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In this method, the woman's ovaries are stimulated with special injectable medications, eggs are collected from her ovaries and fertilized with her partner's sperm. After an incubation period of 3 or 5 days, the embryos are placed into the uterus.

The aim of ovarian stimulation is to obtain as many eggs as possible. Although different medication schemes are used in IVF treatment, these schemes are generally similar to one another.

With the onset of your period, an ultrasonography (USG) examination and a blood measurement are performed at the IVF center. The blood estradiol level should be below 60 pg/ml, the uterine lining thickness should be below 5 mm, and there should be no follicle larger than 10 mm in diameter in either ovary. If suitable conditions are present, daily injections are started (Gonal-F, Puregon, Merional, Menogon, Menapur or Fostimon). Your doses are determined according to your previous IVF response, if any, your age, your weight and the number of antral follicles in your ovaries. Your doctor determines at what dose and for how long you will use the medications. The IVF nurse will most likely explain this to you. The estradiol level in the blood is checked at intervals. At the same time, the development of the follicles is monitored with USG. If the protocol is an antagonist protocol, daily Cetrotide or Orgalutron injections are started on your doctor's recommendation. If the protocol is an agonist protocol, the agonist injections (Lucrin, etc.) are continued. When more than 3 follicles in both ovaries have reached a diameter of 17 mm or more, the trigger injection is given (Ovitrelle or Pregnyl). Egg retrieval is performed 36-40 hours after the trigger injection (usually in the morning).

Medications should be stored in the egg compartment of the refrigerator. Be sure to check the expiration date of the medications. You can generally store them in the refrigerator without problems until the expiration date.

It is a procedure that takes about 10-15 minutes. It can be performed using general anesthesia or local anesthesia. There must be 8 hours of fasting from food and drink before the procedure. The procedure begins with cleaning the vagina. A small needle attached to a transvaginal USG probe is passed into the ovary and the eggs are collected one by one. The collected eggs are handed to the embryologist in the IVF laboratory without any delay. After the procedure, bleeding is checked. After 1-2 hours of rest, the patient is sent home. If general anesthesia was used, only liquid foods should be taken within 12 hours. Solid foods can be taken after 12 hours. Bathing can be done after 12 hours. There should be no sexual intercourse. You should inform your doctor in cases such as shivering, fever, excessive bloating in the abdomen, inability to pass gas, inability to urinate, inability to have a bowel movement, nausea and vomiting, or excessive abdominal pain that does not go away after the procedure.

The collected eggs are fertilized with the sperm your partner provided in the morning. The fertilization procedure is performed under a microscope. A sperm is injected into the egg with a very fine needle. The fertilized embryos are grown in special incubators. You are given information about the development of the embryos every day. They are placed into the uterus on the 3rd day after fertilization or, if the embryos are suitable, on the 5th day.

The embryo or embryos to be placed in the uterus are determined in a discussion involving the laboratory team, your doctor and you. The best embryo or embryos that will allow you to become pregnant are selected. If conditions are suitable, the embryos to be frozen are also determined.

Embryos are placed into the uterus on the 3rd or 5th day. Unlike egg retrieval, it does not require general or local anesthesia. It is a very simple but very important procedure. The embryos are loaded into a very special catheter. Passing this catheter through the cervix and placing it in the uterus must be done with great care. A careless embryo transfer will reduce pregnancy rates. For this reason, embryo transfer should be performed by an experienced doctor. In addition, embryo transfer into the uterus must always be performed under ultrasound guidance. There is no need to rest after the procedure. Sexual intercourse on the evening of the procedure is beneficial and may increase pregnancy rates.

In our country, the Ministry of Health regulates the number of embryos placed in the uterus and has introduced certain rules. In the 1st IVF cycle under the age of 35, at most 1 embryo can be placed in the uterus. In the 2nd cycle as well, 1 embryo can be placed. If there have been 2 IVF failures, 2 embryos can be placed. Over the age of 35, at most 2 embryos can be placed. Unfortunately, more than 2 embryos cannot be placed under any circumstances. It is quite clear that this situation is wrong. There is no such practice in any country in the world, and there is nothing similar in America or European countries. But every IVF center currently has to comply with this rule. IVF centers that do not comply may face closure.

