Породување - Ре Медика | Poroduvanje - Re Medika

GYNECOLOGY AND OBSTETRICS - РЕ-МЕДИКА

GYNECOLOGY AND OBSTETRICS

Department of Gynecology and obstetrics presents a bond between highly experienced team and cutting edge technology. Top protocols are implemented but with individual approach in cure as well as top specialized infertility treatment techniques. We are highly demanded in the field of gynecological surgery and oncogynecology as a multidisciplinary team, all top professionals recognized for decades. This enables safe pregnancy monitoring, childbirth and contemporary gynecological operations.

Department organization :


  • Perinatology and obstetrics

  • Gynecological surgery and gynecological oncology and urogynecology

  • Assisted reproduction and IVF

The hierarchy and team work are very important. This is how all functions immaculate!

Sincerely, Prof. d-r Gligor Dimitrov,Head of gynecology and obstetrics

PERINATOLOGY AND OBSTETRICS


  • Normal and high-risk pregnancy monitoring

  • 4D and 3D ultrasonography during pregnancy

  • Early anomaly screaning in the first trimester of pregnancy

  • Chorion biopsy, amniocentesis

  • Ultrasound scrining and fetus heart evaluation in the 20-22 gestational week

  • Painless childbirth

  • Postnatal unit according to the principal of “Baby friendly hospital””

  • Bili bed Phototherapy

  • Special care with full monitoring- system

PREGNANCY

Duration of pregnancy is 280 days or 40 GW.

At the beginning of pregnancy the following is necessary:

  • Blood group
  • Rh factor
  • Complete blood count test(CBC – every month)
  • Urinoculture

Microbiology testing:

  • Chlamydya
  • Mycoplasma
  • Vagina and cervix

As part of the prenatal monitoring we offer you ultrasound check –up of your pregnancy

First ultrasound – When the regular MC is late, the patient should make an appointment at her gynecologist to find out the reason for the belated period. If it is a pregnancy in question, then the fetal heart action should be determined.
Second ultrasound – From 11-13,6 GW- Down syndrome screening
Third ultrasound– From 18-22GW- Fetal anomaly screening
Fourth ultrasound– From 28-30 GW- Examination of fetal growth and flows

1

The first ultrasound is done at the doctor’s first visit. This is to establish the duration of pregnancy, t.e. fetal gestational week, to exclude or to confirm multiple pregnancy and to confirm the fetal viability. Usually, this is a vaginal check-up, so our advice is you should come with an empty bladder.

2

The second ultrasound is done between 11-13,6 gw to measure fetus nuchal translucency, to measure baby’s nasal bone, as part of the examination for trisomy 21 (Down syndrome). The complete examination for trisomy 21 also, involves double test by taking blood from mother’s vein to determine the level of free B HCG and PAPP-A.

3

The third examination is done between 20-24 gw, to check if the fetus is developing normally, t.e. it is growing, and to exclude or to confirm fetal poor development. Most of the fetuses are healthy, but unfortunately some, may have serious difficulties. In the case you do not want to know of such poor development, you should better not do this examination. If you decide to go through this examination, it will imply that you wish to know everything we would come up to. During the examination, you would be laid on the bed, a gel will be put on your abdomen, and an ultrasound probe will be put. The ultrasound probe provides moving picture on the screen that enables fetus measurement as well as examining all fetus parts and organs. Almost half of the abnormalities that may cause serious damages can be detected while this examination, but the other half cannot be detected. That means, if, for example, the results from the examination are in the range of normal, there is still small possibility that your baby has some abnormality. Different types of abnormalities detected during ultrasound examination are given in the table. Sometimes, during this examination, baby’s gender may be revealed, but we do not do examination just do determine baby’s gender. Determining baby’s gender by ultrasound is with 95% accuracy. If the doctor during the ultrasound notices some fetus abnormalities he will inform you. Most of the abnormalities have to be examined, by rule, by another specialist. Because of different reasons, that examination would be repeated in almost 15%.

4

The fourth examination will be done from 28-32 gw, to check baby’s proper growth, to measure the quantity of amniotic fluid, to check the placenta and its location, position, structure and to measure by colour doppler fetus’s blood vessels velocity. For this examination, you have to have already done tests for hidden diabetes, antibodies in blood test, and blood count test and urine.

 

Abnormalities What abnormality is Possibility to be revealed
Spina bifida Spina bifida Opened spine 90%
Anencephalia Absence of the upper head part 99%
Hydrocephalus Hydrocephalus Increased fluid in the brain ventricles 60%
Bigger heart defects 25%
Dijafragmalna hernia Diaphragmatic hernia Abnormal opening in the diaphragm- the mussle between the chest and abdomen 60%
Egzomfalos/gastroshisis Exomphalos/gastroshisis Weakness of the abdominal wall where the umbilical cord joins it/on the right of the umbilical cord 90%
Bigger defects in the kidneys’ development Missing or abnormal kidney Missing or abnormal kidney 85%
Bigger abnormalities in the extremities development Bone absence or short bone 90%
Cerebral paralysis Increased mussle tone Never
Autism Never
Dawn syndrome It may be connected to heart or intestines abnormalities 40%

CHILDBEARTH PACKAGES

Re-Medika is proud with its top professional team that participates during the childbirth no matter if it is spontaneous or cesarean section(C- section), treating each patient as exceptional and special, from the moment the patient enters the hospital,goes through the outpatients examinations, monitoring the pregnancy with a top medical equipment, monitoring contractions, heart action, until the moment of childbirth.

SPONTANEOUS CHILDBIRTH– pain relief( epidural or spinal analgesia), 3 hospital days, routine laboratory analyses for the baby and the mother, ( including special care );

SURGERY INTERVENTION (CESAREAN SECTION) – Anesthesia- regional ( spinal and epidural ), 5 hospital days, routine laboratory analyses for the baby and the mother, ( including type of special care);

Surgery intervention does not include Post- Surgical treatment and Care, ( except in cases when Re- Medika according to its work policy, makes payment exemption for 1-5 hospital days depending the immenseness of the surgical intervention).

