Your detailed fertility report

Transcription

1 Your detailed fertility report Report prepared for Test Report2 on 15 March About this fertility report reference code: unknown When it comes to fertility, understanding your options can be quite difficult, particularly as each fertility clinic will have different success rates, selection criteria and funding options. The overall success rate of a particular clinic is generally much less important than the likely success rate for your specific conditions. We'll explain your chances of pregnancy with fertility treatment (either IVF or ICSI); useful information to help you understand why you are not getting pregnant, and what may help you achieve a healthy pregnancy. Since our calculations are based on the national records of 874,000 cycles of fertility treatment we can provide you with a more reliable success rate than each individual clinic would be able to. 2 What is my chance of success with IVF/ICSI? We analysed the largest national database of IVF procedure outcomes in the world, containing over 874,000 individual cycles and singled out those cycles from couples that matched your profile. There were 270 cycles that matched your profile, of which 46 resulted in at least one live birth giving you a calculated IVF success rate of 17%. This means that, on average, it would take 6 cycles of IVF for you to become pregnant. To match your profile we had to identify the most important features of the HFEA (Human Fertilisation and Embryology Authority) database information, in terms of their relative impact on your IVF success rates. The three most relevant aspects about you and your partner in matching to others like you are: That your partner has low sperm concentration. That you are planning to use your own eggs. Your age. The four minor aspects about you and your partner are: The number of pregnancies through IVF you have had. page 1 of 18

2 That you and your partner have not been pregnant together. That you have not been diagnosed with tubal disease. That your partner has not conceived with you or with a former partner. These are the factors that most distinguish you from the general group of all IVF patients, who, on average, have a 17% pregnancy rate from each cycle of IVF. We have also used your data to calculate patient-specific success rates from two commonly used mathematical models (Templeton et al, Nelson et al). These models are based on teasing out the relationship between IVF success and certain factors (such as age), but may not be as specific to your circumstances. The Templeton model, developed in 1999, predicts an IVF success rate for patients like you of 6%. The IVFPredict ('Nelson') model, developed in 2011 as an update to the Templeton model, predicts an IVF success rate for patients like you of 11%. Further details about the calculation models are explained in Appendix A towards the end of this report. It is important to note that this report should not replace proper medical advice. We have included the most common factors, but we cannot analyse every factor affecting your fertility. However, this report should provide you with useful information to help you understand what may be affecting your chances, and help you formulate key questions for your doctor. 3 Provision for IVF treatment in your area From the information that you have provided us, it appears that given the fertility treatment that you have had so far, you do not qualify for NHS funding from your region. This means that you are likely to have to see a private clinic. This will typically cost several thousand pounds depending on the treatment (ICSI is more expensive than IVF for example). If you are in an area with several clinics, we would recommend visiting them before choosing where you will do your treatment as it is very important that you feel as relaxed as you can be with the medical professionals there. You can look up all the clinics in your area with their success rates compared to the national average here: page 2 of 18

3 4 The details you provided Her date of birth May 1970 Her weight in kg 80 Her height in metres 1.5 Her body mass index (BMI) [calculated] Using donor sperm 35.6 His date of birth November 1972 His height in metres 1.61 His weight in kg 85 His body mass index (BMI) [calculated] No 32.8 Date started trying for a baby May 2010 Number of previous IVF cycles Number of times pregnant using IVF Number of live births using IVF Number of times pregnant without IVF Has your partner ever got a woman pregnant Have you had your ovarian reserve tested Your ovarian reserve results Female fertility problems Cycle irregularity details Medications Male fertility problems Low sperm concentration details Source of eggs for IVF Using ICSI IVF protocol Country Post code Plan to have IVF Two Once None Never No Yes Medium Cycle irregularity Cycles 25 to 60 days Complementary medicine, Hcg injection Low sperm conc, Abnormal sperm morpho Not filled in Own eggs Dont know Dont know UK SE1 Please select page 3 of 18

