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.

1. Stimulation
2. Ovum Retrieval
3. IVF-Laboratory
4. Embryo transfer
5. Pregnancy test
6. More information about medical, legal and technical possibilities for reproductive medicine

1. Stimulation

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.

1. retrieval needle during aspiration of an oocyte out of a follicle (after hormonal stimulation)
2. (vaginal) ultrasound head
3. rinsing solution
4. tube leading to aspiration pump

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.