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Even religiously recipient erectile dysfunction drugs bangladesh cheap kamagra polo 100 mg fast delivery, the time the embryos may remain frobased programs such as Snowfiakes and Embryos zen erectile dysfunction 21 years old buy kamagra polo 100mg low price, alternative dispositions erectile dysfunction protocol diet order discount kamagra polo online, and dispute resoluAlive impotence young male purchase cheapest kamagra polo, which refer to impotence by age order 100mg kamagra polo otc embryos as unborn chiltion procedures erectile dysfunction net doctor kamagra polo 100 mg on-line. Adoption ments between the donors and the recipients laws prohibit biological parents from relinquishthemselves [17]. These contracts should clearly ing their parental rights until after a child is born, define each partys respective roles, obligations, impose detailed and comprehensive screening intentions, and expectations regarding the donaand qualification requirements for prospective tion and any resulting child(ren), with indepenadoptive parent(s), and typically require court dent legal counsel to separately advise donors and state involvement. Applying this model to embryo donation raises concerning questions 5Florida, North Dakota, Oklahoma, Texas, and such as when embryo donors would be considWashington. Nussbaum when they can change their minds about their to use stem line cells derived from donated decision, and who screens recipients for parenembryos. For example, Snowfiakes has a strong stem cell researchers claiming their own access preference for adopting parents to be married to federal funding was compromised, a federal for at least 3 years, warns that single mothers court of appeals upheld the Obama policy as may wait longer for a placement due to genetic complying with the DickeyWicker amendment, parents specifications, and further requires that a decision the Supreme Court recently declined adopting parents agree not to abort or selecto review [26 ]. At the state level, recently enacted statutes In 2010, countersuits were filed between two refiect the publics and policymakers inconsiscouplesSnowfiake donors and recipients tent positions on stem cell research. The recipients, who had (California, Connecticut, Massachusetts, and already given birth to twins from two of the New Jersey), while others, such as South Dakota, embryos they had received, refused the request, strictly forbid research on embryos regardless of despite a provision in the embryo adoption their source. According to the National contract that provided for the embryos return to Conference of State Legislatures, as of January the donors if they were not implanted within a 2008, 33 states had enacted human cloning legisyear. The recipients claimed that the remaining lation or regulations, which either banned reproembryos were essentially unborn siblings of the ductive cloning altogether or restricted the use of twins they had already delivered and that notpublic funds for that purpose. A number of those withstanding their own agreement to the contract states ban reproductive cloning6; others address terms regarding the embryos return, the rights of the use of public funds for cloning. President Obama has mercial potential of any donated material, and renewed the scientific communitys hope that retain samples for a lengthy period of time [29 ]. The Massachusetts law contains comprehensive While the federal DickeyWicker amendment and extremely detailed informed consent proviremains, banning the use of federal funds for sions, including a definition of informed conresearch in which embryos are destroyed or dissent as the written consent for the donation of carded, the Obama administration has abandoned gametes or embryos used for research conducted its predecessors restrictive interpretation of the pursuant to this chapter which complies with the amendment as preventing the creation of new stem cell lines from privately created and unused 6 See, for example, Arizona, Arkansas, Indiana, Iowa, embryos. Without sufficient should be obtained at the time of the donation, even guidance from the courts or legislatures, and unable when the person has given prior indication of his or to contact patients for further instructions, proher intent to donate to research [31]. A patients permanent patients at the outset of treatment the option address, Social Security number, and drivers to discard any embryos that may remain unused. That said, programs honored without the need for patients to affirm may also elect to shift the presumptive burden of the decision at the close of treatment. In the few resuming contact to the patient, a protocol that reported cases involving a patients change of may reduce their future liability. Cases have form, which includes a Disposition of Embryos been brought against physicians, embryologists, Statement. Civil claims and embryos before undergoing any procedures, given licensing investigations are much more common the possibility of separation, divorce, death or than criminal prosecutions; the latter have incapacitation after embryos have been profocused on substantial misdeeds by medical, duced. Incarceration, probation, monetary the event that either our chosen dispositional fines, and loss of license are all possible consechoices are not available or we fail to preserve any quences for professionals or practices found culchoices made herein, whether through nonpaypable in extreme situations [33 ]. Thus, for clinics using this model conrespective roles, responsibilities, and standards of sent, discard is the clearly stated default option care applied to various professionals. However, clinics may liability for a breach of contract claim may turn still be reluctant to follow through with discard not only on whether there was a breach but also on even when patients have signed such a consent whether the original contract is found to be conform or meet the professional standards of embryo sistent with public policy. Criminal prosecutions, which can be state or federal, depending on the An important legal aspect of embryo disposition nature and scope of the alleged violation, must be is professional liability for their actions or inacbrought under a particular statute and usually tions. Columbia Presbyterian state-specific malpractice law and ethical and Medical Center (1978) No. If a 10 Embryo Donation: Legal Aspects 109 mix-up of gametes or embryos results in a live that both sets of patients probably already birth, potentially explosive custody and malpracexperienced significant difficulties and efforts in tice battles may arise with unpredictable resolutrying to conceive, recipients may not want to tions. Outcomes may turn on a number of factors, inform the genetic parents of the mix-up, who including when the discovery was made, whether would likely want to assert custody rights over the mix-up involved donor gametes or embryos any resulting child. Professionals may also feel (as opposed to both intended parents own genetic tempted to hide such errors out of fear of expomaterial), state law, as well as the original intensure and liability. Because no state has a statute is obligatory to disclose immediately errors in specifically addressing parentage in such situawhich the wrong sperm are used for insemination tions, general state parentage and adoption laws, or gametes or embryos are mistakenly switched as well as constitutional law principles, will and the result is embryo transfer, conception, or guide any parentage and custody resolution. In the California Committee lists possible errors, including insemcase, Robert B. The Committee mistakenly implanted in another woman, ruling encourages clinics to promote a culture of truththat the husband was the father and the woman telling by establishing written procedures for who carried the pregnancynot the fathers error disclosure [37 ]. In the New York In cases where lost, mishandled, or mixed-up case, Perry-Rogers v. Fasano, a couples embryo embryos do not result in a child, the consequences, was mistakenly implanted into a patient who was while serious, are less severe, the potential damalso implanted with her own embryo and then ages are more limited, and settlements, before or gave birth to two children of different races. This agreenecessary to resolve unsettled facts and damage ment broke down and the parties returned to claims. The court ruled that the genetic parents now-closed Ochsner Fertility Center in New were the sole legal parents and denied the Fasanos Orleans sought class action status in a suit against any visitations rights [35]. In a third widely pubthe Center for allegedly mishandling and mislalicized case, a woman who was mistakenly beling embryos. The Center attempted to argue implanted with another couples embryos volunthat the case was one of medical malpractices, tarily completed the pregnancy and