text:
Students Take Hold of Their Future Through Inspiration and Collaboration
Founded in 2016, the Cambridge University 3D Printing Society (CU3DSoc) is still in its infancy. CU3DSoc is comprised of over 30 first and second year undergraduates, predominantly engineering students. With plans to include art, architecture and medical students in their membership over the coming year, CU3DSoc has aspirations to become the focal point for 3D printing within the university. Thanks to access to several Stratasys 3D Printers, the society is undertaking complex engineering projects, with an outline to educate peers and create a nationwide 3D printing network.
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James Roberts, Cambridge University, 3D Printing Society


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Deandre Ayton is having no problem with the competition or the schedule at the NBA level.
Ayton outplayed a fellow top rookie big man for the second time, keeping the Phoenix Suns undefeated in preliminary play in Las Vegas.
Another full day of basketball on Monday, highlighted by Ayton against Orlando's Mo Bamba in a matchup of unbeaten teams, was the third game in four days for the 20 teams in action at the NBA Summer League.
The games are shorter than a regular NBA game — 40 minutes instead of 48 — and there is no travel, but it is still a lot of action in a short amount of time.
Some teams even gave players a rest day during the stretch of games, knowing that there would be more ahead. Every team is guaranteed five games, with the possibility of playing as many as eight games in 12 days.
Ayton did not look like he needed a break after scoring 17 points and grabbing 13 rebounds in the Suns' 71-53 victory over the Magic. The No. 1 pick said it was his first victory over Bamba, the No. 6 pick, after he beat fellow high-school teammate and No. 2 selection Marvin Bagley III on Saturday.
"With all the excitement and all the fans coming out here, it just really made me a lot more comfortable," Ayton said in an interview on NBA TV. "I just want to put on a show for them to be honest and just win as many games as I play."
There will not be any more for Bagley, as an MRI revealed a pelvic bone bruise, the Sacramento Kings said, adding that Bagley would rest for a week or two.
Monday was the last of the 10-game slates on the campus of UNLV. There were only five games yesterday before teams were seeded for tournament play that begins today.
In Monday's other games, it was:
‧ Suns 71, Magic 53
‧ Cavaliers 93, Pacers 88
‧ Thunder 92, Raptors 82
‧ Pistons 105, Pelicans 97
‧ Wizards 87, 76ers 75
‧ Celtics 100, Hornets 80
‧ Mavericks 91, Warriors 71
‧ Nuggets 90, Bucks 83
‧ Rockets 104, Clippers 90
‧ Timberwolves 78, Nets 69

subset: commoncrawl


text:
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There are a couple of things that may be preventing a lecture from downloading to your mobile device. Please consider the following:
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Hi again,
I know the Raspberry Pi is no PowerBook, but what can I expect in terms of programs I can run?
I noticed mixcloud.com (not a program, I know) loads very slow, but Facebook works fine (which is slow on my smartphone). I tried the game Armagetron, but that didn't work.
So, I guess using Gimp or Inkscape is out of the question? I DID read somewhere that Quake III runs on Raspberry Pi. I don't know ANYTHING about games, but I would guess Quake is more demanding then Armagetron or a mixcloud-webpage? The strange thing is, in the graphic on the top right corner, I can see sometimes a cpu usage (if that's what it is) of 10 %, while everything start running slow.
Oh, I don't run more then one program at the same time.
And, if I wanted to, is it possible to "boost" the Raspberry with hardware?


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China Fails to Respond to UN Rights Expert's Question on Panchen Lama
Tibetan UN Advocacy
[Friday, April 25, 2008 19:23]
The People's Republic of China has failed to provide a director response to Ms. Asma Jahangir, the Special Rapporteur on Freedom of Religion or Belief of the UN Human Rights Council, with regard to a specific question she put to the Chinese authorities in a communication of last May on case of the Panchen Lama. The Panchen Lama turns 19 today remaining under enforced disappearance since May 1995.
In a document highlighting cases forwarded to governments that was submitted by Ms. Jahangir to the Seventh Session of the Council held here from 3-28 March, the Special Rapporteur said that she intervened on the case of the Panchen Lama by writing to the Chinese authorities on 9 May, 2007. In that communication, the expert asked: "... what measures the Government has taken to implement the concluding observations of the Committee on the Rights of the Child, adopted on 30 September 2005, where the Committee recommended that your Government should "[a]llow an independent expert to visit and confirm the well-being of Gedhun Choekyi Nyima while respecting his right to privacy, and that of his parents."
Ms. Jahangir's communication observed that Gedhun Choekyi Nyima "was reported to remain in isolation and concerns were expressed about his whereabouts, well-being and fate. It was further alleged that the Chinese Government interfered in the identification and training of significant reincarnations in order to control the political loyalties of these important figures in Tibetan society, weaken the influence of the traditional religious authorities and use the reincarnates' influence among Tibetans."
In a response dated 17 July, 2007 the Chinese authorities totally ignored answering the Special Rapporteur's question on measure taken to implement the recommendation of the UN Child Rights Body. China's answer only said: "Gedhun Choekyi Nyima is a perfectly ordinary Tibetan boy, in an excellent state of health, leading a normal, happy life and receiving a good education and cultural upbringing. He is currently in upper secondary school, he measures 1 m 65 cm in height and is easy-going by nature. He studies hard and his school results are very good. He likes Chinese traditional culture and has recently taken up calligraphy. His parents are both State employees, and his brothers and sisters are either already working or at university. The allegation that he disappeared together with his parents and that his whereabouts remain unknown is simply not true."
Ms. Jahangir's communication to China also stated that: "Given the fact that Mr. Gedhum Choekyi Nyima has most recently turned 18, there have been calls that he should have the right to speak on his own behalf. The Special Rapporteur requested further information on measures envisaged by the Government to ensure that the Tibetan Buddhists may exercise the freedom to train, appoint, elect or designate by succession their religious leaders."
China's respond to the Special Rapporteur repeated its position that Gedhun Choekyi Nyima's confirmation by the Dalai Lama as the Eleventh Panchen Lama "showed utter contempt for the historical precepts and religious rites of the Tibetan Buddhist tradition and were completely illegitimate and invalid."
Another UN human rights expert group which brought up the case of the Panchen Lama this year was through the report of the Working Group on Enforced or Involuntary Disappearance (WGEID) which had been following the case since 1995. In this respect, on 11 March, nine NGOs in a Joint Statement to the Human Rights Council stated: "We are grateful that the WGEID's report to the Council cites the outstanding case of Gedhun Choekyi Nyima, the Eleventh Panchen Lama. But we remain disappointed with the lack of cooperation from the Government of the People's Republic of China. The Working Group concludes in its report that cooperation from governments is indispensable to discovering the fate or whereabouts of disappeared person around the globe."
This NGO statement delivered by Ms. Tsering Jampa on behalf of International Fellowship of Reconcilation (IFOR) and eight other NGOs, asked the "why the Working Group did not seek an official explanation on the this case from the Government of the People's Republic of China, especially when one consider that the last response is now over 10 years old. We raise this question in line with the Working Group's method of work to deal with outstanding cases and the need to send annual reminders to the concerned government," the statement concluded.
Separately on 25 February, 2008, 11 NGOs, including France Liberte: Fondation Danielle Mitterrand and Saami Council in a written statement to the Human Rights Council titled: "The unresolved case of enforced disappearance of Gedhun Choekyi Nyima, the Eleventh Panchen Lama" urged the WGEID and the Special Rapporteur on Freedom of Religion or Belief "to consider continuous interventions to the Chinese authorities to ascertain the truth about the fate of the Panchen Lama."
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by Reb Gutman Locks @ Mystical Paths
Hi Rabbi Locks,
My name is Umar and I hope that you are doing well. Rabbi Locks I had two questions for you concerning Converts and life. Why is it that when people, after studying Philosophy, Theology….convert to other faiths, beliefs. Think of it this way, a Christian woman studies Islam and converts to Islam because she says she knows that christianity is false. Another christian rejects both christianity and Islam and becomes an Atheist. An Atheist studies christianity and Islam and converts to Judaism. My question is this, how do we know who is right and who is wrong? When one says G-d is not a man and the other says G-d became a man, someone here is wrong.
My second question is this, Christians have faith that (their guy) was resurrected, Muslims have faith that Muhammad wasn't just making things up. What do Jews have faith in?
Thank you Rabbi Locks. Have a good one!
Shalom Umar,
You have asked a very good question. It is a question that philosophers have asked for ages: Since all belief is merely belief, how do you know if you are believing in something foolish, or in something true?
Here are a few tests to see if your beliefs are justified: Does what you believe make sense? Some people create a god, via a statue or such, and then go on to say that their "god" created them! Obviously this is foolish.
Where does your belief take you? How do the ones who believe in it live? Are they sensible, calm, loving people? Do they have healthy families? Are they able to provide for their families? Do they contribute to society?
The philosophy you choose will greatly affect your life. For instance, there is a philosophy called "existentialism." Is existentialism true or not? Well, anyone can see that those who really believe in it become depressed. They consider death to be an answer to life! Obviously, this is not a healthy philosophy.
Even scientists change their minds from time to time. Whenever they learn that one of their "facts" is wrong, they simply change their theory and move on. So what is the bottom line? What should we believe in? What is true?
The Torah tells us that when G-d first created the Universe, He did so demanding a standard of Justice. "Justice" means Truth. Whatever a person does he is immediately accountable for, to the letter! Well, G-d saw that His creation could not stand up to such a strict standard, so G-d created Mercy to come into the world and actually throw down Truth, so there could be Peace. Peace is the goal of life. As wonderful as is the Truth, Peace is even more wonderful.
So, what I recommend to you is to test your beliefs and see if they lead to Peace. If they do, then most likely, you will do fine by following those beliefs.
May G-d bless you with a peaceful life.


