As treatment of infertility several thereapies are available. We offer you a friendly and human atmosphere, which offers space for your Feelings, inquiries or worries. Our Team is always at your side with words and deeds.
Optimising the menstrual cycle / Focused Intercourse
Not all couples that come to see us require fertility treatment. Often, it already helps to monitor the cycle (see menstrual cycle monitoring) in order to determine the optimal time for intercourse to conceive. Clomiphen is often prescribed in order to support the oocyte maturation. On the 10th day of the menstrual cylce the first ultrasound is performed to determine the size of the follicles and the thickness of the endometrium. Once a follicle has reached a size of 18 to 22mm ovulation is initiated by injecting an ampoule hcg (5000IE) under the skin. Ovulation will take place 36 hours later which would be the ideal time to conceive.
In experience the best time to give the injection of hcg (Brevactid, Predalon) is at 7pm proceeding with intercourse the following two nights. If the hormone results will reveal that ovulation is already in progress we might vary this pattern accordingly. During the second half of the cycle-three days after ovulation had been triggered by hcg the luteal phase function is supported by administering Utrogest (progesterone) vaginally. The recommendation is to insert both pills in the evening at the same time. Utrogest should be taken for 14 days up to the date of pregnancy test and if the pregnancy test is positive this will be continued through early pregnancy. If the pregnancy test should be negative you will menstruate as soon as you stop taking utrogest.
The therapy instructions “Traffic to the Optimum” can be found here.
If it has been established during the cycle monitoring that no or only incomplete follicular maturation occurs, hormone stimulation is performed. Through the administration of drugs (hormones), this disorder can be ruled out. An irregular cycle also indicates a problem with follicle maturation. The simplest method of hormone stimulation is the administration of clomiphene. 1 to 2 Clomifent tablets from the 3rd to the 7th cycle day supported. Often this therapy is already sufficient. It is used in rotated sexual intercourse and insemination. Clomiphene can also be used to improve chances of pregnancy with a regular cycle and unobtrusive cycle monitoring. » read more
The second option of hormone stimulation is FSH (follicle stimulating hormone) or HMG (human menopausal gonadotropin, which also contains FSH). FSH is a hormone of the pituitary gland that works in the natural cycle of follicular growth. This FSH is included in the different available medicines and will be in low dosage from the 2nd day of the cycle. Most women say goodbye to demonstration and some “practice” these injections themselves. In some couples, the partners take over the injection. Of course, here again the 10th day of the cycle follicle growth is controlled by ultrasound to fix the most favorable terminus for sexual intercourse or insemination. ICSI treatments are always used with FSH or HMG – but in higher doses. For artificial insemination, not just one or two follicles should mature, but several (possibly 6 to 10) follicles. In addition to the FSH / HMG preparation, IVF or ICSI must always be given a second medication that prevents ovulation.
An insemination treatment is suitable for fulfilling the desire for children with slight restrictions of the spermiogram (see Spermauntersuchung). But at the time of ovulation, a fresh semen sample is processed so that the slow are separated from the fast moving sperm. The work-up in the laboratory takes about 1.5 hours, they can of course leave the practice during this time. Thereafter, the well-moving sperm are injected directly into the uterine cavity using a thin, soft plastic tube. The treatment itself only takes a few minutes, you notice almost nothing of this. By overcoming the mucus-filled cervical canal, which is a barrier to sperm, natural fertilization can be achieved with this method, even with reduced sperm count or motility. » read more
In order to determine the optimal time for insemination and to increase the chances of pregnancy, a cycle monitoring is always carried out, the ovulation medically triggered and substituted in the second half of the cycle, the luteal hormone (cycle optimization). Hormone stimulation with clomifene or FSH or HMG in advance is useful in some patients.
Before beginning therapy, you must first apply for reimbursement from your health insurance. You will receive this request from us after the cost and insurance situation has been explained to you in the conversation.
