This document discusses principles and practices of individualization in ART (assisted reproductive technology). It begins by explaining why individualization is important to maximize benefits, minimize risks and complications, and improve the three key dimensions of infertility care: effectiveness, safety, and patient-centeredness.
It describes how stimulation protocols can be individualized based on clinical characteristics and ovarian biomarkers like AMH and AFC. For example, high responders may use an antagonist protocol to minimize OHSS risk, while poor responders' main goal is improved patient-centeredness through strategies to boost compliance. The document advocates tailoring treatment to individual patient subgroups defined by biomarkers to enhance quality and outcomes in ART.
Clinical management of men with nonobstructive azoospermia - Sperm Retrieval ...Sandro Esteves
Reproductive Andrology Workshop III
17-21 January 2016 - Kuwait City - KUWAIT
Organized by: Al Jahra Reproductive Medicine Unit - Ministry of Health
Lecture 4: Sperm Retrieval Methods in Nonobstructive Azoospermia
Clinical management of men with nonobstructive azoospermia - Sperm Retrieval ...Sandro Esteves
Reproductive Andrology Workshop III
17-21 January 2016 - Kuwait City - KUWAIT
Organized by: Al Jahra Reproductive Medicine Unit - Ministry of Health
Lecture 4: Sperm Retrieval Methods in Nonobstructive Azoospermia
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
UNEXPLAINED INFERTILITY &INTRAUTERINE INSEMINATION Dr. Sharda jain Lifecare...Lifecare Centre
UNEXPLAINED INFERTILITY &INTRAUTERINE INSEMINATION DR. SHARDA JAIN , DR. JYOTI AGARWAL
DR. JYOTI BHASKAR
DEFINITION
Unexplained infertility means that couple does not conceive after 1year of unprotected vaginal sexual intercourse, with basic infertility evaluation showing no obvious abnormality.
INCIDENCE
15%to 20% of infertile couples
UNEXPLAINED IS PRIMARILY A
DIAGNOSIS OF EXCLUSION
Clomiphene citrate or aromatase inhibitors for superovulation in women with u...Aboubakr Elnashar
Clomiphene citrate or aromatase inhibitors for
superovulation in women with unexplained infertility
undergoing intrauterine insemination:
a prospective
randomized trial
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
Clinical management of men with nonobstructive azoospermia - Azoospermia Diff...Sandro Esteves
Reproductive Andrology Workshop III
17-21 January 2016 - Kuwait City - KUWAIT
Organized by: Al Jahra Reproductive Medicine Unit - Ministry of Health
Lecture 1: Azoospermia Differential Diagnosis
Clinical management of men with nonobstructive azoospermia - Steps Before Spe...Sandro Esteves
Reproductive Andrology Workshop III
17-21 January 2016 - Kuwait City - KUWAIT
Organized by: Al Jahra Reproductive Medicine Unit - Ministry of Health
Lecture 3: Steps Before Sperm Retrieval in Nonobstructive Azoospermia
Workshop on Management of poor prognosis patientsMatheus Roque
In this presentation, it was discussed new concepts in stratification of low prognosis patients. It was also discussed the differences between LH and hCG, and how they can have an influence during COS.
Similar to Principles and Practices of Individualization in ART (20)
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 - Chances of Harve...Sandro Esteves
Reproductive Andrology Workshop III
17-21 January 2016 - Kuwait City - KUWAIT
Organized by: Al Jahra Reproductive Medicine Unit - Ministry of Health
Lecture 2: Chances of Harvesting Sperm in Nonobstructive Azoospermia
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
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
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.
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.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
- 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
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
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.
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.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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Principles and Practices of Individualization in ART
1.
Principles
and
Prac-ces
of
Individualiza-on
in
ART
Sandro
C.
Esteves,
MD.,
PhD.
Medical
Director,
ANDROFERT
Andrology
&
Human
Reproduc=on
Clinic
Campinas,
BRAZIL
2. Learning
Objec-ves
1. Individualiza-on:
a
quality
concept
2. How
to
individualize
COS
to
different
pa-ent
subgroups
3. How
to
individualize
triggering
4. How
to
individualize
luteal
support
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 2
2015
ANDROFERT
3. Why
individualize?
