IVF

Ankara IVF Treatment

Having children is the right of every couple. The child is the joy of the family and the guarantee of our future. However, sometimes couples may have problems conceiving due to male or female factors. Infertility, that is, the problem of getting pregnant, is an important problem that can have psychological, economic and social repercussions.

In vitro fertilization and inoculation therapy is an assisted reproductive treatment method applied to couples who cannot conceive spontaneously. In our center in Ankara, we evaluate our patients and carry out IVF and vaccination treatments with methods that we plan according to their individual characteristics.

In vitro fertilization was  first performed in England in 1976 and pregnancy was reported by Bob Edwards. Then, the first live birth was achieved by the same team in 1978. (1,2). Since then, approximately 7 million pregnancies   have been achieved by in vitro fertilization all over the world. In the first years, IVF treatment was applied only to women with problems in their tubes, but in the 1990s, the invention of the microinjection (ICSI) method and the achievement of pregnancy became hope for men with sperm count and motility problems.

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When should couples apply to IVF Center?

If there is no known condition that will prevent you from getting pregnant, if your age is under 35 years old, at the end of 1 year, if you are over 35 years old, if you have not been able to conceive despite regular sexual intercourse for 6 months, you should be examined by a physician specialized in the field of reproduction. In the young age group, approximately 85% of couples can get pregnant after 1 year if there is no problem that may prevent pregnancy. While the probability of pregnancy in the first 3 months is around 25% per month in this 1 year, it may be around 15% per month for the next 9 months. 

In the first step evaluation, anatomical evaluation including the vagina, uterus and ovaries in women, determination of ovarian reserve and determination of ovulation status, and sperm analysis in men will be appropriate. If the woman’s age is over 40, I recommend applying for an evaluation after a few months, without wasting time. 

Inability to achieve pregnancy usually develops due to male-related factors in one-third of couples, female-related factors in one-third, and both female and male-related reasons in the remaining one-third, or no problems can be detected. In approximately 15-20% of couples, there is no obstacle to conception. We call this condition  unexplained infertility  .

In couples who have trouble conceiving, the evaluation of both the man and the woman is important.

What is IVF?

In vitro fertilization treatment  is based on the principle of obtaining embryos  after the mature eggs grown and collected in women with various drugs are combined with the sperm of the man (microinjection-ICSI)  . Obtained embryos are followed, the best quality is selected and transferred into the uterus. The remaining quality embryos can be frozen and stored.

Who is recommended IVF Treatment?

In vitro fertilization treatment  is preferred in cases where there is a situation that prevents spontaneous pregnancy due to factors belonging to the woman or the man, and where  pre-in vitro fertilization treatment options  are not successful or these methods will not yield results  .

Medical conditions that require IVF;

  1.  The woman has complete obstruction in the fallopian tubes or the tubes have been previously removed or tied for any disease,
  2.  Presence of severe sperm count and motility problems or no sperm in the semen  (azoospermia) . Immunization treatment can be tried in mild sperm problems.
  3.  The presence of a condition with low ovarian reserve, prolonged inability to conceive, or a condition that may prevent an additional pregnancy,
  4. In women who have failed other treatments before IVF (in case of ovulation problem, polycystic ovary syndrome-PCOS, chocolate cyst-endometriosis or unexplained infertility),
  5. In the presence of advanced female age,
  6.  If there is no result with the vaccination treatment,
  7.  In the presence of a known genetic disease in the family (Spinal muscular atrophy-SMA, thalassemia, hemophilia, cystic fibrosis, metabolic diseases, muscle diseases, etc.), Preimplantation Genetic Diagnosis (PGD) is required for the selection of healthy embryos.
  8.  For preimplantation genetic diagnosis (PGT-SR) in the presence of a translocation that causes breakage or alteration of chromosomes.

How is IVF Treatment Performed?

Before starting IVF treatment, we would like to evaluate the couple in detail and determine the individualized treatment protocols specific to the couple. Therefore, the first evaluation is very important for the success of the treatment.

Initial Inspection and Evaluation

First, we would like to see the couple who are having trouble conceiving for evaluation. In this check-up, we get detailed stories from the man and woman about issues that may be related to reproduction. Then,  by performing a pelvic examination  and  ultrasonography  , we check whether there is an anatomical problem related to the uterus and ovaries and determine the level of ovarian reserve.  We can understand whether there is a problem with the sperm analysis applied to the man  .

How should a man be evaluated in infertile couples?

First of all, a detailed story should be taken. Details such as the development history of the man in childhood, his development in adolescence, sexual life, previous infection, surgery, environmental toxin exposure (working in a very hot environment or in the paint industry, etc.) and treatment that may be toxic to reproductive cells (chemotherapy and radiotherapy) should be questioned.

Height, weight, body muscle-fat distribution, hair growth pattern, external view of the genital area and breasts should be evaluated within the scope of physical examination. Especially in the case of low testosterone, a decrease in hair growth and atrophy in the genital organs can be seen. 

The first analysis to be done is sperm analysis.  After two to six days of abstinence, sperm count and motility are evaluated from the sample produced by masturbation. If abnormal values ​​are detected, the test should be repeated after a few weeks.

The normal reference ranges for sperm analysis according to the recently accepted criteria of the World Health Organization (WHO);

  • Volume: >1.5 ml
  • Sperm count: 15 Million/ml
  • Total sperm count: 39 Million/ml
  • Morphology: 4% normal
  • Total motile sperm rate: 40%
  • Fast motile sperm rate: It should be 32%.

In cases with severe oligospermia or absence of sperm, namely  azoospermia  , hormonal evaluation (FSH, LH, total testosterone, prolactin) and chromosome analysis should be performed. In addition to the absence of sperm, evaluation should be made for the presence of Y chromosome microdeletion. In patients with very low semen volume and no sperm in the semen, evaluation for obstructive azoospermia and, if necessary, analysis for cystic fibrosis gene mutation (CFTR mutation) may also be recommended. 

We do not recommend performing a sperm DNA damage test as an additional test. So much so that this procedure is not recommended in the American Reproductive Association (ASRM) guidelines. Because the presence of DNA damage does not prevent spontaneous conception, but it is also not a threat to the healthy course of pregnancy. 

Problems that can be detected in men after these evaluations;

  • Sperm count deficiency (oligospermia) and/or low motility (asthenospermia)
  • Absence of sperm in the semen (azoospermia),
  • sexual dysfunction,
  • Problems such as retrograde ejaculation may be detected due to previous surgeries or diabetes.

How to Evaluate Women in Infertile Couples?

First of all, a detailed history of the woman should be taken and details such as her developmental history in childhood, her development in adolescence, sexual life, previous infection, surgery and treatment that may be toxic to reproductive cells (chemotherapy and radiotherapy) should be questioned.

It is important to learn the menstrual order. Amenorrhea, in other words, no menstruation can be a sign of ovarian failure or lack of ovulation and creates an obstacle to pregnancy. However, if the menstrual intervals are longer than 35 days, that is, in the presence of oligomenorrhea, ovulation may not be present or it may be irregular. Therefore, it is not an absolute cause of inability to conceive. However, it will make it harder to conceive.

In the physical examination, ultrasonography should be performed to evaluate the general examination, body hair status and internal genital organs. Hormonal evaluation can be performed in patients deemed necessary as a result of the examination. In this way, it can be planned to measure FSH, LH, estradiol, TSH and prolactin levels in the blood.

Genetic tests: It can be done in those with ovarian reserve deficiency at a young age, when there is recurrent pregnancy loss, in case of amenorrhea and when it is clinically suspected.

Hysterosalpingography (HSG) ; In women deemed necessary, HSG can be performed to evaluate the uterine lining and tubal permeability   . The most suitable period for HSG withdrawal is the first days after the end of menstruation. Water-based opaque material is injected into the uterus with a cannula placed through the cervix, serial radiographs are taken at the same time, and images are taken during the passage of the opaque material through the uterus and tubes. Thus, an idea about the inner surfaces of the uterus and tubes and the permeability of the tubes is obtained.

Office/Operative Hysteroscopy:  It is an imaging method that allows viewing the inside of the uterus and the areas where the tubes are opened into the uterus by entering with a light source through the natural opening in the cervix. It can be planned when a congenital anomaly such as polyps, fibroids or intrauterine curtain (septum) is suspected in HSG or ultrasonography. In addition to diagnosing with hysteroscopy, corrective surgery can also be performed in the same session.

Sonohysterography:  It allows visualization of the inside of the uterus by transvaginal ultrasonography performed during the injection of saline solution into the uterus with the cannula inserted into the cervix. In this way, the presence of polyps and fibroids in the uterus can be detected and various congenital uterine anomalies can be recognized. 

Laparoscopy:  It is a method of visualizing the intra-abdominal structures by passing through incisions of 5 to 10 mm on the abdominal skin with a light source. The presence of endometriosis can be confirmed and staged by laparoscopy. In addition, if hydrosalpenx is detected, the tubes can be removed or opened in the presence of adhesions.

However, all these imaging methods are performed when necessary. They do not need to be done routinely in every case. 

Problems that can be detected in women after these controls;

  • Ovulation disorders (Polycystic ovary syndrome-PCOS, Presence of hypogonadotropic hypogonadism)
  • Chocolate cyst (endometriosis)
  • Problems related to the tubes (hydrosalpenx, obstruction in the tubes, etc.)
  • Problems with the uterus (congenital uterine anomalies such as myoma uteri, intrauterine veil, unicorn uterus, double horned uterus, endometrial polyp
  • Decreased egg reserve

What should be considered when coming for the first examination?

 We recommend that you come for the first evaluation one or two months before the planned treatment month, so that we can evaluate you in detail and  perform your recommended routine controls if IVF treatment is required. There is no need for a special timing for menstruation for this first examination. When you come, we would like you to bring all your previous studies, if any.

