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In the largest leak in the history of the Israeli-Palestinian conflict, Al Jazeera has obtained 1,676 classified documents in total.
The documents are derived from a decade of meetings, internal emails, reports and studies, notes, maps and draft agreements.
They detail talks between the Israeli government and the Palestinian Authority, along with the United States.
However, the most controversial revelation so far is the apparent willingness of the Palestinian Authority to give concessions on disputed areas of Jerusalem.
Yasser Abed Rabbo, a senior member of the Palestine Liberation Organisation (PLO) executive committee, said in his reaction to the revelations, "They want to compete with WikiLeaks and come up with parallel stories."
"But WikiLeaks doesn't bring those presenters or people such as Atwan in order to sensationalise and provoke and serve a preordained position."
Al Jazeera's Teymoor Nabili interviewed Adbel Bari Atwan, editor of the Al-Quds Al Arabi newspaper, the man named in Rabbo's reaction to the leaked documents.
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Health Information - Med Help
My MedHelp
Coconut milk health effects
Common Questions and Answers about Coconut milk health effects
Everything works differently for everyone. I could see how
could reduce palpitations if there cuased by low magnesium and potassium.
Read More
I only have a receding hair line and have absolutely no bangs by this point. This started when I was nineteen (I'm 26 now). Perhaps
oil also has restorative
? If so, perhaps it could help my beard, which has oddly been thinning the past year or so (it's always been thick up until that point). I'm sure I'm going to get a reply along the lines of "go see a dermatologist," but I have no money, and a dermatologist doesn't always know all the answers.
Read More
Not for hepatitis, but for overall
. I was asking whether anyone has researched whether
oil will have negative effect on hepatitis B.
Read More
Has anyone experienced any bad side
from the hcg shots? I am administering them myself and just want to know what to look out for.
Read More
I was just curious to see if any of you have already wrapped up your 12 weeks of Incivek. If so, did your side
get any better? Since I have to treat 48 weeks I have been counting down the days until the Incivek is over and hoping that things will get a little easier once this part is over. Thanks!
Read More
Having a little bit of fat in every meal- nuts in breakfast, avocado on a sandwich (in place of mayo), and
or meat in the occasional curry or snack really helps make sure I'm getting enough to get me through the day. Also - I have never in my life lost weight until recently. I was obese at 12. I have a thyroid problem that was only acknowledged and treated recently. In the month after I started taking my thyroid meds I lost 10 lbs. I strongly suggest you get your thyroid tested.
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My daughter is almost 4 weeks old and EBF, I've noticed at night she becomes fussy and will latch on and unlatch the whole time I'm trying to BF, from either side. I'm going through the "deflated" stage where it doesn't feel like there's any milk, so I decided to pump and couldn't even get an oz, not even half an oz, so no wonder why she's fussy. Unless I go a few hours without her eating or pumping, it gets like this, almost no breast milk at all..
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Hi, Yes I agree in part , i too use other oils ,the cocnut oil i use is virgin or unrefined as with all oils in moderation. Never tried the ice cream spoon thngy, funny. Breast milk please.. I wanted to add some info on cocnut oil just for the heck of it. D Coconut oil is the healthiest oil on earth". Once wrongly accused of increasing cholesterol levels, coconut oil is now actually being used by doctors in the treatment of a variety of disorders.
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TRANSLATE THIS PAGE: http://translate.google.com/ ACIDIC STOMACH/ACIDOSIS/DYSPEPSIA/HYPER ACIDITY/STOMACH PROBLEMS ================================================================== Guys, this one is my personal experience of dealing with a very complex issue. You may exercise your own judgment in following some of cure below. You must read this blog in its entirety for at least 2-3 times to understand the cure mechanism.
Read More
Apple cider vinegar has helped me, I also do not drink regualr
, I go with almond ,
or rice
, all non dairy.
Read More
Many of you will not believe the facts on these pages and will continue to avoid
oil and
out of
concerns. Despite the proven benefits. We invite you to investigate further. http://www.thaifoodandtravel.com/features/cocgood.
Read More
cow's milk (hard to find) or goat's
if tolerated. Replace ALL cooking oils with Extra Virgin
Oil (One of the top functional foods-check it out at the coconut research center website) Limited fruit and pure fruit juices. Quality Probiotics and Prebiotics. Some tea and or coffee O.K. Deep conscious breathing. Look into Pranayama Breathing. Will become a habitual event (subconscious) after practicing extensively.
Read More
Things Killing Your Gut U.S. scientists discovered that gut microorganisms not only influence immune cell function, but actually support the production of immune cells that form the first line of defense against infection. About 80 percent of the neurotransmitter serotonin is produced in the gastrointestinal tract—not the brain.
Read More
These two fatty acids and their
are being studied, but for now, we don't have any evidence suggesting that coconut oil is better for you than other saturated fats. The benefits of coconut oil in the diet, if any, are likely to be minimal, and until we have more and better evidence about coconut oil's effect of metabolism and potential role in promoting weight loss, I do not recommend using it. Andrew Weil, M.D.
Read More
I'm not sure if I can drink lactose free
. But I've come to the realization I can't even have ice cream, cheese etc.... Blech! This is gonna be a long 2 weeks!
Read More
I clearly have a number of medical problems, and whether they stem from the longstanding
of having had hypothyroidism without knowing it for a few years too long, or if there's another issue in the works, I don't know. My right ankle bone has been painful and inflamed for no reason at all for the last few weeks, and my insomnia is still going strong.
Read More
I have eliminated refined sugar in exchange I use agave syrup, and I stopped using dairy exchanged for
in my coffee, switch to fresh brewed decaf iced tea, changed to grass fed meats and natural grown veggies not pesticides or processed foods, I added amino acid supplement, malic acid with magnesium supplement and have felt a whole lot better so far these past 3 weeks. Last night not only did I have the energy to set up the patio furniture and firepit by myself!
Read More
This is a medium chain fatty acid also called octanoic acid, that is found naturally in
oil, palm oil, butter fat as well as in human breast
. It is known to have anti-fungal as well as some anti-bacterial and anti-viral properties. One of the difficulties with caprylic / octanoic acid is that, being a medium chain fatty acid, it is very easily digested and absorbed by the body.
Read More
I then switched from other sugars (including honey) to raw agave and palm (
) sugar (other sugars make me CRAVE sweets). I've never used artificial sweeteners. I just never trusted them. When I accidentally ingest aspertame it does terrible things to my bladder. When the sugar cravings hit (frequently) I drank a large glass of oj... as much and as often as I wanted. (Lots of sugar, but no more than I'd been eating.
Read More
I poisoned myself with Thai and indian food which I thought were ok to eat because the dishes I ate were vegan. They contain
, and other highly satureted fats, which will drive cholesterol levels way up. Check nutrition labels on packaged foods, and if you eat out a lot, check with the kitchen as to what is in the food. I got life saving help from the advice of Dr Fuhrman.com. and his book I believe was a God send.
Read More
1 avocado = 31 gr fat 40 potato chips = 20 gr fat 1 medium French fries = 28 gr fat 2 oz bacon = 20 gr fat 1 plain bagel with cream cheese = 19 gr fat 1 cup raw shredded coconut = 27 gr fat 2 oz American or Cheddar cheese ½ cup chopped black walnuts = 35 gr fat ½ cup hazelnuts = 35 grams fat ¼ cup macadamia nuts = 26 gr fat 1 cup trail mix = 20 gr fat 100 gr seasoned croutons = 18 gr fat 3 tbsp bitter = 21 gr fat 2 tbsp nut butter (peanut/almond) = 20 gr fat 2 oz/100 gr sweet dark
Read More
It is lauric acid from human breast
that is also present in
oil is anti-fungal, anti-viral, anti-parasitic, antiprozoic, anti-microbial and causes no inflammation when used in cooking -unlike all other cooking oils. It can also be a substitute for glucose, when glucose uptake is inhibited, supplying fuel for your neurons, as it is one of the few elements that can cross the blood-brain barrier.
Read More
You can then add a 1/2 cup Greek yogurt, almond or
, regular
, fruit, chocolate powder, peanut butter, vegetables or other ingredients to taste. The shakes didn't work well for me, because, while they fill me up, they don't satisfy my need to have something to chew at mealtime, so I'm left craving something. It took me a while to figure out what the problem was.
Read More
If certain foods cause "issues" for you, then I would most definitely avoid them. Are you truly "allergic" or intolerant to sugar, or are you diabetic, meaning that you don't produce enough insulin to convert sugar to energy. All foods are eventually turned into sugar in our body; however, some will raise blood sugar much more quickly than others. I just watched a video this morning that said processed soy may not be good for us either.
Read More
I think it has some amount of
oil in it . . . not sure how much. I was at a natural food festival a few years ago and I had a sample of some coconut butter. It was the best thing I have ever tasted! Unfortunately I don't remember what it was :( Yesterday I went to Fred Myers and pruchased some coconut oil thinking it would taste the same as what I remembered. Sadly it wasn't even close. It's not bad mind you . . .
