Having a miscarriage can be very distressing. To have several miscarriages or a late miscarriage can be devastating.
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1% of all women suffer from recurrent miscarriages. There is strong evidence to support referral to recurrent miscarriage clinic and expert advice help to improve the reproductive outcome. There are gaps in the services offered on the NHS. Stress itself is a risk factor for miscarriage and recurrent miscarriage is a stressful condition so that the vicious cycle can be broken by strong psychological support.
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Women should be reassured of a successful future pregnancy with supportive care. P4 Fertility services in partnership with various Hospitals offer a unique opportunity for the women suffering from recurrent miscarriages to have bespoke services for recurrent miscarriages. Couples benefit from the option of having private care with evidence-based management, personalised approach and tender loving care.

The most commonly used test for ovulation is a progesterone hormone test. It is a blood test. After ovulation, this hormone is released by the ovary. After 7 days of ovulation (release of the egg) progesterone levels reaches to peak, which is 7 days before next expected period. Therefore progesterone test is advised on day 21 of the period based on the cycle length of 28 days. If the cycle is 30 days long, progesterone should be done on day 23. If cycles are irregular, sometimes, it is advised on two occasions in a cycle. Value more than 20, normally indicates ovulation (always check local laboratory standards and reference range). Another reliable test for ovulation is use of ultrasound to check the growth and release of follicle. It is expensive as compared to blood test.

Fertility hormone tests are blood tests. FSH (follicular stimulation hormone) and LH (luteinising hormone) are the hormones released by the pituitary gland (a part in the brain). FSH travels through the bloodstream to the ovaries where it stimulates the growth of follicles. A normal FSH level is somewhere between 2 and 8.9, this is enough to support the growth of one follicle and is how nature normally limits us to singleton pregnancies. FSH levels vary through the cycle it must be measured in the first few days of menstruation (day 2-5 of the cycle). When bleeding starts is considered as day 1 of the period. Estradiol is an ovarian hormone. It is tested along with FSH and LH. It helps to understand whether low FSH is a result of high estradiol or low production of FSH by pituitary.

AMH gives an idea of number of eggs in the ovary. Broadly speaking AMH = quantity of eggs in the ovary (high value of AMH, high number of eggs) Age= quality of eggs. (Higher the age, lower is the quality) The stimulation protocols are based on age and AMH results. At p4 fertility, we analyse all factors including AMH and age to personalise the IVF protocols.

No. AMH is not a good predictor for chances of natural conception.

AMH test is a blood test which can be done at any time during the cycle. AMH is a hormone produced by the growing follicles in the ovaries and is a direct marker of the number of follicles. Therefore, it is used as an ovarian reserve marker. AMH varies with age. Normal levels are interpreted with age. AMH <5pmol/ml is considered as a poor ovarian reserve. Lower levels are indicative of poor reserve and higher levels associated with, but not diagnostic of, polycystic ovaries. AMH varies less through the period cycle and so can be measured at any time. AMH should not be measured with long term use of contraceptive pills, it may show lower levels than normal.

SSR is a relatively low-risk procedure. Possible complications include bruises, haematoma (collection of blood in testis), infection and anaesthetic risks. Anaesthetic side effects include postoperative nausea and vomiting (usually, last for 1-2 hours and can be controlled with medications), postoperative shivering, chest infection (very rare with sedation anaesthesia), awareness (becoming conscious during some part of operation; most patients who are aware do not feel any pain, but may have memories of events in the operating theatre), allergic reaction to the anaesthetic, very rarely anaphylaxis (risk is 1 in 10,000), risk of death or brain damage during anaesthesia (in general the risk is 1 in 100,000 but should be even rarer in sedation for minor procedures such as SSR. After your procedure o Please wear reasonably tight-fitting underpants rather than boxer shorts after your procedure. This will provide some support to your scrotum. o Showering is preferable to sitting in hot baths to prevent infection. o Sexual activity is NOT advised for a week after the procedure.

The sperm retrieved are used on the same day if it is a fresh cycle of IVF / ICSI or sperm can be frozen. The freezing process does not affect the ability of the sperm to subsequently fertilise an egg. However, the sperm retrieved are usually low in numbers, may not be mature and therefore cannot successfully fertilise an egg using standard IVF (In Vitro Fertilisation) technique. Because of this, the embryologist will pick out a single sperm to inject into each egg and this procedure is called ICSI (Intra Cytoplasmic Sperm Injection). It is also possible that no sperm at all will be obtained.

There are a few different types of SSR, and the cause of the sperm problem will determine which procedure is most suitable for you. With P4 Fertility, the most suitable method for you would be discussed based on your reports. PESA (Percutaneous Epididymal Sperm Aspiration) PESA is a short, relatively painless procedure and requires no surgical incisions. A fine needle is inserted into the epididymis through the scrotum and fluid aspirated. This fluid is then inspected under a microscope for sperm count and motility. The procedure takes about 15-20 minutes. TESA (Testicular Sperm Aspiration) TESA is performed if no sperm are found in the epididymal fluid. This is a short, relatively painless procedure and requires no surgical incisions. A fine needle is inserted into the testes and tissue aspirated is then examined for sperm similar to PESA procedure. TESE / Testicular biopsy is performed if no sperm are found in the PESA and TESA procedure. A small incision is made into the testis itself. A small sample of testicular tissue is taken which is examined for sperm. This procedure will cause some pain and tenderness; however, full recovery is expected within a few days. If necessary, the tissue will be sent to the histology laboratory to obtain full biopsy report.

SSR is intended to help men who have no sperm in their ejaculate. This can be the result of several causes: a blockage in the vas deferens (the tube which carries the sperm to the penis); an absent vas deferens; or a blockage in the epididymis, (the structure connecting the testis to the vas deferens.) Most of these men produce healthy sperm in the testicles which can be retrieved by SSR. Unfortunately, some men have testicles that fail to produce any sperm at all (this is called primary testicular failure) and SSR is not a suitable procedure for this condition.

SSR is a technique for collecting sperm from a man’s testicles. It is a minor procedure, carried out under local anaesthetic or as a day case under heavy sedation.

AMH gives an idea of a number of eggs in the ovary. Broadly speaking AMH = quantity of eggs in the ovary (high value of AMH, a high number of eggs) Age= quality of eggs. (Higher the age, lower is the quality) The stimulation protocols are based on age and AMH results. At p4 fertility, we analyse all factors including AMH and age to personalise the IVF protocols.

All women over 40 and younger women with the low ovarian reserve are advised to take at least 6-8 weeks of DHEA supplementation before starting IVF. DHEA dosage for fertility is 75mg daily, which is split into three 25mg doses. Peak effect is seen after 12 weeks of supplementation. As mentioned above there is no evidence to support DHEA in poor responders.

It is normal to have some mild discomfort after egg collection. If you are worried or develop any of the symptoms below, you should seek medical advice. OHSS can range from mild to severe: • Mild OHSS – mild abdominal swelling, discomfort and nausea. • Moderate OHSS – symptoms of mild OHSS, but the swelling is worse because of fluid build-up in the abdomen. This can cause abdominal pain and vomiting. • Severe OHSS – symptoms of moderate OHSS with extreme thirst and dehydration. You may only pass small amounts of urine which are dark in colour and/or you may experience difficulty breathing because of a build-up of fluid in your chest. A serious, but rare, the complication is the formation of a blood clot (thrombosis) in the legs or lungs. The symptoms of this are a swollen, tender leg or pain in your chest and breathlessness. You should report any unusual symptoms to your doctor.

AMH action in the ovary is like a double edge sword. On one hand, it suggests a high reserve. On the other hand, it holds the follicles in the ovary and not let it come out. High levels of AMH suggests a high number of eggs are ready to come out, however, during the treatment cycle, few eggs come out. This happens when AMH is higher than the dose of stimulation medication (FSH) could make follicles free from AMH action. AMH holds follicles like someone holding the bunch of balloons. If FSH doses is not sufficient (which happens due to clinicians’ fear of OHSS), or cycle is coasted, the result is poor quality and less quantity of eggs. When the stimulation dose is higher than AMH negative effect, the risk of hyperstimulation (OHSS) is higher as all balloons get released at once. Stimulation protocols for women with high AMH require true personalisation and use of multiple tricks to strike a right balance of quantity and quality. P4 fertility offers a truly personalised plan for their IVF patients.

AMH test is a blood test which can be done at any time during the cycle. AMH is a hormone produced by the growing follicles in the ovaries and is a direct marker of the number of follicles. Therefore, it is used as an ovarian reserve marker. AMH varies with age. Normal levels are interpreted with age. AMH <5pmol/ml is considered as a poor ovarian reserve. Lower levels are indicative of poor reserve and higher levels associated with, but not diagnostic of, polycystic ovaries. AMH varies less through the period cycle and so can be measured at any time. AMH should not be measured with long term use of contraceptive pills, it may show lower levels than normal.

Although no treatment can reverse OHSS, it will usually get better with time. Treatment is to help symptoms and prevent complications. This includes: • pain relief such as paracetamol or codeine • anti-sickness drugs to help reduce nausea and vomiting • an intravenous drip to replace fluids • support stockings and heparin injections to prevent thrombosis (a blood clot in the leg or lungs). Heparin injections for blood thinning should be continued for 7 days from the cure of your symptoms if you are not pregnant or until the end of the 12th week of your pregnancy. If your abdomen is tense and swollen because of fluid build-up, you may be offered a procedure known as paracentesis. This is when a thin needle or tube is inserted under ultrasound guidance into your abdomen to remove the fluid. You may be offered a local anaesthetic for this procedure. This treatment helps relieve discomfort and improve kidney function and breathing. Rarely, advice may be sought from a more specialist team which may involve anaesthetists and/or intensive care doctors.

Your doctor will ask you to describe your symptoms and will examine you. Besides, your doctor may: • Ask about how much urine you are passing and whether it is darker than normal (concentrated) • Measure your blood pressure, pulse rate and breathing rate • Take an initial measurement of your waistline and check your weight to see whether the fluid is building up or reducing • Arrange an ultrasound scan to measure the size of your ovaries and to check whether there is any fluid build-up in your abdomen • Take blood tests to measure how concentrated your blood is and how well your kidneys are working. A diagnosis is made based on your symptoms, the examination findings and the results of your tests. If you are well enough to go home, you may be advised to attend for regular check-ups.

Negative side effects of DHEA are possible but rare, include: · Oily skin · Acne · Hair loss · Stomach upset Do not take DHEA when you are pregnant. Close monitoring of androgen and SHBG is necessary during DHEA supplementation. We strongly discourage women from DHEA self-supplementation.

In IUI, better quality sperm are separated from sperm that are sluggish, non-moving or abnormally shaped. These sperm are then injected directly into the womb. This may be performed with your partner’s sperm or donor sperm (known as donor insemination). It may be used in the treatment of: · Couples who are unable (or would find it very difficult) to have vaginal intercourse, for example, because of a physical disability or psychosexual problem. · People who need donor sperm but have no female fertility problems, including single women and same-sex couples. · Those who have a condition which means they need specific help to achieve pregnancy safely (for example, men who are HIV positive and have had sperm washing to reduce the risk of passing on the disease to their partner and potential child). · You may be offered IUI with your partner’ sperm if you have unexplained infertility, but the National Institute for Health and Care Excellence (NICE) advise against this, and, as a result, it is generally not funded by the NHS. If you have unexplained infertility and would prefer IUI rather than IVF you are likely to have to pay privately.

Your body naturally produces the hormone dehydroepiandrosterone (DHEA) in the adrenal gland. In turn, DHEA helps produce other hormones, including testosterone and estrogen. Natural DHEA levels peak in early adulthood and then slowly fall as you age. These hormones present in both sexes. These hormones are present in ovary and helpful for the production and development of eggs. In an infertility setting, particularly in conjunction with IVF, DHEA is thought to be useful to treat women with reduced ovarian reserve. However, research so far did not show any significant benefit.

We have done extensive research on poor ovarian response. You may see the research paper ….. Personalised IVF protocols and pre-treatment is the key as one size does not fit all. At p4 fertility, our focus is on personalised poor responder protocols- when, how, what doses, which medications for women with low egg count are low due to low DHEAS (adrenal origin) it may make sense to add DHEA supplement.

DHEA supplementation helps women with low reserve by increasing the androgen levels within their ovarian environments to a normal range. As their immature eggs develop to the ovulation-ready stage in the androgen-enhanced ovarian environment, it is claimed that these eggs mature into better-quality eggs. High-quality, healthy eggs develop into high-quality embryos, which have better chances of implantation and lower risks of miscarriage.

