Embryo transfer on Day 3 or Day 5?

One of the common questions that patients ask about IVF is the difference between doing an embryo transfer on Day 3 or Day 5 following egg pick up. To answer this, we should know a little about the reproduction physiology. When a woman conceives naturally, fertilization occurs in her fallopian tubes. It takes about 3 to 4 days for the fertilized egg to travel through the fallopian tube to the endometrial cavity of the uterus ( mother’s womb). During the transit of the fertilized egg (called a zygote at that stage), the zygote divides into an embryo (by day 2-3) and then further divides to a morula (by day 4) prior to arriving/implanting in the uterus. So, by the time the pregnancy implants in the uterus, it’s at a stage of development called a blastocyst on day 5.

Investigations on this field show that blastocyst transfer (day 5) during IVF treatments results in a significantly higher chance of pregnancy compared to an embryo transfer on day 3.

We have routinely been performing blastocyst culture and transfer for many years and observe significantly higher implantation and pregnancy rates as compared to what we see with day 3 embryos. First of all, it could be that longer incubation of embryos in the laboratory allows healthier embryos to grow, while those that are not healthy generally stop growing. This would increase the likelihood that better quality embryos would be chosen and transferred into the patient’s uterus, potentially increasing the chance for pregnancy. Another possible reason is that it more physiologically mimics that which occurs in nature during a spontaneous pregnancy. IVF labs which have poorer techniques and personnel, tend to favour day 3 transfers, as they may not be able to nurture the growing embryos for 5 days. However, if a very limited number of embryos are available on day 3 and no embryo selection is required, then the benefit of a day-5embryo transfer may be limited to the improved synchronization between embryo and endometrium. Because it is obvious that the best conditioned place for the embryos is the mother’s womb itself.

Finally, a clinic’s success with embryo cryopreservation following extended culture should also be carefully considered. We believe that extended culture to day 5 must go hand in hand with an excellent cryopreservation program in order to maximize patient success.

If you have trouble with Recurrent Pregnancy Loss

if you are experiencing recurrent pregnancy loss (RPL) your doctor should ask some investigations for you. Here is a list of tests to run…

Genetic analysis (chromosome/ Karyotype analysis): Blood samples should be taken from man and woman and tested for some probable abnormalities in the chromosomes, (missing chromosomes or additions to each chromosome, and translocations of chromosomes (in which all chromosomes are present but in different locations).

Anti Phospholipid Antibodies (APA) – cardiolipins are proteins found in many cells in your body. They help regulate blood flow throughout the body. However, when your body looks at the cardiolipins as an enemy or invader, it will attack them by creating antibodies . The three main groups anticardiolipins are: IgG, IgM, IgA.

Anti Cardiolipin Antibodies (ACA)- cells that attack the nuclei of other cells in your body. This is a mistake made by the body, thinking the good guys are the bad guys. Low levels should cause no problems.

Anti Nuclear Antibodies (ANA)- Again this is your body mistaking the good for the bad. Only this time it attacks the nuclei of the cell(s).

Lupus Anti Coaguant (LA)- This is a protein in your blood that causes it to clot in your bloodstream and veins differently than it normally would. To test for this there are actually several tests compiled and then looked at as a whole. These tests are the Activated Partial Thromboplastin Time (aPTT), the Modified Russel Viper Venom Time (VPTT), the Platelet
Neutralization Procedure (PNP), and the Kaolin Clotting Time (KCT). The typical treatment for this is baby aspirin, prednisone, and heparin/low molecular weight heparins.

Anti Thyroglobulin Antibodies (ATA) – Thyroglobulin is the protein that connects with the thyroid, which produces different types of hormones. Antithyroglobulin is usually found with antimicrosomal antibody in the bloodstream. These two antibodies together, attack the thyroid gland and also may couse pregnancy loss.

