The chance of conceiving naturally in a healthy 30-year-old woman is about 20% in a month, so only one out of 5 unprotected women who want a child can get pregnant at the end of a month. This rate reaches 75% after 6 months and 85% after a year. The remaining 10-15% of couples of reproductive age experience infertility problems. In this article, I will explain what is IVF treatment, how is IVF treatment done.
In couples who cannot conceive naturally despite having regular sexual intercourse for a year without using any birth control method, the causes of infertility are investigated and necessary tests are carried out. After the problems and the cause of infertility are determined that prevents a woman to get pregnant, one of the treatment methods such as ovulation stimulation treatment, intrauterine insemination (IUI),or IVF treatment that is more suitable for that couple is decided.
In our IVF treatment Istanbul clinic IVF sometimes is the first treatment option depending on the problems of the couples, and sometimes it is a fertility method that is used to achieve pregnancy in couples who cannot get pregnant with other treatment modalities.
Today, even couples who were known to be unable to get pregnant in the past can become pregnant and have children with IVF treatment.
In the IVF treatment method, the eggs are taken out of the body and fertilized with the male's sperm in the laboratory environment, and the resulting embryo is placed in the uterus. The basic steps of IVF treatment are stimulation of the ovaries with daily hormones, egg collection, fertilization of the egg and sperm in the laboratory (microinjection/ICSI),embryo culture, and embryo transfer.
After infertility investigation and evaluation, when the age of the woman is not advanced or the ovarian reserve is not low, and the tubes of the woman are open, and also the sperm count and quality are sufficient the following methods can be tried before the IVF treatment:
When a woman has problems with ovulation, some medicines are used to stimulate ovulation. Problems with ovulation are common in women with polycystic ovary syndrome (PCOS) who experience menstrual irregularities.
Ovulation treatment can be done with oral pills or daily hormone injections. In general, the first choice is oral medications. The treatment is started on the first 2.- 3. days of the period. The development of the eggs is followed at regular intervals by ultrasound. Pregnancy is achieved by 15-20% with ovulation treatment in one cycle. If pregnancy cannot be achieved despite trying 3-4 treatment cycles, the situation of the couple is reevaluated and intrauterine insemination or in vitro fertilization (IVF) treatment is started.
IUI is done in couples with unexplained infertility, who have sexual problems due to medical diseases such as sexual impotence or psychological reasons, reflux of semen to bladder, vaginismus, in men with low sperm count, motility, or structurally normal sperm or when sperm is frozen due to cancer treatments, endometriosis disease, occlusion of one of the fallopian tubes and ovulation disorders.
In IUI treatment, the sperm of the man is prepared in the laboratory, and the motile and good quality sperm are concentrated in a small amount of liquid and given to the uterus with a tiny catheter. It is a method that is used in couples who cannot have children naturally. The success rate of the IUI method varies depending on the sperm count. If the sperm count and quality are good enough, the pregnancy success rate is 20% per treatment cycle. When pregnancy cannot be achieved after 3-4 IUI trials, IVF treatment is planned.
The easiest and least costly way to reach a happy ending in IVF treatments is first to make the correct diagnosis and remove the obstacles to pregnancy. This requires good evaluation and some diagnostic methods. The tests that can be done in men and women are as follows:
About half of the causes of infertility are due to male-related problems. The most important for the evaluation of men is semen analysis. In cases where the sperm test is not normal, the following assessments may be required:
The FSH, Estradiol (E2),anti-Müllerian hormone (AMH) measurements, and the detection of antral follicle count (AFC) by ultrasound in women who attend for infertility and IVF treatments give an idea about how the ovarian response would be to ovulation stimulation treatments.
In a woman with low ovarian reserve, FSH and E2 levels are high, AMH level is low, and AFC on ultrasound is decreased. However, these tests might not accurately predict whether pregnancy will occur or not. Pregnancy can be achieved even with very low AMH levels.
IVF treatment can be done in women between the ages of 18-45 years. However, as women get older, the chance of pregnancy decreases due to the increased risk of chromosomal abnormality of the eggs, the decreased risk of ovarian reserve, and the increased risk of miscarriage.
Having regular periods does not reflect the egg quality and the ovarian reserve. The live birth rate for women under 35 is around 40% by IVF treatment, however, after the age of 40, the chance decreases with age, and this rate falls to 10-15% for women over 40 years of age. IVF can be done up to the age of 45 years.
