American Hospital, Istanbul
Posted in General Hospitals, İstanbul, Medical Centers
Address: Güzelbahçe Sokak, No:
20, Nişantaşı, 34365, İstanbul, Turkey
Phone: +90 (212) 444 3 777
Fax: +90 (212) 311 21 90
AMERICAN HOSPITAL
ASSISTED REPRODUCTION UNIT
ISTANBUL
You can trust us because we
deliver!
Pregnancy rates equivalent to
most successful centers around the globe! One of the biggest IVF centers in the
country!
More than 20 000 cycles
performed over the last 16 years! State of the art highest technology!
ISO 9001 and Joint Commission International
Accredited Embryology Laboratory!
Academic and Research
Facilities!
(You can search us on the Medline,
just enter Urman B (au))
WE OFFER AMONG MANY OTHERS:
Blastocyst transfer Testicular
sperm extraction Assisted Hatching
Embryo Glue
Slow freezing and
vitrification
Preimplantation Genetic
Diagnosis
A BRIEF HISTORY OF THE
AMERICAN HOSPITAL AND
THE ASSISTED REPRODUCTION UNIT
American Hospital is located
in the heart of Istanbul. It is one of the oldest privately owned hospitals in
the country. Admiral Bristol founded the hospital in 1921. Governed by a board
of directors in the United States until 1995, Vehbi Koç Foundation bought the
hospital and undertook an extensive renovation to bring it up to its current
status. The hospital is tertiary private care facility with 300 beds. Assisted
Reproduction Unit was founded in 1996 and rapidly became one of the most
successful centers in the country performing over 1000 treatment cycles a year.
We receive patients from all over the country and also from abroad. With the
exception of gamete and embryo donation and sex selection the services offered
encompass all assisted reproduction and related
procedures. Assisted Reproduction Unit boasts luxuriously decorated waiting
areas, large operating rooms, and state of the art embryology and
andrology laboratories. A very experienced team of 8 gynecologists, 6
embryologist and embryology technicians and 1 andrologist operate the unit headed by Dr. Bülent Urman. Supporting
personnel include geneticists, dieticians, and psychologists, a very
experienced nursing staff, and secretaries. Besides patient care the American
Hospital Assisted Reproduction Team has also been very active in research and
has published over 100 articles and 170 abstracts in respected scientific
journals. Clinicians and embryologist from the team have been invited to
meetings as guest speakers. Clinical Director of the IVF program Dr. Bülent
Urman is the national representative to the European Society of Human Reproduction
and Embryology (ESHRE) and the past
president of the Turkish Society of Reproductive Medicine. Laboratory Director
of the IVF program Bio. Başak Balaban is the national representative to the
ESHRE, Past President of the ALPHA International Embryology Society, and the
President of the Clinical Embryology Society of Turkey.
WHAT IS IN VITRO
FERTILIZATION?
IVF treatment is a long and
tedious procedure that necessitates commitment from the couple and the team.
Despite significant advances in the field unfortunately not all couples are
expected to conceive. Outcome of the treatment is directly related to woman’s
age and her ovarian reserve. In women who produce an adequate number of eggs
and who are < 39 the outlook is bright as cumulative conception rates of 80%
can be expected with 3 treatment cycles. That is to say those approximately 80
couples out of 100 will conceive when 3 treatment cycles are undertaken. In
women > 39 particularly when the ovarian reserve is diminished, however, the
outcome is bleak as cumulative conception rates will be in the range of 10-30%.
IVF treatment entails
basically three steps that have been fairly standardized throughout the world.
Treatment starts with stimulation of the ovaries to produce many eggs. The next
step is egg collection and fertilization to produce embryos. After
fertilization the embryos are kept in incubators for approximately 3-5 days
after which they transferred into the mother’s womb. Pregnancy test will be
obtained 10-12 days after transfer.
