This document contains information from Dr. Shashwat Jani regarding ovarian stimulation protocols for IUI. It discusses various stimulation options including clomiphene citrate, letrozole, gonadotropins, and combinations. It provides details on dosing, monitoring, and the advantages and disadvantages of different protocols. The goal of stimulation is to develop multiple follicles to improve pregnancy rates with IUI or develop a single follicle for anovulatory patients.
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
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
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
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 .
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
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
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.
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”?
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
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
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 .
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
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
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.
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”?
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
Explore the intricacies of ovulation induction in intrauterine insemination (IUI) with Dr Laxmi Shrikhande's informative slide share presentation. From understanding the hormonal mechanisms to the latest techniques, this presentation offers insights into optimizing fertility through IUI. Whether you're a clinician seeking to enhance patient outcomes or an individual navigating fertility treatments, this resource provides valuable knowledge for your journey towards conception.
Ovarian stimulation for ovulatory disorders and assisted reproduction. From simple induction with oral medications till the controlled ovarian stimulation including different protocols.
How does one increase the chances of success when carrying out intra uterine insemination (IUI) procedures in places carrying out assisted reproductive technologies (ART)?
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
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.
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.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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.
Follow us on: Pinterest
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
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- 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
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!
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
1. Dr. Shashwat Jani.
M. S. ( Obs – Gyn )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com
2. 1.Improvement of Follicular Growth
2.Increasing the Number of Follicles
3.Treatment of Anovulation (PCOS)
4.Better Timing
5.Improvement of Luteal Phase
24-Apr-17
Dr Shashwat Jani.
9909944160 2
3. Optimum Ovarian Stimulation
for IUI
2 – 3 follicles with 18 – 19 mm size.
Endometrium 9 mm thick & trilaminar.
IUI between Cycle D13 and D16, 36-40
hrs. from HCG inj.
24-Apr-17
Dr Shashwat Jani.
9909944160 3
4. Provides more number of follicles with good
quality.
Timing of HCG injection predicts ovulation
better, so as to schedule IUI near ovulation time.
C.O.H. offers more over for fertilization &
implantation, hence increases success.
C.O.H. corrects subtle endocrinopathies which
block ovulation, implantation
24-Apr-17
Dr Shashwat Jani.
9909944160 4
7. Azoospermia with testicular failure
Severely abnormal semen parameters Use
Discretion)
Hereditary disease in man
Severe untreatable Rh isoimmunisation in
wife
Repeated failures with IVF/ICSI
Single women, lesbian couples
Dr Shashwat Jani.
9909944160 724-Apr-17
8. Simple
Cost Effective
Minimal side effects
Best success rates
Patients requiring ovarian
stimulation or induction can be
categorized in two groups :
24-Apr-17
Dr Shashwat Jani.
9909944160 8
9. In these patients there is an established
ovulatory pattern.
Multiple studies have shown improved
pregnancy rates with ovarian stimulation
in these patients as compared to
nonstimulated natural cycles.
Aim : Multiple follicle development
Dr Shashwat Jani.
9909944160 924-Apr-17
10. 20 – 30 % cases of female infertility
Anovulatory patients are further divided
by WHO into 3 categories:
Group I: Hypogonadotrophic
hypogonadism
Group II: PCOS
Group III: Ovarian failure
Aim : Monofollicular development
Dr Shashwat Jani.
9909944160 1024-Apr-17
11. Natural
cycle + IUI
3.3%
CC + IUI
9.5%
CC + hmG
+ IUI
13.3%
hmG + IUI
17.26%
Stimulation Protocol
24-Apr-17
Dr Shashwat Jani.
9909944160 11
13. D 2 FSH
( >10 mlU/ml is s/o low ovarian reserve )
AFC
Ovarian Volume
AMH
HSG / Lap
Dr Shashwat Jani.
9909944160 1324-Apr-17
14. 1. Clomiphene citrate (CC)
2. Letrozole
3. Gonadotropins
4. Clomiphene with Gonadotrophins
5. Letrozole with gonadotrophins
6. Gonadotrophins with GnRH analogues
7. Gonadotrophins with GnRH antagonists
Dr Shashwat Jani.
9909944160 1424-Apr-17
15. The cumulative pregnancy rate per couple
was 33% for IUI & COH, & 18% for IUI alone.
COH has independent positive effect on
pregnancy rate when combined with IUI.
