UK Cypriot Fertility Association (UKCFA) does not encourage gender selection (sex selection), so called "family balancing" for social reasons.

We suggest that there is a 50% chance that couples will have a baby of the gender they desire if they conceive naturally or have IVF treatment without gender selection. However, it is a fact that many couples from the UK travel abroad to have IVF followed by PGD for gender selection. In the light of this information we believe that it is vitally important that the couples receive a through assessment prior to the IVF treatment. The couples should have detailed and honest information prior to treatment and if they go through IVF/PGD for gender selection their treatment must be overseen by an expert in the field whilst they are in the UK. It is our aim to ensure that the IVF part of the treatment that the couples go through in the UK prior to having PGD for sex selection in Cyprus is safe and responsible in the first instance. Your consultants in the UK can only manage the initial part of your cycle, the stimulation of the eggs. This is a vital part as you receive injections to stimulate your ovaries to produce a number of eggs. It is the same process as in IVF. It is important that the follow up is carried out carefully during that stage to ensure safety and an adequate response. At this stage you can decide to stay in the UK and have IVF treatment withouth gender selection or decide to go abroad to complete the treatment.

Couples going abroad for IVF treatment may decide to have gender selection sex selection for family balancing. Although family balancing for social reasons remains illegal in the UK, it is legal in Northern Cyprus.

Here at the UKCFA, we assist couples to prepare for an IVF cycle to be carried out with the understanding that if they wish to consider gender selection, sex selection for family balancing then the couples need to discuss this directly with the Cyprus IVF Centre (CIC).

How is my treatment managed?
UK Cypriot Fertility Association (UKCFA) and Cyprus IVF Centre (CIC) work closely together to coordinate your treatment. You will have part of your treatment in the UK and part in Cyprus. You will undergo In-Vitro Fertilisation in the same way as other patients who do not require PGD. The Pre-Implantation Diagnosis part of your treatment is performed in the laboratory under strictly controlled conditions.

Your treatment will involve the following stages:

UK Management by Consultant Gynaecologists

Initial Consultation
Just like our other treatments such as Egg Donation, we can see you either in London, Liverpool or Manchester. You will have an in depth Consultation with either Mr Kingsland or Mr Gazvani discussing your medical history. It is of great benefit if you bring as much information with you, including results of any recent screening tests you have had done. If you decide to proceed with treatment we will arrange a counselling session for you. This is crucial as we feel it is important for our patients to have ample opportunity to demonstrate they have considered all aspects of IVF with PGD.

Screening Tests and Medication
Both parters will need to be screened for HIV and Hepatitis as well as blood grouping. The male partner will also need a recent semen sample, which we can perform if this hasn't already been done. Providing the results of the screening tests are acceptable, you will be issued with a prescription and a treatment plan. The medication will be delivered direct to your home and your UK coordinator will tell you exactly what to take and when.

Your Medication Regime
Several steps are required to bring you to a stage where you are ready to fly to Cyprus for Egg Collection. The objective is to produce as many eggs as is safe to ensure you have a good number of eggs to fertilise. In brief the steps are as follows:
a) Down Regulation – This phase switches off your body's natural hormone production and allow your medical team to control your treatment. These may be injections or a nasal spray for a period of about 2 to 4 weeks.
b) Follicular Stimulation – Your medical team will confirm with an ultrasound scan that you are ready to start this phase. This stage involves daily injections of a follicle stimulating hormone (FSH) which encourages the ovaries to produce a good number of eggs for collection and fertilisation in Cyprus. Throughout this phase you will have several ultrasound scans which measure the growth of your follicles. This phase lasts about 10-12 days. On a practical note, towards the end of this phase we will tell you when to schedule your flight to Cyprus.
c) HCG Injection – This is a one off injection which prepares your follicles for egg release. This is a crucial injection and must be taken 36 hours before the scheduled egg collection. As you are flying to Cyprus for the rest of your treatment, the timing of this injection is crucial and we will tell you exactly when to take it.

You now travel to Cyprus where you can ecpect to stay between 7 & 10 days. We also can help you plan with this part too.

Your Treatment in Cyprus:

Initial Visit
After being collected in Cyprus you will visit the Cyprus IVF Centre to meet your Doctor and Coordinator. They will go through what to expect at your egg collection and give you some more medication to take after your eggs have been collected. This is called Cyclogest or Gestone and helps maintain the lining of your uterus to improve the chances of your embryos implanting.

