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 .
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
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
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.
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
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LETROZOLE was withdrawn from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”?
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
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
there is a change in attitude for monofollicular ovulation induction to treat infertility: previously clomiphene citrate was the standard drug to start with : Now it is different
Ovulation Induction - Simplified - Dr Dhorepatil BharatiBharati Dhorepatil
What are factors to be considered
Ovarian reserve
Previous ovarian response
Basic hormone profile
Role of FSH & LH
Trigger
Luteal phase support
Pregnancy rate/cycle
Patient selection and work-up
Ovarian stimulation
Monitoring of follicular growth and endometrial development
Timing of insemination
Number of inseminations
Semen preparation
Insemination procedure
Luteal support
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.
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
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”?
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
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
there is a change in attitude for monofollicular ovulation induction to treat infertility: previously clomiphene citrate was the standard drug to start with : Now it is different
Ovulation Induction - Simplified - Dr Dhorepatil BharatiBharati Dhorepatil
What are factors to be considered
Ovarian reserve
Previous ovarian response
Basic hormone profile
Role of FSH & LH
Trigger
Luteal phase support
Pregnancy rate/cycle
Patient selection and work-up
Ovarian stimulation
Monitoring of follicular growth and endometrial development
Timing of insemination
Number of inseminations
Semen preparation
Insemination procedure
Luteal support
PCOD,How are they different ??Difficulties & Solutions made Easy , Dr. Sharda...Lifecare Centre
Tremendous advances and extensive human studies have uncovered the complexity and management of PCOD
Global prevalence -2.2% to 26% Roughly 1 in 15 women worldwide, (Lancet, 2007)
Ovarian Hyperstimulation in Intrauterine InseminationElmar Breitbach
Intrauterine insemination is well established in the treatment of infertility. But which pretreatment leads to the best results? Do we have to trigger ovulation? What about luteal phase support? Whar patients do have the best chances? When do we have to switch to IVF?
Evidence based answers to these questions an a bit of experience based suggestions.
Endometriosis is a painful disorder and can reduce fertility if not treated early. Endometriosis most commonly involves ovaries, fallopian tubes and the tissue lining pelvis.Endometriosis can be a challenging condition to manage.
Fertility enhancing surgeries are usually advised to young women with suspected minimal to moderate disease of tubes, ovaries or uterus.
https://www.femelife.com/ivf-fertility-care/fertility-enhancing-surgeries/
PCOS- An insight into polycystic ovary syndrome
Polycystic ovary syndrome (PCOS) is extremely prevalent and probably constitutes the most frequently encountered endocrine (hormone) disorder in women of reproductive age
Melatonin, a pineal hormone that regulates circadian rhythms, has also been shown to exhibit unique oxygen scavenging abilities. Melatonin supplementation in IVF may lead to better pregnancy rates. Hence role for melatonin in gamete biology is under research.
PGD combines advances in Molecular genetics and in assisted reproductive technology and is conducted before the embryo is placed inside the womb of the woman.Pre implantation genetic diagnosis was introduced to prevent the inheritance of sex linked diseases
A slightly abnormal semen analysis does not mean that a man is necessarily infertile. Instead, a semen analysis helps determine if and how male factors are contributing to infertility
Embryogenesis is the process by which the embryo forms and develops. In mammals, the term refers chiefly to early stages of prenatal development from conception to 8 weeks of pregnancy .Later it is referred to as fetogenesis
Sperm is the male reproductive cell and its main sperm function is to reach the ovum and fuse with it to deliver two sub-cellular structures called embryoOn average, each time a man ejaculates he releases nearly 100 million sperm but it takes only one to make a baby .To meet the waiting egg, semen must travel from the vagina to the fallopian tubes, a tough journey that few sperm survive.
An oocyte is a female gametocyte or germ cell involved in reproduction.It is an immature ovum or an egg
An oocyte is produced in the ovary during female gametogenesis.The female germ cells produce a primordial germ cell pgc which undergoes mitosis to form an oogonium
During oogenesis the oogonium becomes a primary oocyte
Oogenesis consists of several sub processes – oocytogenesis, ootidogenesis and the maturation to form an ovum
Folliculogenesis is a separate sub process and supports all three oogenetic sub process
Intrauterine insemination (IUI) is a fertility treatment that involves placing sperm inside a woman’s uterus to facilitate fertilisation. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilisation.
