Anti-Müllerian Hormone (AMH) is produced by small follicles (pouches which contain the eggs) growing in the ovary. It can be measured in a blood test. The level of AMH reflects how many follicles are growing, which gives an indication of how many eggs are present in the ovary. The number of eggs present in the ovary declines as we age, until menopause, when the supply runs out. The more follicles that are growing, the higher the level of AMH in the blood.

The AMH measurement can predict how strongly the ovaries will respond to the hormones used in an IVF cycle. Certain factors may affect AMH levels. If you have polycystic ovaries (PCO), more small follicles are growing in your ovaries, making it likely that you will respond vigorously to the stimulation drugs. In this situation, your levels of AMH may be elevated. This can identify the information needed to modify your hormone doses accordingly. AMH is also increased in certain pathological tumours of the ovary such as a granulosa cell tumours but these occur rarely. Similarly, if you have a low number of growing follicles, for example due to previous illnesses and pelvic operations, chemotherapy or because you are approaching the menopause, it can be identified through low AMH levels and adapt your dosage of gonadotrophins to try to compensate, but this may not always help.

Research has shown that AMH measurement is the most reliable method of predicting the likely response of the ovary, (better than other tests that you might have heard of, such as FSH or inhibin). However, unfortunately, the NHS does not fund AMH measurement, so they ask patients to pay for it themselves

The benefits perceived are that it improves the doctor’s ability to prescribe the best individualised stimulation regime for your personal needs. In this way, treatment can be optimised and give you the best chance of achieving a successful outcome.

It is recommended that you have it done, especially if you are in one of the following situations:

• Previous poor response

• Older women (age>35)

• If you have ever had a high FSH or a high E2 blood test result

• Low antral follicle count on scan examination.

• Polycystic ovaries (PCO/PCOS)

• Uncertainty about response to gonadotrophin injections.

  ____________________

  AMH Normal Ranges:

Age Range , AMH (pmol/l)

20-29 years , 13.1 - 53.8

30-34 years , 6.8 - 47.8

35 - 39 years , 5.5 - 37.4

40-44 years , 0.7 - 21.2

45 - 50 years , 0.3 - 14.7

Reference-https://www.uhcw.nhs.uk/clientfiles/files/IVF/CRM%20AMH%20Patient%20Information%20(GEN-PI-000213V11).pdf

Using donated sperm 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 sperm of your own

• your own sperm is unlikely to result in a pregnancy

• you have a high risk of passing on an inherited disease

Do you need to pay for a donor?

In the UK, it’s illegal to pay a donor anything other than expenses. This means that most donors donate for altruistic reasons rather than financial gain.

The expenses limit is £35 for sperm donors. Normally the donor’s expenses should be covered in your overall treatment cost but double check with your clinic.

Are there any risks from using donated sperm, eggs or embryos?

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.

Expanded carrier screening (ECS) or testing involves identifying simultaneously the presence or the absence of many gene variants which might be associated with different conditions of varying severity and predictability. The HFEA does not require UK fertility clinics to carry out ECS and gamete donors are not required to have had this screening. You should discuss any questions that you may have about ECS with your fertility clinic.

How can I find a donor?

The safest option is to find a donor from your clinic. This ensures the donor will be given health checks and supported through the process with information and counselling, minimising the chance of something going wrong further down the line.

Some clinics have a list of sperm, egg or embryo donors that you can choose from. Waiting lists can be long however, particularly if you’re after something specific – choose a clinic to view current donor waiting times.

It’s possible for UK clinics to import sperm, eggs or embryos from abroad. However there are strict conditions that need to be met. You’ll need to find a licenced UK clinic who offers import/export services.

Does the donor have any rights to children conceived from their donation?

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.

What can I find out about a potential donor?

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 can choose to use a donor who you do not know by going to a fertility clinic. You will not know the identity of the donor, but you will be able to access anonymous information about them (such as height and eye colour) from your clinic.

Your child will be able to access anonymous information about their donor when they’re 16 years old and they will be able to find out their identity when they're 18 years old.

