Viagra & Assisted Reproduction

In order for successful implantation to occur, an adequately prepared endometrium has to be built up during the menstrual cycle. Endometrial development is regulated by steroid hormones and various growth factors and cytokines. Some of these factors are produced locally and act via paracrine mechanisms; others have to be transferred to the endometrium. Sufficient uterine blood supply is required for these factors to reach the endometrium, especially to its functional layer. Several studies have tried to evaluate the association between the morphologic characteristics of the endometrium and pregnancy rates in assisted reproduction therapy (ART) cycles. Although the results are sometimes conflicting, most studies agree that the endometrium has to reach a certain thickness for successful pregnancy to occur. We have found that endometrial thickness was significantly associated with in vitro fertilization (IVF) outcome. In addition, pregnancy rates were higher when the endometrium was thicker than 8-10 mm.

Various agents that influence blood flow have been evaluated to determine whether their use during ART has an impact on implantation/ pregnancy rates. Antithrombotic agents, aspirin, and heparin have been evaluated by several groups. Two prospective, randomized studies reported opposing results with aspirin use in an unselected IVF population. A third study including donor egg recipients found a positive effect of aspirin on implantation rates among those women whose endometrium was thinner than 8 mm. Heparin was found to improve pregnancy rates among women with thrombophilia and recurrent abortions. Currently the literature does not support the routine use of these medications among infertile women.

Nitric oxide relaxes vascular smooth muscle, an effect that is mediated by cyclic guanosine monophosphate (cGMP). Guanylate cyclase and cGMP have been detected in human myometrium obtained from both nonpregnant and pregnant women. Sildenafil is a selective inhibitor of the type V cGMP-specific phosphodiesterase. With the use of sildenafil, cGMP levels remain elevated, which leads to vascular relaxation and increased blood flow. Sher and colleagues evaluated the effect of sildenafil (viagra), administered in the form of a vaginal suppository, on endometrial development in 4 women who had had thin endometria during previous ART treatment (< 8 mm). Doppler studies revealed a decreased pulsatility index with sildenafil use, and in 3 of the 4 women a significantly thicker endometrium was achieved with the addition of sildenafil. All 3 of these women became pregnant. In a second study from the same group using a larger cohort of women (n = 105), improved endometrial development was achieved among 70% of women selected similarly to that in the initial study. Among these women, a 29% ongoing pregnancy rate was achieved. The pregnancy rate was significantly lower -- only 2% -- among those whose endometrium remained thin despite sildenafil(viagra) use.

The safety of sildenafil among infertile women has not been established, although no increased incidence of adverse events has been observed based on limited information. Most of the reported adverse events with sildenafil involved men with underlying cardiovascular disease or were possibly due to an interaction with other drugs. Animal studies have not revealed any adverse reproductive effects, but there are no human data evaluating sildenafil effects during pregnancy.

The exact mechanism by which vaginally administered sildenafil could improve pregnancy rates is not clear. One possible mechanism is that it may improve the uterine blood supply. Alternatively, sildenafil may have an effect on any of the cytokines that regulate endometrial development or implantation. Further, improved pelvic blood flow can have a beneficial effect on ovarian function. The effects of sildenafil among infertile women need to be evaluated in well-designed studies. The safety has to be established as well. At this point, sildenafil use should be considered experimental.

