Infertility Treatment

ASSISTANT REPRODUCTIVE TECHNIQUES

1- Vaccination (intra uterine insemination)

2-In vitro fertilization(The classical in vitro fertilization method is now abandoned. The ICSI (microinjection) method is used all over the world.
1-VACCINATION (intra uterine insemination)

In this treatment, around 10 million/ml sperm and 14% morphology should be normal in semen analysis in men.

Who Is Vaccination (IUI) Performed?
In women;
1- Mild endometriosis
2- Unexplained infertility
3- Good responses are obtained with vaccination in ovulation inductions made with externally controlled FSH that do not respond to clomiphene citrate treatment.

How Is Vaccination Made? (Intrauterine insemination)
With the controlled ovarian hyperstimulation described above, after 4 to 5 women have grown eggs, inoculation is performed 36 hours after HCG is administered intramuscularly to 10000 units. After the semen is taken from the man, first it is rested for 15 minutes, then the semen is centrifuged for 20 minutes in a concentration (gradient system) centrifuge at 2000 rpm, and the prostatic fluid and dead sperm collected above are taken. Then, it is centrifuged again for 10 minutes at 2000 rpm with HEPES solution. First quality and motile live sperm deposited at the bottom are then injected into the uterus with the help of ultrasound, with a plastic and sterile insemination cannula specific to the woman who is taken to the gynecological table. The patient is lifted by resting on the table for 15 minutes.

When we can’t get an answer to all these, we apply to the IVF method. In vitro fertilization was achieved for the first time in England in 1978 and LUISE BROWN was born. With the invention of microinjection (ICSI) in Belgium in 1992, the treatment of infertility cases such as azoospermia became possible.

 

2-TUBE BABY

As I explained above, classical in vitro fertilization (classical in vitro fertilization, which is explained as putting the sperm and the female egg ovum side by side) has a low chance of success, and after the ICSI (microinjection) method was found in Belgium in 1992, this method is completely applied in IVF centers today.
Microinjection (ICSI) indications:
1- Severe oligoasthenoteratospermia (less than 5 million/ml morphology 4% less than normal motility less than %)
2- Azoospermia (no sperm in the semen fluid) Sperm taken from the testicles with PESA, MESA or TESE.
3- Tubal factor in women.
4- Severe endometriosis
5- Unexplained infertility
6- Recurrent pregnancy losses (for preinplantation genetic diagnosis)
7- Those with genetic disease (for the purpose of PGD)
8- To avoid infecting women with HIV+ men
9- Microinjection is recommended for those who are undergoing cancer treatment by freezing the oocyte or embryo and for those who want pregnancy in the following years.

WHAT ARE THE 5 STAGES OF THE MICROINJECTION PROCESS?

1- PREPARATION
Biochemical, serological, hormonal blood tests. They can be grouped as imaging tests and invasive tests. The most important of these tests are the ovarian reserve tests performed on the 3rd day of menstruation; FSH, E2 and AFS (antral follicle count) tests. Having less than five antral follicles in each ovary or an FSH above 15 ml after 37 years of age is poor ovarian reserve. In addition, invasive tests such as hysteroscopy and laparoscopy can be performed in recurrent IVF failures.

2- KOH (CONTROLLED ovarian HYPER Stimulation)
Here; Drug doses are adjusted according to the patient’s age, success status in previous applications, ovarian reserve, and body mass index. These can be long protocols, antagonist protocols, short and soft protocols. In the long protocol, the pituitary suppression begins on the 21st day of the previous cycle. On the 3rd day of menstruation, KOH is started. The aim of all protocols is to develop a large number of follicles. Follow-up; It is usually done with USG, E2 and sometimes progesterone controls. The induction program takes about 10-12 days. Enlargement of the follicles by 1-2 mm per day is generally good for a good multifollicular development, with an increase of 50% per day in E2. Approximately 10-12 days later, when at least 3 17 mm follicles are seen on USG, 10 000 units of HCG are administered for oocyte maturation (metaphase 2).

3- OPU (OOCYTE PICK UP) EGG COLLECTION PROCESS
Egg retrieval is performed 34 to 36 hours after hCG administration. The procedure can be performed either under general anesthesia with propofol or with local anesthesia with dormicum.

