In vitro fertilization method is the fertilization of eggs collected from the woman outside the body, with sperm taken from her partner in a laboratory environment, and the implantation of the resulting embryos into the woman’s uterus 2 to 5 days later. A girl named Loise Brown was born for the first time in England in 1978 by in vitro fertilization method. Many advances have been made with new treatment methods developed after the 1990s. Today, thousands of couples have children every year through these methods. In vitro fertilization started to be applied to women who had permanent damage to their tubes as a result of infection or surgical procedure, and after a short time, it was also used in the treatment of other causes of infertility. Today, successful results are obtained with in vitro fertilization methods in endometriosis, unexplained infertility cases and male infertility. Microinjection, which has been applied especially in recent years, is described as a revolution in the treatment of men who have sperm in their testicles, even though the sperm count is very low and even there is no sperm in their semen.
IVF treatment is a long and tiring process. IVF treatment consists of 3 stages.
1- Egg stimulation; (controlled ovarian hyperstimulation) Various hormone preparations are used to ensure egg development.
2-Collection of eggs.
3- Fertilization of the egg taken from the woman and the sperm taken from the man to form the embryo and embryo transfer after keeping it in incubators in the laboratory for 3-5 days. A pregnancy test is done 10-12 days after the transfer.
In order to prevent neural tube defects that may occur in infants in folic acid deficiency, folic acid preparations are used in the preparation period of the treatment.
To whom IVF is performed?
In vitro fertilization is applied in cases where the couple is not protected and cannot get pregnant for 1-2 years despite the desire for a child. Those with blocked tubes (external pregnancy, infection, tuberculosis, etc.), those who could not get pregnant despite 3-6 ovulation induction and vaccination, (unexplained infertility, mild endometriosis, mild sperm miscarriage, polycystic ovary syndrome, etc.). Severe sperm disorder in the male (number, low motility). Conventional IVF or ICSI is performed for those with a sperm count of more than 5 million/mL, and ICSI for those with a sperm count of less than 5 million/mL. Cases where the woman is over 40 years old and cannot become pregnant. Endometriosis (advanced stage). Women with common intra-abdominal adhesions.
IVF Stages I
1-Controlled Ovarian Hyperstimulation (Hormonally Controlled Stimulation of the Ovaries)
The first step of the treatment is to obtain a sufficient number of high quality egg cells. Various hormone preparations are used to ensure egg development. The reason for using these drugs in assisted reproductive techniques is to increase the chance of pregnancy by obtaining more eggs and embryos. Controlled Ovarian Hyperstimulation can be applied with different agents and different protocols.
In all protocols, on the second or third day of menstrual bleeding, the ovaries are evaluated by basal ultrasound examination and estrogen determination is made in the blood. For each patient, the most appropriate treatment protocol is determined according to the woman’s age, ovarian reserve, and blood hormone values, and the drug dose to be used is decided. After the start of ovarian stimulation treatment, the patient is called for control at regular intervals. In these controls, the number and size of the developing follicles are checked by performing vaginal ultrasonography. The aim of treatment is to obtain as many follicles with a diameter of 16-20 mm as possible. During the controls, the blood estrogen levels can be controlled and the drug dose can be adjusted. The target is to reach an estrogen level of 200 pg/ml per follicle larger than 14 mm. When the follicles reach a sufficient size, 5,000-10,000 units of Human Chorionic Gonadotropin (hCG) (cracking needle) injection is made to ensure the final maturation of the egg. The period of stimulation of your ovaries, together. Although the duration of the treatment varies according to the person, it is approximately 12-16 days. Egg collection is done 32-36 hours after the cracking needle.
Another factor evaluated during ultrasound follow-ups is the structure and thickness of the endometrium layer that covers the inside of the uterus. On the hCG day, when the endometrium is 6 mm or less, the chance of pregnancy decreases, if it is more than 14 mm, it has a negative effect. Even if pregnancy occurs, the possibility of miscarriage increases.
When drugs that stimulate the ovaries are given alone, the follicles can crack uncontrollably and untimely. This condition is called premature luteinization. In order to minimize this risk, it is necessary to suppress the woman’s own hormones before stimulating the ovaries. For this purpose, drugs that suppress ovarian hormones are used. These agents first cause an overstimulation of the ovaries but then produce a strong suppression. The arousal that occurs at first is called the flare-up effect. In this way, the release of hormones is completely controlled. Printing can be done according to different protocols.
Drugs Suppressing Ovarian Hormones (GnRH analogues):
(Suprecur, Suprefact, Lucrin, Synarel, Decapeptyl) These hormones can be used as a subcutaneous injection or nasal spray.
Drugs Stimulating Egg Development (Gonodotropins):
HMG (urinary preparations; Pergonal, Menogon, Humegon)
FSH (recombinant preparations; Gonal-F, Puregon, Metrodin, Follegon)
HMG is a substance obtained from the urine of menopausal women and contains equal amounts of FSH and LH hormones. FSH alone, on the other hand, is produced artificially either by the separation of these urines or by a new technology, recombinant technology.