Read More
aside from that i have read it has tons of side
from urinary problems to mouth problems. avoid all gerd triggers, chest pains are symptoms of gerd(acid reflux) which is somehow connected to gastritis due to excess acids. avoid: chocolates, milk, tomato based products, oily and fried foods. try eating soup or rice porridge for a week.
Read More
I'll try to help you, Jessica. Before I tell you how to prevent constipation, let me give you a tip that should help A LOT with having all that waste ready to come out and it won't. At the drugstore, pick up "BabyLax" or "PediaLax," it's a very small box of tubes of ointment, squirt two in the rear, and within minutes it'll come on out, and the lubrication in the medicine makes it hurt less.
Read More
There is alot on the net about
Oil and the years spent to disadvantage this
product too! The reason I took this is the many studies on healing your Thyroid glands, one of your most important glands to keep your body functioning well. There are other Healthy products out there too! Another thing I did was try and go Chemical free!
Read More
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Special Offers
Winter Special:
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One Night Free on stays of 4 nights and above (does not include week ends):
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This offer is applicable only when booked directly with us.


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The price of Liquidity Services shares has slipped to $33.01 (a 0.7% change) on heavy trading volume. About 909,000 shares have been traded today, as compared to the 30-day average volume of 746,000 shares. Spikes in volume can validate a breakout or signify a potential turning point.
Liquidity Services Inc. provides full service solutions to market and sell surplus assets and wholesale goods.
Potential upside of 38.8% exists for Liquidity Services, based on a current level of $33.01 and analysts' average consensus price target of $45.83. The stock should find initial resistance at its 50-day moving average (MA) of $40.26 and further resistance at its 200-day MA of $47.13.
In the past 52 weeks, shares of Liquidity Services have traded between a low of $29.30 and a high of $66.57 and are now at $33.01, which is 13% above that low price. Over the past week, the 200-day moving average (MA) has gone down 0.6% while the 50-day MA has remained constant.


text:
Facebook, Priceline, Apple: Tech Winners & Losers
NEW YORK ( TheStreet) -- Facebook (FB) shares gained 0.76% to $27.70 as the social-network company gets set to join the Nasdaq 100 later this week.
Last week, Nasdaq OMX Group (NDAQ) announced that the California-based social network will be joining three indices prior to the market opening on Dec. 12. Facebook will join the NASDAQ-100 Index, the NASDAQ-100 Equal Weighted Index, and the NASDAQ-100 Technology Sector Index.
Facebook will replace Infosys (INFY) in the index.
Apple (AAPL) shares dipped lower in morning trading, off 0.30% to $531.67 as a noted Apple analyst cut his price target on the stock, citing growth concerns.Peter Misek of Jefferies has cut his price target on the Cupertino, Calif.-based firm, pointing to worries that Apple's growth will slow, as well as potential negative margin leverage. Misek lowered his price target to $800 from $900. Misek wrote in his research note he believes Apple's growth will start to slow down in 2014, as the markets become saturated with its products. He believes Apple will launch the iPhone 5S in June or July, compared to the September and October launches for the iPhone 5, and iPhone 4S, respectively.
Priceline.com (PCLN) shares fell 4.18% to $631.54 on heavy volume, as Deutsche Bank downgraded the stock to "hold." Analyst Ross Sandler downgraded the stock on fears of competition in Priceline's core European market, as a "cold war" may heat up. Sandler cited Expedia (EXPE) getting more aggressive acquiring customers, the concerns on the shift to mobile search, and Google (GOOG) eventually going "..deeper into travel vertical search once its regulatory issues are resolved." Traders have been taking profits on names ahead of the fiscal cliff on stocks that have done well in 2012, amidst worries that tax rates will go higher in 2013. Priceline, the online travel company, has enjoyed a strong run year-to-date, gaining 35.69%. Interested in more on Priceline? See TheStreet Ratings' report card for this stock. -- Written by Chris Ciaccia in New York. >Contact by Email. Follow @Commodity_Bull
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Sale Infinity Wine Rack
Now: $79.20
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Design by Ron Arad, 1999.
Made in Italy by Kartell.
Infinity is a colorful and curvilinear, modular bottle-holder. The elements which form the bottle-holder can be fastened together to form an indefinite number of rings inside of which bottles may be stored. It is available in a practical 16-piece gift pack and may be freely composed in an endless interplay of connections. Select from four opaline color options: Opaline, Blue, Yellow and Orange.
Kartell products can be easily recycled. In order to simplify the recycling process, the various components of the Kartell products can be easily separated and reduced to elements made of one single material. And the plastic parts of each product carry, clearly printed, a universal Recycling Identification Mark for ease of sorting and recycling.
For quick ship options that are in stock and ready to ship within 2 business days, please see Infinity Wine Rack - Quick Ship.
Notes: Sold in sets of 16 pieces. Price shown includes shipping.
Material(s): Polypropylene, Polymer
Dimensions: Per Unit: 2.25"W X 5.75"D X 3.5"H
Model(s): KRT-7680 7680
Born in Tel Aviv in 1951, he lives and works in London. He has created world-famous pieces, from Rover Chair and Well Tempered Chair to the Bookworm bookcase. He designs for Kartell, Moroso, Driada, Fiam.See other lights/products from Ron Arad
Kartell works with renowned designers such as Ron Arad, Antonio Citterio, Michele De Lucchi, Ferruccio Laviani, Piero Lissoni, patricia Urquiola, Vico Magistretti, Enzo Mari, Alberto Meda, Paolo Rizzatto and Philippe Starck, who all appreciate the wealth of knowledge that Kartell has about plastics technology and the innovative ways in which it can be effectively applied to items for modern living.
Kartell has over fifty years of experience in designing classic furniture from plastics which has made the company famous in the history of Italian and international design.
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text:
LENMAR CLKBP4L REPLACEMENT BATTERY FOR NOKIA N810 CELLULAR PHONESItem#: YYPT-LENCLKBP4L | Model#: CLKBP4L
Currently Out Of Stock!
You May Consider This Alternative
REPLACEMENT BATTERY FOR NOKIA N810 CELLU Product Details
Manufactured by: Lenmar
Warranty provided by: Lenmar
Mfg Part No: CLKBP4L
UPC No: 029521559569
Box Size: ( Length:0, Width:0, Depth:0)
Shipping Weight: 0.1000 pound(s)
Click here for full warranty and support information
- Limited Warranty: A full text version of the limited warranty
may be obtained by mailing a self addressed, stamped envelope to the
address below and requesting the warranty for item number: YYPT-LENCLKBP4L
Warranty Information
7795 W. Flagler St. Suite 35
Miami, FL. 33144
- Lenmar logos are registered trademarks of Lenmar. All others trademarks and copyrights mentioned herein are the property of their respective owners.


text:
TheO is a ball that lets you toss your iPhone for fun
If you want to get up and move while you game with your iPhone, you should check out TheO ball. Created by Physical Apps, LLC, TheO is a soft foam ball that serves as a cradle for your iPhone or iPod touch. It was introduced at the 2012 Toy Fair in New York where it won the Popular Science Best of Toy Fair 2012 award.
The iPhone or iPod sits in the center of the foam ball and the system lets you toss or roll your iPhone across the floor as part of a game. Currently, Physical Apps has three free games including a bowling app, Hot Potato and Interrogo, a social game you play with friends.
The company is wisely releasing an API so other developers can take advantage of this motion-based system. It's very Wii-like in it's approach to mobile gaming and may catch on if developers can convince people it's OK to toss their US$600 iPhone across the room.
TheO is expected to debut in May with a street price of $24.95. Games will likely be priced from $1.99 to $4.99. You can watch a promotional video of the system below.
[Via AppAdvice]
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Software Updatesmore updates
- Dropbox adds file/folder renaming and Office document editing to iOS app
- Vizzywig 8xHD price tag now a very affordable $49.99
- Automatic targets teen drivers with License+ service
- Dropbox adds support for TouchID
- YouTube for iOS gets updated with full support for iPhone 6 and 6 Plus
- iOS 8.0.1 update now available (Updated -- Don't update!)


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Saipem has completed the acquisition of Bouygues Construction's 50.8% stake in Bouygues Offshore. It also has filed a standing offer for the remaining public shares with the French market authorities. The cash offer price was unanimously recommended by Bouygues Offshore's board of directors. The offer price (Euro 60.08/share) represents about a 25% premium over Bouygues Offshore's one-month average share price prior to Saipem's announcement of the deal with Bouygues Construction. The transaction has received antitrust clearance from the European Commission, and it represents the largest cross-border acquisition in Europe's oilfield services sector. The combined services of the merged firms create a new, worldwide group with superior competitive positioning in the provision of EPIC (engineering, procurement, installation and commissioning) services to the oil industry.
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Rick Ross Talks To Mr Incognito About New Album "Mastermind"
Rick Ross stopped through Friday at the CBS Studios at the Epicenter during the Big Tournament Game Weekend with Mr Incognito to talk about his upcoming sixth studio album "Mastermind" in stores and online on March 4th.
Rick Ross also talks about working with P Diddy, future projects, Wing-Stop and his events going on that weekend.
Rick Ross also let us premiere some of his songs of the new album "Mastermind"
When having the album 80% done, Rick Ross brought it to Diddy to listen and get his input on this LP in comparison to what the media mogul did in the mid-1990s.
