This document discusses monitoring of the ART (assisted reproductive technology) cycle. It describes various methods for monitoring, including ultrasound to measure follicle growth and endometrial thickness, as well as using ultrasound combined with serum estradiol levels. The key objectives of monitoring are outlined, such as predicting ovarian response, monitoring pituitary suppression, evaluating gonadotropin dose, preventing OHSS, determining the optimal time for hCG administration, and avoiding cycle cancellation. Indicators for when to adjust gonadotropin dosage or cancel the cycle are provided. Ultrasound is identified as the most practical monitoring method and combining it with estradiol is particularly useful for high-risk patients.
MONITORING PITUITARY DOWN-REGULATION
If GnRH Agonist is started in the late luteal phase a menstrual bleeding normally indicates that the estrogen is low and FSH can be started.
Blood tests will clearly confirm down-regulation – ovarian/pituitary hormones.
MONITORING PITUITARY DOWN-REGULATION
If GnRH Agonist is started in the late luteal phase a menstrual bleeding normally indicates that the estrogen is low and FSH can be started.
Blood tests will clearly confirm down-regulation – ovarian/pituitary hormones.
Vasundhara Hospital Jaipur is a premier specialty hospital for infertile couples, complete women care, high risk pregnancy management, located in heart of Jaipur.
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the objective is to clarify the problem of recurrent implantation failure , regarding the definition, the caused, diagnosis, and management in cases of IVF
Significant increase in live birth rate is found when IUI is done with stimulation compared with IUI in natural cycle in women with Unexplained Infertility .
Since the first formal description of LPD in 1949 as a possible cause of infertility and recurrent miscarriage by Jones. Innumerable investigations have been undertaken in an effort to verify its existence or to characterize its pathophysiology, diagnosis, and treatment. The consensus of the literature is that LPD does exist and that its cause is multifactorial like abnormal folliculogenesis, inadequate LH surge,inadequate secretion of progesterone by the corpus luteum, aberrant end-organ response by the endometrium.
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
the objective is to clarify the problem of recurrent implantation failure , regarding the definition, the caused, diagnosis, and management in cases of IVF
Significant increase in live birth rate is found when IUI is done with stimulation compared with IUI in natural cycle in women with Unexplained Infertility .
Since the first formal description of LPD in 1949 as a possible cause of infertility and recurrent miscarriage by Jones. Innumerable investigations have been undertaken in an effort to verify its existence or to characterize its pathophysiology, diagnosis, and treatment. The consensus of the literature is that LPD does exist and that its cause is multifactorial like abnormal folliculogenesis, inadequate LH surge,inadequate secretion of progesterone by the corpus luteum, aberrant end-organ response by the endometrium.
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.
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
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.
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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
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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
- 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
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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.
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
2. CONTENTS
I. METHODS OF MONITORING
II. OBJECTIVES OF MONOTORING
1. Prediction of ovarian response prior to COS
2. Monitor the effect of pituitary down-regulation.
3. Evaluate whether the dose of Gnt is adequate
or not
4. Prevention of OHSS.
5. Find the optimal time to give hCG.
6. Avoid cycle cancellation
III. CONCLUSION 3Aboubakr Elnashar
3. I. METHODS OF MONITORING
1. US:
measurements of follicular growth
endometrial thickness.
2. US and serum E2.
3. Power Doppler imaging
Perifollicular blood flow
4. 3D US.
TVS is the most practical way {actual response of
ovaries and uterus}
Aboubakr Elnashar
4. II. OBJECTIVES OF MONOTORING
1. Prediction of ovarian response prior to COS
2. Monitor the effect of pituitary down-regulation.
3. Evaluate whether the dose of Gnt is adequate or
not
4. Prevention of OHSS.
5. Find the optimal time to give hCG.
6. Prevention of cycle cancellationAboubakr Elnashar
5. 1.Prediction of ovarian response to Gnt
Aim:1. Identify poor responder
2. Identify risk of OHSS
Important:
To choose optimal starting dose of FSH.
Methods: Basal AFC, FSH, AMH
AFC: superior to basal day 3 FSH. as well as BMI for
predicting the number of oocytes retrieved for lVF.