Mera Bharat Mahaan

Shipra Bhattacharya

I recently attended the Golden Brush-2008 award function for young artists in the cradle of art- Kolkata! I utilised the few hours I had before the function in browsing through some art galleries, as is my favorite hobby in Kolkata. I was completely over-awed by a small oil on canvas (18" x 18") that I discovered lying amongst some other paintings at the Vikalp Art Gallery at Swabhumi, Kolkata. I bought this splendid work & want to share it with our blogeurs.
Distinguished art critic Manasij Majumdar writes of the artist’s work - "Shipra Bhattacharya has made her presence felt on our art scene since her first solo show in 1981. In her early works she portrayed life-scapes she saw everywhere around, with an immense zest for the figurative idiom and a finesse in execution. Her subject was ordinary people, mostly women folk of the urban and non-urban milieu, painted with loving care in oil and mixed media for their formal and conceptual contours. These were remarkable pictures peopled by diversely positioned figures designed in a richly complexor simple structure and in schemes of piquant colours with splendid tonalor lineal flair. Her drawings done in the mid-80s and later were by no means related to her paintings except in their well-honed execution. The figures and forms in them, evoked in meticulous filigree of pen-and-ink hatchings, had strange awesome elfin looks. They enacted minor fantasies with lively gestures unlike any of the characters in her paintings.
The current series look so fresh unlike her images of the 80's. But these canvases evolve technically and conceptually out of her earlier works. The crowded life-scapes she once painted are missing here. Nevertheless, in portraits of individual faces and figures they delve into the life within. The characters are all women - each with her secret passion seeking fulfilment or innervoid of unfulfilled desire. They are placed either in landscapes of a tender fantasy or fairly realistic urban settings, indoor or outdoor. Oblique visual clues to her subject, often of symbolic and metaphorical nature, enrich Shipra's figurative idiom. What makes her oils most delightful are her smooth brushwork, glowing tonalities of complementary hues often with a soft sensuous sheen; tender dreamy painterly stillness in the faces of her characters, lineal flow fleshing out the beauty of her homely women and their bright colour saris in rhythmic furrows of fold and pleats. No doubt, in less than two decades Shipra's art has scaled a new height."
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Ghost in the machine?

A friend forwarded this article to me from the BMJ archives. I thought it made very good reading sense for my medical colleagues on a Sunday!

"Recently, I was the anaesthetist for some elective caesarean sections. All was running smoothly, with relaxing background music in dimmed ambient light. Despite this, one mother was very anxious about the impersonal medical environment. Thus when the baby was delivered, I allowed her to touch her newborn without any “foreign body” interfering. Not thinking too much, I took the saturation probe off her finger and clipped the probe onto the drip chamber of the infusion set. To my intense surprise, not only did the screen come up with a regular waveform, resembling an electrocardiograph trace rather than an artefact, but it also displayed the “oxygen saturation” of the bloodless solution and the rate of drops infused per minute (figure).Pulse oximeters are used to determine arterial oxygen saturations by using oximetry and Beer-Lambert’s law.1 Diodes send out light of the required wavelength, usually in the red and infrared spectrum as absorbance of body tissues in this range is small. Therefore absorbance essentially results from the presence of oxygenated or deoxygenated haemoglobin. A photometer on the opposite side of the probe detects the transmitted light. The signal is converted to a DC component, representing venous blood and tissue, and an AC component, representing pulsatile flow. Only the latter component is amplified and averaged over a few cycles. Inaccuracies are the result of several factors, including bright ambient light, movement, electrical interference, venous congestion, and various pigments or molecules (such as nail polish, bilirubin, carboxyhaemoglobin, methaemoglobin, or methylene blue).A near-infrared laser at a wavelength of 830 nm was used previously to measure lactic acid non-invasively.2 As Ringer’s solution was infused on this occasion, the lactate component (about 28 mmol/l) of the balanced crystalloid is the likely culprit, causing signal extinction and the generation of a numerical value for “oxygen saturation.” A gelatin solution was later tested, achieving a trace of inferior quality and lower readings. Physiological saline solution on the other hand produced a stronger signal, but even lower saturations. Both traces looked very much like artefacts compared with the one produced by Ringer’s lactate.So what about the pulsatile flow—surely, there was none? Although this all happened just around Hallowe’en, surely there was no supernatural spirit in the machine? No, in fact, it was the regular intermittent light absorption, induced by the falling drops, that had fooled the sensor into recognising an AC component and then displaying a “pulse rate.” - Andreas Kopka
Andreas Kopka is a consultant anaesthetist Greater Glasgow University Hospitals, Southern General Hospital, Glasgow G51 4TF a.kopka@doctors.org.ukI
Not commissioned; not peer reviewed.
1 Davis PD, Parbrook GD, Kenny GNC. Basic physics and measurement in anaesthesia, 4th ed. Oxford: Butterworth-Heinemann, 1998.
2 Pilotto S, Pacheco MTT, Silveira Jr L, Balbin Villaverde A, Zangaro RA. Analysis of near-infrared Raman spectroscopy as a new technique for a transcutaneous non-invasive diagnosis of blood components. Lasers in Medical Science 2001;16:2-9.