  • Normal/ Negative Results: levels less than 1:72
  • Borderline Results: levels between 1:72 and 1:300.
  • Abnormal/ Positive Results: levels higher than 1:300

Further testing is usually required to rule out other issues and is then treated with prednisone and dexamethasone.
If all the tests done are found as normal, then you should think about the possiblity of fetal factors. Actually pregnancy loss may be caused by a maternal factor or a fetal factor.
Until now, most investigations and treatment have concerned maternal factors causing pregnancy loss or recurrent pregnancy loss (RPL). Preimplantation genetic diagnosis (PGD) is the only strategy available to prevent loss due to aneuploidy( genetic abnormality) of the fetus. While it is difficult to measure the true incidence of aneuploid fetuses in RPL, various investigations in which the abortus has been analyzed have quoted that 25–60% of recurrent miscarriages may be caused by embryonic chromosomal aberrations. Thus, aneuploid miscarriages account for a significant number of pregnancy losses. Hence, the use of PGD may be appropriate for this significant subgroup of patients with RPL.
In our Centre, PGD is performed for the embryos where for different indications.

Please go to our page pgd for more information on this subject.

Autologus Immune Cell Transfusion ..A Hope For Ivf Success ?

Although sometimes very good-quality embryos are obtained during the in vitro fertilization (IVF) treatment process and placed into the uterus, pregnancy may not be obtained. This happens because of some probable genetic defects in the embryo or the body’s immune system does not accept the baby. But sometimes we are unable to determine any specific reason despite all the clinical and laboratory research and efforts.

The implementation of a simple, safe and cost-effective treatment protocol is important to improve the pregnancy rate in assisted reproduction. It is particularly important in the case of previous unsuccessful attempts.

Scientific Background:

It is well known that after placing the embryo into the uterus, the inner membrane (endometrium) releases various substances, proteins, growth factors and they become in contact with the embryo. For the conception in humans, primarily hormonal system regulates endometrium for implantation. Besides, there is evidence suggesting that the maternal immune system also participates in embryo implantation when the egg is fertilized. More than two decades ago, early pregnancy factor was reported to be secreted and influence immune cell function and early events related to development and implantation of the embryo (Clarke, 1992; Morton et al., 1992; Morton, 1998).

Takabatake in 1997, reported that immune cells derived from pregnant mice directly promoted endometrial differentiation in a manner independent of the endocrine system. Later, lymphocytes (some type of immune cells) in the thymus gland derived from non-pregnant mice were also shown to enhance endometrial differentiation to induce embryo implantation, suggesting that some populations of immune cells can affect endometrial differentiation and open the implantation window for the embryo (Fujita et al., 1998). To support this, when endometrial epithelial cells were incubated with autologous peripheral blood mononuclear cells (PBMCs), attachment of BeWo cell spheroids was significantly promoted in endometrial epithelial cell culture. (Kosaka et al., 2003). Furthermore, HCG (basic pregnancy hormone) is able to stimulate chemokine production by PBMC (Kosaka et al., 2002).

Together, these findings suggest that the mother’s immune system supports embryo implantation in the uterus as a complementary pathway and that hormones can induce functional changes in PBMC to facilitate embryo implantation (Fujiwara, 2006).

During implantation of the embryo, maternal immune activation and tolerance are not only limited to the uterus but are also observed in the blood predominantly affecting the innate immune system. Also unexplained female infertility, as well as recurrent pregnancy losses and implantation failure, are thought to be associated with some pathological maternal immune tolerance mechanisms.

Clinical Trials

There are few effective clinical approaches to infertile patients with repeated failure in IVF. The first scientific clinical research on this subject was published by Yoshioka et al. in 2006 (1). In this therapy, peripheral blood mono-nuclear cells (PBMC) are isolated from the patients and activated by incubation with HCG for two days. Thereafter, PBMC are freshly isolated from the patient again and combined with the cultured PBMC and then these PBMC are administered into the uterine cavity of the patients to induce adequate endometrial differentiation. Three days later, blastocysts are transferred into the uterine cavity. They applied this treatment to patients with repeated failures in IVF therapy and reported that PBMC treatment effectively improved the pregnancy and implantation rates. According to this study clinical pregnancy rate, implantation rate and live birth rate in the PBMC-treated group (41.2, 23.4 and 35.3%; n = 17 respectively) were significantly higher than those in the non-treated group (11.1, 4.1 and 5.5%; n = 18, respectively).

Osamu et al. have shown in 2011 that intrauterine administration of autologous peripheral blood mononuclear cells increases clinical pregnancy rates also in frozen/thawed embryo transfer cycles of patients with repeated implantation failure. (2). Supportive literature on this is given below as 1-2.

