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IVF at Sher Institutes: A Stepwise Approach
IVF success rates are dependent upon the number of the mature eggs and "competent" embryos available for transfer. A woman undergoing IVF is given fertility drugs for two reasons: (1) to enhance the growth and development of her ovarian follicles in order to produce as many healthy eggs as possible and (2) to control the timing of ovulation so that the eggs can be surgically retrieved before they are ovulated. In cases where the woman has previously received fertility drugs, the subsequent treatment protocol is largely based upon her response to the most recent such treatment regime. If a woman is receiving gonadotropins for the first time, the dosage and regimen is determined by her cycle day (CD) 3 blood FSH antimullerian hormone (AMH), Inhibin-B concentrations, medical history and body type.
Controlled Ovarian Hyperstimulation (COH)
At SIRM, in most cases, the woman begins her cycle of treatment by taking birth control pills (BCP) and having an ultrasound examination to exclude ovarian cysts. The BCP therapy is continued for 10-30 days before initiating daily injections of a Gonadotropin Releasing Hormone agonist (GnRHa) such as leuprolide acetate (Lupron). Both the BCP and Lupron are administered together for an additional two or three days, whereupon the BCP is stopped. The daily Lupron injections are continued until menstruation begins about 3 to7 days after stopping the BCP. By shortening the duration of time on the BCP it is possible to accurately plan the onset of menstruation. In this way we are able to schedule each cycle of IVF to the convenience of the patient and the medical team. Additionally, the combined use of BCP and Lupron reduces the likelihood of Lupron-induced ovarian cyst formation, thereby largely avoiding the need to delay or cancel the cycle of treatment.
As soon as menstruation begins, blood is drawn and if the plasma estradiol (E2) concentration is less than 70 pg/ml, the patient is ready to initiate ovarian stimulation with gonadotropins. If the E2 level is greater than 70 pg/ml, Lupron therapy is continued at the same (or an increased) dosage for a few more days, whereupon the E2 concentration is re-measured. Subsequent failure of the E2 to fall below 70 pg/ml is an indication for a pelvic ultrasound for the detection of an ovarian cyst, the presence of which usually mandates the performance of an ovarian cyst needle aspiration.
Lupron injections are either continued at a reduced daily dosage or (as is now becoming common practice at SIRM), we stop Lupron and switch to low-dose GnRH antagonist (Ganirelix or Cetrotide). On a designated day (usually within a week and a half of the onset of menstruation), a specified regime of gonadotropins (e.g., Gonal F, Follistim, Bravelle, and Repronex) therapy is initiated. Those patients requiring heparin therapy begin this treatment on the first day of receiving gonadotropins.
In a variation on this theme, patients whom have severely diminished ovarian reserve receive intramuscular Estradiol Valerate (E2V) injections (Delestrogen) and/or vaginal estradiol suppositories for a week or longer, prior to and during gonadotropin therapy.
Those patients who have a history of a poor endometrial lining may be prescribed sildenafil (Viagra) vaginal suppositories and oral terbutaline to attempt to improve the uterine lining.
Patients who have activated natural killer cells (NKa) as measured by a K-562 target cell test receive intralipid (IL) therapy by intravenous infusion 7-14 days prior to embryo transfer.
All IVF patients receive oral corticosteroids (dexamethasone or prednisone) daily, commencing with the start of ovarian stimulation and continuing until the first blood beta-hCG test (i.e., pregnancy test). Women who have rising blood hCG levels (a positive blood pregnancy test) 9-11 days after egg retrieval continue taking corticosteroid and heparin (when applicable) beyond the ultrasound confirmation of pregnancy, which is performed at the 6-7 gestational week.
In cases where the blood pregnancy test fails to reveal an appropriate increase in the quantitative beta hCG concentration, heparin therapy is discontinued, and the corticosteroid dosage is slowly reduced over a few weeks and then stopped. Pregnant women continue corticosteroid as well as heparin treatment until the 8th-10th week of pregnancy, whereupon the heparin is abruptly discontinued and the corticosteroid is tapered off over 1-2 weeks and stopped.
Two days after the initiation of gonadotropin injections, the dosage of gonadotropins is substantially reduced, and is then maintained at this lower level until the administration of HCG. Dosage adjustments are sometimes made during the course of the cycle, based upon the patient's response to medication.
Commencing seven days after the initiation of gonadotropin therapy, the patient undergoes serial ultrasound and plasma estradiol evaluations to monitor her ovarian response. These assessments are aimed at determining the ideal day for administering 10,000 IU of hCG to trigger the final maturation of the egg(s) and the production of progesterone by the ovaries. Lupron or Ganirelix/Cetrotide and gonadotropin injections are discontinued on this day and the patient is scheduled for egg retrieval approximately 35 hours after receiving the intramuscular injection of hCG. Subcutaneous heparin injections are discontinued approximately 12 hours prior to the egg retrieval and re-started after the embryo transfer procedure.
All patients receive an oral antibiotics beginning about seven days after the initiation of gonadotropin therapy and continuing for a few days after the embryo transfer procedure.
Egg Retrieval (ER)
ER involves a non-surgical procedure where, under direct ultrasound guidance, a needle is passed along the side of a vaginal ultrasound probe through the top of the vagina into follicles (small fluid filled spaces that each contain an egg), within the ovary(ies). The follicular fluid is aspirated and collected in a test tube, which is promptly delivered to the embryologist(s) for analysis and processing. The procedure itself is relatively painless, however patients commonly experience some residual postoperative abdominal discomfort and /or cramping that rarely persists for more than a few hours. Postoperatively, all patients are given detailed instructions and are discharged within an hour or two with a prescription for analgesics (pain killers) and other medications as indicated.
Sperm Processing
A sperm specimen is usually obtained from the male partner through masturbation. On some occasions however, physical, medical and/or religious constraints demand that sperm be obtained through condom collection following intercourse, or by inserting a needle directly into the testicle(s) under local anesthesia and aspirating sperm. The two variations of this procedure are known as Testicular Sperm Extraction (TESE) and Percutaneus Epididymal Sperm Aspiration (PESA). TESE and PESA are procedures of choice in cases where there is blockage of the sperm ducts (as occurs following vasectomy or following severe injury or infection), where the man is born without sperm ducts (congenital absence of the vas deferens), or in cases where as a result of testicular failure, sperm does not reach the ejaculatory ducts. Sometimes, in cases of retrograde ejaculation, sperm can be collected from the man's bladder. Infrequently, in men with spinal cord injuries, ejaculation is facilitated by electrical stimulation (electro-ejaculation). Donor sperm, obtained from a sperm bank, can be used when indicated.
