Treatment for the wish to have a child - This is how we proceed

First Consultation and Anamnesis

During our first meeting, we will talk extensively about the possibilities of solving your problem. During this first meeting, we will also get to know each other. It is best if you come as a couple to this first consultation, so that we can involve both partners into the solving of the problem. We will always talk extensively about your medical history. Right from the beginning you should ask all the questions worrying  you, and you should point to particular personal circumstances, such as problems in keeping appointments with us due to job-related time problems. We would like to try everything to ensure a stress free treatment. We will provide written information so that you can again think about the possibilities of treatments peacefully at home.

This is how we proceed

Menstrual Cycle Analysis and Surveillance

At the beginning of each individually adapted therapy, we will thoroughly examine the hormonal system in order to diagnose and cure, among other things, malfunctions of the thyroid gland or of male hormonal secretion. The actual surveillance of the menstrual cycle starts generally between the 3rd and the 5th day after the beginning of menstruation by means of Ultrasound and a blood test. Further steps depend on the initial hormonal situation; the aim consists inmedicinally inducing ovulation when the follicles are ripe, and thus being able to state the best time for fertilization. Thus it is possible  for patients with minimal disorders to achieve a pregnancy.

Spermiogram and Andrological Examination

Also at the beginning of the therapy, the male seminal fluid (ejaculate) will be examined. A microscope is used to determine how many semen cells are contained in the ejaculate. Furthermore, the mobility and the shape of the sperms are examined.

In addition to the examination of the ejaculate, we advise a medical examination of the man by an andrologist. He will examine the male sex organs for a curable disorder, e.g. chronic infections or varicose veins on the testes. In case you have not been examined for these disorders, we can recommend a specialised urologist for this examination.

Discussion of Results

After the first results are available, you will be invited to discuss the
results gathered. At the same time, we would like, together with you,
to draw up a plan for further diagnostics and therapy.
You are most welcome to contribute your own ideas and needs.

Treatment Methods

Assessing Tubal Patency by Ultrasound

Assessing tubal patency by using imaging contrast agents and ultrasound is a mostly painless method allowing to determine whether the fallopian tubes are penetrable or not.

The operation is carried out as an outpatient treatment and should be performed a few days before ovulation, since this is the time when the mouth of the uterus is open so that the catheter for delivery of imaging contrast agent may be inserted.

Hysteroscopy

Hysteroscopy (the endoscopy of the uterine cavity) is a very important method to assess the interior of the uterus, since both congenital malformations and pathological alterations can disturb nidation of the embryo or the course of the pregnancy. To do so, a 4-5 mm wide glass rod is inserted into the uterine cavity. With the use of a magnifying lens, the openings of the fallopian tubes, the shape of the uterine cavity and the mucous membrane in the interior of the uterus may be examined. This method can be carried out in outpatients.

Laparoscopy

Laparoscopy is the most exact method of assessing the ovaries. A 5-10mm wide glass rod is used to view the interior of the abdominal cavity and the small pelvis via an optical magnifying mechanism. This allows a precise view of the fallopian tubes in order to determine whether they are mobile and whether they have open funnels for the reception of an egg. Tubal patency will be assessed by rinsing them with a dye solution. Should there be adhesions or other disorders, e.g. endomytriosis, these can often be removed in the same operation. This method is carried out under anaesthesia and can, if so wished, be carried out in outpatients.

Recently, carrying out the endoscopy from the vagina has become possible for selected patients. We are the first practice in Berlin to have taken this innovative technique into our diagnostic programme. The advantage of this method is that it is possible to very gently assess fallopian tubes and ovaries. The disadvantage of this method is, that if there are pathological changes in these organs, one has to change back to a conventional laparoscopy to correct these disorders.

Our practice is very experienced concerning endoscopical operations. We have done several thousand of these operations. We offer reconstituting operations for fallopian tubes, corrections in case of malformations of the interior sex organs, and the removal of myoma. It is our aim to enable a physiological conception wherever this is possible through reconstituting operations.

