Assessusa

Fire poses a major threat to all businesses and should be of prime importance to any managing director or boss. The consequences of a fire can be far reaching and can even leave a business in the same state as the burnt out premises; ruined. If operating in a single premises the effects can be even more devastating, hence the importance of fire risk assessment procedures are an essential component of any health and safety protocol.
For companies who house supplies and other integral business elements in their premises the effects of fire can be even more damaging. In terms of continuity of supply and relationships with buyers, the effects can sometimes never be recouped. An efficient assessment of the risk that fire may pose to your business should be regularly carried out to ensure not only the safety of your staff members, but also to protect your business. An employer’s own conscience should force them to undertake a thorough fire risk assessment, although legal requirements for employers are extensive in ensuring staff safety.
The process of fire risk assessment involves identifying the various sources of ignition that may be present in your business. Not only should an assessment identify the ignition points but also the levels of combustible materials in a workplace. Such materials include soft furnishings and elements of the structure such as a timber frame or desks. The purpose of a fire risk assessment is to minimise the potential for fire in your business premises.
The risk assessment should involve the identification and if possible the elimination of hazards in the workplace. If these elements cannot be eliminated from the day to day uses of the business, fire risk assessment should advise ways in which the hazards can be dealt with and avoided. Usually safe working methods can be developed that put hazardous practises as far away from combustible materials and ignition sources as possible. This may mean that your risk assessment will take a few days to get a true understanding of the patterns of work in your business.
Also, as part of the assessment, the people who work in your premises will be examined. This may include assessing the risk staff members, customers and other members of the public that may have access to your premises. The number of people present in the premises in the event of a fire will also be estimated by the assessment of visitor numbers over a few days.
As a result of this information escape routes and fire safety protocol will be part of the risk assessment to ensure evacuation is carried out efficiently and effectively in the event of fire. As well a the means of escape, fire fighting apparatus and equipment will be assessed as well as the number of people who are able to operate this apparatus in an emergency. Considerations of age, health and agility in terms of the people present on the premises will also be part of the risk assessment. These factors are important especially when considering different working environments such as nurseries, factories or care homes. As a result action plans can vary immensely.
The risk assessment report will ensure that there are sufficient staff members present to cope with a fire should it break out. Also the action plan should focus upon minimising the risk of fire in the first place, by understanding the causes of fire and elements involved, prevention should be more effective. Assessment will also include an appraisal of the current action plan and the working order of the various fire fighting equipment in a business premises.
Fire is a risk that worries most employers, an assessment can inform bosses where they are with ensuring the safety of there staff and how much they need to do to increase this safety. As a legal requirement, following the recommendations of the report is a vital legislative requirement.

Today, with regulations enforcing evermore stringent safety measures concerned with fire, staying abreast of developments can be difficult. Of prime importance is to have a regular fire risk assessment to ensure hazards are kept to a minimum. The duty of a regular fire risk assessment lies firmly in the hands of the ‘responsible person’. It is this person’s job to ensure and manage any fire risks that may be present, either in a business or residential premises. Part of their work is to ensure that effective fire risk assessment procedures are put in place.
But how does this ‘responsible person’ carry out a fire risk assessment? What processes are involved to ensure resident’s or worker’s safety in the prevention and reaction to a fire?
The first step in any fire risk assessment is to identify the hazards that may be present in either a workplace or residential location. There are many hazards to contemplate when conducting a fire risk assessment. It must be understood that almost anything can start a fire, whether this is a naked flame, a heater or even a hair dryer. Understanding the risk posed by such items is fundamental in the assessment, added to this; in the business workplace there may be machinery and equipment that could cause problems.
The second ingredient of fire is any combustible material. Most materials present in either the home or the workplace are flammable in some way. In the workplace, a pile of waste may be just the right material to feed a blaze whereas in the home, soft furnishings are an especially vulnerable material to fire. Recognising the risks that these materials pose is a vital element in reducing the risk of fire; naturally, if the fire has no material to feed off, it will not spread as quickly, greatly improving safety.
The final component of any fire is oxygen. Without oxygen there is no way that a fire can even ignite, let alone spread. For fire risk assessors, the job of keeping oxygen levels under control is understandably difficult as it surrounds us at all times. An assessment should predominantly focus upon the other two ingredients of fire unless the workplace or location has stocks of pressurised oxygen which may in effect intensify a blaze.
The second stage of a fire risk assessment is to recognise the risks not only of the fire itself, but which people will be most vulnerable if a fire does break out. These people can vary greatly in the risks they may encounter as well as the speed of their exit. Of especial importance are those who work with combustible materials or work alone in areas that may be prone to fire. An assessment should also include the numbers of vulnerable people such as young children, the disable or elderly.
While the fire risk assessment is carried out to evaluate the risk of fire, it should also put in place measures to reduce this risk. An assessor should be able to give advice on ways in which to remove flammable materials, or replace them with less flammable materials. They should also be able to advise on the best ways to keep ignition sources away from combustibles. This is all part of fire safety management.
Providing practical advice to workers or residents is also part of the assessor’s responsibilities. Education, on the risks and how to prevent fires breaking out can be invaluable. As regulations become increasingly stringent on ways to make our workplaces and residential areas safer, it is through efficient fire risk assessment procedures that a spearhead of fire safety can be launched.

