What is IVF?
How it is done?
Couple-specific fertility rate test
Treatment of hormonal disorders and anovulation
Surgical applications that increase the chance of getting pregnant (hysterescopic and laparoscopic bloodless surgeries)
Shorter surgery and hospital stay turns into less pain; shorter recovery time; cosmetic benefits; smaller costs…
Endoscopic operations are done primarily by two techniques: In the technique known as laparoscopy, abdominal cavity is viewed on the screens within the operating theater through cameras that allow the visualization of all abdominal organs by the surgical team. After the problem is evaluated and definite diagnosis is made, required surgery is decided and performed by means of laser electric energy, various operating knives and hemostatic devices. Compared to the conventional open surgeries, endoscopic operations are far more advantageous. First of all, this type of operation shortens the time spent in hospital. Most often, patients are not required to stay in the hospital after operations for extrauterine pregnancy, simple ovarian cysts, endometriosis, urinary incontinence, and myoma removal. The patient can be discharged on the same day and can revert back to her daily routine within 48 hours. Due to these advantages, laparoscopic technique is frequently preferred for hysterectomy operations, i.e .removal of uterus for any reason, or even for the surgical removal of tumors. Endoscopic operations are also less costly when compared to the conventional open surgeries.
Another field of application for endoscopic operations is intrauterine surgery, also known as hysteroscopy. During the hysteroscopic operation, intrauterine visualization reveals out polyps, myomas, adhesions, uterine malformations all of which can be treated in a short time without the need to open the abdominal cavity. This approach is not only very successful in the diagnosis and treatment of various problems leading to infertility but also in a range of other problems including and pre- and post-menopausal bleeding with unknown cause, as well as early diagnosis of cancer.
Counseling and applications regarding preservation of fertility
Detection and treatment of insemination (abnormality and DNA damage) of sperms
In men, identification in advance of problems such as genetic predisposition, smoking and alcohol use, stress, being overweight, old age, or other sperm problems that can arise due to various diseases is very important for the treatment. If specific tests reveal that there is increased sperm dysfunction, sperm that is mature and good genetic condition must be selected in order to deliver inside the egg at IVF treatment. If the sperm dysfunction is very severe, changes in the life style and use of vitamins, antioxidants and herbal treatments before starting the IVF treatment could be beneficial.
During the IVF treatment, liquids and techniques that separate the sperms with higher fertilization capacity are utilized. In addition, IMSI performed by special microscopes, “double refraction” method that is performed by polarized microscopy, and the use of computer technology-driven chips inserted in special microscopes, selection of sperms with normal genetic composition and high capacity of fertilization is achieved and success rate can be significantly increased.
Urology and Andrology Counseling
Intrauterine (Artificial) Insemination (IUI)
It is a treatment option that increases the chances of pregnancy plus its efficient, non-invasive nature and easier and cheaper application than in vitro fertilization. Egg is followed up by ultrasonography during ovulation treatment and when the egg cracks, man’s sperm is taken to the laboratory for a 2-3 hours long preparation procedure which involves washing out to separate the seminal fluid. While on the examination table, the woman is inserted with a speculum to easily see the cervix, and the sperm is injected into the uterus with the help of a thin catheter via ultrasonography. Depending on the cause of infertility and the drugs used, pregnancy rates can reach up to 15to 20% after IUI.
Supportive treatments that increase the rate of pregnancy
Choice of drugs for women and dose adjustment
Techniques to reduce stress and anxiety
Psychological relaxing applications
Social, psychological, economic status; previous diseases, tests and responses to the treatment; their ages at time the treatment is started, the functionality of the ovaries or testes, and hormonal status should be considered for everybody that undergoes the treatment. Psychology of the woman and man, their desire to have a child and point of view about being childless; the way they perceive this problem, associate it with their man and womanhood, or reject it; mental stress caused by social and economic pressures; the relationship between the couple, any communication problems, and their feelings and reactions towards each other; and pressure from the relatives etc. negatively affect fertility.