The cause for infertility could be in the male or the female or both or neither-as in ‘Unexplained Infertility.’
Male infertility is usually caused by problems that affect either sperm production or sperm transport.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
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
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
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
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
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
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
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,
An enema is the instillation of a solution into the rectum and sig
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...
Ovulation induction
1. Ovulation
Ovulation
Induction & IUI
Induction & IUI
DR NABANEETA PADHY
DR NABANEETA PADHY
MEDICAL DIRECTOR
MEDICAL DIRECTOR
FEMELIFE FERTILITY FOUNDATION
FEMELIFE FERTILITY FOUNDATION
www.femelife.com
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2. Significant increase in live birth rate
was found when hyperstimulation was
compared with IUI in natural cycle in
women with Unexplained Infertility
Cochrane Systematic review 2008 ; issue 2
However concern about multiple pregnancy and
OHSS remains
3. IUI with controlled OH significantly
improved the probability of conception in
subfertility in men
Conchrane database Syst Rev . 2007
However in case of severe semen defect ( with < 1
million motile sperm after semen preparation ) IUI in
natural cycle should be the treatment of choice.
6. Absent Ovulation
Infrequent Ovulation
Inadequate FSH stimulation
Inadequate corpus luteum function
PCO
Unexplained infertility
To time the Ovulation
To increase the number of oocytes
IVF / ICSI
10. It takes about 10 wks for the primordial follicle to
develop into preantral stage, which is then capable of
gonadotropic responsiveness .
(gonadotropic independent folliculogenesis )
A cohort of these preantral follicles start growing
due to rising FSH. One of them becomes the dominant
follicle (by day 6) which in turn by producing increasing
amount of estrogen, decreases FSH production through
negative feedback causing atresia of less developed
follicles.
12. The role of ovulation inducing agents -The role of ovulation inducing agents -
to disturb this normal relationship byto disturb this normal relationship by
increasing the FSH above threshold whichincreasing the FSH above threshold which
will rescue a follicular cohortwill rescue a follicular cohort
( before they undergo atresia)( before they undergo atresia)
Hence more number of follicles will reach toHence more number of follicles will reach to
the preovulatory stage.the preovulatory stage.
18. * 75 % of conceptions occur during first
three cycles . When no pregnancy is achieved
within 6 treatment cycles alternative therapy
should be chosen.
* Clomiphene should be used for maximum of
12 months in patient’s life time and for a
maximum of 6 months consequently.
19. * Dose more than 150 mg leads to
hypoestrogenic effect on endometrium.
* CC does not appear to increase the chances
of pregnancy in women who ovulate regularly
but failed to conceive after 1 year of
unprotected sex.
20. Drawbacks :
Despite high ovulation rate, low pregnancy rate
1.Multiple pregnancy : 10 %
2.Antiestrogenic – detrimental to sperm
transport and embryo implantation.
3.Sometimes risk of OHSS
21. 5.The effect lasts longer , may be for weeks even
with a single dose of 50 mg. Its presence at the
time of ovulation inhibits progesterone formation
by granulosa cells in luteal phase
6.Can give premature LH surge due toCan give premature LH surge due to
supraphysiological estradiol levelssupraphysiological estradiol levels
7. Cannot be used in patients with
hypogonadotropic dysfunction
22. In search of better drug with improved
pregnancy rate , reduction in the incidence
of multiple pregnancy rate & ……
26. * CC + Dexamethasone resulted in
significant improvement in PR in CC
resistance cases.
