IVF Travel Poland
Your patients are looking for infertility treatment abroad? Help them with the first steps.
Below you will find substantive information that help you in the initial patients diagnosis.
We will take care of the entire fertilization procedure.
- When To Initiate Infertility Diagnosis?
- Factors affecting male infertility
- MALE PARTNER physical examination
- Medical History of the Male Partner
- Diagnostics. Semen TESTS
- Planned proceedings
- Factors affecting female infertility
- Female Partner Physical Examination
- Medical History of the Female Partner
- Diagnostics. Hormone tests
- Tubal patency assessment
- planned proceedings
When To Initiate Infertility Diagnosis?
The woman’s age is the most important factor indicating the possibility of becoming pregnant. Therefore, the stages of diagnosis should not be prolonged. Basic infertility diagnostic can be performed within a maximum of 1-2 cycles. In case of infertility, both partners should always be tested.
In case of infertility lasting over 1 year, the ability of becoming pregnant spontaneously decreases to approximately 15%.
We should assume that every coupe unable to get pregnant after more than 1 year of regular intercourse (not only for pregnancy) should be diagnosed.
Couples are eligible for diagnosis earlier than a year as follows:
The female partner:
- Is over 35 year old
- Had surgery on the reproductive organs, lower abdomen and intra-abdomen (appendix, bowel, urinary tract surgery, endometriosis)
- Had abdominal inflammation
- Had curettage of the uterus (several times) performed
- Has irregular periods, when cycles last more than 35 days, or when menstrual cycles are shorter than 25 days
- Smokes a large number of cigarettes
The male partner:
- Had no offspring with another partner in a relationship where he did not use protection during intercourse
- His previous partner in a new relationship has children
- Has or had "wandering testicles,"
- Had surgery to lower the testicle into the scrotum
- Has or had an inguinal hernia, or had a hernia operation,
- Has or had hydrocele, hydrocele procedures or had testicular trauma
- Has or had varicocele, and had varicocele surgery,
- Had EPS diseases - kidney stones, nephritis
- Has excessive muscle mass - which may indicate the use of steroids, anabolics
- Has gone through common parotitis – mumps
Factors affecting male infertility
- Cryptorchidism> 1 year (should be operated on at 8-12 months of age)
- "Wandering testicles"
- Varicose veins of the spermatic cord in stage III
- Hydrocele of the testicles (injuries, damage to the blood/testicle barrier)
Past or ongoing diseases
- Diabetes - infections, vascular disorders
- Hypertension - medicines
- Inflammation of the genitourinary system (endotoxins, immunology)
- Chronic inflammation of the respiratory system - Kartegener syndrome
- Gastric and duodenal ulcer disease - medicines
- Parotitis - mumps during puberty
Previous surgery on the genitourinary system
- Catheterization (infections, injuries)
- Breaking stones (through the ureter, ultrasound)
- Prostate resection.
- Stimulants - steroids, alcohol, cigarettes - drugs – quantity and period of time
MALE PARTNER physical examination
- Varicose veins of the spermatic cord
- Hydrocele of the testicles – ultrasound
Medical History of the Male Partner
- Tight underwear, tight thick pants
- Sedentary work style (desk work, driver, "busy white collar")
- Overuse of the sauna
- Loose underwear, looser pants, seat beads/rings, contoured seats
- Weight loss
- Varnishers, painters, employees of printing houses, gas stations, car workshops (solvents, heavy metals)
- Farmers, fruit growers, greenhouse workers - without health and safety regulations
- Work at high temperatures - cooks, bakers, metallurgists
Most often we deal with idiopathic infertility, i.e. with an unknown cause.
Abnormal semen analysis results require consultation of a urologist or andrologist. Diagnosis should be extended to additional semen analysis and hormonal tests.
- Does he have children?
- What is their age?
- Has anything happened in man's life since their conception - illness, surgery, stimulants/addictions.
- Was he with another partner with whom he wanted to have children?
- Does the ex-partner have children with another partner?
- What is his profession? Where does he work?
- Did he have any operations?
- Does he have a chronic illness - genitourinary system diseases, hypertension, peptic ulcer disease?
- Are there Any hereditary diseases in the family?
- Does he have a brother? Does the brother have children? - exclusion of the possibility of genetic disorders.
- Does he take any medicine?
- How often does intercourse with his partner occur?
- Is he addicted? To what? For how long?
