Podcasts about Marcu

https://usplasticspact.org/https://www.linkedin.com/in/marcu-alexander-651a905/What is the US Plastics Pact? Who should join the US Plastics Pact? https://www.linkedin.com/in/cory-connors/I'm here to help you make your packaging more sustainable! Reach out today and I'll get back to you asap. This podcast is an independent production and the podcast production is an original work of the author. All rights of ownership and reproduction are retained—copyright 2022.

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Duminica, Aprilie 27 - Sf. Sfintit Mucenic Simeon, ruda Domnului; Sf. Apostoli Aristarh, Marcu si Zinon

6 koncertów w miesiąc? I to na dwóch kontynentach? Kto mógł to zrobić, jak nie Matylda... Zdecydowanie jest co opowiadać, więc musiał powstać o tym cały odcinek. Seventeen, TripleS, Ateez, Taemin, All(h)ours i Evnne - o tych właśnie grupach sobie dziś pogadamy. Jak wyglądały poszczególne koncerty? Czy warto iść na fan meeting w Korei nie znając koreańskiego? Czym charaktertyzują się różne fandomy na wydarzeniach? Zapraszamy do słuchania! __________________________________ Piosenki w odcinku: 1. Seventeen „Let me hear you say”, 2. Ateez „Selfish waltz”, 3. All(h)ours „Gotcha”, 4. Evnne „Syrup” 5. Triples „Cherry Talk”, 6. Taemin „Heaven” __________________________________ Tuba.fm na Tiktoku i Instagramie: https://www.tiktok.com/@tuba.fm https://www.instagram.com/tuba.fm/ __________________________________ Matylda na TikToku i Instagramie: https://www.tiktok.com/@everycraft https://www.instagram.com/_everycraft

LRT OPUS laidos „Be filtro“ svečias – garsios Prancūzijos grupės „Nouvelle Vague“ lyderis Marcas Collinas. Ved. Ramūnas Zilnys

W tym odcinku podsumujemy filmowy miesiąc Marzec i polecimy Wam, lub nie, kilka produkcji które mieliśmy okazje w tym miesiącu obejrzeć.Na jakie filmy poszliśmy do kina i jakie smaczki przygotowały dla nas platformy streamingowe?

Sambata, Martie 29 - Cuv. Marcu, Episcopul Aretuselor; Chiril diaconul

Marcu and Corey What You Know 'Bout That trivia game for Friday March 14th, 2025.

A special episode this week with Marcus Sheridan, author of the new book "Endless Customers." Marcus teaches us about the four-step process for creating more trust with our customers, positioning us as the most known and leading expert in our industry. This includes saying what others aren't willing to say, leaning into video, selling differently and showing your human side.  You will get at least one amazing nugget that will change your business forever. Pick up Endless Customers by Marcus Sheridan today.  ------- Like this episode? SUBSCRIBE on Apple, Spotify or Google. See all Content Inc episodes at the Content Inc. podcast home. Get my personal newsletter today and receive my free goal-setting guide today.  

Dumnezeu să îţi vorbească prin acest mesaj!

Seniorzy w Niemczech dostaną w marcu niższe emerytury, ale dowiedzą się, o ile ich świadczenia wzrosną od lipca. Co jeszcze zmienia się w marcu? Płaca minimalna dla pracowników tymczasowych, tablice rejestracyjne dla niektórych pojazdów, połączenia kolejowe i lotnicze, skład Bundestagu, a nawet czas. Na podcast zaprasza Maciej Wiśniewski. KONTAKT: cosmopopolsku@rbb-online.de STRONA: http://www.wdr.de/k/cosmopopolsku BĄDŹ NA BIEŻĄCO: https://www.facebook.com/cosmopopolsku Von Maciej Wisniewski.

Odcinek poświęcony marcowym wysiewom warzyw i kwiatów. W zależności od warunków glebowych będziemy mogli w części Polski rozpocząć już siewy bezpośrednio do gruntu. Większość, to będą wysiewy na rozsadę. Tydzień po tygodniu, opowiadamy co można i co warto wysiewać w marcu.Szczegółowy terminarz siewów wyślemy w sobotnim newsletterze.Rozmawiają Katarzyna Bellingham i Jacek NaliwajekWarsztaty w ogrodzie Katarzyny: https://thegardenwarsztaty.blogspot.com/Polecam książki:Książka "Plan na warzywnik" Jacek Naliwajek: https://bit.ly/3zwoGv1E-book "Plan na warzywnik": https://bit.ly/3EwJSDiKsiążki Katarzyny Bellingham z dedykacją: https://allegro.pl/uzytkownik/kitty908Polecane ze sklepu (reklama):Nasiona warzyw: https://bit.ly/40A5ynbNasiona pomidorów: https://bit.ly/4hVFuw1Dalie w odmianach: https://bit.ly/3UsxiuuTaca do sadzenia: https://bit.ly/3KYYwCEMiniszklarenka do wysiewów: https://bit.ly/42D7m1cMocne i trwałe multuplaty na rozsady: https://bit.ly/3SaNeA9Akcesoria do wysiewu: https://bit.ly/42GXUMpKonewka o drobnym sicie: https://bit.ly/472hgdPWermikulit ogrodniczy: https://bit.ly/3U4oICeSklep Kasi: https://KasiaBellinghamSklep.pl/Newsletter: https://naturalnieoogrodach.pl/Strona internetowa: https://naturalnieoogrodach.pl/Kontakt: naturalnieoogrodach@gmail.comPodcastu możesz też słuchać na aplikacjach mobilnych:�� Spotify: https://spoti.fi/2IT0uXP�� Apple Podcasts: https://apple.co/2VN51RHZajrzyj do nas: FB: https://www.facebook.com/Naturalnie-o-ogrodach-803749476630224/IN: https://instagram.com/naturalnie.o.ogrodach/Co to za kanał „Naturalnie o ogrodach”?Opowiadamy o ogrodach naturalnych, ekologicznych, pożytecznych, wiejskich, miejskich i angielskich. Propagujemy i zachęcamy do uprawiania ogrodów ekologicznie, w zgodzie z naturą, bez chemii.#naturalnieoogrodach

CU DOMNUL ISUS ÎN FURTUNĂ (1) „Cine este Acesta de Îl ascultă chiar și vântul și marea?” (Marcu 4:41)

DESPRE PUNEREA MÂINILOR „În numele Meu… își vor pune mâinile pe bolnavi și bolnavii se vor însănătoși.” (Marcu 16:17-18)

CU DOMNUL ISUS ÎN FURTUNĂ (2) „El… a zis mării: „Taci! Fără gură!” Vântul a stat şi s-a făcut o linişte mare.” (Marcu 4:39)

Marzec to prawdopodobnie najbardziej intensywny miesiąc roku. W tym odcinku omawiam jego kluczowe wydarzenia: dwa zaćmienia, retrogradację Merkurego, retro Wenus i kończącą się retrogradację Marsa. Przyglądam się także Neptunowi, który przechodzi z Ryb do Barana, zwiastując nowy etap w zbiorowej świadomości. To odcinek pełen wiedzy, który pomoże Ci lepiej zrozumieć nadchodzące zmiany.Chcesz popracować ze swoją motywacją/ odwagą? Zapraszam na Masterclass Mars. Potrzebujesz przygotować się na retro Wenus lub poczuć więcej przyjemności? Masterclass Wenus jest dla Ciebie. A może pakiet?

Nachum Segal presents great Jewish music, the latest news from Israel, an interview with David Marcu, President of Israel Elwyn, and Morning Chizuk with Rabbi Dovid Goldwasser.