"I just took a collective of all my albums, all my experiences, all my moves, all the plays, and all the energy and put it into this one right here," says Ross.
"Coming from the bottom and…Miami, you know grinding all the way up to be one of the biggest entities in the culture…I just put it all on one plante."
Rick Ross also mentioned how he patched up his relationship with Jeezy with just a simple run in with the SC rapper.
"We did it for the South," says Rick Ross, who doesn't have a problem burying the beef since it wasn't money or shared blood related.
"It's an example for the young dudes who are trying to make the real money."
Get A Preview Of "Thug Cry" featuring Lil Wayne Here:
What do you think of the album? Are you going to purchase it?


text:
76 -> 89
still waiting for the representative fat-person's perspective…
#89 Most fat people haven't been able to see their own perspective in years.
I would say she's an attention whore, but I would have to agree with one of the earlier comments, she probably hasn't been laid in years. I don't think she would even know what a cock was if it slapped her in the face, shoved itself down her throat, and gave her the ol' Mikimoto necklace… I'd be happy to try to remind her, as soon as I put down my copy of Fat Celebrity Wanna Sluts…
did they keep trying to roll your friend back in the ocean??
#89, sounds like the skinny-person perspective is about right. I like to eat shit that's not good for me, don't exercise and like my beer.
That's probably why I'm 5'3″ tall and weigh 423 pounds.
Wait, I was channeling Britney there for a minute, that's not me at all.
Dr. Rokter,
well is anyone able to see it?
(if it's unseen, how do we know it exists?)
because they run out of breath from typing so much!!!
I'm not the biggest Mariah fan, but she is looking good these days, at least her outfit covers everything (even if it is skin tight). And man, that sure is a cute pup! Anyone who likes Jack Russell Terriers is aces in my book!
Has anyone else noticed that it looks like she is almost always wearing the same outfit, but in a different color? I guess its because it is the only outfit that (semi) fits her so she just dyes it a different color everyday.. huh.
They tried for a while, but she was tenaciously clinging to the Hot Dog on a Stick stand, so they just rolled her over to the workout area, and used her as a trampoline.
Wow, she looks really dumb in these pictures…she can barely walk, not because of the shoes, but she's sucking in her gut so hard…ahhh those powerful lungs of her not only work so well for singing but for the sucking in of gut!
Ok, I'm sorry guys, Mariah is hot. Anyone see the video with Snoop and Pharrell? Very MILF-ish indeed.
# 7
You are so right, I loved her back then, when she wore clothes and had brain cells. Now she's just a dumb, poorly dressed tramp.
Is it just me or on some level doesn't this seem worse than how Britney dresses b/c she's trying so hard?
i heard Mariah's on a seafood diet
when she sees food, she eats it *POW*
(yes, I went there)
She just looks like a lame banana.
115–noooooooooooooooooooooooooooo (but cute one!)
Dear Ms. Carey,
Choke on a ham sandwich already.
'Fish Readers
#106 Hmmm?
The thing I'll never forgive Mariah for is once, during the last Thanksgiving my grandmother was alive for, she kicked down the front door of our house and started grabbing things off people's plates, lolling her thick, pink tongue in the gravy boat, and mashing her chubby fingers in all the relish and pickle dishes and licking them off. She ate all the potatoes, squash, stuffing, napkins, and two of my cousins. Bitch.
She is an idiot. Everyone of those pictures makes me think of Brian Griffin doing "Peanut Butter Jelly Time". A fat, UGLY Brian.
the pictures made me think of chris farley in tommy boy. everyone sing along, "fat girl in a little dress, fat girl in a little dress."
Man, her forehead looks like the Elephant Man, minus the humps, how old is she now?, like 40? Time to quit dressing like a junior Mariah, imagine what she looks like before they do all that lighting manipulation and stuff for her nearly naked ass in her videos, poor video crew!
#115 – Hit the nail on the head – BONUS!!
She is a 5'9″ BLIMP – bragging how she wears a size 4. In her dreams. She probably has her staff cut off the size 18 tags in her clothes and replace them with size 4 tags.
Wrap her up in foil and write GOODYEAR on her side…..B L I M P
# 80, I was totally thinking the same thing! Better an overly dressed for the occasion, tranny hooker outfit and combed hair than a trailer park pajama bottomed, bra hanging out, barefoot, white trash, cheeto eating, cigarette smoking, knocked up, bedheaded, wigger lovin bitch.
# 115, that was HILarious!
Papa, as always, hats off to you! And that's not an asshat by the way.
you know Mariah has tons of money, yet she dresses like her clothes are from some cheap-ass mall store. But as far as amazon- voluptous chic goes, she's nailed it. horse face is unfortunate. hell of a lot of talent. what a mixed-bag of compliments.
Is it true that fat women have a really hard time dispelling the horrible odors that emit from their vagina because of the fatness and poor bathing/ grooming habits?
MeganHarris, answer yes or no.
Dr. Rokter, the thanksgiving day kerfaffle is making me laugh out loud at my desk in my very quiet office. thanks — between that one and the Southie Irish pipe-fitters beating K-Fed and the Bahston Tahk yesterday the people in my office think I'm a lunatic.
I wonder what kind of space age super fabric they used to make this dress, because that motherfucker looks to be under alot of pressure.
Mariah Carey is fucking clown shoes.
My coworker's sister-in-law used to be a OB-GYN nurse, and before the doctor would see obese women, he'd make them get in there and scrub them down. He'd refuse to get near them because they had so much funk stuck in their folds. She said she'd have to heft the fat apart, just to be able to wash them. And after one particularly smelly patient, they didn't use the room for several days, it stank so bad. So to answer the question, yes, I do think it's true they stink nonstop.
What is this 'walking the dog' shit. She's outside posing. I see no walking happening. None.
Hey guys, lay off the poor stinky fat ladies for a while. Guys (fat or not) can have some stank on them too! BARF!
128 – Thanks for the fun facts. I am now going to shoot myself in the head because of your descriptive and elloquent imagery.
On second thought, let's just shoot all the fat women in the head. Shooting really hot chicks such as myself with vaginas that are clean as a whistle and taste like grape soda isn't going to solve anything.
Does anyone else notice how effing big her forehead is??? What the hell? You could sign aliens by shining light of that thing!
Mariah really needs to stop pretending she's 17. Nobody's buying it but 36-year-old mariah Carey.
Fire her pr person. This stunt makes her look deranged and stupid.
caption to first photo: I'm ready for my scene now.
She's such a screw up. Talent + excess = beached whale.
Who knew whales and dogs could be such pals.
#125 Why thank you. Don't fear laughter. One should never let the straights in one's office dictate how you act. Because that shit is for sissies and girls. And Communists, and fat people, and pederasts, freedom-haters and "malfeasers" (whatever they are), the starting lineup of the New York Yankees, people who watch children's DVDs about religious vegetables, and anyone who uses "ur" instead of "your" or "you're".
At least when her dog takes a shit Mariah will have a nice light snack to keep her strength up.
My cousin was sexually molested by her father from the age of 2 to 10 and suffered from bulemia and anorexia until around the age of 16 she got tired of guys pawing at her and bringing back bad memories. So she ate herself to about a size 16 until she met her now hubby and felt comfortable enough to lose the weight. She's now a size 0 if that. So its not always because someone just likes to sit around and eat too much.
True, but it usually is. I'd say about 99% of obese people are that way because they eat too much, and don't excercise. And if they're doing it because of emotional problems,they still need to eat too much to get that fat, don't they? So many of these people could be thin, if they really wanted to, just like your cousin.
I don't particularly consider Mariah fat, but I do consider her sluttish. You don't have to dress like an aging Skid Row whore to take your dog to pee.
Jesus, that's a little too much info.
120 & 133
Her forehead IS huge. And her hairdo in those pictures probably makes it look even bigger. It's really disturbing.
She isn't fat, but she's always wearing something slutty, which is horribly unattractive.
Also, by the way she's holding that leash, that's probably the first time she's ever walked a dog.
PS. 138, I hope your cousin's father rots away in prison and gets molested by all the other inmates.
Hey girl, yep, you probably have to be eating almost constantly to become obese. Although I hardly saw my cousin eating, I think she waited until she was alone. Now, she just doesn't eat at all. She's like, Oh my God, I ate so much today. When I know she had no breakfast, no lunch, and a salad made of carrots and lettuce for dinner, that granted took up the whole plate, but probably was about 50 calories max. Well anyway enough of that, give me some of your goddamn chocolate. I feel emotionally distressed. I'm a size 7/8 which makes me terribly obese compared to everyone else in here.
Sorry Papa, I'm in a ranting mood today, but I'll feel better after I roll me a big fatty.
142, nope the bastard never did time
gotta love pic #1 where she is trying her hardest to look like she's a diva and at the same time trying her hardest to suck in her tummy and stick out her titts and has anyone one noticed that she really hasnt made it any further than doors wow what a work out mariah the poor dog gets to go for a five foot walk now when she calls hey pooch lets go for a walk he has to wait for 5 hours so his owner can get all skanked out for his 2 second walk i cant wait till he decides enough is enough and eats her in her sleep now that will be a story
she looks like a tall midget
Ha, you and me both. I could never starve myself, I like food too much. I'd be miserable.
