WHAT IS IVF TREATMENT IN BRIEF?
In vitro fertilization treatment is the name given to procedures based on the logic of taking the egg cells produced in the female body out of the body with special needles, fertilizing them with the man's sperm in a laboratory environment, and transferring the resulting embryo or embryos into the female uterus.
For patients who will undergo IVF treatment, an appropriate treatment protocol and drug dosage is determined according to the woman's age, ovarian reserve, blood hormone values and height/weight ratio.
In a long treatment protocol First, ovarian-suppressing hormones are administered as a nasal spray or subcutaneous injection for approximately 10-12 days. Once the patient menstruates, the second part of the treatment begins and hormone therapy is applied to ensure egg development for an average of 8-10 days. Then the eggs are collected.
In short treatment protocols Drugs that will stimulate egg development are started on the 2nd or 3rd day of menstruation, and suppressive drugs to control the hormones secreted by the ovary are added to this treatment in the later days of the treatment.
Patients are monitored with blood hormone levels and vaginal ultrasonography, and when the follicles reach the appropriate size, human chorionic gonadotropin, as it is commonly known, is detected. egg cracking needle is given and egg collection is performed 33-36 hours later.
This procedure is performed under anesthesia to prevent patients from feeling any pain and takes approximately 10-15 minutes.
The embryos to be selected within 2-5 days after egg collection are transferred into the uterus by passing the cervix with the help of a thin catheter. transfer will be done. Embryo transfer is a painless procedure and can be monitored by our patients as it is performed under ultrasonography guidance. Following the embryo transfer, our patients are sent home after approximately 30-45 minutes of bed rest.
Assoc. Prof. on In Vitro Fertilization. Dr. Click to Consult Selman Laçin
IS IVF THE ONLY TREATMENT METHOD FOR COUPLES WHO CANNOT HAVE CHILDREN?
In couples who have difficulty in conceiving, a detailed examination should clarify where the problem originates, the need for treatment should be determined, and the treatment method that will enable the couple to achieve pregnancy in the easiest way should be determined and presented to the couple.
Treatment methods; In the roughest classification, it is the surgical treatment of tube problems, ovulation stimulation and follow-up, insemination and in vitro fertilization treatment. In couples with suitable conditions, pregnancy can be achieved through "intrauterine insemination" treatment, which means sperm is given into the uterus after certain processes, following egg development with medications.
Assoc. Prof. on In Vitro Fertilization. Dr. Click to Consult Selman Laçin
WHEN SHOULD I APPLY FOR INFERTILITY TREATMENT?
In general, it is recommended that spouses consult a doctor if they cannot become pregnant for 1 year despite using any contraceptive method and having regular sexual intercourse. However, today, as the rate of marriage at later ages increases, men who have doubts about infertility are recommended to consult a urologist. Couples must come to the examination with their spouses. In addition to the general physical examination, men also require necessary hormone tests, genetic examinations if necessary, and semen analysis must be re-examined in our center, even if it has been done in the past.
HOW LONG IS THE TIME FOR APPLICATION AFTER APPLICATION?
The most appropriate period for preliminary examinations of men and women is the week after the woman's menstrual period ends and the man is in abstinence for 3-5 days. It is sufficient to allocate 2 days for the initial evaluation. The test results are followed and the treatment method that gives the highest chance of pregnancy for the couple is decided in a joint consultation by the doctors. The duration of treatment in the hospital is approximately 15 days.
Assoc. Prof. on In Vitro Fertilization. Dr. Click to Consult Selman Laçin
HOW LONG DOES IVF TREATMENT TAKE?
In vitro fertilization treatment; It is a process consisting of the stages of egg development, egg collection and fertilization, embryo development and embryo transfer. During this treatment period, no procedure is performed that requires the woman to be hospitalized.
During egg development, blood tests and ultrasound examinations will be monitored, most of the time every other day and rarely daily, and the time spent in the hospital during the follow-up will be kept as short as possible and the couple's daily life and schedules will not be affected. Egg collection and embryo transfer procedures are very easy procedures that do not require hospitalization. Usually this whole process takes around 15 days.
Assoc. Prof. on In Vitro Fertilization. Dr. Click to Consult Selman Laçin
IS THERE ANY AGE LIMIT FOR IN Vitro Fertilization?
If the hormone tests performed on the 3rd day of menstruation and the ovarian capacity seen in ultrasonography indicate that your ovarian functions are appropriate, in vitro fertilization can be performed until the age of 45. However, when performing the procedure on women aged 38 and over, it is recommended to investigate whether your embryos are normal in terms of chromosomes using the preimplantation genetic diagnosis method.
Assoc. Prof. on In Vitro Fertilization. Dr. Click to Consult Selman Laçin
DOES A WOMAN'S AGE AFFECT SUCCESS?
Absolutely yes! So much so that, although a wide range of treatment options are available for all types of male infertility today, the biggest obstacle to treatment is the advanced age of women. The woman's age and the resulting low number of eggs are the most important factors affecting success. However, in women aged 40 and over, who are considered to have good ovarian capacity, pregnancy is achieved in approximately 25-30% of cases by applying preimplantation genetic diagnosis.
DOES THE SUCCESS IN IVF TREATMENT VARY DEPENDING ON SEASONS?
In vitro fertilization practices have been carried out for many years. Experience gained over these years reveals that treatment success does not differ depending on months or seasons.
HOW MANY TIMES CAN IVF TREATMENTS BE REPEATED?
Although there is no known limit for the treatment, 7-8 applications can be made. There should be a break of at least 2-3 months between each application.
DO THE TUBE NECESSARY TO BE OPEN DURING IVF PROCEDURES?
No. After the collected eggs are fertilized with sperm, the resulting embryos are placed in the uterus. (Eggs are collected in the vaginal route under the guidance of ultrasonography.) Therefore, the patency of the tubes does not matter, but if there is fluid accumulation in the tube, the tube must be removed or its connection with the uterus must be cut off, as the flow of this fluid into the uterus will affect the embryo attachment.
IS THE RISK OF MIRROR HIGHER IN IVF PREGNANCY?
No. It is known that approximately 15% of pregnancies achieved spontaneously or through in vitro fertilization methods end in miscarriage. Early miscarriages in spontaneous pregnancies can sometimes be perceived as a few days of menstrual delay followed by a slightly heavier menstrual bleeding. However, blood tests will show that this is a pregnancy loss. Since pregnancy results are monitored with blood tests from the very early period in in vitro fertilization applications, pregnancy losses in each period are precisely defined. This situation causes the misconception that miscarriage rates are higher.
DOES CIGARETTE AFFECT HAVING CHILDREN?
It is thought that long-term and high-volume smoking negatively affects the reproductive system and hormone activity. It should be known that the effect may be especially at the level of the ovaries and that smoking may lead to important consequences such as menstrual irregularity, infertility and early menopause. When pregnancy occurs, it may also lead to developmental delay and low birth weight in the fetus.
DOES STRESS CAUSE INFERTILITY?
Although infertility and its treatment are a very stressful experience, it is difficult to say that infertility occurs due to stress. However, in some cases, high levels of stress can cause changes in hormone levels in women, resulting in impaired egg development.
In addition, excessive stress can cause fallopian tube spasms in women and decreased sperm count in men. In vitro fertilization treatment can also be a very stressful process for some couples.
In our center, our psychologist works with us during the IVF treatment and provides the necessary support to couples in need.
WHAT IS PREIMPLANTATION GENETIC DIAGNOSIS PROCESS AND IN WHICH COUPLES IS IT APPLIED AND WHAT ARE THE ADVANTAGES?
Today, genetic diseases can be identified during pregnancy or after birth. However, possible genetic diseases in the baby can only be determined in the fourth month of pregnancy by methods such as ultrasonography and amniocentesis, and if a serious abnormality is detected, the pregnancy is terminated around the 5th month. This situation traumatizes the expectant mother and father psychologically and physically.