Going overseas

Some people choose to travel abroad for donor treatment. This may be because the cost of treatment is lower or that there is a greater availability of donors.

If you are going overseas for treatment because you have heard that waiting lists are long in the UK, you may want to check with a different clinic. Although some clinics report having long waiting lists, some may have shorter waiting times.

If you plan to go abroad for treatment, it is important to remember that different safety and legal rules may apply.

Before going ahead with treatment abroad, you should carry out thorough research on:

• standards and safety issues abroad

• legal issues surrounding donors and parental responsibility

• the process involved in recruiting and screening donors

• whether there are any limits on the number of families that can be created per donor, and

• what information you can access about the donor and what information the child will be able to access. We don’t collect information about fertility treatments that have taken place in overseas clinics. As a result, children born from donor treatment abroad will not be able to access information from us about their donor.

It is important to remember that if you go to a UK-licensed fertility clinic, the donor has no legal responsibility, or rights, towards the child. This is not necessarily the case when treatment takes place in other countries.

It is important to be aware that many fertility-related interventions such as gamete donation involve complex Halachic questions, which are often specific to a couple’s unique circumstances and therefore require individual Rabbinic guidance. Chana is here to assist you in either consulting with the Rabbi of your choice, or in consulting with our Rabbinic Panel on your behalf if you would prefer.

Reference- https://www.hfea.gov.uk/treatments/explore-all-treatments/using-donated-eggs-sperm-or-embryos-in-treatment/

Fertility patients now have more time to make important decisions about their future following a change to the law that enables all patients to store their eggs, sperm and embryos for up to 55 years, providing they reconsent every 10 years.

From 1 July 2022, all patients can store their eggs, sperm and embryos for their own treatment for up to 55 years, providing they reconsent every 10 years; donors can store their eggs or sperm for use up to 55 years and do not need to renew their consent; and providing patients consent to their sperm, eggs or embryos being used in the event of their death, they can remain in storage for up to 10 years from the date they pass away.

The HFEA is supportive of the new law however it has extensive implications for clinics and for some patients.

Clinics must:

• Audit all their stored material to accurately assess the consent status of any stored gametes or embryos.

• Alongside the relevant information, offer patients counselling every time they are approached about giving or renewing consent.

• Contact patients who have gametes or embryos in storage where there is no effective consent to storage in place or where consent to storage is due to expire within the Transitional Period to renew their consent. This must happen before 30 June 2023.

• Use the new and revised consent forms that reflect these legal changes available on the HFEA website and ensure patients have these consents in place before 30 June 2024.

The new law also has important changes for people who try to preserve their fertility – patients about to undergo cancer treatment or hormone therapy for example. These patients can continue to store their eggs, sperm or embryos for up to 55 years but now they must reconsent every ten years; something they did not need to do previously.

Sperm freezing is the most effective method of preserving a man’s fertility.

You may want to consider sperm freezing if:

• You have a condition, or are facing medical treatment for a condition that might affect your fertility

• You have a low sperm count or the quality of your sperm is deteriorating

• You have difficulty producing a sperm sample on the day of fertility treatment/you may not be around at the time of treatment e.g. if you work away a lot

• You are at risk of injury or death

IVF using frozen sperm is just as successful as IVF using fresh sperm and there are no known risks from using frozen sperm in treatment. Not all sperm survive the freezing and thawing process though. Before sperm is stored, it is usually divided between a number of ‘straws’, which means that not all sperm needs to be thawed at once and it can be used in multiple treatments. From 1 July 2022, all patients can store their eggs, sperm and embryos for their own treatment for up to 55 years, providing they reconsent every 10 years.

When you want to use your sperm, you and your partner will need to have fertility treatment which may involve either insemination, IVF or intracytoplasmic sperm injection (ICSI). Your doctor will discuss this with you when the time comes.

Using donated sperm is a major decision and you should take your time to think about whether it’s right for you. Your chosen clinic should offer implications counselling and you may want to discuss your feelings with a proffesional counsellor at Chana before going ahead.