Stimulation of Ovaries

In order to stimulate the ovaries, we will use hormones the body itself employs (gonadotropines). These preparations are injected into the body. In general, the medication is injected into the abdominal wall. This method is almost painless and can easily be learned. The stimulative treatment is accompanied by ultrasound- and blood examinations. As soon as the desired number of follicles is available, ovulation is induced, also by means of an injection. The luteal phase following ovulation is also intensely supported by hormones in order to avoid a luteal insufficiency from the outset.

In Vitro Fertilization / Embryo Transfer

Since 1978, in vitro fertilization and the ensuing embryo transfer have opened up a therapeutic possibility to help a childless couple in having their own child even if the fallopian tubes are clogged. If childlessness is caused by illnesses of the male partner, under certain circumstances a fertilization outside the body is very likely to be successful.

If fertilization takes place outside the body, a pre-treatment taking four weeks in general takes place first. This pre-treatment aims at an immobilisation of the pituitary gland and of the ovaries. After that, the ovaries are intensely stimulated. Recently it has also become possible to immobilise the pituitary gland accompanying the treatment, and thus avoiding the necessity of carrying out the four-week pre-treatment.

This method aims at the growth of several follicles. As soon as the follicles have reached a certain size, the exact time for the extraction of an egg cell is determined. A fine needle is inserted through the vagina into the ovary, where the follicles are punctured. This operation may be carried out under minor anaesthesia as well as by using pain relievers. The gathered follicles will be tested for their quality. If fertilization is exclusively carried out in vitro, approximately 100,000 mobile semen cells per egg cell are added. Out of these, at least 30% need to show good mobility and a normal shape. After 20 to 24 hours of storage in the incubator it will be determined whether any fertilization processes are discernible. The egg cells are now in the pronucleus state and will develop into embryos. According to the German law for the protection of embryos (Embryonenschutzgesetz), a maximum of three embryos may be transferred; in women under the age of 35, only two embryos will be transferred according to the guidelines of the German Medical Association (Bundesärztekammer). This is due to the risk of triplet pregnancies. 2-3 days after the gathering of egg cells, the embryos may be transferred back into the uterus (embryo transfer).

This operation is completely painless. The subsequent luteal phasewill be supported medically. To facilitate the nidation of the embryo, physical and psychological strains should be avoided in the following two weeks.

 

 

Sperm Microinjection (ICSI)

Sperm microinjection means the direct injection of a sperm into the cytoplasm of the egg cell (intracytoplasmatic sperm injection, (ICSI). This method will become necessary if the sperms are not able to enter the egg cell by their own force. Even if there are only very few sperms or in case of a complete lack of sperms, which would normally mean certain childlessness, achieving a pregnancy is possible by means of this method. The rate of pregnancies afterICSI is high.

TESE, MESA

TESE is the Testicular Sperm Extraction, i.e. the gathering of sperms from the testes. This method will be applied if there are extremely few  or even no sperms to be found in the ejaculate. MESA is the Microsurgical Epidydimal Sperm Aspiration, i.e. the gathering of sperms from the epididymis. Both with TESE and MESA, the sperms will finally be inserted into the cytoplasm of the egg cell by using microinjection (ICSI).

Polar Body Analysis

Chromosome translocation is the most common cause for loss of embryos before and after implantation. Many scientific studies show that spontaneous chromosome translocation is responsible in a large part for the failure of implantation of embryos after an IVF/ICSI therapy, as well as the occurrence of miscarriages in the first trimester of a pregnancy. It is therefore advisable in case of an IVF/ICSI treatment to exclude egg cells with chromosome translocations from being fertilised by applying polar body analysis, and thus increasing the amount of transferred embryos possessing a normal chromosome set.

It is possible to carry out a polar body analysis during an IVF or IVF-ICSI treatment. This examination may provide information on the quality of your egg cells and may improve the chances for a successful treatment.