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 3
2015
ANDROFERT
4. Maximize
beneficial
effects
of
treatment
Minimize
complica-ons
and
risks
Why
individualize?
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 4
2015
ANDROFERT
5. Top
3
clinical
dimensions
for
quality
improvement
in
infer-lity
care
• Effec-veness:
Technical
aspects
to
deliver
the
best
possible
outcome
(e.g.
pregnancy,
live
birth,
cumula=ve
LBR)
• Safety:
Complica=ons
(OHSS),
adverse
effects,
risks
(pa=ent
&
offspring),
errors/mistakes
• Pa-ent-‐centeredness:
Informa=on
and
pa=ent
involvement,
competence
and
aPen=on
of
clinic
and
staff,
accessibility,
coordina=on
and
integra=on,
emo=onal
support
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 5
2015
ANDROFERT
Dancet
et
al.
Hum
Reprod
2011;
Mainz
Int
J
Qual
Health
Care
2013
6. How
stakeholders
value
the
top
3
quality
dimensions
of
infer-lity
care
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 6
2015
ANDROFERT
0%
50%
100%
Doctors
&
embryologists
Nurses
Pa-ents
Safety
Effec-veness
Pa-ent-‐
centeredness
Dancet
et
al.
Hum
Reprod
2013
7. Lack
of
psychological
support
and
poor
quality
of
service
~60%
treatment
discon-nua-on
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 7
2015
ANDROFERT
22
studies
21,453
pa=ents
8
countries
8. Individualiza-on
is
a
quality
concept
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 8
2015
ANDROFERT
Safety
Pa-ent-‐
centeredness
Effec-veness
9. How
to
individualize?
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 9
2015
ANDROFERT
10. Individualizing
S-mula-on
Protocols
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 10
2015
ANDROFERT
• Clinical
characteris-cs
• Ovarian
biomarkers
Iden-fy
who
is
who
• Pa-ent-‐centered
• Effec-ve
• Safe
Protocol
12. AMH
~
AFC
>
FSH
>
Age
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 12
2015
ANDROFERT
13. Popula-on
Cutoff
Sensi-vity
Specificity
Accuracy
AMH
ng/mL
High-‐
responder1
2.1
85%
79%
0.82
Poor
responder2
0.82
76%
86%
0.88
*Beckman-‐Couter
genera-on
II
assay;
1>20
oocytes
retrieved;
2≤4
oocytes
retrieved
Leão
RBF,
Nakano
FY,
Esteves
SC.
Fer5l
Steril
2013;
100
(Suppl.):
S16
AMH
&
AFC
should
be
internally
validated
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 13
2015
ANDROFERT
14. Quality-‐based
individualiza-on
in
COS
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 14
2015
ANDROFERT
High
responders*
Normal
responders*
Low
responders*
Biomarkers
Safety
Pa-ent-‐
centeredness
Effec-veness
*expected
15. High
responders
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 15
2015
ANDROFERT
• Main
goal:
Safety
• Clinical
quality
indicator:
OHSS
• Protocol
of
choice*:
Antagonist
(flexible;
cetrorelix)
Tailored
recFSH
(112.5-‐150
IU/d;
follitropin
alfa;
pen
injector)
*Androfert,
Brazil
16. GnRH
antagonists
in
high
responders
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 16
2015
ANDROFERT
9
RCT;
966
PCO
women
Rela-ve
Risk
Dura-on
of
ovarian
s-mula-on
-‐0.74
(95%
CI
-‐1.12;
-‐0.36)
Gonadotropin
dose
-‐0.28
(95%
CI
-‐0.43;
-‐0.13)
Oocytes
retrieved
0.01
(95%
CI
-‐0.24-‐0.26)
Risk
of
OHSS
Mild
Moderate
and
Severe
20%
vs
32%
1.23
(95%
CI
0.67-‐2.26)
0.59
(95%
CI
0.45-‐0.76)
Clinical
PR
1.01
(95%
CI
0.88;
1.15)
Miscarriage
rate
0.79
(95%
CI
0.49;
1.28)
Pundir J et al. RBM Online 2012; 24:6-22
17. iCOS
(n=118):
rec-‐hFSH
112.5-‐150
IU
+
GnRH
antagonist
(flexible)
cCOS
(n=131):
rec-‐FSH
150-‐225
IU
+
GnRH
agonist
(nafarelin)
39.3
18.5
14.0
57.0
14.3
14.7
4.8
56.0
0
10
20
30
40
50
60
Observed
Excessive
Response
(%)
Oocytes
retrieved
(N)
OHSS
(%)
Pregnancy
(%)
cCOS
iCOS
*p<0.05
*
*
Individualized
vs
conven-onal
COS
in
high
responders
Excessive
response
>20
oocytes
retrieved;
Mild/severe
OHSS
reported;
Leão
RBF,
Nakano
FY,
Esteves
SC.