Your Egg Collection and Semen Production
36 hours after your hCG injection you will attend the clinic for egg collection at a time given to you by the team in Cyprus. The procedure lasts about 30-40 minutes and is done either sedation or general anaesthetic. Using a trans vaginal ultrasound, each follicle is drained and passed straight to the embryologist and in the majority of the cases an egg will be present in each follicle. You will need to rest for a while after this procedure in one of our recovery bays.

At the same time as the woman's egg collection, the male partner needs to produce the Sperm Sample which will be used to fertilise the eggs. We recommend 3 days of abstinence before providing the sample.

Fertilisation and PGD
The Cyprus IVF Clinic uses the ICSI procedure in all cases to fertilise eggs. Each day you will receive a call explaining how many embryos have fertilised and what their quality is. After about 3 days, or when your embryos are at 8 cell stage, the laboratory can perform Pre-Implantation Genetic Diagnosis (PGD) in accordance with the tests that you have agreed with them, which may include selecting the gender.

Embryo Transfer
Using a vaginal speculum, the medical consultant exposes the cervix (neck of the womb), which is then cleaned. The culture medium containing the embryos is loaded in a thin plastic tube called a catheter with a syringe on one end. The doctor carefully guides the catheter through the vagina and cervix, and deposits the embryos into the uterus.

We typically transfer two embryos in accordance with UK regulations. We are aware that multiple pregnancies are associated with an increased risk of miscarriage and
complications during pregnancy. High quality embryos remaining after the transfer can be frozen for use at a later date.

After your embryo transfer you can return home to the UK and continue your normal daily activities, although prolonged strenuous exercise or activity is not recommended. The embryos are quite safe within the uterus and you can walk, bathe, shower and undertake normal daily activities. Sexual intercourse can be resumed whenever you feel like it.

You must continue to take the medication given to you as instructed. After 2 weeks you will perform a pregnancy test.

How Successful is PGD?
So far Cyprus IVF Centre has performed over 400 cases of PGD. Pregnancy rates for under 35 year old women are currently over 50%. In women between 35-39 the pregnancy rate is 37% and women over 40 years old show a current success rate of 18%.Our results.

In a woman’s normal monthly menstrual cycle a single egg (called an oocyte) is released from a follicle that has been developed in one of the ovaries as a result of a complex interaction between the body’s hormones. Dependent upon the timing and frequency of sexual activity the egg will may be fertilised by her partner’s sperm.

The PGD cycle is quite different than this natural process. It is made up of seven stages:

1. Downregulation and stimulation of the ovaries
2. Egg collection
3. Insemination
4. Fertilisation
5. Embryo biopsy
6. Embryo transfer
7. Pregnancy test

Stage 1 – Stimulation of the ovaries with hormones to produce eggs
To maximise the chance of a successful pregnancy we need to transfer up to two embryos into the womb, which in turn normally requires around four to eight embryos to have been cultivated. To achieve this number of embryos, our scientific team would aim to collect 10 or more oocytes. This means that we need to stimulate the female’s ovaries to produce many more than the usual single oocyte, and we do this by means of hormonal stimulation of the ovaries, using drugs which mimic the hormones you naturally produce.

These hormones are given to you both as a nasal spray and an injection under the skin on the tummy. A detailed treatment schedule (in the form of a calendar) indicating the dates and medication to be used will be given to you the treatment starts. This of course will be designed taking your travel and period dates into account.

Buserelin/ Nafarelin medication
This is the medication you will be given. This part of the treatment is known as ‘downregulation’ which:-

Temporarily stops your ovaries from working
Prevents you from releasing the eggs before we have time to collect them

This medication continues throughout the treatment. It is only stopped following your final scan in Cyprus. Instructions to stop this medication will be given by the Cyprus IVF Centre once a decision for egg collection is made.

We perform an internal ultrasound scan after two weeks of downregulation, to check that your ovaries are inactive and contain no large follicles or cysts and that the lining of the uterus (endometrium) is thin.

Please note: It is normal to have a period during this time. It does not mean that the medication is not working, so please do not stop the Buserelin/Nafarelin. If you stop the medication too soon, your eggs could be released before we have a chance to collect them.

