A newborn baby girl has up to 450,000 eggs stored in her ovaries. Her periods will start between the ages of about 10 and 16, when one of these eggs will ripen and be released each month. The egg is released from the ovary and caught by the cilia of the fallopian tube, it is transported using a rippling motion, to the uterus (womb). If the egg is successfully fertilised by a sperm it should implant in the uterus and form an embryo, which develops into a baby and a placenta. The chance of conception (becoming pregnant) in a single menstrual cycle is approximately 18-20 percent. In every 100 couples having regular unprotected intercourse, around 85 will conceive within 1 year. But what happens if there is a problem or delay in the process?

Fertility problems

1 in 4 couples experience an unwanted delay in conceiving and up to 1 in 7 are subfertile (have reduced fertility). Infertility, which is far less common, is defined as a failure to conceive after regular unprotected sexual intercourse for 2 years, when there are no known reproductive issues. Two categories of infertility are often described:
 

• Primary - couples who have never successfully conceived.
   
• Secondary - couples who have had children but are subsequently unable to conceive.

Diagnosis and investigations

If a woman is not pregnant after 1 year of regular unprotected intercourse the NHS recommend an assessment. The GP makes an initial assessment to identify possible causes and give further advice about how to optimise fertility. An earlier visit is recommended if women are over 35 or there are any known risk factors for infertility (i.e. a medical condition).

The GP may carry out certain preliminary tests and give advice:

• Medical history — a couple’s medical history may explain the reasons for a delay.
   
• Physical examination — women may have a pelvic examination or men a testicular and penis examination to rule out abnormalities or problems.
   
• Infection screening - STI’s (sexually transmitted infections) such as Chlamydia can affect fertility and will need treating.
   
• Frequency of sexual intercourse - some couples simply do not have intercourse often enough, every 2-3 days is recommended.
   
• Lifestyle - for both men and women there are several things that will be recommended including: reduce alcohol intake, stop smoking, discuss any medication which is being taken with the GP and identify possible occupational hazards in the work place.
   
• Body Mass Index (BMI) - women and men should try to achieve or maintain a normal BMI as being overweight or underweight may affect fertility.

If a couple have been trying for less than a year to get pregnant the GP may attempt to implement some of the simple strategies listed above before referring on for further specialist tests. However, when a couple have not conceived despite following the above advice and having regular unprotected intercourse for a year or more, then the GP may refer them for more investigations at a specialist fertility clinic. Guidelines state that women over 35 or couples with specific medical conditions should be referred earlier for investigation.

It is important to note that the problem may be a male factor, a female factor, a combination of the two or less commonly unexplained, even after testing.

For men, further investigations may include:
 

• Semen analysis- for assessment of sperm count, motility and quality.

For women further investigations may include:

• Blood tests — to assess the levels of several hormones that play a role in fertility and to assess ovulation (egg release) and ovarian reserve (amount of eggs left).
   
• Pelvic ultrasound — a trans-vaginal ultrasound probe is inserted into the vagina. It measures the size and shape of the uterus and ovaries and determines if there are any structural abnormalities or ovarian cysts.
   
• Genetic tests — may be recommended if there is a suspicion that genetic or chromosomal abnormalities are contributing to infertility. These tests usually require a small blood sample, which is sent to a laboratory for evaluation.
   
• Hysterosalpingogram (HSG) — investigates the uterus and fallopian tubes. It involves inserting a small catheter through the vagina and cervix and into the uterus. A liquid that can be seen on x-ray is injected through the catheter to fill, the uterus and fallopian tubes. An x-ray is taken after the liquid is injected, which shows the outline of the uterus and tubes and an abnormally shaped uterus or blocked fallopian tube would then be visible.
   
• Hysteroscopy — a small tube with a camera is inserted through the vagina and cervix, into the uterus to allow examination of the lining of the uterus and the sites where the fallopian tubes enter the uterus.
   
• Laparoscopy — a thin tube with a camera is inserted through a small incision in the abdomen, allowing the specialist to view the uterus, ovaries, and fallopian tubes. This can detect damage or obstruction of the fallopian tubes, endometriosis, and other abnormalities or problems.

Causes and risk factors

It is known that fertility problems can be caused by many different factors.

For men these can be:

• Low sperm count- reducing the amount of sperm that reaches the egg.
   