Despite standardization of
treatment protocols there is a wide variation in pregnancy rates that basically
stem from laboratory conditions,
experience of the medical staff, and embryo transfer policy. IVF clinics
have been pressurized from the patients and their competitors to increase the
number of embryos transferred into the uterus. However, this has been
associated with an alarming increase in multiple pregnancy rates. Regulatory in
most European countries and Australia issued imposing restrictions on the
number of embryos that can be transferred to a patient. The most recent legislation in Turkey passed
in 2010 allows only one embryo to be transferred for the first two treatment
cycles in women<35 years of age. The transfer of two embryos is allowed from
the third cycle onwards in women<35 and for all cycles in women>35 years
of age.
American Hospital Assisted
Reproduction Unit has been first in the country to incorporate into routine
practice procedures such as embryo freezing, blastocyst transfer, PGD, assisted
hatching, embryo glue, and vitrification.
We have a broad experience in dealing with couples with poor prognosis (age>39,
less than optimal quality embryos, poor ovarian reserve and previous multiple
failed treatments). Third party reproduction that entails the use of donated
gametes is not allowed in Turkey.
BEFORE YOU COME
Long Agonist Protocol
1. Stop smoking if you are a
smoker.
2. Start using Folic acid
pills 0.4 mg/day.
3. Start birth control pills
on the third day of your menstrual bleeding.
4. Start Synarel nasal spray
(1 puff-two times a day) on the 20th day of your bleeding. Alternatively you
can use daily
Leuprolide acetate (LA)
injections (10 U/day subcutaneously).
5. Keep on using the Synarel
nasal spray/LA subcutaneous injections until you come to the clinic.
6. We will perform an
ultrasound examination and start stimulating your ovaries when you come to
Istanbul. Treatment may be initiated any time within the first 10 days of your
menstrual bleeding.
Short Antagonist Protocol
1. Stop smoking if you are a
smoker.
2. Start using Folic acid
pills 0.4 mg/day.
3. Come to the clinic directly
on the second day of your cycle.
4. We will perform an
ultrasound examination and start stimulating your ovaries when you come to
Istanbul. Treatment may be initiated if certain conditions are met such as the
absence of cysts and the presence of a thin endometrium.
5. In women planned to be
treated with the antagonist protocol there is a 10-15% risk of not being able
to initiate the treatment due to the presence of functional ovarian cysts or a
early growing follicle that will suppress the stimulation of other follicles.
STIMULATION OF THE OVARIES
For IVF/ICSI treatment to be
successful the ovaries should be stimulated to produce more than a single egg.
In order to achieve this goal potent drugs called gonadotropins are
administered in a controlled manner. Gonadotropin treatment is self
administered as most of the medications used today can be administered
subcutaneously.
How is the treatment started?
An ultrasound examination is
performed when the patient arrives in the Istanbul. This examination should
coincide with the third to fifth day of the cycle if a long protocol (the nasal
sniff or subcutaneously administered Leuprolide acetate) or the second day of
the cycle if a short antagonist protocol has been planned. If you don’t have
any cysts and the inner lining of the uterus is thin than treatment is
initiated. You may need to undergo a blood test to check for your estrogen
levels if your doctor deems this necessary.
How long does the treatment
last?
The treatment usually lasts
for 10-12 days. During this phase you will be asked to come for periodic
ultrasound examinations. The frequency of these examinations will increase as
the treatment progresses. When the eggs are deemed to be mature a final
injection will be given at a specific time and the eggs collected after
approximately 36 hours.
How much medication am I going
use?
The amount of medications used
to stimulate the ovaries depends on the age of the woman and her ovarian
reserve. While younger women with normal ovarian reserve use lesser amounts,
older women and women with diminished ovarian reserve necessitate larger doses
to stimulate the ovaries. Variation in drug dosage may be up to two-fold.
Can my treatment be cancelled?
If there is inadequate
response from the ovaries (poor response) meaning that the ovaries did not
produce enough eggs to be successful than the treatment may be cancelled and
reinitiated with another protocol. Sometimes only one egg gains dominance and
prevents other eggs from growing (asynchronous growth). This is another reason
for canceling the treatment. Sometimes there will be too many eggs stimulated
(hyper response) that may result in ovarian hyperstimulation syndrome if the
treatment is continued. There are several options that may be exercised in this
instance.
