In Vitro Fertilization (IVF) Guide

The inability to conceive due to sperm or ovaries also affects couples psychologically. Which method will be used in IVF treatment, which is applied to make the couples' dreams of having a child come true, is decided in line with the health status of the patients and the evaluations of the experts. The aim of the treatment is always the realization of fertilization and a healthy pregnancy period.

What is it in Vitro Fertilization (IVF) Treatment

In vitro fertilization is an assisted reproductive method that involves the fertilization of egg cells (oocyte) and semen (sperm) taken from the woman in a laboratory environment and the placement of the fertilized embryo into the uterus of the woman. Pregnancy obtained from a certain number of embryos selected and placed in the uterus progresses in the same course as the pregnancy achieved by normal means. In this sense, the only difference between natural pregnancy and IVF treatment is that fertilization is carried out in laboratories with suitable conditions.

The first successful IVF treatment case, founded by Robert G Edwards in 1971, was seen in England in 1978. The first successful pregnancy in Turkey was concluded with the in vitro fertilization method at Ege University in 1989. Thanks to the development of medical techniques and technologies, different in vitro fertilization techniques are applied, and successful results are obtained.

Which Methods are Used?

Depending on the fertilization of the ovaries, in vitro fertilization treatment is applied with classical in vitro fertilization (IVF) or microinjection (ICSI) methods. The frequently preferred IVF method is generally selected in cases where there is no problem in sperm count and quality, and sperm fertilization is performed by itself. In the ICIS method, the egg is ready for injection, and the sperms are placed in a single egg.

When is it Applied?

For the application of IVF treatment, it is necessary to have sexual intercourse for at least one year without using birth control methods and not to be pregnant during this period. This condition is also called infertility. In the absence of pregnancy during this period, IVF treatment is applied.

Age Limit In Vitro Fertilization

In vitro, fertilization treatment is applied up to the age of 45 in women whose ovarian functions are found suitable by tests performed on three days of the menstrual period. At the same time, it is also checked whether the embryos are ideal with the genetic diagnosis method. However, women over 40 are less likely to have this method successfully than younger women. The decrease in the number and quality of eggs in women, especially after age 35, also affects the chances of success.

Although there is no age limit for men, it is considered that sperm quality decreases due to changes in sperm DNA as age progresses.

Who can Have In Vitro Fertilization (IVF)?

In vitro fertilization (IVF) treatment is applied depending on some factors: 

• In women, the ovaries (fallopian tubes) are closed, damaged, or removed,
• The presence of stickiness that will prevent the fallopian tubes from catching the formed eggs,
• Presence of women at an advanced age when fertility is low,
• Failure to achieve pregnancy with drug therapy,
• In men, the number of sperm is low and of poor quality, or there are no sperm cells at all.
•    Especially women who are older than 30 years of age and have irregular menstrual bleeding, men with low sperm count, as well as men with testicular health problems, should apply to IVF centers to achieve pregnancy.

In some cases, it is expected that normal pregnancy will occur by treating various health problems primarily with drugs or surgical methods. If normal pregnancy is not seen after these problems are resolved, IVF treatment is applied. For example, laparoscopic surgical applications are used first in intra-abdominal adhesions that prevent eggs from being retained. If the adhesions that develop due to ovarian cysts or inflammations are treated and the fallopian tubes acquire the function of holding the eggs, if pregnancy cannot be achieved by regular means, in vitro fertilization treatment is applied again.

In vitro fertilization treatment is also applied to women with endometriosis. This disease occurs when the endometrium tissue, excreted during the menstrual period and covers the inside of the uterus, is found in the fallopian tubes or intestines.

This treatment is also applied in immunological infertility, in which antibodies develop in the ovaries that prevent sperm from adhering. The microinjection method provides successful results, especially in cases where pregnancy cannot be achieved due to infertility seen in men.

What does the Treatment Process Include?

After evaluating the couples' general health status and the reasons for their infertility, specialist physicians inform the couples and the treatment process begins.

Stimulation of the Ovaries

Stimulation of the ovaries and obtaining a large number of eggs form the basis of IVF treatment. Medicated treatment, including hormone injections, is started on the 3rd day of the women's menstrual period. Women can inject themselves after being informed. The arousal process, which lasts about 10-12 days, varies from woman to woman, depending on the reaction of the ovaries to the drug treatment. In this process, where the ovaries should be followed closely, an average ultrasound control is performed every 2-3 days. In these controls, the dose of the drugs is adjusted according to the hormone levels of the women. At the same time, in some cases, a hormone antagonist is given from the navel to prevent premature rupture of the ovaries.