In young patients without a prior pelvic surgery
& with good-post-wash semen quality COH
doubles IUI pregnancy rate.
Hendin B, Falcone T, Hallak J, Nelson D, Vemullapalli S, Goldberg J, et al. Effect of clinical &
semen charachteristics on efficacy of ovulatory stimulation in patients undergoing
IUI. J Assist Reprod Genet 200;17:189-93.24-Apr-17 15
Dr Shashwat Jani.
9909944160
16. Most widely used
Simple to use,
Minimal side effects,
Cost effective
24-Apr-17
Dr Shashwat Jani.
9909944160 16
17. Depletion of ER in pituitary
& hypothalamus due to
prolonged stimulation
Estrogen feedback loop gets
interrupted
FSH secretion increased
leading to multiple follicle
growth
Hypothalamus
Pituitary
CC binds to ER & depletes
receptor concentrations
More smaller follicles are rescued
Multiple follicles develop
estrogen –ve feedback
interrupted
FSH stimulation continues
1
2
3
4
5
17
Clomiphene citrate: Mechanism of action
Casper RF, et al. J Clin Endocrinol Metab. 2006; 91: 760-771.
18. 50-100mg per day for five days .
(up to 200mg per day)
There is no difference in pregnancy
rate whether clomiphene is commenced on
day 2, 3, 4 or 5 of the cycle, although there is
perhaps a tendency to multiple follicular
development the closer the agent is
commenced to menses.
24-Apr-17
Dr Shashwat Jani.
9909944160 18
19. Pregnancy: 30%
Failure (no pregnancy despite
ovulation): 40%
Resistance: no ovulation: 25%
Antiestrogenic effect: 5%
Dr Shashwat Jani.
9909944160 1924-Apr-17
20. Shows excellent result in ….
CC Resistant
CC Failure .
Associated with thicker endometrium and
increased stromal blood flow, thereby providing
a better uterine environment more favorable for
implantation.
Compared to CC, letrozole has been shown
to have higher pregnancy rates.
Dr Shashwat Jani.
9909944160 2024-Apr-17
21. • Inhibits aromatase in ovaries
& peripheral tissues reducing
estrogen levels
• Negative feed back being
active stimulates
hypothalamus-pituitary axis
• GnRH release produces FSH
• FSH-mediated stimulation of
follicle
• Rising estrogen level from
follicle
• suppresses FSH leaving a
single dominant-follicle
Hypothalamus
Pituitary
-ve feedback stimulation
Smaller follicles
undergo atresia
Single follicle develop
estrogen –ve feedback
FSH stimulation
1
2
3
4
6 androstenedione estrogen
aromatase inhibition
GnRH released
Falling FSH
5
21
Letrozole: Mechanism of action
Casper RF, et al. J Clin Endocrinol Metab. 2006; 91: 760-771.
22. Dose
2.5 mg/day start cycle day 3-7, max 7.5 mg/day
(AL-Fadhli et al., 2006; Legro et al., 2014 N Engl J Med)
Comparison with CC (Casper et al., 2006)
High rate of monofolliculer
No direct antiestrogenic adverse effect on
endometrium
Shorter half-life (48hr and 2 wks)
Lower serum E2
24-Apr-17
Dr Shashwat Jani.
9909944160 22
23. In a recent study conducted by Badawy et al,
extended letrozole therapy (2.5mg daily from
day-1 of menses for 10 days) was used for CC
resistant PCOS women…
Higher number of patients ovulated
No of dominant follicles were more
Pregnancy rates were significantly greater
No extra cost
Dr Shashwat Jani.
9909944160 2324-Apr-17
24. Reported by Mitwally et al.
In this protocol letrozole was administered in
the step up doses consisting of one, two,
three, and four tablets of letrozole (2.5mg)
daily on menstrual cycle days 2, 3, 4 and 5
respectively.
Multifollicular development
Higher pregnancy rate
Dr Shashwat Jani.
9909944160 2424-Apr-17
25. Indicated in :
- CC Failure
- Letrozole failure
- WHO Group 1 (Hypogonadotrophic hypogonadism )
Cochrane ( 2007 ) …
“ Gonadotropins might be the most effective drugs
when IUI is combined with ovarian hyperstimulation .”
Dr Shashwat Jani.
9909944160 2524-Apr-17
26. FSH or hMG administered daily from early in
the Menstrual Cycle.