Treatment information meetings
Counseling in collaboration with international centers
IVM (IVF without medication)
These cases can be listed as:
• Cases that IVM is not preferred based on the ovarian ultrasonography results,
• Cases with previously failed IVF treatments and cases which primarily require hormonally induced IVF treatment due to the couple-specific medical history. It should also be emphasized that IVF, in vitro fertilization including hormone stimulation, has a higher success rate than IVM; around 40-50%.
IVF and ICSI techniques
MicroTESE, PESA, and TESA applications
Fertilizing sperm selection (IMSI, double refractory CHIP) techniques
Sperm selection is of crucial importance in microinjection procedure. Selection based only on the sperm motility is not sufficient and functional selection of the sperm not only increases the chances of fertilization but also reduces the risk of miscarriage. The technique in which the mature sperm cells are magnified to great sizes under special lenses for detailed inspection and selection is called IMSI. Double refraction refers to another technique where sperm quality is assessed to enable sperm selection using a special microscope under special polarized light. Chip technology is a very recent and efficient technology and allows the selection of the sperms with highest quality DNA, even under the preparatory stage of the treatment. Thanks to these selection techniques, chance of fertilization is at its highest and miscarriage risk is at its lowest.
Laser applications to eggs and embryos (Zona, Drilling and Assisted Hatching)
Incubators specific for the embryos of couple
Embryo observation system (Embryoscope)
With the question “What can we gain from hourly, daily monitoring of the embryos using special video recorders and applying these on embryonic levels?” in mind, we conducted preliminary studies in collaboration with two centers in Rome and Bologna, and in the light of the data obtained, we started using the procedure that allows us to continuously monitor the development of embryos and select the best among them in CLINIC IVF Laboratory. This study resulted in a significant increase in technical success on patients. It can be used in:
• Couples with sperm count, motility and abnormality problems in combination with IMSI and double refraction techniques
• Women with low egg count to assess embryo quality and possible pregnancy rates,
• Choosing the best embryos for patients who will be transferred with single or double embryos.
• Choosing the embryos to be cryopreserved in the event of multiple embryos and to have an idea on the possibility of pregnancy rates if these embryos are used.
• Establishment and follow up of the quality control in the embryo laboratory.
Egg and embryo support (Cumulus cells co-culture)
It has been shown that if the eggs are kept alongside these cells after the fertilization, the supportive effect of these cells result in better developed embryos and increased pregnancy rates. The procedure is done at no extra cost, and no other invasive methods are required. This technique is called CUMULUS CO-CULTURE METHOD. In this procedure, the eggs that are developed after hormone treatment are collected together with the surrounding cumulus cells. Cumulus cells are separated from the eggs in the laboratory and their development is monitored for two days. After two days, the eggs that are at the embryo stage are transferred to the culture environment that contains cumulus cells. Until the embryo transfer procedure, embryo development and quality is evaluated and when the uterus is ready, the embryo is transferred together with these cells.
This method is proposed as an alternative for patients that have recurring IVF failure, polycystic ovary syndrome, endometriosis, blood clotting problems and/or poor embryonic development. These cells secrete hormones that help the development of embryos and lead to the formation of embryos that have good quality. The procedure has no risk. In this procedure, every patient’s own cumulus cells are co-cultured with their embryos.
Pregnancy vaccine (Balancing the immune system of endometrial wall)
In this study, 40% pregnancy rate is obtained in women who previously failed to get pregnant although placed with a good-quality embryo. Moreover, this technique decreased the rate of miscarriage after IVF by 30%.
This treatment that we choose to call “pregnancy vaccine” aims to use the woman’s own blood cells specifically to obtain the substances that will ensure attachment of the embryo inside the endometrial cavity. This treatment is applied as follows.
Firstly, it should be clarified that the reason behind the failed pregnancies is the related to the endometrial wall. With a variety of tests, the problem can be identified in advance of the IVF. Blood is collected on the day of the egg collection and blood cells called monocytes are separated through special procedures, these cells are then cultured in the appropriate medium. This is called “cell culture” and is done very carefully in special incubators and growth mediums.
