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

      Dr. Geoffrey Sher Recommends

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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.

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      6 Responses to “The Needle vs. the Dish: Should ICSI Be Used in All IVF?”

      1. Jessica says:
        February 18, 2013 at 8:22 pm

        Dear Dr. Sher,
        I very appreciate your expertise and advice. I live in australia and we have a 2 1/2 daughter conceived via icsi. We have subsequently tried to have a second but with no success after 3 stimulated cycles (gonalef -375-450 plus saizen). most recently, i ovulated on day 15 prior to egg collection. my dr has recommended if we try again that take a drug to suppress ovulation (orgalutran) twice daily instead of once. I am 37 and have dor, with typically 2-3 follicles per cyle and we are also dealing with male factor infertility. my husband (also 37) would have to undergo a biopsy to extract sperm. I know this is a difficult question, but I am not sure whether this sounds like such a complex case that we should give up after our 3 tries, or whether you think there is something else we should try? We would love to give our daughter a sibling but disagree whether this should be the end of the road. thanks very much in advance, Jessica from Sydney

        Reply
        • Geoffrey Sher says:
          February 19, 2013 at 5:53 am

          Hi Jessica,

          This sounds like a stimulation issue. What often can happen in women who have diminished ovarian reserve is premature luteinization (also referred to as a “premature LH surge”. It requires a revamp of the stimulation protocol and sometimes even that won’t work. Go elsewhere on this blog and read up on “prematrure luteinization”.

          Good luck!

          Geoff Sher

          Reply
      2. yamzy says:
        March 28, 2013 at 2:21 pm

        Dear Dr Sher,
        Im from Sri Lanka age 33. I have undergone one IVF cycle with an antagonist protocol.I responded so well gonal-f225 and produced 18 eggs. Out of them 14 fertilized.07 fertilized on conventional ivf and two fertilised with icsi.but all fertilised through conventional ivf were highly fragmneted and the 2 icsi ones looked good and transfered. but sadly i didnt fall pregnant. im pcos and my husband who is 32 has low motility. Im thinking to try IVF. what advise you can give…? Is there any reason why those got highly fragmneted? my doctor said it could be sue to the protocol or the laboratory conditions or poor egg quality. but im confused and desperate. pls advise

        Reply
        • Geoffrey Sher says:
          March 28, 2013 at 5:56 pm

          Hi Yamzy,

          My response to you would be the exact same as the response below to “Lisa’s” post. Please read that.

          Geoff Sher

          Reply
      3. mahek says:
        May 4, 2013 at 12:00 am

        we underwent 3 failed icsi cycles.
        first was due to absence of sperms in the biopsies (TESA-ICSI), second there were sperms present(surprisingly) in normal ejaculate(2 consecutive samples given after a gap of one hour)and the semen was cryopreserved, but i was having PCOS and excessive weight gain only made 4 eggs by stimulation, out of which only 2 were mature and only one fertilised and ofcourse i didnot concieve (also suffer hypothyroidism)
        third, i gave good response to stimulation and produced 11 eggs out of which 9 matured but unfortunately my husbands semen(both samples) no sperm found, and the cryopreserved sample was used out of 8 injected again only one divided(which i am not sure of good quality).
        The pregnancy test was obviously negative, what further proceudre can we do.My age is 30 and husband is 33.Thanks you

        Reply
        • Geoffrey Sher says:
          May 4, 2013 at 10:27 am

          There are several issues that need to be addressed. The first is the need for a very strategic and individualized protocol for ovarian stimulation (see below). The second is the accessing of sperm and the 3rd is the fact that most women who have hypothyroidism have an autoimmune cause which in 50% of cases is associated with an immunologic implantation dysfunction (see below).

          I really think we should talk and that I can help here. Please go to the home page of this blog, http://www.IVFauthority.com. When you get there, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.

          1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)

          2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”

          3. “Thyroid autoimmune disease and IVF”

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

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

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

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

          8. “IVF success: Factors that influence outcome”

          9. “Staggered IVF”

          10.“Male Infertility”

          11. “Intracytoplasmic sperm injection (ICSI)”

          12. “Hormonal treatment of male infertility”

          Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail

          Geoff Sher

          Reply

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