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
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
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
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 a CME, sponsored by Serum Institute of India Pvt Ltd in the Convocation Ceremony of Interns at Sagor Dutta Medical College
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LETROZOLE was withdrawn from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”?
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
IUI is a basic but effective form of fertiltiy treatment and can be a viable alternative to the expensive IVF / test tube baby treatment that is normally advised.
This presentation will be very useful for the practising gynecologists, IVF specialists and General practitioners who perform IUI.
Even patients on going through this presentation will be more educated about iui.
Please reach out to me on 9833032120 by whatsapp / Telegram or phone call or email on dalalsj@gmail.com for further details / treatment options.
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)
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
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”?
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
IUI is a basic but effective form of fertiltiy treatment and can be a viable alternative to the expensive IVF / test tube baby treatment that is normally advised.
This presentation will be very useful for the practising gynecologists, IVF specialists and General practitioners who perform IUI.
Even patients on going through this presentation will be more educated about iui.
Please reach out to me on 9833032120 by whatsapp / Telegram or phone call or email on dalalsj@gmail.com for further details / treatment options.
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)
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.
medical management of infertility,think before surgery!!!!ShitalSavaliya1
Nowdays infertility is major issues world wide,It covers both male and female infertility causes,investigation and related treatments.it also includes recent options available at infertility centres.
Management of Intraoperative Haemorrhage in Gynaecological Abdominal SurgeriesRajesh Gajbhiye
This presentation discusses how to tackle intraoperative haemorrhage during Abdominal Gynaecological Surgeries.Various modalities to control haemorrhage,knowledge of vascular anatomy to promptly manage such situation
In this introductory remark at workshop on vaginal hysterectomy where Dr Shirish Seth was operating faculty.
I spoke “lets promote and propagate vaginal hysterectomy which is an indigenous surgery in line with PM Modi’s mission of MAKE IN INDIA.
Vaginal hysterectomy is like Aam admi surgery which is in the best interest of patients and has best scientific evidences in its favour."
Let us not be driven by glamour,gadgets and gimmicks."
In cases of Nulliparous prolapse or even patients deserving child bearing uterus preserving surgeries are done.
Recently even for prolapse if women want to preserve uterus for variety of reasons ,with newer minimally invasive methods it is now gaining popularity.Larger studies and longer followup is required.
How to have quality of life in Advanced ovarian malignancyRajesh Gajbhiye
Presentation given by Dr Rakhi Gajbhiye, Mauli Hospital Nagpur at MGIMS sewagram for an International conference on Womens Health Fatal Disorders Survival with Quality in collaboration with FOGSI.
This was the function to commemorate 100 th birth centenary of Dr Sushila
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.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
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
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
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
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
1. Panel Discussion on Ovulation
Induction In PCOS
DR Rajesh Gajbhiye
Dr Rakhi Gajbhiye
Consultant Gynaecologists,Mauli Women’s Hospital
Nagpur
2. INTRODUCTION
✤ PCOS is the most common endocrinopathy among
the reproductive age group women.
✤ It affects about 12%-21%
✤ Commonest cause of normogonadotropic
anovulation
91% of WHO II cohort.
3.
4. 1st line non pharmacological
Management
Lifestyle Interventions
✤ Weight reduction(5-10%),international guidelines.
✤ Exercise-50 min mod intensity
✤ diet
17. ✤ LETROZOLE: Should be considered first line Tt for
OI in PCOS to improve ovulation, pregnancy and
live birth rates. (International Guidelines)
✤ Monofollicular growth
✤ No antiestrogen action on endometrium and cervical
mucus
✤ Live birth rate is increased
✤ Letrozole resistance is very less
18. Clomiphene citrate and metformin (Guidelines)
Clomiphene citrate could be used alone in women with PCOS to improve ovulation
and pregnancy rates.
Metformin could be used alone in women with PCOS, women should be informed that
there are more effective ovulation induction agents.
Clomiphene citrate could be used in preference, when considering clomiphene citrate or
metformin for ovulation induction in women with PCOS who are obese (BMI is ≥ 30
kg/m2) with anovulatory infertility and no other infertility factors.
If metformin is being used for ovulation induction in women with PCOS who are obese
(BMI ≥ 30kg/m2) with anovulatory infertility and no other infertility factors, clomiphene
citrate could be added to improve ovulation, pregnancy and live birth rates.
Clomiphene citrate could be combined with metformin, rather than persisting with
clomiphene citrate alone, in women with PCOS who are clomiphene citrate-resistant,
with anovulatory infertility and no other infertility factors, to improve ovulation and
pregnancy rates.
