AMH- Anti-Müllerian Hormone 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

ALICE Test is a diagnostic test that detects pathogenic bacteria and can recommend appropriate probiotic or antibiotic treatment, and thereby improve their chances of conceiving.

A successful embryo implantation depends on the health of the endometrium (the lining of the womb). Pathogenic bacteria that can cause chronic endometritis are linked to implantation failure and recurrent miscarriages.

Technique

ALICE tests require only a small amount of endometrial tissue that can be taken at the clinic. It involves a small procedure, which requires no sedation. The sample will then be analysed using the latest Next Generation Sequencing (NGS) technology to provide a complete profile of the bacteria present in the tissue. EMMA test which is like ALICE looks at the endometrial microbiome and assesses healthy bacteria levels that may play a role in embryo plantation.

Who is the ALICE test recommended for?

An ALICE test may be beneficial for any patient looking to conceive, as it provides insights into the microbiological environment that the embryo will encounter during implantation. The test is also recommended to patients with repeated implantation failure or recurrent miscarriages to identify if chronic endometritis is an underlying condition and a cause for their fertility problems.

The ALICE and EMMA (endometrial microbiome metagenomic analysis) test are an adjunct service. They are additional private tests and are not recommended for all patients. Please speak to your consultant about whether it might be beneficial for you.

Reference- https://hsfc.org.uk/alice-test-embryo-implantation/

What is HyCoSy?

HyCoSy stands for Hysterosalpingo Contrast Sonography. It is an investigation of the Fallopian tubes. It is not possible to see the fallopian tubes with normal x-rays or ultrasound. You have been referred for this specialised ultrasound examination which can provide a better view of the Fallopian tubes. This test involves the use of a dye (contrast agent) specially designed for use with this type of test. The dye is safe and will not affect future fertility or have any effect on the fallopian tubes; it is used so that we can see the fallopian tubes much better on the ultrasound scan.

The HyCoSy test is performed by a sonographer with specialist skills in carrying out this type of procedure. A sonographer is a registered radiographer who has undertaken additional training and qualifications in performing and making diagnoses from ultrasound examinations.

Why do I need a HyCoSy?

You will have been sent for this test if you are having difficulty getting pregnant. The fallopian tubes carry the egg from the ovaries to the uterus. If the tubes are damaged or blocked it may be difficult to become pregnant. Your doctor will need this information about your fallopian tubes to understand whether the tubes may be blocked or damaged. This test result can help the doctor to plan any future care you may need.

Can there be any complications or risks?

There is a small chance that you may get a uterine infection after this procedure. Nationally this is approximately 1 in 100 cases.

In the week following your HyCoSy, you must inform your GP as soon as possible if you experience any of the following:

• A high temperature

• Aching limbs

• An offensive smelling vaginal discharge

You must tell the GP of the examination you have had (a Hystero Contrast Sonography) and your GP will prescribe the appropriate antibiotic treatment. Vaginal swabs do not need to be taken. It is important that antibiotic treatment should begin as soon as possible as uterine infections have the potential to block the fallopian tubes.

How do I prepare for a HyCoSy?

The HyCoSy is performed transvaginally (internally), there is no special preparation required. You will be asked to empty your bladder prior to the examination. Therefore, there is no need to attend with a full bladder.

You should ideally be accompanied home (but not on public transport) in case you have any pain or discomfort after the scan. Therefore, you may bring a friend or relative with you to your appointment. They can also accompany you into the examination room if you wish.

*HyCoSy is very similar to the Saline Sonography (Aqua Scan) procedure but uses a contrast solution instead of saline to assess your fallopian tubes. Alternatively, there is an oil based Aqua scan as well.

Booking your appointment

You will be asked to contact the Ultrasound Department on the first day of your menstrual cycle. We will then make a note of this date on your scan request card and if possible, will make an appointment for you to have the scan around 7 – 14 days from the start of your period.

The appointment is made at a time when you will have finished menstruating, but before the 14th day of your cycle, which is the average time in a women’s cycle that ovulation occurs. If it is not possible to book you a scan that month, due to a lack of available appointment times, then we will try to offer you a scan date during your next monthly cycle.