Diagnostics. Semen TESTS
General semen analysis
Basic study in which sperm we assess a concentration in 1 ml, total sperm concentration in the entire ejaculate volume, motility, viability and sperm morphology. In addition, the concentration of round cells and leukocytes is marked.
In the case of a suspected genitourinary tract infection or an increased leukocyte concentration in general semen analysis it is recommended to perform cultures of semen: aerobic, anaerobic and mycogram.
Migration test examining the ability of sperm to transfer from semen plasma to another environment. The correct value is > 3.0 million/ml.
Hyaluronan-sperm binding assay testing the percentage of mature and functional spermatozoa. The correct value is> 80%.
Test for the presence of sperm antibodies.
Sperm DNA fragmentation test to determine what% sperm may have damaged genetic material.
Marker of prostate function.
Seed follicle marker
Neutral alpha-glucosidase (NAG)
Test determining the ratio of free radicals to antioxidants that can neutralize them in semen.
It should be remembered that spermatogenesis, i.e. the process of sperm formation, lasts about 12 weeks. In the event of abnormal semen analysis, we recommend repeating it.
It is important to perform the test:
- while being healthy,
- after a possibly normal lifestyle.
In the event of an abnormal sperm test, the patient is usually referred to an urologist-andrologist in order to broaden diagnostics and possible treatment to improve parameters.
If azoospermia is diagnosed, the chance for these patients is to perform a classic testicular biopsy, thanks to which it is possible to obtain sperm for the IVF - ICSI procedure.
In case of an incorrect HBA test result, it is possible to use additional sperm selection, pICSI, thanks to which the embryologist selects only mature spermatozoa and fertilizes egg cells with them.
With an abnormal sperm chromatin fragmentation result, it is possible to use magnetic sperm selection, eliminating the spermatozoa in which the process of apoptosis has begun.
In the case of infertility lasting more than a year, after confirmed correct ovulation and patency of the fallopian tubes and semen> 5 million/ml, the couple may be directed to insemination (IUI).
Factors affecting female infertility
- Abdominal surgery
- Opening of the uterine cavity,
- Cervical procedures
- Ectopic pregnancies
- ▪umerous curettage of the uterine cavity
Female Partner Physical Examination
- BMI determination - PCO hazard> 30, BMI> 40 - extreme obesity.
- Scars after surgery and laparoscopy
- Features of androgenization
- Insulin resistancy - acantosis nigricans
- Changes at the entrance to the vagina
- Cervical lesions - large erosion
- Change in PH- inflammation
- Soreness/tenderness during examination - suspected endometriosis, adhesions
- Nodules behind the uterus - suspected endometriosis
- Ultrasound examination
- Uterus: fibroids, polyps, defects in septum, arcuate uterus, bicornuate 3D, adenomyosis
- Ovaries - size assessment, cysts, PCO, antral follicles
- Hydrocele of the fallopian tubes
- Fluid in the abdomen - the possibility of inflammatory lesions, endometriosis.
Medical History of the Female Partner
- Was the patient pregnant?
- If so, how did the pregnancy end? Miscarriages, Caesarean section, vacum, ticks, manual placenta separation, curettage after delivery, inflammation.
- Age of first menstrual period?
- Length of monthly cycle?
- <23-25 means ovarian extinction, > 35 days is usually PCOS
- How long does menstruation last (up to 7 days), its flow.
- Past diseases, including chronic diseases?
- Is the patient permanently taking medication? What medication?
- Diseases in the family (e.g. diabetes - the possibility of insulin resistance)?
- Is there a galactorrhoea?
a particularly important aspect in breastfeeding for multigravida/check yourself in a physical examination
- Previous operations?
- Past inflammation of the vagina?
- Painful intercourse?
- Has the patient been treated for infertility?
- If so, with whom (it is important) and for how long? What tests did they do?
- Have any assisted reproduction procedures been performed yet? What was the outcome?
Diagnostics. Hormone tests
The aim of the tests is to assess the hypothalamic-pituitary-ovarian axis.
Hormonal tests performed on the 3-5 day of the cycle: FSH, LH, E2, PRL
tests are performed between 8-10 am, preferably 2 hours after waking up.
Interpretation of FSH
FSH <12 IU norm.
FSH 15-20 IU - very little chance of getting oocytes - direct in vitro qualification.