Many homeowners do not understand much about real estate taxes and for this reason can end up in the position of losing their homes. Real estate taxes or property tax is normally calculated on the land value, the location, the county laws, and other factors. Real estate taxes are utilized for the upkeep of roads and other public services like emergency services and other municipal services enjoyed by the local residents. Real estate taxes are also in one way limited to the United States alone but for almost every country worldwide as well. Other names used for real estate taxes are rates and land levies and every homeowner will have to pay them.

 

How Much in Real estate taxes must I pay?

 

Real estate taxes are assed according to the sale value of your land or home. Rates are likely to be reassessed each year and normal inflationary increases and land values mean that your real estate taxes will increase with them. There are strict laws in place to ensure that these real estate taxes are paid and if you fall behind you are likely to even lose your home. The bill of rights requires that your property tax bill shows your assessment value of the property and the percentage of the how the figure has been arrived at. Real estate taxes can change according to the local municipal needs and area upgrades that need financing so your real estate taxes can change at any time in relation to municipal budgets.

 

Do I benefit from Real estate taxes?

 

Everyone benefits from real estate taxes because this money is used to the good all of all residents. In addition to this there are certain IRS benefits for real homeowners as well. Homeowner, are entitled to deduct payments of real estate taxes that they are paying on their property if you claimed for  itemized  deductions on your tax return.  The IRS allows you to deduct real estate taxes on your main home as well as on any other homes and real estate you own. There are no also limits on the dollar amount of real estate taxes you can deduct either so this is certainly beneficial. For real estate investors with multiple properties and homes, there are also no limits on the number of these houses or properties for which deductions can be claimed for in real estate taxes.

 

How is Real estate Taxes paid?

 

When you pay monthly mortgage payment to a bank or financial institution holding your mortgage then the amount generally includes the real estate taxes that have to be paid on your property. The bank or mortgage holder pays these real estate taxes to the proper taxing county authority on their due dates. When your real estate taxes are included in your mortgage payments then you may claim an IRS deduction only in the tax year you actually pay your real estate taxes.  You will find the real estate taxes paid for the year on the statement than the bank or mortgage lender gives you on the end of the year mortgage statements.  

 

Buying Cheap real estate land and Homes with Tax Liens

 

Knowing the Ps and Qs or real estate taxes and tax lien foreclosures can make investing in real estate very lucrative. As mentioned above real estate taxes are tax deductible from the IRS no matter how many homes you own. If you have the right knowledge it is possible to purchase homes at a fraction of their prices for back real estate taxes but realtors and property investors in the know will rather prefer to keep this knowledge secret. It is possible to purchase luxury dream homes of your own or buy and sell property to make handsome returns if you know where to get your hands on this valuable information. You will find that the investment in information of this nature can also help you save money on your own property as well

 Learn More About Real Estate and Tax Lien Properties

 

It is possible to earn huge amounts of money by investing in property in the long and short term. Like everything else it is people in the know like realtors and real estate brokers that know the best ways of making huge profits from tax lien properties and homes in foreclosures. First time home buyers would certainly benefit hugely by having access to knowledge on how it is possible to purchase tax lien properties and foreclosure but this insider information is not easily available. It is easy enough finding listings in properties for sale of this nature but the steps on procuring then are another issue altogether.