• Low sperm mobility- affecting the number of sperm that reach the egg.
   
• Low sperm quality- abnormal sperm may not be effective.
   
• Erection/ejaculatory difficulties- retrograde ejaculation, where semen is ejaculated into the bladder, or premature ejaculation, when ejaculation happens too quickly.
   
• Testicular infection - causing inflammation of the testes (for example, mumps).
   
• Blockage- preventing the sperm from being ejected.
   
• Surgery- for a hernia or undescended testes.
   
• Testicular injury or abnormality- may result in reduction of fertility.
   
• Chemo/radiotherapy- can reduce the production of sperm.

For women these can be:

• Failure to ovulate- due to hormonal problems or conditions.
   
• Tubal blockage- scarring and obstruction of the fallopian tubes can occur as a result of pelvic inflammatory disease, endometriosis, or pelvic adhesions (scar tissue) from abdominal infection or surgery.
   
• Infection- previous infection can cause scarring in the fallopian tubes, which prevent the egg from reaching the womb.
   
• Structural- problems with the structure of the uterus can include congenital abnormalities (from birth), a uterine septum (a band of tissue that makes the uterine cavity small), fibroids or polyps.
   
• Previous abdominal/pelvic surgery- can cause adhesions (scarring).
   
• Medical conditions- PCOS (Polycystic Ovarian Syndrome) can cause hormonal imbalances and ovulation failure. Endometriosis can cause adhesions, scarring and cysts on the ovaries. Fibroids can cause structural or implantation problems. Diabetes and Thyroid problems can also cause ovulation problems.
   
• Chemotherapy or radiotherapy- can cause damage to ovaries which reduces fertility.
   
• Age- female fertility deteriorates with age. Women aged 35 are half as fertile as those aged 31.
   
• Implantation or endometrial (womb lining) problems.

For both men and women:

• A combination of factors- sometimes the woman and the man may have traits which combine together to prevent conception.
   
• Weight- in women being overweight or underweight can affect ovulation. In men being overweight can affect fertility.
   
• Smoking- affects general health and can affect fertility.
   
• Frequency of intercourse- 2-3 times a week is recommended.
   
• Drugs- some prescription medication and illegal drugs can have an effect on fertility.
   
• Alcohol- for men drinking too much alcohol can have an adverse effect on sperm. It can also be detrimental for women.
   
• Stress- severe stress can affect the menstrual cycle in women and sperm production in men.
   
• Occupational hazards- certain industrial agents such as solvents and pesticides can impact on fertility.

Treatment

The treatment offered depends on the cause of the fertility problems, what is available from the local health authority, or on the choice of private vs NHS care. After the initial advice about lifestyle adjustment and frequency of intercourse, there are three main types of fertility treatment:

• medicines
• surgical procedures
• assisted conception

Medicines:

• Clomifene - promotes ovulation (the monthly release of an egg).
• Tamoxifen - another drug that may be offered to women with ovulation problems.
• Metformin - may be used if a woman is clomifene resistant. It may be useful for women with polycystic ovary syndrome (PCOS) and a body mass index (BMI) of over 25.
• Gonadotrophins - can help to stimulate ovulation, they may also be used to treat male fertility problems.
• Gonadotrophin-releasing hormone (GNRH) agonists - stimulate ovulation.
• Dopamine agonists - in certain cases this may be prescribed to encourage ovulation.

Surgery:

Tubal surgery - can be done in specialist centres. It removes scar tissue in the fallopian tubes, eliminating the narrowing or blockages. Laparoscopic surgery - This type of ‘keyhole’ surgery involves using a camera to look at the woman’s pelvic organs and other instruments can also be used to take samples.

Laparoscopic surgery - can be used for women who have endometriosis (where the womb lining grows outside of the womb) or to destroy or remove cysts (fluid-filled sacs). It can also be used to remove certain types of fibroids (small growths in the womb). In women with PCOS, laparoscopic surgery can help if other treatments have not worked by removing or destroying part of the ovary. This can aid ovulation.

Assisted conception:

Intrauterine insemination (IUI)

IUI can be used if there are no fallopian tube blockages, for same sex couples requiring sperm donation, or where infertility cannot be explained. IUI can also be used if the man has a low sperm count, decreased sperm mobility, erectile dysfunction or premature ejaculation.