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Trending: Matt Gaetz files ethics complaint against Rep. Schiff over impeachment
The Washington Examiner's Susan Ferrechio has caught DNC Chairwwoman Debbie Wasserman Schultz in a bold-faced deception, reporting that Wasserman Schultz participated in a conference call under false pretenses with fellow Congressman Chris Van Hollen and a woman by the name of Annette Capella, a individual that party officials simply identified as a "Medicare recipient from Florida."
From the Washington Examiner report-
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In a conference call Monday, Wasserman Schultz enlisted the help of Annette Capella, described by party officials as a "Medicare recipient from Florida," to warn of the "extreme budget priorities," they believe Rubio is likely to outline in his televised response to President Obama's address.
Capella gave a lengthy and unflattering statement about Rubio, a U.S. senator from Florida and Tea Party favorite. She admitted he is an attractive politician but one who would make life more difficult for seniors by supporting a plan to alter Medicare by reducing benefits.It turns out, however, that Capella is hardly your standard Medicare-dependent Floridian. She's the Democratic Party's state committeewoman for St. Johns County.
The truth was uncovered when the call was opened up to questions. The first query came from a Palm Beach Post reporter, who asked Wasserman Schultz if Capella was the same person listed as the head of the St. Johns Democratic Party.
It was Palm Beach Post reporter George Bennett who asked Capella if she was the very same St. John's Democratic Party Chairwoman that is listed as being the head of the organization. Capella said that she stepped down from that post and is now the party's state committeewoman- how convenient.
Wasserman Schultz was likely hoping to get through the press event standing in solidarity with a "Medicare recipient" rather than with a fellow party official- does anyone out there think that Wasserman Schultz was eventually going to identify Capella as a Democrat state committeewoman?
But it gets worse for Wasserman Schultz and the DNC- both of whom are actively trying to preempt and undermine Senator Marco Rubio's response to Obama's State of the Union address.
It appears that the DNC has omitted key portions of Capella's statement from their official transcript of the call that featured both Wasserman Schultz and Van Hollen.
Here is the ending of Capella's statement (also part of the official transcript) that can also be heard on audio link-
But the DNC didn't publish the following statements by Capella in their official transcript of the event where she refers to Rubio as a "liar" —
We know our country needs to deal with our national debt and the budget deficit- we're very much aware of budgeting- we've done that most of our lives. But we must do so in a balanced manner at the federal level- we cannot do it on the backs of senior citizens as Republicans like Marco Rubio have proposed.
Social Security and Medicare are a sacred trust between the government and the American people. They are our promise- and they are promised to us- to our seniors that we can live our golden years free from the fear of poverty or an illness that causes bankruptcy. It allows us to live with the dignity and respect we have earned after a lifetime of hard work.
Senator Rubio is youthful, attractive, and an engaging speaker. I've had the opportunity to hear him, personally. He is a family man and a son of Cuban immigrants. However, he speaks very nicely but I found that his voting record, he lies what he says.
So tomorrow night I will listen closely to what Senator Rubio has to say. As his constituent I sincerely hope he decides that America's seniors are more important than Tea Party politics or protecting generous tax loopholes for Donald Trump and Big Oil.
How convenient for the DNC to leave out the contentious part of Capella's remarks assuming that they'd get away with it.
[vsw id="5RCF8ySgZnA" source="youtube" width="600″ height="375″ autoplay="no"]
Related: Wasserman Schultz Tries to Preempt Senator Rubio's SOTU Response


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One of the questions was about the opportunities for MNOs to increase revenues from delivering OTT services to their subscribers - "MNOs will be able to monetize OTT traffic by:". Several options were presented, allowing responders (N=81) to mark more than one answer (see the chart below).
The most popular opportunity was "offering subscribers premium services, based on higher QoE for OTT services" (83%) while 44% think MNOs can "encourage subscribers to upgrade to higher service plans" (tiered services). The two may be connected, although "service plans" were not defined in the 2nd option, and may be a higher data cap or other service factors.
"Charging subscribers for the use of certain applications" (for example those that compete with legacy services, such as voice, messaging or video), seems to be a less popular method (25%).


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Thursday, June 6, 2013
by Kitties26 on Thursday, June 06, 2013 19 comments
Guest post - Theresa from It's all about the polish
Where am I? - still at sea, probably off the coast of Port Macquarie I'd say. Probably packing our bags to disembark tomorrow morning.
I'm in the count down to the last three guest posts to show you, and I've still got three awesome blog posts to share. Tonights mani is bought to you by Theresa from It's all about the polish. Theresa has created a stunning skittle mani in a matching colour family. Theresa, please share what you've done.
I'm so excited to be guest posting here today. Cathy is a superstar in the Australian nail community (which she won't like me saying) and it's an honour to be here. I've done my favourite all time nail art which is a skittle. I'm a little bit of a perfectionist and have a little OCD, so to be able to do nails in a matching colour family is just my thing :D. Not that a skittle needs to be in the same colour family, it's just how I like to do them.
I started with a base of Essie - First Timer, it is an awesome new green that is the sister of Essie - Mojito Madness, it is just lighter. Now Essie can be a bit hit and miss with their formula but First Timer is a definite hit. Super easy to apply, no streaks and could be a one coater if you don't mind using a thick coat.
After allowing it to dry for an hour, my choice, (you could do it sooner but when using tape and dotting tools the drier the better) I used striping tape on my index finger and did a coat of Model's Own Apple Pie. For my middle finger I used my dotting tool and Model's Own Apple Pie and Orly White out for the dots.
My ring finger is the gorgeous Color Club - Beyond the Mistletoe and my pinkie is done using the same dots. My thumb which wouldn't behave to photograph has medium sized Apple Pie dots on it.
So as you can see it's a nail art that is relatively easy and is suitable for everyone, I love thinking up designs and if you do try a skittle design let me know, I love to see ALL the skittles :)
Labels: Guest Posts
19 comments:
LOVE the little dots!!!!ReplyDelete
I absolutely love this. Stunning and yet achievable for me.ReplyDelete
I don't know why, but minty colours just work so well in skittles! :DReplyDelete
Love this look, especially the use of Beyond the Mistletoe!ReplyDelete
The two shades of dots looks lovely! Ugh I wish I had more patience for nail art...ReplyDelete
Love it!! You always do great skittles like this Theresa!ReplyDelete
- AnonymousFriday, June 07, 2013
Love the colors & that glitter is so cool!ReplyDelete
So so pretty love it going to pin you on my Pinterest board!ReplyDelete
I love this mani Theresa! xxReplyDelete
About Me
- Kitties26
- I live in Canberra, Australia with my husband, Mr Ten and Miss Eight. My blog is all about nail polish, and a few other bits in between. You can contact me at email@example.com


