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.

However…

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.

42 Comments

  • cindy says:

    Hi
    I’m 27 husband is 35. Were currently doing IVF and I’m on stim day 8. I’m healthy and husband has great sperm count and semen analysis was normal. I had an ectopic pregnancy last year due to scarring of my fallopian tubes. I had a ruptured appendix back in 09 and my doctors believe that’s the reason it took one yr to conceive naturally. I lost that tube and it was suggested to remove the other tube due to hydrosalpinx and to proceed with IVF. As of yesterday stim day 7 I have 7 follicles on each side. My expected egg retrieval is this coming week. My fertility doctor suggested not to do ICSI and go with conventional fertilization. I’m having second thoughts since I’ve heard higher success rates with ICSI but she said there is no reason for us to do ICSI plus it’s costly she said. What are your thoughts?

    • Geoffrey Sher says:

      Respectfully, we do 100% ICSI because we believe that it enhancess fertilization and success. The introduction of 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 congenital absence of the Vas deferens (when a man is born without these major sperm collecting ducts), in cases where the vasa deferentia (ducts that carry the sperm from the testicles to the penile urethra for ejaculation) are obstructed (such as follwing vasectomy or trauma), and in some cases of testicular failure or where the man has impotency, 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.
      There seems to be quite a bit of speculation about the rate of birth defects associated with children conceived through ICSI fertilization. Here are some facts:
      • The performance of ICSI in cases of male factor infertility has been shown to slightly increase the risk of certain embryo chromosome deletions (leading to a slight increase in early miscarriages)
      • There is some evidence that there is an increased potential for a resulting male offspring to have male infertility in later life
      • There is no evidence of any significant increase in the incidence of serious birth defects attributable to the ICSI procedure itself.
      • More relevant is the fact that when ICSI is performed for indications OTHER THAN male infertility there is NO reported increase in the risk of subsequent embryo chromosome deletions, miscarriages or in the incidence of subsequent male factor infertility in the offspring.
      A relatively recent study was performed in Sweden, in which 542 children conceived naturally were compared with 941 children conceived through IVF (440 by conventional IVF & 541via ICSI) . The following parameters were assessed at birth and during the first 5 years of life:
      • Birth health and obstetrical complications
      • Birth defects or malformations
      • Family relationships
      • Physical development
      • Mental, psychological, and social development
      No major differences in birth weight, growth, total IQ, motor development, and behavior problems or parental stress were found between the children conceived with infertility treatments and those conceived naturally.

      Good luck!

      Geoff Sher

  • Deepak Vashisth says:

    Hello Doc,
    First of all thanks for doing this wonderfull job God will always bless you. Love u for this.

    I am 34 year old man and married since 8 years. Having reports done from one doc to another we are now tired and planned to go for IVF or ICSI.
    Sperm count is 50 million and motility is 30%.
    I am also an epileptic patient since 7 years and taking phenytoin regularily. The attacks comes only when i not use the drug otherwise i am ok and no traces found of epilepsy in brain.
    Please suggest the best way for having a baby.
    Thanks and Regards
    Deepak Vashisth

    • Geoffrey Sher says:

      You need to be on your medication. I doubt it is the cause of the problem. 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 “Amazon.com” as a down-load or in book form. It can also be obtained from most bookstores.

      Geoff Sher

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