(Ng et al, 2005)
≤6: longer duration
higher dose of Gnt
less oocytes retrieved.
increased risk of cycle cancellation before OR
≥16: High responder
Aboubakr Elnashar
6. 2. Monitoring the effect of pituitary down-
regulation.
Before starting follicular stimulation:
confirm down regulation (Criteria of suppression):
Hormonal assay
1. E2 < 50 ng/ml
2. LH < 5.0 IU/ml,
3. P4 < 1 ng/m ng/ml
Aboubakr Elnashar
7. TVS:
1. No ovarian cysts
2. Number of small follicles (<8 mm) ≤ 4
3. Endometrial thickness <6 mm predicts down
regulation in 95% of cases
4. Ovarian artery resistance index: 0.9 have the
highest specificity and PPV
If not: stimulation is postponed and the assays
repeated after 2—4 further days of down-regulation.
Aboubakr Elnashar
8. 3. Evaluate whether the dose of GnT is
adequate or not.
1. TVS:
A. 1st US
D4 Stimulation
In PCO
D 5 or 6 stimulation
In normal responder
Number: 6-8 each ovary
With diameter: 11- 12 mmAboubakr Elnashar
9. B. Follow up
Daily or Every other day depending on follicle size
How:
Each follicle is measured in two perpendicular planes.
Then, the average of the four largest diameters is calculated.
mean of two, three or four diameters, measured in one or two planes.
Measure the internal diameter of the follicle in two
planes and the average diameter is then calculated.
Follicles usually grow by 2-3 mm/d.
Aboubakr Elnashar
10. 2. Combining US and E2
In normal responders:
seldom changes the timing of hCG
does not increase PR or the risk of OHSS
(Lass et al, 2003)
E2 D6
300 -600 pg/ml
D6 E2 < 60 pg/ml: PR 7.8 %
If ok: continue the same dose.
If less than that: increase by one ampoule.
If greater than that: decrease the dose by ½ -1
amp Aboubakr Elnashar
11. Important in
1. If risk for OHSS.
2. Poor responder
E2 D5 stimulation:
<700 pmol/l: FSH dose is increased by 75-150 u
US on stimulation D9 or 10.
This is a simple way of early discovery that the
starting dose has been sufficient.
3. US monitoring shows adequate follicular growth
but inadequate endometrial growth
{low E production/follicle due to a low endogenous
LH level}: add rec LH
Aboubakr Elnashar
12. 3. Color Doppler
A significant increased oocyte recovery from follicles with a
high peak systolic velocity as measured by pulsed Doppler
and gray-scale ultrasound (Naigund et al, 2007)
Oocytes from poorly vascularized follicles produced
morphologically poor embryos as compared to oocytes from
highly vascularized follicles.
Follicles with normal perifollicular blood flow contained
oocytes free of cytoplasmatic or chromosomal/ spindle
defects. (Van Blerkom et al, 2008)
high-grade follicular vascularity resulted in oocytes/embryos
that had an increased potential for becoming a full-term
pregnancy. (Chui et al, 2009)
Quantitative and qualitative assessment of peri-
follicular flow allow for a more accurate assessment of
follicular competence. Follicles that have >75% of
their surface perfused, or where PSV is >10 cm/s,
appear to contain an oocyte of satisfactory quality.
Aboubakr Elnashar
13. 4. Combination of power Doppler angiography
(PDA) and 3D-US
for predicting and monitoring ovarian response in IVF-ET
(embryo transfer) cycles.
technique really improves the monitoring of the cycle is still
unclear.
technique is complicated and time consuming, making it less
practical for the daily monitoring of ART cycles.
Aboubakr Elnashar
14. 4. Prevention of OHSS.
Predicting of hyper-response
1. Previous history of OHSS
2. The presence of PCOS
3. Younger age
4. Lower BMI
5. High AMH
Aboubakr Elnashar
15. 1. US :
a. PCO pattern of response to GnRH before GnT
b. Number of follicles >20
Number of small & intermediate size (10-14 mm)
>15
No risk when immature follicles are < 15.