I think 146 might be on speed. Just a hunch.
Damn. :( People like that don't deserve to live.
#142: Mariah isn't fat? Are you blind??? She is grossly obese. What is weird is that she STILL looks disgustingly fat and retarded EVEN AFTER the liposuction. Trust me, she's had lipo. People of her "girth" tend not to have that "muscle line/indentation" on the outside of one's upper thigh. Also, it is evident that she had the fat sucked out of her arms too. I'm just curious why she didn't get the rest of the fat sucked out of her when she got all that work done.
I swear, every time I see a picture of Mariah, she gets fatter and fatter and whorier and whorier and stupider by the second.


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Panasonic Mobile Communications Co., Ltd. announced that it has begun shipments of its P903iX High-Speed mobile phones to NTT DoCoMo, Inc.The P903iX High-Speed is compatible with Foma High-Speed to let the user access high-speed packet communications with receiving speeds of up to 3.6 Mbps in Foma High-Speed areas. The P903iX is also equipped with Windows Media Player as well as a Full Browser and the user can access Windows Media® Video contents on the Internet.The handset is compatible with DoCoMo's new Music ChannelTM service and the user can automatically download music programs of about up to one hour during the late-night hours for listening later. The handset also makes it possible to play entire tunes downloaded with Chaku-Uta Full and SD-Audio seamlessly on the same play list with a multi-function music player.The P903iX enables the user to play SD-Audio up to 75 hours and Chaku-Uta Full up to 70 hours with stereo headphones. The P903iX is compatible with 10MB i-motion and the user can download and watch high resolution video clips from i-mode sites.The handset is also compatible with Bluetooth to let the user access music or receive a phone call when it rings wirelessly, using Bluetooth-enabled wireless headphone (sold separately).
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Terror in America's Schools
The need to prepare first responders to defend our nation's children
America is a nation at war. That's a reality, not political rhetoric. And some of the battles in that war are going to be fought on American soil—in our communities, among our homes and loved ones. Our enemy has promised us that some of those battles will be fought in our schools as our children are captured, tortured and even killed.
Terror in America's Schools 1
A Columbine High School student is rescued by Lakewood Police Department SWAT team leader, Donn Kraemer, during the shooting spree in Littleton, Colo. Many school administrators didn't realize that Kleibold and Harris brought more than 90 explosive devices to the school; had they been successful in detonating them, the incident would have been much worse. (Photos AP/KCNC-TV Denver/ STOCK Photo Jim Jurica)
Terror in America's Schools 2
During the Beslan siege, soldiers, medics and even townspeople joined in the rescue effort, which quickly overwhelmed available forces. (Photo AP /Ivan Sekretarav)
Terror in America's Schools 3
Aida Sidikova, a girl held hostage during the Beslan school siege escapes momentarily, only to return to the school in confusion. Terrorists ultimately killed more than 300 hostages. (Photo Courtesy John Giduck)
Terror in America's Schools 4
In the new era of terrorism, EMS personnel must be trained in combat tactics, and police must be trained in superior first aid. Such situations can produce high numbers of casualties among citizens and police, quickly overwhelming tactical medics. At Virginia Tech?s Norris Hall, two tactical medics would have had to treat 55 people if the police had not been sufficiently trained to assist in providing trauma care. (Photo AP / The Roanoke times, Alan Kim)
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AirTalk for May 6, 2011
Bipartisan budget talks sidestep Medicare and taxes
Saul Loeb/AFP/Getty Images
US Vice President Joe Biden (2nd R) speaks during a meeting of bipartisan members of Congress to begin work on a legislative framework for comprehensive deficit reduction at Blair House, across the street from the White House in Washington, DC, on May 5, 2011. US Representative Eric Cantor listens.
Vice President Joe Biden and top congressional budget negotiators met Thursday, hoping to bridge the wide partisan divide over taxes and spending. Seeking to reduce a $1.4 trillion budget deficit, Democrats and Republicans agreed to focus first on areas of potential compromise, side-stepping raising taxes and the divisive proposal to revamp Medicare. President Obama has said he hopes the talks will lead to an agreement by June, before the federal government hits its debt ceiling. But finding common ground on a deficit reduction strategy will be a struggle. Democrats have criticized House Republicans for passing a fiscal year 2012 budget that Dems claim would weaken Medicare. The GOP meanwhile has blasted President Obama's fiscal blueprint for not cutting enough. If Medicare and taxes are off the table – what should we cut? Why have Republicans backed off calls to overhaul Medicare? Should lawmakers raise the country's $14.3 trillion debt ceiling?
Gail Russell Chaddock, Congressional Correspondent, Christian Science Monitor


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Noll, which fell one short of volleyball state title, pleased with season
BY RYAN HASKELL Post-Tribune correspondent November 10, 2013 10:18PM
Bishop Noll's Asya Hobbs and Carissa Jones block a shot by Providence's Taylor Wilson at Worthen Arena in Muncie, IN on November 9, 2013. | Jim Karczewski\Sun-Times Media
Updated: December 12, 2013 6:30AM
MUNCIE — Bishop Noll ran out onto the Worthen Arena floor at Ball State University for the Class 2A volleyball state championship wearing navy T-shirts that read, on the back, "Uno Mas."
It had been the team's rallying cry since beating North Judson in the regional championship match and had inspired them in the semistate round when the Warriors defeated Madison-Grant (3-0) and Woodlan (3-2) for the school's first semistate crown.
Team members would raise their index finger and indicate "one more" point was needed to finish the game.
But they were never able to do it at the state championship match against state-ranked No. 1 Providence.
The Warriors fell behind in each game and had just one small lead (3-1) in Game 3 as the Pioneers avenged their loss in the state championship against Wapahani in 2012 to beat the Warriors, 25-18, 25-15, 25-20, on Saturday afternoon.
Seniors Asya Hobbs (who finished the season with a school record 271 blocks) and Carissa Jones (who finished the season with 236 kills and 237 digs) came up with the slogan in the summer when they saw the Gatorade commercial glorifying the expression.
But neither of them ever thought it would take them to the school's first-ever state championship match.
"It was disappointing to lose but it was still good to make it this far," Jones said. "This was a great experience overall. Making it here was like, 'Wow!' And though we didn't win, I'm still glad this was my last game as a senior."
Jones and Hobbs had the hardest time matching up with Providence outside hitters Haley Libs (11 kills) and Taylor Wilson (14 kills). The Pioneers defense was also stellar digging up 48 balls and recording 16 blocks compared to Noll's six.
"They were pretty big but our blocking was off," Jones said. "And our defense wasn't able to get into the right position.
"They were very tough on offense, too. I couldn't find a spot to tip to and if I tipped they were there already; it was like they were one step ahead of us the whole time. They were very good on their toes."
Junior Carly Cappello, who had played in three national championship matches with club, was disappointed the team didn't win the ultimate prize, but it wasn't for lack of effort. She tied a match-high with 14 kills and contributed a team-high 13 digs.
"She definitely was the key player at key times for us," Jones said of Cappello. "She kept us in it and did it at the right times for us."
Coach Dave Rodriguez vows that Bishop Noll will be back in the state championship match next year.
"This was an unknown to us," he said. "Now we know what we need to do and what to work on and we have to step it up even more next year.
"We made notes that we need to work on. Every loss from this year we took something from it whether it was tip coverage or attacking the gaps and we made quick adjustments."
He will miss Hobbs and Jones who helped make the Warriors who they were this year, though.
"Besides their numbers, which are astronomical and they both predominately play all the way around, they're both inspirational leaders," Rodriguez said. "They lead in two different ways. Asya is a quiet, follow-my-lead type of player and CJ is vocal, passionate; she always talks to the team and gives the little things. It's what they do off the court with this team that's going to be missed."


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by Mike
The health care system of the United States, as of 2007, costs $2.4 trillion or 17% of the GDP. So why is it so many seem to go without so much?
For health care reform advocates, that is those who support a government run plan, this number of 46 million uninsured has become a rallying cry for their cause. For those against a government sponsored option, the 46 million has been broken down into subsets-and called propaganda-which greatly decreases the number of Americans who cannot readily afford health care or insurance.
This is going to be an honest attempt at presenting the numbers in a very simple way which might shed a little light on both claims to see where the truth lay.
Those against a government option claim that a larger percentage of people not possessing health care are younger Americans who chose not to purchase it, but can afford it, because they view themselves as healthy enough not to need it or feel it gets in the way of purchasing other items they view as necessities. The other argument often cited is that of millions of illegal immigrants are being counted within the number of uninsured.
Let's start off with a recent American Spectator article which states,
In 2007, 17.6 million of the uninsured had annual incomes of more than $50,000 and 9.1 million earned more than $75,000.
Factually this is true as a whole. However once you look at the the data in the Census Bureau's 2007 report on the uninsured and dig, you see a little bit of a different picture.
From the Census Bureau, "Income, Poverty, and Health Insurance Coverage in the United States: 2007."