In some patients, there may be temporary side effects from this medication. The potential side effects are hot flushes, night sweats and mood swings.

FSH injections
Follicle Stimulating Hormone (FSH) injections are given to you as a daily injection over 10 to 14 days to stimulate egg development in the ovaries. We will teach you or your partner to do this or you can arrange to have the injections at your GP surgery or local hospital.

We will explain the potential side-effects of these injections and monitor your response using internal scans. The first scan is usually done nine days after starting the injections.

Deciding the day of your egg collection
Cyprus IVF Centre (CIC) team of doctors, embryologists and nurses decide the best day for your egg collection. The cycle may be cancelled before egg collection if you under or over respond to the medication.

Late at night and about 36 hours before the egg collection, an injection of hCG hormone is given as a 'one off' injection. This medication causes the final stages of egg ripening to take place. The time you need to give yourself this injection at home is very important and will be explained very clearly to you.

Stage 2 – Collection of eggs from the ovaries
You are deeply sedated and monitored throughout the egg collection procedure, which usually takes about 15 minutes. Using an ultrasound probe to guide, a fine needle is passed inside the vagina and through the vaginal wall into each follicle, until we have emptied all the follicles in one ovary. The needle is then removed and the procedure is repeated in the other ovary.

Each egg is placed in special fluid and transferred to an incubator. Not every follicle will contain an egg and sometimes no eggs will be found during an egg collection. We will discuss this with you before the procedure.

After the procedure you will rest on a bed in your private room for about one or two hours.

You will be prescribed the hormone progesterone for 17 days following the egg collection to help the lining of your uterus be as receptive as possible to the embryos.

Stage 3 – Insemination / injection of sperm
Your semen sample is prepared by separating the normal and active sperm from the ejaculated fluid. Fertilisation during pre-implantation genetic diagnosis (PGD) treatment will be done by Intracytoplasmic Sperm Injection (ICSI). ICSI involves injecting a single sperm into the centre of each egg to help achieve fertilisation.

Stage 4 – Fertilisation
The morning after injection / insemination of the sperm, the embryologist carefully examines each egg to see if fertilisation has occurred. We will then call you to tell you how many eggs have fertilised.

Rarely, about one in 100 times, none of the eggs fertilise and there are no embryos to be replaced. This is obviously very disappointing. We will offer you the earliest available appointment to see a PGD team doctor and an appointment to see one of our counsellors if this happens.

Stage 5- Embryo biopsy
Three to four days after fertilisation the embryos will usually have reached the stage of development where gender selection can take place, normally involving a complex and expensive scientific process called Pre-implantation Genetic Diagnosis (PGD). This involves removing one or two cells from each embryo and analysing the chromosomes in carefully controlled laboratory conditions, during which the ‘X’ and ‘Y’ chromosomes are clearly identified. The removal of up to two cells does not damage the embryo’s development in any way, and each embryo will continue to grow normally. Our aim is to reach this stage with a minimum of two good, healthy embryos of the chosen sex available for the fourth and final stage of your treatment – the transfer of the embryos to the female’s uterus.

The types of tests we perform on the embryos will depend upon the reason behind you having PGD. Apart from sex selection, we are able to screen for any genetic disease that can be tested for.

Stage 6 – Embryo transfer
During embryo transfer we place the best quality embryos into your uterus. This is a much simpler procedure than egg collection and there is no need for an anaesthetic. Ultrasound scan is used through your tummy to help us to transfer the embryos where they would have the highest chance of implanting. A speculum, which is the instrument also used during a smear test, is placed in your vagina to clearly see your cervix (neck of the womb). The outside of your cervix is cleaned and any mucus from inside your cervical canal is removed. This mucus might prevent the embryos getting to where we want them to be in the womb.

The soft catheter, which holds the embryo(s), is inserted the neck of your womb. When we are happy that the catheter is in the best position, the embryos are gently dropped off. The catheter is then removed and checked to make sure all of the embryo(s) have been replaced. This process takes about 5 minutes. It is generally painless although some discomfort comes from the scan probe that pushes down on your bladder which needs to be full for the procedure as well as the speculum in the vagina.

How many embryos will be transferred?
Current HFEA guidelines allow us to transfer a maximum of two embryos in women who are under 40 years of age. Transferring two embryos has been shown to maximise your chances of a successful implantation, while presenting minimal risks of more than a singleton pregnancy. It is important to note that the risk of a triplet pregnancy, however small, is not completely excluded despite the transfer of a maximum of two embryos.

