Treatment methods

The gynecological endocrinology deals with all hormonal disorders from puberty until senium. The effective therapeutic influence on the hormonal disorder by experienced specialists, is based on an individual diagnosis. These are mostly in individual cases such as puberty and growth disorders, issues with the hormone balance, hirsutism, acne and hair loss, premature ovarian failure, menopausal symptoms and thyroid dysfunction.

To stimulate the ovaries, we use hormones (gonadotropins) that the body is using as well. These preparations have to be injected. Normally the injection will be given under the skin into the abdomen, which is a very painless and easy method, so that you can easily learn do it yourself. The whole stimulation treatment will be monitored through ultrasound and blood tests. If the required number of follicles is reached, the ovulation will be triggered through an injection. The luteal phase after the ovulation is also intensively supported by hormones in order to prevent luteal weaknesses from the outset.

The insemination will take place when there are disorders in the cervix (for example slime formation or scarring), a decrease in the amount of semen or a mild to moderate limitation to the number and motility of the sperm cells, are the present reason of the unfulfilled desire to have a child.

The semen transmission happens on the day of ovulation. After the man submits his semen, the semen will then be washed with special nutrient solutions and the mobile sperm are filtered and enriched. Afterwards this enriched solution with mobile sperm cells will be injected into the uterine cavity with a very thin and soft special catheter.

The insemination can be done throughout the natural cycle or after hormonal treatment of the ovaries. Our experience however shows, that the pregnancy rates after a hormonal treatment are higher than in the natural cycle. Which treatment is the right one, can only be determined after an individual examination during a meeting. In special cases where the partner has no sperm cells to offer, the semen transmission can also happen with the support of a sperm donation.

This treatment works under the same conditions as the homologous insemination, with the only difference that the we use the donated semen, which has been ordered at a sperm bank beforehand.

Since 1978, with the help of In Vitro fertilization and the subsequent embryo transfer, there has been a new way to help women with closed fallopian tubes to become pregnant. In cases where childlessness is caused by diseases of the husband, the fertilization outside the body, under certain conditions, can lead to very positive results.

Before a fertilization outside the body can take place, the woman has to undergo a pre-treatment of generally 4 weeks that has the goal of immobilizing the pituitary gland and the ovaries. Afterwards, the fertilization outside the body can start by intensively stimulating the ovaries. To avoid the 4-week pre-treatment, you can have an accompanying blocking of the pituitary gland.

The purpose of this treatment is the growth of multiple follicles. As soon as the follicles have reached a sufficient size, the time follicle aspiration will be determined. To do so, the vaginal wall will be entered with a fine needle, to take a puncture of the ovarian follicles that are present in the ovary. The operation can either be done with shallow anaesthesia or by taking painkillers. The oocytes will then be tested on their quality. In pure in vitro fertilization, approximately 100,000 mobile sperm cells are added per oocyte. Of these, at least 30% must have good mobility and be normally formed. After 20-24 hours of being stored in the incubator, we will assess if fertilization processes are visible. The oocytes, which are now in the pronuclear stage, develop into an embryo. According to the “Embryonenschutzgesetz” a maximum of three embryos may be transmitted. Although for women < 35 years, the guidelines of the “Bundesärztekammer” allow only the transfer of 2 embryos, as the risk of triplets is higher. 2-3 days after the oocytes retrieval, the embryos can be returned to the uterine cavity (embryo transfer). This procedure is completely painless. The following luteal phase will be medically supported. To enhance the embryo implantation any physical and mental load should be avoided.

Sperm microinjection means the direct introduction of a sperm into the cell plasma of the oocyte (intracytoplasmic sperm injection, ICSI). This method becomes necessary when the sperm cannot enter the egg cell without external support. Even with only a small number of sperm, this method gives you a chance to become pregnant. The pregnancy rates after a ICSI treatment are high.

TESE stands for testicular sperm extraction, so the extraction of sperm from the testes. This treatment method is used when the ejaculate only contains some or even no sperm at all. MESA stands for the microsurgical epididymis sperm extraction, so the recovery of sperm from the epididymis. With both the TESE and the MESA treatment, at the end the sperm will be microinjected (ICSI) into the cell plasma of the oocyte.