At p4 fertility, predictive and preventive care are two vital pillars to avoid any complications. To minimize the risk of developing OHSS, we predict the risk very carefully. The stimulation protocol and dosage of medications are chosen to minimize the risk of OHSS. However, despite the personalising protocol, to balance the success and risks, there is a small chance that ovaries will be hyper-stimulated. When we suspect the risk during monitoring of cycle, we use various evidence-based strategies to reduce the risk without compromising the chances of success. Freezing all embryos and use of agnostic (Buserline ) trigger injection are commonly used strategies to reduce OHSS risk.

Fertility drugs, usual gonadotrophins, are used to stimulate the ovaries during IVF treatment to make eggs grow. Sometimes there is an excessive response to these drugs, leading to OHSS. Overstimulated ovaries enlarge and release chemicals into the bloodstream. Fluid from the blood vessels leaks into your abdomen and in severe cases into the space around the heart and lungs. OHSS can affect the kidneys, liver and lungs. A very small number of deaths due to OHSS have been reported.

Ovarian hyperstimulation syndrome affects women taking injectable hormone medications to stimulate the development of eggs in the ovaries. Ovarian hyperstimulation syndrome is a potentially serious complication of fertility treatment, particularly of in vitro fertilisation (IVF). Too much hormone medication in your system can lead to ovarian hyperstimulation syndrome (OHSS), in which your ovaries become swollen and painful. A small number of women may develop severe OHSS, which can cause rapid weight gain, abdominal pain, vomiting and shortness of breath. Occasionally it may occur after oral medications such as clomiphene.

No. AMH is not a good predictor for chances of natural conception.

Ovarian hyperstimulation syndrome (OHSS) in IVF/ICSI cycles may occur either as an early (early-onset) or a late pattern (late-onset). When OHSS develops more than 10 days after egg collection in a cycle which had embryo transfer is called late-onset OHSS. This type of OHSS is difficult to predict, therefore, hard to prevent. Late-onset OHSS may indicate embryo implantation. Late OHSS nearly always occurs with pregnancy. OHSS develops as the hormones released by implanting embryo stimulates the ovaries. Late OHSS tends to be more prolonged and severe than the early form as there is ongoing hormonal stimulation from pregnancy.

Ovarian reserve tests are developed by IVF clinics to predict how a woman having IVF treatment would respond to the drugs used to stimulate the ovaries and ultimately how many eggs she may produce. Ovarian reserve can be assessed through blood tests to measure two important hormones: follicle-stimulating hormone (FSH) and anti-Müllerian hormone (AMH) or by an ultrasound scan that counts the growing follicles within each ovary. As all of these ovarian reserve marker tests have some limitations, P4 fertility, with its personalised and predictive approach, advice on appropriate ovarian reserve marker tests and its personalised interpretation. Every test, if not done correctly or not interpreted correctly may result in misinformation. Age is a golden predictor for the success of fertility treatment. The ovarian reserve markers should be combined for personalised prediction. We first time proposed the approach of combing age and AMH together for prediction. (Link to paper: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963310/ )

Many women can be managed as outpatients, but you may need admission if: • your pain is not helped by pain-relieving medications • you have severe nausea and vomiting • your condition is not getting better • you will be unable to attend hospital easily for monitoring and follow-up. If you are vomiting, you may need a drip to replace the fluids you have lost. The fluid will help to keep you hydrated and may contain sugar and carbohydrates (for energy), and minerals and chemical elements (for regulating and maintaining the organs in your body). It is important that, if you are admitted to a hospital which is not the one where you had your fertility treatment, your care is discussed and coordinated with a specialist in this condition.

There are three stages of eggs in the ovary at any given time for a fertile woman. The first stage is eggs which are in sleeping stage- these eggs do not respond to any stimulation and there is no test to find the number of these eggs. The second stage is eggs which are started to wake up but not ready to get stimulated in the cycle. During this stage, eggs may have some activity but they are not seen on an ultrasound scan as their follicle is small. Some of these follicles release AMH. The third stage is Antral follicle which could be seen on an ultrasound scan. Commonly called as AFC or antral follicle count. This stage follicles release AMH. These eggs are ready to get stimulated in the cycle. Therefore, useful ovarian reserve over the period of time is estimated by AMH. AFC explains the estimated eggs which can come out in the given cycle. FSH measurement is an indirect measure of the reserve, high FSH means low reserve. But being indirect measure and changing values during the menstrual cycle, FSH is not a reliable marker of the reserve. AMH levels are stable over a period of time and very slowly change. AFC may be different from cycle to cycle, depending upon a pool of eggs coming out from the first two stages. At P4 fertility, we personalise the reserve testing and when and how to stimulate.

• To lower the risk of developing a blood clot in your legs or lungs, you will be advised to continue wearing support stockings and taking heparin (blood-thinning) injections until 12 weeks of your pregnancy. • You may be at increased risk of developing pre-eclampsia or giving birth to your baby prematurely. However, there are no known risks to your baby’s development as a result of OHSS.

It is important to note that alone, DHEA for fertility is unlikely to be effective for women with a reduced ovarian reserve who are trying to conceive. Not all women have reduced androgen levels in the ovary. The individualisation of the protocols is the key. It is advisable to measure androgen levels and DHEAS levels to find out the origin of low androgen in ovary if at all it is present. If androgens in ovarian micro-environment are low due to low DHEAS (adrenal origin) it may make sense to add DHEA supplement.

It is a good question, as technically, one egg one sperm can make one baby. It is possible to have a baby with one good quality egg. However, recent research showed, there is a strong association between the number of eggs and chances of a baby; chances of having a baby at end of IVF cycle rise with an increasing number of eggs up to 15 (https://academic.oup.com/humrep/article/26/7/1768/2913935). An average number of eggs collected per cycle is 9. But the rise in quantity does not mean a rise in quality. Therefore the balance of quality and quantity is important which is what we aim for at p4 fertility.

No. It is not licenced in the UK. There is no research evidence to support its use. It is available as a food supplement on the internet.

Most of your symptoms should resolve in 7–10 days. If your fertility treatment does not result in a pregnancy, OHSS usually gets better by the time your next period starts. If you become pregnant, OHSS can get worse and last up to a few weeks or longer. What should I do if I have mild OHSS? If you have mild OHSS, you can be looked after at home. Ensure that you drink fluids at regular intervals depending on how thirsty you feel. If you have pain, take paracetamol or codeine (no more than the maximum dose). You should avoid anti-inflammatory drugs (aspirin or aspirin-like drugs such as ibuprofen), which can affect your kidneys. It is advisable to remain active to reduce the risk of thrombosis.

As with any fertility treatment, the younger the woman is the higher her chances of getting pregnant. You’re also more likely to get pregnant if you have fertility drugs to stimulate your natural cycle. For women aged under 35, about 18% of IUI cycles result in a healthy baby being born. Women aged 35 to 37 have a 14% success rate and the birth rate for women aged 38-39 is 12%. For women over 40, your chances are lower (5% for women aged 40 to 42 and 1% for women aged over 42). Many women will have several cycles of IUI before they have a successful pregnancy so it’s worth considering that when you’re thinking about the costs of treatment.

Low AMH does not mean anything more than the low ovarian reserve. It does not mean simply that there are low chances of success. As explained above, AMH measures pool of eggs including those not ready to get stimulated. Age predicts the quality and AMH predict the quantity. Therefore, at p4 fertility, the focus is on when to stimulate, how to stimulate and how to get maximum eggs which are ready to get stimulated for this group of women (low AMH). Low AMH tells clinician to personalise the strategy 9 rather than using standard approach) to get a good number of eggs out. Our truly personalised protocols help to get this right. We focus on the cycle to get a good number of eggs out with pre-treatment optimisation. We have good success rates for this group with AMH<5 pmol/l. We do not advise against treatment based on AMH alone.

Mild OHSS is common in women having IVF treatment; affecting as many as 33 in 100 women (33%). However, just over 1 in 100 women (1%) will develop moderate or severe OHSS. The risk is higher in women who: • have polycystic ovaries • are under 30 years old • have had OHSS previously • get pregnant in the same IVF cycle as they get their symptoms, particularly if this is multiple pregnancies (more than one baby).

Call for medical help if you develop any of the symptoms of OHSS, particularly if the pain is not getting any better or if you start to vomit, have urinary problems or chest pain or have difficulty breathing. You should have the details of your fertility unit to call for help and advice. If you are unable to contact your fertility clinic, contact: • The A&E department at your local hospital or • Your general practice or • The NHS on 111.

IUI allows the body to do more on its own than IVF, so it’s a more natural but also less successful form of treatment. In IUI, the highest quality sperm is selected and injected into the uterus where they are left to fertilise the eggs naturally. In IVF, the eggs are removed from the body and fertilised in the lab. This means that IUI is a less invasive procedure which involves fewer drugs than IVF. It’s also considerably less expensive – one cycle of IUI is typically a quarter of the price of one IVF cycle. However, IUI is also less successful than IVF. Once you’ve injected the sperm, you’re allowing the body’s natural processes to take over whereas in IVF you have more control – you can check the egg has fertilised and select the best embryo(s) to put back into the womb. Success rates for IUI are generally around a third of that for IVF.

Recurrent miscarriages and neural tube defects are potentially associated with MTHFR. The Genetic and Rare Diseases Information Centre says studies suggest that women who have two C677T variants are at an increased risk of having a child with a neural tube defect. Though there’s little evidence to support it, some doctors suggest taking blood clotting medications. Extra folate supplementation may also be recommended. At P4 fertility, we plan personalised care with the support of the latest available research. To discuss your condition please book an appointment.

The abbreviation “MTHFR” stands for methylenetetrahydrofolate reductase. A genetic mutation may lead to high levels of homocysteine in the blood and low levels of folate and other vitamins. There’s been a concern that certain health issues are associated with MTHFR mutations.

Sometimes there is a reason found for recurrent and late miscarriage. In other cases, any underlying problem is not found. Most couples are likely to have a successful pregnancy in the future, mainly if test results are normal. Several factors may play a part in causing recurrent and late miscarriage: • Age: The older you are, the higher your risk of having a miscarriage. If the woman age is over 40, more than 1 in 2 pregnancies end in a miscarriage. Miscarriages may also be more common if the father is older. • Antiphospholipid syndrome (APS): APS (a syndrome that makes your blood more likely to clot) is uncommon but is a cause of recurrent miscarriage and late miscarriage. • Thrombophilia: Thrombophilia is an inherited condition in which your blood is more likely to clot. It may cause recurrent miscarriage and late miscarriages. • Genetic factors: In about 2–5 in 100 couples (2–5%) with recurrent miscarriage, one partner will have an abnormality on one of their chromosomes. Chromosomes are the genetic structures within our cells. Although this may not affect the parent, it can sometimes cause a miscarriage. • Weak cervix: Weakness of the cervix is known to be a cause of miscarriage from 14 to 23 weeks of pregnancy which can be challenging to diagnose when you are not pregnant. It may be suspected if in a previous pregnancy, your waters broke early, or if the neck of the womb opened without any pain. • Developmental problems of the baby: Some abnormalities of the baby may lead to a miscarriage but are unlikely to be the cause of recurrent miscarriage. • Infection: Any infection that makes you very unwell can cause a miscarriage. Milder diseases that affect the baby can also create a miscarriage. The role of infections in recurrent miscarriage is unclear. • The shape of the uterus: It is not clear how much an abnormally shaped uterus contributes to recurrent miscarriage or late miscarriages. However, minor variations do not appear to cause miscarriage. • Diabetes and thyroid problems: Diabetes or thyroid disorders can be factors in miscarriages. They do not cause recurrent miscarriage, as long as they are treated and kept under control. • Immune factors: It has been suggested that some women miscarry because their immune system does not respond to the baby in the usual way. It is known as an alloimmune reaction. There is no clear evidence to support this theory at present. Further research is needed.

Recurrent miscarriages and neural tube defects are potentially associated with MTHFR. The Genetic and Rare Diseases Information Centre says studies suggest that women who have two C677T variants are at an increased risk of having a child with a neural tube defect. Though there's little evidence to support it, some doctors suggest taking blood clotting medications. We may recommend extra folate supplementation. At P4 fertility, we plan personalised care with the support of the latest available research. To discuss your condition, please book an appointment. Read more about MTFTR below.

The majority of sporadic or one-off miscarriages are due to unpreventable chromosomal abnormalities. Chromosomes are building blocks of cells. In many cases, a new embryo will have more or fewer than the 23 chromosome pairs it’s meant to have. It's nature's mechanism to miscarry those embryos, which are not destined to develop into a healthy foetus. The risk for chromosomal abnormalities goes up as woman age. The quality of a man's semen also seems to play a role. Many other medical factors can cause miscarriage. Sometimes it is not possible to find out the cause for a miscarriage.