How much time should I allocate when I come for the first examination?

First of all, we create a file for our couples who come for the first examination and take their detailed histories. Then, we conduct their examinations and discuss their situation in detail and inform them. If there is a need for IVF  , we determine individualized treatment protocols for the couple and tell them when and how to start treatment. If additional tests are required, couples can have these tests done at any health institution and send them to us.

After the evaluation of men and women, we determine a personalized, individualized treatment protocol according to the individual characteristics, age and ovarian reserve of each couple. Because with individualized treatment, the  chance of success in IVF  is higher. Although IVF treatment is started with the woman’s menstrual day, sometimes, according to the selected drug protocol, it may be necessary to use some drugs before menstruation. 

IVF Treatment Stages

We can collect IVF treatment stages under 6 main headings.  Let’s take a look at the details of IVF treatment together.

1-) Stimulation of the ovaries:

The aim of IVF treatment is to obtain multiple eggs after stimulating the ovaries with appropriate drug protocols. For this purpose, drugs in the form of injections are generally used. Although it is sometimes necessary to start with premenstrual preparations according to the treatment protocol chosen according to the individual characteristics of the person, ovarian stimulation mainly starts with menstruation. 

The protocols we use in IVF treatment; 

  1. Long Protocol (GnRH agonist protocol, luteal estrogen priming protocol) 
  2. Short Protocol (GnRH Antagonist protocol, progesterone primed protocol)
  3. Microdose Protocol (OC-Mikrodose flare up protocol)
  4. Ovarian Sensitizing Protocol
  5.  Minimal Stimulation Protocol
  6.  Dual Stimulation Protocol (Double ovarian stimulation in the same cycle)

While determining the dose of egg enlargement drug to be used in the treatment, it would be beneficial to evaluate many issues together. When determining the dose;

  • patient’s age,
  • If available, the response to the previous IVF trial,
  • body mass index,
  • The number of antral follicles in both ovaries, that is, the ovarian reserve should be taken into account.

By paying attention to all these issues, stimulation with the lowest possible dose will help to achieve both patient safety and high success rates. 

After the treatment is started, the daily dose of medication is started.  It is very important that the medicines to be taken are used regularly as described. Our nurse will explain to you in detail about this.

How Many Days Does Ovarian Stimulation Last?

The use of ovarian stimulating drugs usually takes 8-10 days.  During this period, it is necessary to measure the size of the egg sacs, namely the follicles, by measuring estradiol in the blood and ultrasonography in certain processes. During ovarian stimulation, determining the individualized drug use protocol and dose according to the individual characteristics of the woman and the ovarian stimulation response, if any, is of vital importance in terms of the response to be received and thus the success of IVF. Inadequate use of the drug dose may decrease the response, while overuse of the dose may increase the risk of developing overstimulation syndrome (OHSS). 

In the presence of polycystic ovary syndrome  (PCOS) or in cases with a high ovarian response and more than 18 egg sacs with a size larger than 11 mm on the day of the cracking injection, it is preferable to freeze all embryos obtained that month and not to make fresh transfers in order to avoid the risk of OHSS. we are doing. 

After the follow-up, when the egg sacs reach the desired size, we plan the egg collection process 34-36 hours after the cracking needle. In general, we prefer to make cracking needles when the size of at least 3 egg sacs exceeds 17 mm in our applications. The purpose of applying the cracking needle is not to crack the eggs, but to ensure their final maturation. 

In 10-15% of patients, treatment can be canceled due to inadequate response during ovarian stimulation or incompatible follicular development. 

How should nutrition be in IVF Treatment?

During ovarian stimulation, no special diet is required in terms of nutrition. We recommend that you consume vegetables and fruits as normal of the season, and not to use alcohol and cigarettes. If you need to use medication for any other reason, you should definitely ask us and make sure that it is necessary. During this period, it will be okay to go to work, do light sports and have sexual intercourse until the last days of stimulation. 

2- Egg Collection (OPU)

Egg collection is the process of collecting the fluid inside the egg sacs (follicles) that are enlarged by ovarian stimulation. Egg collection is performed with transvaginal ultrasonography and under a light general anesthesia so that you do not feel pain. The egg collection process  takes about 10-15 minutes. With the vaginal method, the contents of the egg sacs (follicles) formed in the ovaries are emptied by entering with a needle, along with transvaginal ultrasonography, and the fluid taken is sent to the laboratory for detailed examination. The fluid sent by our embryologist is examined in the laboratory, and the eggs are taken and transferred to another container.

After the collection, it is sufficient to rest in our clinic for 30-45 minutes. It will not be a problem for you to return to your daily life afterwards.

When is Egg Collection Processed?

After starting ovarian stimulation with menstruation, there are slight differences from person to person, but after 8-10 days of egg stimulation, when the egg sacs reach the desired size, a cracking needle is applied and egg collection is planned 2 days later. In other words, egg collection is done 12-14 days after menstruation on average.

What Should Be Considered Before Collecting Eggs?

We perform the egg collection procedure under light anesthesia so that you do not feel any pain. For this reason, we recommend that you fast, like fasting, and do not eat or drink anything after 12 pm the day before the egg retrieval day. In addition, we would like you to take a shower the day before the procedure and come to our center without using perfume or deodorant. If you have a medicine that you are using constantly, you can drink your medicine with a little water by telling us on the morning of the procedure.

What Should Be Considered After Egg Collection?

In our center  , we almost always perform egg collection  under anesthesia. For this reason, we host you in our center for 30-45 minutes after the procedure. Then you can leave our center. However, since you are under anesthesia, we recommend that you do not drive, work and stay away from work that requires attention on the day of the procedure. There is no restriction in terms of food.

Since egg retrieval is performed with the help of a needle advanced from the vagina, there may be light spotting in the first few days after the procedure,  but  we do not expect heavy bleeding. We recommend that you do not have sexual intercourse for 7-10 days in order not to feel pain and to avoid the risk of infection.

What Are the Risks of Egg Collection?

Egg collection is done by reaching the ovaries with the help of a needle advanced from the vein with the help of ultrasonography and the egg sacs that have been enlarged in the ovary are collected. Very rarely, there may be a risk of infection related to the uterus, tubes and ovaries due to the collection process and the risk of injury to the intestine and intra-abdominal large vessels, but this risk is almost non-existent in experienced hands.

Is There Any Pain After Egg Collection?

It is normal to feel some groin and lower back pain after egg retrieval, but this pain can be completely controlled with painkillers. We do not expect to feel very severe pain, but if you have such a complaint, please inform us.

Is it necessary to use medication after egg retrieval?

One day after the egg retrieval day, we start our patients with whom we plan a fresh transfer, with supportive drugs in order to increase the probability of embryo attachment. Which drugs you should use will be explained by our nurses in accordance with the protocol chosen for you. Our nurses will also tell you how long you will continue to take the supplements made in this recipe, if pregnancy is achieved, after your test day.

3- Microinjection (ICSI) and Embryo Tracking Process

On the day of egg collection, the cells around these eggs are thawed and the maturity level of the eggs is evaluated and tested. Approximately 80% of the eggs collected under normal conditions are mature (mature). Only mature eggs can be processed.


With Which Methods Is Fertilization Provided In In Vitro Fertilization?

In vitro fertilization is achieved by in vitro fertilization (IVF) or microinjection (ICSI) methods.

In the in vitro fertilization (IVF) method, sperm are placed around each mature egg and fertilization is expected. In the microinjection (ICSI) method, 1 sperm is injected into each mature egg. Although the microinjection (ICSI) method was first used especially in couples with sperm problems, we apply the microinjection (ICSI) technique to every couple in our center, regardless of the reason for not getting pregnant, since the fertilization rates are higher.

On the day of egg collection, all mature (mature) eggs are microinjected under a special microscope on the same day. That is, a sperm belonging to the spouse is injected into each egg with a special technique, and then the eggs are taken into special devices called incubators. The day after the microinjection (ICSI) procedure, approximately 17 hours after the procedure, all eggs are evaluated for their fertilization status. Under normal circumstances, we would expect approximately 75-80% of ICSI eggs to be fertilized.

How Is In Vitro Fertilization Treatment Done If Sperm Count Is Too Few or No Sperm?

If, on the day of egg collection, motile sperm cannot be obtained as much as the number of eggs collected from the semen produced by the spouse, or if there is no sperm in the semen, that is, if there is azoospermia, it may be necessary to obtain sperm surgically. For this purpose, sperm can be searched for by drawing fluid from the sperm collecting channels in the ovaries (testes) of the male (PESA) or by taking small pieces of testicular tissue under the microscope (micro-TESE). In azoospermia cases, 50-55% sperm can be obtained in the first application with the Micro-TESE method.


How Are Embryos Followed After Fertilization?

After fertilization, the embryos continue to be followed in special media, in the devices we call incubators, in an environment that mimics the oxygen, humidity and temperature of the female body.

After fertilization, the cells of the embryos divide into two every 12-14 hours, so that the embryo reaches an 8-cell state 72 hours after collection. The development of embryos until the 4th day is called the cleavage stage, and the development from the 5th day is called the blastocyst stage. The embryo, which has reached the blastocyst stage, has now reached 250-300 cells. For this reason, the number of cells is no longer mentioned as in the cleavage stage, embryos are classified from 1 to 5-6. 

How is Quality Defined in the Embryo at the Cleavage Stage (2nd and 3rd day)?

Embryos are evaluated for quality under the microscope 2 and 3 days after collection day. In this evaluation;

  • cleavage dynamics,
  • The difference in diameter between cells,
  • The proportions of dead parts in the embryo volume are checked and a quality is determined for each.

