Methods of Treatment

Ovulation Induction

In a woman with regular menstruation, one egg is selected from the ovaries every month, and if this egg ruptures at the time of ovulation and encounters sperm in the tubes, fertilization occurs. However, this will not happen in women who do not have regular periods and have ovulation problems. Therefore, the aim of ovulation induction is to ensure the development of one or two follicles with the medications given. When the follicle matures, the trigger hormone to be added will enable this egg to mature and crack. Performing a timely intercourse or intrauterine insemination (vaccination) 36 hours after the application of the trigger hormone will increase the chance of pregnancy. In order to perform these procedures, the tubes must be open, sperm examination must be normal and it must be proven in advance that there is no other condition that can prevent pregnancy.

Intra-uterine insemination (IUI)

This is the process of selecting the best motile sperm and delivering them into the uterus with the help of a thin catheter. The semen sample is prepared then separated from seminal plasma, cell residues and leukocytes, and fast-moving sperms are selected and delivered into the uterus.

The fastest moving sperm obtained after the procedure is injected into the uterus through a catheter. By this way, the vagina and cervix are passed and the sperm is placed closer to the egg. The procedure is completely painless and does not require anesthesia. The ovulation induction methods mentioned above are used to develop the eggs before IUI. The chance of success with IUI in unexplained infertility cases varies between 15-18%.

IVF processes

In case of failure with conventional treatment methods or in case of presence of any of the following factors, in vitro fertilization processes can directly be started.

Severe male factor (severe defect in sperm parameters, significant decrease in sperm count (<5 million/mL), lack of mobility, severe deformity or non-availability of sperm in semen)

Tubal factor (adhesion or obstruction in the tubes or surgical removal of the tubes)

Severe endometriosis

Long-term (over 3 years) and unresponsive to other treatments, unexplained infertility cases

Unresponsive ovulation problems to conventional treatments

Elder maternal age (>38 years) or cases where egg reserve is significantly reduced

Single gene disorders and the cases which require HLA-compatible embryo selection

IVF treatments consist of the following steps:

• Superovulation (controlled ovarian hyperstimulation, KOS)
• Egg collection process (OPU)
• Fertilization in a laboratory environment
• Embryo culture, embryo freezing (FET) if necessary
• Embryo transfer (ET)

The first stage of IVF procedures is known as controlled ovarian hyperstimulation, COS, which aims to ensure the development of a large number of eggs. For this purpose, the woman's ovarian reserve, age, weight, and previous treatments, if any, are evaluated and the medication use protocol and medication doses that may be most suitable for the female patient are decided. These decisions are made according to the patient and customized treatment protocols are adopted. Therefore, the treatment may differ from one patient to another.

• Treatment protocols:

In IVF applications, the aim is to obtain a sufficient number and quality of eggs from the woman. In applications, the choice of protocol varies according to the patient. In this selection, the experience and success of the IVF center are important criteria. Egg augmentation is achieved by means of a protocol selected in accordance with the woman's age, ovarian reserve, hormone values, body mass index, and responses to previous treatments if any. In COS treatments, which can be applied in different ways according to the characteristics of the cases, the eggs are brought to a certain stage of maturation with the help of stimulating medications called a gonadotropin. In this process, medications called agonists or antagonists are used to prevent the eggs to crack at an undesirable time.

• Egg Collection Process (OPU)

Egg collection is performed vaginally under mild anesthesia (sedoanalgesia). Thus, you will be asked not to eat or drink anything as of 12:00 p.m. on the previous evening and to come to the center hungry at the agreed time in the morning.

For the relevant procedure, an injection attached to the ultrasonography probe is used and the egg inside the follicle is aspirated by ultrasound by entering into each follicle. Most of the time, the procedure is easily tolerated and does not cause any serious pain. If you feel pain after the procedure, you can take paracetamol tablets. At the end of the procedure, you will be fed with liquid foods for a while and allowed to leave the hospital after being kept under observation for approximately one or two hours. Although rare, complications such as bleeding and infection may arise out of egg collection procedures. In such a case, if you are under observation at the hospital or bleeding is suspected, laparoscopy may rarely be required.

It is recommended that you contact your doctor if any of the following symptoms occur after the egg collection procedure.

