IVF - IN VITRO FERTILIZATION

yumurta toplanması spermlerin yıkanması mikroenjeksiyon icsi embriyo 1. gün embriyo 2. gün embriyo 3. gün embriyo 4. gün morula embriyo 5. gün blastokist embriyonun vücuda verilmesi
IVF - In Vitro Fertilization

Choice of Clinic

There is an abundance of clinics to choose from but not all of them offer quality at international standards.  IVF and infertility treatment requires close follow up and can be stressful. You will need a clinic that has a warm atmosphere and can comprehensive medical services.

When choosing an IVF clinic, please watch for these

  • Do the clinicians answer your questions and address your personal concerns
  • Does the staff satisfy your personal needs? Are you able to see your doctor close to the appointment time without much delay?  Is your clinician able to set aside sufficient time for you or does he/she seem pressed for time and extremely busy?
  • Do they practice all of the techniques in Artificial Reproductive Technology?
  • Do you believe that the doctors keep up with advancements in their field?
  • What is the pregnancy rate in general and for people in similar situations as yours? Did they explain this to you in detail?

In our clinic techniques in Artificial Reproductive Technology are practiced successfully. These are:

  • Ovarian stimulation
  • Classic IVF
  • Artificial Insemination
  • Microinjection - ICSI (IntraCytoplasmic Sperm Injection)
  • ICSI with sperm obtained from testicular tissue samples
  • ICSI with Spermatid (immature form of spermatozoa used when mature sperm is not found)
  • Embryo and egg freezing
  • Embryo biopsy and genetic analysis - PGD (Preimplantation Genetic Diagnosis)
    • Single gene mutation and HLA typing in embryos
    • Aneuploidy tests, sex chromosome analysis (FISH, PCR)
  • Extended culture of embryos and blastocyst transfer
  • Tearing of the zona pellucida (Assisted hatching)
  • Reduction of embryos when a multiple pregnancy of triplets or more occur

In addition to ART, a variety of procedures are done to ascertain the cause of infertility and, if possible provide, many kinds of surgical treatments (such as use of Laser or electrocauter to open blocked tubes or treatment of endometriosis) can be performed laparoscopically.

This document is to help familiarize you with the procedures associated with ART. Please read carefully and do not hesitate to ask questions.

 

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When should you seek treatment ?

The best time to make an appointment at our clinic is on the second or third day of your menstrual period (if you are menstruating).  If you are not menstruating or if your periods are irregular, then come when it is most convenient.  For those who live in another city, we recommend that you come on Monday or Tuesday.  Please bring reports of any tests that you have had done previously.  Couples who have decided to start treatment and have had all their necessary tests done should set aside 2 hours for the initial consultation and instruction.

 

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For Whom is IVF Recommended ?

Normally the egg that is released by the ovary it is ‘caught’ by one of the fimbriae and transported along the fallopian tube to the uterus.  Fertilization usually ocurrs in the tubes and then the developing embryo implants in the uterus about one week after ovulation.  When the egg is fertilized and cultured outside the body, this is called In Vitro Fertilization (IVF).  The most common reasons for IVF are:

  • Blocked tubes
  • If sperm count is too low to fertilize the egg in vivo or if the quality is poor
  • When there’s no sperm in the ejaculate, in which case a tissue sample is taken from the testes and sperm from the sample, if found, is used for microinjection into the egg.
  • Immunological problems
  • Unexplained factors causing difficulty to conceive even after artificial Insemination or ovarian stimulation.

 

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For Whom is IVF Not Recommended ?

Women of advanced age or patients with extremely poor quality sperm have a very low chance of pregnancy.

  • Women over the age of 45
  • Men who do not have sperm in their ejaculate or in tissues obtained from the testes.  Using donor sperm is illegal in Turkey but there are countries where this is practiced legally.
  • Women who do not have a uterus for various reasons.  Some countries allow surrogacy for this patient group.
  • Women who do not have ovaries or do not ovulate even when stimulated with drugs.  We can provide information for women in this group after performing the necessary tests.

 

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How Often Can I Try IVF ?