After this evaluation, the embryo is defined as 7/2a, 8/2ab. The ideal number of cells in embryos that have reached day 3 is 7 to 8 cells. In case of having less or more cells than this, the possibility of attachment to the uterus, that is, pregnancy, will decrease.

As a rule, in our clinic, we decide to follow the embryos up to the blastocyst stage in our patients who have 1 more quality embryo than the number of embryos to be transferred. The reason is that not every embryo can complete its development from the cleavage stage to the blastocyst stage. We can achieve higher pregnancy rates with embryo transfer that continues its development and has turned into a good quality blastocyst. For this reason, it provides us with the opportunity to choose the embryo, which will be more likely to attach to the uterus, with a more accurate decision.

In order to make all these evaluations, the embryos must be taken out of the incubator once a day and examined under the microscope in a short time. However, in time lapse incubators, which are a special type of incubator, the images taken inside the incubator can be evaluated on the computer screen after the embryos are lifted into the incubator once after microinjection, without ever being taken out.

For more detailed information on this subject, you can  review my Embryo Tracking Process  article.

However, it is vital that laboratory conditions and incubators have appropriate temperature, humidity and gas ratios so that embryos can be safely kept in the laboratory environment until the blastocyst stage. Because we know that in the presence of good laboratory conditions, if the embryo cannot reach the blastocyst stage, it will not be able to complete this development in the uterus. 

How is the quality of the embryo evaluated at the 5th day, that is, at the blastocyst stage?

The embryo, which reaches the 5th day, now has around 250-300 cells. In the embryo, the outer cell layer (trophectoderm) that will later form the placenta and the inner cell mass, which will form the baby, have begun to separate. For this reason, the number of individual cells can no longer be counted, and while embryos are classified from 1 to 5 according to their degree of enlargement, they are evaluated as A, B and C according to the appearance of the inner and outer cell layer. For this reason, definitions such as 4/AA, 4/AB, 5/AB, 4/BB are used when talking about embryo quality at the blastocyst stage.

Which embryos are considered good quality on day 5?

After the 5th day evaluation, embryos of 3-4-5, A and B quality are evaluated as good quality. Since the pregnancy rates will be very low with the transfer of embryos in the developmental stages before the 3rd, we prefer not to transfer those embryos on the 5th day, but to follow them in the laboratory for 1 more day and then freeze them on the 6th day if they reach the appropriate quality. Because the last day to transfer is the 5th day, we do not transfer on the 6th day.

Therefore, when the 5th or 6th day is evaluated, we accept the embryos that we define as 3,4 or 5 and A and B as good quality.


4- Embryo Transfer?

2 days after the egg retrieval day, we transfer embryos on the 5th day, that is, in the blastocyst stage, in patients with the appropriate quality and number of embryos according to the existing embryo quality, and on the 3rd day, in the cleavage stage, in patients who have a small number of embryos and therefore do not have a choice.

With embryos in the blastocyst process, that is, transplanting 5 days after collection, the chance of pregnancy increases compared to the 3rd day transfer. Because some embryos cannot continue their development in the 3 to 5 stages and are naturally eliminated. Thus, the embryo with a high chance of attachment to the uterus can be selected with higher accuracy. Of course, it should not be forgotten that the embryo can be followed up to the 5th day in the laboratory, only in the presence of appropriate laboratory conditions.

You can read more detailed information on this subject by reading ‘Microinjection and Embryo Tracking’.

In our clinic, we also transfer on the 5th day in 70-75% of our freshly transferred patients.

Embryo transfer is done by constricting urine. Because when the bladder is full, the inclination of the uterus is corrected and thus, it is possible to see clearly from the abdomen with ultrasonography, and it can be transferred much more easily. Stages of embryo transfer process;

  1.  In order to perform embryo transfer, an examination instrument (speculum) is placed in the vagina and the cervix is ​​cleaned with sterile liquid.  
  2.  Then, firstly, the entry route into the uterus is mapped with an empty trial catheter.
  3.  Afterwards, the embryo-loaded transfer catheter is passed through the cervix and the embryos are transferred into the uterus.
  4.  During the procedure, the uterus is observed by ultrasonography of the abdomen and the place where the embryos will be placed is clearly seen and decided. 

How is it decided how many embryos to transfer?

In accordance with the Regulation on Assisted Reproductive Treatment Practices and Assisted Reproductive Treatment Centers, the number of embryos to be transferred is restricted. In this context, while single embryo transplantation is allowed in the first 2 applications in women under 35 years of age, 2 embryos can be transferred from the 3rd attempt under 35 years of age, or in all trials if the female age is over 35 years old.

How many minutes does the embryo transfer process take, is there any pain during the transfer?

The embryo transfer process takes approximately 2-3 minutes and pain is not felt during the transfer. After the transfer process is completed, our patient is taken to his room on a stretcher and can leave our clinic after resting for 30-45 minutes. Our patient can go to the toilet 10-15 minutes after the transfer or urinate on disposable sliders in bed. 

What should be considered after embryo transfer?

After embryo transfer  , some supportive drugs that increase the chance of the embryo attaching to the uterus should be used, and these drugs may vary according to the drug protocol and treatment method we apply to the couple. Our nurses will inform you about which drugs you should use and for how long.

There is no harm in traveling after embryo transfer. Our patients coming from outside of Ankara can return to their homes on the same day if they wish. Traveling by road or air does not have an advantage over each other.

Although there is no direct relationship between physical activity and the chance of embryo attachment after embryo transfer, we still recommend our patients to rest at home for the first 2-3 days and to restrict physical activity. After 3 days, you can return to daily life. We recommend that you rest as much as possible and not work if possible until the day of the pregnancy test.

How should it be fed after embryo transfer?

There is no special diet after embryo transfer, but it has been reported that a diet that is mainly Mediterranean cuisine, that is, vegetable oils, fruits, vegetables and fish, has some positive effect on pregnancy rates. 

At the same time, it is important to consume seasonal fruits and vegetables, not to consume foods with long shelf life, additives, and not to use cigarettes and alcohol.

5- IVF Treatment Pregnancy test

The last step in IVF treatment  is to determine the presence of pregnancy by performing a blood pregnancy test.

When is a pregnancy test done after IVF treatment?

In IVF treatment, we detect the presence of pregnancy by performing a blood pregnancy test 14 days after egg collection. In frozen embryo transfers, we recommend performing a blood pregnancy test 9 days after embryo transfer at the blastocyst stage and 14 days after the cleavage stage (3rd day) embryo transfer.

We consider the first pregnancy test value to be above 30 miu/ml positive, and we plan the first pregnancy control to coincide 7-10 after the last blood value, after following its rise in the blood several times with an interval of 2 days.

Will there be an ectopic pregnancy after IVF treatment?

Ectopic pregnancy can develop around 1.5-1.8% after fresh applications and around 1% after frozen embryo transfers. 8.9

6- Embryo Freezing

Except for those transferred, the embryos can be frozen and stored in couples with good quality embryos. In our clinic, we prefer to freeze embryos with the vitrification technique on the 5th or 6th day, almost always on the 5th or 6th day in suitable conditions, since the survival rates are higher after thawing and the chance of pregnancy increases.

Who is embryo freezing for?

Couples who can freeze embryos;

  1. In couples with good quality embryos other than embryos transplanted after embryo transfer,
  2. In the presence of polycystic ovary syndrome  , that is, in patients with good ovarian response after stimulation, to avoid the risk of overstimulation syndrome (OHSS),
  3. In couples who are found to have a problem with the uterus or tubes during ovarian stimulation (myoma uteri, endometrial polyp, hydrosalpenx, etc.) and it is decided not to make a fresh transfer,
  4. In couples whose embryos were biopsied within the scope of preimplantation genetic diagnosis (PGT-M) or screening (PGT-A & SR),
  5. In couples who are planned to freeze embryos within the scope of fertility preservation approach, and
  6. In the same month, dual stimulation, namely Dual Stimulation, can be applied to the planned couples.

Embryo freezing can be applied to which quality embryos?

We can freeze embryos at the blastocyst stage, that is, those that have reached the 5th or 6th day, with expansion level of 3,4,5 and inner and outer cell layers of A or B quality. Since the chance of pregnancy after thawing will be close to none, we do not freeze the blasts at the stage before 3 and the blasts with inner and outer cell quality C.

Although rare, we can freeze embryos on the 3rd day, that is, at the cleavage stage, in couples with a low number of embryos and whom we will not go for blastocyst follow-up.


What technique is embryo freezing done?

Embryos can be frozen by slow freezing technique or vitrification method. In our center, we use the latest technology vitrification method because the results are much better.

What is the vitrification method?

The vitrification method is a method that allows embryos to be stored by freezing. In this technique, while freezing the embryos, the temperature is quickly reduced with the freezing solutions used specifically, and the liquid in the embryo is allowed to come out and the freezing solution is replaced. Then the embryos are lifted into liquid nitrogen tanks at -196 0C. The process is completed in approximately 3-4 minutes.

Its advantage over the slow freezing method is that the freezing process time is much shorter and the survival rate in blastocyst stage embryos after thawing is around 98-99%.

What is the chance of success with frozen embryo transfers?

With the thawing of frozen embryos at the blastocyst stage, survival rates are around 98-99%, and pregnancy rates close to fresh application can be obtained at least. Especially under the age of 30, pregnancy rates are around 60%.

Are pregnancies obtained after frozen embryo transfer safe?

In pregnancies obtained after thawing frozen embryos, the risk of major and minor anomaly in the baby is at the same rate as the babies born from pregnancies obtained by spontaneous or fresh application in IVF. However, birth weight may be slightly higher in babies born after transplantation of frozen embryos.

How long can frozen embryos be stored?

In accordance with the Regulation on Assisted Reproductive Treatment Practices and Assisted Reproductive Treatment Centers, embryos can be stored for 5 years if the couple allows the embryos to be stored frozen each year. At the end of 5 years, if the couple wishes, it can be kept for an additional 5 years after the approval of the Ministry of Health.