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I read that today is National Boss Day. It is a good idea to have a boss appreciation day, but what if you are self employed? Do you pat yourself on the back?
Some will say that your clients are the boss, but in their case every day is client appreciation day. Every day entrepreneurs work for their clients and give them all they can.
When I look around my office space Toronto, I see two main types of people. Those who are entrepreneurs and those who are operating a branch office for a foreign based company. For the most part, most of these people are their own bosses. Yes, even the people who work or represent foreign companies are essentially their own boss. They are accountable to the head office, but they run the Toronto branch office like it is their own.
Examples of client appreciation day can be seen every day at my downtown Toronto office space, these are demonstrated by the amazing support staff who answer the phones and make the complimentary coffee. Maybe there needs to be a support staff appreciation day. I think I will take it upon myself and bring in Tim Bits for the amazing support staff in my office space for lease Toronto.


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Scrap Metal
Scrap metal processing and recycling applications require heavy duty material handling systems to accommodate the different materials and weights to be processed.
Hindon is a leading supplier of bulk material handling equipment for scrap metal processing and recycling applications, with over 25 years of experience. We offer expert design, engineering and manufacturing services, ensuring that all customers receive a custom solution to their material handling challenge.
Partnering with the top manufacturers in the industry, we can provide the bulk material handling equipment that meets our customer's exact requirements. We offer:
Invicta Vibrators – Used for feeders, conveyors, hoppers and screening equipment, Invicta vibrators provide reliable performance for high volume operations. They are able to withstand the harsh environments found in scrap metal processing plants and steel mills.
Sibre Brakes – Hindon's line of Sibre Brakes offers a wide range of designs for conveyor and hoist braking applications.
- Fail Safe Brakes – Used by overland or downhill conveyor systems to provide reliable holding and single stop operation in the event of a power loss or fault in the variable frequency drive or PLC in the drive system. We offer a full line of disc and drum brakes for heavy duty applications.
- Spring-Applied Brakes – Used for overhead hoists, spring-applied brakes provide safe holding and e-stop for heavy weight loads.
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We offer full support from the initial consultation through installation and follow-up services. We also offer full inspection, maintenance and repair services
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Monthly Archives: June 2017
Your Summer Workout Playlist
We've already concluded that music can help your fitness performance – but what music should be on your playlist for Summer 2017? We put the question to some of our friends and colleagues to get their top picks for motivational songs you need to have on your summer workout playlist – see the top ten tracks they came up with … Continue reading
Posted in Sport and Exercise, Uncategorized
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7 Simple Ways to Stay Hydrated
We all know that drinking plenty of water helps to keep our bodies healthy, but fitting in those extra glasses per day can be a real challenge for most people. While we'll probably drink water with meals, we need to remember to stay hydrated throughout the rest of the day. Especially if you're maintaining an active lifestyle, drinking plenty of … Continue reading
Posted in Health and Nutrition
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Does Music Help Your Fitness Performance?
For most people, listening to music when they work out is not just a preference, it's essential. At the gym, all the chart toppers blast from speakers, and you'll more often than not see your fellow gym-mates wearing headphones with their very own workout playlist playing. Listening to music while you work out isn't a new idea by any means, … Continue reading
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How to Become a Morning Person
Often seen as people who can get a lot more done with their day, as being calm and cool characters with heaps of time to complete their daily tasks, becoming a morning person is one of the most desirable healthy changes that a person wants to make. Of course, for most of us this just isn't a reality. Snoozing the … Continue reading
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Bowerman Airport Hosts Vintage WWII Aircraft June 20 - 22,
Tours and Flights Available
June 2012 - The Collings Foundation's Wings of Freedom Tour will be offering the public a chance to see and explore a collection of rare WWII Vintage Aircraft next week at Bowerman Airport, a facility of the Port of Grays Harbor.
On display will be a Boeing B-17 Flying Fortress, a Consolidated B-24 Liberator and a North American P-51.
WWII Veterans can tour the aircraft at no cost, while there is a nominal fee for the public.
Click here for more information regarding times, cost, and event information.
Bowerman Airport is located at 1380 Airport Way, Hoquiam, WA 98550.
Founded in 1911, the Port of Grays Harbor is one of Washington State's oldest port districts and Washington's only deep-water port located directly on the Pacific Ocean. The Port of Grays Harbor operates 4 deepwater marine terminals, the Westport Marina, Bowerman Airport and hundreds of acres of marine industrial property. Only 1-½ vessel hours from open sea, Grays Harbor offers rail and highway access to markets throughout North America.


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7X4.5X23 Music keepsake box. Plays amazing grace. Photo can be inserted.
Online ordering is for shipping to a person's home . It is not to be used for local delivery to a funeral home. In check out, please let us know in the "notes" section, how you would like your card to read. For instance, with deepest sympathy on the loss of your father. Love The Jones Family. Please call if this product is to be delivered locally. (see our local list of funeral homes under how to order) 724-861-8180
2 in stock


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When you're building a home, buying a newly-built home or having repairs done to your existing home or business, you will need to hire a home contractor. The process can be stressful because it is hard to determine who the best choice for your particular project is. Many home and business owners fail to understand that most general contractors don't require state licensing or training. Local building codes means that these are standards in which the best practices are followed. Many building code inspectors are not licensed and trained to examine a home to ensure it is built safely. Also all electricians, carpenters, heating and air conditioning technicians and masons aren't always required to undergo testing as well as plumbers and roofers.
When you're having your home built or remodeled, construction is a liability. There is always a risk that something could go wrong. When or if these thing occurs, the homeowner will want them repairs and without additional costs. If a home was built to an architect's plans and the builder and workers followed those instructions then the architect is liable. If the general contractor changed any of these instructions then the contractor is liable. When neither wants to pay, many will call their local building department, but it's important to note that they are never liable. If your contractor doesn't want to pay, you will have to go to court to get these costs back in a civil lawsuit.
Licensing & Training
In many cities, the only requirements to become licensed as a general contractor are proof of liability insurance and paying a license fee. That's it. There are no testing requirements. Some of the sub-contracting trades such as electricians do require a test, but only two trades require a state license in many states, roofers and plumbers. Check into the requirements for your particular state before hiring these individuals.
Building Codes
Each municipality is allowed to set their own specific local building codes. It's important that all of these codes are followed closely so that fines don't ensue. These codes are typically bare minimum requirements that a worker must do in order to legally build a home in your particular town and/or state. The codes will say nothing in particular about quality of the work or the durability of the home overall.
How Can Homeowners and Business Owners Protect Themselves?
There are many things that every homeowner or business owner should do in terms of due diligence. While these are not foolproof, they do help weed out some of the sub-standard people from the hiring list.
- Request copies of the contractor's license, their liability insurance policy information and their workman's compensation insurance policy information. Always double check the information is accurate and active. Also by having this information, a homeowner has the information in hand if a claim needs to be made.
- Make sure that you verify the name, address and business location of the contractor. If they aren't listed on the Better Business Bureau nor have relatively no Google search results, beware.
- Make sure that you only hire contractors that are members in good standings in professional organizations. These associations generally require testing and experience.
- Always read all quotes, specifications, paperwork and/or quotes thoroughly. If you don't understand them, never sign them. If necessary, hire a lawyer to read through them and make any necessary changes to protect your home or business. Compare quotes based upon price as well as materials, details, timeline and the scope of the work overall. A contract should define the work, the materials used and other specifics. Who will do the work should be clearly explained in the document. Also make sure that all workers are qualified and experienced and direct employees of the contractor themselves for insurance and workman's compensation reasons.
- Consider hiring a state-licensed home inspector to check work when the project is done. They will be unbiased and are paid for their expertise.
- Beware of any contractor that uses a P.O. Box as an address.
- Verify a license and make note of the license number. Check with the state contractor licensing board that the number is valid and active.
- Beware of a contractor that demands you pay upfront or in cash. Always have a record of payment.
- Any contractor that will provide you a discount for recommending customers should be avoided too.
- Any contractor that tries to pressure you into signing a contract that you don't understand, has blank spaces or haven't read is to be avoided.
- The contractor themselves are responsible for the construction permits.
- Any contractor that acts you to use your home as security for a home improvement loan is a scam.
It is a home or business owner's responsibility to remain informed.