There are no set limits.  Provided that eggs that are collected fertilize normally, chances of pregnancy is the same with each attempt.  Just as in rolling dice, the probability of getting a six in the first try is low but the probability increases proportionate to the number of tries.  One can try as often as 10-12 times.

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What are the Stages Of IVF Treatments ?

• Suppression of hormones • Ovulation induction (stimulation of ovulation)
• Egg collection • Insemination of eggs
• Embryo Transfer • Pregnancy test

Every couple need a tailored treatment for ovulation induction. The age of the partners, ovarian reserve, the history of previous ivf trials, the need for cost reduction etc may effect the protocol.


Suppression of Hormones:

We use Lucrin vials and/or oral contraceptives for this purpose.  We will explain the protocol to you.  The following is an overview of the drugs used and their side effects.

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Stimulation of ovaries :

Recruitment and development of ovaries is stimulated by Gonal-f, Pergonal, Metrodin, Puregon, Merional, Fostimon and Menogon used either by themselves or in combination of two or more.  Normally these drugs are used for a period f 8-15 days.  When the largest follicle attains 15mm, then close observation is required to prevent premature ovulation.  This will be explained when you begin treatment.

Mainly there are 4 types of ovulation induction

GnRH agonist protocols: These drugs are used to suppress ovaries. They normally first stimulate ovaries, because they make the pituitary gland secrete more FSH hormones which stimulate the ovaries. After 5-7 days of injection of these drugs, they desensitize the pituitary glands. Therefore they prevent the secretion of final maturation hormone, LH and prevent spontaneous ovulation.

Long Protocol: GnRH agonist drugs are used a week before the menstruation starts. This is called the mid-luteal phase of the cycle. After 7-10 days of drugs usage, the ovaries are generally suppressed and may respond to the gonadotropins more evenly.

Short Protocol: GnRH agonists starts after the menstruation bleeding, usually on day 2 or 3 and with the gonadotropines.

Antagonist Protocol: These drugs act immediately and their effect usually last about a day. Therefore they can be used in replace of agonist drugs and for shorter time of injections. Their main purpose is like agonists to stop ovulation before the egg collection.

Drugs used during treatment:

  • Lucrin: This is administered subcutaneously.  Unless told otherwise, a daily dose is usually 0.05-0,10 cc.  We recommend that you take your drugs at the same time in the evening at around 6-7pm.

The initial dose is taken on different days depending on the type of protocol used:

  • Long protocol:  Begins on the 20th day of your period.  The last dose will be the day before that Pregnyl or Ovitrelle is used.
  • Short protocol:  Starts on the first day of menstruation, and stimulation drugs are initiated on the second or third day of menstruation.  Lucrin will be used until the day of Pregnyl or Ovitrelle..

Injections are done with insulin syringes.  The needle is finer and it is easier to measure out 0.5 cc’s.

  • Lucrin flakon:  This is administered subcutaneously and the daily dose is 0.05-01,0 cc.
  • Cetrotide ampule:  This is administered subcutaneously and also suppress hormone production but using a different mechanism.
  • Orgalutron / Cetrotide syringe: This is administered subcutaneously and has the same mechanism of action.
  • Pergonal, Menogon amp. (hMG):  Doses depend on the patient’s age and prior treatments.  We recommend that you take the drugs at the same time every day at around 6pm.  The actual drug is in powder form and is diluted with fluid from separate ampulles.  1-2 ampules of fluid is sufficient to dilute 6 ampulles of powder.  The drug is administered subcutaneously.
  • Puregon and Gonal-f (rec FSH):  Administered subcutaneously.  Used to stimulate ovaries.  This drug is obtained through genetic recombination and contains pure FSH. 

The syringes are single use and must be disposed of after use.

  • Pregnyl, Ovitrelle (hCG) amp:  This is the last drug in the induction protocol.  The drug is administered subcutaneously when the follicles which contain the eggs reach a certain size.  Egg collection is performed 34-40 hours after injection.

