Doctor Ebru COŞKUN
IVF TREATMENT CONSENT FORM
Patient’s;
Name and Surname :
Recommended Treatment:
Date of Recommendation:
Suitable Patients for In Vitro Fertilization :
1.Patients who have ovulation disorders and cannot conceive in spite of induced ovulation.
2.Patients with mild male factor (includes patients with total sperm count with forward motility over 5 million). In these patients, in vitro fertilization treatment is applied if conception cannot be achieved despite ovulation induction + vaccination (IUI) with twice daily injections (gonadotropin).
3.Patients with severe male factor (includes patients with total sperm count with forward motility below 5 million, and/or sperm obtained through surgical methods).
4.Patients with unexplained infertility (patients with normal ovulation, normal tubes and normal sperm tests). In case the couple have been married for at least three years and not being able to conceive despite ovulation induction + vaccination (IUI) with twice daily injections
(gonadotropin), in vitro fertilization treatment is applied.
5.In patients where it is laparoscopically proven that both tubes are blocked, IVF treatment is applied. Also those patients who cannot conceive for a year after their tubes have been surgically opened are within this group.
6.Patients with severe pelvic adhesions.
7.Patients with reduced ovarian reserves.
8.Early stage endometriosis patients. In case of inability to conceive despite ovulation induction+ vaccination (IUI) with daily injections (gonadotropin) twice, in vitro fertilization treatment is
applied.
9.Advanced stage endometriosis patients. In-vitro fertilization treatment is applied if these
patients have undergone a surgical operation and cannot become pregnant within a year or if
they cannot conceive despite ovulation induction + vaccination (IUI) with twice daily injections (gonadotropin).
The Patient’s Condition is Defined in Item:
How is IVF treatment performed?
The treatment consists of three stages:
1. Stage: Stimulation of the Ovaries
This treatment aims to stimulate the ovaries through daily injections in order to obtain 8 to 15 eggs.
If this process will be carried out according to the method called the “long protocol”, it should begin at the 21st day of the menstrual cycle. Suppressive injections are given until the menstruation. After
the suppression is achieved, medical treatment is started in order to stimulate the ovaries. The treatment lasts for approximately 10 days. On the other hand, in the “short protocol”, treatment for the stimulation of the ovaries starts on the SECOND or THİRD menstrual day; and new medication is added later to prevent early breaking of the follicle. Your physician will determine which protocol will be applied to you.
2. Stage: Harvesting Your Eggs
When your eggs are mature enough, you will be administered the follicle breaking injections. The timing of these injections shall be determined by the clinic. Within 35-36 hours as of this injection, your eggs will be harvested. This procedure shall be carried out under anesthesia (in case of very few eggs, your physician may choose to perform the procedure under local anesthesia). Therefore, you should have fasted and refrained from drinking water before you arrive at the hospital. During the procedure, a needle is stuck into the ovaries through the vaginal route accompanied by
ultrasound imaging and the eggs are aspired. The total duration of the procedure is no longer than
15-20 minutes. Following the procedure, you will be observed for 1 or 2 hours at the hospital. The patient’s husband should also give a sperm specimen on the same day. Therefore, a sexual fasting period is recommended as of the day the injection to break the follicle.
3. Stage: Transfer of the Embryos
The eggs will undergo fertilization (through the classic or microinjection methods) and you will be informed about their development on a daily basis. Depending on the condition of the embryos, theeggs will be transferred within 2, 3 or 5 days after the harvesting procedure. Your physicians will make the decision on the right timing. According to the Assisted Reproduction Treatment Regulation
of the Turkish Ministry of Health, on the first and second trials before the age of 35, a single embryo shall be transferred; while two embryos can be transferred in the third and following trials. In all the IVF procedures over the age of 35, a maximum of two embryos can be transferred. It is important to maintain a full bladder when arriving to the clinic for the transfer, since this will render the procedure easier and more successful. The procedure is not painful. You will be asked to stay at the hospital for 2 to 4 hours following the transfer. In some cases, embryo development is not suitable for transfer; In this case, the IVF process will be terminated without embryo transfer.
Rates of Success with IVF Treatment
When a single embryo is transferred, the rate of live births is 25%. If the grown embryos are of high quality, you may be proposed to freeze the remaining embryos. In case no conception is achieved and the remaining embryos are thawed to repeat the procedure, the total ratio of live births increases to 40-45%.
The risks:
Certain risks are present in every stage of the procedure:
1. Stage
a) If only very few eggs develop, your physician may cancel the procedure or change to a fertilization through injection.
b) In case of an excessive response, the procedure may be cancelled or the eggs can be frozen for that month in order to be transferred in the coming months.
c) In spite of all the measures, the eggs may break before the required time point. The procedure may be cancelled in this case.
d) Mild pain in the groin area, feeling of fullness, bloating and increased vaginal discharge may beobserved during the course of the procedure.
2. Stage
a) There is a possibility that the follicles may not contain eggs.
b) Vaginal bleeding from the region where the needle is inserted may be observed. In this case, stitches may be needed at this spot.
c) The procedure may lead to injury in the large blood vessels or the intestine. Also, complications related to the anesthesia may occur. In certain cases, the patient may need to be taken to emergency surgery. Even death has been reported. However, these are very rare complications and no such complication has occurred in our clinic in the course of the approx. 5000 procedures performed to date.
d) Pelvic infections may occur (<1%). In this case, intensive Antibiotherapy may be needed.
e) Pain in the groin area may occur after the harvesting of the eggs. These are usually transient pains responding well to painkillers.
3. Stage
a) A full bladder may give you serious discomfort. The bladder may have to be emptied through catheterization following the procedure.
b) During the embryonic development stage, the transfer may be cancelled if the fertilization is not successful; if the eggs do not divide, or the quality of the embryo is insufficient.
c) Rarely, the procedure may have to be cancelled due to the narrowness of the cervix.
Ovarian Hyper Stimulation Syndrome (OHSS)
This syndrome is characterized by the overstimulation of the ovaries and the excessive increase in the permeability of the blood vessels, leading the fluid within the veins to leak and collect in the cavities of the body. Mild or medium forms of the condition are observed in 30-35% of the patients.
The complaints usually start following the injection to break the follicles and the condition manifests itself through abdominal pain, bloating, dizziness, nausea, vomiting and diarrhea. Severe forms of the condition may cause respiratory distress. In serious cases, the syndrome may require intensive
care and even lead to life-threatening disorders. The incidence of serious cases is 1-2%. Especially patients with low body weight, with polycystic ovary syndrome and those in whom more than 20 eggs have been harvested are under risk. Patients who present with these symptoms are admitted to the hospital and administered saline. Their urinary output is followed up and sometimes a catheter is placed within the abdomen in order to remove the collected fluid.
Ectopic Pregnancy
Although the embryos are placed within the uterus, ectopic pregnancies are observed in 5% of the patients in whom pregnancy is achieved. This condition is treated either medically or surgically.
Declaration
The patient should declare verbally and in written form that she “
has been adequately informed on every point concerning the procedure including multiple pregnancies and failure to achieve
pregnancy
Written Declaration of the Patient
Signature (Mrs.) :
Signature (Mr.) :