Levitra Professional

Shamsuddin Akhtar, MBBS

• Associate Professor
• Department of Anesthesiology
• Yale University School of Medicine
• New Haven, Connecticut

Possible additional Removal of underarm nodes chemotherapy may be omitted if sentinel node (before radiation) biopsy done pre-chemotherapy finds no cancer erectile dysfunction treatment with exercise buy 20mg levitra professional visa. After mastectomy or lumpectomy impotence nitric oxide best purchase levitra professional, more be followed by radiation therapy to the whole chemotherapy may be recommended erectile dysfunction medscape buy levitra professional 20 mg line, depend breast and sometimes to the surrounding ing on the tumor size and number of positive lymph nodes depression and erectile dysfunction causes 20 mg levitra professional fast delivery. If the tumor was hormone nodes with radiation erectile dysfunction treatment pills buy levitra professional canada, or the decision to treat receptor-positive erectile dysfunction natural remedies at walmart safe 20mg levitra professional, hormone therapy should the skin after mastectomy is based on the same be given. This is followed by nodes, if the cancer has shrunk enough, radiation therapy to the chest wall, followed by radiation therapy to the the lymph nodes above the collarbone, breast and the lymph nodes above the and, if they are enlarged, internal nodes collarbone, and, if they are enlarged, next to the sternum or breastbone. If the tumor does not the status is unknown, hormone therapy is shrink, the patient should discuss treatment recommended. Likewise, if hormone was not done on the original cancer or was receptor tests were not done or were negative, negative, it should be done on a new biopsy testing for these should be done. The area of the recur cancer has returned to the area of the breast, rence and surrounding tissues should receive underarm lymph nodes, or nearby tissue. Or radiation therapy, if it has not been given it may be systemic, which means that cancer before. If the recurrence surgery, the woman should have radiation is local and the woman has had a mastectomy, therapy if it was not given before. Hormone therapy with or without 75 Treatment Guidelines for Patients ovarian ablation is appropriate for the fol and whether or not she is premenopausal or lowing patients: postmenopausal. For postmenopausal women, an aromatase inhibitor or antiestrogen would be the first the specific treatment is based on what type choice. Premenopausal women may be of treatment the patient has received before treated with an antiestrogen alone. If the tumor does not shrink after bone, either pamidronate or zoledronic acid, 3 different chemotherapy regimens, stopping along with calcium citrate and vitamin D, chemotherapy and providing supportive care should be given to strengthen the bones. This is because the the treatment recommendations depend use of drug treatments during the early part upon how long the woman has been pregnant. Hormone therapy should not be first trimester of pregnancy, some chemother started until after the patient has given birth. These include pamidronate and Treatment that is added to increase the effec zoledronate. It usually refers Breast-conserving treatment or therapy to hormonal therapy, chemotherapy, or radi Surgery to remove a breast cancer and a small ation therapy added after surgery to kill any amount of benign tissue around the cancer, remaining cancer cells and increase the without removing any other part of the breast. Antiestrogen the method may require an axillary dissection A substance that blocks the effects of estrogen and usually requires radiation therapy after on tumors (for example, the drug tamoxifen). Antiestrogens are used to treat breast cancers Breast reconstruction that depend on estrogen for growth. They are used to treat hormone-sensitive Reconstruction can be done at same time as breast cancer in postmenopausal women. The removal of a sample of tissue to see Chemotherapy is often used in addition to whether cancer cells are present. In the extent of the cancer, the presence or absence breast, a passage through which milk passes of spread to lymph nodes, and the presence from the lobule (which makes the milk) to the or absence of spread to other body organs. These ducts are the starting point for Clinical stage is the stage determined only by most breast cancers. This includes determination the most common type of non-invasive of the size of the cancer and evaluation of breast cancer. The final stage is the pathological stage which is determined from microscopic Estrogen examination of the tumor and lymph nodes. A female sex hormone produced primarily by Clinical stage is used for initial treatment the ovaries, and in smaller amounts from planning. In breast cancer, estrogen may Clinical trial help the growth of breast cancer cells. Research studies test new drugs or treatments and compare them to current, standard Fibroadenoma treatments. Before a new treatment is used on A type of benign breast tumor made of people, it is studied in the lab. On clinical suggest the treatment works, it is tested for examination or breast self-examination, it patients. Cyst Fibrocystic changes A fluid-filled mass that is usually not cancer A term that describes certain benign changes (benign). Because these signs sometimes mimic women with no evidence of lumps or other breast cancer, a diagnostic mammogram, symptoms. This includes 2 x-ray views of each ultrasound, or even a biopsy may be needed breast (top to bottom; side-to-side). Cancer cells are graded by how much they Tumors can be tested for hormone receptors look like normal cells. Grade 1 (also called to see if they can be treated with hormones well-differentiated) means the cancer cells or anti-hormones. In other words, they A test to see whether a breast tumor has hor tend to grow more slowly and metastasize mone receptors and is affected by hormones slower. Histology the way the cancer cells look under the In situ microscope (described as type and arrange Cancer in situ is localized in its original place ment of tumor cells). Hormone A chemical substance released into the body Internal mammary lymph nodes by glands, such as the thyroid, pituitary, or Lymph nodes located inside the chest, next ovaries. The substance travels through the to where the sternum (breastbone) and the bloodstream and sets in motion various body ribs come together. For example, prolactin, which is Intraductal papillomas produced in the pituitary gland, begins and Small, finger-like, polyp-like, non-cancerous sustains the production of milk in the breast growths in the breast ducts that may cause a after childbirth. When 84 many