The 18-24 year old demographic represents 7,991,000 of the uninsured and the 25-34 year old group comprises the other 10,329,000 of the 17.9 million they are citing. (Page 30 of 84) But the claim that the average yearly incomes of these two groups is $50,000, is not backed up by the Bureau report.
What is is the median income of these two groups represented as a whole averages $31,790/year for the 15-24 group and $51,016/year for the 25-34 group. (Page 15 of 84)
Looking further you see the income to poverty ratio of these two demographics is surprisingly high. (The poverty to income ratio of is the representation of person(s) below, at, or slightly above the poverty line.)
The 18-24 sits at 6,306,000 below, at, or slightly above the poverty line. The 25-34 demographic is 6,704,000 below, at, or slightly above. (Page 24 of 84) So, the total number of people within these two demographics who more than likely cannot afford health insurance is 13,010,000. Keeping in mind that the number of uninsured within these two demographics sits at approximately 18,320,000. By taking the difference of these numbers it leaves you with a deficit of 5,310,000 between those we know cannot afford health care and those who possibly can afford it.
It seems on this point there might be something to consider to the Spectator's point. However, their numbers are obviously exaggerated.
The non-citizen uninsured claim is far easier to confirm. The Spectator states that,
Just a quick look inside the Census Bureau data shows that 9.7 million of the uninsured are not citizens of the United States.
The Census Bureau actually confirms this number on page 30 of 84. According to their 2007 study, 9,737,000 are non-citizens of the United States.
So what we are left with by this amateurish look at the Census data is the advocate claim of 46 million uninsured reduced by 15,047,000. Leaving us with 30,953,000 Americans who apparently cannot afford health care insurance.
The final claim AmSpec makes is that,
When all these factors are put together, the 2003 BlueCross BlueShield study determined that 8.2 million Americans are actually without coverage for the long haul, because they are too poor to purchase health care but earn too much to qualify for government assistance.
So their number is 8.2 million. I have to respectfully disagree.
On a side bar, you will notice an item of interest on page 30 of 84 the greatest percentage of the uninsured come form median income groups ranging from $25,000 to $75,000 and above. Out of the "46 million persons uninsured," the combination of all of these median income groups is 32,118,000 people. This leaves 13,539,000 who make under $25,000/year, making up the rest of the uninsured.
By my highly untrained and dull mind, the number of Americans who cannot afford health care apparently sits somewhere between 13.5 million and 30.9 million. As a percentage of the population this is anywhere from about 4.5% to a little over 10%.
Now you can do with these numbers what you like. This is just the data extrapolated from the Bureau, how you want to interpret it or form your opinion is solely up to you.


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» News
Pelosi Admits They Have a Photoshopping Staff on Hand in DC
How tough is it to make a birth certificate?
» 3 Comments
And a damned talented bunch they are, too!
Wait until another Administration organization removes citizens from the American picture.+6
You know what else was so obviously photoshopped was the 'war room' picture of Obama during the OBL raid. That thing was so poorly put together it made you wonder what kid they took out of 7th grade PC class to make it! Really horrible job.. Kinda like the BC!+6
Pelosi needs to hire a new bunch with better skills. Her photos are still sickening or scary as hell at best.+1


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Inshore and nearshore speices, these fish are found around natural and artificial reefs; especially near navigation markers in 15 to 20 feet of water.
Atlantic spadefish spawn in the spring and summer and travels in large schools. Small juveniles are almost totally black and are known to drift on their sides and mimic floating debris. These fish feed on crustaceans, small encrusting invertebrates, and may nibble on tentacles of jellyfish.
This species is not currently eligible for a state record.
Though there are no close resemblances, these fish are frequently and mistakenly called angelfish.
Image Credit: © Diane Rome Peebles
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Thinking about taking off my cork and applying some Pebble Tape, maybe thinking about using shrink wrapping also, what are the pro's and cons of each?
post #1 of 15
4/16/08 at 12:27pm
Thread Starter
SWJ, watch out- do not call it a 3m tape or he will PM you and laugh at your face because you don't know the slang. he said all the builders in new jersey will laugh in your face for calling it 3m.
his aka is surfcaster34, which he will use to PM you.
I think you guys are talking about 2 different products. The 'pebble' tape is NOT like sand paper or skateboard grip tape. It is bumpy vinyl or whatever, but not sandy. Don't see any reason to use the sand paper stuff on a rod handle. Unless you haven't learned to wipe the broofish slime on your waders just above your boots!!


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Hello all well i just created this account because i lost my password to my email for my other account.I went by the screen name Purple pancakes and 1sparrow.My real name is Abraham Gomez but everyone calls me Andy germ so i guess it just stuck.
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Disclosures: Wendy Kuohung, MD Nothing to disclose. Mark D Hornstein, MD Consultant/Advisory Board: WINFertility [Infertility, endometriosis]. Robert L Barbieri, MD Nothing to disclose. Deborah Levine, MD Nothing to disclose. Kristen Eckler, MD, FACOG Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
INTRODUCTION — An infertility evaluation is usually initiated after one year of regular unprotected intercourse in women under age 35 years and after six months of unprotected intercourse in women age 35 years and older. However, the evaluation may be initiated sooner in women with irregular menstrual cycles or known risk factors for infertility, such as endometriosis, a history of pelvic inflammatory disease, or reproductive tract malformations.
The basic evaluation can be performed by an interested and experienced primary care physician or an obstetrician-gynecologist. The primary care physician generally should refer the patient to a specialist for treatment of infertility. Many gynecologists initiate treatment prior to referral to a reproductive endocrinologist. This decision depends upon the results of infertility tests and clinician experience.
Multiple tests have been proposed for evaluation of female infertility. Some of these tests are supported by good evidence, while others are not. This topic will provide an evidence-based approach to the evaluation of female infertility. The etiology and treatment of female infertility, as well as the etiology, evaluation, and treatment of male infertility, are discussed separately.
●(See "Overview of infertility".)
●(See "Causes of female infertility".)
●(See "Overview of treatment of female infertility".)
●(See "Causes of male infertility".)
●(See "Evaluation of male infertility".)
●(See "Treatment of male infertility".)
INITIAL APPROACH — Both partners of an infertile couple should be evaluated for factors that could be impairing fertility. The infertility specialist then uses this information to counsel the couple about the possible etiologies of their infertility and to offer a treatment plan targeted to their specific needs.
It is important to remember that the couple may have multiple factors contributing to their infertility; therefore, a complete initial diagnostic evaluation should be performed to detect the most common causes of infertility, if present. When applicable, evaluation of both partners is performed concurrently [1].
The recognition, evaluation, and treatment of infertility are stressful for most couples [2]. The clinician should not ignore the couple's emotional state, which may include depression, anger, anxiety, and marital discord. Information should be supportive and informative. (See "Psychological stress and infertility".)
History and physical examination — Findings on history and physical examination may suggest the cause of infertility and thus help focus the diagnostic evaluation. Components of the infertility history are listed in the table (table 1).
History — The most important points in the history are:
●Duration of infertility and results of previous evaluation and therapy.
●Menstrual history (cycle length and characteristics), which helps in determining ovulatory status. For example, regular monthly cycles with molimina (breast tenderness, ovulatory pain, bloating) suggest the patient is ovulatory and characteristics such as severe dysmenorrhea suggest endometriosis.
●Medical, surgical, and gynecological history (including sexually transmitted infections, pelvic inflammatory disease, and treatment of abnormal Pap smears) to look for conditions, procedures, or medications potentially associated with infertility. At a minimum, the review of systems should determine whether the patient has symptoms of thyroid disease, galactorrhea, hirsutism, pelvic or abdominal pain, dysmenorrhea, or dyspareunia. Young women who have undergone unilateral oophorectomy generally do not have reduced fertility since young women have many primordial follicles per ovary; however, prior unilateral oophorectomy may impact fertility in older women as they may develop diminished ovarian reserve sooner than women with two ovaries [3].
●Obstetrical history to assess for events potentially associated with subsequent infertility or adverse outcome in a future pregnancy.
●Sexual history, including sexual dysfunction and frequency of coitus. Infrequent or ineffective coitus can be an explanation for infertility.
●Family history, including family members with infertility, birth defects, genetic mutations, or mental retardation. Women with fragile X premutation may develop premature ovarian failure, while males may have learning problems, developmental delay, or autistic features.
●Personal and lifestyle history including age, occupation, exercise, stress, dieting/changes in weight, smoking, and alcohol use, all of which can affect fertility.
Physical examination — The physical examination should assess for signs of potential causes of infertility. The patient's body mass index (BMI) should be calculated and fat distribution noted, as extremes of BMI are associated with reduced fertility and abdominal obesity is associated with insulin resistance.
Incomplete development of secondary sexual characteristics is a sign of hypogonadotropic hypogonadism. A body habitus that is short and stocky, with a squarely shaped chest, suggests Turner syndrome.
Abnormalities of the thyroid gland, galactorrhea, or signs of androgen excess (hirsutism, acne, male pattern baldness, virilization) suggest the presence of an endocrinopathy (eg, hyper- or hypothyroidism, hyperprolactinemia, polycystic ovary syndrome, adrenal disorder).
