Steps in IVF treatment

For an effective treatment, acquiring sufficient and high-quality sperms and eggs (ova) is essential. There are many ovarian stimulation protocols applied in this respect. Decision about which of these treatments are applicable to you is taken in the light of the data (age, ovarian count, body mass index, smoking, procedure characteristics – PGD) taken from you.

Treatments and medications applied are as follows;

Long-protocol: Starts generally at the 21st day of the menstrual period of the previous month for the patients with sufficient ovarian reserve. Priorly, a contraceptive pill may also be given. Lucrin, Decapeptyl,Synarel nasal spray are administered at certain doses and the self- control system of your body is suppressed. The purpose is to prevent the operation of the ovaries beyond our control. These medications are pursued until the egg (ovum) is collected.When you menstruate, ovary stimulating medications specifically chosen for you (puregon, gonal-f, megonon, menopur, merional,fostimon) are given for 10-12 days.

Short protocol (antagonist): At the 2nd or 3rd day of menstrual bleeding, ovary stimulating medication
is given after examination. Depending on your response to the treatment, medications like orgalutran or cetrotide are added at certain days of the treatment in order for your egg not to be ovulated early. This treatment can be applied to all patient groups, but it is particularly applied to patients with ovarian reserve.

Co-flare and microdose protocol: This treatment is applied mainly to the patients with decreased ovarian reserve.The treatment in Co-flare protocol is applied by beginning lucrin or decapeptyl in the 1st or 2nd day of menstruation and by adding ovary stimulating medication in the following
days. As for microdose protocol, following the use of contraceptive pills for 21 days, the medication called LUCRIN is diluted and injected at certain doses and in the following days, the other stimulating medications are added.

The Modified protocol in which co-flare and antagonist protocols are applied together (ultrashort agonist + antagonist protocol). Addition Clomiphene or Letrozole into the Antagonist Protocol

After choosing the appropriate protocol, a 10-12 days follow-up period starts. In this period, the patient comes to the clinic 3-4 times for an ultrasound examination and if required, a hormone analysis (estradiol, lh, progesterone) is performed and the response to the treatment is controlled. Addition or reduction of the medications are done according to the results. The treatment continues until follicles-the saccules filled with fluid involving egg and its supportive cells inside the ovary – reach at 18 mm and above size. At this phase, it is vital to continue the treatment studiously.

When the size of your follicles reach at 18 mm, medications named Pregnyl, Ovitrelle, Choriomon, Gonapeptyl, lucrin are applied to mature your eggs (ova) so that they can be taken easily. After 34-36 hours of application of the medication, the procedure of collecting the eggs (Oocyte pick-up/OPU) is performed.

In our unit, depending on the answer given to the treatment, maturation is done with the protocol called dual trigger (combining medication containing HCG with Gonapeptyl) or with Analog
Trigger (giving only Gonapeptyl and no HCG) to prevent ovarian hyperstimulation.

The procedure is performed under anesthesia administered intravenously. It is a pain-free procedure and no different than a vaginal examination. With a specifically designed needle, saccules full of fluid are aspired with a special pump.

After laboratory analysis, eggs are picked from the fluid. At the date of this procedure, as a preparation for embryo transfers, medications containing progesterone (progesterone 200 mg cap, crinone gel,proluton ampul, progestan ampul) starts. Antibiotic (tetra 250 tb – tetradox 100 mg), prednol 16 mg tb are used for 4 days.

While the treatment is planned, the data about the male patient has been taken before. According to this, at the date of egg collection, your husband gives fresh sperm sample with a 2-5 days sexual abstinence. The duration of the abstinence is reminded to your husband at your follow-up period.

For the couples taking treatments due to a serious male factor, the sperm sample is taken from testicles or testicular annexes (TESA, micro-TESE, PESA,MESA). The material left from the samples used for the procedure is saved within the legal time.

For the patients with no sperm motility in the previous examinations, TESE procedure may be required. The goal is to acquire more motile-live sperm samples of higher quality.

After collection, your eggs are stored in specifically prepared containers called incubators for 3-4 hours. Following this, a separation procedure (hyaluronidase application) of supportive cells (cumulus) from the egg is performed.

After the microscopic analysis, it is determined whether they are mature or not. In patients with a sperm count of 15 million and over , sufficient motility (40% and over) and normal morphology, a conventional or classical system in which each egg cell is covered with 100 thousand sperms can be applied.

Good clinics around the world apply this method to up to 65% of the eligible patients. However, in our country, microinjection is applied to all of the patients.

In microinjection ,1 sperm is injected to each egg cell. This method is applied to patients whose ovarian reserve is decreased and a limited number of eggs could be collected. Also, in patients with a limited number of sperm or previously performed TESE procedure. In the microinjection method, the rate of fertilization is around 70-80%.

The fertilization is controlled generally after 16-19 hours (the morning of the following day). If fertilization happens, at 25th hour the early division, at 48th and 72nd hour the division controls are performed. (CLEAVAGE PERIOD) for the embryos under video monitoring, these processes are done with intra-incubator automatic assessment completely. Our laboratory is equipped with the Embryoscope incubator.

Your egg (ovum) which was fertilized and achieved first cell division mainly uses the mother cell structure. Afterwards the embryo has its unique divisions.

Until the embryos have been delivered to the uterus, they have been kept in special fluids imitating the uterus and in special cabinets so called incubators where heat and gas characteristics are adjusted automatically.

Generally, embryo transfer is performed on the 2nd -3rd day. For the eligible patients (those with many high quality embryos) a 5th day transfer can also be done to choose the best embryo. This situation is convenient for 20-30% of the patients only. Transfer procedure is painless and if there is no special
necessity, it is applied without anesthetics and the patient is expected to have a full bladder. The procedure is not different from an ordinary gynaecological examination.

Embryo/s loaded to a special catheter are transferred to you by the help of ultrasound. The progesterone medications (progestan ampul, progestan 200 mg cap, crinone gel, proluton ampul) that were started at the day of egg collection should be used until pregnancy test. In our unit, for the patients who have the best embryos on the 3rd day, an additional 5th day transfer can also be done (sequential transfer). This method is reserved for the patients with unsuccessful attempts before and for those over the age of 35.

If you have extra embryos of good quality after the procedure, these are stored by cryopreservation on 2-3rd day or 5th day according to their days. This method reduces the costs for future attempts and increases your chances of pregnancy. Besides, embryo cryopreservation is also used for endometrium problems, infection, allergy, PGD embryo saving.

Your embryos can be stored for 5 years. While the available data presents 5% lower pregnancy rate compared to fresh cycles, it offers higher pregnancy rates for some patient groups (patients with high number of eggs where increased estradiol hormone production or progesterone production can harm endometrium, patients with failed attempts).

For unmarried women with reduced ovarian reserve and women who will face medical treatment in the future, which will give harm to ovaries, we can also freeze oocytes.

15 days after the egg (ovum) collection, a blood test for pregnancy (beta-hcg) is done. To the patients with positive results, the test is repeated 2 days later.

The patients with a proper increase are invited to an ultrasound examination 2 weeks later. In the first 3 months of your pregnancy, progesterone medications continue to be used.