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.
Hormonal Stimulation
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 medication (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 Clomifen. The follicle maturation is supported by taking 1-2 Clomifen tablets from the 3rd to the 7th day of cycle. Often this therapy is already sufficient. It is used in rotated sexual intercourse and insemination. Clomifen can also be used to improve chances of pregnancy with a regular cycle and unobtrusive cycle monitoring.
The second option for hormone stimulation is injection therapy with the gonadotropins FSH (Follicle Stimulating Hormone) or HMG (Human Menopausal Gonadotropin, which also contains FSH). FSH is a hormone of the pituitary gland that causes follicle growth in the natural menstrual cycle. This FSH is contained in
the various meidcations available, and is injected under the skin in small doses once a day, starting on the 2nd day oft he cycle. Most women self-administer these injections after demonstration and some „practice“. Some couples prefer to have the partner do the injecting. Follicular growth is again monitored with ultrasound from the 10th day of the cycle, in order to determine the most favourable date for targeted intercourse or insemination. In the case of stimulation for IVF or ICSI treatments, FSH or HMG is also used – but in higher doses. This is because for artificial insemination, multiple mature follicles are required (i.e. 6 to 10 instead of one or two). In addition to the FSH/HMG preparation, a second drug must always be injected during IVF or ICSI, which prevents premature ovulation.
Insemination
An insemination treatment is suitable for fulfilling the desire for children with slight restrictions of the spermiogram (see Sperm analysis). At the time of ovulation, a fresh semen sample is processed so that the slow moving sperm are separated from the fast moving sperm. The work-up in the laboratory takes about 1.5 hours, you 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.
In order to determine the optimal time for insemination and to increase the chance of a pregnancy, cycle monitoring is always performed. Ovulation is triggered with medication, and the corpus luterum hormone is substituted in the
second half of the cycle (cycle optimization). Hormone stimulation with clomiphene, 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.
In-vitro-Fertilisation IVF
IVF is the abbreviation for „In Vitro Fertilisation“ and means „fertilisation outside the body“. This therapy is performed, for example, in women with tubal occlusion, but also in couples where all other therapeutic methods have already been exhausted. In order for IVF to be successful, sperm production with sufficient concentration and motility is required, as well as a healthy uterus and at least one functioning ovary in the woman. 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.
- Stimulation
- Ovum Retrieval
- IVF-Laboratory
- Embryo transfer
- Pregnancy test
1. Stimulation
First, the ovaries must be stimulated so that more eggs mature than in the natural menstrual cycle. The stimulation takes place around the 2nd day of the cycle, with hormones (FSH or HMG), which are usually injected by the women themselves under the skin with a thin needle. In order to monitor the response of the ovaries to the medication, the first ultrasound check is performed on day 8 of the cycle. This can be done at our practice or at your gynecologist’s office, who will then send us the results. The size of the follicles determines the next steps, in terms of further dosage of medication and the next ultrasound check. Hormone stimulation is continued until the eggs are mature with a follicle size of around 20mm, which is usually after 10-12 days. At this point, ovulation is induced with an evening injection of the hormone HCG. 36 hours later the egg collection (follicle puncture) and sperm delivery take place in our practice, before ovulation actually occurs.
2. Follicle Punction (Egg collection)
Follicle puncture is performed with ultrasound-guidance through the vagina. For this purpose, a thin hollow needle is attached to the ultrasound probe, which is inserted into the vagina. The needle is used to pierce through the vaginal membrane into the follicles located directly behind it, and to aspirate all the follicular fluid. The procedure is performed on an empty stomach under sedation and lasts 10-15 minutes. Afterwards, the patient rests in our recovery room and may drink and eat. Pain medication is available, although it is rarely required. The sperm delivery is done in parallel with the follicular puncture and couples can go home together afterwards, but the woman may not drive herself due to the anaesthesia.
3. IVF Lab
During the egg collection, the aspirated follicular fluid is immediately transferred to the laboratory. The eggs in the fluid are retrieved, counted and stored in an incubator. The partner’s sperm are prepared and combined with the eggs in a nutrient rich solution in the early afternoon. Then – without further manipulation – fertilisation takes place. The next morning, a microscope is used to check how many of the eggs are fertilised. This can be recognised by the presence of two nuclei (pronucleus stage), which will fuse later as the cell becomes an embryo. Around 50-70% fertilisation rate can be expected from IVF. You will be informed about the fertilisation result by our laboratory staff immediately by phone, and the date for embryo transfer will be set. The fertilised eggs continue tob e cultured in the incubator until transfer. If there is a surplus of fertilised eggs,
these can be frozen (cryopreservation) in the pronuclei stage after consultation with you. Cell division begins during the course of the first day and the embryos are cultured in the lab until day 5. They are observed daily, which allows for good differentiation and selection of an embryo with optimal developmental potential. There is also the option to culture embryos in the Embryoscope, which is an incubator with cameras built in. This way, the embryos can be observed around the clock without disturbing them or exposing them to light and temperature changes.
