text:
Trash Stash
[edit] Project Name
Trash Stash
[edit] Proposer
Jarrod Hicks firstname.lastname@example.com
[edit] Summary
Create a trash and utility room behind the kitchen
[edit] What Will Be Done
Please see the drawings for further clarification.
File:Noisebridge - Sheet - A503 - Trash Stash.pdf
Clean out the room. Remove the existing open framing. Remove the dishwasher and the cabinetry above it. Open up the Kitchen wall behind the dishwasher. Move the water heater further from the entrance to the room. Install organizational hardware for cleaning equipment. Move trash cans into space. Bonus: Install floor sink for cleaning, filling, and emptying mop buckets.
[edit] What Areas in the Space Will This Affect
Kitchen and the storage room south of it.
[edit] Who Will Be Doing It
Jarrod Hicks and anyone I can convince to help.
[edit] Why This Will Be Good
We can relegate all the trash and cleaning equipment to a place more out of sight. And possibly reduce its visual and olfactory presence in the space. A floor sink would make mopping easier, which may lead to it occurring more often. It would also provide a place to keep more hazardous cleaning away from the dishes. The framing material may be useful for other changes.
[edit] Why This Will Be Bad
The addition of a floor sink is expensive, and pluming and drainage issues are a risk. The room may need to be reframed if the existing framing is providing some sort of structure.
Johny Radio: I suggest the room behind the kitchen is far too potentially useful, due to it's proximity to the kitchen, for projects, such as vinegar making, mushroom growing, other food-hacking projects, storage of large bulk food containers, such as raw coffee beans being brought in by the coffee hackers. I suggest the elevator anteroom (currently used for nothing in particular) is a superior location for storage of large trash bins. For one thing, it's close to the elevator, so trash barrels do not need to be hauled through Noisebridge to get them to the elevator. And, it keeps possible flies and other pests away from the kitchen. The barrels should be enclosed in an air-sealed unit, to prevent infestation.
[edit] How Long Will It Take
Unknown, but closure should not be required.
[edit] In A Fantastic World, What Extra Budget Would You Like
Money for pluming and the sink will be required. If the room doesn't need additional framing, then the rest of the project is demo and throw out work.
[edit] Are There Any Other PFAs This Would Work Well With
The fermentation / Biohacking storage loft.
[edit] Are There Any Other PFAs This Would Contradict
Not currently


text:
Perennially packed, noisy with chatter and with tables spilling on to the broad pavements of Chiswick High Road, this venture (from the Soho House group) continues to strike a chord with the dapper denizens of W4. Pitched between a grand café and an art deco bar, it's cleverly nailed a look that transcends generations; parents and teenagers can dine together at a venue that offends neither's sensibilities.
The all-day menu is accessible, featuring fail-safe favourites such as full english breakfast, buttermilk pancakes, croque monsieur, steaks from the grill and simple mains such as plaice goujons with fries. Vitamin smoothies are an antidote to the comfort food, but given that our waitress visibly wrinkled her nose when describing their hyper-nutritious contents, we're not sure how often they're ordered.
Mostly, customers are here for hangover-friendly dining. A fish pie was packed with succulent chunks of salmon and haddock, while avocado on toast came with a perfectly poached egg. Desserts are knowingly retro: black forest gateau or crêpes suzette, for instance. Prices are a little high, given that portions are on the modest side, but no one here gives a hoot.
|Venue name:
|High Road Brasserie
162-166 Chiswick High Road
|Opening hours:
|Meals served 7am-11pm Mon-Thur; 7am-midnight Fri; 8am-midnight Sat; 8am-10pm Sun
|Tube: Turnham Green
|Main courses £11-£16
|View Menu
|Do you own this business?
You may be interested in:
Average User Rating
3 / 5
Rating Breakdown
- 5 star:0
- 4 star:2
- 3 star:3
- 2 star:0
- 1 star:1
Chic and elegant...great for people watching. Great food and amazing raspberry flirtinis!
Nice winelist, decent food, commited service. Advisable to ask for a quiet table to avoid en vogue Chiseick show offs, parading their screaming kids around.
I used to really like this place for a simple midweek meal. As previous users have said, they once did an excellent beef burger. But the quality of the food has absolutely nose-dived over the last year, going from quite good for simple dishes, to completely inedible. Such a shame. (Unlike others, I've always personally found the staff to be very pleasant.)
Not up to the standards of the other Soho House venues. Food is decent and they do make a pretty mac & cheese off the menu, but the attitude of the staff is generally poor. You'd think being in Chiswick, where most diners are local, you'd go out of your way to keep people happy but I've not found that to be the case.

subset: commoncrawl


text:
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text:
Welcome to PCS Events!
PCS Event Productions is a Miami Catering and Event Design Company dedicated to producing exceptional events in the South Florida area - Miami, Ft. Lauderdale, the Palm Beaches and the Upper Keys.
Our IN-HOUSE services include:
- Catering & Customized Menus
- Equipment Rentals
- Premium Linen Rentals
- Lighting & Draping
- Lounge Furniture Rentals
- Floral Arrangements
- Chuppahs, Arches & Ceremony Decor
- Cakes for Special Events
- Dessert Stations
- Event Planning
Weddings & Bridal Showers
Every wedding is as exceptional as the couple getting married and at PCS Event Productions we love making your dreams come true. Let us take care of all the countless details while you enjoy the most memorable day of your life. With several packages available to suit your budget while expressing your one-of-a-kind style, we will take care of as many or as few of the details as you like.
Learn more about the perfect wedding.
Corporate Functions
We have extensive experience in staging corporate functions, national conferences, sales meetings, holiday parties, grand opening receptions & other business events.
Let us empower your business. Learn more about corporate events.
Private Parties
PCS Events offers custom menus uniquely tailored to your event and expressly deisgned to suit YOUR STYLE and BUDGET--with options for every occasion.
- Birthdays
- Baby Showers
- Graduations
- Proms
- Intimate Dinners
- Fundraisers
- Charity Events and much more!
Let us bring your party to life.


text:
by Nancy Campbell of Above Rubies - Do You Have Sons? As he was nearing death, David encouraged his son, Solomon with these words, "Be thou strong therefore, and show thyself a man" (1 Kings 2:2). The HCSB translation says, "Be strong and be courageous like a man." I like the Knox Version. Wherever it talks about being strong and courageous, he translates it, "Play the man." In other words, to act like a man means to be strong and courageous. … [Read more...]
Quoting Quiverfull: Raising Men Not Wimps?
Quoting Quiverfull: Navel Gazing Teens?
by Scott Brown of The Marriage Blog and Ladies Against Feminism - The Problem With 17 Year-Olds Who Hang Around 17 Year-Olds Time Magazine recently came out with an article,"The New Greatest Generation", contending that the idea of seventeen year olds hanging out with seventeen-year olds is a bad idea. … [Read more...]
Quoting Quiverfull: Practicing For Divorce?
by Vaughn Ohlman of Persevero News - Practice For DivorceOur modern society… including the church, has implemented forms of getting married that are, literally, practice for divorce. Oh, they don't go by that name, but they follow that pattern, they implement those principles. … [Read more...]
Quoting Quiverfull: Why Have Babies?
by Candice Watters from the Boundless blog and Ladies Against Feminism We live in a world where people take great pains and lots of pills to prevent babies when they don't want them, and spare no expense to get them when they do. According to our culture, babies before you want them are an accident, mistake or crisis — a result of a birth control failure. And if you can't have them naturally when you decide you're ready, … [Read more...]
Fascinating Womanhood Review: The Ideal Woman
by Samantha cross posted from her blog Defeating The DragonsThis chapter is titled "The Ideal Woman: From a Man's Point of View," making sure, in case we forgot, that women's lives need to revolve around men, and there's also plenty of "if you don't do what I tell you to, your husband will never love you" to go around. This is the chapter where she explains two terms that Helen will be using throughout the book: "angelic qualities," and "human qualities." There's even an amazing little diagram at the end of the chapter: … [Read more...]
Quoting Quiverfull: What is a Christian Homemaker?
by Jennifer from her blog The Focused Homemaker In our feministic culture we may not know what a homemaker truly is and what she truly does. Have you recently quit your job to become a full-time homemaker? Maybe you've recently married or just had your first child and won't be returning to college. In any case, my desire today is to encourage homemakers, new and "old-pro" alike. … [Read more...]
Quoting Quiverfull: Let's All Have More Babies!
by Vaughn Ohlman of Persevero News in Demographic Death Demographic Death. The death of a society or group due to a lack of birth, or an abundance of death. Not a literal killing of everyone, or a complete cessation of births, but that point, mathmatically, where a society tips over into oblivion. … [Read more...]
Quoting Quiverfull: What Boys Like?
by Anna Sophia and Elizabeth Botkin of Visionary Daughters - Brothers and Sisters in Christ: How to Think About Young Men A number of young women have asked us about relationships with young men. They want to know how a young woman should interact with those of the opposite sex, or should she at all? … [Read more...]
Voices of Sister-Moms: DoaHF's Story
Cross posted from Heather Doney's blog Becoming Worldly"DoaHF" is a pseudonym chosen by the author. Her story is part of a "Voices of Sister-Moms" blog series here on Becoming Worldly.Introduction: Quiverfull Sorority of Survivors (QFSOS) and Voices of "Sister-Moms" … [Read more...]
Quoting Quiverfull: Is Racism Driving the QF Movement?
by Nancy and Colin Campbell from a transcript from an Australian television show called A Woman's PlaceMike Munro is the narratorMike Munro: This church teaches that true happiness can only be achieved if women obey their men. … [Read more...]


text:
Associated Press
GOLD BAR — Rescuers are responding to an emergency beacon alert from a missing hiker in eastern Snohomish County.
KIRO-TV reports the alerts began around 10:30 p.m. Wednesday from the 2,400-foot elevation of Mount Persis, which is off U.S. 2 east of Gold Bar.
The hiker is described as a 39-year-old man from Seattle.
A mountain rescue team and helicopter waited for daylight Thursday to begin the search.


text:
Rent San Francisco Giants 1st edition today, or search our site for other textbooks by Tucker Elliot. Every textbook comes with a 21-day "Any Reason" guarantee. Published by Black Mesa Publishing.
Need help ASAP? We have you covered with 24/7 instant online tutoring. Connect with one of our Statistics tutors now.