If we find a cause, we offer possible treatment options along with p4 fertility recurrent miscarriage support package to improve your chance of a successful pregnancy. There is currently no evidence that heparin and aspirin treatment reduces the possibility of a further miscarriage. Women who have supportive care from during early pregnancy assessment unit from the beginning of pregnancy have a better chance of a successful birth. For couples where no cause for recurrent miscarriage has been found, 75 in 100 (75%) will have a successful pregnancy with this care. It is worth remembering that most couples will have a successful pregnancy the next time even after three miscarriages in a row.

Conditions that have been proposed to be associated with MTHFR include: Recurrent miscarriages in women of child-bearing age Pregnancies with neural tube defects, like spina bifida and anencephaly Cardiovascular and thromboembolic diseases (specifically blood clots, stroke, embolism, and heart attacks) Depression, anxiety, bipolar disorder, schizophrenia. Colon cancer, acute leukaemia, chronic pain and fatigue, nerve pain and migraines.

Stress: a very significant emotional trauma such as suffering the loss of a parent or loved one could add to the risk of miscarriage. But run-of-the-mill stresses from work or busy home life are not going to lead to a lost pregnancy.

The quality of a man's semen may play a role. Poor sperm quality can be the cause of miscarriage in about 6% of couples.

When a miscarriage happens three or more times in a row, it is called recurrent miscarriage. Recurrent miscarriage affects 1 in 100 (1%) couples trying to have a baby.

Finding out whether there is a cause for your recurrent miscarriage or late miscarriage is essential. We will be able to give you an idea about your likelihood of having a successful pregnancy. There may be treatment available to help you. At P4 fertility Recurrent Miscarriage service, we extensively investigate for all possible causes for recurrent miscarriages and tailor the treatment for you. We collect the previous investigations results from you; we have structure history sheet to pay attention to every clinical detail. Following your assessment, we recommend a personalised investigation plan for you. It includes blood tests, scans or camera tests where necessary.

Folic acid is a vitamin (B9). It is present in certain foods, and you can take it as tablets. If you're planning to have a baby, you must take folic acid tablets for three months before you conceive. It protects your future baby against conditions called neural tube defects, such as spina bifida. Few women may need a higher dose of folic acid.

If you lose a baby before 24 weeks of pregnancy, it is called a miscarriage. If this happens in the first three months of pregnancy, it is known as an early miscarriage. Unfortunately, early miscarriages are common, with 10–20 in 100 (10–20%) pregnancies ending this way. Late miscarriages, after three months of pregnancy but before 24 weeks, are less common: 1–2 in 100 (1–2%) pregnancies end in a late miscarriage. Miscarriages could be broken down into two categories. The first, sometimes called "sporadic" or "spontaneous" miscarriage, refers to when women lose one or two pregnancies in a row and the second category is a recurrent miscarriage.

Royal College of Obstetricians and Gynaecologists UK and American College don’t recommend testing for variants unless a person also has very high homocysteine levels or other health indications.

This service is for private patients or eligible insured patients. You may refer yourself to our dedicated recurrent miscarriage clinic, or your doctor can refer by contacting us, Please comment recurrent miscarriage clinic on referral and bring all your test results for the consultation. P4 consultant will personalise the plan for further tests and management. New research has highlighted various causes for multiple miscarriages. At P4 fertility, we analyse tests and arrange the treatment plan for the next pregnancy, including a tailor-made plan for medications and ultrasound scanning schedule. When you find yourself pregnant, we will offer you early pregnancy scans and an ongoing program of appointments. We have a unique approach to managing recurrent pregnancy loss with personalised care for the patient along with counselling support where necessary by our dedicated team. Recurrent Miscarriage clinic is not designed to handle gynaecological emergencies. Your care within NHS will be routine, and our service is additional support with tailor-made treatment for you.

You can have either one or two mutations — or neither — on the MTHFR gene. These mutations are often called variants. A variant is a part of a gene’s DNA that’s commonly different, or varies, from person to person. There are two variants, or forms, of mutations that can occur on the MTHFR gene. Having one variant is called heterozygous which is less likely to contribute to health issues. Some people believe having two mutations called homozygous which may lead to more serious problems.

There's no reason to think a cup or two of coffee could trigger a miscarriage. A little caffeine is safe. It's more challenging to know if pounding cup after cup of coffee all day long could be harmful. But even then, caffeine's links to miscarriage are uncertain. Excessive alcohol, smoking and obesity are risk factors for miscarriages.

We appreciate the need for in-depth analysis of all cycles and multidisciplinary team discussion. Please book your appointment with a note to book you for multiple failed cycle clinic. We encourage you to send us all your previous cycle’s documents and tests results or bring it for the consultation. We allow extra time for these consultations. We take the case to MDT (multidisciplinary discussion) which involves embryology team, clinicians, counsellors and nurses. We seek advice, where necessary in rare conditions, from our other internationally recognized experts across the globe. Informal enquiries are welcomed about this service.

Every biological process, let it be in nature or triggered artificially, follows a logical pattern. The outcome is related to the whole process and the steps taken during the process. For example, when you get fewer eggs than expected during IVF or fewer eggs fertilized than expected, it is a result of multiple small steps taken until that point. Therefore, the analysis of each small step during the journey is essential. P4 fertility care offers an in-depth reflection on each cycle. We divide the steps based on the biological process with a full explanation of the couple.

If you have two or more failed fresh cycles of IVF or ICSI, you should book an appointment with us requesting IVF analysis clinic. IVF analysis clinic offers extra time for the couple to have in-depth review and discussion on cycles. In normal busy IVF clinics in most of the centres, doctors could not offer enough time to review, analyse and plan for next cycles. Therefore, the chances of missing significant clues from previous cycles are very high. At P4 fertility we recognise this. We offer in-depth homework before the consultation, during the consultation and after consultation. Our philosophy at P4 fertility is left no stones unturned. We prefer to get notes before we see a couple. We encourage you to send us your previous notes before the appointment by contacting us. Attention to detail is not about perfection. It’s about excellence, about constant improvement.

First and foremost, it is important to find out what did happen in previous cycles, why did it happen and what was done about it. Next set of questions are where we, in terms of fertility potential, are. At P4 fertility service, we have a structured approach for couples with multiple failed IVF or ICSI cycles. We divide every cycle into parts and analyse them with MDT. We discuss with other clinicians. We call it analysis clinic. With the P4 approach, we use prediction, prevention, participation and personalisation of the treatment plan by paying attention to every detail. The bottom line is “not to leave any stones unturned”. There no set formula for everyone. The care is individualised, and evidence-based interventions are discussed as every step. The most important part of the analysis clinic is attention to every detail.

Step 1 Consultation – With our consultant. During the consultation your consultant will give you individualise advise and guidance based on your medical history, assess your ovarian reserve and your family planning goals that will help you decide whether egg freezing is right for you. Step 2 Ultrasound scan and Anti Mullerian Hormone (AMH) test – To assess your egg reserve to give you a personalized prediction of the number of eggs expected per cycle, protocol and drug cost. Step 3 Follow-up Consultation – With your consultant to confirm the decision, plan the treatment and discuss any questions you may have following your tests. Once you confirm that you have decided to go ahead with egg freezing, we will advise you to complete the regulatory paperwork and consent process. Step 4 Treatment Start Date – We start your treatment from day 1 of your menstrual cycle. The nursing team will advise you on when, how and which injections to take based on the planned protocol. Step 5 Monitoring – During stimulation the nursing team will monitor your follicle growth in your ovaries (follicles are sacs in the ovary where eggs grow) via frequent scans. The length of the monitoring phase is dependent on how many follicles there are and how fast they are growing. Once your follicles are at an appropriate size, we advise you to take a trigger injection to cause final egg maturation and your egg collection will be booked. Step 5 Egg collection – An egg collection is a short procedure which lasts around 30 minutes. Egg collection can be performed under general anaesthetic or sedation depending on the patient's preference (administered by a Consultant Anaesthetist). Eggs are surgically removed using transvaginal ultrasound guidance. Tubes containing the fluid aspirated from each follicle are passed to the embryologists who identifies each egg and collects them in a labelled Petri dish and stores them in an incubator. Each egg is then assessed for suitability for freezing (immature or post-mature eggs will not be frozen). All suitable eggs are then prepared for freezing using vitrification methods.

If you're not ready for a family: Not everyone feels ready for motherhood at the same time. You might want to preserve your fertility because you haven't met the right partner, you don't feel financially or emotionally ready, or you have other life plans you want to pursue. If you're having cancer treatment: If you're having certain types of cancer treatment, including chemotherapy or radiotherapy, you might want to consider freezing your eggs, sperm or embryos. This is because some of the drugs used in cancer treatment can cause infertility, especially in high doses. If you're a transgender person: If you're a male transitioning to a female or a female transitioning to a male, you may want to preserve your fertility before you start hormone therapy or have reconstructive surgery. Both treatments can lead to the partial or total loss of your fertility.

Egg freezing is a treatment that allows women to freeze their eggs in order to preserve fertility. The process involves stimulating your ovaries to grow and to aid maturation of your eggs which are then surgical removed in a egg collection procedure. These eggs will then frozen for your future use. Women consider egg freezing for delaying pregnancy without affecting chances of success in future, women with cancer, women with ovarian cysts, endometriomas or any genetic issues that can result in loosing eggs faster than average.

Step 1 – You need to book an appointment with a consultant to plan embryo creation and transfer. General medical health and risks of pregnancy, chance of success and assessment of welfare of the child, consents and explanation of the frozen embryo transfer process will be explained. Step 2 – If you have a partner at this stage and want to use his sperm, we will test the sperm and infection screening tests will be conducted. If you decide to use donor sperm, we will arrange counselling and an appointment with the donor sperm coordinator. The consultant will assess future pregnancy risks and plan with obstetricians if required clinically. Step 3 – The nursing team will arrange scans and advise you on medications based on the protocol to prepare your lining of the womb for embryo transfer. Step 4 – The embryologist will thaw your eggs when the womb's lining is ready. They will perform an ICSI procedure, which means injecting the sperm into the eggs to create embryos. You may use your partner's sperm or donor sperm to create an embryo. Please remember that the cost of all future procedures is not included in the egg-freezing process. Step 5 – The team will inform you about the number of eggs that have survived, the number of fertilized eggs, the quality of embryos created and the embryo transfer date. Step 6 – The consultant will perform the embryo transfer. You will continue with advised medications until the pregnancy test date, typically two weeks from embryo transfer.

If you have frozen eggs that you don't want to use; you have several different options: Donate them to research: Research on eggs, sperm and embryos is invaluable in helping scientists to understand the causes of infertility and develop new treatments. Donate them to training: Trainee embryologists need eggs to practice different techniques, such as fertilizing them with sperm in the lab. Donate them to someone else: You may be eligible to donate your eggs. Discard them: Some people prefer to discard their eggs. Eggs no longer needed are removed from the freezer and allowed to perish naturally in warmer temperatures or water.

The number of eggs collected per cycle is critical for overall success of the egg freezing treatment. It is also dependent on a number of individual factors including the quality of the eggs frozen. Women may require multiple cycles of ovarian stimulation and egg collection to freeze a sufficient number of eggs. Researchers developed a mathematical model to predict the probability of live birth based on female age and the number of cryopreserved oocytes to aid patient counselling. According to the model, women at 34, 37 or 42 years would need to cryopreserve 10, 20, and 61 oocytes, respectively, to obtain a 75% likelihood of having at least one live birth.

Women who leave it late to embrace motherhood are often criticised for gambling with their fertility and risking their own and their baby's health. But now a leading academic says many women may delay getting pregnant. Professor Elizabeth Gregory says older mothers are financially secure and happy to put their careers on hold while they bring up baby and are more likely than younger first-time mothers to be in stable relationships. They also live longer. The average age of British women giving birth is stable at 29, but the numbers of women choosing to start families in their late thirties and early forties have risen sharply. In 2006 in England and Wales, more than 22,000 women over 40 had babies, of whom nearly 5,500 were giving birth for the first time. (The Guardian)

Not all frozen eggs will survive the thawing process. On average, around 85% of eggs survive the thawing process. We use the vitrification technique. This is a rapid freezing method whereby the egg is placed into a highly concentrated solution of cryoprotectant and quickly immersed into liquid nitrogen at temperature of -1960C using patient specific labelled plasticware designed for this purpose. The development of oocyte vitrification techniques has significantly improved oocyte survival compared to traditional freeze/thaw techniques (81-89% vs 46-67%). Studies have shown no difference in clinical pregnancy, miscarriage, or live birth rates between fresh and frozen oocyte cycles. The success rates of egg freezing significantly depend on the number of eggs collected and the age at which they were frozen. One study showed that women who froze their eggs before 36yrs of age needed 12 eggs to achieve one live birth, while women between 36-39yrs required 30 eggs to achieve one live birth.