papillomas exist, breast cancer risk is of tissue removed and is usually a sign that slightly increased. In a simple or Drugs that block the ovaries from producing total mastectomy surgeons do not cut away estrogen. Non-invasive radical mastectomy (now rarely performed) cancer that has not spread beyond the lobules. Swelling in the arm is caused by the spread of cancer cells to distant areas of excess fluid that collects after lymph nodes the body by way of the lymph system or and vessels are removed by surgery or treated bloodstream. This type of therapy can shrink Preoperative chemotherapy some tumors, so that they are easier to remove. Chemotherapy given before surgery to shrink Nodal status some breast tumors, so they can be removed Indicates whether a breast cancer has spread with less extensive surgery than would other (node-positive) or has not spread (node-nega wise be needed. Also called neoadjuvant tive) to lymph nodes in the armpit (axillary chemotherapy. The number and site of positive lymph Progesterone nodes can help predict the risk of cancer A female sex hormone released by the ovaries recurrence. For exam contain the eggs (ova) that, when joined with ple, women with breast cancer that is small, sperm, result in pregnancy. A palpable mass A type of breast-conserving surgery that in the breast is one that can be felt. A type of breast-conserving surgery that removes more breast tissue than a lumpec Radiation tomy (up to one-quarter of the breast). It is Treatment with high-energy rays (or particles) also called a segmental mastectomy or a to kill or shrink cancer cells. Most of the time, pathologic stage is Radiation therapy may be used to reduce the the most important stage since involvement size of a cancer before surgery, to destroy any of the lymph nodes can only be accurately cancer cells left behind after surgery, or, in evaluated by examining them under a micro some cases, as the main treatment. Computerized equipment A type of breast-conserving surgery that maps the location of the mass and this is removes more breast tissue than a lumpectomy used as a guide to place the needle. Measures taken to relieve symptoms and Sentinel node mapping and biopsy improve quality of life, but that are not In a sentinel lymph node mapping and biopsy, expected to destroy the cancer. Pain medica the surgeon injects a radioactive substance tion is an example of supportive care. Lymphatic vessels carry these materials Lymph nodes located in the area just above to the sentinel lymph node (also called the the collarbone. The doctor can see the blue dye or detect the radioactivity (with a Geiger Systemic therapy counter) in the sentinel node, which is cut out Treatment that reaches and affects cells and examined. If the sentinel node contains throughout the body; for example, chemo cancer, more axillary lymph nodes are therapy. But if it is free of cancer, the patient Tamoxifen can avoid additional axillary surgery and its this antiestrogen drug blocks the effects of potential side effects. Side effects Blocking estrogen is desirable in some cases Unwanted effects of treatment, such as hair of breast cancer because estrogen promotes loss caused by chemotherapy or fatigue their growth. During an ultrasound the computer trans forms the echoes into a picture called a Toremifene sonogram. Stage A method of describing the size and location Ultrasound of cancer based upon characteristics of the High frequency sound waves used to produce tumor, the lymph nodes, and whether there is images of the breast. For a more comprehensive glossary, you may Stereotactic needle biopsy visit the American Cancer Society Web site at A method of needle biopsy that is useful in Solove Research Institute at the University of Utah Memorial Sloan-Kettering at the Ohio State University Cancer Center Eric P. The FoxO3a expression correlated with various clinicopathological parameters, 1 1(1. High FoxO3a expression is signifcantly correlated with poor2 Recurrence disease-free survival (p=0. However, the inhibition of FoxO3arevealed to decrease cellular migration compared with negative controlin wound healing assay. Cinicopathologic Background:Starting in 2013, genetic testing laboratories incorporated additional genes parameters were analyzed (Table 1). Our purpose is to describe common pathologic Results:All tumors were triple negative. Recent studies have shown that both tumor characteristics, such Syed Salahuddin Ahmed, Jabed Iqbal, Aye Aye Thike, Jeffry Chun Tatt Lim, Puay Hoon as grade and proliferation rate as well as host response, including immune infltrate, Tan. Histological assessment may not always translate into tumor behaviour, were evaluated using the recommended consensus guideline from the International posing challenges in clinical management. Biomarker expression was correlated with clinicopathological parameters and outcomes. Patient age ranged from 15 to 79 years (mean and median 43 years), tumour size ranged from 8 to 250mm (mean 51, median 58). These markers may promote new therapeutic paradigms in management, especially for malignant tumors. The aim of this study was to determine the and identify other predictors of outcome. Immunohistochemistry was performed using antibody and analyzed using nSolver Analysis Software (V2. Statistical analysis was performed using t test and were selected, reviewed and confrmed by image analysis. Caitlin Andrews, Elizabeth A Mittendorf, Juhee Song, Kelly K Hunt, Aysegul A Sahin, Yun Wu. There was no signifcant difference in age, menopausal status, radiologic mass, calcifcations, detection mode, sampling method, percentage of cores involved, radiopathologic concordance and multiplicity between the groups. University of Bergen, Bergen, Norway; Haukeland University Hospital, Bergen, Norway; Vestfold Hospital Trust, Tonsberg, Norway; Akerhus University Hospital, Lorenskog, Norway. Design:A population based cohort of node positive breast cancer (n =218), as part of the prospective Norwegian Breast Cancer Screening Program (1996-2009), was used. Univariate survival analysis (log-rank test) showed that number of positive in a subset and that these patients may beneft from anti-androgen therapy. Of antibodies and evaluated by two pathologists, concordant results were recorded. Patients were categorized into low (1), Maglio, Stefano Pizzolitto, Elisa Ober, Fabrizio Zanconati, Giovanni Falconieri. Conclusions:There is a remarkable instability in the genomic content of chromosome 1. Gonzalo Barraza, Robert L Schmidt, Elke Jarboe, Jason M Wells, Nicole Winkler, Rachel E Factor. Numerous retrospective studies, but only one prospective carcinoma, as many cases occur in females and in males <30 years old.