THE FOLLOWING SERVICES THAT ARE NOT INCLUDED IN THE PACKAGES, ARE SURCHARGED, IF NEEDED AND ON MEDICAL INDICATION ( FOR THE MOTHER AND/OR THE NEWBORN).

  • Extra charge for additional hospital days, accordingly medical indication, necessary for the mother and/or the newborn, to spend more than the already calculated days, according the official price list of Re- Medika
  • Extra charge for the pathohistological material and treatment, if the one is indicated
  • Extra charge for Blood and Blood derivatives, ( if there is a need of procurement)
  • Extra charge for non- standard medicaments/ preparations for one time use according medical needs
  • Extra charge for X-rays, non –routine laboratory analyses, ultrasound and evaluations
  • Extra charge for special and/or intensive care after ( 3 days of spontaneous childbirth or 5 days for C-section)
  • Extra charge for apartment use by your choice
  • Blood type and RH- factor determining, according medical needs ( mother RH negative or neonatal jaundice) or if parents wish
  • Baby’s screaning for 37 metabolism illnesses “Syn Lab”- Germany through “Adria Lab” laboratory

PAINLESS CHILDBIRTH

The birth of a baby in the embrace of a smiling, pain-free mother is one of the most exciting and noble moments in medicine. Pregnancy is the time to make some decisions for you and your baby. We hope the information provided here will help you to make the right choice so that childbirth will remain an unforgettable moment in your life. The Re-Medika Anesthesiology Team is at your disposal 24 hours / 7 days a week.

BE INFORMED, THE CHOICE IS YOURS

FACTS ABOUT EPIDURAL ANALGESIA

In Remedika over 70% (adjusted number) of patients giving birth spontaneously, give birth painless with a help of an epidural analgesia.
It presents the most efficient method in the treatment during labor
It is the only method by which the act of birth can be fully pain relieved
In average, every third woman in the developed countries uses this method while delivery
In some hospitals percentage is above 90%
8 out of 10 would choose the same method for the next childbirth
Epidural analgesia does not have side effects for the newborn baby

PREPARING FOR DELIVERY

We recommend visiting prenatal pregnancy classes. A team of specialists obstetricians, pediatricians, anesthesiologists, psychologists and midwives will introduce you to the changes you may expect during pregnancy and childbirth. You will learn breathing exercises, posture during delivery, they will explain techniques for pain relief and as well as acceptance and care of the newborn. You can additionally get to know and talk to anesthesiologists when you come to regular maternity care and CTG checks. The presence of the partner during childbirth, which we particularly support at ReMedika, is of invaluable importance as psychological support for the mother but also for the partner.

WHY IS THE TREATMENT OF CHILD DELIVERY PAIN SO SPECIFIC?

The childbirth act, especially for the women who give birth for the first time, may be very painful and almost always there is a need to help the woman in labour. The presence of the fetus is limiting the choice and the quantity of the analgesic that the doctor may administer to the mother. Analgesics used in the treatment of labor pain administered intramuscularly or in a vein are transmitted through the placenta and may cause some undesired effects on the baby after the birth. This is the reason why the dosage that is safe for the newborn is inefficient in treating the labor pain.

HOW THE LABOR PAIN BEGINS?

Childbirth is special and unique for every woman. Towards the end of pregnancy begin contractions of the uterus, at first rare, and then they are more often and stronger, which causes the labor pain, which strength is different at every woman during delivery. Towards the end of the birth itself, also, there is the pain of stretching the soft birth canals. The percentige of women in labor who do not ask for pain relief is very small, and the rest have a great benefit of the pain relief. The first time of childbirth is usually the longest and the labor pain is the strongest. There are lots of factors that have an impact on the pain:

Size and position of the baby
Strenght of the uterus contractions
Pain tolerance of the woman in labor
Pelvis and birth canal dimensions
Use of stimulation by the obstetrician in order to start or speed up the process of birth

Types of pain relief

Today almost 80% of the women in labor ask for some type of pain relief.
The most efficient and mostly used techniques are the region techniques, which include epidural, spinal and the combined epidural- spinal analgesia. Their biggest advantage is the efficiency and absence of side effects for the baby. That is also the reason why they are so widely spread in the developed countries, above 90% in some hospitals.

The epidural analgesia is with no doubt the most efficient method in the treatment of labor, especially for the primipara whose childbirth lasts longer than usual. It is available to all the women in labor who are interested. The side effects are extremely rare as use of anticoagulant therapy or infection of the place where the epidural cateter is placed.

WHAT IS EPIDURAL ANALGESIA?

The method is consisted of placing a thin epidural cateter (1mm) in the part of spine known as loin after skin local anesthesia. The best time to be placed is when the rhythmical contractions are shorter and more painnful and when the cervix is 3-4 cm dilated. The procedure is done in a sitting or side position, patient’s knees are towards her abdomen and her chin towards the chest bone, so the back’s loin part should be straight up. The administration of medicine through the epidural cateter near the nerves enables to cut the conduction of pain from the uterus and soft birth paths towards the brain where every sensation is actually formed including the pain.

The effects of the pain relief may be felt after 20-30 minutes, and the medicine is administered constantly through a special pump, until the birth is finished. Mother feels warmness and light numbness in the legs and the lower body, the pain is lost, but the contractions are felt. Throughout the whole childbirth, mother’s blood pressure and her heart frequency are controlled, and through the CTG, baby’s puls and the uterus contractions are controlled.

Only in Re-Medika, the so called Epidural Analgesia is applied that is controlled by the patient, where the woman in labor through a special pump by herself controls the quantity of the medicine applied through the epidural catheter, thus, controlling the level of pain.

WHEN IS SPINAL ANALGESIA APPLIED?

Spinal analgesia is a rarely used technique and the effect is after 2-3 minutes. This technique is applied only when we expect that the childbirth is finished in the following 2 hours. Its biggest flaw is that the medicine can be applicated only once and cannot be added more times, but, another punction has to be done, if the childbirth is not finished.

The combined spinal- epidural technique uses the adventages of the previous two- fast effect and duration until childbirth is finished. It is mostly used in the so- called “walking” epidurals ,when the patient may be mobile during the childbirth.

WHAT IF THE CHILDBIRTH HAS TO BE FINISHED WITH A C-SECTION?

