General Health and Diet

PATIENT INFORMATION IN VITRO FERTILISATION (IVF) TREATMENT CYCLE We will endeavour to start your treatment as soon as possible, but occasionally to ensure safety within the laboratory, and to always maintain our high standards, we may not be able to allow you to commence treatment immediately. You should only have to wait one month It is important that you do not become pregnant in a menstrual cycle in which you are taking hormonal drugs. Therefore from day 1 of the cycle on which you are starting treatment, You must only have protected intercourse (use a condom) If you have had unprotected intercourse in the same cycle that you are due to start taking the down-regulating drugs we will have to cancel your treatment due to the potential risks of these drugs to an early pregnancy. PRIOR TO TREATMENT General Health and Diet In the three months prior to starting any stimulation drugs we would advise that as a couple you should consider the following recommendations: SMOKING Smoking can be dangerous during pregnancy and can also decrease your chance of conceiving. Therefore it is imperative that neither of you smoke. ALCOHOL Alcohol should be kept to a minimum (less than 5 units per week) for both partners. CAFFEINE Caffeine intake should be reduced. Caffeine can be present in coffee, tea, cola and chocolate. DIET Simple dietary guidelines we believe to be helpful are to avoid snacking between meals (including healthy snacks i.e. fruit, muesli bars, fruit juices and smoothies). If you want to eat these types of foods add them into one of your 3 meals a day. Meals should always have some protein content i.e. fish, eggs, meat, cheese or pulses. Try to keep the carbohydrate content in each of your meals lower than the amount of protein e.g. Instead of a large bowl of pasta with small amount of protein, change and have a portion of meat or fish with small side helping of pasta or rice or potatoes. We also advise that you avoid soft cheese, pate, liver, sword fish and shell-fish from the day of treatment FOLIC ACID You should take folic acid 400 micrograms daily from 3 months before the scheduled treatment cycle. This is a Department of Health advice for all women wishing to conceive and not just for assisted conception treatment. This vitamin has been shown to reduce the chance of spina bifida and is available from chemists. You should continue with it for as long as you are trying to conceive and for the first three months of pregnancy. Also it is good advice to eat a balanced diet with plenty of vegetables and raw fruit. We would recommend taking folic acid combined in with a multivitamin product specific to pregnancy. 1 Next review: Mar 2013

WEIGHT Normal body weight for both partners will increase your chances of success. We will work out your body mass index for you and advise you whether you should lose weight. Equally a low body mass index can also reduce success. There are individual situations when it may not be possible to start treatment until there is a weight reduction. SCREENING We will need hard copies of the results of various tests to be in place and in date before you can commence treatment. A list of those will have been sent to you with your initial consultation documentation. They need to be repeated annually. Your GP may possibly help with screening but if this is not possible, we can arrange all your screening to be done here. DURING TREATMENT MILK We advice all women to drink 2 litres of water and in addition up to 1 litre of milk per day from the beginning of the period in which they are commencing treatment. This will ensure that you are well hydrated and have a good intake of protein and calcium. It has been suggested that this may improve pregnancy rates. DIET AND FLUID It is important, particularly during the stimulation drugs, that you drink plenty of fluid. This can help with the prevention of the onset of ovarian hyperstimulation. EXERCISE Gentle exercise during treatment is good. Please avoid high impact exercise. Walking, Pilates, yoga etc are an excellent way of keeping mobile. Swimming is also excellent although probably not advised following embryo transfer. There is a small study that has shown an increase in miscarriage rate possibly following infection picked up in public pools. Please ask a nurse if you are uncertain what you should or shouldn t do. ALTERNATIVE THERAPIES Please avoid all Chinese medicines and some aromatherapy oils during treatment. Some of the medicines may actually be harmful, as are certain oils used for aromatherapy. Many of our patients have acupuncture and we have information in the waiting room. Please help yourself. We would recommend that carrying on with as normal life as possible will help you both to keep the balance of treatment in perspective. Taking lots of time off work is not necessary unless there is a clinical indication to do so. We will advise you when that is recommended. Remember that you may need to have fresh IVF more than once. Many couples will need at least 3 cycles of fresh treatment before they achieve an ongoing clinical pregnancy. 2 Next review: Mar 2013