In recent years, developments in genetic science allow genetic examination to be carried out on embryos developed in the laboratory using in vitro fertilization methods, before pregnancy occurs, and the placement of selected healthy embryos into the uterus of the expectant mother. This method is called pre-pregnancy genetic diagnosis (Preimplantation Genetic Diagnosis-PGT).
Pre-pregnancy genetic diagnosis is carried out by taking a cell from the embryos that develop as a result of fertilization of the egg and sperm cells obtained from the expectant mother and father in a laboratory environment.
Special methods called Fluorescence In Situ Hybridization (FISH) or Polymerase Chain Reaction (PCR) are used for genetic diagnosis. Diagnosis of numerical chromosome disorders such as monosomy or trisomy (Down syndrome and other trisomies) and single gene diseases (such as hemophilia, Mediterranean anemia, cystic fibrosis, muscular dystrophies) in the unborn baby is possible with PGT. Thus, the birth of healthy babies is ensured by transferring disease-free, healthy embryos to the expectant mother.
Pre-pregnancy diagnosis:
• In couples who are carriers of a genetic or hereditary disease,
• In couples who have previously had a child or children with a genetic disease,
• For the purpose of HLA genotyping (tissue typing),
• In the identification of diseases that show genetic predisposition
• In women in the older age group (37 years and above) accepted for assisted reproductive techniques,
• In couples with recurrent early pregnancy miscarriages,
• In couples who have not been able to achieve pregnancy with assisted reproductive techniques despite numerous applications, or who have lost their pregnancies due to miscarriages,
• It can be applied in cases of chromosomal disorders or genetic diseases associated with severe male infertility.
WHAT IS THE IMPORTANCE OF PGT IN DISEASES LIKE THALASSEMIA, HEMOPHILIA ETC AND IS IT POSSIBLE TO PERFORM TISSUE TYPING IN EMBRYOS?
Individuals transmit the hereditary disease they carry to their children at varying rates. Therefore, identifying genetic diseases in couples and embryos is important for couples to have healthy children. Today, it has become possible to identify many hereditary diseases at the embryo level with the DNA analysis method. In order to identify the genetic disorder that causes a hereditary disease, the structure of the gene that causes the disease must be determined. As a result of the research, the structure of many genes that cause diseases such as B-thalassemia, Hemophilia, Cystic Fibrosis, Sickle Cell Anemia, Muscular Dystrophies and Fragile X have been determined and methods for their genetic diagnosis have been developed.
With this method, genetic analyzes are first performed in our center to show the genetic disorder in the blood samples of the parents and the sick children, if any. Afterwards, the genetic structure that causes the disease is multiplied using special methods in the cells taken from the embryos obtained by in vitro fertilization of couples who are carriers of hereditary diseases, and the gene region of the screened disease can be identified by DNA analysis method. As a result, while embryos carrying hereditary diseases are eliminated, healthy embryos can be transferred to give birth to children without genetic diseases. As a result of the research, the structure of many genes that cause diseases such as B-thalassemia, Cystic Fibrosis, Sickle Cell Anemia, Hemophilia, Muscular Dystrophies and Fragile X have been determined and methods for their genetic diagnosis have been developed.
Moreover; In diseases such as B-thalassemia, Fanconi anemia and leukemia, in addition to detecting healthy embryos by DNA sequence analysis method, HLA genotyping (tissue typing) process can also be applied at the same time and the tissue type of the embryos can be determined. In families with children diagnosed with thalassemia or leukemia by HLA genotyping method, after determining the tissue types of the mother, father and child, embryos whose tissue type is compatible with the patient child can be selected among the embryos that do not carry the disease.
Healthy pregnancies achieved in this way provide treatment for sick children by using the cord blood and bone marrow of healthy born children. With this method, the family is also protected from medical and psychological trauma due to pregnancy termination following the prenatal diagnosis process. Moreover; Pre-pregnancy diagnosis is a very important technique as it enables families to have healthy children and provides treatment opportunities for sick people due to the health problems that sick people face throughout their lives, difficulties in treating diseases and high treatment costs.
As a result of today's studies, it will be possible to identify many more diseases in embryos by determining the genetic structure of diseases.
CAN IT BE KNOWN WHETHER THE FERTILETED EGGS (EMBRYOES) ARE ABNORMAL BEFORE THEY ARE PLACED INTO THE WOMEN?
Yes. By applying preimplantation genetic diagnosis, embryos with chromosomal disorders can be selected and only healthy ones can be transferred.
ARE THERE PRECAUTIONS THAT CAN BE TAKEN ABOUT GENETIC PROBLEMS BEFORE PREGNANCY OCCURS?
Yes. Preimplantation Genetic Diagnosis method is applied for this purpose. With this method, the embryos obtained by in vitro fertilization in families at risk for hereditary diseases are examined and healthy embryos that are found to be free of disease are transferred. The success rate decreases with the advanced age of the woman (35-45), and when pregnancy is achieved, it may end in miscarriage. Since chromosomal disorders in eggs increase with age, embryos obtained from couples undergoing in vitro fertilization treatment are biopsied when they reach the third day. Following the evaluation of one or two cells obtained within a few hours using molecular diagnostic methods, healthy embryos are separated and transferred. It provides information about the chromosomal disorders (Trisomy 13,16,18,21,22,15,17 and X,Y) that increase the most with age and are compatible with life. With this method, the pregnancy rate can be increased and the risk of miscarriage is reduced in older women who obtain sufficient embryos.
WHAT ARE THE ADVANTAGES OF PREIMPLANTATION GENETIC DIAGNOSIS?
1. It increases the chance of pregnancy and reduces the chance of miscarriage.
2. Families are enabled to have healthy children.
3. The family is protected from medical and psychological trauma due to pregnancy termination.
4. In diseases such as thalassemia, the baby to be born with tissue typing provides treatment opportunities for the sick children of the family.
5. Pre-pregnancy diagnosis; It is a much more useful and cheaper diagnostic method compared to the health problems that sick people face throughout their lives, the difficulties in treating diseases, and the high treatment costs.
CAN GENETIC DISEASES BE OBSERVED IN THE EMBRYO OF COUPLES WITH NORMAL CHROMOSOME ANALYSIS?
Yes. In genetic tests performed on blood cells taken from couples, the chromosome structure may be found to be normal. However, the embryo receives half of its genetic structure from the mother's egg cell and the other half from the father's sperm cell. For this reason, although the genetic structure of the body cells is normal, some couples may have chromosomal disorders that can only be seen in the reproductive (egg or sperm) cells, and this disorder can be transferred to the embryos. Such genetic disorders in embryos can be detected with pre-pregnancy genetic diagnosis.
WHAT IS THE EFFECT OF CONSULTAN MARRIAGE ON THE EMERGENCE OF GENETIC DISEASES?
Consanguineous marriages are marriages made between people who are related by blood. According to the degree of kinship, the closest one is cousin marriages, which we call first degree consanguineous marriages, and they are marriages between the children of aunts, uncles and uncles. The rate of consanguineous marriage in our country is 21-40% and varies depending on the region. In general, anomalies resulting from various reasons are detected in 2-3 of every 100 children born in society. This risk may increase to 4-5% in couples who are married to consanguineous relatives.
WHO ARE THE PEOPLE AT GENETIC RISK?
• Couples who are carriers of a genetic or hereditary disease
• Couples who have previously had a child or children with a genetic disease
• Those with structural anomalies detected in their body
• History of a child with mental retardation
• Anomalies of sex development
• Developmental delay and short stature
• Couples with a history of a genetic disease in close relatives (such as a 1st cousin).
• In couples with recurrent miscarriages and stillbirths
• Women over 37 years of age
• Couples who cannot achieve pregnancy despite the application of assisted reproductive techniques many times.