Monitoring with USG ( and Hormonal assays )
is mandatory
Trigger ovulation with hCG when follicular
maturity attained
Significantly improve pregnancy rates from
IUI, in contrast to natural cycle IUI.
Risk of multiple pregnancy
Dr Shashwat Jani.
9909944160 2624-Apr-17
27. Advantages:
high efficacy:
ovulation rate : >95 % per cycle
conception rate: 20 - 30 % per ovulatory cycle
Limitations:
Serious complications can occur:
multiple pregnancies
▪ Twins 25%
▪ Higher order 5 %
ovarian hyperstimulation syndrome
long term complication ? ovarian cancer
require intensive monitoring in specialist centre
expensive
24-Apr-17
Dr Shashwat Jani.
9909944160 27
28. Depends on the D2 LH / FSH /E2 levels.
If LH FSH containing gonadotrophins are
indicated,
Whereas if serum FSH (>10 mIU/ml),
LH + FSH is used for ovarian stimulation.
For ovarian stimulation in patients with
hypogonadotrophic hypogonadism, a
combination of LH and FSH is used.
Dr Shashwat Jani.
9909944160 2824-Apr-17
29. A. Conventional regimen
B. Low dose step up regime
C. Step down regime
Dr Shashwat Jani.
9909944160 2924-Apr-17
30. Days 7 14 21 28
hCG
150 IU 112.5 IU 75 IU hCG
Foll. 10 mm
75-150 U daily
6 12
hCG
Foll. 16mm
37.5 IU 75 IU 112.5 IU 150 IU
Chronic Low dose Step up regimen
Step down
Conventional Regime
24-Apr-17
Dr Shashwat Jani.
9909944160 30
31. CC resistant OR CC Failure Cases
Started from D2 / D3
75 - 150 IU /day
Serial USG for monitoring
D 8 S. estradiol
Widely accepted protocol .
PR up to 30 %
Dr Shashwat Jani.
9909944160 3124-Apr-17
32. Useful in PCOS
AIM :
To find the “threshold“ level of FSH
which will lead to the development of a single
preovulatory follicle.
Less complication
But , unphysiological as FSH is very high in late
follicular phase compared to natural cycle.
Dr Shashwat Jani.
9909944160 3224-Apr-17
33. Low starting dose (37.5- 75 units/day )
Stepwise increase in subsequent doses
E2 & USG on D7
D8 E2 > 200 pg/ml OR follicle > 10mm
Ct. Same dose.
If E2 or Follicle size not achieved on D8
increase dose by 37.5 IU /day .
Dr Shashwat Jani.
9909944160 3324-Apr-17
34. HMG / FSH 150 IU/day from D2
Continued till Dominant follicle become 10mm
on USG
Decrease the dose .
112.5 IU/day for next 3 days
75 IU day till time of HCG.
Dr Shashwat Jani.
9909944160 3424-Apr-17
35. Sequential use of CC f / b FSH or HMG.
CC ( 100 mg ) 1 daily from D2 to D6.
FSH or HMG ( 75 / 150 IU ) on D6 & D8.
TVS on D8 onwards
Additional FSH / HMG given.
Dr Shashwat Jani.
9909944160 3524-Apr-17
36. Higher pregnancy rate than with CC alone .
More cost effective, as the dosage of
gonadotrophins is reduced .
Lesser multiple pregnancy rate than with
gonadotrophins alone .
Lower incidence of OHSS, as compared to the
conventional regime.
Kemmann E, Jones J R. Sequential clomiphene Citrate menotrophin therapy for
induction or enhancement of ovulation.Fertil Steril 1983;39:772-9
Dickey R P, Olar T T, Taylor S N, Curole D N, Rye P H . Sequential clomiphene citrate and
Human menopausal Gonadotrophin for ovulation induction: comparison to clomiphene
citrate alone and human menopausal gonadotrophin alone.. Human Reprod 1993; 8:56-
59Dr Shashwat Jani.
9909944160 3624-Apr-17
37. Good alternative to CC in patients with
unexplained infertility undergoing
gonadotrophin stimulated COH cycles
combined with IUI therapy.
In a prospective nonrandomized study by
Mitwally and Casper it was shown that
aromatase inhibition with letrozole reduced
the dosage of FSH required for COH without
any undesirable antiestrogenic effects,
Dr Shashwat Jani.
9909944160 3724-Apr-17
38. The pregnancy rate achieved was
also significantly lower in the
CC + FSH group (10.5%) compared
with the letrozole + FSH group (19.1%)
and FSH only group (18.7%).