The treatment schedule is patient specific and is dependent on the outcome of preliminary tests. For emergency patients the work-up time will be shorter before eggs are collected. The egg freezing process is very similar to IVF treatment, except that the eggs are not inseminated with sperm, they are frozen immediately. Provided all the work-up is complete and all criteria has been met, it takes approximately two weeks from the start of your cycle to the point of egg collection and egg freezing.

The most significant determinant of egg freezing success is the patient's age at which egg freezing takes place. Data from research suggests that the highest discriminating factor for success was freezing eggs before 36 years of age and ideally in their 20s or early 30s. In the UK in 2016, only 32% of the 1173 egg-freezing cycles were in Women aged 35 or below. Storage of ten oocytes gave a cumulative live birth rate of 42.8% in women 35 years and under (compared to 25.2% in women 36 years and over). Women who electively froze their eggs at 35yrs or below were able to achieve a cumulative live birth rate of greater than 90%, although this required using 24 eggs.

The main risk is development of ovarian hyperstimulation syndrome (OHSS). Whilst symptoms are usually only mild in most patients (bloating, nausea, pain, shortness of breath), some people can become quite unwell and require hospital admission. We use Buserelin triggers in high-risk women to significantly reduced the risk of OHSS. Risks associated with egg collection include infection needing antibiotics, bleeding (although the serious bleeding risk is very low, 1-2 per 100), damage to other organs (1 to 2 per 1000 cases), empty follicles, failure to achieve desired quantity or quality of eggs, low or no response to stimulation, eggs don’t survive the thaw process and eggs fail to fertilize in the future.

There are several key factors to consider before deciding to freeze your eggs. The age at which you freeze your eggs is crucial to your chances of eventually having a baby. Ovarian reserve and egg quality decline with age. Women with low ovarian reserve do not respond as well to hormone stimulation and frequently end up with a lower number of eggs to freeze. We advise patients to consider freezing eggs before age 35 and preferably in the 20s or early 30s to ensure a good number of eggs are collected. Depending on your age, you may require multiple cycles of hormone stimulation and egg collection to achieve a sufficient number of eggs to give you a realistic chance of success.

There are no known adverse effects on children born from frozen eggs; there are no long-term follow-up studies due to the recent nature of the egg-freezing technique. However, the research on frozen embryos did not show any impact and data so far does not show any adverse effects.

Under current regulations from the Human Fertilisation and Embryology Authority (HFEA), eggs can remain in storage up to a maximum of ten years although in some circumstances this period of time can be extended up to 55 years. It should be understood that once the consented period of storage is reached, the eggs have to be thawed in accordance with current legislation.

The first step in your journey is to book in with your consultant. You can book your consultation by following the link below: www.bir.p4fertility.co.uk/book-online

There are many reasons for women opting for egg freezing including medical and social reasons. Some of the main reasons why women decide to cryopreserve their eggs include: The age at which women are having children is increasing. Some women want to wait for the right partner and so want to preserve their ‘younger’ eggs for potential use in the future to have their own genetic child. The quantity and quality of eggs decline with age. Women's fertility potential begins to fall in their early 30s and then more significantly after 35yrs. If you are not currently in a position to start a family or you do not think you will be for several years, then freezing your eggs before your mid-30s can provide some protection against the decline in fertility potential seen after 35yrs of age. Life threatening medical conditions – treatment for these may leave the ovaries inactive therefore eliminating the change of the woman being able to produce her own eggs. Non-life threatening medical conditions – these may reduce the fertile life span or prevent her from trying to get pregnant whilst treatment is ongoing. Family history of early menopause. In couples in whom there is personal or religious belief which prevents more than a defined number of eggs to be fertilised (during IVF treatment), the remaining eggs that have not been inseminated could then be frozen for future use.

The preliminary tests are required to assess suitability for egg freezing and are part of the work-up for egg freezing. These tests include the following: 3D pelvic transvaginal ultrasound scan – This helps us to get a clearer picture of your womb, ovaries and pelvis. The quality of your endometrium is also checked. This helps to calculate the dosage of medication you may require for stimulation. Anti Mullerian hormone blood test (AMH) – This helps us to measure your ovarian reserve i.e. determines the expected number of eggs. We also required infection screening tests which include HIV, hepatitis B and Hepatitis C. Please note we do not offer egg-freezing cycles to any women who test positive for any of these infections.

The first cycle provides us with information for planning the second cycle. You do not need to undergo all tests for the second cycle. You do not need to pay additional fees for freezing.

Egg quality and ovarian reserve fall with increasing maternal age; therefore, we believe that if you want to freeze the eggs, you should do so before you are 35 or as soon as you can. Women should consider the risks in pregnancy with advanced maternal age. There is an increased risk of miscarriage, pregnancy-induced hypertension, and gestational diabetes and an obstetric plan should be in place at an advanced age.

When considering the costs of freezing your eggs, it is essential that you also think about the future costs of any IVF treatment that you will later require in order to use your frozen eggs. The total costs can also vary depending on the number of egg-freezing attempts you require to achieve a fair number of eggs and the number of embryo transfer attempts you need to achieve a pregnancy. You also have to pay a yearly storage fee. On average, the total cost (for one cycle of egg collection, medication, and storage fees for one year) is approximately £4000 in Birmingham clinic. Please speak with our team to get update costs and exact quote for your treatment.

An ultrasound scan and blood tests (semen analysis of your partner if you chose embryo freezing) are requested before treatment. There is a theoretical risk of viral (HIV, Hepatitis B & C) cross-contamination between samples that are stored in liquid nitrogen. You (and your partner if you go for embryo freezing) will be screened for HIV and Hepatitis B & C.

Currently, women using their frozen eggs in treatment have a success rate of 18% (30% with frozen donor eggs), which offers no guarantee of achieving a successful pregnancy and birth with one round of egg freezing. 30% success rate if egg freezing is performed under 35 years of age. We have an ethical responsibility to be clear that egg freezing below the age of 35 offers women their best chance of creating their much longed-for family.

There are several fertility treatments options available for women with endometriosis. The suitability of the treatments depends on the severity of the endometriosis, the woman’s age, how long they have been trying to conceive and whether there are other fertility factors. We tailor fertility treatment and suppression of endometriosis with P4 fertility protocols. For infertility caused by endometriosis, rates of pregnancy are much improved with IVF treatment. Exactly which treatment is right for you depends on a variety of individual factors such as egg reserve, so we offer tailor-made treatment protocols depending on each patient’s needs.

If fertility and having a baby is your primary goal, then you should see a fertility doctor then an endometriosis specialist. If you are getting symptoms of pain with endometriosis and that is your primary concern than having a baby, you should see an endometriosis expert first. This is because every expert thinks primarily on what the best option of the patient in their area of expertise is. If you are keen to have baby, although you have been diagnosed with endometriosis or there is a suspicion of endometriosis, the best option is to consult fertility consultant. At P4 fertility, we discuss the endometriosis in detail with the latest evidence-based treatment options to balance your individual need. In few women, it is wise to have minimal invasive and minimum damaging treatment for endometriosis before IVF, on the other hand, it would the best decision to start IVF immediately with suppression endometriosis with fertility drugs for another group of women. Endometriosis has various grades of severity and organ involvement. If the ovarian reserve is already on the lower side of the normal range, any further surgery in the pelvis on or around ovaries could damage the eggs in ovaries. This could further result in poor ovarian reserve. It requires discussion on an individual level if the endometriosis is resulting in large chocolate cyst / endometriotic cyst. The complexity is, if such cyst is excised completely, there is a chance that it will reduce ovarian reserve (total number of eggs ovaries have). If it is not operated, it can cause difficulty in getting all follicles during IVF egg collection. Therefore, at P4 fertility we trust on personalised plans as not one size (one approach) fits all.

Tests usually include a pelvic ultrasound scan. This may be a transvaginal scan to check the uterus and ovaries. It may show whether there is an endometriotic (also known as a ‘chocolate’) cyst in the ovaries or may suggest endometriosis between the vagina and rectum. You may be offered a laparoscopy, which is the only way to get a definite diagnosis. This is carried out under a general anaesthetic. Small cuts are made in your abdomen and a telescope is inserted to look at your pelvis. You may have a biopsy to confirm the diagnosis and images may be taken for your medical records. Your doctor may suggest treating the endometriosis at the time of your first laparoscopy, either by removing cysts on the ovaries or treating any areas on the lining of your pelvis. This may avoid a second operation. Sometimes, however, the extent of endometriosis found means that you may need further tests or treatment. The procedure, including any risks and the benefits, will be discussed with you. After your operation you be will be told the results. You can often go home the same day after a laparoscopy.

Common symptoms include pelvic pain and painful, sometimes irregular or heavy periods. It can cause pain during or after sex and can lead to fertility problems. You may also have pain related to your bowels, bladder, lower back or the tops of your legs, and experience long-term fatigue. Some women with endometriosis do not have any symptoms. Endometriosis can cause pain that occurs in a regular pattern, becoming worse before and during your period. Some women experience pain all the time but for others, it may come and go. The pain may get better during pregnancy and sometimes it may disappear without any treatment

Yes. An endometriotic cyst is a good medium for bugs to grow. During egg collection, there is a risk of introducing an infection inside. It can result in severe infection. We advise antibiotics for such women at the time of egg collection.

Endometriosis can be a difficult condition to diagnose. This is because: • the symptoms of endometriosis vary so much • the symptoms are common and can be similar to the pain caused by other conditions such as irritable bowel syndrome (IBS) or pelvic inflammatory disease (PID); • different women have different symptoms • some women have no symptoms.

The exact cause of endometriosis is not known but it is hormone-dependent. This means that, just like the endometrium which response to hormonal changes resulting in a period, the endometrial-like tissue located outside the womb also bleeds. This bleeding can cause pain, inflammation and scarring, and can damage your pelvic organs. Endometriosis may be found: • on the ovaries, where it can form cysts (often referred to as endometriomas or ‘chocolate cysts’) • in the peritoneum (the lining of the pelvis and abdomen) • in or on the fallopian tubes • on, behind or around the womb • in the area between the vagina and the rectum. Endometriosis can also occur within the muscle wall of the womb (adenomyosis) and occasionally on the bowel and/or bladder. It may sometimes be found in other parts of the body, but this is rare.

Pain-relieving medication: There are several different medications to help relieve your pain. Hormone treatments: These treatments reduce or stop ovulation (the release of an egg from the ovary) and therefore allow the endometriosis to shrink by decreasing hormonal stimulation. Various options include combined oral contraceptive (COC) pill or patch, an intrauterine system (IUS/Mirena®), progestogens injections, tablets or implants and GnRH Agonist (Prostap). Surgery: Surgery can treat or remove areas of endometriosis. The surgery recommended will depend on where the endometriosis is and how extensive it is. This may be done when the diagnosis is made or may be offered later. Success rates vary and you may need further surgery. Possible operations include: • laparoscopic surgery (keyhole surgery) – when patches of endometriosis are destroyed or removed • laparotomy (Open operation) – for more severe cases

Getting pregnant can be a problem for some women with endometriosis. Hormonal treatment is not advisable when you are trying to conceive, and surgical treatment may be more appropriate. There is an association between infertility and endometriosis. Endometriosis may cause a toxic effect on eggs, sperms and embryos, and impairment of tubal motility: endometriotic implants secrete pro-inflammatory chemicals called cytokines. It may lead to an abnormal follicular environment, high in cytokines. In cases of moderate and severe endometriosis chances of natural conception are reduced. This is because more adhesions can trap the egg and stop it from moving down the Fallopian tube. The inflammation and irritation caused by the endometriosis can affect fertility. Inflammation of the fimbria, which picks up the egg and transports it into the fallopian tube, causes swelling and scarring so the egg may not reach its destination. As well, the inflammation damages the sperm and eggs when they are exposed to the inhospitable environment caused by the endometriosis. In more advanced cases, the endometriosis starts to cause adhesions, and the pelvic organs become stuck to each other, resulting in decreased function. Endometriosis can also block the fallopian tubes.

