IVF Treatment Stages

The process of IVF (In Vitro Fertilization), in which the egg and sperm are subjected to certain procedures under laboratory conditions to achieve pregnancy and the resulting early-stage baby cells (embryos) are placed into the mother’s uterus, is explained step by step in detail below so that you can read and understand it more easily.

It must be remembered that this treatment process is a very special and important period. The golden key to success in treatment is: the doctor performing the treatment being fully aware of their responsibility and carrying out this procedure with conviction, and the prospective mother and father choosing their doctor and hospital carefully, supporting each other, and going through this process as calmly and stress-free as possible.

IVF – Stage 1 (Evaluation of the Couple)

At the beginning of the treatment, an appointment will be arranged for your detailed examination. Your general health check-up and gynecological examination will be performed for the success of your treatment and for your own health.

Please bring with you all previous test results, imaging films, and operation notes. These results will be evaluated and unnecessary tests will not be repeated.

Blood tests: These include the necessary hormone analyses for each partner, Hepatitis and HIV tests as preparation for treatment, and blood groups. In addition, if a previous IVF treatment has failed or ended with pregnancy loss, the necessary investigations aimed at determining the cause will be carried out.

A detailed ultrasound evaluation and examination of blood flow with Doppler ultrasound will be performed. If any problem is detected, it will be discussed with you in detail in terms of your health and the chance of success, and the necessary treatments will be applied first.

Sperm analyses: Male fertility primarily depends on sperm count, motility, and fertilization capacity. Therefore, all these analyses must be performed reliably. All these tests are carried out in our clinic. The necessary physical environment has been provided so that you can give a sperm sample in comfort.

IVF – Stage 2 (Creating the Treatment Plan)

An appointment will be arranged for you to discuss all your results and examination findings in detail with your doctor, and on the appointment day, your situation will be evaluated together.

Individualized treatment options are discussed and the most appropriate treatment for you is planned, and the time to start treatment is scheduled.

Extensive information about the treatment is provided. Videos related to the subject are shown. Information forms about IVF treatment are presented and your consent is obtained. You can discuss your problems and wishes with your doctor at every stage of your treatment. Phone numbers that you can easily reach at any time will be given to you.

IVF – Stage 3 (Ovarian Stimulation = Hormonal Hyperstimulation)

The ovaries are stimulated with hormonal treatment to obtain a large number of high-quality eggs.

Your treatment consists of two phases:

1. Suppression of your ovarian functions with GnRH analogues (preparations such as daily Lucrin injections, Supracur-Synarel-Suprafact nasal sprays)

On day 21 of your menstrual cycle, treatment is started to suppress your ovarian functions. In this way, a temporary menopause is created in the body; hot flashes, sudden sweating, restlessness, and headaches may occur, and irregular bleeding may also be seen during this period. The instructions for the medications to be used will be explained to you in detail.

Long protocol

This is a frequently used protocol. The preparatory treatment is started on day 21 of the cycle (it may be between days 18 and 22). This protocol may delay the expected menstruation by a few days. If the delay is more than one week, please call our clinic and inform us of your situation.

The preparatory treatment is carried out with GnRH analogue preparations. These preparations are usually administered as injections. There is also a nasal spray form, but because of possible problems with drug absorption, it is not widely used in recent years.

GnRH preparations in injection form include drugs such as Lucrin and Decapeptyl, and those in spray form include preparations such as Supracour and Synarel. This treatment should be continued until the administration of the hCG injection, which we call the trigger shot (Ovitrelle or Pregnyl), that provides final maturation of the eggs. No serious side effects have been identified; if any side effects are observed, please inform your doctor.

Lucrin: In the long protocol, Lucrin is started on day 21 of the cycle. Unless otherwise stated, the daily dose is 20 units. Lucrin is administered once daily subcutaneously at the prescribed dose. Menstruation may be delayed by a few days beyond the expected date. If the delay is more than one week, please call our clinic and inform us of your situation. Lucrin is continued until the day of Ovitrelle or Pregnyl. Training on how to administer the medication is provided by us. It is taught by having the patient self-administer under supervision, and the necessary documents are given.

