Fertility treatment options

The investigations described hereafter show the procedures as an example. Based on the findings, certain investigations may not be necessary or others may have to be done additionally.

Preliminary investigations of the male and the female partners

A transvaginal ultrasound scan is performed to view the ovaries, the fallopian tubes and the uterus. A number of hormone levels will be determined to rule out disorders of oocyte maturation.

Furthermore, blood tests at the beginning of the menstrual cycle may be necessary to measure the levels of oestrogen, LH, FSH, testosterone, prolactin and thyroid-stimulating hormone (TSH). Additionally, the levels of progesterone might have to be measured in the second half of the menstrual cycle. Sometimes it helps to chart your basal body temperature to get information about the course of your menstrual cycle. However, the probability of ovulation before the temperature increase of about 0.5 °C is only 70 percent. An ultrasound scan can therefore be performed as well between day 10 and 12 of the menstrual cycle.

A man's fertility can be determined with a microscopic assessment of the sperm (semen analysis). The male partner will be asked to provide a semen sample collected through masturbation at the laboratory. In the laboratory, the semen sample will be examined under the microscope to evaluate whether the ejaculate contains a sufficient number of sperm cells with a normal shape and good motility. Since sperm quality fluctuates a lot, a second analysis should be performed after not more than three months.

Examination of the fallopian tubes using laparoscopy

In some circumstances, if all the investigations yielded normal results, the assessment of tubal patency might be the next step. There are several methods for this assessment. A special ultrasound scan often provides sufficient information. However, sometimes a laparoscopy needs to be performed for a more precise diagnosis. Frequently, it is not the tubal patency which is impaired, but the function of the fallopian tubes regarding oocyte transport and nutrient supply of the oocyte. Therefore, you should seek our advice before the laparoscopy is performed. In many cases, this procedure is not required for further treatment planning.

If you choose to have laparoscopic surgery, the following procedure will be performed: Under general anaesthetic, surgical instruments are inserted into the abdominal cavity through a tiny incision inside the umbilicus and at the top of the pubic hair line. After the introduction of a small amount of gas into the abdominal cavity, the fallopian tubes and the uterus can be inspected and, as appropriate, adhesions may be removed. Only very small scars are left. However, this procedure carries certain risks. Please consult us for questions regarding risks and potential complications.

Examination of the fallopian tubes using tve or tvhl

In the Kinderwunschzentrum Ludwigsburg, we offer TVE / TVHL (transvaginal endoscopy / transvaginal laparoscopy) which are good alternatives to classic laparoscopy. In this procedure, no incision is made and the abdominal cavity does not need to be insufflated with gas. Instead, a tiny endoscope camera (3 mm diameter) is inserted through the vagina into the cavity behind the uterus. Compared to classic laparoscopy, the assessment of the fallopian tubes, ovaries, and fimbriae is in this procedure usually even more accurate. It is a gentler procedure with little risk, no stitches are needed and the patient can go home afterwards. One disadvantage of this method is, however, that you may still need a laparoscopy afterwards if there are greater adhesions or alterations. Depending on your situation, further investigations might be required. When the results of the investigations are available, we will thoroughly discuss the treatment options with you.

Treatment options: overview

Sometimes we find out during the first appointment: Sexual intercourse took place infrequently or at the wrong time of the month. If this is the case, cycle monitoring and sex at the right time of the month usually help. But if a disorder of oocyte maturation is present, medication administration is usually required.

Hormonal stimulation
The hormonal therapy of the woman usually starts on day 5 of the menstrual cycle (i.e. fifth day of the period). A small amount of a fertility hormone will be injected on a daily basis. The hormonal therapy can be done with various drugs. Some drugs (menotropins) contain two hormones: LH (luteinizing hormone) and FSH (follicle-stimulating hormone). LH is not always required to stimulate ovulation. Many women produce enough of it. For these women, highly purified FSH is available (e.g. follitropin). Highly purified FSH does not need to be injected into the muscle; it can be applied subcutaneously (under the skin). You, or if you prefer your partner, can do this at home.

From day 8 of the menstrual cycle, the oocyte maturation has to be monitored using ultrasound and blood tests.
The dosage regimen will be adapted based on the success of the treatment. Once the follicle is big enough, the ovulation will be triggered using another hormone, human chorionic gonadotropin (HCG). Eventually, the fertilization will take place via intercourse or with the help of artificial insemination.

Homologous / heterologous insemination
Artificial insemination is often performed if the semen quality is the reason for infertility: If the sperm count or motility is low or if the sperm cells are malformed, artificial insemination might be a promising method, since it reduces the distance the sperm has to travel to reach the oocyte. The sperm of the male partner (=homologous insemination) is directly introduced into the uterus using a fine tube (catheter) at the time of ovulation. In order to do this, the semen has to be processed in advance. In this procedure, mainly intact sperm with high motility is concentrated and used for insemination.

Usually it is useful to support oocyte maturation at the same time. This should specifically be done if not only the man's fertility is reduced, but the female partner experiences menstrual disorders or if the poor semen quality has to be compensated with the presence of several ovarian follicles.

Another possibility is artificial insemination with donor sperm (i.e. heterologous or donogenous insemination). For this purpose, several approved German or international sperm banks supply us with donor sperm. The Kinderwunschzentrum Ludwigsburg also helps lesbian couples, provided that they are civil partners (according to German LPartG) and they meet some other requirements.