Fer5l
Steril
2013;
100
(Suppl.):
S16
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 17
2015
ANDROFERT
*
18. Poor
responders
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 18
2015
ANDROFERT
• Main
goal:
pa-ent-‐centeredness
• Clinical
quality
indicators:
– Compliance
(drop-‐out
rate)
– Pa-ent
burden
(cancela-on
rate)
• Protocol
of
choice*:
Antagonist
(flexible;
cetrorelix)
recFSH
+
recLH
(follitropin
alfa
+
lutropin
alfa
2:1
ra=o:
300
IU
recFSH
+
150
IU
recLH);
from
s=mula=on
D1
*Androfert,
Brazil
19. Pregnancy
rates
increased
by
30%
in
poor
responders
treated
with
rLH+rFSH
Lehert et al Reprod
Biol
Endocrinol
2014,
12:17
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 19
2015
ANDROFERT
20. Lehert et al 2012
Increase
of
≈1
oocyte
per
1,000
UI
in
poor
responders
treated
with
rLH
+rFSH
Lehert et al Reprod
Biol
Endocrinol
2014,
12:17
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 20
2015
ANDROFERT
21. Individualized
vs.
Conven-onal
COS
in
Expected
Poor
Responders
(N=118)
72.0
3.5
45.0
20.0
46.6
4.8
23.3
26.8
0
20
40
60
80
Observed
Poor
Response
(%)
Oocytes
retrieved
(N)
Cancella=on
(%)
Pregnancy/cycle
(%)
cCOS
(Long
GnRHa
+
300-‐450
IU
recFSH
alone)
iCOS
(GnRH
antagonist
+
rFSH
(225-‐300
IU)
+rLH
(75-‐150
IU))
Expected
poor
response:
AMH<0.82
ng/dL;
Observed
poor
response
<5
oocytes
retrieved;
Leão
RBF,
Nakano
FY,
Esteves
SC.
Fer5l
Steril
2013;
100
(Suppl.):
S16
*p<0.05
*
*
*
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 21
2015
ANDROFERT
22. Normal
responders
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 22
2015
ANDROFERT
• Main
goal:
effec-veness
• Clinical
quality
indicators:
number
oocytes
• Protocol
of
choice*:
<35yr:
Antagonist
+
recFSH
cetrorelix
(flexible);
187.5-‐262.5
IU/d
follitropin
alfa
pen
injector
>35yr:
Antagonist
+
recFSH/recLH
cetrorelix
(flexible);
follitropin
alfa
+
lutropin
alfa
2:1
ra=o;
225-‐300
IU/d;
from
s=mula=on
D1
*Androfert,
Brazil
23. Nega-ve
predictor
Posi-ve
predictor
van Loendersloot et al. Hum Reprod Update 2010; 16: 577–589
Female
Age
(OR=0.95;
CI:
0.94-‐0.96)
Number
of
oocytes
retrieved
(OR=1.04;
CI:
1.02-‐1.07)
Level
1a
Predictors
of
pregnancy
in
IVF
14
studies
>30,000
pa=ents
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 23
2015
ANDROFERT
24. What is the optimum number
of retrieved oocytes to
increase pregnancy rates ?
a. 4 to 8
b. 9-12
c. 13-17
d. The higher the better
25. 0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 20 25 30 35 40
Livebirthrate(%)
Oocyte number
Observed live birth rate Predicted live birth rate
Sunkara
et
al.
Hum
Reprod
2011
450,135 IVF cycles
Best
chance
of
live
birth
is
associated
with
~15
oocytes
number of oocytes that
best optimized LBR was 15
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 25
2015
ANDROFERT
26. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 26
2015
ANDROFERT
...irrespec-ve
of
age
group
27. The
higher
the
cohort
size,
the
higher
the
chance
of
having
euploid
embryos
Ata
et
al.