2. Stimulation of your ovaries with preparations such as FSH (recombinant preparations; Gonal-F, Puregon) and HMG (urinary preparations; Menogon, Merional).

Within the first five days of your next menstruation, based on the results of blood tests and ultrasound performed in our center, if appropriate, hormone treatment to stimulate your ovaries will be started. With the ultrasound, it is checked whether there is any cystic structure in your ovaries that may prevent treatment or reduce the chance of success. The structure of the uterus is also examined. At the same time, with color Doppler ultrasound, the blood flow of the ovaries and uterus is assessed. In the blood test, estradiol (E2) is checked to determine whether ovarian functions have been sufficiently suppressed, and FSH hormone is checked to assess ovarian reserve.

While continuing the GnRH analogue you are using (Lucrin-Decapeptyl or Supracur-Synarel, etc.) without interruption, gonadotropin drugs such as Gonal-F, Puregon, Menegon, Merional, Fostimon, which are selected as the most suitable for you, are started. The method of use and doses of these medications will be explained to you in detail and recorded on your medication cards and given to you. These drugs are used to obtain a large number of eggs, and their efficacy and safety are similar to each other. Pergonal and Menogon are administered intramuscularly. Gonal-F and Puregon can be administered intramuscularly or subcutaneously. The advantage of subcutaneous administration is that the injection can be given by the patient herself or her partner. The duration of ovarian stimulation varies from person to person but is approximately 12–16 days. During this period, your response to treatment will be monitored hormonally (estradiol follow-up) and by ultrasound (follicle tracking). The number of tests to be performed will be adjusted according to your body’s response. Any dose changes will be communicated to you by phone and explained in detail by the responsible nurse.

When a sufficient number and size of follicles are obtained on ultrasound and your hormone levels reach an adequate level, hCG (drugs such as Ovitrelle, Pregnyl) will be administered so that the eggs can complete the final stage of their development. The instructions for hCG will be explained to you in great detail by our doctors or the responsible nurses, as any error in administration may result in failure to retrieve eggs. While you are being informed about the egg retrieval procedure, the possible number of eggs to be obtained from you and the chance of success will be discussed again.

Use of antagonists

Preparations called antagonists, which have recently been introduced into use, are applied in the treatment of our patients. There are currently two preparations on the market: Cetrotide and Orgalutran. In the antagonist treatment scheme, gonadotropin preparations, that is, hormone injections such as Gonal-F, Puregon, Pergonal, Menogon, are started within the first 5 days of menstruation, and according to follicle tracking and hormone analyses, daily antagonist injections are added to the treatment at a certain stage of development. The antagonist is given until the period of hCG administration (Ovitrelle, Pregnyl) before egg retrieval. With antagonist treatment, the goal is to prevent spontaneous release of the egg from the developing follicles so that the eggs can be collected during the egg retrieval procedure. In other treatment protocols, preparations such as Lucrin-Synarel-Supracur, which are started on days 20–21 of the cycle, perform the same function. The antagonist treatment scheme was previously used mainly in patients with low ovarian reserve to increase response, or more accurately, to reveal the existing capacity without prior suppression and then to allow healthy egg retrieval with the antagonist in the final stage. Today, it can also be offered to other patients who meet appropriate criteria.

IVF – Stage 4 (Egg Retrieval)

The egg retrieval procedure is an extremely important stage in IVF treatment and has a decisive effect on success. This is because the number and quality of the eggs collected are the cornerstone of the treatment, and these features are closely related to the doctor performing the procedure and the technique used. In addition, as it is a minor surgical procedure, it has vital importance. For all these reasons, the experience of the doctor performing the procedure is extremely important.