In order for the cell growth to be appropriate and continuous, and also for the sufficient secretion of the required substances, the culture medium is supplemented with the hormone CRH that is released from the brain. After two days of culturing, cytokines and growth hormones that will help the embryo to settle into the endometrial cavity are secreted by the monocytes and build-up in the culture medium. In the meantime, the eggs are fertilized by the sperms and embryos are obtained in the laboratory.
Preferably, the quality of the embryo is assessed by a method called “embryoscopy” and the embryo to be transferred to the endometrial cavity is selected. Then the decision is made on the day of transfer.
On the day of the transfer (usually 2nd or 3rd day), endometrial cavity is examined through 3D ultrasonography and the thickness of the endometrial wall is measured in order to choose a region to transfer the embryo. The fluid obtained in the laboratory and named as “pregnancy vaccine” is injected into the endometrial cavity a day before or on the day of the embryo transfer.
This procedure creates a suitable environment in the uterus for the implantation of the embryos to be transferred, in other words, makes the uterus suitable for the pregnancy. Our studies have shown that the endometrial wall that is pre-treated with this method has a higher rate of accepting the transferred embryos and thereby increase the chances of pregnancy. In addition, since the embryo is more secure after this procedure, miscarriages might be prevented.
In CLINIC IVF Center this procedure is used:
• In cases where IVF treatment failed even though good quality embryo was used
• If the intrauterine fails to become thicker
• In cases with polycystic ovary disease
• In cases with chocolate cysts
• If advanced clotting problems of microveins affecting endometrial wall
• In cases where various tests identified a implantation problem in the uterus due to various reasonsSignificant increase in pregnancy rates are documented upon the use of this procedure.
Balancing Technique (Balancing the embryo and endometrial wall for pregnancy)
It has been shown that in women with polycystic ovary disease, endometriosis and related chocolate cysts, immune system disorders that cause clotting in capillary veins, two or more unexplained failures of IVF treatment, there are drawbacks in the egg, embryo or endometrial wall that prevent pregnancy or decrease the chances of getting pregnant.
Abovementioned diseases cause inappropriate and irregular release of hormones, which in turn affect the eggs during their development in the ovary. Insufficient immune system retards the development and maturation of the eggs. This delay is caused by the lack of sufficient support from the special surrounding cells and fluids that support the eggs for maturation, which are also affected by these diseases. As a result, both likelihood that the egg gets fertilized decreases and the quality of the cell cluster that will later form the embryo is compromised such that its ability of settling down into the endometrial wall is decreased.
With the balancing technique, problems regarding the egg, embryo and endometrial wall are addressed and they are made fit for the pregnancy. On one hand, embryos develop in the most suitable conditions; on the other hand the inner lining of the uterus is made ready for the implantation of the embryos. Thereby the balance between two systems is achieved, increasing the pregnancy rate and significantly decreasing the miscarriage rate.
In IVF applications without the balancing, since there is an established standard approach, couple-specific treatment is not possible. Pregnancy rates cannot be improved up to the desired levels due to the persisting problems if these problems in sperm, egg, embryo, and endometrial wall are not recognized and addressed with appropriate scientific and laboratory techniques. Even if there is an achieved pregnancy under these circumstances, risk of miscarriage is quite high. As a result, treatments that are conducted with great effort, hope and economic investment have trouble in giving the expected results. In IVF treatments, the current point of view is to have a “Healthy Pregnancy from the Sperm and Egg” and Balancing Technique is a new insight within this point of view. The basis of this approach is to identify and eliminate the problems in reproduction cells and organs and creation of a “balance” between them by means of the trained and experienced hands with the help of scientific data and technology to increase the pregnancy rate.