Polar body analysis is at the present time the only possibility for carrying out an examination of chromosomes of unfertilised egg cells within legal limitations. The following pieces of information are to help you gain an overview on this special method of analysis, and what will be implied for you if you decide to have this additional examination.
General Information
When an egg cell is ripe, its double chromosome set will be reduced to a single chromosome set through a first meiosis. One set of chromosomes remains in the egg cell, while the second set of chromosomes is discharged by forming the 1st polar body. After a sperm has entered the egg cell, the 2nd meiosis sets in, dividing every chromosome into two chromatides. One set of chromatides remains in the egg cell, whereas the 2nd set of chromatides is discharged by forming the 2nd polar body. Normally, the number of chromosomes in the egg cells and in the respective polar bodies is same. It is acknowledged, however, that mistakes in chromosomal allocation may occur, which lead to anomalies in the number of chromosomes (Aneuploids) in the respective egg cells concerned. If such a chromosome translocation occurs, the number of chromosomes in the egg cells and in the respective polar bodies differs.
Recent scientific research has found egg cells of patients that are older than 35 years to show a rate of chromosome translocation of over 50%. (Pellestor et al., Hum. Genet., 112, 2003). This means that over half of the egg cells are not capable from the outset to lead to a healthy pregnancy.
This is one of the reasons why with the increasing age of women the chance for the occurrence of a pregnancy decreases, with a simultaneously increasing risk of miscarriages due to chromosome disorders, or even of the birth of a child suffering from a chromosomal disorder (e.g. Down Syndrome or Trisomy 21). The aneuploidies (translocations) of chromosomes 13, 15, 16, 18, 21, and 22 are especially relevant (Wieacker et al., Reproduktionsmedizin, 18, 2002). These anomalies are mainly ascribed to chromosomal translocations happening in the egg cells during the 1st meiosis.
(Abruzzo und Hassold, Environ. Mol. Mutagen., 25, 1995).
Carrying out an Analysis of Aneuploidies with polar bodies
In principle, polar body analysis shows the genetic stat of the egg cell by carrying out a cytogenetic analysis of the polar bodies. This aims at identifying chromosomally disturbed egg cells in order to exclude them from the further fertilization process. The extraction of the polar bodies (polar body biopsy) necessary for this examination is done 2-3 hours after the ICSI has been carried out by opening up the egg cell wall by means of a laser. These polar bodies are then used to produce microscopical preparations, and several chromosomes will be made visible by a special dyeing method, the so-called Fluorescence In Situ Hybridyzation (in short: FISH).
In this way, the number of special chromosomes in the polar bodies can be determined, allowing a conclusion about the chromosome set of the belonging egg cells. If the polar body shows a copy of a certain chromosome, it can be assumed that there is a copy in the belonging egg cell. This is normally the case. If the preparations made from the polar bodies do not show a copy of a certain chromosome, it can be assumed that the belonging egg cell will contain one copy too many and that thus a chromosome dislocation will have taken place. Further culturing of such an egg cell is therefore not advisable.

Polar body biopsy with an ensuing FISH analysis is an internationally recognized method which is successfully used for diagnostics of chromosomal dislocations.
(Munné et al., Prenat. Diagn. 20, 2000).
According to current knowledge, a damage to the egg cell inferred by this examination can be excluded. The extraction of the second polar body cannot always be guaranteed, as it is still closely attached to the egg cell at the time of the biopsy, and a forceful extraction would lead to damage to the egg cell. In this case, the examination would only be carried out using the first polar body. We offer to find out the allocation of the chromosomes 13, 16, 18 and 22 in your egg cells by applying the FISH analysis after extraction of the polar bodies. Naturally you will be informed on the results of the examination in the course of your treatment.