Pergonal and Menogon are administered intramuscularly. Gonal-F and Puregon are applied intramuscularly or subcutaneously.
Drugs That Make Egg Crack (Human Chorionic Gonadotropin) (hCG):
Pregnyl, Profasi, Choragon
Protocols Used in IVF Treatment:
Long Protocol: It is the most preferred KOH protocol all over the world. On the 21st day of your period, GnRH analogs are applied to suppress your ovarian functions. On the 3rd day of the following menstrual bleeding, whether there is suppression or not is understood by the blood test to be performed. If the blood estrogen level is decreased, it means that suppression is achieved. The GnRHa application is not terminated. On the same day, the treatment of drugs that stimulate the ovaries (hMG or FSH) is started. GnRHa and hMG or FSH are used together until the cracking injection is done.
Short Protocol: GnRHa application is started on the first day of menstrual bleeding and continued until the end of the treatment (the day of the cracking injection). Starting from the 3rd day of menstrual bleeding, hMG or FSH is added to the treatment.
Ultrashort Protocol: GnRHa is started on the first day of menstrual bleeding and stopped after 3 days of administration. Treatment is continued with hMG or FSH. The aim is simply to take advantage of the flare-up effect.
New protocols used in egg development:
Use of GnRH-Antagonists (Orgalutran and Cetrotide)
With these drugs, egg development treatment can be applied from the second or third day of the woman’s menstruation without the need for a preparation and suppression period before the egg development stage. Thus, the time allocated by the patient for the procedure can be shortened, and the dose of medication to be used is reduced, reducing both time and cost. In the antagonist treatment scheme, Gonadotropin preparations are started within the first 3 days of menstruation, daily antagonist injections are added to the treatment at a certain developmental stage according to follicle monitoring and hormone analysis. The antagonist is continued until the period of hCG administration. With the antagonist treatment, it is aimed that the eggs will not be ejected spontaneously from the developing follicles, that is, they can be collected during the egg collection process.
Usage of Clomiphene Citrate (Klomen, Gonophene) and Aromatase Inhibitor (Letrozole ‘Femara’):
In women with reduced ovarian reserve, the alternative approach is to allow the eggs to grow in the first seven days of menstruation with drugs called clomiphene citrate or letrozole. The aim here is to increase the levels of the woman’s own hormones with the help of the aforementioned drugs, and to increase the egg quality by using fewer drugs that stimulate egg development.
ICSI in the Natural Cycle
As a last alternative, microinjection can be performed by following the woman’s self-growing single egg every month, in women with limited ovarian reserve and whose ovarian development cannot be achieved with medication.
The most serious complication of ovulation induction is Ovarian Hyperstimulation Syndrome (OHSS) and can be seen in 1.3% of cases. Drugs that stimulate egg development rarely cause overstimulation of the ovaries and accumulation of fluid in areas such as the abdominal cavity and the chest cavity under the skin. Serious cases require hospitalization. The duration of treatment is variable. Embryo transfer may be delayed or canceled in women at high risk of OHSS.
IVF Stages II
2-Egg collection process (Oocyte pick-up, OPU)
Egg collection is the process of evacuating the fluid-filled structures called follicles, which contain eggs, by means of a needle adapted to the trans-vaginal ultrasonography probe. The embryologist reports whether there are eggs in the follicle fluid collected in the tubes. If the egg does not come, the follicle cavity is washed by giving a special liquid and the egg that may have remained in it is tried to be removed (Flushing). In this way, the process is continued until all follicles are aspirated. After all follicles over 10 mm are emptied, the egg collection process is terminated. The total duration of this process usually does not exceed 30 minutes. After the eggs are collected, they are examined in the laboratory to evaluate the number of eggs and whether they are mature. Fertilization is applied to mature eggs. After the egg collection procedure, the patient can go home after resting for 1-2 hours. With the application of progesterone after the Egg Collection Process, the endometrium is supported and a suitable environment is created for the embryo to settle into the uterus. (Luteal support)
The complication rate of oocyte retrieval is very low. Depending on the needle used during egg collection, there is a very low risk of infection and bleeding. If infection occurs, antibiotics can be given intravenously. Very rarely, hospital observation or laparoscopy may be required. Very rarely, injuries to adjacent organs such as bowel, bladder, vessels, and pelvic abscess can be seen. In particular, the presence of endometrioma is an important risk factor for pelvic abscess since the blood it contains is a suitable medium.
On the day of egg retrieval, a male who has abstained for 3-5 days gives a sperm sample. In some cases, it may be necessary to collect sperm from the testicles by aspiration or biopsy. If it is determined beforehand that sperm cannot be obtained from normal semen (i.e. cases where sperm cannot be seen in the semen are ‘azoospermia’ or cases with no quality and movement even though it is seen), sperm will be tried to be obtained from the testis by needle or biopsy before the egg collection day.