4 5 What factors can I change? There are three main factors that you can change about your IVF procedure to potentially increase the likelihood of a successful cycle. We have calculated these below, but must stress that this is in no way a substitute for the knowledge and experience of your fertility specialist. Impact of use of donor eggs: Some couples opt to use eggs from a different woman in order to overcome certain ovarian problems or egg quality issues. Your likely pregnancy rate without use of donor eggs is 17%, however with use of donor eggs this may be around 16%. Typically, when a woman chooses to use donor eggs, this can be explained by fertility conditions affecting egg quality above and beyond the information collected in this report. In this case the likely pregnancy rate without donor eggs is likely to be lower than 17% in practice. Impact of use of ICSI: Intra-cytoplasmic sperm injection (ICSI) is a technique that involves directly injecting a selected sperm into the egg, and can be particularly successful for certain malefactor issues. Your likely pregnancy rate without use of ICSI is 12%, however with use of ICSI this may be around 15%. Using ICSI instead of traditional IVF may increase the cost by about 2000 ($4000) 6 Your chances of success over time Currently, if you were to use your own eggs on a cycle of IVF treatment, your chances of getting pregnant would be 17%. However you may not be at the point of starting this treatment, or may have decided to postpone this for a little while longer. Typically the chances of a successful IVF procedure fall as you get older. The following graph shows your chances of successful IVF now and up to 10 years from now (from a single cycle) using your own eggs. Explanation of the different lines and bar chart colours is given in Appendix A towards the end of this report. It is important to know that one of the key factors in fertility levels and success rate of fertility treatment is the woman's age. The graph shows your chances of getting pregnant with a single cycle of IVF treatment over the next 10 years - your chances will generally decrease with increasing age. The dashed lines above and below each bar are the error bars for each year, showing the range of success rates for fertility treatment. As explained before, there page 4 of 18

5 Chance of successful IVF using your own eggs 22% 20% 18% 15% 12% 10% maximum chance chances from HFEA minimum chance Increasing chance of successful IVF cycle 8% 5% 2% 0% now Years from now are various mathematical models to identify the chances of success with fertility treatment, which do not rely on the national records, so we wanted to provide you with this information as well. There are different types of hormonal treatment that you can receive for an IVF treatment, it is even possible to have natural (unstimulated) IVF, however because the chances of pregnancy are lower with this treatment it is rarely offered. During hormonal stimulation, you will be monitored by internal ultrasound scans to check that the ovaries are getting ready to produce enough eggs (usually around 5-10 will be produced). Please note that some fertility clinics will have an age limit on their fertility treatments. It is important to take this into account if you are planning to postpone treatment. 7 About male factor infertility Male factor infertility, particularly related to sperm count, concentration or quality are very common issues, with around 30-40% of IVF patients having at least one identified male factor. The World Health Organisation (WHO) has periodically published 'normal' sperm parameters to assist in the interpretation of individual semen test results. These are briefly summarised below, however older sets of reference values are in common use (notably the use of a "20 million sperm per ml" concentration reference). page 5 of 18

6 World Health Organisation 2010 Reference Semen Parameters: Semen parameter Sperm count (sperm concentration) Total sperm count (concentration X volume) Volume Normal level above 15 x 10 6 /ml above 39 x 10 6 above 1.5 ml ph between 7.2 and 7.8 Motility Morphology Vitality above 50%, note that this may sometimes appear as categories a, b, c and d or I, II, III, IV. In that case the motility is equal to a+b or I+II above 8% if the test was done before 2010 and above 4% if the test was done after above 60% of live sperm It must be noted that the definition of 'normal' used in the generation of the WHO semen parameters is the population 5th percentile for men who's partners had a "time-to-pregnancy" of 12 months or less. What this means is that, for a given parameter, only 5% (or 1 in 20 men) of the normally fertile population have a value below this number. However, you can still get pregnant naturally if your semen parameters are below the indicated value - indeed, 1 in 20 of the normally fertile population are below the indicated value, and those men achieved pregnancy in less than a year. It is also important to note that there are seven parameters defined, so the chance of a normally fertile man getting a result below at least one of these parameters is much, much greater than 5%. 8 About low sperm concentration The World Health Organisation 2010 definition of 'normal' sperm concentration is 15 million sperm per millilitre (15 x 10 6 /ml), however the earlier definition using 20 million sperm per millilitre is still in common use. It is important to remember not to take sperm count or concentration results in isolation from other semen parameters; in particular, a negative result from a home sperm tests should only be used to indicate that a full sperm test should be undertaken. Couples who decide to go for fertility treatment may be offered either IVF or ICSI depending on their medical history. ICSI is very similar to an IVF cycle, except that one sperm will be chosen by the clinic to be injected directly into the egg. This page 6 of 18