FSH> 20 inability to obtain egg cells - qualification for a donor cell. FSH> 10 repeated 2 times in young patients may indicate extinction of ovarian function.
LH/FSH = 1 - standard.
LH/FSH> 2 indicates PCO-s and the possibility of no ovulation.
Interpretation of the PRL
PRL is measured in the morning on an empty stomach 2 hours after waking up.
The PRL norm for women is 1-25 ng/ml, the PRL norm for men is 1-20 ng/ml.
About 1% of the population has hyperproalktinaemia,
5 - 14% of women with secondary amenorrhea, 75% with galactorrhoea and primary amenorrhea,
30% with pituitary microadenoma (PRL> 50-100 ng/ml).
Contrast magnetic resonance imaging (MRI) should be performed and treatment with carbergolin should be initiated
½ tabl. 2 x a week or 1 tabl. Once a week.
Tests done at any day of the cycle:
- AMH, TSH, FT4, FT3
- TPO and TG thyroid antibodies
- IgG IgM anti-cardiolipin antibodies
- Vit D3, Helicobacter pyroli
- Insulin resistancy: glucose and insulin concentration after a 75 g glucose dose consumption at 0-60-120 min.
Thrombophilia testing done for miscarriages or ineffective in vitro procedures
- Protein S, Protein C, AT III
- Mutation of the Prothrombin gene
- MTHFR mutation
- Factor V Leiden mutation
- PAI, HPA1-a
- Lupus anticoagulant
Karyotype in both partners
AMH interpretation - currently the most important ovarian reserve marker. Low
AMH depending on age indicates the extinction of ovarian function.
The norm is AMH 1.5-4.0 ng/ml,
AMH 0.5 - 1.5 ng/ml, - reduced ovarian reserve, quick diagnostics: in vitro or insemination (IUI) when the couple do not want or cannot carry out IVF.
AMH <0.5 ng/ml, - means extremely reduced ovarian reserve - difficulties in obtaining follicles in the in vitro procedure, consideration of the donor cell after unsuccessful cycles.
AMH> 4.0 ng/ml suggests suspected PCO syndrome. In older patients, PCO-s may mask ovarian reproductive failure.
Interpretation of TSH, FT4 FT3, ATA - thyroid function assessment. Frequent hypothyroidism reduces the chance of pregnancy. Antithyroid antibodies may suggest an active immune process. Properly adjusted treatment can affect a woman's fertility. Ideally, TSH values fluctuate around 1,
Vitamin D3 concentration
There was a clear seasonality in getting pregnant depending on vitamin D3 concentration. Balancing deficiencies can significantly affect fertility.
tubal patency assessment
Techniques for assessing tubal patency:
Sono HSG (based on ultrasound) - good visibility of the uterus, average visibility of the fallopian tubes, no relation between the ovary and the fallopian tube, no assessment of the fallopian tubes. High costs of contrast agents. The procedure is easy to perform and not very painful for the patient.
HSG (based on x-ray image) - good visibility of the uterine cavity and fallopian tubes. Time-lapse photography possible. No relation between the ovary and the fallopian tube, hyphae fallopian tubes not documented, low cost of contrast media, high cost of x-ray equipment. The need for an X-ray technician. Irradiation.
Hydrolaproscopy - (HSC and hydrolaproscopy). Great visualization of the uterine cavity, the possibility of visualization of the fallopian tubes and the relationship between them and the ovaries. The possibility of visualization of adhesions, endometriosis. No knowledge of the inside of the fallopian tube - assessment of post-inflammatory changes. Cannot be done with a rear bent uterus, pelvic adhesions. Poor documentation capability, need for intravenous anesthesia (anaesthesiologist, nurse, instrumentalists), expensive equipment (HSC, hydroaproscope, video track). Possibility of intestinal and vascular complications. The procedure requires high operator skills.
Laparoscopy with HSC – excellent visualization of the uterine and abdominal cavities. Opportunity to visualize the ovary - oviduct relationship. Tubal hyphae evaluation.
Assessment of endometriosis, adhesions, fallopian tube patency. Lack of knowledge about the inside of the fallopian tube.
- assessment of post-inflammatory changes. The possibility of visual documentation. Necessity of an operating room, endotracheal anesthesia. Possibility of intestinal and vascular complications. Expensive equipment.
- laparoscope, hysteroscope, operating room. A large and expensive operational team.
- anesthesiologist, nurse, instrumentalist, assistance.
