This document discusses the management of Ovarian Hyperstimulation Syndrome (OHSS) in OI/IUI cycles. It begins with an overview of OHSS, noting its incidence, risk factors, pathogenesis involving vascular endothelial growth factor, and clinical classification. The document then discusses strategies for preventing OHSS, including identifying at-risk patients; using a mild ovarian stimulation protocol with low-dose gonadotropins; canceling cycles or using a GnRH agonist for final oocyte maturation instead of hCG; and administering intravenous colloids or dopamine agonists secondarily. The goal of management is to maximize treatment success while minimizing complications and risks like OHSS and multiple pregnancies.
OVERVIEW
Aim
Definition
Prerequisites
Individualisation of patient.
Ohss free IUI. Clinic
{Strict cancellation of cycle if OHSS is suspected}
Newer trends
Sucess Rates in IUI with COH
PROGNOTIC FACTORS to increase Pregnancy Rates..& discussion
Invited Lecture delivered by Dr Sujoy Dasgupta in the Annual Conference of ISAR (Indian Society of Assisted Reproduction) held at Kolkata in November, 2019
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
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
Ovarian Reserve Testing in Infertility Dr. Jyoti Agarwal Dr. Sharda JainLifecare Centre
The Best Gametes
Give The Best Result
OVARIAN RESERVE
Plan fertility preservation
Fertility outcome
Response to ovarian stimulation
Predict pregnancy rate
Monitor fertility decline
Fertility after chemotherapy and cancer treatment
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.
OVERVIEW
Aim
Definition
Prerequisites
Individualisation of patient.
Ohss free IUI. Clinic
{Strict cancellation of cycle if OHSS is suspected}
Newer trends
Sucess Rates in IUI with COH
PROGNOTIC FACTORS to increase Pregnancy Rates..& discussion
Invited Lecture delivered by Dr Sujoy Dasgupta in the Annual Conference of ISAR (Indian Society of Assisted Reproduction) held at Kolkata in November, 2019
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
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
Ovarian Reserve Testing in Infertility Dr. Jyoti Agarwal Dr. Sharda JainLifecare Centre
The Best Gametes
Give The Best Result
OVARIAN RESERVE
Plan fertility preservation
Fertility outcome
Response to ovarian stimulation
Predict pregnancy rate
Monitor fertility decline
Fertility after chemotherapy and cancer treatment
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.
“Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.”
Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%.
An increase in the incidence of shoulder dystocia has been recorded over the last 20 years. Incidence appears to be increasing as birth weights increase.
This presentation briefly discuss the polycystic ovary syndrome in terms of pathogenesis, features and management. Then, It moves on to discuss the various guidelines laid down by Endocrine Society in 2013 for the management of patients with polycystic ovary syndrome.
Improving Success by Tailoring Infertility Treatments - We are all individualsSandro Esteves
Aula ministrada pelo Dr. Sandro Esteves no 5th. Dubai International Obs-Gyne & Fertility Conference & eXHIBITION DIOFCE 2010, em 05 de novembro de 2010.
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
Air quality: is it that important? And if so, how to measure and control it?Sandro Esteves
Quality and Risk Management in the IVF Laboratory; Redlara Brasil, Belo Horizonte, 14-15 September 2016
Content:
1.Air quality: is it that important?
2. How to control?
3. How to measure?
Novel concepts in male factor infertility: clinical and laboratory perspectivesSandro Esteves
Presentation Objectives:
1. Update on the WHO reference values for semen parameters, and understand the role of sperm DNA fragmentation testing to decision-making strategies;
2. Learn how to counsel azoospermic men seeking fertility, and the role of gonadotropin therapy in this infertility condition;
3. Understand the benefits of microsurgery to both sperm retrieval and varicocele treatment;
4. Appraise the role of medical and surgical interventions to infertile men undergoing ART.
Public lecture - Stem Cell and Male InfertilitySandro Esteves
Reproductive Andrology Workshop III
17-21 January 2016 - Kuwait City - KUWAIT
Organized by: Al Jahra Reproductive Medicine Unit - Ministry of Health
Public Lecture - Stem Cell and Male Infertility
Clinical management of men with nonobstructive azoospermia - Role of IVF Labo...Sandro Esteves
Reproductive Andrology Workshop III
17-21 January 2016 - Kuwait City - KUWAIT
Organized by: Al Jahra Reproductive Medicine Unit - Ministry of Health
Lecture 5: Role of IVF Laboratory in Nonobstructive Azoospermia
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.
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
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
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.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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!
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
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.
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
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
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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.