Sperm must undergo a biochemical and structural changes known as capacitation, before an egg can be fertilized. Capacitation (which under normal circumstances takes place in the woman's reproductive tract) must be accomplished in the embryology laboratory prior to insemination of the eggs. Motile sperm are processed and activated in specialized culture media and sophisticated techniques are used to enhance poorly mobile sperm.
Fertilization in the Laboratory
Conventional IVF: In vitro fertilization literally means "fertilization in glass". Fluid aspirated from ovarian follicles is examined in the embryology laboratory. The eggs are identified and extracted, and are placed in a specialized culture medium. Several hours later, approximately 50,000-100,000 processed sperm are placed around each of the eggs. The eggs and sperm are allowed to incubate together in a carefully controlled environment. Approximately 16-24 hours later, the eggs are inspected microscopically for fertilization as evidenced by the presence of two nuclear bodies. These binuclear unicellular bodies are referred to as "pro-nuclear embryos".
Intracytoplasmic sperm injection (ICSI): The ICSI procedure involves the direct injection of a single sperm into each egg under direct microscopic vision. The successful performance of ICSI requires a high level of technical expertise. ICSI has literally revolutionized IVF. Initially, ICSI was used specifically to achieve fertilization in male infertility. When ICSI is employed in such cases, the IVF birth rate is unaffected by the presence and severity of the male factor. In fact, even when the absence of sperm in the ejaculate requires that ICSI be performed on sperm obtained through Testicular Sperm Extraction (TESE), the birth rate is no different than when IVF is performed for indications other than male infertility. Today, it is commonly used in conventional (non-male factor) cases. At SIRM, we advocate the use of ICSI in virtually all IVF.
Assisted Hatching: In selected cases where it is felt that the zona pellucida (the envelopment of the embryo/blastocyst) is unusually tough or thickened, a process known as assisted hatching (AH) may be employed. The process involves deliberately making a small aperture in the wall of the embryo (usually with a laser) so as to promote hatching (rupturing) and thereby facilitate implantation. It remains controversial as to whether AH actually improves pregnancy rates.
Selecting the Best Embryos for Transfer
Once embryo division (cleavage) has begun, the embryo will continue to divide at regular intervals. (Embryos that divide the fastest are considered the healthiest and the most likely to implant.) Embryos may be transferred 3 days after fertilization when they are divided to the 6-9 cell stage or as expanded blastocysts, 5-6 days post-fertilization when they comprise 100 or more cells with a small collection of fluid inside). Since embryos that fail to become blastocysts are almost always abnormal and incapable of propagating a healthy baby, it is my personal preference to preferentially advocate that blastocysts rather than cleaved embryos be transferred.
1. Graduated embryo scoring (GES) system: The GES system scores each individual embryo out of a maximum of 100 points. Those embryos that are not transferred to the uterus are subsequently re-examined 2-3 days later to determine whether they have developed into blastocysts. Embryos that on day 3 post fertilization have 6-9 cells and have a GES of >70, are the ones that are most likely to develop into blastocysts. Blastocysts are graded on the basis of their cellularity, differentiation of their outer cellular layer (the trophectoderm), the inner core of aggregated cells (the inner cell mass) and the development of a demonstrable collection of fluid inside the blastocyst (an expanded blastocyst) Blastocysts that contain more cells, have a more expanded blastocele, a more prominent inner cell mass and have a well differentiated trophectoderm have the highest grade and are the ones that are most likely to be "competent" (i.e. likely to propagate a viable pregnancy).
2. Early embryo transfer vs. blastocyst transfer: It has long been recognized that the more advanced the embryo's state and rate of development, the more likely it is to implant successfully into the uterine lining. It is also well established that "poor quality embryos" tend to divide (cleave) and develop more slowly, and are much more likely to arrest before reaching the blastocyst stage. It is therefore not surprising that researchers would focus on trying to grow embryos to the blastocyst stage in order identify "good quality embryos" that are more likely to implant successfully, by their ability to survive to the blastocyst stage of development.
3. CGH analysis of eggs and embryos: This very promising method of selection, currently in use at the Sher Institutes for Reproductive Medicine (SIRM), allows identification of all chromosomes, providing a much more complete analysis than its commonly used alternative – Fluorescence in Situ Hybridization (FISH). CGH performed on the egg/embryo overcomes the inadequacies of previous methods of embryo selection. A recent SIRM study published in Fertility & Sterility (May, 2007) and another soon to appear in the same journal demonstrates a birth rate of more than 60% per chromosomally normal embryo transferred. Now, for the first time, there is a highly reliable method for differentiating between "competent" and "incompetent" embryos.
With the advent of CGH embryo selection, the goal of "one embryo/one baby" is closer than ever to becoming a reality. CGH-based embryo selection also eliminates the current incentive to transfer multiple embryos at a time in order to improve the chance of success. Embryo selection by CGH holds the potential to decrease the cost per IVF baby and lead to a reduction in overall reproductive health care costs.
Embryo Transfer
Undoubtedly, embryo transfer (ET) is a rate limiting step in IVF. It takes confidence, dexterity, skill and a soft touch to do a good transfer. Of all the procedures in ART, this is inarguably the most difficult to teach. It is a true art and we have seen many women fail to conceive simply because this procedure was not performed optimally.
Shortly before the embryo transfer, the embryos/blastocysts are put together in a single laboratory dish containing growth medium. The laboratory staff informs the clinic coordinator that the embryos are ready for transfer, and the coordinator prepares the patient and informs the physician that a transfer is imminent.
Embryos/blastocysts are transferred to the uterus via a thin Teflon catheter. This procedure is conducted under ultrasound guidance with the woman on her back (in the lithotomy position) and with a full bladder.
Today all embryo transfers should be performed under direct ultrasound guidance to ensure proper placement in the uterine cavity. This practice, properly conducted, will significantly enhance embryo implantation and pregnancy rates. We prefer to perform all embryo transfers when the woman has a full bladder. This facilitates the visualization of the uterus by abdominal ultrasound and causes reflex nervous suppression of uterine contractility. The patient is allowed to empty her bladder 10-15 minutes following the embryo transfer.
It is important that the woman be as relaxed as possible during the embryo transfer because many of the hormones that are released during times of stress, such as adrenaline, can cause the uterus to contract. Accordingly we offer our patients 5mg of oral diazepam (Valium) about a half hour prior to the embryo transfer, to relax them and reduce apprehension.
Some IVF programs believe that imagery helps the woman relax and feel positive about the experience, thereby reducing the stress level. In such a program a counselor and/or clinical coordinator may help the woman focus on visual imagery for a few minutes immediately prior to embryo transfer so as to enhance her relaxation.
