15
percent of the population is considered infertile.
Infertility is described as not having a baby after
6 months of unprotected intercourse. Infertility
is increasing in modern communities. In men declines
in sperm count due to toxic environment and possible
evolutionary effects are noted. Also women due to
educational and career concerns are married at a
later age. Average menopausal age ranges between
48 and 52 in women. We now know that, several years
before the menopause women are unable to bear children
due to the diminished ovarian function.
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Historically,
the menopausal age did not change and the chance
of having a baby is very slim as the female approaches
menopause. Therefore we recommend that all women
especially with the family history of early menopause
should have a baby at an earlier age. All the infertility
treatments and even IVF cannot be successful if
women’s ovarian function is diminished. |
HOW
DO WE APROACH THE INFERTILE COUPLE ?
We first evaluate the male partner. Two or three
sperm counts one month apart are ordered and evaluated.
WHO (World Health Organization) and Krugers` criteria
is used to analyze the sperm parameters.
If
the sperm count is abnormal, hormonal tests and
ultrasound of the testes is performed. This way,
hormonal and vascular problems may be detected.
In male infertility however, medical and surgical
therapies are getting less and less popular due
to high failure rates.
Therefore
for male infertility, currently artificial insemination
or IVF/ICSI is recommended, depending on sperm count
results.
For
WOMEN,
| We
order FSH, LH, E2, PRL, and TSH hormon levels on
the third day of the period. If
these are normal, ovulations are monitored with
ultrasound. If
there is an ovulation problem it is treated by oral
medications or hormonal injections, monitored by
ultrasound.If
the ovulation is normal, then Hysterosalpingography
( X-ray of the uterus and tubes) is performed to
rule out the tubal blockage. |
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If
there is a problem with the tubes, laparoscopic
correction is tried in certain cases. However, in
recent years due to highly successful IVF/ICSI results,
tubal surgery is performed less often.
In
some couples no cause is found. This is called as
unexplained infertility. In this group, firstly
3 to 6 months of ovulation induction treatment is
given. If
this is unsuccessful, artificial insemination is
used for 3 to 6 months as well.
If
all these fail, then IVF/ICSI should be performed
In general, below age 40 with normal hormones of
the female, classical treatments are successful
in almost 70 percent of the cases. IVF/ICSI would
be the answer if the classical treatments are unsuccessful,
the sperm count is very low, and both tubes are
blocked.
The
age of woman is a serious factor. If the age is
over 40, the chance of getting pregnant is lessened,
so the classical non-IVF treatments should be given
for a short time only. Therefore IVF/ICSI is used
earlier and more often.
IVF/ICSI
In
1978, the first test tube baby Louisa Brown is born
in London. This revolutionized the infertility technology.
Millions of IVF babies have been born and procedure
is getting more and more popular.
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In
normal conditions, women produce an egg and this
egg is captured by the Fallopian Tube. Egg travels
in the tube and meets the sperm. Fertilization occurs
in the tube and 2-3 days later, the fertilized egg
(zygote) enters the uterine (womb) cavity. Under
natural circumstances, this zygote implants in the
endometrium (lining of the womb) and the chance
of pregnancy is 20% only. For some reason, these
events cannot occur in infertile couples.
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| IVF/ICSI
procedure mimics these natural events. Women receive
hormonal injections to increase their number of
available eggs. The eggs are monitored closely by
ultrasound. When they reach to 18-20 mm in size,
they are triggered by HCG injection to complete
maturity which happens after 36 hours. At this time
patients are taken to the operation room and under
sedation anesthesia eggs are retrieved by ultrasound
guided follicle puncture. |
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Meanwhile,
male partner gives sperm. Sperm is evaluated and
most mobile and normal part is taken to be used
for the IVF/ICSI procedure.
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In
normal IVF procedure, eggs are placed in a Petri
dish and inoculated with 100.000 sperm per egg.