 

Making Money with Tax Liens properties is very lucrative

 

It is possible to pick up tax lien properties and properties in foreclosure at a fraction of their actual value and you can either buy and sell these properties or hold on to them to reap maximum returns over the longer period. Once you have purchased tax lien properties at these low prices you can sell them at values below the real market value and they will be snapped up by bargain hunters and new home buyers fast. Most realtors and real estate brokers with information on how to buy tax lien properties are already wealthy because laying your hands on these properties is not such common knowledge.

 

How much money do you need to make money with Tax Lien properties.

 

Buying tax lien properties and foreclosed homes does not take huge amounts of capital and if you know the right techniques of working properly you can make your initial investment and much more back in a very short period of time. Re- investing the profits plus your capital a few times over can result in you owning a number of tax lien properties and a flow of income which can result in you accumulation wealth beyond your wildest dreams! What is important though, is on knowing what these techniques are, and also where you can source information on foreclosed homes and tax lien properties yourself.

 

Will I need to work through a realtor?

 

If you look at current websites that list homes in foreclosures and tax lien properties they will invariably be through a real estate agent. Of course the realtor in this case will be making a tidy profit form the deal. They will already know the insider information on how this real estate niche works and will be reaping the benefits from it. You do not really need to know everything about being a realtor to make money from tax lien properties and foreclosed homes if you know where you can get the information that will guide you in how to go about it. Anyone one that has access to this knowledge is not likely to share it, especially realtors and property investors already in the know. People that are involved with properties of this nature already will not be happy to share it with any one either.

 

How can I start making Money with tax lien and foreclosure properties?

 

Sourcing information on property investment and some background on property sale procedures is your first step to making money in tax lien properties. When you know exactly how and where to buy tax lien properties and trade with them  you will not only enjoy the experience but it can make you very wealthy in quite a short time as well.

Learn More about Owning a Dream Home for Next To Nothing here

There are dozens of ways to save a lot of money when you purchase your home which people do no really thing about. Realtors are not always as helpful as they should be when it comes to property for sale and buying homes. First time homebuyers can save tons of cash by doing a little research upfront. When it comes to property for sale this is vital because besides your car property is one of the biggest investments in your life! Knowing how to manage your mortgage properly can save you thousands of dollars over the long term. Take heed of some useful tips that can make owning your own home a pleasure rather than a noose around your neck.

1. When you start out to buy your first home have a good look at what property is for sale in the county you wish to settle in. If you are looking for investment real estate, then also have a look at the general values in the area. When applying for your mortgage then try and secure a better interest rate and put as much money down as a deposit. Look for information on how to find cheap property for sale listings, foreclosure pending sales and tax lien certificate buys. 2. Aim to put down as much as possible on the price of the property and look for sale by owner property for sale where you can negotiate a better price. Obviously you cannot find listings of homes of this nature through realtors so it will mean a little legwork on your part.3. Buy into an up-market cluster development in the construction phase, rather than an existing home; as this saves you transfer duty.  New construction homes and property for sale that is earmarked for future development are good investments if you are just looking for good investment placing. If you are looking for a home of your own find out ways to buy cheap homes information in books and on the internet. Insider information on property for sale may be one of the best investments you ever make. 4. If you are looking to purchase a home for yourself then make sure the monthly repayments will be manageable before you sign any papers with the financial institution. If you can find a cheap home that is well within your budget it can be worth paying a little more every month that the actual installment.

5.  If you purchase property that already has excellent equity in it then after a few months take an additional mortgage to settle in full; your bank overdraft, your credit cards and your creditors, using the debt consolidation facility on your bond – thus avoiding excessive interest charges.  Plough the money you would have been paying in interest back into your mortgage.

 

Investing In Real EstateIf you are looking for property for sale as an investment then this a very attractive way of making a good return on your money but certain factors need to be taken into consideration to ensure you get maximum returns. If you do not know much about investing in real estate then once again it is certainly sensible to do your homework first.  Sometimes investing in real estate can be more lucrative by doing it yourself rather than using the services of a realtor. The most important factors that must be considered in property investment are the location and the future potential of the property.