text:
Patience premiere tomorrow night at the party block in ocmd. The doors open at 830 and the show starts at 930!! Half price booze and ballyhoo! on stage!!! let me know if you can make and well do some shots.
thursday night Patience premiere at liquid surf shop in DE. Starts around 8. outside on the big screen. BYOB!!!!
let me know if you are planning on making any of these


text:
3. Northstar-At-Tahoe, California
Jussi Oksanen, Northstar-at-Tahoe. PHOTO: Kevin Zacher
If you're lucky, your Tahoe trip will be all powder, but let's face it—odds are high that you'll be riding the parks at Northstar. And why wouldn't you? They've got rippable terrain smeared all over the trail map. With unique obstacles like pole jams, a gondola cabin stall, rock stalls, the step-up/wallride, and signature Oakley and Forum "F" bombs features, Northstar is taking the park experience into uncharted territory. Their giant Superpipe is also one of the best. The Burton Stash park puts a fresh, natural twist on park play, while more traditional hits like the big step-downs on Moonshine make you wish you were a local.


text:
http://www.eliterestaurantequipment.com/winco-1-round-pastry-basting-brush-wfb-10r.html http://www.eliterestaurantequipment.com/media/catalog/product/cache/1/image/265x/9df78eab33525d08d6e5fb8d27136e95/w/c/wcwfb-10r.jpg WFB-10R Winco
Winco WFB-10R - 1" Round Pastry/Basting Brush
Shop With Confidence
We have one goal in mind: provide food service professionals with all the products they need under one roof at affordable prices. Since then we have succeeded in creating an innovative, easy to use website that meets the needs for food service professionals throughout the United States and Canada. Food service experts, programmers, developers, content writers, technical support staff, and warehouse employees work together to make certain that we provide the best service and industry knowledge on the web.
Return Policy: All stocked items may be returned to us if the item has not been used and is in original packaging. In order for returns to be accepted, your items must be returned within 30 days from receipt. Please note when placing an order you agree to our return policies. Please contact a customer solutions specialist before returning an item. We will create a return authorization for you and send you an e-mail with instructions on how to complete the return. You will be credited 24-72 hours upon receipt and inspection of returned product(s). Products returned may be subject to restocking fees. All parts are non-refundable.
Ask A Question Winco WFB-10R - 1" Round Pastry/Basting Brush
You will receive a phone call and/or email answering the question above as soon as possible. Questions are generally answered same business day. If time is of the essence please call us: (888) 886-7279.
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Quick Overview
This Winco 1" Round Pastry/Basting Brush [WFB-10R] is the perfect tool for your bakery service establishment. This item has a wooden handle and pastry bristle perfect for adding extra glaze to that special dessert. This pastry brush will allow to to evenly distribute glaze over you favorite dessert. To clean this pastry brush soak in warm-hot water and dry.
Product Description
|Model #:
|Ship Weight:
|0.14 lbs.
|Handle Material:
|Bristle Material:
|Boar Hair
|Handle Type:


text:
Washington : Government Printing Office
Page 1532
Whereas, pursuant to authority contained in the act of Congress approved March 1, 1907 (34 Stat. 1015, 1039), certain townsites were established within the Blackfeet Indian Reservation, Montana, and
Whereas, there are certain undisposed of lands within the Townsite of Browning which are desired by the Indians and for which there appears to be no public demand, and
Whereas, the Tribal Council and the Commissioner of Indian Affairs have recommended restoration of the lands involved to tribal ownership:
Now, therefore, by virtue of the authority vested in the Secretary of the Interior by sections 3 and 7 of the act of June 18, 1934 (48 Stat. 984; 25 U.S.C. 463a), I hereby find that the restoration to tribal ownership of the lands listed below will be in the public interest and the said lands are hereby restored to tribal ownership for the use and benefit of the Blackfeet Indian Reservation, Montana, and are added to and made a part of the existing reservation, subject to any valid existing rights:
Page 1533
Block 34, lots 3, 4, and 5.
JOHN A. CARVER, Jr.,
Assistant Secretary of the Interior.


text:
Dismiss Notice
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Discussion in '1973-1991 K5 Blazer | Truck | Suburban' started by River, Sep 16, 2000.


text:
If you are part of the original Web-APP dev team and you wish to contact me, please use
this form
We're almost ready to release Web-APP 3! We should be back up and running in or before September 2014. Thanks for your patience.
Some Features of Web-APP 3
News posting
Social networking
Member profiles
Private messages
Photo, video and link sharing
Auto-post articles to Twitter and/or Facebook
Comment moderation on/off
Full privacy control of profile info and status updates
Block content
Ad content
RSS content integration
Security minded
Security Notice
All previous versions of Web-APP (including all forks) written in Perl have some security problems that some of the developers have known about for quite a few years. Many of these have been fixed, but there are many more that the Perl versions of Web-APP contain that can cause serious harm to your server.
You should know that
you downloaded Web-APP from, all existing Perl versions contain security problems. So, be careful if you decide to continue using any of them. This is one reason work with Web-APP 3 began. The security problems with the Perl versions are too numerous. One of the security issues involved a former developer who installed a program within the overall code which he used as a backdoor to hack other servers or to gain personal information of users. This was fixed in later versions of Web-APP from .org and web-app.info. There are also security problems with login credentials which can allow a hacker to login to the admin account.
The Web-APP team is no longer programming in Perl.


text:
hi, im little newbie , sorry for my english , well the doubt is about i can´t install any distribution of linux in that machine, i´ll like to install it BT4 but only appears me SQUASHFS error: Major/minor mismatch , older squashfs 3.1 filesystems are unsupported , with all the options i put when i load the disc.
i send the information with a extern optical driver in usb to the machine
i´ve hearded that if i downgrade the bios i can get install ubuntu 8.10 but i want backtrack , or something like that , or gentoo, please if somebody can tells me how to i´ll appreciate it. cheers.


text:
2013 Industry Insights Summit
Wednesday, April 24, 2013 at 1:00 PM - Saturday, April 27, 2013 at 4:00 PM (PDT)
Event Details
|Trends, Activities & Opportunities from the Most Promotion Friendly Companies Around
Industry Insights is an annual event hosted by The L.A. Office that caters specifically to the Entertainment Marketing community. Industry power players religiously attend our events to gather the most up-to-date information on innovative partnership concepts, technological advancements, and entertainment marketing opportunities on the horizon.
|Relevant Content For Senior Level Promotion Executives
Industry Insights presenters are asked to design their presentations around current trends, activities, challenges and opportunities within both the presenter's company as well as their industry. Spring Insights sessions will focus on non-traditional marketing partnerships and will introduce speakers from companies involved in Technology, New Media, Communications, Social Networking, etc. Click here for more information about the Summit.
|Brand Marketers Continue To Endorse The Value In Industry Insights!
"Participating in the Industry Insights Forum as a speaker was very worthwhile. On one level, Celebrity Cruises benefited by gaining exposure for our brand and dispelling myths about the cruising industry and specifically how our brand delivers a truly differentiated experience. On another, we created excitement for entertainment marketers to consider new ways to connect with potential audiences with a premium vacation brand. All in all, a terrific experience for Celebrity Cruises."
-- Lisa Kauffman, Vice President, Marketing, Celebrity Cruises
"The Industry Insights Summit brings together some of the top partnership marketing minds in the entertainment industry to gain insights into industries that are investing in entertainment media and partnerships. The variety of speakers, presentation formats and events allow for a number of ways for all in attendance to forge new alliances and friendships."
--Jed Selkowitz, Director, Entertainment Marketing, Coca-Cola
|Trends, Activities & Opportunities From The Most Partner-Friendly Brands
We work closely with each presenter to ensure that they deliver a reasonable balance of company and industry information that is relevant to today's promotional marketers. While every speaker delivers a unique presentation, dozens of key entertainment marketing executives and past attendees have helped us develop an outline that guides our speakers to deliver content that meets the needs of Insights attendees. Click here for more specific information about our 2012 Industry Insights Summit speakers to get an idea of who to expect at this year's event!
|The Who's Who In Marketing Will Be There... Will You?
Year after year, the who's who in entertainment marketing and promotions participate in the Insights program.
Our sold out 2012 Industry Insights Summit attendees will give you a great idea of who you'll see at the 2012 Forum.
Click here to see who attended the 2012 Industry Insights Summit in April.
|Our 2013 Host Hotel - The Surf & Sand
Book Your Room at The Surf & Sand!
1555 South Coast Highway
Laguna Beach, California 92651
Phone: (800) 837-9230
|Registration Pricing & Discounts
Register now and take advantage of our early pricing specials. Registrations may be transferred within your company up to 2 weeks prior to the event.
Register online today or call The L.A. Office at (310) 275-2088.
|Year After Year, Deals Are Born At Insights!
The caliber of attendees creates an environment perfect for the open exchange of ideas and networking. Each year, Insights is credited for the creation of numerous partnerships.
Here are just a few of the partner relationships to come out of the Insights program:
|People Are Always Talking About Insights
From our Past Attendees at the Industry Insights Summit and Forum...
"The Industry Insights Summit is the single most valuable event full of fabulous content and important networking opportunities. It's so beneficial to have all these professionals in one spot at one time."
"The Industry Insights Summit was by far the best conference I have ever attended in my 20 year career. It was so great to meet so many like-minded professionals in the industry who were all about making connections and finding the best possible partnerships for their brands."
"If you are in the partnership marketing business, the Industry Insights Summit is perhaps the most valuable three days you will spend "working" all year. It is a veritable gold mine of contacts and content. Don't think about it- just sign up now."
"The Summit provides a terrific balance of relevant presentations, high-level attendees, and effective networking all in a perfect setting."
"It's a valuable tool to learn innovative practices across industries, identify opportunities, and develop business relationships and friendships."
"The best event for networking I have had the pleasure to attend."
"A valuable couple of days of thought-provoking, serious, and productive networking. I came away with some concrete new opportunities to grow my business."
"I always look forward to seeing my peers and meeting new friends at Insights."
"It was worth it in the first 45 minutes."
"One of the most productive, informative, and business generating events I have ever attended."
"Each year, this event helps us build long-lasting friendships in business."
And from even more past attendees...
"The Industry Insights Summit was full of unique content and the intimate setting led to great networking and an unexpected partnership for Target!"
"This year I already connected with at least 3 potential partners."
"For the past two years, I have left the Industry Insights Summit with new and strengthened relationships. Last year's Summit spurred at least one major deal for Teleflora so I'm definitely already signed up for 2009!"
"I accomplish more in 2 days attending Industry Summit than I do in 2 months in the office! The group was small enough that I was able to have quality one-on-one time with key representatives from various aspects of the business which led to a major promotion for one of our US locations. I would definitely recommend Industry Insights as the #1 event to attend each and every year."
"The best conference I've been to this year! The opportunity to connect with like-minded people in an entertaining, intimate environment was exceptional. The potential partner connections I made will be invaluable, hearing from and spending time with high level in-the-know decision makers will prove to be a great use of time and help me drive business results. I'll be back!"
"Conferences come and go, but there is something special about the Industry Insights Summit. It is a unique opportunity to spend quality time with quality people who are at the top of their game in a very relaxed, no pressure environment. We are all in the relationship business, and Industry Insights is where relationships are made."
People are always talking about the Insights Program. Click here and tell us about your Insights experiences and success stories!
When & Where
The Surf & Sand Hotel
1555 South Coast Hwy
Laguna Beach,
Wednesday, April 24, 2013 at 1:00 PM - Saturday, April 27, 2013 at 4:00 PM (PDT)
Add to my calendar