In these couples, a detailed family history should first be taken by a geneticist and a family tree should be created. It is necessary to obtain detailed information about the disease considered in the family and previous pregnancies, if any. Sick children and family members should be examined and necessary tests should be requested. After all these procedures, if the disease is diagnosed or a genetic cause is detected, the couples are given detailed information about the detected problems.
The family is informed about the problems that the genetic disease may cause, its consequences, risks in new pregnancies, and what to do before and after pregnancy. After these procedures, the risks of couples' new pregnancies can vary from no risk of recurrence to 100%. While preimplantation genetic diagnosis may be recommended for some couples, genetic diagnosis during the prenatal period is recommended for some patients.
CAN GENETIC PROBLEMS BE IDENTIFIED AFTER PREGNANCY?
Yes. There are some screening tests that should be applied during pregnancy. (11-14 screening test - double test - triple test) These screening tests give us information about the genetic risk during pregnancy. When such a risk is identified, 11-14. It is possible to perform chromosome analysis of the baby by taking a biopsy from the fetus's partner at 2 weeks or by taking a sample of the fluid in the baby at 16-18 weeks. In addition, ultrasonography also helps us in this regard.
WHAT ARE THE PRELIMINARY TESTS AND MAIN TESTS IN IVF TREATMENT?
Tests required for diagnosis and treatment of infertility: for women; blood group, complete blood count, hormone tests such as FSH-LH-estradiol (second or third day of menstrual bleeding), TSH, free T4, prolactin, HBsAg, AntiHBs, AntiHCV, Rubella IgM-IgG, Toxoplasma IgM-IgG tests for the preliminary identification of existing infections or immunity... If deemed necessary, tests for other systemic diseases, microbiological and genetic tests can also be added. A uterine film (hysterosalpingography) should be taken to evaluate the tubes and the inner cavity of the uterus. For men; spermiogram, blood group, HBsAg, AntiHBs, AntiHCV (jaundice screenings), hormone tests (FSH, LH, total testosterone, prolactin and TSH) and genetic tests should be performed when necessary.
DO I NEED A NEW UTERUS FILM (hsg-hysterosalpingography) BEFORE IVF TREATMENT?
No, a new HSG is not absolutely necessary if you have not had an operation or an inflammatory gynecological disease after this procedure and if the film is more than 2-3 years old. However, if your doctor, who examines you and evaluates your uterus and ovaries with ultrasound, thinks it is necessary, this will be requested from you.
DO THE SPERM AND EGGS USED BELONG TO THE PARTIES THEMSELVES?
Absolutely yes. One of the conditions required for these transactions is that the official marriage documents be delivered to us. For whatever reason, men who do not produce sperm or couples who cannot develop eggs are not accepted for treatment. The reproductive cells to be used in treatments are definitely the own cells of the legally married spouses.
WHAT ARE THE CHANCES OF SUCCESS WITH THESE TECHNIQUES?
It is necessary to determine the chance of success in in vitro fertilization treatment according to the characteristics of the couple. Because many parameters such as ovarian capacity, age factor and serious male factor affect the chance of success in in vitro fertilization. In couples with embryo transfer, the chance of success is 55% for women under the age of 37 with good ovarian reserve, while this chance is around 30% for women over the age of 40. In this age group, the high rate of genetic anomalies should be reduced and preimplantation genetic diagnosis practices should be performed, and thus, the chance of pregnancy is tried to be increased by transferring genetically determined normal embryos.
IS THERE A RISK OF GIVING THE WORLD TO AN ABORMAL CHILD AFTER THESE TREATMENTS?
There was no difference in physical and mental development between babies born with treatment and babies born naturally.
WHAT ARE THE MEDICATIONS USED FOR PREPARATION FOR IVF?
Folic acid deficiency can cause a very important problem in babies, which we call neural tube defect, which includes problems in the brain and spinal cord and negatively affects the baby's health. This situation can be prevented by using folic acid a few months before pregnancy. For this reason, pure folic acid preparations or vitamins containing folic acid are used during the preparation period of the treatment. Treatment of microbes that may be present in the cervix or semen will also increase the chance of success in in vitro fertilization treatment. For this reason, the use of antibiotics is recommended for both men and women during the preparation period.
WHAT ARE THE SEROLOGICAL TESTS CARRIED OUT BEFORE STARTING IVF TREATMENT?
Before starting in vitro fertilization treatment, some blood tests for both men and women are of great importance for the couple to have a healthy baby. These tests are: HbsAg, anti-Hbs, anti-HCV, anti-HIV(I+II), Rubella lgG, Toxoplasma lgG. With the tests to be performed, existing infections in couples can be identified, and necessary precautions can be taken to protect the baby immediately after birth. Determining immunity against infections such as hepatitis B and rubella allows the patient to be vaccinated when necessary before entering treatment, and the patient's treatment is started following confirmation of immunity. These examinations are also important in terms of protecting the healthcare personnel who will perform the treatment from contamination and taking precautions to prevent contamination during freezing of sperm or embryos obtained from the couple and other laboratory procedures.
ARE THERE ANY MICROBIOLOGICAL TESTS CARRIED OUT BEFORE STARTING IVF TREATMENT?
The first examination of the patient is also important for evaluating the lower genital, that is, reproductive system, for infections. A detailed screening can be performed with cervical culture, direct smear, mycoplasma culture and chlamydia antigen detection. Existing infections are important for both infertility treatment and the general health of couples. These infections disrupt the vaginal flora and cause negative changes in the natural discharge of the cervix. Since mycoplasma and chlamydia infections frequently accompany infertility, performing the necessary treatment also increases the success of in vitro fertilization treatment.
IVF TREATMENT AND USE OF ADDITIONAL MEDICATIONS
In families who apply to in vitro fertilization centers with the desire to have a child, detailed information is obtained at the first meeting, and past and present diseases are also learned. Thus, patients are planned to start their desired pregnancy in the healthiest way; If possible, infertility treatment is started after first treating the current disease and ensuring recovery. In this way, any harm that may be caused to the baby due to the use of certain medications during pregnancy is prevented. It is also known that some drugs used during infertility treatment may have negative effects on follicle and egg development. For this reason, patients' drug use is minimized as much as possible. The treatment of some diseases, such as depression, makes the treatment easier and increases the chance of success. In some chronic diseases, it would be correct to start infertility treatment after the exacerbation periods of the disease have passed and to plan the medications used continuously in consultation with our colleagues in the relevant branches, anticipating infertility treatment and a possible pregnancy.
ARE THERE ANY SIDE EFFECTS OF THE MEDICINE WE USE?
When drugs are used by injection, minor bruises and discomfort may occur at the injection site. Nasal sprays and subcutaneous injections may cause complaints similar to fatigue, muscle and joint pain, and temporary menopausal complaints. The drugs we use to enlarge the ovaries may, in rare cases, cause overstimulation of the ovaries in sensitive women. The situation that occurs in this way is called "Ovarian Hyperstimulation Syndrome". Hyperstimulation syndrome is a risk for women with polycystic ovaries and a large number of eggs. To prevent this, these patients are treated with the lowest possible dose. In very serious cases of this condition, medical problems that require hospitalization may also occur.
CAN WE UNDERSTAND CASES WITH POOR RESPONSES IN PRIORITY?
Having sufficient number and quality of eggs obtained is of great importance in the success of in vitro fertilization treatment. Knowing the number of eggs in the ovaries and the conditions affecting the number of eggs helps us understand in advance how the patient will respond to treatment. Some of these are being a woman aged 35 or over, being overweight, smoking, previous ovarian surgeries, previous inflammatory diseases, the presence of endometriosis and the presence of ovarian cysts. In addition, an FSH level of 10 MIU/ml and an estradiol level of over 75 pg/ml on the 2nd or 3rd day of menstrual bleeding, a poor response to previous treatments, an excess of ampoules used, and detection of problems with the uterine lining are guiding findings in identifying patients who will respond poorly to treatment.