 

Unless you know the secrets of making fast returns on investment property then investing in real estate is better over long term periods. Maximum return can be gained by buying the land and cheap homes at a low price and waiting for a while for values to increase as they are developed. There are certain niches in the real estate market that allow fast maximum returns on real estate investing. People in the know however would prefer keeping this to themselves. A little research can open many doors in the property for sale market and whether you are a new home buyer or seeking investment in real estate it can be incredibly rewarding.

 

Learn More about Real estate Investing

 

 

Few people even consider making money in real estate investing because they think it to be extremely difficult. Most people will also rather go through a realtor company or property broker to help them buy their homes but if they knew that it was possible to save thousands of Dollars by having a little knowledge on how real estate works, they would definitely rather do it on their own. If you visit any real estate website, there is always a lot of technical terms and jargon written on it making dealing in property matters look seriously complicated. In reality this is not so, and with a little reading and research you can buy your own home and even become involved in real estate investing that can make you a lot of money in both the short and long term if it pleases you.

 

The right way to invest in Real estate for maximum returns

 

It does not really matter whether you already own your own home or are a new home buyer. Certain inside information can help you secure land and homes at a fraction of their value if you know how it is done. This is through the purchase of tax lien properties and foreclosed homes which can be located all over the United States. Knowing where to find these listings and how to go about buying and selling these homes can make real estate investing hugely lucrative. It is possible to own a luxury home you would never have considered possible just by doing a little research, and finding out where y to get insider information. Armed with this knowledge making money with real estate investing will become second nature and you can build wealth and own the home of your dreams quite easily.

 

Invest in Foreclosed homes and tax Lien Properties.

 

It is not only professionals’ realtors and property investment brokers that can make money on foreclosed homes and tax lien properties; anyone can do it if they had the right knowledge.  Many realtors already have the inside information and have become extremely wealthy knowing how to secure foreclosed homes and tax lien properties which they purchase and sell, at huge profits to home buyers who are none the wiser. You will find that in the majority of cases realtors live in large luxury homes as well that have been procured from sales of this nature.

Real estate investing for the long term is considered far more sensible than short term property buying and selling because this will allow you to absorb any market fluctuations but either way the value of properties are apt to increase over the longer term.

 

Real estate investing with knowledge on how to purchase tax lien homes and foreclosed properties allows you to enjoy the best of both worlds. Although location is considered important when looking at real estate investing; buying and selling of tax liens and foreclosure properties can be done anywhere all over the United States and resold for fast returns.

 

Learn More About Buying Cheap Homes here

 

 

 

You were lured to Canada by Canadian immigration officers who’s promise of lucrative career opportunities and a better life abroad were all to seductive to pass up. As a highly educated professional in your native country you are well respected, your salary allows you to live in a big house, feed and educate your children, and enjoy the social status that comes along with it. But these immigration officers advise you that your credentials automatically qualify you for entry into Canada. Where you can find a job in your field for 10 times as much as what you could make in your country. Your decision is easy. After spending $15,000 for a ticket, application fees, and money in the bank, you’re finally ready to start your new life abroad. Leaving your wife and kids behind may not have been easy, but you know that in 1 year you will be settled in Canada with your 6-figure income and your three-story mansion on the hill with your family. After a long journey you arrive in Canada your credentials in tow, you anxiously begin your job search only to find out the credentials that you obtained outside of Canada do not meet Canadian qualifications and the only work you can get is driving a cab or working in the labour market.

Many newcomers have been mislead by the Canadian government into immigrating to Canada with the hopes of a better life. The Foreign Credential Assessment Office established a year ago offers hope for highly skilled immigrants to get their credentials recognized in order to utilize their skills. Though this program is long over due, it is a big step toward acknowledging the issues of foreign professionals working in our labour market.

The continued problems with racial discrimination in the work place have yet to be addressed.