7. Having
Difficulty
Conceiving
1Boivin J, et al. Hum Reprod 2007;6:1506; 2ObGyn Research 2003, EMD Serono;
3Domar AD. Fertil Steril 2004;81:271
Treated
by
Infertility
Specialist
20% stop treatment before finishing
clomiphene citrate (CC)2
23% complete CC and then stop2
45% never seek the doctor1 100
Treated by
ObGyn
55
31
25-40% consult but never start
treatment2
60-65% drop out before completing
treatment3
20
8
8. Esteves, 8
Shift of Fluid from Intravascular to Third Space
hCG
Vascular Permeability
Intravascular Volume
Depletion and
Haemoconcentration
Extravascular Transudate
Accumulation
No direct vasoactive
activity
Vasoactive
Substances
VEGF
Aetiopathogenesis
Albert et al. Mol Hum Reprod. 2002;8:409; Chen et al. Hum Reprod. 2000;15:1037;
Gómez et al. Endocrinology. 2002;143:4339
9. Esteves, 9
VascularEndothelial
GrowthFactor
1Yan et al, J Clin Endocrinol Metab 1993; 77:1723; 2Neulen et al, J Clin Endocrinol Metab
1995; 80:1967; ; 3Wang et al, J Clin Endocrinol Metab 2002; 87:3300;
4Pellicer et al, Fertil Steril 1999; 71:482;
Induces endothelial cell proliferation
Increases capillary permeability
VEGF and OHSS:
• VEGF is expressed in human ovaries1
• VEGF mRNA expression increases in
granulosa cells after hCG administration2,3
• Elevated VEGF levels in serum, plasma, and
peritoneal fluids4
10. Esteves, 10
Early onset Late onset
Lyons CA et al., Hum Reprod 1994, 9:792.; Mathur RS, Fertil Steril 2000, 73:901;
Papanikolaou et al.,Hum Reprod. 2005; 20:636.
ClinicalAspects
Exogenous hCG
administered for final
oocyte maturation
Endogenous hCG
produced by
implanting blastocyst
3–7 days after hCG 12 -17 days after hCG
Predicted by high number
of growing follicles and
elevated E2 levels
Predicted by number of
gestacional sacs
(multiple pregnancy)
Higher risk of preclinical
miscarriage
More likely to be
severe
11. Esteves, 11
ClinicalAspects
Severity of symptoms, signs and
laboratory findings
Rabal et al., 1967
Schenker and Weinstein, 1978
Golan et al., 1989
Navot et al., 1992
Rizk & Aboughar, 1999
12. Esteves, 12
Abdominal
distension/
discomfort
Mild nausea,
vomiting
Diarrhea
Enlarged
ovaries
No relevant
laboratorial
alteration
Lacking clinical
significance
Fiedler & Ezcurra. Reprod Biol Endocrinol 2012, 10:32
OHSS-Classification
Similar to Mild +
Ascites
Hct >41%
WBC >15,000
Hypoproteinemia
Require careful
monitoring
Intractable nausea/vomiting
Severe dyspnea; Hydrothorax
Oliguria/anuria; Tense ascites
Low central venous pressure
Rapid weight gain; syncope
Severe abdominal pain
Venous thrombosis
Hct >55%; WBC >25,000
Creatinine >1.6
Creat. Clearance <50 mL/min
Hyponatremia: <135 mEq/L
Hyperpotassemia: >5 mEq/L
Elevated liver enzymes
Hospitalization;
Intensive care unit
Mild Moderate Severe
13. Esteves, 13
Papanikolaou et al.,Hum Reprod. 2005; ;20:636-41;
Humaidan et al., Fertil Steril. 2010; 94: 389-400.
Psychological burden
High cycle cancellation rates
Higher risk of miscarriage
Severe Cases May Get Even Worse
Acute renal failure
Arrhythmia
Thromboembolism
Pericardial effusion
Massive hydrothorax
Arterial thrombosis
Sepsis
Adult respiratory
distress syndrome
Complications
18. Esteves, 18
Which are the Biomarkers?
●Hormonal Biomarkers: FSH, Clomiphene
citrate challenge test, Inhibin-B,
Anti-Mullerian Hormone (AMH);
●Functional Biomarkers:
Antral Follicle Count (AFC);
●Genetic Biomarkers: Single Nucleotide
Polymorphisms for FSH-R; LH/LH-R; E2-R;
AMH-R.