IVF (in-vitro-fertilisation) stands for fertilisation outside of the body. This therapy helps patients where the woman has, for example, a fallopian tube blockage, or couples that have been unsuccessful with other therapies. Before commencing therapy an application needs to be submitted to your health insurance concerning the costs. The application form is available in our clinic once the costs and the insurance situation have been explained to you during consultation. » read more
Some women will obtain an injection to suppress the bodies own hormones (Downregulation) and will start 14 days later with hormone stimulation (agonist protocol). Other wonen will start hormone stimulation on the 2nd day of the menstrual cycle. These women will also have to inject a second medication beginning on the 7th day of the menstrual cycle to suppress ovulation (antagonist protocol). There are also other methods of stimulation which will only be used in individual cases. The medication for the hormone stimulation contains FSH (follicle stimulating hormone) or HMG (human menopausal gonadotropin), which will stimulate the ovaries to produce several follicles. Once a day, always at the same time, FSH/HMG is injected under the skin- mostly by the women themselves. An ultrasound is performed on the 8th day of menstrual cycle to determine the number of follicles on the left as well as the right ovary and to determine the thickness of the endometrium. If it is not possible to perform an ultrasound on this day the ultrasound can be moved to day 7 or 9. To do so, you can come to our clinic or see your gynaecologist, who will inform us about the results. Once the follicles have reached a certain size hormone levels (estradiol and LH) are determined from a blood sample which will provide additional information on stimulation results. Depending on the size of the follicles we will decide on further medicine doses as well as the day for the next ultrasound. If you have been at our clinic for ultrasound you will obtain this information the same day by telephone after 2pm. The hormone stimulation is continued until the follicles have reached a size of about 20mm, then the oocytes are expected to be mature. Usually this will take 10 to 12 days but can also take 8 or 16 days. Afterwards ovulation is triggered by injecting hcg. Two days later before ovulation occurs the ovum retrieval and sperm donation take place in our clinic.
2. Ovum Retrieval
The ovum retrieval is performed through the vagina under ultrasound guidance. A needle attached to an ultrasound head is used to penetrate through the vaginal wall into the follicles located directly behind. The entire liquid contained in the follicles is extracted. For this procedure you are required to have fasted (no food, drink or smoke as of 6 pm the previous night). The procedure will take about 10 to 15 minutes during which you will get a short anaesthesia. Then you will rest in our clinic and are free to drink and eat. If required we will administer painkillers. Parallel to the ovum retrieval the sperm donation takes place. Once everything is fine you are both ready to leave. However, due to the anaesthesia the woman is not allowed to drive herself. From the day of the ovum retrieval onwards the women should administer 2 pills of Utrogest (progesterone) 3 times daily into her vagina.
3. IVF Laboratory
The liquid that is obtained during the ovum retrieval is brought directly into the laboratory where the oocytes are extracted, counted and stored in the incubator. Parallel to the ovum retrieval the sperm donation takes place. The sperm of the partner are prepared and are added to the woman´s oocytes in the afternoon. Then the fertilisation will take place- practically on its own. After about 15 to 18 hours the oocytes are examined under the microscope to determine how many are fertilised. On average 50 to 70% are expected to have been fertilised. The fertilised oocytes are recognised by 2 pronuclei present in the oocytes (pronucleus stage), which will fuse later (embryo). Our laboratory staff will inform you about the fertilisation rate by phone as well as make an appointment for the embryo transfer (1 to 2 days later). The fertilised oocytes chosen for transfer are cultivated further in the incubator. During the same day the first cell division is expected. The rest of the fertilised oocytes can be cryopreserved if you desire. If you do not want cryopreservation the other oocytes have to be discarded. On the day of transfer an embryo usually consists of 4 to 8 cells. On the morning of the transfer the embryos are checked and photographed. These photos are shown and explained to you immediately before transfer. The fertilised oocytes develop through cell division into an embryo (ideal scenario):
Day of Ovum retrieval + 1= Pronucleus stage
Day of Ovum retrieval + 2= Four-Cell-Stage
Day of Ovum retrieval + 3= Eight-Cell-Stage
Day of Ovum retrieval + 4= Sixteen-Cell-Stage (Morula)
Day of Ovum retrieval + 5= Blastocyst (expanded or hatched)
4. Embryo transfer
On the morning of the transfer omit the Utrogest. Two to three days after the ovum retrieval the embryos are transferred into the uterus using a soft plastic catheter. The procedure will only take a few minutes. You will hardly notice it. A slightly filled bladder will make the transfer easier. Afterwards you may directly leave and also go to the toilet. After transfer you will just continue taking 2 pills Utrogest 3 times daily. We recommend the transfer of two embryos. In this case the statistical pregnancy rate is 25 to 30%. However, the pregnancy rate will drop once the women have reached the age of 40. About 15% of pregnant women are expecting twins. The maximum number of embryos that is allowed to be transferred in Germany is 3 by law. Increasing the number of embryos from 2 to 3 does not increase the prospect of a pregnancy significantly but you would risk a pregnancy with triplets.