Preparation for HSG:
Vaginal culture with antibiogram. in the preceding cycle In the case of infection, treatment - the need to repeat, postponing in the event of inflammation.
From the 15th day of the cycle preceded by rinsing with Tantum Rosa 2 times a day (irrigator) + Metronidazole 0.5 twice a day for 10 days or Gynalgin 2 x1 into the vagina.
Having sex after menstruation before HSG procedures is prohibited.
HSG is performed on a fasting patient.
Anesthesia for any of the procedures requires biochemical blood tests as determined by the anaesthesiologist. All procedures require testing for infectious diseases, HBC, HCV, HIV, WR
Obstruction of both fallopian tubes is a direct indication for the in vitro procedure. In people who do not accept in vitro, sometimes, attempts are made to unclog the fallopian tubes with various techniques, but the effectiveness of these procedures is negligible.
Tubal patency does not mean its proper functioning.
The fact that the contrast passes through the fallopian tube is encouraging, but we still know nothing about the hyphal apparatus, the ciliary system in the fallopian tube and their relationship to the ovary. Our knowledge is slightly higher if patency is checked by hiseterolaparoscopy.
One blocked fallopian tube
One obstructed fallopian tube is an indication for intrauterine insemination (IUI) in a cycle where ovulation occurs in the ovary on the patent side.
It is appropriate to use slight ovarian stimulation to increase the chance of ovulation on the patent side. We then use cheap drugs such as clomiphene or letrozole. It makes no sense to carry out more than 4-6 inseminations because the total costs of these procedures outweigh the in vitro cost.
Lack of ovulation in hyperprolactinemia
There is often no ovulation in hyperprolactinemia. Lowering prolactin using carbergoline usually normalizes the cycle. Light stimulation with clomiphene or letrozole improves the results. It is necessary to exclude pituitary adenoma by MRI. We apply the procedure to patients up to approximately 33 years of age.
Lack of ovulation - PCO-s
As treatment for PCO, the following is recommended:
- Weight reduction in cooperation with a dietitian. This gives greater effectiveness than self-control, but still the effectiveness of therapy is low.
- At BMI> 35, bariatric surgery should be considered.
- Myo-inositol 2 x 1 dietary supplement - as an element supporting treatment.
- Metformin - additional support, especially with insulin resistancy.
- In the absence of ovulation in PCO-s, clomiphene stimulation is used 1x 1/2 tabl. 2-6 d.c. and ovulation monitoring.
- HCG chorionic gonadotropin is administered subcutaneously to burst the Graff follicle.
Lack of ovulation
Lack of ovulation is an indication for laparoscopic ovarian cauterization with a thin needle, not a spatula or hook. The cauterization procedure is not recommended for patients >38 years of age because it reduces the ovarian reserve.
After cauterization, the patient undergoes re-stimulation with Clomiphene. If there is no effect, we combine Klomifen and FSH (37.5-75IU). In the absence ofan effect, we recommend in vitro stimulation and the IVF procedure.
STIMULATION FOR IN VITRO
The goal of ovarian stimulation is to increase egg cell production.
Preparation for stimulation:
Irrigation Tantum Rosa 2 x plot + Metronidazole 2 x 1/10 days
- Screatching the endometrium
- Long protocol with a GnRH analogue
- Cycle with GnRH antagonist
- A long cycle with a reduced dose of analogue
- Repeated cycles
- Ultra long protocol
- The short protocol
- The long protocol
- The starting dose
- The choice of FSH dose depends on:
- Types of stimulation
- Supervision over stimulation:
- Luteal support
for in vitro
Screatching the endometrium
Screatching, a microdamage of the endometrium for better embryo implantation on day 18-22 of the cycle. At the same time, we carry out tests in accordance with the Act and perform an ultrasound to assess ovarian follicles and the possible occurrence of cysts. We write out the stimulation for the next cycle according to the selected protocol.
Long protocol with a GnRH analogue
12-14 days before the start of stimulation, we give the GnRH analogue, it is about half the luteal phase about 20 d.c.
Stimulation with FSH begins when on day 2-3 of the E2 cycle <<50 pg/ml and P <1.0. If the concentrations are higher then the GnRH analogue continues. The disadvantage of this protocol is the large number of injections. The advantage is the ability to control the cycle time - it is said to be a more effective protocol by 2-3% compared to the cycle with the antagonist.
