Infertility and IVF

What is infertility?

Not getting pregnant without using contraception for a certain period of time. This period is usually one year. In cases where couples are older, treatment methods can be used before one year. Approximately 15% of couples worldwide suffer from infertility.

Assisted reproductive treatment

In the case of interfertility, tests can detect problems in the male, female or both partners. In addition, in about 20% of infertile couples, all tests may be normal, this group is called the unexplained infertility group. In the cases described above, treatment is directed towards the cause, and if the cause is not found, assisted reproductive methods are generally tried. The most advanced of these treatments today is in vitro fertilization.

What are the methods used in infertility treatment?

IUI (Intrauterine Insemination – Vaccination)

The ovaries are stimulated with medication to develop 2-5 egg-bearing follicles. When the time is right, a hatching injection is given. Sperm sample is prepared in the embryology laboratory. The sample with an increased density of high quality sperm is introduced into the uterus in the examination position with a very thin plastic cannula.

IVF (In Vitro Fertilization – in vitro fertilization)

The ovaries are stimulated with medication and the eggs are collected with the help of ultrasound under light anesthesia before hatching. In a laboratory environment, 50,000-100,000 sperm are placed around each egg and fertilization is expected to occur. Once fertilization has occurred, the appropriate number of embryos are placed in the uterus.

ICSI (Intra Cytoplasmic Sperm Injection – microinjection)

It is identical to the IVF technique except for the fertilization stage. A single sperm is placed in each of the collected eggs under a microscope. Once fertilization has occurred, the appropriate number of embryos are placed in the uterus.

TESE (Testicular Sperm Aspiration)

In cases where there are no sperm in the semen taken from a man due to blocked or underdeveloped sperm ducts or very low sperm production, it is a method of extracting fluid from the testicles with a needle and not obtaining sperm. Developing or mature spermatozoa obtained by this method are used in the ICI method.

TESE (Testicular Sperm Extraction)

In cases where the tesa method fails or in cases of severe lack of sperm production, it is a method of surgically removing a piece from the testicles. The resulting, developing or mature spermatozoa are used in the ICI procedure.

Embryo Cryopreservation

If IVF results in more quality embryos than the number of embryos to be transferred to the patient, these embryos can be frozen and stored for future attempts at the request of the couple. Thanks to the freezing procedure, an IVF attempt can be performed without the need to stimulate the ovaries and collect eggs again.

Embryo Trimming (Assisted Hatching)

This method involves thinning the wall of the embryos under a microscope. This is thought to make it easier for the embryos to attach to the uterus. It is used in patients of advanced age, with thick-walled embryos or in patients who had problems with intrauterine attachment in previous attempts.

Blastocyst Transfer:

About 5 days after fertilization, the embryo (blastocyst) is ready to shed its shell (zona pellucida). With recent developments, embryos can be stored in the laboratory until this stage. Embryo transfers at the blastocyst stage are useful to identify the best quality embryos; however, this method requires at least 5 very high quality eggs 3 days after fertilization.

In Vitro Fertilization (drug-free IVF)

This method is the maturation of eggs outside the body. It is especially preferred for people with polycystic ovaries who respond excessively or not at all to ovulation-stimulating drugs. eggs are collected without drug stimulation and matured in laboratories.

How is infertility treated?

Pre-interview

At this appointment, your doctor will review all your previous tests and treatment. In some cases, new tests may be ordered. Based on this data, we will decide together with you whether IVF treatment is necessary.

Program Preparation

Doctor Consultation

Once you have made the decision to enter the IVF program, your doctor will examine you and describe the procedures necessary for entry into the program. During the examination, your ovaries and uterus will be examined by ultrasound, a pap smear and culture will be taken from the cervix, the length of the uterus and cervical passage will be examined. In addition, tests such as hormone levels, uterine film, male spermiogram will be completed. All of these procedures can be done in one “menstrual period”. From this appointment, folic acid, a vitamin, is started.

Folic acid has a protective effect against anomalies of the nervous system and bone structure that may occur during pregnancy when it is started to be used regularly before pregnancy and continued in the first 3 months of pregnancy.

You will be informed about the general flow of the program, such as the time and place of arrival for ultrasound and blood tests, the use of medication, telephone numbers you can reach at any time, and financial matters. It is useful to write down any questions you may have before this meeting. Our experience shows us that many of the unwritten questions are forgotten.

The doses of medication prescribed by your doctor will be explained to you and you will be given written information such as the start and control dates. Ask repeatedly about even the smallest detail you do not understand in this section. A mistake in the use of medicines can result in both financial loss and the loss of your precious time.

Introduction to the program

Stimulation of the ovaries

Starting on the second or third day of menstruation, the hormone fsh and/or fsh+lh is injected under the skin of the abdomen. This is done with very fine-tipped needles, also known as insulin needles; injection pens can also be used for convenience. The injections should be given at the same time every day, preferably between 17:00 and 19:00. While these medications are being administered, the number and size of follicles are measured by ultrasound and hormone levels are measured by blood test.

The follicle development time varies between 1 and 2 weeks depending on the response of the eggs. In the last days of this period, injections to prevent hatching (antagonist) are added to the program to be administered in the morning and again under the skin. Up to 10% of the participants in the program may be canceled because the ovarian response is not appropriate. This decision is made in consultation with the couple’s mother. Those who do not have an adequate ovarian response can rejoin the program under necessary follow-up and with different drug protocols.