In case when the baby is not dropping even though the cervix is dilated, or the umbilical cord is short and holds the baby, childbirth has to be done by C-section. The epidural catheter may be used for the C-section anesthesia, and more concentrated solution of the medicine is administered that blocks in total the legs and the lower part of the abdomen, up to the chest. Thus, the general anesthesia for C-section is being avoided and the mother is awaken so she can hear the baby’s first cry and then to see and touch her baby when put on her chest by the pediatrician. Simply, a moment to remember.

ARE THERE COMPLICATIONS WHILE EPIDURAL ANALGESIA?

Sometimes there might be some difficulties in locating the epidural area so a slight pain may occur on the puncture spot, it lasts for a day or two and is without any complications. There are rare cases when a headache might occur after the epidural analgesia.

RE-MEDIKA CHILDBIRTH

RE-MEDIKA CHILDBIRTH – MOTHERS AND BABIES’ FRIEND

Gynecology and obstetrics department together with the Deprtment of neonatology and pediatrics as well as the childbirth operation theaters are situated on a separate floor in the hospital, available from different sides. The accommodation and care for every woman in labor is our aim, as well as that, our patients to feel comfortable and safe.

Re-Medika is proud of its top professional team that participates during the childbirth no matter if it is spontaneous or cesarean section(C- section), treating each patient as exceptional and special, from the moment the patient enters the hospital, through the outpatient practice examinations, monitoring the pregnancy with a top medical equipment, monitoring contractions, heart action, until the moment of childbirth.

On daily basis, 24 hours, top professional highly educated team actively is involved: specialist gynecologist obstetrician, specialist anesthesiologist, specialist pediatrician neonatologist, as well as midwives, anesthetic nurses, a team highly responsible for our patients’ needs.

Kindness, professional tone and top proficiency are present through the whole preparation process with the respect to the psychological condition of every pregnant woman, having its place the psychological support by the psychologist. Generosity and responsibility towards every patient in Re- Medika is on daily basis, respecting every patient, regardless ones political, national and religious orientation.

Our strategic orientation are our patients’ needs. Thus, always, through interaction with the future parents their wishes and needs are defined and arranged, with an aim the moment of giving birth of the new member or members, to be remembered as something special for the whole life.

Neonatology department is separate from the other premises, specially adapted as a new environment for the babies. Here, the top protocols are functioning. There is a shift for 24 hours, with a constant monitoring and controlling. Babies are calm, relaxed and peaceful constantly monitoring and satisfying their needs.

The RUMING IN system is implemented, which involves adapting of the mother and the baby in the same room. An immense gratitude is payed to the top medical nurses’ team who will unselfishly prepare you for the everyday care of your baby. You will be presented with the nursing lessons, bathing- your- baby lessons, good education and advices from best pediatricians that will be necessary for you in the bringing up, and development of your baby.

 

The team of pediatricians is always at your disposal in the further monitoring of the growth and development of the baby, as partners, together with the parents, having mutual goal of bringing up a healthy child.

The feeling that you are special and truly very important to us, the entire surrounding, accommodation, the staff, the hygiene and lots of other parameters, everything that Re-Medika offers, are challenge enough to pay a visit to the hospital and to find out why Re-Medika is so special and unique.

THANK YOU FOR YOUR CONFIDENCE, IN ADVANCE.
WE AWAIT FOR YOUR ARRIVAL! THE REST IS OUR CONCERN!

THE ROLE OF MIDWIFE

Obstetrics as profession is main link from the unbreakable chain that is called health. The midwife with her professional competences and empirical experiences takes care for her patients’ health, provides care to the pregnant women and the newborns.

PARTICIPATION DURING CHILDBIRTH (DURING EVERY CHILDBIRTH, IN RE-MEDIKA, GYNECOLOGIST- OBSTETRICIAN AND A MIDWIFE, ACTIVELY, ARE TAKING PART, ALSO, ANESTHESIOLOGIST AND PEDIATRICIAN ARE PRESENT).

The midwife is a medical person who is constantly with the pregnant woman after she is admitted by the gynecologist- obstetrician at the delivery unit.

The midwife runs some protocol procedures for every pregnant women:

Administrative

She fills out obstetric history with personal information, Baby’s chart, an Anesthesiology form which is in fact questionnaire for the complete health condition, Admission consent, childbirth registration form that after the childbirth is sent to the registry office to obtain the birth certificate.

Medical

  • CTG (Cardiotocographic monitoring the contractions and the baby’s heart beats)
  • Sets intravenous “butterfly” needle and takes blood for laboratory anlises, if not previously done

We recommend that you should carry all prior lab microlab and other medical diagnosis.
Every pregnant woman should check for her blood type and Rh factor and to bring the result with her.

  • Pelvic measurements
  • Body Weight (BW)
  • Hight (H)
  • Monitoring the blood preassure
  • Administers the pregnant woman preparation for colon cleansing, and takes care of your genital area

USES SUPPORTING METHODS

Woman’s menthal image and the contraction and childbirth preparation will have its influence on the childbirth process.
Of course, partner’s support or the person chosen for this moment, will have positive influence on the emotional stability.

  • Breathing instructions

Explaining the birth delivery positions:
Lithotomy position or semi -lying and Semirecumbent position or semi- sitiing
The midwife should estimate the best efficient body position in each phase and to suggest that to the woman in labor .