The embryo transfer procedure: When the woman is sufficiently relaxed, she is helped into the appropriate position and made as comfortable as possible. (In programs that rely on relaxation therapy, a counselor or nurse is usually present at the patient's bedside, coaching her in relaxation exercises during the procedure.) When the woman is in the proper position, and her bladder is adequately filled, the physician first inserts a speculum into the vagina to expose the cervix and then may clean the cervix with a solution to remove any mucus or other secretions. An abdominal ultrasound transducer is placed suprapubically on the lower abdomen and the uterus is clearly visualized. The physician then informs the embryology laboratory that embryo transfer is imminent and awaits the arrival of the transfer catheter that will be loaded with the embryos.
The physician gently guides the catheter through the woman's cervix into the uterine cavity. When the catheter is in place, the embryologist carefully injects the embryos into the uterus, and the physician slowly withdraws the catheter. The catheter is immediately returned to the laboratory, where it is examined under the microscope to make sure that all the embryos have been deposited. Any residual embryos would be re-incubated, and the transfer process would usually be repeated to transfer the remaining embryos.
The ET procedure is usually painless and takes less than thirty minutes to complete. Sometimes a prior trial embryo transfer (performed on the 8th day of gonadotropin stimulation) points towards potential difficulty in transferring the embryo(s)/blastocyst(s) to the uterus. In such cases, the procedure may be performed with patient under anesthesia.
Transmyometrial Embryo Transfer (TMET): In rare cases where the shape or partial obstruction of the canal leading in to the uterus (i.e. the cervical canal) severely complicates conventional embryo transfer, this method can be used. The patient is first anesthetized, then, using sterile technique, a needle is passed along the side of a transvaginal ultrasound probe through the wall of the uterus, into the uterine cavity. A very thin catheter is then passed through the needle with its tip protruding into the uterine cavity. The needle is partially withdrawn and the blastocyst(s)/embryo(s) are injected. After the embryo transfer, the woman remains immobile for approximately one hour and is thereupon discharged with specific instructions.
Post Embryo Transfer Management
Immediately prior to being discharged following the embryo transfer procedure, an exit interview is conducted, whereby the patient/couple is/are given directions.
Hormonal supplementation usually involves the administration of intramuscular injections of progesterone and/or vaginal suppositories (comprising estradiol valerate and micronized progesterone) until a blood pregnancy test is performed approximately eight days later (the chemical diagnosis of pregnancy). In selected cases, such progesterone treatment can be replaced with Crinone or Endometrin vaginal applications, once or twice daily. If the pregnancy test is negative or the plasma hCG levels fail to rise appropriately in the ensuing days, all hormonal support is abruptly discontinued.
A positive pregnancy test, followed by an appropriate rise in the plasma HCG concentration, is usually an indication to discontinue daily progesterone injections in favor of three times weekly intramuscular injections of hCG 5000 IU, along with daily vaginal estradiol and progesterone suppositories until the 8th week of pregnancy. In patients who experience an exaggerated response to ovarian stimulation with gonadotropins, hCG administration is withheld (for fear of increasing the risk of severe ovarian hyperstimulation), and intramuscular progesterone injections are continued along with vaginal estradiol and progesterone suppositories until the 8th week of pregnancy. Following an appropriate rise in HCG concentrations, the oral corticosteroids are continued until the 10th week of pregnancy. Thereupon, it is tapered down and stopped within a week or two. Heparin injections are continued until the 10th week of pregnancy and thereupon abruptly discontinued.
An ultrasound examination is performed approximately 2-3 weeks after the chemical diagnosis of pregnancy, at which time, designated patients with viable pregnancies, receive a final administration of intralipid (in some cases additional monthly doses of intralipid must be be administered ).
Embryo Cryopreservation (Freezing)
There have been dramatic advances in the technology of freezing and storing human embryos for future use. We cryopreserve (freeze) embryos as blastocysts. The recent introduction of "ultra-rapid freezing" (vitrification) which so rapidly freezes the embryo that it avoids ice formation in the blastomeres has revolutionized embryo freezing. Now, very few chromosomally normal embryos are lost in the freeze/thaw process and pregnancy rates with thawed pre-vitrified blastocysts are hardly different from that reported following the transfer of fresh blastocysts.
4 Responses to "IVF at Sher Institutes: A Stepwise Approach"
Thank you so much for your very detailed post. I am hoping to cycle next Spring and am so nervous. Your post helped ease some fears. Although I am still a little nervous about the trial transfer and actual since I had a difficult time with my HSG back in '07.
Thanks for the affirmation. This is the SIRM "culture", the way (with some variations on the theme) that we conduct IVF. It is not the only way, but after 32 years of developing the aproach (getting to here) it is clearly a "work in progress" but it has stood the test of time!
Good luck!
Geoff Sher
Geoff Sher
Dr. Sher- thank you so much for the information on TMET. I am a patient of Dr. Schultz, and my cervix has certainly been a "troublemaker" through-out this process. Yesterday was the 6th attempt to complete a fluid U/S, and it was still not successful due to the shape and extensive scarring of my cervix. Following my appointment, she said that she felt a gestational surrogate or TMET are our best chances at this point. She said she was going to try to consult with you on my case. Today has been very rough, trying to deal with everything. I pray that you will have some answers to help us on our journey for having a baby.
I interacted with MK on this and would be happy to do the TMET, but I cannot come to Illinois to do this. You would need to come to Las Vegas for the cycle.
Please discuss with your RE.
G-d bless!
Geoff Sher
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Almost 150 years ago, many Confederate soldiers, like numerous visitors atop Lookout Mountain today, peered off the rocky slopes down into the city of Chattanooga and never knew what lurked in the forest below, just beyond the river. Somewhat hidden on the ridge of Moccasin Bend were Union artillery batteries ready and waiting to pounce upon troops and supplies moving along the slopes of the imposing mountain.
As one Confederate put it, the "Moccasin battery, at the base of Lookout Mountain, was busy with its 'thunder tongues,' and … the shelling was, at times, incessant."
Take a hike to those Union artillery positions on Moccasin Bend in order to learn about the lives of those soldiers who were looking up toward the great mountain, defending the city against their Confederate foes.
As a reminder, comfortable, supportive footwear, appropriate clothing for the weather and water are recommended for this program.
For more information about programs at Chickamauga and Chattanooga National Military Park, contact the Chickamauga Battlefield Visitor Center at 706-866-9241, the Lookout Mountain Battlefield Visitor Center at 423-821-7786, or visit the park's website at nps.gov/chch.