FOLLICLE COUNT AND ITS IMPORTANCE
The number of eggs in the ovaries is directly related to the response to treatment. With the help of ultrasound, the eggs in the ovaries are counted and the ovarian reserve is determined. Accordingly, patients with high, normal, borderline and poor response are detected. It is important to make this distinction because the type of treatment to be given (long or short treatment) and the initial injection dose will be adjusted accordingly.
WHAT IS THE DIFFERENCE OF MICROINJECTION FROM IVF METHOD?
In the in vitro fertilization method, sperm and eggs taken outside the body are brought together in a special environment in the laboratory and fertilization is expected to occur spontaneously. Sperms that have insufficient movement and fertilization capacity, are few in number, and show severe deformity cannot penetrate the egg on their own and ensure fertilization. In this case, sperm is injected into the egg and fertilization is achieved. This procedure is called microinjection (ICSI).
IS IT BETTER TO USE DRUGS CALLED ANTAGONISTS FOR EGG STIMULATION?
Antagonists, developed and used in recent years, have begun to be frequently used in in vitro fertilization treatment to prevent the premature rise of the hormone that stimulates ovulation. In antagonist therapy, the treatment duration is shorter and fewer doses of egg stimulating injections are required. Shortly after the antagonist injection is stopped, the pituitary gland regains its former function, complaints such as hot flashes, vaginal dryness, reluctance are not encountered, and excessive ovarian suppression or exacerbating effects that occur due to long-term use of the needles we call analog are not observed. Pregnancy results with these drugs are the same as the classical protocol. It is especially advantageous in patients with poor or high response and in couples with time constraints.
WHAT IS THE EFFECT OF OVARIAN CYSTS ON IVF?
In patients with cysts detected in their ovaries before treatment, treatment can be started if the cyst is less than 3 cm in diameter and does not increase the estradiol hormone level in the blood. During the use of analog needles, which are used to suppress the ovaries before treatment, simple cysts may occur as a result of the inflammatory effect of these needles. If these cysts are smaller than 3 cm but the hormone level in the blood is high, the duration of the analogue used is extended. If they are larger than 3 cm, if the size of the cyst is not reduced even though the duration of use of the needle is extended, this cyst fluid can be withdrawn with the help of a needle. The mechanical effect of the mass occupying space in the ovary is eliminated. More eggs can be obtained from these patients who undergo cyst aspiration.
WHAT TESTS DO WE DO IN CASE OF REPEATED ADJUSTMENT FAILURE?
TIB (recurrent implantation/attachment failure) is a term we use when we cannot get pregnant despite good embryos being transferred through in vitro fertilization attempts made 3 or more times before. In such cases, we usually perform some tests to reveal some conditions that may be the underlying cause; To investigate possible chromosome problems with genetic tests called peripheral karyotype, which are requested from both couples together, to take a uterine film (HSG) or perform an operation called hysteroscopy to evaluate the endometrium layer, which we call the inner wall of the uterus, to request some blood tests related to clotting mechanisms to reveal possible blood clotting problems of the woman, to request PRL and TSH tests to reveal prolactin hormone problems and thyroid gland-related problems are the points that need to be evaluated before a new trial.
WHAT IS EMBRYO GLUE?
Embryo glue is a new culture medium used during embryo transfer. It has been shown that the chance of the embryo to adhere to the uterus increases with the effect of the substance called hyaluronan it contains. In fact, the most important role in this increase is played by developments in growing embryos under laboratory conditions. In in vitro fertilization applications, reproductive cells are combined under laboratory conditions, not in the mother's body, and embryos are grown in special liquids in a way that mimics their development in the womb. This is one of the important points that limits the efficiency of treatment in in vitro fertilization applications. Laboratory conditions will never be able to fully imitate the properties provided by the mother's body. However, developments in laboratory conditions increase this similarity day by day, and in this case, it is directly reflected in the success of treatment. Embryo-adhesive is the trade name for a special culture medium. This culture medium is the liquid that houses the embryos in the catheter and carries the embryos during the transfer into the uterus. The feature of this liquid is the substance called hyaluronan. There is no study showing that adding this substance to the embryo transfer culture fluid increases the chance of embryos adhering in the uterus, but the use of embryo glue increases the chance of pregnancy. Hyaluronan is a substance whose importance has been proven in many other branches of medicine to date, and plays a role in determining intercellular connections and the unique properties of tissues. It is not clear what role this substance plays in the relationship between the embryo and endometrium. One of the most important points in treatment is to ensure good quality egg cell development. At this point, the appropriate drug protocol and drug dose must be selected correctly for the individual, egg development must be monitored accurately and meticulously, the cracking needle must be administered at the right time, and egg collection and embryo transfer procedures must be carried out in the healthiest way. Embryos cannot be attached to the inner wall of the uterus. The embryo (if it is healthy) attaches itself to the inner wall of the uterus. It is not possible for an embryo that does not have the potential to adhere to the inner wall of the uterus by any process or substance.
THINING THE MEMBRANE OF THE EMBRYO - ASSISTED HATCHING (AHA) TO WHOM AND HOW IS IT APPLIED?
Assisted hatching (AHA): It is the process of thinning the surrounding membrane or creating an opening to facilitate the attachment of the embryo to the uterine wall. AHA is applied to embryos obtained from cases aged 35 and over, to embryos that divide slowly in cases where the membrane surrounding the embryo is thick, to cases in which pregnancy could not be achieved despite good quality embryo transfer in previous attempts, to cases with borderline or high FSH hormone (12 MIU/ml and above), to embryos to be subjected to embryo biopsy, to embryos obtained after freezing and thawing.
AHA can be made by chemical, mechanical or laser methods. It is thought that this process ensures harmony between the embryo and the uterine wall and increases adhesion, especially in embryos surrounded by a thick membrane and developing slowly. In our center, AHA (embryo membrane thinning process) is routinely applied to all embryos before transfer.
WHAT IS THE IMPORTANCE OF INTRUTERINE POLYPS AND MYOMAS IN IVF TREATMENT?
Benign structures originating from the inner wall of the uterus, that is, the endometrium, which we call polyps, are important depending on their size. It is generally accepted that polyps smaller than 1 cm do not affect the outcome and course of treatment. If there are polyps larger than this size, this structure must be removed before treatment with a procedure called hysteroscopy. Myoma is a generally benign tumor arising from the muscle layer of the uterus. In the presence of a myoma, the location of the myoma, especially its proximity to the endometrium, and whether it disrupts the integrity and smoothness of the place where the embryo will be placed, called the endometrial cavity, are important. If it puts pressure on the endometrial cavity and prevents the placement of the embryo, it must be removed by hysteroscopy before treatment. The size of myomas that do not damage the endometrium is important and is usually 7 cm. Removal of fibroids may be considered. Surgery is required because myomas of this size may cause problems if they grow during pregnancy. However, if the woman is older, that is, over 38, surgery is not a priority and treatment can be started immediately in order to avoid wasting time. In summary, if there is a myoma, the decision for surgery is made considering the location of the myoma, its size, the woman's age and previous treatments, if any. Generally, treatment should be started 4-6 months after myoma surgery.
HOW DOES THE PRESENCE OF ENDOMETRIOMA (CHOCOLATE CYSTS) AFFECT IVF?
Structures known as endometriomas or chocolate cysts are structures located in the ovaries that can affect ovarian capacity, that is, the number and development of eggs. However, the size of these structures is also important. Usually 3cm. Underlying endometrioma cysts do not require surgery. For larger cases, surgery may not be considered in every patient. The decision for surgery should be made taking into account the ultrasound evaluation of the ovaries, the patient's age and previous attempts, if any.