Collecting the Eggs

After the eggs reach a specific size, a hormone injection is applied to crack them, and the collection process is carried out. Timing is of great importance in the collection process. Eggs are collected 34-36 hours after the hormone injection, mostly under general anesthesia. In the procedure, the needle guided by ultrasound is passed through the vagina, and the eggs are reached. While generally, 1 to 40 eggs are obtained, there may be cases where eggs are not accepted, although very rarely. Couples are discharged a few hours after the collection, which takes 20-30 minutes on average.

Fertilization of Eggs

Collected eggs are fertilized by various methods in a suitable laboratory environment, and embryo formation is ensured. On average, fertilization takes place between 12 and 15 hours. After that, the day will be placed in the uterus by selecting quality eggs.

Embryo Transfer

Depending on the quality of the embryos, a maximum of 2 days is expected to transfer fertilized eggs, also known as pre-embryo or zygote, into the uterus. Transfer involves leaving the embryos taken into the catheter by passing them through the cervix. Embryo transfer, which is performed without the need for anesthesia, is served with ultrasonography.

While the number of embryos transferred is one in women under 35, the maximum is two in other women. After embryo transfer, couples can leave the hospital immediately.

After the transfer, progesterone or estrogen hormone supplementation is made by injection for two weeks.

Pregnancy Test

A pregnancy test is performed to understand whether pregnancy has occurred on average 12-14 days after embryo transfer. If the test is positive, an ultrasound control is performed approximately ten days later to see the condition of the gestational sac..

What is Assisted Hatching?

In some cases, although embryos are formed during IVF treatment, pregnancy does not occur. This is usually caused by problems during the embryo's attachment to the uterus. The assisted nesting method ensures that the embryo reaches a specific size, gets rid of the membrane (zona pellucida) surrounding it, and attaches to the endometrial tissues. It is aimed at the embryo to tear this membrane by opening a hole in the membrane with chemical methods or laser technology. During this process, the embryo is fixed, but no damage is done to the embryo.

The Assisted Hatching method is mainly used in cases where the zona pellucida is thick, women are over 35 years old, and after unsuccessful IVF treatments.

What is it Insemination (IUI)?

Vaccination, also known as Intrauterine Insemination (IUI), is the implantation of sperm cells into the egg during or near ovulation in women. Vaccination is applied to patients with unexplained infertility and, early-stage endometriosis and vaginismus. However, vaccination is also appropriate in cases where the passage of sperm through the cervix is prevented, and premature ejaculation or erectile dysfunction is observed.

The Difference Between Insemination and IVF

Vaccination is sometimes preferred before in vitro fertilization treatment is applied. It is one of the most suitable treatment methods for infertility, also known as infertility. For the vaccination to be used, in addition to unexplained infertility in men, one of the fallopian tubes should be open in women, and advanced endometriosis (such as a chocolate cyst) should not be present. At the same time, the number and quality of sperm in men should not be too low.

What is Microinjection (ICSI) Treatment?

In IVF, which is the classical IVF method, sperm and eggs are brought side by side, and the sperm are expected to fertilize the egg. In the microinjection method, also known as intracytoplasmic sperm injection (ICSI), the sperm cell is taken into a glass needle and injected directly into the egg, ensuring fertilization. Microinjection applications are performed when the sperm count is insufficient, the motility is below average, and the cells cannot fertilize the egg.

The most important advantage of the microinjection method is that men with problems in sperm motility and number can also benefit from the in vitro fertilization method.

To Whom is it Applied?

Microinjection, which is different from the IVF method only in the fertilization process, is applied in cases where the sperm count and quality are low, as well as in the presence of sperm antibodies that prevent fertilization, fertilization by the classical method, and in cases where there is a problem in fertilization despite the absence of a certain sperm problem.

What is drug-free in in vitro fertilization (IVF) treatment?

In the classical IVF treatment, hormone-containing needle therapy is applied to obtain more eggs and embryos. However, some women's ovarian capacity is insufficient to produce many eggs. In cases where the number of ovaries is low, and the chance of success with hormone injections is low, a non-drug treatment method in which women's menstrual cycles are followed is preferred. In this method, which focuses on egg quality instead of egg number, women are either not given any medication or very low doses of hormones. The continuation of the procedures is similar to classical IVF. Following the natural spawning process, the eggs that come to the appropriate size are collected by needle. After fertilization, the embryo is placed in the uterus.