Endometriosis is a condition where tissue similar to the inner lining of the womb (endometrium) is found elsewhere, usually in the pelvis around the womb, ovaries and fallopian tubes. It is a very common condition, affecting around 1 in 10 women. You are more likely to develop endometriosis if your mother or sister has had it. Endometriosis usually affects women during their reproductive years. It can be a long-term condition that can have a significant impact on your general physical health, emotional wellbeing and daily routine.

Please request an appointment by contacting us and request ONE STOP specifically. We will send you a questionnaire for clinical details and then plan your tests.

Your menstrual cycle begins on the first day of your period and continues up to the first day of your next period. For all medical purposes, when you start bleeding is counted as day one of the period. If bleeding starts in the night, count next day as day one of the period. Ovulation happens about 14 days before your period starts. If your average menstrual cycle is 28 days, you’re most fertile two to three days leading to and at the time of ovulation (when an egg is released from your ovaries), which usually occurs 12 to 14 days before your next period starts. This is the time of the month when you're most likely to get pregnant. If your cycle is of 30 days, your ovulation day is around day 16. If your average menstrual cycle is 35 days ovulation happens around day 21 and your most fertile days are days 19,20 and 21. If you have shorter cycles, say 21 days, ovulation happens around day 7 and your most fertile days are days 5, 6 and 7.

Yes, we do. Managing weight is one of the key steps to achieve success. Our advice is personalised to you.

When the periods are regular and no other medical issue, 80% of couple conceive in first year of trying and 50% of remaining may get conceived in next year. Therefore, if you both do not have any pre-existing medical condition, it is reasonable to seek help after two years of trying naturally. If you are on certain medications, you are known to have endometriosis, PCOS or previous chlamydia infection, it is advised to see a doctor sooner than later. If age of the woman is above 37 years, it is suggested to seek help early.

Tomatoes are rich source of lycopene, an antioxidant believed to improve sperm motility, structure, and activity. You can also add olive oil to cooked or processed tomatoes for improving the absorption of the antioxidant. Walnuts are rich in omega 3 fatty acids. All kinds of berries, including blueberries, strawberries, cranberries, and blackberries, contain powerful anti-inflammatory and antioxidants quercetin and resveratrol. Pomegranates may improve the testosterone levels and sperm quality and increase sex drive. Ginseng, also known as Ashwagandha, it is an aphrodisiac root used in traditional medicinal practices. Other good food items are, citrus fruits, whole wheat and grains, most fish, especially wild salmon, cod, and haddock, most shellfish, especially oysters, vitamin D, dark chocolate, garlic, bananas, broccoli, turmeric, asparagus, most leafy greens, especially spinach and kale, fermented nuts and seeds.

In our opinion, the common sense approach is the best approach. There are some obvious food items such as trans fats, processed foods, canned food etc, which are not good for general health as well as for fertility. On the other hand, green leafy vegetables, fruits, berries, and nuts contain high levels of antioxidants, vitamins and micronutrients. Antioxidants are the substances that cleanse our body from stress-related damaging chemicals. Vitamins, antioxidants, and micronutrients such as selenium, zinc is good for cell functions. Similarly, they are good for sperm and eggs. You do not need to follow a strict fertility diet plan, which may be counterproductive by adding undue stress in your busy life! Think of wide variations in dietary practices all over the world, but every country has fertile population. The common-sense approach and gentle change in daily lifestyle help most of the couples. There is no need to follow a strict diet plan as long as your height-to-weight ratio (BMI) is in normal range.

Processed meats/ food, Trans fats, Soy products, Pesticides and bisphenol which act as xenoestrogens—chemicals that mimic estrogen (pesticides could be present on fruits and vegetables and BPA is used in food packaging and cans), and High fat dairy products may cause reduced motility and abnormal shape of sperms.

The cost varies with investigations required for you and your partner. It could range from £190 to £870. But don’t worry. You will get the detailed cost plan after your fertility questionnaire. This will be before you commit to attend this service. Therefore, no hidden charges or any surprises. The cost includes consultant appointment. Boosting chances of getting pregnant Naturally: You need to go for any fertility treatment only after you have done everything to achieve natural pregnancy. Booking an appointment with P4 Fertility does not mean you have to go for any fertility treatment. We encourage natural conception in couples with good fertility potential and time to try it. You may choose to book test to check for fertility potential and discuss your chances of natural conception. P4 Fertility designs the personalised ways to assist natural conception.

It is often stressful to plan everything based on ovulation day. We do not recommend testing for ovulation regularly when trying for natural conception. The tests for ovulation add extra stress and stress is not good for conception. As the fertile window is of few days, intercourse (sex) every two to three days is enough to have better chances of conception. In fact, it has been shown that couples following above advice were more successful than couples using ovulation tests or apps to plan sex. The only explanation to this is stress related damage to sperms and eggs. The reason we suggest that intercourse every 2- 3 days is enough as Sperm live for around five days. Eggs can only be fertilised for around 24 hours (one day) after being released from the ovary. Eggs and sperm need to come together at the right time for fertilisation to happen to create an embryo. There is a high possibility of egg and sperms coming together when intercourse happens every 2-3 days. Therefore, it is not essential to absolutely check for ovulation and plan intercourse on the day. It could be rather counterproductive.

At P4 Fertility, we use your clinical history and request the most appropriate tests and use evidence-based models to predict the chances of conception naturally and with various treatment options. This allows you to make an informed decision on when and how to proceed with creating a family. Everyone is different clinically, socially, and psychologically. Everyone’s personal circumstances are different and so is the fertility potential. Our ethos is personalised care with personalised prediction.

There are two types of surrogacy: Full surrogacy (also known as host or gestational surrogacy) is when the eggs of the intended mother or a donor are used and there is, therefore, no genetic connection between the baby and the surrogate. Partial surrogacy (also known as straight or traditional surrogacy) involves the surrogate’s egg being fertilised with the sperm of the intended father. If you go down this route, we recommend you have treatment at a licensed UK fertility clinic.

More and more hopeful parents are having surrogacy treatment overseas. In UK law, surrogacy is treated as an altruistic act so paying a surrogate anything more than reasonable expenses is illegal. However, commercial surrogacy is permitted in some other countries. Many people who have treatment abroad are very happy with the quality of care they receive, but you need to do your research first. Legal arrangements differ from country to country and getting a passport and getting your child back to Britain can be a very difficult and time-consuming process. You should also know that even if you’re named on a foreign birth certificate as the legal parents of your child, you’ll still need to apply for a parental order when you return to the UK. This is because UK law recognises the surrogate as the legal parent(s) until you have a parental order. The Foreign and Commonwealth Office have produced guidance for people considering having surrogacy treatment abroad.

Surrogacy may be appropriate for women with a medical condition that makes it impossible or dangerous for them to get pregnant and give birth. These include: Absence or malformation of the womb Recurrent pregnancy loss Repeated in vitro fertilisation (IVF) implantation failures. It’s also a popular option for male same-sex couples who want to have a family and can be used by single people.

Surrogacy involves a lot of complicated legal issues which is why you should seek independent legal advice, especially if you’re having treatment overseas. The most important thing to know is that, in the UK, the surrogate is the legal mother of the child unless you get a parental order from the court; even if the eggs and sperm used are yours or donated (ie, she’s not genetically related to the child). Once you have a parental order for the baby, the surrogate will have no further rights or obligations to the child. Who the second legal parent is at birth will depend on your circumstances? If the surrogate is married or in a civil partnership, her partner will automatically be the second legal parent (until a parental order is granted), unless it can be shown that her partner did not consent to her treatment. If the surrogate is single, then the man providing the sperm (if he wants to be the father) will automatically be the second legal parent at birth. However, the surrogate can nominate a second legal parent such as the intended mother or non-biological father if you’d all prefer. To do this, both the intended second parent and the surrogate will need to give their consent before the sperm, egg or embryo are transferred. The law previously only allowed two people to apply for a parental order, however, it has recently been changed and it is now possible for one person to apply for a parental order if you are a biological parent of the child (i.e., your eggs or sperm were used to create the baby). This is a complicated area so you should discuss this with our team.

If you’re using the surrogate’s eggs, your chances of having a baby will depend on how old she is. Women over 35 can be at greater risk of health problems or complications during pregnancy, which is something else to consider. The age of the woman who provides the egg is the most important factor that affects the chances of pregnancy.

At p4 fertility, we discuss the individual plan. We offer personalised treatment and discuss the estimated cost. You’re not allowed to pay a surrogate in the UK. However, you are responsible for reimbursing any reasonable expenses that the surrogate incurs such as maternity clothes, travel expenses and loss of earnings. Expenses vary. According to a report by Surrogacy UK, surrogates typically receive £10,000-£15,000, although this will depend on your circumstances. For example, extra expenses may apply if your surrogate has twins. You’ll also need to pay for your clinic treatment. Costs for this vary depending on what you’re having. If you’re using your eggs and sperm or donated eggs from someone who isn’t the surrogate, you’ll need to have in vitro fertilisation (IVF), which is more expensive than IUI. If you’re using sperm that isn’t of the highest quality you may need to have intracytoplasmic sperm injection (ICSI) treatment, which is an additional cost on top of IVF.

Success rates for surrogacy depend on many factors, including: The surrogate’s ability to get pregnant The age of the woman whose eggs are being used The success of the treatment you’re having (ie, IUI, IVF or ICSI) The quality of the father’s or donor’s sperm.

We (or third parties acting on our behalf) may transfer, store or process information about you in countries outside the EEA. Where this is the case we take the required steps to ensure that your personal information is protected.

We may collect information about you when you request any information about us or our services, submit your personal details and/or complete any forms on the website, contact us via social media or use our live chat facilities on our website. This information will come directly from you. In limited circumstances we may also receive information about you on your behalf, such as where you have asked a family member to contact us, or if your GP contacts us directly. Personal information, or personal data, means any information about an individual from which that person can be identified. It does not include data where the identity has been removed (anonymous data). We may also collect special categories of personal information about you. This includes personal information relating to details about your health, and genetic and biometric data, race or ethnicity, religious or philosophical beliefs, sex life, sexual orientation, political opinions, or trade union. If you provide personal information to us about other individuals (including medical or financial information) you should inform the individual about the contents of this Privacy Notice. We will process such information in accordance with this Privacy Notice. We have set out details below about the types of personal information we are likely to collect and use about you when you use our websites or interact with us via social media. The extent of the information we collect and use will depend on what information you choose to provide to us or what information is provided to us on your behalf. Personal data general information you provide, such as your name, address, contact details, date of birth, gender and next of kin information relating to appointments information regarding your ability to pay for services and payment information information regarding your experiences with us information you provide in surveys or feedback information relating to any complaint you may make against us or our staff information about your areas of interest, if you are signing up to receive our update emails information you send in any job application or speculative enquiries in relation to job vacancies, such as employment history or qualifications information when you visit our websites. p4 Fertility uses Google Analytics and cookies in order to improve our service and user experience and to analyse how the website is used. Aside from the approximate location (IP address), the information collected by Google Analytics is anonymous traffic data including browser information, device information, and language. The collected information is used to provide an overview of how people are accessing and using p4 Fertility's websites. For more information about our use of cookies, please see our cookie policy. Special categories of personal data details of your current or former health condition, including information about medication, lifestyle and other information that may be relevant to your health e.g. employment history, family conditions; race; ethnicity; sex life or sexual orientation, religious or philosophical beliefs information relating to criminal convictions (including offences and alleged offences and any court sentence or unspent criminal conviction) in limited circumstances, we may process other sensitive personal information including details of your political opinions; and trade union membership, for example, where it is relevant to your health or social history