relinquished the child to the genetic parents [36]. In each of these three cases, the parties also brought suits 9There have been numerous cases in which individual against the physicians or medical programs couples have filed suit or threatened to do so, where liability is clear, such as where an individual couple, who has responsible for the errors. Nussbaum which would have limited liability and monetary since the fraudulent scheme involved money and damages, but the court found that storage of correspondence crossing state lines. The intended parents and gestational carwere thus not available to the defendant embryriers were found to have been largely unaware of ologist or program. Attorney of patients have raised interesting issues of priNeiman was sentenced to 5 months in jail and vacy for those patients who have not agreed to 7 months of home confinement; Attorney release of their identities. The most recent court Erickson was fined $70,000 and sentenced to 5 decision allowed some, but not all, of the requested months in prison, followed by 9 months of home classes to be certified in light of the difficulty confinement [41]. Even as a tentative consensus wire fraud for transmitting and filing fake slowly develops in state courthouses and legisladocuments in connection with an international tures regarding legal interpretations of embryos surrogacy scheme they had devised. The three and their various dispositions, science races women recruited American gestational surrogate forward, creating new innovations and paradigms carriers, sent them to the Ukraine to be implanted to which ethics and the law will struggle to with embryos created from unrelated donor respond. Without the experimental limitation, the patient(s)controls the embryos because the it is predicted that egg freezing will ultimately be gamete donors have disavowed any parentage used not only for donation but also for some rights prior to any match with intended parents. As such, those who are able to pay tens of thousands of embryo disposition issues will continue to be a dollars. An alternative perspective would suggest concern for practitioners and patients, who will that this demand demonstrates the continued want to ensure the legal aspects of embryo disponeed to press for expanded insurance coverage sition are fully addressed as patients move forfor infertility treatment, much as consumer advoward with their family building efforts. This cates have done with significant success in the chapter has hopefully shed some light on the past years [43]. Criminal ProcedureKilling Human Embryos or lifted its experimental label from oocyte cryoFetuses. The embryo wars: At the epicenter of uals and couples needing donor eggs to build science, law, religion, and politics. As egg freezing becomes more mainstream com/2011/10/28/opinion/the-personhood-initiative. What is the Ohio National Academies human embryonic stem cell Personhood Amendment. Statutory and case law Recommendations for gamete and embryo donation: governing the practice of third-party reproduction. Embryo Donation: 1 1 Psychological Aspects Lindsay Childress-Beatty compared to those using donated gametes [1 ]. Introduction In spite of the parallels to aspects of other forms of family building, the importance of unique Embryo donation shares characteristics of, and combination of characteristics embryo donations is also distinct from, other forms of family buildcalls out for separate consideration in research ing that involve the use of assisted reproductive and counseling. Rather than one parent having a genetic link, as found in donor insemination or egg donation, both parthe State of the Research ents share a similar lack of genetic connection to on Embryo Donation the resulting offspring. The fact that the parents raise a child with whom they do not share a the research on the psychological aspects of genetic connection makes embryo donation embryo donation is characterized by its very more akin to adoption. Apart from research concerning the important prenatal gestational connection with decision by donor couples to relinquish excess the child not found in adoption. In some ways, embryos for various purposes, little research speembryo donation may also challenge the boundcifically considering the psychological aspects of aries of our Western concept of family by conembryo donation exists. Very few research studnecting two separate family units of parents and ies have considered the impact of embryo donagenetically full siblings. In that manner, it may tion on the child and families created by such be more controversial than the use of donated means or on the families who have donated. Numerous research than to another couple, and those using articles utilize the same small samples. For some donated embryos to build their family were seen areas of inquiry, qualitative rather than quantitaas needing the most counseling, even when tive research is the norm. This dearth of research is not surprising, given the limited number of children conceived by embryo donation to date. This aspect may be important as the Decision to Use Donated they consider the relationship of each of their Embryos for Family Building extended families to the resulting child. Recipient couples may also be comforted by the new the decision by recipient couples to use donated research on epigenetics. In addition to the benefit embryos has received little attention in the of having control over the prenatal environment, research. It may be a faster route to parenthood [5 ] or Impact of Embryo Donation appear to provide more control to the couple than on the Psychological Functioning adoption. Recipient couples may view the proof the Resulting Child cess as one with fewer challenges and unknowns in terms of timing, physical characteristics and An important question for practitioners, donor racial and ethnic background of the offspring, and recipient parents, and society at large is screening requirements, and prenatal exposure to whether children conceived via donor embryo toxins and alcohol. In size that the resulting child will fit seamlessly spite of the societal ambivalence over embryo into the extended family with no hint of the donation, research to date does not suggest absent genetic connection. Indeed, some recipiadverse psychological outcomes for embryoent couples may have a bias that the donated donation children. This is consistent with findembryos will be healthier and have a superior ings regarding children conceived using assisted genetic inheritance than adoption because of the reproduction generally [8, 9 ]. Conversely, couples using donated research on the psychological functioning of the embryos may also fear that those embryos are not children conceived is lacking. Two main studies as healthy as those used by the donor couple to utilized a small sample of British donor embryo build their family [6]. These three studies appear to be the over the prenatal environment, the pregnancy sole research on the psychological functioning of allows the couple to experience typical social and children conceived via donor embryo currently communal rites of passage into parenthood via available in English. In these limited samples, the pregnancy and childbirth, such as baby showers, overwhelming majority of parents were British prenatal birthing classes, and shared discussion Caucasians, and embryo-donation mothers and of pregnancy symptoms and childbirth experifathers were older than the comparison parents. The experience of pregnancy also contribBased on this very limited research, embryoutes to the mothers perception of self as mother donation children do not appear to be at increased [7]. In addition, family dynamics and perceptions risk for negative psychological functioning. This of future parenting may play a role in the decilack of negative psychological functioning sion. Some couples may choose embryo donation seems to hold both for early life and functioning to have equity between them through a parallel, in later childhood. Similarly, preschool embryoenting has found few, and generally non-adverse, donation children did not significantly differ from distinctions [8, 9, 12]. As is the case in all areas of adopted children on the same characteristics, with psychological issues in embryo donation, very the exception that adopted children scored signififew research studies consider the implications on cantly higher on the measure of conduct probparenting of children conceived via embryo donalems [3]. However, these studies also find no signifiembryo-donation children held true for middle cant negative distinctions in terms of parenting. No significant group differabove average in terms of expressed warmth, ences were found for total difficulties, conduct mothers sensitive responding, and parentchild problems, emotional symptoms, or peer problems interactions during their childs preschool years in [10]. Similarly, in