Reproductive medical treatment options

What happens during hormonal stimulation?

A hormone treatment is carried out from the 3rd day of the cycle . Various preparations can be administered which contain the hormone LH (luteinising hormone) or the hormone FSH (follicle stimulating hormone). These hormones stimulate egg cell maturation. Egg maturation is monitored by ultrasound and blood tests from the 8th day of the cycle . If the follicle is large enough (approx. 18-20 mm), ovulation is triggered with another hormone, human chorionic gonadotropin (hCG).

Fertilisation then takes place either via sexual intercourse or with the help of insemination.

Intracytoplasmic sperm injection

This is advanced development of in-vitro-fertilisation. Under a special microscope, a single sperm is drawn into a thin pipette and inserted directly into the egg cell.

This method is mainly used when the cause of childlessness lies with the man. This usually happens, if only a few sperm cells are produced or the existing ones are hardly mobile. The sperm cells are then not able to penetrate the shell of the egg. ICSI imitates this natural process. The further process of fertilisation, i.e. the fusion of the maternal and paternal genetic material, remains unaffected by this.

In-vitro-Fertilisation (IVF)

IVF literally means "procreation in the glass bowl". Fertilisation of the egg and sperm cells takes place outside the uterus in a small dish. This method is used, if the woman's fallopian tube is blocked or if the quality of the sperm cells is very poor, or if pregnancy has not occurred as a result of insemination. First of all, hormonal stimulation stimulates the formation of several eggs in the ovary. With the help of ultrasound, the eggs are then usually sucked out of the ovary via the vagina (transvaginal follicle puncture). The egg cells obtained in this way are then brought together with the sperm cells obtained by masturbation in a nutrient fluid. In most cases, the egg and sperm cells remain in a warming cabinet at 37 º Celsius for 24 hours. Then a microscope is used to check whether fertilisation has taken place. If this is the case, a maximum of three fertilised eggs are usually transferred into the uterine cavity after a further 24-48 hours (embryo transfer). For women under the age of 35, it is recommended that only two fertilised eggs be returned. This reduces the risk of multiple pregnancies. Prerequisites for medically assisted fertilisation are:

• You should be married or living in a stable partnership.
• Women should be younger than 40 years (in exceptional cases 45 years)
• Should be vaccinated against rubella
• Results for HIV test and hepatitis test should be negative.
• Only egg and sperm cells of the spouse/partner may be used. Take a look at exceptional cases Insemination with donor sperm

Cryopreservation

On average, three to ten eggs are obtained during hormonal stimulation. This is necessary because not all eggs are suitable for fertilisation. However, only a maximum of three fertilised eggs per IVF cycle may be inserted into the uterus in order to limit the risk of multiple pregnancy.

If more than three egg cells are fertilised and sperm cells have penetrated but no fusion of the genetic material has taken place, the cells can be frozen. In this pronuclear stage, the egg cell with the sperm is not yet considered an "embryo".

The egg cells can be thawed in later cycles and then be returned to the uterus after the fusion of the nuclei. The pregnancy rate with this procedure is lower than the one with normal in-vitro-fertilisation.

In vitro Maturation

In vitro maturation is a variant of in-vitro-fertilisation. The difference between conventional IVF and this, is the collection of immature eggs instead of mature ones.

For the "in vitro maturation”, only a slight hormone stimulation is required. The immature eggs are removed from the ovary. They mature for one to two days in the petri dish and are then fertilised. For maturation, the hormones FSH (follicle stimulating hormone) and HCG (human chorionic gonadotropin) are added to the nutrient fluid. After two more days, the fertilised eggs are inserted into the uterus.

By far, this not a routine procedure. In Germany, it is carried out only at very few centres. Currently there are no long-term studies available. Experts are still discussing whether this kind of procedure can lead to chromosomal damage.