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BERLIN, Vt. — Vermont has been awarded $30 million in federal funds and insurance payments toward the replacement of its state hospital in Waterbury, made unusable by flooding from Tropical Storm Irene, officials said Tuesday. |


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Ecoxotic Panorama Actinic Blue LED Light Fixture
Ecoxotic Panorama Actinic Blue LED Light Fixture
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Ecoxotic Panorama Actinic Blue LED Light Fixture
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Nature has selected for it, you should too.
It`s a well-known fact blue light penetrates the furthest in the ocean, your coral have naturally selected for this wavelength as a source of energy. Having a predominant peak wavelength of 445 nm the Panorama Actinic Blue provides your corals not only the spectrum for producing visually stunning colors, but the wavelength nature has selected for energy and growth.
Color it up and keep it colored up!
Adding the proper amount and type of blue light is known to be the one of the most important ingredients to getting your corals to color up and stay colored up. Due to the high levels of PAR in the Panorama Actinic Blue, achieving lasting vibrant coloration in your corals has never been easier.
Dawn, Dusk, Moon (Mood) Lighting
Introducing the 4th dimension of aquarium lighting, "Mood Lighting". Why limit your aquarium experience to just dawn and dusk lighting, with the simple turn of a dial you can adjust the intensity of the Panorama Actinic Blue to create eye popping mood setting effects. Treat your family and friends to a whole new dimension of aquarium enjoyment.
A Coral-Color-Popping-Shimmer-Machine
Lets face it, you want your corals to "POP" just like you have seen in photos. Now you can enjoy the rich colors your coral have been keeping from you. The intense shimmering blue stimulates the natural vibrant fluorescent colors in coral and fish, creating a whole new visual dimension. Now you don`t have invest in expensive photo editing software to get your corals to pop
Water resistant, low voltage, and mercury free keeps it safe for you, your fish and the environment. Operating on 24 volts means no induced voltage into your aquarium leading to ailments such as lateral line disease, and no risk of shock. Since there are no lamps to replace, there is no hazardous mercury for disposal.
Out of the Box Equipped
Place it directly on your aquarium with the docking mounts, or to the inside of your canopy with the retrofit brackets. All of the necessary hardware from brackets to dimmers makes it The Complete Lighting Solution.
Money Saving Efficiency
Exceptional performance doesn`t have to be at the expense of your wallet. Highly energy efficient LED`s make the Panorama Marine 50% more efficient than comparable 2xT5 HO fixtures and best of all, no annual lamp replacements. No other light offers you a return on your investment like the Panorama Marine.
445nm Blue LEDs
High PAR for increased coral growth and color
Dimmable, adjustable intensity
Complete system, includes all accessories
Cool, silent, ultra-safe voltage, water resistant
Sleek, low profile
50% more efficient than comparable T5 HO systems
Dimensions: 22.75" x 1.75" x 1"
Weight: 2.2 lbs.
Total Watts: 25
# of 445nm Blue LEDs: 20
Input Voltage: 24V DC Constant Voltage
Connection: DC Barrel 2.1 x 5.5mm
What`s Included:
Polished Reflector
Docking Mounts
Power Supply
Inline Dimmer
Canopy Brackets
Main Features
What's in the Box
Product Manuals & Documentation
Manufacturer Info
Ecoxotic Aquarium Supplies
Ecoxotic grew out of a small tribe of aquarium hobbyists who believed the focus of the aquarium industry was no longer on the hobbyist. Keeping an aquarium has become a chore: they are too complicated and the industry is fraught with inefficiencies and misinformation. Essentially, the thrill of having an aquarium is gone. So, we created a company where we could be more creative, spread our passion for change and cultivate a new tribe of hobbyists. Focusing on our core beliefs has resulted in a product line that is simple, elegant, easy-to-use and makes fish keeping fun again. When we design a new product, innovation, simplicity and environmental responsibility are core tenets for the team. We draw Inspiration from inside the hobby – specifically from freshwater, marine and reef aquarists – and outside the hobby (specifically our wives and their friends.) This design philosophy is applied across our entire product line, which includes modular LED aquarium lighting fixtures, integrated aquariums and accessories.
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its nice
2/27/2013 from Los Osos, CA UNITED STATES
Experience Level:
its a nice light great color sleek need 2 to light the hole 86g tank
2 of 2 People found this review helpful, did you?
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Ecoxotic Panorama Actinic Blue LED Light Fixture
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May 28, 2013
"Marine Depot has an awesome selection for all your saltwater needs. The website is user friendly and if you have any questions, the staff have an educated answer."
May 24, 2013
"Marine Depot had the best price I could find with quick shipping! I will definitely continue shopping with Marine Depot in the future."
May 21, 2013
"It's nice to have an online store you can trust! Great prices, great customer service! My orders have all been delivered on time or early. If you have questions they have answers. Marine Depot is MY store!"