{Number of the immature follicles is more important
than the number of mature follicles in predicting
OHSS.
c. Doppler:
low intraovarian vascular resistance
Combination of E2 & US: best chance for prediction
Aboubakr Elnashar
16. 2. E2: High or rapid slope
<1000 pg/ml: No OHSS
>3000-4000 pg/ml: HCG should be withheld
<3500 pg/mL: No OHSS (Asch et al 2005)
3500-5999 pg/mL: 1.5%
6000 pg/mL: 38%
Cases with severe OHSS are seen with E2 <1500
pg/ml.
Small fraction of cases will be with excessive E2:
slope of rise of E2 is more accurate (considered if
the value is doubled).
Aboubakr Elnashar
17. Do not trigger ovulation with the intention of fresh
ET in women who have:
E2>3500 pg/ml or
>20 follicles on US
(NICE, 2013)
Aboubakr Elnashar
18. 5. Find the optimal time to give hCG.
Ovulation when?
35-42 h after the onset of LH surge which triggers
resumption of meiosis inside the oocyte
HCG when?
3 or more follicles of size ≥17 mm
Endometrial thickness more than 8 mm
Aboubakr Elnashar
19. OR when?
When most of the follicles are large enough to
suggest the presence of mature oocytes.
Optimal oocyte recovery and fertilization rates can
be obtained from follicles between 14 and 24 mm in
diameter.
Oocyte recovery rates start to decrease after the
follicles exceed 24 mm in diameter.
No difference in the oocyte quality obtained from
follicles between 18 and 22 mm in diameter: more
convenient and predictable planning of oocyte
collection.
At least 35 h after HCG
Aboubakr Elnashar
20. US signs of impaired implantation at the time of
hCG administration
1. An endometrial thickness of <7 mm
2. Endometrial volume <2 cm3
3. Endometrial thickness >14 mm
4. Absence of multilayered endometrium
5. Uterine artery PI >3.0
6. Absence of subendometrial or reduction in the
endometrial vascularized area
Aboubakr Elnashar
21. If Endometrial thickness ≤7
1. Prolong ovulation induction until endometrial
thickness of >7 mm is achieved.
2. If pregnancy is not achieved, in a subsequent
cycle the ovulation induction regimen is changed
to allow for a better endometrial development.
Aboubakr Elnashar
22. 6. Cycle cancellation
Define:
discontinuation of ovarian stimulation prematurely
without oocyte retrival.
Incidence
12% of all IVF cycles are cancelled before egg
collection.
Women's age Cancellation rate
Less than 35 7.7-10%
35-37 11.6-14.7%
38-40 14.6-19.5%
Over 40 19.1-24.6%
Aboubakr Elnashar
23. The main reasons
1.No or poor egg production (83%)
2.Patient’s personal reasons (10%)
3.Excessive response to ovarian stimulation and
risk of developing OHSS (5%)
4.Medical illness (1%).
(SART 2005 and HFEA 2006 Reports).
AMH:
all cases that was cancelled due to poor response
had AMH < 0.4 ng/ml. (La Marca et al., 2006)
all cases that was cancelled due to high risk of
OHSS had AMH >7 ng/ml.
Aboubakr Elnashar
24. Indications
1. Follicular growth is delayed:
ovarian stimulation over 10 days:
< 3 follicles > 16 mm & E2 < 600 pg/ml.
2.OHSS is suspected:
each ovary contains > 10 follicles < 16 mm &
E2 > 3500 pg/ml
Ovary size > 80 mm
3. Basal LH is elevated:
LH > 10 IU/l or a premature LH surge occurs
4. Elevated serum P4:
>1.5 ng/ml is detected prior to ovulation induction.
Aboubakr Elnashar
25. CONCLUSION
Two-dimensional ultrasound scanning of follicular
size is still the method of choice for monitoring IVF
cycles, irrespective of the protocol used for COH.
It is the most practical, and is still reliable enough
for monitoring ovarian stimulation with
gonadotropins.
Combining ultrasound monitoring of follicular size
with E2 is particularly valuable for monitoring poor
responders as well as those at risk for OHSS.
Aboubakr Elnashar