A clinic is likely to recommend donor conception if:

• You’re not producing sperm of your own

• Your own sperm is unlikely to result in a pregnancy

• You have a high risk of passing on an inherited disease

Do you need to pay for a donor?

In the UK, it’s illegal to pay a donor anything other than expenses. This means that most donors donate for altruistic reasons rather than financial gain. The expenses limit is £35 for sperm donors. Normally the donor’s expenses should be covered in your overall treatment cost but check this with your clinic.

Are there any risks from using donated sperm, eggs or embryos?

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.

Expanded carrier screening (ECS) or testing involves identifying simultaneously the presence or the absence of many gene variants which might be associated with different conditions of varying severity and predictability. Although we provide guidance to UK fertility clinics about donor screening in the HFEA’s Code of Practice, there is currently no national guidance in the UK specific to ECS. The HFEA does not require UK fertility clinics to carry out ECS and gamete donors are not required to have had this screening. You should discuss any questions that you may have about ECS with your fertility clinic.

How can I find a donor?

Either the clinic will assist with finding a donor or a sperm bank. This ensures the donor will be given health checks and supported through the process with information and counselling.

Some clinics have a list of sperm, egg or embryo donors that you can choose from. Waiting lists can be long however, particularly if you’re after something specific – choose a clinic to view current donor waiting times. Be aware that although the clincis waiting lists can be long the sperm and egg banks operate with few constraints resulting in a possibly shorter wait.

It’s possible for UK clinics to import sperm, eggs or embryos from abroad. However there are strict conditions that need to be met. You’ll need to find a licenced UK clinic who offers import/export services.

Does the donor have any rights to children conceived from their donation?

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.

What can I find out about a potential donor?

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.

Going overseas

Some people choose to travel abroad for donor treatment. This may be because the cost of treatment is lower or that there is a greater availability of donors. If you are going overseas for treatment because you have heard that waiting lists are long in the UK, you may want to check with a different clinic. Although some clinics report having long waiting lists, some may have shorter waiting times.

If you plan to go abroad for treatment, it is important to remember that different safety and legal rules may apply.

Before going ahead with treatment abroad, you should carry out thorough research on:

• Standards and safety issues abroad

• Legal issues surrounding donors and parental responsibility

• The process involved in recruiting and screening donors

• Whether there are any limits on the number of families that can be created per donor, and

• What information you can access about the donor and what information the child will be able to access. We don’t collect information about fertility treatments that have taken place in overseas clinics. As a result, children born from donor treatment abroad will not be able to access information from us about their donor.

It is important to remember that if you go to a UK-licensed fertility clinic, the donor has no legal responsibility, or rights, towards the child. This is not necessarily the case when treatment takes place in other countries.

From 2023 all donor conceived individuals will have the legal right to access the identity of their donor.

Reference: https://www.hfea.gov.uk/treatments/fertility-preservation/sperm-freezing/

Egg freezing is one way of preserving a woman’s fertility so she can try to have a family in the future. It involves collecting a woman’s eggs, freezing them and then thawing them later so they can be used in fertility treatment.

A woman’s chances of conceiving naturally fall as she gets older because the quality and number of her eggs drops. Egg freezing can be an attempt to preserve fertility by freezing the eggs when the woman is young, and the eggs are of the highest quality.

Is egg freezing right for me?

You might want to consider freezing your eggs if:

• You have a medical condition or need treatment for a medical condition that will affect your fertility, such as cancer (in this case NHS funding may be available depending on where you live).

• You’re worried about your fertility declining but you’re not ready to have a child or you haven’t found the right partner – this is often called ‘elective egg freezing’.

• You’re at risk of injury or death (for example, you’re a member of the Armed Forces who is being deployed to a war zone).

• You don’t want to have leftover embryos after IVF treatment for ethical reasons.

What Does Egg Freezing Involve?

Firstly, you'll need to be tested for any infectious diseases like HIV and hepatitis. This has no bearing on whether you can freeze your eggs or not but is to ensure that affected egg samples are stored separately to prevent contamination of other samples.

You'll then start the IVF process, which usually takes around two to three weeks to complete. Normally this will involve taking drugs to boost your egg production and help the eggs mature. When they’re ready, they’ll be collected whilst you’re under general anesthetic or sedation.