With Canada’s so called “ job shortage” will companies now hire these skilled immigrants once there credentials meet their standards? Or will they continue to hire foreign temporary workers for inexpensive labour? Here are 4 reasons why companies might be reluctant to hire these immigrants once their credentials are recognized:

 

 

 

There are many good candidates that are not being hired simply because of racial discrimination. Immigrants are often more educated than local Canadians, but a Canadian born worker with less education is more likely to make more money. Some immigrants are told they are over qualified for a job or do not have sufficient Canadian experience for the position. This is also an issue common for non-white Canadians born in Canada. In order to guarantee the equal employment opportunities of skilled immigrants, a sufficient anti racial legislation needs to be implemented using methods that encourage interracial cooperation. Discrimination in Canada can be combated in the following ways:

 

 

 

Newcomers to Canada will benefit from the Foreign Credential Assessment process. However, further information is required for prospective newcomers to understand the barriers of finding a job in their field. Overseas services are also available to further assist perspective newcomers before settling in Canada. As we already know the Canadian government is not always forthcoming about their true motives, be sure to do a lot of research, and ask a lot of questions.

In our school and college days we used to give tests to keep a track of our knowledge and efficiency, but when we grow up we start living in this illusion that we are mature and we don’t need them now. But the fact is that we need them throughout our lives, as everyday is a new learning experience be it a job or any profession, we actually need to brush them up every now and then. Hence, it becomes essential to keep self assessing yourself by giving different skill tests matching your area of expertise.

The instant and efficient means of accessing your skillset is available online. Nowadays, many new websites prepare online skill testing tools which create valid skill-based tests which consist of multiple subjects and competency levels as well. In freelancing and outsourcing world online skill tests can be really beneficial in terms of finalizing the final service provider. A buyer can encourage the potential vendor to perform some given skill tests complementing his area of expertise or domain, this eventually will help buyer to select the best out of all to undertake his important work assignment.

Some consider online skill tests as an advanced hiring tool. Many companies widely use it as part of the screening process or pre- employment tool which saves time while giving more accuracy and defensibility to their hiring decisions.

I request all of you to come and provide me with your feedback and suggestions on the importance of the online skill tests and its benefits to the service providers.

In 2004, the UK’s then Prime Minister, Tony Blair, talked about a possible renaissance of nuclear power generation as a means to combat global warming and, over the past few years the current administration seem to be walking the same path albeit with a view to security of energy supply being high on the topical agenda.

In 2007, John Hutton, the then Business Secretary, said that becoming energy independent is not the same as becoming self-sufficient. Instead it means having a mix of energy sources to call upon, including from countries that have open and transparent markets.

“We will always need energy sources from other countries,” Mr. Hutton said. “Our strategy for the UK in the 21st century must focus on ensuring we do not become dependent on any one supplier, country or technology.

“The best way to deal with that uncertainty is to diversify the risk. This is a modern definition of “energy independence” in an interdependent world.”

This stance, of course, raises more questions than it provides answers – What is the scope for new nuclear power generation given the existing generation capacity stock and its likely evolution?

What are the costs and benefits associated with nuclear relative to a do nothing case where new investment in electricity generation is likely to flow to gas fired plant?

The answers to these questions could be summarised as follows:

Should the private sector take commercial decisions to invest in new nuclear, the economic analysis suggests that there is scope for adding a relatively small amount of new nuclear capacity in the period to 2025.

Nuclear new build could be added to replace existing nuclear plants scheduled for closure; the bulk of the existing fleet will have reached the end of its design life by 2025. In addition, new nuclear capacity might be added to meet demand growth. This would require switching current gas fired base-load plant to operation as mid-merit or peaking plant.

It is likely that the first new nuclear plant could be added by around 2021, if not before, assuming a seven/eight year pre-development period (for pre licensing, public enquiry, licensing, etc.) and construction.

Adding new nuclear capacity could help to reduce forecast carbon emissions, and to reduce the level of forecast gas consumption / imports. Within power generation, new nuclear appears to be a cost effective means for meeting carbon emissions reduction targets. Adding new nuclear capacity would not preclude investment in other forms of low carbon generation.

Investment in nuclear new build would result in carbon abatement cost savings sufficient to offset the nuclear cost penalty relative to gas fired plant in a central gas price scenario.