What preparation protocols are used for frozen embryo transplant?

For the transfer of frozen embryos, the uterus must first be made suitable for transfer. There are 3 different preparation protocols we use for this purpose. However, there is no significant difference between the protocols in terms of pregnancy rates. The preparation protocols we use for this purpose;

1-) Hormone replacement therapies (HRT);

It is made ready for intrauterine transfer with the support of estrogen starting from menstruation and then added progesterone. It is the most frequently preferred preparation protocol because it can be completed with a small number of follow-ups and is easy to apply. We prefer this protocol especially in the presence of menstrual irregularity and in patients who will come from outside the city for transfer.

2-) Natural cycle preparation protocols;

It is based on the principle of determining the time of ovulation by following the naturally developing follicle of the person. For this reason, it is necessary for our patient to have regular menstruation in order to perform the natural cycle protocol. The advantage of this protocol is that there is no need to use any preparation and supplementary medication. However, the disadvantage is that frequent ultrasonography and blood tests are required for the detection of ovulation in days. For this reason, we generally prefer to apply it to our patients living in Ankara.

3-) Minimally stimulated preparation protocol;

We can apply this protocol in patients who have menstrual irregularity and cannot apply the HRT protocol due to various medical problems. For this purpose, egg development is ensured with pills or low-dose gonadotropin-derived drugs, and when the follicle reaches a sufficient size, the transfer time is determined after the use of cracking needles.

Why is the chance of success in IVF is not the same for every couple?

The chance of success in IVF treatment varies according to the individual characteristics of the couple.  Factors that may affect the success of treatment in IVF ;

  • One of the most important factors is the age of the woman. If the woman’s age is 38, especially over 40, the probability of the eggs produced to be chromosomally problematic, that is, unhealthy, increases. Accordingly, the risk of miscarriage and loss of pregnancy, which occurs with the possibility of becoming pregnant, increases and the possibility of live birth decreases. At the same time, the risk of unhealthy babies with chromosomal anomalies increases. In other words, as the woman’s age progresses, the chance of pregnancy with embryo transfer of similar quality decreases compared to younger women.

Our upper age limit for IVF treatment  is 45 years, since there is almost no chance of a live birth afterwards.

  • Ovarian reserve; The number of eggs in the ovaries, that is, the multiple egg development capacity that a woman will give to ovarian stimulation, we call the ovarian reserve. If the ovarian reserve is good, the number of embryos to be obtained during IVF treatment will increase, and in addition to the transferred embryo, the probability of obtaining embryos of quality to be frozen will increase. At the same time, the increase in our probability of transferring embryos at the blastocyst stage, that is, on the 5th day, will offer the chance to choose the best embryo and increase pregnancy rates. For this reason, the chance of success in IVF is negatively affected in proportion to the severity of the low ovarian reserve, and the risk of not reaching the transfer in the treatment, in other words, the cancellation risk increases. However, the adhesion rate of the obtained embryo will be close to women with similar characteristics who have good reserves. 
  • Embryo transfer day;  The fact that embryo transfer is performed at the blastocyst stage, that is, on the 5th day, increases the chance of pregnancy even more compared to the 3rd day, that is, the cleavage stage. Because with embryo transfer at the blastocyst stage, we can select the embryo with a higher probability of attachment to the uterus with higher accuracy. However, of course, if there is no choice, embryo transfer can be done on the 3rd day, and we have many patients who became pregnant in this way.
  • Embryo quality;  The quality of the embryo to be transferred is an important factor in terms of pregnancy rates. The chance of pregnancy will be higher with 3,4,5 and A or B quality embryos in transfers at the blastocyst stage and with clean embryos with 7 and 8 cells on Day 3 in transfers at the cleavage stage.
  • Factors that have a negative effect on IVF success;
    • Hydrosalpenx: In  the presence of obstruction in the tubes and a fluid-filled tube (hydrosalpenx), the fluid in the tube may drain into the uterus, reducing the chance of embryo attachment and increasing the risk of ectopic pregnancy and miscarriage in the pregnancy that occurs. Therefore, embryo transfer after tube removal in the presence of hydrosalpenx will increase the probability of pregnancy. 
    • Recurrent IVF failure;  As the number of previous unsuccessful attempts increases, the probability of conceiving with a new application may decrease, especially after 3 unsuccessful attempts. In couples with recurrent IVF failure, it can be planned to make sure that there is no problem especially in the tubes, that there is no pathology related to the uterus, and that chromosome analysis is performed when necessary.
    • Uterine factors;  In the presence of thinness of the inner wall of the uterus, adhesions in the uterus, polyps or myoma uteri pressing into the uterus, pregnancy results will be adversely affected after IVF treatment.
    • Smoking:  In case of heavy smoking, the number of eggs to be obtained as a result of in vitro fertilization will decrease as well as the general health harms of smoking. For this reason, we recommend our patients who will start IVF treatment to quit smoking.
    • Obesity:  In case of excess weight, even with IVF treatment, the results may be adversely affected. In fact, in a study, when 500,000 IVF cycles were evaluated, it was found that the probability of pregnancy after IVF treatment decreased by 6% and the probability of live birth by 13% in women with excess weight at the obesity limit.

IVF Treatment Prices

The way we will choose IVF treatment prices  , the treatment process we will apply is completely planned according to the individual characteristics of the couple. For this reason, some couples can be transferred in the month of induction, while in some couples we freeze the embryos obtained and then plan the transfer with the application of freeze-thaw. In addition, the need for preimplantation genetic diagnosis may arise in couples with advanced female age or a family history of genetic disease. For this reason  , pricing in IVF treatment  will be given to you by our team after the first evaluation. However, before you come to our center, you can also be informed by phone about an approximate price, depending on your situation, while talking to my assistant by phone.

IVF Treatment in the Presence of Male Infertility-Azospermia

Azoospermia is the condition where there is no sperm in a man’s ejaculate (semen). While it is seen with a probability of 1% among men in the general population, it can be detected with a probability of 10-15% in the evaluation made in couples who cannot conceive spontaneously. 

In order for a man to be diagnosed with azoospermia, the absence of sperm must be detected in the sperm analysis performed twice, at least 4-6 weeks apart, during the period of sexual abstinence for 2 to 6 days.

In particular, in cases with very few sperm in the semen, that is, in cryptospermia cases, since a single number of sperm cannot be seen directly by examination, but can be seen by checking the sample after centrifugation, it is vital to perform the analysis in an experienced way in the in vitro fertilization laboratory in order to distinguish between azoospermia and cryptospermia. will be. Because the small number of sperm detected in this way can be used during IVF treatment and biopsy may not be necessary to obtain sperm from the man. 

It would be appropriate to examine azoospermia cases under 2 main headings;

Azoospermia (Obstructive Azoospermia) Developing Due to Obstruction in Sperm Carrier Channels

There is no problem in sperm production in the testis. However, there is a problem in the collecting ducts that the sperm travels from the testicles to the discharge during ejaculation. Conditions that can cause problems in the sperm carrier channels:

  1. past infections,
  2. Trauma to the testicles,
  3. previous surgeries or
  4. Congenital absence of sperm carrier channels.

Generally, the success of surgical correction in these cases is very limited. However  , within the scope of IVF treatment  , sperm can be obtained effectively by drawing fluid from the ducts (epididymis) or testicles with an injector (PESA/TESA), and fertilization and pregnancy can be achieved at rates close to ejaculate sperm. 

It is important to detect the absence of congenital vas deferens ducts in cases with obstructive azoospermia. Because in some of these cases, cystic fibrosis, which is also common in Turkey, can be a disease or carrier. In terms of the presence of this disease, which can give symptoms of severe lung disease, the man and, if necessary, the woman should be advised to examine for the presence of a cystic fibrosis mutation. If a mutation is detected in the same region in the spouses, the risk of developing cystic fibrosis in their babies may be around 25%, and in this case, Preimplantation Genetic Diagnosis (PGD-M) may be required.

You can find detailed information  in my Preimplantation Genetic Diagnosis (PGD-M)  article.

In cases of obstructive azoospermia, we prefer to perform the procedure on the day of egg collection, since the probability of sperm being found in the fluid drawn from the canals with an injector (PESA, TESA) is almost 100%. Fertilization and pregnancy rates with sperm taken in this way are almost close to semen sperm. 

Azoospermia (Non-Obstructive Azoospermia) Developing Due to Production Insufficiency in Testes

 In these cases, there is insufficient sperm production from the testicles. Non-obstructive causes of azoospermia;

1-) The presence of a genetic problem that will prevent sperm production in the testis;

The most common cause is Klinefelter syndrome, and these men have a 47,XXY chromosome arrangement. More rarely, there may be deficiencies in the regions responsible for sperm production on the Y chromosome (AZF regions a, b, c) or in the presence of translocations that lead to breakage and displacement in the chromosomes.

In these patients with azoospermia, structural or numerical abnormalities can be seen in the chromosomes with a probability of 10-15%. The most common of these problems is Klinefelter Syndrome. In men with Klinefelter Syndrome, the chromosome sequence is 47,XXY. However, in these cases, 55-57% sperm can be obtained by performing TESE (micro-TESE) under microscope, and pregnancy can be achieved with in vitro fertilization treatment. We published our experience and results, which includes the 3rd largest series in the world, in a prestigious international journal years ago. 

In addition, after the chromosome analysis performed in these patients, breakage and displacement, that is, translocation, can be detected in the chromosomes. After such a diagnosis, in these cases, in addition to in vitro fertilization,  Preimplantation Genetic Screening  (PGT-SR) will be required. 