At this point, instead of mixing the eggs with sperm (as in conventional IVF) a cryoprotectant (freezing solution) will be added to protect the eggs. The eggs will then be frozen either by cooling them slowly or by vitrification (fast freezing) and stored in tanks of liquid nitrogen. The latest statistics show that vitrification is more successful than the slow cooling method.

Most women will have around 15 eggs collected although this isn’t always possible for women with low ovarian reserves (low numbers of eggs). When you want to use them, the eggs will be thawed and those that have survived intact will be injected with your partner’s or donor’s sperm.

How much does egg freezing cost?

The average cost of having your eggs collected and frozen is £3,350, with medication being an added £500-£1,500. Storage costs are extra and tend to be between £125 and £350 per year. Make sure you get a full-cost treatment plan from your clinic so you're not caught out by unexpected 'extras'.

Thawing eggs and transferring them to the womb costs an average of £2,500. So, the whole process for egg freezing and thawing costs an average of £7,000-£8,000.

Egg freezing is not normally available on the NHS unless you are having medical treatment which could affect your fertility (for example, treatment for cancer).

How safe is it?

IVF is mostly very safe, although some women do experience side effects from their fertility drugs. These are usually mild, but in extreme cases women can develop ovarian hyperstimulation syndrome (OHSS), which is potentially fatal, so you should familiarise yourself with the symptoms.

The major risk is that it won’t work – read more about success rates below.

It’s also important to know that as you get older, there is more risk of pregnancy-related complications and health problems for both you and your baby.

How successful is egg freezing?

Freezing eggs is a rapidly changing field. If you do decide to freeze your eggs, make sure you choose a clinic that has plenty of experience and ask to see their most recent success rates for women your age.

When looking at success rates for frozen eggs, numbers tend to be quite low. The technology for egg freezing has also improved over the years which means older data isn’t comparable to current success rates. We advise patients to look at success rates for fresh IVF cycles with patients using their own eggs in their age band. We consider these rates to be more reliable as there are much higher numbers of fresh embryo transfers each year compared to egg freezing.

What decisions do I need to make about my eggs?

You’ll need to complete consent forms before you start treatment specifying how you want your eggs to be used. This includes information on:

• how long you want the eggs to be stored for (the standard period is 10 years)

• what should happen to your eggs if you were to die or become unable to make decisions for yourself

• whether the eggs are to be used for your own treatment only, or whether they can be donated for someone else’s treatment, or used for research or training if you don't want to use them

• any other conditions you may have for the use of your eggs.

You can vary or withdraw consent at any time, either before treatment or before the eggs are used in research or training. If this happens, your eggs will not be used.

How can I find a clinic that offers egg freezing?

You can search for licensed UK clinics the HFEA website. You'll need to enter your postcode and then update your search criteria to look for clinics offering fertility preservation.

How long can my eggs be stored for?

From 1 July 2022, all patients can store their eggs, sperm and embryos for their own treatment for up to 55 years, providing they reconsent every 10 years; donors can store their eggs or sperm for use up to 55 years and do not need to renew their consent; and providing patients consent to their sperm, eggs or embryos being used in the event of their death, they can remain in storage for up to 10 years from the date they pass away.

What happens when I want to use my eggs?

Eggs that have been frozen and thawed must be fertilised using a fertility treatment called ICSI, as the freezing process makes the outer coating around the eggs tougher and sperm may be unable to penetrate it naturally under IVF.

This will be an extra cost on top of the fee for collecting, freezing and storing your eggs unless you have NHS funding.

What if it doesn’t work?

If none of your frozen eggs lead to a successful pregnancy, depending on your age you might want to try conceiving naturally or start IVF treatment. You can have IVF with donor sperm or eggs (or both) depending on your situation. You might also want to explore other options for having a family, such as adoption.

What if I don’t use my eggs or I have some left over?*

If you have frozen eggs you don’t want to use, there are a number of different options that will be presented to you:

• Donate them to research*: Research on eggs, sperm and embryos is invaluable in helping scientists to understand causes of infertility and develop new treatments.