In the clinic we use this solution when 1.5 <AMH <4-4.5. The AFC number should be included.
The disadvantages are quite frequent spotting, bleeding in the first DTA cycle, and trouble with excessive growth and number of Graff follicles (PG) and the appearance of fluid - risk of OHSS occurence.
Cycle with GnRH antagonist
This is the most popular protocol currently and accounts for about 97% of all stimulations.
It is applied whenever the AMH concentration is above 4-4.5 due to the threat of OHSS and when it is lower than a 1.5 reduced ovarian reserve. Between 1.5-4.5, an interchangeable long protocol or other types of stimulation can be used.
On the 1-2 day of the cycle we determine E2, FSH, LH, Progesterone. If E2 is not more than 50 pg/ml and Progesteroneis not more than 1, then from the 2nd to 3rd day of the stimulation FSH is applied.
Check up after 6 days of stimulation and every other day thereafter. The inclusion of a GnRH antagonist (Cetrotide 0.25 mg/amp) is recommended when the lead PG is> 14-15 mm. If it is even larger, then 2 ampules of antagonist are given. once, then one at a time.
The GnRH antagonist can be given up to 36 hours before ovarian puncture.
The disadvantage of this solution is low cycle control.
The advantage, however, is the comfort for patients, the low number of punctures and the fact that PG maturation can be triggered using the GnRH analogue (200 mg - 2 amps), which reduces the risk of OHSS, the dose of FSH consumed is also lower. The protocol is particularly convenient for egg cell donors.
A long cycle with a reduced dose of analogue
The protocol is currently used sporadically. The procedure is based on a long cycle, reducing the dose of the analogue by half (50 mg/day) from the day FSH stimulation begins. This protocol is used in cycles in women with reduced ovarian reserve – AMH <1.0 and especially below 0.5-0.7.
The advantage is less analogue and less pituitary suppression.
The disadvantage is the theoretical fact that PG may spontaneously break before puncture. It is also a procedure that is not comfortable for the patient.
at extremely low AMH values <0.5 When the response to the antagonist cycle is very poor, 2-3 Graff follicles (PG) stimulation can be repeated in the next cycle by freezing ova from the given cycle. Administration of FSH in the first cycle is weaker due to lower sensitivity to FSH. It seems that a better solution is to prepare the pool of ova in one cycle for better recruitment in the next cycle.
Ultra long protocol
Ultra long protocol is used in patients with endometriosis and adenomyosis.
It consists of using the GnRh analogue for 3-6 months (Zoladex, Synarella, Dipherelin) and initiating stimulation.
The disadvantage is the high cost of analogues and FSH due to the higher dose. The process is long and requires many injections and patience on the part of the patient. The advantage is that it reduces the immunological response of endometriosis and changes on the part of adenomyosis
The short protocol
with the GnRH antagonist means:
- a shorter stimulation,
- a lower risk of OHSS,
- a lower risk of poor response,
- less predictable E2 profile,
- a greater risk of premature luteinisation,
- a potentially higher risk of ovulation,
- more attention from the doctor.
The protocol is ultimately used for patients with PCO-s and poor responders
It gives the possibility of using aGnRH trigger - analogue instead of HCG (Ovitrelle, Pregnyl), and therefore a lower risk of hyperstimulation.
The long protocol
- longer stimulation
- a higher risk of OHSS
- a greater risk of poor response
- a predictable E2 profile
- a low risk of premature luteinisation
- a low risk of ovulation
- more attention from the patient - injections from the 21st day of the preceding cycle
- ultimately, in patients with endometriosis and adenomosis (ultra long).
It is recommended to use additional drugs from the 2nd day of the Acard cycle 1 x75 mg + Encorton 10 mg 1 tabl. morning.
The starting dose
The routine starting dose is 150 IU FSH for 6 days followed by dose modification.
The choice of FSH dose depends on:
- the patient's age,
- effects of previous stimulation,
- body weight,
- smoking cigarettes,
- doctor's experience,
- the goal we are heading to,
- patient's beliefs
Types of stimulation
- Classic - equal FSH dose throughout the stimulation.
- Step down - giving a higher dose and then reducing it after 3-6 days:
- in cycles with low AMH (less than 1 ng/ml = 14 mmol/l).
- when we care about a large number of cells and we are afraid of OHSS.