The support group included time for members both to voice their concerns about the impact that infertility was having on their lives as well as to provide support to each other erectile dysfunction treatment methods cheap levitra professional 20 mg on-line. During the one-year follow-up study period erectile dysfunction with diabetes type 1 levitra professional 20mg overnight delivery, 55% of the mind/body patients and 54% of the support group patients experienced a live birth erectile dysfunction breakthrough purchase levitra professional 20 mg on-line, compared to only 20% of the control subjects adderall xr impotence buy levitra professional without a prescription. The mind/body patients experienced a decrease in negative symptoms such as anxiety and depression adderall xr impotence buy levitra professional 20mg line, the support patients remained the same erectile dysfunction definition generic levitra professional 20 mg, while the control patients experienced a worsening of symptoms. In a subsequent study in Japan, 74 subjects were randomized to either a five-session mind/body group or a routine care control group (23). The mind/body subjects experienced a significant decrease in psychological distress and natural killer cell activity while the control subjects experienced no change. In addition, 38% of the mind/body subjects became pregnant during the study period compared to 13. Clinical pregnancy rates for cycle 1 were 43% for both groups but for cycle 2, they were 52% for the mind/body patients and 20% for the controls. One (25) concluded that skill-based interventions were more effective than more traditional therapy, and the other (26) concluded that interventions of at least six sessions are more effective than shorter ones. Mind/body interventions have been well researched; their effectiveness has been established with a variety of medical and psychological conditions, including hypertension, menopausal symptoms, premenstrual symptoms, insomnia, chronic pain, anxiety, cardiac arrhythmias, chemotherapy side effects, depressive symptoms, and gastrointestinal problems. The application of mind/body techniques to infertility began in 1986 and the clinical use is increasingly rapidly. The goal of the program was psychological symptom reduction, not pregnancy, and this message was disseminated to all interested patients. After the first 50 women completed the program, it was noted that they were experiencing significant psychological symptom reduction as well as a higher-than anticipated pregnancy rate (27). At this point in time, after 18 years of clinical practice, pregnancy rates within six months of program completion average 45% to 50% and every psychological parameter measured, including anxiety, depression, hostility, and confusion, decrease significantly. In addition, patients report significant reductions in physical symptoms, such as insomnia, headaches, abdominal pain, and gastrointestinal symptoms. Health care professionals from around the world have been trained as group leaders and uniformly report the same positive changes. All potential participants must attend an intake appointment with the group leader. They are mailed a long questionnaire that they are instructed to bring to the intake. Groups are normally led by a mental health professional with extensive knowledge of infertility. They serve as role models as well as being a liaison between the leader and the patients. If there are two patients with similar circumstances (for example secondary infertility, recurrent miscarriages, or a history of a stillbirth), they are paired up; otherwise it is done on a geographical basis. Buddies are asked to speak to one another at least once per week and each buddy pair brings in a snack for the group once. Patients with any kind of infertility diagnosis may attend, including those with endometriosis, ovarian dysfunction, advanced age, male factor, premature ovarian failure, recurrent miscarriage, tubal blockage, and unexplained infertility. The groups include married heterosexual women, single women, lesbian women, and women with secondary infertility (although secondary patients may only have one child, women with more than one child are referred for individual counseling since their presence would be likely to upset the primary patients). Each session incorporates relaxation training, social support, and a new stress-management strategy. Despite the fact that the first half hour of social support is optional, virtually all participants choose to attend. This is the time to share their stories, compare experiences, and complain about their husbands/mothers-in-law/ doctors. Group leader and peer counselor introductions, research on the stress/infertility connection, the physiology of the relaxation response, participant and partner introductions, program mechanicsa 2. Physiology of diaphragmatic breathing, mini relaxation exercises, effective communication 3. The impact of lifestyle behaviors on fertility: weight, smoking, alcohol, exercise. Assertiveness, goal setting, summary, goodbyes aHusbands/partners attend these sessions. The next one is focused on self-nurturance, after which lifestyle habits are addressed. The next sessions are dedicated to cognitive approaches to stress reduction, such as cognitive restructuring, journaling to express negative emotions, and effective communication strategies. One of the sessions includes guest lectures by prior participants who moved on to either adoption or egg donation. At the first session, each participant is asked to describe what they hope to get out of the program, that is, where they hope to be by the tenth session. Thus, at the tenth session, each patient is asked whether or not they reached their goal. This tends to be a very emotional time, since each patient recounts her emotional state a mere 10 weeks ago and thanks the group, and group leader, for helping her get to a much healthier place. At the tenth session, participants complete a similar but shorter questionnaire to the one they completed prior to the intake. Each patient is offered an appointment with the group leader to review their progress, compare their pre with their postprogram status, and set goals for their continued improvement. Patients consistently experience statistically significant reductions in all measured physical and psychological symptoms. As opposed to their sole identity as an infertile woman at the intake, they leave as healthy active women who happen to be experiencing infertility. Their distress can make them difficult to treat, may make treatment less effective, and increases their tendency to drop out of treatment that might have been successful for them. Psychological interventions can decrease psychological symptoms and are associated with increases in pregnancy rates. The psychological impact of infertility: a comparison to women with other medical conditions. A prospective study of stress among women undergoing in vitro fertilization or gamete intrafallopian transfer. Differential efficacy of group and individual/couple psychotherapy with infertile patients. Cumulative probability of live birth after three