a separate sample of 27 embryothe same study of 21 British donor embryo families donation families with children in middle childof children aged 25 [3]. At middle childder, oppositional defiant, depressive, or anxious hood, there were no significant differences in symptoms, somatic complaints, peer problems, mothers warmth measured in terms of enjoyment prosocial behavior, or neurodevelopmental disorin play, enjoyment in motherhood, expressed ders such as autism spectrum disorder [11 ]. However, no research it is unclear whether this over-involvement will to date explores whether difficulties arise when lead to difficulties for the children. The levels of the children reach adolescence, with its ageover-involvement for both embryo-donation appropriate focus on identity formation, or conmothers and fathers were moderate. The measiders the perceptions in adulthood of surement of over-involvement included factors embryo-donation children on their conception. In addition, the child-centered family life of embryo-donation families may not Parenting the Donor Embryo Child result in an overall negative parenting experience for the child. In the middle childhood years, the the lack of adverse outcomes on the psychologiembryo-donation parents were not significantly cal functioning of the resulting child could, in different in terms of supervision while the children part, result from the positive parenting of couples were playing outdoors and while chaperoned [10 ]. Childress-Beatty They were also not significantly different in their disciplinary interactions viewed by ease of bedSecrecy and Disclosure time, frequency of disputes, and level of battle of Embryo-Donation Status [10]. In both studies, embryo-donation mothers were the oldest and the couples had been trying One area where families created through embryo for a child the longest [3, 10]. This level of overdonation may differ from families created through involvement may simply refiect that having had other family-building options is in terms of secrecy such difficulty conceiving, the embryo-donation and nondisclosure of embryo-donation status. As parents simply wanted to spend as much time a practical matter, couples may believe that they with their children as possible [3, p. Given will be able to maintain secrecy concerning the that these parents are the oldest, the parents may use of donated embryos from family, friends, and also recognize that this parenting phase of life the child due to the existence of a pregnancy. However, the in countries where information concerning the increased emotional over-involvement and donor couple is maintained for the resulting child, secrecy (discussed below) could have a negative the couple may choose to not disclose his or her impact as the children reach the adolescent tasks origins to the child [5], and the child may not of developing autonomy and self-identity [10 ], know to request information [2]. However, given and additional research is needed to address the the realities of modern genetic testing and social impact of these parenting factors. Defensive responding was related to donor programs increasingly offering the option the parents willingness to answer questions and of non-anonymous donation and mental health report or admit difficulties. However, defensive professionals advocating in the literature for disresponding may simply refiect recognition of close to offspring [13]. Currently, the limited increased social stigma surrounding conception research on the issue suggests that embryovia embryo donation, lack of social permission donation parents are less likely to disclose inforto complain or feel frustrated, or a social desirmation concerning conception and genetic origin ability bias [3]. In the sample of British famiresearch findings or will have any significant lies used in several related research studies, only impact on the children. Almost No significant differences between couples who 43 % of the embryo-donation parents were not built their family via embryo donation versus planning on disclosing to the child [3 ].

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Patients found to erectile dysfunction and diabetes buy 100mg kamagra polo with amex have a shortened cervix fi 20 mm current pregnancy and those with a previous infant affected should be offered progesterone therapy erectile dysfunction doctors augusta ga kamagra polo 100 mg visa. If the culture is negative and the patient should also be referred to erectile dysfunction injections cost purchase kamagra polo 100 mg overnight delivery a physician trained in the care of has not delivered within 5 weeks of the initial sample erectile dysfunction treatment austin tx 100mg kamagra polo otc, obtain high-risk obstetrical patients erectile dysfunction 45 year old male kamagra polo 100 mg line. Excessive weight gain during conception erectile dysfunction medicine in ayurveda discount 100mg kamagra polo with amex, or they should avoid exposure and be pregnancy increases the risk for complications of delivery vaccinated in the immediate postpartum period. Nonfrom fetal macrosomia, such as labor dystocia, shoulder immune postpartum women should receive the first dose dystocia, and need for operative delivery. Inadequate weight gain is associated with preterm delivery, intrauterine growth restriction, and low birth Influenza. Begin breastfeeding education for all counseling, the following are important: pregnant women during the initial visit with the clinician. Folate supplementation before and offered to pregnant women who express a desire to during pregnancy has been shown to reduce the risk for breastfeed and for those who are still undecided on feeding neural tube defects and is recommended for all patients. Breastfeeding provides substantial health benefits While national guidelines suggest a dose of 0. Feeding infants artificial milk (formula) is mg daily is recommended, beginning at least three associated with an increased likelihood of chronic disease in months prior to conception and continuing through the children (obesity, asthma and diabetes). Women with a prior pregnancy complicated by a neural tube defect should supplement Exercise. Exercise during pregnancy is safe and beneficial their diets with folate 4 mg daily, beginning at least one to both mother and fetus. There is no evidence of risk to fetal month prior to conception and continuing through the well-being or that prolonged activity incurs a higher risk for first trimester. Calcium supplementation is more times weekly) mild to moderate exercise is recommended for women who have a low intake of recommended for all healthy pregnant women. Recommended supplementation: 2 g and amount of exercise can be tailored to the patient based of elemental calcium daily. No specific number should be established prior to 20 weeks gestational age and of movements should occur within a set time frame; reviewed prior to planning any intervention. Patients who experience decreased fetal movement after 24 weeks Ovulation induction, artificial insemination, a single gestation should contact their clinician immediately for intercourse record, ovulation predictor assay, or basal phone triage and possible in-person evaluation. All patients body temperature measurement are typically accurate to after 32 weeks gestation should be evaluated for fetal well 3 days. Clinician-initiated discussion is recommended, as patients Ultrasound performed by a trained sonographer is may not raise the topic. Gestational Age Determination by Ultrasound Prenatal discussion of this option should be included in Gestational Expected Variation in Sonographic contraceptive counseling. Age (weeks) Measurement In addition, in the State of Michigan, patients with Medicaid 6-10 3 days by crown-rump length desiring permanent sterilization (eg, tubal ligation) are 10-14 5 days by crown-rump length required to have a signed consent at least 30 days in advance 14-21 7 days by the average of multiple of the procedure. To facilitate biometric parameters appropriate follow-up of infants, the identification of a > 28 weeks 21 days by the average of multiple newborn care provider should be made prior to 36 weeks biometric parameters gestation. For patients with sonographic dating established at or beyond 24 weeks, a second ultrasound examination is suggested 3-6 Delivery Planning weeks later to evaluate for appropriate growth. Timing of Delivery Membrane Sweeping Planned delivery of uncomplicated pregnancies (either by Membrane sweeping may be offered to women at every visit induction of labor or cesarean delivery) should be avoided beginning at 38 weeks gestation. However, it is reasonable to offer induction pain, cramping, and spotting after membrane sweeping. However, certain situations require consultation and management by a Decreased risk for abnormal placentation in future physician trained in the care of high-risk obstetrical