The risk of multiple pregnancy is increased with clomiphene citrate use and therefore
monitoring needs to be considered.
19.
20. Metformin with Gonadotrophins
In patients with CCR-PCOS undergoing ovulation induction
with gonadotrophins, the addition of metformin increases
the rates of clinical pregnancy and live birth and reduces the
cancellation rate.
§ In patients with PCOS undergoing assisted reproduction
technniques, metformin co-treatment reduces the OHSS risk
and increases the pregnancy rate. No evidence exists of
reduced spontaneous abortion risk in women with PCOS who
have undergone pre-gestational metformin tretment.
§ No evidence exists of increased risk of major anomalies
in women with PCOS undergoing metformin treamtent during
the first trimester.
§ Adequately powered RCT are needed to evaluate the
efficacy of metformin treatment in different PCOS phenotypes.
RBM online 2016
26. Choice of FSH
Urinary or recombinant follicle stimulation hormone can be
used in women with PCOS undergoing controlled ovarian
hyperstimulation , with insufficient evidence to recommend
specific follicle stimulating hormone (FSH) preparations.
28. Gonadotrophins
Gonadotrophins could be used as second line pharmacological agents in women with PCOS
who have failed first line oral ovulation induction therapy and are anovulatory and infertile,
with no other infertility factors.
# Gonadotrophins could be considered as first line treatment, in the presence of ultrasound
monitoring, following counselling on cost and potential risk of multiple pregnancy, in
women with PCOS with anovulatory infertility and no other infertility factors.
Gonadotrophins, where available and affordable, should be used in preference to clomiphene
citrate combined with metformin therapy for ovulation induction, in women with PCOS with
anovulatory infertility, clomiphene citrate-resistance and no other infertility factors, to
improve ovulation, pregnancy and live birth rates.
Gonadotrophins with the addition of metformin, could be used rather than
gonadotrophins alone, in women with PCOS with anovulatory infertility, clomiphene
citrate-resistance and no other infertility factors, to improve ovulation, pregnancy and live
birth rates.
Either gonadotrophins or laparoscopic ovarian surgery could be used in women with PCOS
with anovulatory infertility, clomiphene citrate-resistance and no other infertility factors,
following counselling on benefits and risks of each therapy.
33. lap ov drilling ?
✤ CC Resistance
✤ LH hypersecretion
✤ PCOS pts require assessment of pelvis
34. . Laparoscopic ovarian surgery (Guidelines)
Laparoscopic ovarian surgery could be second line therapy for
women with PCOS, who are clomiphene citrate resistant, with
anovulatory infertility and no other infertility factors.
Laparoscopic ovarian surgery could potentially be offered as
first line treatment if laparoscopy is indicated for another
reason in women with PCOS with anovulatory infertility and
no other infertility factors.
Risks should be explained to all women with PCOS
considering laparoscopic ovarian surgery. Where laparoscopic
ovarian surgery is to be recommended, the following should be
considered:
35. ● comparative cost
● expertise required for use in ovulation induction
intra-operative and post-operative risks are higher
in women who are overweight and obese
● there may be a small associated risk of lower ovarian
reserve or loss of ovarian function
● periadnexal adhesion formation may be an associated
risk
36. No evidence of a significant difference in rates of
a) clinical pregnancy,
b) live birth
c) miscarriage in women with clomiphene-resistant
PCOS undergoing LOD compared to other medical
treatments.
The reduction in multiple pregnancy rates in women
undergoing LOD makes this option attractive.
38. Monitoring starts..
• D7,D8,D9…any day could be a start in IUI cycle
if IVF D5
• Growth pattern to be followed..Day X 2mm
appro.,doppler flow
• Alternate day monitoring is advisable if required
changed according to the need
• Sustained growth…is must In healthy follicles, genes
direct cytodifferentiation, proliferation, and follicular fluid
formation.
Hormones-E2,Progesterone
39. Clinical classifications
✤ Group A : Mild variety, minimal clinical and
biochemical hyperandrogenicity and ovarian
changes
✤ Group B: Moderate
✤ Group C : Severe degree of clinical,Biochemical of
Hand PCOM
41. Protocols for group A &B
✤ Step 1 Protocol
✤ CC 50mg twice daily or Letrozole (2.5mg twice
daily)
✤ day d3-d7
✤ HMG/FSH ( 75 IU) on day 3
✤ + Dydrogesterone 10mg BD/Natural progest.200 mg
BD
42. Step 2 protocol
✤ CC/Letroz 2.5mg BD from d3 to d7+
✤ HMG / FSH on d3 and d8
✤ Follicular study from day 10
✤ HCG trigger lead follicle 17-18mm
✤ IUI/TI
43. STEP 3 PROTOCOL
✤ Interrupted
✤ Gn alternate day 3,5,7,9 overlapping with CC,LZ
✤ Sequential
✤ Gn started after CC,LZ
✤ d4 or d5 and given continuously till lead follicle 17-
18mm
44.