2 Timotei 4.9-22 9. Caută de vino curând la mine.10. Căci Dima, din dragoste pentru lumea de acum, m-a părăsit şi a plecat la Tesalonic. Crescens s-a dus în Galatia, Tit în Dalmatia.11. Numai Luca este cu mine. Ia pe Marcu şi adu-l cu tine; căci el îmi este de folos pentru slujbă.12. Pe Tihic […]

ATITUDINEA CORECTĂ (2) „...Toate lucrurile sunt cu putinţă celui ce crede!” (Marcu 9:23)

Duminica, Ianuarie 19 - Cuv. Macarie Egipteanul, Arsenie si Marcu; Cuv. Eufrasia

RECOLTA TA ESTE ÎN CURS DE COACERE! „...Sămânţa încolţeşte şi creşte fără să ştie el cum.” (Marcu 4:27)

ASCULTĂ MAI ATENT! „Ascultaţi-Mă toţi şi înţelegeţi.” (Marcu 7:14)

NU ÎNCETA NICIODATĂ SĂ ÎNVEȚI (2) „Să-L iubești pe Domnul Dumnezeul tău… cu tot cugetul tău…” (Marcu 12:30)

NU ÎNCETA NICIODATĂ SĂ ÎNVEȚI (1) „Să-L iubești pe Domnul Dumnezeul tău… cu tot cugetul tău…” (Marcu 12:30)