Consultation
A consultation with one of the physicians involved is necessary before polar body analysis is carried out. Should you wish to have this additional examination, we ask you to sign the attached declaration of consent, which will then be countersigned by the physician.
Recommendations
A limitation of the polar body analysis lies in the fact that only those chromosomal anomalies may be detected that are inherited from the mother. Chromosomal anomalies inherited from the father cannot be detected by using this method. As FISH analyses are carried out on single cells with the polar body analysis, a statistical safeguard of the results is not possible. Wrong-positive and wrong-negative results cannot be completely excluded. In case of a pregnancy we recommend that you make use of the various possibilities of prenatal diagnostics aside from polar body analysis. Our examinations within polar body analysis include only the chromosomes 13, 16, 18, 21, and 22. Translocations of other chromosomes may therefore not be excluded. Also, there is a 5% chance of a remaining risk for a numeric anomaly of the chromosomes examined if the second polar body has not been examined.
In case of a pregnancy prenatal examinations such as sonography, blood tests and genetic analyses of chorionic villi and amniotic fluid make it possible to detect major malformations of the child or genetic disorders. Should you have any further questions about this subject, we recommend you seek specialised advice on human genetic.
Aims of Polar Body Analysis
1) Avoiding the transfer of embryos with chromosome translocations, which cannot lead to a pregnancy or, in case of a pregnancy, would lead to a miscarriage entailing a curettage connected with great psychological and physical pains.
2) Compilation of a prognosis for treatment. From the experience of international science we know that women who only produce egg cellswith chromosome translocations will most probably not produce healthy egg cells in further treatment cycles. Acknowledging this may be very bitter, but it can lead to the decision not to try for further treatment and thus be spared the burden and costs that are in no relation to the chances of getting a healthy child. Please contact us for further information.

 

 

Cryopreservation of Sperms and Fertilized Egg Cells

Cryo-TESE If required, sperms can be frozen, e.g. if the male partner cannot be present at the practice during the active therapy, due to job-related or other reasons. If necessary, the sperms can be thawed and used for fertilization.

Unfertilized egg cells may be, just like fertilized egg cells in the so-called pronucleus state, successfully frozen and then be used at a later stage to induce a pregnancy. Fertilized egg cells are frozen if too many fertilized egg cells result from an IVF-treatment that cannot be transferred immediately.

Unfertilized egg cells may be frozen if a damage of the ovary is feared, which may severely complicate or even prevent the occurrence of a pregnancy.

These may be intrusive treatments like operations, radiation or chemotherapy due to malign illnesses. Some women may just not yet have found the partner for life, with whom they might want to have children, or it is not yet possible for them to have a child because of job-related reasons. It is possible to freeze egg cells an age of e.g. 25 or 30 years and become pregnant with these at an age of 40 or 43 years. Contrary to the stock of egg cells in the ovary, frozen egg cells do not age.

How We Take Care of High-Risk Pregnancies During the First Three Months

After fertilization outside the body, it is often necessary to hormonally support the pregnancy with natural hormones. Until the heartbeat of the embryo is detectable, the pregnant woman will be taken care of in our practice. After that follows surveillance of hormones as well as therapeutic manipulation, including controls by ultrasound in cooperation with the patient's gynaecologist. Because of this intensive care for early pregnancies, the proportion of hormonally caused miscarriages is reduced.

Acupuncture

The implementation of acupuncture may be neurophysiologically indicated and may be used before or during an intended therapy against sterility. This will stimulate bodily processes that improve the chances for a successful treatment especially in psychologically disturbed female patients.

Diagnostics of Trace Elements and Harmful Substances

Just like acupuncture, diagnostics of trace elements and harmful substances represent an important factor in the overall concept of a holistic treatment of sterility. This is especially important for patients exposed to harmful substances.

Gynäkologische Endokrinologie

Gynaecological Endocrinology is concerned with all hormonal disorders from puberty to the senium. Effectively therapeutically influencing the hormonal disorder by experienced specialists is based on an individual analysis. In the individual case, this may concern disorders during puberty and growth, disorders of the hormonal balance, hirsutism, acne and loss of hair, premature exhaustion of the ovaries, change of life complaints in problematic cases, disorders of the prolactinsecretion and disorders of the thyroid gland.

Qigong

What is Qigong?
Qigong is a system of exercises taken from Traditional Chinese Medicine. Chi (Qi) Gong or Chi Kung are synonyms for this. Qigong means "Work with Qi“ in exact translation. Qigong comprises a multitude of exercises to develop and spread the Qi within the body.