Although sperm production in men continues until advanced ages, sperm quality, and sperm motility decrease. Sperm DNA damage increases with age. These are the factors that reduce the success of IVF.
After the initial examination and tests, the treatment protocol and the doses of drugs are determined depending on the age and the ovarian reserve of the woman and the results of ultrasound examination and, if necessary, hormone tests in the blood. The common purpose of ovulation treatments is to produce more than one egg in a trial. The ovaries are stimulated using daily hormone injections. The drug type and dose may vary depending on the patient and the treatment protocol.
Treatment is started on the 2nd or 3rd day of menstrual bleeding and the patient is followed at regular intervals by vaginal ultrasonography to check the number and size of the developing follicles (small fluid-filled cystic structures containing eggs). The aim of treatment is to obtain as many follicles with a diameter of 16-20 mm as possible.
The goal in IVF treatments is to obtain a sufficient number of eggs capable of fertilization. While the daily hormone injections continue, one more daily hormone treatment is added to prevent the eggs from rupturing prematurely. Otherwise, the eggs may rupture spontaneously before the day of egg collection.
Another factor that is evaluated during ultrasound follow-ups is the structure and thickness of the layer that covers the inside of the uterus, called the endometrium. Since the embryo will be placed in the endometrium, the thickness and structure of the endometrium are extremely important.
The ovulation stimulation duration is variable but the average time is 8 to 10 days. If the follicles reach a sufficient size, hCG injection (trigger shot) is performed to ensure final maturation.
The eggs are collected approximately 35-36 hours after the injection of hCG. On the day of OPU, the couples come to the IVF center together. Since egg retrieval is performed with mild anesthesia, the woman should be fasting and should not take any food or fluid in the last 6 hours.
OPU is performed easily and comfortably with vaginal ultrasonography. While the patient is in the gynecological examination position vaginal ultrasonography is started after being covered with sterile cloths and cleaning the vagina. The fluid in the follicles that contain eggs is aspirated with a needle under the guidance of vaginal ultrasound. The fluid is given to the embryology laboratory and it is examined under a microscope whether it contains eggs. The egg in the follicle fluid is transferred to a culture fluid and placed in the incubator.
The OPU is continued until all follicles are aspirated. It takes about 15-20 minutes to aspirate the follicles of both ovaries. After the egg collection procedure, the patient can go home after resting for 1-2 hours in the clinic.
After the eggs are collected, progesterone hormone treatment is started in order to prepare the inner wall of the uterus for embryo transfer.
On the day of egg retrieval, the partner also gives sperm. Masturbation is the ideal method for sperm retrieval. The semen obtained is taken into a special container and is expected to liquefy. Liquefied semen is examined for sperm count, motility, and shape. In men who do not have live sperm in their semen, sperm is searched surgically (TESA/TESE).
Approximately 2-4 hours after eggs collection, the cells around the eggs are cleaned and evaluated whether they are mature or not. The microinjection/ICSI is performed by injecting a single sperm into each egg with the help of a special tool called a micromanipulator.
The eggs that are ICSI performed are put back into the culture medium in the incubator in the embryology laboratory, and the development of the embryos is followed in the next days. When the appropriate development stage is reached, one or two of the high-quality embryos are transferred into the uterus.
Approximately 70% of the collected eggs are mature and suitable for fertilization. About 70% of them will also be fertilized. For example, a woman with 10 eggs will develop an average of 5 embryos. This is an average and the number may be above or below it.
Embryos can be transferred any day between Days 2 and 5 from the two-cell stage to the blastocyst stage. During embryo transfer, the patient lye in a gynecologic position. After the speculum is inserted into the vagina, the cervix is cleaned with sterile saline solution. The embryologist loads the embryos to be transferred in a catheter. Under the guidance of abdominal ultrasound, the embryos are placed into the uterus.
Embryo transfer does not require anesthesia as it is a painless procedure. Progesterone hormone is continued in the form of injection, suppository, or cream to support the endometrium after the transfer. This treatment, called luteal phase support, is continued until the 8th-10th week of pregnancy in case of pregnancy.
Prof. Dr. Nilgün TurhanGynecology, Obstetrics and IVF Treatment Specialist
PROF. DR. NILGÜN TURHAN
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