A) PRELIMINARY EVALUATION
İRENBE is a "Women's Health Center" at the same time. Every woman applying to out clinic is evaluated in terms of her general and gynecological situation. Complete blood count, blood type, preprandial blood glucose, lipid profile, level of some vitamins in the blood, thyroid function tests, cervix swab evaluation (pap smear), breast examination - ultrasonography andmammography are conducted on women. Necessary consultations are requested towards your diagnosed diseases. Your ovary reserve and possible gynecological problems are studied with the examination conducted in the 2. or 3. day of the menstruation. If necessary, it might be asked for some hormone analyses. Cervix roentgen might be required for determining the situation of the cervix cavity and the tubes right after the menstruation finishes. If the patient is male, he gives a sperm sample with a sexual abstinence for 3-5 days. A new sample, if necessary urological examination, hormone analysis and genetic analysis might be requested in the patients with negative sperm analysis results.
It might be necessary to conduct hysteroscopy (monitoring the uterus cavity with a camera) and laparoscopy (monitoring the abdominal cavity with a camera, performing the necessary medical intervention=closed surgery) under anesthesia towards the problems identified by examinations and analyses.
It might be necessary to fix the health problems of the applicant couples, if there are, (diabetes, goiter, anemia, heart disease), for those patients with high body mass index to lose weight and to stop smoking before starting to the treatment. If it is regarded necessary, reinforcement of insufficient vitamins and antioxidant can also be done.
What is Ovary Reserve?
Every woman is born with a certain amount of egg cell. The number of the eggs which is around 7 million in 20. gestational week in a girl in the mother's womb decreases gradually starting from this week and it drops to 2 million in the time of birth and 400 thousand in the puberty. These cells, which are programmed to disappear, are chosen in the first 5 days of the menstruation every month and one or two of them are matured. A woman can ovulate only 400 of them approximately during the whole reproduction period. The age of the ovary is not always parallel with the age of the body. Although the decrease in the ovary reserve becomes clearer starting from the age of 35, this decrease may progress extremely rapidly and/or early. Genetic factors, smoking, living conditions of poor quality, surgeries carried out on the ovary, chocolate cyst (endometrium), chemotherapeuticagents and radiationmay also affect the number of the eggs negatively. The patients with these in their pasts must be evaluated earlier.
Although many of the methods (AFC (ultrasonographically showing the number of the existing egg vesicles during menstruation) FSH-ESTRADİOL, AMH) used in the evaluation of the egg reserve identify your response to the treatment, they may not always show your pregnancy per cent clearly.
B) STARTING TO THE TREATMENT
Even though the reason is man factor, the woman takes treatment in the in vitro fertilization. In order to have an efficient treatment, it is essential to have sufficient amount of egg and sperm of good quality. In this sense, there are many egg stimulation protocols being applied. It is decided which of these treatments are suitable in the light of personal data (age, egg count, body mass index, smoking, procedure features-PGD etc.).
In this sense, the treatments and medicines are as follows;
1) Long protocol
For the patients with sufficient egg reserve, it generally starts in the 21. day of the menstruation cycle before the month that the treatment will start. Contraceptive pills can also be prescribed in advance. Your body's own control system is suppressed by injecting certain doses of GnRH-analogs. The purpose here is to prevent your ovaries to work beyond our control. These medicines are used until egg is collected. When you have your menstruation, the medicines adjusted suitably for you are applied to you for 10-12 days.
2) Short protocol (antagonist)
The egg-stimulant medicines are started to be applied after the examination in the 2. or 3. day of the menstruation. GnRH-antagonist medicines are added for your eggs not to crack on its own in certain days of the treatment depending on your response to the treatment. This treatment is mainly applied to the patients with insufficient egg reserve as much as it can be applied to any patient groups.
3) Co-flare and microdoseprotocol
This treatment is mainly applied to the patients whose egg reserve has decreased. The treatment in Co-flare protocol is applied by starting to use GnRH agonist in the 1. or 2. day of the menstruation and by adding egg-stimulant medicines.
4) Modified protocol where Co-fare and antagonist protocol are applied together (ultra short agonist + antagonist protocol)
5) Clomiphene citrate or letrozole in antagonist protocol
6) Consecutive stimulation
Double stimulation in the same cycle (this kind of application gives result in cases with insufficient egg reserve.)
C) MAINTENANCE OF THE TREATMENT
A follow-up period for 10-12 days starts after the selection of the suitable protocol. In this period, your response to the treatment is checked by conducting ultrasonographic examination and if necessary hormone analysis (estradiol, LH, progesterone) coming to the clinic 3-4 times. Addition or reduction for medicine is applied according to the results. The size of the vesicles filled with liquid containing egg cells called FOLLICLE is approximately 18 mm.
It is very important to maintain the treatment meticulously in this phase.
D) FİNAL PHASE (EGG MATUREMENT OR CRACKING)
When the size of your follicles becomes 18 mm, it is ensured that your eggs are matured and obtainable by gibing the suitable injections, the procedure to gather the eggs are carried out under anesthesia from the vaginal route and by the help of ultrasound 34-36 after the application of the medicine.
The eggs are put in specially-prepared devices called incubator 3-4 hours after gathering the eggs. Purification from the sustenacular cell mass (Cumulusoophorus-granülozacells) around themprocedure starts following this.It is identified whether it is matured or not under microscope. The conventional method, also known as classical method, applied in a way that 100 thousand sperms will be surrounding each egg might be applied for patients with sperm count of 15 million and above, sufficient mobility (40% and above) and normal morphology.The successful clinics around the world apply this method for 25% of their suitable patients. On the other hand, 1 sperm is injected into each egg in microinjection. This method can generally be applied in patient groups whose egg reserve has decreased, from whom few amount of egg can be obtained, with small sperm count or from whom sperm can be obtained by surgery as much as in other patient groups. Impregnation rate in microinjection is around 70-80%.
Whether impregnation is successful is generally checked 16-17 hours after the impregnation procedure (the following morning). If the impregnation is successful, cell division controls are conducted (CLEAVAGE PERIOD). These processes are carried out automatically in the incubator for embryos in the video follow-up. Fertilized eggs (embryos) stay in special liquids and special environments (incubator=devices of which the heat and gas features are adjusted) imitating the mother's womb until they return to the uterus.