in vitro fertilization/intracytoplasmic sperm injection cycles. A prospective investigation into the reasons why insured United States patients drop out of in vitro fertilization treatment. Reasons for dropout in an in vitro fertilization/ intracytoplasmic sperm injection program. Investigation into effectiveness of counseling on assisted reproductive techniques in Turkey. Effect of psychiatric group intervention on natural killer cell activity and pregnancy rate. The efficacy of psychological interventions for infertile patients: a meta analysis examining mental health and pregnancy rates. The mind/body program for infertility: a new behavioral treatment approach for women with infertility. It may challenge the ways in which people feel about themselves and their relationships with their partner, family, and friends. For those going through infertility, this often is the first time that an experience in life may feel totally beyond their control. Most people assume that if they only work hard enough, they will succeed and achieve their goals, including when to become parents. Being faced with infertility often runs counter to the experiences and expectations of individuals and couples about life. Not being able to get pregnant when they want to and feeling a lack of control in this area can be frustrating and frightening. These feelings can then get amplified by the disappointment of repeated failed treatment. Indeed, the uncertainty as to whether they will ever conceive and have a healthy baby can create mounting anxiety. The infertile couple is surrounded by peers who are pregnant with their first, second, or third child, while they struggle with infertility treatments and feeling increasingly resentful, angry, and isolated from their usual supports. For women, infertility challenges their long-held assumptions of being mothers someday. The longer that infertility continues, the more a sense of helplessness and hopelessness can take over, which can lead to greater depression. These factors can shape how people experience and handle this particular life crisis. Moreover, women and men can demonstrate very different ways of coping with the diagnosis of infertility. Women often feel anxious and depressed because they are mindful of the limits of their biological clock. There is the heightened awareness of the urgency of time and a painful reminder of disappointment each month when there is no pregnancy. Women are sometimes angry with themselves or their partners for not starting to build their family sooner. In some cases, for women who had a prior termination of pregnancy, they may come to feel that their infertility is a punishment for having had an earlier abortion. Women, who are faced with infertility, often want to discuss their feelings and concerns with their partners, which can dominate their conversations when the couple spends time together. Generally speaking, men may tend to respond with optimism, assuring their partner of a positive outcome. His wife, age 39, was convinced that she would have problems conceiving because of her history of erratic menstrual cycles. The husband complained that his wife had become totally obsessed and preoccupied with having a baby to the exclusion of his needs. The counselor met weekly with the couple, helping them to communicate more effectively with each other. Their increased ability to partner together and to appreciate each of their different coping styles allowed this couple to proceed more effectively with infertility treatment. The role of the infertility counselor is multifaceted and ever-changing depending on the request of the physician, the expressed needs of the individual or couple, and the level of distress and crisis in their life. The counselor can serve the role of a clinical evaluator, consulting member of the health care team, supportive counselor, bereavement counselor, patient advocate, or more broadly, psychotherapist. Furthermore, the infertility counselor can make referrals to resources in the community and be a liaison to other mental health professionals, such as psychopharmacologists and psychotherapists, on behalf of the health care team. Counseling can offer support in dealing with the unique stresses of ongoing medical treatments and the uncertainty of outcome, including the possibility of unsuccessful treatment cycles. If an individual or couple is having a difficult time going through the medical process, seeing a counselor one-on-one can help address the issues that are specific to the individual or couple and provide the needed support and strategies. Counseling is helpful for those who are having difficulty making informed treatment decisions or choosing treatment options. It is also useful for those who have experienced a miscarriage and are grieving this very powerful and real loss. The counselor can offer acute bereavement counseling in response to the immediate loss as well as assist them in the resolution of their grief overtime. The counselor can also provide resources to bereavement support groups, readings, and Web sites. Being able to do some grief work initially will help those who have faced loss to move forward with the medical process with more emotional resiliency. Counseling is also recommended for people who are facing the end of medical treatment and are having difficulty making this decision, or wishing to discuss other options and alternatives, such as the use of donor egg or donor sperm, gestational care arrangement, adoption, or childfree living. If the individual or couple is experiencing stress, depression, or anxiety to a degree that is significantly affecting their life or making it hard to enjoy life, it is advisable to refer them to a counselor before any medical treatment begins. This can be in the form of individual counseling, couples counseling, a support group, a mind/body program, or a combination of these options.

Observation on curative effect of sal Journal of Medical Sciences 2016; 3: 11-17 erectile dysfunction treatment germany 20 mg levitra professional fast delivery. Buqihuoxueqingre drugs productive outcome after hysteroscopic proxi combined with interventional therapy in the mal tubal cannulation-an outcome analysis over the counter erectile dysfunction pills uk levitra professional 20mg with visa. Fertility & Comparison between transvaginal sonography Sterility 2005; 83: 1595-1606 erectile dysfunction psychological purchase cheap levitra professional on-line. Clinical observation of cook guide wire in the treatment of tubal ob laparoscopic salpingostomy in treatment of struction infertility impotence l-arginine levitra professional 20 mg online. China Medicine & Pharma distal tubal seeper infertility the clinical obser cy 2016; 8: 111-113 causes of erectile dysfunction in young adults buy cheapest levitra professional and levitra professional. Academic Journal of Chi productive outcome after hysteroscopic pro nese Pla Medical School 2014; 7: 701-703 erectile dysfunction treatment san francisco 20mg levitra professional with visa. Clinical study of the tubal obstructive in Aust N Z J Obstet Gynaecol 2012; 52: 470 fertility treated with