7 typically costs 20-30% more than a classic IVF cycle, but the chances of success are higher than for an IVF treatment if the sperm count is very low, or the sperm morphology poor. It typically takes 3 months for new sperm to be produced. This means that by changing some lifestyle factors and repeating the test 4-5 months later, the results may have improved In order to do a sperm test, you can use home kits which only measure the concentration and tell you if your sperm concentration is above or below 20M/ml. These tests do not tell you if the sperm are well-shaped or swim well. You can find these tests online Alternatively you could do a test at a fertility clinic as this will check for all aspects of the semen sample. Your doctor may be able to provide you with this test paid on the NHS (if you live in the UK) but in most cases this will be paid for privately (at greater cost than the home tests) The results of a test are usually valid for 6 months. Studies have shown that for sperm count as low as 5 million, chances of natural conception over a year may be as good as an IVF cycle if the other sperm parameters (motility and morphology) are within the normal limits. 9 About abnormal sperm morphology The morphology is the "shape" of the sperm, and indicates how well it has developed. It is expected that most of the sperm are abnormally shaped, so you should expect the "normal morphology" or "normal forms" parameter to be below 20%. The normal value defined by the World Health Organisation (WHO) varies from 4% to 10% normal depending when the sperm test was performed (the technique has greatly changed over the last 10 years). Poor sperm morphology can affect the chances of pregnancy as the fertilisation rate is lower than when the morphology is normal. Couples who decide to go for fertility treatment may be offered either IVF or ICSI depending on their medical history. ICSI is very similar to an IVF cycle, except that one sperm will be chosen by the clinic to be injected directly into each egg. This typically cost 20-30% more than a classic IVF cycle, but the chances of success are higher than for an IVF treatment if the sperm count is very low, or the sperm morphology poor. Men who are overweight (Body Mass Index or BMI over 25) often have fewer normal sperm, and losing weight can have a positive effect on the overall morphology in as little as 3 months. So before a fertility treatment, and for natural conception, it is worth considering a weight loss plan if weight is an issue. page 7 of 18

8 10 Multiple male factors Very often several male factor issues occur together, for example poor sperm morphology (many mis-shapen sperm) will often correlate with a low number of sperm swimming correctly (because so many are mis-shapen). There are also a range of physical factors that can cause male infertility, such as retrograde ejaculation, which can mean that no matter how good the sperm themselves are, they are simply not getting to the right place at the right time (they end up in the bladder). What really matters for your chances of conception are the total number of healthy, well-formed, rapidly swimming sperm making their way towards the egg (i.e. good sperm concentration, sample volume, motility, morphology and vitality). For a man at the lower boundary of all of these parameters, this would result in a little over 250,000 healthy, well-formed, rapidly swimming sperm (only about 1% of the whole sample). In cases of multiple identified male factors, you should seek advice in interpreting the results of your test because of the complex relationship between the various semen and physical parameters. It is likely that in cases of multiple male factors your fertility specialist will advise the use of ICSI rather than IVF, which although significantly more expensive than IVF can dramatically improve the success rate in cases of multiple male factors, because the scientist performing the sperm injection can manually select one of the few healthy, well-formed, rapidly swimming sperm.for more information you can contact To improve sperm count and quality, men are advised to follow the recommendations below in the Improving sperm quality section. The cause may be due also in part to occupational factors such as physical activity, shift work, heat, X-ray, and agricultural pesticides. A full review of the possible causes of your sperm test results could help you understand which adjustments to make resulting in improved chances of pregnancy both with IVF and natural conception. 11 Improving sperm quality To maximise the quality of his sperm the man should: Stop smoking altogether (or reduce smoking as much as possible). Reduce alcohol intake as much as possible. Focus on choosing to eat healthily - eat lots of fruit and vegetables and vary the diet to ensure a balanced intake of all nutrients and minerals. Consider specially formulated preconception vitamins for him as a supplement to their balanced diet. Preconception supplements can help enable that all the vitamins and minerals are present to help produce goodpage 8 of 18