Increasing the implantation rate of the endometrial wall (Injury technique)
Hysteroscopy is the gold standard to evaluate the endometrial cavity. With the latest update to this technique, office hysteroscopy, hysteroscopy can be performed in a simple office or examination room, without any anesthesia, in a very short time and any uterine problems can be diagnosed and treated at the same session. For example, structural problems such as adhesion regions at the endometrial cavity, polypoid formations, uterine septum, and pathological problems such as endometrial hyperplasia, endometritis can be treated and pregnancy rate can be increased. We, as Gürgan Clinic, have done many scientific studies on office hysteroscopy and recurrent miscarriages and published our findings in scientific journals. We, therefore, offer this approach to our patients with great confidence.
The latest technology is to induce the uterine cells in order to enhance the acceptance of the embryo by the endometrial cavity. Endometrial cavity is examined by office hysteroscopy and small incisions (micro trauma/injury) are made at all surfaces with a special micro device. This increases the vitality and holding the potential of the endometrial cells. We, as Gürgan Clinic, are continuing this study in collaboration with Sheffield University, UK, and published our positive results in high impact scientific journals. This technique brings a new modality to increase the success rate of IVF treatment and have created a significant hope for the cases with recurrent failure.
Kliniğimizde tecrübeli embriyologlar transfer edilecek embriyoların seçimi konusunda son derece yetenekli olup; uzun süre inkübatörde kültür edilerek ulaşılan ve Blastokist denilen beşinci gün embriyo transferini de tavsiye etmektedirler. Blast transferi gebe kalma şansını arttırırken aynı zamanda çoğul gebelik şansını da azaltmaktadır. Ayrıca blast embriyo transferi embriyo ile endometrium arasında en iyi balansı sağlayacaktır. Doktorunuz sizin tedavi siklusunuza uygun olmak şartıyla, fazla sayıda embriyo edilen iyi prognozlu kişilerde 5.gün transferi konusunda embriyologlar ile yakın iletişim halinde olacaktır.
Egg development follow up with 3D and 4D ultrasonography and embryo transfer
Egg follow up during the course of IVF treatment is made in more detail by 3D and 4D ultrasonography and the same technology is used in embryo transfer.
Embryo and blastocyst biopsies and genetic elimination before pregnancy (PGD, PGS, CGH)(PGD, PGS, CGH)
a. Advanced age in man and woman
b. Serious sperm problems
c. Excessive use of ovarian stimulation drugs
d. Recurrent IVF failure, single gene diseases within the family
e. Recurrent miscarriages
If the couple is experiencing any of the abovementioned problems, genetic examination of the embryo before implantation may increase the chances of pregnancy and decrease the risk of miscarriage and abnormality in select cases. Genetic diagnosis (PGD, PGS, Trophecoderm biopsy) before the pregnancy (preimplantation) is based on specific examination of the cells collected from the embryos on the 3rd or 5th day of fertilization and the elimination of the problematic cells, followed by the implantation of the genetically robust cells to into the endometrial cavity. The couples and the embryos to undergo this diagnosis must be carefully selected:
1. If the procedure is performed on Day 3, particularly, the embryo quality may be compromised and chances of getting pregnant may be decreased even if the embryo was found to have a good quality.
2. This procedure should be performed only if it is investigated and thereupon seen that this procedure will increase the couple’s chances of pregnancy. The couple should not pay significant amounts of money and have false hopes if this procedure is not going to work for them.
Sperm, egg and embryo cryopreservation
1. After the treatment having too many good quality embryos that can be transferred. If pregnancy is not successful or if a second pregnancy is planned for later, these cells can be used.
2. In males who have difficulty to donate sperm.
3. When good quality sperm is detected in males with advanced sperm problems.
4. In situations where the endometrial wall is under- or over-developed, which require cryopreservation of the embryo, only to be transferred later into a ready endometrial wall under control.
5. In women at risk of losing their fertility, egg and/or embryo might be frozen to be used in the future.
6. Cryopreservation of the immature eggs to be matured and used later.
7. Cryopreservation of the ovarian tissue.
However, it is clear that these procedures should be implemented by experienced, knowledgeable hands in a center furnished with all of the available technical infrastructures and facilities that adheres to all of the required rules and regulations.