For IVF/ICSI treatment to be
successful the ovaries should be stimulated to produce more than a single egg.
In order to achieve this goal potent drugs called gonadotropins are
administered in a controlled manner. Gonadotropin treatment is self
administered as most of the medications used today can be administered
subcutaneously.
How is the treatment started?
An ultrasound examination is
performed when the patient arrives in the Istanbul. This examination should
coincide with the third to fifth day of the cycle if a long protocol (the nasal
sniff or subcutaneously administered Leuprolide acetate) or the second day of
the cycle if a short antagonist protocol has been planned. If you don’t have
any cysts and the inner lining of the uterus is thin than treatment is
initiated. You may need to undergo a blood test to check for your estrogen
levels if your doctor deems this necessary.
How long does the treatment
last?
The treatment usually lasts
for 10-12 days. During this phase you will be asked to come for periodic
ultrasound examinations. The frequency of these examinations will increase as
the treatment progresses. When the eggs are deemed to be mature a final
injection will be given at a specific time and the eggs collected after
approximately 36 hours.
How much medication am I going
use?
The amount of medications used
to stimulate the ovaries depends on the age of the woman and her ovarian
reserve. While younger women with normal ovarian reserve use lesser amounts,
older women and women with diminished ovarian reserve necessitate larger doses
to stimulate the ovaries. Variation in drug dosage may be up to two-fold.
Can my treatment be cancelled?
If there is inadequate
response from the ovaries (poor response) meaning that the ovaries did not
produce enough eggs to be successful than the treatment may be cancelled and
reinitiated with another protocol. Sometimes only one egg gains dominance and
prevents other eggs from growing (asynchronous growth). This is another reason
for canceling the treatment. Sometimes there will be too many eggs stimulated
(hyper response) that may result in ovarian hyperstimulation syndrome if the
treatment is continued. There are several options that may be exercised in this
instance.
Embryos are transferred into
the uterus usually between 2 and 5 days after egg collection. During the time
they spend out of the body they are kept in culture medium in incubators that
mimic the fallopian tubes. Embryo transfer is an easy procedure that is done
without anesthesia or sedation. The embryos are loaded into a plastic catheter
that is then introduced into the uterus via the cervical canal. The number of
embryos transferred depends on the age of the woman, previous failed treatment
attempts and embryo quality. Turkish IVF legislation mandates the transfer of a
single embryo in the first two attempts in women < 35 and two embryos
thereafter. Two embryos can be transferred to women > 35 years of age. The
transfer of more than two embryos is not allowed under any circumstance.
After transfer there are
usually excess embryos that can be frozen for later use. Only embryos that are
of good quality are suitable for freezing. In Turkey, according to regulations
embryos can be stored for 5 years. Embryo freezing does not harm the embryo. We
currently prefer vitrification over slow
freezing as the former is associated
with higher survival rates after thawing higher pregnancy rates after
transfer. There are over 700000 babies
worldwide that were born after the transfer of frozen-thawed embryos. American
Hospital of Istanbul has a very
successful embryo-freezing program. Our
pregnancy rates for frozen-thawed embryo transfers are approximately equal to
fresh transfers. A couple can elect to have their frozen embryos replaced after
an unsuccessful attempt or after delivering a baby. Preparation for frozen
embryo transfer is a relatively simple procedure that entails stimulation of
the inner lining of the uterus with orally used medications.
SPERM RETRIEVAL IN AZOSPERMIC
SUBJECTS
In men who have no spermatozoa
in the ejaculate, sperm need to be retrieved either form the epididymis or the
testes. When the etiology of azospermia is obstructive (blockage to the canals
bringing the spermatozoa from the testes to the ejaculate) sperm can be
retrieved from the epididymis using a needle aspiration technique. In men with
azospermia due to defective sperm production, sperm can be obtained from the
testes usually with an open surgical procedure. Both procedures are performed
under general anesthesia. While sperm can be retrieved in almost 100% of
subjects with obstructive azospermia, only 40-50% of the subjects will yield
viable spermatozoa. Azospermia may be associated with certain genetic
disorders. There may be mutations in the cyctic fibrosis gene in men with
obstructive azospermia. Chromosomal abnormalities and Y-chromosome
microdeletions may be associated with nonobstructive azospermia. It is advised
that genetic testing be undertaken in all men with azospermia.