WAYS OF PAYMENT

IN CASH; PAYMENT CARDS: VISA; MASTER; DINERS; AMERICAN EXPRESS;
POSSIBILITY OF INVOICE PAYMENT, BEFORE PATIENT LEAVING THE HOSPITAL ( Information phone num: 02 2603 100)
INSURANCE COMPANIES;

• Global Benefits Group;
• Cigna;
• AETNA Global Benifit ;
• International SOS Tricare Department;
• Eurosig-Kosovo;
• Eurosig-Albania;
• Allianz Worldwide Care;
• AP COMPANIES;
• Geo Blue;
• ILLYRIA;
• Triglav;
• Eurolink;
• Med Uniqa;
• Sigal Uniqa-Kosovo;
• Winner;
• Sigma;
• Global Blue;
• Winer – Macedonia
• Eurolink – Macedonia
• Triglav -Macedonia

GYNECOLOGICAL SURGERY AND GYNECOLOGICAL ONCOLOGY AND UROGYNECOLOGY


  • Examination, PAP- test, HPV- typization, biopsy, laser treatment of precancerous condition

  • Video colposcopie

  • Vaginal 3D and 4D Colour Doppler ultrasonography for genital organs tumors

  • AdmInistering TCA for the HPV infections

  • Abdominal and vaginal surgery on gynecological benign and malignant tumors

  • Laparascopy and histerescopy surgical treatment 

  • Urodynamics

  • Corrective surgery for incontinence and genital statics

  • Non- invasive, laser treatment, incontinence treatment, genital statics, perimenopause symptoms

  • Menstrual disfunctions treatment and postmenopause

  • Conservative and surgical treatment of chronic pelvic pain and pelvic inflammatory disease

ASSISTED REPRODUCTION WITH IVF

Dear All,

Child crowns the relationship between two individuals, it uprights the family relations, circles the relationship between partners and absolutely gives meaning to our lives. The process of conceiv is fascinatingly sophisticated and depends on the whole range of factors with greater or smaller influence.

Sadly, some people have problems and are in need of assistance in order to fulfill their wish for offspring.
In our Centar for Assisted Reproduction and in vitro fertilization- which is part of PHI Re-Medika, we help your dream for offspring to come true.

Highly qualified team, cutting edge equipment, contemporary procedures and standards we use, guarantee for the quality of our service.

In R.Macedonia, we are pioneers in establishing certain procedures in gynecology and assisted reproduction in order to improve diagnostic and treatment of infertility. In 2012 for the first time in our country we introduced the preimplantation genetic analysis by performing the first embrio biopsy. Following the trends for creopreservation of fertility, we introduced the technique for fast freezing or vitrification by which for the first time in our country the first baby was born from a frozen egg cell. We introduced the laser assisted hatching technique in embryology, IMSI, we started the sperm donataion process, egg cells and embrions.

In 2016 for the first time in our country we implemented the latest technique for ovary rejuvenation or the so called, rejuvenation of the ovaries in terms of improving patients’ ovarial reserves as well as those who are in a premature menopause, and in 2017 the first baby from a surrogate mother was born.

All this lead us to a great progress in resolving the infertility which brought better results where other methods did not succeeded. This is what makes us powerful and safe in resolving infertility. The results we have reached in the previous period position us on the top itself among the centers in the region. Our professional tem will be always with you so you may surpass and overcome the problems in easier and simple manner and to reach the desired goal. We stand for you, because your victory is ours, too…

Yours truly,
Assoc. d-r Zoranco Petanovski,
Head of Department of Assisted Reproduction and In Vitro Fertilization

IVF LABORATORY ACREDITATION

Assisted reproduction and in vitro fertilization laboratory accreditation with ISO 15189:2013 standard confirmed the work quality and staff competence ,and at the same time new control systems were introduced that enable perfect conditions for gametes processing and embryo’s development. External control by IVF experts confirmed our team’s success to create system in which administrative, laboratory and medical procedures are turned into daily routines.

By implementing this standard, constant monitoring of laboratory equipment is facilitated ( planning and implementing of precautionary maintenance, calibration and control), constant staff education, monitoring the quality indicators, constant upgrading the laboratory services by implementing new tecniques, as well as monitoring the complete process from conceiving until baby’s birth. The combination of precise controlled laboratory conditions, use of new generation of media and the top technical equipment, promise ideal conditions for assisted embryo’s growth and development .

The knowledge we have about the preimplantation development and the constant education and training for the new IVF tecniques are our prime mover since the very beginning. High percentage of pregnancies and the number of born children is the best evidence for the Lboratory quality work.

By expanding the Laboratory with new premises the IVF Center will be able to help even more couples offering them the most sophisticated fertility processes to make their dream of becoming parents come true.

IVF LABORATORY

Assisted reproduction and in vitro fertilization Center in PHI Re- Medika, has recently moved into new premises, in the expanded part of the hospital. The new laboratory is constructed according the latest international standards by Europian and American association of humane reproduction and in vitro fertilizatioin that stands for a high control standards of the work quality and services towards the patients. The ISO standards of the IVF laboratory (first of a kind in our country), as well as its expand is one more proof that we are dedicated to a continuous improvement of the work quality and services we offer to our patients.

What kind of methods are used in the assisted reproduction and have you got any plans to expand the listing?

Our laboratory moto is providing ideal conditions for creating, evaluation, transfer and preservation of our patients’ embryos. Along the existing IVFequipment, the laboratory is enriched with he latest working stations and the state –of-the- art incubators ( benchtop) that are multiple chamber small incubators, and bigger control of the environment where the embryos are developing is allowed, of each couple individually.

The Center has its own ventilation net protected with HEPA (High Efficiency Particular Air) and activated air carbon system for the highest level of air purification ( low number of particules and purified from of evaporated organic components). This type of ventilation helps outdoor air contaminents to be removed so not to influence on the embryos’ development. This type of filters are placed separately in each of the incubators in order to provide immaculately clean microenvironment for the embryos.

Having this equipment and controlled environment (gases concentration, temperature, humidity, specific pH) natural conditions for the development of the embryos are imitated, the same as the mother’s womb. The use of highly sophisticated microscopes with high resolution provide proper choice sperm for fertilization, and proper selection of embryos for transfer through morphology analysis and classification of the same.

In addition to the Center, a specialy designed area for cryopreservation of the reproductive material is prepared ( sperm, egg cells, testicular tissue and/or embryos), there are bigger number of tenks with liquid nitrogen for their preservation and thus, the number of places for cryopreservation is incriesed for the patients in need of this method. Besides the standard methods that are practiced in the Center, new ones are to be introduced from the area of DNA fragmentation of spermatozoids, as well as introduction of the ovarial cryopreservation and rejuvenation technique, ones that are reletivelly new and in the phase of experimentation even in the world’s IVF centers.

What will the expanding mean for the patients?

