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This structure permits membrane proteins proteins are synthesized in this organelle purchase generic atorlip-5 from india cholesterol medication for stroke. Electron microscopy reveals in a manner that arranges the polar heads toward outer sur- rough endoplasmic reticulum buy atorlip-5 5mg with visa cholesterol values wiki, which contains ribosomes on faces and their hydrophobic side chains projecting into the the side exposed to the cytoplasm and smooth endoplasmic interior buy generic atorlip-5 5 mg line cholesterol test home kit. Fatty acids and phospholipids bilayer plain, or they may rotate on their long axis. This is the are synthesized and metabolized in smooth endoplasmic retic- Singer–Nicholson “fuid mosaic. Amphipathic lipids and globular secreted proteins, are synthesized in the rough endoplasmic proteins are spaced throughout the membrane. Cells such as plasma cells that produce antibodies sistency permits movement of the proteins, glycoprotein, and or other specialized secretory proteins have abundant rough receptors laterally. Following forma- tion, proteins move from the rough endoplasmic reticulum to the cytoskeleton is a framework of cytoskeletal flaments the Golgi complex. They maintain the cell’s inter- form from the endoplasmic reticulum and fuse with Golgi nal arrangement, shape, and motility. Once the secreted protein reaches the acts with the membrane of the cell and with organelles in the endoplasmic reticulum lumen, it does not have to cross any cytoplasm. Microtubules, microflaments, and intermediate further barriers prior to exit from the cell. Microtubules help to determine cell shape by polymerizing the Golgi apparatus consists of a stack of vesicles enclosed and depolymerizing. They are 24-nm diameter hollow tubes by membranes found within a cell and serves as a site of gly- whose walls are comprised of protoflaments that contain α cosylation and packaging of secreted proteins. In addition to their interaction with myo- sin flaments in muscle contraction, actin flaments may Golgi complex: Tubular cytoplasmic structures that partici- affect movement or cell shape through polymerization and pate in protein secretion. Microflaments participate in cytoplasmic membranous sacs on top of each other termed cisternae. The molecular structure consists of three 180-kDa Primary lysosome Phagosome heavy chains and three 30- to 35-kDa light chains arranged Digestion into typical lattice structures comprised of pentagons or hexagons. These structures encircle the vesicles and are asso- Secondary ciated with receptor-mediated endocytosis. Microtubules arriving from the rough endoplasmic reticulum are processed form a sturdy cytoskeleton. Although not critical for the cell movement of chemotaxis, they are needed for A lysosome (Figure 2. The major component of enclosed by a membrane that contains multiple hydrolytic microtubules is tubulin, a dimeric protein. Lysosomes occur in numerous cells but are mal growth factor may bind to their receptors in the coated especially prominent in neutrophils and macrophages. The pit or migrate toward the pit following binding of the ligand enzymes are critical for intracellular digestion. Coated vesicles are vesicles in the cytoplasm usually encir- cled by a coat of protein-containing clathrin molecules. Coated vesicles A ribosome is a subcellular organelle in the cytoplasm of a convey receptor–macromolecule complexes from an extra- cell that is a site of amino acid incorporation in the process cellular to an intracellular location. Totipotent means having the potential for developing in various specialized ways in response to external/internal stimuli; of a cell or part. It apparently has a role in embryo- hematopoietic cells, are generated in the bone marrow. The genesis in cells linked to migratory patterns of hematopoietic stem cell compartment is composed of a continuum of cells stem cells, melanoblasts, and