Under the conditions of embryo culture, an embryo undergoes the same stages of development as it would do in its natural environment of the fallopian tubes and uterus of the woman.

• On the first day after taking the egg, the ovum has two pronuclei in the case of fertilization (PN stage).
• On the second day after the egg retrieval, the fertilized egg has already divided twice. The embryo now consists of 4 cells.
• On the third day after egg collection, the embryo consists of 8 cells.
• On the fourth day after the egg collection, there is an embryo with 16 cells or it is already in the morula stage.
• On the fifth day after the egg collection, the embryo shows the stage of the morula or blastocyst (bladder germ).

A retention of the embryo in this developmental dynamic, indicates a possible defect of the embryo with the inability for further development and implantation. After the four- or eight-cell stage, the embryo determines its own development with its genes. Therefore, the observation of embryonic development from the eight-cell stage is of considerable prognostic significance. Only 30% of all PN stages reach the blastocyst stage. This is based on the fact that a large proportion of oocytes from the outset have a chromosome disorder. This is estimated at about 50%.

Usually, in Germany, the fertilized ova are incubated over a period of 2 to 3 days in the incubator and then transferred to the uterus. The further fate of the embryos introduced into the uterus can then no longer be assessed. In particular when it does not come to a pregnancy, the statements on the reasons are very little.

There is also the possibility to incubate the embryos until the fifth or sixth day after the egg retrieval and then to transfer them to the uterus. This enables a much better assessment of embryo development and vitality. In addition, the rate of pregnancy by culture is higher until day 5 (> 40%), than after culture until day 2 (about 20-30%).

At the time of ovulation, the ovum in in an oocyte shell which is called zona pellucida. This is the place where the first cell divisions take place after the fertilization process. The embryo remains in this shell until the 6^th day of fertilization, then it should hatch, like a baby chicken and afterwards nestle in the mucous membrane of the uterus. Some patients have the problem that the eggshell is too hard, so that the embryo cannot hatch and thus cannot implant. According to scientific research, some patients benefit when the oocyte sheath is removed with a laser treatment. Patients > 38 years, who have undergone multiple embryo transfers without endometriosis and who have received cryopreservation of oocytes, have been shown to have higher pregnancy rates then patients who haven’t had this additional treatment.

Statistics show that only 8-20% of embryos that have been transferred to the uterus, develop to a successful birth. Most likely this is caused by the limited development potential of embryos. Stress factors of the embryonic culture and a dysfunction of the embryos attachment to the endometrium, may also play a role. Therefore, scientists developed a special embryo-transfer-media (for example: embryo glue, UTM medium), to lead to a higher chance of implantation.

A study from a couple of years ago shows that by removing a fine tissue strip of the endometrium in the previous month of the embryo transfer, wound healing processes will start, and this has led to better success rates. The tissue is removed with a very fine cannula, often during a hysteroscopy.

The wound healing is also likely to release growth hormones and other factors that have a positive effect on the implantation process.

If necessary, sperm can be frozen, for example if the man cannot be present throughout the treatment due to his work situation. At a later point of time, the sperm will then be thawed and used for fertilization. Sperm taken from the testicular tissue can also be frozen like this.

Unfertilized oocytes, as well as fertilized oocytes can be frozen and used at a later stage to induce pregnancy. Fertilized oocytes are frozen when there is an excess of fertilized eggs in an IVF treatment that cannot be transferred immediately.

The advantage of vitrification is, that unlike in the slow freezing methods, no ice crystals form during vitrification that could damage the cell. The survival rate of the thawed cell in case of vitrification is 97%, which is close to the rates of freshly obtained oocytes.

Some women suffer in finding the right man that they want to have a family with, or sometimes their job situation makes it impossible to concentrate on a family. In this case, it is possible to freeze oocytes in the age of 25 to 30, to then have the option to become pregnant at a later point. Whilst the oocytes stock in the ovaries age, the frozen oocytes don’t.