Center growth means opportunity for admittance of bigger number of patients and expanding the range of methods in order to increase the percentage of pregnancy. Our patients have confidence in us to help them in the process of creating their offspring, and our duty is to offer them the best possible conditions to fulfill that. The friendly approach of our professional team of doctors, embriologists and medical nurses will continue in the future admitting more patients in even more comfortable work conditions. We invite all the patients who want to make their dream come true and to produce offspring to visit us or call us for any consultancy / check up in the IVF center premises.

To what extent is the work success?

According to the world statistics it is considered that the biggest enemy for offspring producing is women age. For the women above 37 year of age, the ovarial reserve is substantially lowered, that is the number of egg cells lowers down, qualitatively and quantitatively.

The IVF procedure success depends on many factors, but according the statistics, it is 52% for women to 30 years of age, 45% for the women to 35 years of age, 22% for the women to 40 and for women above 41 is 18%.

INFORMATION FOR THE PATIENTS

Preparing the pair for IVF procedure
On the first scheduled examination you should bring all documents from all the previous diagnostic- treatment interventions related to infertility. This visit is kind of an introduction into the IVF procedure and you will be given the basic information such as the list of necessary documents for the assisted reproduction program.

Realization
After the complete check of your documents gynecologist determens the most appropriate stimaulation protocol, as well as the time for its beginning. A nurse from the IVF department will explain to you the way of administering the therapy and the further following of the induce cycle. There are different protocols and treatments for stimulation, so listen to the instructions carefully. Your first step is to inform the nurse about your next period. If you have any troubles concerning your menstrual cycle you should inform us and a treatment will be provide for you to regulate your cycle. The nurse will give you a phone contact for better coordination, and to inform her about the first day of your next period.

Monitoring IVF stimulated cycle
It is a process that lasts for 3-4 weeks from the beginning of ovulation induction until the day of egg cell puncture. In this process you are under constant supervision by the medical team, controlling your hormone status and US check up on every 3-4 days. All this time intervals are variable and changeable depending the stimulation protocol which will be chosen for the patient.

Intervention schedule
When the egg cells ( follicles) will reach specific dimensions and maturity, upon the doctor’s estimation according the ultrasound check up and the hormone level ( estradiol and LH ) puncture follicles date is chosen. The final instructions for therapy administering are important as well, and they will be explained by the nurse or the doctor. For the intervention itself, a preparation is needed for the couple for IVF puncture.

Egg cell puncture

On the day when the egg cells are collected you will be hospitalized early in the morning. Please do not eat or drink anything because of anesthesia administering. When you arrive at the hospital, please check in on the information desk, and the nurse from the IVF department will admit you to fill in and sign all the necessary documents regarding the IVF procedure.  The nurse will give you psychological support and will answer all the necessary questions before the intervention. You will be accommodated at the IVF department and the embryologist, anesthesiologist and your gynecologist will come to see you. The duration of the procedure is 10-15 minutes long and is done under general short intravenous anesthesia. During and after the intervention, antibiotic and analgesic treatment is administered. After the intervention, you are sent in the bed in your room, to recover from the intervention. You might feel a little dizzy and nauseous because of the anesthesia, and you might be given a therapy for that. The observation time is different for every patient. When the nurse from the IVF department will estimate that your condition is stable you will be discharged and the scheduled therapy that you are about to take after the intervention will be explained to you. Also, you will be instructed regarding certain conditions after the puncture.

Day after puncture
If you are in the IVF/ICSI program, you will get the results next morning. You will contact the embryologist and disscuss the results and the final decision for the embryio transfer and the possibility of freezing the rest of the embryos. It is necessary to leave your phone number and be available so we can contact you.

Embryiotransfer

The embryo transfer procedure is done 3-5 days after the egg cell puncture. Usually, there is no need of anesthesia, because this is relatively simple painless procedure by which embryos are carefully placed into the uterus by a fine catheter. For the procedure itself adequate preparation is needed for the embryo transfer. It would be better if the patient is with full bladder during the procedure, so an abdominal ultrasound may be used, by which the position of the catheter on the uterus may be controlled. After the embryo transfer procedure, you should rest for 2 hours in the recovery room, and then go home. You will be given instructions for the scheduled therapy and also, it is strongly advised that you should rest for the following three days. The pregnancy test is done 13-14 days after the embryo transfer procedure. The blood is taken from a vein and the results are after one hour. If you like, you can do a home pregnancy test with the first urine. Anyway, please inform us about the results from the pregnancy test.

IVF LABORATORY SERVICES

  • Sperm count – analysis of the number, concentration and morphology of spermatozoa in the ejaculate
  • Semen culture –microbiological analysis of the ejaculate
  • Intrauterine insemination– transferring specilly washed semen directly into woman’s uterus
  • In vitro –fertilization (IVF)
  • Intracytoplasmic injection of one sperm cell in the egg cell (ICSI) -it is done in couples with not enough normal sperm and the motility of the sperm is bad,as well as pairs with previous unsecessfull pregnancies. By using high tech microscop, only one quality sperm cell is isolated and is injected into the egg cell.
  • Intracytoplasmic morphologically selected sperm injection with x 6000 inlargement with high- tech microscop (IMSI)
  • Laser assisted hatching -technique that enables abstraction of small part of the external embryo shell thus making easy the furthure development and implantation into woman’s uterus
  • Preimplantation genetic diagnosis (PGD) top sophisticated technology for genetic analysis of single embryo cell. It is a genetic analysis of the embryos about the most common chromosomic anomalies that allowes choosing genetically stable embryos.
  • In vitro maturation of immaturate egg cells extracted while in vitro treatment (IVM)
  • Embryo transfer on the day three or day five ( blastocyst)
  • TESE – minimal invasive sperm retrieval technique by biopsy of testicular tissue
  • Embryo transfer from other IVF laboratories
  • Egg cells cryopreservation
  • Embryo cryopreservation
  • Sperm and testicular tissue cryopreservation
  • Egg cells donation- cooperation with First Egg Bank, Belgium
  • Sperm donation – cooperation with Europen sperm bank, Danmark

IN – VITRO PROCEDURE WITH DONOR MATERIAL

Legal regulation for fertilization with donor material ( sperm, egg cells or embryos) is conducted in 2008 when the Law on biologically helped fertilization is passed in Repubic of Macedonia. In order to fulfill the patients requirements in need of donor material, the first private general hospital “Re-Medika” the same year signed the contract with sperm donation bank Europian sperm bank from Danmark. Our cooperation is on a very high scale and until today materials from 450 donors are used.