Adding new nuclear plants would also partially mitigate risks associated with dependence on imported gas. In particular, costs associated with insuring against the risk of fuel supply interruption (e.g. through adding gas storage capacity) could be reduced as nuclear plant is added. Investment in new nuclear capacity would also provide a hedge against the risk of high gas prices.

Nuclear investment is not justified at the higher end of the range of costs, or in a low gas price world, or in a central gas price world where there is no carbon price.

When we raise the nuclear word; we raise the history of fear; a history of mistakes and the unknown. The lack of scientific guarantees, the accidents that were Chernobyl and Windscale (as was) all draw on the fear of the past and the average person in the street worries whether nuclear is the right decision.

To allay fear means confidence and trust must be built; built by the industry, built by the regulators and built by the government. Trust and confidence is underpinned by doing the right thing and this means making sure the latest knowledge is applied, the best practice rules and procedures are in place, and quality/compliance processes are implemented and followed right through the supply chain from Tier 1 downward.

Many companies address quality as a necessity to their operation but it is often seen as an internal business cost, rather than as an asset. In the energy market, especially the nuclear sector, quality compliance has to have the highest regard and is integral to the confidence for the industry to remain effective.

What is often missed with the stereo view of quality is that quality can also be the value-add differentiator that wins new orders, or the catalyst for change/improvement and that bring those additional savings and gives a competitive edge in tough market conditions.

The quality functions within a company can be the major factor that supports the production process and the ultimate delivery to the customer. It is also instrumental to a company in retaining their accreditations and certifications which are required to do business in their particular business sector, without which new business could not be won and existing business cannot be retained.

Proquis clients have stated that their introduction of a Proquis solution demonstrated between 60% and 70% reduction in administrative effort and repetitive workload for the quality team, senior managers and workforce and they achieved their returns on investment in under 12 twelve months.

Therefore, if a company could also save 60% to 70% of that effort, either as a direct reduction, or as a return by allowing the refocusing of your highly skilled quality professionals and managers to produce new improvements and better savings on the core processes (which they currently do not have enough time to review effectively now); then does that not justify time in reviewing the potential of a Proquis solution for your organisation?

Examples of Proquis Clients –

UK Nuclear Sector Nuclear Decommissioning Authority                                       US Dept of Energy                                                                                                                                                           Nuclear Research Dept – Argonne IL

Proquis is an ISV (Independent Software Vendor) of system solutions for the quality and compliancy arena. The Proquis solutions have been very successful in highly regulated sectors like nuclear, defense and aerospace, where there are many stakeholders, including both local/national governments and governmental regulators, each being highly influential in the business operational delivery, strategy and planning.

We would not pretend to know the specific problems facing your business, it has a unique situation, however we would like to gain an initial opportunity to understand those current issues facing your organisation, and discuss if any particular areas could be identified where our assistance could provide an appropriate solution for additional savings and performance improvement.

Acknowledgements – HMG, BBC, Daily Telegraph

Background

Definition of unexplained infertility: Infertility cases in which the standard infertility testing has not found a cause for the failure to conceive.

The definition of what “standard testing” consists of is not agreed upon by all experts. Unexplained infertility is also referred to as idiopathic infertility. Medical studies have reported that 0-26% of infertile couples have unexplained infertility. The most commonly reported figures are between 10-20% of infertile couples. However, those percentages are from studies in which all the women had laparoscopy surgery to investigate the no longer done as part of the routine fertility workup. Therefore, we are not finding all of the causes of infertility that we used to – leaving more couples in the unexplained category. The current rate of unexplained infertility is probably about 50% for couples with a female partner under age 35 and about 80% by age 40 (see discussion below about female age issues).