germ cells. They may be altered genetically in vitro precursor cells that are multipotential with the capacity to and introduced into mouse blastocysts to give rise to mutant yield differentiated cell types with different functions and murine lines. Pluripotency: the versatility to differentiate into one of An erythroid progenitor is an immature cell that leads to various types of cells. A pluripotent stem cell is a continuously dividing, undif- ferentiated bone marrow cell that has progeny consisting of Erythropoiesis refers to the formation of erythrocytes or additional stem cells together with cells of multiple separate red blood cells. Bone marrow hematopoietic stem cells may develop into cells of the myeloid, lymphoid, and erythroid lineages. Erythropoietin is a 46-kDa glycoprotein produced by the kidney, more specifcally by cells adjacent to the proximal Differentiation istheprocesswherebydevelopingaprecursor renal tubules, based on the presence of substances such as cell or an activated cell achieves functional specialization. It is useful (end-stage) hematopoietic cells in the blood are considered to in the treatment of various types of anemia. Some progenitor cells are precursors of erythrocytes, others are precursors of polymorphonuclear Hematopoiesis is the development of the cellular elements leukocytes and monocytes, and still others are megakaryo- of the blood including erythrocytes, leukocytes, and plate- cyte and platelet precursors. A gauge of the number of lets from pluripotent stem cells in the bone marrow in fetal hematopoietic progenitors in a specimen capable of forming liver. It is regulated by various cytokine growth factors syn- a colony comprised of a specifc type or types of hematopoi- thesized by bone marrow stromal cells, T cells, or other types etic cells. An A hematopoietic cell is a term referring to both an erythro- inducible endothelial–leukocyte adhesion molecule that pro- cyte and a leukocyte. Surface adherent leukocytes undergo a large A hemocytoblast is a bone marrow stem cell. Both Ca2+ and protein kinase C play a undifferentiated and serves as a precursor for multiple cell key role in the activation pathway. It is a common pluripotent hematopoietic precur- ity of phagocytes to bind and ingest opsonized particles. These cells are also demonstrable in the yolk sac Leukocyte adhesion molecules are facilitators of vascular and later in the liver in the fetus. The three main families of leukocyte adhesion mol- lead to the formation of granulocytes, monocytes, and ecules include the selectins, integrins, and immunoglobulin macrophages. These defciencies prevent granulocytes cells from which all lymphocytes are derived. Pluripotent from migrating to extravascular sites of infammation, lead- hematopoietic stem cells give rise to these progenitors. It consists of at least fve high molecular weight glycopro- teins present on the surface of the majority of human leuko- A myeloblast is a myeloid lineage immature hematopoietic cytes (mol wts: 180, 190, 205, and 220 kDa). The variation between the isoforms is all in the of granulocyte precursors and possesses nongranular baso- extracellular region. The principal types of tyrosine phosphatase that is expressed in various isoforms leukocytes in the peripheral blood of man include polymor- on different types of cells, including the different subtypes phonuclear neutrophils, eosinophils and basophils (granulo- of T cells. Leukopenia is the reduction below normal of the number of white blood cells in the peripheral blood. Leukocyte adhesion molecule-1 is a homing protein found on membranes, which combines with target cell specifc gly- coconjugates. It helps to regulate migration of leukocytes A progenitor cell no longer contains the capacity for self- through lymphocytes binding to high endothelial venules and renewal and is committed to the generation of a specifc cell to regulate neutrophil adherence to endothelium at infam- lineage.