In conclusion, intrauterine administration of autologous PBMC may promote implantation and clinical pregnancy rates in patients who had experienced repeated failure of IVF–embryo transfer therapy. Thus, although the precise mechanism remains unknown, intrauterine administration of autologous PBMC may become an effective approach for increasing the pregnancy rate during IVF treatment.

Since recent evidence suggests that some populations of maternal immune cells positively enhance embryo implantation, we offer our patients with repeated implantation failure this supportive treatment to increase their chance of getting pregnant.

Advanced Age and Pregnancy Chance

high age

Marriage and maternal age is continuously postponed by women today. Causes for this postponement include to strengthen the professional carrier, concern to provide financial assurance or trying to be ready for being a mother psychologically.  The important issue is that woman should be aware effectiveness of age on a healthy pregnancy and potential to get pregnant.  Physiologically, the most appropriate fertility age for a woman is between 20 to 30 years of age.
Advanced age is not a definite obstacle for a pregnancy, however, the period to obtain pregnancy becomes longer by aging.  While chance to get pregnant in any month under thirty years is 20%, this chance has been reported as 5% only after 40 years.

In other words; while a 25 year old woman may get pregnant within a couple of months in general, this period may be loner than 6 months for normal women over 35 years.  Risk for miscarriage also increases by aging.
While pregnancy chance decreases over 40 years even for advanced level infertility treatments such as in-vitro fertilization, risks of miscarriage and babies with anomalies increase.  “Ovum quality” reduces by an aging woman, this causes decrease on fertilization capacity by a sperm.  In case of fertilization of these ova, more risk appears in terms of genetic disorders.  For example, Down Syndrome (third copy of 21st chromosome instead of second, Mongolian baby) is frequent in children of elder women.  When girls are born, there are 400,000 ova in their ovaries.  No ovum production occurs after the birth and woman’s ova reduces and becomes older irreversibly by age.

Chance for fertilization of the ovum by a sperm and occurrence of a well qualified embryo after fertilization reduce by aging.  Possibility of conclusion of pregnancies obtained by miscarriage also increase. Capacity of endometrium (inner layer of the uterus) to hold fertilized egg reduces by advanced age and pregnancy chance also reduces. Endometriosis which cause intraabdominal bleeding and infertility and intrauterine occupying myoma are frequent by aging.

Furthermore, many women may experience inflammations which may obstruct the tubes, ectopic pregnancy, appendicitis, endometriosis or  surgical procedures due to different causes and these may affect infertility.
However, it should be reminded that biological age of women is more important than chronological age for reproduction health.  While a 45 year old woman produced ova regularly, a very younger woman may enter into menopause period earlier in some cases.  When couples over thirty five years old can not obtain pregnancy, they should not wait for more than six months to refer to a physician.

Of course aging does not affect women only.  Although a menopause like women exists in men, sexual functions reduce and changes appear in pregnancy creation capacity by aging.  Frequently, a slight decrease appears in testosterone levels by aging and this may cause decrease in libido as well. It has been shown in men that testicles become smaller and softer by aging.  Sperm forms and motilities also tend to worsen even less.

Despite these changes, there is not any maximum age limit for men to have a child.  First, it should be searched whether medical problems may exist when pregnancy occurs.  For example, hypertension or diabetes may cause problems during pregnancy period.  FSH and estradiol (E2) measurements performed to assess pregnancy potential at 2nd to 4th day of menstrual cycles and evaluation of ovaries by ultrasonography provide important information.
Another important issue to be known by women in advanced age group is that they are more likely to carry a baby with genetic malformations than a young woman.  It is possible to reveal this with come interventions such as amniocentesis or chorionic villus sampling when they get pregnant.  Please click for more information about amniocentesis.
For old infertile women who can not achieve pregnancy despite efficient treatment (insemination and in-vitro fertilization), ovum donation, in other words, purchase of ova of young women from some centers abroad may be considered.  However, since our law does not allow this, this procedure can not be performed within territory of Turkish Republic.
Pregnant women with advanced age may face many problems during their pregnancy period.  For example, hypertension, gestational diabetes, premature delivery, miscarriage are more frequent in these pregnant women.
Appearance of systemic diseases also increase during pregnancy in advanced age.  All these should not fear expectant mothers.  These risks may be minimized with a careful monitoring and timely interventions by experienced physicians!

