enterolysis done along with bilateral ovarian
cystectomy. Blocked tubes on both sides.
Patient taken for IVF in view of poor ovarian reserve (AMH
1.5) and blocked tubes with ultra long protocol. INJ
LEUPRIDE DEPOT 3.75
ANTAG PROTOCOL in treatment cycle.
Recombinant FSH used for ovarian stimulation.
7 M2 oocytes retrieved and 3 blastocysts were formed.
All the embryos were frozen due to poor endometrial lining
Patient conceived in first frozen embryo cycle with blastocyst transfer.
64. CASE 4 - Recurrent endometrioma
Patient details: 23 years unmarried with bilateral very
large endometriomas.
Laparoscopic surgery was done B/L Cystectomy done
She came to us after marriage again with H/O bilateral
endometrioma 5 cms each
FOR which Laparoscopic surgery was done again outside
No comment on tubal patency. Told verbally ok
65. CASE 4 - Recurrent endometrioma
Investigations: Semen Analysis suggestive of 1 to 5 million count hence IUI
not possible. Suggested LIFE STYLE ADVICE
Management:
Tab dydrogesterone 10 mg from day 5 to day 25 was given for 6 months .
At follow up we had advised her to take tab Letrozole 2.5 mg from day 3
– day 7 + antioxidants vit C ,E BD ( H & w )
She conceived naturally with letrozole and few years later again
conceived spontaneously without even ovulation induction.
NO DEPOT WAS GIVEN. NO IVF DONE
67. Do not remove small ovarian
endometriomas
(specially a diameter<4 cm)
-Impairs ovarian function,
-AMH decrease may happen
68. Do not recommend repeated
follow-up serum CA-125 (or other
currently available biomarkers)
measurements in women
successfully using medical treatments for
uncomplicated endometriosis in the
absence of suspicious ovarian cysts