- Step up - a cycle when we are afraid of OHSS and want to recruit a smaller number
- PG, and then increase the dose because PG slowly increases (poor stimulation).
Supervision over stimulation:
- ultrasound test every other day after 6 days of FSH injection.
- There cannot be a day off (without FSH) until the trigger has been given.
- E2 assessment after 6 days of stimulation.
- Dose modification depending on the number and size of follicles
- Giving the trigger at the right time: mono, dual, double
- Progesterone assessment when triggering is less than 1.5pg/ml, the patient may have a fresh transfer, above that we freeze embryos and serve in the next cycle.
- Estradiol on trigger day above 3500 ng/ml high risk of OHSS, we give the agonist instead of HCG and we refrain from a fresh transfer
- Estradiol around 200 ng/ml for each mature follicle.
- Endometrial thickness assessment: less than 8mm on the day of transfer, much less chance of implantation
- Progesterone on the day of transfer below 11 pg/ml low chance of implantation
- A trigger for Graff follicular maturation (PG) and possible ovulation.
- Used for insemination (IUI) or ovulation assessment in PCO and for in vitro procedures.
- Classic model - 5000-10000 IU HCG 36-37 hours before ovulation or ovarian puncture
- The Analogue aGnRH model used in the in vitro procedure when we do not make a fresh transfer for fear of hyperstimulation or when we delay the transfer due to immunology. Much greater luteal failure of the corpus luteum.
- 1-2 amp. Gonapeptyl-triptorelin, Dipherellina 35-36 hours before puncture.
- Dual Trigger - an analogue of GnRH and HCG, is used when:
- There were few mature oocytes in previous procedures.
- In patients with extremely low AMH. We give HCG (5000-10000 IU) simultaneously 36 hours before the puncture and 0.1-0.2 GnRH analogue 37 hours before the puncture.
Due to the fact that the corpus luteum in stimulated cycles is characterized by a shorter life expectancy and worse functioning. It is considered appropriate to administer Progesterone or progestogens - similar to progesterone to maintain or replace the action of the corpus luteum.
- Methods of administration:
- Oral - retroprogesterone - Duphaston
- Utrogestan 300-600mg (3 x 1-2 capsules)
- Crinone 1-2 doses daily
- Oil forms of Progesterone solutions - allergies, swelling, redness.
- Water - Prolutex 1 x 1 amp.
- For skin in gels - hard to standardize dose.
- In IUI insemination - it is not considered necessary to administer Progesterone. Sometimes Utrogestan is used
- 2-3x 100 mg
- With In Vitro - we give Utrogestan 3 x 2 capsules (600mg) and 1 ampoule of Prolutex.
- Duphaston is not used to maintain/replace the corpus luteum progesterone function for in vitro use
- PUNCTURE STAGES (OPU)
- OPU preparation
- Puncture performance
- Observation after puncture
- Complications of ovarian stimulation and puncture
- Information after puncture
- E.T. embryo transfer - transfer of fresh embryos
- Crio embryo transfer C.E.T. transfer of frozen embryos
- Embryo transfer preparation:
- Cancellation/abandonment of the Embryo transfer
PUNCTURE STAGES EMBRYOTRANSFER
PUNCTURE STAGES (OPU)
The couple arrive:
- with tests according to the Act on Infertility Treatment.
Male Partner: Blood type, HBs HCV, HIV, WR, Toxoplasmosis
- with a completed medical history
- with signed consent for punctures
- with puncture tests performed - Morphology, APTT.
- on an empty stomach - without food or drink for at least 6 hours.
The couple arrive:
- with tests according to the Act on Infertility Treatment.
Female Partner: Blood type, HBs, HCV, HIV, WR, Toxoplasmosis, Rubella, Chlamydia from the cervical canal, vaginal culture
Male Partner: Blood type, HBs HCV, HIV, WR, Toxoplasmosis
- with a completed medical history
- with signed consent for punctures
- with puncture tests performed - Morphology, APTT.
- on an empty stomach - without food or drink for at least 6 hours.
The puncture is performed under general intravenous TIVA anesthesia conducted by an anesthesiologist or in intravenous analgosedation and local anesthesia after previous administration of Ketonal and Pyralgin. Transvaginally, using a long needle, the suction of ovarian follicles is suction filtered under ultrasound control.
The procedure takes about 15 minutes.
Under intravenous general anesthesia
- Greater comfort for the patient
- Possibility of anesthesiologist supervision over the patient
- The patient will not move
- Troublesome arrangementavailability and a more expensive procedure.