After the follicles in the ovaries reach the desired size, an appropriate dose of trigger injection (hCG) is administered, and 34–36 hours later, the egg retrieval procedure is performed. The procedure can be done under general or local anesthesia. The general anesthesia used is not as heavy as surgical anesthesia. It contains painkillers and sedatives and is a sedo-analgesia application. Egg retrieval is performed quite easily and comfortably with vaginal ultrasound. The patient lies in the gynecological examination position, and after being covered with sterile drapes and the vagina is cleaned, vaginal ultrasonography is started. With a needle passed through a guide attached to the vaginal ultrasound probe, the ovaries are reached. Each follicle is entered and its contents are aspirated with the help of a special aspirator. The collected fluid is immediately sent to the laboratory and examined under a microscope to see whether it contains an egg; if an egg cell is present, it is separated. If no egg can be obtained from a follicle, the follicle cavity is washed with a special fluid through the same needle and any egg that may have remained inside is attempted to be collected. The procedure continues until all follicles are aspirated. Aspiration of both ovaries takes approximately 15–20 minutes. After the procedure, the patient is taken to the recovery room to rest for a while.

Sometimes, despite a high number of follicles, no egg cells are found inside them. Or not every follicle yields an egg; for example, when there are 10 follicles and a maximum of 10 eggs are expected, 4, 5, 6, or 7 eggs may be obtained. This is because it is not possible to see the eggs during the monitoring phase. One of the most important reasons for the condition called empty follicle syndrome, in which all follicles turn out to be empty, is an error in the timing or dose of the hCG (trigger injection) administration by the patient.

During the egg retrieval procedure, the aspirated follicular fluid is immediately sent to the laboratory. This fluid is examined under a special microscope, and the eggs it contains are placed into culture medium and transferred to the incubator. The incubator keeps the temperature at 37°C and the carbon dioxide level at 5–6%. Mature egg cells become ready for fertilization after 4–6 hours. After ovulation treatment, approximately 80% of follicles with a diameter of 16–22 mm yield eggs suitable for fertilization.

Obtaining Sperm from Your Partner:

There is no restriction on sexual activity for the woman before HCG (Ovitrelle or Pregnyl) administration. Before the egg retrieval procedure, men should arrange a period of sexual abstinence not exceeding 3–5 days, but even if this abstinence period is not followed, in the microinjection technique the best sperm will be selected anyway.

On the day of egg retrieval, the man delivers the sperm sample to the laboratory in the morning (usually between 09:00–10:00). Especially couples who may have difficulty providing a sperm sample by masturbation outside the home without their partner may bring a sperm sample obtained at home.

After the sperm sample is obtained, it must be delivered to the IVF laboratory within a maximum of 30–45 minutes. If the sample is brought from outside the hospital, it should be kept at room temperature, protected from light, and delivered to the laboratory within 1 hour. After delivering the sperm sample, the man should remain at the hospital for about an hour; rarely, if necessary, a second sperm sample may be requested on the same day.

In some cases, it may be necessary to obtain sperm from the testes by aspiration or biopsy. If it has been determined in advance that sperm cannot be obtained from the ejaculate (cases where no sperm is seen in the semen, or where sperm are seen but have no motility or quality), sperm will be attempted to be obtained from the testis by needle or biopsy by our urology specialists, with whom we work together in our center, either before or on the same day as egg retrieval. As the latest technology, during testicular biopsy, multiple biopsies are taken under the microscope using a microsurgical technique, with very detailed evaluation of the testis, in what we call the mapping method. The chance of obtaining sperm will be discussed with you in detail at the beginning of treatment. In addition, the procedure will be performed by the most specialized experts in this field. In our practice to date, we have been able to achieve the highest success rates attainable by world standards.

After the Egg Retrieval Procedure:

Generally, the patient can leave the hospital after about one hour and is advised to rest at home for 24 hours.

1. Do not drive a car within 24 hours and do not return to work unless necessary.

2. Determine your own limitations regarding movement (exercise).

3. There are no restrictions on food and drink; do not smoke or consume alcohol.

4. You may take a shower or bath with warm water after 24 hours.

5. Do not have sexual intercourse.

6. You may use painkillers containing paracetamol (such as Parol).

7. You will start using Crinone gel or Progestan capsules on the day of egg retrieval.

Progesterone administration:

With progesterone administration, the inner lining of the uterus (endometrium) is supported and an appropriate environment is created for implantation into the uterus.