* Significant increase in PR in CC cycles
when pretreatment with oral contraceptives
than CC alone in PCOS
29. In last few years , it has added another
option for the ovarian stimulation
30. First report by Casper and Mitwaly group in
2001 , saying ,
“ Preliminary evidence suggest that AI
may replace CC in future because of
similar efficacy and less side effects. ”
32. * Inhibition of estrogen synthesis by
aromatase inhibition - release estrogenic
negative feedback
(Mitwally and Casper 2001)
* Accumulation of androgens locally
may increase follicular sensitivity to
FSH
(Vendola et al 1998)
34. Results
1.CC is superior to AI as first line of
treatment
2.Both have equal results as far as
ovulation rate, and pregnancy rates are
concerned
3.Letrozole can replace CC as first line of
treatment
36. *Short half life
* Implantation rates improve with the
reduction of supra-physiologic level of
estrogen associated with COH,which is
believed to have deleterious effects on the
embryos or the endometrium
* Reduction of estrogen levels during
induction cycles may prevent a premature
surge of LH
37. * Letrozole is safe, convenient, inexpensive
and has the potential to replace Clomiphene
as the first line of choice for OI, especially
when it has to be used along with
gonadotropins
* Letrozole used with sequential FSH
administration significantly reduces the FSH
dose for COH & hence becomes cost
effective therapy
38. * Improvement is seen in ovarian
response to FSH in poor responders
42. On evaluating effectiveness of IUI ,
pregnancy rates are significantly
higher in women who received
gonadotropins
Hughes 1997, Cohlen 1998 , Guzick et al 1998
43. Reducing the dose of
gonadotropins without
compromising pregnancy rate
would definitely reduce the overall
costs & possibly improve the cost
effectiveness of IUI treatment
46. Adjunctive Therapy with FSH in poor
responders
Mitwaly and Casper (2001) examined the use of
Letrozole with FSH for poor responders
undergoing ovarian superovulation and IUI
Letrozole 2.5 mg/day from Day 3 to Day 7 was
used with FSH(50-225 IU starting on day 7)
* Significant reduction in the FSH dose
* An improvement in ovarian response to FSH
47. Comparison of daily and alternate day
rFSH stimulation protocols for IUI
Tulandi T ,et al Fertil Steril 2008 March
* Total dose needed was greater in daily
injection group
* CPR was 42% in daily inj group
Vs
19% in alternate –day group
49. The recognition that Insulin Resistance has
a pivotal role in the pathogenesis of PCOS
revolutionalized our understanding of this
complex disorder
50. Metformin combined with CC is more effective
in ovulation induction as compared with CC
alone especially in obese PCOS
Cochrane review
Jan 2008
However , the optimal duration for metformin
treatment before initiation of CC is unknown as
in Cochrane review they could not find any data
over short term Vs long term metformin
pretreatment.
51. Use of Metformin in PCOS : Metanalysis
Metformin alone, CC alone & Met + CC
Outcomes : Ovulation rate , PR & LBR
Conclusion :
1.Metformin improved the odds of ovulation in women
with PCOS when compared to placebo
2.When combined , there is increase in ovulation & PR
especially in obese PCOS & CC resistance cases.
52. EBM :
1.There is evidence that metformin is effective in
restoring ovulation in anovulatory cycles with
PCOS
2. It is more cheaper option than laparoscopic
ovarian drilling as the second therapeutic step
in PCOS with CC resistance
3. Coadministration of metformin can prevent
hyperstimulation in PCOS on treatment with
gonadotropins in IVF cycles
58. 1.CC was the first line of treatment for OI
for many decades.
2.In CC resistance cases , Metformin + CC
& Dex + CC has shown significant
improvement in PR and got upper hand
in treatment of CC resistance over
laparoscopic drilling
3.AI have the potential to replace CC as the
first line of treatment with its several
advantages
59. 4. Addition of low dose gonadotropins to oral
ovulogens significantly improves PR in IUI
5. Letrozole is superior to CC whenever
gonadotropins have to be added
6. There is no role of Bromocriptin in CC
resistance cases with normal prolactin levels
7. Pretreatment with OC pills is useful
8. Tamoxifen and CC has comparable results but
combination of two does not improve PR
61. Case 1
26 yrs old, married for 3 yrs, laparoscopy done , Found to
be PCOS. Drilling done , semen analysis shows count 10
million with rapid motility 10%
What next- IUI or not
62. Case 2
25 yrs old female , primary infertility ,prolactin level is 56
pg/ml
How to manage
Start bromocriptine/ pergolides or not
63. Case 3
Day 3 LH for a 25 yr old is 7 IU
Drugs to be used for ovulation
induction ?
64. Case 4
Young couple , patent tubes, male factor
normal, ovulation induction and IUI done
for 3 cycles , failed
What next ?
65. Case 5
Young couple , h/o ectopic pregnancy
twice affecting both tubes, but managed
medically. Recent HSG shows bilateral
patent tubes
Shall we proceed for IUI ?
66. Case 6
38 yr old lady recently married , asking for IUI
HOW TO COUNSEL ?