It will also be important to examine the presence of loss in the AZF-a, b and c regions of the Y chromosome, especially in cases with deletions in the AZF-a and b regions, to determine that the probability of obtaining sperm even with the micro-TESE method is close to none and to inform the couple. 

2-) Hypogonadotropic hypogonadism ; Due to the insufficiency of the hormones (GnRH, FSH and LH) secreted from the hypothalamus and pituitary gland in the brain, there is insufficient production of sperm and testosterone from the testicles. This condition is found in 2-5% of patients with non-obstructive azoospermia. 

In cases with hypogonadotropic hypogonadism, drug therapy may have a stimulating effect on sperm production. In this way, with sperm throwing into the semen, treatment with semen sperm can be provided without the need to obtain sperm surgically in IVF treatment. In some patients, it is possible to reach normal sperm count and motility and to achieve spontaneous pregnancy.

3-) Endocrine and metabolic diseases;  In the presence of prolactin-secreting pituitary adenoma, sperm production may be adversely affected, or in the presence of diabetes mellitus, sperm may flow into the urinary bladder due to backward ejaculation.

4-) Insufficient sperm production in the testicular tissue:  It is the situation where there is no sperm production due to insufficiency in the testicular tissue, although no cause can be determined.

Except for the rare cases of hypogonadotropic hypogonadism mentioned above, externally administered various hormone-containing drugs, vitamins, antioxidants and operations do not have any effect on increasing sperm production or increasing the probability of obtaining sperm after biopsy (TESE) procedure. In the presence of non-obstructive azoospermia, micro-TESE is the only way to obtain sperm.


Micro-TESE

Micro-TESE is the method of examining the testicles (man’s balls) under a microscope and then taking millimeter-sized pieces from both testicles and evaluating them for the presence of sperm. At the time of the procedure, it is always under local anesthesia and takes between 30-45 minutes. After 1 hour of rest after the procedure, our patient can leave our clinic. 

In the presence of non-obstructive type (non-obstructive) azoospermia, both testicles are evaluated in detail under the microscope, and millimeter-sized samples are taken from multiple points and examined by our embryologist in the laboratory. At this point, we perform the micro-TESE procedure one day before the egg collection day, since it is important to have enough time to scan the collected tissues sufficiently and to avoid unnecessary egg collection in case no sperm can be found.

Especially in terms of increasing the probability of finding sperm after Micro-TESE, the experience of the urologist who performs the procedure, and the fact that sperm production can sometimes only exist in a small part of the testis, will be examined with a microscope and a sample will be taken from the place where there is a high probability of sperm retrieval, which will increase the chance of success. For this reason, the professional experience of the person performing the procedure and his experience in this field are vital. In an experienced hand, the sperm retrieval rate can be around 50-55% after the first micro-TESE procedure.

How Long Does the TESE Procedure Take? What Should Be Considered After?

The TESE process takes approximately 30-40 minutes. Afterwards, our patient can leave after resting in our clinic for a while.

The TESE procedure does not cause any complaints other than mild pain for a few days. There is no need to use drugs other than the use of painkillers and antibiotics recommended by our urologist.

Why is TESE done after the spouse’s eggs are grown, although there is a possibility that no sperm will come out?

Since the sperm obtained by the micro-TESE method is few in number, we want to use it fresh, and loss may occur after freezing-thawing, we  almost always prefer to perform the micro-TESE procedure one day before the egg collection day by stimulating the ovaries of the woman in azoospermia  cases. With the micro-TESE application, we can obtain 50-55% sperm. I would like to remind you that only matured sperms that have completed all developmental stages can be used for microinjection. If sperm can be obtained once, the chance of finding sperm increases up to 90% in repeated TESE applications.

Unfortunately, we do not recommend retrying if sperm cannot be found after the micro-TESE procedure performed by sampling from multiple points in a good hand. However, if a single point biopsy was taken and it was not performed under microscope, a retry may be recommended. 

TREATMENT IN THE PRESENCE OF POLYCYSTIC OVER SYNDROME (PCOS)

Polycystic ovary syndrome (PCOS) is a hormonal disorder frequently seen in women of reproductive age. It is a complex genetic disease and the reason why it develops is not known exactly. Although its incidence varies according to the diagnostic criteria used, it is around 8-13% on average (13). However, it is more likely to be seen in people who have trouble conceiving, who are overweight, have insulin resistance or diabetes, whose body hair started at an early age, and whose close relatives have PCOS.

How is Polycystic Ovary Syndrome (PCOS) Diagnosed?

If 2 of the 3 findings below are present, we diagnose our patient as  PCOS  . 

  • Menstrual irregularity (usually 6-8 or fewer periods per year); It is often seen from adolescence. In the majority of patients, menstrual irregularity may be in the form of infrequent menstruation, while in some, it may be in the form of non-medication. However, this is not the rule. Some patients may have regular periods.
  • Elevated masculinity (Androgen) hormone levels; As a clinical reflection, increase in male pattern hair growth (above the lips, chin, nipples, thighs and arms, back and waist), intense hair loss, acne can be seen or only high androgen hormone (testosterone, DHEAS, androstenadione) levels in the blood can be detected. 
  • Polycystic ovary image; In the past, it was accepted that more than 12 egg sacs (antral follicles) of 2-9 mm in size were seen in both ovaries in the ultrasonographic evaluation. However, today, this number has been updated as more than 20 egg sacs for each 2 ovaries, thanks to highly sensitive ultrasonography devices. 

What are the risks that a woman may face in terms of health in polycystic ovary syndrome?

A woman diagnosed with Polycystic Ovary Syndrome faces  some risks throughout her life. In this context, if we talk about the increasing risks;

  • Overweight and increased risk of diabetes: Approximately half of the patients are overweight. Insulin resistance and hyperinsulinism are observed in most of the patients, regardless of excess weight. Weight loss and, if necessary, drug therapy can be considered in those with insulin resistance. At the same time, the risk of developing type 2 diabetes increases throughout life in the presence of PCOS. 
  • Elevated cholesterol levels: The risk of elevated blood lipid levels is high in PCOS patients. In addition, if the woman has insulin resistance or diabetes, the risk of developing coronary heart disease is also increased. 
  • Depression and anxiety: An increase in the frequency of depression and anxiety and an increase in the likelihood of eating disorders have also been reported in the presence of PCOS. 
  • Menstrual irregularity: The risk of thickening (hyperplasia) or cancer in the inner wall of the uterus may increase in women who have menstrual irregularity, i.e., menstrual intervals are every 3-4 months or less, and the regularity is not maintained by medical treatment, or is neglected. 
  • Difficulty conceiving (infertility): Women who have irregular menstrual cycles and do not ovulate spontaneously may have trouble conceiving.

How Should the Treatment Be in the Presence of Polycystic Ovary Syndrome?

In the presence of PCOS, it is necessary to plan the treatment approach according to whether there is a desire for pregnancy or not.

Treatment in the period without a pregnancy plan;

  • Regulation of lifestyle: The primary goal in PCOS patients should be regulation of lifestyle. For this purpose, regulating nutrition, increasing carbohydrate-poor diet and exercise and achieving weight loss may eliminate menstrual irregularity and ensure regular menstruation in some patients. Even losing 5-10% of body weight can be beneficial for regulating menstruation. At the same time, weight loss will contribute to the improvement of insulin resistance and blood lipid values ​​to be in the normal range. 
  • Ensuring menstrual regularity: The use of combined birth control pills can be considered in order to prevent the development of new hairs, reduce oily skin and acne complaints, regulate menstruation, and prevent pregnancy in cases with regular menstruation, especially in patients with increased body hair growth.

The use of cyclic progesterone to protect the inner wall of the uterus can also be considered in cases with irregular menstruation and who do not want to use the contraceptive pill. In this respect, it is recommended to use drugs for 10-14 days every 2 months. However, this treatment will not benefit the hair growth and acne problem. 

  • Prevention of hair growth: In terms of excess hair growth, the use of antiandrogenic drugs can also be considered in patients who do not benefit from using birth control pills for 6 months or who do not want to use birth control pills. However, if this treatment is to be applied, it should be reminded that pregnancy should be avoided absolutely. It should also be recommended to use epilation methods to remove existing hairs. Because these treatments prevent the growth of new hairs, but epilation methods should be applied to remove existing hairs.
  • Insulin resistance treatment: Appropriate treatment should be initiated, when necessary, with the support of an endocrinologist.

During the pregnancy plan:

Thanks to the video below, you can get more detailed information about Polycystic Ovary Syndrome.