Are there any risks for the baby?
Advanced age may not be risky for pregnant women, but also risky for their babies.
As mentioned before, one of the important problems appeared during pregnancies over 35 years is possibility of increased chromosome abnormality.  Down Syndrome (mongolism) keeps an important place among these.  Please click for more information about Down Syndrome.  When the baby is delivered earlier due to pregnancy-induced diseases, pregnancy-induced hypertension, diabetes and placenta abnormalities, the baby is exposed to risks of early delivery.  Please click for more information about these problems experienced during pregnancy.

Finally, it should be recognized that infertility problems are experienced, pregnancy process becomes harder and pregnancy and delivery complications increase when pregnancy age is postponed.

What is IMSI? To Whom Should it be Applied?

ivf doctors

Intracytoplasmic Morphologic Sperm Injection (IMSI) technique has been developed by Benjamin Baartoy in 2004.  The purpose for this technique is to select best quality sperms and obtain a high fertilization ratio after microinjection.  High quality sperm and ovum will affect embryo development and increase pregnancy rate.

Some sperm abnormalities may be defined with normal microscopes with approximate 400 to 600 zoom.  These microscopes are used in microinjection (ICSI) technique; sperm selection is performed via a microscope with 6000 enlargement lens system in IMSI technique.  So, any abnormality which may exist in the sperm and can not be seen with a normal microscope may be detected and this technique allows selection of normal sperms.  In case of an abnormality called Vacuole on sperm head which is not detected by normal microscope, DNA carrying the genetic information may be damaged, this may cause abnormal embryo development.  IMSI reduces the risk to place sperms with damaged DNA into the ovum.

In which patients groups is IMSI recommended? 

  • Men over 35 years
  • Patients with abnormal sperms detected in the sperm test
  • Patients whom well qualified embryo can not be obtained in previous applications unless well ovum quality.
  • Those who have unsuccessful treatment history
  • Those who have miscarriage history in previous pregnancies
  • IMSI technique may be applied for ladies with less ova to increase fertilization ratio. In recent studies, better embryo development, higher pregnancy rates and less pregnancy losses have been detected by using sperms selected by IMSI technique.  (Antinori et al, 2008; Bartoov et al, 2002)

Since IMSI technique requires trained laboratory staff and expensive lens system, it is an expensive procedure; however an additional fee is requested in our center and used for all necessary patient groups.

I Had In-vitro fertilization Treatment But I Could Not Get Pregnant…

I Had In-vitro fertilization Treatment But I Could Not Get Pregnant…  What should I do? 

You have decided to have children to enlarge your family and stiffen your happiness and started to try on this matter.  6 months, one, two years…no result…You have visited a physician whom you heard that she/he is an expert on the field…examinations, tests, radiological examinations, follow-ups…no solid findings and no result are obtained.  You asked “What will happen now?” and your physician suggested “insemination” at first step; your physician told you to try “once or twice”…You accepted, drugs, injections, insemination, waiting with hope…result; negative again.
You say OK and decide to have in-vitro fertilization and refer to a famous center…
Injections, drugs, ovum collection, transfer processes and hopeful waiting period starts… You wish to obtain pregnancy at this time.

Result: Negative, disappointment, anger and tension again…

You have many questions straining your mind… Is there any mistake done at some stage? Is there anything missed?  Should we refer to another center?  However, they recognize us, should we try in the same center?  We have lost much money as well.  Will they request same amount for the procedure again? etc., etc.

It is natural that when pregnancy does not occur spontaneously, couples start a journey through in-vitro fertilization and microinjection treatments by hope to be assisted by advanced technology.  However, disappointment is much if no result is obtained form such treatment.  Of course chance of each couple is specific for them.  Some will obtain good results eventually if they have more embryos frozen during ivf treatment.  Because, it is known that couples who are not at advanced age have a chance to obtain pregnancy up to 85% after first 3 procedures.  However, if age of the lady is over 40 years, embryo may be obtained difficultly unless high dose drugs, this means the process is difficult.
It should be said first that couples with high pregnancy chance must continue on their treatments.  According to the researches, 30 to 35% of the couples who could not achieve pregnancy during their first treatment do not continue on in-vitro fertilization due to financial problems or psychological stress.  So, many couples who may obtain a positive result from the treatment are condemned to have a childless life if no spontaneous surprise appears.
First, review of all details of the treatment with your physician and manifestation and correction of a problem if any and then preparation of conditions for retry.