A broad-based purchase atorlip-5 paypal cholesterol levels per age, U-shaped flap including mucosa buy cheap atorlip-5 5 mg on-line cholesterol medication causing kidney disease, submucosa purchase atorlip-5 cheap online cholesterol and crp test, and varying thickness of muscle is created with enough length to provide a tension-free repair. Sphincteroplasty the opening of the tract in the muscle is closed with figure eight sutures. The flap is sutured into place with absorbable Overlapping sphincteroplasty is used when there is a defect in interrupted sutures. The vaginal tract opening is left open to the external anal sphincter causing incontinence in the setting drain. A curvilinear incision is made at the dentate line in sepsis, and flap failure, though the risk of these should be low. A flap of cosa, extending cephalad beyond the internal opening of the vaginal mucosa inferior to the fistula is elevated and the rectal fistula. A levatorplasty is often the internal and external anal sphincters are located laterally done to enhance tissue coverage. Initial success rates reported were 86–100 % [52 – 54]; in patients with Crohn’s disease is that non-diseased tissue is however, long-term maintenance of continence was worse. An advantage to the transrectal approach is Gutierrez reported only 40 % of patients treated with sphinc- that the repair is done on the high-pressured side of the fistula. Colon and Rectal ter ins imbricated when a layered repair is performed; (d) the external Surgery. This technique is especially useful in patients with extensive, distal rectal cir- Tissue interposition grafts bring healthy, non-diseased, well cumferential ulceration or scarring, but with sparing of the vascularized tissue into the diseased region for repair. Patients should undergo bowel prep are multiple different types of tissue interposition grafts. A transperitoneal approach may be Gracilis transposition grafts are performed by mobilizing the needed to sufficiently mobilize the rectum. A circumferential muscle, detaching it from the tibia, and tunneling the muscle incision is made at the dentate line, extending into the subcutaneously to the perineum. All patients were diverted, and 11 of 12 were eased anal mucosa is excised, and the rectum is pulled caudal reversed [62]. The gracilis muscle is not ideal for this pur- to the dentate line and sutured to the anoderm without ten- pose since the distal end of the muscle is narrow and does not sion. The Martius flap initially referred to tissue 4/5 patients with Crohn’s anovaginal fistulas treated with interposition using bulbocavernosus muscle, but has more sleeve advancement flap, three of which were diverted at the recently been used to describe either a labial fat pad graft, time of the procedure [61]. The omentum is the ventral extent of the pedicle and tunneled underneath the mobilized 2/3 of the way from the hepatic flexure to the labia minora to the fistula site and sutured into place. Many splenic flexure, taking care to ligate the branches of the right of the earlier reports described the Martius flap for the treat- gastroepiploic artery but to preserve the arcade. Though tulas healed within 3 months, though two of the seven initial results appear promising, this technique is relatively patients with Crohn’s ultimately underwent proctectomy for new, and further studies are needed before conclusions are worsening anal disease [64]. Unfortunately, recurrence rates are An omental flap may be placed laparoscopically for high high with virtually all of these procedures. They found that the use of and a piece of omentum interposed into the rectovaginal immunomodulators was significantly associated with better Fig. Treatment of ano- vaginal and rectal defects; (b) vaginal and rectal closure; (c) graft con- vaginal or rectovaginal fistulas with modified Martius graft. Colorectal struction; (d) tunneling graft; and (e) interposition between the vaginal Dis 2007;9(7):653–6. Reprinted with of the omental flap; (d) perineum 3 months after fixation of the omental permission) flap. Predictive factors of response of perianal Crohn’s dis- with higher failure rates [66]. A long- made, particularly with regard to biologic agents, and with term, randomized, double-blind study. Azathioprine and 6-mercaptopurine for the various treatment modalities so the best option may be chosen treatment of perianal Crohn’s disease in children. Combining infliximab with 6 mercaptopurine/azathioprine for fistula therapy in Crohn’s dis- ease. Anal endosonogra- fistulas in Crohn’s disease—subgroup results from a placebo- phy in the evaluation of perianal sepsis and fistula in ano. Ultrasound study of