Sperm Assessment

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We are aware that sperm collection in a medical setting is uncomfortable for many men. We do our best to try to make the situation easier for you and practice the utmost discretion. There are two separate sperm collection rooms in our practice. When you have a spermiogram appointment, one of our laboratory staff will take you to the donor room where you will be given a sterile cup with your name on it and can ask any questions you may have. In the donor room, which can be locked from the inside, you will have plenty of time to provide a sample. Relevant videos are available to you, and your partner can of course accompany you.
The evaluation for a spermiogram takes some time, so there is no need to wait in the practice. The result will be sent to you by mail, or you can request it by

phone. Before a spermiogram, sexual abstinence should be observed for three to five days. If sperm collection at the clinic is not an option for you, it is also possible to collect the ejaculate at home and transport it to the clinic, keeping it warm, for examination. The examination is carried out immediately upon receipt of the sample in our laboratory. The number (concentration), motility (movement) and shape (morphology) of the sperm are assessed under a microscope. If an infection is suspected, a bacterological examination can be arranged. The spermiogram findings are decisive for our therapy recommendation, however a man’s spermiograms are subject to certain fluctuations, and a follow up test is often recommended in the case of initial abnormal results.

Important information to our Spermiogramm

Normal values of sperm
Normozoosperm normal ejaculate parameters
Oligozoosperm reduced concentration of sperm
Asthenozoosperm reduced mobility of sperm
Teratozoosperm reduced morphology of sperm
Oligoasthenoteratozoosperm (OAT) reduced concentration, mobility and morphology
Azoosperm no sperm in the ejaculate
WHO 2021 normal values of sperm
Concentration (number of sperms) >= 15 millions/ml or total number of sperms >= 39 Mio.
Progressive mobile sperm (categories A+B) >=30 %
Local and immobile sperm (categories A+B+C) >=42%
Morphology (Sperm form, different guidelines
here)		 4%

Laboratory tests

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The hormonal balance in the body is a delicate interplay between many parameters. Thus, various hormonal disorders can be the cause of a woman not becoming pregnant or having repeated miscarriages. A blood test can detect malfunctions of the thyroid gland, the pituitary gland (e.g. elevated prolactin levels) or even the adrenal cortex and ovaries (e.g. elevated male hormones). The hormones of the ovary (estradiol, corpus luteum hormone) change during the cycle and are therefore determined at various time points, often multiple times during a cycle.
Some general hormonal disorders are common, for example hypothyroidism, elevated prolactin levels (hyperprolactinemia) or diabetes mellitus including its

precursor. These should be properly controlled with medication before the start of targeted gynecological treatment. We offten apply strcter criteria to infertility patients than perhaps your family doctor or internist. If this alone is not sufficient, hormone stimulation can be carried out, i.e. egg maturation, ovulation and support oft he corpus luteum phase. Before fertility treatment, serological tests for HIV, hepatitis B and C are necessary in both partners. Chromosomal analysis from a blood sample in both the man and woman is recommended prior to ICSI therapy and for diagnosis in cases of repeated miscarriages. These blood samples can of course also be taken in our practice.

Consultation

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Regardless of whether you are seeking medical advice for the first time, or your gynecologist or urologist has already determined that you need fertility therapy, you are welcome to make an appointment at our practice – preferably together with your partner. Please bring any previous test results with you. You may not need any new examinations. After one year of regular sexual intercourse without contraception, pregnancy occurs in about 85% of all couples. There can be many reasons why it has not yet worked for you. The most common reasons include cycle disturbances, damage to the fallopian tubes or limited sperm quality.
During an initial consultation with you, we first discuss your „history“. Is your cycle regular? Have you already had infertility treatments? The completed

questionnaires, which you will have access to once you make your appointment, also contain helpful information for us. We can then arrange the necessary diagnostic measures depending on how long you have been trying to get pregnant. It is however not always possible to find a reason for the absence of pregnancy and this is called idiopathic infertility. Often an initial recommendation can be given at the end of the consultation. Sometimes we also arrange a further consultation. It is important to us that you are able to ask all your questions and address all your concerns during the consultation. Ultimately, you decide whether and when a particular therapy will be carried out.

Social Freezing

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Social Freezing – when the desire to have children is in the future

The prophylactic freezing of unfertilised eggs enables a later fulfillment of the desire to have a child. Many women want to postpone motherhood until „later“ due to various life circumstances. The reasons for this can be very different and vary from for example, if the right partner has not yet been found, or if career and children would currently be difficult to reconcile. Unfortunately, the biological clock of women and men „ticks“ at different speeds. A woman’s fertility depends on the condition of her eggs. From a medical point of view, the ideal age for pregnancy is between 18 and 25, when the eggs are of the highest quality. From the age of 30, egg cell vitality and thus fertility decline. This continues rapidly from age 35.

In social freezing, the age oft he woman at the time of egg collection is also a decisive factor for success. The younger the eggs are, the better their quality. The

course of treatment in the first phase ist he same as that of IVF treatment. Hormone treatment is used to stimulate the ovaries to produce eggs. The stimulation and the growth of the follicles are monitored by ultrasound. If sufficiently large follicles are present, the eggs are punctured via the vagina in a short procedure and vitrified (frozen) in the laboratory. During vitrification, the sensitive cells are frozen in liquid nitrogen so quickly that no damage occurs to the cell membrane and all physical processes come to a standstill, thus preservation is possible for decades. In order to have enough frozen eggs for a future therapy to attempt a pregnancy, several rounds of stimulation and egg collection may be necessary. Approximately 15-20 oocytes are recommended as a depot.