The first application in in-vitro fertilization provides important information for further treatment of female and male problems.  Kinds of the drugs used, their doses, response of ovaries to these drugs, ratio of fertilization of ovum by sperm, embryo quality and count, easiness and difficulty of transfer and concentration of the couple onto the treatment will be used for further treatment.  Strategy changes done according to the date will absolutely increase the achievement rate.

You should assess subjects such as genetic researches, evaluation of immune system, uterus film, assessment of intrauterine structure by a camera, biopsy from intrauterine membrane, co-culture of intrauterine tissue, selection of sperms by enlarging 6000 times with a special microscope for microinjection, pregnancy vaccination if they are deemed necessary by your physician with her/him in detail.

In summary, you should go on… You should know that couples who try without loosing hope, will reach their desire and have their babies.

Why is my ovum count less? Is there any solution for this?

It is known that ovum of women of which they will use lifetime develops during their intrauterine life and they are born with these ovum. No ovum is produced after then. Reduction of ovum in the ovaries by aging is a normal and physiological process.

Number of ovum that a girl has while she is 5 months old during intrauterine life is about 6 to 7 million; this number decreases to 1 to 2 million at birth, slowly reduces during childhood and such reduction continues by spending 350 to 400 ovum through ovulation until menopause. These ova is stored in spaces with fluid called follicles in the ovaries. When a girl enters into fertility age, menstrual cycles starts monthly.

The ovary develops one ovum per cycle. This may be more rarely. If this ovum combines with sperm cell from man, pregnancy occurs. The highest age for pregnancy for a woman is about 25 years. Pregnancy ratio reduces by age and this reduction accelerates since 35 years and significantly reduces after 40 years. To be able to get pregnant becomes almost impossible for women who had births before. Personal differences will play an important rule for sure, but pregnancy rate is below 5% even in-vitro fertilization is applied after 45 years. Reduction in ovary reserves and loss of fertility function accordingly does not mean menopause. The woman may have menstrual cycle, however, chance for pregnancy reduced.

The answer of the question “I have my periods, why can not I have child?” lies under this physiology. Women who have early menopause in their families should be careful in particular. Ovary reserve is consumed earlier in these women. Some difficulties may be experienced at 10 years from genetically programmed menopause age; for example, a women who will enter into menopause at 40 years starts to struggle to have child since 30 years. Therefore, ladies who have early menopause in their mothers and sisters should not postpone to get pregnant.

Besides advanced age and genetic factors, other factors that may cause early reduction on ovary reserves are as follows:

1. Some different factors such as endometriosis disease and chocolate cysts may affect ovarian reserve and capacity to get pregnant.

2. Radiotherapy and chemotherapy: Since cancers appeared within young ages have become treatable, this has caused reproduction problems more frequently for survivors.

3. Previously undergone ovary operations: No matter cyst removal operation is performed carefully, capacity will increase because number of ova will decrease.

Especially, removal of endometriosis cysts known as chocolate cysts may reduce ovarian capacity in thet side. It is essential that such surgeries should be performed by competent surgeons by caring normal tissues maximally. This subject may be a disadvantage in laparoscopic operations. Open surgery of those who have bilateral dermoid or chocolate cyst and maximum care on normal tissues should be discussed well with the physician.

The success in in-vitro fertilization applications is significantly associated with number of ova collected. Except excess numbers, to try to obtain 5 ova and over is ideal. According to the researches conducted, selection chance decreases when ova less than 5 is obtained and pregnancy ratios may be lower than expected. Changes in drug treatment in women whose ova are collected do not provide a significant advantage in general. Different drugs called short protocols may be tried in women whom long protocols (lucrin and similar drugs) are applied during previous treatments. While partial increase may be provided in number of ova by increasing the drug dose, this increase does not reflect to pregnancy ratios in fact. There are studies that number of ova may be increased in women with poor ovarian response by using the drug named Clomiphene which has been used from of old and by treatments applied with tablets called aromatase inhibitor.

