Treatment: Intracytoplasmic sperm injection (ICSI)
Treatment: Intracytoplasmic sperm injection (ICSI)
ICSI involves the direct injection of a single sperm into each egg under direct microscopic vision. The successful performance of ICSI requires a high level of technical expertise. In centers of excellence, when ICSI is employed, the IVF birth rate is unaffected by the presence and severity of male infertility. 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 differentia are obstructed (such as following 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.
The introduction of ICSI has made it possible to fertilize eggs with sperm derived from men with the severest degrees of male infertility and in the process to achieve pregnancy rates as high, if not higher than that which can be achieved through conventional IVF performed in cases of non-male factor related infertility. 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) as well as the 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.
Another major advantage of doing conventional ICSI is that it affords the opportunity to remove the cumulus complex of cells that envelop the harvested egg and so enable the embryologist to evaluate microscopic parameters that point to maturity. This cannot be done with conventional IVF as the removal of these cells would virtually preclude conventional fertilization in the Petri dish.
A study was performed in Sweden, in which 542 children conceived naturally were compared with 941 children conceived through IVF (440 by conventional IVF and 541 by ICSI) . The following parameters were assessed at birth and during the first 5 years of life: a) birth health and obstetrical complications, b) birth defects or malformations, c) family relationships, d) physical development, e) mental, psychological, and social development. No major differences in birth weight, growth, total IQ, motor development, behavior problems, or parental stress were found between the children conceived with infertility treatments and those conceived naturally.
About 12-15% of conventional IVF is associated with unanticipated absent or poor fertilization. This has led many to conclude that male infertility may be an “occult phenomenon” in some men. In fact, new tests of sperm DNA integrity (SDI) have demonstrated that DNA damage may be present in sperm from men with both normal and abnormal semen analyses and that male infertility is equally prevalent in such cases. Thus disappointments associated with unanticipated failed fertilization might be averted through routine performance of ICSI. There simply does not seem to be any practical downside to this approach which is now routine practice throughout our system.
There are no data suggesting that ICSI should not be performed in all cases of in-vitro conception. In all cases, female factor or male factor (normal or abnormal spermatozoa), the use of ICSI eliminates the majority of barriers to fertilization. If fertilization still does not occur, then there is a greater chance of it being a genetic reason, and the risk of genetic abnormalities in normal spermatozoa should not be of greater concern than those in abnormal spermatozoa. In summary, both the safety and scientific viewpoints strongly support the use of ICSI for all indications.
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