patients. If a patient chooses to pursue a trial of labor, a signed by being open minded and educating themselves regarding informed consent document that delineates the risks and those that they do not know. A model of shared decision making and support for patient autonomy should guide all patientprovider interactions. Postpartum Assessment Recommended postpartum follow up is a contact at 10-14 Related National Guidelines days after delivery and an office visit 4 weeks postpartum. That search of live deliveries between 2-14 months prior to the included literature through December 2007. A Medline measurement end date for patients fi 12 years of age, who search for literature published since that time was performed. Specific third trimester through the delivery date; and 3) between searches were performed for: genetic screening & counseling delivery date and 56 days postpartum. This document was updated in 2017 and was substantially truncated to only 22 bullet points of Disclosures recommendation. American Academy of Pediatrics / American College of Review and Endorsement Obstetricians and Gynecologists (editors). Mott Childrens Hospital and Von Voigtlander Womens Comprehensive guideline on the management of Hospital. Practice Committee of the University of Michigan Faculty Group Practice and the Executive Committee for Clinical Caring for our future: the content of prenatal care. A report Affairs of the University of Michigan Hospitals and Health of the Public Health Service expert panel on the content of Centers. A report on effective and efficient approaches for Acknowledgments prenatal care, developed by the Public Health Service expert panel. The following individuals are acknowledged for their contributions to previous versions of this guideline. Ann Arbor, prophylaxis for preventing maternal genital herpes simplex Michigan: University of Michigan Health System, 2012. Advisory Committee on ecommendation-summary/low-dose-aspirin-use-for-theImmunization Practices Recommended Immunization prevention-of-morbidity-and-mortality-from-preeclampsiaSchedule for Adults Aged 19 Years or Older United preventive-medication States, 2018. Evidence-based Review of studies of folic acid supplementation on risk prenatal care: Part I. General prenatal care and counseling of neural tube defects to determine effective dosing. Randomized controlled trial of delivery of patients with mild gestational hypertension at term. Progesterone and preterm birth prevention: translating clinical trials data into clinical practice. Goldfarb Editor Third-Party Reproduction A Comprehensive Guide 1 23 Third-Party Reproduction James M. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publishers location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. The use of general descriptive names, registered names, trademarks, service marks, etc. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. Pref ace Third-party reproduction includes any process in which a person other than the one(s) desiring to have a family provides sperm or eggs or use of a uterus so that another person or couple can have a child. For many years, third-party reproduction was limited to the use of donor sperm and was not done openly. The first use of sperm donation is thought to have occurred in 1884, but it was done without the wifes knowledge and it was not reported in a journal until 25 years later. As late as 1954 the Supreme Court of Cook County stated that even if the husband consented to the donor insemination, it was considered adultery and the child was illegitimate. It was not until 1964 that the first state, Georgia, passed a law recognizing children born from donor insemination as long as written consent was obtained from the husband and wife. The use of donor insemination increased greatly in the 1960s, and the first commercial sperm bank opened in 1971. The opening of their clinic in Norfolk, Virginia, was very controversial at the time. Donor insemination involves at most three peoplethe sperm donor, the woman who is inseminated with the sperm, and the womans partner or husband, if she has one. There are essentially no medical risks with donor insemination, and the cost of donor insemination is relatively little. Also, in contrast to sperm donation, gestational carriers and egg donors are at risk for medical complications, and the cost of using gestational carriers and egg donors is extremely high. Thus, it is not surprising that vii viii Preface the advent of these more complex third-party reproduction procedures has generated so much interest and controversy. Third-Party Reproduction: A Comprehensive Guide utilizes experts in the field to address the medical, psychological, ethical, and legal aspects of sperm donation, egg donation, embryo donation, and the use of gestational carriers. In addition, there are chapters on the medical and ethical aspects of posthumous reproduction, religious aspects of third-party reproduction, and how to avoid pitfalls of third-party reproduction. This comprehensive guide to third-party reproduction will provide practical insights to all involved with third-party reproduction as well as patients who are considering third-party reproduction. Goldfarb Contents Part I Oocyte Donation 1 Medical Implications of Oocyte Donation. Severson Part V Posthumous Reproduction 17 Medical Aspects of Posthumous Reproduction. Gibbons Introduction donor oocytes and may increase the opportunities for potential recipients. Over the years, and choices have expanded progressively, with many claims have been lodged regarding the most advances relying on the availability of the medical consequences for donor, mother, and patients own genetic material. The demand strates the existence of some misconceptions of for fertility treatments using oocyte donation the past and the need to update previous recomhas increased exponentially. The process in mendations addressing the management of which donors participate resembles the one for donor programs. There are some important particular procedonation process and detail possible medical dural differences, however, that are specific to implications for donors, recipients, and offthe donors and recipients cycles, representing spring. We will explore these possibilities and an added challenge for the reproductive endorelated new fields that might either create new crinology team. Gibbons donors with the recipients husbands sperm folpregnancy, with delivery at 38 weeks via schedlowed by uterine lavage with a specially created uled cesarean section [3]. Embryo recovery took place 5 days after recipient with no ovarian function of her own furinsemination, and the synchronization of the ther substantiated the observations that exogenous recipients endometrium was achieved with oral estrogen and progesterone could reliably produce contraceptives [1, 2]. Lutjen (Australia), who reported in Nature on a 25-year old with priIndications for the Use of Egg mary ovarian insufficiency [3]. It was remarkable Donation for the use of donor oocytes from an infertile patient (with tubal factor) that were inseminated New Perspectives with the recipient partners sperm. The resulting single two-cell classification of patients, based on a womans embryo was transferred to the recipients uterus, ovarian function (Fig. This approach and the recipient was maintained on continuous will initially distinguish between women with and estrogen and progesterone support throughout the without recognizably altered ovarian function. These women are generically termed as poor ovarian couples/individuals can now use donor eggs, ferresponders. Continued attempts using their own tilize the eggs with their sperm, and then put eggs may put them at increased risk for miscarresulting embryos into the uterus of a gestational riage and will definitely greatly increase cancelcarrier. This area continues to be primary or secondary amenorrhea and characterthe subject of controversy that shifts constantly, ized by symptoms related to low estrogen and an depending on the social, legislative, and scientific associated increase in gonadotropin serum conarenas. Furthermore, menopause is defined as premature or age appropriate, if the ovarian function cessation occurred before or after the Current Practice Recommendations patient reached 40 years of age, respectively. In the subject of oocyte donation has been, since its addition, women undergoing radiation and/or cheinception, embroiled in much controversy, with motherapy are at risk for premature ovarian failure important socio-medical-economic implications if they do not undergo fertility-sparing procedures for all the participants. This proceedings, selection requirements, preand creates a system with multiple medical checkpost-selection medical workups, medications, points that will increase program safety by corside effects, their shortand long-term associated rectly and carefully identifying inclusion