anal fistulas with hydrogen peroxide London position statement of the world congress of gastroenterol- enhancement. Pre-operative assessment of colitis organization: when to start, when to stop, which drug to anal fistulas using endoanal ultrasound. Endorectal advancement flap for cryptoglan- under anesthesia for evaluation of Crohn’s perianal fistulas. Healing of perineal glue is effective healing perianal fistulas in patients with Crohn’s Crohn’s disease with metronidazole. Efficacy of fibrin sealant in the ing adipose-derived adult stem cell administration to treat complex management of complex anal fistula: a prospective trial. Total anal sphincter saving technique for fistula-in-ano; the in the treatment of rectovaginal and complex fistulas. Perianal term results of overlapping anterior anal-sphincter repair for obstet- Crohn disease: predictors of need for permanent diversion. Carcinoma of the intestinal tract in Crohn’s disease: srectal vs transvaginal approach. Fürst A, Schmidbauer C, Swol-Ben J, Iesalnieks I, Schwandner O, treatment of rectovaginal fistulas in Crohn’s disease: response to Agha A. Martius flap: an adjunct for technique for the identification of recurrent elusive fistulas. Songne K, Scotté M, Lubrano J, Huet E, Lefébure B, Surlemont Y, tovaginal fistulas: endoluminal sonography versus endoluminal Leroy S, Michot F, Ténière P. Schloericke E, Hoffman M, Zimmermann M, Kraus M, Bouchard rectovaginal fistulae in Crohn’s disease. Analysis of function and predictors of failure in women under- ences outcome in rectovaginal fistula repair. Tuberculosis Fistulas 20 Pravin Jaiprakash Gupta be recognized, because they require specific treatment. Else, Introduction this results in recurrence of fistulas after routine surgical treatment. Extrapulmonary tuberculosis can attack any Anal fistula is a very common condition found in 34–66 % of organ; ano-perineal disease (1 % of digestive tract incidence) all anorectal abscesses, and while most of the anal fistulas is much more rare [5 ]. In 1882, Robert Koch isolated the bacillus, grew it in tuberculosis is attributable to bovine tubercle bacilli entering pure culture, and demonstrated its pathogenic capacity. Although anal tuberculosis is relatively losis have been reported in the literature [4].

The frozen stage is due to significant pathologic thickening of the joint capsule (Figs order atorlip-5 5mg visa creatine kinase cholesterol medication. The intra-articular administration of local anesthetic will not improve the limitations of range of motion purchase atorlip-5 with a visa cholesterol test that measures particle size. Stage 4 is known as the thawing stage and is characterized clinically by gradual return of shoulder function although in many patients full recovery efforts remain elusive despite all treatment buy genuine atorlip-5 line cholesterol ratio very low. Arthroscopy will reveal organized mature fibrotic adhesions within the joint space (Fig. A: Stage 1 adhesive capsulitis is characterized by fibrinous synovial inflammatory reaction without adhesions or capsular contracture. B: Histologic findings of stage 1 adhesive capsulitis demonstrate rare inflammatory cell infiltrate; hypervascular, hypertrophic synovitis; and normal capsular tissue. A: Stage 2 adhesive capsulitis demonstrates a thickened, hypervascular synovitis described as having a Christmas tree appearance. B: Hypertrophic, hypervascular synovitis with perivascular and subsynovial scar formation is seen on histologic examination for stage 2 capsulitis. A: Scarring of the superior labrum is seen on arthroscopic examination, and minimal synovitis is present with stage 3 adhesive capsulitis. B: Capsular biopsy demonstrates dense, hypercellular, collagenous tissue with a thin synovial layer exhibiting features similar to other fibrosing conditions. The abnormal signal (edema) of the axillary pouch is easier to appreciate with the fat saturation sequence (white arrows) (B). Thickening and edema of the rotator interval structures (arrows) and axillary recess (thick arrows). Although both clinical syndromes occur more frequently in woman, frozen shoulder secondary to crystal deposition disease, which is known as Milwaukee shoulder, has its average onset in the seventh decade of life. Unlike adhesive capsulitis which is usually unilateral, Milwaukee shoulder is bilateral over 60% of the time, with the patients knees often simultaneously affected. Although like frozen shoulder secondary to adhesive capsulitis, episodes of antecedent trauma or overuse can be identified, patients with Milwaukee shoulder frequently are suffering from calcium pyrophosphate deposition disease, hyperparathyroidism, Charcot