text:
Kevin Donnelly has been a very naughty boy but Education Minister Christopher Pyne isn't reaching for the cane.
Dr Donnelly, one-half of Mr Pyne's curriculum review panel, has reopened a furious debate after saying measures such as caning are very effective.
He says it should be up to schools to decide how best to mete out punishments.
The Greens and the NSW Teachers Federation have called for Dr Donnelly's resignation, while state governments have lined up to condemn his views.
Stephen Breen, president of the WA Primary Principals' Association, said it was now hard to see Dr Donnelly as a credible adviser.
Federal Labor leader Bill Shorten called on the government to clarify its position on corporal punishment.
However, Mr Pyne says Dr Donnelly's views are a matter for him.
"Dr Donnelly, along with Professor Ken Wiltshire, are undertaking a review of the national curriculum which has nothing to do with managing student behaviour," his spokesman told AAP.
The minister personally doesn't support any form of corporal punishment.
But his spokesman said questions about classroom and student management should be directed to state governments, who directly run schools.
Corporal punishment in schools was phased out by most states from the 1980s.
WA Education Minister Peter Collier acknowledged it was still used in two private schools in that state.
"I believe we have moved on from corporal punishment," he said.
"However, in a free society, parents need to be able to make informed decisions about what they believe to be the best interests of their children."
NSW Premier Mike Baird said the cane might have been effective but he didn't want to see it reintroduced.
He received something similar to the cane when he was in school and has remembered it "for a long time".
Victoria, Queensland and South Australia also said corporal punishment wouldn't be returning to their state schools.