Presented in partnership with Fertility and Sterility onsite at the 2024 ANZSREI meeting in Sydney, Australia.  The ANZSREI 2024 debate discussed whether patients with unexplained infertility should go straight to IVF. Experts on both sides weighed the effectiveness, cost, and psychological impact of IVF versus alternatives like IUI. The pro side emphasized IVF's high success rates and diagnostic value, while the con side argued for less invasive, cost-effective options. The debate highlighted the need for individualized care, with no clear consensus reached among the audience. View Fertility and Sterility at https://www.fertstert.org/ TRANSCRIPT: Welcome to Fertility and Sterility On Air, the podcast where you can stay current on the latest global research in the field of reproductive medicine. This podcast brings you an overview of this month's journal, in-depth discussion with authors, and other special features. F&S On Air is brought to you by Fertility and Sterility family of journals in conjunction with the American Society for Reproductive Medicine, and is hosted by Dr. Kurt Barnhart, Editor-in-Chief, Dr. Eve Feinberg, Editorial Editor, Dr. Micah Hill, Media Editor, and Dr. Pietro Bordoletto, Interactive Associate-in-Chief. I'd just like to say welcome to our third and final day of the ANZSREI conference. We've got our now traditional F&S podcast where we've got an expert panel, we've got our international speaker, Pietro, and we've got a wonderful debate ahead of us. This is all being recorded. You're welcome, and please think of questions to ask the panel at the end, because it's quite an interactive session, and we're going to get some of the best advice on some of the really controversial areas, like unexplained infertility. Hi, everyone. Welcome to the second annual Fertility and Sterility Journal Club Global, coming to you live from the Australia and New Zealand Society for Reproductive Endocrinology and Infertility meeting. I think I speak on behalf of everyone at F&S that we are so delighted to be here. Over the last two years, we've really made a concerted effort to take the podcast on the road, and this, I think, is a nice continuation of that. For the folks who are tuning in from home and listening to this podcast after the fact, the Australia and New Zealand Society for Reproductive Endocrinology is a group of over 100 certified reproductive endocrinologists across Australia and New Zealand, and this is their annual meeting live in Sydney, Australia. Today's debate is a topic that I think has vexed a lot of individuals, a lot of patients, a lot of professional groups. There's a fair amount of disagreement, and today we're going to try to unpack a little bit of unexplained infertility, and the question really is, should we be going straight to IVF? As always, we try to anchor to literature, and there are two wonderful documents in fertility and sterility that we'll be using as our guide for discussion today. The first one is a wonderful series that was published just a few months ago in the May issue, 2024, that is a views and reviews section, which means there's a series of three to five articles that kind of dig into this topic in depth. And the second article is our professional society guideline, the ASRM Committee Opinion, entitled Evidence-Based Treatments for Couples with Unexplained Infertility, a guideline. The format for today's discussion is debate style. We have a group of six experts, and I've asked them to randomly assign themselves to a pro and a con side. So I'll make the caveat here that the things that they may be saying, positions they may be trying to influence us on, are not necessarily things that they believe in their academic or clinical life, but for the purposes of a rich debate, they're going to have to be pretty deliberate in convincing us otherwise. I want to introduce my panel for today. We have on my immediate right, Dr. Raewyn Tierney. She's my co-moderator for tonight, and she's a practicing board-certified fertility specialist at IVF Australia. And on my immediate left, we have the con side. Going from left to right, Dr. Michelle Quick, practicing board-certified fertility specialist at IVF Australia. Dr. Robert LaHood, board-certified reproductive endocrinologist and clinical director of IVF Australia here in Sydney. And Dr. Clara Bothroyd, medical director at Care Fertility and the current president of the Asia Pacific Initiative in Reproduction. Welcome. On the pro side, going from right to left, I have Dr. Aurelia Liu. She is a practicing board-certified fertility specialist, medical director of Women's Health Melbourne, and clinical director at Life Fertility in Melbourne. Dr. Marcin Stankiewicz, a practicing board-certified fertility specialist and medical director at Family Fertility Centre in Adelaide. And finally, but certainly not least, the one who came with a tie this morning, Dr. Roger Hart, who is a professor of reproductive medicine at the University of Western Australia and the national medical director of City Fertility. Welcome, pro side. Thank you.  I feel naked without it. APPLAUSE I've asked both sides to prepare opening arguments. Think of this like a legal case. We want to hear from the defence, we want to hear from the plaintiffs, and I'm going to start with our pro side. I'd like to give them a few minutes to each kind of introduce their salient points for why we should be starting with IVF for patients with unexplained infertility. Thanks, Pietro. To provide a diagnosis of unexplained infertility, it's really a reflection of the degree investigation we've undertaken. I believe we all understand that unexplained infertility is diagnosed in the presence of adequate intercourse, normal semen parameters, an absence ovulatory disorder, patent fallopian tubes, and a normal detailed pelvic ultrasound examination. Now, the opposing team will try to convince you that I have not investigated the couple adequately. Personally, I'm affronted by that suggestion. But what possible causes of infertility have I not investigated? We cannot assess easily sperm fertilising capability, we cannot assess oocyte quality, oocyte fertilisation potential, embryonic development, euploidy rate, and implantation potential. Surely these causes of unexplained fertility will only become evident during an IVF cycle. As IVF is often diagnostic, it's also a therapeutic intervention. Now, I hear you cry, what about endometriosis? And I agree, what about endometriosis? Remember, we're discussing unexplained infertility here. Yes, there is very good evidence that laparoscopic treatment for symptomatic patients with endometriosis improves pelvic pain, but there is scant evidence that a diagnostic laparoscopy and treating any minor disease in the absence of pain symptoms will improve the chance of natural conception, or to that matter, improve the ultimate success of IVF. Indeed, in the absence of endometriomas, there is no negative impact on the serum AMH level in women with endometriosis who have not undergone surgery. Furthermore, there is no influence on the number of oocytes collected in an IVF cycle, the rate of embryonic aneuploidy, and the live birth rate after embryo transfer. So why put the woman through a painful, possibly expensive operation with its attendant risks as you're actually delaying her going straight to IVF? What do esteemed societies say about a diagnostic laparoscopy in the setting of unexplained infertility? The ESHRE guidelines state routine diagnostic laparoscopy is not recommended for the diagnosis of unexplained infertility. Indeed, our own ANZSREI consensus statement says that for a woman with a minimal and mild endometriosis, that the number of women needed to treat for one additional ongoing pregnancy is between 3 and 100 women with endometriosis. Is that reasonable to put an asymptomatic woman through a laparoscopy for that limited potential benefit? Now, regarding the guidelines for unexplained infertility, I agree the ASRM guidelines do not support IVF as a first-line therapy for unexplained infertility for women under 37 years of age. What they should say, and they don't, is that it is assumed that she is trying for her last child. There's no doubt if this is her last child, if it isn't her last child, sorry, she will be returning, seeking treatment, now over 37 years of age, where the guidelines do state there is good evidence that going straight to IVF may be associated with higher pregnancy rates, a shorter time to pregnancy, as opposed to other strategies. They then state it's important to note that many of these included studies were conducted in an area of low IVF success rates than those currently observed, which may alter this approach, suggesting they do not even endorse their own recommendations. The UK NICE guidelines, what do they say for unexplained infertility? Go straight to IVF. So while you're listening to my esteemed colleagues on my left speaking against the motion, I'd like to be thinking about other important factors that my colleagues on my right will discuss in more detail. Consider the superior efficacy of IVF versus IUI, the excellent safety profile of IVF and its cost-effectiveness. Further, other factors favouring a direct approach to IVF in the setting of unexplained infertility are what is the woman's desired family? We should not be focusing on her first child, we should be focusing on giving her the family that she desires and how we can minimise her inconvenience during treatment, as this has social, career and financial consequences for those impediments for her while we attempt to help her achieve her desired family. Thank you. APPLAUSE I think the young crowd would say that that was shots fired. LAUGHTER Con side? We're going to save the rebuttal for the time you've allocated to that, but first I want to put the case about unexplained infertility. Unexplained infertility in 2024 is very different to what it was 10 and 20 years ago when many of the randomised controlled trials that investigated unexplained infertility were performed. The armamentarium of investigative procedures and options that we have has changed, as indeed has our understanding of the mechanisms of infertility. So much so that that old definition of normal semen analysis, normal pelvis and ovulatory, which I think was in Roy Homburg's day, is now no longer fit for purpose as a definition of unexplained infertility. And I commend to you ICMART's very long definition of unexplained infertility, which really relies on a whole lot of things, which I'm going to now take you through what we need to do. It is said, or was said, that 30% of infertility was unexplained. I think it's way, way less than that if we actually look at our patients, both of them, carefully with history and examination and directed tests, and you will probably reduce that to about 3%. Let me take you through female age first. Now, in the old trials, some of the women recruited were as old as 42. That is not unexplained infertility. We know about oocyte aneuploidy and female ageing. 41, it's not unexplained. 40, it's not unexplained. 39, it's not unexplained. And I would put it to you that the cut-off where you start to see oocyte aneuploidy significantly constraining fertility is probably 35. So unexplained infertility has to, by definition, be a woman who is less than 35. I put that to you. Now, let's look at the male. Now, what do we know about the male, the effect of male age on fertility? We know that if the woman is over 35, and this is beautiful work that's really done many years ago in Europe, that if the woman is over 35 and the male is five years older than her, her chance of natural conception is reduced by a further 30%. So I put it to you that, therefore, the male age is relevant. And if she's 35 and has a partner who's 35 years older than her or more, it's not unexplained infertility. It's related to couple age. Now, we're going to... So that's age. Now, my colleagues are going to take you through a number of treatment interventions other than IVF, which we can do with good effect if we actually make the diagnosis and don't put them into the category of unexplained infertility. You will remember from the old trials that mild or moderate or mild or minimal endometriosis was often included, as was mild male factor or seminal fluid abnormalities. These were really multifactorial infertility, and I think that's the take-home message, that much of what we call unexplained is multifactorial. You have two minor components that act to reduce natural fecundability. So I now just want to take you through some of the diagnoses that contribute to infertility that we may not, in our routine laparoscopy and workup, we may not pick up and have previously been called unexplained infertility. For instance, we know that adenomyosis is probably one of the mechanisms by which endometriosis contributes to infertility. Chronic endometritis is now emerging as an operative factor in infertility, and that will not be diagnosed easily. Mild or minimal endometriosis, my colleagues will cover. The mid-cycle scan will lead you to the thin endometrium, which may be due to unexpected adhesive disease, but also a thin endometrium, which we know has a very adverse prognostic factor, may be due to long-term progestin contraception. We are starting to see this emerge. Secondary infertility after a caesarean section may be due to an isthma seal, and we won't recognise that unless we do mid-cycle scans. That's the female. Let's look at the male. We know now that seminal fluid analysis is not a good predictor of male fertility, and there is now evidence from Ranjith Ramasamy's work that we are missing clinical varicoceles because we failed to examine the male partner. My colleagues will talk more about that. We may miss DNA fragmentation, which again may contribute via the basic seminal fluid analysis. Now, most of these diagnoses can be made or sorted out or excluded within one or two months of your detailed assessment of both partners by history and examination. So it's not straight to IVF, ladies and gentlemen. It's just a little digression, a little lay-by, where you actually assess the patient thoroughly. She did not need a tie for that rebuttal. LAUGHTER Prasad. Thank you. Well, following from what Professor Hart has said, I'm going to show that IVF should be a go-to option because of its effectiveness, cost-effectiveness