Tüp Bebek Tedavisi (IVF – İVF)

Under the subject of infertility treatment procedures the most researched topic is test tube baby treatment. Tube baby treatment, or in vitro fertilisation (IVF), refers to the insemination of the female egg with the male sperm outside of the female’s body. IVF is a group of different types of treatments, and choosing the correct treatment type for the patient increases the chance of success. Therefore, receiving medical consultancy services for patients interested in IVF treatments in advance of the procedure helps make correct and rapid steps towards a pregnancy.

IVF treatments can be described in short as the collection of the female eggs after maturation, insemination of the eggs in the laboratory environment with sperm provided by the male, observing the development of the embryos and accordingly placing them in the mother’s uterus (aka the endometrium). Suppose a sperm is particularly chosen to inseminate the egg and is placed inside the egg. In that case, this is called the ICSI treatment and is a routine procedure by some IVF centres as this procedure increases the chance of success.

IVF treatment is not a difficult process; it is a beautiful and exciting period where the patient, the doctor, the embryologist and the patient consultant must collaborate. IVF treatment has difficulties of its own. However, these will be memories of the efforts made for a beautiful result when the family is blessed with a baby.

As all test tube baby treatments require specific procedures such as collecting the egg and observing the development of the embryo, for these to be done correctly, they should be done in IVF units of the hospitals or in IVF centres. In an infertility clinic, there is a polyclinic area where patients are consulted and examinations are made, and there is a separate unit where IVF treatment procedures are done. An IVF unit involves an operation room where only IVF treatments take place, an embryology laboratory where the eggs and embryos (babies at the cellular stage) are developed, and an andrology laboratory where sperm observation and preparation are made. In addition to where the IVF treatment is made, who will make the treatment is equally important. A test tube baby should only be done by an infertility specialist who has received a diploma or a certificate in IVF treatments. Only gynaecologists who have received additional training and achieved authorisation have enough knowledge to apply these procedures. IVF treatments made by gynaecologists who have not received further training on these treatments are not only inconvenient for success but also illegal. Therefore, selecting the IVF treatment specialist is more important than choosing the IVF centre. The guidance of the patients’ doctors and the consultancy service given by the consultants on their websites provide instructive help for patients, allowing them to meet the best IVF specialist who can provide their treatment requirements. Asst. Prof. Burcu Özbakır has studied IVF treatments in Great Britain and is the only doctor with a diploma equivalent to high expertise.

As the choice of a group of patients to receive a particular type of IVF is a significant factor, initially, the medical data of the patient couple is evaluated by the IVF specialist, and only after that, a specific type of IVF treatment is advised to the couple. The conditions of IVF treatment are as follows:

• Female patients with ovulation issues
• Female patients with tubes that are either blocked or damaged
• Patients with blockage at the cervix or with sperm antibodies which disable the transfer of the sperm through the cervix
• Patients with issues regarding the number, structure, or motility of the sperm
• Couples with unaccountable infertility issues
• Female patients with endometriosis (chocolate cyst)
• Couples that do not benefit from intrauterine insemination
• Couples with faulty immune systems (immunological factor)
• Couples that want to store embryos
• Situations where the embryos need to go through genetic screening
• Female patients with vaginismus
• Male patients with erection or ejaculation issues

The treatment is a process defined following the investigations before the treatment. Both the treatment plan and the IVF medications and doses are determined before the test tube baby process. The steps of the infertility treatment are described to the patients in detail, and preparations are completed. For example, scanning some infectious diseases may be vital for both treatment timing and choosing the type of treatment. In some cases, it might be required that the patients use antibiotics before the IVF procedure, and in some cases, the sperm might need to be additionally washed.

