1-IUI (intra uterine insemination)
2-In Vitro Fertilization (classical in vitro fertilization method has been abandoned today. ICSI (microinjection) method is used all over the world.
1- IMMUNIZATION (intra uterine insemination) uterine insemination)
In this treatment, in the semen analysis of the male, around 10 million/ml sperm and around 14% morphology should be normal.
To Whom IUI Is Performed?
In women;
1- Mild endometriosis
2- Unexplained infertility
3- Not responding to clomiphene citrate treatment and externally controlled Insemination in ovulation inductions with FSH given in a form After the egg is grown, vaccination is done 36 hours after HCG 10000 units is administered intramuscularly.After semen is collected from the man, it is first rested for 15 minutes, then the semen is rotated for 20 minutes in concentration (gradient system) centrifuge at 2000rpm, then the prostate fluid and dead sperm collected above are taken. Then, it is centrifuged again with HEPES solution for 10 minutes at 2000 rpm. The first quality and motile live sperms that settle at the bottom are then injected into the uterus with the help of ultrasound, through a special plastic and sterile insemination cannula to the woman taken to the gynecological table. The patient is removed after resting on the table for 15 minutes.
2- IN-VIEW BABY
As I explained above, classical in vitro fertilization (described as leaving the sperm and the female egg side by side) Since the success rate of in vitro fertilization is low, after the ICSI (microinjection) method was discovered in Belgium in 1992, this method has been applied in in vitro fertilization centers in the following years and today.
Microinjection (ICSI) indications:
1- Advanced oligoasthenoteratospermia (those with morphology less than 5 million/ml and motility less than 4% than normal)
2- Azoospermia (absence of any sperm in the semen fluid) with PESA, MESA or TESE sperm taken from the testicles.
3- Tubal factor in women.
4- Severe endometriosis
5- Unexplained infertility
6- Recurrent pregnancy losses (preinplantation genetic diagnosis
7- Those with genetic diseases (for the purpose of PGD)
8- In order not to infect HIV+ men to women
9- For those undergoing cancer treatment, oocyte or embryo freezing is recommended and microinjection is recommended for those who want pregnancy in the future.
WHAT ARE THE 5 STAGES OF THE MICROINJECTION PROCESS?
1- PREPARATION
Biochemical, serological, hormonal blood tests. They can be grouped as imaging tests and invasive tests. The most important tests are the ovarian reserve tests performed on the 3rd day of menstruation; FSH, E2 and AFS (antral follicle count) tests. Having fewer than five antral follicles in each ovary or having an FSH level above 15 mIu after the age of 37 indicates poor ovarian reserve. Apart from this, in case of recurrent in vitro fertilization failures, invasive tests such as hysteroscopy and laporoscopy can be performed.
2- KOH (CONTROLLED OVARIAN HYPER STIMULATION)
Here; Drug doses are adjusted according to the patient's age, success in previous applications, ovarian reserve, and body mass index. These can be long protocols, antagonist protocols, short and soft protocols. In the long protocol, pituitary suppression begins on the 21st day of the previous cycle. KOH is started on the 3rd day of menstruation. The aim of all protocols is to ensure the development of a large number of follicles. Follow-up; It is usually done with USG, E2 and sometimes progesterone checks. The induction program takes approximately 10-12 days. A 1-2 mm growth of follicles every day and a 50% increase in E2 every day is generally good for good multifollicular development. Approximately 10-12 days later, when at least 3 17 mm follicles are seen on USG, 10 000 units of HCG are administered for oocyte maturation (metaphase 2).
3- OPU (OOCYTE PICK UP) EGG COLLECTION PROCEDURE
Egg collection is performed 34 to 36 hours after HCG application. The procedure can be performed either with general anesthesia with propofol or with local anesthesia with dormicum.