traditional Chinese medi 475. Gansu Journal of Tradi ization under laparoscopy for proximal tubal tional Chinese Medicine 2010; 12: 73-74. Selective salpin treatment of proximal tubal obstruction in gography and fallopian tube catheterisation by duced infertility. Proximal tubal dis fect of clinical examination on women with ease: the place for tubal cannulation. We also acknowledge the many people who spoke openly about their own experiences with assisted conception in order to help others experiencing a similar journey. Important notice: the information provided in this booklet does not replace any of the information or advice provided by a medical practitioner and other members of your healthcare team. Please note that throughout this booklet, the generic name of a medication will be stated frst followed by the brand name in brackets. Scientific advances over the past three decades have helped millions of women overcome problems with fertility. Secondary infertility is where a couple is unable to conceive after they have already had a pregnancy or child. While the rate of infertility has not increased in recent years, we are now more aware of the issue as more and more women and men seek treatment. By the time she reaches puberty, each month, during her reproductive years, about 20 eggs are used even though usually only a single egg matures and is released. By the ffth or sixth decade of life, most women will have depleted the egg supply they were born with. While keeping yourself ft with regular exercise and a healthy diet is important, unfortunately your body knows exactly how old you are and there is no way to reverse the ageing of your ovaries and eggs. From puberty to the menopause, the inner lining of the uterus (the endometrium) provides a suitable environment for embryo implantation and development during pregnancy. Beneath the surface of the ovaries are thousands of microscopic structures called ovarian follicles. Fallopian tubes the fallopian tubes consist of two tubes approximately 10 cm long that lead from the uterus and end in fnger-like projections called fmbriae. Fertilisation normally takes place in the fallopian tube, as can be seen in the fgure on this page. Fallopian ducts that end in fnger-like projections that ova pass through tubes from ovaries to tubes hover over, but are not attached to , uterus. Fertilisation normally takes place in the fallopian tube, as can be seen in the figure on page 6. Blastocyst: the morula continues to divide, creating an inner group of cells with an outer shell. Women who smoke are more likely to have difculty conceiving, may not respond as well to infertility treatments and are at increased risk of miscarriage, complications during the birth and of having a baby with a low birth weight. For men, prolonged cycling can cause damage to the groin and there is also the risk of damage to the testicles from contact sport. For women, a body fat level just 10-15% above or below normal can contribute to infertility. For women, increasing your intake of folic acid (known as folate in its natural form) before conceiving and for the frst three months of pregnancy can reduce the risk of having a baby with neural tube defects such as spina bifda. The first day of bleeding (not spotting) is the first day of your menstrual cycle. Mark the days you had intercourse by encircling the temperature dot as shown Day of Cycle:36. Drugs: after two or three Month: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 Year: 37. For your frst appointment with a specialist or fertility clinic, it is best to go as a couple. X-rays are then used to visualise the uterus and fallopian tubes to determine if any blockages are present. It may take two or three visits to the clinic or specialist to complete the necessary tests, and may take between one to six months to establish a diagnosis. We have already discussed some of the lifestyle factors that can afect your fertility. Blockages may arise as a result of scarring due to infection or previous abdominal surgery. Pelvic infammatory disease (pid) due to sexually transmitted diseases such as chlamydia or gonorrhoea, is the main cause of tubal infertility. Because this tissue still acts the same as that found in your uterus and responds to changes in your hormones during your menstrual period, the tissue breaks down and bleeds causing pain before and after your period, scarring and adhesions (organs sticking together). For more detailed information on endometriosis or polycystic ovary syndrome, ask your doctor for a copy of the Pathways to Parenthood booklet specifically on those topics. Testing and diagnosis the testing period can be stressful, invasive, and expensive, and you may feel uncomfortable, guilty, and even fearful about the possible results. By asking for and relying on the support of your partner and by communicating openly with them throughout the evaluation, diagnosis and treatment phases, you may fnd that your relationship grows stronger. Side efects: side efects may include facial fushes, headaches, breast soreness, nausea and vomiting or abdominal discomfort and bloating. Where clomiphene citrate acts to stimulate the release of gonadotrophin-releasing hormone, gonadotrophins act directly on the ovary, promoting follicular development. Human chorionic gonadotrophin (hCg) causes the fnal maturation and release of an egg. Side efects: these may include mood swings, abdominal discomfort, backaches, fatigue and tender breasts. When used in combination with injected gonadotrophins (see previous page), it allows for more reliable timing of the egg collection and usually an increased number of eggs being available for in vitro fertilisation (ivF). Stage 2: egg retrieval once ovarian stimulation is complete and follicles have matured, your doctor will try to retrieve as many eggs as possible, although all the eggs may not be used in the current ivF cycle. Stage 3: Fertilisation about two hours before the eggs are retrieved, a semen sample is collected from the male partner and processed to select the strongest, most active sperm. AccessAustralia and the Donor Conception Support group have many resources on the issues relating to donor insemination (see contact details page 32). Frozen embryos are frozen and stored and most will remain unchanged for long periods of time. Where there are treatments planned that may result in infertility, clinical causes or history of present or predisposing factors for infertility. The care should be sensitive, informed and backed by patient information literature, and couples should be informed of a patient support group. An expert not directly involved with the infertility management should offer counselling before, during and after treatment. Women on anticonvulsants, or with diabetes, or with a history of a child with a neural tube defect should be offered 5 mg folic acid per day. Depending on the timing of the menstrual periods, this test may need to be conducted later in the cycle. Women with co morbidities should be offered laparoscopy and dye as other pelvic pathology can be assessed at the same time. Lead practice to obtain relevant information