9 quality sperm. Vitabiotics has a very good range for conception and pregnancy (one of the only ones on which scientific studies have performed and show a clear improvement). You can find a supply of 1 month vitamin for both you and your partner here Avoid wearing tight trousers or underwear as these can over-heat the testes and therefore affect sperm count and quality. Men should therefore try to wear looser clothing. If they work all day sat at a desk or in a vehicle, standing up regularly to avoid over-heating of the testes is also recommended. Avoid exposure to heat, X-rays, or agricultural pesticides. 12 The effect of age on fertility A woman's age is one of the most important factors in fertility as fertility reduces with age. This is the case both for fertility treatment and for natural conception. The absolute age is important, but there are now tests available to help measure ovarian reserve (the relative age of the ovaries) and how likely the woman is to conceive naturally or through assisted treatment. The most common tests are for the two hormones FSH and AMH, measured by a simple blood test. If you have not measured your AMH or FSH (ovarian reserve markers) in the last 6 months we would recommend doing so. You should ask your doctor for more information. Generally in the UK the FSH test is free of charge whilst the AMH test is paid for privately. You can get both tests from a private laboratory AMH: and FSH: As seen in the figures in the report, the IVF success rate decreases with age, and typically clinics will have a limit on the ovarian reserve test result when they select patients. The reason is that as the ovaries get older, they won't respond as well to hormonal stimulation. Instead of a collection of eggs as may be expected in a patient, only 2-4 may be produced when the ovarian reserve is low. Ultimately, the chances of a healthy pregnancy are greatly reduced. In the UK, many clinics only accept patients under the age of 39 years old. The quality of the egg is also often a problem, with the genetic composition of the egg being more frequently abnormal. This can have effects such as recurring miscarriages - where pregnancy is technically achieved but does not hold. page 9 of 18

10 13 The effect of weight on fertility Given the information that you have provided, your Body Mass Index indicates that you are overweight. It is clear that not all women who are overweight have difficulties conceiving, but when a woman is having difficulties conceiving, being overweight can contribute even further to making conception a challenge. Along with experiencing a delay in conception, there is also an increased risk of miscarriage for women with a BMI of over 30. If your cycles are irregular then losing weight can help to regularise them, and relevel the hormones which control your fertility. Five percent of weight loss is usually recommended, but your doctor will be able to advise you on your ideal weight to help your fertility. The approach to losing weight whilst trying to conceive should be considered carefully. A very strict diet is unlikely to be very good for your fertility. The most effective way of losing weight whilst trying to conceive is supervised weight loss programs or group programs including exercise combined with dietary advice. These approaches are likely to lead to the best results, impacting positively on your fertility. Many fertility clinics will have a BMI requirement before they will allow you to undergo IVF treatment. This is due to the lower success rate seen in those with higher BMI, but also due to the associated increased risks for your health. Both cases suggest that reducing BMI can be beneficial both for the patient and their chances of a successful pregnancy through assisted treatment. Overweight men can have problems with sperm quality that is linked with their weight. The reason for this is that the fatty tissue is storing some of the hormone affecting sperm production, and therefore the hormonal balance is disrupted. This is usually visible in sperm test results. Losing weight can dramatically improve the sperm test results, and therefore your fertility both for natural conception and for IVF. 14 General conclusions While many couples choose to undergo fertility treatments, it is important that you are fully aware of the potential risks. Clinics are very well monitored and the doctors will care for you as well as they possibly can. However, as with every medical procedure, risks are present. The most common risk is ovarian hyperstimulation caused by the hormonal treatment. This can lead to hospitalisation for several days, and in very rare cases more serious complications (having said this, very few cases of death are reported every year due to complications). page 10 of 18