Observation after puncture
After puncture, the patient stays under observation in the clinic for 2-4 hours. She is discharged home only when no intra-abdominal bleeding or major vaginal bleeding is observed. The patient is to immediately inform the doctor and report to the hospital if there are disturbing symptoms at home: fainting, hypotension, increasing abdominal pain, fever. She cannot stay alone and cannot drive. It is good for her to avoid strain and work for 2-3 days.
Complications of ovarian stimulation and puncture
- Bleeding into the abdomen
- Bladder bleeding
- Hematoma in peritoneum, retroperitoneal
- Vaginal bleeding
- Anesthesia complications
Information after puncture
Immediately after the puncture, the patient is informed about the number of cumulus (cloud) collected containing egg cells.
After about 3 hours, the embryologist informs how many mature egg cells were obtained.
The partner is to collect sperm or the donor sperm is thawed.
Embryologists and the gynecologist agree with the patient on what embryological procedure they will perform discussing the advantages and disadvantages and what type of sperm selection they will use.
In the following days the patient is informed about the number of correctly fertilized cells and how the embryos develop. On the 5th day the decision is made on the number of blastocysts administered (in accordance with the Act) and on possible vitrification - freezing of excess embryos. According to Polish law, we have to freeze surplus embryos, we don't have to freeze egg cells.
E.T. embryo transfer - transfer of fresh embryos
We perform the transfer:
- on day 5 of embryo culture (puncture date is day zero) after cultivation to the blastocyst stage.
- on the 2-3 day when:
- there are no more than 1-2 embryos
- the patient is from abroad and has no time having to return home early.
Crio embryo transfer C.E.T. transfer of frozen embryos
Day zero is the day of ovulation. In the case of anovulatory cycles, day zero is calculated based on the length of the patient's standard cycle or tests determining the receptivity of the ERA endometrium. We perform the transfer on the day when embryos were frozen.
Conditions for the E.T. and C.E.T.
- No features of ovarian hyperstimulation
- On day zero, progesterone less than 1.5 ng/mL (4.7 nmol/L)
- On the day of transfer or the day before, progesterone above 11 ng/mL
- Endometrium at least 7mm thick, less only in justified cases
- Lack of fluid and polyps in the uterine cavity
- No hydrocephalus of the fallopian tubes.
- The patient has no fever, no signs of inflammation of the vagina and pelvis.
Embryo transfer preparation:
- Presence 1 hour before the transfer when we check the thickness of the endometrium.
- "Calming" medications. Sometimes we also attach an IV drip with Atosiban to prevent uterine contractions, or drugs commissioned by immunologists
- Maximum filling of the bladder
- Execution of E.T. , C.E.T.
- After inserting a standard vaginal speculum - the one used when performing a cytology test, we insert the embryo with a thin catheter. The procedure requires a full bladder, which first bends the uterus to facilitate transfer, and secondly allows visualization of the catheter by ultrasound. The transfer takes about 15 minutes and is painless.
In cases where the uterus is very anteriorly or back bent and to enter it, we need to use a sharp tool - a volsella - we suggest the patient to have anesthesia. The patient rests at the Clinic for 1-2 hours.
Cancellation/abandonment of the Embryo transfer
In the following cases:
- Fluid or polyp in the uterine cavity
- Too thin endometrium <7 mm.
- Too many follicles> 30
- Too high E2 level -> 5000 pg/mL (18000 pmol/L
- Hydrocele of the fallopian tube
- Inflammation of the vagina and pelvis
- In vitro with gamete adoption
- Adoption of an egg cell
- Sperm adoption
- Embryo adoption
- Donor selection
- The phenotype
Adoption of Reproductive Material
In vitro with gamete adoption
An alternative for couples who do not have their own reproductive material is the adoption of ova, semen or embryos. Donors are selected based on the phenotype, i.e. a set of biological and genetic features, such as body composition, eye and hair color, blood type, and the donor is selected on the same terms. The whole procedure is completely anonymous.
Adoption of an egg cell
The offer is addressed to patients who do not have their own egg cells or their quality is insufficient for fertilization. The reason may be low AMH, lack of ovaries or their dysfunction, genetic loads, cancer or other that may result in fetal malformations.
The offer is directed to couples where on the male side the following were diagnosed: bad sperm parameters or lack of sperm in the sperm, genetic loads, cancer.