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"Go forth and multiply," and wow did my Gertrude Jekyll rose get busy.
Look carefully at this image of two Gertrude Jekyll canes. The one on the right has thirteen times more flowers than the one on the left. You might wonder why and how this happened.
Well, I took the tip of an exuberant long cane and bent and tied it to a lower cane. The stress on the forced curve of the cane encouraged bud eyes to develop bloom-bearing stems. The method is called pegging or tying.
I first saw this treatment in England at Sissinghurst –– this shrub of Zephirine Drouhin, in Vita's rose garden, is tied to 4 arcs made from branches inserted around the shrub. One of the arcs is somewhat visible in this picture –– it looks like part of the shrub. I wouldn't have been the wiser if there hadn't been several other specimens that weren't fully leafed out yet. The living armatures that the gardeners created looked like globes. I couldn't wait to get home and try it myself
Certain David Austin roses are great contenders for pegging –– many of you know the ones –– they shoot up eight and ten-foot bloomless canes in late summer. I used to cut the gangly things down, but not any more.
It's a challenge to photograph tying in action, because luxuriant growth usually hides the handiwork. And you want it hidden, but I happened to catch this cane on David Austin's Othello displaying its prowess. In this case, I simply tied the cane to a nearby branch. Sometimes the branch might be on another shrub altogether –– whatever works.
The fresh new growth many Heritage roses produce after blooming is fun to use for pegging. I wait until the canes have matured a little before bending. For several years, I pegged my Madame Hardy into big loops, tying the tips to the bottom of the shrub. Here (pardon the brightness of fresh mulch) you can see the first appearance of leaves. By bloom time the canes disappeared into a mound of leaves and flowers.
Ramblers, with their pliable canes, peg really well. This is a Chevy Chase that I previously would chop at the knees, because of its tight location. It became quite a showpiece with pegging. This photo is at the beginning of the bloom cycle, near the end it was a mass of red. CC climbs a fence in another area of the garden. My husband eventually dug this one up––it took 2 hours! I gave it to my friend Susan who is a florist. CC laterals are a bouquet on a stem, and hard to beat for bloom production.
As you might have figured by now, I don't use actual pegs and I try to avoid ties. I like to spiral a thorny cane around itself or another cane. The grip of thorns is often very helpful for keeping the connection in place.
Here's an example of two canes entwined around each other into a nice curving arch.
Take a look at your rose canes and observe the possibilities. Experiment. One year I'll peg a shrub and the next year I might not. Realize that cane length can mean increased bloom production if pegged, tied, looped, or entwined.


text: The last time I did a bullet journal update was all the way back in May so I wouldn't be surprised if you assumed it had been a fad and I'd gone back to my usual disorganisation. Well turns out, this millennial system has actually worked wonders for me and almost a year later and I'm still hooked. When I initially set it up, I did quite a lot of research and actually, whilst I know a lot of people change up their bullet journals a lot, I found most of my original spreads worked nicely for my life. However, come the end of December I was ridiculously excited to get a new one and start afresh. So today I thought I'd share some updates I've made to my setup for 2018.