11 Some reports have also shown that children conceived through ICSI may have a higher risk of complications and birth abnormalities than children conceived naturally or through IVF. More research is needed to understand why this happens. We would recommend that you discuss the risks carefully with your doctor before deciding to undergo any treatment or medical procedure. 15 General tips on fertility There are some lifestyle changes that can help to optimise your fertility to help you conceive naturally, or improve your chances of assisted conception. Smoking Smoking has been linked to infertility in both men and women, leading in some cases to early menopause in women. It also increases the risk of low birth weight and premature births. Try to reduce or stop smoking to give yourself the best chances of conceiving. Your doctor and pharmacist are here to help you do this, it is important to talk about this with them, and get help to reduce smoking. Drinking alcohol Alcohol should be avoided when trying to conceive. Alcohol can affect the fertility levels of both men and women. Excessive alcohol intake also increases the risk of miscarriage. Research has shown that drinking alcohol causes a decrease in sperm count and motility. Alcohol also inhibits the body's absorption of nutrients such as zinc, mentioned above, which is a very important mineral for male fertility. The NICE guidelines in the UK now recommend avoiding alcohol during the first 3 months of pregnancy to reduce miscarriage. When you are trying to conceive, you could be pregnant for up to 2 weeks before seeing a positive pregnancy test, which is why avoiding alcohol altogether is recommended. Vitamins and diet - male and female When trying to conceive, nutrition and lifestyle choices should be carefully considered. Some changes will not only increase the chances of conceiving, but will also help to ensure a safe delivery of the baby. Focus on maintaining a well balanced diet throughout your conception journey with the following tips. page 11 of 18

12 Choose lots of fruits and vegetables in your daily diet. Nuts and seeds are also advised as they contain high amounts of essential Omega 3 and 6 fatty acids that help to improve fat and protein metabolism, lessening the risk of hormone imbalance and improving the quality of sperm in men and eggs in women. Vitamins and minerals not only help to maintain normal function of your body, but also increase the body function in normalizing the production of certain hormones. We recommend vitamin supplements specially formulated for couples trying to conceive e.g. Pregnacare, for couples who feel that their diet may not be providing enough. Zinc deficiency is thought to play an important role in infertility. Within males, it reduces the volume of semen - compromising the probability of fertilisation. Some food sources which contain zinc are seafood, beef, lamb, wheat germ. Fertile window: detecting ovulation For most couples, falling pregnant is quite easy, but for about 1 in 6 couples this process takes more than a year. During that time, some couples will manage to maintain regular intercourse as recommended by the NICE guidelines (every 2 days), while for others this can be more difficult due to personal and professional lives. Monitoring ovulation can be useful to help time intercourse, and several methods can be used to do this. Commericailly available urine 'LH' ovulation tests will typically give you a 1-2 day window when to have intercourse. Commericially available ovulation monitors (DuoFertility and Clearblue Fertility monitor) will generally give you a greater number of days covering your fertile window, and more days, and this may be better to give you more opportunity. If temperature is used as a measurement by the monitor, then ovulation can be confirmed (as well as predicted), which can help identify ovulatory disorders that are associated with around 30% of female fertility. Generally the hormone based monitors (Clearblue) are recommended in the first 6-12 months of trying, and then couples should consider methods tailored to each individual such as DuoFertility. Temperature-based monitoring BBT (basal body temperature) has been used since the 1930s to help women identify ovulation. Once ovulation has occurred, the natural chance of pregnancy is very small as the most fertile days are on the day of ovulation and just before. So only monitors which allow the woman to record other information can provide the necessary predictive power. page 12 of 18