The advantages of drug-free IVF treatment, which is preferred in women with insufficient egg reserves, are as follows: 

• Shorter duration of treatment compared to IVF, which is the classical IVF treatment,
• Low or no side effects because no medication is used,
• Less clinical and ultrasound controls,
• The risk of developing complications is very low,
• Injection applications are either very few or not at all,
• Lower cost.

What is the PRP Method?

PRP, also known as egg rejuvenation, is one of the new methods. PRP (Platelet Rich Plasma), which means platelet enriched plasma, is obtained from people's blood and contains no additives. Especially in cases where the chance of pregnancy is low due to various reasons, the PRP method is used. Platelet-rich plasma is applied to women's ovaries and activates the stem cells. Since it is a painful procedure, the procedure is usually performed under anesthesia; with the help of a needle, the vagina is entered, and PRP injection is made into the ovaries. In this way, it is aimed to increase ovarian functions. PRP applications increase the chance of pregnancy in older women with low ovarian reserve and individuals with early menopause.

Sperm Obtained Procedures

Sperm, as well as eggs, are of great importance in realizing fertilization and obtaining quality embryos. In this sense, the stages of securing sperm are also one of the critical stages of IVF treatment.

Sperm are collected from males on the day the eggs are collected. To obtain the correct and sufficient sperm, it is recommended that men undergo sexual abstinence 3-5 days before the collection day. In this way, living cells are more in the semen obtained by various methods. In specially prepared masturbation rooms, semen samples are taken, and multiple processes are passed in the laboratory. The best quality and motile sperm are selected from the semen extracted from waste and liquids and used for fertilization.

In some cases, sperm cells are not seen in the semen obtained by masturbation. In this condition, also called azoospermia, different surgical methods are used to take samples from men:

Epididymal Sperm Aspiration Under the Microscope (MESA)

It is the method used when there is a blockage in the main channels (vas deferens) that carry sperm to the penis, although average or near-normal sperm production is observed in the testicles as a result of the tests, or if these channels are not present congenitally. In the MESA method performed under the microscope, a small incision is made, and a fluid sample is taken from the epididymal canals, which are the canals that transmit sperm to the vas deferens. Sperm in these fluids are separated in andrology laboratories.

Perkutan Epididimal Sperm Aspirasyonu (PESA)

PESA is the process of sperm aspiration through the skin by entering the epididymis with a small needle. One of the most essential advantages of this method is that no incision is needed in the operation, which is usually performed under sedation or local anesthesia.

Testicular Sperm Aspiration (TESA)

The TESA method is used to obtain sperm in fertilization by microinjection. In the surgical operation, which is performed under local anesthesia, a needle is inserted into the testicles, and the sperm is aspirated. After the egg collection, the obtained quality sperm is injected into the eggs.
TESA: It is preferred when there is an obstruction in the genital tract of men, testicular problems, and after a vasectomy operation.

Testicular Sperm Extraction (TESE)

The TESE method is generally applied when testicular sperm aspiration does not work. In the biopsy operation, a small incision is made in the testicles, and tissue samples are taken from different parts of the testis. The process of obtaining sperm cells from these tissue samples is called TESE. Surgery performed under general anesthesia is sometimes performed under a microscope. Based on the magnification of tissues with a microscope and called micro TESE, this process increases the probability of finding sperm cells compared to the classical TESE method.
Under normal conditions, freezing of reproductive cells is prohibited according to Ministry of Health regulations. However, sperm cells can be frozen and stored after TESE and TESA procedures, which are within the scope of medical necessity and can be reused after unsuccessful IVF attempts.
Men can be discharged on the same day after all these methods, which enable sperm used during fertilization in microinjection or IVF treatments to be obtained. Pain and aches in the operation area for a few days are normal. 

Which Tests are Performed?

Before couples start IVF treatment, some tests are applied to women and men to understand the obstacles to pregnancy. These simultaneous tests generally include sperm and hormone tests for men and hormone tests and hysterosalpingography (HSG) tests for women. As a result of the tests, problems are determined, and IVF treatment is planned.