SIS (SALINE INFUSION SONOGRAPHY, ENDOMETRIUM EVALUATION BY ADMINISTERING FLUID INTO THE uterus), TO WHOM, ACCORDING TO WHAT, HOW AND WHEN IS IT DONE AND WHAT IS ITS IMPORTANCE?
SIS (saline infusion sonography) is a procedure performed by injecting fluid into the uterus under ultrasonography guidance when there is a suspicious appearance, polyp or myoma image regarding the endometrium, which we call the inner wall of the uterus, during ultrasound examination. With the effect of the fluid given with the help of a thin catheter, information can be obtained about myomas, polyps and adhesions originating from the inner wall of the uterus. This procedure does not require anesthesia and does not cause serious pain. It is generally recommended to do it within a week after the end of menstruation. HSG (hysterosalpingography, uterine film) is an extremely important examination to reveal whether there is a problem with the woman's tubes in couples who do not have a sperm problem as a result of the evaluations. Uterine film is a type of x-ray film taken during the passage of a fluid into the uterus through the tubes. The fluid given in the uterine film may be oily or water-based. This is a technical issue and is the decision of the person shooting the film. There is no serious pain or suffering during the uterine film shooting. Sometimes, especially in women who have problems during intercourse, anesthesia may be required. With the uterine film, it can be understood whether there is a problem in the permeability and structure of the tubes, as well as problems originating from the inner wall of the uterus. Generally, the first 3-4 days after the end of menstruation are the most suitable days for filming.
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Hysteroscopy is a type of operation that allows visual examination of the inside of the uterus. It is a minor operation that can be performed under anesthesia or under local anesthesia under office conditions. However, in the presence of a large polyp or myoma, operating room conditions may be required. If a problem in the uterus is detected or suspected by administering fluid into the uterus or by ultrasound or uterine film, the inside of the uterus must be examined by hysteroscopy before in vitro fertilization treatment. Hysteroscopy is the only method for the diagnosis and simultaneous treatment, that is, removal, of intrauterine adhesions, polyps or intrauterine myomas. In hysteroscopy, the inside of the uterus is visually visualized by passing a thin instrument with an optical device on its tip through the cervix. In the meantime, the problematic structures detected can be eliminated. Generally, the patient can leave the clinic and return home 2-4 hours after the procedure. The best time for this procedure is one week after the end of menstruation.
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WHEN AND TO WHOM IS LAPAROSCOPY PERFORMED?
Laparoscopy is an endoscopic surgery in which the inside of the abdomen can be observed by entering a needle through the navel. It is the best method, called the gold standard, in revealing the damage and problems in the tubes in our patients who have problems with the tubes. It is usually done within a week of the end of menstruation and under anesthesia. You can go home after staying in the hospital for 4-6 hours. However, if there are serious problems with the tubes, for example, a large hydrosalpinx has been removed or the inside of the abdomen is detected to be very adherent, in such cases, overnight hospitalization and observation are recommended. In couples where no problems are detected as a result of the evaluations, the condition of the tubes can be determined precisely by laparoscopy. In other words, laparoscopy is an endoscopic surgery that is recommended and proven to be beneficial for couples who apply to have a child and no problems are detected in the tests performed, couples who are suspected of having problems with their tubes through uterine film, and women who have large hydrosalpinx detected with uterine film or ultrasound and need to remove these structures.
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WHAT IS THE EFFECT OF HYDROSALPENKS (FLUID ACCUMULATION IN THE CHANNELS) ON IVF TREATMENTS?
Hydrosalpinx is the name given to the swollen, fluid-filled parts of the tube that occur as a result of tube obstruction. Hydrosalpinx can usually be detected with a uterine film and sometimes during an ultrasound examination. Switching to in vitro fertilization treatments in the presence of hydrosalpinx carries some risks. The fluid in these fluid-filled swollen parts of the tube leaks back into the uterus, making it difficult for the embryos transferred to the uterus at the end of the in vitro fertilization treatment to adhere. For this reason, it is recommended to remove hydrosalpinxes, especially those that are large in size and can be observed with ultrasound, before treatment. In patients who cannot be seen with ultrasound but whose hydrosalpinx is revealed by uterine film, laparoscopy can be performed first to get a definitive idea about these structures or direct treatment can be started. While open surgery can be performed to remove these structures, an endoscopic surgery approach, usually called laparoscopy, is more preferred. In laparoscopy, these structures can be removed by entering the abdomen under anesthesia with a needle from the umbilicus and using certain tools. In patients with a lot of adhesions in the abdomen or in people who are likely to damage the ovarian reserve due to age, the relationship of these structures with the uterus can be interrupted during laparoscopy.
WHAT IS PCOS?
The condition, called polycystic ovary syndrome and defined as the presence of many cysts in the ovaries, is seen in young women and in 25-45% of women who want to have children. The reason for this definition is the typical ultrasonography finding in patients; Many follicles are arranged side by side, surrounding the ovaries in the form of a necklace. Additionally, the complaint of not having regular menstrual periods is very common. There is a complaint of long periods of menstruation and some patients complain of amenorrhea. Excessive hair growth and weight gain are frequently accompanying findings. It is one of the most common problems in women who apply to infertility centers to have children, because these women do not have regular egg development in their ovaries. Excessive weight gain affects the situation even more negatively, along with increased hair growth. Therefore, our first recommendation to our patients is to lose weight. In patients who manage to lose weight and whose height/weight index falls below 28 kg/m2, the rate of positive response to treatment increases and spontaneous pregnancies may even occur. There is increased insulin resistance in these patients, and the use of metformin, one of the drugs that increases insulin sensitivity, increases success. Pregnancy is largely achieved by applying drugs that promote egg development (clomiphene citrate, rec - FSH) in appropriate doses to women who want children. In cases where it is not successful, in vitro fertilization treatment can also be tried.
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DOES OBESITY AFFECT HAVING CHILDREN?
Body weight being higher than normal according to height is determined by body mass index. Body Mass Index (BMI): Calculated as kg/m2. It is stated that if this value is >30 kg/m2, regular egg development in women may be negatively affected. In in vitro fertilization applications, in these cases, the ovaries respond less to hormone drugs and fewer follicles develop. In addition, the distribution of fat tissue in the body is also important. Increased waist/hip circumference ratio, that is, central obesity, when accompanied by some hormonal irregularities and insulin resistance, also negatively affects pregnancy. Starting treatment after losing weight, with endocrinological (hormonal disease specialist) consultation and appropriate diet and exercise accompanied by a dietician, if necessary, will both increase the chance of pregnancy and protect patients from obesity-related problems that may occur during pregnancy. These include hypertension, gestational diabetes, large babies, difficult birth and some problems related to the baby after birth.
WHEN IS THE USE OF METFORMIN (GLUCOPHAGE, GLYPHOR, GLUCOFEN) REQUIRED?
Although metformin is a drug used in the treatment of diabetes, it is also widely used to increase insulin sensitivity in polycystic ovary syndrome, which is one of the most common causes of infertility in women. In these patients, high blood insulin levels, increased insulin resistance, and high androgen hormones that cause excessive hair growth improve after an average of 2 months of use of this drug; It is also possible for patients to menstruate regularly and become pregnant normally. The forms of metformin available in our country are glyfor, glucophage, glucofen and gluformin. 500 mg 3 times a day with meals. or 850 mg twice daily. It is recommended to take it. Liver and kidney functions should be checked before starting the medication. Side effects such as nausea and diarrhea usually subside within a week. Metformin use is continued throughout the treatment period and until the 8th–10th weeks of pregnancy. There is no information about abnormal baby birth after the use of this drug.
WHAT ARE THE GOOD DEVELOPMENT CRITERIA OF THE EMBRYO?