Chicken Soup For The Beer

"Sometimes when I reflect back on all the beer I drink I feel shamed. Then I look into the glass and think about the workers in the brewery and all of their hopes and dreams. If I didn't drink this beer they might be out of work and their dreams would be shattered. Then I say to myself, "It is better that I drink this beer and let their dreams come true than be selfish and worry about my liver."
~ Jack Handy


"I feel sorry for people who don't drink. When they wake up in the morning, that's as good as they're going to feel all day. "
~Frank Sinatra

"When I read about the evils of drinking, I gave up reading."
~ Henny Youngman

"24 hours in a day, 24 beers in a case. Coincidence? I think not."
~ Stephen Wright

"When we drink, we get drunk. When we get drunk, we fall asleep. When we fall asleep, we commit no sin. When we commit no sin, we go to heaven. Sooooo, let's all get drunk and go to heaven!"
~ Brian O'Rourke

"Beer is proof that God loves us and wants us to be happy."
~ Benjamin Franklin

"Without question, the greatest invention in the history of mankind is beer. Oh, I grant you that the wheel was also a fine
invention, but the wheel does not go nearly as well with pizza."
~ Dave Barry

BEER: HELPING UGLY PEOPLE HAVE SEX SINCE 3000 B.C.!!!
~ "Unknown"

Remember "I" before "E", except in Budweiser.

To some it's a six-pack, to me it's a Support Group. Salvation in
a can!

And saving the best for last, as explained by Cliff Clavin, of Cheers. One afternoon at Cheers, Cliff Clavin was explaining the
Buffalo Theory to his buddy Norm. Here's how it went:
"Well ya see, Norm, it's like this... A herd of buffalo can only move as fast as the slowest buffalo. And when the herd is hunted, it is the slowest and weakest ones at the back that are killed first. This natural selection is good for the herd as a whole, because the general speed and health of the whole group keeps improving by the regular killing of the weakest members. In much the same way, the human brain can only operate as fast as the slowest brain cells. Excessive intake of alcohol, as we know, kills brain cells. But naturally, it attacks the slowest and weakest brain cells first. In this way, regular consumption of beer eliminates the weaker brain cells, making the brain a faster and more efficient machine. That's why you always feel smarter after a few beers.

Dark Humor

Lesbian Whips Lawsuit

A lesbian woman, from California, US, is appealing a court decision that upheld a decision made by her doctors to withhold fertility treatment from her on religious grounds. Her case will be heard in the California Supreme Court, the highest court in the state, after having been heard in various courts over the past five years. The woman, Guadalupe Benitez, who is now 33, was kept on a waiting list for fertility treatment for almost two years, before she was told that neither of her two doctors - Christine Brody and Douglas Fenton - would treat her. She claims that each doctor said that treating her and allowing her to have children, because of her sexual orientation, conflicted with their religious beliefs. Both of the doctors deny that this was the reason they denied her treatment, and say that it was the fact she is unmarried that was the deciding factor. However, at the time, Ms Benitez had been with the same partner for 15 years, and the couple had also legally registered their domestic partnership. Since the case was originally filed, Benitez has received fertility treatment elsewhere and given birth to a son, now three years old, and twin daughters.
Ms Benitez's case was initially unsuccessful in the state courts, but she won an appeal three years ago, the court finding that patients can sue health care providers who discriminate against patients on the basis of sexual orientation, and that federal law does not exempt health care providers from the civil rights laws. Later, in 2004, a court found that doctors working in the commercial sector must comply with the State's anti-discrimination laws and treat all patients equally, whatever the religious beliefs of the individual doctors. However, on appeal by the doctors, this decision was later overturned.
Jennifer C. Pizer, one of the lawyers acting for Ms Benitez, said that 'our client's doctors' behaviour goes against established medical ethics and violates California civil rights law'. She added that the 'doctors claim a right not to comply with California's civil rights law because they are fundamentalist Christians and they object to treating a lesbian patient the same way they treat other patients'. Ms Benitez said that she was intent on taking the case as far as it would go as the doctors 'humiliated my family and me by refusing to perform the insemination procedure after they'd been treating me and promising it to me for nearly a year'. She added 'I don't want anyone else to have to suffer the humiliating treatment by their doctors that I endured'.