Tenderness or masses in the adnexae or posterior cul-de-sac (pouch of Douglas) are consistent with chronic pelvic inflammatory disease or endometriosis. Palpable tender nodules in the posterior cul-de-sac, uterosacral ligaments, or rectovaginal septum are additional signs of endometriosis.
Vaginal/cervical structural abnormalities or discharge suggest the presence of a müllerian anomaly, infection, or cervical factor.
Uterine enlargement, irregularity, or lack of mobility are signs of a uterine anomaly, leiomyoma, endometriosis, or pelvic adhesive disease.
These conditions are described in detail separately:
●(See "Pathogenesis, clinical features, and diagnosis of endometriosis".)
●(See "Clinical features and diagnosis of pelvic inflammatory disease".)
●(See "Clinical manifestations and diagnosis of congenital anomalies of the uterus".)
●(See "Clinical manifestations and evaluation of hyperprolactinemia".)
●(See "Diagnosis of and screening for hypothyroidism in nonpregnant adults".)
●(See "Diagnosis of hyperthyroidism".)
●(See "Clinical manifestations of polycystic ovary syndrome in adults".)
●(See "Clinical manifestations and diagnosis of Turner syndrome (gonadal dysgenesis)".)
●(See "Epidemiology, clinical manifestations, diagnosis, and natural history of uterine leiomyomas (fibroids)".)
Diagnostic tests — In addition to the history and physical examination, the initial diagnostic evaluation consists of:
●Semen analysis to detect male factor infertility.
●Documentation of normal ovulatory function. Women with regular menses approximately every four weeks with moliminal symptoms are almost always ovulatory.
●A test to rule out tubal occlusion. We usually perform a hysterosalpingogram (HSG), but laparoscopy with chromotubation may be more appropriate in women suspected of having endometriosis. Indigo carmine can be used for the chromotubation dye. (See 'Role of laparoscopy' below.)
Risk factors noted from the couple's history may indicate the need for additional testing after the initial infertility evaluation.
Preconceptional laboratory screening may also be undertaken at this time so these results can be used for diagnostic and therapeutic counseling. Genetic screening should be offered in accordance with risk as defined by ethnicity. The components of preconception evaluation and counseling are discussed separately. (See "The preconception office visit", section on 'Laboratory assessment'.)
Semen analysis — The semen analysis is the cornerstone of the assessment of the male partner of an infertile couple. In addition to the standard analysis, specialized analyses can be performed in some laboratories. The semen sample should be collected after two to seven days of abstinence and should be submitted to the laboratory within one hour of collection [4].
It is difficult to predict the likelihood of pregnancy based upon the results of semen analysis alone, as there is extensive overlap between the semen parameters of fertile and infertile men. If the semen analysis is abnormal, the clinician should review details of specimen collection and transport with the patient, repeat the test due to the marked inherent variability of semen analyses, and consider referral to a urologist or other specialist in male reproduction.
The techniques for semen analysis and interpretation of results are discussed in detail separately. (See "Evaluation of male infertility", section on 'Standard semen analysis'.)
Assessment of ovulatory function — Assessment of ovulatory function is a key component of the evaluation of the female partner since ovulatory dysfunction is a common cause of infertility. The treatment of women with ovulatory dysfunction is aimed at improving or inducing ovulatory function; a variety of treatment strategies is available. (See "Overview of treatment of female infertility".)
In women who do not have grossly abnormal menstrual cycles indicative of ovulatory dysfunction, laboratory assessment of ovulation should be performed. Ovulation is most easily documented by a mid-luteal phase serum progesterone level, which should be obtained approximately one week before the expected menses. For a typical 28-day cycle, the test would be obtained on day 21. A progesterone level >3 ng/mL is evidence of recent ovulation [5].
An alternative is to have the patient use an over-the-counter urinary ovulation prediction kit. These kits detect luteinizing hormone (LH) and are highly effective for predicting the timing of the LH surge that reliably indicates ovulation. Home kits have a 5 to 10 percent false positive and false negative rate. Therefore, serum confirmation can be useful in patients who are unable to detect a urinary LH surge.
Other methods of determining ovulation, such as daily ultrasounds to follow the development and ultimately the disappearance of a follicle (the most accurate method of documenting ovulation [6]) and endometrial biopsy to document secretory changes in the endometrium are too expensive or invasive for routine diagnostic assessment of ovulation.
If the progesterone concentration is <3 ng/mL, the patient is evaluated for causes of anovulation. The minimal work-up includes serum prolactin, thyrotropin (TSH), follicle-stimulating hormone (FSH), and assessment for polycystic ovary syndrome (PCOS). The etiology and diagnostic evaluation of anovulation are reviewed separately. (See "Etiology, diagnosis, and treatment of secondary amenorrhea".)
Assessment of ovarian reserve — Diminished ovarian reserve can refer to diminished oocyte quality, oocyte quantity, or reproductive potential. The identification of diminished ovarian reserve is an increasingly important component of the initial infertility evaluation as patients are presenting for diagnostic evaluation later in their reproductive lifespan [7]. However, there is no ideal test for assessing ovarian reserve. A number of screening tests are utilized, but no single test is highly reliable for predicting pregnancy potential. Therefore, coordination of tests provides the best assessment.
For women over 35 years of age and younger women with risk factors for premature ovarian failure, we suggest testing ovarian reserve with a day 3 FSH level. Other tests such as the clomiphene citrate challenge test (CCCT), antral follicle count, and anti-müllerian hormone (AMH) level are utilized by some specialists and in special circumstances. These tests have good specificity for predicting a poor response in in vitro fertilization (IVF) cycles, but have more limited value for predicting IVF outcome.
Day 3 FSH and CCCT — Both the day 3 FSH level (where day 1 is the first day of full menstrual flow) and the CCCT, which is a provocative test for measurement of FSH, are widely used for screening ovarian reserve. The CCCT involves oral administration of 100 mg clomiphene citrate on cycle days 5 through 9 with measurement of day 3 and day 10 FSH levels and day 3 estradiol level.
The basis of these tests is that women with good ovarian reserve have sufficient production of ovarian hormones from small follicles early in the menstrual cycle to maintain FSH at a low level. In contrast, women with a reduced pool of follicles and oocytes have insufficient production of ovarian hormones to provide normal inhibition of pituitary secretion of FSH, so FSH rises early in the cycle [8].
Meta-analyses of nonrandomized studies concluded that basal cycle day 3 FSH and the CCCT testing perform similarly for predicting ability to achieve a clinical pregnancy in women undergoing infertility treatment [9,10]. With either test, a normal result is not useful in predicting fertility, but a highly abnormal result (we use FSH >20 mIU/mL) suggests that pregnancy will not occur with treatment involving the woman's own oocytes.
Based on these findings and the cost advantage and simplicity of the day 3 FSH, we obtain a day 3 FSH concentration and consider a value less than 10 mIU/mL suggestive of adequate ovarian reserve, and levels of 10 to 15 mIU/ml borderline. The upper threshold for a normal FSH concentration is laboratory dependent; cutoff values of 10 to 25 mIU/mL have been reported because of use of different FSH assay reference standards and assay methodologies.
We also check a cycle day 3 estradiol level, although there are conflicting data as to whether it is predictive of ovarian reserve and the response to ovarian stimulation (as in IVF) [11,12]. We consider a value <80 pg/mL suggestive of adequate ovarian reserve, but other cut-offs are also utilized. In one prospective study of women undergoing IVF, day 3 estradiol levels >80 pg/mL resulted in higher cycle cancellation rates and lower pregnancy rates, and estradiol levels >100 pg/mL were associated with a 0 percent pregnancy rate [13].
Elevated basal estradiol levels are due to advanced premature follicle recruitment that occurs in women with poor ovarian reserve. High estradiol levels can inhibit pituitary FSH production and thus mask one of the signs of decreased ovarian reserve in perimenopausal women. Thus, measurement of both FSH and estradiol levels helps to avoid false-negative FSH testing.
If CCCT is performed, we consider FSH less than 15 mIU/mL on both day 3 and day 10 suggestive of adequate ovarian reserve; an elevated FSH level on either day 3 or day 10 suggests decreased ovarian reserve. Estradiol can be measured on day 3, but a cycle day 10 estradiol is not part of the standard CCCT as it reflects the magnitude of the ovarian follicular response to clomiphene 100 mg daily for five days, not ovarian reserve.
If the day 3 FSH or CCCT is abnormal, the patient should be referred to a reproductive endocrinologist to discuss further diagnostic and treatment options. These options depend on the results of other diagnostic tests, the patient's age [14], and other factors and may include aggressive ovulation induction, IVF, or use of donor oocytes. However, patients with markedly diminished ovarian reserve rarely conceive without the use of donor eggs.