A good IVF center should have a good embryo freezing program. If embryo freezing cannot be performed, the quality of the IVF center should be questioned. The embryos to be frozen must meet certain conditions. Embryo freezing has many advantages. If pregnancy is not achieved in a fresh IVF cycle, a chance of pregnancy again can be provided by using some simple medications without stimulating the ovaries again. The rate of multiple pregnancy decreases. The Ministry of Health allows storage by freezing for 5 years. After 5 years, with the joint consent of the mother and father, the frozen embryos are either discarded or placed in the mother's uterus.

After embryo transfer, progesterone treatment is given until the pregnancy test. Vaginally administered progesterone (Crinone 8% gel) is more effective than other methods.

The blood pregnancy test is done 12 days after embryo transfer.

When the ovaries are overstimulated, fluid leaks from the ovaries into the abdominal cavity, and conditions such as abdominal bloating, nausea and vomiting, inability to eat, difficulty breathing, excessive weight gain and inability to urinate may develop. In this case, be sure to contact your doctor. Hospitalization may be necessary in some cases. In some cases, fluid may need to be drained from the abdominal cavity.

Government support can be obtained for IVF by getting a health report (with 3 signatures). It is sufficient to apply to the centers authorized to issue this report. Your doctor must determine that IVF is necessary in order for the report to be issued. In addition, to receive government support:

• The woman's age must be between 23 and 39. If she is even one day over 40, the report cannot be issued.
• Even if the report is issued by obstetrics and gynecology specialists, the man may need to be seen by a urologist.
• If the report is to be issued for unexplained infertility, 3 years of official marriage must have been completed. For other causes, the 3-year marriage period is not required.
• There must be no healthy child registered in the woman's or the man's civil registry.
• For those covered by the Retirement Fund, BAĞ-KUR and SSK (SGK), it is necessary to have paid premiums for at least 5 years (intermittent payment is also accepted) and to have paid premiums for more than 900 days in total.
• You must have been working for the last 90 days.
• There is no time restriction for Green Card holders.
• At present the government pays for IVF twice.
Documents required to obtain the report
• 1 copy of a civil registry record with history showing that there are no children registered to the woman and the man (separately for the woman and the man). It can be obtained from population directorates.
• 1 photocopy of the identity card (the woman's)
• 1 photocopy of the marriage certificate
• 1 photograph (the woman's)
• For SSK and Bağkur, a document showing the number of premium days (can be obtained from the relevant institutions)
• For Retirement Fund patients, a service record (can be obtained from the relevant institutions)

IVF treatment generally lasts between 15 and 20 days, although it varies according to the ovarian stimulation protocol applied to you. During this treatment you need to come to the IVF center at various intervals. It is enough for the man to come for only 1 day (he comes to provide a sperm sample on the morning the eggs are collected).

You do not need to be hospitalized at any stage.

If you smoke before IVF treatment, quit and do not drink alcohol.
If your partner smokes before IVF, he needs to quit 70 days beforehand.
Excess weight negatively affects the pregnancy rate in IVF treatment. Therefore, if possible, lose weight before IVF treatment.
Coffee should not be consumed during IVF treatment.

After IVF treatment has started, if there is not an adequate ovarian response or if your blood estradiol values drop suddenly, egg stimulation may be cancelled by your doctor. The treatment may be cancelled if no sperm can be found from your partner (azoospermia patients), if no eggs or no eggs suitable for fertilization are obtained at egg retrieval, or if fertilization has not occurred. Also, if your ovaries are overstimulated, the fertilized embryos may be frozen and the treatment may be cancelled.

• If the tubes are swollen (hydrosalpinx), the swollen tube or tubes must be removed laparoscopically before IVF. If they cannot be removed, their connection to the uterus must again be cut laparoscopically. Removing swollen tubes increases the pregnancy rate and decreases the ectopic pregnancy rate.
• If there is an endometrioma (chocolate cyst) larger than 4 cm in the ovaries before IVF, it must be removed laparoscopically. If it is smaller than 4 cm, there is no need to remove it.
• If there is an endometrioma smaller than 4 cm before IVF, aspirating it with a needle before the procedure is not recommended because it increases the infection rate.
• Aspirating non-functional cysts larger than 1 cm (estradiol below 60 pg/ml, endometrial thickness below 5 mm) with a needle before the procedure is recommended before IVF.
• The presence of polycystic ovary disease is not negative for IVF; on the contrary, it is positive. In a study we conducted, we found that the IVF pregnancy rate in women with polycystic ovary disease was higher than in the control group. We presented this study to the world in 2005 in "Fertility and Sterility," one of the most respected infertility journals in the world. This study can be found among my academic publications.