45.
46. Step 4 protocol
✤ Group C PCOS
✤ Grossly androgenised with e/o hyperinsulinemia
✤ Pretreatment
✤ ISA,Lifestyle changes
✤ OC Pills
✤ OV drilling
✤ Downregulate LH,androgen make her fit for OI+ IUI,IVF
47.
48. Third line management
In the absence of an absolute indication for IVF ± ICSI,
women with PCOS and anovulatory infertility could be
offered IVF as third line therapy where first or second line
ovulation induction therapies have failed.
50. . A gonadotrophin releasing hormone antagonist protocol
is preferred in women with PCOS undergoing an IVF ±
ICSI cycle, over a gonadotrophin releasing hormone
agonist long protocol, to reduce the duration of
stimulation, total gonadotrophin dose and incidence of
ovarian hyperstimulation syndrome (OHSS) .
(International PCOS guidelines)
54. Ovulation Trigger,When to give HCG..
•Triple line Endo >7mm,follicle >17mm
• Perifollicular and subendometrial Hallo…oedema
• Cumulus presence..30-40%
• Follicular volume..0.6 to 1.5ml
• Flow Indices…PSV: >10,RI:<0.5
• Perifollicular Vasularity..3/4th
• Sub Endo vasularity..minimum 5 spiral vessels
reaching to zone 4,ant & post,RI<0.6
• Endo peristalsis 3to5/ min
55. Triggering final oocyte maturation with a gonadotropin-
releasing hormone (GnRH) agonist and freezing all suitable
embryos could be considered in women with PCOS having
an IVF/ICSI cycle with a GnRH antagonist protocol and at an
increased risk of developing OHSS or where fresh embryo
transfer is not planned.
Human chorionic gonadotrophins is best used at the lowest
doses to trigger final oocyte maturation in women with
PCOS undergoing an IVF ± ICSI cycle to reduce the
incidence of OHSS.
In IVF ± ICSI cycles in women with PCOS, consideration
needs to be given to an elective freeze of all embryos.
57. Dual Trigger
✤ Described by Shapiro.Both GnRh A followed by
hCG (1000-2500 IU)
✤ OHSS risk is minimised by GnRh agonist
✤ luteal fn was rescued by added hCG
61. ✤ Titration of COS
✤ Use of less aggressive stimulation protocol
✤ Monitor ovarian response carefully
✤ If >2 follicles abort cycle or convert IVF
✤ Use antagonist protocol
✤ agonist trigger
✤ Coasting
✤ Elective single embryo transfer
63. OHSS FREE CLINIC
With the advent of GnRH agonist triggering the concept of OHSS free clinic
has come. It is based on the three segment approach to prevent OHSS
• Segment A
It consists of optimization of the ovarian stimulation, including GnRH
agonist triggering in a GnRH antagonist cycle.
• Segment B
It consists of optimum cryopreservation methods for oocyte or embryo
vitrification.
• Segment C
Includes embryo replacement in a receptive, non-stimulated endometrium
in a natural cycle or with artificial endometrial preparation. (PAUL
DEVOERY hum reprod 2011)8
66. In-vitro maturation
In women with PCOS, is in-vitro maturation (IVM) effective for improving
fertility outcomes?
term in vitro maturation (IVM) treatment cycle is applied to “the maturation in
vitro of immature cumulus oocyte complexes collected from antral follicles”
(encompassing both stimulated and unstimulated cycles, but without the use of a
human gonadotrophin trigger).
In units with sufficient expertise, IVM could be offered to achieve pregnancy and
livebirth rates approaching those of standard IVF ± ICSI treatment without the risk
of OHSS for women with PCOS, where an embryo is generated, then vitrified and
thawed and transferred in a subsequent cycle.
67. Conclusion
✤ The rational of ovulation is to ensure an optimal number of
mature oocytes on one hand and to prevent OHSS on the
other hand.
✤ Lifestyle interventions and oral ovulation drugs form the first
line
✤ Gonadotropins and LOD -second line
✤ IVF-third line-antagonist protocol with agonist trigger and
Freeze all
✤ OHSS free clinic is the need of hour.