PREIMPLANTATION GENETIC DIAGNOSIS
Preimplantation genetic
diagnosis (PGD) is a procedure whereby a single cell is removed from the embryo
on day 3 to perform genetic testing. PGD can detect certain chromosomal
abnormalities (i.e. trisomies, monosomies, translocations, etc.) and single
gene defects (i.e. thalassemia, fragile X syndrome, etc.) and can also be
performed for HLA typing. Full scopes of PGD services are provided in the
American Hospital. Please contact your doctor for your specific condition.
OUTCOME OF IVF PREGNANCIES
Approximately 80% of
pregnancies achieved via IVF/ICSI carry to term and result in delivery of
healthy baby/s. Delivered infants were shown to be normal when compared with
infants that were naturally conceived. Only certain subsets of IVF babies
(those that were conceived with the use testicular spermatozoa) may carry sex chromosome
abnormalities detectable by amniocentesis or alternatively with PGD. In all
other instances, long term follow-up of infants showed normal motor and
neurological and behavioral development.
LONG TERM CONSEQUENCES OF IVF
TREATMENT Ovarian stimulation has been linked to an increased risk of ovarian
and breast cancer. However, none have been proven beyond doubt. As infertility
itself has been reported to be risk factor for both malignancies it is still
unknown whether some of the reported increased risks are associated with the
treatment or infertility itself. Studies and long term follow-up are still
ongoing. In the mean time women who received IVF treatment but failed to
conceive are advised to have their annual gynecologic check-ups and yearly
mammograms (depending on the age).
SUCCESS RATES OF IVF IN THE
AMERICAN HOSPITAL Success depends on women’s age and if present previous failed
IVF/ICSI attempts. IVF is most successful in women < 35 years of age. In
this age group pregnancy rates may be as high as 40% with a single and 55% with
a double embryo transfer. However, pregnancy rates start to decline after 35
and more so after 39. Theoretically a chance of conception beyond the age 45 is
zero. The graphic below displays the clinical pregnancy rate (ultrasound
visible pregnancy sac) per embryo transfer in the American Hospital of
Istanbul.
SERVICES PROVIDED
IN THE ASSISTED REPRODUCTION
UNIT OF THE AMERICAN HOSPITAL*
Controlled ovarian
hyperstimulation and patient follow-up with serial hormone measurements and
ultrasonography
Transvaginal egg retrieval
Fertilization by IVF or ICSI Laser Assisted Hatching Blastocyst transfer Embryo
Glue
Embryo freezing on day 3 or
day 5 (slow freezing and vitrification) Testicular sperm retrieval in
azospermic patients (needle and open biopsy) Sperm freezing and testicular
tissue freezing
Preimplantation Genetic
Diagnosis (PGD) for aneuploidy screening
PGD for single gene defects
PGD for molecular disorders PGD for HLA typing
SERVICES THAT WE ARE UNABLE TO
PROVIDE
Oocyte and sperm donation
Embryo donation
Surrogacy
Sex selection
* These services are provided
all year round including national and
international holidays.
REASONS FOR CANCELLATION OF
TREATMENT
REASONS FOR CANCELLATION OF
TREATMENT
Your treatment may be
cancelled for several reasons:
1. The ovaries may respond
inadequately and the treatment is cancelled prior to egg retrieval.
2. Despite the presence of
follicles no eggs may be retrieved. The reason for this is two-fold. The
follicles may contain no eggs (empty follicle syndrome). This is seen in <
1% of the patients. The follicles may prematurely rupture prior to egg
retrieval procedure. This is seen in 3-5% of the patients depending on the stimulation
protocol.
3. The eggs may not fertilize.
This is very rare in the microinjection era. However in approximately 2-5% of
the patients no fertilization may be seen due to abnormal eggs.
4. Fertilized eggs may not
cleave. This is also very rare and due to abnormal eggs.