text:
Infertility in womenPelvic inflammatory disease; Polycystic ovaries
An in-depth report on the causes, diagnosis, treatment, and prevention of female infertility.
Risk Factors
Risk factors for female infertility include:
- Age. Fertility begins to decline when a woman reaches her mid-30s, and rapidly declines after her late 30s.
- Weight. Extreme weight levels, either high or low, can contribute to infertility.
- Smoking. Cigarette smoking can impair a woman's fertility.
- Alcohol. More than 2 drinks a day may impair a woman's fertility.
Infertility may be caused by an underlying medical condition that damages the fallopian tubes, interferes with ovulation, or causes hormonal complications. These medical conditions include:
- Pelvic inflammatory disease
- Endometriosis
- Polycystic ovary syndrome
- Premature ovarian failure
- Uterine fibroids
If you have been unable to conceive after 1 year of unprotected sex, talk with your doctor about having your fertility evaluated. Fertility testing should especially be performed if a woman is over 35 years old or if either partner has known risk factors for infertility. An analysis of the man's semen should be performed before the female partner undergoes any invasive testing.
Treatment for infertility should first address any underlying medical condition that may be contributing to fertility problems. If this step does not restore fertility, there are several treatment approaches:
- Lifestyle measures (such as maintaining a healthy weight, quitting smoking,limiting alcohol consumption, timing sexual activity with regard to the ovulation cycle)
- Drugs to induce ovulation, such as clomipheneor gonadotrophins
- Assisted reproductive technologies (ART), such as in vitro fertilization (IVF)
Lifestyle Tips for Optimizing Natural Fertility
In 2013, the American Society for Reproductive Medicine issued recommendations for how couples can increase the likelihood of achieving pregnancy (this applies to couple who have no evidence of infertility):
- For women who have regular menstrual cycles, having sexual intercourse every 1 - 2 days during the "fertile window" (the 6 days leading up to and including ovulation) can increase the chances for conception.
- Couples should avoid using water-based sexual lubricants because they can damage the sperm's ability to swim.Instead, try mineral oil, canola oil, or commercial "fertility friendly" labeled products.
- There's no evidence that certain sexual positions, or resting after sex, boosts fertility or increases the odds for getting pregnant.
Fertility Preservation for Cancer Patients
In 2013, the American Society for Clinical Oncology (ASCO) released updated guidelines on fertility preservation for patients with cancer. ASCO recommends:
- Begin the conversation with your health care team as early as possible, before you begin cancer treatment. Timing is very important.
- For women, ASCO recommend embryo and egg freezing (cryopreservation) as the most well-established methods for fertility preservation. For men, sperm cryopreservation is the only established method. Other cryopreservation methods are considered experimental and are not recommended.
- Some women who are undergoing pelvic radiation or gynecological surgery may be candidates for certain procedures that can help conserve fertility. They should discuss their options with their doctors.
Infertility is the failure of a couple to become pregnant after one year of regular, unprotected intercourse. In both men and women the fertility process is complex.
Infertility affects about 10% of all couples. About a third of infertility problems are due to female infertility, and another third are due to male infertility. In the remaining cases, infertility affects both partners or the cause is unclear. Although this report specifically addresses infertility in women, it is important for the male partner to be tested at the same time.
The Female Reproductive System
The primary organs and structures in the reproductive system are:
- The uterus is a pear-shaped organ located between the bladder and lower intestine. It consists of two parts, the body and the cervix.
- The cervix is the lower portion of the uterus. It has a canal opening into the vagina with an opening called the os, which allows menstrual blood to flow out of the uterus into the vagina.
- Leading off each side of the uterus are two tubes known as the fallopian tubes. Near the end of each tube is an almond-sized organ called an ovary. Women have two ovaries, one located on each side of the uterus.
- Ovaries are the "factories" for egg production. Ovaries contain hundreds of thousands of follicles (from folliculus, meaning "sack" in Latin). Each ovarian follicle houses an immature egg. .
- At the beginning of a menstrual cycle, several ovarian follicles begin to develop, but only one follicle becomes dominant. The dominant follicle produces a mature egg, which is released at the time of ovulation. Usually, only one egg is released. (Multiple births occur if two or more eggs are released and fertilized. Fraternal twins develop from two separate eggs that are fertilized by two separate sperm. Identical twins develop from a single fertilized egg that splits to form two embryos.)
Reproductive Hormones
The menstrual cycle is regulated by the complex surge and fluctuations of many different reproductive hormones, which work together to prepare a women's body for pregnancy.
The hypothalamus (an area in the brain) and the pituitary gland control six important hormones:
- Gonadotropin-releasing hormone (GnRH) is released by the hypothalamus.
- GnRH stimulates the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
- The female hormones estrogen andprogesterone, and the male hormone testosterone are secreted by the ovaries at the command of FSH and LH.
The Menstrual Cycle
During a woman's monthly menstrual cycle, her body prepares for conception and pregnancy. The average menstrual cycle is about 28 days but anywhere from 21 days to 35 days is considered normal. The menstrual cycle is divided into three phases: Follicular, Ovulatory, and Luteal.
Follicular Phase. The follicular phase begins with the first day of menstrual bleeding:
- At the start of the follicular phase, estrogen and progesterone levels are at their lowest point. This causes the uterine lining to break down and shed.
- At the same time, the hypothalamus produces gonadotropin-releasing hormone GnRH, which stimulates the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH and LH trigger the production of estrogen.
- As FSH levels increase, they stimulate the growth and maturation of eggs in the follicles. About 15- 20 follicles are stimulated, but only one follicle continues to mature.
- The dominant follicle produces estrogen. The other follicles stop growing and disintegrate.
Ovulatory Phase. The ovulatory phase occurs halfway through the menstrual cycle (about 14 days after the start of the follicular phase.) Ovulation, the critical process for conception, occurs during the ovulatory phase. A woman's fertile period starts about 3- 5 days before ovulation and ends 24- 48 hours after it. During the ovulatory phase:
- The increase in estrogen from the dominant follicle triggers a surge in LH. As estrogen levels rise, they prompt the cervix to secrete more mucus to help nourish and propel sperm to the egg.
- The LH surge signals the dominant follicle to burst and release the developed egg into the fallopian tube. The release of the egg is called ovulation. Once in the fallopian tube, the egg is in place for fertilization.
- The egg can live for 24- 48 hours after being released. (Sperm can live for 3- 5 days.) A woman is most likely to get pregnant if sex occurs in the 3 - 5 days before ovulation or on the day of ovulation.
Luteal Phase. The luteal phase begins immediately after ovulation and ends when the next menstrual period starts. The luteal phase lasts about 12- 16 days. During the luteal phase:
- After releasing the egg, the ruptured follicle closes and forms corpus luteum, a yellow mass of cells that provide a source of estrogen and progesterone during pregnancy. These hormones help the uterine lining to thicken and prepare for the egg's implantation.
- If the egg is fertilized by a sperm cell, it implants in the uterus and pregnancy begins.
- If fertilization does not occur, the egg breaks apart. The corpus luteum degenerates, and estrogen and progesterone levels drop.
- Finally, the thickened uterine lining sloughs off and is shed along with the unfertilized egg during menstruation. The menstrual cycle begins again.
Fertilization and Pregnancy
Conception occurs when an egg is fertilized by a sperm. The so-called "fertile window" is about 6 days long. It starts about 5 days before ovulation and ends the day of ovulation. Fertilization occurs as follows:
- Sperm can survive for 3 - 5 days after they enter the fallopian tube. The egg survives 24 - 48 hours unless it is fertilized by a sperm.
- The fertilized egg is called a zygote. The zygote immediately begins to divide until it becomes a ball of cells known as a blastocyst.
- The blastocyst moves from the fallopian tube into the uterus where it is implanted in the uterine lining. Implantation takes place about 6 - 10 days after fertilization. Implantation is when pregnancy begins.
- The inner cells of the blastocyst become the embryo, which develops into the fetus. The outer cells of the blastocyst become the placenta. The placenta is a thick blanket of blood vessels that nourishes the fetus as it develops.
- The developing embryo produces and secretes the protein human chorionic gonadotropin (hCG), which helps signal the corpus luteum (the yellow tissue formed from the ruptured follicle) to continue to produce estrogen and progesterone. HCG is the hormone detected by pregnancy tests. After about 10 weeks, the placenta takes over production of progesterone and estrogen, and the corpus luteum degenerates.
Typical Menstrual Cycle
Menstrual Phases
Typical No. of Days
Hormonal Actions
Follicular (Proliferative) Phase
Cycle Days 1 - 6: Beginning of menstruation to end of blood flow.
Estrogen and progesterone start out at their lowest levels.
FSH levels rise to stimulate maturity of follicles. Ovaries start producing estrogen and levels rise, while progesterone levels remains low.
Cycle Days 7 - 13: The endometrium (the inner lining of the uterus) thickens to prepare for egg implantation.
Cycle Day 14:
Surge in LH. Largest follicle bursts and releases egg into fallopian tube.
Luteal (Secretory) Phase, also known as the Premenstrual Phase
Cycle Days 15 - 28:
Ruptured follicle develops into corpus luteum, which produces progesterone. Progesterone and estrogen stimulate blanket of blood vessels to prepare for egg implantation.
If fertilization occurs:
Fertilized egg attaches to blanket of blood vessels that supplies nutrients for the developing placenta. Corpus luteum continues to produce estrogen and progesterone.
If fertilization does not occur:
Corpus luteum deteriorates. Estrogen and progesterone levels drop. The blood vessel lining sloughs off and menstruation begins.
Most cases of female infertility are due to medical conditions that cause:
- Ovulation problems
- Blocked fallopian tubes
- Structural problems in the reproductive system
- Problems with quality of cervical mucus or eggs
Ovulation Problems
Ovulation is the release of the egg that occurs during the monthly menstrual cycle. Problems that affect ovulation, and the hormones involved with ovulation, are the most common cause of female infertility. They include:
- Polycystic Ovarian Syndrome (PCOS). Women with PCOS do not ovulate regularly and they experience infrequent or absent menstrual cycles. In PCOS, the ovaries produce excessive amounts of androgens (male hormones), particularly testosterone. Increased androgen production results in high levels of luteinizing hormone (LH) and low levels of follicle-stimulating hormone (FSH), so that follicles are prevented from producing a mature egg. Without egg production, the follicles swell with fluid and form into cysts. The elevated levels of androgens can also cause obesity, facial hair, and acne. PCOS poses a high risk for insulin resistance, which is associated with type 2 diabetes.
- Premature Ovarian Failure (Early Menopause). Premature ovarian failure is the early depletion of follicles before age 40, which, in most cases, leads to premature menopause. It is often caused by hormonal issues such as adrenal, pituitary, or thyroid gland deficiencies. It can also be caused by genetic disorders such as Turner syndrome and fragile X syndrome. Certain types of autoimmune disorders (type 1 diabetes, systemic lupus erythematosus, Addison's disease) are associated with premature ovarian failure. Radiation and chemotherapy cancer treatments can also cause early menopause.
- Hormonal Imbalances. Imbalances with reproductive hormones such as FSH, LH, estrogen, and progesterone can interfere with ovulation.
Blocked Fallopian Tubes
A blocked fallopian tube can prevent sperm from reaching and fertilizing the egg. Blockage in the fallopian tubes can also prevent a fertilized egg from traveling to the uterus for implantation. Conditions that can block or damage fallopian tubes include:
- Pelvic Inflammatory Disease (PID). PID refers to infection in the pelvic are and reproductive tract, including the fallopian tubes. PID is a complication of bacterial infection. The most common causes are sexually transmitted diseases, especially chlamydia and gonorrhea. In addition to infertility, PID can increase the risk for ectopic pregnancy, where the embryo implants in the fallopian tube or another location outside of the uterus.
- Endometriosis. Endometriosis is a condition in which cells that line the uterus grow in areas outside of the uterus, such as the ovaries. Endometriosis rarely causes a complete inability to conceive, but it can reduce fertility both directly and indirectly. Implants in the fallopian tubes may block the egg's passage, while implants that occur in the ovaries can prevent the release of the egg. Severe endometriosis can form bands of scar tissue (adhesions) between the uterus, ovaries, and fallopian tubes that prevent egg transfer.
- Uterine or Abnormal Scarring. Adhesions can be caused by conditions besides endometriosis. Adhesions that form after abdominal or pelvic surgery or infection can restrict the movement of ovaries and fallopian tubes and may cause infertility. Asherman syndrome, for example, is scarring in the uterus that may be caused by surgery, repeated injury, or unknown factors.
- Uterine Fibroids. Uterine fibroids may contribute to infertility by blocking the fallopian tube, or by distorting the shape of the uterine cavity. Fibroids may also impair blood flow to the uterine lining.
Other Causes of Female Infertility
Other possible causes of female infertility include:
- Elevated Prolactin Levels. Prolactin is a hormone produced in the pituitary gland that stimulates breast development and milk production in association with pregnancy. High levels of prolactin (hyperprolactinemia) reduce gonadotropin hormones and inhibit ovulation. Hyperprolactinemia in women who are not pregnant or nursing can be caused by an underactive thyroid gland or pituitary adenoma. (Pituitary adenomas are benign tumors that secrete prolactin.) Some drugs, including oral contraceptives and some antipsychotic drugs, can also elevate levels of prolactin.
- Congenital StructuralAbnormalities. Congenital reproductive tract abnormalities may cause infertility. These malformations typically affect the uterus or vagina. Daughters born to women who took the drug diethylstilbestrol (DES) during pregnancy are at increased risk of having uterine or fallopian tube structural abnormalities associated with infertility. Some women who are born with uterine or other reproductive tract malformations are still able to have successful pregnancies. Surgery can correct some of these problems.
- Cervical Mucus. Low amounts of cervical mucus or poor quality cervical mucus can contribute to infertility. Cervical mucus problems may be related to hormonal imbalances, prior surgeries,or certain medications.
- Egg Quality. As women age, the number and quality of their eggs diminish. Younger women can also have problems with egg quality, usually because of medical conditions or treatments that impair the ovaries. Radiation and chemotherapy cancer treatments, for example, can damage ovaries and affect egg development.
Risk Factors
In the U.S., about 11% of women ages 15 - 44, or about 6.7 million women, have problems getting pregnant or carrying a baby to term.
Fertility declines as a woman ages. Fertility begins to decline when a woman reaches her mid-30s, and rapidly declines after her late 30s. As a woman ages, her ovaries produce fewer eggs. In addition, the quality of the eggs is poorer than those of younger women. Older women have a higher risk for eggs with chromosomal abnormalities, which increase the risk for miscarriage and birth defects. Older women are also more likely to have health problems that may interfere with fertility.
The American Society of Reproductive Medicine recommends that a woman over age 35 should consider consulting a reproductive specialist if she has attempted unsuccessfully to conceive for 6 months
Although most of a woman's estrogen is manufactured in her ovaries,smaller amounts areproduced by fat cells, which transform male hormones produced by the adrenal glands into estrogen. Because a normal hormonal balance is essential for the process of conception, extreme weight levels (either high or low) can contribute to infertility.
Being Overweight. Being overweight or obese can contribute to infertility in various ways. Obesity is also associated with polycystic ovarian syndrome (PCOS), an endocrinologic disorder that can cause infertility.
Being Underweight. Body fat levelsthat are significantlybelow normal can completely shut down the reproductive process. Women at risk include:
- Women with eating disorders, such as anorexia or bulimia nervosa.
- Women on very low-calorie or restrictive diets are at risk, especially if their periods are irregular.
- Strict vegetarians might have difficulties if they lack important nutrients, such as vitamin B12, zinc, iron, and folic acid.
- Marathon runners, dancers, and others who exercise very intensely.
Cigarette smoking can harm a woman's ovaries and contribute to a decrease in eggs. Studies show that women who smoke are more likely to reach menopause earlier than women who do not smoke. And, studies indicate that smokers require more IVF cycles to conceive than nonsmokers. Nonsmokers exposed to excessive passive cigarette smoke may have similar risks. Some evidence also suggests that marijuana use may impair a woman's fertility. .
Alcohol and Caffeine Use
Alcohol and caffeine use may contribute to infertility. In any case, doctors recommend that women trying to conceivelimit themselves to 1 alcoholic drink a day. For caffeine, 1 – 2 cups of coffee a day do not appear to affect fertility, but higher amounts may cause impairment.