According to all previous studies, the chances of pregnancy seem to increase in women suffering from the disease "PCO syndrome" (disease in which the ovary forms many small immature egg cells); in other cases, the probability of pregnancy is lower than that with "normal" IVF. Research is underway for possibilities of pregnancy in women who had to undergo chemotherapy at a young age. The first child using his method was born in December 2005 in Germany.

Insemination

The most common reason for insemination is a slight male fertility disorder, few number of sperms or sperms with too little mobility in the effusion. During insemination, the sperm obtained by masturbation are introduced directly into the uterus. Before this, the semen is cleaned by special procedures and the mobile sperm cells are focused on (this process is called preparation). At the time of ovulation, which is often triggered by hormonal stimulation, the sperm are introduced into the uterus with a thin tube. It is particularly important here to monitor egg maturation with ultrasound. This is the only way to determine the quantity of follicles and prevent multiple pregnancies. The purpose of the method is to shorten the sperm cells' path to the egg at the optimum point in time. The pregnancy rates of this method depend on many factors such as the quality of the sperm, the age of the woman, the length of time for which the couple has had the desire to have children and the pre-treatments. The number of treatments usually exceeds six treatment cycles only in exceptional cases.

Insemination with donor sperm

Also called donogenic (donum = gift) or heterologous insemination, this means performing an insemination with semen from a donor. This method

• should be considered, if there are no fertile sperms available
• should be considered in case of hereditary diseases of the partner or in the partner's family
• should be considered in case of serious infections (e.g. HIV)
• is a good option for single or lesbian women.

Semen transmission can take place in the natural cycle or after hormonal treatment of the woman. In exceptional cases, semen transfer can be carried out in combination with IVF or ICSI treatment with the approval of the respective state medical association.

The treatment raises psychological and ethical questions for the couple or single woman. A comprehensive explanation of the couple or the single woman about the legal, medical and social aspects as well as written consent before the start of treatment are required by law. Due to the special situation of "shared parenthood", however, additional psychosocial counselling, e.g. in a pro familia counselling centre, is recommended. This can involve, among other things, the relationships between father-child, mother-child, parents and one another, fears about the sperm donor, parentage, maintenance and inheritance law or the question of whether or when the child should be informed about the particular type of procreation.

The semen usually comes from a sperm bank. The donor waives claims such as the identity of the child conceived with his semen and is himself protected from claims by the recipient couple. So that the child in later years has the option to get to know his genetic origin, it should be ensured that the executive practice within the scope of a voluntary self-commitment ensures that all documents are kept for 30 years. At present only the 10-year storage of medical documents is prescribed by law.

This procedure differs from in-vitro-fertilisation and embryo transfer by the fact that during a laparoscopy, egg cells are sucked off and brought directly into the funnel (tube) of the fallopian tube with previously prepared sperm cells. Fertilisation therefore takes place in the woman's body. It is used in cases of long-standing female sterility,

• even if the cause of male fertility disorders
• has not been clarified.
• Special forms of endometriosis can be found in cases where the uterine mucosa cells are scattered and stick to the funnel (tube) area, preventing the collection of the egg cell after ovulation.

The prerequisite is an unobstructed fallopian tube. The success rate is approx. 20 births per 100 transfers. The risk of ectopic pregnancy is increased with this procedure (10-20 percent). A disadvantage here is that a laparoscopy has to be performed under general anaesthesia.

If there are no sperm cells in the ejaculation, it is possible to obtain sperm from the epididymis (MESA) or from the testicles (TESE). With these methods, sperm can still be found in up to 75 percent of cases.

The removal of sperm from testicular or epididymal tissue takes place as part of a small surgical procedure. The tissue can then be frozen. In IVF/ICSI, the sperms are used as needed.

Restoration of the patency of the fallopian tubes

There are several reasons for a woman's re-fertilisation. It is performed when the fallopian tubes are closed due to inflammation or endometriosis (the presence of uterine mucosa outside the uterus). Most surgeries are performed to reverse the sterilisation of the woman.