• Donate them to training*: Trainee embryologists need eggs to practice different techniques, such as fertilising them with sperm in the lab.

• Discard them: Some people prefer to discard their eggs. Eggs that are no longer needed are simply removed from the freezer and allowed to perish naturally in warmer temperatures or water.

*Please be aware that donating genetic material for use by other people, or for research purposes, involves complex Halachic questions with potentially far-reaching ramifications. As such, it is essential to consult with a Rabbinic authority with specific expertise in this area when deciding upon a course of action. Chana is happy to support you in arranging this, if you would find this helpful.

Reference- https://www.hfea.gov.uk/treatments/fertility-preservation/egg-freezing/

There are options available for women to preserve their fertility. Your doctor should discuss this with you and the fertility clinic or assisted conception unit. It's important to understand that these methods are not always successful or suitable for everyone.

The possible options for preserving fertility include:

• Freezing embryos

• Freezing eggs

• Freezing ovarian tissue

If you choose to do so, these must be done before starting chemotherapy.

Freezing Embryos

You have fertility drugs to stimulate your ovaries to produce eggs. Doctors can then collect (harvest) the eggs and use your partner’s sperm to fertilise them in a laboratory, creating embryos. They then freeze the embryos until you want to have a baby, when the embryo is returned to your womb to grow there. This is called in vitro fertilisation (IVF).

It’s quite a complicated process and is not always successful. It is important to understand that the embryos are the joint property of you and your partner. Both of you will need to agree to use them later.

Freezing Eggs

You may not have a partner now. You can have just your eggs frozen until you’re ready to have a baby. The process is very similar to IVF. You have drugs to stimulate your ovaries to make eggs. Doctors then collect and freeze them until you are ready for them to be fertilised.

Freezing Ovarian Tissue

You can have a small operation to remove some ovarian tissue, which is then frozen. This is called ovarian tissue cryopreservation. The tissue is put back once your cancer treatment has finished. If the ovarian tissue starts working normally, the ovaries may produce eggs and so you remain fertile. This is a new treatment that is still in development.

The number of cryopreservation services are increasing across the UK. Ask your specialist if this is suitable for you and whether they can refer you to one of these services.

Ovarian Stimulation and Possible Risks

Ovarian stimulation is not suitable for everyone. It takes at least 2 weeks to stimulate the ovaries. If you need to start chemotherapy straight away, there may not be time for you to have it. The drugs given to stimulate the ovaries increase the levels of the hormone oestrogen. Oestrogen may encourage some cancers to grow, such as breast cancer.

Your specialist will talk through your options and explain any risks.

Ovarian Suppression

In certain cancers your doctor may suggest a 3-4 weekly injection of a Gonadotropin-releasing hormone (GnRH) agonist, such as Zoladex. This is a long-acting hormone drug that is used to make a woman go into the menopause for a short time. This is called ovarian suppression.

The hormone drug needs to be given at least a week before chemotherapy starts. It will stop your ovaries from working and may protect them from the harmful effects of chemotherapy and help to preserve your fertility.

You might experience menopausal symptoms such as hot flushes. This treatment is not suitable for everyone and is not always successful.

Getting Pregnant After Chemotherapy

Most doctors will advise women that it’s best to wait 2 years after chemotherapy treatment before becoming pregnant.

This is not because pregnancy could affect cancer. It’s because if your cancer was going to come back, it would be most likely to do so within two years. You would then need more treatment – and this would be very difficult if you were pregnant or had a young baby.

Other Fertility Options

There are other options you could consider if cancer has affected your fertility:

• Using donor eggs

• Using donated sperm so doctors can freeze embryos rather than eggs

• Using donated embryos

• Surrogacy (when another woman carries the baby for you)

These are difficult decisions, and some options may not be straightforward. For example, some of them aren’t always funded by the NHS. There is also a shortage of donors.

Chana is here to help support anyone going through these decisions, you are not alone.

Reference - https://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/chemotherapy/fertility/women/ways-to-keep-fertility