https://www.youtube.com/embed/vfwR5xtzThA

  • Regulation of life style: Our first step recommendation for those who are overweight and have menstrual irregularity due to lack of ovulation is to implement a diet and exercise program that will provide weight loss. In many patients, 5-10% weight loss can improve ovarian function and also contributes positively to insulin resistance and blood lipid levels. In other words, even losing 4-7 kilos for a woman who is 70 kilos can cause spontaneous ovulation.
  • Ovulation treatment: In PCOS patients, if there is no additional reason for not being able to conceive and the spouse’s sperm values ​​are normal, the first-line treatment is ovulation replacement drug treatments. Ovulation can be achieved with these drugs, which are used in pill form for only 5 days each month. These drugs are easy to use and inexpensive. Ultrasonography follow-up is not required during use. Approximately 30-40% of patients can achieve pregnancy after 6 months of use at the dose at which ovulation is achieved. However, in case of excess weight, resistance to these drugs may occur and no response may be obtained.
  • Second-line treatment: If there is no additional reason for not being able to conceive and the spouse’s sperm values ​​are normal, if there is no response or failure to the pill treatment, low-dose daily injection treatments, which are used daily, can be tried as the second-line treatment. In order to stimulate ovulation, using drugs called gonadotropins in very low daily doses, 1 or 2 egg sacs, namely follicles, are enlarged. When the follicles reach the desired size, a cracking needle is applied. With this method, ovulation can be achieved in 95% of patients. Pregnancy rates are around 23-25% when vaccination is done together. In cases where pregnancy cannot be achieved despite 2 or 3 attempts, IVF treatment should be started in patients.
  • Ovarian drilling process: In the past, in patients who did not respond to ovulation treatment with pills, ovarian drilling was commonly performed to reduce male hormone production by making holes in the ovary with the effect of heat by laparoscopic method. Thus, spontaneous ovulation could be achieved in some patients with the decrease in male hormone levels produced. However, nowadays, this procedure has been avoided due to the fact that it is a surgical procedure, it can cause adhesions in the abdomen, the unresponsiveness with the new generation pill treatment is close to nothing, and the existence of effective daily injection treatment options.  
  • In vitro fertilization treatment: In vitro fertilization treatment can be performed when there is no response to the first 2 steps of treatment, or if there is an additional reason for not being able to conceive of a woman or a man. In vitro fertilization is the treatment method with the highest chance of pregnancy and the chance of pregnancy is much higher in these patients compared to women without polycystic ovary syndrome. Because more eggs can be obtained than their peers and the possibility of blastocyst transfer, that is, the 5th day transfer, increases, it is possible to choose the best embryos on the day of transplantation. In addition, since a large number of embryos of good quality can be obtained, it is also possible to store the embryos other than the transferred embryos by freezing with the rapid freezing technique, that is, the vitrification method. With IVF treatment,

Considerations While Performing IVF Treatment in the Presence of PCOS

In particular,   it is vital to determine the appropriate drug dose during ovarian stimulation in IVF . Because PCOS patients have much more egg cells (Antral Follicle) than other women, there is a high risk of excess response. In addition, if there is excess weight, it may be necessary to increase the dose of the drug in order to get an adequate response. The dose range in which unresponsive and excessive response is obtained in PCOS patients is quite narrow. Therefore, the experience of the physician is very important, especially in this group of patients.

In addition, in cases with more than 18 egg sacs with a size greater than 11 mm on the day of the cracking needle, freezing of all embryos obtained that month and not fresh transfer should be recommended to avoid the risk of overstimulation syndrome (OHSS). 

While performing IVF treatment in PCOS patients;

  • Choosing the appropriate drug protocol for ovarian stimulation,
  • Adjusting the drug doses used according to the patient,
  • Proper selection of the cracker needle type and
  • It is very important to minimize the risk of overstimulation syndrome (OHSS).

Preimplantation Genetic Screening-PGT-A

One of the most important determinants of pregnancy, whether spontaneously or with assistance, is the age of the woman. A woman’s age is important in terms of both ovarian reserve and egg quality. When a girl is born, she is born with a fixed number of egg cells in her ovary and there is no chance of producing new eggs throughout her life. From puberty to menopause, there is always a consumption of that fixed number every month, and therefore, as age progresses, the number of eggs decreases and in addition, the risk of producing eggs with missing or excess chromosome content increases.

Why is it harder to conceive and the risk of having a baby with anomaly increases as a woman gets older?

As women get older, the time taken to get pregnant is getting longer, and the risk of resulting pregnancy in miscarriage increases. The most important reason for this situation is the increase in the incidence of abnormalities such as deficiency or excess in chromosomes, which are our building blocks, in the eggs produced as we age. This makes it difficult to become pregnant, and also leads to an increased risk of miscarriage in an existing pregnancy or an increased risk of having a baby with anomaly. While the probability of chromosomal problems in the embryos formed in women aged 26-29 is around 20-25%, this rate rises to 80-90% in the age group of 44-45.

Thanks to the PGD method  , a cell sample is taken from the embryo obtained by in vitro fertilization before it is transferred to the uterus, and a cell sample can be taken to evaluate whether it is chromosomally healthy.

What are the steps of PGT-A application?

To briefly mention the steps of PGT-A application;

  • First of all, the woman’s eggs are enlarged with the appropriate drug treatment scheme.
  • When the egg sacs reach the appropriate size, a cracking needle is applied and the eggs are collected under light anesthesia.
  • Microinjection (ICSI) is performed by injecting 1 sperm into each mature egg and fertilization status is recorded the next day.
  • Embryos in the blastocyst stage (which has reached the 5th or 6th day) are biopsied from the part that will form the baby’s mate (trophoectoderm) and the embryos are frozen one by one.
  • Cell samples taken from the embryo are sent to the genetics laboratory and screened for all the chromosomes that are our building blocks (22 pairs of somatic plus X and Y sex chromosomes).
  • According to the PGT-A result, if an embryo that is evaluated as chromosomally normal is found, the transfer of the healthy embryo is planned by performing freeze-thaw application. 

Is it not possible to understand whether the embryo is healthy or not without a biopsy?

We know very clearly that even embryos that are considered to be of very high quality in the laboratory can be detected as chromosomally problematic. In other words, the shape of the embryo being very smooth is not an indication that it is chromosomally healthy. For this reason, as the age of IVF application increases, the chance of getting pregnant decreases despite good quality embryo transplantation and the risk of resulting pregnancy with miscarriage or loss of a baby with anomaly increases. 

What is the chance of success after PGT-A application?

After PGT-A, if an embryo with a healthy chromosome sequence is detected, with a single embryo transfer, female age loses its importance and a pregnancy chance of 70-74% can be obtained regardless of age. At the same time, the risk of miscarriage, which increases with the age of the woman, decreases dramatically in pregnancies obtained by the PGT-A method. Because, the basis of the increased risk of miscarriage as women get older is the presence of chromosomally problematic embryos. While the risk of loss is around 40% in pregnancies obtained beyond the age of 38, this rate rises to 60-70% in the 43-44 age group. However, in pregnancies obtained by PGT-A method, the risk of miscarriage decreases to 8-10% in all age groups.

As a result, live birth rates are around 55-60% even in the 42-45 age range. However, it should not be forgotten that the PGT-A method is used to determine the current chromosomal status in the embryo. It has no corrective effect on the embryo.

In the past, biopsy was performed on embryos on the 3rd day for this purpose, whereas in recent years it is now performed at the blastocyst stage (5th or 6th day). Advantages of biopsy at the blastocyst stage;

  1. While the embryo has ideally 7 to 8 cells on the 3rd day, when it reaches the blastocyst stage, it has more than 250 cells, and the inner cell layer, which will form the baby, and the outer cell layer (trophectoderm), which will form the baby’s mate, are differentiated. Thus, while a single cell can be taken in the 3rd day biopsy, 3-4 cells can be taken from the outer cell layer without touching the inner cell layer that will form the baby in the biopsy at the blastocyst stage. In this way, sampling is made from a smaller volumetric part of the embryo and examination is made from 3-5 cell samples instead of one.  
  2. When biopsy is performed on the 3rd day, only certain chromosomes are examined, while all chromosomes can be evaluated in detail by performing a biopsy at the blastocyst stage.
  3. There are studies showing that the probability of pregnancy with transfer after the 3rd day biopsy is lower than the embryos without biopsy. Biopsy at the blastocyst stage does not have any negative effect on the adherence of the embryo.

In other words, with the PGT-A Method;

  • The chance of pregnancy at the age of 38 and beyond (between 38-45 years) goes up to 70-74% with a single healthy embryo transfer,
  • The risk of losing the resulting pregnancy by miscarriage regresses to 8-10%,
  • Multiple pregnancy and pregnancy with anomalies are protected. 

For this reason, we recommend the PGT-A method in addition to IVF treatment in our patients whose female age is 38 years and older. The PGT-A method can also be applied in couples with recurrent pregnancy loss or recurrent IVF failure, although its effectiveness is controversial.

GENETIC DIAGNOSIS IN EMBRYO (PGT-M)

Preimplantation Genetic Diagnosis (PGD) is based  on revealing the structural and numerical disorders of the chromosomes (PGT-SR) or recognizing the diseases known to exist and inherited through a single gene (PGT-M) before the embryo is transferred to the uterus. For this purpose, when they reach the blastocyst stage from embryos obtained after in vitro fertilization treatment applied to the couple, cell samples are taken from the outer cell layer (trophectoderm) and the embryos are frozen and stored. After the examinations required by the existing medical condition (an anomaly in chromosomes, a detected genetic disease, etc.) in the cell samples taken are performed, the embryo, which is reported as healthy, is transferred into the uterus. Preimplantation Genetic Screening  , screening for all chromosomes in addition to embryos We recommend doing it. 

Genetic diseases for which PGT-M can be performed;

  • thalassemia,
  • metabolic diseases,
  • Duchenne muscular dystrophy and some other muscle diseases,
  • Cystic fibrosis,
  • Spinal muscular atrophy (SMA)
  • sickle cell anemia,
  • Tay sachs disease
  • hemophilia and
  • HLA compatible embryo selection is required for bone marrow transplantation.

In couples who will undergo PGT-M for the diagnosis of genetic disease, as a first step, the region of the change in the gene that is known in the family and causing the genetic disease is determined, and then the couple undergoes in vitro fertilization and the biopsy process begins from the embryos obtained by going through the legs mentioned above in the PGT-A application. The number of single gene diseases that can be diagnosed with PGT-M is increasing day by day.

PGT-M process can be applied in 3 different ways;

1. Polar body analysis from egg cell,


2. Analysis made by taking a cell from the 3rd day embryo in the cleavage stage,


3. Analysis of 3-5 cells taken from the trophectoderm part of the embryo that has reached the fifth or 6th day, which will form the baby’s mate. It is recommended to take a cell sample at the blastocyst stage and examine it. 

Today, it is learned from studies conducted on a large number of patients that the analysis performed by taking a single cell from the 3rd day embryo for PGD can be harmful to the embryo. It also has a negative effect on pregnancy rates.