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The first injection molding machine was registered in 1872, and celluloid was used to produce simple everyday items such as hair combs. After some year later injection molding process was improved.
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Infertility affects approximately 13-14% of reproductive-aged couples. It is defined as the inability to conceive after 1 year of properly timed, unprotected intercourse. This definition is based on the cumulative probability of pregnancy.
Table 1. Cumulative Probability of Pregnancy in Couples With Normal Fertility (All Reproductive-aged Women) (Open Table in a new window)
Monthly Probability
Cumulative Probability
Cycle fecundability is the probability that a single menstrual cycle will result in pregnancy (see Table 1 above). Cycle fecundity is the probability that a single cycle will result in a live birth. Assuming a constant monthly probability of conceiving (fecundability) of 20%, the theoretical cumulative pregnancy rate after 12 months is 93%. However, studies show that this number is actually lower. A famous study conducted in the 1950s showed that 50% conceived within 3 months, 72% within 6 months, and 85% within 12 months. [1] Other cohort studies have produced similar results.
Fecundability and fecundity are dependent on multiple factors as described below, but one of the most important is the female partner's age. Cycle fecundability decreases as the number of oocytes decreases. Cycle fecundity also decreases, largely due to an increase in miscarriages. See the image below.
The number and quality of a woman's oocytes declines with age. The decline in the number of oocytes begins at 20 weeks' gestation when the female fetus has approximately 6-7 million oogonia (largest lifetime endowment). The number of oocytes decreases to approximately 2-3 million at birth and decreases again to 300,000 by the time of puberty. Interestingly, the human female has lost most of her eggs before she is even capable of reproducing. At present, the pool of eggs is believed to be nonregenerable.
After the onset of puberty and menses, the female human ovary recruits at least 30-50 oocytes during each menstrual cycle. The oocytes compete with one another to become the dominant follicle and eventually ovulate to be released as an egg capable of being fertilized. Prior to the onset of menopause (10-15 y), menstrual cycles shorten and rapid follicular loss occurs because more oocytes are being recruited.
The birth rate among US women has dropped from 106.2/1000/year in 1950 to 62.9/1000/year in 2014 [2] . This has coincided with several social trends including later marriage, increased divorce rates, improvement in contraception and access to family planning, increased educational level achieved among women, and a greater number of women in the work force. Interestingly, the birth rates by age have dramatically shifted, with birth rates in women aged 15-29 years decreasing and birth rates among women aged 30-44 years increasing from the years 1990–2014.
Though not as abrupt or noticeable as menopause in women, changes in fertility and sexual functioning do occur in men as they grow older. One review of the literature shows that, currently, there is not enough data to show a clear effect of advancing paternal age on ART outcomes. [3] A recent retrospective analysis of 2,627 intracytoplasmic sperm injection (ICSI) cycles showed paternal age had no effect on pregnancy outcomes and parameters of embryo quality. Both studies point out to the need for more studies in this topic with long term follow up [4] .
For related information, see Medscape's article Infertility.
Cause of Infertility
LenThe cause of infertility can be easily identified in some couples. In other couples the cause is much less clear, and multiple factors may contribute. The major recognized causes of infertility are listed in Table 2.
Table 2. Causes of Infertility (Open Table in a new window)
Obtaining a thorough history and physical examination is essential in evaluating an infertile couple.
The questions asked during the evaluation should include the following topics:
History of prior pregnancues and outcomes of each pregnancy
Length of time of sexual activity without conctraception
Current and past medical/surgical problems and recent changes in health
Employment and potential chemical/environmental exposures
Family history of miscarriages
Personal and family history of birth defects or inheritable disorders
Updated medicine list (including any over-the-counter medicine or herbs)
Tobacco, alcohol, and drug use
Coital frequency and any sexual dysfunction
Thorough gynecologic history, including pelvic pain, discomfort with intercourse, menstrual cramps, cycle length, and duration of flow
Prior pelvic infections
Use of prior contraception
Prior infertility work up or treatments
Diagnostic Tests
When evaluating an infertile couple, diagnostic studies should be selected as indicated. If the history is unclear, then tests that address the above-mentioned major categories of infertility should be obtained.
Male factor testing
After a medical history and physical examination, semen analysis is the single best test for evaluating for male factor infertility.
For optimum and consistent results, abstinence is required 3-5 days prior to semen collection. The World Health Organization (WHO) has established methods for semen analysis, but methods may vary among facilities. Additionally, the WHO has established normal reference values.
Another commonly used method for evaluating morphology is the strict Kruger method. Although no particular measurements can be used to discriminate between fertile and infertile men, odds of male infertility increase with increases in the number of semen parameter abnormalities.
Volume - At least 2 mL or greater
Sperm concentration - 20 million/mL or more
Motility - At least 50% or more with forward progression
Morphology - At least 30% or more normal forms (14% strict Kruger criteria)
White blood cells - Fewer than 1 million/mL
Round cells - Fewer than 5 million/mL
More recently, other tests have been devised to evaluate sperm. The Halosperm test and the Sperm Chromatin Structure Assay (SCSA) have been devised to evaluate the DNA fragmentation of sperm. Some studies suggest that a DNA fragmentation of greater than 30% is associated with a lower probability that the male partner will be able to initiate a pregnancy that carries to delivery.
Ovulatory function testing
Women of reproductive age who have regular menstrual cycles lasting from 21-35 days are likely ovulatory. However, for patients to become more accustomed to predicting ovulation so that they can appropriately time intercourse, they may wish to initiate basal body temperature monitoring or use luteinizing hormone (LH) detection kits.
Basal body temperature (BBT) monitoring is largely a historical method for determining the correct timing of intercourse. A 0.5–1.0ºF rise in temperature is noted 2 days after the luteinizing hormone (LH) peak, which occurs after the day of ovulation. This results from progesterone production from the corpus luteum. This should be done with a special mercury thermometer before rising from bed. Since most studies show that the best day to introduce sperm into the female reproductive tract is either the day of ovulation or the day before ovulation, BBT monitoring -is not useful for coital timing in a current cycle but best serves as a method to confirm the time of ovulation and helps the patient to predict future cycles based on data she has gathered over prior cycles. This method is inexpensive but time-consuming and cumbersome. Urine LH kits are a more useful method to prospectively predict the day of ovulation; however, they can be expensive and result in confusing results, particularly in thesetting of the use of clomiphene citrate, patients with oligo-ovulation, or if pregnancy has occurred.
A deficiency in progesterone production by the corpus luteum (CL) has historically been attributed to infertility and recurrent pregnancy loss in many women with otherwise unexplained miscarriages. The significance and presence of an inadequate luteal phase (also referred to as luteal phase defect [LPD]) has been questioned throughout the literature. Traditionally, diagnosis of an LPD has been determined histologically (a lag of >2 days of an endometrial biopsy compared with the day of the cycle, based on the actual day of ovulation). Some physicians prefer to use low luteal phase progesterone levels (< 10 ng/mL) 6 days after ovulation as their method of diagnosis, with good correlation to histologic findings if repeated in 3 separate menstrual cycles. Isolated LPD (by histological criteria) are observed in 30-40% of healthy fertile couples as well as infertile couples, implying that this defect mustbearepetitive event to be a true cause of infertility or miscarriage. Little evidence suggests that the addition of exogenous progesterone benefits pregnancy outcomes, suggesting a potential defect in endometrial receptivity during the implantation stage.
Ovarian reserve testing
Several simple tests for ovarian reserve exist. Initial testing usually includes cycle day 3 laboratories including follicle stimulating hormone (FSH), estradiol (E2), and leuteinizing hormone (LH). Typically, if the FSH level is greater than 15 mIU/mL or the estradiol level is greater than 75 pg/mL, the prognosis is poor. Day 3 antral follicle scans and ovarian volume may also be used to evaluate ovarian reserve and are simple and accurate.
In patients older than 40 years or for whom poor ovarian reserve is suspected, a clomiphene citrate challenge test may be performed. Clomiphene citrate (100 mg PO qd) is administered on cycle days 5-9. FSH and estradiol levels are drawn on days 3 and 10. If the day-3 or day-10 FSH level is greater than 15 mIU/mL or the day-3 estradiol level is greater than 75 pg/mL, the test results are considered abnormal. The rationale is that if the woman has an elevated day-10 estradiol level due to the clomiphene, yet her FSH level is not suppressed (estrogen suppresses FSH by a negative feedback mechanism), she has significant decreased ovarian reserve.