Under certain circumstances, you have rights under data protection laws in relation to any personal information that we hold about you. You will not have to pay a fee to access your personal data (or to exercise any of the other rights). However, we may charge a reasonable fee if your request is clearly unfounded, repetitive or excessive. Alternatively, we could refuse to comply with your request in these circumstances. We may need to request specific information from you to help us confirm your identity and ensure your right to access your personal information (or to exercise any of your other rights). This is a security measure to ensure that personal data is not disclosed to any person who has no right to receive it. We may also contact you to ask you for further information in relation to your request to speed up our response. We try to respond to all requests within one month. Occasionally it could take us longer than a month if your request is particularly complex or you have made a number of requests. In this case, we will notify you and keep you updated. If you wish to exercise any of the rights set out below, please contact the DPO using the contact details set out below. Details of your rights are set out below. The right to access your personal information You are usually entitled to a copy of the personal information we hold about you and details about how we use it. Your information will usually be provided to you in writing, unless otherwise requested. If you have made the request electronically (e.g. by email) the information will be provided to you by electronic means where possible. You are entitled to the following under data protection law. Under data protection law we must usually confirm whether we have personal information about you. If we do hold personal information about you we usually need to explain to you: The purposes for which we use your personal information. The types of personal information we hold about you. Who your personal information has been or will be shared with, including in particular organisations based outside the EEA. If your personal information leaves the EU, how we make sure that it is protected. Where possible, the length of time we expect to hold your personal information. If that is not possible, the criteria we use to determine how long we hold your information for. If the personal data we hold about you was not provided by you, details of the source of the information. Whether we make any decisions about you solely by computer and if so details of how those decision are made and the impact they may have on you. Your right to ask us to amend or delete your personal information. Your right to ask us to restrict how your personal information is used or to object to our use of your personal information. Your right to complain to the Information Commissioner's Office. We also need to provide you with a copy of your personal information. If you are a patient of p4 Fertility and you wish to request details of or a copy of your medical records, please contact the hospital at which you have received the care and treatment. For all other requests for any personal information we may hold (such as employment records, if you are an ex-employee) please direct your request to the Data Protection Officer, using the contact details below. The right to request correction of your personal information We take reasonable steps to ensure that the personal information we hold about you is accurate and complete. However, if you do not believe this is the case, you can ask us to update or amend it. The right to request erasure of your personal information In some circumstances, you have the right to request the erasure of the personal information that we hold about you. This is also known as the 'right to be forgotten'. However, there are exceptions to this right and in certain circumstances we can refuse to delete the information in question. In particular, for example, we do not have to comply with your request if it is necessary to keep your information in order to perform tasks which are in the public interest, including public health, or for the purposes of establishing, exercise or defending legal claims. The right to object to the processing of your personal information In some circumstances, you have the right to object to the processing of your personal information. However, there are exceptions to this right and we do not have to "pause" the processing of your information where, in particular, if it is necessary to keep your information in order to perform tasks which are in the public interest, including public health, or for the purposes of establishing, exercise or defending legal claims. The right to request a transfer of your personal information In some circumstances, we must transfer personal information that you have provided to us to you or (if this is technically feasible) another individual/ organisation of your choice. The information must be transferred in an electronic format. The right to object to marketing As detailed in the 'marketing' section above, you can ask us to stop sending you marketing messages at any time and we must comply with your request. You can do this by contacting the DPO. The right not to be subject to automatic decisions (i.e. decisions that are made about you by computer alone) You have a right to not be subject to automatic decisions (i.e. decisions that are made about you by computer alone) that have a legal or other significant effect on you. The right to withdraw your consent You have the right to withdraw your consent where we rely upon this as a legal ground for processing your information. You can do this by contacting our DPO. The right to complain to the Information Commissioner's Office You have the right to complain to the Information Commissioner's Office if you are unhappy with the way that we have dealt with a request from you to exercise any of these rights, or if you think we have not complied with our legal obligations under data protection law. More information can be found on the Information Commissioner's Office website: https://ico.org.uk/ Making a complaint will not affect any other legal rights or remedies that you have.

We process your personal information for the purposes set out in this Privacy Notice. We will only use your personal data when the law allows us to. Each time we use your data we must have a legal justification to do so. The particular justification will depend on why we are using your data. When the information that we process is classed as "special categories of personal information", we must have a specific additional legal justification in order to use it as proposed. Generally, we will rely on the following legal grounds for processing your personal data: Taking steps at your request so that you can enter into a contract with p4 Fertility and/or a clinician to receive healthcare services from us, or for the purposes of that contract. If we have a contract with you, we will process your personal information in order to fulfil that contract (that is, to provide you with our products and services). Taking steps at your request so that you can enter into an employment contract with p4 Fertility, or for the purposes of that contract. We have an appropriate business need (a 'legitimate interest') to process your personal information and those interests are not overridden by your privacy rights. We will rely on this for activities such as administration and service improvement. Further details of those legitimate interests are set out in more detail below. We may process special categories of personal information about you because: It is necessary for the purposes of preventive or occupational medicine, providing you with medical diagnoses, providing you with healthcare or for the management of our healthcare services. It is necessary for reasons of substantial public interest, such as insurance-related purposes or for preventing or detecting fraud. The use is necessary in order for us or a third party to establish, exercise or defend our legal rights. You will find further details of our "legal grounds" for each of our processing purposes set out below. Providing healthcare and related services Legal grounds: The use is necessary to provide you with healthcare and other related services. The use is necessary for fulfilling our contract with you for the delivery of healthcare. The use is necessary for fulfilling our legitimate interests (e.g. an appropriate business need) and those interests are not overridden by your privacy rights. Additional legal grounds for special categories of personal data: The use is necessary to provide you with healthcare and other related services. The use is necessary to protect your vital interests where you are physically or legally incapable of giving consent. The use is necessary for an insurance-related purpose. The use is necessary to protect your vital interests where you are physically or legally incapable of giving consent. Administration and management of healthcare services (such as maintaining records, receiving professional advice) Legal grounds: The use is necessary to provide you with healthcare and other related services. The use is necessary to comply with a legal or regulatory obligation. The use is necessary for fulfilling our contract with you for the delivery of healthcare. The use is necessary for fulfilling our legitimate interests (e.g. an appropriate business need) and those interests are not overridden by your privacy rights. Additional legal grounds for special categories of personal data: The use is necessary for the purposes of preventive or occupational medicine, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services. The use is necessary in order for us or a third party to establish, exercise or defend our legal rights. Service improvement, evaluation and audit (in order to improve the healthcare services that we provide) Legal grounds: The use is necessary for compliance with a legal or regulatory obligation. The use is necessary to provide you with healthcare and other related services. The use is necessary for fulfilling our legitimate interests (e.g. an appropriate business need) and those interests are not overridden by your privacy rights. Additional legal grounds for special categories of personal data: The use is necessary for the purposes of preventive or occupational medicine, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services. You have given us your explicit consent. Communicating with you and resolving any queries or complaints that you might have. Communicating with any other individual that you ask us to update about your care. Legal grounds: The use is necessary to provide you with healthcare and other related services. The use is necessary for compliance with a legal obligation. The use is necessary for fulfilling our contract with you for the delivery of healthcare. The use is necessary for fulfilling our legitimate interests (e.g. an appropriate business need) and those interests are not overridden by your privacy rights. You have given us your explicit consent. Additional legal grounds for special categories of personal data: The use is necessary for the purposes of preventive or occupational medicine, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services. The use is necessary in order for us or a third party to establish, exercise or defend our legal rights. You have given us your explicit consent. Complying with our legal and regulatory requirements Legal grounds: The use is necessary for compliance with a legal obligation. The use is necessary for fulfilling our legitimate interests (e.g. an appropriate business need) and those interests are not overridden by your privacy rights. You have given us your explicit consent. Additional legal grounds for special categories of personal data: The use is necessary for the purposes of preventive or occupational medicine, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services. The use is necessary in order for us to establish, exercise or defend our legal rights. You have given us your explicit consent. Clinical research and development Legal grounds: The use is necessary to provide you with healthcare and other related services. The use is necessary for compliance with a legal obligation. The use is necessary for fulfilling our legitimate interests (e.g. an appropriate business need) and those interests are not overridden by your privacy rights. You have given us your consent. Additional legal grounds for special categories of personal data: The use is necessary for the purposes of preventive or occupational medicine, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services. We need to use the information for reasons of substantial public interest. The use is necessary for reasons of public interest in the area of public health, such as ensuring high standards of quality and safety of health care. The use is necessary for public interest or scientific research purposes so long as it is subject to appropriate safeguards. You have given explicit consent. Safeguarding purposes (for example, in order to ensure the health and safety of an individual) Legal grounds: The use is necessary for compliance with a legal obligation. We need to use the information to protect your vital interests or the vital interests of a third party. The use is necessary to provide you with healthcare and other related services. Additional legal grounds for special categories of personal data: We need to use the information to protect your vital interests or the vital interests of a third party and you or the third party are physically or legally incapable of giving consent. We need to use the information for reasons of substantial public interest, such as the use being necessary in protecting an individual from neglect or physical, mental or emotional harm and protecting the physical, mental or emotional wellbeing of an individual. You have given us your explicit consent. Preventing and investigating fraud. This might include sharing your personal information with third parties such as the police or fraud prevention agencies, or carrying out fraud, credit, anti-money laundering and other checks Legal grounds: The use is necessary to provide you with healthcare and other related services. The use is necessary for fulfilling our legitimate interests (e.g. an appropriate business need) and those interests are not overridden by your privacy rights. Additional legal grounds for special categories of personal data: We need to use the information for reasons of substantial public interest. Carrying out marketing activities and providing marketing information to you Legal grounds: The use is necessary for fulfilling our legitimate interests (e.g. an appropriate business need) and those interests are not overridden by your privacy rights. You have given us your consent. For employment and pre-employment purposes, such as considering job applications from you, carrying out pre-employment checks and entering into an employment contract Legal grounds: Taking steps at your request so that you can enter into an employment contract with BMI Healthcare, or for the purposes of that contract. We have a legal or regulatory obligation to use your personal information. The use is necessary for fulfilling our legitimate interests (e.g. an appropriate business need) and those interests are not overridden by your privacy rights. You have provided your consent to our use of your personal information. Additional legal grounds for special categories of personal data: We need to use the information for reasons of substantial public interest. It is necessary for the management of our healthcare services. It is information that you have made public. You have provided your explicit consent.

We will only keep your personal information for as long as reasonably necessary to fulfil the relevant purposes set out in this Privacy Notice and in order to comply with our legal and regulatory obligations.

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From time to time, we may share your personal information with others. We will keep your personal information confidential and only share it with those listed below for the purposes explained in the previous section. Sharing within the p4 Fertility, Aarna private limited and Agrni promotions group of companies We may share your information with other companies in the p4 Fertility, Aarna private limited and Agrni promotions group, for example, in order to provide you with healthcare services or progress your employment application. Sharing with third parties We may share information with the following third parties: Clinicians or other healthcare professionals involved in your treatment Other staff involved in your healthcare, such as receptionists, secretaries and administrative assistants Organisations from which you are receiving healthcare services, such as your GP or dentist Third parties who are involved in your healthcare, such as insurers Other private sector healthcare providers The Private Healthcare Information Network Third parties involved in research or audit projects NHS organisations, including NHS Resolution, NHS England, Clinical Commissioning Groups, NHS Foundation Trusts, NHS Trusts, or the Department of Health as well as third parties that have contractual relationships with such NHS organisations Government bodies such as the Home Office and HMRC Regulators, such as the ICO, the Care Quality Commission, Health Inspectorate Wales, and Health Improvement Scotland The police and other third parties where reasonably necessary for the prevention or detection of crime Anyone that you have asked to communicate with us on your behalf, or have named as an emergency contact, such as your representative, next of kin or carer Debt collection agencies Our insurers Our third party services providers and advisers, such as IT suppliers, actuaries, auditors, lawyers, marketing agencies, document storage and management providers and tax advisers Preferred partners for credit agreements Credit referencing agencies Any third parties involved in the sale, transfer or disposal of all or a part of our business We may communicate with these third parties in a variety of ways including, but not limited to, email, post, fax and telephone.

In this Privacy Notice we use "we", "us", "our" , "p4 Fertility", "Aarna private limited" or "Agrni promotions" to refer to p4 Fertility, Aarna private limited and Agrni promotions. We will advise you in our communications with you of the specific company within the p4 Fertility Healthcare group of companies which is making decisions about the use of your personal information.

If you’re having treatment at a licensed fertility clinic in the UK, your donor will have no legal rights or responsibilities to any children born with their sperm, eggs or embryos. This means: They will have no legal obligation to any children conceived from their donation. They won’t be named on the birth certificate. They won’t have any rights over how the child will be brought up. They won’t be required to support the child financially. If you don’t have treatment with a licensed clinic the situation is more complicated. There’s a risk that your donor will be considered a parent by law – with all the rights and responsibilities that brings. Talk to a solicitor to find out more about how this applies to you.

Using donated sperm, eggs or embryos is a major decision and you should take your time to think about whether it’s right for you. You may want to discuss your feelings with friends, family or a professional counsellor before going ahead. A clinic is likely to recommend donor conception if: You’re not producing eggs or sperm of your own Your sperm or eggs are unlikely to result in a pregnancy You have a high risk of passing on an inherited disease You’re in the same-sex couple, or You’re single.