OHSSManagement
19. Esteves, 19 La Marca et, Hum Reprod 2009;24:2264; Fleming et al, Fertil Steril 2012;98:1097.
Dimeric glycoprotein; ~140KDa
Product of GCs of early follicles
Pre-antral and small antral (≤4-8mm)
AMH
21. Esteves, 21
AMH
Fleming et al. RBM online 2013;26:130;
Rustamov et al. Hum Reprod. 2012; 27:3085; Nelson & La Marca. RBM online 2011;23:411;
Assays have different performances
DSL and Immunotech
Beckman-Couter generation II
Fully automated ELISA (to be released)
Lack of international standardization
and EQC
Sample instability
Collection in EDTA
Storage at room temperature (up to 40% increase)
No separation of serum from blood before postage
Shortcomings and Pitfalls
22. Esteves, 22 Broekmans et al. Fertil Steril, 2010; 94:1044-51; Scheffer et al. Hum Reprod 2003;18:700
Sum of antral follicles in both
ovaries by TVUS at early
follicular phase (D2-D4):
2-10 mm (mean diameter)
Greatest 2D-plane
AFC
Reflect No. AF at a given
time that can be
stimulated by medication
23. Esteves, 23
Lee et al., Hum Reprod 2008, 23:160–167
Cut-off: 3.36 ng/mL
Sensitivity : 90.5%
Specificity: 70% in IVF
AMH
Cut-off: 16 AF
Sensitivity: 100%
Specificity: 93%
AFC
AFC
Checa et al. Fertil Steril. 2010; 94:1105-7
Prediction of excessive response
in IUI with 75 IU/d rec-hFSH
24. Esteves, 24
Low dose step-up gonadotropin protocol
Starting dose: 37.5 – 75 IU
Adjustments according to ovarian response
Sengoku et al. Hum Reprod. 1999; 14:349-53; Cantineau et al., Cochrane Database Syst Rev.
2007; 18:CD005356., Humaidan et al., Fertil Steril. 2010; 94:389-400
Pen devices:
Precise dose delivery
Adjustments by small increments
Self-administration
OHSSManagement
25. Esteves, 25
2 RCT (n= 297)
Low dose step-up in IUI
Cantineau et al., Cochrane Database Syst Rev. 2007; 18(2):CD005356
OHSS 13% 2.7% 5.52
(95% CI: 1.85 to 16.52)
Pregnancy 31.1% 28.2% 1.15
(95% CI: 0.69 to 1.92)
OHSSManagement
26. Esteves, 26
GnRH-agonist
rather than hCG for
LH trigger
Patient frustration
Waste of time and money
Risk ovulation and
intercourse
Risk of multiple pregnancy
and late OHSS onset
Cantineau et al., Cochrane Database Syst Rev. 2007;18:CD005356;
Delvigne & Rozenberg Hum Reprod Update. 2003;9:77-96
OHSSManagement
27. Esteves, 27
LH/FSH Unload
Which and How:
Triptorelin 0.2 mg
Leuprolide acetate 1 mg
Buserelin 0.2-0.5 mg
Griesinger et al. Hum Reprod Update. 2006;12:159-68.
When:
Same criterion of hCG
14 h
20 h
14 h
48 h
20 h
4 h
GnRHa LH surge vs
natural cycle
OHSSManagement
28. Risk for OHSS markedly reduced:
3% 0% to 2.6%
Esteves, 28
GnRH-agonist vs hCG: 11 RCT – 1,055 women
Fresh
autologous
cycles (8 RCT)
Live birth Pregnancy
Moderate/
severe OHSS
OR 0.44
(0.29 - 0.68)
OR 0.45
(0.31 - 0.65)
OR 0.10,
(0.01 to 0.82)
Youssef et al. Cochrane Database Syst Rev. 2011
Chance of Pregnancy also reduced:
30% 12% to 22%
OHSSManagement
29. Esteves, 29
Aboulghar & Mansour. Hum Reprod Update 2003;9:275;
Humaidan et al. Fertil Steril 2012 ;97:529; Engmann & Benadiva Fertil Steril 2012;97:531
Modified Luteal Support in IVF:
hCG bolus OPU day (1,500 UI) or 3x 500 UI boluses;
recLH; intense progesterone + estradiol; combined
Risk Difference for Pregnancy:
18% (Before) vs 6% (After Modified LP Support)
IVF: luteal phase insufficiency
LH suppressed due to Estrogen
Management
30. Study N Trigger
Luteal
support
Findings
Romeu
1997
761
hCG
X
1.5 mg
Leuprolide
Acetate
(2 doses
12/12h)
1,000- 2,500
IU hCG D0,
D2, D4 luteal
phase
99% ovulation rate; Similar E2
and P4 levels, miscarriage rates
Pregnancy Rates
LA (27.3%) vs hCG (17.3%;
p=0.0007); No OHSS in LA group
Romeu et al. J Assist Reprod Genet. 1997; 14:518;
Pirard et al. Hum Reprod. 2005; 20:1798; Diaz et al. J Reprod Med. 2008; 53:33.
LHTriggerwithGnRHa
inIUI
Esteves, 30
Pirard
2005
24
hCG
X
0.2 mg
Buserelin
0.1 mg
Buserelin
different
schemes
Higher P4 levels at D14 with
every day buserelin
Diaz,
2008
48
hCG
X
0.2 mg
Triptorelin
-----
Higher FSH and LH rise 24h after
triptorelin;
Higher P4 levels 48h after hCG,
albeit suboptimal
32. Esteves, 32
Youssef et al. Cochrane Database Syst Rev. 2011;16:CD001302.