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Egg collection :

This procedure is done 34-40 hours after hCG is administered.  For example if hCG is injected on Monday night at 24:00, the egg collection procedure will start at approximately 10 am on Wednesday.  Since we use general anesthesia during egg collection, we ask that you come to the clinic after a 6 hour fast.  The procedure lasts 5-30 minutes.  The procedure causes very little discomfort to the patient because we use general anesthesia or local anesthesia in conjuction with sedation.  This procedure involves using a needle attached to a vaginal probe which pushes through the vaginal wall to reach the follicles and aspirate their fluid.  We ask the husband to collect sperm at this time.  This procedure is simple and carries very little risk of complication, but in the event that there is a complication such as heavy bleeding, surgery may be required.  Normally the patient can go home a few hours after the procedure.

  • You should come to the clinic one hour before the scheduled procedure.
  • Because general anesthetic will be used, you should come to the clinic after a minimum four hour fast.
  • You and your husband should come together.
  • A two day period of sexual abstinence is preferred, but not necessary.
  • If you experience pain after the procedure, you can use Parol tablet (paracetamol) up to 4-6 times a day.
  • Please inform the staff if semen collection will be difficult in a hospital setting before the day of egg collection.

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Embryo Transfer :

Eggs are inseminated with the partner’s sperm.  Fertilization is verified two days after insemination.  Please do not try to get information before the second day.  For example if egg collection was done on Wednesday, the embryos will be examined on Friday and the embryo transfer day will be decided upon.  The transfer procedure is painless and does not require anesthetic or sedation.  Normally it takes about 10 minutes.  Depending on the number of embryos and their quality, the day of transfer may vary from the 2nd day to the 5th day.  Patients usually rest for about 20 minutes after the procedure.  Sexual intercourse is not allowed for two days after the procedure.  The patient can resume her normal daily activities a day after the procedure.

You will be asked to use certain drugs on the day of Embryo Transfer until the pregnancy test.  The drugs prescribed will vary according to the patients’ needs. You will use one or more of Progesterone in oil ampule, Pregnyl ampule veya Progestan tablet, Duphaston tablet, and Proluton-depot ampule.  If the pregnancy test is positive, you will continue using the drugs until the 8-10th week of pregnancy.  If the pregnancy test is negative, you will be asked to discontinue the drugs.

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Pregnancy Test and Ultrasonography :

A pregnancy blood test will be done 12-14 days after egg collection.  If the test is positive, the pregnancy must be confirmed by ultrasound 10-15 days after the pregnancy test.  Using the egg collection day as reference, 28-30 days afterwards, doctor’s can see the baby’s heart beat in ultrasound scan.

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When Multiple Pregnancy Occurs ?

Increasing incidences of multiple pregnancies are seen as a result of ART.  The goal of recent studies is to reduce the number of embryos while maintaining a high pregnancy rate.  We have succeeded in keeping the number of transferred embryos low without compromising our high pregnancy rate.  Fetal reduction is done under ultrasound guidance and is used for multiple pregnancies of 3 or more.  The procedure is usually performed at 10-12 weeks of gestation.

 

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FAQ

  • A normal couple has a 20-25% chance of pregnancy every month
  • Sperm production takes 70 days and is continuous in the adult male. 
  • Women are born with approximately 400 thousand eggs. About 1000 eggs are dissipated every month.
  • When the egg reserve is exhausted, the woman enters menopause and she ceases menstruating.
  • Infertility drugs do not affect the age of menopause onset
  • A male leaves 100 million sperm cells in the woman’s vagina after sexual intercourse
  • Only 15-100 can reach the egg
  • Among infertile couples :

    30% are male factor
    30% are female factor
    40% are a combination of the two

  • Provided that a suitable treatment method is chosen, 60% of couples who attempt IVF can get pregnant
  • One out of every ten couples are infertile and 15-20% are of have unexplained infertility
  • 25% of patients in this group get pregnant naturally during 1-2 years waiting period of treatment
  • 10-30% of all pregnancies end in miscarriage
  • Intracytoplasmic Sperm Injection (ICSI) is the term used for a technique where one single sperm is injected into a single egg
  • Gametes from the husband and wife are used.
  • Use of microinjection for patients who have normal fertilization with does not increase success rates

 

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