The Needle vs. the Dish: Should ICSI Be Used in All IVF?

20 Aug
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The introduction of Intracytoplasmic Sperm Injection or ICSI has made it possible to fertilize eggs with sperm derived from men with the severest degrees of male infertility. What’s more, pregnancy rates achieved by this method of fertilization are as high, if not higher, than those of conventional IVF performed in cases of non-male-factor infertility.

ICSI involves the direct injection of a single sperm into each egg under direct microscopic vision and requires a high level of technical expertise.  In fact, even when there is an absence of sperm in the ejaculate such as occurs in cases of a) congenital absence of the Vas deferens (when a man is born without these major sperm collecting ducts), b) in cases where the vasa deferentia (ducts that carry the sperm from the testicles to the urethra for ejaculation) are obstructed (such as following vasectomy or trauma), and c) in some cases of testicular failure or where the man has impotence, ICSI can be performed with sperm obtained through Testicular Sperm Extraction (TESE), or aspiration (TESA). In such cases, the birth rate is usually no different than when IVF is performed for indications other than male infertility.

When evaluating all available information regarding the use of ICSI…here is what  emerges:

The performance of ICSI for male factor infertility is associated with:

  1. A slight increase in certain structural embryo chromosomal abnormalities (e.g.,  deletions).
  2. A slight increase in the incidence of miscarriages
  3. A slight increase in the incidence of birth defects
  4. An increased potential that male offspring will also present with male infertility later in life.


When ICSI is performed for indications OTHER THAN male infertility there is:

  1. No increase in the risk of subsequent embryo chromosome deletions
  2. No increase in the incidence of miscarriages
  3. No increased incidence of birth defects
  4. No increased potential for a resulting male offspring to be infertile in later in life

It follows that the complications  associated with ICSI are likely attributable to the indication for which ICSI is being done (the male factor infertility) rather than with the ICSI procedure itself.

The observation  that ICSI, when performed for the treatment of male infertility increases the potential for  resulting male offspring to  be infertile  later in life,  suggests that ICSI allows sperm that carry DNA with male factor infertility characteristics to the egg at fertilization.

Given the above, in my opinion, there is really no down side to performing ICSI on all patients undergoing IVF. There are a number of reasons why there is a strong movement afoot to perform ICSI across the board, regardless of whether there is proven sperm dysfunction.

First, it is mandated for the treatment of all cases of male infertility, anyway. Second, as mentioned above, it is not the procedure of ICSI itself that causes complications, but rather the indication for which ICSI is done.

Thus the performance of ICSI across the board should be an acceptable policy. Here are a few points that support this position:

  • IVF is associated with unanticipated absent or poor fertilization in 12-15% of cases. In fact, newer tests of sperm function such as the sperm chromatin structure assay (SCSA), have shown that DNA damage may be present in sperm derived from men with both normal and abnormal semen analyses. Undoubtedly, male infertility is present in such cases regardless of whether the semen analysis is “normal” or “abnormal”.  Forced fertilization of eggs using ICSI will help couples avoid the disappointment associated with unanticipated failed fertilization that might otherwise occur in such cases.
  • Fertilization in the Petri dish requires an interaction between sperm and the cumulus cells that surround the egg. During many IVF procedures, there is a need to remove the surrounding cumulus cells in order to examine its structure, its maturity and to prepare it for preimplantation genetic screening (PGS). Having removed the cumulus cells, the egg is far less capable of being fertilized spontaneously, thus mandating ICSI in such cases.
  • In all cases of infertility, whether of female, male or “unexplained” nature, regardless of sperm function, ICSI bypasses most dysfunctions, eliminating the majority of barriers to fertilization. If, in spite of ICSI, fertilization still does not occur, then there is a greater chance of the underlying cause being genetic/chromosomal (involving egg and/or sperm), making the argument for routine ICSI even more compelling.

The proposition for “universal”, use of ICSI is based on a higher fertilization rate than by conventional IVF, the fact that male infertility is often “occult” (not revealed through traditional sperm analyses) , the need to perform ICSI when cryopreserved sperm is used in IVF, and the necessity to do ICSI in all cases of PGD/PGS. However, the most compelling justification might be the fact that the procedure of ICSI itself, apparently does no damage.


  • Zuma says:

    I am 32, dh is 35. I had lap for removal of stage 4 endo a year ago….started trying naturally and also had 2 rounds of failed IUI. Sperm count is very good. Planning to go for IVF…should we do icsi? What is the rate of multiples and birth defects from this? What are our chances given stage 4…during iui my antral follicle count was about 10. I have read about implantation being an issue with endo. Please advice. Thanks in advance.

    • Geoffrey Sher says:

      I recommend ICSI to ALL my IVF patients. As for birth defects with endometriosis. It is not increased over regular conception, Multiple rates are also the same and linked to the # of embryos transferred at any given age. Finally, it is a fact that 1/3 of women who have endometriosis (regardless of its severity have an immunologic implantation dysfunction (see below).

      Please go to the home page of this blog, . When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
      1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)

      2. Ovarian Stimulation for IVF: The most important determinant of IVF Outcome” (Nov. 2103)

      3. “Agonist/Antagonist Conversion Protocol”

      4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.

      5. “Endometriosis”

      6. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)

      7. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)

      8.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

      9. “IVF success: Factors that influence outcome”

      10. “Use of the Birth Control Pill in IVF”

      Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype with me so we can discuss your case in detail.

      Finally, perhaps you would be interested in accessing my new book (recently released). It is the 4th edition (and a re-write) of “In Vitro Fertilization, the ART of Making Babies”. The book is available through “” as a down-load or in book form. It can also be obtained from most bookstores.

      Geoff Sher

      P.S: Please go to
      To view a video-tutorial by Linda Vignapiano RN, Clinical Manager at SIRM-Las Vegas.

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