From microinjection or in vitro fertilization; Fertilization is observed after 16–20 hours (day 1). After 48 hours (day 2), 3-4 cell embryos are observed. After 72 hours (day 3), embryos containing 6–8 or more cells are observed and intercellular fusion begins. On the morning of the 4th day, the number of cells cannot be counted clearly and embryos that reach the morula stage are formed. The embryo on the 5th or 6th day is called blastocyst and the number of cells is more than 60. Embryos that meet these criteria are considered normally developing embryos.
HOW DO WE SELECT THE EMBRYO? and HOW DO WE PREVENT MULTIPLE PREGNANCY?
Embryo transfer can usually be done on the day immediately after fertilization, that is, between the 2nd and 5th day. When choosing the embryos to be transferred, the physician, embryologist and patient must decide together how many embryos will be transferred. When making this decision, it is worth noting that, according to the regulations in our country, the number of embryos to be transferred is limited to 3 if there is no valid reason. This number may increase in cases such as poor embryo development and advanced maternal age. According to the criteria valid in our center, the principle of giving two embryos to women younger than 35 years of age who have not had previous unsuccessful attempts, who have the so-called top quality embryos, has been adopted. This number may increase as the woman's age increases, in the presence of previous unsuccessful attempts and as the quality of the embryos to be transferred decreases, but since it is known that giving more than 4 embryos does not increase the chance of pregnancy, this number is not exceeded except in very rare cases. Additionally, when genetic research is done on embryos, the results may be limited in number. For example, in patients who have a single embryo with a healthy genetic structure or who are treated and researched in terms of HLA (Tissue compatibility) compatibility, the number of embryos is determined according to the results of these examinations.
HOW IS IT DECIDED ON WHICH DAY THE EMBRYO WILL BE TRANSFERRED?
It is decided on which day the transfer will be made by looking at criteria such as the woman's age, the reason for in vitro fertilization treatment, the results of previous attempts, if any, embryo development characteristics, whether preimplantation genetic diagnosis will be performed, the number of eggs obtained, the number of developing embryos and the daily development rate of the embryo. Transfers can be made on days 2, 3, 4, 5 and 6, the earliest being day 2 and the latest being day 6.
HOW TO DECIDE TO HOLD EMBRYOES UNTIL THE BLASTOCYST PERIOD, WHAT ARE THEIR BENEFITS?
It is possible to grow embryos beyond the 3rd day, depending on the number of eggs obtained, their quality, the characteristics of the fertilized egg (zygote), and the daily development and division rate of the embryo. In natural pregnancies, the period when the embryo reaches the uterus is the blastocyst period. The uterus accepts the embryo in this period more easily and the embryo-intrauterine compatibility reaches its highest level in this period. For this reason, transfer of 5th or 6th day embryos that have reached the blastocyst stage is more advantageous in order to increase intrauterine attachment and to protect against the risk of multiple pregnancy by allowing fewer embryos to be placed in the uterus.
IS THERE A RISK IF THE SPERM SAMPLE IS BROUGHT FROM HOME OR FROM OUTSIDE?
For example, the transition from the gel consistency when given to the liquid state occurs faster and healthier at body temperature (37°). Since sperm motility shows its true value at body temperature, the most accurate evaluation can be made on a sample that has not been kept outside. Under normal circumstances, the sperm sample to be given in a special room prepared in our center is evaluated after being kept at room temperature for 20 minutes. If the sample is to be brought from home in extreme cases, it should be kept at body temperature, under the armpit or between the palms, and delivered to the center in a period not exceeding 10 minutes.
SPERM EVALUATION RESULT
The semen sample should be collected after a 3-4 day sexual abstinence, in a clean glass or plastic container, without leaking, and preferably by masturbation. Samples must be examined within 2 hours. The best method is to take at least 2 sperm samples at 2-3 week intervals and use samples that support each other as a basis. There is no need for repetition in samples found to be normal.
Semen analysis WHO reference values:
Volume: > 1.0ml
Sperm Density: > 20 million/ml.
pH: 7.2
Vitality: > % 25
Motility (movement) > 50% (a+b motility) or 25% (a motility)
Morphology (shape) > 15% (strict criterion)
leukocyte < 1 million
MAR test (Proportion of sperm adhering to particles) < 50%
IBT (Proportion of sperm adhering to particles) < 50%
Sperm Motility is classified in 4 groups +4: Fast forward movement (a) +3: Slow, non-linear movement (b) +2: In-situ movement (c) +1: Immobile (d)
The movement of the sperm is especially related to the anatomically and functionally intact midsection and tail. Diseases such as infections, tail-related abnormalities, varicocele, alcohol, antisperm antibodies, immotile cilia syndrome may cause sperm motility disorder. Sperm morphology is as important for fertilization as its number and movement. For fertilization to occur under normal conditions, the average percentage of sperm in normal shape was found to be 30%, and if it fell below 15%, it was observed that the fertilization rate decreased. In IVF treatment, when the normal sperm rate is over 14%, the fertilization rate is 88%, when it is 4-14%, it is 63%, and when it is below 4%, it is 7.6%. According to the results of semen analysis, we can encounter 4 different situations: 1. All parameters are normal 2. Azoospermia (absence of spermatogenetic elements, no sperm found in the sample) 3. Common abnormalities in sperm count, motility and morphology 4. Isolated problems specific to one of the seminal features.
WHY IS IT NEEDED IN SOME CASES TO TAKE A SECOND OR 3RD SPERM SAMPLE IN A ROW?
In cases where the sperm count is found to be very insufficient, it may sometimes be necessary to take more than one sample to obtain more sperm. In the first example, sperm are taken from the sperm carrier channels (vas deferens). In the second example, it is possible to obtain less mature sperm in the epididymal channels. With the possibility of obtaining a higher rate of fast motile sperm, a second or rarely a third sample is needed. This procedure is performed in men whose sperm count and motility are very limited.
IF A PART OF THE EJACULATE IS LOST WHILE GIVING A SEMEN SAMPLE, WILL IT PRESENT A RISK IN TERMS OF EVALUATION?
The first part of the semen sample given is very important as it contains more sperm cells. If the first part of the sample leaks out or is lost during sperm collection, this should be reported to the laboratory staff, and if possible, the sample collection should be repeated.
WHY DO SPERM CHARACTERISTICS AND NUMBER CHANGES AT DIFFERENT TIMES?
There are many factors that affect semen parameters. Diseases, medications used, chemical and environmental factors affect sperm characteristics. For this reason, if medication has been used and there is no febrile illness, the method adopted in our center is to evaluate at least two sperm samples every 3-4 weeks and make a decision based on the average of these samples.
WHAT SHOULD BE DONE IF THE NUMBER OF SPERM IS TOO LOW OR NO SPERM IS FOUND IN THE SPERM TEST?
First of all, men are evaluated by a urologist. After the necessary hormonal and genetic examination (such as chromosome analysis, Y chromosome and microdeletion, FTR mutation) is performed, the woman begins to prepare for treatment. TESE, TESA, MESA, PESA are the methods to be used to obtain sperm. If no reproductive cells are found, treatment is discontinued.
WHAT ARE THE REASONS IN PATIENTS WHO HAVE NO SPERM IN THE SEMEN ANALYSIS?
In case of no sperm in the semen, which we call "Azoospermia", there can generally be two reasons: Sperm production in the testicle has decreased or there is sperm production but there is a problem in the channels that provide the ejaculation. These two reasons can be detected as a result of the patient's examination and hormone tests. In recent years, genetic analysis has become very important with the emergence of the importance of new genes in male infertility.
HOW IS TREATMENT APPLIED IN CASES OF INFERTILITY DUE TO LACK OF TESTICULAR SPERM PRODUCTION?