4. Embryo transfer
During embryo transfer, an embryo is inserted into the uterine cavity with a soft plastic tube using ultrasound guidance. We recommend the transfer of a single good embryo. Up to 5 surplus day 5 embryos can be frozen (cryopreserved), if they have a good quality. The statistical probability of pregnancy is between 30-40%, however this pregnancy rate does decrease after the age of 40. When transferring two embryos, a high-risk twin pregnancy develops in 20% of pregnant women.
5. Pregnancy test
In the two weeks following embryo transfer, until the pregnancy test, the embryo should develop further and settle in the uterine lining. Restrictions in lifestyle such as stopping exercise/sports or being written off sick from work, are not necessary during this time. However, many women find these last 12-14 days particularly stressful, as „nothing more happens“. The pregnancy test is performed 12-14 days after the embryo transfer (depending on which day the embryo was transferred) with a blood test at your gynecologist or our practice. Even if bleeding has already started, a pregnancy test is necessary, as bleeding is not uncommon in early pregnancy.
ICSI
ICSI (Intracytoplasmic Sperm Injection) is a special method of in vitro fertilisation. It is used when there is a severe sperm quality disorder (see sperm testing). In this case, it is assumed that the sperm cannot penetrate an egg by itself. Thus, with conventional IVF treatment, where eggs and sperm are simply placed together in a culture dish, fertilisation would not occur. Therefore, in ICSI therapy, a single sperm from the partner is injected into each mature egg. To do this, the egg is placed under a microscope, aspirated with a glass capillary and held in place. Then a sperm with good motility is drawn up into a second thin glass capillary and inserted directly into the egg. ICSI is therefore an additional process in the laboratory, but for the patient the treatment steps are identical to IVF therapy.
Before starting the therapy, it must be determined whether conventional IVF or ICSI is required. The corresponding application for cost coverage can be submitted to your health insurance company. You will receive this application from us after the cost and insurance situation has been explained to you during your consultation with us. For ICSI therapy, two spermiograms are required at intervals of 12 weeks, which meet the criteria oft he health insurance companies. It is therefore possible that a further spermiogram will be required after the initial consultation. It is also recommended that a chromosomal analysis be performed on both partners. The new Artificial Insemination Guidelines 2017 regulate that men must be examined by a physician with an andrology qualification prior to ICSI therapy.
Blastocystculture
Significant progress has been made in the cultivation of fertilised oocytes (eggs) in recent years. According to a new legal interpretation of the Embryo Protection Act, it is now also possible in Germany to cultivate several fertilised oocytes for up to 5 days (when they reach the blastocyst stage), on an individual basis. During development tot he blastocyst stage, about 60% oft he fertilised oocytes come to a developmental stop. This natural selection during culture results in one or two well developed embryos at the blastocyst stage, which can be transferred with a higher pregnancy rate than transferring embryos at an earlier point during the cycle. If there are more than one good blastocyst, there is the option to freeze the rest to be used in future pregnancy attempts.
The goal is a single-embryo transfer, i.e. the transfer of one good embryo capable of development in order to achieve a singleton pregnancy where possible. The
number of fertilised oocytes tob e cultured until day 5 is determined individually for each therapy, taking into account the age oft he patient, the number of oocytes and, if applicable, the embryo quality in previous cycles. It is not permitted to freeze a large number of embryos at the blastocyst stage, which is why we carefully consider how many embryos to culture further in the lab past the pronuclei stage.
Our goal is to work with couples to create the optimal conditions for achieving pregnancy and ultimately, the birth of a child. Therefore we work together with you to determine the best path for your individual situation.
Embryoscope +
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.
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.
Assisted Hatching with Laser
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.
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).
Testicular biopsy
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.
Donor Insemination, IVF or ICSI with Donor sperm
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.
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.
Cryopreservation
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.
Treatment cycles with cryopreserved pronuclear stage cells (“cryo cycle”)
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.
Social Freezing
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.