The number of embryos transferred is limited to lower the risk of a multiple pregnancy. Triplet pregnancies have a significantly increased risk of complications including miscarriage, high blood pressure and premature birth and even twins have more problems with delivery and at birth. Premature babies have an increased risk of complications, such as a weakened immune system, physical and mental disability and feeding and breathing difficulties.

What happens after embryo transfer?
You will know if the treatment has been successful 10-12 days after embryo transfer.
We appreciate that this wait can be difficult for many people. Please do not be tempted to perform a pregnancy test earlier than advised. The hCG injection can stay in your blood stream for eight to 10 days and this will make the test positive, even if you are not pregnant. Please continue to take progesterone vaginally twice a day.

Unfortunately, there is no evidence that anything you do at this stage will increase the chance of you becoming pregnant. We encourage you to return to work but you may prefer to have a few days off around the time of transfer. Having a bath or sexual intercourse is not known to affect the chances of pregnancy.

What happens if there are spare normal embryos?
It is possible to freeze embryos from a PGD cycle for later use. A frozen embryo, which has been thawed, is less likely to implant into the lining of the uterus than a fresh embryo, especially when it has been biopsied. We are selective about the embryos we choose to freeze but we will attempt to freeze any embryos that are suitable. Embryos are frozen at an extremely low temperature, which makes sure they do not deteriorate over the number of years they are stored. Even if you get pregnant in your initial attempt at treatment, you may wish to use frozen embryos, if possible, to expand your family at a later date. If you have frozen embryos, it is essential that you keep in touch with us to let us know what you wish to do with them and tell us of any changes of address.

Frozen embryo cycle
In a Frozen Embryo Transfer Cycle (FET) we thaw your frozen embryos and transfer any that are suitable into your uterus. Our survival rate is good following thawing, but not all embryos will survive this process. An advantage of a frozen cycle is that we do not need to use hormone injections to stimulate the ovaries nor do any further genetic testing of the embryos.

Stage 7 – Pregnancy test
All women should perform a pregnancy test 12 days after the embryo transfer, even if they bleed before this time. This is essential because some patients could miscarry one of a twin pregnancy or have an ectopic pregnancy. This is an uncommon but potentially serious complication. Please inform us about the results of the pregnancy test whatever the outcome.

A positive pregnancy test
This means that one or more embryos have implanted, but we will not be able to see this on a scan until you are about six weeks pregnant (four weeks after embryo transfer). We will usually scan you to:

See how many embryos have implanted
Have they developed a heartbeat?

Sadly, we sometimes diagnose miscarriages and ectopic pregnancies at this stage.

If you are pregnant we will refer you back to your GP to arrange antenatal care at your local hospital. Unfortunately, a number of pregnancies can still miscarry even if these early scans are encouraging.

A negative pregnancy test
Sadly, this means that the treatment has been unsuccessful. If you have not already started bleeding, a period will come in the next few days. This might be heavier than normal due to the medications you have taken.

We know this can be a very disappointing time and will offer you an appointment to discuss the cycle and possible treatment options for the future. You might also find it helpful to speak to one of our counsellors.

PGD – An Overview
Gender selection by way of PGD is conducted as a procedure during an in vitro fertilization cycle (IVF). The female undergoes ovulation induction with Follicle Stimulating Hormone (FSH) to develop many eggs. These eggs are collected under anaesthesia and injected (Intracytoplasmic Sperm injection – ICSI) with the partner’s sperm. The resultant embryos are cultured from 3-5 days during which time the pre-implantation genetic diagnosis procedure is conducted.

Two days after fertilisation, embryos consist of around eight cells. At this stage is it possible to safely remove a single cell, analyse it for a range of gender-specific chromosomal disorders and ensure only unaffected embryos are implanted in the womb. This specialist technique is called Pre-implantation Genetic Diagnosis (PGD).

A single cell, carrying material used to support the foetus's development, is removed from the embryo and its chromosome structure is analysed in carefully controlled laboratory conditions, with the X and Y chromosomes clearly distinguishable. The removal of a single cell does not damage the embryo's development in any way, and each embryo will continue to grow normally.