Antral follicle count (AFC) — Ultrasound examination can be used to determine the number of antral follicles (defined as follicles measuring 2 to 10 mm in diameter). On transvaginal ultrasound, the ovaries are visualized in their transverse and longitudinal planes and the antral follicles are counted and measured; the size of the follicle is the mean of two perpendicular diameters, one of which should be the largest dimension of each follicle [15,16]. A low AFC ranging from 4 to 10 antral follicles between days two and four of a regular menstrual cycle suggests poor ovarian reserve. AFC thresholds will vary by center and should be prospectively tested within a center to be most useful as a predictive tool [17-20]. Most clinicians perform an AFC during the early follicular phase, although a retrospective cohort study showed no difference in the predictive value of AFC for poor ovarian response when measured at different phases of the menstrual cycle [21]. Although AFC is a good predictor of ovarian reserve and response, it is less predictive of oocyte quality, the ability to conceive with IVF, and pregnancy outcome [22].
Anti-müllerian hormone (AMH) — Anti-müllerian hormone (AMH) is a member of the TGF-beta family and is expressed by the small (<8 mm) preantral and early antral follicles. The AMH level reflects the size of the primordial follicle pool, and may be the best biochemical marker of ovarian function across an array of clinical situations [23]. In adult women, AMH levels gradually decline as the primordial follicle pool declines with age [24]; AMH is undetectable at menopause [25].
The AMH level appears to be an early, reliable, direct indicator of declining ovarian function. It may play an especially useful role in identifying reduced ovarian follicle pool in certain types of patients, such as cancer patients [26] and patients who have had significant ovarian injury from radiation or surgery. In patients planning IVF, AMH level correlates with the number of oocytes retrieved after stimulation, and is the best biomarker for predicting poor and excessive ovarian response [11,27-29]. However, its diagnostic accuracy for predicting live birth is poor so it should not be used to exclude couples from IVF/ICSI [30].
There is no consensus on the threshold value suggestive of reduced fertility potential [11,25,26,31-35]. Interpretation of AMH levels is laboratory assay-dependent [36-38], there is no international standard; therefore, clinicians should be guided by their own laboratory's reference ranges. In general, a level well-above the laboratory's lower threshold for normal suggests adequate ovarian reserve. As the level falls below the lower limit of normal, the probability of diminished ovarian reserve progressively increases, with very low levels suggesting pregnancy is less likely to occur and the patient will have a poor response to IVF [11,31]. One review suggested the following general guidelines [39]:
●AMH <0.5 ng/mL predicts reduced ovarian reserve with less than three follicles in an IVF cycle
●AMH <1.0 ng/mL predicts baseline ovarian reserve with a likelihood of limited eggs at retrieval
●AMH >1.0 ng/mL but <3.5 ng/mL suggests a good response to stimulation
●AMH >3.5 ng/mL predicts a vigorous response to ovarian stimulation and caution should be exercised in order to avoid ovarian hyperstimulation syndrome
AMH can be measured anytime during the menstrual cycle and typically demonstrates minimal intercycle and intracycle variability since the growth of small preantral follicles that express it is continuous, not cyclical. Reliable AMH kits [40] are readily available from multiple vendors and AMH measurements can be obtained from large clinical reference laboratories [41,42]. AMH level is being used to manage patients in Europe [43].
Assessment of fallopian tube patency — We perform HSG as the first-line test for evaluation of tubal patency because of its therapeutic, as well as diagnostic, benefits [44]. Non- or minimally invasive alternatives to HSG for investigation of tubal subfertility include chlamydia antibody testing and/or hysterosalpingo-contrast sonography (HyCoSy) [45].
When the diagnosis is in doubt, more invasive tests can be used to confirm the diagnosis, and provide an opportunity for concurrent therapeutic intervention. These tests include laparoscopy with chromotubation and fluoroscopic/hysteroscopic selective tubal cannulation.
Hysterosalpingogram — We obtain a HSG to look for tubal occlusion in all patients, unless laparoscopy is planned [46,47]. Either water or lipid soluble contrast media can be used. HSG also provides information about the uterine cavity. Women with abnormalities on HSG should be referred to a reproductive endocrinologist to discuss treatment options. (See "Hysterosalpingography".)
HSG is not useful for detecting peritubal adhesions or endometriosis [46]. We perform diagnostic laparoscopy and chromotubation in women suspected of having endometriosis or pelvic adhesions related to a previous pelvic infection or surgery. Ablation of implants and lysis of adhesions, when indicated, can be performed at the same procedure (see 'Role of laparoscopy' below).
A meta-analysis of 20 studies involving 4179 patients compared HSG and laparoscopy with chromotubation (the gold standard); the calculated sensitivity and specificity for diagnosis of tubal patency were only 65 and 83 percent, respectively [46]. However, when subgroups of women undergoing HSG were analyzed, HSG appeared to have very high specificity and sensitivity for diagnosing distal tubal occlusion or major distal tubal adhesions, but much lower specificity for diagnosing proximal tubal occlusion.
Proximal tubal occlusion on HSG often represents testing artifact due to tubal spasm or poor catheter positioning leading to unilateral tubal perfusion. Given these deficiencies, findings of proximal tubal occlusion on HSG could be confirmed by a secondary test such as a repeat HSG, fluoroscopic or hysteroscopic selective tubal perfusion, or laparoscopic chromotubation if definitive diagnosis will influence further management.
Diagnostic HSG also appears to have therapeutic effects. A systematic review of 12 randomized trials found that pregnancy rates were significantly higher in subfertile women who underwent tubal flushing with oil soluble media than in those who did not undergo HSG (OR 3.30, 95% CI 2.00-5.43), and that pregnancy rates were similar whether oil or water soluble media were used (OR 1.21, 95%CI 0.95-1.54) [44].
Chlamydia antibodies — Chlamydia trachomatis IgG antibody testing is a simple, inexpensive, noninvasive test with some evidence supporting its use as a method for predicting the presence of tubal disease. Studies suggest that antibodies to chlamydia are more predictive of infertility than an abnormal HSG or a history of previous use of a copper IUD [48-53]. Multiple tests are available [54], but not widely utilized given only limited data supporting their use. A cost-effective approach might be to screen women at low risk of tubal disease with chlamydia antibodies. A negative test is associated with <15 percent likelihood of tubal pathology and thus does not require further assessment [55]. False positives are due to cross reactivity withC. pneumoniae, do not distinguish between remote and persistent infection, and do not indicate whether infection resulted in tubal damage [55]; therefore, an HSG is performed if the test results are positive [56]. Women at high risk of tubal disease would be screened by HSG primarily.
In a study correlating results of five chlamydia antibody tests to laparoscopy findings in 315 subfertile women, the diagnostic performance of micro-immunofluorescence testing was superior to ELISA testing [57]. However, there was significant cross-reactivity with C. pneumoniae antibodies for all tests except the pELISA Medac. Thus, positive test results from other modalities should be confirmed with this ELISA. In this study, a positive pELISA Medac had sensitivity and specificity of 55 and 87 percent, respectively, for tubal pathology at laparoscopy.
Chlamydia antibody testing can be used to screen women with an allergy to shellfish or iodinated contrast agents who cannot undergo an HSG. In women without risk factors for tubal disease, a negative test does not require further tubal assessment. If the test is positive, a sonohysterogram may be performed; presence of fluid in the cul-de-sac after intrauterine infusion of saline indicates patency of at least one tube.
Hysterosalpingo-contrast sonography — Hysterosalpingo-contrast sonography (HyCoSy) uses ultrasound to view the uterus, tubes, and adnexa before and after transcervical injection of echogenic contrast media. It is a safe, well tolerated, quick and easy method for obtaining information on tubal status, the uterine cavity, the ovaries, and the myometrium using conventional ultrasound [58]. In a 2014 systematic review of studies that compared HyCoSy with HSG for diagnosis of tubal occlusion in subfertile women, both tests had high diagnostic accuracy compared with laparoscopy (reference standard), with no significant difference between them. For HyCoSy, sensitivity was 0.92 (95% CI 0.82-0.96) and specificity was 0.95 (95% CI 0.90-0.97) per tube for diagnosing tubal occlusion. Tubal spasm and tubal fistula, as well as operator error could account for misdiagnoses.
Assessment of the uterine cavity — In addition to assessment of tubal patency, HSG may identify developmental or acquired abnormalities of the uterine cavity with potential effects on fertility, such as submucous fibroids, a T-shaped cavity (associated with DES exposure), polyps, synechiae, and congenital müllerian anomalies. An experienced ultrasonographer can usually distinguish between a uterine septum and a bicornuate uterus. Abnormalities found on HSG generally require further evaluation by other imaging modalities (ultrasonography or magnetic resonance imaging), hysteroscopy, or laparoscopy and referral to a reproductive endocrinologist.
Ultrasonography is a useful test for evaluation of suspected leiomyomata, while saline infusion sonohysterography is the best imaging modality for detection of submucosal leiomyomas and is much better than routine ultrasonography for diagnosis of intrauterine adhesions, polyps, and congenital uterine anomalies [59]. As discussed above, HyCoSy is a simple, time-efficient, and effective method for evaluation of tubal patency, the uterine cavity, and the myometrium [58].
Hysteroscopy is the definitive method for evaluation of abnormalities of the endometrial cavity, and also offers the opportunity for treatment at time of diagnosis. In patients undergoing laparoscopy, performing hysteroscopy at the same time and omitting HSG is efficient.
