Tüp Bebek (IVF / ICSI) | Burcindemirel

In Vitro Fertilization (IVF/ ICSI)

IVF treatment and suitable candidates

In vitro fertilization (IVF/ICSI) is a treatment method that we use to increase fertility in patients who want to get pregnant but are unsuccessful, when the first-line treatments of ovulation induction (OI) or insemination (IUI) do not provide results, or when these treatments are not suitable at the beginning.

In vitro fertilization treatment is the process of retrieving eggs from the ovaries, which have been stimulated to mature with medication, and then fertilizing them with the partner's sperm in a laboratory environment and then transferring them into the uterus as fertilized eggs, or embryos.

Who are suitable candidates for IVF?

Women with missing or blocked fallopian tubes
Women who have endometriosis and are unable to conceive after medical or surgical treatment for this condition
Women with impaired ovulatory function who are unable to conceive after regular ovulation induction and/or insemination
Women with unexplained infertility
Women with sperm problems in their partners
Families who are offered pregnancy after preimplantation genetic testing (PGT) for chromosomal or genetic reasons

IVF process

After your detailed medical history is taken by your IVF specialist, a physical examination, an ultrasound and HSG evaluation, and appropriate blood tests are performed, your personalized treatment is planned for you. In line with this plan, your treatment usually begins on the 2nd-3rd day of your menstrual period (sometimes from the last period of the previous period, depending on the treatment chosen) with injections that you can comfortably administer at home, as described to you in full detail.

The first step of treatment:

Controlled Ovarian Stimulation (COS) and Monitoring of Follicular Development

Hormone injections are prescribed to stimulate the follicles in the ovaries to produce healthy, mature eggs for an average of 10-12 days (the duration varies depending on the response of your ovaries to the treatment). You will usually be invited to the clinic in the morning on the 5th day of starting the hormone injections to perform the first control ultrasound and give blood tests to follow up on the treatment. At this stage, another hormone injection is added to your treatment to prevent your eggs from cracking early. Afterwards, you will need to be followed up with blood tests and ultrasounds at 1-3 day intervals to monitor your response to the treatment and to determine the timing of the cracking injection. Egg cells develop inside fluid-filled cysts called follicles. When the follicles reach a mature size, another hormone injection is given to complete the maturation of the eggs. This is also administered with an injection that you can do yourself at home. Egg collection will be performed 34-36 hours after this injection, which is described as the cracking injection.

Up to 20% of treatments may have to be cancelled prior to egg collection. Treatment cancellations are usually due to insufficient follicle development or inadequate response, and are more common in women over the age of 35. When cycles are cancelled due to poor response, alternative medication strategies can be planned to ensure a better response in a future attempt. Sometimes a cycle may have to be cancelled to reduce the risk of ovarian hyperstimulation syndrome (OHSS). Another reason for cancellation is premature ovulation. Despite the use of various medications to prevent this condition, a small percentage of cycles experience LH surges and ovulation early. When this occurs, the cycle may be cancelled because it is not known when the LH surges will start and when the eggs will mature.

Egg collection

The egg collection procedure (OPU) is performed in an operating room environment under light sedation, 34-36 hours after the trigger needle. Under ultrasound guidance, the follicles are reached vaginally with an egg collection needle and the follicle fluid is aspirated. This fluid is evaluated by embryology specialists to examine the presence of an egg. If present, the maturity level of the egg is determined.

Fertilization and Embryo Culture:

Once the eggs are retrieved, they are examined in a laboratory for maturity and quality. Fertilization of mature eggs can be accomplished through conventional IVF, where motile sperm are separated from the semen, usually obtained by masturbation (alternatively, sperm can be obtained from the testicles, epididymis, or vas deferens of men who have no sperm in their semen due to blockage or lack of production) and placed with the oocytes and incubated overnight, or through intracytoplasmic sperm injection (ICSI), where a single selected sperm is injected directly into each mature egg.

Conventional IVF

Conventional IVF is a method that allows eggs to be naturally fertilized with sperm in a laboratory environment. The collected mature eggs are brought together with motile sperm prepared in a special nutrient medium and kept in an incubator overnight. Once fertilization occurs, embryo development is monitored and the highest quality embryos are selected for transfer to the uterus. This method is preferred in cases where sperm quality is sufficient and is one of the in vitro fertilization applications closest to the natural selection process.

Intracytoplasmic sperm injection (ICSI)

In this method, the cell layer surrounding the egg (cumulus cell layer) is removed by the embryologist and it is determined which eggs are mature or immature. Then, under a microscope, sperm with normal shapes (including head, tail and the connection between head and tail) and normal swimming function are selected one by one and a single sperm determined to be normal is injected into each mature egg with a special glass needle.