Egg maturation period: The treatment timing of the couple depends on the female patient's menstruation cycle, and the treatment is initiated according to this cycle. Therefore, the treatment does not begin on a random day if the patient has regular menstrual cycles. According to the menstrual cycle of the female patient, the treatment protocol could be short or long. If the long protocol is chosen, the injection that controls the ovulation is started on the 21st day of the menstrual cycle, and the egg is developed by adding other egg-developing injections through the following menstrual cycle. If the short protocol is chosen, egg-developing injections start on the first 5 days of the menstrual cycle. After the eggs mature, injections that control ovulation are added to the treatment. The IVF injections that help develop the egg and control the ovulation are sometimes done subcutaneously (under the skin) and intramuscularly (in the muscle). Injections that are done under the derma are usually tiny and are done either on the belly or the arm, and the patients can make their own injections after a brief training. The injections done in the muscle are usually applied to the buttocks and, therefore, should be done by a nurse. The medications used in IVF treatments are not only injections but also include vitamins, antibiotics, medicines for the immune system and those for the coagulation system, given based on the patient's clinical condition.

During the treatment, the woman undergoes vaginal ultrasound several times to monitor the effects of the egg development drugs taken, to adjust the dose if necessary, and to add or remove medications if necessary. The reason for performing ultrasounds vaginally is that the measurements and images are much more accurate than ultrasounds viewed from the abdominal area. During the ultrasound, the follicles belonging to the developing eggs in the ovaries, namely the tiny egg cysts filled with fluid, are counted, each being measured individually. The growth rates of these measured follicles are monitored with serial ultrasounds, and the necessary medication adjustments are made. Another follow-up performed while monitoring egg development is the endometrium, or the thickness of the inner wall of the uterus, in in vitro fertilisation. The endometrium, where the baby will attach, also thickens under the effect of these stimulating drugs and its nutrition increases.

In both long and short-protocol treatment management, when the eggs are fully mature, an HCG-like drug called an IVF trigger injection is applied, and the eggs are collected between 34-36 hours after the injection. The timing of the egg collection process is critical because, in early collection processes, the number and quality of the eggs obtained will be worse. When it is too late, the eggs may not be collected because they will rupture. Since all the details can affect success, team harmony and success are higher when the IVF stages are shared with the patient.

Collection of the eggs: The eggs are collected while the female patient is under mild anaesthesia (sedoanalgesia), so the female is asleep and cannot feel pain. However, it is also not complete anaesthesia; therefore, she wakes up immediately after the procedure and does not undertake the risks of general anaesthesia. The duration of the collection is approximately 10-20 minutes and depends on the number of eggs, the experience of the infertility specialist, and the general condition of the patient’s eggs. Following the mild anaesthesia of the patient, the genital area is cleaned, and the eggs are collected one by one with the help of a sterile needle that goes through the vagina and into the abdomen. During this collection, the follicles that contain the eggs are continuously observed via vaginal ultrasound. The process ends after all mature eggs are collected and the collected eggs are transferred to the embryology laboratory. Before the end of the process and right before the patient wakes up, the doctor uses a trial catheter to check if the entrance to the uterus is easy. This enables the decision of which catheter or equipment should be used during the embryo transfer and increases the chance of success on the transfer day.

Fertilisation of the eggs: The question “How is IVF made?” also covers the creation process of the baby and actually begins with this step. After the collected eggs are rested, the cells around each egg are cleared, enabling a clear vision of the egg. At this stage, four types of eggs are observed. The egg type M2 refers to the eggs ready to be fertilised; the number of these eggs is the most important factor. The egg type M1 refers to those not prepared to be fertilised yet but almost complete their maturation. Sometimes, after a while, these eggs might transform into M2 eggs. Therefore, the M1 eggs are rested, and those transformed into M2-type eggs are also taken into the procedure. The egg type GV refers to those that are not available for fertilisation, are not fully matured, and are therefore not useful. Eggs that are called postmature or anomaly are those that are too old or have an abnormal look and these eggs are not used as they are unhealthy.