When we speak about the egg cells donation, the law enables even young women, citizens of the Republic of Macedonia may be egg cells donors and they wil be payed a fee in the amount of two monthly salary by the institution they donated for. But, because of the low output and high demand of egg cells, we cooperate with the egg cells bank “First egg bank” from Belgium.

The choice of donors is done by the patients themselves who have an insight into the donors’ profiles through the official Banks’ Internet pages.

What examinations are necessary for the donors?

On the person who applies for a donation material, proper examinations has to be conduted ( infectous diseases tests, sexually transmitted diseases, caryotype – with an aim to inspect the chromosome structure, cystic fibrosis tests, thalassemia) as well as to go through legal and psychological counselling. If the needed criteria are fulfilled, the person may donate his/her biological reproductive material.

Can the child make contact with the donor and when?

In “Europian sperm bank” there are two types of donors: the so called opened and anonymous sperm donors. Children born from open donors when come of age, may apply to the bank to make a contact to the biological father, but only on their request.

This is not the case for the fertilizations done by material from anonymous donors.

On the other hand, “Europian sperm bank” has right to inform the donors about the number of children conceived by their material, but these donors have not parental and legal rights towards these children.

Where can one apply for in vitro permission with donor material?

One can apply for in vitro fertilization permission with donor material, it is necessary the institution to submit documents from the pair or the single mother together with donor’s documents sent from the bank to the Committee for biomedical helped fertilization to the Ministry of health. The Ministry gives consent if the legal requirements are met.

What documents are needed for application?

Donor material receivers should submit the following documents:
– Marriage certificate or birth certificate for single mothers ( not older than 6 months)
– Consent for biologically helped fertilization ( with notarial validation)
– Copy of identity cards from both partners
– Psychological and legal counsseling report conducted by the facility

The persons who would like to apply for egg cell donors should submit the following documents:
– Marriage certificate or birth certificate for non married women ( not older than 6 months)
– Consent for biologically helped fertilization ( with notarial validation)
– Copy of identity cards
– Psychological and legal counsseling report conducted by the facility
– Filled -in questionnaire ( from the institution) for the complete applicant’s history of hereditary diseases and death cases in the family back to third- degree     relative, if they are adopted or have chronical, malignant, methabolic and autoimmune diseases.
– Blood count results, glycemia, sedimentation, EEG ( not older than 6 moths and can be accepted from another institution)
– Anamnesis of regular menstrual cycles ( from patient’s own gynecologist)
– Gynecological examination with ultrasound of ovaries and antral follicle count report
– Results from microbiological vagina and cervix swabs for pathological bacteria, mycoplasma and chlamydia ( not older than 6 months)
– Results from infectious screening for Hepatitis B, hepatitis C and HIV
– Cariotype results- blood analysis to determine the chromosomes number and structure in the cells
– Beta thalassemia- blood analysis to determine presence/ absence of this genetically transmitted disesase to offspring
– Cystic fibrosis- blood analysis to determine presence/absence of this genetically transmitted disease to offspring
– Basic hormone status on day 3 of menstrual cycle : FSH, LH, PRL, E2, TSH, if possible, Anti Mullerian hormone.

За сите прашање Ви стои на располагање М-р Сребра Иљовска во ИВФ центарот
Контакт телефон: 072 443 401
Е-маил: siljovska@remedika.com.mk

WHY FREEZING EGG CELLS?

Women’s ovaries are full with egg cells that are formed into follicles ( round – like structures filled with liquid needed for normal growth and development of egg cells). Women unlike men are born with certain number of egg cells ( around 2 millions) which drops every month in woman’s life. Untill adolescence there are only 25% left from the ovarian reserves ( 300.000 egg cells) of which 400 ovulate till the end of the reproductive period. Eventhough no one cannot predict the quantity of reserves in certain period in life, the statistics show significant dropping of fertility after the 37 years of age.

We live in modern, dynamic time when counsciously or non counsciously we postpone the biological clock for fertilization.

Fertility cryopreservation is a new technique by which the egg cells from woman’s ovaries are punctured, freezed and preserved. Later, when the woman is ready for pregnancy, the eggs are defrosted, fertilized and the created embryos are transferred into the uterus.

This procedure is intended for several categories of patients:

• Malignant diseases
For patients with diagnosed malignant disease whose treatment involves chemo or radio therapy. This kind of therapy destructs the egg cells. By cryopreservation procedure, before the beginning of therapy, it is possible for these women to become mothers later in life.

•IVF procedure
During IVF procedure, some of the patients have numerous egg cells and some of them may be freezed and used for the next cycle. Thus, woman is not going to be administered with a new hormone stimulus, but at a specific time of the cycle the eggs are unfrozen and fertilized by the standard method for the IVF procedure.

• Postponing the pregnancy
Women who postpone the pregnancy because of certain situations (education, career) , now have opportunity to freeze their own egg cells and to become pregnant later in life.

• Early menopause
For patients with family history of early menopause, it is better to freeze the egg cells in case of instant premature menopause.

•Egg cells donation
In the program for egg cells donors, the woman donor, frstly, is subjected to genetic screening for the most usual genetic diseases. After the hormone stimulus of the ovaries an aspiration of oocytes is done and their cryopreservation. When the oocyte acceptor is ready for the embryo transfer, the egg cells from the donor are unfrozen and fertilized with the partner’s sperm and the embryos are transferred into the acceptor’s uterus.

Following the cryopreservation fertility trends we implemented the fast freezing technique or vitrification by which egg cells are freezed in specially controlled conditions in liquid nitrogen on -196C degrees until next use.

By implementing this technique the first baby was born from frozen egg cell for the first time in our country.