text: 25 years ago, in the summer 1987, Eldhestar started to offer guided tours in the area around the volcano Hengill. To celebrate this 25 eventful years, we not only organized two Anniversary Tours – the "Paradiestour" and "Landmannalaugar from the West". We also gave out a book together with the photographer Elisabeth Haug. Eldhestar – Fun, Wide Vision & Adventure just arrived from the printer and we are very proud to hold our very first own book in our hands. On 70 pages we share with you pictures from our tours as well as memorable stories from the past years. Elisabeth shares her magnificent pictures and describes her insights to the company and the beautiful Icelandic horse. We hope you will enjoy our stories and pictures from 25 years with Eldhestar and have a good laugh about the one or other thing that went wrong during the years on our tours.


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History will be written at the Geko Ypres Rally this year, as both Peugeot and Ford will showcase their new R5 cars. The new Ford Fiesta R5 will be driven by Belgian world rally championship driver Thierry Neuville, while former Geko Ypres Rally winner Kris Meeke will be at the wheel of the Peugeot 208 T16.
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This cozy and elegant restaurant serving Mediterranean cuisine and author,has plenty to offer in their menus, Cocktails, Spanish Wines,Gastronomic Menu and all paired with our wines of Castile and the restof Spain. Restaurant"Panoramic" with its unbeatable views, hosts a range of customers from all segments, since it can accommodate up to 200 people, where you can enjoy from a romantic dinner to enjoy a tailor made menu of the client, with the help of our entire team of professionals who will be during your evening.
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text: Main Content Senate Bill 0178 (2003) rss friendly link printer friendly Sponsors Beverly S Hammerstrom - (primary)Gilda Jacobs, Ron Jelinek Categories Education, teachers; Education, employees; Safety, Education; teachers; certification in cardiopulmonary resuscitation; require for new teacher certification. Amends 1976 PA 451 (MCL 380.1 - 380.1852) by adding sec. 1531d. Bill Document Formatting Information [x] The following bill formatting applies to the 2003-2004 session:- New language in an amendatory bill will be shown in bold (rather than UPPERCASE).- Language to be removed will be stricken.- Amendments made by the House will be blue with square brackets, such as: [House amended text].- Amendments made by the Senate will be red with double greater/lesser than symbols, such as: <<Senate amended text>>. (gray icons indicate that the action did not occur or that the document is not available) Documents Senate Introduced Bill Introduced bills appear as they were introduced and reflect no subsequent amendments or changes. As Passed by the Senate As Passed by the Senate is the bill, as introduced, that includes any adopted Senate amendments. As Passed by the House As Passed by the House is the bill, as received from the Senate, that includes any adopted House amendments. Senate Enrolled Bill Enrolled bill is the version passed in identical form by both houses of the Legislature. Senate Fiscal Analysis COMMITTEE SUMMARY (4-29-03)This document analyzes: SB0178 History(House actions in lowercase, Senate actions in UPPERCASE) Date JournalAction 2/12/2003SJ 12 Pg. 132REFERRED TO COMMITTEE ON HEALTH POLICY


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19Dec |
University closedownThe University of Newcastle will be closed from 5pm on Wednesday 19 December 2012 until 9am on Thursday, 3 January 2013. Find out more… |
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Mental health and mining in the research spotlightAn internationally-respected mental health researcher at the University of Newcastle will lead an important new project into the extent and impact of mental health problems in the Australian coal industry. Find out more… |
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text:
Area #sales Total sales Median sales
Catoosa 47 $6,121,134 $112,900
Walker 31 $3,447,125 $93,900
Dade 11 $1,410,050 $104,250
Whitfield 10 $962,500 $81,000
Chattooga 2 $159,632 $79,816
Totals 101 $12,100,441 $101,200
Based on the above stats, there is a small decrease in the total number of sales compared to September sales of 110. There is also a decrease in the total dollar sales compared to September. The median sale increased for October compared to September's of $99,650.
Information on this report is not guaranteed. There is no express or implied warranty by the MLS of the accuracy of information, which should be independently verified. Article prepared and submitted by Sales Manager/Associate Broker Joanna Jackson with Jackson Realty.
Article prepared and submitted by Joanna Jackson, sales manager/associate broker with Jackson Realty.