4- ICS (MICROINJECTION)
Oocytes collected by the Opu process are rested for 2 to 4 hours. Metaphase 2 ( mature oocytes); On the same day, microinjection is performed with sperm taken from the man in the morning. It is the process of introducing the sperm into the cell fluid by perforating the membrane of the oocyte under the control of a micromanipulator and microscope. Division of the zygote into two cells in the first 24 hours of follow-up; If there are 4 cells in the 48th hour, 7-8 cells in the 72th hour, smooth and symmetrical, and very little fragmentation, it is considered as a first quality embryo.

5- EMBRYO TRANSFER
It is usually done 3 days after the OPU. The desired 7-8 cell embryo transfer is of good quality. The transfer made without any coercion is called type 1 and type 2. The chance of success is very high. Difficult transfer (type 3 and type 4) has a lower chance of success. Progesterone is started 2 days before the transfer to prepare the endometrium. If pregnancy has occurred, it is continued until the 10th week of pregnancy. 15 days after embryo transfer, BHCG is checked in the blood. It is repeated every 3 days. After 15 days, it can be examined with USG.

In our country, 40-50% pregnancy per cycle is achieved under 35 years of age in successful centers and clinics. It decreases to 15% after the age of 41-42 and to 3% after the age of 45.

 

WHAT ARE THE COMPLICATIONS OF MICROINJECTION?
1- Multiple pregnancies: It is a serious problem both for the family and for our country. The inadequacy of premature care services further increases the problem. For this, 1-Further improvement of freezing programs, 2-Single embryo transfer, 3-5th day blastocyst transfer started to bring solutions to this problem.
2- Ectopic pregnancy: It has doubled. Early diagnosis, the benefit of the drug called methotrexate in early diagnosis, and transfer away from the fundus in embryo transfer may be solutions.
3- OHSS (Ovarian overstimulation syndrome): It ranges from mild to severe cases. Very close follow-up is required. In the case of severe OHSS, hospitalization may be necessary. In the prevention of OHSS; Measures such as 1-reducing the HCG dose, 2-IVM (early collection of eggs at the GV level), 3-Cycle cancellation, 4-Coasting can be counted.

WHAT CAN BE DONE IN REPEAT IVF FAILURES?

It is necessary to re-do all the evaluations of the patient from the beginning. 1- If there are adhesions (synechiae), septum, supmicous fibroids, intramural fibroids over 4 cm, and endometrial polyps in the uterus, they can be corrected by hysteroscopy and laparoscopy operations. 2-Hydrosalpinxes, which cause obstruction in the tubes seen on ultrasound, can be either removed or ligated by laparoscopy because they both secrete toxic substances and prevent the implantation of embryos (holding in the uterus) with mechanical effect. 3-KOH (changes can be made in egg-stimulating protocols. Short antagonist protocols can be tried instead of long (long) agonist protocols. 4-In those with poor ovarian reserve, protocols with latresol can be tried instead of microdose flare up protocols. 5-If the woman is over 40 and has bad ovarian reserve. If there is a reserve, oocyte donation (egg donation) can be tried 6-IVM Application: Collecting eggs in the early period, that is, in the periods when the follicles are approximately 13-14 mm in size (GV periods), and maturing them outside.

REPEATED EARLY PREGNANCY LOSSES (HABITUAL ABORTIONS)

Finally, I would like to talk about recurrent early pregnancy losses with a few sentences. Definition of recurrent early pregnancy loss: 3 or more involuntary termination of pregnancy before the 20th week. The most common causes here are advanced maternal age and men with azoospermia. It is recommended in these patients; In terms of chromosomal anomalies, preimplantation genetic diagnosis is made in 2nd and 3rd day embryos in IVF programs and healthy embryos are transferred. Another important recurrent early pregnancy loss is inherited clotting (thrombophilia) problems. Fibrinogen, factor 5, serum homocysteine ​​mutation tests, antithrombin III, protein C, protein S tests are performed and when any abnormality is found, an average of 2000 to 4000 units/day subcutaneous (SC) heparin should be administered.

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