Yes/No from other practice to include in the referral. Sterilisation or vasectomy excludes patients from assisted conception If there has been previous fertility Amend referral and include details, including Yes/No treatment If rubella susceptible, offer vaccination and advise not to become pregnant for a month following vaccination Has folic acid been commenced Should be a non-smoker for at least 3/12 months (must be non-smoker for 6 months before referral to fertility assisted conception service). Men who smoke should be informed that there is an association between smoking and reduced semen quality (although the impact of this on male fertility is uncertain), and that stopping smoking will improve their general Yes/No health Yes/No Alcohol intake should be Excessive alcohol intake is detrimental to semen moderate quality. There exists a variety of interventions that include those performed under hystero scopic, laparoscopic and laparotomic direction; an evolving spectrum of image guided procedures, and an expanding number of pharmaceutical agents, each of which has value for the appropriately selected and counseled patient. This guideline has been developed following a systematic review of the evidence, to provide guidance to the clinician caring for such patients, and to assist the clinical investigator in determining potential areas of research. Where high level evidence was lacking, but where a majority of opinion or consensus could be reached, the guideline development committee provided consensus recommendations as well. Leiomyomas are listed as the diagnosis for Minimally Invasive Gynecology, Elsevier, at reprints@elsevier. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Entirely within endometrial cavity Abstracts of research presented at symposia and scientific conferences were not No myometrial extension (pedunculated) considered adequate for inclusion in this document. When reliable research was not available, expert opinions from gynecologists were used. Type I, 50% myometrial extension (sessile) Studies were reviewed and evaluated for quality according to a modified method outlined by the U. Dramatic results in uncontrolled experiments also the uterine wall at the time of diagnosis, myomas are referred could be regarded as this type of evidence. Furthermore, the expression of estrogen and progester one receptors is signicantly higher in submucous myomas compared with subserosal myomas [5]. In addition, submu and despite the prevalence and clinical impact of these le cous myomas have signicantly fewer karyotype aberrations sions, there is a dearth of high-quality research available to than outer myometrial myomas, regardless their size, which guide the clinician in the treatment of patients with these may be important in retarding their growth and their cellular tumors. Whereas the develop mas can be useful when considering therapeutic options, ment of hysteroscopically-directed surgical techniques including the surgical approach. Anatomically, the human uterus comprises 3 basic is not a candidate for resectoscopic surgery. On the basis of their relationship to are relatively simple and provide a framework for both 154 Journal of Minimally Invasive Gynecology, Vol 19, No 2, March/April 2012. Many of these limitations have been incorporated fertility rates after treatment at a mean of 41 months were into another classication system that has been designed to 49%, 36%, and 33% in type 0, 1, and 2 lesions, respectively take into account 4 criteria: the penetration of the myoma [11]. At this time, there are insufficient data to sug decit experienced during the procedure. However, this sys gest which system(s) provide the best combination of clini tem was not analyzed with respect to its ability to predict cian acceptance and clinical and research utility. Special Article Practice Report on Submucous Leiomyomas 155 potentially useful compromise, at least for the present, cous myomas were found in 23. In another large, single-site, retro may be useful to consider in selected clinical situations spective study of hysteroscopic ndings in 4054 women and in the context of basic science and clinical research. It seems in women in the sixth decade it may rise above 1% of hyster likely that in most instances the mechanical or molecular ectomy specimens [13, 14], and for resectoscopic surgery it mechanisms involved in endometrial hemostasis are dis has been reported in 0. There are no turbed, but, to date, unfortunately there are no available stud data specic to submucous leiomyomas.

Systematic review of randomised controlled trials of sildenafl (Viagra) in the treatment of male erectile dysfunction erectile dysfunction drugs wiki buy levitra professional cheap online. High effcacy of gonadotropin or pulsatile gonadotropin-releasing hormone treatment in hypogonadotropic hypogonadal men erectile dysfunction treatment discount levitra professional 20mg without a prescription. Subcutaneous self-administration of highly purifed follice-stimulating hormone and human chorionic gonadotrophin erectile dysfunction homeopathic drugs buy cheap levitra professional 20mg on line. Prevalence of Chlamydia trachomatis in Singaporean women undergoing termination of pregnancy erectile dysfunction doctors raleigh nc discount 20 mg levitra professional amex. Routine screening for Chlamydia trachomatis in subfertile women-is it time to start Chlamydia trachomatis erectile dysfunction vacuum pump medicare generic 20mg levitra professional fast delivery, a hidden epidemic: effects on female reproduction and options for treatment erectile dysfunction other names buy generic levitra professional 20mg online. Chlamydia trachomatis, tubal disease and the incidence of symptomatic and asymptomatic infection following hysterosalpingography. Endometriosis and infertility: a laparoscopic study of endometriosis among fertile and infertile women. A quantitative overview of controlled trials in endometriosis-associated infertility. A systematic review of the accuracy of ultrasound in the diagnosis of endometriosis. The second-look laparoscopy for evaluation of the result of medical treatment of endometriosis should not be performed during ovarian suppression. Microsurgical reversal of sterilisation is this still clinically relevant today The following advice could be given to couples to optimise their natural fertility: A) Advise couples to time sexual intercourse to o o coincide with ovulation. The following should be conducted as part of investigations of infertility: A) Semen analysis for men. In the management of infertility in women with polycystic ovary syndrome, A) Preconceptional counselling should be o o provided to emphasise the importance of lifestyle, especially weight reduction and exercise in overweight women, smoking and alcohol consumption. B) the recommended frst-line treatment for o o ovulation induction is the anti-estrogen clomiphene citrate. C) Metformin should be routinely used in o o combination with clomiphene citrate for ovulation induction. D) Patients presenting with polycystic ovary o o syndrome, particularly if they are obese, have a strong family history of Type 2 