and risks, potential complications, and realistic outexclusion criteria. Because of the vary, nowadays the scientific community, along complexity of oocyte donation, the vast volume with organizations that represent both the legislaof information should to be provided in a steptive and sociological branches of society, has wise approach. Donor program records should tried to find common principles to guide the parremain confidential as predefined by contractual ticipants engaged in oocyte donor procedures agreements along with participants specifica[29]. It is not uncommon for treatment abnormal findings or specific risks associated centers to close, change location, or be integrated with particular types of patients. Given twenty-first-century portion of these patients are older and more prone technology and recent advances of electronic to have certain chronic diseases. Having an estabrecommend that these records should, when poslished referral to tertiary centers to be followed sible, become a permanent part of both the treatby high-risk obstetrical teams is highly recomment center and a centralized national registry. Another special group, as discussed earlier, are patients with Turners syndrome. They are prone to the development of cardiovascular Candidate Selection and Screening disease and endocrinopathy, among many other chronic medical conditions. It is of major imporRecipients and Partners tance to assess their cardiovascular status because the evaluation of recipients should begin with of their increased risk for aortic dissection during acquisition of medical and reproductive histories, pregnancy [22 ]. Psychological screening and continuous the steady rise in the demand for donors in the support should be provided to both recipient and last decade has been tempered by the reality of partner. A complete general physical and pelvic the limited pool of donors available, the impact of examination of the recipient should follow. It is the ever-growing costs of egg donation programs, commonly recommended that the uterine cavity and increased numbers of potential recipients on be assessed through the use of hysterosalpingogthe waiting lists [4244]. A 10-year review of donor screening In the presence of a uterine anomaly, hysterosfound that up to 62 % of the initial candidates copy may be warranted for both diagnostic and eventually would be excluded [45]. Volunteer donor cycles are further IgM]; hepatitis C antibody; Neisseria gonorclassified according to the number of recipients, rhoeae and Chlamydia trachomatis testing; and as exclusive or nonexclusive donor cycles.

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The identity practices of young people are sometimes commonly portrayed as problematic; a period during which young women are at risk of sexual coercion and engaging in anti-social behaviour such as underage sex which risks pregnancy and sexually transmitted infections (these themes will be taken up more specifically in Chapter Three) erectile dysfunction doctor in miami 100mg kamagra polo free shipping. The period of adolescence is widely understood in many education erectile dysfunction when drunk purchase kamagra polo now, health and social settings to erectile dysfunction pills for heart patients buy 100mg kamagra polo mastercard be one of transition erectile dysfunction after age 40 generic 100mg kamagra polo mastercard, oscillating between the vulnerable and innocent age of childhood into an increasingly autonomous state of adult life xarelto erectile dysfunction order kamagra polo discount. The journey between the two is conceptualised as a tricky time that creates unique issues drugs for erectile dysfunction philippines safe 100 mg kamagra polo. There are specifically gendered issues in relation to adolescence that I will also consider in this chapter. Organic and unanticipated research: researching with young women My research approach was participatory, which included ongoing opportunities for the participants to shape the nature and the methods of the empirical research. I created a permissive and organic space where the young women were able to choose and lead the direction of the research and control their involvement. And, as seen in Chapter One, it was also very difficult to achieve ethical approval. Here I outline the research process working with year 8 young women, their involvement in the project and how they selected the method. Year 8 is the second year of high school where the students are aged 12 13 years old. Upon being granted permission from a high school to recruit young women, I attended the school on the day of the first vaccinations administration 81 in October 2013 And I took several photographs of the school hall and nurses station (Figures 7, 8, 9). I made contact with the nurses who would be there on the day and offered to help prepare the hall. I placed my surveys, pens, information sheets and consent forms on the stage at the front of the hall and waited whilst the health care assistant registered the students and their consent forms. The Deputy Head Teacher of the school suggested I use surveys as a way to at least get some data, whereas I had initially planned to simply inform the young women of the project and ask for any interest. Once the first few young women were being vaccinated I sat with the others and told them I was from a university doing a project about their experiences of the vaccine and wanted to know what they thought of it. In blue boxes on this survey there were seven questions and there was a yellow box they could fill in if theyd like to talk to me after that day about it. Of almost 80 young women that day I received 29 survey responses and 12 put their name and contact details down for wanting to get involved further. On the next vaccine date I attended the school again and two of the young women agreed to meet me at lunch time. During the vaccine administration I reminded some of the young women of my project and invited them to come to see me at lunch time too if they were interested. The room that I booked was immediately opposite the schools reception and the security door which leads to the Head Teachers office and other staff offices. It was a small meeting room often used for meetings with parents or visitors to the school. This is where I had sat previously as I 85 waited to meet the Deputy Head Teacher to discuss access to the school. It is also where the naughty kids have to wait to learn their fate, or the sick kids wait for their parents to collect them. I used what are commonly referred to in academic research as creative methods (Allen, 2011). They are inspired largely by the everyday creative work of youth practitioners, facilitators and trainers. Indeed there are many examples of activities and tools developed by youth and community workers and they are often printed inhouse on office photocopiers. Wigan Youth Services Owt for Nowt resource pack of activities that can be carried out with no budget. This is where I provide details of the methods I used to facilitate the young womens interest and involvement in the research. Following this I then move on to presenting and analysing the research materials from each young womans diary. The first small group discussion During this first session I discussed confidentiality and reminded the young women of the aims of the project. I then delivered an activity using four A5 sized images (Figures 10, 11, 12, 13) that showed some examples of different research methods. They were; a diary, scrap booking method, a one-to-one research conversation and a focus group discussion. I told the young women that if they had any other ideas of how to record their views and experiences they could let me know. They asked me to go to the local Pound Shop and gave me a list of things that they wanted such as stickers, coloured pens and bits and bobs (Sunshine) and told me to meet them at a set place in the school grounds at the end of the school day. At subsequent group sessions the young women asked me for other materials and told me that the glitter was messy and the coloured pens were too thin to colour anything in with. Being told what to do, where to shop for the materials and what to buy demonstrates a positive engagement in the project. I interpreted this as a way that the young women tested boundaries and saw to what extent they could take control and ownership over the project. I had provided them with having the choice of methods, so could they also then choose other things and make modest demandsfi The answer was yes, and I happily responded and felt confident that the young women would feel a greater sense of investment in the research as a result. They provide a framework by which workers can prompt thinking and ideas on a particular subject. For example, in the past I have used this activity for young people involved in recruitment to generate interview questions for potential