In reality, there are probably hundreds of “causes” of infertility. What this means is that there are a lot of things that have to happen perfectly in order to conceive and have a baby. As a simplified example:

 A weak link anywhere in chain can this cause failure to conceive

The above list is very oversimplified, but the point is made. There are literally hundreds of molecular and biochemical events that have to function properly in order to have a pregnancy develop. The standard tests for infertility barely scratch the surface and are really only looking for very obvious factors, such as blocked tubes, abnormal sperm counts, ovulation regularity, etc. These tests do not address the molecular issues at all. That is still for the future…2

The subtle causes of sub fertility that have been proposed as underlying unexplained infertility are as follows3

Ovarian and endocrine factors

 Abnormal follicle growth

Luteinized unruptured follicles and ovarian cysts

Hyper secretion of LH

Hypersecretion of prolactin in the presence of ovulation

Reduced growth hormone secretion /sensitivity

Cytological abnormalities in oocytes

Genetic abnormalities in oocytes

Antibodies to zona pellucida

  Peritoneal factors

 Altered macrophage and immune activity

Mild endometriosis

Antichlaydial Ab

  Tubal factors

 Abnormal peristalsis or cilliac activity

Altered macrophage and immune activity

  Endometrial factors

 Abnormal secretion of endometrial proteins

Abnormal intergrin/adhesion molecules

Abnormal t cell and natural killer cell activity

Secretion of embryo toxic factors

Abnormalities in uterine perfusion

 Cervical factors

 Altered cervical mucous

Increased immunogenicity

General immune factors

Altered cell mediated immunity

  Male factors

 Reduction in motility, acrosome reaction, oocyte  binding ,and zona penetration

Ultrasructural abnormalities of head morphology

  Embryological factors

 Poor quality embryos

Reduced progression to blastocyst

Abnormal chromosomal complement-increased miscarriage rate

Unexplained infertility and female age

Women are born with certain number of eggs and when they attain menarche they start releasing these eggs cyclically. As the woman ages they run out of there eggs and quality of eggs will become poorer too. Therefore the likelihood of a diagnosis of unexplained infertility is increased substantially in women 35 and over – and greatly increased in women over 38. Since we do not have a “standard category” called egg factor infertility, these couples sometimes get lumped in to the “unexplained” infertility category. Most women over 40 who try to get pregnant will have difficulty, and fertility over age 44 is rare – even in women who are ovulating regularly every month. The point is that the older the female partner, the more likely that there is an egg related issue causing the fertility problem. Unfortunately, there is currently no specific test for “egg quality”.2

Unexplained infertility and Mild endometriosis

It is not quite clear whether mild endometriosis causes infertility and treating mild endometriosis improve the fertility rates. Some recent studies has shown surgical treatment for mild endometriosis increases the fertility. Some experts would also consider infertility associated with mild endometriosis to be in the “unexplained” category. This is because a cause and effect relationship has not been definitely established between mild endometriosis and fertility problems.

Chance for getting pregnant on own – without fertility treatment – for couples with unexplained infertility

The duration of infertility is important. The longer the infertility, the less likely the couple is to conceive on their own. After 5 years of infertility, a couple with unexplained infertility has less than a 10% chance for success on their own.

One study showed that for couples with unexplained infertility and over 3 years of trying on their own, the cumulative pregnancy rate after 24 months of attempting conception without any treatment was 28%. This number was found to be reduced by 10% for each year that the female is over 31.4

Treatment options for unexplained infertility

Ovarian stimulation and/or intrauterine insemination (IUI)

Intrauterine insemination vs. timed intercourse – no medications involved

Studies have been shown that chances of pregnancy is increased with intrauterine insemination  compared to timed intercourse.

Clomid and timed intercourse

Glazener et al .treated 100women,43% of whom were porous ,with either clomid 100mg from days 2-6 and placebo in a randomized cross over study. Overall there was a 50% increase in pregnancy rates after 3 cycles of treatment. Benefit was seen in after 3 years of infertility and more so in parous women.The same study showed that there were no conception in women over 35 years.5 This suggest that these women are not suitable candidates for clomid treatment and should be treated vigorously with assisted conception methods.

Clomid plus IUI

Treatment with Clomid tablets plus IUI improves fertility rates. For unexplained infertility, studies have shown that for women under 35, monthly success rates for Clomid plus insemination are about 10% per cycle. This pregnancy rate holds up for about 3 tries and the success rate is considerably lower after that.

Deaton et al carried out a randomized study between timed intercourse or clomid with IUI, and showed that monthly fecundity was 9.5% in clomid plus IUI group compared to control group- a significant difference.6  In the same study it has been showed that there was no difference in number of follicles between conception and non conception cycles, suggesting that the insemination component have a more important influence than the Clomid does on outcome- but success rates are higher when both are used together.

