Definitions of Infertility and Assisted Reproduction Technologies
It is the situation of not being able to get pregnant for 1 year by taking care of the regular and ovulation time. In cases where couples are older, treatment methods can be applied before one year.
Assisted Reproduction Technologies
As a result of examinations performed in the case of infertility, problems may be detected on both sides of the woman, man or both. In addition, in approximately 20% of infertile couples, all examinations may result normally; this last group is called “unexplained infertility”.
In the cases described above, the treatment for the cause, although the cause is not found, generally reproductive methods are tried. The most advanced of these treatments today is the IVF method.
Intrauterine Insemination (IUI)
The ovaries are stimulated with medication and follicle development carrying 2-5 eggs is provided. When the time comes, the cracking needle is given. Sperm sample is prepared in the embryology laboratory. The sample with increased quality sperm density is delivered into the uterus at the examination position with a very thin plastic cannula.
In Vitro Fertilization – Tube Baby (IVF)
The ovaries are stimulated with medication and the eggs are collected under ultrasound with the aid of ultrasound before cracking. In the laboratory environment, 50,000 – 100,000 sperm are placed around each egg and fertilization is expected to occur. When fertilization occurs, an appropriate number of embryos are placed in the uterus.
Intracytoplasmic Sperm Injection – Micro-injection (ICSI)
It is the same as the IVF technique, except for the fertilization phase. A single sperm is placed in each of the eggs collected under a microscope. When fertilization occurs, an appropriate number of embryos are placed in the uterus.
Testicular Sperm Extraction (TESE)
It is the method of removing parts from the testicles by surgical intervention when the results cannot be obtained from the TESA method or in cases where there is a high level of sperm production deficiency. The developing or mature sperm obtained are used in the ICSI method.
This method is to thin the walls of the embryos formed under the microscope. In this case, it is thought that it may be easier to cling to the uterus. It is used in older ages, in thick-walled embryos or in patients who have had problems with adhesion in previous attempts.
Approximately 5 days after fertilization, the embryo (blastocyst) is ready to discard its outer membrane (zona pellucida). With the developments in recent years, embryos can be stored in this laboratory until this period. Embryo transfer during the blastocyst period is beneficial because the embryos are closer to the time they naturally fall into the uterus. At least 5 quality embryos are required 3 days after fertilization for the application of this method.
Embryo transfer is the most important part of the IVF procedure. The procedure is carried out on the 3rd or 5th days of embryo development. Today, embryo transfer is done with the help of ultrasound, full of bladder. The embryos formed are fed into the uterus with the help of a thin plastic catheter. The transfer procedure is a procedure that does not require anaesthesia, which is not different from any gynecological examination. Number of embryos transferred T.C. Limited to 3 by the Ministry of Health.
Embryo Freezing (Cryopreservation)
As a result of IVF application, when more quality embryos are obtained than the amount to be transferred to the patient, these embryos can be frozen and stored for later experiments at the request of the couple. Thanks to the ice cream process; Embryo transfer is performed without the need for stimulating the ovaries and collecting eggs again.
In Vitro Maturation (Non-drug IVF)
This method is the maturation of eggs outside the body. It is especially preferred in people with Polycystic Ovaries who respond excessively to medications that stimulate ovulation. Eggs are collected without drug warning and ripened in the laboratory.
At this appointment, your doctor will examine all your examinations and treatments. In some cases, new examinations may be requested. Based on these data, you will be decided on the need for IVF treatment.
Preparation for the Procedure
Once you have decided to enter the IVF program, your doctor will examine you and complete the procedures required to enter the program. During the examination, your ovaries and uterus will be examined with ultrasound, a swab will be taken with a swab from the cervix, the length of the uterus and the passage of the cervix will be examined. Also; tests such as hormone levels, uterine film, male spermiogram, and serology will be completed. All of these operations can be done in one period. From this meeting, the use of vitamins called folic acid is started. When folic acid started to be used regularly before pregnancy and continued to be used in the first 3 months of pregnancy, it was found protective against nervous system and bone structure anomalies that may occur in the baby.
Meeting with IVF coordinator
The IVF coordinator firstly checks that your file is complete. It also gives you information about the general flow of the program, such as the time of arrival and place of application for ultrasound and blood analysis, the use of medicines, telephone numbers you can reach at any time, financial issues. Please note the questions that come to your mind before this meeting. Our experience shows that many of the unwritten questions are forgotten.
The second part of the interview consists of explaining the medicines and doses determined by your IVF doctor and giving you information such as the start and control date. Ask again and again, even the smallest detail you don’t understand in this section. A mistake in drug use can cause both financial loss and loss of your valuable time.
Entry to the Procedure
The suppression of hormones
The timely and irregular effects of hormones produced by the body (for example, preventing ovulation) are required in order to get appropriate answers from the drugs given during the program. Generally, drugs to suppress hormones are started on the 2nd or 21st day of menstruation. This drug, used as a subcutaneous injection, is administered 1 time per day.
At the end of this period, which normally takes 1 to 3 weeks, blood analysis is done and hormone levels are evaluated. The appreciation that hormones are not suppressed can be extended this period. Up to 5% of those who participate in the program may have to leave the program because their hormones are not suppressed. These patients can be re-programmed in the next menstrual period.
Short-term treatment: Hormone therapy is started on the 2nd day of menstruation. In order to prevent the timeless and irregular effects (ovulation) of the hormones produced by the body, hormone suppressant 5-day treatment is started on the 8th-9th day of menstruation. The amount of medication and duration of use used in this form of treatment are small.