RBM
Online
(2012)
24,
614–620
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 27
2015
ANDROFERT
28. Do you take into account the
severity of male factor
infertility when planning COS?
a. Yes
b. No
c. Never though about it
29. 41.4
47
43.3
20
100
64
61
34.2
Sperm
retrieval (%)
2PN
Fertilization
(%)
Top Quality
Embryos (%)
Live Birth (%)
Non-obstructive (N=365)
Obstructive (N=146)
P<0.01
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 29
2015
ANDROFERT
30. 3,412
cycles
Oocyte
number
and
LBR
at
Androfert
(ICSI
cycles
involving
severe
male
factor)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 30
2015
ANDROFERT
0%
10%
20%
30%
40%
50%
60%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
20
25
Number
of
oocytes
Clinical
pregnancy
Live
birth
31. Each
addi-onal
warming
cycle
increases
the
chance
of
achieving
a
live
birth
40.4% 48.0%
ET #3
(FET) 49
ET #2 (FET)
239
ET #1 (fresh)
822
50.5%
+18.8%
+25.0%
Female Age ≤38
332/822
63/239
17/49
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 31
2015
ANDROFERT
32. Oocyte yield by gonadotropin
↑
1.5
oocytes
(GnRH
antagonist
cycles)
Devroey
et
al.,
2012
↑
3.1
oocytes
(GnRH
antagonist)
Bosch
et
al.,
2008
↑
1.8
oocytes
(GnRH
agonist
cycles)
MERIT
Study,
2006
↑
2.8
oocytes
(GnRH
agonist
cycles)
Hompes
et
al.,
2008
↑
2.1
oocytes
(16
RCT;
different
protocols)
Lehert
et
al.,
2010
Higher
with
rec-‐FSH
vs.
hMG,
HP-‐hMG,
and
uFSH
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 32
2015
ANDROFERT
33. LH
supplementa-on
improves
clinical
pregnancy
in
women
>35
yr
Hill
et
al.
Fer5l
Steril
2012
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 33
2015
ANDROFERT
34. LH
ac-vity
by
rec-‐LH
vs
hMG
Adapted
from:
Leao
&
Esteves.
Clinics
2014;
69(4):
279–293.
Product
LH
ac-vity
(IU/vial)
LH
content*
Purity
hMG
75
hCG
~5%
HP-‐hMG
75
hCG
~70%
Lutroprin
alfa
(rec-‐hLH)
75
LH
>99%
2:1
Follitropin
alfa
+
Lutroprin
alfa
(rec-‐hFSH
+
rec-‐hLH)
75
LH
>99%
*hCG
concentrated
or
added
during
purifica-on
process
(8IU
hCG
~
75IU
LH)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 34
2015
ANDROFERT
35. LH
and
hCG
elicit
different
gene
expression
LH
hCG
LHR
and
FSHR
expression
(Trafficking
of
re=noic
acid
:
RXRB,
TTR,
ALDH8A1)
Meiosis
and
follicular
matura-on
(TRA
:
RXRB,
TTR,
ALDH8A1;
IL11;
AKT3)
Follicular
development
(IL11;
AKT3)
Cellular
growth
(RXRB,
TTR,
ALDH8A1;
IL11;AKT3)
Ovarian
stereodogenesis
(TRA
:
RXRB,
TTR,
ALDH8A1)
Embryo
development
&
survival
(AKT3)
Aromatase
inhibi-on
(PPARS)
Apoptosis
enhancement
(DNAsi)
LH
hCG
Grondal
ML
et
al.
FerFl
Steril
2009;
Menon
KM
et
al.
Biol
Reprod
2004;
Ruvolo
et
al.
Fer=l
Steril
2007
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 35
2015
ANDROFERT
36. COS
with
LH
ac-vity
delivered
by
rec-‐
LH
vs
hMG
in
IVF
Authors,
yr.
Design
N
Main
findings
Buhler
&
Fisher,
2011
Matched
case-‐
control
4719
Higher
CPR
in
fixed
2:1
rec-‐
FSH
+
rec-‐LH
(31%)
vs
hMG
(26%)
and
vs
combo
(rec-‐FSH
+
hMG,
25%);
p=0.02
Fábregues
et
al,
2013
Cross-‐over
study
66
Higher
N
oocytes
in
fixed
2:1
rec-‐FSH
+
rec-‐LH
(9.8)
vs
HP-‐
hMG
(7.3);
p<0.01.