LAW REGULATION

Legal regulation for fertilization with donor material ( sperm, egg cells or embryos) is conducted in 2008 when the Law on biologically helped fertilization is passed in Repubic Macedonia. In order to fulfill the patients requirements in need od donor material, the first private general hospital “Re-Medika” the same year signed the contract with sperm donation bank Europian sperm bank from Danmark. Our cooperation is on a very high scale and until today materials from 450 donors are used.

When we speak about the egg cells donation, the law enables even young women, citizens of the Republic of Macedonia may be egg cells donors and they wil be payed a fee in the amount of two monthly salary by the institution they have donated. But, because of the low output and high demand of egg cells, we cooperate with the egg cells bank “First egg bank” from Belgium.

The choice of donors is done by the patients themselves who have an insight into the donors’ profiles through the official Banks’ Internet  pages.

What examinations are necessary for the donors?

On the person who applies for a donation material, proper examinations has to be conduted ( infectous diseases tests, sexually transmitted diseases, caryotype – with an aim to inspect the chromosome structure, cystic fibrosis tests, thalassemia) as well as to go through legal and psychological counselling. If the needed criteria are fulfilled, the person may donate his/her biological reproductive material.

Can the child make contact with the donor and when?

In “Europian sperm bank” there are two types of donors: the so called opened and anonymous sperm donors. Children born from open
donors when come of age, may apply to the bank to make a contact to the biological father, but only on their request. This is not the case
for the fertilizations done by anonymous donors.On the other hand, “Europian sperm bank” has right to inform the donors about the
number of children conceived by their material, but these donors have not parental and legal rights towards these children.

“Re- Medika” has its own register and keeps records to inform the two banks for the number of born children by each donor, respectively. According the law regulation, one donor may be used for two born- alive children.

Where can one apply for in vitro permission with donor material?

One can apply for in vitro fertilization permission with donor material, it is necessary the institution to submit documents from the pair or the single mother, together with donor’s documents sent from the bank to the Committee for biomedical helped fertilization at the Ministry of health. The Ministry gives consent if the legal requirements are met.

Donor material receivers should submit the following documents:

  •  Marriage certificate or birth certificate for non married women ( not older than 6 months)
  • Consent for biologically helped fertilization ( with notarial validation)
  • Copy of identity cards from both partners
  • Psychological and legal counsseling report conducted by the facility

The persons who would like to apply for egg cell donors should submit the following documents:

  • Marriage certificate or birth certificate for non married women ( not older than 6 months)
  • Consent for biologically helped fertilization ( with notarial validation)
  • Copy of identity cards from both partners
  • Psychological and legal counsseling report conducted by the facility
  • Filled -in questionnaire ( from the institution) for the complete applicant’s history of hereditary diseases and death cases in the family back to third- degree relative, if they are adopted or have chronical, malignant, methabolic and autoimmune diseases.
  • Blood count results, glycemia, sedimentation, EEG ( not older than 6 moths and can be accepted from another institution)
  • Anamnesis of regular menstrual cycles ( from patient’s own gynecologist)
  • Gynecological examination with ultrasound of ovaries and antral follicle count report
  • Results from microbiological vagina and cervix swabs for pathological bacteria, mycoplasma and chlamydia ( not older than 6 months)
  • Results from infectious screening for Hepatitis B, hepatitis C and HIV
  • Cariotype results- blood analysis to determine the chromosomes number and structure in the cells
  • Beta thalassemia- blood analysis to determine presence/ absence of this genetically transmitted disesase to offspring
  • Cystic fibrosis- blood analysis to determine presence/absence of this genetically transmitted disease to offspring
  • Basic hormone status on day 3 of menstrual cycle : FSH, LH, PRL, E2, TSH, if possible, Anti Mullerian hormone

MEASUREMENT OF RESULTS

Infertility is a heterogeneous disease with multifactorial etiology that affects around 15% of the pairs in the reproductive period in the world population ( Dada, et al., 2008). The infertility rate varies in differnet states and regions, but , anyway, the number of pair visiting the assisted reproduction centers has increased (Bolvin et al.,2007).

The success of accomplished pregnancies varies in different centers having in mind the techniques, media as well as protocols of hormone stimulation.

The last publication of the Consorcium for IVF monitoring by the Europian association for human reproduction and embryology has published paralleling results from 34 countries from 1005 centres. 399 020 cycles are statistically processed that are equal to 1067 cycles of one million population. The rate of clinical pregnancy for ICSI per aspiration and transfer was 28.7 and 32%.

The ratio of achieved single, twin and triple pregnancy is 79.8,19.4 and 0.8%, respectively. (Ferraretti AP, Goossens V, Kupka K et al., Аssisted reproductive technology in Europe, 2009: results generated from European registers by ESHRE. 2013. The European IVF-monitoring Consortium, for The European Society of Human Reproduction and Embryology, Hum Reprod, 28:9; 2318–31).

In R.Macedonia there is a law regulation for the assisted reproduction, but still there is not prepared a national registry for the number of patients and the success of the IVF procedures on a state rank. That is the case why the work analysis and the achieved success of the IVF center are compared to the results achieved in the other regional and prestigious IVF centers presented with publicatons of the Europian association for human reproduction.

From 2008 with the passing of the Law on biomedical fertilization the IVF procedure may be performed at the expense of the Health insurance fund which helped to increase the number of patients who are in need of this service.

In the Assisted reproduction and in vitro fertilization Center at PHI Remedika from the period of 2007 -2016 more than 7000 cycles at patients are completed, and the results according the age, the outcomes of pregnancies are presented on the following diagrams:


Diagram 1. Percentige of positive pregnancy test according the age group for 2013
Positive
Negative
to 31 years of age
Above 40 years of age


Diagram 2. Analysis of achieved pregnancy according the patients’ age group ( clinical pregnancy, biochemical pregnancy, miscarriage, blighted) for 2013.
Biochemical, Clinical


Diagram 3. Percentige of single, twin and triple pregnancy for the period of 2007- 2012.