IVF
20% Human
Albumin (50 mL)
6% Hydroxyethyl
starch (HES); 1L
No. Studies
(patients)
8 RCT
(n=1,660)
3 RCT
(n=487)
Severe OHSS
OR: 0.67
(95% CI: 0.45-0.99)
OR: 0.12
(0.04-0.40)
CPR
OR: 0.76
(0.48-1.21)
OR: 1.2
(0.49-2.95)
OI and IUI: Data Not Available
HowtoAvoidOHSS
Increase oncotic pressure and reverse leakage of fluid
Bind mediators of ovarian origin
33. Esteves, 33
Youssef et al., Hum Reprod Update. 2010;16:459-66;
Tang et al. Cochrane Database Syst Rev. 2012; 15;2:CD008605.
IVF
Youssef, 2010
4 RCT (n=570)
Tang, 2010
2 RCT (n=230)
OHSS
OR = 0.41
(95% CI: 0.25-0.66)
OR 0.40
(95% CI: 0.20-0.77)
Severe
OHSS
OR 0.50
(0.20-1.26)
OR 0.77
(0.24-2.45)
CPR
OR 1.07
(0.70-1.62)
OR 0.94
(0.56-.59)
Miscarriage
Rate
OR 0.31
(0.03-3.07)
OR 0.31
(0.03-3.07)
HowtoAvoidOHSS
Decrease incidence of early-onset OHSS
34. Esteves, 34
Cabergoline, Quinagolide, Bromocriptine
dopamine agonists
Basu et al. Nat Med 2001;7:569–74; Gomez et al. Endocrinology 2006; 147:5400–11.;
Soares. Fertil Steril. 2012; 97:517-22.
HowtoAvoidOHSS
In vitro studies:
Activation of dopamine receptor-2 (Dpr2) promote
internalization of VEGFR-2 (become
unreachable for VEGF);
Cabergoline in rats:
Phosphorylation of VEGFR-2 reduced by 42%;
Inhibition of VEGF production in cultured granulosa cells
exposed to hCG.
35. Esteves, 35
Most effective regimen:
0.5 mg daily for 8 days
Start on the day of hCG
administration;
Ideally a few hours before hCG is
given
Soares. Fertil Steril. 2012; 97(3):517-22.
HowtoAvoidOHSS
No major complications
36. Esteves, 36
1Minaretzis et al. J Clin Endocrinol Metab. 1995;80:430; 2Fridén & Nilsson. Acta Obstet Gynecol Scand.
2005;84:812; 3Asimakopoulos et al. Fertil Steril. 2006;86:636; 4Taylor et al. J Endocrinol. 2004;183:1;
5Lainas et al. Reprod Biol Endocrinol. 2012;10:69; 6Lainas et al. Hum Reprod. 2013; April 26.
HowtoAvoidOHSS Supress endogenous LH secretion (luteolytic effect)
Decrease vasoactive cytokines producted by corpus luteum1
Direct effect on the ovary reducing VEGF production2,3,4
Lainas et al., 20125
40 pts.; early-onset severe OHSS
Ganirelix (0.25 mg) daily from
D5-D8 after oocyte retrieval +
embryo freezing
NO HOSPITALIZATION;
Rapid resolution of OHSS
Lainas et al., 20136
22 pts.; early-onset severe OHSS
Ganirelix (0.25 mg) daily from D5-D7
after OPU + embryo transfer; 172
controls at risk of OHSS
NO HOSPITALIZATION;
Rapid resolution of OHSS;
No late-onset OHSS;
LBR: 41% (Antag.) vs 43% (controls)
37. Esteves, 37
OHSS has a dramatic psychological effect
in patients’ life; those who suffer from it
are unwilling to continue treatment.
OHSS must be PREVENTED rather than
treated.
Improving patients’ welfare starts at
identifying who are at risk for OHSS, and
continues by individualization of the
ovulation induction protocol.
KeyMessages OHSS: Management in
OI/IUI Cycles
38. Esteves, 38
Improving patients’ welfare starts at
identifying who are at risk for OHSS, and
continues by individualization of the
ovulation induction protocol.
KeyMessages
GnRH-agonists LH trigger virtually
eliminates OHSS; luteal phase support
is required.
OHSS: Management in
OI/IUI Cycles
39. Esteves, 39
Secondary prevention by albumin, HES
and carbegoline are useful but not fully
eliminate the risk.
GnRH Antagonists during luteal phase
holds promise to treat OHSS in early
stages.
KeyMessages OHSS: Management in
OI/IUI Cycles