ICSI

Definition of ICSI

A procedure where the embryologist directly injects a single sperm into the egg, causing fertilization. This may be helpful in cases where there is poor quality sperm from the male partner, or where there is an issue with the egg where fertilization can't occur due to changes in the membranes surrounding the egg.

ICSI is an acronym for intracytoplasmic sperm injection - which is a long, fancy way of saying "inject sperm into the middle of the egg". ICSI is a very effective method to get fertilization of eggs in the IVF lab after they have been retrieved from the female partner. IVF with ICSI involves the use of specialized micromanipulation tools and equipment and inverted microscopes that enable embryologists to select and then pick up individual sperms in a tiny specially designed hollow ICSI needle. Then the needle is carefully advanced through the outer shell of the egg and egg membrane and the sperm is then injected into the inner part (cytoplasm) of the egg. This will usually result in normal fertilization in approximately 70-85% of eggs injected with viable sperm. First, the woman must be stimulated with medications and have an egg retrieval procedure so that we can obtain several eggs in order to attempt in vitro fertilization and ICSI.

Previous to ICSI, the only options to couples where the male partner had a low sperm count, a complete absence of sperm in his semen, a damaged or even absent vas deferens, an irreversible vasectomy or a host of other problems was to adopt, use a sperm donor or deal with the possibility of never having children. Understandably, many couples did not care for these limited options.

Using micromanipulation technology, ICSI allows fertility specialists to fertilize an egg using just one sperm. While it is preferred to use sperm from a semen sample, specialists can retrieve sperm from the testicles if it is necessary. Once sperm has been collected, the specialist will draw a single sperm into a needle and inject it directly into an egg that has been collected from the female partner through the usual retrieval methods. This process bypasses the conventional IVF methods of fertilization, thereby ensuring that fertilization has taken place. The fertilized eggs are then left to culture for a few days before being transferred back to the woman's uterus. ICSI is always used alongside IVF.

Who is Suited for ICSI?

Couples that are infertile due to any of the following reasons may want to consider using ISCI with their IVF treatment.

• Low sperm count
• Poor sperm motility
• Abnormally high amount of morphologically atypical sperm
• Experienced fertilization failure for unknown reasons in a previous IVF cycle
• Lack of any sperm in ejaculate due to CAVD, failed vasectomy reversal, failure to produce sperm, or an obstruction in the epididymus due to past inflammation
• Retrograde ejaculation
• Immunological factors

Additionally, men who have been diagnosed with testicular cancer may choose to freeze a semen sample before undergoing treatment as this can later be used in ICSI.

Indications for ICSI

• Couples who have had unexplained fertilization failure in a previous IVF cycle.
• Decreased sperm concentration, providing enough viable sperm can be recovered for injection of eggs.
• Decreased sperm motility, including totally immotile sperm (e.g. Kartagener's syndrome), providing sperm are viable.
• Unusually high percentage of morphologically abnormal sperm, including round- headed sperm (globoazoospermia).
• Complete absence of sperm in the ejaculate due to an obstruction (obstructive azoospermia) caused by conditions such as congenital absence of the vas deferens (CAVD), post-inflammatory obstruction of the epididymis or vas and failed vasectomy reversal. Testicular sperm extraction (TESE) is used to retrieve sperm for ICSI.
• Complete absence of sperm in the ejaculate due to defective sperm production (non- obstructive azoospermia). Patients who have normal sperm formation in at least some areas of the testis (identified by testicular biopsy), providing enough viable sperm can be retrieved with TESE. Ejaculatory dysfunction caused by retrograde ejaculation (enough sperm are usually recovered from the urine) or paraplegia (electroejaculation or TESE).
• Immunological factors; antisperm antibodies in female sera, follicular fluid or on sperm caused by vasectomy or genital tract infection.
• Testicular cancer patients with semen samples frozen prior to treatment.

Success with ICSI

While the fertilization rates with ICSI remains pretty high at between 60% and 70% depending on the quality of sperm used, pregnancy rates remain about the same as they do with IVF. Approximately 20% to 25% of couples undergoing ICSI and IVF will have a live birth. However, one concern among many experts is how healthy this procedure is for the resulting children.

Because ICSI is used mainly in men with extremely poor sperm quality, the fact that it allows an egg to be fertilized with any sperm, rather than the strongest, has caused concern that congenital defects may be passed on at a greater rate. Additionally, it is a relatively new procedure and the long term effects in children conceived through ICSI have yet to be properly analyzed. However, so far no studies have shown that children conceived with ICSI do have any increase in congenital defects. If there is a known risk of genetic diseases or disorders in your family, though, you may want to consider using PGD.

Moreover, because ICSI is used alongside IVF, couples undergoing this treatment do have an increased risk of ectopic pregnancy as well as multiple births.

How is ICSI performed?

• The mature egg is held with a specialized holding pipette.
• A very delicate, sharp and hollow needle is used to immobilize and pick up a single sperm.
• This needle is then carefully inserted through the zona (shell of egg) and in to the cytoplasm of the egg.
• The sperm is injected in to the cytoplasm and the needle carefully removed.
• The eggs are checked the next morning for evidence of normal fertilization