If you use a donor through your fertility clinic you’ll be able to find out: a physical description (height, weight, eye and hair colour) the year and country of birth their ethnicity whether they had any children at the time of donation, how many and their gender their marital status their medical history A personal description and goodwill message to any potential children (if they chose to write one at the time of their donation). You won’t be able to find out any information that might reveal who the donor is.

Donor: donor woman will go through a cycle of stimulation and egg collection. Eggs are collected and fertilized with your parker’s sperms in the laboratory. Recipient: Your womb is prepared simultaneously using hormones to be ready for the embryo. In some cases, it is difficult of synchronising the egg collection and the preparation of the recipient woman, embryos could be frozen and stored so that they may be placed in the uterus at the optimum time.

Sperm sharing is the procedure whereby the male partner provides sperm samples for freezing up to a maximum of 100 ampoules for donation to other patients. In return, the female partner receives one cycle of IVF or up to 6 cycles of Intra-Uterine Insemination at a reduced cost. It will, however, delay the start of your treatment by about 5 months. Anyone between 18-40 years of age can be considered for sperm sharing. However, we have to undertake tests to screen sperm sharers, to ensure that More information on donor egg /sperm/embryo conception https://seedtrust.org.uk/

If you use a donor through a licensed UK fertility clinic there are very few risks. Your donor’s family history will be checked to make sure they don’t have any serious genetic diseases that could be passed onto any children you conceive. They’ll also be checked for infections including HIV, hepatitis, syphilis and gonorrhoea. If you’re using a donation from someone you know, but are still having treatment at a clinic, they’ll go through all the same checks.

It’s natural for some people who have been conceived with the help of a donor to want to know about their donor or siblings. They might want to see what characteristics they’ve inherited from their donor, or what similarities they share with their siblings. When your child reaches 16, they’ll be able to find out the same information that you can find out about a potential donor at the time of the donation. When they’re 18 they can find out their donor’s name, date of birth and last known address and it’s up to them if they want to try and get in touch.

You will not get any donor identifiable details. You will receive the match form with various characteristics to choose a donor from. All donors used now in the UK are identifiable, people aged 16+ (if contemplating marriage) or 18, who ask the HFEA, will be told whether or not they were born as a result of licensed donor assisted conception treatment, and if so, whether they are related to the person they want to marry. Also, they will now be able, on reaching the age of 18, to learn the identity of the donor or donors, if conceived after 1st April 2005.

The chance of success using donor eggs depends largely on the age of the donor, and only women under the age of 36 years are accepted as donors. Therefore, it has very good chances of success. The national data showed

Women who are themselves undergoing IVF, and who can be expected to produce a good number of eggs, may elect to donate some for the treatment of others, subject to health screening and counselling. Treatment may be available at a much-reduced cost for suitable donors, and full details of this scheme are available on request.

It is much more difficult to obtain donated eggs than sperm because the donor has to undergo the complete process of IVF except for the embryo transfer, entirely for the benefit of someone else. It is legally permissible to use eggs supplied by a donor known to the recipient, but that has the potential to cause serious psychological and social problems for all concerned, including resulting children, and the policy of the Fertility Centre is generally to use anonymous donors where possible. All donors are health-screened according to HFEA Regulations, including an HIV test, but the risk of HIV transmission is very remote, and it is not legally required to quarantine the embryos in the same way as donor sperm. This can, however, be achieved by storing the embryos and re-testing the donor before transfer. Ethnic minority donors are rare. Therefore, waiting list for them could be longer.

Where a woman has poor quality few eggs or she is incapable of producing eggs because of premature menopause, or there is a substantial risk of passing on a hereditary disease, it may be possible to obtain eggs from a donor, and these can be fertilised with your partner’s sperm and embryo is placed in the womb.

The private fertility consultation appointment with us is of 30 min. It allows enough time for a thorough discussion. You are encouraged to take all your previous clinic letters and any available reports with you. Do not bother to request any further documents from your last NHS or private clinic before the appointment. We will personalise the treatment for you and may request records as required directly from your provider on your behalf. During your consultation, we take your history, discuss the treatment and plans with you. There is no need for clinical examination in most of the cases. We arrange investigations as required. We do not treat you as a number but as a person! It is an opportunity to ask any questions. Your participation in your care is our central principle.

You are encouraged to contact us as soon as you decide to reschedule the appointment. It will help other waiting patients to use this slot.

If you think that you need a follow-up appointment with us to discuss any more information, your results or any treatments - please use the online booking system or contact us. The follow-up appointment cost is £150.

There are no parking charges for all our patients. Car park spaces vary according to the locations of the clinics and are enough to cater need of our patients.

It is standard policy to write a summary letter to you. If you wish, copy it to your GP following consultation. If you do not want to copy the letters to GP or /and your home address, please let us know at the time of consultation.

You may consider booking either by using the online booking system or contact us. We may have some appointments convenient for you, which includes consultations on Saturday.

If you book an appointment and did not attend on the day will be charged as £25 admin cost for any DNA appointments. If you wish to reschedule or cancel it please do so at least 24 hours before appointment time to avoid DNA charges.

Please book an appointment either by using our online booking system or by contacting us.

You pay for what you get at P4 Fertility @Priory. We do not offer packaged treatment or multiple treatments in one cost package. In package cost, you often end up in paying for many tests which you do not need. We do not treat and charge patients in blocks. At P4 fertility@ priory, personalised treatment is the ethos, and this means every plan is costed as per personal needs. It ensures you pay for what you need. Any subsequent cycle, should you need it, is personalised from experience of the first cycle. Therefore, offering multiple cycles in one go, we believe, means treating patients as customers that is against our ethos.

Yes, you may. If you can get a better deal somewhere else, you may choose to buy drugs from an outside pharmacy.

Fertility tests are available on the NHS. Any operations such as camera tests and keyhole surgery are possible on the NHS. Ovulation induction using tables in PCOS as per local guideline is available on NHS. The treatment which requires funding approval includes assisted conception treatment such as IUI, IVF, ICSI, and egg or sperm storage. There are criteria for such funding. These criteria are different from place to place. IVF funding is a classic example of a postcode lottery. CCG contacts IVF treatment to local NHS or private IVF unit, and within the contract, the criteria are clearly defined. The rules vary with local CCG and where the patient's GP is based. For example, Scotland funding is available for three cycles of IVF. In some part of England, it can range from0 to three cycles. National guideline-recommended 3 IVF cycles to eligible women under 40, only 12% CCG follow this. Please check the availability of funding for your treatment with your doctors. At p4 fertility, our team is happy to advise you on NHS funding within West-Midlands based on your details. Visit fertility fairness website for further information. http://www.fertilityfairness.co.uk/

Only assisted conception treatment (IVF/ICSI) is not funded by the NHS in certain circumstances, for which you pay. You are eligible to receive full care including medications, scans and consultation on the NHS at your local hospital. Therefore, you are likely to receive complete care on NHS for any other part of your pregnancy. We advise you to contact your GP once you are clinically pregnant.

Full Consultation: £200 Follow up Consultation: £150 You pay for what you get at P4 Fertility. There is no full packaged cost where you end up paying for things you don’t need, or you already have!

Love to pay in instalments without any additional cost. Yes, you can. You need to pay for the first consultation. Once you complete your first appointment, you can apply for a BMI Card. BMI Priory offers you BMI card. A credit card interest-free for the first 12 months. You may choose to pay in instalments over the next 12 months without attracting any interest. Pay with THE BMI CARD which offers: · A credit card interest-free for the first 12 months · Credit limit up to £20,000 (subject to eligibility) · No annual charge, membership fee or deposit required · Applications of up to £7,000 may get approval within 48 hours of receipt of the signed agreement. Please allow 2-3 weeks for higher loan amounts · Further information: speak with doctors at the time of consultation. Or see https://www.bmihealthcare.co.uk/paying-for-treatment/flexible-finance The flexible finance decisions are made by BMI Priory Hospital or their partner finance providers. P4 Fertility does not have any role in arranging the flexible fincance.

Our IVF treatment cost is cheaper than you think! We have drawn up the figures below to illustrate the costs you can expect to encounter. Please note that prices charged by other departments in the hospital such as Pharmacy or Pathology may be changed independently of The Fertility Centre. You should be aware that all prices can vary from those quoted below and procedures and drugs may be added depending upon clinical need. You will receive your cost plan at your first consultation.

Folic acid is a vitamin (B9). It is present in certain foods, and you can take it as tablets. If you're planning to have a baby, you must take folic acid tablets for three months before you conceive. It allows it to build up in your body to a level that gives the most protection to your future baby against birth defects such as neural tube defects, spina bifida. You can also try to eat more foods that contain folate, which is the natural form of folic acid. But diet alone does not have enough folic acid for pregnancy.

If you have a higher risk of having a pregnancy affected by neural tube defects, you will be advised to take a higher dose of 5mg folic acid. You may have a higher risk if: • You have diabetes • You or your partner have a neural tube defect • You have had a previous pregnancy affected by a neural tube defect • You or your partner have a family history of neural tube defects • You have epilepsy • You are a heavy drinker. To get a higher dose to talk to your doctor because 5mg tablets aren’t available without a prescription

1. Processed meats/ food, Trans fats, Soy products 2. Pesticides and bisphenol which act as xenoestrogens—chemicals that mimic estrogen (pesticides could be present on fruits and vegetables, and BPA is used in food packaging and cans) 3. High-fat dairy products may cause reduced motility and abnormal shape of sperms

Please read the following table

You can eat more foods that contain folate, which is the natural form of folic acid. But diet alone does not have enough folic acid for pregnancy. You should take folic acid tablets. The foods that contain folate include: · broccoli · brussels sprouts · spinach · asparagus · peas · chickpeas · fortified breakfast cereals.

Most women are advised to take a 400mcg supplement every day. You can get these from most pharmacies, supermarkets, and health food shops. You can also get folic acid in some pregnancy multivitamin tablets. If you do, make sure the tablet does not contain vitamin A. High doses of vitamin A can cause developmental problems in the first three months of pregnancy.

Don't worry, the risk of problems is minimal. Start taking folic acid now and until week 12 if you have not reached it yet. You don't need to take after 12 weeks folic acid (though it is not harmful) as the neural tube will have fully developed. You can talk to your GP or midwife if you have any concerns.

Tomatoes are a rich source of lycopene. It is an antioxidant believed to improve sperm motility, structure, and activity. You can also add olive oil to cooked or processed tomatoes in enhancing the absorption of the antioxidant. Walnuts are rich in omega-three fatty acids. All kinds of berries, including blueberries, strawberries, cranberries, and blackberries, contain potent anti-inflammatory and antioxidants quercetin and resveratrol. Pomegranates may improve the testosterone levels and sperm quality and increase sex drive. Ginseng, Also known as Ashwagandha, it is an aphrodisiac root used in traditional medicinal practices. Other useful food items are, citrus fruits, whole wheat and grains, most fish, especially wild salmon, cod, and haddock, most shellfish, especially oysters, vitamin D, dark chocolate, garlic, bananas, broccoli, turmeric, asparagus, most leafy greens, especially spinach and kale, fermented nuts and seeds.

In our opinion, the common-sense approach is the best. There are some distinct food items such as trans fats, processed foods and canned food, which are not suitable for general health as well as for fertility. On the other hand, green leafy vegetables, fruits, berries and nuts contain high levels of antioxidants, vitamins and micronutrients. Antioxidants are the substances that cleanse our body from stress-related damaging chemicals. Vitamins, antioxidants and micronutrients such as selenium, zinc is suitable for cell functions. Similarly, they are good for sperms and eggs. You do not need to follow a strict fertility diet plan, which may be counterproductive by adding undue stress in your busy life! Think of wide variations in dietary practices all over the world, but every country has a fertile population. The common-sense approach and gentle change in daily lifestyle help most of the couples. There is no need to follow a strict diet plan if your height to weight ratio (BMI) is in the normal range.

One in seven couple struggles to get pregnant. Four key factors are required for natural pregnancy. 1. Sperms, 2. Normal womb, 3. Open tubes (called fallopian tubes) 4. Eggs released by ovary every month When something goes wrong in any or some of these organs, it leads to difficulty in getting pregnant. 30% of the time the problem can be in men 40% of the time it is something wrong in women 10% combined both have something that causes difficulty in getting pregnant 20% Unexplained means the couple have open tubes, normal womb and normal sperm count One of the reasons there is an increased in demand for fertility treatment is from same-sex couples. Due to medical advances, cancer survival is great, that lead to patients coming for fertility treatment afterwards. We do fertility preservation in a few cases before cancer treatment.

