Bumiputera Sarawak Bumiputera Sabah. Others Foreigner. Had previous natural pregnancy Previous IVF pregnancies. IVF live births.

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1 a. Date of notification: b. Name of reporting site: c.name of doctor in charge: AI : FEMALE PATIENT DETAILS & DEMOGRAPHICS (Instruction: if Mykad is not available, please complete Old IC or other ID document no) (Female patient) 2b. Other ID 4i. Date of 5. Ethnic group Mixed, specify _ 6a. address: (for follow up purpose) A2. MEDICAL HISTORY 1. Obstetrical ne history: 6b. Mobile number: Had previous natural live birth Had previous natural pregnancy Previous IVF pregnancies IVF live births Previous DI pregnancies DI live births Previous Oocyte Donor pregnancies Donor Insemination (DI) 2. Co-morbidity ne Diabetes Retinopathy Hypertension Obesity Gestational CVA 3. Cause of Tubal disease/origin Uterine factor Diminished ovarian reserve Other female factor Infertility: Endometriosis PCOS Unexplained / unspecified / idiopathic Male factor BI : PARTNER DETAILS & DEMOGRAPHICS (Instruction: if Mykad is not available, please complete Old IC or other ID document no) 2b. Other ID (last / lastest pregnancy) Previous IUI < 20 weeks >= 20 weeks partner 4i. Date of 5. Ethnic group 6a. address: 6b. Mobile number: Mixed, specify _ 7. Cause of infertility 8. Number of years married 2b. Other ID ne B2 : DONOR DETAILS & DEMOGRAPHICS (Autofill but editable) Azoospermia Oligozoospermia Avoidance of genetic disorder donor 4i. Date of 5. Ethnic group Mixed, specify _ 6. Gender Male Female 7. Medical history ne Diabetes Retinopathy Hypertension CVA, specify 8a. address 8b. Mobile number 9a. Marital status Single Married Cohabit Divorced Widowed 10. Was the donor adopted? as ) 11. Any biological children 10i. Ethnic group: Biological mother's Biological Father's 12.i Height (m) 12.ii Weight (kgs) 13. Date gametes 14. Donor Eggs produced for use Sperms Embryos 15. Donations Donation to other centres Donation to other patients within the reporting centre ADD New Donor Finalized Version 1.10 Last updated on 16 June 2014 Page 1 Mandatory fields

2 COMMENT APPENDIX A2.3.Cause of Infertility: Male Factor - Detailed male factor(s) related to reasons for treatment cycle C2.5a. Embryo transfer: Other reason no embryo were transferred 1. Aspermia (no semen) 2. Azoospermia 3. Oligozoospermia 4. Asthenozoospermia Globozoospermia 7. Necrozoospermia 8. High Sperm DNA Fragmentation 9. Retrograde Ejaculation 10. Erectile Dysfunction 11. Sperm Antibodies 12. Klinefelter Syndrome 13. Avoidance of genetic disorder 14: Oligo Terato Asthenozoospermia 15: Varicocele 16: Vasectomy 17: Male double 88. t specified Combination: 71: Oligozoospermia,and Asthenozoospermia 72: Oligozoospermia,and 73: Asthenozoospermia and 74: Oligozoospermia and Asthenozoospermia and 1. oocytes 2. utilizable oocytes 3. normal fertilization 4. Freeze all 5. sperm 6. utilizable embryos 7: Poor endometrium lining Only applicable for FET cycle 61. Failed thawed 62. Poor embryo development 63. As a result of positive genetic test A2.3.Cause of Infertility: Other Female Factor - Detailed female factor(s) related to reasons for treatment cycle 1. Fibroids 2. Ovulation disorder 3. Premature ovarian failure 4. Maternal age 5. Turbal Blocked 6. Menopause D.2. Complications experienced by patient/oocyte donor during this cycle 1. ne 2. IVF medication side effect requiring change in intended treatment 3. Adverse reaction to anaesthetic 4. Moderate/Severe OHSS requiring paracentesis 5. Moderate/Severe OHSS requiring culdocentesis 6. OHSS requiring IV hydration 7. Infection 8. Haemorrhage requiring blood transfusion 9. Thromboembolism 10. Ovarian torsion 11. Bladder/Bowel injury 12. Patient death 13. Catheter with blood C1.4i. Cancellation or abandonment: Reason for cancellation or abandonment E.4. Reason Lost to Follow Up 1. Patient illness 2. Patient personal reason 3. Patient error 4. Low ovarian response 5. High ovarian response 6. Premature ovulation 7. Premature luteinisation 8. Donor illness 9. Donor personal reason 10. Donor error 11. access to ovaries 12. Under response 13. Over response 14. Maternal age 15: eggs found, converted to IUI 16: Poor endometrium lining 17: Due to no sperm after TESA or fresh ejaculated or frozen back up 1. Back to origin country 2. Back to own gynae doctor / other centre C1.2c.ii Hormonal Type F2.5. Abnormality: 1. ne 2. Clomiphene citrate 3. Aromatase inhibitor 4. OCP 5. Estrogen patch 6. hmg 7. HP-hMG 8. rec-fsh 9. u-fsh 10. rec-lh 11. u-hcg 12. rec-hcg 1. Brachial plexus injury 2. Caput succedaneum 3. Cephalohematoma 4. Clavicular fracture 5. Facial nerve injury 6. Hyperbilirubinemia 7. Hypoglycemia 8. ne 88. te: Please contact dm@hpmrs.com.my to add codelist (for the dropdown) or the Name of doctor in charge Finalized Version 1.10 Last updated on 16 June 2014 Mandatory fields Page 2