PGT performed with cells taken from the trophectoderm tissue of the embryo, which has reached the 5th or 6th day, seems to be more advantageous because it gives the opportunity to work with a larger number of cells (3-5 cells). In addition, it is thought to have less harmful effects on the embryo, as in the 3rd day embryo biopsy. Since it provides the opportunity to take more cells instead of a single cell, it is possible to work on more materials and the risk of not being diagnosed is eliminated. However, of course, the laboratory conditions, the presence of competent personnel in the field of embryo biopsy and embryo freezing-thawing are critical for the application of this method. We are also in our clinic 5./6. We prefer to take a biopsy from the embryo and perform PGD.

With the rapid advances in the field of genetic engineering, the repair of problematic genes will be possible in the very near future. Although the determination of the entire genetic structure at the embryo level and the replacement of diseased genes seems like science fiction today, it seems likely that these will happen in the future. These practices also have an ethical dimension that cannot be ignored. For this reason, it is very important to examine the ethical dimensions in detail.


Vaccination Treatment

 

Vaccination treatment is the process of transferring concentrated and mobile sperm into the uterus by washing the sperm created by the man’s masturbation at the time of ovulation by the woman, clearing it from the immobile sperms and other cells. 

 

In order for the vaccination treatment (intrauterine insemination-IUI) to be performed, ovulation must be achieved, at least the presence of an open tube on one side and sufficient motile sperm must be obtained after washing. 

 

Which Couples Can Vaccination Treatment Be Applied to?

 

Vaccination treatment especially;

 

  • In couples with sexual dysfunction such as vaginismus in women or erectile dysfunction in men,
  • In the presence of polycystic ovary syndrome (PCOS) without spontaneous ovulation or hypogonadotropic hypogonadism, 
  • In couples who have unexplained difficulties in conceiving,
  • In those with mild endometriosis,
  • It can be applied to couples with mild sperm count or low motility. 

How to Provide Egg Development for Vaccination Treatment?

 

After ovulation, it is only the first 24 hours when the egg cell can be fertilized. Therefore, the timing of vaccination should be done accordingly. Vaccination treatment can be done after the woman’s self-development of the egg sac is followed up and then the ovulation is detected, or it can be done after the use of ovulation-stimulating pills or daily injections. Studies have shown that pregnancy rates are higher than other stimuli by providing egg sac development with daily injection and vaccination after cracking injection. However, ensuring the development of the egg sac with daily injection should be done carefully and the dose should be adjusted so that there is no development of more than one or 2 egg sacs. Excess egg sac development will create the risk of uncontrolled multiple pregnancy. 

 

How to Prepare Sperm for Vaccination?

 

On the day of vaccination , after 2-6 days of sexual abstinence, the man is asked to produce sperm by masturbation. Ideally, sperm should be produced in an isolated room in the center where sperm preparation and inoculation will take place.

 

During sperm production, no lubricants or chemicals should be used in terms of non-toxicity. The semen sample produced in a sterile container should be delivered to the biologist who will prepare it. During sperm washing and preparation, dead cells, prostate fluid, dormant cells and substances called prostaglandins in the semen are removed as they may cause contractions in the uterus or an allergic reaction in the woman. 

 

The two most commonly used methods for sperm preparation are ‘swim up’ and ‘density gradient centrifugation’ techniques. Although the studies show that they are not superior to each other in terms of pregnancy rates, we prefer to prepare sperm with the ‘density gradient centrifugation’ technique in our center because more motile sperm can be obtained.

 

In couples with more than 5-10 million motile sperm after washing, the chance of pregnancy is significantly higher than with less sperm. 

 

Is Vaccination a Difficult Process?

 

While the woman is coming for the vaccination process, being congested with urine will make it easier to pass through the cervix. After a speculum is placed in the vagina, the concentrated sperm drawn into a soft catheter is transferred into the uterus by following the catheter tip with abdominal ultrasonography. It is important not to touch the apex of the uterus (fundus) in order not to cause uterine contractions during the procedure. The process is completed in 2-3 minutes. After vaccination, there is no need to rest and normal life can be returned. In women with vaginismus, the vaccination process can also be performed under light anesthesia. 

 

What are the Chances of Pregnancy After Vaccination and How Many Times Should It Be Tried?

After vaccination, in couples who do not have a chance of pregnancy, ovulation problems and sexual dysfunction, and who do not have low sperm count and motility, around 17%, PCOS, etc., which causes ovulation problems. If it is applied to couples who cannot conceive due to discomfort or sexual dysfunction (in the presence of vaginismus or erectile dysfunction in men), it will be around 25%.

Vaccination treatment can be tried 3-4 times depending on the reason. 

When should a pregnancy test be done after vaccination treatment?

A blood pregnancy test should be done to see if pregnancy has occurred after vaccination. This amcal blood test should be done 14 days after the vaccination date. If the first blood test value is higher than 30 miu/ml, it is considered pregnancy. Then, the rise of the blood value is followed with an interval of 2 days and the first ultrasound is planned approximately 7-10 days after the last test.

Frequently asked Questions

1. When should couples who cannot conceive apply to an IVF center?

Couples who cannot conceive despite regular sexual intercourse should apply for examination and evaluation at the end of 1 year if the woman’s age is under 35, and at the end of 6 months if the age is 36 and over. However, if the woman has menstrual irregularity, a known negativity about the tubes, or if it is known that there is a contradiction in the sperm values ​​of the spouse, it would be correct to make the first evaluation without waiting for this period.

2.What should I pay attention to for the first application?

We recommend that you set your appointment in advance when you come for the first examination and evaluation. You do not need to make a special timing regarding your period when making an appointment. You can make an appointment on any day you want (except Sunday). We recommend that you bring all your previous examination results with you, if available.

After this initial evaluation, we can choose the treatment method that is suitable for the couple and make a special treatment plan for the couple. Because with individualized treatments, the chance of pregnancy is higher.

3- Is it obligatory to have IVF for every couple who cannot conceive?

Couples who cannot conceive are evaluated in terms of detailed history, physical examination, ovarian reserve, and the presence of a possible disease that may prevent pregnancy. After this evaluation, treatment options such as ovulation stimulating pill treatment and ovulation vaccination can be applied if the age is young in couples with isolated ovulation problems.

4- How long does the ovulation vaccination treatment take?

Treatment begins on the 2nd or 3rd day of menstruation, and egg development is provided primarily with drugs containing low-dose gonadotropins. This process takes 8-10 days on average. Then, a cracking needle is made and the grafting process is carried out at the time of ovulation. In other words, vaccination is done 10-14 days after menstruation.

5- How is vaccination done?

Coinciding with the time of ovulation, the sperm produced by the partner are collected and washed in the laboratory, and then transferred into the uterus with the help of a soft catheter. The procedure takes about 2-3 minutes and the urine is squeezed to improve the position of the uterus.

6- What should be considered after vaccination?

After vaccination, it is sufficient to rest for 30 minutes in our center. Then you can return to your home. There is no problem for our patients coming from outside the city to travel on the same day.

It is not necessary to rest after vaccination. You can return to your normal daily life. The support drugs you will use until the day of the pregnancy test will be explained to you by our nurses.

7- When is the pregnancy test done after vaccination?

Pregnancy can be understood by measuring BhCG ​​in the blood performed 14 days after the vaccination date. If the value is above 30 mu/ml, we can talk about the presence of pregnancy.

???? Who needs IVF?

Conditions that may require IVF after evaluation;

  • If a woman has an ovulation problem (Polycystic ovary syndrome-PCOS, hypogonadotropic hypogonadism) and pre-in vitro fertilization treatment options have not been successful,
  • If the woman has a tube obstruction (hydrosalpenx), a history of tubal ligation or a surgical absence,
  • In the presence of severe adhesions between the uterus, tube and ovaries due to endometriosis,
  • In couples with low ovarian reserve, advanced age or long inability to conceive,
  • In case of severe low sperm count or complete absence (azoospermia) in men,
  • In case of problems in sexual intercourse due to female or male factors (vaginismus, erectile dysfunction, etc.),
  • In vitro fertilization treatment can be considered for preimplantation genetic diagnosis (PGT-M & SR&A) in case of a known genetic disease in the family or a chromosomal structural or numerical problem in one of the spouses, or in the presence of advanced female age.

9-) What stages does IVF treatment consist of?

In vitro fertilization treatment consists of ovarian stimulation, egg collection (OPU), fertilization of eggs (Microinjection-ICSI), embryo culture and development follow-up, embryo transfer and freezing of suitable embryos, if any.

10- How many days does IVF treatment last?

Within the scope of IVF treatment, ovarian stimulation begins with menstruation and lasts approximately 8-10 days. Then, the eggs are collected 34-36 hours after the cracking needle and the embryo transfer is planned approximately 3 or 5 days after the egg collection day. Therefore, the treatment is completed within 2.5 to 3 weeks from the menstrual period.

11- When is the pregnancy test done after IVF treatment?

A pregnancy test can be performed 14 days after the egg retrieval day. If frozen embryo transfer has been performed, we recommend performing a blood pregnancy test 9 days after the blastocyst stage embryo transfer and 11 days after the cleavage stage 3rd day embryo transfer. If the value is above 30 miu/ml, the presence of pregnancy is mentioned. Then, the rise is followed for 2 more times and if there is no problem, the first ultrasonography can be performed 7-10 days after the last test.

12- How should one be fed during IVF treatment?

Although there is no special diet, there are studies showing that the results can be better with a diet that is mainly Mediterranean cuisine (vegetables, fruits, fish and olive oil). In addition, I recommend consuming seasonal vegetables and fruits, avoiding alcohol and cigarettes.

13- Is it possible to have sexual intercourse during IVF treatment?

It is okay to have sexual intercourse during ovarian stimulation. However, we recommend that you do not hear, as there may be pain after the egg retrieval process and there may be a risk of infection.