During IVF treatment, your expectation of pregnancy should be in line with the pregnancy rate your doctor has given you. A negative pregnancy result after excessive expectations can affect you, and therefore your family, negatively. If you feel tense before IVF treatment, you can receive psychological support with your doctor's approval.

This is a really difficult decision for patients. Today, many IVF centers use all sorts of improper methods to attract patients out of commercial concerns. With promises that are not based on truth, such as "we use new techniques" and "our pregnancy rates are very high," they exploit patients' desire to have a baby. Unfortunately, some television programs are also used for this. For good centers:
• How long has the center been in operation?
• Is it authorized to issue reports?
• Is it audited by international organizations?
• Is there an embryo, sperm and egg freezing program?
• What percentage of the frozen embryos survive?
• What are the pregnancy rates from frozen embryo transfer?
• What is the take-home baby rate?
• Does it have the infrastructure to treat you if a problem arises (for example, when the ovaries are overstimulated)?
Good centers should meet these conditions.

• If you have had a pregnancy before, in whatever form, your chance of becoming pregnant with IVF is greater than if you have never been pregnant.
• Advanced female age is the most important factor affecting the pregnancy rate in IVF. Over the age of 40, pregnancy rates fall very significantly. For women at these ages, months matter. IVF should be started without losing time, as soon as possible.
• Removing fibroids and polyps located in the area of the uterus where the embryo will be placed, by hysteroscopy, increases pregnancy rates.
• If there is a uterine septum, cutting it hysteroscopically increases pregnancy rates and reduces the risk of miscarriage.
• In repeated IVF failures, examining the inside of the uterus by hysteroscopy and treating any problem found may increase the pregnancy rate.
• Techniques said among the public to increase the pregnancy rate, such as the "screwing" method, the "gluing" method, co-culture and lymphocyte immunization, have no definitively proven benefit.
• Although studies have been published suggesting that the use of acupuncture in IVF treatment increases the pregnancy rate, more evidence is needed before it can enter clinical practice.
• Determining the genetics of the embryo (PGD) before placing it in the uterus is beneficial if there is a genetic disorder in the family; when the mother and father are normal, performing PGD does not increase the pregnancy rate but rather decreases it. Taking a piece from a healthy-developing embryo for genetic analysis usually harms the embryo.

Painkillers should not be taken during IVF treatment.
The use of aspirin does not increase IVF success.
Ovulation-inducing drugs do not cause ovarian cancer.

Poor ovarian response can be predicted before IVF (anti-Müllerian hormone, FSH and E2 on day 3 of the period, determining the antral follicle count during the menstrual period). An anti-Müllerian hormone level below 0.5 ng/ml indicates poor ovarian response with 85% accuracy. Also, having fewer than 5 antral follicles in both ovaries during the menstrual period, or, if there was a previous IVF cycle, having had fewer than 5 eggs collected from both ovaries, indicates poor ovarian response.
Having had ovarian surgery before, having had an ovary removed before, heavy smoking, the presence of advanced-stage endometriosis, and having received chemotherapy or radiation therapy before are risks for poor ovarian response.

The pregnancy rate of what is known as drug-free IVF (IVM, in vitro maturation) is lower than that of classical IVF.
Stem cell transplantation in men without sperm or women without ovaries is still at the research stage, and positive results have been obtained in mouse experiments. Its entry into routine clinical practice will happen sooner or later, but it is not available yet. For this reason, ask your doctor from time to time whether this method has started to be used.
The preferred form of freezing is embryo freezing. However, sperm and egg freezing are also performed successfully in single patients. In patients for whom cancer treatment (chemotherapy or radiation therapy) is planned, an evaluation must be made before treatment.

Azoospermia is the complete absence of sperm in the semen. It is seen in 1% of men in the general population. It accounts for about 10-15% of the causes of male infertility. Among couples who present with infertility, 5% have azoospermia in the man.

Azoospermia should not be confused with aspermia. In aspermia, there is no semen at all. Sperm normally cannot be seen with the naked eye; they can only be seen on microscopic examination. In azoospermia, semen comes out normally, but it contains no sperm, which cannot be seen with the naked eye anyway.

There are 3 types of azoospermia.
Pretesticular azoospermia
It makes up 2% of azoospermias. Because of problems in the walnut-sized gland in the brain (the pituitary), sperm are not produced in the testes. It can develop due to congenital or acquired problems. It is seen in conditions such as taking medications containing testosterone from outside, hyperprolactinemia, hypopituitarism, Kallmann syndrome and Prader-Willi syndrome. Blood FSH is low. There is no sperm production.