Evaluation of uterine anomalies depends on the anomaly.
●(See "Overview of hysteroscopy".)
●(See "Saline infusion sonohysterography".)
●(See "Clinical manifestations and diagnosis of congenital anomalies of the uterus".)
●(See "Hysteroscopic myomectomy".)
●(See "Intrauterine adhesions".)
ROLE OF LAPAROSCOPY — The role of laparoscopy in the evaluation of infertility is controversial. Laparoscopy is invasive and expensive. Findings at laparoscopy usually do not alter the initial treatment of the infertile couple when the initial infertility evaluation is normal or when it shows severe male factor infertility. Couples with a normal infertility evaluation (ie, unexplained infertility) typically undergo a trial of ovarian stimulation with or without intrauterine insemination and many will conceive without further intervention. Couples with tubal or male factor infertility are typically offered IVF as one of their treatment options. (See "Unexplained infertility" and "In vitro fertilization".)
No randomized trials have assessed the cost effectiveness and timing of diagnostic laparoscopy prior to ovulation induction in couples with unexplained infertility. Laparoscopy is indicated in women in whom endometriosis or pelvic adhesions/tubal disease is suspected based on physical examination, HSG, or history (eg, current dysmenorrhea, pelvic pain, or deep dyspareunia; previous complicated appendicitis, pelvic infection, pelvic surgery, or ectopic pregnancy) [60-62]. When we perform laparoscopy, we also perform chromotubation to assess tubal patency and hysteroscopy to evaluate the uterine cavity. For this reason, if laparoscopy is planned, then HSG can be omitted [63].
The advantage of performing laparoscopy early in the evaluation of women suspected of having endometriosis or pelvic adhesions is that surgical therapy can be initiated, while avoiding potentially ineffective or unnecessary empiric medical treatment for ovulation induction. Endometriosis, if identified, can be excised/ablated at the time of the diagnostic procedure and pelvic adhesions can be lysed. (See "Pathogenesis and treatment of infertility in women with endometriosis".)
The use of laparoscopy to treat infertility is covered in detail separately. (See "Reproductive surgery for female infertility".)
Postcoital test — In agreement with other experts [1,64], we do not recommend postcoital testing.
The postcoital test has poor diagnostic potential and predictive value [65,66] that is due, in part, to the lack of consensus on a normal versus abnormal test result and to low inter- and intraobserver reproducibility [67]. In addition, interventions designed to improve cervical factor infertility have not been effective, while widely used infertility therapies, such as intrauterine insemination and IVF bypass the cervix so improving cervical factors becomes irrelevant. Importantly, a randomized trial that compared the outcome of infertility investigations with and without the postcoital test showed no difference in pregnancy rates at 24 months [68]. Thus, incorporation of the postcoital test in standard infertility evaluations increases the number of tests and treatments, but has no effect on the pregnancy rate.
Endometrial biopsy — Endometrial biopsy has been performed for two reasons: (1) to document a secretory endometrium, which is indirect evidence that ovulation has occurred, and (2) to evaluate whether the maturity of the secretory endometrium is in phase (ie, consistent with menstrual cycle date) or out of phase (ie, luteal phase defect). It is not a good test for either indication because it is invasive, expensive, uncomfortable, unnecessary for evaluation of ovulation, and ineffective for assessment of endometrial receptivity (ie, the ability of the endometrium to allow the blastocyst to attach, invade, and implant).
As discussed above, ovulation is optimally assessed using serum progesterone level >3 ng/mL obtained in the late luteal phase (see 'Assessment of ovulatory function' above).
Although endometrial receptivity during the implantation window is crucial for achieving pregnancy, histological assessment of endometrial response has a poor correlation with fertility [69-73]. For example, when repeated endometrial biopsies are performed in normal fertile women, half will have a single out-of-phase biopsy (using two-day or greater lag criteria) and over one-quarter will have sequential out-of-phase biopsies [74,75]. Moreover, in one study of 619 women with regular menstrual cycles, a biopsy that was out-of-phase by greater than two days was actually more common in fertile women than in infertile women (at day 21 to 22: 49 versus 43 percent; at day 26 to 27: 35 versus 23 percent).
Thus, it appears that histological dating does not discriminate fertile from infertile couples [74,75]. As the treatment of luteal phase defect does not improve pregnancy outcome in infertile women, luteal phase evaluation by histological dating of the endometrium is not worthwhile.
The American Society of Reproductive Medicine (ASRM) affirmed the lack of benefit of the endometrial biopsy in the evaluation of the infertile female and does not recommend use of this test [1].
Endometrial biopsy is appropriate when endometrial pathology is strongly suspected.
Basal body temperature records — Basal body temperature charts are the least expensive method for detecting ovulation, but interpretation of the charts can be difficult and subject to wide interobserver variation [76,77]. We prefer serum testing for assessment of ovulatory status in women with irregular cycles (see 'Assessment of ovulatory function' above).
Progesterone released from the corpus luteum at the time of ovulation has potent effects on the hypothalamus, one of which is to increase body temperature. As a result, daily temperature monitoring can be used to document progesterone production and, therefore, ovulation. The woman takes her temperature by putting the thermometer under her tongue every morning while she is still in the basal state (ie, before she gets out of bed, uses the bathroom, or has anything to eat or drink) and records the temperature on a chart. Although there is an expected amount of daily variability, an approximately 0.5ºF rise in body temperature can be detected in the luteal phase of the menstrual cycle compared with the follicular phase. In a normal cycle, the temperature rise begins one or two days after the LH surge and persists for at least 10 days. Thus, temperature changes are sufficient to retrospectively identify ovulation, but they occur too late to be useful for timing intercourse.
Zona-free hamster oocyte penetration test — This test is also known as the sperm penetration assay. Conflicting literature exists on whether the hamster oocyte test predicts human oocyte fertilization [78,79]. The utility of test results depends, in part, on the experience of the laboratory performing the assay. We do not order this test since the results would not influence our clinical management. (See "Evaluation of male infertility", section on 'Zona-free hamster oocyte penetration test'.)
Mycoplasma cultures — We do not suggest obtaining routine Ureaplasma urealyticum and Mycoplasma hominis cultures given that there is minimal evidence for a role of these organisms in female infertility [80].
Testing for antibodies — Routine testing for antiphospholipid, antisperm, antinuclear, and antithyroid antibodies is not supported by existing data [81]. Although an association between antiphospholipid antibodies and recurrent pregnancy loss has been established, the other autoimmune factors remain under investigation as markers of fertility treatment failure. (See "Pregnancy in women with antiphospholipid syndrome".)
Karyotype — There is a general consensus to counsel and offer to karyotype the male partner if there is severe oligospermia, as these men are at higher risk of karyotypic abnormalities. Separate testing for Y chromosome microdeletions may also be offered. We suggest karyotyping women with very early premature menopause (prior to age 40) and both partners if there have been recurrent pregnancy losses. In most other circumstances, karyotyping is not indicated as part of the initial evaluation because of the low incidence of abnormalities in women with unexplained infertility, endometriosis, or tubal factor infertility [82]. Karyotype may be useful in patients with these conditions who have failed initial treatment approaches and plan to undergo IVF, although the cost-effectiveness of universal karyotype screening prior to IVF has not been established [83].
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient information: Infertility in women (The Basics)" and "Patient information: Infertility in couples (The Basics)")
●Beyond the Basics topics (see "Patient information: Ovulation induction with clomiphene (Beyond the Basics)" and "Patient information: Evaluation of the infertile couple (Beyond the Basics)")
●We suggest that an infertility evaluation be offered to couples who have not been able to conceive after 12 months of unprotected and frequent intercourse (Grade 2C). Earlier evaluation (eg, after six months) is indicated in some couples, such as those in whom the female partner is over 35 years of age or has a history of oligo/amenorrhea, known or suspected tubal disease or endometriosis, a history of chemotherapy or radiation therapy, and those in whom the male partner is known to be subfertile. (See 'Initial approach' above.)
●The history and physical examination are directed at identifying signs and symptoms suggestive of the etiology of the infertility. (See 'History and physical examination' above.)
●The basic infertility evaluation of all couples consists of:
•Semen analysis. (See 'Semen analysis' above.)
•Assessment of ovulatory status by history or laboratory testing. (See 'Assessment of ovulatory function' above.)
•Determination of tubal patency and presence or absence of abnormalities of the uterine cavity, usually by hysterosalpingogram. (See 'Assessment of fallopian tube patency' above and 'Assessment of the uterine cavity' above.)
●Ovarian reserve is assessed with day 3 follicle-stimulating hormone (FSH) and estradiol levels in women over 35 years of age and younger women with risk factors for premature ovarian failure. Other tests such as the clomiphene citrate challenge test (CCCT), antral follicle count, and anti-müllerian hormone (AMH) level are utilized in special circumstances. (See 'Assessment of ovarian reserve' above.)
●Diagnostic laparoscopy is indicated for women with suspected endometriosis or pelvic adhesions. When we perform laparoscopy, we also perform chromotubation to assess tubal patency and hysteroscopy to evaluate the uterine cavity. (See 'Role of laparoscopy' above.)
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.