Environmental Factors
Exposure to environmental hazards (such as herbicides, pesticides, and industrial solvents) may affect fertility. Estrogen-like chemicals that interfere with normal hormones are of particular concern for infertility in men and for effects on offspring of women. Phthalates, chemicals used to soften plastics, are under particular scrutiny because they may disrupt hormones.
Stress and Fertility
Neurotransmitters (chemical messengers in the brain) act in the hypothalamus gland, which controls both reproductive and stress hormones. It is not clear if stress has any significant effect on fertility or fertility treatments. Several large studies indicate it does not.
Doctors recommend that both male and female partners get tested for infertility if pregnancy fails to occur after 1 year of regular unprotected sexual intercourse, or after 6 months if a woman is over age 35. (Most couples who do not have fertility problems conceive within the first 6 months of attempting pregnancy, and typically within the first 3 months.)
Fertility testing is particularly important if a woman is over 35 years old or if either partner has known risk factors for infertility. An analysis of the man's semen should be performed before the female partner undergoes any invasive testing.
Ovulation Home Tests
Before beginning an expensive fertility work-up, you can try the following steps at home. They are free or low-cost and may be helpful:
- Monitor basal body temperature. Basal body temperature (BBT) is the body's temperature at rest. Basal means lowest. The BBT is the body's natural lowest temperature, and it typically occurs upon awakening in the morning. Because BBT increases slightly (less than0.5 degree Fahrenheit) during ovulation, tracking and charting your BBT may help you determine when ovulation takes place. You can monitor your BBT by taking your temperature at the same time every morning using a regular thermometer or a special digital BBT thermometer that stores and displays the data.
- Test the consistency of your cervical mucus. Collect some mucus between two fingers and stretch it apart. If you are near the time of ovulation, the mucus will stretch more than 1 inch before it breaks. As an alternative, at-home kits can test saliva as substitute for checking cervical mucus.
- Usean over-the-counter urine testto detect luteinizing hormone (LH) surges. This helps determine the day of ovulation. Tests are also available to measure levels of follicle-stimulating hormone (FSH). However, these at-home tests may not be as accurate as those performed in a doctor's office.
Medical History and Physical Examination
The first step in any infertility work up is a complete medical history and physical examination. The doctor will ask about the patient's history of sexual activity, including frequency and timing of intercourse. Menstrual history, lifestyle issues (smoking, drug and alcohol use, and caffeine consumption), any medications being taken, and a profile of the patient's general medical and emotional health can help the doctor decide on appropriate tests.
Laboratory Tests
Several laboratory tests may be used to detect the cause of infertility and monitor treatments.
Hormonal Levels. Blood and urine tests are taken to evaluate hormone levels. Hormonal tests for ovarian reserve (the number of follicles and quality of the eggs) are especially important for older women.
Examples of possible results include:
- High follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels and low estrogen levels suggest premature ovarian failure.
- High LH and low FSH may suggest polycystic ovary syndrome or luteal phase defect.
- High FSH and high estrogen levels on the third day of the cycle predict poor success rates in older women trying fertility treatments.
- LH surges indicate ovulation.
- Blood tests for prolactin levels and thyroid function are also measured. These are hormones that may indirectly affect fertility.
Clomiphene Challenge Test. Clomiphene citrate (Clomid, Serophene, generic), a standard fertility drug, may be used to test for ovarian reserve. With this test, the doctor measures FSH on day 3 of the cycle. The woman takes clomiphene orally on days 5 and 9 of the cycle. The doctor measures FSH on the tenth day. High levels of FSH either on day 3 or day 10 indicate a poor chance for a successful outcome.
Tissue Samples. To rule out luteal phase defect, premature ovarian failure, or absence of ovulation, the doctor may take tissue samples of the uterus 1 - 2 days before a period to determine if the corpus luteum is adequately producing progesterone. Samples taken from the cervix may be cultured to rule out infection.
Tests for Autoimmune Disease. Tests for autoimmune disease, such as hypothyroidism and type 1 diabetes, should be considered in women with recent ovarian failure that is not caused by genetic abnormalities.
Imaging Tests and Diagnostic Procedures
If an initial fertility work-up does not reveal abnormalities, more extensive tests may help reveal abnormal tubal or uterine findings. The four major approaches for examining the uterus and fallopian tubes are:
- Ultrasound (particularly a variation called saline-infusion sonohysterography)
- Hysterosalpingography
- Hysteroscopy
- Laparoscopy
Combinations of these imaging procedures may be used to confirm diagnoses.
Ultrasound and Sonohysterography. Ultrasound is the standard imaging technique for evaluating the uterus and ovaries. It is also used for detecting fibroids, ovarian cysts and tumors, and obstructions in the urinary tract. It uses sound waves to produce an image of the organs and causes very little discomfort.
Transvaginal sonohysterography uses ultrasound along with saline infused into the uterus, which enhances the visualization of the uterus. This techniquecan be more accurate than standard ultrasound in identifying potential problems. It is currently the gold standard for diagnosing polycystic ovaries.
Hysteroscopy. Hysteroscopy is a procedure that may be used to detect the presence of endometriosis, fibroids, polyps, pelvic scar tissue, and blockage at the ends of the fallopian tubes. Some of these conditions can be corrected during the procedure by cutting away any scar tissue that may be binding organs together or by destroying endometrial implants.
Hysteroscopy may be done in a doctor's office or in an operating room, depending on the type of anesthesia used. The procedure uses a long flexible or rigid tube called a hysteroscope, which is inserted into the vagina and advanced through the cervix to reach the uterus. A fiber-optic light source and a tiny camera in the tube allow the doctor to view the cavity. The uterus is filled with saline or carbon dioxide to inflate the cavity and provide better viewing. This can cause cramping.
There are small risks of bleeding, infection, and reactions to anesthesia. Many patients experience temporary discomfort in the shoulders after the operation due to residual carbon dioxide that puts pressure on the diaphragm.
Hysterosalpingography. Hysterosalpingography is performed to discover possible blockage in the fallopian tubes and abnormalities in the uterus:
- The doctor inserts a tube into the cervix through which a special dye is injected. (The patient may experience some cramping and discomfort.)
- The dye passes into the uterus and up through the fallopian tubes.
- An x-ray is taken of the dye-filled uterus and tubes.
- If the dye is seen emerging from the end of the tube, no blockage is present. (In some cases, hysterosalpingography may even restore fertility by clearing away tiny tubal blockages.)
- If results show blockage or abnormalities, the test may need to be repeated. In case of blockage, hysterosalpingography may reveal a number of conditions, including endometrial polyps, fibroid tumors, or structural abnormalities of the uterus and tubes.
There is a small risk of pelvic infection, and antibiotics may be prescribed prior to the procedure.
Laparoscopy. Laparoscopy is a minimally invasive surgical procedure. It requires general anesthesia and is performed in an operating room. The surgeon makes a very small incision below the belly button and inserts an instrument called a laparoscope, which is similar to a hysteroscope. (The difference is that a laparoscope is inserted through the abdomen, while a hysteroscope is inserted through the vagina and cervix.) Through the laparoscope, the surgeon can view the uterus, fallopian tube, and ovaries. Laparoscopy is most helpful for identifying endometriosis or other adhesions that may affect fertility.
Treatment for infertility should first address any underlying medical condition that may be contributing to fertility problems. Drugs, surgery, or both may be used to treat these conditions. Surgery may also be used to repair blockage in fallopian tubes.
Fertility Treatment Approaches
Several approaches are used to treat infertility:
- Lifestyle measures (such as maintaining a healthy weight, quitting smoking, refraining from excessive alcohol use,timing sexual activity with ovulation cycle)
- Drugs to induce ovulation, such as clomiphene and gonadotrophins
- Assisted reproductive technologies (ART) such as in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI)
Choosing a Fertility Clinic
Some doctors recommend that if a couple fails to conceive after 1 - 2 years of frequent unprotected sex, they should consult a fertility expert. Women who are 35 or older, however, may want to begin exploring their options if they do not become pregnant within 6 months to a year.
Choosing a good fertility clinic is important. Those offering assisted reproductive techniques are not always regulated by the government, and abuses have been reported, including lack of informed consent, unauthorized use of embryos, and failure to routinely screen donors for disease.
The clinic should always provide the following information:
- The live-birth rate (not just pregnancy success rate) for other couples with similar infertility problems. (Multiple births, such as twins or triplets, are counted as one live birth.)
- Such statistics should include high-risk women, such as those who are older or fail to produce eggs. (Some disreputable clinics give success percentages that exclude high-risk women from their total, thereby making the percentage of success much higher.)
Advanced fertility procedures and medications are extremely expensive and often not covered by insurance. Couples should be cautious about offers of rebates in the event of failure; the clinics offering them are often significantly more expensive than those that don't offer such gimmicks.
Special Considerations for Patients with Cancer
Women who are undergoing cancer treatments and who want to become pregnant should see a reproductive specialist to discuss their options These discussions should take place as early as possible, and before cancer treatment starts.
According to the American Society of Clinical Oncology's guidelines, the best fertility preservation methods for female cancer patients are embryo and oocyte (egg) cryopreservation. This procedure involves harvesting and freezing a woman's eggs (oocytes), and can be followed by in vitro fertilization and freezing of embryos for later use. It requires several weeks of pre-treatment with ovarian stimulation drugs, so planning is very important.
Ovarian transposition, which involves moving one or both ovaries outside of the treatment field, may be an option for some women who are undergoing pelvic radiation. If you are going to be having gynecological surgery or radiation as part of your cancer treatment, discuss with your doctors any options for procedures that may help conserve fertility. And, be sure your doctors clearly explain to you how various cancer treatments could affect your fertility.
Embryo and oocyte cryopreservation are well-established methods that have excellent chances for success. At this time, other fertility preservation methods such as ovarian tissue cryopreservation, are still considered experimental and the American Society of Clinical Oncology does not recommend them.
Medications to treat infertility can be divided into three main categories:
- Medications for Ovarian Stimulation. These drugs are often used alone as initial treatment to induce ovulation, particularly for women who have medical conditions that cause irregular or dysfunctional ovulation. They may also be also used along with assisted reproductive technologies (ART), such as in vitro fertilization or intrauterine insemination, to stimulate multiple eggs to grow in the ovaries, a process called superovulation. The main drugs used for ovarian stimulation are clomiphene, (follicle stimulating hormone (FSH), luteneizing hormone (LH), and human menopausal gonadotrophin (hMG).
- Medications for Oocyte Maturation. Drugs such as human chorionic gonadotropin (hCG) are used during ART to help the ovarian follicles ripen (mature)
- Medications to Prevent Premature Ovulation. These drugs are used during ART to help prevent premature ovulation. They include GnRH agonists and GnRH antagonists.
Other drugs may also be used. For example, letrazole (Femara) is an aromatase inhibitor that is not approved for treatment of infertility but is often used "off-label" for ovarian stimulation.
Clomiphene citrate (Clomid, Serophene, generic) is usually the first fertility drug prescribed for women who have ovulation problems. (It is less likely to work for women who have normal ovulation.)
Unlike more potent drugs used in superovulation, clomiphene is gentler and works by blocking estrogen, which tricks the pituitary into producing follicle-stimulating hormone (FSH) and luteinizing hormone (LH). This boosts follicle growth and the release of the egg. Clomiphene can be taken by mouth, is relatively inexpensive, and the risk for multiple births (about 5%, mostly twins) is lower than with other drugs.
One or two tablets are taken each day for 5 days, usually starting 2 - 5 days after the period starts. If successful, ovulation occurs about a week after the last pill has been taken. If ovulation does not occur, then a higher dose may be given for the next cycle.
If this regimen is not successful, treatment may be prolonged or additional drugs may be added. (Women who have polcystic ovarian syndrome often receive metformin in addition to clomiphene to help treat insulin resistance that may affecting their ovulation function.) Doctors usually do not recommend more than 6 cycles.
Mood swings are a very common side effect of clomiphene. Other side effects include hot flashes, breast tenderness, nausea, pelvic discomfort, and ovarian cysts.
If clomiphene does not work or is not an appropriate choice, gonadotropin drugs are a second option. Gonadotropins include several different types of drugs that contain either a combination of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), or only FSH. Whereas clomiphene works indirectly by stimulating the pituitary gland to secrete FSH, (which prompts follicle production), gonadtropin hormones directly stimulate the ovaries to produce multiple follicles.
Gonadotropins are given by injection. (Your doctor may show you how to self-administer the injection.) Gonadotropins include:
- Human Menopausal Gonadtropins (hMG), also called menotropins
- Human Chorionic Gonadotropins (hCG)
- Follicle Stimulating Hormone (FSH)
- Gonadotropin-releasing hormone (GnRH) analogs, which include GnRH agonists and GnRH antagonists
Gonadotropin drugs are either natural compounds extracted from urine or synthetic compounds that are genetically engineered in a laboratory using recombinant DNA.
Human Menopausal Gonadotropin (hMG). HMG drugs, also called menotropins, contain a mixture of both FSH and LH. These drugs (Menopur, Repronex, Humegon) are all derived from the urine of postmenopausal women. HMG is administered as a series of injections 2 - 3 days after the period starts. Injections are usually given for 7 - 12 days, but the time may be extended if ovulation does not occur. In such cases, a shot of human chorionic gonadotropin (hCG) may trigger ovulation.
Human Chorionic Gonadotropin (hCG). Human chorionic gonadotropin (hCG) is similar to LH. It mimics the LH surge, which stimulates the follicle to release the egg. Natural hCG drugs, derived from the urine of pregnant women, include Pregnyl, Profasi, Novarel, and APL. Ovidrel is the only available genetically modified hCG drug. Ovidrel has fewer side effects at the injection site, and its quality can be better controlled than the natural drugs. It is generally used after hMG or FSH to stimulate the final maturation stages of the follicles. Ovulation, if it occurs, does so about 36 - 72 hours after administration.
Follicle Stimulating Hormone (FSH). Urofollitropin (Bravelle, Fertinex) is a purified form of FSH, derived from the urine of postmenopausal women. Follitropin drugs (Gonal-F, Follistim) are synthetic versions of FSH. These FSH drugs are sometimes given in combination with an hCG drug.
GnRH Analogs (Agonists or Antagonists). Gonadotropin-releasing hormone (GnRH) is a hormone produced in the hypothalamus part of the brain. GnRH stimulates the pituitary gland to produce LH and FSH. GnRH analogs are synthetic drugs that are classified as either agonists or antagonists. They are similar to natural GnRH but have very different actions. While natural GnRH stimulates LH and FSH, these drugs actually prevent the LH and FSH surge that occurs right before ovulation. This action helps prevent the premature release of the eggs before they can be harvested for assisted reproductive technologies.
- GnRH agonists include leuprolide (Lupron, generic), nafarelin (Synarel), and goserelin (Zoladex).
- GnRH antagonists include ganarelix (Antagon) and cetrorelix (Cetrotide). GnRH antagonists suppress FSH and LH more than GnRH agonists, and they may require fewer injections.
Risksof Superovulation
Superovulation is the process of using fertility drugs to stimulate the development of multiple follicles (eggs) in the ovaries. Superovulation is also called controlled ovarian stimulation.
Potential risks and complications of superovulation include:
- Multiple Births. Superovulation increases the risks for multiple births, approximately 20% for twins and 2 - 5% for triplets. The exact risks depend in part on the drug used and whether it is used along with ART.
- Ovarian Hyperstimulation Syndrome. The most serious risk of superovulation is ovarian hyperstimulation syndrome (OHSS), a condition in which the ovaries become enlarged and filled with fluid. In severe cases, this can lead to life-threatening complications including blood clots, liver and kidney damage, and dangerous fluid and electrolyte imbalances. Symptoms include abdominal bloating and pain, weight gain, nausea and vomiting, and shortness of breath.