In vitro fertilization (IVF)
If there is no chance for you to get pregnant with the treatment options described above, in vitro fertilization might be a promising way to conceive. In this treatment, the oocyte and the sperm is brought together outside the body if conception inside the body is not possible. This applies for example if you suffer from tubal dysfunction, endometriosis, if the male fertility is reduced, infertility is due to antibodies or if no cause for infertility can be found.

In this treatment, fertilization occurs outside the woman's body: Sperm cells are added to the egg in a culture dish and after fertilization has occurred, inserted back into the uterus using a thin tube (catheter).

In a first step, the fallopian tubes are stimulated with fertility drugs to produce several eggs. Doing this increases the chances for success of the treatment. The same fertility drugs that are used in normal stimulations are also used for in vitro fertilization, yet with higher doses.

Using ultrasound and a fine needle, the oocytes are usually collected vaginally. Eventually, the collected eggs are mixed with the sperm cells in a growth medium in the laboratory. Therefore, this process is actually not an "artificial fertilization" as such, since the process of fertilization happens without human intervention. The place where this occurs, however, is not inside but outside the body.

Usually, the egg and the sperm cells are incubated for 24 hours at a temperature of 37 °C. After this incubation time, we will check whether the oocytes have been fertilized. If they are fertilized, we will wait for another 24 hours and then 2 (max. 3) fertilized oocytes will be introduced into the uterine cavity (embryo transfer).

Prolonged culture / blastocyst transfer
Sometimes the appropriate procedure is to incubate the fertilized oocytes for up to five (if applicable up to six) days (i.e. blastocyst stage) and then transfer them. We routinely apply this technique and we are going to discuss the benefits and the disadvantages with you. Having this treatment performed in a foreign country (e.g. in Austria) is pointless, since the treatment options in Germany are by now even better than in many neighbouring countries in Europe.

Egg freezing (cryopreservation)
After a hormonal stimulation, usually 3 to 10 oocytes can be retrieved. This is a desired effect, because not every egg is suitable for fertilization. Not more than 3 viable embryos may be transferred into the uterus per menstrual cycle in order to reduce the risk of multiple pregnancy.

Once the sperm cells have penetrated the eggs, but before the DNA synthesis has happened (PN stage), it is possible to successfully freeze these eggs if they seem appropriate for this procedure. Before the synthesis of the male and female DNA has occurred, such a pronuclear (PN) oocyte is not considered to be an embryo, therefore human life has not yet begun. The pronuclear oocytes can be thawed in later menstrual cycles to be transferred into the uterus after the union, which is in embryonic stage.

This is an established and secure procedure, however, the overall pregnancy rates are slightly lower compared to fresh (not frozen) PN oocytes. Additionally, not all thawed eggs become an embryo through further development. There is no evidence, however, that children who grew from cryopreserved PN oocytes show a worse development or are affected by more diseases than children from normal treatment cycles.

Microinjection (ICSI)
Microinjection is an advancement of in vitro fertilization. As with IVF, several mature eggs are collected from the female body after hormonal stimulation. Then, under a special microscope, a single sperm cell is aspirated into a micropipette and transferred directly into the oocyte. Thus, this procedure is called intracytoplasmic sperm injection (ICSI).

This method is particularly successful if the cause for infertility can be found in the male partner, e.g. because of a low sperm count or reduced sperm motility. In a fertilization in a culture dish, these sperm cells are not able to penetrate the coat surrounding the oocyte. Thus, the microinjection simulates the natural process of a sperm cell penetrating the oocyte. The actual fertilization, that is the union of the paternal and maternal DNA, is not affected by that.

If there is no sperm in the ejaculate, for example due to an obstruction of the vas deferens or to previous cancer surgery, that does not mean there is no medical solution for you. You often find sperm capable of fertilization in the epididymis or testicles.

MESA stands for microsurgical epididymal sperm aspiration and is the retrieval of sperm from the epididymis. TESE stands for testicular sperm extraction. In this procedure, a sample of tissue (biopsy) is taken from the testicles. With these treatments, sperm cells can be found in up to 75 % of all cases. Both procedures are performed in conjunction with mircoinjection. The retrieval of testicular or epididymal tissue is a minor surgery which can be performed in the Kinderwunschzentrum Ludwigsburg. Immediately after the surgery, the retrieved tissue will be processed and frozen. The testicular sperm extraction (TESE) only has to be performed once, even if several treatment cycles are required for the female partner.

Seminal plasma rinse
The embryo's implantation into the maternal endometrium is a complex process. In order to prevent a rejection of the embryo, the development of immune tolerance is crucial. Seminal plasma appears to take an active part in this process.

Seminal plasma (ejaculate without sperm cells) mainly consists of the seminal vesicle secretion and one quarter of prostate gland secretion and it contains a variety of chemical messengers, e.g. TFG and interleukin. These chemical messengers induce vascular growth and affect inflammatory or other immune responses.

A complex interaction of chemical messengers of the seminal plasma, the uterine cells and the immune system takes place during the implementation of the embryo. The seminal plasma conditions the female immune response and causes an immune tolerance of the embryo. Furthermore, the seminal fluid causes a molecular and cellular alteration of the endometrium to support the implementation and development of the embryo.

Thus, the seminal plasma is of great importance in the implementation of the embryo or in the preparation of the endometrium for implementation, and the development of a stable and intact pregnancy.