Before taking patients who have not had successful results from two or more IVF applications before, a differentiated treatment protocol should be planned for the patient, taking into account the previous experiences of the patient.
1- If the obtained embryo quality is good or very good but pregnancy is not achieved, the methods to be applied are:
A- Office Hysteroscopy:In cases where there is no pregnancy despite at least two good embryos are given, 20% of the diseases that prevent the embryo from being retained such as intrauterine polyps, adhesions, fibroids and intrauterine sections can be diagnosed and treated during the same procedure.
B- Opening or Removing Diseased Tubes (Channels) by Laparoscopy Method: If fluid has accumulated in the tubes (hydrosalpinx) due to adhesions, obstructions in the tubes or due to the obstruction of the mouth of the tubes (hydrosalpinx), it has been proven that when the embryo is placed in the uterus, this obstruction, as a result of adhesion and hydrosalpinx, leaks into the uterus and thus prevents the embryos from being retained. This problem, which causes the embryo to fall, is eliminated as a result of opening the tubes of these patients with the laparoscopic (closed) method, removing them or plugging the tubes into the area where they come out of the uterus.
C- PGD (Preimplantation Genetic Diagnosis) (Genetic Examination of Embryos): A blastomere (cell) of the 8-cell embryo can be taken and a biopsy can be performed, and the chromosome structure and some gene defects of the embryo can be determined before it is placed in the mother’s womb. Parallel to the developments in gene technologies in recent years, these techniques, which were used very limitedly only in research centers, can now be used more widely and practically. Although the subject develops extremely rapidly, it should be used in a limited group of patients in the clinic (risk of sexually transmitted diseases – muscle dystrophies, hemophilia, etc. translocations, chromosome number disorders, some known gene defects).
These techniques never claim to be 100% healthy children. In fact, most experienced centers still recommend classical antenatal diagnosis methods, amniocentesis and chorionic villus biopsy, in pregnancies obtained after using these methods. Preimplantation genetic diagnosis method is applied successfully, especially in women over 38 years of age with more than three embryos, when embryo transfers are performed after genetic diagnosis, pregnancy close to the young age group is achieved. In addition, if there have been more than two unsuccessful IVF, it is beneficial to do it. It should be used to select healthy embryos, as there may be genetically problematic embryos as a result of fertilization in men with impaired sperm count.
D- IMSI (Selected Sperm Microinjection with Microscopic Augmentation): It is a method that increases success especially in men with low sperm count and movements. For this application, very special microscopes equipped with advanced technology are used. In the procedures performed using the IMSI technique, the intracellular structures and cell nuclei of the sperm, which are magnified 16,000 times more than a normal microscope, are examined in detail, and thus the best quality sperm can be selected without degenerating. Then, the success increases with the microinjection process with these sperms.
E- HLA-G5:Determining the HLAG5 protein produced by embryos with the highest adhesion ability and using it in embryo selection will increase the pregnancy rate.
F- PICSI: Selection of mature sperm during microinjection is a method used to separate those with genetic defects. A special protein found in the cell membrane of genetically normal sperm allows these sperm to adhere to plaques prepared in the laboratory. Sperm that do not have this protein, on the other hand, cannot cross the plate barrier and success is increased with this technique that allows it to be used outside.
G-Assisted Hatching (AHA): It is a technique developed to increase the rate of attachment of embryos to the uterus. In this technique, the sheath (zona pellucida) surrounding the embryo is thinned by laser, acid or mechanical methods. These methods do not have any superiority to each other, and any of them can be used according to the experience of the center. On the day of transfer, the embryos are evaluated together with the patient’s age and history, and it is decided whether this procedure will be applied or not. This process can also be used to transfer cryopreserved embryos. This method can increase the pregnancy rate in fertilized cells. However, this issue has not been fully clarified.
2-Methods to Increase Success in Cases with Bad Embryo:
A- IVM (In Vitro Maturation): The groups where this method, also known as drug-free IVF treatment, will be tried; Patients who do not obtain mature eggs despite drug stimulation, patients whose embryo quality is poor and cannot be explained for any reason, patients with polycystic ovary disease, patients with the risk of accumulation of fluid in the abdomen and mature eggs cannot be retrieved, and patients who will receive chemotherapy or will be sterilized. Eggs are collected early, often without the need for medication. It is grown with special methods in the laboratory environment, matured, and then microinjection is performed. With this method, better quality embryos will be obtained in the above-mentioned patient groups and the risk of overstimulation will be eliminated. However, it should be noted that this method is only suitable for 5%-15% of all IUF cases.
B- DEFRAGMANTATION (Removal of Harmful Particles in the Embryo): As some embryos develop, some unwanted particles are formed along with normal cell division. These particles, called fragments, also reduce the success of the treatment. Therefore, very experienced teams clean these particles with special techniques under the microscope and special micro pipettes, called defragmentation, and increase the pregnancy rates with the given embryo.
C- Endometrial Co-KDI type (Artificial Womb): It is a method used in patients with repeated unsuccessful in vitro fertilization and those with poor quality embryos. A small piece taken from the uterine tissue (endometrium) of these patients is combined with the mother’s serum and some special substances to prepare a new environment. The retrieved eggs are grown in this environment after the microinjection process, resulting in better quality embryos. This method is successfully applied to eligible patients.
D- Differentiation of Drug Treatment to Achieve Success: Highly experienced gynecological endocrine (hormone specialist) specialists can obtain better quality eggs by changing the ovulation programs applied to patients, and the success of treatment is increased by arranging them individually according to this patient. For example, in order to obtain higher quality eggs in patients with PCO, very special programs called patient-friendly are applied to produce higher quality embryos and the success will be increased.