What to expect during your treatment cycle PRE-TREATMENT ASSESSMENT SCAN It is important that all aspects of tailoring your treatment are undertaken to give you optimal chances of success. Before you commence your first treatment cycle a pelvic assessment scan will be undertaken. This allows us to look at your ovaries in order that we are more able to judge the correct dosage of stimulating drugs you will require. We will also look at your womb and asses the uterine cavity to exclude fibroids and any other anomalies. This is a chargeable scan and not part of your cost of treatment, however it will usually only need to be done once. This scan is particularly helpful for those patients who may have polycystic ovaries and require other oral medication during the treatment cycle. IMPLICATIONS APPOINTMENT Anyone seeking treatment here will be required to come in to the clinic for an information session covering all aspects of their treatment. This appointment is with one of our fertility nurses, and is arranged for either a Tuesday or Thursday. Couples will need to attend together. You should expect to be here for at least 2 hours, and you will have a chance to ask questions. CONSENT Prior to commencing treatment, consent forms must be signed. There are several consent forms to sign. These include taking consent for treatment by IVF by the surgical procedure of egg collection. There are also Human Fertilisation and Embryology Authority (HFEA) consent forms to be completed regarding the use and storage of gametes and embryos. You will be given plenty of time to read and ask questions about all consent forms before signing. A Nurse will guide you through the consents so that you fully understand the documents you are signing. TREATMENT PLANNING APPOINTMENT Once all consent forms have been completed and we have hard copies of all your tests we can plan your treatment for you. You will need to contact us when your period starts, to book this appointment which will also be arranged for either a Tuesday or Thursday. The appointment will last approximately 30 minutes. It is at this appointment that you will be given your treatment plan and we will teach you how to do your injections. Sometimes we will combine this appointment with your Implications appointment. DOWN-REGULATION INJECTIONS Down-regulation drugs switch off the pituitary gland, which produces Follicle Stimulating Hormone (FSH) and Luteinising Hormone (LH). By doing this it ensures that the eggs are not released from the follicles before they are collected. This allows for more control over the development of the follicles. The most common drug that we use for down-regulation is called Buserelin but there are alternatives. Down-regulation drugs are short-acting and therefore need to be taken regularly and at the same time each day. Buserelin is usually started on day 21 of your cycle and the dose is 0.5ml daily. We advise that you give this injection in the evening and before 8pm. Before starting this medication it is important that you do not become pregnant. Therefore intercourse must be protected (i.e. use condoms). This is because you would start your 3 Next review: Mar 2013

medication before you would know if you were pregnant and we do not know how the drugs used may affect a developing foetus. It is important to continue with the down-regulation drugs until instructed to stop by the nurse, (which will be 2 days before your egg collection). You should expect a period to start at about your normal time, if you have not bled we still wish to see you for the baseline scan appointment. SIDE EFFECTS OF DRUGS Down-regulation drugs work by suppressing the production of hormones from the pituitary gland in the brain, which stimulate the ovaries to develop the follicles. After approximately 14 days administration of these drugs the normal function of the ovaries will be switched off. However, once the ovaries are switched off and the oestrogen levels in the blood are low, some women experience symptoms. These include hot flushes, feelings of depression, irritability and headaches (it is alright to take Paracetamol). Whilst taking down-regulation drugs the period may be different (sometimes lighter, but also may be heavier). These symptoms usually stop when the FSH injections start. BASELINE ULTRASOUND SCAN Attend for your baseline ultrasound scan as instructed on your treatment plan, the scans are performed with a vaginal probe and therefore a full bladder is not required. This scan will be performed even if you are still bleeding. If your scan shows any persisting cysts or follicles in the ovaries, or if the lining of the uterus (endometrium) is too thick your cycle may be delayed and you will be advised to continue with the down-regulation drugs for a further 5 to 7 days when the baseline scan will be repeated and re-assessed. Sometimes a blood sample for the hormone Oestradiol may be collected at the same time to give us further information. Occasionally, if the down-regulating drugs have not had the desired effect the treatment cycle will have to be stopped and reviewed by the consultant. FOLLICLE STIMULATING HORMONE (FSH) INJECTIONS Once the baseline scan has confirmed that the down-regulating drugs have been effective the nurse will confirm the day to start the FSH injections and also the dose to take. The starting dose of the drug will have been decided in advance by your consultant and will depend on your age, baseline hormone results and responses to previous stimulated cycles. FSH is usually prescribed as Menopur although there are alternatives. You will be given a medication chart to take home with this information in writing remember to bring this back with you to each scan for the nurse to write down the continuing dose which will depend on your response. These injections should also be at the same time each evening. CONTINUED FOLLICLE MONITORING (Progress scans) In order to monitor the response to FSH injections you will need to attend for further scans on certain days. Some of these appointments for scans are possible to predict in advance, but please do be prepared to have to alter days of scheduled attendance if the response to the injections is not as we had predicted. We will use the results of the scans (and possibly blood tests) to adjust the dose of FSH injections and to determine the date and time of the trigger injection of Human Chorionic Gonadotrophin (hcg). This injection of hcg matures the eggs within the follicles and MUST be given at a set time, 36 hours prior to egg collection. This information will be given to you on the same day as your final scan. 4 Next review: Mar 2013