- Cancer Concerns. There has been concern that clomiphene and gonadotropins may increase the risks for ovarian and breast cancer. Most evidence to date does not indicate that ovulation-stimulating drugs increase the risks for these types of cancers. Some studies suggest that clomiphene, which is chemically related to the breast cancer drug tamoxifen, may actually decrease the risk for breast cancer.
Assisted Reproductive Technologies
Assisted reproductive technologies (ART) are medical techniques that help couples conceive. These procedures involve either:
- A couple's own eggs or sperm
- Donor eggs, sperm, or embryos
Fertilization may occur either in the laboratory or in the uterus. In the U.S., the number of live birth deliveries from ART has doubled in the last decade. About 48,000 live births (deliveries of one or more infants) occur in the U.S. each year using assisted reproductive technologies. According to the Centers for Disease Control (CDC), over 1% of all babies born in the United States every year are conceived using ART.
Technically, the term ART refers only to fertility treatments, such as in vitro fertilization (IVF) and its variants, which handle both egg and sperm.
Intrauterine Insemination (IUI)
Artificial insemination (AI) involves placing the sperm directly in the cervix (called intracervical insemination) or into the uterus (called intrauterine insemination, or IUI).
IUI is the standard AI procedure. It involves placing washed sperm into the woman's uterine cavity through a long, thin catheter. The procedure is performed when a woman is ovulating and is used for patients whose tubes are not blocked from endometriosis or scarring.
- A woman will first be given three cycles of clomiphene pills to stimulate egg production, at the same time having sexual contact with her partner timed around ovulation.
- If she fails to conceive, three additional cycles of clomiphene are used, combined with IUI.
- If the clomiphene-IUI combination does not work, the woman receives three cycles of IUI combined with injections of a gonadotropin-stimulating hormone drug.
- If this method fails, the woman may be a candidate for in vitro fertilization (IVF). Some insurance plans only cover IUI and do not pay for IVF.
IUI is the least complex and least expensive of fertility procedures and is often tried first in uncomplicated cases of infertility. However, it may pose a greater risk for multiple births and have a lower chance for pregnancy success than IVF. For these reasons, some doctors recommend that couples who fail to conceive after three cycles of clomiphene-IUI proceed directly to IVF.
In Vitro Fertilization (IVF)
Most assisted reproductive technologies procedures use in vitro fertilization (IVF). An in vitro procedure is one that is performed in the laboratory. Advances in these procedures have dramatically increased the rate of live births. IVF can be performed with a woman's own eggs and sperm, or with donor eggs and sperm.
In the past, IVF was used mainly to treat women with damaged fallopian tubes. It is now used as a fertility treatment for cases when the woman has endometriosis, the man has fertility problems, or the cause of a couple's infertility is unexplained.
A standard IVF cycle is divided into the following steps:
- Ovarian Suppression. The patient receives treatment with either a GnRH agonist (Lupron) or GnRH antagonist (Antagon, Cetrotide). Sometimes birth control pills are given as pre-treatment. The purpose is to prevent premature ovulation and make sure that the follicles will ripen at the same time.
- Ovarian Stimulation. Ovarian-stimulating drugs, such as clomiphene, FSH, or LH, are used to prompt the ovaries to produce multiple eggs. The patient receives ultrasounds to monitor the growth of egg follicles and blood tests to check hormone levels. A cycle may be canceled if not enough follicles are produced or if there is a risk of ovarian hyperstimulation syndrome (see Medications section).
- HCG Trigger Injection. About 8 - 14 days later, an injection of human chorionic gonadotropin (hCG) is given to foster egg maturation. The timing of this shot is very important for the success of the IVF procedure.
- Egg Retrieval. About 34 - 36 hours after the hCG injection, the eggs are retrieved. To retrieve the eggs, the doctor inserts an ultrasound-guided probe into the vagina. A needle is then used to drain the liquid from the follicles, and several eggs are retrieved. The woman begins taking progesterone or another type of medication to help prepare the lining of the uterus to support the embryo.
- Fertilization and Embryo Culture. The doctor will examine the eggs to evaluate their quality and maturity. Selected eggs are placed in a culture in the laboratory and transferred to an incubator. They are then inseminated with sperm, either by placing sperm together with the egg or injecting a single sperm into the egg (see ICSI section below).
- Embryo Transfer and Cryopreservation. One or more embryos are implanted in the woman's uterus2 - 6 days after egg retrieval. The doctor will discuss with the patient the appropriate number of embryos to be implanted. Excess embryos may be frozen and saved for future use. (The live birth rate is usually lower with cryopreserved embryos.) It takes about 9 - 12 days to determine if pregnancy has been achieved.
Embryo Transfer Guidelines. In 2013, the American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technologies (SART) updated its joint guidelines on the number of embryos that should be transferred during IVF procedures.The new guidelines include distinctions between cleavage-stage (2 - 3 days after fertilization) and blastocyst (5 - 6 days after fertilization) embryos.
The guidelines recommend:
- For women under the age of 35, a single embryo transfer or no more than 2 embryos (either cleavage-stage or blastocyst)
- For women between ages 35 - 37, no more than 2 cleavage-stage embryos
- For women between ages 38 - 40, no more than 3 cleavage-stage embryos or 2 blastocysts
- For women ages 41 - 42, no more than 5 cleavage-stage embryos or 3 blastocysts
- For women older than age 43, there are insufficient data to recommend a limit on the number of embryos
These embryo numbers are recommended for women with favorable prognoses. For patients who have failed to become pregnant after at least two IVF cycles, or who have a less favorable prognosis, the doctor may consider adding one additional embryo. The guidelines apply to both fresh and frozen embryos.
Other IVF Procedures. Some IVF procedures use adaptations called gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT), which transfers the gametes (egg and sperm) into a women's fallopian tube rather than her uterus. In GIFT, the egg is harvested as with IVF and mixed with sperm, and is then injected into the woman's fallopian tube where fertilization occurs. In ZIFT, the egg is fertilized with sperm in the laboratory before being transferred to the fallopian tube. For GIFT and ZIFT a woman must have at least one functioning fallopian tube.
Success Rates. Not all IVF cycles result in pregnancy, and not all IVF-achieved pregnancies result in live births. When a woman's own eggs are used, results are better with fresh embryos than frozen embryos. According to the most recent statistics from the U.S. Centers for Disease Control (CDC), about 29% of ART cycles (mostly IVF) with fresh embryos resulted in a live birth of one or more babies. Success rates provided by fertility clinics are not always a reliable indicator as they depend on many variables, especially the age of the woman.
Data indicate that the chances ofART resulting in live birth are about:
- 40% for women younger than age 35
- 30% for women ages 35 - 37
- 20% for women ages 38 - 40
- 10% for women ages 41 - 42
- 5% for women ages 43 - 44
Some women try acupuncture during an IVF cycle to increase their chances for pregnancy success. While acupuncture is not harmful, there is no conclusive evidence that it boosts success rates.
Complications. Data have been conflicting on whether IVF increases the risk for genetic abnormalities and birth defects. In general, the overall risks for birth defects appear to be small. Studies indicate that most children conceived through IVF are healthy and have normal cognitive development and school performance.
The main risk of IVF is the consequences of multiple pregnancies. Multiple pregnancies increase the risks for a mother and her babies. In particular, there is increased risk for premature delivery and low birth weight. These factors can cause heart and lung problems and developmental disabilities in children.
Intracytoplasmic Sperm Injection (ICSI)
Intracytoplasmic sperm injection (ICSI) is an assisted reproductive technology used for couples when male infertility is the main problem. It involves injecting a single sperm into an egg obtained from in vitro fertilization (IVF). The procedure is very simple:
- A tiny glass tube (called a holding pipet) stabilizes the egg.
- A second glass tube (called the injection pipet) is used to penetrate the egg's membrane and deposit a single sperm into the egg.
- The egg is released into a drop of cultured medium.
- If fertilized, the egg is allowed to develop for 1 - 2 days, then it is either frozen or implanted.
The greatest concern with this procedure has been whether it increases the risk for birth defects. Many, but not all, studies have reported no higher risks of birth defects in children born using ICSI procedures. However, if the father's infertility was due to genetic issues, this genetic defect may be passed on to male children conceived through ICSI.
Another concern has been whether the ICSI procedure is being overused. Some doctors recommend ICSI for women who have failed prior IVF attempts or who have few or poor-quality eggs, even if their male partners have normal semen measurements. According to the Society for Assisted Reproductive Technology, there is little evidence that ICSI helps improve pregnancy success for couples who do not have a problem with male factor infertility.
Lifestyle Changes
Although there are no dietary or nutritional cures for infertility, a healthy lifestyle is important. Some ovulatory problems may be reversible by changing behavioral patterns. Some tips include:
- Maintain a healthy weight. Women who are either over- or underweight are at risk for fertility failure, including a lower chance for achieving success with fertility procedures.
- Stop smoking. Smoking adversely affects infertility in both men and women. Everyone should quit.
- Avoid excessive exercise if it causes menstrual irregularity. However, moderate and regular exercise is essential for good health.
- Limit excessive caffeine and alcohol consumption. High levels of alcohol and caffeine are associated with decreased fertility.
- Avoid most commercial water-based sexual lubricants (Astroglide, KY Jelly). They can interfere with sperm motility and survival.
- Avoid any unnecessary medications.
Planning Sexual Activity
The "Fertile Window". Couples can optimize their chances for conception by planning sexual intercourse during the woman's fertile window:
- The so-called "fertile window" is 6 days long, starts 5 days before ovulation, and ends the day of ovulation.
- In a woman with a 28-day menstrual cycle, ovulation usually occurs around day 14 (14 days after the start of her menstrual period), which means the fertile window occurs from days 9 - 14. However, the length of menstrual cycles – and fertile windows -- vary from woman to woman.
- The chances for intercourse resulting in pregnancy are considered to be highest during the fertile window and especially on the 3-day interval that ends on the day of ovulation. Fertility doctors recommend having sex every 1 - 2 days during the fertile window.
In addition to tracking their menstrual cycle, women can try methods such as charting basal body temperature to monitor ovulation (see Diagnosis section of this report). This method is not always successful, but it may when combined with other approaches.
Frequency of Intercourse. Evidence indicates that chances are best for conception when sexual intercourse occurs every 1 - 2 days, especially during the fertile window. Less frequentsexual intercourse (2 - 3 times a week) also achieves good results. However, couples need to make their own personal choices about what amount of sexual activity is appropriate, comfortable, and desirable. Datasuggest that abstinence (not having sex) of more than 5 - 10 days may adversely affect sperm health.
Sexual Practices. There's no evidence that any particular sexual postions, or resting after sex, help increase the chances for pregnancy. There's also no evidence that whether or not a woman achieves orgasm affects the likelihood of her becoming pregnant. Couples should be aware that water-based vaginal lubricants (Astroglide, KY Jelly, saliva) can damage sperm's ability to swim and should not be used. For lubrication, try mineral oil, canola oil, or commercially available "fertility friendly" products such as Pre-Seed, which do not harm sperm.
Dealing with Stress
The fertility treatment process presents a roller coaster of emotions. There are almost no sure ways to predict which couples will eventually conceive. Some couples with multiple problems will overcome great odds, while other, seemingly fertile, couples fail to conceive. Many of the new treatments are remarkable, but a live birth is never guaranteed. The emotional burden on the couple is considerable, and some planning is helpful.
- Decide in advance how many and what kind of procedures will be emotionally and financially acceptable and attempt to determine a final limit. Fertility treatments are expensive. A successful pregnancy often depends on repeated attempts.
- Prepare for multiple births as a possible outcome for successful pregnancy (especially if assisted reproductive technologies are used). A pregnancy that results in a multiple birth introduces new complexities and emotional problems
- Determine alternatives (adoption, donor sperm or egg, or having no children) as early as possible in the fertility process. This can reduce anxiety during treatments and feelings of disappointment in case conception does not occur.
On a reassuring note, a large study of infertile women indicated that stress levels do not affect the outcome of fertility treatments. The study found no difference in stress levels between women who became pregnant and those who did not. Women who are feeling stressed by problems with fertility or the challenges of the fertility treatment process should not feel additionally concerned that their emotional state may affect their chances of becoming pregnant.
- www.asrm.org -- American Society for Reproductive Medicine
- www.sart.org -- Society for Assisted Reproductive Technology
- www.theafa.org -- American Fertility Association
- www.acog.org -- American College of Obstetricians and Gynecologists
- www.cdc.gov/reproductivehealth/index.htm -- Centers for Disease Control: Assisted Reproductive Technology Reports
Boivin J, Griffiths E, Venetis CA. Emotional distress in infertile women and failure of assisted reproductive technologies: meta-analysis of prospective psychosocial studies. BMJ. 2011 Feb 23;342:d223.
Centers for Disease Control and Prevention, American Society for Reproductive Medicine, Society for Assisted Reproductive Technology. 2011 Assisted Reproductive Technology Fertility Clinic Success Rates Report. Atlanta (GA): US Dept of Health and Human Services; 2013.
Davies MJ, Moore VM, Willson KJ, Van Essen P, Priest K, Scott H, et al. Reproductive technologies and the risk of birth defects. N Engl J Med. 2012 May 10;366(19):1803-13. Epub 2012 May 5..
El-Toukhy T, Sunkara SK, Khairy M, Dyer R, Khalaf Y, Coomarasamy A. A systematic review and meta-analysis of acupuncture in in vitro fertilisation. BJOG. 2008 Sep;115(10):1203-13. Epub 2008 Jul 23.
ESHRE Capri Workshop Group. Intrauterine insemination. Hum Reprod Update. 2009 May-Jun;15(3):265-77. Epub 2009 Feb 23.
Hoover RN, Hyer M, Pfeiffer RM, Adam E, Bond B, Cheville AL, et al. Adverse health outcomes in women exposed in utero to diethylstilbestrol. N Engl J Med. 2011 Oct 6;365(14):1304-14.
Hudson MM. Reproductive outcomes for survivors of childhood cancer. Obstet Gynecol. 2010 Nov;116(5):1171-83.
Jain T, Gupta RS. Trends in the use of intracytoplasmic sperm injection in the United States. N Engl J Med. 2007 Jul 19;357(3):251-7.
Jensen A, Sharif H, Frederiksen K, Kjaer SK. Use of fertility drugs and risk of ovarian cancer: Danish Population Based Cohort Study. BMJ. 2009 Feb 5;338:b249.
Jensen JR, Morbeck DE, Coddington CC 3rd. Fertility preservation. Mayo Clin Proc. 2011 Jan;86(1):45-9.
Jensen A, Sharif H, Svare EI, Frederiksen K, Kjaer SK. Risk of breast cancer after exposure to fertility drugs: results from a large Danish cohort study. Cancer Epidemiol Biomarkers Prev. 2007 Jul;16(7):1400-7. Epub 2007 Jun 21.
Lobo RA. Infertility: Etiology, diagnostic evaluation, management, prognosis. In: Lentz GM, Lobo RA, Gershenson DM, Katz VI, eds. Comprehensive Gynecology. 6th ed. Mosby Elsevier; 2012:chap 41.
Loren AW, Mangu PB, Beck LN, Brennan L, Magdalinski AJ, Partridge AH, Quinn G, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013 Jul 1;31(19):2500-10. Epub 2013 May 28.
Luke B, Brown MB, Wantman E, Lederman A, Gibbons W, Schattman GL, et al. Cumulative birth rates with linked assisted reproductive technology cycles. N Engl J Med. 2012 Jun 28;366(26):2483-91.
Mains L, Zimmerman M, Blaine J, Stegmann B, Sparks A, Ansley T, et al. Achievement test performance in children conceived by IVF. Hum Reprod. 2010 Oct;25(10):2605-11. Epub 2010 Aug 17.
Manheimer E, Zhang G, Udoff L, Haramati A, Langenberg P, Berman BM, Bouter LM. Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis. BMJ. 2008 Mar 8;336(7643):545-9. Epub 2008 Feb 7.
Practice Committee of American Society for Reproductive Medicine; Practice Committee of Society for Assisted Reproductive Technology. Criteria for number of embryos to transfer: a committee opinion. Fertil Steril. 2013 Jan;99(1):44-6. Epub 2012 Oct 22.
Practice Committee of American Society for Reproductive Medicine in collaboration with Society for Reproductive Endocrinology and Infertility. Fertil Steril. 2013 Sep;100(3):631-7. Optimizing natural fertility: a committee opinion.
Practice Committee of the American Society for Reproductive Medicine. Smoking and infertility: a committee opinion. Fertil Steril. 2012 Dec;98(6):1400-6. Epub 2012 Sep 6.
Practice Committee of the American Society for Reproductive Medicine. Use of clomiphene citrate in infertile women: a committee opinion. Fertil Steril. 2013 Aug;100(2):341-8. Epub 2013 Jun 27.
Williams CL, Bunch KJ, Stiller CA, Murphy MF, Botting BJ, Wallace WH, et al. Cancer risk among children born after assisted conception. N Engl J Med. 2013 Nov 7;369(19):1819-27.
Zegers-Hochschild F, Adamson GD, de Mouzon J, Ishihara O, Mansour R, Nygren K, et al. International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) revised glossary of ART terminology, 2009. Fertil Steril. 2009 Nov;92(5):1520-4. Epub 2009 Oct 14.
Related Informationec
Review Date: 12/21/2013�
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.