and safety. Now, let me first talk about the effectiveness, and as this is an interaction session, I would like to ask the audience, please, by show of hands, to show me how many of you would accept a medical treatment or buy a new incubator if it had a 94% chance of failure? Well, let the moderator please note that no hands have been raised. Thank you very much. Yet, the chance of live birth in Australian population following IUI is 6%, where, after IVF, the live birth is 40%. Almost seven times more. Now, why would we subject our patients to something we ourselves would not choose? Similarly, findings were reported from international studies that the hazard ratio of 1.25 favouring immediate IVF, and I will talk later about why it is important from a safety perspective. Cost-effectiveness. And I quote ESHRE guidelines. The costs, treatment options have not been subject to robust evaluations. Now, again, I would like to ask the audience, this time it's an easy question, how many of you would accept as standard an ongoing pregnancy rate of at least 38% for an average IVF cycle? Yeah, hands up. All right, I've got three-quarters of the room. OK. Well, I could really rest my case now, as we have good evidence that if a clinic has got an ongoing pregnancy rate of 38% or higher with IVF with single embryo transfer, then it is more effective, more cost-effective, and should be a treatment of choice. And that evidence comes from the authors that are sitting in this room. Again, what would the patients do? If the patients are paying for the treatment, would they do IUI? Most of them would actually go straight to IVF. And we also have very nice guidelines which advise against IUI based on cost-effectiveness. Another factor to mention briefly is the multiple births, which cost five to 20 times more than singleton. The neonatal cost of a twin birth costs about five times more than singletons, and pregnancy with delivery of triplets or more costs nearly 20 times. Now, the costs that I'm going to quote are in American dollars and from some time ago, from Fertility and Sterility. However, the total adjusted all healthcare costs for a single-dom delivery is about US$21,000, US$105,000 for twins, and US$400,000 for triplets and more. Then the very, very important is the psychological cost of the high risk of failure with IUI. Now, it is well established that infertility has a psychological impact on our patients. Studies have shown that prolonged time to conception extends stress, anxiety, and depression, and sexual functioning is significantly negatively impacted. Literature shows that 56% of women and 32% of men undergoing fertility treatment report significant symptoms of depression, and 76% of women and 61% of men report significant symptoms of anxiety. Shockingly, it is reported that 9.4% of women reported having suicidal thoughts or attempts. The longer the treatment takes, the more our patients display symptoms of distress, depression, and anxiety. Safety. Again, ESHRE guideline says the safety of treatment options have not been subjected to robust evaluation. But let me talk you through it. In our Australian expert hands, IVF is safe, with the risk of complications of ectopic being about 1 in 1,500 and other risks 1 in 3,000. However, let's think for a moment on impact of multiple births. A multiple pregnancy has significant psychological, physical, social, and financial consequences, which I can go further into details if required. I just want to mention that the stillbirth rate increases from under 1% for singleton pregnancies to 4.5% for twins and 8.3% for higher-order multiples, and that multiple pregnancies have potential long-term adverse health outcomes for the offspring, such as the increased risk of health issues through their life, increased learning difficulties, language delay, and attention and behavior problems. The lifelong disability is over 25% for babies weighing less than 1 kilogram at delivery. And please note that the quoted multiple pregnancy rates with IUI can reach up to 33%, although in expert hands it's usually around 15%, which is significantly higher than single embryo transfer. In conclusion, from the mother and child safety perspective, for the reason of medical efficacy and cost effectiveness, we have reasons to believe you should go straight to IVF. We're going to be doing these debates more often from Australia. This is a great panel. One side, please. Unexplained infertility. My colleagues were comparing IUI ovulation induction with IVF, but there are other ways of achieving pregnancies with unexplained fertility. I'm going to take the patient's perspective a little bit here. It's all about shared decision-making, so the patient needs to be involved in the decision-making. And it's quite clear from all the data that many patients with unexplained infertility will fall pregnant naturally by themselves even if you do nothing. So sometimes there's definitely a place in doing nothing, and the patient needs to be aware of that. So it's all about informed consent. How do we inform the patient? So we've got to make a proper diagnosis, as my colleague Dr. Boothright has already mentioned, and just to jump into IVF because it's cost-effective is not doing our patients a justice. The prognosis is really, really important, and even after 20 years of doing this, it's all about the duration of infertility, the age of the patient, and discussing that prognosis with the patient. We all know that patients who have been trying for longer and who are older do have a worse prognosis, and maybe they do need to look at treatment quicker, but there are many patients that we see that have a good prognosis, and just explaining that to them is all they need to achieve a pregnancy naturally. And then we're going to talk about other options. It's wrong not to offer those to patients, and my colleague Dr. Quick will talk about that in a moment. Look, we've all had patients that have been scarred by IVF who've spent a lot of money on IVF, did not fall pregnant, and I think the fact that they weren't informed properly, that the diagnosis wasn't made properly, is very frustrating to them. So to just jump into IVF again is not doing the patients a justice. And look, there are negatives to IVF. There's not just the cost to the patient, the cost to society. As taxpayers, we all pay for IVF. It's funded here, or sponsored to some degree, and it's also the family and everyone else that's involved in paying for this. So this is not a treatment that is without cost. There are some harms. We know that ovarian hyperstimulation syndrome still exists, even though it's much less than it used to be. There's a risk of infection and bleeding from the procedures. And we can look at the baby. The data still suggests that babies born from IVF are smaller and they're born earlier, and monozygotic twinning is more common with IVF, so these are high-risk pregnancies, and all this may have an impact on the long-term health of the babies somewhere down the track at the moment. That is important to still look out for. But I come back to the emotional toll. Our colleagues were saying that finishing infertility quicker helps to kind of reduce the emotional toll, but the procedure itself does have its own toll if it doesn't work, and so we've got to prepare patients, have them informed. But at the end of the day, it's all about patient choice. How can a patient make a choice if we don't make a proper diagnosis, give them a prognosis and offer them some other choices that exist? And running the anchor leg of the race for the pro side. IVF in couples with unexplained infertility is the best tool we have in our reproductive medicine toolkit for multiple reasons. Professor Hart has clarified the definition of unexplained infertility. As a reflection of the degree of investigation we've undertaken. He's explained that IVF is often importantly diagnostic as well as therapeutic, both demonstrating and overcoming barriers to natural conception. Dr Stankiewicz has convinced us that IVF is efficient, safe and cost-effective. My goal is to show you that IVF is the correct therapy to meet the immediate and big picture family planning goals for our patients with unexplained infertility. More than 80% of couples with defined unexplained infertility who attempt IVF treatment will have a baby. In Australia, ANZSREI data shows us that the average age of the female patients who present with primary unexplained infertility is over 35 years. And in fact the average is 38 years. We're all aware that the average age of first maternity in Australia has progressively become later over the past two decades. Currently it stands in the mothers and babies report at 32 years. If the average age of first maternity is 32 years, this means that at least 50% of women attempting their first pregnancy are over 32 years. Research I conducted in Melbourne University with my student Eugenie Pryor asking university students of their family planning intentions and aspirations demonstrated that most people, male and female, want to be parents and most want to have more than one child. However, in Australia, our most recent survey shows that births are at an all-time low, below replacement rate and falling, with an ever greater proportion of our population being unable to have the number of children they aspire to and an ever growing proportion seeking assisted reproductive care. Fertility declines with age. Factors include egg quality concerns, sperm quality concerns and the accumulation of pathologies over time. Adenomyosis, fibroids, endometriosis are concerns that no person is born with. They exist on a spectrum and progress over time and may be contributing factors for unexplained infertility. Our patients, when we meet them, are the best IVF candidates that they will ever be. They are the youngest they will ever be and they have the best ovarian reserve they will ever have. They will generate more euploid embryos now than they will in years to come. The sooner we get our patients pregnant, the sooner they will give birth. It takes nine months to have a baby, 12 months potentially to breastfeed and wean and of course most patients will need time to care for a young infant and recover prior to attempting another pregnancy. IVF and embryo banking may represent not only their best chance of conception with reduced time to pregnancy but also an opportunity for embryo banking to improve their cumulative live birth rate potential over time. By the time our 38-year-old patient returns to try to conceive for a second child, she will undoubtedly be aged over 40. Her chance of live birth per cycle initiated at IVF at this stage has reduced phenomenally. The ANZSREI dataset from our most recent report quotes that statistic to be 5%. Her chance of conception with an embryo frozen at 38 years, conversely, is one in three to one in four. There is no room for doubt that IVF gives couples with unexplained infertility not only the most effective treatment we have to help them have a baby, but their best opportunity to have a family. Last but certainly not least, Dr. Quick, to round out the con sides arguments before we open up for rebuttal. And I'll make a small plea that if you have questions that you'd like to pose directly to the panel, prepare them and we'll make sure we get to them from the audience shortly. Thank you. So, whilst we have heard that we may be bad doctors because we're delaying our patients' time to pregnancy, I would perhaps put it to you that unexplained infertility is a diagnosis which is made based on exclusion. So perhaps you are the bad doctors because you haven't looked hard enough for the cause of the unexplained infertility. So, in terms of the tests that we all would do, I think, we would all ensure that the woman has an ovarian reserve. We would all ensure that she has no structural anomaly inside the uterus. We would all ensure that her tubes are patent. We would all ensure that she has regular cycles. We would ensure that he has a normal semen analysis. I think these are tests that we would all do when trying to evaluate a couple for fertility who are struggling to conceive. And therefore, the chance of them getting pregnant naturally, it's never going to be zero. And one option therefore, instead of running straight to IVF, would be to say, OK, continue timed intercourse because the chance of you conceiving naturally is not actually zero and this would be the most natural way to conceive, the cheapest way to conceive, the least interventional way to conceive. And whether that be with cycle tracking to ensure appropriate timed intercourse, whether that be with cycle tracking to ensure adequate luteal phase support. When you clear the fallopian tubes, we know that there are studies showing an improvement in natural conception. Lipidol or oil-based tubal flushing techniques may also help couples to conceive naturally. And then you don't have this multiple pregnancy rate that IVF has. You don't have the cost that you incur with IVF, not just for the couple but to Australian society because IVF is subsidised in this country. You don't have the risks that the woman goes through to undergo IVF treatment. You don't have the risks that the baby takes on being conceived via IVF. And so conceiving naturally, because it's not going to be zero, is definitely an option for these couples. In terms of further tests or further investigations that you could do, some people would argue, yes, we haven't looked hard enough for the reason for infertility, therefore we know that ultrasound is notoriously bad at picking up superficial endometriosis. We know that ultrasound cannot pick up subtle changes in the endometrium, as Dr Boothroyd referred to chronic endometritis, for example. So these patients perhaps should undergo a hysteroscopy to see if there is an endometrial issue. Perhaps these patients should undergo a laparoscopy to see if there is superficial endometriosis. And there are meta-analyses showing that resecting or treating superficial endometriosis may actually help these couples conceive naturally down the track and then therefore they avoid having more interventional treatment in order to conceive. There is also intrauterine insemination with or without ovarian stimulation, which may improve their chances of conceiving naturally. And that again would be less invasive, less intervention and cheaper for the