HORMONE BLOOD TESTS On some days you may need to have blood taken for hormone (Oestradiol) assessment. This gives us further information to be able to assess whether your ovaries are responding appropriately to the drugs. This blood test will be taken after your scan and we will contact you later in the day once the consultant has reviewed the information and decided whether or not the dose of the FSH injections should be changed. PLEASE ENSURE WE HAVE UP TO DATE CONTACT INFORMATION SIDE EFFECTS OF DRUGS The FSH injections stimulate the production of follicles and hormones within the ovary. Whilst receiving these injections some women experience breast tenderness, increase in vaginal secretions and abdominal distension. If their ovaries over respond, this abdominal distension may be considerably more uncomfortable. Sometimes the injections cause local skin irritation. The majority of women do not experience any side effects, and if they do they are usually short lived and will cease when the treatment is finished. Occasionally the ovaries will respond much more than anticipated and there will be a risk of developing Ovarian Hyper Stimulation Syndrome (OHSS) See OHSS section THE EGG COLLECTION Your egg collection will probably be on or about the day that we have planned for, but the precise day may vary according to how your ovaries respond to the FSH injections. The final decision will be taken at least two days before the egg collection. Please be aware that we have 4 Consultants. Any of the 4 Consultants may carry out the egg collection procedure and / or embryo transfer procedure. All of our Consultants are very experienced in the field of IVF. On the day of your egg collection you must not have anything to eat or drink from midnight of the preceding evening. You should report at the arranged time (usually 7am) to the receptionist in the main reception. You will be escorted to your room by the ward clerk. The ward nursing staff will perform routine pre-operative checks and you will be seen by the anaesthetist prior to transfer to the operating theatre. A member of ACS staff will also see you before you go to theatre. The egg collection is normally performed under general anaesthetic. The operation time is about 30 minutes and the eggs will be collected by performing vaginal scanning and needle aspiration of the eggs through the vagina. Very occasionally no eggs are obtained but usually we are aware there has been poor ovarian response and we have discussed this possibility with you prior to the egg collection. At the time of the egg collection in theatre, you will be given antibiotics (Metronidazole and Cefuroxime) which are to decrease the risk of pelvic infection. If you are allergic to these antibiotics please inform us. After the egg collection you will be observed in the recovery area in the operating theatre suite and then return to the ward about 30 minutes later when the anaesthetist is happy with your recovery. You should be able to go home approximately 4 hours later. Please note that you should have a responsible adult to escort you home and stay with you overnight and you will not be fit to drive a car for 24 hours due to the general anaesthetic. 5 Next review: Mar 2013