Preparations given for luteal support may be in injection, gel, or capsule form; they may be in the form of injections [Ovitrelle-Pregnyl], vaginal gel [Crinone vaginal gel], or vaginal capsules [Progestan cap]. The method of use and dose of these preparations will be explained to you in detail and documentation will be provided. Progesterone administration is started on the day of egg retrieval and, if pregnancy occurs, is usually continued until the 10th week of pregnancy.

8. If any of the situations listed below occur, call your doctor at the emergency number given to you, regardless of the time:

a. Fever higher than 38°C when measured,

b. Excessive vaginal bleeding [a small amount of bleeding is normal].

c. Very severe and persistent pain [a small amount of pain is normal],

d. Weight gain of more than one kilogram on two consecutive days,

e. Inability to urinate, accompanied by increasing pain, 8–10 hours after the procedure

IVF – Stage 5 (Fertilization)

While oocytes (eggs) are being collected from the woman, the man also provides sperm. The ideal method for obtaining sperm is masturbation. In individuals who do not have live sperm in their semen, sperm are obtained surgically. The obtained semen is collected in a special container and allowed to liquefy. The liquefied semen is examined in terms of sperm count, motility, and morphology.

In patients planned for IVF, the most important criterion is the number of motile sperm. The examined sperm are prepared for fertilization. Sperm preparation is important for two reasons. The first is to remove foreign proteins present in the semen, and the second is to trigger certain reactions and make the sperm hyperactive.

After the egg culture and sperm preparation are completed, the fertilization process is carried out. A single sperm, selected as good in terms of motility and morphology, is placed into each egg cell with the help of a special system. In the presence of a male factor or in cases of unexplained infertility, microinjection (ICSI) should be preferred. Sixteen to eighteen hours after the procedure, it is checked whether fertilization has occurred. In a fertilized egg, the number of nuclei, which was one, has increased to two.

The fertilized eggs are placed back into the culture medium and allowed to develop to more advanced stages. When they reach the appropriate stage, a certain number of the best-quality embryos are selected and transferred into the woman’s uterus.

IVF – Stage 6 (Embryo Transfer)

The embryo transfer procedure can be performed on day 2, 3, 4, or 5 following the observation of 2-pronuclear fertilization. Before deciding on the day of transfer, the following parameters should be considered.

Embryo Quality

Number of Embryos

Endometrial Thickness

Woman’s (Patient’s) Age

Previous Unsuccessful IVF Attempts

Whether pregnancy has occurred or not / pregnancy history

Number of treatment cycles

Before embryo transfer and before deciding on which day it will be performed, the embryology team and doctors must make a joint decision, taking the patient’s profile into account.

In some cases, while the patient’s E2 level and follicle development are ideal, endometrial thickness may not be suitable for the transfer procedure. In such situations, the patient’s embryos can be frozen on day 2 or 3, and later, after preparing the patient’s uterine lining, the frozen embryos can be thawed and transferred.

To support implantation, at the first embryo stage, that is, on day 2, the fertilized oocytes are placed into a solution in which their own (homologous) cumulus cells have been cultured, and the transfer procedure is performed from this medium on day 2, 3, 4, or 5, regardless of the day.

In addition, if the zona of the embryos is thick on the day of transfer, assisted hatching (AHA) is performed by thinning the zona with the help of a laser, and then the transfer is carried out.

Before embryo transfer;

– A trial transfer should have been performed

– The cervical canal and uterine position of the patient should be determined

– Performing the embryo transfer procedure under ultrasound guidance allows easier placement of the catheter and ensures that the embryos are placed in the correct location within the uterus, making the transfer easier.

In conclusion, regardless of which day embryo transfer is performed, certain key factors must be considered when making this decision. Each patient should be evaluated individually, and in order to achieve implantation and pregnancy, the embryo and the uterine lining must be in harmony, and our role is to provide the necessary infrastructure to achieve this harmony.

On the morning of the day on which the embryos will be transferred, they are checked and selected, and then brought from the laboratory by the embryologist in a special catheter and handed to the physician who will perform the procedure. Under abdominal ultrasound guidance, the embryos are placed into the uterus by the physician. Unless there is a special condition, embryo transfer does not require anesthesia. The procedure takes about 5–10 minutes.