Higher
N
frozen
embryos
in
recLH
Dahan
et
al,
2014
Observa=onal
201
Higher
N
oocytes
in
rec-‐LH
(12)
vs
hMG
(10);
p=0.008.
Higher
CPR
rec-‐LH
(36%
vs
20%;
p=0.02)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 36
2015
ANDROFERT
37. Individualizing
trigger
and
LPS
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 37
2015
ANDROFERT
High
responders
Normal
responders
Low
responders
Safety
Pa-ent-‐
centeredness
Effec-veness
38. 14h
14h
20h
48h
0
20
h
Natural
LH
surge
hCG
Adapted
from
Chan
et
al.
Hum
Reprod.
2003;18:2294-‐7
Day
6
hCG
and
GnRHa
elicit
final
follicular
matura-on
as
surrogates
for
the
mid-‐cycle
LH
surge
GnRHa
36-48 h
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 38
2015
ANDROFERT
Day
8
39. GnRH-‐agonist
vs
hCG
trigger
Fresh
autologous
cycles
Moderate/
severe
OHSS
OR
0.10
0.01-‐0.82
Live
birth
OR
0.44
0.29-‐0.68
Youssef et al. Cochrane Database Syst Rev. 2011
High
responders
Fresh
ET
Freeze
all
GnRH-‐a
trigger
One
size
trigger
does
not
fit
all
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 39
2015
ANDROFERT
40. Freeze-‐all
embryo
policy:
is
it
for
all?
• Non-‐inferior
in
effec-veness
in
high-‐
quality
vitrifica-on
programs,
but…
• Safety
– Increase
ART
unit
workload
– Perinatal
outcome
• Higher
rate
of
large
for
gesta-onal
age
(Wennerholm HR 2013)
• Pa-ent-‐centeredness
– Psychological
&
cost
burden
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 40
2015
ANDROFERT
41.
Modified
LPS
for
fresh
ET
in
GnRH-‐a
trigger
No.
follicles
day
OPU
1,500
IU
hCG
at
OPU
&
1,000
OPU+5
&
standard
LPS
≤
14
1,500
IU
hCG
at
OPU
+
standard
LPS
15-‐25
1,000
IU
hCG
at
OPU
+
standard
LPS
or
Freeze
all
26-‐30
Freeze
all
>30
Humaidan
et
al.
Hum
Reprod.
2013;28(9):2511-‐21
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 41
2015
ANDROFERT
14h
14h
20h
48h
0
20
h
4h
GnRHa
Natural
LH
surge
Luteal
phase
defect
42. Individualizing
trigger
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 42
2015
ANDROFERT
Normal
&
poor
responders
rec-‐hCG
u-‐hCG
hCG
trigger
43. RCT
N
Effect
Oocytes
retrieved
9
1409
MD:
-‐0.04
95%
CI:
-‐0.69
to
0.61
Live
birth
6
1,019
OR:
1.04
95%
CI:
0.79
to
1.37
Miscarriage
7
1,106
OR:
0.69
95%
CI:
0.41
to
1.18
Severe
OHSS
3
549
OR:
1.49
95%
CI:
0.54
to
4.1
Youssef
et
al.
Cochrane
Database
Syst
Rev.
2011;
13(4):CD003719
Databases
searched
up
to
January
2010
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 43
2015
ANDROFERT
44. Farrag et al. JARG 2008; 25:461-6
8.4
7.3
7.1
4.7
0
2
4
6
8
10
No. Retrieved oocytes
No. MII with mature
cytoplasm
rec-hCG (250 mcg; n=42)
u-hCG (10,000 IU; n=47)
*p<0.01
*
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 44
2015
ANDROFERT
45. Effec-veness
RCT
comparing
trigger
with
rec-‐hCG
(250
mcg)
vs
u-‐hCG
(10,000
IU)
on
delivery
rates
in
eSET
antagonist
cycles
26.7%
44.1%
Delivery rate (%)
u-hCG
rec-hCG
N=119
aged<32
OR:
2.16
(95%
CI:
1.01-‐4.67;
p=0.04)
Papanikolaou
EG
et
al.