You may notice some vaginal bleeding but this should not be excessive. If you need to stay in hospital overnight for medical reasons, no extra fee will be charged. Prior to being discharged you will be seen by a nurse from the Victoria Wing and an embryologist do not leave until this has happened. THE SEMEN SAMPLE The male partner will need to produce a semen sample on the day of the egg collection, having abstained from ejaculation for 2 to 3 days before. The embryologist will ask the man to produce his sperm sample at some point during the morning of the egg collection. If you feel there may be difficulty in producing the sample please let us know so that we can arrange for a sample to be produced and stored before the egg collection. If we are using frozen sperm or surgically retrieved sperm then you will be advised of the quality of this sample on the day of the egg collection. HORMONE SUPPORT AFTER EGG COLLECTION (LUTEAL SUPPORT) Following the egg collection your body needs the hormone Progesterone to maintain the endometrium. This is usually given as progesterone (Cyclogest) pessaries 400mg which need to be given twice daily into the rectum or vagina. Occasionally progesterone is given as an intra-muscular injection. Alternatively, we will prescribe hcg as luteal support. This stimulates the ovaries to produce their own progesterone and can be the preferred option when fewer eggs have been collected and the Oestradiol level is not raised excessively. hcg is usually prescribed as Pregnyl. DAY AFTER EGG COLLECTION The embryologist will telephone you on the morning after the egg collection to inform you of the number of eggs that have fertilised normally i.e. number of embryos. Unfortunately, occasionally none of the eggs fertilise and transfer cannot be performed. It is vital that we have a current up to date contact number for you. THE EMBRYO TRANSFER In the days following the egg collection, the embryologists will keep you informed about the timing of your planned transfer. Please be aware that this may be a provisional day and time as the embryologists may advise extended culture of embryos in order to be able to make the best decision on which embryo to transfer. You should report directly to the Victoria Wing at the arranged time. Embryo transfer is usually a simple painless procedure lasting 5 to 10 minutes and does not require a general anaesthetic or full bladder. The nurse will escort you to the Treatment room and ask you to prepare as you would if you were having a smear test. The embryologist and consultant will and ask you to confirm your full name and date of birth. We have a rigorous witnessing procedure that ensures that each stage of the movement or use of egg, sperm or embryo(s) will be witnessed by two members of staff The embryologist will now tell you about the development and quality of your embryo(s) and the final decision can be made about the best number of embryos to transfer. If you are in the category of patients which we consider to have a very good chance of becoming pregnant we will transfer one embryo only. If not, then up to a maximum of two embryos will be transferred. Patients who are over 40 years old may, legally have three 6 Next review: Mar 2013

embryos transferred but in many cases we do not recommend this. Your consultant will have discussed this with you prior to embryo transfer. The chance of any embryo implanting is dependant on a variety of factors including age, quality of embryos and any other relevant history, i.e. previous pregnancy. When making this decision we are balancing the chance of a pregnancy with the risks of a multiple pregnancy (see risks of multiple pregnancy section) You will be able to see the embryo(s) chosen for transfer on the monitor EMBRYO STORAGE Prior to commencing treatment we will need to know whether or not you would wish to freeze and store any excess embryos. If you wish for embryo storage, the embryologists will discuss the best stage for embryo storage, depending on the exact circumstances. Please note that embryo freezing, storage and subsequent replacement is not included in the IVF fee. For more information see patient information sheet on embryo freezing. If we feel you are at risk of developing moderate or severe Ovarian Hyper Stimulation Syndrome (OHSS) we will probably discuss freezing and storage of all suitable embryos and the transfer of embryos in a subsequent cycle. FOLLOW UP We will advise you when to do your pregnancy test (11 to 14 days after embryo transfer). Please be aware that Cyclogest pessaries may delay your period from starting even if you are not pregnant. It is therefore important to do the pregnancy test on the correct day. During this time you may experience increased discharge from the vagina and some low abdominal pain. If you have any concerns about any symptoms you are experiencing contact the ACS unit. Please do not use commercial pregnancy tests as these are not as accurate and can be misleading. As a requirement of HFEA you must inform the ACS unit (Victoria Wing) of the outcome of your treatment cycle and the outcome of pregnancy. Please ensure you contact a member of staff with this information. If the pregnancy test is positive you will be offered a scan to check the pregnancy. At this scan we hope to see a viable, intrauterine pregnancy. Unfortunately about 15% of pregnancies will miscarry and there is a chance of an ectopic pregnancy. You will need to continue cyclogest pessaries from positive pregnancy test until at least 12 weeks of gestation. If multiple pregnancy is confirmed at 6 7 week scan, Cyclogest continues until 28 weeks gestation. If you were given hcg as luteal support you will need to commence taking Cyclogest following a positive pregnancy test. HELP LINE The fertility unit is staffed Monday to Friday from 07.30 to 17.30 hrs. Outside these hours an answer phone is used. If leaving a message please inform us of the day & time message was left. If there is an Emergency a member of the team is always on call and can be contacted via the unit mobile 07740422717, or via the main hospital switchboard 01483 227800 7 Next review: Mar 2013