patient. And we know that therefore there are a lot of other treatment options available to help these couples to conceive. And if it's less invasive, it's more natural, it's cheaper, that ends up being better for the patient. Psychologically as well, which the other side have brought up, even with Dr Stankiewicz's 38% ongoing pregnancy rate, that also means that 62% of his patients are not going to be pregnant. The psychological impact of that cannot be underestimated because for a lot of patients, IVF is your last resort. And when you don't get pregnant with IVF, that creates an issue too for them. Embryo banking, which was also brought up, what happens when you create surplus embryos and what's the psychological impact of having to deal with embryos that you are then not going to use in the future? So therefore for those reasons we feel that IVF is not your first line treatment for couples who are diagnosed with unexplained infertility. There are many other ways to help these couples to conceive. We just have a multitude of things to unpack. And I want to start off by opening up an opportunity for rebuttal. I saw both sides of the panel here taking diligent notes. I think all of us have a full page worth of things that kind of stood out to us. Since the pro side had an opportunity to begin, I'm actually going to start with the con side and allow the con side to answer specific points made by the pro side and provide just a little bit more detail and clarity for why they think IVF is not the way forward. My learned first speaker, wearing his tie of course, indicated that it was all about laparoscopy and IUI, and it's way more than that. I just want to highlight to you the paper by Dressler in 2017 in the New England Journal of Medicine, a randomised controlled trial of what would be unexplained infertility according to the definition I put out, the less than 35 ovulatory normal semen analysis. And the intervention was an HSG with either oil-based contrast or water-based contrast. And over the six months, there was clear separation, and this is an effective treatment for unexplained infertility or mild or minimal endometriosis, however it might work. And there's probably separation out to three years. So as a single intervention, as an alternative to IVF, the use of oil-based contrast is an option. So it's not just about laparoscopy and IUI. I guess the other thing the second speaker did allude to, fairly abysmal success rates with IUI being 6%. That is a problem, and I would like to allude to a very good pragmatic trial conducted by Cindy Farquhar and Emily Lu and their co-workers in New Zealand that really swung the meta-analysis for the use of clomiphene and IUI to clinical efficacy. And they reported a 33% chance of live birth in their IUI and clomiphene arm. I'm going across to Auckland to see what the magic is in that city. What are they doing? The third speaker did allude to the problem of declining fertility, a global problem, and Australia is not alone. We have solved the problem to date, which we've had for 40 years, with immigration. But Georgina Chambers' work shows beautifully that IVF is not the answer to the falling fertility rates. It is a way more complex social problem and is probably outside the scope of today's discussion. So those are my three rebuttals to our wonderful team. Thank you very much. So... You can't bury them. We'll give them an opportunity. Thank you for the opportunity. So I'd like to address some of the points that my learned debaters on the opposition raised. The first speaker really suggested quite a few things that we probably omitted, like endometritis, failing to examine the male. I think things like that... I think, at a good history, that is essential what we do as part of our investigation. We're looking for a history of cesarean section, complications subsequent to that. We're doing a detailed scan, and that will exclude the fact that she's got a poor endometrium development, she's got a cesarean scar niche. A good history of a male will allude to the fact that he has some metabolic disorder, degree of hypogonadism. So we're not delaying anything by these appropriate investigations. Adenomyosis will be raised. I talked about a detailed gynaecological examination. So I honestly think that a very... As my opening line was, a detailed gynaecological scan, obviously with a very good history taken, is essential. We're not delaying her opportunity to go straight to IVF if we've addressed all these factors. The second speaker talked about shared decision-making, and we'd all completely agree with that. But we have to be honest and open about the success, which my second speaker talked about, the success of the treatment we're offering. And one thing we should sort of dwell on is it's all... It's a fundamental description of the success of treatment is probably all about prognostic models, and that who not model, that's the original model about the success of conception, is really... Everything flows on from that, which basically talks about a good prognosis patient. 30% chance of live birth after a year. That's what they talk about, a good prognosis patient. Perhaps the rest of the world is different to your average Australian patient, but if we talked about that being a good prognosis, you've got a one in three chance of being pregnant by a year. I think most of our patients would throttle us. So that is what all the models are sort of based on, that being a good prognosis patient. So I completely agree with the second speaker that we do have a shared decision. We have to be honest with our patients about the success. We have to be honest about giving them the prognosis of any treatment that we offer. But really, as my third speaker was talking about, it's about giving the patient the opportunity to have a family, minimal career disruption, minimal life disruption. We have to be honest and talk about the whole picture. They're focused on the first child because really they can't think beyond that. We're talking about giving them the family that they need. The third speaker spoke very eloquently about the risks associated with the treatment we offer. I believe we offer a very safe service with our IVF, particularly in Australia, with our 2% twin pregnancy rate. We talk about the higher risk of these pregnancies, but they perhaps don't relate to the treatment we're offering. Perhaps, unfortunately, is the patient, if she's got polycystic ovary syndrome, if she's more likely to have diabetes, premature delivery, preeclampsia. So I think often the risks associated with IVF and potentially the risks associated to the child born from IVF perhaps don't relate to the treatment of IVF per se. It may well be the woman and perhaps her partner, their underlying medical condition, which lead those risks. So I strongly would encourage you to believe that you take a very good history from your patient, you do a thorough investigation, as I've alluded to, looking for any signs of ovulatory disorder, any gynaecological disorder by a detailed scan, checking tubal patency and a detailed history and the similarities from the man, and then you'll find you're probably going straight to IVF. APPLAUSE I'd like to talk a bit about the embryo banking and having been in this field for a long time, as a word of caution, we're setting a lot of expectations. I remember going to an ASRM meeting probably 10 years ago where they had this headline, all your embryos in the freezer, your whole family in the freezer, basically expecting that if you get four or five embryos frozen that you'll end up with a family at the end. We all know that for the patient, they're not a percentage, it's either zero or 100%. And if all the embryos don't work, they don't have a family at the end, you know, it didn't work for them and their expectations haven't been met. And the way we talk about the percentages and that we can solve the patient's problems, that we can make families, it doesn't always happen. So the expectations our position is setting here, we're not always able to meet and so we're going to end up with very unhappy patients. So this is just a warning to everyone that we need to tell people that this doesn't always work and sometimes they'll end up with no success at all. And from that point of view, I think the way it's presented is way too simplistic and we've got to go back to looking at the other options and not promising things we can't always deliver. So just taking into account all our esteemed interlocutors have said, we don't necessarily disagree with the amount of investigations that they described because nowhere in our argument we said that as soon as the patient registers with the receptionist, they will direct it to an IVF lab. I think to imply so, we'd be very rich indeed. Maybe there are some clinics that are so efficient. I don't know how it works overseas, but certainly not in Australia. The other point that was made about the cost of IVF and our, again, esteemed interlocutors are very well aware from the studies done here in Australia that actually every baby that we have to conceive through IVF and create and lives is actually more than 10 to 100 times return on investment because we are creating future taxpayers. We are creating people that will repay the IVF treatment costs over and over and over again. So I'll put to you, Rob, that if you are saying that we can't do IVF because it costs money, you are robbing future treasurers of a huge amount of dollars. I hope the American audience is listening. In America, we call embryos unborn children in freezers in certain parts and here they're unborn taxpayers. Con side, final opportunity for rebuttal before some audience questions and one more word from the pro side. Well, actually, Dr Stankiewicz was very happy to hear that you're not going to send your patients straight to the IVF lab because we've managed to convince you that that's not the right thing to do. I clearly have forgotten how to debate because I did all my rebuttals at the end of my presentation but essentially I'll recap because when we're talking about IVF, as we're saying, the chance of pregnancy is not going to be 100% and so there is a psychological impact to IVF not working. There is a psychological impact to banking embryos and creating surplus embryos that eventually may not be used and they were my main rebuttal points in terms of why IVF was not the first-line treatment. Thank you. So we've heard from the opposition some very valid points of how our patients can be psychologically impacted when fertility treatment is unsuccessful. I will again remind you that IVF is the most successful fertility treatment we have in our treatment armoury. We are most likely to help our patients have a baby with IVF. The cumulative pregnancy rates for IVF have started back in the late 70s and early 80s in single-digit percentages. We now, with a best prognosis candidate, have at least a one-in-two chance of that patient having a baby per embryo transfer and in our patients with unexplained infertility, the vast majority of our patients will have success. We also heard from the negative team about the significant chance of pregnancy in patients with expectant management. You're right, there's not a 0% chance of natural conception in patients who have unexplained infertility, but there is a not very good chance. We know from data that we've had for a really long time, going back as far as the Hutterite data, to today's non-contradictory models, which tell us that a couple's chance of conception per month in best prognosis candidates is one in five. If they've been trying for six months, it's one in ten. If they've been trying for 12 months, it's only 5%, and if they've been trying for 24 months, it's less than 1%. So it may not be zero, but it isn't very good. In terms of our team reminding us of the extended ICMART definition of unexplained infertility, we don't argue. When we say someone has unexplained infertility, we make the assumption that they have been comprehensively diagnosed by a robust reproductive endocrinologist, as everyone in this room is. And I would say one closing rebuttal. IUI success rates have been the same for the last 50 years, whereas IVF success rates continue to improve. Why would you offer your patient a treatment from 50 years ago when you can offer them one from today? Thank you. APPLAUSE I'm going to take a personal privilege and ask the first question, in hoping that the microphone makes its way to the second question in the audience. My colleagues on the pro side have said IVF, IVF, IVF. Can you be a little bit more specific about what kind of IVF? Do you mean IVF with ICSI? Do you mean IVF, ICSI, and PGT? Be a little bit more deliberate for us and tell us exactly how the patient with unexplained infertility should receive IVF. As I said in my statement, I think it's a diagnostic evaluation. I think there is an argument to consider ICSI, but I think ICSI does have some negative consequences for children born. I think perhaps going straight to ICSI is too much. I think going straight to PGTA perhaps is too much, unless there is something in their history which should indicate that. But we're talking about unexplained infertility. So I believe a standard IVF cycle, looking at the opportunity to assess embryonic development, is the way to go. I do not think you should be going straight to ICSI. I think the principle of first do no harm is probably a safe approach. I don't know whether my colleagues have some other comments, but I think that would be the first approach rather than going all guns blazing. I can understand, though, in different settings in the world, there may have... We're very fortunate in Australia, we're very well supported from the government support for IVF, but I think the imperatives in different countries may be different. But I think that approach would be the right one first. We'll start with a question from the audience. And if you could introduce yourself and have the question allowed for our members in the audience who are not here. It's Louise Hull here from Adelaide. The question I would like to put to both the pro and con team is that Geeta Mishra from the University of Queensland showed that if you had diagnosed endometriosis before IVF, you were more likely to have a pregnancy and much less likely to have high-order IVF cycles. Given that we now have really good