Tests Applied to Women

First, basal hormone tests are applied to women to understand the quality and number of eggs (ovarian reserve). E2, LH, TSH, PRL, and, in some cases, DHEAS and total testosterone tests applied on the 2nd or 3rd day after the start of menstruation give information about the low ovarian reserve. FSH values of 12 and above and E2 values above 80 pg/ml mean that ovarian reserve is low. The doses of the drugs to be used in the treatment are also determined according to these values.
Medicated uterine film (hysterosalpingography) and office hysteroscopy tests, taken by injecting contrast fluid into the uterus, are applied both to understand whether there is any problem in the tubes of women and to understand the structure of the uterus. The fact that the uterus is in a structure that does not support the baby's development, the presence of adhesions, fibroids, and polyps, and the closure of the fallopian tubes reduces the success rate in IVF treatment. Thanks to the hysterosalpingography test, these situations are known in advance, and precautions can be taken.
A transvaginal ultrasound done on women in the basal period gives information about both the uterus and the ovaries. With this method, the presence of uterine fibroids and polyps and whether there is an anatomical problem in the uterus is clearly understood. At the same time, ovarian reserve is evaluated, and whether there is polycystic ovary syndrome and endometrioma (chocolate cyst) is determined.
In addition to these tests performed on all women undergoing IVF treatment, some tests may be requested. Aids (HIV), Hepatitis B (HbsAg), and Hepatitis C (Anti HCV) tests are performed primarily to understand the diseases that can be transmitted to the baby after pregnancy. The Rubella Ig G test is performed to understand the risk of rubella in women, and the blood group test for women and men if there is blood incompatibility. Protein S, Protein C, INR, aPTT, and PTT tests are applied to avoid any problems in blood coagulation. Most women also have a complete blood count (hemogram) to understand platelet and anemia problems.

Tests Applied to Men

Before starting IVF treatment, all men undergo standard semen analysis (spectrogram). This analysis provides information about the morphological structure of the sperm as well as the sperm count, motility, and quality.
When necessary, hormone tests requested from men are PRL, FSH, LH, and total testosterone. In particular, a high FSH value means the testicular reserve is low. In some cases, HbsAg, HIV, Anti HCV, and blood group tests, which are also applied to women, are also performed on men.
If the sperm reserve is low, a urological examination and chromosome analysis are also performed if azoospermia is observed. 

What are the Risks of In Vitro Fertilization (IVF) Treatment?

Like every treatment method, IVF has some risks that arise from the drugs or procedures used during the treatment. However, these risks can be predicted and managed.

Ectopic Pregnancy

The development of the fertilized egg outside the uterus instead of inside the uterus is called an ectopic pregnancy. The probability of ectopic pregnancy, which usually occurs due to problems in the fallopian tubes, during IVF treatment is lower than in natural pregnancy. Ectopic pregnancy, which can be diagnosed with ultrasonography and blood tests at an early stage, can be treated with medical methods or surgical operations.

Multiple Pregnancies

The high number of embryos transferred to women increases the success rate of IVF treatment. However, as the number of embryos increases, the risk of multiple pregnancies increases. Multiple pregnancies occur in one out of every four successful IVF attempts. Multiple pregnancy has adverse effects on the health of both women and babies. In this case, the risks of preterm birth and miscarriage are higher than single embryo transfer. Preeclampsia, also known as diabetes, hypertension, and pregnancy poisoning, may develop during pregnancy due to multiple pregnancies in women. Complications such as bleeding more than usual may occur during delivery. Babies, on the other hand, have physical and mental developmental disorders as well as death due to preterm birth. Spasticity, underdevelopment of lung capacity, cerebral hemorrhage, multiple organ disorders, and permanent disabilities are the most common problems.
To prevent multiple pregnancies, which can cause severe consequences for mothers and babies, the number of transferred embryos should be minimized. Sharing a single embryo to women under the age of 35 in the first two attempts and moving a maximum of two embryos to other women reduces the risk of multiple pregnancies.

Side Effects Related to Drug Use

Stimulant hormone drugs and other drugs used to obtain high-quality and large numbers of eggs cause some side effects:

• Sudden mood changes due to hormone supplementation,
• Redness, bruising, or pain at the injection site
• Nausea and vomiting,
• Diarrhea
• Abdominal pain,
• Allergic reaction.