It is important to do this test before the 14th day. If the HyCoSy scan is carried out after 14 days into your cycle and you have conceived that month, the scan procedure would ‘flush’ the embryo out of the uterus.

Please inform the Ultrasound Department if you have had an allergic reaction in the past to the dye used (ExEm foam) or any other ultrasound contrast agents. The scan will take approximately half an hour. A member of the ultrasound team will call you into the scan room. The sonographer will discuss the procedure with you and gain your verbal consent to continue. Prior to the scan commencing you will be asked to empty your bladder and will then be shown into the examination room. You will be made comfortable on the examination couch and a transvaginal (internal) ultrasound will be carried out.

A speculum is then placed into the vagina (like a cervical smear examination) and a catheter (tube) is inserted into the uterus. Dye is then injected down the catheter and if the fallopian tubes are open, the dye will be seen within the tubes on the ultrasound scan. Not seeing dye in the tubes does not always mean the tubes are blocked but this information is useful for your doctor to help in planning your care and future treatment.

Whilst this scan is unlikely to be painful, some ladies may experience ‘period type’ pains during and shortly after the scan. You are therefore advised to take an anti-inflammatory pain relief such as Ibuprofen or Neurofen half an hour before the examination. If you are unable to take anti-inflammatory pain relief, Paracetamol may be taken instead. Please note that pain relief tablets are not provided by the Ultrasound Department.

What happens afterwards?

The sonographer performing the examination will give you the results immediately after the test. A written report will be sent to your specialist doctor who referred you for this test. You will be able to discuss the results at your next outpatient appointment. Providing you do not have any post scan complications; you will be able to leave the department immediately following completion of the scan.

Reference- https://www.hey.nhs.uk/patient-leaflet/hysterosalpingo-contrast-sonography-hycosy-pre-test-information/

What is sperm DNA damage?

It takes around two months for mature sperm to be made and how the genetic material, DNA, is packaged in the sperm is complex. It has been suggested that during sperm cell maturation the DNA is susceptible to factors which may cause the DNA strands to break or fragment, furthermore that this may cause failed IVF cycles or miscarriage.

Several different tests might be used by your clinic to assess the level of DNA damage in your sperm. There is some evidence for a relationship between sperm DNA damage and the outcome of fertility treatment. However, the evidence is conflicting and depends on the type of test used by the clinic. The results of a sperm DNA damage test are unlikely to impact on the management of your treatment.

Is this test safe?

Sperm DNA damage testing is a non-invasive procedure performed on a semen sample, usually before treatment as an additional diagnostic test. This test does not carry any additional known risks for the person undergoing fertility treatment or any child born because of fertility treatment.

Reference- https://www.hfea.gov.uk/treatments/treatment-add-ons/sperm-dna-damage/

Male fertility problems can have a variety of causes. The most common cause is that the man’s semen has too few normal sperm to fertilise the egg. The first step in identifying the male factor fertility problem is a semen analysis.

A semen analysis should be carried out for any couple seeking treatment for fertility problems regardless of whether there is an identified female problem or a suspected male factor problem. It is a simple procedure which may reveal important information. Even if the male partner has previously fathered children, a semen analysis is necessary since problems may have developed in the intervening time.

A semen analysis includes the following tests:

• Semen volume and appearance

• Sperm concentration

• Number of sperm that are swimming (Motility and progression)

• Number of sperm that are normally shaped (Morphology)

Sperm concentration is usually considered to be the most critical factor and is expressed in terms of the number of million sperm per millilitre of semen. Sperm motility, or the number of sperm that are active, is usually expressed as a percentage of the total number of sperm.

Progressive motility is a more accurate value as it measures the percentage of sperm moving in one direction only (instead of round in circles) as these are the most likely sperm to fertilise the egg. Progressive motility is the most useful test from a semen analysis to predict fertility treatment success.

The number of sperm that are normally shaped, i.e., with normal morphology, is expressed as a percentage of the total number of sperm in the ejaculate.