diabetes or are over the age of 40, should be offered a glucose tolerance test. In the management of male infertility, A) Semen analysis should be done as the primary o o investigation. B) Advice on cessation of smoking, steroid use o o and withdrawl of offensive medication should be given at the primary care setting. B) Chlamydia trachomatis should be treated o o promptly to prevent future repercussions, including tubal infertility. C) the assessment of tubal patency should be o o considered in all infertile women. Gametogenesis Research Center, Kashan University of Medical Sciences, Kashan Iran. Anatomical Sciences Research Center, Kashan University of Medical Sciences, Kashan, Iran. Hosein Nikzad is an academic member (Professor) in Kashan University of Medical Sciences and teach anatomy and embryology courses for medical and paramedical students for 20 years. Untl now, he published more than 40 manuscripts at the natonal and internatonal jour nals. Now, he is head of gametogenesis research center in Kashan University of Medical Sciences. Article info: A B S T R A C T Received: 7 Jun 2013 Accepted: 25 Aug 2013 the inability to have a child is a baleful event for millions of couples in their life, and a large percentage of them have a personal frustration. The problem of infertility in couples is distributed equitably between the two sexes. Among different methods, medicinal plants Key Words: have been used in many Nations to treat male infertility problems. These medicinal herbs are used to treat sperm disorders, dysfunctioning of the libido, 2 sexual asthenia and erection. Male Infertility, Herbs provide a therapeutic option, which is affordable and available for infertile couples, Herbal Medicine, and herbalism is the main form of treatment in our health system. So in this review, we have Reproductive System, summarized most of the data dealing with the positive effects of plant extracts on mammalian Sperm reproductive system. Studies have shown that semen parameters in Infertility is recognized as the inability to con 25 to 40% of young males are below the standard of the ceive after 12 months of sexual practice with World Health Organization [5]. Infertility is one of surgery, chemicals and herbal drugs and laboratory meth I the problems of human society. Herbal plants has been fertility problems which 40% of these problems are due famous from ancient times among people and in recent to male factor [2, 3]. Reproductive ability in the male years, a multilateral approach has been appeared on using contain the production of semen containing normal sper herbal medicines along with medical care they get from matozoa (quality) in the adequate number (quantity), to their health care provider [7, 8]. Different such as herbal plants have more benefts since they are reasons are involved in the occurrence of male infertility less invasive and less costly physical and emotional treat such as genetic disorders, genital duct obstruction, vari ment compared with other methods. The aim of this pa cocele, decreased sperm production, decreased semen per is to critically review the available literature on herbal * Corresponding Author: Hossein Nikzad, PhD Address: Gametogenesis Research Center, Kashan University of Medical Sciences, Kashan Iran Tel/Fax:: +98 (31) 55621158 E-mail:nikzad h@kaums. We searched in Google scholar, Science direct and these studies showed that the antioxidant defense sys Pubmed for different types of plants, which have effect tems of testicular tissue protect the testes against oxi on fertility process using their scientifc names. Then we dative damage and can reduce free radicals effectively chose the plants that have positive effect on fertility and and decrease the damage of spermatogenic cells [13]. Information from selected articles was ity, in cases where oxidative stress is involved [15]. Results & Discussion consumption of 6 g of green tea in 600 mL of water for 7 days could increase plasma glutathione and improve Tea the post exercise increase in lipid hydroperoxidase [17]. The main reason for harmful effects to increase the number and motility of this interest is the awareness of people about the thera spermatozoa especially after 28 days of treatment [18]. Tea contains, group of cat echins that includes catechin, epicatechin, gallocatechin, Carrot epigallocatechin, catechin gallate, epicatechin gallate, gallocatechin gallate, and epigallocatechin gallate and Daucus carota commonly known as "Carrot" belongs vitamins, minerals polyphenols, favonols (theafavins, to the family of Apiaceaeis, a useful vegetable being used thearubigens), adenine, theobromine, theophylline, xan worldwide. Many studies have been done on chemical thine, gallotannin, small amounts of aminophylline and composition of this plant and a large number of active a yellow volatile oil which is solid at room temperatures ingredients such as volatile oils, steroids, tannins, favo and has strong aromatic smell and favor [9]. It has been re rent researches have shown that both green and black ported that carrot can increase the potency in men, while tea contain favenoids such as quercetin, kaempferol and in women it stimulates menstruation, and seeds are more myricetin, which have strong anti-toxic and anti-carci effective than other parts of the plant [19]. Both antioxidative and androgenic Garlic (Allium sativum) has been used as a medicine activity of Z. Ginger has been shown that decreases lipid phide is the bioactive organosulphur component of gar peroxidation and increases glutathione content in blood lic, which have antioxidant effects [23]. Some studies have reported that garlic nale have a benefcial effect on male reproductive func harmsthe function of testes and has spermicidal effects tions in rats, which are confrmed by other studies on the on spermatozoa but some others demonstrated the op increased sperm counts, motility, testosterone, and de posite effect [25]. It increase in the number of empty seminiferous tubules in was also observed that the administration of ginger can testes and a decrease in the level of testosterone. Also, a decreased prostate productive organ which might be due to the androgenic weight was associated with a reduction in citric acid con activity of ginger [31]. Rats fed with a clearly increased level of testosterone in the rats even garlic water extract over 3 months showed an increase in in spite of receiving 5 mg/kg/day gentamicin comparing epididymis spermatozoa [27]. It has spermatogenesis stop at the primary spermatocyte stage been demonstrated that, ginger have an antioxidant and with 50 mg of oral administration of garlic powder for androgenic activity in dose of 50 mg/kg/rat, which have 70 days [28]. Some of these different results In another study, administration of 50 mg/kg/cock and might be due to the type of preparations used like garlic 100 mg/kg/cock ginger to 28, 32, 36, 40 and 44 week powder [26, 28], water extract [27], aged garlic, raw age rats, signifcantly increased the concentration and garlic juice and heated garlic juice [30] or the doses and motility of sperms in ejaculation volume. Zingiber Offcinale commonly called