5. Azospermic husband may not
yield spermatozoa to needle aspiration or open biopsy. In this case the
treatment is cancelled prior to egg retrieval.
6. No normal embryos if PGD is
performed. In this case embryo transfer is not performed.
EGG COLLECTION INFORMATION
LEAFLET
Your follicles have matured
and you are ready for egg collection. Please be sure to adhere to the
following: You should have your hCG (Ovitrelle) injection …………… IU on
…………….. at ……………….hours. Please be
present in the clinic on ……………. at …………….hours.
Be sure to come with an empty
stomach. Do not eat or drink after midnight.
Your husband has to accompany
you as he will be asked to present a semen sample that will be used to
fertilize your eggs.
Egg collection can be performed
under local or general anesthesia. Be sure to discuss this with your physician
as you will be asked which method you prefer.
WHAT TO DO AFTER EGG
COLLECTION?
After your eggs are collected
you will stay in the hospital for approximately 2 hours. You are allowed to
lead your normal life after egg collection. There is no need to rest. It is
advised that you refrain from intercourse. There may be slight bleeding in the
form of spotting after the procedure. This should last no more than 24 hours.
The next day after egg
collection please call the clinic and speak to one of our embryologists (Başak Balaban or Aycan Işıklar;
+90 212 444 3
777/1620-1621). They will give you
information regarding the number of fertilized eggs and the approximate day of
embryo transfer.
Use the following medications
as directed:
1. Crinone gel-once a day
intravaginally in the morning. You can insert your first crinone when you
arrive home after egg collection.
Thereafter use the gel in the
mornings.
2. Monodox tablet-twice a day
on an empty stomach.
3. Prednol tablets-once a day
with a full cup of milk. If you have gastric problems Prednol may not be
suitable for you.
Please inform your doctor.
There may be other medications
that may be used specifically for you. Your doctor or the nurse coordinator
will give information regarding these.
You can come to the embryo
transfer on a full stomach. Embryo transfer is a simple procedure that will
cause no or minimal pain. Please come for embryo transfer with a partially full
bladder.
WHAT TO DO AFTER EMBRYO
TRANSFER?
Congratulations!
You have successfully
completed your treatment cycle.
Please adhere strictly to the schedule regarding medications that
has been given to you by our nurse coordinator.
1. Continue using the Crinone
gel as prior to OPU.
2. Continue using Monodox and
Prednol until the tablets given to you are finished.
3. Your physician may have
prescribed other medications specific for you. Please use them as instructed.
Strict bed rest has never been
shown to increase the pregnancy rate in IVF. Therefore you can continue with
your life as usual. It is advised that you refrain from intercourse and
physical exercise. Travel via car or plane is permitted.
Pain in the groins can be
encountered after embryo transfer. This does not imply that you will
menstruate. Sometimes there may be slight spotting before the pregnancy test.
This does not always mean that the treatment has failed.
Have a blood pregnancy test
(ß-hCG) done 12 days after embryo transfer and report the result to the nurse
coordinator.
Telephone numbers to contact
Seval Çalışkan (Nurse Coordinator) IVF Clinic +90 212 444 3 777/1601
Mobile +90 532 270 44 15
Dr. Bülent Urman
Professor and Head
Department of Obstetrics and
Gynecology Assisted Reproductive Unit BulentU@amerikanhastanesi.org
AMERICAN HOSPITAL SERVICES
For the services below please
contact American Hospital International Patients Program.
+90 212 444 3 777 ext: 8759
e-mail: international@amerikanhastanesi.org
- Assistance with hospital admission and appointment scheduling.
- Coordination of all patient appointments with specialists for consultations and medical procedures.
- Facilitation of second opinions.
- Translation services organiziation.
- Transfer vehicle organization.
- Advance financial and billing arrangements, including detailed estimates.
- Appointments for family members who request routine and preventive medical care.
- Transfer to local facilities within Turkey and to international facilities.
- Medical assistance for local organizations within Turkey for international organizations.
- From our patients’ initial inquiries through their follow-up medical care back home, the International Patient Programs Office act as a single point of contact to assist patients throughout their stay.