Dr Shashwat Jani.
9909944160 3824-Apr-17
39. In almost 15-20 % of cycles of CC or HMG
Due to multi follicular development,
Estradiol Increases
Premature LH surge
Cycle Cancellation.
Dr Shashwat Jani.
9909944160 3924-Apr-17
40. To avoid this endogenous LH interference,
Exogenous Gonadotrophins & GnRH
analogues are used for OI.
Mainly useful in IVF.
Recent Cochrane review has concluded that
GnRH analogues do not significantly
improve pregnancy rates in IUI.
Dr Shashwat Jani.
9909944160 4024-Apr-17
41. Act by competitive inhibition of
GnRH receptors, which results in
rapid decline in FSH /LH levels, thus
preventing premature LH surge.
Can be given in a single dose or daily
dose regimen.
Dr Shashwat Jani.
9909944160 4124-Apr-17
42. 1. Lubeck Protocol:
Gonadotrophins are started as usual
and antagonist is started when the follicle
reaches a size of 14 mm, or from 6 day of
stimulation onwards in a dose of 0.25mg / day
till the day of HCG injection.
Dr Shashwat Jani.
9909944160 42
Diedrich K , Diedrich C , Santos E , Zoll C , Al-Hasani S , Reissmann T , et al. Suppression of the
endogenous luteinizing hormone surge by the gonadotrophin-releasing hormone antagonist
Cetrorelix during ovarian stimulation . Hum Reprod. 1994; 9:788-791.
24-Apr-17
43. 2. French Protocol :
Gonadotrophins are started as usual
and a single dose (3 mg) of antagonist is
given when serum E2 level is about 150-200
pg/ml and follicular size is 14 mm .
Dr Shashwat Jani.
9909944160 43
Olivennes F , Fanchin R , Bouchard P , de Ziegler D , Taieb J , Selva J , et al. . The single or dual
administration of the gonadotropin-releasing hormone antagonist Cetrorelix in an in vitro
fertilizationembryo transfer program. Fertil Steril. 1994;62:468
24-Apr-17
44. 1. Allows the manipulation of follicular
development so that IUI can be avoided at
weekends without any detrimental effect on PR.
2. Compared to agonist , it is relatively simple
and inexpensive. There is no suppression of
oestrogen and the effects are easily reversible.
3. Antagonists are associated with lower
rates of OHSS.
Dr Shashwat Jani.
9909944160 4424-Apr-17
46. D2 TVS
Serial TVS from D8 to look for follicular
development ( Number & Size ).
Normally follicle grow 2 – 3 mm/day
helps in determining exact time to trigger
ovulation
Prevent OHSS
Endometrium: look for thickness &
appearance.
Triple line ET of > 9 – 10 mm is ideal .
Dr Shashwat Jani.
9909944160 4624-Apr-17
47. In Natural Cycle : Serum E2 level correlates
with development of dominant follicle.
In Stimulated cycle: it reflects the total
output of all developing follicle irrespective of
size.
Problem : Inconvenience , Cost , daily Prick
Mainly used in Gonadotrophin cycle on D8 ,
Value > 200 pg/ml Good response.
Dr Shashwat Jani.
9909944160 4724-Apr-17
48. > 4 follicles of > 16 mm OR > 8 follicles of > 12 mm
Serum Estradiol
> 1500 – 2000 pg / ml
Cancel the cycle
If < 1500 pg/ ml use GnRH analogue to trigger
ovulation
Dr Shashwat Jani.
9909944160 4824-Apr-17
49. Premature LH surge is known to occur in
20 to 24% of patients undergoing ovarian
stimulation after the leading follicle reaches
16 mm.
The LH surge can be detected either by
doing a daily blood or urinary LH assay, once
the leading follicle exceeds 16 mm.
When LH surge detected Inj. HCG given &
IUI planned.
Dr Shashwat Jani.
9909944160 4924-Apr-17
50. Ideally 36 -38 after HCG administration
OR
After Confirmation of Ovulation.
50
Dr Shashwat Jani.
990994416024-Apr-17
51. The HCG injection is necessary as the LH
secreted by the body may not be adequate
enough, to induce the necessary maturational
changes in all oocytes, if there are many
follicles in the ovary.
Numerous urinary LH kits are available to
detect LH surge. They are easy to use and are
cost effective.
Dr Shashwat Jani.
9909944160 5124-Apr-17