The most serious but rare complication associated with drug use is ovarian hyperstimulation syndrome (OHSS). Ovarian hyperstimulation syndrome is defined as the overreaction of the eggs to the hormonal drugs applied to support egg development and obtain more follicles than desired. This syndrome, which usually occurs at the latest seven days after the egg collection process, is seen in 2% of the cases.
Although the exact cause of OHSS is not known, risk factors include polycystic ovary syndrome, being under 30 years old, low body weight, and having had this syndrome before. Especially young women with polycystic ovary syndrome, a common reproductive disorder, are at the most significant risk. 
OHSS usually resolves within a few weeks, depending on the severity of the complaints and whether pregnancy is seen, and usually does not affect the pregnancy. Mild, moderate, or severe symptoms include bloating, nausea and vomiting, constipation or diarrhea, rapid weight gain, and shortness of breath. Rest, plenty of water consumption, and light exercises are recommended to treat the syndrome. In severe symptoms, painkillers can also be taken.
How to continue in vitro fertilization treatment after ovarian hyperstimulation syndrome occurs is planned according to pregnancy status. If the syndrome is diagnosed early, embryo transfer is delayed until recovery is achieved. The most important reason for this is that these syndromes usually aggravate during pregnancy, and recovery takes a long time.

What is the Succes Rate of the Treatment?

The success rate in IVF treatment varies according to many factors. However, it is possible to talk about a one-third success rate in general. While the success rate in women under 30 is 45-50%, it is around 15-20% in advanced age. It is predicted that all in vitro fertilization trials with the developing techniques will be successful in the following periods.
On the success of the treatment:

• Women's age,
• Infertility of unknown cause
• The quality and number of sperm,
• The status of the ovarian reserve,
• The condition of the fallopian tubes and uterus,
• The presence of endometriosis disease and fibroids that prevent the egg from sticking in the uterus,
• Alcohol and cigarette use
• Overweight
• Psychological factors such as stress are influential.

How to Increase Success Rate?

In addition to egg and sperm quality, the laboratory environment significantly impacts the success rate in IVF treatment. Physicians' experience and the embryo laboratories' high-quality equipment increase the success rate by an average of 80%. It is essential to evaluate the couples' medical histories and problems in detail, use appropriate drugs, and determine the proper treatment method. On the other hand, the correct timing of stimulating the eggs and collecting and placing the embryos in the uterus significantly increases the live birth rate.
Freezing Embryos: One of the most critical factors increasing the probability of pregnancy is the freezing and storing of quality embryos. Quality embryos are selected even if the transfer into the uterus is not made in the egg collection process. Thanks to these frozen and stored embryos, in case the IVF treatment fails, women do not need to undergo the egg collection procedure by applying hormone treatment again. Embryos maintain their quality even as the woman ages, increasing pregnancy chances.
Preimplantation Genetic Diagnostic Test (PGD): Pre-implantation Genetic Diagnostic Test (PGD), which is performed before the embryo is transferred into the uterus, is a diagnostic method used for early diagnosis of genetic diseases and for determining the number of chromosomes. In this way, it is aimed to give birth to healthy babies.
Chromosome number is considered when determining which embryos created by the microinjection method will be used. By choosing embryos with an average chromosome number, the risk of miscarriage associated with the chromosome is reduced.
PGT diagnostic tests are generally applied in older women, recurrent IVF treatment failures, and advanced infertility in men. Thanks to genetic diagnostic tests that exclude these factors that reduce the probability of success, embryos without anomalies are selected, and the likelihood of success increases.
The PGT test is applied to the embryo formed by the ovary and sperm combined with the microinjection method. On the 5th or 6th day of development of the embryos, a sample is taken from the cells for biopsy, and chromosome screening is performed. Today, healthy embryos are selected and transferred into the uterus, among which 24 chromosomes are scanned.
Genetic diagnostic tests have been used in almost all IVF trials in recent years. In this way, information is obtained about congenital anomalies that may occur at birth and in the future. Healthy birth and development of babies are ensured even if couples have genetic diseases.
Blastocyst Transfer: The 5th or 6th day of embryo development is called the blastocyst period. The primary purpose of blastocyst transfer is to select more likely-to-attach embryos. Embryo transfer is not done earlier, as the embryos are much more likely to adhere at this stage. In this sense, the low-quality embryos reveal themselves at this stage, and the treatment is continued with the best-quality embryos.
Another advantage of transfers during this period is that multiple pregnancies can be prevented. By transferring only 1 or 2 high-quality embryos, the risk of triple pregnancy is reduced, and the chance of pregnancy is increased.