13 Appendix A - Explaining the calculation methods and your graphs Your chances of successful IVF has been calculated using three methods: 1. method detailed in Templeton A, Morris JK, Parslow W (1996)Factors that affect outcome of invitro fertilisation treatment. Lancet 348: method detailed in Nelson SM, Lawlor DA (2011)Predicting Live Birth, Preterm Delivery, and Low Birth Weight in Infants Born from In Vitro Fertilisation: A Prospective Study of 144,018 Treatment Cycles PLoS Med 8(1): e doi: /journal.pmed IVFPredict. 3. using a direct comparison of patients from the entire HFEA database matching your situation (from over 874,000 IVF cycles). The HFEA database has recorded the anonymous details of every IVF patient in the United Kingdom since See The Templeton model (method 1 above) is likely to be the least accurate and is based on a model from a small dataset, the IVFPredict model (method 2 above) is likely to be more accurate and uses a model based on HFEA data whilst our calculation (method 3 above), which compares the chances of success with people matching your situation using the most up-to-date HFEA data, is likely to be the most accurate. Explanation of the charts The top of the dark blue solid bar shows your chances using our calculation directly from the HFEA dataset (method 3). The lower dashed line (if present) shows the lowest chance calculated from the three methods and the higher dashed line shows the highest chance calculated from the three methods (including uncertainty in the calculations). maximum chance chances from HFEA minimum chance Increasing chance of successful IVF cycle page 13 of 18

14 Appendix B - Fertility glossary Fertility brings with it a lot of references to procedures, medication and conditions. Read our helpful descriptions for the most commonly used terms. AMH test (for ovarian reserve) A simple blood test which measures the level of AMH (Anti-Mullerian Hormone), a hormone that is released by your ovaries. This can be used to estimate a woman's ovarian reserve (egg supply) to give an indication of how much longer they will be fertile and how successfully she may respond to IVF treatment. You can buy it here: Aneamia An Iron deficiency may cause problems with the thyroid and thyroid hormone levels. Such disturbances are linked with a higher risk of miscarriage and the reduced fertility. Blood-hormone pregnancy test A blood test that will confirm whether you are pregnant or not. The hormone measured by this test is Human Chloronic Gonadotropin hcg (a hormone very similar to LH). Body Mass Index (BMI) The Body Mass Index indicates if you are underweight, normal or overweight. It is calculated by dividing your weight (in kg) be the square of your height (in metres). Body basal temperature (BBT) The lowest temperature the body reaches while sleeping. Particular patterns of BBT can indicate which phase of the menstrual cycle a woman is entering and can therefore be used as an aid to conception. BBT is achieved after at least a couple of hours of deep sleep. Cervical mucus When you are approaching your day of ovulation, your cervical mucus adjusts the environment of your vagina to make it more welcoming to sperm. This is when you are most likely to notice an increased volume in mucus and a change in consistency. These secretions aid the migration of sperm and help to nourish them on their journey to the egg. Cervix The opening between the uterus and the vagina. The position of the cervix changes during the cycle. It is closed, low and firm during the infertile phase, and becomes open, high and soft during the fertile phase. page 14 of 18

15 Clearblue ovulation tests Urinary test to measure the level of LH which should increase just before ovulation. These tests typically give you 1-2 days to have intercourse. You can buy them here: Clearblue Fertility monitor Computerised monitor telling you when to do a urinary LH test, and will generally give you 4-5 days when you are fertile. The monitor doesn't predict into the future when this will happen and doesn't confirm ovulation. You can buy them here: Clomid (clomifene) Clomid can be given to regulate hormones such as oestrogens even when the cycles are regular. Most doctors would prefer to prescribe Clomid which will support adequate production of progesterone in the luteal phase and also regulate the hormones in the first half of the cycle. Corpus luteum This is formed as the result of the changes occurring to the ovarian follicle following ovulation. Its function is to secrete progesterone which is extremely important for conception as it prepares the lining of the uterus to receive the embryo. DuoFertility monitor Sensor worn under the arm to measure temperature while your sleep, with a computerised monitor to analyse the results. The monitor will give you 5-6 days notice on your 4-5 most fertile days and confirms ovulation. A fertility advisory service is provided to assist in the interpretation of your measurements. You can buy from here: Fallopian tubes The tubes (ducts) through which the egg travels from the ovaries to the uterus once it is released. The egg is usually fertilised by sperm here. Fertile window The phase of the menstrual cycle that is most favourable for conception. It usually begins a few days before ovulation and ends the day after ovulation. Flare protocol Name of one of the protocols (treatments) given to a woman to stimulate the ovaries to produce several eggs, this is usually used before and IVF cycle. For this protocol, the medication starts 2 days after the start of menstruation. FSH or follicle stimulating hormone A pituitary hormone which stimulates the development of the ovarian follicles in women and the production of sperm in men. This hormone is often used in IVF cycles to induce the production of many eggs. This hormone can also be measured in your blood to assess your ovarian reserve. You can buy the test here: page 15 of 18