non-invasive diagnostics, we're actually... A lot of the time we can pick up superficial or stage 2 endometriosis if you get the right scan. We're going to do IVF better if we know about it. Can you comment on that impacting even the diagnosis of unexplained infertility? Thanks. I'd love to take that. Can I go first, Roger? LAUGHTER Please do. Look, I'd love to take that question. It's a really good question. And, of course, this is not unexplained infertility, so this is outside the scope here. And I think, really, what we're seeing now, in contrast to where we were at the time of the Markku study, which was all... And the Tulandy study on endometrioma excision, we now see that that is actually damaging to fertility, particularly where there is ovarian endometriosis, and that we compromise their ovarian reserve by doing this surgery before we preserve their fertility, be it oocyte cryopreservation or embryo cryopreservation. So I think it's a bit outside the scope of this talk, but I think the swing of the data now is that we should be doing fertility preservation before we do surgery for deeply infiltrated ovarian endometriosis. And that would fit with Gita's findings. A brief response. Thanks very much, Louise. Yeah, we're talking about unexplained infertility here, and my opening line was we need a history, but a detailed gynaecological ultrasound. I think it's important it's a really good ultrasound to exclude that, because the evidence around very minor endometriosis is not there. I agree with significant endometriosis, but that's not the subject of this discussion. But I do believe with very minimal endometriosis there is really no evidence for that. Janelle MacDonald from Sydney. I'm going to play devil's advocate here. So everyone is probably aware of the recent government inquiry about obstetric violence. I'm a little concerned that if we are perceived to be encouraging women to IVF first, are we guilty as a profession of performing fertility violence? That's just digressing a little bit, just thinking about how the consumers may perceive this. I think our patients want to have a baby, and that's why they come to see us, and that's what we help them to do through IVF. I'm not sure the microphone's working. And just introduce yourself. I'm from Sydney, Australia. Can I disagree with you, Roger, about that question about minimal and mild endometriosis? I'm 68, so I'm old enough to have read a whole lot of papers in the past that are probably seen as relics. But Mark Khoo published an unusual study, because it was actually an RCT. Well, sorry, not an RCT. It was a study whereby... Well, it was an RCT, and it was randomised really well. It was done in Canada, and there were about 350 subjects, and they were identified to have stage 1 or stage 2 endometriosis at laparoscopy. And the interesting thing is it was seen as an intervention which didn't greatly increase the chance of conception, but it doubled the monthly chance of conception. So there was clearly a difference between those patients who didn't have endometriosis and those that had stage 1 and stage 2 endometriosis. So the intervention did actually result in an improvement. One of the quotes was, well, I heard since then, well, it didn't make much difference. But when you realise that infertility is multifactorial, there were probably other factors involved as well. So any increase like that in stage 1 and stage 2 endometriosis sufferers was clearly beneficial for them. So I wouldn't disagree with you completely, but I do think you've got to take it on board that there is some evidence that surgical intervention can help. And certainly in those patients whereby the financial costs of IVF are still quite, even in Australia, astronomical. Many patients can get this through the public sector or the private sector treatment of their endometriosis laparoscopically very cheaply or at no cost. Thanks, Dr Persson. So you're right that there was also a counter-randomised controlled trial by the Grupo Italiano which was a counter to that. And actually did not show any benefit. But I believe the Marcu study demonstrated an excess of conception and with treatment of minima and endometriosis of about 4% per month for a few months. So absolutely, that shared decision-making. Personally, I wouldn't like a laparoscopy to give me an extra 4% chance of a natural conception for four months, which I think the data was. So basically, the basis to my statement that I said without going into great detail was a review article published by Samy Glarner recently in Reproductive Biology and Endocrinology. And their conclusions were what I basically said, that from looking at all the data, there is no real evidence of intervention for minor endometriosis. We're not talking about pain or significant diagnosed endometriosis on the outcomes of IVF, ovarian reserve, egg quality, embryo development, and euploidy rate. So that was the basis of my... I hate to disagree... I hate to agree with my opponents in a debate, but I'm going to... But there is actually a new network analysis by Rui Wang and some serious heavyweights in evidence-based medicine that pulls together the surgical studies. And the thing that made the most difference to this of mild and minimal endometriosis from a fertility point of view, not pain, is the use of oil-based uterine contrast. And I commend that paper to you, which fits with exactly what Roger is saying. Hi, my name's Lucy Prentice.  I work in Auckland. And I just wanted to point out the New Zealand perspective a little bit. Where we come from a country with very limited public funding for IVF. I'm currently running an RCT with Cindy Farquad directly looking at IVF versus IUI for unexplained infertility. And I'd just like to point out that both the ASRM and ESHRE guidelines, which are the most recent ones, both suggest that IUI should be a first-line treatment with oral ovarian stimulation. We have no evidence that IVF is superior based on an IPD meta-analysis published very recently and also a Cochrane review. And although we would love to be able to complete the family that our patients want from IVF and embryo banking, that option is really not available to a lot of people in New Zealand because of prohibitive costs. We know that IUI with ovarian stimulation is a very effective treatment for people with poor prognosis and unexplained infertility. And I also would just like to add that there's not a cost-effectiveness analysis that shows an improvement in cost-effectiveness for IVF. There's also never been a study looking at treatment tolerability between the two, so I don't think that you can say that IVF is a treatment that people prefer over IUI. So I may turn around and shoot myself in the foot based on our results that will be coming out next year, but I think at the moment I don't think you can say that IVF is better than IUI with ovarian stimulation for unexplained. We have time for two more questions from the audience, and we have two hands in the back. Now we can. It's the light green. OK. Hossam Zini from Melbourne. Thank you very much for the debate. It's very interesting. The problem is that all of the studies that have been done about comparing IUI to IVF, they are not head-to-head studies. The designs are different. They are having, like, algorithmic approach. For example, they compare three or four or five cycles of IUI to one cycle of IVF. But about 10 years ago, our group at the Royal Women's Hospital, we have done a study, a randomized control study, to compare IUI to IVF head-to-head, and we randomized the patients at the time of the trigger who only developed, so we did a low stimulation to get two to three follicles only, and that's why it was so hard to recruit lots of patients. So the criticism that was given to the study that it's a small sample size, but we end up with having IVF as a cost-effective treatment. Our IVF group had a live birth rate about 38%, and on the IUI, 12%. And with our cost calculations, we find out that the IVF is much more cost-effective than the IUI. But I believe that we all now believe in individualized kind of treatment, so patients probably who are younger than 34 years old probably wouldn't go straight to IVF. Maybe I'll do a laparoscopy and a histroscopy first, okay, and we may give them a chance to achieve a natural conception in the next three months or so. Patients who are older than 35, 37 years old probably will benefit straight from IVF. But again, in day-to-day life cases, we will not force the patient to go straight to IVF. I will talk to her and I'll tell her, these are your options, expectant treatment. This is the percentage that you would expect. IUI, this is what you expect. IUI with ovulation induction, this is what you expect. IVF, this is what you expect. And then she will discuss that with her partner and come back to me and tell me what she wants to do. Thanks. I saw a hand show up right next to you, so I'll add one more question given our time limitation. Thanks so much, Kate Stone-Mellon. I'd like to ask our panel to take themselves out of their role playing and put themselves in another role where they were the head of a very, very well-funded public service, and I'd like to ask the two sides what they really think about what they would do with a patient at the age of 35 with 12 months of unexplained infertility. Well, can I say that? Because that's my role in a different hat. LAUGHTER So, yeah, I run the state facility service in Western Australia. We looked at the data, because obviously that's what we're doing, IUI, IVF, and unfortunately we stopped doing IUI treatment. The success rate was so low. So we do go straight to IVF with unexplained infertility. Disappointing, as I'm sure you hear that, Kate, that we do. We looked at the data. Yeah, I think that I would still offer the patients the options, because some people don't want to do IVF. Even though it's completely free, they may not still want to do the injections and the procedure and take on the risks of the actual egg collection procedure. I don't know, religious issues with creating embryos. Yeah, I would still give patients the option. We have time for one more question in the back. We'll take the other ones offline afterwards. We'll get you a microphone just to make sure our listeners afterwards can listen. Following on from the New Zealand experience, which I've experienced... Hello? Yeah. From the New Zealand experience, and having worked here extensively and in New Zealand, you're not comparing apples with apples, Claire. That unexplained couple in New Zealand will wait five years to get funding and currently perhaps another two years to get any treatment. That's then an apples group compared to the pilot group who may, in fact, walk past the hospital and get treatment. The other thing about this, I think, that we need to forget, or don't forget, is the ethics of things here, two of which is that the whole understanding of unexplained infertility needs research and thinking. And if it wasn't for that understanding of what is the natural history of normal and then the understanding of pathology, we wouldn't do a lot of things in medicine. So if we have got a subgroup here that's unexplained, it's not just to the patient, we have a responsibility to future patients and ourselves to be honest and do research and learn about these factors. Now, it doesn't answer the debate, but it is something that's what drives the investigation and management of unexplained delay. And, for example, at the moment, there's quite a discussion about two issues of ethics, one about the involuntary childlessness of people that don't get to see us but don't have those children that they wanted to have because they didn't want to undergo treatment, or it was the involuntary childlessness of a second or subsequent child. And that's quite a big research issue in Europe, I realise, at the moment. And the final thing is about the information giving. The British case Montgomery 2015 has changed consent substantially, for those of you from England, that all information given to patients must include and document the discussion about expectant management versus all the different types of treatment, for and against and risks. And we're not currently doing that in IVF in this area, but if you read about what's happened in England, it's transformed consent in surgery. And I think a lot of our decision-making isn't in that way. So there are a couple of ethical principles to think about. Wonderful questions from the audience. Since we're coming up at the end of our time, we typically end the debate with closing remarks, but we'll forego that for this debate. And I'd actually like to just poll the audience. After hearing both the pro and the con side's arguments, by a show of hands, who in the audience believes that for the patient with unexplained infertility, as defined and detailed here broadly, should we be beginning with IVF? Should we be going straight to IVF? So by a show of hands. And I would say probably 50% of the room raised their hand. And those who think we should not be going straight to IVF? It feels like a little bit more. 40-60, now that I saw the other hands. Well, I'm going to call this a hung jury. I don't know that we have a definitive answer. Please join me in a round of applause for our panelists. In America, we would call that election interference. I wanted to thank our panelists, our live audience, and the listeners of the podcast. On behalf of Fertility and Sterility, thank you for the invitation to be here at your meeting and hosting this debate live from the Australian New Zealand Society for Reproductive Endocrinology meeting in Sydney, Australia. Thank you. This concludes our episode of Fertility and Sterility On Air, brought to you by the Fertility and Sterility family of journals in conjunction with the American Society for Reproductive Medicine. This podcast was developed by Fertility and Sterility and the American Society for Reproductive Medicine as an educational resource and service to its members and other practicing clinicians. While the podcast reflects the views of the authors and the hosts, it is not intended to be the only approved standard of living or to direct an exclusive course of treatment. The opinions expressed are those of the discussants and do not reflect Fertility and Sterility or the American Society for Reproductive Medicine.    

