Gynecology and Obstetrics Specialist Op. Dr. Aret Kamar from Istanbul Women's Health and IVF Center explains the effects of uterine anomalies on reproductive health and the treatments applied in this regard. Here is our interview with Op. Dr. Aret Kamar.
In which areas of IVF treatment and reproductive health does the legislation in Turkey allow patients from abroad to be treated? What can and cannot be done in IVF treatment in Turkey according to the law?
"Anything can be done after couples have an official marriage. Surgery can be performed, IVF can be performed. The only condition is that the couples must have a civil marriage and document it. Of course, the situation can be a little different in each country. In our country, there is a marriage certificate showing the official marriage. In some countries, only religious marriages are performed. If they have an official marriage accepted according to the dynamics of their own country, if they have a document of this, we ask them to send us the translation from the notary. Then we can try in vitro fertilization."
“FOREIGN PATIENTS CAN HAVE IN VITRO FERTILIZATION TREATMENT AND EMBRYO FREEZING IN TURKEY IF THEY ARE LEGALLY MARRIED”
Turkey is very successful in egg freezing, sperm freezing or embryo freezing. But are there any restrictions on patients coming from abroad for IVF treatment?
"Yes, there are. Embryo freezing is a stage of IVF. Married couples can have IVF in Turkey and freeze their embryos. But since egg freezing and sperm freezing is something that single people need to do, a report is required. For the report, you need to apply to a training research hospital or a university hospital with your Turkish Republic ID number. Since the report requires the Republic of Turkey ID number, foreign patients cannot have egg and sperm freezing in Turkey. However, if the patients coming from abroad are Turkish citizens, there is no problem. Because some of them have dual passports. Foreign patients can only undergo IVF treatment."
So, there is no problem with foreign patients in terms of embryo transfer.
“There is no obstacle after the official marriage.”
“EMBRYO FREEZING SYSTEMS ARE VERY RELIABLE NOWADAYS”
And is there a restriction on the number of embryos that can be transferred, depending on the age of the woman?
"Yes. We normally apply this embryo limitation. Actually, embryo limitation is not a bad thing. Of course, the important thing for us is that our patient gets pregnant. However, triplet or quadruplet pregnancies with excess embryos are considered complications of IVF treatment. Therefore, we have a question mark even in the case of twins. I mean, can the expectant mother carry a twin baby? Can she give birth safely? Can both babies come out on time? Will she give birth early? Will the expectant mother's blood pressure rise while trying to give birth to these babies and endanger her health? So actually, even a twin baby is something that we look at as if it would be better not to have, it would be better to have a single baby. However, when we tell a woman who has not been pregnant for years, “Your baby will be twins”, they are very happy, they are very happy. They do not know very clearly the problems that can occur in twin pregnancies. Therefore, we recommend giving one baby, that is, one embryo, as much as possible in young patients, patients under the age of 35."
In women over 35 years of age, we recommend 2 embryo transfer in order not to reduce the pregnancy rate as the egg quality starts to decrease. Today, we do not use the approach of giving 3 or 5 embryos for the woman to get pregnant. We used to do this in the past because the freezing technology was not very good. We used to freeze embryos in packs of four. There was a system called slow freezing. It took 4 hours to freeze one person's embryos. During the 4 hours, if there was a small interruption in electricity, that work could be disrupted. If half of the embryos we froze and thawed turned out to be intact, we were very happy. Imagine now, for women who have one egg or two eggs, you collect an egg, combine it with sperm and then freeze the embryo. In this way, you accumulate, accumulate, accumulate, accumulate, and then thaw them. You can also do genetic testing on them. You can also put them inside and get pregnant. But now imagine a situation like in the past, where almost half of the embryos you freeze and thaw go to waste. At that time, because these freezing systems were not developed, we used to say let's put these embryos in and let her get pregnant and then we'll see. But nowadays, because we trust the freezing systems, we prefer to put in a reasonable number of embryos after freezing.
A woman has a chance of getting pregnant once a month. So let's say we are talking about a young girl, 30 years old. This girl has a 75 percent chance of getting pregnant even if everything goes well. If we give 3 embryos, this rate is not 100 percent. If we give 4 embryos, it is not 100 percent. When you give more embryos, after two embryos you only increase the chance of multiple pregnancy. Let's say a girl has 4 beautiful embryos. We gave 4 of them at once, she had a 75 percent chance. If she doesn't conceive, the 4 embryos are wasted. But if we give them two at a time, she has a 75 percent chance of success in the first attempt and a 75 percent chance of success in the second attempt. Because we have two embryos. Therefore, the more we introduce the embryos in installments, the higher the chance of achieving pregnancy. Therefore, we are never in favor of giving many embryos."