In patients with high levels of the hormone secreted from the brain and enabling sperm production and small testicle sizes, it is possible to become biological fathers by finding sperm from the testicle and micro-injection method. In the past, multiple biopsy methods were used to find sperm by randomly taking tissues from various parts of the testicle. In our center, we conduct testicular sperm research with a new surgical method under the microscope, which will be a pioneer in Turkey. First in the world, NY Cornell Medical Faculty. We apply this method successfully in our center. In the new operation technique, the testicle is completely opened with a single incision, the tissue is magnified 20 times with a microscope, the areas where sperm production is detected and tissue samples are taken from those areas. Therefore, the chance of success is higher than the random method used in the past and it is possible to obtain a higher number of sperm. The patient's tissue loss is very low in the microsurgical method. This ensures minimal damage to the testicles from the operation and minimally affects the testosterone hormone release of the testicles. Another advantage of the microsurgical method performed under a microscope is that the vascular structure in the capsule surrounding the testicular tissue is seen and the incision is made without damaging the vessels feeding the testicle. This minimizes possible complications after the operation. With this method, we find sperm rates as high as 55-65% in our patients who were not successful with the old operation method and who previously had sperm deficiency due to some genetic structural reasons.
WHAT IS MICRO TESE?
Male infertility accounts for approximately half of this rate among childless couples in society. In other words, male factor may be a problem in approximately half of infertile couples. In cases related to men such as azoospermia (no sperm), retrograde ejaculation (ejaculation of sperm backwards), as well as women's age factor, it may be necessary to start treatment without waiting for this period. In vitro fertilization treatment has allowed men to have children even if there is no sperm in their semen. However, performing this procedure requires the presence of even a small amount of sperm production in the patient's testicles. In other words, sperm must be obtained from the patient's testicles. Obtaining sperm from the testicles is done using different methods depending on the patient's condition. Testicular biopsy may be performed in men whose semen analysis does not detect any sperm. With this procedure, the reason for the absence of sperm is revealed. In other words, this method reveals whether it cannot be seen in the semen because sperm cannot be produced or whether it cannot be seen in the semen because there is an obstruction. TESE is a method used to find small sperm-producing foci within the testicle in cases with severe disorders in sperm production. The presence of sperm is investigated by taking a few millimeter-sized pieces from a few foci from the testicle. Microtesting is the process of finding sperm from tubes where sperm is produced under a microscope. With this method, there is a 36%-68% chance of finding sperm in cases that are not due to obstruction, that is, in cases where there is a problem in sperm production. With the microtese method, the chance of finding sperm in each biopsy increases with less testicular tissue. In other words, this chance is higher than the classical TESE procedure. Another advantage is that it minimizes vascular injuries in the testicular tissue area during biopsy and helps the embryologist find sperm more easily in small pieces.
HOW LONG SHOULD THE PATIENT HAVE TO REST AFTER MICRODISSECTION TESE?
Since the patient receives general anesthesia after the operation, he is kept under observation for 2-3 hours and then sent home. Dressing and control are performed 2 days after the procedure. It is recommended to avoid excessive physical activity, long journeys, and long-term driving for an average of 7 days. Sexual activity should not be performed for 15 days.
IS GENERAL ANESTHESIA USED DURING SPERM RECRUITMENT BY SURGICAL METHOD?
The process of finding sperm from the testicle can be performed in two ways: under local and general anesthesia. Procedures performed under local anesthesia include obtaining sperm from the testicle with a needle (PESA-TESA) or removing testicular tissue with a small incision (TESE). These methods can be chosen when it is certain that sperm is produced in the testicle and there is no sperm in the semen due to obstruction. In our center, the process of finding sperm from the testicle under a microscope (Microdissection TESE) is applied to patients with sperm production disorder in the testicle and no sperm in the semen. General anesthesia is used in the operation performed with this method. When using an operating microscope, general anesthesia is preferred since it is difficult for the patient to lie still for a long time with local anesthesia. The operation performed under microscope guidance has many advantages over the previously applied local multiple testicular biopsy method. The structures within the testicle are examined in great detail with an operating microscope at x20 magnification and samples are collected from the areas where sperm is produced. During the testicular incision, areas with low vascularity are selected using a microscope and the incision is made, which minimizes the bleeding that will occur during the operation. It also ensures the protection of the vascular structure that nourishes the testicle. Since very little tissue is removed (70 times less than multiple biopsies), it does not cause a decrease in the level of testosterone hormone in the blood.
THE IMPORTANCE OF GENETIC EXAMINATION IN MALE INFERTILITY
In recent years, advances in the field of genetics have enabled us to obtain very important information about the causes of male infertility. Deletions in the genes on the Y chromosome, one of the sex chromosomes, cause a decrease in sperm production in the testicle or no sperm production at all, even though the body structure and functions are normal. Likewise, in genetic diseases such as number anomalies in sex chromosomes, such as the most common 47 XXY Klinefelter syndrome, testicular development may be inadequate and sperm production may be reduced. In addition, if the ducts that carry sperm from the testicles are not present at birth, although there is normal sperm production in the testicle, sperm cannot be seen in the semen because there is no way out. This is genetically caused by a disease called Congenital Bilateral Vas Deferens Agenesis (CBAVD). In our center, all genetic examinations performed in the world for male infertility are performed.
WHAT IS SPERM FISH AND TUNEL TEST?
These are diagnostic tests that can be applied to couples with recurrent miscarriages or those with morphological defects in the sperm. They are evaluated differently in terms of their results. Sperm prepared in Sperm FISH application are marked with fluorescent dye and examined for some chromosomes. The aim here is to determine how much of the sperm is defective in terms of genetic material. If this rate is increased, the selection of suitable sperm alone will not be sufficient and the embryos will need to be genetically screened. TUNEL test, on the other hand, examines the integrity of the filamentous structure (chromatin) rather than the chromosomal disorder of the genetic material in the sperm. Sometimes, even if the sperm is numerically normal, it may show partial or complete degeneration due to various effects, and the existence of such a condition can be determined by this test. If this condition is determined by the TUNEL test, the negative effects that may cause DNA fragmentation in the sperm (breakdown in genetic material) in channels other than the testicle should be investigated and sometimes TESE procedure can be applied when necessary.
WHAT ARE SPERM WASHING TECHNIQUES?
1-Swim-up
2- Gradient (Precipitation)
Svim-up: It is the process of obtaining mobile and fast sperm cells by washing the ejaculate (sperm) sample taken from the patient with midium. Note: The Svim-up method is applied to sperm samples with good motility, number and morphology. Gradient: It is the process performed by filtering and settling the ejaculate sperm sample taken from the patient through a special medium. Note: Gradient method number is applied to sperm samples with impaired motility and morphology. The aim of both washing techniques is to obtain the best quality sperm cells and apply them in a procedure deemed appropriate by the doctor.
DOES BIOPSY PROCEDURE FOR GENETIC DIAGNOSIS PURPOSES HAVE HARM ON THE FURTHER DEVELOPMENT OF THE EMBRYO?
When the biopsy process is performed under appropriate technical conditions and by experienced people at a time when the embryo contains 7 or more cells (blastomeres), it does not harm the further development of the embryo.
ARE THE EMBRYOES TREATED BEFORE THEY ARE TRANSFERRED?
"Assisted Hatching" (shaving, peeling) process is routinely used on the 3rd day of embryo development. This procedure is applied to people over 35 years of age, with high basal hormone levels, in cases where pregnancy has not occurred despite good embryo transfer in previous applications, in cases where the egg membrane is thick, in cases where unwanted residues need to be cleaned, and in cases where a biopsy will be taken for genetic research.
WHAT IS THE LASER METHOD? IS IT USED BY YOU?
During the process of thinning the membrane surrounding the embryo, a laser device along with mechanical procedures and acid is applied to shave the outer wall. A laser device is used in our hospital. The superiority of laser use over other methods has not been demonstrated.
WHAT ARE THE REASONS FOR TRANSFERRED EMBRYO FAILURE TO CURRENT DESPITE THEY BEING OF GOOD QUALITY?