The most common choice for embryo adoption is for sterile couples who do not have their own reproductive material due to illnesses they have undergone. Donors are usually couples who have previously undergone the in vitro procedure and donated unused embryos for adoption.
Choosing a donor based on a photo or meeting is not possible in Poland. In accordance with the applicable infertility treatment Act, the data is classified. This is to guarantee donor anonymity. These principles are in accordance with Polish law and are propagated by the European Commission. The purpose of phenotypic matching of donors to recipients is to maintain visual similarity and a group of blood adequate to the blood group of the partners.
contains information about:
- eye color,
- hair color,
- body weight,
- hair type.
Donors of biological material can be both women and men who meet a number of criteria and have made an informed decision to be a donor.
They are also couples who became pregnant due to in vitro fertilization and transferred the remaining genetic material for adoption. They are always young people, under 35 years of age, without addictions, who have undergone a thorough health check.
Any genetic loads are checked, as well as the results of virological tests. The purpose of such thorough verification is to make sure that there are no contraindications to being a donor and that the biological material is of the highest quality.
- What determines the effectiveness of IVF treatment?
- The percentage of clinical pregnancies depending on the patient's age:
- Time Lapse
- Assisted Hatching
Effectivenes in vitro
What determines the effectiveness of IVF treatment?
- The age of the woman
- Embryo quality
- Quality of gametes
- Embryologist's work
- Laboratory equipment
- Endometrial receptivity
- Embryo transfer professionalism – the Doctor's experience
- State of emotional tension - stress
- Uterus structure
- Screatching in the preceding cycle, if it is not easy to enter the uterine cavity, we suggest hysteroscopy or
- Dilaplan for 24/48 hours in the preceding cycle.
- Trial transfer
We always make a trial transfer before the actual one. If we have problems entering the uterus due to the shape of the cervical canal, it is better to refrain from transfer than to condemn it to failure.
The percentage of clinical pregnancies depending on the patient's age:
<30 years old - 43.4 %
30-34 years old - 39.9 %
35-39 years old – 28.6%
40-44 years old – 11.7%
PROCEDURES INCREASING EFFECTIVENESS
Embryo monitoring system - Time Lapse
It enables 24-hour remote observation of developing embryos without having to remove them from the incubators. It also allows to repeatedly observe the development of each embryo, so that the embryologist can choose the embryo with the best development potential, increasing the chance of pregnancy. It is also easy to eliminate genetically abnormal embryos, e.g. triploids.
EmbryoGlue enzyme that increases the implantability of the embryo
Studies show that using the enzyme increases the chance of getting pregnant by 10% to 15%, helping the embryo nest in the uterus. In our Clinic, it is applied with couples free of charge.
Pre-implant genetic screening (PGS)
They allow you to determine if there is the correct number of chromosomes in an egg cell or embryo. Indications for conducting PGS tests are usually the age of one of the patients or both patients. Testing is also recommended for couples who have had repeated embryo implantation failures, miscarriages, and patients with high-grade male infertility.
Preimplantation diagnosis (PGD)
It allows for the genetic evaluation of ova before or after fertilization, or embryos before being inserted into the uterus. Thanks to this method, an embryo without a genetic defect is selected for transfer. PGD is recommended for patients diagnosed with genetic disease carriage and family history of these diseases.
ERA endometrial receptivity study
The ERA study allows to accurately determine at what time the embryo should be placed in the uterus, so that the transfer ends in pregnancy. It is addressed to women after a minimum of two in vitro treatment failures, when the embryo was developing properly and there was no result in pregnancy. Administration of embryos into the uterine cavity prematurely or too late may cause the endometrium not to accept the embryo, which in turn results in another unsuccessful in vitro test.
Assisted Hatching embryo incision
AH supports the embryo in getting out of the casing (which may be too thick or too hard), which increases the chance of embryo implantation in the uterine cavity, especially in patients over 35 years of age.
Salve Medica R Warsaw Clinic is popular among the patients who are most demanding and who value quality. The clinic is located in a very attractive location, approx.5 km from the Fryderyk Chopin airport - at al. Wilanowska.
Near the airport there are many comfortable hotels for people with different preferences. The clinic is located near a shopping mall and many dining options.
Take advantage of the time spent in Warsaw, the capital of Poland. Discover the most important attractions and fall in love with it like we did.