Fer5l
Steril
2010;
94:2902-‐4
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 45
2015
ANDROFERT
46. RCT
N
Odds-‐ra-o
Local
site
reac-ons*
rec-‐hCG
vs.
u-‐hCG
3
374
0.39
95%
CI:
0.25
to
0.61
Driscoll
et
al.
2000:
27%
vs
42%
ERHCG
group
2000:
23%
vs
45%
Abdelmassih
et
al.
2005:
23%
vs
45%
Youssef et al. Cochrane Database Syst Rev. 2011; 13(4):CD003719
* Pain and/or inflammation
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 46
2015
ANDROFERT
47. hCG
preferences
in
treatment-‐
experienced
pa-ents
at
Androfert
Total (n=76)
60%
29%
3%
8%
prefer new pen
prefer pre-filled syringe
prefer lyophilized powder to reconstitute
Not matter
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 47
2015
ANDROFERT
48. Why
immature
oocytes?
1. Follicles
<13mm
2. LH
receptor
deficiency
3. Blood/intrafollicular
level
barely
achieved
4. Not
enough
-me
for
intrafollicular
hCG
ac-on
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 48
2015
ANDROFERT
Trigger
is
the
most
important
injec-on
of
the
cycle
49. Weight (kgs) 55 64 90
Blood volume (lts) (7% of weight) 3.8 4.4 14
Fat (kgs) (essential 13.5% of weight) 7.4 8.6 27
hCG Blood Threshold
hCG Intrafollicular Threshold
Blood represents about 7% of the body mass or about 4.5 kg
(volume ~ 4.4 liters) in a 64 kg (141 lb) person." Cameron, J.. Physics of the
Body. 2nd Edition. Madison, WI:, 1999: 182.
Injecting hCG: Size and BMI
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 49
2015
ANDROFERT
50. What is the optimum interval
between trigger and oocyte
retrieval?
a. 34 to 35h
b. 35 to 36h
c. 36-38h
d. >38h
e. Doesn’t matter much
51.
63
73
76
79
82
Oocyte
maturity
%
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 51
2015
ANDROFERT
52. Individualizing
LPS
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 52
2015
ANDROFERT
Normal
&
poor
responders
Fresh
ET
FET
53. In
FET
cycles,
all
of
the
current
methods
of
endometrial
prepara-on
appear
to
be
equally
effec-ve
in
terms
of
ongoing
pregnancy
rate*
• Meta-‐analysis
of
20
compara=ve
studies
• ~13,000
cycles
• Natural
and
ar=ficial
cycles
with
and
w/o
GnRH
agonist
• Safety
&
pa-ent-‐centeredness
not
addressed
Groenewoud
ER
et
al.
Hum
Reprod
Update.
2013;19:458-‐70
*in
eumenorrhoic
pa-ents
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 53
2015
ANDROFERT
54. Luteal
phase
abnormal
in
s-mulated
cycles
• Corpus
luteum
func-on
dependent
on
pulsa-le
LH
release
from
pituitary
• Supraphysiologic
steroid
levels
(by
mul-follicular
development)
inhibits
LH
secre-on
• Low
LH
levels
causes
luteolysis,
implanta-on
failure
and
shortened
luteal
phase
Jones 1996; Albano et al 1998; Beckers et al 2000; Tavaniotou et al Hum Reprod 2000;
Fauser & Devroey 2003; Trinchard-Lugan et al 2002; Sherbahn 2013
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 54
2015
ANDROFERT
55. LPS
mandatory
in
s-mulated
cycles
• hCG
vs.
Placebo
or
No
treatment:
Higher
ongoing
PR
(OR=1.75; 95% CI: 1.09-2.81)
• Progesterone
vs.