Collating all studies together a recent systematic review, Hughes et al. reported that treatment with clomid is superior to no treatment or placebo (95% CI 1.5-4.65).7

Injectable gonadotropins plus intercourse

This is less extensively studied. However a study by Mascarenhas et al demonstrated that super ovulation with gonadotrophins significantly increased the pregnancy rates in unexplained infertility.8

Injectable gonadotropins (shots of FSH hormone) plus IUI

Several studies showed improved pregnancy success rates with injectable FSH plus IUI treatment as compared to no treatment. A meta-analysis by Hughes9 indicated that FSH plus IUI increases the pregnancy rate by 2.3 times than compared to FSH plus timed intercourse.

It is most likely that super ovulation and IUI  both independently increase fertility potential, with relatively more fertility benefit coming from the IUI component.

Assisted reproductive technologies

IVF

In vitro fertilization (IVF) has high success in young women with normal ovarian reserve (normal FSH levels) and unexplained infertility. Most couples with unexplained infertility with a female partner under age of 35 could try about 3 artificial inseminations and if fail to pregnant  it is sensible to have IVF. On the other hand women over 35 years should have been offered IVF as a first line treatment.

GIFT

Gamate intrafallopian transfer goes one step further than superovulation/IUI as it involves the collection of oocytes and sperm into fallopian tubes. The main disadvantage compared to IUI is the need of laparoscopy and more complicated ovarian stimulation regimes. Compared with GIFT the main advantages of IVF are, that being able to study the fertilization, gives the opportunity to transfer best quality embryos to the uterus, and it also gives couple with surplus fertilized oocytes which can be cryo preserved for future use.

A large multi-center randomized study performed by European Society of Human Reproductive and Emryology to compare five treatments for unexplained fertility .The study concluded that there was no significant difference in outcome between them.(super ovulation 15% per cycle, super ovulation 27%,superovulation/IUI 27%,GIFT28%,IVF26%.10

 In summary, strategic management of unexplained infertility should focus on the efficacy of the method ,cost effectiveness and invasiveness of the procedures involved. Evidence suggest that there would be little or no benefit if treatment start in  a woman less than 35 years. Therefore it is worth considering superovulation and/or IUI for 3 cycles after 3 years of infertility, and if not successful go for IVF. However for older women (over 35) to consider IVF straight away.

References

1. Hull MGR, Glazener CMA, Kelly NJ et al.(1985), Population study of causes,

2. Unexplained Infertility

http ;//www.advancedfertility.com/unexplain.ntm( accessed 11/03/2008).

3. Adam, H.B. & Howard, S.J, (2003), Infertility In Practice, Churchill Livingstone, London.

4. Collings JA ( 1989), Natural course of unexplained infertility, Proceedings of the Serono symposium on unexplained infertility : basic and clinical aspects. Serono Aries Publishers, Rome.

5. Glazener CMA, Coulson C, Lambert PA et al, ( 1990), Clomiphene treatement for women with unexplained infertility : placebo-controlled study of hormonal responses and conception rates. Gynecol Endocrinol 4: 75-83

6. Deaton JL, Gibson M, Blackmer KM, Nakajima ST, Badger GJ & Brumsted JR, (1990), A randomized, controlled trial of clomiphene citrate and intrauterine insemination in couples with unexplained infertility or surgically corrected endometriosis. Fertil Steril 54 : 1083- 1088.

7. Hughes E, Collins J, & Vandekerchhove P (2002),Clomiphene citrate for unexplaine subfertility in women. Cochrane Database of systematic Reviews, Issue 1, 2002.

8. Mascarenhas L, Khastgir G, Davies WAR & Lee S, ( 1994),Superovulation and timed intercourse: can it provide a reasonable alternative  for those unable to afford assisted conception ? Hum Reprod  9: 67 -70

9. Hughes EG (1997), The effectiveness of ovulation induction and intrauterine insemination in the treatment of persistent infertility : a meta-analysis. Hum Reprod 12 : 1865-1872

10. Crosignani PG, Walters DE & Soliani A, (1991), ESHERE multicentre trail on the treatment of unexplained infertility : a preliminary report. Hum Reprod 6: 953-958.