Tubal disease testing
In patients with unremarkable history or examination findings, a hysterosalpingogram (HSG) performed 2-5 days after the cessation of menstrual flow is the procedure of choice to evaluate tubal anatomy and patency. The risk of infection is extremely low, and most patients do not require antibiotic prophylaxis unless the patient has a history of pelvic infection. Additionally, if distal tubal occlusion is found, treatment should be provided because the risk of infection increases and treatment has been show to prevent infection in these cases. Pretreatment with nonsteroidal anti-inflammatory drugs is recommended with the rare patient requiring a mild sedative.
The HSG is a radiographic technique in which a dye is injected into the cervix. This dye fills the uterus and eventually the tubes. If the tubes are patent, dye spills out into the abdominal cavity. The test requires approximately 10 minutes to complete. This procedure is primarily diagnostic, but it may possibly be therapeutic (for approximately 6 mo), primarily when using an oil-based dye. Additionally, it provides imaging of the uterine cavity.
A history of pelvic inflammatory disease, septic abortion, ruptured appendix, tubal surgery, or ectopic pregnancy should alert the physician to the possibility of tubal damage. In these patients or in patients with significant pelvic pain during the physical examination, proceeding to a diagnostic laparoscopy rather than an HSG may be prudent given the probability of pelvic pathology. In this case, the tubes and the rest of the pelvis may be directly inspected and a chromopertubation may be performed. During this procedure, dye is injected through the cervix and into the uterus. If the dye is seen to spill from both of the tubal openings, the fallopian tubes are presumed patent.
Cervical disease testing
Women who have had cervical cone biopsies or trauma to the cervix are at risk for cervical abnormalities and cervical stenosis. If a cervical abnormality is found, the most logical approach is to recommend bypassing the cervix with intrauterine inseminations (IUI), especially if the rest of the findings from the infertility evaluation are normal.
In the past, suspected cervical factor infertility was tested with a postcoital test (PCT), looking at the interaction of cervical mucous and sperm at a specified time after intercourse during the perio-ovulatory phase of the cycle. A lack of consensus exists regarding the accuracy, precision, and use of the PCT in the modern infertility evaluation, and it is now rarely used in practice.
Uterine disease testing
Similar to tubal disease, obtaining a history from the patient is the most important diagnostic tool. A history of repetitive abortions, uterine surgery, postpartum uterine infections, retained products of conception, or postpartum curettage should alert the clinician to a possible uterine factor. A history of abnormal bleeding, such as heavy menses, midcycle spotting, or irregular bleeding, may represent an intrauterine fibroid, polyp, or synechiae. Malpresentation during pregnancy or recurrent pregnancy loss often suggests a uterine anomaly, such as a septum or bicornuate uterus.
A screening transvaginal ultrasonography performed immediately following the cessation of menses may demonstrate a uterine leiomyoma (fibroid) or an endometrial polyp. HSG typically used to evaluate the fallopian tubes can also be used to evaluate the uterine cavity.
If the patient has known blocked tubes and is scheduled for in vitro fertilization (IVF), a sonohysterogram (SHG) or office hysteroscopy (HSC) may be performed. An SHG is performed by placing a small catheter in the uterine cavity and instilling sterile saline to separate the endometrial walls under ultrasonographic guidance. SHG is more sensitive than an HSG in delineating fibroids and polyps. HSC allows for direct visualization of the cavity via an optic fiber.
Testing for endocrine abnormalities
Any evidence of the following should warrant selective hormonal studies.
Hirsutism or hair loss
Abnormal weight gain
Oily skin or acne
Purple striae on the abdomen
Irregular menses
Heat or cold intolerance
Headaches, visual problems or lactation without prior pregnancy
If the patient displays hirsutism, with or without menstrual irregularity, androgen studies such as dehydroepiandrosterone sulfate (DHEA-S), total testosterone, and 17-hydroxyprogesterone should be performed. If unusual weight gain or fatigue develops, a thyroid-stimulating hormone (TSH) should be obtained. If galactorrhea or irregular menses occurs, measuring the prolactin level should be considered. Acanthosis nigricans suggests hyperinsulinemia. If diabetes is suspected, a glucose tolerance test should be obtained.
Unexplained infertility
By definition, a physician makes the diagnosis of unexplained infertility after all tests are completed, including a diagnostic laparoscopy with or without a hysteroscopy. In modern practice, unexplained infertility is considered after all test results are negative, prior to any surgery, and in a patient with an unremarkable history and physical examination findings.
Treatment & Management
The prevalence of infertility over the last 30 years has been stable, but the treatment and demand for infertility services has increased substantially during that time. This increase is due to several factors: changes in population demographics (older couples trying to conceive), increased patient awareness and access to services, and advances and improvements in fertility treatments.
Treatment of male factor
Confirm any abnormal study result with a repeat semen analysis (SA) at least 4 weeks apart. The average time of sperm turnover is approximately 60-70 days. Since semen parameters can be affected by acute illness and environmental factors, a repeat SA will give a more accurate reflection of overall semen quality. If results remain abnormal, refer the patient to a urologist to evaluate for any genetic, anatomic, hormonal, or infectious causes. If the volume is less than 1 mL, consider retrograde ejaculation and obtain an analysis of the urine. If the sperm concentration is less than 20 million/mL, yet the swim-up extraction yields at least 1 million total motile sperm, intrauterine inseminations (IUI) is the treatment of choice. If sperm counts are extremely low or if motility is poor, in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) may be required.
Treatment of ovulatory dysfunction
If a patient has a normal ovarian reserve, determining the potential cause of the ovulatory defect is prudent. The practitioner should consider the following scenarios prior to initiating treatment. In the presence of obesity and chronic anovulation, polycystic ovarian syndrome (PCOS) or Cushing disease may be evident and in the case of hirsutism, the patient may have elevated androgen levels or hyperinsulinemia, requiring further testing. In a patient with low body mass index and low gonadotropin levels, weight gain and decreased exercise may improve fertility. If oligomenorrhea remains, ovulation induction can be achieved with exogenous gonadotropins. If the physical examination findings are unremarkable, ovulation induction is the next treatment approach to consider.
The following clomiphene citrate (CC) treatment regimens are often used for ovulation induction in patients with idiopathic ovulatory dysfunction or PCOS:
Clomiphene citrate (50 mg on days 2-6 or days 5-9)
Clomiphene citrate (100 mg on days 2-6) plus follicle stimulating hormone (FSH) (1-2 amps starting on day 8)
Clomiphene citrate plus human chorionic gonadotropin (hCG) for ovulation induction [5]
Elevated androgen levels – Dexamethasone (0.25 mg/d) plus clomiphene citrate
Hyperinsulinemia with elevated androgens -Metformin (500 mg tid) plus clomiphene citrate. Many women spontaneously ovulate on metformin alone; thus, many clinicians allow a trial of 1-3 mo prior to adding clomiphene citrate. However, recent data suggest that clomiphene citrate alone may be more efficacious at achieving a live birth than metformin or the combination of metformin with clomiphene citrate.
Aromatase inhibitors (letrozole) (2.5 mg PO on cycle days 3-7) has been shown in early studies to work as well as clomiphene citrate to induce mono-ovulation and to have little or no adverse affect on endometrial thickness.
The goal of therapy is to achieve 3 ovulatory cycles; 40-50% of women should become pregnant in this timeframe in the absence of any other abnormalities. If conception has not occurred after 3 clomiphene citrate cycles, the practitioner should investigate other causes of infertility. No more than 6 consecutive cycles are recommended because of the theoretical risk of borderline ovarian tumors and extremely low pregnancy success rates after this point.
Evidence suggests that starting clomiphene citrate earlier (day 2 or 3 rather than day 5) is more beneficial because this conforms to a more typical cycle length of 28 days. Beginning on cycle day 2 or 3 promotes ovulation around days 12-16, which is more physiologic and may avoid delayed ovulation and excessive maturity of the oocyte. Studies from the 1970s in women with documented delayed ovulation (after cycle day 16) revealed a higher relative miscarriage rate. This was believed to be caused by meiotic dysfunction within the oocyte.
Ovulation (LH) predictor kits are much easier for patients to use when clomiphene citrate is started on day 2 or 3. LH levels are normally elevated after the patient takes clomiphene citrate, and the half-life of the medication is 5 days. Thus, in a cycle day 5-9 regimen, a patient may receive a false-positive reading if she follows the directions on the kit and starts monitoring on cycle days 12-13.
Evidence demonstrates that a day 2 or 3 clomiphene citrate start allows the endometrium to thicken to a more normal, physiologic range. Endometrial thinning is a well-known adverse effect of clomiphene citrate. An endometrium that is thinner than 7-8 mm has been associated with a lower pregnancy rate in IVF cycles.