OVARIAN HYPER-STIMULATION SYNDROME (OHSS) If the ovaries over respond to the FSH injections and a large number of follicles develop there is a risk that OHSS may develop. When there are a large number of follicles it is possible that the ovaries will enlarge and release chemicals into the bloodstream that make blood vessels leak fluid into the body. OHSS is classified as Mild, Moderate or Severe. If there are signs of moderate to severe OHSS prior to the egg collection you may be advised not to have the trigger injection, and must not have unprotected intercourse (use a condom), your egg collection will be cancelled and you must continue on the downregulation drugs until all the follicles have collapsed. Once this has happened, a new cycle of treatment with a lower dose of FSH injections can be restarted. If at egg collection a large number of eggs are harvested we may advise that all suitable embryos are frozen and stored, to be transferred at a later date. This is because the hormone produced when a pregnancy occurs will exacerbate any OHSS already present. Therefore it would be unwise to transfer an embryo until all of the follicles have collapsed and the hormone levels returned to normal. The stored embryos would then be thawed and transferred at a later date. Some patients could still develop OHSS in the two weeks after their egg collection. The majority will develop a minor or moderate form of the condition; their ovaries become enlarged with multiple cysts and ascites (fluid in the abdominal cavity), causing abdominal discomfort. The most severe form of OHSS only occurs in 1 1.5% of patients receiving fertility injections. It is characterised by nausea, vomiting, ovarian enlargement and ascites, causing marked abdominal pain and distension. The abdominal distension may prevent the proper movement of the diaphragm (the muscle between the chest and abdomen) so that the woman may feel extremely breathless. She may feel weak and faint due to a reduction in her circulating blood volume (hypovolaemia). In the most extreme situations there is a reduction in the blood flow through the kidneys, resulting in a reduction in urine output. If this occurs it may lead to renal failure requiring treatment with renal dialysis. Those women who develop severe OHSS require hospital admission, usually for a few days, occasionally for longer, to relieve their symptoms and to monitor their progress. Management of severe OHSS may include aspiration of some ascitic fluid from the abdominal cavity. It will include maintaining the circulating blood volume by administering intravenous fluids, which will also substitute the fluids lost by vomiting. OHSS symptoms can be exacerbated by pregnancy but usually do not persist after the first three months when the hormone production supporting the pregnancy shifts from the ovaries to the placenta. In the majority of cases the symptoms disappear within a few weeks. Those patients who are not pregnant recover much more quickly, usually by the time they have their next period. The Symptoms you should be concerned about are as follows: Abdominal bloating and discomfort Heartburn or indigestion Reduced frequency of passing urine (we advise drinking 2 litres water daily) General feeling of lethargy Difficulty in breathing If you have any of these symptoms please do not hesitate to contact a member of the Victoria Wing nursing team on our 8 Next review: Mar 2013

EMERGENCY CONTACT NUMBER 07740422717 If admitted to hospital give the OHSS card immediately to the nursing staff. RISKS OF MULTIPLE PREGNANCIES A multiple pregnancy is where 2 or more foetuses develop in the uterus at the same time. Twins or a higher order pregnancy can undoubtedly bring many joys, but both parents need to be realistically prepared for the possibility of potential problems. A multiple pregnancy will place a much greater strain on the mother and carries a higher risk of miscarriage. Complications (such as high blood pressure or bleeding) are more likely to occur and can arise earlier in the pregnancy. Most multiple pregnancies are delivered early (before 40 weeks). The average length of pregnancy is 37 weeks for twins and 34 weeks for triplets. There is a high rate of caesarean section for twin pregnancies and the majority of triplets are delivered in this way. The birth weight of twins and triplets is generally lower than that of singletons. Any pre term baby is more likely to die than one who is born at full term, so twins and triplets are at much greater risk than singletons. Babies who are born very prematurely are also more likely to have complications which can lead to long term problems in the functioning of their lungs or heart and, in particular their brain. The problems of caring for more than one baby can be considerable and include emotional as well as financial aspects. There are no additional state benefits for multiple births in the UK, yet the every day costs are much greater. The cost of nursery equipment, clothes, food and childcare is inevitably substantial and many mothers who hoped to return to work after the birth have found the cost of childcare makes this financially nonviable. Many parents own physical and mental health suffers as a result of caring for twins or more. Depression is more likely and this, like other problems, can affect their relationships with each other, the wider family or friends. Your consultant and nurse counsellor will discuss these issues with you further but if you have any questions please do not hesitate to ask. For those who are younger, who already have a child or children or who want to minimise the chances of a multiple pregnancy, we would normally transfer a single embryo. We believe that more couples should be opting for single embryo transfer in these circumstances. The clinical team will be able to advise you of our recommendations throughout your treatment. We suggest you look at the following website for further information: www.oneatatime.org.uk You can also contact the Multiple Birth Foundation: www.multiplebirths.org.uk With any pregnancy there is a small chance of ectopic pregnancy (3%) The risk of miscarriage is 15% in singleton pregnancies of rising to 21% in triplet pregnancies. If three embryos are transferred, the chance of a triplet pregnancy is dramatically increased as is the chance of miscarriage. 9 Next review: Mar 2013