16 Gonadotrophins Group of hormones involved in the reproductive system including LH and FSH. GnRH agonist Name of one of the protocol (treatment) given to a woman to stimulate the ovaries to produce several eggs, this is usually used before and IVF cycle. The GnRH agonist protocol is also called the "long protocol", and is usually started the week before the start of the menstruation. GnRH antagonist As for the GnRH agonist, it refers to an IVF protocol. It can also be called the 'short protocol'. Hormone A chemical substance which is produced by an endocrine gland and is then released into the bloodstream. Implantation The "embedding" of the embryo in the uterine tissue, allowing it to establish contact with the mother's blood supply for nourishment. Implantation usually occurs 5 to 10 days after fertilisation. IVF treatment or in vitro fertilisation A fertility treatment involving the collection of the egg and the sperm and the fertilisation of the egg in a test-tube or Petri dish. Once fertilised, the egg is replaced into the woman's womb. IVF literally means 'fertilisation in glass'. ICSI Intra-cytoplasmic sperm injection is an in vitro fertilization procedure in which a single sperm is injected directly into an egg. This is often used in the case of male factor infertility. LH, or luteinising hormone A pituitary hormone which stimulates the gonads. In women, LH induces the production of estrogens by the ovaries and the high levels of LH mid-cycle trigger the release of enzymes which allow the egg to be released from the follicle (ovulation). Libido Sexual desire. Luteal phase The post-ovulatory phase of the menstrual cycle. During this phase, the corpus luteum (or yellow body) produces progesterone, and the endometrium (uterine lining) thickens to support the implantation and growth of the embryo. page 16 of 18

17 Menstrual cycle The period of time lasting from the first day of your menstruation to the day before your next menstruation (period). During each menstrual cycle, an egg is usually released. Menstruation or period The cyclical shedding of the endometrium (uterus lining), which occurs about two weeks after ovulation. Oestrogens The group of female sex hormones. The principal oestrogen involved in fertility is oestradiol. Oestrogens are mainly secreted by the ovaries, but they can also be produced by adipose tissue (fat). Ovarian follicle A fluid-filled structure inside the ovary which contains the egg. During each cycle, an egg develops within a follicle inside the ovary. This follicle grows up to 2 cm in diameter until it is ready to release the egg. Ovarian reserve AMH is produced by follicles developing within the ovaries which contain immature eggs. The process of a follicle maturing into an egg that is then released at ovulation takes several months. To ensure a woman can ovulate regularly, there are follicles at every stage of development within the ovaries. The amount of AMH present is related to the number of follicles which are developing and so this is why the test can be used as a guide of ovarian reserve since these numbers decrease as a woman approaches the menopause. FSH is another hormone that can be used to asses ovarian reserve. You can buy the tests here: Ovulation The release of the egg from the ovarian follicle. This occurs between the follicular and the luteal phases of the menstrual cycle. PCOS Polycystic ovary syndrome is a condition affecting many women. In some cases it can also affect fertility. It is an endocrine (hormonal) disorder due to high levels of androgens. It can cause irregular cycles and problems with ovulation. Pituitary A gland located at the base of the brain near the hypothalamus. The pituitary secretes several hormones including gonadotrophins (LH and FSH) in response to the hormonal stimulation of the hypothalamus (GnRH). page 17 of 18

18 Progesterone The hormone produced by the corpus luteum after ovulation and during pregnancy. It has a role in inhibiting the development of further follicles and in the thickening of the endometrium (uterus lining). It is secreted in a pulsatile fashion, and directly causes small changes in body temperature, which is the basis for the BBT method of ovulation monitoring. page 18 of 18