4- ICSI (MICROINJECTION)
Oocytes collected with the OPU procedure take 2 to 4 hours. is rested. Metaphase 2 (mature oocytes); Microinjection is performed with sperm taken from the man in the morning of the same day. Under the control of a micromanipulator and microscope, the sperm is released into the cell fluid by puncturing the oocyte membrane. process. In the first 24 hours of follow-up, the zygote divides into two cells; If there are 4 cells at the 48th hour and 7-8 cells at the 72nd hour, if it is smooth and symmetrical, and there is very little fragmentation, it is considered a first quality embryo.
5- EMBRYO TRANSFER
It is usually done 3 days after OPU. What is desired is a good quality embryo transfer with 7-8 cells. Transfer made without any force is called type 1 and type 2. The chances of success are very high. The chance of success is lower in difficult transfer (type 3 and type 4). Progesterone is started 2 days before the transfer to prepare the endometrium. If pregnancy occurs, it is continued until the 10th week of pregnancy. 15 days after embryo transfer, BHCG is checked in the blood. If +; It is repeated every 3 days. It can be examined with USG after 15 days.
In our country, in successful centers and clinics, pregnancy is achieved per cycle at a rate of 40-50% in women under the age of 35. It decreases to 15% after the age of 41-42 and to 3% after the age of 45.
WHAT ARE THE COMPLICATIONS OF MICROINJECTION?
1- Multiple pregnancies: For both the family and the family. It is also a serious problem for our country. The inadequacy of premature maintenance services further exacerbates the problem. For this, 1- Further improvement of freezing programs, 2- Single embryo transfer, 3- Blastocyst transfer on the 5th day have begun to bring solutions to this problem.
2- Ectopic pregnancy: It has increased two-fold. Early diagnosis, the benefit of the drug called methotrexate in early diagnosis, and transfer away from the fundus in embryo transfer may be solutions.
3- OHSS (Ovarian Overstimulation Syndrome): It varies from mild to severe cases. Very close monitoring is required. In severe cases of OHSS, hospitalization may be necessary. In preventing OHSS; Measures such as 1-Reducing the HCG dose, 2-IVM (early collection of eggs at the GV level), 3-Cycle cancellation, 4-Coasting (withholding the gonadotropin dose for 1 to 3 days) can be listed.
REPEAT TUBE. WHAT CAN BE DONE IN CASE OF BABY FAILURE?
It is necessary to re-do all evaluations of the patient from the beginning. 1-If there is adhesion (synechia), septum, supmycose myoma, intramural myoma larger than 4 cm, endometrial polyp in the uterus, hysteroscopy and laparoscopy surgery are performed. It can be corrected with these. 2-Since hydrosalpinxes, which cause obstruction in the tubes visible on ultrasound, both secrete toxic substances and prevent the implantation of embryos (clinging to the uterus) by mechanical effect, these tubes can be either removed or tied by laparoscopy operation. 3-Changes can be made in KOH (egg stimulating protocols. Short antagonist protocols can be tried instead of long agonist protocols. 4-Latrezole protocols can be tried instead of microdose flare up protocols in those with poor ovarian reserve. 5-If the woman is over 40 and has bad ovaries If there is a reserve, oocyte donation (egg donation) can be tried. 6- IVM Application: Collecting the eggs in the early period, that is, when the follicles are approximately 13-14 mm in size (GV periods) and maturing them outside.
REPEAT EARLY PREGNANCY LOSSES. (HABITUAL ABORTUSES)
Finally, I would like to talk about recurrent early pregnancy losses in a few sentences. The definition of recurrent early pregnancy loss is: 3 or more involuntary terminations of pregnancy before the 20th week. The most common reasons here are These are men with advanced maternal age and azoospermia. It is recommended for these patients to perform preimplantation genetic diagnosis on 2nd and 3rd day embryos in in vitro fertilization programs in terms of chromosomal anomalies and to transfer healthy embryos. Another important factor in recurrent early pregnancy loss is hereditary clotting (thrombophilia) problems.
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