arthropathy, and dialysis-associated arthropathy. Although some patients may experience a milder form of this disease, most patients experience a rapid progression of both pain and decreasing range of motion due to extensive destruction of the extraskeletal deposition of calcium crystals into the shoulder joint (Fig. Clinically, the constellation of symptoms associated with Milwaukee shoulder resembles the clinical presentation of acute gout, for example, hot, swollen, extremely painful affected joints, and is hence called pseudogout. Large joint effusions are often present and synovial fluid analysis will often reveal surprisingly low leukocyte counts, large numbers of erythrocytes, and basic calcium phosphate crystals, which are sometimes mixed with calcium pyrophosphate (known as apatite). Radiographic, magnetic resonance, and ultrasound evaluations can reveal a striking amount of destruction of the articular cartilage and underlying bone of the glenohumeral joint, destruction of the coronoid, lysis of the distal clavicle, and calcification and tears of the musculotendinous units of the rotator cuff often resulting in a high-riding humeral head (Fig. Like the treatment of frozen shoulder secondary to adhesive capsulitis, treatment of Milwaukee shoulder is aimed at identifying and treating underlying diseases, for example, hyperparathyroidism, the use of anti-inflammatories including short-course glucocorticoid therapy, intra-articular injections of local anesthetic and steroid, both as a diagnostic and therapeutic maneuver, manipulation under anesthesia, and extracorporeal shock wave therapy all accompanied with aggressive physical and occupational therapy. Unfortunately, unlike the treatment of frozen shoulder secondary to adhesive capsulitis which is usually successful, the treatment of Milwaukee shoulder is often disappointing despite everyone’s best efforts. Sonographic image of the shoulder of a patient with Milwaukee shoulder demonstrating a supraspinatus calcium deposit appearing as a well-circumscribed, anechoic focus with posterior acoustic shadowing (arrow). A linear high-frequency ultrasound transducer is placed over the lateral tip of the acromion in the coronal plane and angled slightly toward the scapula (Fig. The supraspinatus tendon is then identified as it exits from beneath the acromion and curves over the head of the humerus to attach to the greater tuberosity. The tendon should be carefully examined for calcifications or tendinopathy that may be contributing to the patient’s shoulder pain. The glenohumeral joint is then identified as a fluid- containing structure beneath supraspinatus tendon (Fig. Although the normal or mildly inflamed glenohumeral joint most often appears on ultrasonic imaging as a hypoechoic curvilinear layer of fluid sandwiched between a hyperechoic layer of bursal wall and peribursal fat, inflammation and distention of the bursal sac may make the bursal contents appear anechoic or even hyperechoic. The posterior joint is then evaluated by placing the ultrasound transducer below the scapular spine (Fig. The joint and surrounding tendons and soft tissues are then carefully evaluated for joint pathology including articular erosions, bursitis, synovitis, synechiae, loculations, cysts, and calcifications (Figs. Correct coronal position for ultrasound transducer for ultrasound evaluation of the glenohumeral joint. The posterior glenohumeral joint is examined by placing the patient’s arm across the chest with the hand on the contralateral shoulder. C: Ultrasound image showing osseous irregularity of the humeral head with subchondral cyst (arrow) and synovial hypertrophy (asterisk). D: Ultrasound image showing joint effusion (arrow) and synovial hypertrophy in the posterior aspect of the shoulder joint (asterisk). Hemophilic arthropathy of shoulder joints: clinical, radiographic, and ultrasonographic characteristics of seventy patients. Transverse ultrasound image of right shoulder at the reflection pulley demonstrating crystal deposition in patient with Milwaukee shoulder. Ultrasound image of the right shoulder demonstrating massive subdeltoid bursitis and the complete destruction of the rotator cuff and transverse ligament complex in a patient suffering from Milwaukee shoulder. Ultrasound image of right shoulder demonstrating significant crystal arthropathy and concurrent severe subdeltoid bursitis in patient with Milwaukee shoulder. Ultrasound image of the right shoulder demonstrating significant destruction of the glenohumeral joint capsule with a massive joint effusion and bursitis in a patient with Milwaukee shoulder. Diseases that predispose the patient to the development of frozen shoulder can be divided into two general categories: (1) those that occur within the shoulder and proximal upper extremity, for example, calcium deposition disease, rotator cuff tendinopathy, subdeltoid bursitis, biceps tendon tendinopathy, postimmunization shoulder pain, etc. Regardless of the underlying cause of adhesive capsulitis, failure to quickly diagnose and treat this condition 274 uniformly results in a poor clinical outcome. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique. The suprascapular artery and vein accompany the nerve through the suprascapular notch. The nerve then passes beneath the supraspinatus muscle, and curves around the lateral border of the spine of the scapula to pass through the spinoglenoid notch to enter the infraspinous fossa (Fig. The suprascapular nerve provides much of the sensory innervation to the glenohumeral and acromioclavicular joint and provides motor innervation to the supraspinatus and infraspinatus muscles of the rotator cuff. The nerve is subject to entrapment and compression anywhere along its path, but in particular when it passes through the suprascapular and spinoglenoid notch (Fig. Entrapment and/or compression of the suprascapular nerve can result in motor, sensory, and proprioceptive deficits in the shoulder. The nerve provides no cutaneous sensory innervation, but provides rich sensory innervation to the glenohumeral and acromioclavicular joints (Fig. The suprascapular nerve arises from fibers from the C5 and C6 nerve roots of the upper trunk of the brachial plexus with some contribution of fibers from the C4 root. The suprascapular nerve and artery pass proximally beneath the superior transverse scapular 276 ligament through the suprascapular notch.

Chapter 68: Female Reproductive System: Functional Anatomy order atorlip-5 with visa cholesterol and foods, Oogenesis and Follicular Development 607 Primary Oocytes the oocytes undergo two meiotic divisions (the meiotic cycle) at different stages of development to produce a haploid ovum cheap 5mg atorlip-5 with mastercard cholesterol definition and importance. First Meiotic Division the first meiotic division starts in primary oocytes during fetal life buy atorlip-5 5 mg online cholesterol levels when to take medication, which occurs at about 8th week of pregnancy is arrested in prophase. However, the first meiotic division is not completed in fetal life, not even till puberty; in fact, it is completed just prior to ovulation. Therefore, the life span of a primary oocyte can be up to 50 years, as ovulation can continue up to this age. The suspension of oocyte division in prophase for such a long period depends on the internal hormonal Fig. The stroma of ovary has two parts: environment provided by the surrounding supporting cortex and medulla. Note that the cortex contains ovarian follicle in different stages of development. Secretion of female sex hormones and peptide hor- uterine life so that only about 1 million primary oocytes mones. By the time of puberty about the primary function of ovary is to develop ovarian 200,000 and by the age of 30 only about 26,000 oocytes follicles and release ovum at the time of ovulation, and to remain in the ovary. At menopause, ovaries are virtually secrete steroid hormones that control various reproduc- devoid of oocytes. During a woman’s life, only about 400 oocytes are ovulated and the other oocytes degenerate. A major difference in male and female gametogen- Unlike spermatogenesis that starts at puberty and con- esis is that the process of spermatogenesis is a con- tinues throughout life, the process of oogenesis starts in tinuous phenomenon and the production of sperm is fetal life and ceases at menopause. Also, the process of unlimited, whereas primary oocytes degenerate with development of each spermatocyte is completed in few age (Application Box 68. As new oogonia cannot be manufactured in ovary, the intrauterine life is completed with ovulation that occurs oocytes totally disappear at the time of menopause. The stages of development of oocytes occur in three an oocyte may be as old as 50 years. The oocyte that ovulates at about stages: Oogonium becoming primary oocyte, primary 40 years of age is about 25 years older than the oocyte that ovulates at the age of 15. This one of the important factors that contribute to the oocyte converted to secondary oocyte, and finally second- anomalies in children born to older woman as the aged-eggs oocyte ary oocyte developing to mature ovum. Oogonia Becoming Primary Oocyte Primary Oocyte Converted to Oogonia Secondary Oocyte the primordial germ cells (oogonia) migrate from the yolk sac of embryo to the