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£179,649 pa
Office to rent Bruton House, Whitfield Street, Gloucester, GL1
The ground floor configuration provides a dedicated reception suite and separate access to the upper floors. The combination of ground floor reception and offices and first floor suite may be highly suitable for a public facing organisation. CAR PARKING available.
£153,696 pa
Office to rent 69 London Road, Gloucester, Gloucestershire, GL1 3EH
Located in a prominent position on London Road a main arterial route from the M5 Motorway into Gloucester City Centre. Prospect Point is laid out over five floors with a central core.
Office to rent Pullman Place, Gloucester, GL1
The property offers a GOOD SPECIFICATION with mainly open plan floor plates, raised access floors, air conditioning and 2 passenger lifts. There are male and female toilets on each floor and there is a GENEROUS LEVEL OF PARKING with 23 spaces allocated to each floor.
Office to rent 7th Floor Llanthony Warehouse, Llanthony Road, Gloucester, Gloucestershire, GL1 2EH
The suite comprises the 7th floor and offers two large open plan areas. There are kitchen facilities within the suite and both male and female wcs on level 6.
Office to rent Pullman Place, Great Western Road, Gloucester, GL1 3EA
The property offers a good specification with mainly open plan floor plates, raised access floors, air conditioning and 2 passenger lifts. There are male and female toilets on each floor and there is a generous level of parking with 23 spaces allocated to each floor.
Office to rent 3 to 4 The Parade Court Road, Brockworth, Gloucester, Gloucestershire, GL3 4EW
1st Floor offices are accessed via a separate front door and stairway. The offices are provided with kitchen facilities, WC , air conditioning and gas fired central heating.
Light Industrial to rent Unit 14, Severnside Trading Estate , Gloucester , Gloucestershire, GL2 5HS
Severnside Trading estate is situated on Sudmeadow Road to the south west of Gloucester City Centre. Junction 12 of the M5 Motorway is only a short distance away. The property comprises a mid terrace industrial unit of steel frame construction with brick block walls and profiled cladding to the ...
Office to rent Lennox House, 7 Beau Spa Road, Gloucester, Gloucestershire, GL1 1XB
Grade II Listed building comprising end of terrace 3 storey building plus basement, linked via an accommodation bridge to a modern four storey building. The buildings are traditionally constructed and provide modern amenities including kitchen facilities.
£113,212 pa
Office to rent Southgate House, Southgate Street, Gloucester, GL1
The property comprises a four storey purpose built office building originally built for the Bank of England in the early 1990s. Facilities include a MANNED RECEPTION, passenger lifts raised access floors, CAR PARKING, air conditioning to the ground floor and mechanical ventilation to first floor.
£93,550 pa
Office to rent Spa Road, Gloucester, GL1
TO LET the Grade II Listed Lennox House Building. The office comes with 46 CAR PARKING SPACES and is set over TWO BUILDINGS linked by an accommodation bridge. Building one is set over THREE STOREYS and building two is set over FOUR STOREYS.


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By Lisa J. Ariffin
KUALA LUMPUR, May 10 — Indonesian human rights activists alleged that Malaysia is the "most unsafe" destination for their migrant workers and urged Jakarta to freeze all diplomatic ties with Malaysia until the issue is rectified.
The Jakarta Post reported today that the activists asked Indonesian President Susilo Bambang Yudhoyono to take tough action against the Malaysian government, which they hold responsible for alleged violence against Indonesian migrant workers, until Putrajaya improves protection for the group.
"Among the destination countries for migrant workers, Malaysia is the most unsafe for Indonesian workers as between 600 and 700 Indonesians die of various causes, including torture, shooting and exploitative acts by their employers," Migrant Care executive director Anis Hidayah was quoted as saying by the Jakarta Post.
She added that Yudhoyono did not have to consider the "brotherhood" between the two countries and urged the premier to be tough instead.
Thaufiek Zulbahary of Solidaritas Perempuan, an NGO providing legal advocacy for female migrant workers, said the Indonesian government should also delay sending workers to Malaysia until the government takes steps to protect them.
The activists also accused Putrajaya of intimidating Malaysian human rights activist Irene Fernandez, the executive director of Tenaganita, "who has long stood up for migrant workers".
The Jakarta Post had on Monday reported Fernandez as saying, among others, Malaysia was not safe for Indonesian workers because it did not have a legal framework or specific laws to protect migrant workers.
She was also reported to have said that it was not in the police's power to shoot dead three Indonesian nationals, who had been suspected of burglary and robbery, in an incident in Port Dickson recently.
Fernandez has since come under heavy fire locally for her criticism, which detractors say has painted Malaysia in a negative light, was unpatriotic and be detrimental to Malaysia's bilateral relations with Indonesia.
Yesterday, Fernandez announced that she has been hauled up by the Malaysian Anti-Corruption Commission (MACC) for an "interview" tomorrow over statements attributed to her that alleged corruption by police and the court system here.
She has since disputed the remarks and said The Jakarta Post will print a correction to the article.
But while Fernandez said she would willingly offer her statements to the graftbusting agency, she stressed that she would not back down from her stand that Malaysia continues to be a "completely" unsafe environment for Indonesian workers.
The activist, who was once jailed for exposing the allegedly poor conditions at local immigration centres, also refused to apologise for her statements, demanding instead that the government and her critics apologise to her.
She will meet with MACC officials at its Putrajaya headquarters at 10am on Friday.
Indonesia recently lifted the moratorium on the supply of domestic workers to Malaysia, but Indonesian Manpower and Transmigration Minister Muhaimin Iskandar has repeatedly said Jakarta would not send workers until Putrajaya could ensure their protection.


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Contact us
Building Services
Phone Hours 8am - 5pm
Counter Enquiries 8:15 - 4:30
(08) 9550 3749
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Building Services
The commencement of the Building Act 2011 on 2 April 2012 introduces a new building approval process for Western Australia.
The Building Act and the Building Regulations 2012 replace the Building Regulations 1989 and much of the Local Government (Miscellaneous Provisions) Act 1960, and amends a range of associated acts.
Building Services is responsible for the assessment and approval of building works within the City of Mandurah under the Building Act 2011. Building Services is also responsible for the assessment and approval of works under the Caravan Parks and Camping Grounds Act 1995, including Park Homes and Annexes.
Under the Building Act 2012 a building permit is required before commencement of most building work. In many cases the builder obtains the permit.
Formal approval (a building permit) is required for any building work involving the development of new structures, alterations or extensions and changes in ground levels. These include:
- Swimming Pools & Spas
- Sheds/ Garages/ Workshops
- Patios/ Verandahs/ Gazebos/ Pergolas
- Retaining Walls
- Residential Dwellings/ Granny Flats/ Additions & Alterations
- Commercial Buildings including fitouts and refurbishments
- Industrial Buildings
If the total value of the work exceeds $20,000 a permit can only be issued to a registered builder or in some circumstances an owner builder.
Greater detail is provided in the relevant information sheets by clicking here.
Building Services also offers the following non-statutory services:
- Confirmation that Planning Environmental Health and Infrastructure requirements have been met prior to lodgement of a Permit Application
- Detailed project advice from a Building Surveyor
- Certificate of Construction Compliance
- Certificate of Building Compliance
Please contact Building Services direct on 9550 3749 for further details on these services.