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Marcu 15.1-5 1. Dimineaţa, preoţii cei mai de seamă au făcut îndată sfat cu bătrânii, cărturarii şi tot soborul. După ce au legat pe Isus, L-au dus şi L-au dat în mâinile lui Pilat.2. Pilat L-a întrebat: „Eşti Tu Împăratul iudeilor?” „Da, sunt”, i-a răspuns Isus.3. Preoţii cei mai de seamă Îl învinuiau de multe […]

Obiecții împotriva mântuirii eterne (partea XI)Divorț și recăsătorireDivorțul este de mult timp un subiect complex și controversat în biserică. În cultura noastră de astăzi, mulți oameni sunt afectați de acesta într-un fel sau altul. Cu toții cunoaștem pe cineva, fie un membru al familiei sau un prieten apropiat, care a experimentat durerea unei căsnicii rupte. Sau poate tu însuți ai trecut sau treci printr-un divorț. Dacă da, sunt sigur că nu trebuie să vă spun cât de dureros și devastator poate fi acesta, atât pentru adulți, cât și pentru copiii implicați în situație. Mai mult decât atât, ca și copil al lui Dumnezeu, sunt sigur că te-ai întrebat de mai multe ori: „Mă va mai ierta Dumnezeu dacă divorțez sau mă recăsătoresc? Voi rămâne mântuit sau îmi voi pierde mântuirea pentru totdeauna?” Toate acestea sunt întrebări bune și pertinente, în special pentru credincioșii care au trecut deja prin acesta sau intenționează să o facă. În primul rând, trebuie să aflăm din Biblie care cazuri de divorț sau recăsătorire sunt păcate. În al doilea rând, pentru acele situații în care despărțirea de partenerul de căsătorie este un păcat, trebuie să stabilim, din nou, cu ajutorul Scripturii, dacă acest tip de păcat este de neiertat și îi poate face pe credincioși să-și piardă mântuirea veșnică. Imoralitatea sexuală și partenerul necredinciosExistă două cazuri clare în care divorțul este permis de Dumnezeu și nu este considerat un păcat în Scriptură. Primul motiv admisibil, descris de Isus în Matei 5:31–32 și Matei 19:9, este infidelitatea prin imoralitate sexuală, care se aplică ambilor soți:Matei 5:31–32 (NTR)31 S-a mai zis: «Oricine divorțează de soția lui să-i dea o scrisoare de despărțire».32 Dar Eu vă spun că oricine divorțează de soția lui, dintr-un alt motiv decât cel al preacurviei, o împinge să comită adulter, iar cel ce se căsătorește cu o femeie divorțată comite adulter.Matei 19:9 (NTR)9 Dar Eu vă spun că oricine divorțează de soția lui, în afară de caz de preacurvie, și se căsătorește cu alta comite adulter.Unii lideri spirituali din trupul lui Cristos de astăzi susțin că, pe baza acestor două pasaje, numai imoralitatea sexuală este un motiv valid pentru a desface o căsnicie. Dacă este așa, înseamnă că apostolul Pavel L-a contrazis pe Isus. În 1 Corinteni 7:15, el adaugă o a doua situație în care divorțul nu este un păcat, aceea a unui soț necredincios care dorește să se despartă:1 Corinteni 7:12–15 (NTR)12 Celorlalţi vă spun eu, nu Domnul, că, dacă un frate are soţia necredincioasă şi ea vrea să stea cu el, el să nu divorţeze de ea,13 iar dacă o femeie are soţul necredincios şi el vrea să stea cu ea, ea să nu divorţeze de soţul ei.14 Căci soţul necredincios este sfinţit prin soţia lui, iar soţia necredincioasă este sfinţită prin fratele, altfel copiii voştri ar fi necuraţi, dar aşa sunt sfinţi.15 Însă dacă cel necredincios vrea să se despartă, să se despartă. În astfel de circumstanţe, fratele sau sora nu sunt legaţi. Dumnezeu v-a chemat la pace.Mai târziu, vom vedea că, atunci când Isus spune în Matei 5:31–32, Matei 19:9 și Marcu 10:2–12 că un bărbat nu trebuie să se despartă de soția sa din niciun alt motiv, în afară de imoralitate sexuală, el are în vedere o anumită controversă fierbinte din vremea Lui despre acest subiect, care se baza pe Deuteronom 24:1–2. Abuzul fizic și emoționalPoate întrebi: „Dar cum rămâne cu abuzul fizic, abuzul emoțional sau neglijarea unui soț? Este vreunul dintre aceste motive acceptabil pentru divorț? Ce spune Biblia despre aceasta?” Nu există un răspuns ușor, deoarece nici Biblia nu are un răspuns clar, negru pe alb, la această dilemă. Aici lucrurile se complică și intră în zona gri, de aceea trebuie să ne bazăm pe Duhul Sfânt pentru a ne oferi revelația și înțelegerea inimii Sale în această chestiune. Dacă privim cu atenție Scriptura, cu o inimă deschisă și sinceră, vom afla că ea are o soluție la această problemă provocatoare.În primul rând, vă invit să observați, prin câteva exemple, un principiu general valabil și anume că dragostea și mila lui Dumnezeu sunt întotdeauna mai mari decât dreptatea Sa.Fără a-Și diminua în vreun fel neprihănirea și pedeapsa pentru păcat, El este mereu în slujba de a încuraja, de a zidi și de a restaura viețile oamenilor, în ciuda greșelilor și eșecurilor lor. El întotdeauna se bucură să-Și vadă copiii fericiți și bine. Chiar și în vremurile Vechiului Testament, în timpul Legii lui Moise, când Dumnezeu părea foarte crud și aspru în pedepsele Sale pentru actele de neascultare ale oamenilor, El a făcut totul din grijă față de ei și pentru că nu exista altă cale de a realiza ceea ce trebuia să facă pentru umanitate. În momentul în care devenim părinți, putem începe să înțelegem și să experimentăm o licărire din inima lui Dumnezeu pentru copiii Săi. Indiferent cât de răi pot fi copiii și indiferent ce lucruri rele ar putea face, tații și mamele normale nu vor renunța niciodată la ei și vor face întotdeauna tot ce le stă în putere pentru a-i vedea bine și fericiți. Când Adam și Eva au păcătuit mâncând fructul interzis al pomului cunoașterii binelui și a răului, Dumnezeu i-ar fi putut lăsa să moară pentru totdeauna, conform dreptății Sale, și să nu-i răscumpere niciodată. Însă, datorită dragostei Lui nemărginite, El a găsit o cale, deși dureroasă, anevoioasă și costisitoare, de a salva omenirea de la distrugerea veșnică, fără a-Și diminua dreptatea. În Matei 12:1–8, ucenicii lui Isus smulgeau fire de grâu și le mâncau de Sabat pentru că le era foame, iar fariseii i-au acuzat că au făcut ceva de neîngăduit în ziua de odihnă. Să vedem care a fost răspunsul lui Isus:Matei 12:1–8 (NTR)1 În vremea aceea, într-o zi de Sabat, Isus trecea printre lanurile de grâu. Ucenicii Lui erau flămânzi, aşa că au început să smulgă spice de grâu şi să mănânce.2 Când au văzut fariseii lucrul acesta, I-au zis lui Isus: – Uite, ucenicii Tăi fac ce nu este voie să se facă în ziua de Sabat!3 El le-a răspuns: – N-aţi citit ce a făcut David atunci când i s-a făcut foame atât lui, cât şi celor ce erau cu el?4 Cum a intrat în Casa lui Dumnezeu și a mâncat pâinile prezentării, pe care nu era îngăduit să le mănânce nici el, nici cei ce erau cu el, ci doar preoții?5 Sau n-ați citit în Lege că, în zilele de Sabat, preoții profanează Sabatul în Templu și totuși sunt nevinovați?6 Dar Eu vă spun că aici este Cineva mai mare decât Templul!7 Dacă aţi fi ştiut ce înseamnă: „Milă doresc, nu jertfă!“, n-aţi fi condamnat nişte nevinovaţi!8 Căci Fiul Omului este Domn şi al Sabatului!Isus le amintește mai întâi din Vechiul Testament de o ocazie în care regele David a mâncat pâinile pentru punere înaintea Domnului, din casa lui Dumnezeu, lucru care nu îi era îngăduit, pentru că, doar preoții aveau voie să mănânce din ele, dar Dumnezeu nu l-a pedepsit. Din nou, aceasta este o situație în care dragostea și mila Lui au fost mai mari decât legea Sa deja stabilită. Apoi, Isus oferă un alt exemplu în care preoții încalcă sfințenia Sabatului și sunt tot nevinovați. În relatarea aceleiași împrejurări din Marcu 2:23–28, Isus chiar spune că Sabatul a fost făcut pentru om și nu omul pentru Sabat, punând din nou bunăstarea oamenilor mai presus de legea s...