COUNSELLING Our team at the Victoria Wing will give support, before, during and after treatment, providing information and implications counselling and guidance to explore relevant issues. Undertaking treatments can be an emotionally stressful time for you and your partner and it can help to talk things over with someone else. We provide a Counselling Service which is available to every couple or individual attending the Victoria Wing (first six sessions only are free of charge). This counselling is confidential and we would encourage that you make use of this service. Treatment where eggs are being donated or received or when donor sperm is being used will require a mandatory session with our counsellor before any treatment can commence. This is to ensure all legal aspects of donor gametes is fully understood by all parties involved in treatment COMPLAINTS If at anytime during your treatment you are not happy with the standard of care received, Please inform the ACS Manager or her deputy. If you feel you wish to complain, please write to the complaints officer: Mrs Carole Ingleby - Hospital Matron Nuffield Health Woking Hospital, Shores Road, Woking, Surrey. GU21 4BY We are constantly striving to achieve excellence within the department, however we appreciate that you may feel there are areas which do not come up to your expectations. We would like to know about this. We want your treatment to progress smoothly for you. 10 Next review: Mar 2013

What you Need to Know Before Treatment Begins Before commencing with the proposed treatment, please ensure you have been given the following information: The limitation and possible outcomes of the proposed treatment. The possible side effects and risks of treatment. The technique involved. All alternative treatments. The costs involved and costs of alternative treatment. The availability of counselling facilities. The possible disruption to your normal life. Your general practitioner (GP) is not obliged to prescribe the medication you may require for your treatment. Please remember that all screening tests will need to be repeated on an annual basis. Treatment cannot take place with out of date screening. FEE STRUCTURE The IVF fee includes all scans, nursing services, egg collection, egg / sperm and embryo culture, embryo transfer, doctor s and anaesthetist fees, bed and theatre for one operation under GA. It also includes one pregnancy test and then either a follow up consultation or scan to confirm the viability of the pregnancy. The follow up consultation must be taken up within 6 months. It does not include: HFEA fee Pelvic assessment scan. Any investigation required before treatment. Drugs. Any additional procedures i.e. embryo freezing and storage, blastocyst transfer A second general anaesthetic for embryo transfer. Cost of treatment will be discussed with you before treatment starts at the information session with the nurse. We will be able to estimate what it will cost you as individuals, but please be mindful that drug charges are difficult to predict at the onset of treatment. Please see the separate price list for details. WHEN TO PAY Payment must be made in full prior to the treatment cycle commencing. Cheques should be made payable to Nuffield Health, and all major credit cards are accepted. We also offer you the facility for 'Banker's Automated Clearing Services' (BACS) which is a simple and cost effective way to make payments directly from your bank account to another bank account. For further information please discuss with our Accounts administrator The hospital will require details of a credit card before treatment starts, please discuss this with the ACS financial administrator if this is difficult for you. HFEA The HFEA (Human Fertilisation and Embryology Authority) are the government body that regulate IVF in the UK. The HFEA are notified of the outcome of each treatment cycle and this information is stored confidentially by the authority. At the age of 18 any child can request this information from the HFEA if they were conceived by IVF. 11 Next review: Mar 2013