Chromosomal maldistribution (aneuploidy) contributes significantly to the loss of embryos before and after implantation of a pregnancy. Numerous studies have shown that the implantation failure of embryos following IVF / ICSI therapy, as well as the occurrence of abortions in the first trimester of pregnancy, are to a large extent due to spontaneously arising chromosomal misdistribution. For IVF / ICSI treatment, therefore, it is reasonable to exclude oocytes with chromosome maldistribution from the fertilization process, by using polar body diagnostics, and therefore to increase the number of transferred embryos with a normal set of chromosomes. It is possible to perform a polar body diagnosis as part of a planned IVF or ICSI treatment.

This examination can give specific information on the quality of the oocytes and improves the chances of a successful treatment. The polar body diagnostics offers the opportunity for chromosomal screening of an unfertilized oocyte, as long as it is within the legal framework.

In principle, in a polar body diagnosis, cytogenetic analysis of the polar bodies, reveals the genetic status of the associated oocytes. The goal is to identify chromosomally abnormal oocytes in this way, and to exclude them from the further fertilization process. The removal of the polar bodies (polar body biopsy), which is necessary for this examination, takes place approximately 2-3 hours after performing the ICSI, by opening the oocyte cover with the help of a laser.

This method is used to detect heavy genetically disorders of the embryo. The embryos have to mature to the blastocyst stage until embryoblast (from which the embryo develops) and trophectoderm can be distinguished from one another. This is done with the help of finest technology and will be genetically examined trough modern analysis methods (next generation sequencing).

This special incubator allows egg cells and embryos to be cultured from fertilization to retransmission into the uterus under constant conditions of temperature and pH in a constant nutrient solution. A fixed camera in the microscope observes the cells day and night and documents even the finest changes during the division processes. Thus, with the help of a computer-assisted analysis, an even more accurate assessment of the quality and development of the embryos can be made.

The ERA test examines the optimal time to return the fertilized embryos by taking a tiny amount of tissue from the uterine lining followed by a testing of important genes.

When only a few oocytes grow, a very high hormone dose is often not necessary – according to hormone levels and ultrasound examination, the patient will be stimulated with the lowest possible hormone dose.

Patients that suffer from cancer, often have to face a treatment that can harm the oocytes and the fertility. For those patients, we offer a protection and cryoconservation of the oocytes and of ovarian tissue. We also counsel you on any hormonal concerning questions.

Unfertilized egg cells can be frozen if there is a fear of ovarian damage, which could make a pregnancy difficult or even impossible at a later time. This can be done by interventional treatment such as surgery, radiation or chemotherapy for malignant diseases.

The unfulfilled wish for children is perceived by many couples as a major burden with an impact on the social, emotional and partnership well-being. Psychological counselling as well as support is often helpful.

Our psychologists Dr. med. Friederike Taraz and Dr. med. Corinna Pirsig have many years of experience in this area and are happy to advise our patients.

In addition to traditional medicine, there are also alternative methods that can complement the treatment. These include traditional Chinese medicine, classical Homeopathy, Acupuncture and Ayurveda. Stress reduction and relaxation benefit fertility.

Uterine mirroring: With a thin optic, the uterine cavity will be illuminated. For a better overview, the uterine cavity is deployed with water or CO2 gas.

Transvaginal Hydrolaparascopy: With the help of an only 3 mm thick tube trough the vagina the abdominal cavity will be entered. Through this tube we can then import an optics for viewing the uterus, fallopian tubes and ovaries. The advantage of this access to the abdominal cavity, is the significantly lower postoperative discomfort compared to the normal entering of the abdominal wall from the umbilical fossa. There are also no visible scars from the punctures of the working channel. The disadvantage is, that larger operations cannot be performed transvaginal, which is not necessary in many patients though. It is therefore important to examine in advance, which patients are suitable for this technique.

Smaller interventions, such as egg retrieval, hysteroscopy and the transvaginal Hydrolaparaskopie are carried out in our clinic in the Rankestraße. Major operations, such as myoma removal, endometriosis surgery and malformation operations are held inpatient in the DRK-Klinikum Berlin by Dr. med. Bloechle who will be operating as an attending physician.