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- Price: $75.00
- Exclusive Price: $4000.00
Expert Business Website Template 39871 Resources Page
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5th Annual Latino Open Golf Tournament
- May 04, 2012
- Location: Reunion Resort and Club
- Address: 7593 Gathering Drive, Reunion, FL 34747
- Time:1:30 pm
- Admission: Prices vary
- Event Website
- firstname.lastname@example.com
- Add to Itinerary
The 5th Annual Latino Open brings together golf enthusiasts and community leaders for a good cause. Immediately following the tournament, participants can attend the 19th Hole Winner's Hour Reception. During the reception, golfers will receive individual and team awards while enjoying dinner and beverages, live entertainment, a live art auction and more.


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Letters from April 12, 2000
A city task force is aggressively suing business owners, some of whom are facilitating crime in their neighborhoods. And some of whom are just making donuts.
Find everything you're looking for in your city
Find the best happy hour deals in your city
Get today's exclusive deals at savings of anywhere from 50-90%
Check out the hottest list of places and things to do around your city


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Person Page
John Newton (Newton) Oliphant
A member of the infamous Quantrill's Raiders and Bloody Bill Anderson's Confederate guerrillas in MO during the Civil War. Killed in action in Oct. 1864. His family home in Johnson Co., MO, was burnt down in the spring of 1862 along with several others, reportedly by the local Union militia. The house was said to be a meeting place for "bushwhackers," and Capt. Houts had been heard by a number of persons threatening to set fire to the place.
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Never been to Morro de Sao Paolo before, and the island is beautiful (of course). Hotel was somewhat disappointing. Located on the 3rd beach, a bit far from the "hub" of activity and even farther from the port. Cost is reasonable as a less expensive option. Rooms are clean, but minimal. Huge swimming pool is a BIG plus. Have to... More
- Also Known As:
- Hotel Village Paraiso Tropical Morro De Sao Paulo, Brazil - Bahia
- Official Description (provided by the hotel):
- Village Paraiso Tropical is nestled in one of the most breathtaking and pristine areas of Brazil, Morro De Sao Paulo. Located on the norther part of the island of Tinharè, 60 kilometers south of Salvador Bahia, Morro is the perfect destination for the more demanding and discerning traveller, and Hotel Village Paraiso tropical is the optimum choice for those who love untouched natural scenery worlds away from a frenetic modern lifestyle; the ideal place in which to savour warm Brazilian hospitality offered with international standards and quality. ... more less
- Reservation Options:
- TripAdvisor is proud to partner with Booking.com, Hotels.com, Expedia, Venere and Priceline so you can book your Hotel Village Paraiso Tropical reservations with confidence. We help millions of travellers each month to find the perfect hotel for both holiday and business trips, always with the best discounts and special offers.


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The median home value in Mechanicsburg, OH is $97,600. This is lower than the county median home value of $108,800. The national median home value is $152,300. The average price of homes sold in Mechanicsburg, OH is $97,600. Approximately 56.48% of Mechanicsburg homes are owned, compared to 32.64% rented, while 10.88% are vacant. Mechanicsburg real estate listings include condos, townhomes, and single family homes for sale. Commercial properties are also available. If you see a property you're interested in, contact a Mechanicsburg real estate agent to arrange a tour today! Learn more about Mechanicsburg Real Estate.
Elegant and stunning describe this custom built brick home. Driving up the tree lined lane you'll love this stately home. The huge entry greets you with beautiful tile, woodwork and view of the great room. The vista view from the large corner windows in the grt rm is gorgeous! With nearly $100,000 in updates you'll be impressed. Updates include new wood floors, chimney/fireplace, oven and tile backsplash, new front windows, and more. The gorgeous, new roof is a barrel style, stone covered steel roof with a 50 year warranty. The kitchen is large and open to the family rm. The master suite is a retreat with huge closet and spa-like bath. The LL is a walkout and is mostly finished. No detail missed here with marble floors, high ceilings. It is plumbed for a full bath and wet-bar. This space is perfect for entertaining. The park-like setting is both relaxing and inspiring, you simply must experience it. An additional 6+ acres is available! See it today and make it yours!
This one owner home has been meticulously cared for inside and out with heart and soul. Built in 1998. Sitting on 1.104 ac.lot. From the moment you walk in the front door you will fall in love with the huge Great room, with cathedral ceilings, Fresh paint, New carpet,nice windows and a door that leads out to a private deck and Screen in porch.The dining room has a tray ceiling and Fresh paint, New carpet and loads light.Super nice kitchen w/nice cabinets, pantry, New lighting, New faucet, New bead board.There is a laundry/mud room off of the 2 car attached garage. Bathrooms are updated with, sinks, toilet, flooring, & fresh paint. The Three bedrooms are beautifully painted with New carpet, ceiling fans,nice size closets. Basement is a walk out & super clean w/waterproofing painted walls loads of storage. There is also a HUGE pole barn with electric and water, pellet stove for heat and 1 automated door opener.
14x70 mobile home stationed on 1.288 acres in the country. Home can be built on land or exchange mobile home out for a double wide. Rely on your own measurements.
Real Living Petkus Realtors 210 West National Road Vandalia, OH 45377 Email Us | Visit our Real Estate Website


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19th Jun 2013
GE Thinks it's Time to Put Industrial Data in the Cloud
Internet tools are just starting to be applied to industrial tasks such as maintaining equipment and optimizing operations, but the wealth of data being produced by industrial systems could make this a major focus of development in the coming years.
19th Jun 2013
Microsoft Slashes Surface RT Prices by 60% for Schools
Microsoft today confirmed that it has heavily discounted the Surface RT tablet to universities and K-12 schools, cutting the price of the entry-level model by 60%.
19th Jun 2013


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Every now and then, a book comes along that transforms my body and soul–in the literal sense too because I starve and sleep-deprive myself in order to finish reading as soon as possible. There was The Time Traveler's Wife, The Eyes of the Dragon, Food for Millionaires, Life of Pi, A Great and Terrible Beauty, My Sister's Keeper, Eat Pray Love, The House of the Spirits, The Harry Potter series and much much more but I am terrible at remembering titles.
The Hunger Games is no exception. In fact, if anything, it is like all my favorite books rolled into one fantastic trilogy. There's the love story, the action, the drama, the mystery, the conspiracy, the humor, the meaningful message that stays with you on the state of our world.
Continue Reading »