5. Pregnancy test
The following 2 weeks the embryos are supposed to continue development and implant into the endometrium. We would ask you to continue administering the Utrogest during this time. Additionally, taking one tablet of ASS 100 daily will increase the blood circulation. It is not necessary to change your way of life, abandon sports or even get sick-leave. Most women find these two weeks especially straining as ‘nothing seems to be happening’. 14 days post transfer the pregnancy test is evaluated from a blood sample taken in our clinic or at your gynaecologist. Even if menstruation has already started a pregnancy test is required as bleeding can even occur during early pregnancy.
ICSI (Intracytoplasmaxic sperm injection) is a special form of assisted reproductive therapy. This therapy is applied when sperm quality (see sperm analysis) is highly impaired. In this case, it is assumed that the sperm are not able to fertilise the oocytes on their own. Hence, no fertilisation would be expected when applying conventional IVF therapy where sperm and oocytes are only incubated together. Therefore, during this therapy one sperm is injected into one oocyte. For you the therapy will be identical as in IVF but there are some additional working steps in the laboratory. » read more
Before commencing therapy it needs to be determined whether IVF or ICSI is recommended for you. Then the application form concerning costs for your health insurance can be submitted. You will receive the application form after having been explained the costs and insurance situation during consultation.
Health insurance requires two spermiograms 12 weeks apart before supporting an ICSI therapy. Therefore it may be necessary to have a second sperm evaluation after consultation. It is also recommended to have a chromosomal analysis of both partners before starting therapy, for which we can draw blood after consultation.
The ICSI method has been successfully performed for over 10 years. Investigations have shown that the method itself has not led to an increased number of malformation in children.
Nowadays it is possible to cultivate embryos outside the body for up to 5 to 6 days. After fertilisation of the oocytes the pronuclei will fuse during the first day. Ideally the oocytes have reached a four- or eight-cell-stage on the 2nd to 3rd day respectively. The embryo will continue division and will have developed into an 64- or 128-cell-stage on day 5, referred to as blastocyst. The delayed transfer on day five allows further observation of the development. It is worth mentioning, that only every third oocyte is expected to develop up to this stage and all others will arrest in their development. Even the embryos capable of developing will start to show differences. Cultivating several embryos at the same time has the advantage of being able to identify the embryos with the best potential (selection). When these cells are chosen for transfer the implantation potential is higher. » read more
The blastocyst transfer, after expanded cultivation, is mainly performed abroad, but no advantage has been shown in comparison to transfer on day 2 or 3. Crucial for a higher pregnancy rate is actually the selection out of several embryos. Hence, couples in Germany and patients with only a few oocytes do not profit from expanded cultivation. A study in Germany has revealed that the pregnancy rate is even reduced after blastocyst cultivation without selection in comparison to transfer on day 2 to 3. This was expected as the German law only permits a maximum of 3 embryos to be cultivated past the pronucleus stage. In Germany embryos- not oocytes at pronucleus stage- are protected by the embryo-protection-law: it is permitted to develop only as many embryos in the laboratory as will betransferred. Hence, on the day after ovum retrieval two fertilised oocytes (max. three) are chosen for further cultivation and eventually transferred. All other fertilised oocytes need to be cryopreserved, if you wish, or otherwise need to be discarded. As long as German law does not permit to expand the culture to several oocytes to select embryos most likely to develop, we recommend cryopreservation. Even 1 or 2 cryo transfers make it possible to achieve pregnancy rates higher than the average pregnancy rates perovumpetrieval. Additionally a cryocycle is much less strain on the body with much lower costs involved.