Pre-prepared sperm are placed into the womb using a small plastic tube. The best quality specimens are selected. It is performed at the same time as ovulation in order to increase the chance of conception. A low dose of supportive hormones are given to the woman in order to increase the likelihood of conception.

The NHS report that provided a man's sperm and a woman's tubes are healthy, the success rate for IUI in women who are under 35 is around 15 percent for each cycle of treatment. The National Institute for Health and Clinical Excellence (NICE) recommend that couples should be offered up to six cycles of IUI. However, the criteria can vary according to circumstances and the policy of each local area health authority.

Private options

Private fertility clinics also offer IUI. Costs vary from £500 to £1,000 for each cycle of treatment. Private centres will often treat couples who do not fulfil the NHS criteria or couples who want quicker treatment.

In Vitro Fertilisation (IVF)

IVF refers to the process where an egg/s is fertilised by a sperm outside the womb. When other treatment options have not been successful IVF treatment may be advised and some conditions may require IVF, for example: blocked fallopian tubes, no ovulation, surrogacy, egg donation, severe endometriosis or unexplained male factors.

The IVF process involves several stages:

Ovarian stimulation - periods are suppressed using hormonal treatment. This is usually done by daily injections or a nasal spray and it takes approximately 2 weeks. FSH (follicle stimulating hormone) is then given via injection for around 12 days, this stimulates the ovaries to produce multiple eggs.

Egg retrieval - when the eggs are mature, human chorionic gonadotrophin (HcG) is given. This causes ovulation approximately 40 hours later. Just prior to ovulation the eggs are retrieved by a needle inserted through the vagina into the ovaries, using ultrasound to guide the process. Usually between 8 and 12 eggs at a time are removed.

Fertilisation - harvested eggs and sperm are put together in a laboratory. In conventional IVF the sperm and egg are mixed and left for around 18 hours in a special culture. However, in about 40 percent of cases, fertilisation is assisted by actually injecting the sperm into the egg. This is a procedure known as ICSI (Intercytoplasmic sperm injection). When fertilisation has taken place the embryos are then cultured in an incubator to help them grow.

Transfer - If the eggs have been fertilised normally, then usually 2 are identified. They are transferred on either the second, third or fifth day of development, depending on the number and quality of the embryos. This is performed by passing a catheter through the vagina, through the cervix and into the middle of the uterine (womb) cavity. Progesterone is given to prevent bleeding and keep the womb lining intact. This gives the embryos a chance to implant. Approximately 12 days later a pregnancy test is performed to see if implantation has been successful. If the pregnancy test is positive then an ultrasound scan is used to confirm the growing pregnancy, 14 days later.

The HFEA (Human fertilisation and embryology authority) report that the latest figures (2009) show that 25.2 percent of IVF treatments using a woman's own fresh eggs result in a live birth. However, every situation is different and many factors can influence success, such as age and the reason for the fertility problem.

NHS Guidelines on IVF

Many PCT’s offer IVF treatment on the NHS and the local GP will be able to inform couples of the policy in their area. Each PCT has its own guidelines on who is eligible, but in general NHS treatment is available to couples who do not have a child in their relationship, and where the woman is between 23 and 39 years old at the time of treatment. Usually the cause of infertility has to be identified, or if no causes are found then the couple must have been suffering from unexplained infertility for at least 3 years. The number of IVF cycles available varies around the country, but it is usually between 1 and 3 cycles, using fresh eggs. Waiting lists can also vary, although most NHS units are able to offer treatment within 18 weeks.

Private IVF Options

There are many private IVF centres around the UK. The cost of treatment depends on individual clinics but average costs are between £3,000 and £8,000 for 1 cycle. Treatment can be almost immediate depending on the stage of a woman’s cycle. Private centres will often treat couples who do not fulfil the NHS criteria or couples who want quicker treatment. For more information on fertility and IVF see our expert interview.

If you would like to tell us your story so we can help and inform other women; there is more infromation available HERE

This interview was recorded in April 2010.

 

IVF: Text Version

Hi there, today we are here to discuss IVF. IVF is a subject frequently reported about in the press and seems to cause a great deal of controversy and confusion. We are here today to clear up some of these myths by speaking to Mr. Stuart Lavery, consultant gynaecologist and specialist in reproductive medicine and surgery at Hammersmith and Queen Charlotte’s and Chelsea Hospital, London.