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Elmhurst Apartments for Rent
(show city information)Apartment Finder is the ultimate tool for searching for apartments for rent in the Elmhurst, IL area. With map-based searching, you'll find just what you are looking for in minutes. You can customize your search many ways and your results will be refreshed in a flash. Browse apartment communities in real time, with photos, floor plans, and more! Your search for Elmhurst, IL apartments is over. The Apartment Finder features include faceted browsing, map-based search, and search results by neighborhood, county, university campus, military base and more. If you are seeking a Elmhurst, IL apartment for rent, you have come to the right place.
The Retreat at Danada Farms 22 Vivaldi Court, Wheaton, IL 60189 Map1 BR - 3 BR$1,310 - $3,080(877) 243-5789
Wheaton 121 121 North Cross Street, Wheaton, IL 60187 MapStudio - 3 BR$1,260 - $3,350(877) 531-3812
Elm Creek Apartments & Townhomes One Elm Creek Drive, Elmhurst, IL 60126 Map1 BR - 3 BR$1,284 - $7,017(877) 526-7601


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Site Archives used brand names
High-End Consignment Shopping: Two Warnings
With the economy in the doldrums, many people are getting their luxury fix by shopping at high end consignment stores. These stores specialize in luxury goods and brands. It's possible to pick up Prada, Tiffany, Gucci, and other high end brands for a fraction of what they would cost new. Many items have been used [...]
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Find what you're looking for quickly by using our keyword search. Can't find it? Try our links below.


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By Jeff Walsh
A lot of times, when reviewing gay movies, I think that I am judging them far more critically than they may have been intended. Usually this frame of reference occurs when I think of the number of movies I have enjoyed in packed theaters of gay audiences, where every sassy comment and sexual remark was met with roaring laughter and people yelling back at the screen.
When I'm writing a critical review of a movie, I often wonder, would I have enjoyed this movie if I had watched it in that setting, as opposed to just popping in a DVD at home, myself, after work? It doesn't mean the movie would be any better, of course, but just shows how much the power of community can inform the experience.
On Sunday, I had the opposite experience watching an almost-completed print of "We Were Here: Voices from the AIDS Years in San Francisco." I knew it was going to be a heavy movie, given the subject matter, but I had no idea just how palpable the depths of sorrow flowing through the audience would be.


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Old School Activity Workouts
Work these activities that come with a built-in workout into your routine.
More Galleries
Want to make her orgasm? Here are 9 (sexologist-approved!) sex positions that'll get her off every time.
Watch six trainer/athletes attempt to power through a 15-minute full body CrossFit workout.
Copyright © 2013 Weider Publications, LLC, a subsidiary of American Media, Inc. All rights reserved.


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Dramatic Funk Themes Vol 2 – Thrilling Rare Grooves From UK's Leading Music Libraries1970-1980Various
CD (Item 490331) Show Up (Germany), 1970s — Condition: New Copy
Stunning funk from the UK sound library scene of the 70s – a second great entry in this series that really ups the ante for the genre! The tunes here are pulled from a host of leading production companies at the time – and they offer up a sweet array of instrumental modes from the period – from jazzy riffing grooves to more ambitious soundtrack numbers with a really complicated vibe – yet one that never strays from the core funk promised in the title! In addition to offering cover scans of the original record, the package also tells a brief history of each imprint involved – Peer, Rouge, Programme, Bruton, and others – kind of a mini-lesson in sound library stalwarts – set here to some very groovy tunes. Titles include "City Police" by Dave Gold, "Nevada Junction" by Steve Gray, "Hot Property" by Keith Mansfield, "Fuel Injection" by Alan Hawksworth, "Flash Barrier" by John Hawksworth, "Beatin It" by T Elerth, "Thrust" by Nick Ingman, "Fast Drive" by Frank McDonald & Gerry Shury, "Gun Man" by John Saunders, "Product Efficiency" by Johnny Pearson, "Punch Drunk" by Duncan Lamont, "Riff Raff" by Martin Kershaw, and "Hit Man" by Sound Prospect. © 1996-2013, Dusty Groove, Inc. |
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Cosmic Future Groove Vol 1 – Spaced Out Disco & Funkified Electronic Themes 1975 to 1987: Spacey funk and electronic sound library grooves from the mid 70s to early 80s – great stuff with a focus on the neon lighted, pulsating synth enhanced sounds of a perceived future – and previously ... read more Sound Library (CD) 16.99 |
Colours Of Funk – German Sound Library Of Golden Ring & Happy Records 1974 to 1979: Heavy funk in a variety of cool colors – the first-ever collection of work from German sound library labels Golden Ring & Happy Records – and a real revelation to our ears! Grooves are ... read more Sound Library (CD) 19.99 | ||||
Chorus: The "chorus" in the title is appropriate – as there's a flurry of wordless vocals in the mix of this one! The record feels a bit like some of Ennio Morricone's more vocal-oriented soundtracks ... read more Sound Library (CD) 9.99 |
Soundsational Sort Of Soul (Soundsational/Birds & Brass Are Back): Birds, brass, and plenty of grooves – two sublime UK sound library sets, back to back on a single CD! "Birds" here is used in the UK slang for women – and the combo sports wordless ... read more Sound Library (CD) 6.99 | ||||


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USA's Venus Williams (C) attends the French Tennis Open match of her sister USA's Serena Williams playing against France's Caroline Garcia at the Roland Garros stadium in Paris, on May 29, 2013. AFP PHOTO / KENZO TRIBOUILLARDKENZO TRIBOUILLARD/AFP/Getty Images
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1 Meetup Group matches "New York Jets Football" near San Diego, CA
Welcome to the biggest and best Jets fans group in San Diego. Come join us this season and watch what may be the most celebrated Jets team since our Super Bowl III squad! J-E-T-S! Jets! Jets! Jets!
Get an alert email when new Meetup Groups like this start near you.
You'll get advice, help finding members, and tools to make running a Meetup Group easier.


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