Stimulation of the ovaries
When it is determined that hormone levels decrease to the desired level, LH + FSH or only FSH injected intramuscularly or under the skin are used. Care should be taken to make injections at the same time every day. While the application of these drugs continues, the number of follicles and blood analysis is evaluated with ultrasound, hormone levels are measured. Follicle development time varies between 1 and 3 weeks, depending on the response of the eggs. Since the ovarian response of 10% of the program participants is not appropriate, their programs can be cancelled. This decision is made with the approval of the couple. Those who do not have an appropriate ovarian response can rejoin the program under the necessary follow-up and with different drug protocols.
Ultrasound follow up
Ultrasound examinations are done vaginally. This method provides much more detailed information compared to ultrasound made from the abdomen and saves you from boredom as the bladder is made empty. Follicles are fluid-filled sacs that are considered and measured as dark oval shapes on ultrasound, and are considered to contain eggs. During the ultrasound process, disposable covers are attached to the ultrasound device. The lubricant gel used is also water-based and has no side effects and does not leave stains on your clothes.
After the use of medicines that stimulate the eggs, blood levels are examined on certain days and hormone levels are examined. You will be informed in advance for these analyzes.
Since all patients’ bloods have been collected, personal analysis will affect all patients of the day, as laboratory analysis begins. Therefore, we ask you to be careful about blood donation and ultrasound watches.
When the follicle numbers and sizes, hormone levels, and intrauterine tissue reach the proper level, human chorionic gonadotropin (hCG) is injected into the muscle to mature the eggs and crack the follicles. The hormone hCG cracks the follicles within 36 to 40 hours. In the IVF procedure, the follicles are emptied without ovulation and the eggs are collected. Since timing is extremely important in this regard, it is necessary to pay utmost attention to comply with the information given by hCG injection. You will be told orally and in writing on an injection at a certain time after 20:00 hCG day.
Make your subcutaneous needle last time on hCG. Bring the empty hCG box you use with the injection time on it and bring the egg collection day with you.
No needles will be used the day after HCG injection. On the next day, come to the hospital with your partner at the specified time in the morning and be hungry (avoid eating, drinking and smoking before 6 hours).
Firstly, a sperm sample will be taken from your spouse or, if necessary, an operation will be collected from the testicles. Egg collection is done in the operating room and sterile conditions. During this procedure, you will receive a superficial anaesthetic that eliminates pain but does not lose consciousness completely. Egg collection is done with a needle and aspiration system attached to a vaginal ultrasound. Pain complaints are extremely rare during and after anaesthesia. On the same day, you will be discharged after visiting the IVF doctor and receiving information about your egg count and further procedures. Although it is not late at the time of discharge, we recommend that you devote all the days to IVF and do not make another program, considering every possibility. Rarely, eggs cannot be obtained from the follicles emptied. The most common reason for this is that hCG injection is not applied at the right time and in the right way.
From the day of egg collection, 2 ampoules of progesterone injection or vaginal gel should be used at once and within the same syringe. This application will continue under all conditions until your IVF is discontinued. Please do not leave your medicine without talking to your IVF doctor.
Embryos do not develop from every egg. If the number of eggs collected is too low or there is a fertilization problem in the eggs, embryo transfer may not be possible. Therefore, you can get information about the development of embryos by calling the day after egg collection. In the following days, the embryos formed will be placed in the uterus. Anaesthesia is not required, as this procedure is performed as a normal examination. You do not need to be hungry while coming to the hospital. In the gynecological examination position, a pre-specified number of embryos are placed in the uterus with a plastic tube. The bladder must be full during this procedure. Following the procedure, you can be discharged after a short rest. Again, your IVF doctor will give you information about embryo transfer and the following days. We recommend you to rest at home on the same day, you can continue your normal life in the following days.
On the 12th day after embryo transfer, a pregnancy test will be performed by looking at the hormone ß – HCG in the blood. There may be situations when pregnancy continues despite bleeding. Therefore, the test should be done even when you have menstrual bleeding. If the tests are positive in this period, pregnancy is called “biochemical pregnancy”. According to the test result, vaginal ultrasound examination is required to see the gestational sac approximately 10 days later.
Like any treatment method, ovarian stimulation and assisted reproductive techniques also have risks;
1 – The drugs used may show side effects such as headache, tenderness in the breasts, fatigue, hot flashes, irritability and very rarely nausea.
2 – As a result of the body’s hypersensitivity to drugs, a picture called hyperstimulation may occur. Normally, a group of patients may experience mild pain in the ovary and abdomen. In hyperstimulation, these pains can increase a lot, and symptoms such as fluid accumulation in the abdomen and difficulty in breathing can be added, depending on the severity of the table, and a situation that can go up to hospitalization may occur. Hyperstimulation resolves spontaneously over time under general care. If pregnancy occurs, the recovery period is a little longer.
3 – Ectopic pregnancy occurs when embryos given into the uterus are placed outside the uterus. It is rare, diagnosed with low levels of positive or borderline blood tests, pain, and absence of a sac within the uterus. Treatment with the drug can be tried, if it is not answered, it is treated laparoscopically.
4 – Multiple pregnancies are seen more frequently than normal pregnancies because of giving more than 2 embryos in general. In cases where three or four of the embryo are involved, 9-11 of pregnancy. It is suggested that the number of live babies should be reduced to two by entering with a needle from the abdomen accompanied by ultrasound. This process risk does not exceed the risks that may occur in a triplet or quadruplet pregnancy.
5 – Menstrual irregularities may occur in the periods following an unsuccessful IVF application.
6 – With the studies conducted, no evidence has been shown that the stimulation of the ovaries with hormone drugs increases the risk of breast, uterus, and ovarian cancer especially in the future.
7 – The risk of anomaly in children born with IVF method was not different from normal births.