What does “Qi” mean?
Qi is the Chinese word for the form of energy that is essential to the growth and well-being all beings. Accordingly, all creatures possess Qi. Where there is no Qi, illness, degeneration and death set in. The best English translation may be 'power of life’. The Qi of a human being flows through the whole body along the energy channels, the Meridians. Where the Qi can flow freely and in a sufficient quantity, well-being and all-over health will set in.

Where does Qi act in the body?
One of the basic principles of Chinese medicine is that health of body and soul are inseparable. Both essentially depend on the Qi. Ideally, Qi is present throughout the body. Along the meridians, it flows to all those places where it is needed. Qi exists in a multitude of forms, one form of absorbing it is with breathing air. It is subsequently saved in several places in the body, the so-called dantians. It takes care of a even temperature, a good immune system, a balance of body liquids, a well-balanced metabolism, and energy and muscle power. We receive Qi mainly in two ways: Firstly, every human has a stock of Qi. This is essential for the lifetime, which can span 120 years, if the Qi is optimally cared for. In addition to this, there is the Qi from our environment which is transformed from our breath and food. The exchange and flow of Qi is inhibited by negative factors such as today's conditions of life that unfortunately include stress and an incorrect diet. To counter these obstacles active Qigong has been practised in China for 3000 years and is also recommended by doctors.

Why is taking part in the class good for me? Qigong has a positive impact on the relaxation and blood circulation within your body, it strengthens your vital force and your body's defences against the environment, and helps you to achieve a more even balance and joy of life. Through participation in the class, you can build a good basis for our work and replenish it. Lastly, Qigong helps to strengthen your health and your resilience. This alone is enough of a reason for us to make it possible to help you share the experience of Qigong.

A Healthy Diet/ Dietary Supplements

During pregnancy, the nutritional requirements of the body increase both for mother and child. This need is often not met by modern nutritional habits. We therefore offer advice on questions about nutrition as well as about possibilities of additional special preparations aiming at an optimal/ideal provision of vitamins, mineral nutritients and trace elements. It is often wise to optimally complement your nutrition already before getting pregnant. It is widely acknowledged, for example, that a lack of certain vitamins (folic acid) can lead to grave deformations in the child (spina bifida/split spine). Dietary supplements taken before conception can prevent such deformations. We will be glad to advise you individually on this subject.

Avoiding Harmful Substances

Our organism is widely exposed to environmental pollution. Apart from keeping in check free radicals (these are highly reactive chemical substances reacting with other components in our body and thus destroying their function) that the body's metabolism itselfproduces, our body has to fend off a multitude of harmful substances contained in chemicals, e.g. in food, air, and water in order to maintain its normal functions. Every human being has systems to regulate the decomposition of and the defence against such harmful substances. But the capacity of those systems differs widely among individuals. This means some people tolerate such pollution without developing any illnesses, and some people do not. Within certain limits, it is possible to measure burden on the body by applying harmful substances diagnostics. For example, the damage to the body by free radicals can be measured by examining the so-called redox state. In case of an impairment too large for the organism, a change in lifestyle and a systematic dietary supplementation may strengthen the body's defences and lead to recovery of health. Should you have any further questions, please feel free to ask.

Collaboration

The main basis for high diagnostic accuracy and above-average therapy success lies in the interdisciplinary collaboration with other specialists.

Andrological Diagnostics
  • Andrological Diagnostics (specialised urologists in Berlin)
  • Creation of a spermiogram and analysis
  • Gathering of sperms from the epididymis (Microsurgical Epididymal Sperm Aspiration, MESA) and from the testes (Testicular Sperm Extraction, TESE)
  • Determination of the markers of the accessory glands of trace elements in sperm
Psychological Care

Psychological Care (Margerite Marcus, physician and family therapist)

Consultations will take place as one-to-one interviews and with the couple. In some cases, they are a main prerequisite for a successful treatment.

Acupuncture (Frau Dr. med. Kielkowski)

Treatment according to traditional Chinese acupuncture both as an exclusive or as an accompanying treatment for the wish to have a child.