• Fever of 38 C° or higher,
• Excessive vaginal bleeding (mild or staining bleeding is normal),
• Along with the increased pain 8-10 hours after the procedure; weakness, fainting sensation, pain hitting the shoulders,
• Sudden weight gain, nausea, vomiting, diarrhea, difficult breathing, abdominal distension

The obtained eggs will be fertilized with your spouse's sperm on the same day using IVF or ICSI methods. Sperms taken from the patient's spouse are left around the eggs obtained in the IVF (in-vitro fertilization) process and the sperms are expected to fertilize the egg. ICSI (intracytoplasmic sperm injection-microinjection) method is now preferred by many centers due to its much higher success rates and is routinely applied in our center (Video-2). In this method, a sperm selected for each egg is injected directly into the egg using microscopes that provide 200-400 times magnification with the help of micropipettes. The microinjection procedure in our country was first performed in 1994 by Prof. Semra Kahraman, MD, and her team, and the first live births were delivered. Sperms obtained from ejaculation or testicles can be used for microinjection, and whether the eggs are fertilized or not is controlled on the next day. Embryos obtained from fertilized eggs are checked every day for their development. In our center, embryos are cultured mostly until the 6th day and assured to reach the blastocyst stage.

• Embryo transfer

The embryos to be selected on the 3rd-4th or 5th-6th days after the egg retrieval process are transferred into the uterus with a thin catheter (Video 2). The day on which the embryos are to be transferred is determined by the joint decision of our doctors and embryologists according to the development status of your embryos. Embryo transfers are the last step of the IVF procedure and constitute an extremely important procedure. Embryo transfer under appropriate conditions is a factor that increases success in IVF treatment and its importance cannot be ignored. Therefore, the attention and care of the doctor and embryologist who will perform the transfer is of great importance as well.

One of the most important factors determining the success of IVF procedures is the quality of the transferred embryos. The transfer of a large number of embryos does not increase the chance of pregnancy, but it also leads to the risk of multiple pregnancies. Multiple pregnancies increase the occurrence of serious risks such as premature birth and accordingly inadequate lung development, the tendency to infections, and mental retardation in infants. In addition, both the mother and the developing infants may encounter many medical problems during pregnancy. Therefore, the Ministry of Health has imposed a limitation on the number of embryos to be transferred in order to reduce the risk of multiple pregnancies. In our center, in order to enable the selection of the best embryo, especially in cases where a large number of good embryos develop, embryo transfer is preferred on the 6th day (blastocyst period). The best single embryo selected during the blastocyst period is transferred, thus increasing the chance of pregnancy while reducing the risk of multiple pregnancies, and the remaining good embryos are frozen and stored upon the consent of the couples.

Besides, all embryos that develop in some risky situations may need to be frozen necessarily. All obtained embryos are frozen, in particular, if excessive stimulation of the ovaries (OHSS: Ovarian Hyperstimulation Syndrome) develops due to hormone medications given for egg development in patients with high ovarian reserve. Embryo transfer is performed 1-2 months after egg collection.

In addition, in patients who are planning to undergo preimplantation genetic diagnosis, all of the embryos are frozen, if the intrauterine tissue is not of sufficient thickness to adhere to the embryo during treatment, in cases such as large polyps, excessive fluid accumulation in the uterus before the transfer or fluid monitoring in the tubes.

The basic principle in embryo transfer is to place the embryo at the point to be determined in the uterus with as little trauma as possible. Since it is a painless procedure, it does not require anesthesia. In order to facilitate embryo transfer, a catheter transfer rehearsal is performed on the day the patient comes for the first examination and thus precautions are taken for possible difficult transfers.

In order to determine the most appropriate place where the embryos will be given in the uterus and not touch the intrauterine membrane, it is preferred to perform the embryo transfer procedure with a full bladder (urinary bladder) and accompanied by ultrasonography. In this way, the angle between the cervix and the uterus is determined, and the route of the transfer catheter is determined so the procedure is held in a less traumatic manner. The use of ultrasound with high resolution also affects the success positively by providing a better view of the transfer process.

During the transfer process, the mucus in the cervix is cleaned with a sterile rod, and the embryos are left in the uterus with the help of a thin and soft catheter. The choice of a soft catheter in transfer also reduces the risk of bleeding in the cervix. Since the ends of the catheters we use can be observed by ultrasonography, the point where the embryos will be left in the uterus can clearly be determined. After the transfer of the embryos loaded into the catheter is done gently, the catheter is slowly removed and our embryologists check that all of the embryos are transferred under the microscope.

After the embryos are placed in the uterus, a half-hour rest is sufficient. Longer bed rest has not been proven to increase the chance of pregnancy.

Prepared by the Medical Editorial Board. Our health library contents have been prepared for informational purposes only and with the scientific content on the registration date. For all your questions, concerns, diagnosis or treatment about your health, please consult your doctor or health institution.