ginger belongs In the other study, administration of 1000mg/kg to to the family of Zingiberaceae. It contains several com rats for 28 days showed a signifcant weight increase pounds including acid, resins, vitamin C compounds, fo compared to the control group. This activities of testicular antioxidant enzymes and restore 5 November 2013, Volume 10, Number 4 sperm motility of cisplatin-treated rats beside protec crease in the weight of testes, cauda epididymis dies and tion against cisplatin-induced testicular damage [41]. Cinnamomum (family of Lauraceae) species con Rose Oil tain volatile oils, tannins, terpenoids, mucilage, oxa lates and starch. Different chemical constituents of Rose oil is extracted from rose fowers by steam dis C. Rose oil is a lucid, light yellow, and volatile antiulcerogenic andcytotoxic effects. There are fve major constituents in oil such as citro tract of Cinnamomum increased the weight of testes, nellol, geraniol, nerol, linalool, and phenylethyl alcohol caudae epididymidies and seminal vesicles in the treated [43]. Based on the results of aldehyde/carboxylic acid male mice, indicating a possible stimulation of hormon test that is used to show long-term antioxidant activity, al levels in the animals. Also, the sperm count and motil Wei & Shibamo to have reported that rose oil has an ity of the treated animals were signifcantly higher than antioxidant activityalmost equal to a-tocopherol, which the control group [48]. The increase in number and motility of sperm and Leydig cell counts, seminif In another study, oral administration of erous tubule diameters, and decreasing the number of C. Another study showed vesicles, improved semen quality and quantity, and in signifcant histopathological improvement in testes and creased serum insulin and testosterone levels. Koul and Kapil, reported that vent adriamycin-induced cytogenetic and damages of piperine, isolated from P. The antioxidant effect of fenugreek is ascribed (ginsenosides Rb1, Rb2, Rc, Re and Rg1) which are more to the presence of favonoids and polyphenols. Flavonoids, the effect of fenugreek against testicular toxicity of carben main group of total phenolic constituents, are found in dazim may be associated with the antioxidant activity of greater concentration in the ginseng [58]. It has been reported that the polyphe different effects like protecting muscle from exercise in nolic extract of fenugreek seeds has an antioxidation effect duced by oxidative stress, improving erectile parameters in vitro [52]. A study showed that in rabbits, a fenugreek such as penile rigidity, girth, erection duration, libido and seed powder containing diet (30%) for 3 months could sig patient satisfaction [59]. Ginseng causes a signifcant de nifcantly decrease male testis weight [~25%] and sperm crease in total chromosomal aberrations, sperm abnormal concentration [~43%], indicating a toxic effect of fenu ities and increase in testosterone concentration and sperm greek seeds on seminiferous tubules and the interstitial numbers and motility [57, 60]. Their spermatogenesis hypoplasia when compared with that in protective effect may be due to the higher ability to elimi the control group [53]. In an duced higher relative weights of the accessory sex gland, other study, the epididymal sperm count was increased all prostate lobes, the seminal vesicle, and the testes [54]. Tou et al `suggested that it is impor chemotherapeutics, such as 5-fuorouracil, mitomycin tant to establish the age of exposure and dose of faxseed C, vinblastine, and cyclophosphamide [59]. The ginseng that will provide the most health benefts with the fewest extract could give effective protection against radiation risks [56]. Administration of ginseng before gamma radiation treatment signifcantly protected Ginseng the germ cell population against the gamma radiation in mice [60]. Ginseng roots contain different pharmaceuti thenospermic patients were increased by treatment with cal constituents ginsenosides (saponins), polyacetylenes, P. Until now, 38 ginsenosides have been separated from ginseng roots, with fve main ginsenosides 7 November 2013, Volume 10, Number 4 can effectively prevent the testicular toxicity induced by increases fertility. Piacente et al, found that Maca also contained (1R, 3S) 1-methyltetrahydro In another study, it was found that the sperm count in carboline-3 carboxylic acid [69]. Maca has been found the testes and epididymides of the male rats treated with to have antioxidant properties in vitro and in vivo [67]. Flavonoids, the major group of total phenolic com pounds, are found in parsley which either scavenge free Pumpkin (Cucurbita pepo L. Pumpkin seeds improve libido and semen quality by elevating the serum testosterone level [74, 75]. It has Lepidium meyenii, a traditional Peruvian crucifer been demonstrated that pumpkin seeds and daily rich ous vegetableknown as Maca used in the distant past, diet of zinc can decrease the undesirable side effect of belongs to the Brassicaceae family. The hypocotyl, the lead contaminants and improve the sexual health status comestible part of the plant, can increase sperm produc [72]. Traditionally, the dried hypocotyls of Maca are perplasia of the ventral prostate lobe by reducing protein boiled and used as juice [67]. Pumpkin seeds improve sexual stimulation sential amino acids Arginine, a constituent of Maca, that and intromission and ejaculatory latency [76]. Therefore, Pumpkin is proposed for fertility effect in male rats rather than a compound that 8 November 2013, Volume 10, Number 4 both the prevention and treatment of infertility in male anti oxidant with inhibitory effect on lipid perioxidases, animals [4]. Sesame can also increase the diameter of the no effect on testicular histology when administered at a seminiferous tubules in a dose-dependent manner [82]. Tannins are classifed as antioxidants, at a high dose and could be Allium cepa come pro-oxidant by increasing lipid per oxidation [77]. S-Methylcysteine sulphoxide is bioactive organosulphur components of Sesame onion which have antioxidant properties [23]. Sesame rat/day) for 20days increases sperm count, viability, and improves epididymal sperm reserved with larger sper motility. The onion fresh juice can signifcantly increase matocytes in a dose-dependent manner. Sesame can also the recovery of sperm health parameters, such as count, increase body weight in a dose-dependent manner. Sesame has positive effects on the storage capac ity for the sperm in the epididymis in a dose-dependent Apium graveolens manner [82]. However, a diet con revealed the presence of terpenes such as limonene, taining sesame seed did not affect on epididymal tissue favonoids like apigenin and phthalide glycosides [91]. Furostanol is one of the saponins in Tribulus terres annual wormwood or sweet Annie isan aromatic an tris stimulates spermatogenesis and improves the quality nual plant which is the source of essential oils and ar and quantity of sperm [96]. Also, it enlarges central lumen of the seminiferous stimulates germinative and endocrine functions of the tubules.

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