Why PGD?
Babies born with chromosome abnormalities occur in:-

1 in 1,000 births in women aged 30 or younger
1 in 350 births by 35
1 in 100 births by 40
and ultimately 1 in 25 births by 45

The purpose of PGD is to select only healthy embryos (for the chromosomes we can so far test for) for implantation in the hope of achieving more pregnancies, less spontaneous abortions and less affected offspring.

Who can benefit from PGD?
Either one of a couple carrying a single gene defect, by testing for specific genetic disorders:-

Women aged 35+, by testing for age-related chromosomal disorders
Younger women with repeated unexplained miscarriages, by testing for chromosomal disorders
Couples wanting to balance their family

What are the advantages of PGD?
The ultimate advantage of PGD is the increased likelihood of a healthy baby.

Greater live birth rate
35 years old: 50% live birth rate on 1st cycle.
80% live birth rate on 3 cycles
40 year old: 40% live birth rate on 1st cycle.
60% live birth rate on 3 cycles

Lower risk of malformed babies and pregnancy termination.
The chance of a woman delivering a baby with a genetic disorder is 1% if she is 35-39 years old and 3% if she is 40-45.
PGD decreases the chances of having to terminate a pregnancy if a foetus is found to be abnormal.

Reduction in spontaneous abortions
In women 35 or older about 15% of pregnancies spontaneously abort, with 50% or more of those miscarriages being caused by abnormalities.

By transferring only normal embryos the number of pregnancies reaching term should increase. In one study a significant reduction in spontaneous abortions occurred after PGD, from 23% to 9%. The increase in implantation and the significant decrease in spontaneous abortions resulted in a significant increase in ongoing pregnancies and delivered babies.

Risks of Treatment
Ovarian hyper-stimulation syndrome (OHSS) is the most serious complication of this treatment. Any patient undergoing ovulation induction is at risk of developing OHSS, although some more than others. Ovarian hyper-stimulation syndrome may be classified as mild, moderate or severe by symptoms and signs.

The worst cases seem tends to be associated with pregnancy. Severe OHSS is a life threatening complication.

The symptoms usually begin 4-5 days after the egg collection. The majority of women have a mild or moderate form of the syndrome and invariably resolve within a few days unless pregnancy occurs, that may delay recovery. Patient may complain of pain, a bloated feeling and mild abdominal swelling. In a small proportion of women, the degree of discomfort can be quite pronounced.

Your Stay in Cyprus
It is necessary for all our gender selection couples to stay around 10 days in Cyprus where the remainder of the treatment is carried out. We recognise the additional complications this creates for some of our patients, but for the time being there is no better alternative and you can plan your visit to suit your diary!

During your week-long stay abroad you and your partner will need to attend the Clinic on two or occasionally three separate occasions. On the first visit – the morning after your arrival – the female partner will undergo an ultrasound scan examination. At this point a decision will be taken regarding the rest of the treatment and the timing of the egg collection.

Around 36 hours prior to egg collection you will be advised to use your β-hCG injection. The timing of this injection is vital as it triggers the final maturation of your eggs.

On the day of egg collection the male partner will be asked to produce his sperm sample. The same afternoon all suitable eggs will be injected with a sperm each (ICSI) to enable fertilisation. This is known as Day 0 (Zero). On the second shorter visit, usually in the late afternoon of Day 4 (or on the morning of Day 5) the female will receive her chosen embryos. (See chart below). Consequently, you will find that most of your week is free to spend as you wish ¬sightseeing, shopping, or relaxing in or around your hotel. All we ask is that you avoid over-exertion and stressful situations!

We appreciate that it may sometimes be necessary for the male partner to return home after providing his sperm sample. This is possible as we can freeze the sperm to use for ICSI later. We, however, always encourage couples to plan their diaries so they can stay together throughout this week, providing mutual care and support. We hope you will be able to do this.

Our Travel Arrangements section is full of useful information to assist you with your stay in Cyprus

Counselling
We have specialist counsellors within the team. All couples are obliged to undergo counselling (can be done over the phone) prior to treatment.

How can counselling help?
We appreciate that trying to conceive through PGD can be stressful. Counselling provides support from a trained professional who understands what is involved in your treatment and can offer you the time to talk over your options or concerns. Most people find that having someone to discuss this with makes all the difference between feeling stressed and worried to feeling more able to cope.

For more information please contact Jemma Hand UK Coordinator