new youth and community workers, as well as in sexual pleasure workshops for participants to think about pleasurable and exciting activities involving the whole body and senses. I gave the young women an A4 piece of paper along with some pens, coloured felt tips and stickers etc. Having an initial focus that distracted from the participants personal experiences was chosen 89 specifically to help them ease into the process of providing feedback. Using the body activity or external resource, in addition to the young women and me, is often referred to as the common third in social pedagogy practices ( This allows both the researcher and the researched to collaborate in a shared experience, which develops the relationship between me as the researcher and the young women as those being researched. This creates the potential for both to learn and be equal in the doing of the activity. Figure 14 Sunshines body drawing 90 Figure 15 Emilys body drawing the second small group discussion I was in contact with the young women between the session in December and March via Facebook messaging, email and/or text message, whichever way they had asked me to be in contact. Based upon the observations I had made during the vaccine administration sessions I sent messages with prompts and questions to guide the young women to create their diaries. Also during this time the school had re-allocated the meeting room we met in during the first workshop and so we were allocated the video-conferencing room upstairs above the 91 reception area. This room was locked and was in the area next to the staff room and staff toilets. We met there at lunch time and it seemed as though the Figure 16 Ainsleys body drawing 92 Figure 17 Lexis body drawing young women were apprehensive but felt cool being in a usually restricted area only meant for staff and other important adults. During this session at Wendy Chicken Shop school I planned a bin it, keep it activity (Figure 18) as a way of the young women having the opportunity to shape the direction of the research. They then wrote down the different things that they wanted to bin or keep doing the diaries. This allowed me to plan activities that were more relevant to their interests and those which would, hopefully, help to retain their involvement in the project. There wasnt necessarily a consensus of feedback but it did give me the insight to prompt fewer written tasks and more creative tasks. For example, from the audio recording of this session two young women disagreed about the writing tasks: Ali: What do you think is nice, what have you been enjoying, what do you want to keepfi And what do you think is annoying and you think I cant be arsed with that, I dont want to do that anymorefi So write them on there and then you put them next to bin it or keep it and then Ill keep them separately. Ali: But if you dont want to write as much, or youd rather do drawing ones or something like thatfi The young women agreed that the nurses asked them silly questions and they all seemed keen to share this with me. As a follow on question to this, I also asked them: Ali: So if you were going to be asking somebody else, what kind of questions would you ask themfi Ainsley: Us 95 Ali: So theres four of you, how many questions would you create each to make a surveyfi It also led to a survey that was created during the sessions but which it was decided that I would type up, print out and send two copies in the post to each of the young women. The young women used these surveys to varying extents and, where they had them completed by friends, they also glued them into their diaries. The key interest of the survey is that it was instigated by the young women themselves. So the bin it, keep it activity provided information that allowed me to understand what mattered most to the young women. This is just one example of the way in which I facilitated the young womens participation and investment in the project which mean embracing an organic and unanticipated trajectory for the research. The third small group discussion this session started with the young women describing to me the diary entries they had made since the last session. It was planned as the final session and one where we could review the tasks and look to finish off the diaries. During Ainsleys reading aloud these reasons, I asked follow up questions to the reasons why 96 people do and do not have the vaccines. However, Ainsley was more interested in assessing the levels of creativity and colour in her diary than engaging in a discussion of the list shed prepared stating Im guna jazz mine up tonight, it just looks boring. Emily quietly but unashamedly told me she hadnt done the previous task and then took to rifling through the latest selection of craft materials I had brought along. I had sent Emily a sheet of all the tasks I had set for her to tick against when she had completed them. Emily: [mumbles to mimic the health care assistant] Go to your class Ainsley: Thats the one that I said Ali: the one that gives you the Ainsley: Yeah, the papers. She showed me what she had done and seemed pleased with the extra things she had included in her diary: Ali: Look at you with ribbons! Collecting the diaries Together with the young women we arranged a date for me to come to the school and wait in the reception area at lunch time to collect the diaries. This was based on them leaving enough time to complete their diary tasks, decorate them and finish school work before the summer holidays began. Lexi had forgotten her diary and so we arranged that I would collect it from her home after school. Emily sat with me in the reception area, on the naughty seats, and went through the diary with me as she wanted to make sure she had done everything we had agreed. Each of the young women received a fi20 voucher for a shop of their choice (New Look). It evidences the ways in which my participatory orientation to the research was practiced. It suggested ways in which skills from youth and community work can be merged with academic research to build a permissible and positive research space. A chance encounter: recruiting a refuser As much as I celebrate the participatory approach and methods I used here, I also recruited two young women through a chance encounter whilst I was running a workshop at the Adventure and Empowerment Girls Work Conference at Manchester Metropolitan University (September, 2013). At the end of the conference I caught up with Suzzanne who also worked in a sexual health setting as a youth and community worker and we chatted about common experiences and issues in the workplace. Following this discussion I asked Suzzanne if shed be willing to be involved in my project, and whether her daughter (Beth Hester Who) would be too. I explained that the young women from Wendy Chicken Shop school had selected the diary methods and I offered Beth the chance to be involved too. I embraced this chance opportunity which offered the project the experiences of an additional two young women through unexpected 9 means. At this stage I now had six young women interested in being involved in the research project. Home visit 9 Despite some initial involvement in the project, Celia later withdrew from the process and I have no research materials from her. We walked to their home and Beth made me a coffee apologising for the soya milk and rolling her eyes at her parents veganism. Luckily, because I knew Suzzanne, I had brought vegan chocolate brownies and Beth seemed to settle and feel less embarrassed at what she had anticipated I would think was an unusual lifestyle. During this meeting I had planned to introduce myself to Beth and discuss the project, much in the same way that I had done with the young women at Wendy Chicken Shop school. As there was only one young woman, the planning for this visit mainly involved discussion prompts and mental reminders to cover the topics of consent, incentives and general interest in the project. Beth and I chatted alone in the living room, occasionally having to stop and shoo her younger sister away. Beth told me that she doesnt see Celia outside of school but that shed pass on the information about the project the next day. After our chat, I was invited to see her bedroom and was treated to a duet of In the Jungle on ukulele, which Beth had been teaching her younger sister to play. I left Beth with the project information sheet as well as a diary and various craft materials similar to those that I had given to the young women at Wendy Chicken Shop school. Paired research conversation at work I kept in touch with Beth via text message to Suzzannes mobile phone. I sent Beth the questions and prompts that had been generated via the sessions at Wendy Chicken Shop school in an attempt to keep the materials fairly consistent. Suzzanne and Beth both told me that Beth felt more articulate when she speaks and she had skipped a few of the prompts.