genital ridge at about 6th week of In fetus, oogonia develop into primary oocyte, which gestation. Thus, all eggs present at birth are primary oocytes 608 Section 7: Reproductive System Fig. Note, first meiotic division of oocyte begins during fetal life and completes prior to ovulation, whereas second meiotic division completes at the time of fertilization. The primary oocyte that is destined for ovulation is called follicular growth or folliculogenesis. This division results in production of two structures: Thus, a single ovarian follicle may develop from fetal one is the daughter cell, called secondary oocyte con- life till menopause. However, the cytoplasmic division is grossly unequal nant follicle finally matures and releases ovum, in this process in which the secondary oocyte retains whereas rest others undergo degeneration (atresia). Thus, the polar body becomes com- atresia during the reproductive life of a woman. Stages of Follicular Development Secondary Oocyte Forming Ovum Folliculogenesis occurs in four stages: Stages 1– 4 (Figs. The second meiotic division occurs in the secondary oocyte after ovulation, and is arrested in metaphase. Thus, meiotic cycle is the ovarian follicle, also called Graafian follicle begins as a completed only on fertilization. The primordial follicle consists of a primary oocyte ing 23 chromosomes and the second polar body are at the center surrounded by a layer of spindle cells formed (Fig. Chapter 68: Female Reproductive System: Functional Anatomy, Oogenesis and Follicular Development 609 Figs. The oocyte is maintained in prophase of its first mei- division is arrested in prophase. Stage 4 (Tertiary Follicular Stage) Stage 2 (Primary Follicular Stage) This is the final stage of follicular development. The size of oocyte In this stage, the spindle cell layer surrounding the base- increases to about 80-140 µm. A type of glassy material consisting of mucopolysac- theca interna and outer theca externa. Theca interna cells multiply to form multiple cell lay- thick layer between the oocyte and the granulosa cell ers and become steroidogenic. The primordial follicle becomes primary follicle at mechanical support to the follicle from outside. The prophase of first meiotic division of oocyte is whereas granulosa cells remain avascular as blood maintained. A long with the expansion of theca cell layer, a fluid- Stage 3 (Secondary Follicular Stage) filled space is created in the midst of granulosa cells, the primary follicle becomes secondary follicle in this called as antrum (Fig. Therefore, the follicle stage during which the granulosa cells divide and form in this stage is also called early antral follicle and the several layers of cells around the oocyte. All these development occur slowly in the prepubertal This is the most rapid stage of development. After 5–7 days of onset of menses, a single follicle losa cells are highly steroidogenic. The size of the antrum and the amount of antral fluid slowly resulting in release are increased significantly. This pushes the oocyte to of oocyte from the follicle, the process called ovulation. The antral fluid contains many hormones such as results in functional ovum (fertilized egg). It also contains plasminogen activator, mucopolysac- Corpus Luteum Formation charide, proteins, electrolytes, glycosaminoglycans and Luteinization proteoglycans. The granulosa cells in this stage are anatomically blood, and at this time, the follicle is called corpus hemor- divided into three compartments: antral, cumulus and rhagicum. Antral granulosa cells: Granulosa cells lining the antral Now, the follicle is called corpus luteum and its appearance cavity are called antral granulosa cells (Discus proliger- heralds the beginning of luteal phase of the cycle. The corpus luteum is a yellow body made up of endo- Cumulus granulosa cells: Granulosa cells surround- crine tissue that consists of granulosa luteal cells, ing the oocyte are cumulus granulosa cells (cumulus theca luteal cells and fibroblasts (Fig. It maintains the early part of pregnancy by secreting luteum are respectively called as granulosa lutein cells progesterone in adequate concentration till the pla- and theca lutein cells. Luteal granulosa cells are vascular unlike the follicular Infertility occurs due to luteal deficiency (Clinical Box 68. Progesterone secretion reaches its peak in menstrual secretion of progesterone from malfunctioning corpus luteum, cycle at about 7 days after ovulation, which correlates pregnancy is terminated very early. These hor- by demonstrating a low progesterone level in the midluteal phase in successive cycles.

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