3 a. Patient Name: b. Identification Card Number: CI. CYCLE A. This Cycle treatment type B RECIPIENT 1. Cycle date 2. Cycle date type 3a. Downregulation (If available - not required by HPMRS, for center used only) ne (natural cycle) Stimulated Cycle (Start date of stimulation or last menstrual period (natural cycle) IVF ICSI IVF & ICSI GIFT (with donor eggs) FET, please complete FET form i. Name DONOR i. Name Buserelin Lucrin (Autofill from B2.13 Date gametes produced for used but editable - IF DONOR) Downregulation Dose Unit Downregulation Dose Unit Antagonist cycle (short cycle) (Check the box if stimulation is not done at your centre) Agonist (long cycle) ORIGIN UNKNOWN (for FET only) Stimulation performed by other centre, specify centre name: 3b. Number of stimulation day 3c.i Stimulation Dose 3d. Luteal Support 4. Main reason for this cycle (intending to produce / thaw embryos and/or collecting eggs) Progesterone Immediate Patient Treatment For storing embryos Frozen cycle (FET) autofill For Research Units: iu / per day mg : HCG ) 3c.ii. Hormonal type: (see codelist) Donation a) b) For storing eggs (egg freesing) For Donation Other, specify: c) d) 5. Cancellation or abandonment ) 5a. Date of cancellation or abandonment 5b. Primary reason: (See codelist) C2. COLLECTION FROM PATIENT / DONOR 1. OPU Date 2. Egg origin 3a. Number of egg collection was attempted 4. Outcome of eggs collected from the patient/donor t applicable (Enter 0 if not applicable, example: enter 0 (zero) if no eggs retrieved) Fresh own Frozen own Fresh donor Frozen donor a. Collected: b. Inseminated / injected: (If this form is reporting the use of frozen or donated embryos/eggs, this section should be left blank or enter as Zero.) 3b. if "0" no egg collected, due to poor response to drugs? (Autocalculated from C3A : FRESH & FROZEN - 5a.Number of eggs used) (Autocalculated from C3C : EGGS(S) INSEMINATED - 1. Number of eggs inseminated) c. Discarded: 5a. Embryo transfer (ET) d. Donated for use in Research: e. Donated for use in Treatment (fresh): f. Stored for future patient use: g. Donated for use in Treatment (frozen): h. Freeze date (for FET only): Embryo transfer Date & Time: (dd/mm/yyyy hh:mm) (Autocalculated from C3C : EGGS(S) INSEMINATED - 4. Number of eggs ) (Autocalculated from C3E : EMBRYO STORAGE & DONATION - donated to research) (Autocalculated from C3E : EMBRYO STORAGE & DONATION - donated to treat others (fresh)) (Autocalculated from C3E : EMBRYO STORAGE & DONATION - 2. Number of embryos stored for future patient use) (Autocalculated from C3E : EMBRYO STORAGE & DONATION - 5. Number of embryos donated to treat others (frozen)) (If embryos are transferred on more than one day, enter the first transfer date.) Risk of OHSS Failed thaw Abnormal development Other: As a result of positive genetic test (see codelist) Please add page 3 and 4 for EACH Cycle Finalized Version 1.10 Last updated on 16 June 2014 Mandatory fields FET Page 3