Fig 1 Fig 2 Fig 1 and 2: age related decline Girls are born with a fixed number of immature eggs in their ovaries. The number of eggs decreases as women get older. At birth, most girls have about 2 million eggs, at adolescence that number has gone down to about 400, 000, at age 37 there remain about 25,000. By age 51 when women have their menopause, they have about 1000 immature eggs, but these are not fertile. At every menstrual cycle one of the immature eggs will mature and be released during ovulation. The eggs that are not released die and get re-absorbed into the body. The quality of the eggs also gets poorer as women get older. All other things being equal the number and quality of the woman’s eggs determines her fertility. Women’s fertility will continue to decrease every year, whether or not she is healthy and fit because the number and quality of the eggs decreases with age. Even if a woman is not ovulating (for example if she is taking the contraceptive pill, or is pregnant), the number of eggs continues to decline at the same rate. How quick a woman’s fertility declines will depend on a combination of genetic and lifestyle (e.g. smoking) factors. Men are not born with their sperm. Men produce sperm daily. Men’s fertility also starts to decline around age 40 to 45 years. The decrease in fertility is caused by the decrease in the number and quality of the sperm they produce. Men can have fertility problems even if they can still have sex and have an ejaculation. If you are concerned about your age and your fertility, you may consider having your fertility tested.

The straight young couple is advised to try one year provided the periods are regular, normally 80% of couple conceive within a year. After one-year start seeking help and investigations, it takes time on NHS to get referrals and appointments, if all investigations are normal, they are advised to try for two years as remaining 50% of 20% get conceived in the second year. After two years of trying its time for treatment. The same-sex couple should seek help when they are in a stable relationship and ready to start a family. If there is a known medical condition such as polycystic ovaries, or womb surgery or endometriosis in women or testicular problems in men, the couple should seek help earlier than this. Age of the women is the top predictor of the success of fertility treatment, currently, NHS funding criteria do not permit IVF after a certain age. Most of the time the upper age limit is 40 years. Therefore, older women especially above 37 -38 should seek help sooner than later.

By definitions, no pregnancy after 2 years of trying is defined as subfertility. Absolute infertility is when there are no gametes that mean no sperms or eggs. It is diagnosed with the tests.

Fertility tests are available on the NHS. Any operations such as camera tests and keyhole surgery are available on the NHS. Ovulation induction using tables in PCOS as per local guideline is available on NHS. The treatment which requires funding approval includes assisted conception treatment such as IUI, IVF, ICSI, and egg or sperm storage. There are criteria for such funding. These criteria are different from place to place. IVF funding is a classic example of a postcode lottery. CCG contacts IVF treatment to local NHS or private IVF unit and within the contract, the criteria are clearly defined. The criteria are various with local CCG and where the patient’s GP is based. For example, Scotland funding is available for three cycles of IVF. In some part of England, it can range from0 to three cycles. National guideline-recommended 3 IVF cycles to eligible women under 40, only 12% CCG follow this. Please check the availability of funding for your treatment with your doctors. At p4 fertility, our team is happy to advise you on NHS funding within West-Midlands based on your details. Visit fertility fairness website for further information. http://www.fertilityfairness.co.uk/

Egg release: Subfertility is most commonly caused by problems with ovulation, the monthly release of an egg. Some problems stop an egg being released at all, while others prevent an egg being released during some cycles but not others. Ovulation problems can be a result of: Polycystic ovary syndrome (PCOS) when periods are not regular, there could be abnormal facial hair growth, Thyroid problems – both an overactive thyroid gland and an underactive thyroid gland can prevent ovulation Premature ovarian failure – where a woman's ovaries stop working before the age of 40, this can happen due to genetic problems, as a result of cancer treatment, it can be associated other autoimmune conditions, it could run in families. Therefore, is a sister, cousin or mum had a history of premature ovarian failure, women should seek help sooner than later. Tubes are required for meeting egg and sperm what we call fertilization and then the transfer of fertilised egg. Any damage to the tube can cause subfertility or ectopic pregnancy. Scarring from surgery, sexually transmitted infections, and chlamydia damages tube. Womb: poly, fibroid in the cavity of the womb, some conditions from birth can have womb abnormalities. In some conditions, there is the absent womb. Endometriosis: when tissue like lining of the womb (endometrium) is present outside the womb is called endometriosis. It can cause fertility problems. Please check information on endometriosis in relevant section.

The chance of success using donor eggs depends largely on the age of the donor, and only women under the age of 36 years are accepted as donors. Therefore, it has very good chances of success. The national data (from HFEA website) showed

First thing as mentioned above, when a couple decides to have a baby, timing to seek help is important. GPs normally check medical history, advice on lifestyle measures such as stopping smoking, getting height and weight ratio (BMI) within the normal range as these can stop couple getting pregnant and part of funding criteria. Start folic acid. Baseline tests are done by GP such as sperm test, hormonal tests, which helps to diagnose PCOS thyroid conditions, problems with sperms. Normally General Practitioners (your doctors) are advised to refer a couple to secondary care to fertility consultants for further tests and treatment. Conditions like PCOS, thyroid, any polyp or fibroid in the womb, endometriosis could be treated in a hospital setting with secondary care. If requires the consultant from these hospital settings refer them to sub-specialist consultants in tertiary centres with IVF units and other facilities like ours at Birmingham Women’s Hospital. Certain special circumstances require referral to territory centres or IVF centres directly. Special circumstances include clear indications for assisted conception such as blocked tubes, no sperms, same-sex couples, premature stopping of the function of ovaries, surrogacy, fertility preservation.

“Human conception is one of the most ineffective conceptions in nature,” Thirty per cent of pregnancies is lost between implantation and the sixth week. Clinically miscarriage is only called miscarriage after diagnosis of pregnancy, therefore many implantation failures go unaccounted for. Having one miscarriage can be devastating enough but having one after another is often a very traumatic experience. Miscarriages are divided into two categories, the first, sometimes called “sporadic” or “spontaneous” miscarriage, refers to when women lose one or two pregnancies in a row. Most sporadic miscarriages are attributable to unpreventable “chromosomal abnormalities in the baby and cannot be predicted or prevented. Fortunately, they are not very likely to happen again. It’s nature’s mechanism to miscarry those embryos, which are not destined to develop into a healthy fetus. The risk for chromosomal abnormalities goes up as a woman age. But no one’s sure just why that is, it could be the quality issue of eggs and embryos. There are many possible causes for recurrent miscarriage, including genetic and hormonal problems; infection and thrombophilic (blood-clotting) defects; uterine problems and cervical weakness. Unfortunately, even after investigation, it’s not always possible for doctors to identify the cause for recurrent miscarriage. Nearly 50% of recurrent miscarriages are unexplained. However, most couples who have had recurrent miscarriage have a good chance of having a baby in the future. The quality of a man’s semen also seems to play a role. “Poor sperm quality can be the cause of miscarriage in about 6% of couples. Although three or more consecutive pregnancy losses are called recurrent miscarriages, we advise the couple to seek help after two miscarriages one after another. The couple can get a referral to the hospital, many hospitals have recurrent miscarriage services. Fertility experts are trained to manage recurrent miscarriages. There are national centres such as ours for miscarriage research. Couples with some medical issues are treated accordingly. Couples with an unexplained recurrent miscarriage should be offered appropriate emotional support and reassurance. There is good evidence that appropriate care improves the success rate.

Sperm test has three main parts, how many sperms are there, that is count, How they move, that is motility and how they look that is called morphology. World Health Organization defines criteria for normal sperm parameters. If one test shows some problem, we may repeat the test as various things can change sperm levels, such as any other sickness, medications at the time of the test, how the test was performed etc. If count is less than normal, poorly moving or lazy sperms or not having a good number of normal-looking sperms are the main cause for subfertility in men. Smoking can cause sperm problems. Damage to testicles, due to surgery or trauma, undescended testis, genetic problems such as extra chromosomes, cystic fibrosis are other medical causes. Sometimes it could be due to no obvious reason. It is worth mentioning about Muscle building injections what we call anabolic steroids, testosterone supplements.

Winner Quality Improvement Project Presentation East Midlands Winner BSGE- Ethicon Laparoscopic Gynaecology Training Fellowship The prize for Oral Presentation at European College of Obs and Gynae Congress UK The prize for Oral presentation at ISGE Congress, Italy Gold Medal Obstetrics and Gynaecology by University of Mumbai Dr N. A. Purandare awards by University of Mumbai The prize for Oral presentation at Mumbai Obs and Gynae Society Conference

Dr. Jeve is a Principal Investigator for randomised control trials at the University of Birmingham. He received a Ph.D. for his research on “Role of Ovum in Reproductive Outcomes” He studied ovaries in depth. He worked at the University of Glasgow with Prof Richard Fleming when pioneering work on serum AMH was done. His research titled “Accuracy of first-trimester ultrasound in the diagnosis of early embryonic demise” resulted in changes to the National and international guidelines. He has authored National Guideline on Recurrent Implantation Failure. ​ Publications: ​ Key Book Chapters: ​ Stimulating the poor responders, Jeve YB Bhandari H, Editors- Kovacs, Rutherford &Gardner How to Prepare Eggs & Embryo to Maximize IVF Success, Cambridge University Press Management of Recurrent Miscarriages. Reproductive Medicine, Jeve YB. Editor- Dr Gautam Allahabadia Challenges, Solutions, and Breakthroughs: Jaypee Brothers Publication; 2014. Key Publications: Time to consider ovarian tissue cryopreservation for girls with Turner’s syndrome: an opinion paper, Human Reproduction Open 2019 (3), (Link) Strategies to Improve Fertilisation Rates with Assisted Conception: A Systematic Review. Hum Fertil (Camb). 2017 May 26:1-19. (Link) Effective treatment protocol for poor ovarian response: A systematic review and meta-analysis. J Hum Reprod Sci. 2016 Apr-Jun;9(2):70-81 (Link) Donor oocyte conception and pregnancy complications: a systematic review and meta-analysis. BJOG. 2016 Aug;123(9):1471-80 (Link) A three-arm age-matched cohort study to compare the obstetric outcome of ovum donation pregnancies. Int.J Gynaecol Obstet.2016;133(2):156-8 (Link) Evidence-based management of recurrent miscarriages. J Hum Reprod Sci. 2014; 7(3):159-69. (Link) Definition and epidemiology of unexplained infertility. Obstetrical & Gynaecological Survey 2014; 69(2):109-15. (Link) The combined use of anti-mullerian hormone and age to predict the ovarian response to controlled ovarian hyperstimulation in poor responders: A novel approach. J Hum Reprod Sci. 2013;6(4):259-62. (Link) Accuracy of first-trimester ultrasound in the diagnosis of early embryonic demise: a systematic review. Ultrasound in obstetrics & gynecology. 2011;38(5):489-96.(Link) Predicting Postpartum Haemorrhage (PPH) during caesarean section using the Leicester PPH Predict Tool: a retrospective cohort study: Am J Perinatol. 2017 Aug 28. Work-related musculoskeletal injuries amongst obstetrics and gynaecology trainees in the East Midland region of the UK. Arch Gynecol Obstet. 2017 Jul 12. Knowledge of human papillomavirus and the human papillomavirus vaccine in European adolescents: a systematic review. Sex Transm Infect. 2016 Jan 20 Comparison of techniques used to deliver a deeply impacted fetal head at full dilation: a systematic review and meta-analysis. BJOG 2016 Feb;123(3):337-45 Placental dysfunction in obese women and antenatal surveillance strategies. Best Practice & Research Clinical Obstet & Gynaecology. 2014. The Role of Ultrasound Simulation in Obstetrics and Gynaecology Training: A UK Trainees' Perspective. Simul Healthc. 2016 Jul 6. Knowledge, skills and attitude of evidence-based medicine among obstetrics and gynaecology trainees: a survey. JRSM-short reports2013; 4(12) Complication rates for elective caesarean section: hospital specific consent counselling. BJOG, 120: 3–64. (Abstract) Secondary Post-Partum Haemorrhage Due to Secondary Uterine Arterio-venous Malformation following Caesarean Section. Journal of pharmaceutical and biomedical sciences. 2013; 28:643-5 Response to Antenatal HIV testing and prevention of parent to child transmission: an experience in a peripheral hospital in India. J Obstet Gynecol India. 2009; 59:124-6. A rare case of ovarian malignancy presenting as neurological paraneoplastic syndrome. J Obstet Gynecol India 2009;59(5):483-5. Traumatic transfundal rupture of full term non-scarred uterus. J Obstet Gynecol India 2009; 59(4):352-53.

Declaration of conflict of interest*: Dr. Yadava Jeve, various positions and conflicts of interests *Please contact us if you require any further details /information on conflict-of-interest declaration.