14- What should be considered after embryo transfer?

We recommend resting and resting physically, especially for the first few days after the transfer. Then, you can return to daily life at a slow pace. The drugs you need to use after the transfer will be explained to you by our nurses.

Our patients coming from outside the city can return to their homes by land or air.

15- On which day is the embryo transfer performed?

Embryo transfer can be performed at the cleavage stage (day 3) or at the blastocyst stage (day 5). We determine the transfer day according to the quality and number of embryos. We prefer to go to the 5th day and transfer at the blastocyst stage if there is at least 1 more embryo than the number we plan to transfer in our clinic. This is because we select the embryo that has continued its development and has a higher probability of attaching to the uterus more accurately.

16- How is the embryo quality defined on the 3rd day?

The ideal cell number of embryos that have reached day 3 is 7-8 cells. In addition, a quality is determined for embryos according to whether there is a difference in diameter between cells and the proportion of dead parts in the embryo volume.

17- How is day 5 embryo quality defined?

The cell number of embryos reaching the blastocyst stage reaches 250-300 cells. Therefore, individual cell numbers are not counted. A classification is made from 1 to 5 according to the degree of expansion of the embryo, and they are classified as A, B and C according to the quality of the inner cell mass and outer cell mass. As a result, a quality such as 4/AA, 5/AA, 5/AB is determined for the embryos. After this evaluation, embryos with a degree of expansion of 3, 4 or 5 and embryos with A and B according to inner and outer cell mass are considered to be of good quality.

18- On which day and with what technique is embryo freezing done?

Embryo freezing can be done in the cleavage stage, that is Day 3, or in the blastocyst stage, that is, on the 5th or 6th day. We prefer embryo freezing at the blastocyst stage and with vitrification technique, since survival and pregnancy rates are better after thawing in our center.

19- If pregnancy does not occur in IVF treatment, when can a new application be started?

If there is no need for an additional test after detailed evaluation with a negative in vitro fertilization application, there is no need to pause for a new application. It can be started when the couple feels ready.

20- How much are IVF treatment fees?

We make the treatment planning of each couple specific to the couple. Therefore, we do not have a standard practice for every couple. In addition, if embryo freezing or preimplantation genetic screening (PGT-A) is performed, pricing may vary slightly. Detailed information on this subject will be given by our team according to your specific treatment.

21- If a man does not have sperm in the semen, that is, if there is azoospermia, how can sperm be taken?

In men with azoospermia, if the cause is obstructive azoospermia, fluid is drawn from the sperm collecting ducts or testicles with a syringe (PESA/TESA) or if there is non-obstructive azoospermia, small pieces are taken from the ovaries (testes) of the male. Sperm can be obtained with the TESE method.

22- What is the rate of obtaining sperm by surgical methods in the presence of azoospermia (no sperm in the semen)?

In the presence of obstructive (obstructive) azoospermia, the probability of finding sperm with the PESA/TESA method is around 100%, while in the presence of non-obstructive type (non-obstructive) azoospermia, it is around 50-55%.

23-What is Micro TESE?

Micro-TESE is the process of performing a biopsy on the ovaries (testes) of the man in order to obtain sperm for use in in vitro fertilization in men who do not have sperm in the semen. The testicular tissue is examined in detail under the microscope and multiple samples are taken from the areas where sperm is likely to be found. Our embryologists examine the samples under the microscope and evaluate the presence of sperm. With this method, the probability of finding sperm in experienced hands in the first application is around 50-55%.

24- If the man has low sperm count, will drug treatment be beneficial?

In case of low sperm count in men, hormonal drugs, vitamin supplements or any operation to be performed will not have an effect on increasing sperm count and motility. The only patient group in which drug therapy is beneficial is hypogonadotropic hypogonadism patients who have problems in the secretion of FSH and LH from the brain.

25- How many times can IVF treatment be done?

There is no number limit for IVF treatments as long as the characteristics of the couple are suitable. You can try as many times as you want.

26- Do the drugs used in IVF create a cancer risk?

Drugs used in IVF treatment do not increase the risk of uterine, breast and ovarian cancer, regardless of the dose and duration of administration.

27- How many embryos can be transferred in IVF treatment?

In accordance with the Regulation on Assisted Reproductive Treatment Practices and Assisted Reproductive Treatment Centers, in IVF applications in women under 35 years of age, a single embryo can be transferred in the first 2 applications, while 2 embryos can be transferred from the third attempt under 35 years of age, or in all trials if the female age is over 35 years of age. can be transferred.

28- What are the chances of success in IVF treatment?

The success after IVF treatment is determined by the age of the woman at the time of application, the quality and number of the transplanted embryos, the day on which the embryo is transferred and the experience of the physician performing the transfer. In this context, the chance of pregnancy rises to 58-60% with good quality embryo transfer under the age of 30, which is in the blastocyst stage in the first application.

29- Should chocolate cyst be removed before IVF treatment?

Since operations for chocolate cysts  (endometrioma) can cause loss of intact ovarian tissue even if performed by the most experienced hands, and the presence of chocolate cysts does not adversely affect the chances of success in IVF, we do not perform any surgery for cysts before in vitro fertilization.

30- Does the chance of pregnancy decrease in IVF in the presence of hydrosalpenx (tube with a clogged end and filled with liquid)?

Hisdrosalpenx is the obstruction of the end of the tube where it opens into the abdominal cavity and the accumulation of fluid in it. The liquid in the tube flows backwards to the uterus, reducing the chance of the embryo transferred into the uterus to attach and increasing the risk of miscarriage. For this reason, after IVF treatment in the presence of hydrosalpenx, the probability of live birth is reduced by half. In the presence of hydrosalpenx, we strongly recommend that the tube be removed before the treatment.

31- If myoma uteri is detected, should it be taken before IVF treatment?

Myoma uteri are always benign formations that develop in the muscle layer of the uterus. Depending on the area they are located in the uterus, they can be located outside of the uterus (subserous), in the muscle layer of the uterus (intramural) or in a location that puts pressure on the inner wall of the uterus. While subserous fibroids and intramural fibroids, if not very large, do not have adverse effects on a possible pregnancy, submucous fibroids that press on the inner wall of the uterus may have effects that reduce the pregnancy rate or increase the risk of miscarriage. Therefore, the operation decision should be made in every woman according to the number, size and location of myoma.

32- What is hysteroscopy and to whom is it performed?

Hysteroscopy is a method of viewing the inside of the uterus by entering with a light source. Thus, it can be understood whether there are intrauterine adhesions, endometrial polyps, fibroids and intrauterine curtains, and corrective operation can be performed in the same session.

33-Which treatments can be applied in Polycystic Ovary Syndrome?

In non-ovulation types, if there is no additional reason for not being able to conceive and the woman is young, ovulation-stimulating pills or vaccination treatments can be tried. In vitro fertilization is recommended for patients who do not respond to these treatments.

34-What is the chance of success with treatment in Polycystic Ovary Syndrome?

Approximately half of the patients catch pregnancy with a 6-month application at the dose at which ovulation is obtained in patients treated with pills. However, excess weight may be the cause of resistance to this treatment and it may be difficult to ovulate.

With vaccination treatment, pregnancy can be achieved around 25% per month of application. It is recommended to ensure egg development with daily injection for vaccination, but to limit the number of eggs developed to 1-2 to prevent multiple pregnancy.

With IVF treatment  , the chance of pregnancy in the young age group is approximately 60%, and in addition, the chance of producing embryos of high quality to be frozen is high.

35-What is overstimulation syndrome (Ovarian Hyperstimulation Syndrome- OHSS)?

Due to VEGF secreted from the developing egg sacs, vascular permeability increases and a picture that causes fluid accumulation in the abdominal and thoracic cavity, elevation in liver enzymes, and deterioration in kidney functions may occur. We call this overstimulation syndrome (OHSS). OHSS is a picture especially seen in patients with good reserve and collected many eggs, and it can even be life-threatening in neglected cases. Therefore, in order to prevent this syndrome during IVF treatment, we apply a short protocol in patients with good reserve, carefully determine the dose required for ovarian stimulation, apply a special fracturing needle, and do not transfer in that month in patients with more than 15 eggs collected. We freeze embryos. With these measures, we have not had any patients who have developed OHSS in recent years.

36- On which day of the menstrual cycle is IVF treatment started?

In vitro fertilization treatment is started on the 2nd or 3rd day of menstruation, even if different drugs are used for preparatory purposes.

37-Is it necessary to be married for IVF treatment?

In order for us to be able to do IVF and vaccination treatment, it is essential that couples are officially married.

38-Can gender selection be made with IVF treatment?

It is forbidden to examine the embryos obtained as a result of IVF treatment to determine the gender. However, when determining the embryo without the disease with a preimplantation genetic diagnosis that shows only a sex-linked transition, the gender can be determined if there is a medical necessity.

39-Who can have preimplantation genetic screening (PGT-A)?

As the woman’s age progresses, the risk of error in terms of chromosomes, which are our building blocks, especially in eggs produced after the age of 40, that is, the risk of developing eggs and embryos with missing or extra chromosomes increases, and this increases the risk of babies with anomalies, especially Down Syndrome. In this context, the PGT-A method can be applied to determine the chromosomal status of the embryo before it is transferred to the uterus.

40- In which disease history can preimplantation genetic diagnosis (PGT-M) be used?

Preimplantation genetic diagnosis (PGT-M) can be applied especially in the presence of a known genetic disease or affected child in the family. Genetic diseases for which PGT-M can be performed; It can be done for some muscle diseases such as thalassemia, cystic fibrosis, metabolic diseases, Duchenne muscular dystrophy, sickle cell anemia, spinal muscular atrophy (SMA) and tissue compatible sibling birth for sibling marrow transplantation.

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