4 a. Patient Name: b. Identification Card Number: Instruction: Where different techniques are used on different eggs/embryo s (such as ICSI or IVF), or where sperm from different people is mixed with/injected into the eggs, these treatments should be recorded on different section (ADD C3). If there are two 'embryo freezing 'dates (two different time point within a cycle) please record each date on different section (ADD C3) C3A : FRESH & FROZEN 1. Egg insemination 2. Gamete date source 3. Treatment type IVF GIFT (with donor eggs) 4. Source of (Autofil but editable) ICSI FET sperm 5a. Number of eggs retrieved C3B : THAWED EGGS(S) USED 1. Thawed egg(s) used? C3C : EGGS(S) INSEMINATED 1. Number of eggs inseminated C3D : EMBRYOS CREATION & USE C3E : EMBRYO STORAGE & DONATION 2. Number of eggs fertilised normally 1. Embryo(s) thaw date 2. Number of embryos thawed 4. Screening type ne (default) PGS 7. Embryo stage at transfer 1. Embryo freezing /donation date donated to treat others (fresh) 7. Age of the embryo (complete 2 & 3) D. EARLY OUTCOME / CYCLE OUTCOME 1. Primary early outcome/ cycle outcome Cycle not completed to transfer C3A : FRESH & FROZEN 1. Egg insemination date 2PN Cleavage C3B : THAWED EGG(S) USED C3C : EGG(S) INSEMINATED C3D : EMBRYOS CREATION & USE t pregnant Heterotopic Ectopic Miscarriage PGD HLA Compacted morulae Blastocyst C3E : EMBRYO STORAGE & DONATION 2. Eggs thawed date 5. Assisted hatching technique 8. Elective Single Embryo Transfer? Donated eggs, donated sperm Donated eggs, patient partners sperm ne (default) Acid 2. Number of embryos stored for future patient use Mechanical Laser Patient eggs, donated sperm Patient eggs, patient partners sperm Ejaculate fresh Ejaculate frozen Epididymal fresh thawed 3. Number of viable embryos transferred 9. Number of embryos Epididymal frozen Testicular fresh Testicular frozen developed 3. Developmental freezing stage of embryos 5. Number of embryos donated to treat others (frozen) (Only applicable if treatment type : FET donated to research 2. Gamete source 3. Treatment type IVF GIFT (with donor eggs) 4. Source of (Autofil but editable) ICSI FET sperm 5a. Number of eggs retrieved 1. Thawed egg(s) used? 1. Number of eggs inseminated 2. Number of eggs fertilised normally 1. Embryo(s) thaw date 2. Number of embryos thawed 4. Screening type ne (default) PGS 7. Embryo stage at transfer 1. Embryo freezing /donation date donated to treat others (fresh) 7. Age of the embryo (complete 2 & 3) PGD HLA 2PN Compacted morulae 2. Eggs thawed date 5. Assisted hatching technique 8. Elective Single Embryo Transfer? (if Intrauterine fetal pulsation was seen please submit an outcome form in due course) Biochemical pregnancy only Patient request for embryo transfer despite being advised against it 5b. Number of eggs used / matured Donated eggs, donated sperm Donated eggs, patient partners sperm ne (default) Acid 2. Number of embryos stored for future patient use 5. Number of embryos donated to treat others (frozen) Intrauterine fetal pulsation seen Embryo transported from another centre Mechanical Laser Patient eggs, donated sperm Patient eggs, patient partners sperm Ejaculate fresh Ejaculate frozen Epididymal fresh 5b. Number of eggs used / matured (Only applicable if treatment type : FET Embryo transported from another centre thawed 3. Number of viable embryos transferred 9. Number of embryos Epididymal frozen Testicular fresh Testicular frozen developed 3. Developmental freezing stage of embryos donated to research i.. of gestational sacs seen: (please also complete the below) ADD C3 If Intrauterine pulsation(s) are seen, then please supply the number of gestational sacs. 2PN (Pro Nuclei) Morula (please also complete the below) ADD C3 2PN (Pro Nuclei) Morula 2. Complications experienced by patient/ oocyte donor during this cycle as ne) 3. Estimated date of birth Finalized Version 1.10 Last updated on 16 June 2014 Page 4 Mandatory fields FET

5 a. Patient Name: b. Identification Card Number: E : PREGNANCY OUTCOME 1. This outcome is a result of the following treatment type 2. Date of successful treatment cycle to which outcome relates 3. Number of gestational sacs with detected fetal pulsation 4. Clinical Pregnancy 5. Pregnancy criteria 8. Pregnancy Outcome Delivery (Auto complete from cycle outcome as, if Intrauterine fetal pulsation seen) Known to be ongoing at 20 weeks Evidence by ultrasound of an intrauterine sac (with or without a fetal heart) Examination of products of conception reveal chorionic villi Miscarriage Induced abortion A definite ectopic pregnancy that has been diagnosed laparoscopically or by ultrasound / t documented 6. Selective reduction performed as ) (due to fetal abnormality/other reasons) 7. Fetal abnormality in a pregnancy Mandatory if Clinical Pregnancy is (Please record the number of weeks gestation for all cases including IVF ICSI IVF & ICSI GIFT (with donor eggs) FET as ) (Fetal abnormality in a pregnancy ending < 20 weeks or by selective reduction) Planned caesarean Emergency caesarean rmal delivery Lost to follow up Pregnancy terminated, specify 2i. Cycle ID 2ii. Cycle date /unreported outcome Maternal death prior to birth (complete date of death below) Pregnancy ended before number of fetuses could be determined Instruction: Date of successful treatment cycle to which outcome relates - please enter the Cycle date with clinical pregnancy seen (to link the pregnancy outcome to the relevant cycle) Heterotopic (Autofill but editable from Section D Earcly Outcome) Lost to follow up 1. Fetal reduction as ) time: 3. Sex Male Female 4. weight 5. Abnormality to ) 1. Fetal reduction as ) time: 3. Sex Male Female 4. weight 5. Abnormality to ) 1. Fetal reduction as ) time: 3. Sex Male Female 4. weight 5. Abnormality to ) Finalized Version 1.10 Last updated on 16 June 2014 Page 5 Mandatory fields