Hello Stuart and thank you very much for joining us today.

Hi, good morning.

Can I start by asking you at what point you would recommend couples actually start to think about IVF?

It really depends on the individual circumstances of the particular couple. There are all sorts of reasons why people may have difficulty conceiving, and IVF is only one of the potential solutions. Normally we recommend people should consult their doctor if they have been trying regularly for at least a year and if conception hasn’t happened, then it is sensible to seek some advice to see how things need to be looked into. That doesn’t automatically mean you need to be instantly signing up for IVF, because there are all sorts of things that can be done to improve you chances of things happening naturally. Sometimes there may be specific things that have happened to you in the past such as abdominal surgery, problems with your ovaries, irregular periods, and if anything like that has happened it may be sensible to seek medical advice earlier.

Is there a long waiting process for IVF?

It really depends whereabouts you live in the country. NHS provision for IVF has actually been one of the big good news stories about funding recently, and funding is now much more widespread and access to that funding is much quicker for couples. In our own clinic at Hammersmith we have increased our NHS provision of IVF by over 100% and waiting times are now in the region of about 12 weeks. So although this is not ideal this is a significant improvement on how waiting lists were until quite recently.

How would you suggest a couple goes about choosing the right clinic?

This is a very difficult question. There are all sorts of important issues that couples should take into account. One of them should be geography – you don’t want to have to travel too far for your clinic, you want a clinic that is reasonably accessible. The reputation of the clinic is important, what are the results like and what do patients and professionals feel about the clinic. Many clinics may have extremely good reputations but may not necessarily come near the top of the league table, because they will often take on patients who are more challenging and who have a lower expectation of success. So the opinion of your GP will be important and the opinion of friends and colleagues will be important. Then there are certain intangibles when you visit a clinic - whether you feel comfortable and confident in the environment and with the professionals you are dealing with.

Are there any tests you must have to make sure that IVF is needed?

Yes and important accurate diagnostic tests are really important. The reason for that is that IVF may not be the most sensible option; these tests will also give you an idea about an accurate expectation of your success. This is important to know upfront because there are massively varying expectations of success depending on your own particular circumstances and the clinic you may visit. The sort of test that would be standard would be an investigation on the female side of hormonal status. This would look into issues about ovarian reserve, so how many eggs you still have left. Issues about whether you are ovulating regularly and then checks of your anatomy such as an ultrasound scan to look at your ovaries and your uterus, and a test of your fallopian tubes to make sure your tubes are not blocked, this is usually called an HSG although there are some other alternatives. On the male side a good and accurate semen analysis is important to see what contribution the male factor may be making.

Once a woman has decided on IVF how long will the process take?

Again this will vary according to where she lives in the country. For most centres access to NHS IVF care is within 18 weeks, if a patient is having a treatment privately then really there shouldn’t be any waiting list. She may be able to embark on treatment with her next period, following all of the investigations.

What can women do to prepare for the process and continue to do throughout the treatment?

There are several things you can do to try and optimise your chances of IVF working. It is important that women are on folic acid supplementation, as this is very important for embryonic development. There are certain lifestyle factors that can be addressed; smoking will significantly reduce the chances of success from IVF both on the male and the female side, so stopping smoking is absolutely critical. The role of alcohol and caffeine intake is a little bit more controversial, some people will recommend complete abstention from alcohol and coffee, and other people will just recommend that these things are only taken in moderation. A persons weight is also important, if you can get your Body mass index down to less than 30kg per square metre, this is also associated with both safer treatment and more effective treatment.

What types of diseases in women can cause problems in fertility?

The main problems that we tend to see in this country, are problems with ovulation, so the issue where a woman may have eggs but she may not be releasing them in a regular or predictable fashion. Some people will also have blocked fallopian tubes and so they may be producing good quality eggs each month but the eggs and sperm may be blocked from meeting. In many situations there will be a mixed factor, so it will be partly male; there may be some problems with the sperm count, and also partially female and this accounts for an increasing proportion of patients.

Can a couple’s lifestyle help their fertility?

Yes, most importantly by how often and how frequently they have sex. It is amazing that we all live busy lifestyles in 2010 and it is sometimes amazing in the fertility clinic when couples address how frequently they are having intercourse and it’s not as often as they should. So there are certain lifestyle issues one can address in terms of how busy you are and how much time you give to each other, to enable you to have an active sex life around the time when the woman may be fertile. Other issues include modification of diet and then environmental influences such as alcohol and smoking.