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In compliance with the General Appropriations Act, Article IX, Rider 167, passed by the 75th Legislature, the Texas State Board of Examiners of Professional Counselors (board) files this plan to review rules effective prior to September 1, 1997. The board plans, generally, to review its rules set forth at 22 Texas Administrative Code, Part XXX, Chapter 681, Professional Counselors, to determine whether the reasons for adoption continue to exist, and whether revised rules would better serve those reasons.
Specifically, the board plans to solicit input into the review process by filing a notice of intent to review with the Texas Register and notifying interested parties. The board plans to consider the public comments along with input from its staff and committees and to (i) delete those rules for which the reason for adoption no longer exists, (ii) readopt those rules for which the reasons for adoption still exist and which continue to effectively and efficiently serve those reasons, and (iii) revise those rules for which the reasons for adoption still exist but which can be amended to better serve those reasons. Deleted and revised rules will be submitted to the Texas Register in accordance with the Administrative Procedure Act and in the typical format, while readopted rules will simply be noted in the notice of readoption filed with the Texas Register without publication of the rule text. The board plans to complete this review by the end of 1998.


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CARY - Chain reaction collision between three school activity busses on eastbound Highway 64 at Edinburgh Drive. Dispatched about 10:30 a.m. Occupants included about 113 eighth-graders on a field trip from Asheboro. Cary Fire Department responded with two engines, one ladder, one rescue, and two Battalion Chiefs. EMS second alarm dispatched, along with additional resources. Total of 14 ambulances from Cary, Apex, Wake County, and Six Forks EMS, plus four EMS district chiefs, one EMS chief, one Deputy Medical Directory. Total of 36 patients transported with minor injuries, one adult and 35 students. Other students and adults walked in groups to nearby hotel for shelter. Three transit busses requested. Units included Cary E3, E4, L3, R4, B1, B2, C2; EMS 51, 9, 42, 41, 52, 4, 124, 3, 14, 121, 123, 1, 32, 43, 6; D5, D2, D1, D4, M91, EMS 500, MD-20. "B" shift.
Mike Legeros photographs.
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Ok.. Do you know how to interpretate the info from commands?..
Take a close look at it, at the iwconfig....
Let me quote:
wlan1 IEEE 802.11bg ESSID:"XXXX_XXX"
Mode:Managed Frequency:2.437 GHz Access Point: XX:XX:XX:XX:XX:XX
Bit Rate=54 Mb/s Tx-Power=20 dBm
Retry long limit:7 RTS thrff Fragment thrff
Encryption keyff
Power Managementff
Link Quality=44/70 Signal level=-66 dBm
Rx invalid nwid:0 Rx invalid crypt:0 Rx invalid frag:0
Tx excessive retries:0 Invalid misc:0 Missed beacon:0
You can have 100% power on signal, BUT "Link Quality" will define that, LINK..You are little bit above 60%, and man, I've got many many time seeing that problem...Bad Link Quality, BAD conection, no matter the strenght...It means too much interference (RFI noise, walls, windows, any aluminum mesh in windows, bricks, etc...).
Get close to AP, the link quality says so.
If problem still even with a much better quality, (>= 85%), you might have a bad Alfa.