Before or during the collection of eggs from a female patient, the male patient provides a sperm sample. A frequently asked question is, “Who is the sperm collected from?” Since the patient does not receive a sperm donation in standard IVF treatment, only the male partner’s sperm sample is used. The excess sperm sample used is discarded unless the patient has a special request for freezing. The best results are achieved if the sexual abstinence is between 2-4 days before sperm is provided in IVF treatment.

The embryologist washes and concentrates the given sperm sample. After the eggs are collected, the fertilisation process begins. In a traditional IVF treatment, a certain number of sperm are placed in the same area per egg, and the sperm is expected to perform fertilisation. ICSI, or intracytoplasmic sperm injection, can also be added to IVF treatment in some cases or all treatments. In the ICSI process, the best sperm in terms of movement and structure are selected from among the sperm and a sperm is injected into each egg. In other words, in the ICSI process, the sperm does not make an effort to penetrate the egg membrane and enter but is placed directly into the egg. Since this process is a method that increases the success of the treatment, it is added to routine IVF treatment by our centre.

Growing of the embryos (embryo culture): The first laboratory control is made a day after fertilisation, where the number and quality of the fertilised eggs are recorded. While 2 PN shows healthy fertilisation, 1 PN or 3 PN are signs that a healthy fertilisation may not have occurred. For some eggs, fertilisation might not be observed. The fertilisation rate during IVF treatment depends on the quality of the egg, the quality of the sperm, and the laboratory conditions. Embryos, babies at the cellular level following fertilisation, are regularly observed in a special feeding environment and in a special laboratory setting. While those that have not developed in good quality in the development period lag in growth, the good ones continue growing nicely. The embryo production period is susceptible and includes observations and management, so the laboratory environment must be well-organised and cared for. The embryologist shares all the information they receive during embryo control with the patient and the doctors.

While the embryos being monitored continue their development process, the female patient is given additional hormone support in the form of pills, gel, suppositories or injections to help the inner wall of the uterus mature.

Embryo transfer: After the embryos become available for transfer, the IVF therapy is finalised with the embryo transfer. If no problems are observed with the cervix or the shape of the uterus, embryo transfer is an easy process and does not require anaesthesia. The transfer is an emotional process, and it is therefore important for the female patient to be involved in it for motivation. The embryo or the embryos are placed in the most optimum place in the uterus by our infertility specialist via a thin catheter that goes through the cervix. The transfer can be made between 1st and 6th days of the development of the embryo but the most frequently used development days are 3rd and 5th. While the success rate of an embryo which made it to the 5th day is higher than that of an embryo on the 3rd day, some embryos cannot survive in the outer environment when the duration is prolonged, and their development might stop. Therefore, the day the patient receives the embryo depends on the embryo development rate, which is determined after the doctor, the embryologist, and the patient have a discussion. All decisions over embryos are made as a group in our IVF centre.

Another issue is how many embryos will be transferred. Medically, a maximum of three embryos are used as the transfer limit. However, this number is limited to 1 or 2 in many countries. As the number of embryos transferred increases, the chance of pregnancy in IVF increases. Therefore, patients can choose reliable countries where they can transfer up to 3 embryos. The laws in Cyprus legally allow the transfer of 1 to 3 embryos depending on the patient's condition. On the other hand, as the number of embryos transferred increases, the possibility of multiple pregnancies (especially twin pregnancies) increases. Since multiple pregnancy is a pregnancy that is more difficult to follow and riskier, the number and quality of embryo development, the clinical condition of the patient, and the patient's expectations are variables such as the patient's expectations. The doctor and the patient, who are aware of the embryo developments, meet, and the most appropriate management for the patient can be determined following this meeting.

On the day of the transfer, the embryos designated to be transferred are placed in embryo glue without any extra payment required. This increases the chance of adhesion after transfer and allows for a higher chance of pregnancy success. Right before the transfer, the embryos also go through a hatching operation, which doesn’t require any extra payment. This process makes a part of the embryo lining thinner using a special beam and increases the chance of adhesion of the embryo.