MANY PATIENTS FROM THE BALKAN COUNTRIES COME TO TURKEY FOR IVF TREATMENT"
From which countries do most patients come for IVF treatment? Why has Turkey become a center of attraction for couples living abroad for IVF treatment?
"Compared to many other countries, IVF treatment in Turkey is successfully performed at more affordable prices. Therefore, there is a very serious demand from neighboring countries for cheaper and successful treatment. When we say the Balkans, we can count Bulgaria, Greece, Kosovo, Albania, Macedonia and Romania. In addition to the Balkans, many patients come from Ukraine, Russia, Armenia, Iran, Iraq and Syria. We also receive applications from African countries, especially from North Africa. There are even people from Nigeria. There are some countries we have not even heard of. We even look on the map to see where this country is. Turkey is a center of attraction in IVF. You can even come from America. Because an IVF treatment in America costs around 20 thousand dollars including tests. In Turkey, it costs almost one tenth of that. Now, those whose jobs are suitable for staying here can come to Turkey for treatment. As you know, after the pandemic, those who work from home have already started to increase. Those who can work at home and carry out their work come to Turkey and stay, have IVF, and have a vacation. Including hotel accommodations, they receive IVF treatment at a much more affordable price than having IVF in their country."
“IVF TREATMENT IS PERSONALIZED, SO THE DURATION VARIES”
Let's ask from the point of view of patients living in Greece. If they are thinking of coming to Turkey, how many days do they need to spend and how many times do they need to come and go to Turkey?
"An IVF treatment is more or less 20 days including the transfer. So, the growth process of the egg and egg collection is 10-12 days. After egg collection, embryo development takes 4-5 days. When the patient rests for 1-2 days after the transfer is included, it takes 20 days. Of course, this period varies individually. Sometimes it may be necessary to accumulate eggs in women with few eggs. Some patients' endometrium or hormones are not very favorable. "Let's not transfer you this month. Let's do it next month". In patients with genetic problems, we can say, "Let's save your embryos and see which ones are healthy first. So in some cases, the treatment may take a little longer.
Men do not have to stay here, women can come for treatment. If they have an obstetrician-gynecologist in their home country and the laboratory conditions are suitable, they can also come directly for egg collection. They send their results remotely. We advise them remotely and tell them to do this or that. When the egg is ready, they can come for transfer.
Everyone's treatment is different. In other words, the treatments that need to be done specifically for a couple are different. If patients in Greece and other countries contact you in advance, we will look at their test results and inform them about what kind of treatment they need and how long they need to stay. We can provide information about the approximate duration of treatment specific to their condition."
TREATMENT OF UTERINE ANOMALIES IN WOMEN WITH CLOSED SURGERY
IVF treatment is equal, it is not a standard treatment. It is a treatment customized for the individual and the couple. There are also uterine deformities in women. What kind of problems and deformities related to the uterus prevent pregnancy? Which of these are solved with surgery, laparoscopic surgery, popularly known as “closed surgery”, and which are solved with assisted reproductive techniques so that couples have the chance to embrace their babies?
"Some of the IVF patients may need surgery. If there is a problem that may cause a problem with the uterus holding the baby, it is necessary to correct it surgically. What are these? First of all, problems related to the inner layer we call endometrium. These can be a fibroid that has grown into the uterus. There may be a polyp affecting the inside of the uterus. As you said, there is a congenital deformity. There is a curtain there. The curtain may be cut. She had a cesarean section before. The caesarean wound has not healed. It may be necessary to clean it. Sometimes there may be blockages in the tubes. We call it hydrosalpenx. This hydrosalpenx can prevent the baby from attaching to the uterus because it drains fluid into the uterus. These need to be cleaned before implanting the baby. Sometimes there are fibroids on the uterine wall, ovarian cysts and chocolate cysts. These may also need to be removed in order to collect eggs easily. We have an advantage. As you said, we can do these with closed surgeries. In other words, the patient can have surgery on the day she arrives and return to her country the next day. If there is a surgery that needs to be done, we can see most of them in the uterine film and ultrasound. While the patient is asleep during egg collection, we correct the things that need to be corrected. The next day the patient goes back to her hometown with her surgical problem solved and her eggs retrieved. Then, depending on the condition of the embryos and the surgery performed, we call the patient here to transfer them 2-3 months later."
We have come to the end of our conversation. What do you recommend especially to women from Greece, a neighboring country, a friendly country, who have a problem with the uterus, a deformity? Sometimes there is a chance of pregnancy naturally by correcting the existing problem with laparoscopic surgery without the need for IVF, right?
"If they can send us their ultrasound reports and uterine films, we can give preliminary information about what needs to be done specifically for patients abroad. If surgical treatment is necessary, is it enough to correct this problem only by looking at their other tests? Or should other treatments be applied along with the correction of this problem? We can inform foreign patients on all these issues before they come to Turkey."