There are studies published that ovarian response improves by acupuncture. If no benefit is provided from these above, a drug-free treatment called natural cycle may be tried. May new ovum production be achieved in woman? Despite classical information, new studies have shown that there are root cells in women’s ovaries. Studies to perform new ovum production and obtain pregnancy over these cells are performed on experimental animals. So, we hope in a near future that women with reduced ovarian reserve may become mother.

What is AMH Test and Measurement?

What is AMH?

Anti-Mullerian Hormone (MIS) is a glycoprotein secreted from ovum directly. Ovum up to 6 mm is secreted from ovular cells (granulose cells). AMH secretion starts at 36th gestational week in girls and continue until menopause. AMHmeasurement becomes common to present current ovum reserve and it is considered to have a strong relationship with ovum count. When ovum count decreases, blood levels of this indicator reduces. AMH secretion is not associated with Follicle Stimulating Hormone (FSH) which is another marker.

AMH measurement has some advantages when compared with FSH. – AMH measurement may be performed in anytime during the month; however, FSH levels vary. – AMH is not affected by blood estrogen levels; FSH is suppressed with high dose estrogen; low doses may be deceptive. – AMH does not have great changes between months; single measurement is sufficient; FSH reduces by age. – AMH may provide a preliminary information for ovary response to be obtained in the treatment; it may be helpful in bad response or over stimulation may be helpful. However, it should be reminded that AMH levels does not provide an exact result for pregnancy and it is not a determinant for menopause age as well; pregnancies have been obtained with very low AMH levels. Blood AMH values performed on a healthy woman under 38 years with normal ovum count at 3rd day of menstrual cycle is 2.0 to 6.8 ng/ml; however it was found higher in patients with polycystic ovary.

Fertility Potential (Fertility: AMH levels ng/ml)

  • Optimal Fertility 4.0- 6.8
  • Sufficient Fertility 2.2 – 4.0
  • Low fertility 0.3 – 2.2
  • Very Low fertility 0.0 – 0.3
  • High Level (Risk for over stimulation) >6.8

AMH measurements may be used to determined fertility potential and treatment response of the woman. Serum AMH levels are associated with ovum count in the ovary; a woman with low AMH levels will probably give bad response to the treatment. Furthermore, AMH levels will provide a warning about reduced ovum reserve.

There is a relation between increased ovum cells (granulose) and AMH in women with polycystic ovary. AMH levels have been found 6.8 ng/ml in women with PCO; this value helps to diagnose polycystic ovary and inform Over Hyperstimulation Syndrome (OHSS) risk that may be developed during the treatment before.

Intrauterine Insemination or In-vitro Fertilization?

As is known, the first approach for couples who do not have any evincible problem, in other words, were diagnosed with idiopathic infertility is intrauterine insemination for several times and then in-vitro fertilization treatments if no pregnancy occurs.

The regulation to issue an In-vitro Fertilization Treatment Report in our country stipulates to perform intrauterine insemination twice. However, validity of such approach has started to be discussed all over the world. Researches conducted has shown that in-vitro fertilization may also be considered directly for the couples who have desire to have a baby and do not have any evincible problem. A sample for these studies is the following study.

According to a multi-centered study (1) published in Fertility & Sterility journal which is one of the most reputable infertility journals in the world in August, 2010; In-vitro Fertilization directly has been found more economic and superior than intrauterine insemination for 3 times and then in-vitro fertilization treatment.

Details of the study were; 503 women whose ages ranged between 21 and 39 and who have been diagnosed with idiopathic infertility in USA have been divided into two groups randomly.

Intrauterine insemination by using clomiphene citrate (clomen, seropehen, gonaphene) drug, intrauterine insemination by using FSH (injection treatment) and in-vitro fertilization treatment if no pregnancy occurred have been applied; in-vitro fertilization have been applied to the other group directly and groups have been compared for achievement and cost.

Consequently, in-vitro fertilization treatment directly has been found more successful and economic than the other treatments.