Ultrasound Monitoring

Ultrasound examinations are performed vaginally. This method provides much more detailed information than abdominal ultrasound and saves you a lot of trouble as the bladder is empty. In the ultrasound image, what are seen and measured as dark oval shapes are follicles, i.e. fluid-filled sacs that are thought to contain eggs. During the ultrasound procedure, the ultrasound device is fitted with a disposable sheath that is constantly changing. The lubricant gel used is also water-based, so it has no side effects and will not stain your clothes.

Hormone Monitoring

After the start of ovulation stimulants, blood is taken on certain days to check hormone levels. You will be informed about these tests in advance. Since the laboratory analysis starts after all patients have had their blood drawn, a delay of even one person will affect all patients on that day. It is therefore very important that you are meticulous about the timing of your blood transfusion and ultrasound.

HCG Injection

When the number and size of follicles, hormone levels and intrauterine tissue are at the appropriate level, human chorionic ganadotropin (hcg) is injected to mature the eggs and make the follicles rupture. The hcg hormone ruptures the follicles within 36-40 hours. In IVF, the follicles are emptied and the eggs are collected without ovulation. Since timing is extremely important in this regard, the information given with the hcg injection should be followed with the utmost care. You will be informed verbally and in writing to take the injection at a specific time after 20:00 on the day of the hcg. take your last anti-ovulation medication on the morning of the hcg. do not take any ovulation stimulating medication on the day of the hcg injection. bring the empty hcg box with you on the day of the egg collection, with the time of injection written on it.

Egg Collection

The day after the HCG injection will be free. On the following day, come to the hospital with your partner at the specified time in the morning and fasted (do not eat, drink or smoke for 8 hours beforehand). First of all, sperm will be collected from your partner by normal ejaculation or, if necessary, from the testicles. Egg retrieval is performed in the operating room and under sterile conditions. During this procedure you will receive a superficial anesthetic that eliminates pain but does not make you lose full consciousness.

Egg retrieval is performed with a needle and aspiration system attached to a vaginal ultrasound. Pain during and after anesthesia is extremely rare. On the same day, you will be visited by the IVF team and will be discharged after receiving information about your egg count and further procedures. Although the discharge time is usually not too late, we recommend that you reserve that day entirely for the IVF and do not schedule anything else. In rare cases, eggs are retrieved from the follicles that have been emptied. The most common reason for this is that the hcg injection is not administered at the right time and in the right way.

Progesterone Use

From the day of the egg retrieval, you will receive two anpul progesterone injections in the same syringe or a vaginal gel once a day. This will continue under all circumstances until it is stopped by your IVF doctor. Please do not stop taking your medicine without talking to your fertility doctor.

Embryo Transfer

Not all eggs develop embryos. If the number of eggs collected is too small or if there is a problem with fertilization, embryo transfer may not be possible. For this reason, you can get information about embryo development by phone at noon the day after the egg collection. In the following days, the embryos will be implanted into your uterus. Since this procedure is performed like a normal examination, there is no need for anesthesia; you should be hungry when you come to the hospital. In the gynecological examination position, a plastic tube will be used to insert a predetermined number of embryos into the uterus. Following the procedure, you can be discharged after a short period of rest. The IVF team will give you information about the embryo transfer and the following days. We advise you to rest at home on the same day; in the following days you can lead your normal life. progesterone injections will continue during this period.

Pregnancy Test

On the 13th day after the embryo transfer, a pregnancy test will be performed by looking for the hormone b-hcg in the blood. This test will be repeated two days later. The first test should be done even if you have menstrual bleeding; there may be cases where the pregnancy continues despite bleeding. If the tests are positive during this period, this pregnancy is called a “biochemical pregnancy”. If the gestational sac, the baby and the heartbeat can be seen by ultrasound, this is called a “clinical pregnancy”. Once a clinical pregnancy is detected, a normal pregnancy follow-up is performed.

Complications

Like any treatment, ovarian stimulation and assisted reproductive techniques have their risks:

– The medicines used may rarely cause side effects such as headache, breast tenderness, tiredness, hot flushes, irritability and nausea.

– Normally, a group of patients may experience mild pain in the ovaries and abdomen, but with hyperstimulation, this pain can become very severe and, with the addition of symptoms such as fluid accumulation in the abdomen and difficulty breathing, can lead to a condition that can lead to hospitalization depending on the severity of the condition. Hyperstimulation resolves spontaneously over time under general care. If pregnancy occurs, the recovery period is slightly longer.

– Ectopic pregnancy occurs when embryos introduced into the uterus implant outside the uterus. It is rare and is diagnosed by low but borderline positive blood tests, symptoms such as pain and the absence of a sac in the uterus. It is mostly removed laporoscopically in the abdomen.

– Multiple pregnancies are more common than normal pregnancies, usually due to the introduction of 3 or 4 embryos. however, pregnancy rates are also reduced when 2 embryos are introduced to prevent this. if three or four embryos fail, it is recommended to reduce the number of live babies to two by inserting a needle into the abdomen with ultrasound guidance at 9-11 weeks of pregnancy. The risk of this procedure does not exceed the risk of a triplet or quadruplet pregnancy. According to the laws and regulations in our country, 1 embryo transfer is allowed in the first 2 IVF applications under the age of 35; 2 embryo transfers are allowed in the applications at the age of 35 and over and/or after two unsuccessful IVF applications.

– Menstrual irregularities may occur in the period following an unsuccessful IVF procedure.

– Studies have shown that ovarian stimulation has an effect on increasing the risk of cancer in the future.

– The risk of anomalies in children born by IVF was not found to be different from the risk of anomalies in naturally occurring pregnancies.

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