Treatment cycles with cryopreserved pronuclear stage cells (“cryo cycle”)

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In the so-called cryo cycle, the cryopreserved cells are thawed and transferred after a few days culture, into the uterus. In most cases, the transfer takes place in a spontaneous cycle, i.e. without prior stimulation. The transfer is therefore not as stressful for the body as a fresh cycle. It may be useful to thin the outer shell of the embryo. This procedure (see Assisted Hatching) facilitates the hatching of the

embryo for implantation. Again, we recommend transferring one well-developed embryo. Our doctors will discuss the appropriate procedure and the number of cells to be thawed and embryos to be transferred with you individually. We require the written consent of both partners for thawing.

Cryopreservation

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In IVF or ICSI therapy, the fertilised eggs are in the pronuclear stage the morning after follicle punction. These pronuclear stage cells are further cultured. However, if several fertilised eggs are viable, some can be frozen (cryopreservation)for later use. Storage takes place in liquid nitrogen at -196 degrees Celsius and is can be maintained for many years. If the first treatment does not result in pregnancy, or if further therapy is desired after the birth of a child, the frozen cells can be thawed and cultured without having to repeat the stimulation and egg collection.

If cryopreservation of surplus pronuclear stage cells is not desired, they will be discarded. Unfortunately, cryopreservation of pronuclear stage cells and the subsequent thaw cycles are not covered by health insurance.

In principle, all female and male germ cells can be frozen unfertilised or fertilised. Sperm and testicular tissue (see testicular biopsy) can for example also be cryopreserved. A patient may choose to freeze sperm before a planned testicular operation or chemotherapy, even if there is currently no desire to have children. Likewise, donor sperm for donor inseminations is stored and shipped frozen.

Unfertilised eggs can also be retrieved and frozen for fertilisation at a later date.

Mature embryos, usually blastocysts, can also be frozen and stored for years. However, the goal is never to obtain embryos for storage.

Donor Insemination, IVF or ICSI with Donor sperm

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If, in the case of a severely limited spermiogram, all available options – inseminations, ICSI therapy, testicular biopsy – have been unsuccessful or are not desired for any reason, it is possible to use frozen sperm from special sperm banks (donor sperm) for a therapy.

Unfortunately, donor sperm therapies are not included in the services provided by health insurance companies. Before commencing a therapy, couples commission the sperm bank to provide donor sperm. A suitable donor who

resembles the partner in height, stature, nationality, hair and eye colour and matches in blood type is then selected. The donor sperm is then sent to our practice frozen in liquid nitrogen. Prior to this, the donor has been extensively screened for infectious diseases. Our experience shows that couples who have chosen this path are very happy about their decision afterwards. We are also able to help female homosexual couples achieve pregnancy using donor sperm.

Testicular biopsy

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In some men, no sperm are found in the ejaculate (azoospermia). Some men expect this diagnosis e.g. after surgery or chemotherapy, other men are completely surprised because they feel healthy (and usually are). First of all, the diagnosis must be confirmed by a second spermiogram with a clear interval of 2-3 months. A careful examination by an andrologist, a urologist with special training in male fertility, should be performed. A cause fort he absence of sperm, e.g. vas deferens obstruction or inguinal testis in childhood, cannot always be found. Unfortunately, causal therapy is not possible.

In order to fulfil the desire for a child, an attempt can be made to obtain sperm cells from the testicular tissue. Such a testicular biopsy is called TESE (Testicular Sperm Extraction). For this purpose, a small tissue sample i staken from the testicle in a short surgical procedure under anaesthesia, and frozen in several

portions. If sperm are found after trial thawing of one of these portions, ICSI treatment can be planned. The frozen material is usually sufficient for several treatment cycles.

Of course, this method can also be considered for men who have undergone sterilisation and now wish to have children.

However, if the testicular tissue has been damaged to such an extent that no sperm can be detected even in the testicular biopsy, having a biological child is unfortunately not an option. Couples in this situation can consider therapies with donor sperm, and should have good chances of success.

Assisted Hatching with Laser

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Until shortly before implantation in the uterus, the embryo is surrounded by a protective shell, the zona pellucida. In ordert o implant in the uterine lining, the embryo must hatch out of this protective shell, which usually happens on ist own. However, under certain circumstances, the protective shell may be particularly thick or hardened, making hatching difficult or impossible. Assisted hatching is a technical procedure in which we facilitate the embryo’s hatching from the protective shell. This is generally a harmless procedure for the embryos.

The simplest and safest method is laser hatching, as the area for hatching can be set very specifically as can the size and depth of the break in the shell. The

embryo is placed under a microscope and targeted with the laser beam.
We recommend laser hatching in especially for the transfer of embryos after cryopreservation and thawing, as these embryos may exhibit hardening oft he zona pellucida. In rare cases, assisted hatching may also be indicated in fresh cycles (e.g. in older patients >38 years of age or after repeated unsuccessful IVF or ICSI therapy despite optimal conditions).Studies with laser technology have been convincing so far and show a positive effect (Wan et al. 2014; Ebner et al. 2005).

Embryoscope +

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The Embryoscope + is an incubator equipped with a camera that allows undisturbed monitoring of embryo development. With continuous rather than static analysis, the Embryoscope + creates optimal culture conditions fort he embryos. At regular intervals (every 10 minutes), each embryo is photographed without having to be removed from the incubator. Thus, they remain protected in the stable and warm environment of the Embryoscope + for the entire cultivation period.

The embryos can be monitored over a period of 5-6 days and individually assessed according to various criteria such as division rate and cell number. In

addition, state-of-the-art software monitors the embryos almost without interruption, providing additional feedback for the laboratory staff to use as part of their assessment. This allows the selection of the best developed embryos for transfer. These ideal selection options combined with undisturbed cultivation lead to improved pregnancy rates.
Our practice has two Embryoscope + which each have room for 15 patients and all their embryos. Thus, many of our patients can benefit from the monitoring of embryonic development.