Achievement rate for oral drug + intrauterine insemination has been calculated as 7.6% per application; achievement rate for injection + intrauterine insemination has been found as 9.8% and achievement rate for in-vitro fertilization directly has been found as 30.7%. For cost analysis; to choose in-vitro fertilization directly for a couple desiring pregnancy means a profit of 2,624 USD.

Reindollar RH, Regan MM, Neumann PJ, Levine BS, Thornton KL, Alper MM, Goldman MB. A randomized clinical trial to evaluate optimal treatment for unexplained infertility: the fast track and standard treatment (FASTT)trial. Fertil Steril. 2010 Aug;94(3): 888-99

Varicocele Operation Actually Necessary? Varicosele treatment

Varicocele is abnormal enlargement appeared in veins returning from the testicles to the heart.  While no findings appear on mild varicocele cases, it may cause disorders in sperm production and motility by progression during years.

It is reported that decrease on testicles sizes and disorders on testosterone production may appear in severe cases.  Temperature of the bags called scrotum which protects the testicles is generally lower by several degrees than body temperature.  In other words, a cooler media than the body temperature is required for healthy sperm production.

By development of blood ponding because of varicose in the bags, the increased temperature may affect sperm production negatively and spoil reproduction function.  Besides the temperature increase, another theory suggested is that harmful wastes  and free radicals from the kidneys and surrenal glands because of increased vascularization and blood building up may accumulate in the testicles.  Thus, it is told that sperm motility and quality may be affected in particular.

Incidence of varicocele has been detected as 25% in men with defective sperm test and as 12% in men with normal sperm parameters.  Furthermore, 35 to 40% of men who refer due to infertility have varicocele.  However, it should not be forgotten that varicocele may be detected in a significant part of healthy men with children incidentally.   It is generally detected on the left side; the vein on the left is longer and because this vein is connected perpendicularly onto the main vein, the blood can not be discharged completely.  Sometimes it is bilateral and rarely on the right side only.

How is it diagnosed? 

The most important diagnosis method is physical examination.  It is diagnosed by palpation of the vein and nerve formation entering into the testicles.  Intraabdominal pressure is increased by inducing coughing or straining during the examination and enlarged vascular structure is identified.  Varicocele may be searched with Doppler ultrasonography, however, it is reported that varicocele detected by ultrasonography only is not significant clinically and operation is not required.  Therefore, treatment of non-palpable mild varciocele is not suggested.

Varicocele treatment is surgical; veins are tied by an operation from the groin area visually or under a microscope.  Use of microscope during the surgery provides clear identification of the veins and preservation of the vessel which feeds the testicle.  Varicocele is most common cause for male infertility which may be treated by microsurgery methods.

A recovery by 60 to 70% may be achieved in spermiogram values in varicocele cases which are diagnosed correctly and treated by successful application of microsurgery methods (1).

However, there is conflict on research about how much pregnancy rates are recovered by recovery on the sperm count (2).

In general, cases who can not achieve pregnancy despite the recovery in sperm analysis results within 6 months at least following varicocele operations should pass to intrauterine insemination (IUI) or in-vitro fertilization – microinjection procedures.  Pregnancy may achieve by sperm washing and insemination in mild sperm disorders.  An Urologist is consulted if necessary.

Insemination is not useful for severe sperm disorders and in-vitro fertilization – microinjection treatment should be applied.  In case of absence of sperm in the sperm sample given, if obstruction is not detected as a cause, in other words, a decrease in sperm production exists, in-vitro fertilization and microinjection should be performed with sperms that will be obtained from parts taken from testicles (microTESE).  Varicocele operation is a waste of time for asoospermic men who have no sperm.  Another important issue is that varicocele detected in young men on adolescent age should be treated even they are not married.  It is suggested that disruption on sperm quality in the future may be prevented.

In summary; is sperm values are lower for a man in couples whom woman has not any fertility problem and an apparent varicocele which may be detected clinically, not by ultrasonography exists, treatment may be considered.  Otherwise, treatment is not necessary.  Also, varicocele should have spoilt the sperm values to start the treatment.  In other words, if sperm is normal, it may not be treated even varicocele is palpable.  Because insufficient scientific data that varicocele operation facilitates to obtain pregnancy and high achievement rates on in-vitro fertilization, it is more natural for couples to prefer microinjection, in-vitro fertilization rather than to have varicocele operation and wait for 6 months.