After the procedure, hormonal medications in the form of injections or suppositories are given to support the uterine lining. If pregnancy occurs, this support is continued until the 10th week of pregnancy. If pregnancy does not occur and menstruation begins, the treatment is discontinued. A pregnancy test is performed on day 12 after embryo transfer.

On the day of embryo transfer, the time you should come to our center will be communicated to you by our team by phone. Before the transfer, you will again be informed about the number and quality of the embryos and the number of embryos to be transferred will be specified.

With the special broadcast system connected to our laboratory, you can have the opportunity to view your embryos before transfer.

Embryo transfer is a short procedure. As it is painless and risk-free, it does not require anesthesia. However, if you wish, the procedure can also be performed under anesthesia. Your partner may be with you during the transfer.

During the transfer procedure, as in a pelvic examination, the cervix is visualized comfortably with the help of a speculum placed in the vagina, the vagina is cleaned, and the embryos are transferred with the help of special catheters.

After embryo transfer, you can return home after resting for approximately 1.5 or 2 hours (scientifically, resting for more than 30 minutes to 1 hour has not been shown to have any benefit, but a longer rest period is provided). Rest at home for about 2–3 days; you may get up for toilet and meals.

Until your pregnancy test result is obtained:

Do not have sexual intercourse

You may take a standing shower with warm water 3–4 days after embryo transfer,

Do not go to places such as saunas,

Avoid strenuous sports,

Adjust your diet to prevent constipation,

If you need to use any medication during this period, please contact us in advance,

You may have low back and groin pain similar to menstrual cramps and a small amount of bleeding for 1–2 days; do not worry,

If you experience excessive abdominal bloating, difficulty breathing, nausea-vomiting, or a decrease in the amount of urine, please inform our center.

You may take a long trip only 3–4 days after embryo transfer.

Rest in bed as much as possible.

After embryo transfer, a medical report may be issued by our doctors depending on the result of the pregnancy test.

IVF – Stage 7 (Pregnancy Check)

The period between embryo transfer and the pregnancy test is a very difficult and exciting time for couples. Two weeks after the transfer, a blood pregnancy test [β hCG] is requested. Your test results will be communicated to you by our doctors. Even if vaginal bleeding starts before you have the pregnancy test, you must still have your blood drawn for the test on the scheduled day and contact your doctor, because contrary to what you may think, the bleeding may be due to an ectopic pregnancy or a threatened miscarriage, or your normal pregnancy may continue despite the bleeding.

In Conclusion;

If your pregnancy test is positive, you will be informed by phone how often you need to repeat the test, and when your blood result reaches a level at which the gestational sac can be seen on ultrasound, you will be given an appointment at our center and detailed information will be provided about ongoing prenatal care.

If your pregnancy test is negative, an appointment will be given for a consultation, during which your results will be discussed in detail and planning for a new cycle will be made.

Tips for Our Patients

Tips and Recommendations for Our Patients

– When you start treatment, do not impose very strict rules on yourself. Try to feel relaxed. We can help as much as possible, for example by arranging some appointment times to suit you. Continue your normal daily life.

– Be very careful when administering or having your injections administered, and supervise the person who is giving them. Follow the schedule that will be written in detail on your medication cards. The success of the treatment partly depends on you. Incorrect applications reduce success. If there is any point you do not understand, please contact us.

– Obtaining a large number of eggs does not necessarily mean obtaining a large number of embryos, nor does it mean that success will increase greatly. For example, 10–20 eggs may be collected. However, egg quality may be low or fertilization may not occur optimally. As a result, the number of embryos to be transferred will not exceed a certain number, although it is individualized. Therefore, do not make comparisons such as “many eggs were collected from another patient, my egg number is very low”. If it is anticipated that the number of eggs obtained will be at a level that may reduce success, this information will be shared with you before the egg retrieval procedure.

– Do not give too much information about your treatment to people around you; unnecessary comments and suggestions may confuse you and disrupt your concentration.

– Be realistic about the success of your treatment; do not expect miracles.