Surgical techniques

The surgery is performed under general anaesthesia about two days after menstruation. There are two different methods to make the fallopian tubes unobstructed again. The fallopian tubes can be seen by the way of laparoscopy or with a small abdominal incision. First, the scarred ends or damaged sections of the fallopian tubes are removed. In laparoscopy, the intact ends of the fallopian tubes are sutured together with fine instruments. During surgery with an abdominal incision, the ends are sutured layer by layer under a special microscope or with so-called "magnifying glasses" (microsurgical procedure). The re-fertilisation of the woman requires a great deal of surgical experience and is only offered at special centres.
Depending on the method used and the level of difficulty, the surgery can take between one and three hours.

Prospects of success

Surgery is more promising when it comes to reversing a sterilisation procedure. Most specialists assume that pregnancy is more likely to occur, if re-fertilisation is performed using microsurgical procedures, i.e. an abdominal incision. The figures for the birth rate vary between 30 and 70%. For diseases of the fallopian tubes (inflammations, adhesions), the chances of success of a birth after re-fertilisation surgery are 30% and lower, for the reversal of a sterilisation after cutting the fallopian tubes (procedure most frequently used in Germany) the birth rate is approx. 50%, for the reversal of a sterilisation with clip method (frequently used procedure in Belgium and Switzerland) over 70%. The promptness and whether a pregnancy shall occur ultimately depend last but not least on the age of the woman and the current fertility of the two partners. Therefore, both should be examined before a surgery.

Desire to have children - surgery or artificial insemination?

If the fallopian tubes are blocked, the desire to have children can also be fulfilled with the help of reproductive techniques (IVF). However, according to some studies the re-fertilisation surgery is more promising. Since both methods have risks, the couple must take their decision carefully. One advantage of re-fertilisation is that the actual pregnancy occurs "naturally" and further pregnancies are possible, while artificial insemination takes place in the laboratory and must be repeated, if the couple wants to have children again.

Complications

In less than 5% of cases, there are wound healing disorders, infections and postoperative bleeding, rarely injuries to other organs or thromboses. Since the surgery takes place in the abdominal cavity, an infection can lead to peritonitis and by extension to a life-threatening condition. In case of postoperative bleeding, surgery may be necessary again. Adhesions can occur after the surgery. Pregnancy increases the risk of ectopic pregnancy (5% as per some surveys) Ectopic pregnancies are more common, if the fallopian tubes are damaged by inflammation or endometriosis.

Costs

The surgery is only covered by the health insurance, if the fallopian tubes have closed due to an illness, e.g. inflammation, endometriosis, etc. After sterilisation, the costs of approx. 2,000 to 4,500 € (re-fertilisation per laparoscopy below 1000 €) are not covered. There may be exceptions, if the sterilisation is carried out for medical reasons and today, there are better treatment options available for HIV infection or some genetic diseases, for instance.

Centres

The surgery should only be carried out at centres that perform the surgery frequently. Let your gynaecologist or a pro familia-counselling centre near you guide you as regards to the centres that are specially trained for this.

Restoration of the patency of the sperm duct

There are different reasons for the re-fertilisation of the man. It is performed when a sperm duct is blocked due to a congenital malformation or a persistent inflammation. Most surgeries are performed to reverse male sterilisation (vasectomy). A re-fertilisation surgery is a microsurgical procedure. It is performed under a special microscope and with very fine instruments.

Surgical techniques

As a rule, the surgery is performed under general anaesthesia. The sperm ducts are exposed via two small skin incisions on the scrotum. There are two different methods to open the sperm ducts again:
With the more frequently used method, first the two scarred ends of the sperm ducts are cut off. Then, during the surgery, it is checked whether the open end of the sperm duct, which comes from the epididymis, contains sufficient sperm fluid and is normally composed. Only when there are enough fertile sperm are the two separated ends of the sperm duct sewn together again under the microscope with fine sutures in "several layers" (so-called vasovasostomy). If this is not the case (after all in approx. 23% of cases), another method is chosen. The upper end of the seminal duct is sutured directly to the fine tubules of the epididymis (so-called tubulovasostomy). This method requires a lot of surgical experience and is not offered at all centres.
Depending on the method used and the level of difficulty, the surgery can take between one and three hours.