Single pregnancy, twin pregnancy, triple pregnancy

MEDICAL SERVICES IN THE GYNECOLOGY AND OBSTETRICS DEPARTMENT

 Gynaecological consultation and examination
Colposcopy
Cervical cytology (PAP smears)
Vaginal Ultrasound
Additional charge for Colour Doppler and 4D
Package: Exam+Colposcopy+PAP+Ultrasound examination
Package: Exam+Colposcopy+PAP
Vaginal flora examination
Routine Ultrasound examination during pregnancy
Package – GUS + consultation
Package – Complete Screening for Anomalies in 1 (first) Trimester: (US, Biochemical Analysis, Risk Calculation)
US Screening in pregnancy
US Screening for Anomalies and Cardiological Screening of the Fetus (18 – 23 GW)
Biochemical Analysis for risk calculation for anomalies in fetus growth – 1, 2, 3 trimester
Cardiotocography (CTG)
Cardiotocography package (CTG)
Control examination following intervention – up to 15 days
Consilium – subspecialist examination and opinion
Genetic consultation
Anal and rectal examination; Marshall test; Retractor test
LBS
Vagina toilet
Control Ultrasound examination without biometry before delivery
Abdominal US routine examination
Parenting preparation center
Application of HPV vaccine Cervarix (two doses of vaccine, the third dose is given free)
Application of HPV vaccine Silgard (three doses are paid)
Premature birth test
Test for broken water
Applying three chlorine acid of PVU
IUD Insertion
Ultrasound-guided IUD removal
Insertion of IUD –Nova T 380
Insertion of IUD-Mirena
Application of vaginal pesary
Removal of granulations and suturing surgical material
Gynecological interventional diagnostics and therapy
Amniocentesis / chorion-biopsy
Amniocentesis / chorion-biopsy at twin pregnancy
Cervical Biopsy Endometrium Polypectomy
Endometrial aspiration
Excision biopsy
LEETZ
Fractional Dilation and Curettage (D&C)
Biopsy + cervix EEC
RCUI / D&C for pregnancy rests
Ultrasound guided D&C for pregnancy rests
Marsupialization
Laser vaporization
CTG stress test
Day Clinic
MBA

 

Gynecological and Obstetric Surgery – Gynecological and Obstetric Surgery 
Normal labor and spontaneous delivery
• Epidural Anesthesia • Episiotomy suture • Cervical rupture suture • Manual removal of placenta • Manual revision of uterine cavity • Forceps delivery • Vacuum extractor delivery • Breach delivery • Twins – vaginal delivery
Sectio Caesarea – Caesarean Section
HTA –Total Abdominal Hysterectomy
Cyst removal
Laparotomy – treatment of extra uterine pregnancy
Myomectomy
Corrective surgical treatment of uterine anomalies
Salpingectomy and surgical treatment of uterine tube
Surgical treatment of endometriosis
Surgery for Pelvic Inflammatory Disease (PID)
Explorative Laparotomy
Total abdominal hysterectomy + Pelvic Lymphadenectomy (Endometrial carcinoma)
Radical Hysterectomy by Wertheim-Meigs (Cervical carcinoma)
Surgical treatment of ovarian carcinoma
Simple Vulvectomy
Extirpation of vaginal cyst
Conisation
Conisation by ultracision
Diagnostic laparoscopy
Diagnostic hysteroscopy
Laparoscopic surgery (treatment of infertility)
Hysteroscopic surgery (treatment of infertility)
Laparoscopic Adnexectomy
Laparoscopy – treatment of extra uterine pregnancy
CEF / Hysteroscopy + CEF
Laparoscopic Hysterectomy
Laparoscopic Myomectomy
Cerclage
Laparoscopic cerclage
Laparoscopic cystectomy
Extra charge for pathohistology of operated uterus/ Sur charge for patho-histology of operated uterus
Slinglike colposuspension/ Slinglike colposuspension
Lumbosacral colposuspesion/ Lumbosacral genitosupensions (hystero-, trachelo-, vaginal suspensions)
HTV – Total Vaginal Hysterectomy / HTV – Total Vaginal Hysterectomy
Anterior vaginal repair; Posterior vaginal repair
TVT – Tension-Free Tape
HTA slyngoidal colposuspension
Adnexectomy and cystotomy
Ending the pregnancy by induction-for fetal abnormalities
Vaginosuspensio lumbosacralis et Colposuspensio slingoides with net
Hysterosuspensio et colposuspensio slingoides with net
Plastic repair of vagina – Hymen plastics
Birth preparedness
Prenatal diagnosis for chromosomopathy
Mini sling
Laparoscopic PRP rejuvenation
Intra-muscular application of therapy

MEDICAL SERVICES IN THE IVF LABORATORY


  • Sperm count – number analysis, concentration and morphology of spermatozoa in the ejaculate

  • Semen culture- microbiological analysis of the ejaculate

  • Intrauterine insemination- transferring specilly washed semen directly into woman’s uterus

  • In vitro-fertilization (IVF)

  • Intracytoplasmic injection of one sperm cell in the egg cell (ICSI) – it is done in couples in cases of not enough normal sperm and the motility of the sperm is bad,as well as in pairs with previous unsecessfull pregnancies. By using high tech microscop, only one quality sperm cell is isolated and is injected into the egg cell

  • Intracytoplasmic morphologically selected sperm injection with x 6000 inlargement with high- tech microscop (IMSI)

  • Laser assisted hatching -technique that enables abstraction of small part of the external embryo shell thus making easy the furthure development and implantation into woman’s uterus

  • Preimplantation genetic diagnosis (PGD) – top sophisticated technology for genetic analysis of single embryo cell. It is a genetic analysis of the embryos about the most common chromosomic anomalies that allowes choosing genetically stable embryos.

  • In vitro maturation of immaturate egg cells extracted while in vitro treatment (IVM)

  • Embryo transfer on the day three or day five ( blastocyst)

  • TESE – minimal invasive sperm retrieval technique by biopsy of testicular tissue

  • Embryo transfer from other IVF laboratories

  • Egg cells cryopreservation

  • Embryo cryopreservation

  • Sperm cells and testicular tissue cryopreservation

  • Egg cells donation – cooperation with First Egg Bank, Belgium

  • Sperm donation – cooperation with Europian sperm bank, Danmark

DOCTORS

NURSES

  • Makedonka Ristovska
    Department nurse at the gynecology and obstetrics department
  • Danica Kazioska Radeska
    Department nurse at the IVF department