The embryo is a microscope incubator where embryo development can be monitored undisturbed. Through a dynamic rather than static analysis it creates optimal living conditions for the embryos. At regular intervals (every 15 – 20 minutes), each embryo is photographed without having to be taken out of the incubator. Thus, there are no changes in the temperature and the pH in the culture medium. » read more
The embryos can be monitored over a period of 5-6 days and specified for some criteria such as, rate of division or fragmentation. With the help of special software, it is possible to make an almost complete observation of embryo development, even at night, in order to make an excellent selection of good embryos with the best development opportunities.
The embryo is rebuilt from a protective covering, the zona pellucida, until just before implantation in the uterus.
In order to be able to move into the lining of the uterus, the embryo hatched from this protective cover and was usually passed on its own. However, under certain circumstances, the protective cover may be independent of whether it is activated or not. It will be impossible. Assisted Hatching is a technical procedure in which the embryo facilitates hatching from the protective cover. The embryos are usually not damaged. The simplest and fastest method is the laser hatching, because the hatching is very large and the depth and depth is precisely adjustable. The embryo is fixed with a holding pipette (as with the ICSI) and crossed with the laser beam. » read more
In particular, we recommend the transfer of oocytes in the pronuclear space and blastocysts after cryopreservation because the embryos may be able to prevent the zona pellucida. In exceptional cases, Assisted Hatching may also be indicated for fresh cycles (eg in older patients> 38 years or repeat successful IVF or ICSI therapy despite optimal conditions).
The data available in the studies on a higher pregnancy rate are ambiguous.
Studies using laser technology are overweight and have a positive effect (Wan et al 2014, Ebner et al., 2005).
In some mens ejaculate there is no sperm to be found (azoospermia). Some men are already aware that this might be the case for them, e.g. after surgery or chemotherapy, other men are completely surprised because they feel and mostly are healthy. First, the diagnosis must be confirmed by a second spermogram with a clear interval of 2 – 3 months. Careful examination by an andrologist, a (mostly) urologist with special training in male fertility, should be performed. A cause of the absence of sperm, e.g. Vaginal closure or inguinal testis in childhood, can not always be found. A causal therapy is unfortunately not possible. In order to fulfill the desire of the child, it may be attempted to obtain sperm from the testicular tissue. Such testicular biopsy is referred to as TESE (Testicular Sperm Extraction). For this purpose, a small tissue sample is taken from the testicles in a short surgical procedure in short anesthesia and deep-frozen in several portions. » read more
If sperm can be found after the test thawing of a sample portion, an ICSI treatment can be planned, which then uses another portion of the sample. The frozen material is sufficient for several treatment cycles.
Of course, this method is also suitable for men who were sterilized and now have a desire 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, there is unfortunately no hope for a biological own child. These couples can be recommended with very good chances of success therapies with donor sperm.
Donor insemination, IVF or ICSI with extraneous sperm
If in very severely restricted spermiogram of the man all available options – insemination, ICSI therapy, testicular biopsy – were unsuccessful or are not desired for certain reasons, it is possible to use frozen semen from special sperm banks for a therapy. Before starting therapy, you must visit a notary to authenticate a document. In it, you acknowledge the common parenting of the future child, thus relieving the sperm donor of any later maintenance claims. Unfortunately, foreign sperm therapies are not among the benefits of health insurance. » read more
At the beginning of the therapy you assign the sperm bank with the supply of donor seeds.