What are the ideal conditions for IVF?

Ideally one needs to be as physically, mentally and emotionally prepared for it as possible. So you need to get yourself in good physical shape; having a good diet, you need your weight to be under control, you need to make sure that you have removed things from your environment such as smoking and excess alcohol intake. Then you need to realise this will be a stressful time consuming treatment and that you need to give enough time and space in your busy life to allow you to focus on this treatment. It will involve many trips to the clinic, it will be emotionally stressful, your hormones will be manipulated to a degree and therefore it is important you have some good support systems around you, to allow you to cope with the stresses of the treatment.

Could you outline the main stages of IVF treatment?

Initially a full and accurate series of investigations are needed, this will tell you first of all is IVF the sensible way forward? and may also indicate the type of IVF that you should have, because there are many variations of IVF, both in terms of the protocols, the treatment doses and the different ways that eggs can be fertilised. Most IVF treatments in the United Kingdom will last approximately six weeks. The first two weeks is dedicated to daily injections which shut a woman’s hormonal system down (essentially temporarily put the ovaries asleep) and during that time the woman may feel the hormonal side affects such as hot flushes or night sweats. The second two weeks consists of daily injections to stimulate the ovaries to grow and mature the eggs, and during that time the woman will need to attend the clinic on several occasions for monitoring, which will include blood tests and scans. When there are sufficient eggs that are mature, she will need to undergo a very minor operation to collect the eggs which is usually done through the vagina and a very fine needle is passed through the vagina into the ovaries and the eggs are aspirated. That morning the husband will give us a semen analysis and in the afternoon we will put the eggs and sperm together. Hopefully the two will be interested in each other and the next morning we will know whether any embryos have formed. These embryos are kept in culture for between two and five days, and then the best one, two or three embryos are transferred to the uterus.

What kind of difficulties can occur during an IVF cycle?

There are really hurdles to get over at every stage, it is not an easy treatment. Initially we need to see will the woman respond to the drugs, so will we be able to stimulate the ovaries and collect eggs. Then surgically, will we be able to find the eggs and successfully get them out of her body. We then need to make sure the eggs and sperm interact properly to give us embryos and then will those embryos grow and develop in the culture medium in the laboratory, before we put them back in the woman. The most difficult stage is that last phase when the embryos are put back into the woman’s uterus, because at the moment we don’t have a great understanding of what makes certain embryos stick and implant, and what makes other embryos fail to implant. This is the particular area of IVF which is the most common place for us to fail in 2010.

How long must they wait to find out if the treatment has been successful and the embryo has implanted?

Usually one will know about 12 days following the embryo transfer whether you are pregnant. This is usually done with a pregnancy test, either a urine test or a blood test and if you do have a positive blood test, we will do an ultrasound scan about 14 days later, and at that stage we should actually see a pregnancy sac and possibly a heart beat within the uterus.

If a pregnancy does not occur, how soon can the process be repeated?

This is quite variable. It is important to realise that the IVF puts a huge physiological stress on the body, the ovaries are swollen and enlarged, sometimes to six or seven times their normal size. If one goes in again with further treatment too quickly then the quality and the quantity of the eggs that will be collected will be compromised. So most units will recommend a two-three month break in between treatments.

Are there any particular complications or side affects a woman can experience whilst undergoing IVF?

Yes and these are important, this is treatment that is not risk free. Initially there will be some side affects from the drugs and that can be associated with feeling temporarily menopausal. So you may have hot flushes, night sweats, sleep disturbance and emotionally can be more of an up and down time. But perhaps the worst side affect that you can experience in IVF is the ovarian hyper stimulation syndrome. This is quite rare but quite serious, and it is where the woman’s body shows an excess response to the drugs that are given. So instead of producing a controlled number of eggs such as 8-12, the woman can produce between 20 or 30 eggs and she can become very unwell and require admission to hospital. So it is something that every IVF unit should be monitoring closely to try and prevent.

How high is the success rate? And does this differ for different ages and types of infertility?