Marcu 14.32-42 32. S-au dus apoi într-un loc îngrădit, numit Ghetsimani. Şi Isus a zis ucenicilor Săi: „Şedeţi aici până Mă voi ruga.”33. A luat cu El pe Petru, pe Iacov şi pe Ioan şi a început să Se înspăimânte şi să Se mâhnească foarte tare.34. El le-a zis: „Sufletul Meu este cuprins de o […]

Marcu 14.22-25 22. Pe când mâncau, Isus a luat o pâine; şi, după ce a binecuvântat, a frânt-o şi le-a dat, zicând: „Luaţi, mâncaţi, acesta este trupul Meu.”23. Apoi a luat un pahar şi, după ce a mulţumit lui Dumnezeu, li l-a dat, şi au băut toţi din el.24. Şi le-a zis: „Acesta este sângele […]

Marcu 13.1-7 1. Când a ieşit Isus din Templu, unul din ucenicii Lui I-a zis: „Învăţătorule, uită-Te ce pietre şi ce zidiri!”2. Isus i-a răspuns: „Vezi tu aceste zidiri mari? Nu va rămâne aici piatră pe piatră care să nu fie dărâmată.”3. Apoi a şezut pe Muntele Măslinilor în faţa Templului. Şi Petru, Iacov, Ioan […]

Marcu 12.13-17 13. Apoi au trimis la Isus pe unii din farisei şi din irodieni, ca să-L prindă cu vorba.14. Aceştia au venit şi I-au zis: „Învăţătorule, ştim că spui adevărul şi nu-Ţi pasă de nimeni; căci nu cauţi la faţa oamenilor şi înveţi pe oameni calea lui Dumnezeu în adevăr. Se cade să plătim […]

Marcu 11.12-26 12. A doua zi, după ce au ieşit din Betania, Isus a flămânzit.13. A zărit de departe un smochin care avea frunze şi a venit să vadă poate va găsi ceva în el. S-a apropiat de smochin, dar n-a găsit decât frunze, căci nu era încă vremea smochinelor.14. Atunci a luat cuvântul şi […]

Marcu 10.1-12 1. Isus a plecat de acolo şi a venit în ţinutul Iudeii, dincolo de Iordan. Gloatele s-au adunat din nou la El; şi, după obiceiul Său, a început iarăşi să-i înveţe.2. Au venit la El fariseii; şi, ca să-L ispitească, L-au întrebat dacă este îngăduit unui bărbat să-şi lase nevasta.3. Drept răspuns, El […]

Marcu 10.13-16 13. I-au adus nişte copilaşi ca să Se atingă de ei. Dar ucenicii au certat pe cei ce îi aduceau.14. Când a văzut Isus acest lucru, S-a mâniat şi le-a zis: „Lăsaţi copilaşii să vină la Mine şi nu-i opriţi; căci Împărăţia lui Dumnezeu este a celor ca ei.15. Adevărat vă spun că […]

STAI ÎN CREDINȚĂ! „Toate lucrurile sunt cu putinţă celui ce crede!” (Marcu 9:23)

14. Când au ajuns la ucenici, au văzut mult norod împrejurul lor, şi pe cărturari întrebându-se cu ei.15. De îndată ce a văzut norodul pe Isus, s-a mirat şi a alergat la El să I se închine.16. El i-a întrebat: „Despre ce vă întrebaţi cu ei?”17. Şi un om din norod I-a răspuns: „Învăţătorule, am […]

Marcu 9.2-13 2. După şase zile, Isus a luat cu El pe Petru, pe Iacov şi pe Ioan şi i-a dus singuri deoparte pe un munte înalt. Acolo S-a schimbat la faţă înaintea lor.3. Hainele Lui s-au făcut strălucitoare şi foarte albe, de o albeaţă pe care niciun înălbitor de pe pământ n-o poate da.4. […]

Marcu 10.17-22 17. Tocmai când era gata să pornească la drum, a alergat la El un om, care a îngenuncheat înaintea Lui şi L-a întrebat: „Bunule Învăţător, ce să fac ca să moştenesc viaţa veşnică?” 18. „Pentru ce Mă numeşti bun?”, i-a zis Isus. „Nimeni nu este bun decât Unul singur: Dumnezeu. 19. Cunoşti poruncile: […]

Marcu 8.10-21 10. Isus a intrat îndată în corabie cu ucenicii Săi şi a venit în părţile Dalmanutei. 11. Fariseii au venit deodată şi au început o ceartă de vorbe cu Isus; şi, ca să-L pună la încercare, I-au cerut un semn din cer. 12. Isus a suspinat adânc în duhul Său şi a zis: […]

RUGĂCIUNEA TREBUIE ÎNSOȚITĂ DE CREDINȚĂ „Orice lucru veţi cere, când vă rugaţi, să credeţi că l-aţi şi primit, şi-l veţi avea.” (Marcu 11:24)

Marcu 7:1-231. Fariseii şi câţiva cărturari, veniţi din Ierusalim, s-au adunat la Isus.2. Ei au văzut pe unii din ucenicii Lui prânzind cu mâinile necurate, adică nespălate. –3. Fariseii însă şi toţi iudeii nu mănâncă fără să-şi spele cu mare băgare de seamă mâinile, după datina bătrânilor.4. Şi când se întorc din piaţă, nu mănâncă […]

Marcu 6:1-61. Isus a plecat de acolo şi S-a dus în patria Lui. Ucenicii Lui au mers după El.2. Când a venit ziua Sabatului, a început să înveţe pe norod în sinagogă. Mulţi, când Îl auzeau, se mirau şi ziceau: „De unde are El aceste lucruri? Ce fel de înţelepciune este aceasta care I-a fost […]

Marcu 5.21-24 21. După ce a trecut Isus iarăşi de cealaltă parte cu corabia, s-a adunat mult norod în jurul Lui. El stătea lângă mare.22. Atunci a venit unul din fruntaşii sinagogii, numit Iair. Cum L-a văzut, fruntaşul s-a aruncat la picioarele Lui23. şi I-a făcut următoarea rugăminte stăruitoare: „Fetiţa mea trage să moară; rogu-Te, […]

Marcu 4.35-41 35. În aceeaşi zi, seara, Isus le-a zis: „Să trecem în partea cealaltă.”36. După ce au dat drumul norodului, ucenicii L-au luat în corabia în care se afla şi aşa cum era. Împreună cu El mai erau şi alte corăbii.37. S-a stârnit o mare furtună de vânt care arunca valurile în corabie, aşa […]

Marcu 3:31-35 31. Atunci au venit mama şi fraţii Lui şi, stând afară, au trimis să-L cheme.32. Mulţimea şedea în jurul Lui, când I-au spus: „Iată că mama Ta şi fraţii Tăi sunt afară şi Te caută.”33. El a răspuns: „Cine este mama Mea şi fraţii Mei?”34. Apoi, aruncându-Şi privirile peste cei ce şedeau împrejurul […]

Marcu 2.1-12 1. După câteva zile, Isus S-a întors în Capernaum. S-a auzit că este în casă2. şi s-au adunat îndată aşa de mulţi, că nu putea să-i mai încapă locul dinaintea uşii. El le vestea Cuvântul.3. Au venit la El nişte oameni care I-au adus un slăbănog, purtat de patru inşi.4. Fiindcă nu puteau […]

Marcu 1:16-28 16. Pe când trecea Isus pe lângă Marea Galileii, a văzut pe Simon şi pe Andrei, fratele lui Simon, aruncând o mreajă în mare, căci erau pescari.17. Isus le-a zis: „Veniţi după Mine, şi vă voi face pescari de oameni.”18. Îndată, ei şi-au lăsat mrejele şi au mers după El.19. A mers puţin […]

Marcu 1:1-8, 14, 15 1. Începutul Evangheliei lui Isus Hristos, Fiul lui Dumnezeu.2. După cum este scris în prorocul Isaia: „Iată, trimit înaintea Ta pe solul Meu, care Îţi va pregăti calea…3. glasul celui ce strigă în pustiu: „Pregătiţi calea Domnului, neteziţi-I cărările”,4. a venit Ioan care boteza în pustiu, propovăduind botezul pocăinţei spre iertarea […]