Ovulation induction can also be initiated with exogenous FSH. During such cycles, FSH is generally started on cycle day 3 and the patient is monitored for development of 1-2 dominant follicles. When 1-2 dominant follicles have grown to the appropriate size, ovulation is hormonally induced and IUI is performed.
Treatment of tubal disease
IVF offers the best chance for conception in patients with significant tubal disease. Often, if only 1 tube is affected, ovarian stimulation with gonadotropins produces mature oocytes in the ovary near the patent tube. In patients with minimal or moderate tubal disease, laparoscopic lysis of adhesions and procedures should be performed to normalize tubal function, with an emphasis on prevention of adhesion recurrence. In patients with an irreparable hydrosalpinx, removing the tube or disconnecting it from the uterus may reduce the risk of a tubal pregnancy and enhance embryo implantation if the patient requires IVF.
Pregnancy rate following treatment can be dependent upon location of tubal disease (see Table 3 below).
Laparoscopic lysis of adhesions offers an opportunity to conceive either naturally or with minimal types of therapy. If only proximal tubal occlusion is present, these obstructions can be fixed with a balloon tuboplasty under fluoroscopic guidance similar to the common angioplastic procedure in cardiology.
Table 3. Treatment of Tubal Pathology (Open Table in a new window)
Pregnancy Rate (3-6 mo)
Lysis of adhesions
Mild distal obstructive disease
Moderate distal obstructive disease
Severe distal obstructive disease
Proximal tubal obstruction
Treatment of cervical factor
Intrauterine inseminations may offer a reasonable option for treatment. The presence of antisperm antibodies in the female or male warrants IUI. If the antibodies are on the sperm itself, washing the sperm with a chymotrypsin/galactose preparation may improve sperm motility.
Treatment of uterine factor
An operative hysteroscopy is usually required to lyse adhesions or remove endometrial polyps or submucosal fibroids. Intramural fibroids and subserosal fibroids may be removed by laparotomy, traditional laparoscopy or robotically assisted laparoscopy. At present, none of the commercially available barriers have been proven to be better at adhesion prevention over excellent surgical technique. In severe cases of uterine pathology, the best option for conception may be through the use of a gestational carrier.
Treatment of endocrine abnormalities
Ensure that any endocrine abnormality is normalized prior to attempts at conception. Keep in mind that women with luteal phase defects also have ovulatory dysfunction. Clomiphene citrate, as previously mentioned, and luteal phase progesterone supplementation may be potentially effective treatments. The recommended progesterone is either micronized progesterone in vaginal suppositories (50-100 mg bid) or progesterone vaginal cream (Crinone 8%; 90 mg/d). Oral micronized progesterone may be used but causes significant somnolence and adverse central nervous system effects (eg, depression).
Treatment of unexplained infertility
The choice of treatment protocol depends on how aggressive the couple wants to be with their efforts to conceive. Most physicians start with either clomiphene citrate or gonadotropins in conjunction with IUIs. Patients should completely understand the success rates (see Table 4) and the risks of multiple pregnancy with any treatment protocol.
Table 4. Unexplained Infertility and Pregnancy Rates per Cycle According to Treatment (Open Table in a new window)
Pregnancy Rate, %
No treatment
IUI alone
Clomiphene with timed coitus
Clomiphene with IUI
Gonadotropins with timed coitus
Gonadotropins with IUI
In vitro fertilization (IVF)
Modern IVF generally involves controlled ovarian hyperstimulation with exogenous gonadotropins, harvesting the eggs via transvaginal ultrasonographic-guided aspiration, co-culture of eggs and sperm in culture (or intracytoplasmic injection of sperm into the oocyte), and placement of the resultant zygotes (2-5 d later) directly into the uterus.
The first IVF pregnancy was achieved in 1978. Since then, the number of IVF centers and IVF procedures performed has increased dramatically. An intense effort to obtain insurance coverage for these services has also occurred. With the support of organizations such as RESOLVE (ie, the National Fertility Association), 15 US states provide coverage for these services. Currently, 3 states (Massachusetts, New Jersey, and Rhode Island) offer full coverage. Other states exempt health maintenance organization programs, private insurers, or companies with few employees. Other states offer limits to their coverage. In states that provide full coverage, the actual cost per paid subscriber is not substantial. A recent study in Massachusetts calculated that the increase is only $25 per year per subscriber.
As a result of the Fertility Clinic Success Rate and Certification Act, the US Centers for Disease Control and Prevention (CDC) gathers information from 422 of the 475 clinics throughout the United States. Information from 2005 shows that 134,260 assisted reproductive technique (ART) cycles were performed resulting in 38,910 live births (deliveries of one or more living infants) and 52,041 infants.
Complications can arise during IVF. The incidence of first trimester venous thromboembolism in relation to IVF was 0.2%, which is a 10-fold increase over the background population. The 6-7% of IVF pregnancies complicated by ovarian hyperstimulation had a 100-fold increased risk, as opposed to the 5-fold increase in its absence. However, with the advent of certain modifications in IVF treatment protocols, particularly the use of leuprolide injection rather than hCG for final oocyte maturation, the incidence of ovarian hyperstimulation will significantly decrease. No increased risk related to frozen embryo replacement cycles or IVF after the first trimester was noted. Treating women with hyperstimulation with heparin thromboprophylaxis during the first trimester and treating women at high risk for hyperstimulation with frozen embryoreplacementislikelyto lower the venous thromboembolism risk. [6]
Other assisted reproductive techniques
Gamete intrafallopian transfer (GIFT) was developed in 1984 for women with unexplained infertility. GIFT is much less utilized, but to certain religious and ethnic communities (in which fertilization inside the woman's body is the only type allowed), it is considered more acceptable. During this procedure, the patient undergoes a controlled ovarian hyperstimulation. The oocytes are retrieved transvaginally under ultrasonographic guidance, and 3-4 oocytes are placed via laparoscopy into one of the fallopian tubes along with sperm.
During zygote intrafallopian transfer (ZIFT), oocytes are retrieved similar to IVF and GIFT and they are allowed to fertilize in vitro in the laboratory as in IVF. A day after fertilization (2 cell stage), 3-4 embryos are transferred via laparoscopy into one of the fallopian tubes. If the embryos are allowed to develop to greater than a 2-cell stage, the procedure is termed tubal embryo transfer (TET). The only benefit to a ZIFT or TET versus the more traditional IVF is for women who are thought to have compromised embryo quality due to embryo in vitro culture. Placing these zygotes or embryos back into their own natural incubators is thought to enhance subsequent development with improved pregnancy rates.
With the development of enhanced culture media, the success rates for IVF are now comparable, if not better, to those of GIFT and ZIFT, and IVF is less invasive than GIFT and ZIFT.
Interpreting IVF success rates
Comparing one program's success rate to another is difficult because of all the variables involved, including the program's selection criteria, patient demographics, and insurance coverage. In general, like any statistical analysis, the more IVF cycles a program has performed, the more valid the numbers are. The cancellation rate is a critical number. If the rate is high, the program is possibly very selective for the patients it allows to proceed to egg retrieval. This type of program would rather cancel the patient's procedure than have a low chance for success. The implantation rate refers to the pregnancy rate divided by the number of embryos transferred.
If the implantation rate is low and the pregnancy rate is high, this suggests that the program is transferring a large number of embryos per patient to achieve that success. Chances are good that the program's multiple pregnancy (eg, twins, triplets, and higher order multiples) rate is high. Optimally, the better programs have a low cancellation rates, good pregnancy and implantation rates, and high singleton pregnancy rates compared with multiple pregnancy rates.
The ultimate critical number is the birth rate because this represents the final goal of the patient and the physician. This goal is also less vulnerable to misinterpretation than the pregnancy rate (single positive hCG vs serial increases) or the clinical pregnancy rate (gestational sac vs fetal pole vs fetal pole with heartbeat).
IVF outcomes
2005 data for IVF outcomes are summarized and results can be viewed on the CDC and Society for Assisted Reproductive Technology Web sites. Outcomes are stratified based on cycle type (fresh IVF, frozen embryo IVF, donor IVF, and maternal age). Overall, 134,260 ART cycles were performed in the United States in 2005 resulting in 38,910 live birth deliveries. For reference, in 1996, 14,507 deliveries resulted from 64,681 ART cycles. Because more than 1 infant is born during a live-birth delivery (eg, twins) in some cases, the total number of infants born is larger than the number of live-births. From 1996-2005, the percentage of transfers resulting in live births for fresh–nondonor cycles increased from 28% in 1996 to 34% in 2005.
In a 2012 study of 612 preterm infants, use of assisted reproductive technologies was not associated with adverse neonatal outcomes. Survival without severe morbidity was significantly higher among infants born using assisted reproductive technologies compared with spontaneously conceived preterm infants, probably because of differences in pregnancy and neonatal characteristics. [7]