It’s particularly sensitive to the age of the woman. All of the success rates are usually available on clinics websites and national data is collect by the HFEA, who collate this data and all clinics success rates are available to patients on the HFEA website. The biggest thing that determines them is female age and for patients who are relatively young; under the age of 35 are coming through for treatment, they can expect success rates of over 50% per attempt. As we get older then success rates decline rapidly, so by the time we reach 40 success rates are more down to in the region of 20%, and they fall even faster over the age of 40.

How high is the possibility for multiple births during IVF?

This is a very important issue and clinics and the HFEA are doing an enormous amount of work to try and reduce the risk of multiple pregnancy. Many patients are often quite happy to get pregnant with a twin pregnancy or even a triplet pregnancy but they may be unaware of the inherent dangers in multiple pregnancy; particularly in terms of increased risks of miscarriage or in terms of premature birth and babies being in intensive care units. So many units these days for young women in their first cycle will recommend that only one embryo is transferred and this has led to a massive reduction in the field of multiple pregnancy, particularly twins. Under the age of 40, we are no longer allowed to put 3 embryos back, and so we can only do that over the age of 40. So multiple pregnancy is a very important issue and it is something that must be very closely discussed between the couple and their doctors when the decision is made about how many embryos to return.

Is there a higher chance the baby will be born through birth defects with IVF?

There is quite a lot of data available now on IVF babies because of the amount of IVF babies that have been born. There does appear to be a very small increased risk of birth defects from babies born as a result of IVF. Most of those birth defects can be explained by the increased age of women undergoing IVF and also by the increased incident of multiple pregnancy in IVF. But even if one were to control for these two variables, so to only look at young women who had one baby on board, there still seems to be a very small increase in risk of problems to the baby. What we don’t yet know is, is that a result of the IVF procedure itself, so something technical related to putting the eggs and sperm in the laboratory or is it something intrinsic to that couples eggs and sperm, where nature has meant it has been quite difficult for them to reproduce and IVF may be forcing the issue by allowing them to become pregnant, or it could possibly be a combination of the two.

Are there age limits?

There are age limits on the NHS. Most people will allow you to have treatment on the NHS up until your 40th birthday. The chance of IVF working beyond the age of 44 is actually very remote. So even if you were a private patient, it is unusual to have treatment over the age of 44.

On the lower end are there restrictions?

Yes and we think this is slightly strange. Many health authorities will only fund treatment over the age of 23 and I have several patients who are 20/21 who are trying to conceive. For example there may be a problem with their husbands sperm so there is no way these women can get pregnant without IVF, but the health authority is making them wait until they are 23 until they have a baby, so that seems to be slightly unfair.

Is that private as well?

No, privately there would be no minimum age gap.

Can I ask what kind of research is being done around IVF? And how the research helps in the treatment of IVF?

IVF remains a very new treatment, even though we have been doing it for a few years we are still learning an enormous amount about the field. Most research at the moment is concentrating on the area of implantation. So that area where the embryos are returned to the uterus and the issues that make some embryos stick, latch-on and give a pregnancy and other embryos not implant. So people are looking at issues within the lining of the uterus to see whether there can be some factors that make a uterus more welcoming or more friendly to an embryo or equally more hostile. We can learn an enormous amount both about fertility and about miscarriage. The second area of research is looking at the embryo. At the moment the fact is that we used to judge whether an embryo is good quality by what it looks like and so if an embryo is growing quickly and has crisp nuclei we extrapolate that it is a good quality embryo, however the really important issues are the genetic and chromosomal make up of the embryo. So there are some very new tests available which allow us to examine the embryo or the egg from a genetic perspective and then only transfer the egg or the embryo into the uterus that’s deemed to be normal from a genetic point of view. These things are very exciting but they are very new and so we need to approach them very cautiously and not get swept away by our enthusiasm.

I’d just like to say thank you very much for joining us today, it has been a very useful discussion.

You are very welcome, thank you.

To find out about our research follow these links:
 

• Correlation of receptors to the outcome of IVF treatment

• Investigating the possibility of removing and freezing part of a woman’s ovaries prior to her having cancer treatment. Then re-implanting to help fertility.

• The Royal College of Obstetricians and Gynaecologists website has a wide range of information and guidelines on many women’s health topics. This can be found at: www.rcog.org.uk/womens-health/patient-information

• Human Fertilisation and Embryology Authority: www.hefa.gov.uk/

• NHS Choices website also has a range of health information. This can be found at: www.nhs.uk