The next day, visualization of two pronuclei confirms that the egg has been fertilized. One pronucleus has developed from the egg and the other from the sperm. After IVF or ICSI, 65% to 75% of mature eggs are generally fertilized. Lower rates may occur if the sperm and/or egg quality is poor. Sometimes, fertilization may not occur at all, even if ICSI has been used. Two days after egg retrieval, the fertilized egg divides to become a 2- to 4-cell embryo. By the third day, a normally developing embryo will contain about 6 to 10 cells. By the fifth day, a fluid space forms inside the embryo, and the placenta and fetal tissues begin to separate. An embryo at this stage is called a blastocyst. Embryos can be transferred to the uterus anytime between 1 and 5 days after egg retrieval. (usually day 3 or 5) If it continues to develop successfully in the uterus, the embryo will hatch from the surrounding zona pellucida and implant in the endometrium/lining of the uterus approximately 6 to 10 days after egg retrieval.

Embryo Transfer

The next step after fertilization is embryo transfer. On the gynecological examination table, while your bladder is full, your IVF specialist will use a vaginal speculum to visualize the cervix. The tip of the transfer catheter, which is placed in the cervix under ultrasound guidance, is gently advanced to the inner border of the cervix. After the fluid containing one or more embryos suspended in a specific culture medium in the embryology laboratory is transferred to the correct location of your uterus by passing through the catheter, which has been prepared in advance and is placed in the cervix, with a transfer catheter (a long, thin sterile tube) that has a syringe at one end. The procedure is usually painless, but some women may experience mild cramping during the procedure.

The maximum number of embryos transferred is planned to be 1 or 2, in accordance with the rules set by a regulation, based on the patient's age and other individual patient and embryo characteristics. Since each embryo has a reasonable probability of implantation and development, the number of embryos to be transferred should be determined for each patient and the probability of achieving pregnancy based on the number of embryos transferred should be calculated by comparing it with the risk of multiple pregnancies.

Egg Freezing

After embryo transfer, any embryos that are not transferred can be cryopreserved (frozen) for future transfer. Cryopreservation makes future IVF cycles, if necessary, less costly and less invasive, as there are no treatments or follow-ups until embryo transfer. Embryos can be stored for long periods of time after they are frozen (live births have been reported using embryos frozen for 0 years).

Not all embryos will survive the freezing and thawing process. Before undergoing IVF, a decision must be made as to whether to cryopreserve any excess embryos.

Pregnancy Test

The first pregnancy test is usually done with a blood test about 10 days after embryo transfer. Pregnancy hormone levels are monitored with blood tests every few days in the early stages of pregnancy, then once the pregnancy is more developed and the beta hCG level exceeds 1500 iU/ml, an ultrasound should be performed to determine if the pregnancy is present and that it is in the uterus.

Risks of Assisted Reproductive Treatments (ART)

The Medical Risks of ART Depend on Each Specific Step of the Procedure

Controlled Ovarian Hyperstimulation (COH) carries the risk of ovarian hyperstimulation, where the ovaries grow excessively and can lead to serious health issues (OHSS).
In Ovarian Hyperstimulation Syndrome (OHSS), fluid can accumulate in the abdominal cavity and chest, and women may experience bloating, nausea, vomiting, or loss of appetite. Up to 30% of women undergoing ovarian stimulation may develop mild OHSS, which can usually be managed with pain relievers and reduced activity.

In moderate OHSS, fluid accumulation in the abdomen may occur and gastrointestinal symptoms may develop. These women are closely monitored and generally respond well to simple outpatient treatments. This condition usually resolves on its own unless pregnancy occurs, in which case rising hormone levels may delay recovery by a few weeks. In about 2% of women, severe OHSS can develop, characterized by excessive weight gain, fluid accumulation in the abdomen and chest, electrolyte imbalances, blood thickening, and in rare cases, blood clots, kidney failure, or death.

If breathing becomes difficult, draining fluid from the abdomen with a needle may be medically necessary. Women with severe OHSS typically require hospitalization until symptoms improve. If pregnancy occurs, OHSS may worsen. In some severe cases, pregnancy termination may be considered.

Although early reports suggested an increased risk of ovarian cancer in women using fertility drugs, numerous recent studies support the conclusion that fertility drugs are not linked to ovarian cancer. However, uncertainty remains about whether there is any risk, and research on this topic is ongoing. Regardless of prior ovulation drug use, all women are advised to have annual gynecological exams for ovarian screening.

There are also risks associated with the egg retrieval procedure. Using an aspiration needle to collect eggs can cause bleeding, infection, and damage to the bowel, bladder, or blood vessels. Fewer than 1 in 1,000 patients will require major surgery to repair complications from the egg retrieval process. In rare cases, infection may occur due to OPU (Ovum Pick-Up) or embryo transfer.

In all assisted reproductive technologies, transferring multiple embryos increases the likelihood of a multiple pregnancy. While some may consider twins a happy outcome, multiple births are associated with many complications, which become more severe and common with triplets and each additional fetus. Women with multiple pregnancies may need to remain in bed or hospitalized for weeks or even months to delay premature birth. The risk of preterm delivery is high, and some babies may be born too early to survive.