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When your symptoms receive one of these labels erectile dysfunction causes mental cheap 100 mg kamagra polo overnight delivery, conventional treatments may cause needless suffering and expense and give far less than satisfactory results erectile dysfunction meme discount 100mg kamagra polo mastercard. Even after surgery erectile dysfunction self test effective kamagra polo 100 mg, cortisone shots erectile dysfunction yahoo buy kamagra polo in united states online, and physical therapy erectile dysfunction doctors raleigh nc kamagra polo 100 mg sale, symptoms can remain unchanged and sometimes worsen erectile dysfunction caused by vyvanse purchase kamagra polo 100mg. When trigger point therapy is tried first, more extreme measures can often be avoided (Simons, Travell, and Simons 1999). Carpal Tunnel Syndrome and Thoracic Outlet Syndrome Libby, age forty, suffered with chronic pain in her shoulders, arms, and hands. When she went out walking on her lunch hour, the swelling in her hands became so uncomfortable that she often held them up in the air for relief. Her doctor had urgently recommended carpal tunnel surgery to arrest the condition before it got worse. He didnt know whether it would help her shoulder pain but said it was worth a try. She felt like she was in a corner and didnt know what else to do but go through with it. On the recommendation of a friend, Libby decided to try trigger point therapy before committing to surgery. Massage immediately decreased the pain in her shoulders and arms and the numbness and swelling in her hands. After three massage sessions and some coaching, she was able to continue the massage herself. Some of the pain in her forearms and hands tended to come back after working all day at the computer, but she was able to minimize it with the massage techniques she had learned. Libby determined that, although her job with an insurance company had made all her symptoms worse, her problems actually had started with whiplash shed suffered in an auto accident three years earlier. Trigger points created in her scalenes by the accident accounted directly for many of her symptoms and had predisposed muscles in her forearms and hands to trigger points of their own. When confronted with pain, numbness, tingling, stiffness, burning, or swelling in the hands and fingers, the tendency is to identify the condition as carpal tunnel syndrome or peripheral neuropathy and do no further thinking about it. If the treatment for carpal tunnel was noninvasive, quickly improved symptoms, had no side effects, and was cheap, there would be little controversy. However minimal a procedure, there are usually consequences to cutting into human tissue. Doesnt it make more sense to figure out where the problem originates rather than to cut away at the site of the symptomfi Trigger points in the scalenes, brachialis, forearms, and hands can mimic all of the symptoms of carpal tunnel. With severe symptoms, there may be multiple sites Pthomegroup Chapter 6Elbow, Forearm, and Hand Pain 133 of impingement coming from multiple muscles of the neck, upper back, chest, arm, and hand. It is important to identify the individual problem and treat it as minimally invasively as possible. Equally as important, if not more so, is the elimination of perpetuating factors that created the problem in the first place (Simons, Travell, and Simons 1999). The carpal tunnel is formed in the wrist by the carpal bones and the ligaments and other fibrous tissues that keep them together. The median nerve and several tendons pass through the carpal tunnel on their way to the fingers and hand. The nerve and tendons can be compressed when this passageway is swollen or otherwise restricted. Although numbness and tingling in the hands, the most easily recognized signs of carpal tunnel syndrome, are clearly the effects of nerve compression, these symptoms may not be coming from the carpal tunnel. The critical impingement frequently occurs in the thoracic outlet, the opening behind your collarbone through which the nerves and blood vessels pass on their way to and from the arm. The impeded return of blood and lymph from the arm is often the cause of the swelling in the wrist and hand that in turn may cause the restriction in the carpal tunnel. When this happens, carpal tunnel surgery may release the constriction in the wrist and relieve the symptoms in the hand to a degree, but it doesnt treat the real cause. Its the thoracic outlet that needs attention, not the carpal tunnel (Simons, Travell, and Simons 1999). The size of the thoracic outlet is reduced when trigger points shorten the scalene muscles in the front of the neck. Tight scalenes pull the first rib up against the collarbone, squeezing the blood vessels and nerves that pass between them. Pressure on these nerves is often the cause of numbness and tingling in the hands and fingers. The pectoralis minor, triceps, brachialis, and certain forearm muscles are also capable of compressing the nerves of the arm and causing numbness in the forearms and hands. When the nerves are being compressed at multiple sites, it can be called double or multiple crush syndrome. Its not helpful when a physician labels your problem peripheral neuropathy; this term is only a fancy way of saying that something is pressing on a nerve and making your hands or feet numb (Simons, Travell, and Simons 1999). Use the Other Symptoms Guide at the beginning of this chapter to help track down the likely sources of numbness in your elbows, forearms, and hands as well as the various origins of pain, burning, or other sensations in those areas. For each area that has such symptoms, start at the top of the list and check the listed muscles one at a time for trigger points. Keep in mind that a good rule in troubleshooting your carpal tunnel symptoms is to start with the scalenes. Theyre often at the very root of the trouble, setting up a chain of effects all the way down the line. A little attention to your scalenes can make an immediate improvement in many of your shoulder, arm, and hand symptoms. Note that numbness in the hands and fingers can also be caused by trigger points in the serratus posterior superior, serratus anterior, teres minor, pectoralis minor, triceps, coracobrachialis, brachialis, supinator, extensor carpi radialis brevis, flexor carpi ulnaris, flexor digitorum, and pronator teres. Tennis Elbow (lateral epicondylitis) the traditional explanation for epicondylitis, or tennis elbow, is that you have tendinitisin other words, that the tendons around your elbow have suffered microscopic tears through injury or overuse. As with any true itis, there should be symptoms of inflammation: localized heat, redness, swelling, pain, and sometimes loss of function. A diagnosis of tendinitis is an easy one to make, but it may be the wrong one unless youve had an obvious physical injury. Therefore, this