Prospects of success

The surgery is more promising, if the reason for the occlusion of the sperm ducts (e.g. sterilisation/vasectomy) has occurred recently enough. It is therefore possible that the sperm duct is unobstructed again and yet no pregnancy can occur. There are several reasons for this. If the sperm ducts are blocked, the sperms in the lower sperm ducts become congested. The testicular or epididymis tissue can change and be damaged. In some cases, the man's body can develop antibodies against its own sperm.
In comparative international studies, the pregnancy rates after surgery are around 30%, if sterilisation took place more than 15 years ago and around 75%, if surgery took place less than three years ago. In total, about half of all men who have a surgery performed can father a child again. However, it can take several months before pregnancy occurs, as the epididymal tissue must first recover. Usually after two months, a control spermiogram is carried out.
How quickly and whether a pregnancy can occur depends last but not least on the current fertility and the age of the partner. If the surgery is unsuccessful, it is possible to operate again.

Desire to have children - surgery or artificial insemination?

If the sperm ducts are blocked, the desire to have children can also be fulfilled with the help of reproductive techniques (MESA/TESE in combination with ICSI). After all tests, however, refractive surgery is much more promising. Another advantage of re-fertilisation is that the actual pregnancy occurs "naturally", while artificial insemination entails many risks for the partner as well.

Complications

In less than 5% of cases, there are wound healing impairments, infections and haematomas after the surgery. These can be unpleasant, last longer and require follow-up treatment. However, since the surgery takes place outside the abdominal cavity, the operation is considered to be relatively low-risk.

Costs

The surgery is only covered by the health insurance company, if the occlusion of the spermatic ducts is due to a disease, e.g. inflammation, congenital malformation, etc. After sterilisation, the costs of approx. 2,000 to 4,000 € are not covered. There may be exceptions, if the sterilisation is carried out for medical reasons and today, there are better treatment options available for HIV infection or some genetic diseases, for instance.

Centres

The surgery should only be carried out at centres that perform the surgery frequently. In any case, one should have experience with both surgical techniques so that the surgery can be extended without problems, if no sperm emerges from the lower end of the sperm duct. Let your urologist or a pro familia-counselling centre near you guide you as regards to the centres that are specially trained for this.

In expert circles, the effectiveness of natural remedies in the treatment of infertility has been discussed time and again. While many orthodox medical practitioners assume, that the natural methods merely produce a placebo effect (effect that occurs when couples are treated with drug-free tablets), representatives of the alternative methods have positive experiences to tell from their daily work.

It is a fact that naturopathic methods usually treat people holistically. They take mental health, nutrition, pollutants from the environment and basic organic diseases into account. Thus they often lead to an improvement in mental and physical well-being. Some studies have shown positive effects in cases of minor fertility disorders, such as irregular menstrual cycles, corpus luteum deficiency or slight restrictions in sperm quality.

The treatment approaches of naturopathy are manifold. Relaxation procedures, contaminant removal, homeopathy, Chinese naturopathy, including acupuncture and Bach flower therapy are just some of the methods used. Whether you prefer to simply wait and decide whether or not to make use of naturopathic or reproductive treatment options, is totally up to you.

Further information

Zentralverband der Ärzte für Naturheilverfahren und Regulationsmedizin e.V. (Central Association of Physicians for Naturopathy and Regulation Medicine)

Deutscher Zentralverein homöopathischer Ärzte (German Central Association of Homeopathic Physicians)

Verband deutscher Heilpraktiker e.V. (Association of alternative practitioners in Germany)