Mixture is placed in incubators and following day
eggs are checked for fertilization. In normal circumstances
with a good sperm count approximately 70/80 percent
of the eggs are fertilized. The eggs continue to
divide and two days after the egg recovery they
achieve 4 cell stage. On the third day, embryos
reach 8 cell stage. Same day, healthiest three embryos
are taken and placed in the women’s uterus
by plastic catheter. In our center all the embryo
transfers are performed under careful ultrasound
guidance in which uterus is seen easily, and embryos
are transferred exactly 2cm below the top of the
cavity. This gives the best pregnancy chance. Pregnancy
test is performed 12 days later. |
ICSI PROCEDURE
In IVF procedure sperm and egg are placed in the
same dish and fertilization of the eggs by the sperm
is expected. However, if the sperm count is extremely
low or the sperm is mostly abnormal, fertilization
cannot occur. Even with the normal sperm sometimes
fertilization cannot happen for some unknown reason.
In ICSI procedure single sperm is taken and injected
into the egg by means of micro needles which guarantees
the fertilization.
ICSI
procedures are getting more and more popular, because
it does not take a chance of “sperm not fertilizing
the egg”. In our clinic, ICSI is used routinely
and therefore the pregnancy rates are increased.
Unlike other clinics in the western world, there
is no surcharge for ICSI in Jinemed Hospital, Istanbul.
Sometimes
no sperm is found due to congenital absence of connecting
tubes between the testes and the penis. In this
situation, sperm can be found by testicular biopsy.
This is called TESE procedure. Sperm achieved this
way can also be used for ICSI.
Increasing
the pregnancy rates
In order to increase the success rates, certain
procedures are performed as necessary. For example,
some embryos have a thick outer layer which prevents
the embryos to attach the lining of the womb. To
solve this problem, the laser is used to thin out
the outer layer. This is called the Assisted Hatching.
Also in some cases, the embryos are transferred
not 3 but 5 days after the egg recovery to select
best embryos. 5th day embryo is called blastocyst
and this procedure is called blastocyst transfer.
In
multiple IVF/ICSI failures, one reason maybe chromosomally
abnormal embryos. For this reason PGD (preimplantation
genetic diagnosis) is performed. With this technique
one cell from the 4 cell embryo is taken carefully
and examined for chromosome analysis. Embryos, which
have normal chromosomes are then selected, and transferred
to the woman’s uterus the following day.
In
some IVF/ICSI cycles several embryos are produced
and three of them are given, remaining good quality
embryos are frozen for the future use. Embryo freezing
is a well developed technique today that allows
women to have another chance of pregnancy. Embryo
transfer is much cheaper than regular cycle because
no medication is used and no anesthesia is required.
Embryos are frozen for several years and can also
be used in the future if the couple desires another
child or if the first cycle is unsuccessful.
Ovarian
Cortex Freezing
For
young women with certain types of cancer (breast,
lymphomas, etc.), chemotherapy is required which
is detrimental for ovarian functions. If these women
desire future pregnancy part of the ovaries should
be removed and frozen. This is done laparoscopically.
Outer layer of the ovary contains numerous eggs
which can be frozen and used for ICSI procedures
in the future. This new technique seems very promising
and available at Jinemed along with very few clinics
in the world. Approximate medical cost is $10.000
Sperm and Egg Donation
Egg
and sperm donation is not legal in Turkey. Therefore
we cannot do these programs in Istanbul, however
we have associated clinics in northern Cyprus and
Greece. We can prepare the patients for this procedure.
Under our guidance and supervision, we will send
you to these clinics. Average medical cost is 6000
euro for egg donation and 4000 euro for sperm donation.
We
wish you great success in your treatments and we
are happy to welcome you to our beautiful city of
Istanbul with its famous Bosphorus and historical
places such as Topkapi Palace, and Hagia Sophia.
You will also enjoy the famous Turkish cuisine with
Doner Kebabs, Shish Kebabs, and delicious fish.
It will not only be a medical visit but culinary
experience as well.