There, a suitable donor, who resembles the partner in size, stature, nationality, hair and eye color and agrees in the blood group, then selected. The donor sperm is then sent frozen in nitrogen to our practice. Previously, the donor was extensively examined for infectious diseases. Our experience shows that couples who – contrary to all prejudices – have chosen this path, are in hindsight very happy about their decision. Recently, we have the opportunity to help female homosexual couples to the desired child.
The morning after IVF or ICSI therapy the oocytes are at the pronucleus stage. At this point in time the best developed oocytes are chosen for transfer and ultivated further. After 2 to 3 days they will have developed to a four- or eight-cell-stage and are transferred back into the uterus. If there are several additional developable pronucleus stages, they can be frozen (kryopreserved). Kryopreserved cells are stored at -196°C and can be kept for several years. » read more
If the first therapy was not successful or after having given birth wishing to have a second try you are able to use these oocytes first before starting a new IVF/ICSI cycle.
If you do not want to freeze the redundant fertilised oocytes they are going to be discarded. Unfortunately kryopreservation and the subsequent cycle of treatment are not covered by health insurance.
Cycle of treatment with cryopreserved oocytes at the pronucleus stage (called cryo cycle)
It is important that the endometrium has sufficiently built up during a cryo cycle. As support oestrogen pills (Gynokadin) should be administered from the 2nd day of your menstrual cycle onwards. On the 10th day of your menstrual cycle an ultrasound is performed to determine the thickness of the endometrium. Usually no follicles develop using oestrogen pills. It may be that more ultrasound examinations are required until the endometrium has build up to the desired thickness. Then we allocate a day for transfer. Three days before transfer you would commence administering 2 pills of Utrogest into your vagina daily (best at night) to support the endometrium until the day of pregnancy test.
One of our laboratory staff will contact you the following day to inform you about the results as well as make an appointment for transfer. The transfer procedure is exactly the same as it is with an IVF or ICSI therapy. The oestrogen pills (Gynokadin), the Utrogest and additionally ASS 100 for better blood irculation should be taken up to the date of the pregnancy test 14 days after transfer. Since the embryos are transferred without prior high dose hormone stimulation with ovum retrieval, the cryocycle is much less strain on the body. However, the resulting pregnancy rate is lower than that with ‘fresh’ embryos. Cryopreservation- storage for later use- is also applicaple to testes tissue and perm. This means that testes tissue or sperm can be frozen before a testes operation or chemotherapy, even if there is no acute desire for children. The Donor sperm is also stored and delivered in liquid nitrogen. Even multiple-cell embryos can be frozen in a special procedure called vitrification.
Social freezing – if the wish to have children is fulfilled later
The precautionary freezing of unfertilised oocytes allows a later fulfillment of the desire to have children. Many women want a shift in motherhood to “later” because of different circumstances. The reasons for this can be very different. For example, if the right partner for family planning has not yet been found, or if work and children are still difficult to reconcile. Unfortunately, the biological clock of woman and man is “ticking” at different speeds. The fertility of the woman depends on the condition of her eggs. From a medical point of view, the ideal age for pregnancy is between 18 and 25. Here, the eggs have the highest quality. Already from the age of 30, the oocyte vitality and thus the fertility decrease, even very fast at the beginning of the 35th year of life.
The precautionary freezing of unfertilised oocytes allows a later fulfillment of the desire to have children.
Many women want a shift in motherhood to “later” because of different circumstances. The reasons for this can be very different. For example, if the right partner for family planning has not yet been found, or if work and children are still difficult to reconcile. Unfortunately, the biological clock of woman and man is “ticking” at different speeds. The fertility of the woman depends on the condition of her eggs. From a medical point of view, the ideal age for pregnancy is between 18 and 25. Here, the eggs have the highest quality. Already from the age of 30, the oocyte vitality and thus the fertility decrease, even very fast at the beginning of the 35th year of life.