condition has been renamed tendinosis, or pain at the attachment of a muscle to a bone. If the pain is spot specific, it is likely that the muscle is pulling at the attachment or at the location where muscle becomes tendon. Remember that muscle is the contractile tissue of the unit, not the tendon, yet much of the treatment is focused at the symptomatic tendon. It is better therapy to unload the short, tight muscles that create strain at the attachment site. This includes treating the trigger points and massaging the whole muscle to loosen it up. When the pain is deep, achy, and spread over a wide area, it is likely that trigger points are referring pain from elsewhere. In both cases, it is therapeutic to deactivate trigger Pthomegroup 134 the Trigger Point Therapy Workbook points and restore normal resting muscle length. After treating the muscle and the trigger point directly, a protocol of stretching the shortened muscles and strengthening the opposing long and weak muscles may further the therapy and prohibit a recurrence. When stretching and strengthening is done too soon, not only can it delay recovery, it can also worsen the condition. Travell and Simons believed that trigger points in the forearm muscles, not tendinitis, are the most common cause of pain and weakness in the elbow. Other muscles sometimes contribute to the problem, as can be seen in the Pain Guides and Pain Illustrations for this chapter (Simons, Travell, and Simons 1999). Pain in the inner elbow, which is less common than pain in the outer elbow, is called golfers elbow (medial epicondylitis), though it probably results less frequently from playing golf than from overexercise or overuse in the workplace. Observe that the list of muscles potentially involved in inner elbow pain is quite different from the list for outer elbow pain. In troubleshooting either condition, remember that two or more muscles may be creating pain at the same place. Safe Massage of the Forearms and Hands Its easier than you might think to get rid of the pain and other symptoms in your forearms and hands. You can make things worse, however, if you dont use your hands intelligently when applying trigger point massage. You need to give scrupulous attention to ergonomics, or the safe, effective use of your hands as tools. Also, massage of the forearms and hands becomes easier and more efficient when you have a good understanding of the function and location of the individual muscles. It helps to be familiar with the bones of the forearm and hand so that you can make use of their bony landmarks in locating muscles. Ergonomics You wont get much massage done before completely trashing your forearms and hands if you go about it in uninformed ways. You may not realize how tiring it is for the hands and forearms, for instance, to do massage with your thumb working in opposition to the fingers (figure 6. The reason for this is that all the muscles in the forearm participate in the grasping function, and the harder you grip something, the harder they all contract. The forearm muscles, whose function is to operate the hands and fingers, work harder than any other muscles in the body, pound for pound. Unfortunately, its so natural to grasp with the hand that people do it without thinking. Its best to avoid using your hands at all in massage if you can find any other way. Supported fingers or the supported thumb largely eliminate the use of the forearm muscles (figures 3. The fingers or thumb are held as nearly perpendicular to the skin as possible so that the force is applied through their very tips. With this technique, the supported fingers or supported thumb function as the end of a very long prod that has a straight line to the elbow. When this is done correctly, the shoulder muscles and the weight of the body do most of the work, and the muscles of the forearm and hand can remain relatively relaxed. Pthomegroup Chapter 6Elbow, Forearm, and Hand Pain 135 People who try to do massage with long nails find that their hands tire quickly and that they are unable to do some of the most useful techniques. A tennis ball, 60 mm high bounce rubber ball, or a lacrosse ball against a wall is the most useful tool for massage of your forearms and hands. Throughout this chapter, I offer nuggets of information about how to most easily use the ball-on-a-wall technique. For some individuals, using the ball on a table or dresser top may be more comfortable or accessible than using the ball on a wall. In this day when most of us overuse computers, video gaming equipment, smartphones, and/or cell phones, it is invaluable to know how to self-treat our arms and hands. Bony Landmarks the ability to find and massage specific muscles depends on being able to find nearby bones. The better you are at locating these landmarks, the better youll be at locating trigger points. The sharp bony ridge all along the underside of your forearm is the shaft of the ulna. The knob on the little finger or pinky side of your wrist is the ulnas lower end: this is called the styloid process. When you turn your hand over, the lower end of the radius moves the entire hand around D the lower end of the ulna a full 180 degrees. You E can remember that supination is when the hand is palm up, as if you were to drink soup from your hand. Feel it turn (supinated), and the hand on the right as you turn your hand over and back several times. The epicondyles are parts of the enlarged lower end of the humerus, or upper arm bone. Because of this great flexibility, the carpals also serve as shock absorbers, protecting the wrist by spreading stresses over a greater total surface area. Trigger points in these muscles are the source of some kinds of finger and knuckle pain. There are no muscles in the fingers, just lots and lots of tendons, through which the fingers are moved by remote control by the muscles in the forearm and hand. Pthomegroup 136 the Trigger Point Therapy Workbook Explore your forearms and hands, feeling for these various bones. The better mental picture you have of the bones, the better youll be at picturing the muscles in there, too. Although its an upper arm muscle, the muscle is included in this chapter because the trouble it causes is felt in the hand. The brachialis lies under the biceps, covering the front of the lower half of the upper arm bone, the humerus (figure 6. Its upper end attaches to a bony mound on the outer surface of the humerus about halfway down, just below the attachment of the deltoid muscles. You may also feel some degree of pain in the front of the shoulder and just below the crease in the elbow (not shown). There may be an oppressive ache or tightness on the outside of the upper arm near the elbow. Compression of the radial nerve that passes through the brachialis can make the thumb and the back of the forearm tingle or feel numb (Simons, Travell, and Simons 1999).


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