Sperm Search Methods in Azoospermic Men:
MESA: Microsurgical epididymal sperm aspiration
PESA : Percutaneous testicular sperm aspiration
TESA : Testicular sperm aspiration
TESE: Testicular sperm extraction
IVF Stages III
3-Fertilization (IVF-ICSI)
The eggs obtained during the Egg Collection Process are evaluated in the laboratory with a special microscope. After the immature (immature) or degenerate eggs are sorted out, mature eggs (MII oocyte) are placed in the culture liquid and kept in the incubator for about 4 hours at 37 degrees Celsius, keeping the 5-6% carbon dioxide rate constant. On the day of the Egg Collection Process, the spouse also gives sperm. In men who cannot find live sperm in their semen, sperm is searched surgically. The semen obtained is taken into a special container and it is expected to be liquefied. Liquefied semen is examined for sperm count, motility and shape. Semen is prepared by going through washing processes. After the egg culture and sperm preparation processes are completed (fertilization), the fertilization process is started.
In the classical in vitro fertilization (IVF) method, the sperms are left next to the collected eggs and they are expected to fertilize the egg on their own. Only one sperm cell (spermatozoa) can enter each egg. After the spermatozoa have passed the outer membrane called the zona pellucida around the egg, other sperm cells cannot pass through this membrane. Conventional IVF is used when the man is completely normal and infertility is due to the woman.
Pre-implantation genetic diagnosis (PGD) in those with sperm count below 5 million/mL, Azoospermia, that is, in men who have no sperm in the sperm analysis (sperm is obtained by PESA/MESA/TESE or TESA methods.), in couples who have failed with the previously tried Conventional IVF method. Microinjection (ICSI) (Intra-Cytoplasmic Sperm Injection) method should be preferred in order to increase the chance of pregnancy. Before the ICSI procedure, the cells around the eggs (cumulus cells) are cleaned and then a predetermined single sperm cell is injected into each egg with the help of a special tool called a micromanupilator.
Fertilization is checked 16-18 hours after the Fertilization Process. Fertilized eggs are put back into the culture medium and expected to develop. High-quality embryos brought to the transfer stage are transferred into the uterus of a certain number of women.
IVF Stages IV
4-Embryo Transfer
Embryos are transferred to the uterus between the 2nd and 6th day after egg retrieval at any stage from the two-cell stage to the multicellular blastocyst stage. The most preferred transfer time is the second or third day when the embryos reach the 4-8 cell stage. (Transfer is done on the 4th day for those with pre-implantation genetic diagnosis, and on the 5th-6th day for those with blastocyst transfer.) The selection of embryos to be transferred is very important. The best quality embryos that have been divided according to the developmental stage are selected.
Embryo Transfer is performed under ultrasound control with a full bladder in order to place the catheter more easily and to monitor exactly where the embryos are placed in the uterus. The procedure is painless and does not require anesthesia. After the speculum is placed in the vagina on the gynecological table, the vagina and cervix are cleaned with sterile serum or special fluids. With the help of a thin catheter, the embryos are left in the most suitable area of the endometrium, and the catheter is withdrawn slowly. During this procedure, the catheter should not touch the fundus part of the uterine cavity in order not to cause contractions in the uterus. After the transfer process is completed, the catheter is checked by the embryologist to make sure that all the embryos have been delivered. The number of embryos to be transferred usually varies between 2-4. While determining the number of embryos, the age of the woman, the quality of the embryos and previous unsuccessful IVF attempts are taken into account. Multiple pregnancy rates increase when more than two embryos are transferred. After the best quality embryos are transferred, if there are any remaining embryos, they can be frozen and stored.
The patient can go home 1-2 hours after the embryo transfer. It was determined that longer bed rest did not increase the chance of pregnancy. Home rest is sufficient for the first 24 hours, then you can return to your normal life. You should not engage in excessive sports activities and sexual intercourse until you learn the pregnancy test result. You should absolutely not smoke from the start of your treatment. A pregnancy test is performed on the 12th day after Embryo Transfer.
5-Pregnancy test
A pregnancy test (beta-hCG) performed on the 12th day after Embryo Transfer determines whether there is a pregnancy or not. Those who test positive are called for a second pregnancy test on the 14th day. In a healthy intrauterine pregnancy, the blood beta-hCG value increases approximately two times after two days. In values that do not increase in this way, ectopic pregnancy (ectopic pregnancy) is considered. Sometimes after a while, the blood beta-hCG value drops to zero. This is called a biochemical pregnancy.
After a regular increase in beta-hCG values on the 12th and 14th days, it is considered clinical pregnancy and called for the first pregnancy ultrasound 2 weeks later. In this first ultrasound, it is investigated whether there is a pregnancy sac in the uterus. Whether the pregnancy is twin triplets or not can be determined by the number of sacs seen on this first ultrasound.