Testicular azoospermia (non-obstructive azoospermia)
In this type of azoospermia, the problem is in the testes. The testes may be absent, smaller than normal, or of normal size. It is the most common type of azoospermia. 49-93% of azoospermias are of this type. The blood FSH level is increased. There is no sperm production.
Causes
• Congenital chromosomal abnormalities
• Klinefelter syndrome (seen in 15-30% of non-obstructive cases)
• Y microdeletion (seen in 10-20% of non-obstructive cases). It has 3 types: A, B and C. Type B is the worst, and the chance of finding sperm is almost nonexistent. Type C is the best.
• Undescended testis
• Sertoli cell-only syndrome
• Having had testicular inflammation in adulthood
• Exposure to trauma
• Exposure to radiotherapy
• Exposure to chemotherapy
• Testicular torsion

Post-testicular azoospermia (obstructive azoospermia)
In this type, although sperm are produced, they cannot pass into the semen. It makes up 7-53% of azoospermias.
Causes
• Congenital absence of the vas deferens (associated with cystic fibrosis)
• Obstruction due to infections
• Retrograde ejaculation or absence of ejaculation altogether

Patients with azoospermia must be seen by a urology specialist. Examination of the scrotum and testes and determination of blood testosterone, FSH, LH and inhibin-B values are necessary. Genetic testing must be performed.

Treatment should be directed at the cause. In the presence of pretesticular azoospermia, pulsatile GnRH treatment can be applied. Alternatively, human chorionic gonadotropin (hCG) can be given at 1,000-2,500 IU twice a week. Human menopausal gonadotropin (hMG) 150 IU three times a week can be added to hCG treatment. With one year of treatment, a pregnancy rate of 80% is achieved.

In testicular azoospermia, treatment is IVF with the microinjection method. Sperm can be obtained from the testes by different methods.

In post-testicular azoospermia, IVF can be planned directly, or surgical treatment can also be planned. In retrograde ejaculation, medication can be tried.

The easiest way to obtain sperm from a man is to collect semen by masturbation.

In cases such as absence of sperm in the semen, retrograde ejaculation, or inability to provide a sample, it may be necessary to collect sperm using certain methods.

Micro-TESE (obtaining sperm from the testis by biopsy):
In men with no sperm at all in their semen (affecting 1% of men) (azoospermia), this is the finding of sperm or germ cells by making an incision in the testes under general or local anesthesia. It is performed by a urologist; pieces are taken from the testis under a microscope without damaging the blood vessels and given to the embryologist for examination. The search for sperm can sometimes take 6-7 hours. Micro-TESE has many advantages over conventional TESE. Because it is performed with the vessels visible under the microscope, the damage to the testis is minimal. There is also a large difference in the amount of tissue removed. The chances of finding sperm are similar.

The complete absence of sperm in the semen can be obstructive or non-obstructive. The chance of finding sperm is higher in the obstructive type. The non-obstructive type is divided into 5 types among itself. However, the chance of finding sperm is on average 50%.

PESA (percutaneous epididymal sperm aspiration):
It has a place in obstructive azoospermia. It can also be applied if there is difficulty in providing semen or if ejaculation is backward (retrograde ejaculation). A small needle is inserted into the channels called the epididymis above the testes and fluid is drawn. This fluid is screened for sperm.

MESA (microsurgical epididymal sperm aspiration):
This is the collection of semen from the epididymal channels above the testis by performing microsurgery under a microscope.

TESA (testicular sperm aspiration):
This is a method in which a needle is inserted directly into the testes, without making an incision, and the fluid is aspirated.

For high pregnancy rates in IVF, a patient-specific individualized IVF protocol, a very good IVF laboratory and good clinical practice are required. According to the regulation published by the Ministry of Health of the Republic of Türkiye in March 2010, in the 1st and 2nd IVF cycles under the age of 35 (the woman's age), only 1 embryo can be placed in the uterus, and in the 3rd and subsequent IVF cycles, at most 2 embryos can be placed in the uterus. Over the age of 35, at most 2 embryos can be placed in the uterus. In other words, the number of embryos placed in the uterus has been reduced by law. For this reason, the embryos to be placed in the uterus need to be of very, very high quality, so that despite their small number they can implant in the uterus and a pregnancy can be achieved.

A blastocyst embryo is the name given to the embryo at day 5 after fertilization, and it has a higher likelihood of implanting in the uterus than day-3 embryos.