IVF and Microinjection (ICSI)
What is IVF?
Assisted reproductive techniques are one of the most classical methods of treatment. In Vitro Fertilization (IVF), can be translated into fertilization in the glass or in the tube. It was first applied in the world in 1978 in England-Cambridge and as a result a healthy baby was born. For many years, the development of egg cells with various pills or hormone needles was achieved, and the washed sperms collected in the laboratory were left in the same glass container with the eggs and allowed to fertilize each other. In this classic method, sperm cells must have enough numbers and movement to fertilize the egg cells. Therefore, fertilization was not possible in patients with very limited sperm functions in terms of number and movement.
Although the IVF method has been gradually abandoned since the microinjection method in the 90s, it is still being used in some centers.
When is IVF used?
-Tubes are closed (In this case, the sperm cell has no chance to fertilize the egg).
-Low sperm count, movement or normal-shaped sperm (morphology):
These problems can all happen together or separately. In a patient whose sperm numbers and mobility are within normal limits, if the percentage of sperm with a normal appearance is less than normal, IVF is required.
Patients who could not get results with intrauterine vaccination:
-IVF can be started after 3 times of failed vaccination.
Causes of unexplained infertility:
Despite all examinations, there is no reason to explain infertility by 20%. In this case, especially in women aged 36 and above, IVF is considered in the foreground.
Cases of severe endometriosis:
Endometriosis is a disease characterized by the growing of the lining of the intrauterine membrane (endometrium) inside the uterus, tubes, ovaries and/or intra-abdominal membrane, which allows the woman to have regular menstruation every month. Bleeding may occur in these non-uterine areas during each menstrual period. As a result, cysts in the abdomen, adhesions in the abdomen, and cysts in the ovaries may occur. Advanced cases may require IVF.
Stages of IVF treatment
It is useful to start with the folic acid pills before treatment. A suitable treatment protocol is selected according to the patient's age, body mass index, number of candidate eggs and hormonal status. Treatment protocols are usually short or long protocols. The purpose of this treatment is to stimulate the development of egg cells in the ovaries with the help of hormone injections that are applied to the abdomen or arm area daily. This is called controlled ovarian hyperstimulation (COHS). During the treatment, vaginal ultrasound is monitored at two-day intervals. In these examinations, the diameter of the egg sacs, called follicles, which develop and grow in both ovaries are measured. When necessary, the level of estrogen hormone (Estradiol = E2) in the blood is checked. Follicle diameters should be 18-20 mm, treatment is continued until the size is reached. The duration of treatment is about 8-10 days. HCG hormone needle is used for the final maturation of the egg cells within the follicles that reach the sufficient size. Egg collection is carried out 35-36 hours after this needle. Egg collection is usually done under general anesthesia. It takes about 10-15 min. After this procedure, the patient is discharged after a rest period of 1-2 hours, i.e. the procedure is a one-day procedure. After this process, the eggs are cleaned from the surrounding cells and microinjection process is applied. Then they are stored in cupboards called incubators (at 37 C body temperature, at a certain O2 and CO2 level) with providing appropriate conditions and daily development follow-up. On day 3 or 5, appropriate embryos are selected and transplanted into the uterus (Embryo transfer). General anesthesia is not required for this procedure. Intra-uterine embryos are transplanted with abdominal ultrasound. The patient needs to drink water two hours before and the urine bag should be full.
Long Protocol
In the long protocol, the patient begins the Gonadotropin Releasing Hormone Agonists (GnRHa) on the 21st day of her menstruation [single-dose depot injection, daily low-dose injection, nasal spray, etc.] and FSH or FSH-LH hormone needles are given to improve the eggs on the 3rd day of the next period. In the ultrasound the egg sacs called follicles should have a diameter of 18-20 mm. The needles are continued until this size is reached. When it is decided that the follicles reach sufficient size, the chorionic gonadotropin hormone (hCG) is injected into the eggs to stimulate the final maturation of the eggs and become ready to crack. Egg collection is carried out 35-36 hours after this needle.
Microinjection (first used in the 1990s) is nowadays more commonly used where the collected eggs are removed from the cells around after an ovum pick-up operation and a device called micromanipulator under the microscope is used to inject a sperm cell into each egg cell. This method is called Microinjection or ICSI (Intra Cytoplasmic Sperm Injection). The steps of embryo development and embryo transfer in the laboratory are the same as in IVF.
Egg cell (ovum, oocyte)
Microinjection process (ICSI)
Pronucleus (Day 1 fertilized egg)
2-cell embryo
4 cell embryo
8-cell embryo
In cases where the number of embryos is adequate and the quality of development is good, they are developed in the laboratory until the 5th day and the Blastocyst transfer is applied on the 5th day.
Day 5 embryo (blastocyst)
Short protocol
In this protocol, on the 3rd day of menstruation, hormone needles are started which directly develop the eggs. After 4-5 days, when the follicles reach a certain diameter, Gonadotropin Releasing Hormone Antagonists are added to the treatment. The aim is to prevent the eggs from spontaneous or premature cracking and to improve the egg quality. Both drugs are continued until the day of the egg cracking needle. The subsequent egg collection, laboratory steps, microinjection and transfer the same as in the long protocol.