IVF / ICSI FLOWCHART Semen analysis Patient initial consultation with consultant & nurse Nurse s implications counselling appointment Patient contacts unit at start of period for treatment plan Egg Collection hcg injection & prepare for Egg Collection Admission for Egg Collection Semen sample commence downregulation Yes Eggs collected NO Embryologist and consultant to discuss future management Re scan 1 week No day 14 Baseline Scan scan Commence luteal support Yes Commence stimulation Scan day 6 for follicular development Embryos formed Eggs inseminated /injected Embryo transfer Failed fertilisation? Consultant and patient informed Scan Scan EMU day 14 for outcome No Positive Negative Follicular criteria met? Yes Early pregnancy scan Team review or consultant consultation 12 Next review: Mar 2013

PATIENT INFORMATION SHEET FREEZING AND SUBSEQUENT REPLACEMENT OF HUMAN EMBRYOS TO BE READ WITH PATIENT INFORMATION SHEET FOR IVF / ICSI The following should give you some idea of what embryo freezing and frozen embryo replacement cycles entail. If you would like more details of any information mentioned below please ask one of the embryology team. Embryo freezing (or cryopreservation) is a method of storing embryos from an IVF or ICSI cycle for later use, by cooling and storing them at very low temperatures. During the freezing process the embryos are put into freezing solutions containing cryoprotectants to try and replace some of the intracellular (inside the cells) water to prevent ice crystal formation. Unfortunately, cells may still become damaged by the water inside the cells of the embryo forming ice crystals, which then expand and rupture the cell membrane. There are two methods of freezing embryos. These are known as slow freezing and vitrification. All the embryos are stored in liquid nitrogen vessels which are held at -196 C. Slow Freezing Slow freezing is a method of cryopreservation which has been used here since the clinic opened, and which has been used worldwide for over 25 years. The embryos are put into increasing concentrations of cryoprotectants and are then loaded into straws for storage. These straws are then put into a machine which slowly decreases the temperature of the embryos. Vitrification Vitrification is an alternative method of cropreserving embryos and blastocysts. The embryos are placed in a high concentration of cryoprotectants then loaded into very thin straws. These straws are immediately plunged into liquid nitrogen, this cools them very quickly. This method of cooling is so rapid that the water molecules within the solution containing the embryos are unable to form ice crystals. BENEFITS The main benefit of freezing embryos is that the woman may not require controlled ovarian hyperstimulation and egg collection in order to have a further embryo transfer. There may be enough frozen embryos for more than one attempt at frozen embryo transfer. DISADVANTAGES Some embryos do not survive the freeze / thaw process and occasionally no embryos survive. The other disadvantage is that as the best embryos or eggs are usually replaced in the IVF or ICSI cycle, the remaining embryos that are stored may have less chance to implant and the pregnancy rate is lower than in conventional IVF or ICSI. IMPORTANT POINTS TO UNDERSTAND The quality of embryos may not be good enough to allow freezing. Embryos that are frozen may not survive the freeze / thaw process. There is no guarantee that the transfer of thawed embryos will result in a pregnancy. The pregnancy rates are lower than in fresh IVF or ICSI transfer. 13 Next review: Mar 2013

Extensive experience in humans and animals has shown no evidence of an increase rate of foetal abnormality compared to natural conception or IVF or ICSI. CONSENT FOR EMBRYO STORAGE Signed consent for embryo storage must be obtained from both partners before the procedure. You will also need to specify the maximum number of years that you consent for the embryos to be kept in storage for. You may request disposal of the embryos at any time. Each year we will write to you and ask you whether you wish to continue storage of embryos and/or sperm. There will be a charge for each year of storage. This letter will be sent to the address we currently hold for you. Whilst we will endeavour to contact you it is your responsibility to ensure we have up to date information so that your embryos and/or sperm can remain in storage. If the fees are not paid we can choose to dispose of any stored sperm and/or embryos. When the storage period is coming towards the end we will contact you at least 6 months prior to ask you what you wish to do with the stored embryos and/or sperm. If there is no response the embryos and/or sperm will be disposed of at the end of the legal consent to storage. When embryos are in store and one partner withdraws their consent we will endeavour to contact the other partner to notify them of this. A period of 12 months from the withdrawal of consent will be allowed for the couple to reach a final decision (except if this period extends past the statutory storage period). If this cannot be resolved within this period the embryos will be discarded. 14 Next review: Mar 2013