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Topic: age
I have noticed peoples ages have disappeared-why is that?
cholangiocarcinoma.org :: Cholangiocarcinoma Foundation Discussion Board
a resource for patients, friends, caregivers and loved ones.
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I have noticed peoples ages have disappeared-why is that?
Janet, wow, no one can pull anything over on you!!! I just checked the profiles and you are so right! Hope you are doing better, girl!
I didn't catch that either. I wonder why? Good job Janet. How are you doing?
... just as I was considering admitting to mine, too!!
I dont mind admitting mine... 35. I dont think I look 35, perhaps 30 or at least in my eyes. And this should be embarrassing because I act like I am 12. There is a 23 yr gap between my age and my actions. Despite cancer being very adult, I am not quite ready to grow up yet!
The information expressed is not medical advice. The discussion boards are not intended to replace the services of a trained health professional or to be a substitute for the medical advice of physicians or other healthcare providers. Read the full disclaimer.


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|Learning to Teach
|Written by Toby Sumpter
|Saturday, 01 May 2010 09:04
In the last article in this series, we established the biblical principle that education is intensely personal. Not only is it personal, but it is always personally related to Jesus. All learning is covenantal; we are either betrayers or disciples in our learning and teaching.
If we are aiming to be disciples, we are aiming to deliver Jesus as the apostles did, handing over the customs, words, stories, and teachings of Jesus, such that our disciples have actually learned Christ, having actually heard Him and having been taught by Him (Eph. 4:21).
Jesus assumes this same pattern when He says: "A disciple is not above his teacher, but everyone who is perfectly trained will be like his teacher" (Lk. 6:40). Teachers must always aim to see themselves in their students. In other words, our students are not studying subjects; they are studying us. In practical terms, we mean that we want our students to learn to mimic or imitate us in some small skill. Perhaps we want our students to scrawl a letter in a particular fashion, follow a series of computations in a particular way, or analyze a story or poem paying attention to the sorts of elements that we – the teacher – have previously pointed out. But more globally, we, like Paul, are always urging our students to imitate us as we imitate Christ (1 Cor. 4:16, 11:1). Education is always concerned with imitation. And imitation is more than just ideas or words. Imitation involves facial expressions, attitudes, actions, and more. How did Paul and the other apostles deliver Jesus to the saints? They delivered Jesus through stories and actions and instructions. We see this most clearly in the sacramental instructions delivered by Paul to the Corinthians (1 Cor. 11:23). In the Lord's Supper, we imitate Paul who was imitating Jesus. In the Lord's Supper, we are learning Christ as we imitate our Teacher. We seek to become like Jesus as we follow His example and instructions. And those who learn Christ well will become like Christ the Teacher.
This idea seems to be rooted in the Hebrew language. The engine of the Hebrew language is in the verb. The verb is where most of the action is. There are a number of verb forms which can morph verb meanings, leaning in one direction or another: passive, reflexive, etc. One form frequently intensifies the meaning of verbs. So for example, in the case of the verb "to kill," when it is transposed into the intensive form, the same verb becomes "to slaughter." The meager act of taking life grows up into a Bruce Willis blockbuster massacre. But back to our point, in the case of the verb "to learn," the same verb transposed into the intensive form becomes "to teach." Those who learn well become teachers, and more specifically, those who learn Christ well, become conduits of His person. And all disciples are called to strive for this, that our lives might present Christ in all that we do. But surely, at the very least, the act of teaching must strive for this consciously.
But education-as-discipleship must imitate Jesus, who was the Master Teacher. How did Jesus teach the first disciples? He taught them in the same way all faithful parents teach their children. He taught them when they were sitting in the house, when they were walking by the way, when they were lying down, and when they were rising up (Dt. 6:7: 11:19). Discipleship takes place in action, around meals, through sharing life together. It is not an accident that Jesus did not start a synagogue where He called the twelve disciples to join Him eight hours a day, five days a week for three years (summers off of course, along with Christmas and Easter). Jesus taught the disciples through living with them, and inviting them to live with Him and share their lives together.
I'm not suggesting that faithful Christian schools must become boarding schools, and classroom time is certainly not a problem in itself. But if education, Christian education, is the act of delivering Jesus to others, then education is not primarily a transfer of information. Education is a complex transfer of the habits, customs, rituals, sayings, stories, values, morals, songs, and jokes of the teacher to the students until the students are walking around looking, sounding, and acting like their teacher. And ultimately that Teacher is Jesus. We will know if we have succeeded in teaching Jesus to our students if they grow up into Jesus and grow up into disciples who likewise have learned Jesus so intensely that they overflow and become teachers of the same Jesus to those they come in contact with. In other words education is evangelistic, and faithful Christian education produces evangelists in every sphere of human life.
A final suggestion in conclusion: Christian schools ought to seriously consider how they conform to this standard. At the center of Christian life is a feast, feasting on the Word in all of His glorious forms in worship. But this is the way Jesus has always trained disciples. Running through the gospels are feasts, dinners, meals, and more feasts. And if there is no dinner, you can bet that Jesus will have the crowds sit down, and He will provide one. It is not likely that Christian education can take this point too seriously. Learning and discipleship ought to reflect this. If we are teaching Jesus, if teachers are seeking to imitate the Teacher such that students come to resemble Him, we should be constantly spreading a feast, inviting our students to a meal, sitting down with them around food and drink: Laughter, stories, songs, and breaking bread from class to class, you know, like the early church.
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