In case of recurrent failure despite the transfer of 2-3 good quality embryos, couples should first investigate with further examinations. Such as genetic examination of men and women, possible endocrine diseases, the presence of factors that increase blood clotting, evaluation of the inside of the uterus by hysteroscopy or hysterophygraphy. However, in approximately 20-25% of patients, no cause can be considered. In cases where no cause is found despite the factors investigated, further immunological examinations (for both partners) are required.
CAN EMBRYOS BE FROZEN?
In our center, embryo freezing is done when more embryos of good quality are obtained than the number required for transfer. If there are at least 3-4 more embryos of similar quality to the transferred embryos, freezing is performed. Embryos l. It is frozen between the 5th and 5th days. Frozen embryos are stored in our hospital for no longer than 3 years, in accordance with the regulations published by the Ministry of Health.
IS THERE A CHANCE OF ETERNAL PREGNANCY DURING IVF TREATMENT?
As with naturally occurring pregnancies, ectopic pregnancy can be seen in 2-3% of patients undergoing IVF. In fact, this rate is slightly higher than the rate of ectopic pregnancy that occurs in spontaneous pregnancies. Because in some women who require in vitro fertilization, the reason is problems in the tubes. Sometimes, if these problems cause a partial blockage instead of completely blocking the tube, it may be possible for the embryos to pass into the tube after the transfer and cause an ectopic pregnancy. Patients whose blood pregnancy hormone levels do not rise sufficiently after IVF treatment are followed up for ectopic pregnancy. Later, the diagnosis is made by not detecting pregnancy on ultrasonography despite a certain hormone level or by monitoring the pregnancy outside the uterus with USG. In patients diagnosed with ectopic pregnancy, the treatment is usually surgical, mostly laparoscopic. In some patients, the ectopic pregnancy may regress with observation alone or may be terminated with an external medication (Methotrexate).
WHAT EXAMINATIONS ARE DONE IF PREGNANCY DOES NOT OCCUR DESPITE MANY APPLICATIONS IN IVF TREATMENT?
TIB (recurrent implantation/attachment failure) is a term we use when we cannot get pregnant despite good embryos being transferred through in vitro fertilization attempts made 3 or more times before. In such cases, we usually perform some tests to reveal some conditions that may be the underlying cause; To investigate possible chromosome problems with genetic tests called peripheral karyotype, which are requested from both couples together, to take a uterine film (HSG) or perform an operation called hysteroscopy to evaluate the endometrium layer, which we call the inner wall of the uterus, to request some blood tests related to clotting mechanisms to reveal possible blood clotting problems of the woman, to request PRL and TSH tests to reveal prolactin hormone problems and thyroid gland-related problems are the points that need to be evaluated before a new trial.
WHAT DO HIGH FSH VALUES Indicate? AT WHAT FSH VALUE IS DOUBLE TREATMENT NOT ACCEPTED?
FSH (Follicle Stimulating Hormone) hormone is a hormone released from the pituitary gland in the brain and stimulates the woman's ovaries, ensuring the development of eggs in structures called follicles. In women whose ovarian reserve has decreased, that is, whose egg development and hormone secretion capacity has not decreased, the FSH hormone begins to gradually increase and tries to compensate for this deficiency. This rise is the body's natural mechanism of maintaining balance. Generally accepted; The fact that the FSH value measured on the 3rd day is below 10 mIU/ml reflects that the ovarian reserve is normal. Higher values indicate that the ovarian reserve is decreasing. At values between 10 and 15, it is understood that fewer eggs will be obtained from the treatment and the chance of pregnancy decreases. It is known that the chances decrease significantly at values between 15 and 20. At day 3 FSH levels higher than 20, it is unlikely that results will be achieved with In Vitro Fertilization Treatment and pregnancy will occur. Therefore, at higher values, treatment is generally not initiated without informing the couple.
DOES USE OF HIGH DOSES OF HORMONE DAMAGE THE OVARIAS?
In studies conducted to date, it has not been scientifically shown that the drugs and hormone applications used in in vitro fertilization treatment harm the ovarian capacity. However, it is known that the ovarian reserve in women aged 35 and above decreases rapidly over the years, and it is clearly observed that the response of the ovaries decreases in trials performed with a break of one or two years at this age.
HOW LONG SHOULD BE THE TIME BETWEEN TWO IVF TREATMENTS?
For the second attempt, a break of approximately 2 months is sufficient. In people whose ovaries contain a large number of eggs and have reached large sizes, they are expected to return to normal sizes. In women with a small number of eggs and small ovarian size, the second attempt can be started even after 1 month. There was no difference in the success of treatment between a longer break and a shorter break. What is important in the length of the interval to be given is that the couple is financially and morally ready for a second treatment. It is known that although the chance of pregnancy remains approximately the same for each attempt for the first three attempts, the chance decreases slightly in subsequent attempts.
IF IVF FAILURES FAILS, WHEN CAN WE GIVE FROZEN EMBRYOS?
After an average of 1-2 months, frozen embryos can be thawed and transferred to the mother's womb. This procedure can be done by using drugs that thicken the uterine lining for only 2 weeks, and two ultrasonography examinations during the treatment are also sufficient. Therefore, it is a much easier and less expensive form of treatment than normal in vitro fertilization treatment.
CAN WE DETERMINE GENDER IN IVF TREATMENT?
No, this method is strictly prohibited by law in Türkiye. However, there may be a genetic disease that is transmitted depending on gender. In this case, gender determination can be made with PGT.
WHAT IS THE ROLE OF GENETIC FACTORS IN THE OCCURRENCE OF INFERTILITY?
Today, reduced fertility is detected in approximately 15% of couples. In most of these cases, the cause is male infertility. The pathogenic cause of male infertility, especially in people without sperm, is obstructive azoospermia, characterized by decreased sperm production due to Y chromosome microdeletions or congenital absence of the vas deferens due to cystic fibrosis transmembrane regulator (CFTR) gene mutations. In addition, numerical anomalies in sex chromosomes and structural chromosome disorders cause problems in spermatogenesis and therefore in fertilization. In addition, KAL (X-linked inherited Kalman syndrome), DAX1 (X-linked inherited Congenital Adrenal Hypoplasia), GNRHR (GnRH secretion disorder) and PC1 (prohormone convertase 1) gene mutations that cause hypogonadotropic hypogonadism and Androgen Receptor gene mutations can be observed together with spermatogenesis failure. In addition, carriers of some genetic disorders may be observed in couples with a history of recurrent pregnancy losses or stillbirth, which are called secondary infertility.
DOES THE RISK OF CHROMOSOMAL DISORDERS IN THE BABY INCREASE DURING ICSI?
ICSI, or microinjection, is performed by mechanically introducing sperm into the egg, selected according to criteria such as shape and motility. This situation causes some steps that must occur naturally for fertilization to be skipped and is thought to cause the formation of new chromosomal disorders in embryos that are not inherited from the mother or father. These disorders can occur numerically or structurally in the 23 pairs of chromosomes. While numerical disorders can be observed as single chromosomes (monosomy) or three (trisomy), structural disorders are observed as interchromosomal part exchange (translocation), microdeletion, and duplication. However, most of these problems can end in miscarriages in the early stages of pregnancy, and very few of them lead to live birth. Genetic disorders have an important place among the causes of miscarriages, but there are many other factors as well. Today, it is debated whether microinjection applications increase minor congenital defects.
IS IN VIBIT BABY RELIGIOUSLY HARAM?
In the repeated statements made by the members of the Presidency of Religious Affairs and the Supreme Council of Religious Affairs, it has been stated that in vitro fertilization is not haram according to Islam. In in vitro fertilization, the aim is to have a child. It is absolutely not a sin for the man's sperm to be placed in the uterus of the woman he is married to and the birth event occurs. The Islamic religion is open to all kinds of formations that are not sins. Claims coming from unauthorized sources and hearsay should not be relied upon.