If our patients have good-quality embryos left, the remaining embryos can be stored on behalf of our couple with our patients' approval. In this way, if pregnancy is achieved, the same difficulties will not be experienced again for a second baby. If pregnancy is not achieved, a second treatment opportunity will be obtained much more easily.

The entire treatment process is determined according to the patient's treatment protocol. In patients who have applied a short protocol, the total treatment duration is 17-21 days. Since the treatment is started before menstruation in patients who have started a long protocol, the total duration, including drug treatment, is approximately 24-28 days. Since most of our patients do not live in Cyprus, to shorten this period, only the first part of our patients' drug treatments can be done where the patient is, and our doctor makes all arrangements regarding the drugs as a result of the examinations they have done in their home country. After our patients' eggs mature, they come to Cyprus, and the procedural parts of our treatment are completed there. In this way, the period our patients need to be in Cyprus will be approximately 7-9 days, depending on the day of the embryo transfer.

IVF therapy is a sensitive period and the precautions that are taken after it increase the rate of success. Therefore, our support must continue after the treatment as well as during the treatment.

Examples of the factors that affect the success of an IVF treatment are the egg reserve of the female patient, the sperm quality of the male patient, the number and quality of embryos that are transferred, the thickness of the uterus wall of the female patient and the uterus structure, the stress level of the couple, the compliance of the couple, the technical competence of the embryologist and the doctor, and the laboratory quality. As many variables already become definite before the embryo transfer, it is important that the patients keep calm after the embryo transfer and not be overwhelmed with stress. The medications the specialist advises should be used accordingly, and any additional issues should be reported to the consultant.

During the IVF treatment, it is advised that the patient takes good care on the day of the embryo transfer and lie down for a few hours after the transfer, which is known to increase the chance of success. However, the patient is not advised to lie down continuously for long periods following the embryo transfer. This increases the stress levels and might even decrease the chance of success. What the patients need to do is to be as active as during a pregnancy.

It is advised that after the IVF treatment, the patient does not consume clary sage tea, green tea, or beverages that contain caffeine, such as coffee and cola. Additionally, the patient is advised to refrain from eating foods that will keep her abdomen bloated. If the patient eats and drinks as if there’s a pregnancy she will not encounter any issues.

After the IVF treatment, the pregnancy test is usually done on the 12th day following the embryo transfer and this test looks at B-Hcg levels in the blood. If the pregnancy test is done before the advised day, a positive result could be seen; however, this is due to the trigger injection, as it might also give positive results as if there’s a pregnancy. On the 12th day, the effect of the trigger injection is gone, and therefore, such risk is no longer in the picture, and the positive result received with a pregnancy test shows a pregnancy. The patient should share the result with the doctor or with the consultant. The levels of this test are informative. However, the results received in the repetition of the test 2 days later are also vital as they track the speed of increase in B-Hcg levels. While in 2 days this number usually doubles, a minimum of 66% increase should be observed. After the positive pregnancy test, the patient should continue using her medication regularly as advised. Our doctor regulates and follows what our patients need to do after the formation of the pregnancy and which medications to use.

As with all treatments, there is a possibility that pregnancy may not occur in IVF treatment. In such a case, a repeat test may be requested if necessary. It is recommended that patients with confirmed test results discontinue their current medications. In patients with treatment failure, detailed examination of the files and taking precautions before a new attempt may increase the chance of success in a subsequent attempt.

Test-tube baby treatments in Cyprus are protected under law and regulations and are prepared according to all patient-protecting precautions. Therefore, IVF treatment can be done legally. One of the frequently asked questions about the law is if there is a condition of marriage for IVF treatments. In Cyprus, a couple does not need to be married to receive IVF therapy. If the patients recognise each other as partners and if their eggs or sperm are being used in the treatment, the names of the couple are registered into their file without the requirement of a marriage. In many countries, including Turkey, marriage is a must for receiving such therapies, but patients who are not married can legally have their IVF treatments in Cyprus.

Due to the law, we cannot share information on egg-freezing prices on our website. You can contact us for detailed information.