Placebo
or
No
treatment:
Higher
clinical
PR
(OR=1.83; 95% CI: 1.29-2.61)
Higher
ongoing
PR
(OR=1.87; 95% CI: 1.19-2.94)
Higher
live
birth
rates
(OR=2.95; 95% CI: 1.02-8.56)
Level
1a
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 55
2015
ANDROFERT
56. Gelbaya et al Fertil Steril. 2008; Kolibianakis et al Hum Reprod. 2008;
Jee et al Fertil Steril. 2010; van der Linden et al Cochrane Database 2011
High-‐quality
evidence
on
LPS
in
s-mulated
cycles
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 56
2015
ANDROFERT
57. P routes & types Evidence Effect Conclusion
Vaginal as effective
as IM/oral
13 RCT; 2
MA; >2,000
cycles
Similar CPR, LBR
& miscarriage True
Vaginal safer and
more patient-
friendly than IM/oral
3 RCT; 1
MA; >2,000
cycles
Lower side effects;
Increased patient
satisfaction
True
Among vaginal P,
patients prefer gel
7 RCT; 1
MA; >2,400
cycles
Easier to use;
better adherence;
lower discharge
True
Schoolcraft et al 2000; Yanushpolsky et al-2008; Zarutskie & Phillips 2009; Polyzos et al 2010;
van der Linden et al Cochrane 2011
High-‐quality
evidence
on
LPS
in
s-mulated
cycles
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 57
2015
ANDROFERT
58. 1
hour
3
hours
2
hours
4
hours
Time
Bioadhesion of vaginal P is essential
because it takes ~4h to reach steady
state in the uterus (first-pass effect)
Bulletti C et al. Hum Reprod 1997
aqueous
lipid
-ssue
micronized
progesterone
in
an
‘oil-‐in-‐water’
emulsion
(Crinone®
8%)
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 58
2015
ANDROFERT
59. Similar
outcome
in
low
vs.
high
dosage
Crinone
8%
(90
mg/d)
vs.
200-‐800
mg/d
(capsules;
tablets;
pressaries)
No.
studies
No.
OR;
95%
CI
Live
birth
2
1485
1.01;
0.81-‐1.26
Clinical
PR
12
4973
1.04;
0.92-‐1.17
Miscarriage
rate
8
2350
1.27;
0.85-‐1.89
Mul-ple
PR
4
905
0.95;
0.57-‐1.58
Van der Linden et al Cochrane 2011
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 59
2015
ANDROFERT
60. Vaginal
P
started
at
the
-me
of
OPU
reduces
uterine
contrac-ons
at
the
-me
of
ET
4.6
2.8
4.5 4.2
UC on day of hCG UC on day of ET
Crinone started on the day of OPU (n=43)
Crinone started on the evening of ET (n=41)
P<0.001
Fanchin et al. Fertil Steril 1999
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 60
2015
ANDROFERT
61. Luteal-‐placental
shiw
on
P
produc-on
occurs
around
7-‐12th
gesta-onal
week
0
100
200
300
400
500
600
700
800
900
0
10
20
30
40
50
60
70
80
4 5 6 7 8 9 10
E2(pg/mL)
P(ng/mL)
Gestational age in weeks P E2
Scott et al. Fertil Steril 1991; 56:481
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 61
2015
ANDROFERT
62. Principles
and
Prac-ces
of
Individualized
ART
at
Androfert
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 62
2015
ANDROFERT
High
responders
Normal
responders
Low
responders
Clinical
features
+
AMH
Antagonist
protocol;
tailored
COS
rec-‐FSH
(112.5-‐150
IU)
+
tailored
trigger
(GnRHa
or
rec-‐hCG);
tailored
LPS
(modified
LPS
or
vaginal
P
gel
OPU)
Antagonist
protocol;
tailored
COS
w/rec-‐
FSH
(<35yr)
or
rec-‐FSH+rec-‐LH
2:1
ra-o
(>35
yr);
rec-‐hCG
trigger;
LPS
vaginal
P
gel
Antagonist
protocol;
recFSH
+
recLH
2:1
ra-o
+
rec-‐hCG
trigger;
LPS
vaginal
P
gel
63. Principles
and
Prac-ces
of
Individualiza-on
in
ART
Conclusions
• Individualiza-on
is
a
quality
concept
• Safety,
effec-veness
and
pa-ent-‐centeredness
are
important
principles
in
a
quality-‐based
individualized
infer-lity
care
• Novel
biomarkers
combined
with
new
devices
&
drug
regimens
can
be
used
to
deliver
a
high
quality
evidence-‐based
individualized
ART
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 63
2015
ANDROFERT
64. Thank
you
اشكر Obrigado
This
presenta-on
is
available
at
hxp://www.slideshare.net/
sandroesteves