In a 2015 systematic review and meta-analysis of the influence of endometriosis on assisted reproductive technologies outcomes from 36 studies (of 1346 articles), investigators found similar outcomes for live births between women with endometriosis who underwent in vitro fertilization and intracytoplasmic sperm injection and women without endometriosis. [8] However, women with severe endometriosis had lower live birth rates, clinical pregnancy rates, and mean number of retrieved oocyte relative to those without endometriosis. The investigators noted there remains not enough evidence to support recommending surgery routinely before women undergo ART. [8]
In another 2015 report that assessed the risk of ectopic pregnancy with assisted reproductive technology over 10 years (2001-2011) in the United States, 9,480 of 553,577 pregnancies were ectopic (1.71%) (including 485 that were heterotopic; these data were combined for analysis). [9] The investigators noted a decrease in ectopic pregnancy rates (2001: 2.0%; 2011: 1.6%) (P< 0.001), and fresh, nondonor cycles had an ectopic pregnancy rate of about 2.0%, whereas it was 1.0% for fresh, donor cycles. However, among fresh, nondonor cycles, the greater the number of embryo transferred resulted in an increased risk of an ectopic pregnancy. [9]
Guidelines for embryo transfer
Multifetal gestations are associated with greater risks for both mothers and infants, including higher rates of caesarean section, prematurity, low birth weight, and infant disability or death. In response to the significant numbers of higher order multiple pregnancies generated from ART, the American Society of Reproductive Medicine (ASRM) released guidelines for the number of embryos transferred in 1999. These were modified in 2006 based on newer data. See Guidelines on number of embryos transferred.
In 2005, the percentage of multiple-infant live births decreased from 38% of all live births in 1996 to 32% in 2005 for fresh-nondonor ART cycles.
Increasing the number of embryos transferred from 1 to 2 not only increases the chance for a live birth but also increases the likelihood of a multiple-infant pregnancy. However, transferring more than 2 embryos may not increase the overall live birth rate. A meta-analysis of randomized trials on single and double embryo transfer found that compared with double embryo transfer, elective single embryo transfer results in a higher likelihood of delivering a term singleton live birth though it also has a lower pregnancy rate. [10]
Many variables affect the decision of how many embryos to transfer. Factors such as the patient's age, embryo quality, number of prior failed IVF cycles, and use of frozen-thawed embryos are important to consider. New data from Europe suggest that a single embryo transfer in the appropriate patient results in approximately a 35% pregnancy rate with a less than 1% multiple pregnancy rate. These patients typically have embryos that are frozen, ensuring that their cumulative pregnancy rate using either fresh or frozen embryos is similar to transferring 2 or more embryos. Single embryo transfer is appropriate in certain situations where the likelihood of a multiple pregnancy is high. This may include women younger than 35 years, women who conceived with first IVF cycle, women with only tubal factor infertility, women with concerns about multiple gestation, and donor egg recipients.
Kresowik et al found that twinning rates were reduced and pregnancy rates maintained after introduction of a mandatory single-embryo transfer policy in women younger than 38 years, with at least 7 zygotes, no prior failed fresh cycles at the center, and with at least one good-quality blastocyst. [11]
Factors contributing to IVF success
The most important factor that determines a successful cycle is the female patient's age. As mentioned previously, decreases in fecundity rates are observed beginning as early as age 30 years. The dramatic effect that age has on fecundability is also observed in ART. Most egg donors are aged 20-35 years, allowing for an optimal control group to observe these differences.
Ultimately, the success of ARTs mimics the overall fecundity trend observed in the general fertile population. That is, pregnancy and live birth rates start to decrease beginning around age 30 years and continue to decrease until the chance of having a live birth is so low that the benefit of ARTs must be evaluated. In women older than 40 years, the chance of having a liveborn infant with a chromosomal abnormality also increases.
Weight may also play a part in IVF success. A retrospective study found that women of normal body weight have a higher chance of pregnancy and live birth following IVF than either underweight or obese women. Women with morbid obesity (BMI >40) have a significantly decreased chance of success with IVF. [12, 13, 14]
A large retrospective study evaluating data from the Society for Assisted Reproductive Technology suggested that the process of ovarian stimulation with gonadotropins was an independent risk factor for low neonatal birth weight compared with women who conceived with a singleton pregnancy. [15]
Oocyte retrieval
Oocyte retrieval is performed approximately 36 hours after 10,000 U of hCG is administered to allow for the resumption of meiosis, cytoplasmic maturation, and loosening of the oocytes within the follicle. This allows for a lower optimal vacuum pressure during aspiration and ultimately less oocyte damage.
The 3 basic methods to retrieve oocytes are laparoscopic, transabdominal, or transvaginal. The laparoscopic approach was used frequently in the 1980s, especially when a GIFT procedure was planned. Often, only the follicles that could be seen on the surface of the ovary were removed, and, if the ovary was very mobile, traction was required to support the ovary as the follicles were aspirated. Associated morbidity occurred with the procedure, which included infection and injury to the pelvic organs. General endotracheal anesthesia was usually used, and the patient's recovery often lasted 2-3 days. As the quality of ultrasonographic images and culture media improved, the need for laparoscopy decreased.
In 1981, ultrasonographic-guided aspiration was first described. Initially, the transabdominal approach was used, usually with the aspirating needle going through the bladder, which, when full, provided a window of visualization for the person operating the abdominal ultrasonographic probe.
Although still used for retrieval of oocytes from ovaries that are adhered high up in the pelvis or to the fundus of the uterus, the transabdominal approach was superseded by the transvaginal approach. The first transvaginal retrieval was performed in 1984 and has now become the procedure of choice because of its ease and low morbidity.
Intracytoplasmic sperm injection (ICSI) is the treatment of choice for couples in whom the male partner has azoospermia or severe oligospermia. ICSI is also indicated for men with significant antisperm antibodies, low sperm motility, or significantly abnormal sperm morphology (Kruger strict morphology < 4%). [16]
ICSI is used when poor fertilization occurs with regular insemination techniques in the laboratory. ICSI may be used when a limited amount of sperm is available, such as in couples where the man has stored sperm prior to chemotherapy. ICSI is indicated in certain preimplantation genetic (PGD) procedures—specifically those cases being evaluated for single-gene recessive disorders. This prevents the potential contamination of the specimen with sperm that may be attached to the egg.
Sperm can be obtained from the ejaculate or directly from the epididymis. Recently, success was obtained with spermatids from testicular biopsies.
The potential transmission of a genetic abnormality is a possibility when ICSI is performed. The normal barrier for morphologically abnormal sperm that tend to have genetic abnormalities (ie, zonal pellucida) is bypassed with ICSI. Morphologically normal sperm may also have genetic abnormalities. Approximately 10% of sperm from healthy men have chromosomal abnormalities. Men who are infertile have a 5-7% chance of having a chromosomal abnormality. Chromosomal abnormalities include microdeletions of the long arm of the Y chromosome in areas AZFa, AZFb, and AZFc (DAZ or deleted in azoospermia region). These deletions can be passed on to male offspring, with resulting oligospermia.
Some data suggest a 30% increase in birth defects in children conceived with ICSI. Overall, this implies that the risk of having a child with a birth defect from ART with ICSI goes from a normal baseline of 3% to, at most, 4%.
Approximately 1-2% of men with azoospermia have genetic translocation, Klinefelter syndrome (47,XXY), or a congenital bilateral absence of the vas deferens, which is associated with mutations in the cystic fibrosis transmembrane regulator (CFTR) gene or the 5T allele.
In the situation where the male partner has the CFTR mutation, the female partner should also be screened for cystic fibrosis. In any couple undergoing ICSI for male factor infertility, a karyotype and Y-DNA mapping should be considered if the sperm concentration is less than 5 million/mL, and genetic counseling should be offered. Prenatal testing of ICSI pregnancies has revealed an incidence of 0.83% of sex chromosome abnormalities (higher than those reported for spontaneous pregnancies).


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Three types of beans are topped with a simple dressing in this chilled side salad. A great recipe for a potluck or family cookout.
1. Combine green beans with enough salted water to cover. Bring to a boil over high heat. Reduce heat to medium and cook 10 minutes or until crisp-tender; drain and rinse. In a large bowl, combine green beans with black beans and chickpeas. Set aside.To make dressing:
2. In a small saucepan, stir together onion, vinegar and sugar. Cook over medium heat just until sugar dissolves. Remove from heat. Whisk in oil, mustard, and black pepper. Add to bean mixture; toss to coat. Cover and chill for 4 to 12 hours, stirring occasionally.