PICSI – A worthwhile upgrade to ICSI?

A few months before going for our IVF treatment I had intense pain in my abdominal region, after a number of tests and operations I was diagnosed with Chronic Prostatitis. Sadly, other than the pain, one of the other known complications is that it can impact fertility!

For a couple about to embark on IVF this was a bit of a kick in the teeth! I had another SA (Semen Analysis) just before our IVF treatment and it showed a dramatic drop from around 60 million sperm per ejaculate to around 19 million sperm per ejaculate. But on the positive my normal forms had increased from 2% to 3%.

However, this meant that we may need ICSI to help our eggs fertilise. At the time I had no idea what ICSI was so started delving into the world of IVF treatment add-ons and found PICSI – which I like the sound of, the word sounding much like ‘Pixie’  a cheerful mischievous sprite… does PICSI match the phonetics?

What is PICSI

PICSI was developed to try and improve the success rates of ICSI IVF cycles (link to regular ICSI information).

PICSI also known as Physiological intracytoplasmic sperm injection, is  a technique which places the sperm sample in a compound which is found naturally within your body called hyaluronic acid often just called HA –  this is the same substance which is also used in the IVF treatment add-on embryo glue (link to our article).

In theory the sperm that bind to the HA (which is a chemical involved in the acrosome reaction and also implantation) have been shown to have less DNA damage and aneuploidy (an unusual number of chromosomes). The sperm which have bound to the HA are then selected. They should in theory be of better quality which should lead to a greater chance of fertilisation and a reduction in non-viable embryos.

Once an appropriate sperm is selected through PICSI then the treatment continues as a regular ICSI IVF treatment.

 

What does the evidence say about PICSI as a whole and PICSI IVF success rates?

Many clinics that sell PICSI as an IVF treatment add-on do so under the following circumstances:

  • Extremely low sperm count or morphology
  • Previously low number of fertilised eggs or not fertilised after ICSI
  • Repeated miscarriage and/or repeated embryo transfer without implantation

These are very similar to the requirements for ICSI except the second one.

It’s easy to blindly trust advise given by commercial clinics, doctors and specialists when it comes to health treatments and the same is true of fertility treatments.

But one of the things that I think is not done enough, is that patients don’t do enough research to be able to critically analyse and question the information they are being given, which can mean that they ‘may’ be sold treatments that either they don’t need or won’t give them the benefit they are looking for.

This is particularly true for IVF. Many couples have spent years and years trying, their desire to have children is absolute and many will do anything. This gives clinics an opportunity to emotionally sell products which might not be right for patients but generate additional revenue.

Please, don’t think that all clinics do this because MANY don’t. But you need to think logically, and fact check before agreeing to certain IVF treatment options.

Sorry, I digressed slightly, what does the evidence say about PICSI?

Ultimately it demonstrates that PICSI isn’t really effective in terms of live birth rates, but may very slightly reduce the miscarriage rates, although more research is required to confirm this.

Let’s look at this in a little more detail:

We’re going to look at 2 very recent studies

  1. July 2019 Cochrane literature review of control group studies called: ‘Advanced sperm selection techniques for assisted reproduction’ which you can find here
  2. Feb 2019 A medium sized controlled study titled: ‘Physiological, hyaluronan-selected intracytoplasmic sperm injection for infertility treatment (HABSelect): a parallel, two-group, randomised trial’ which can be found in The Lancet here

The Cochrane (gold standard in healthcare) study looked at 8 control group studies of 4147 women. It determined that the trials were of low or very low quality – this was due to imprecision in the analysis, the low numbers involved in the trials and determined there was a high risk of performance bias, due to who did these studies.

But using the meta data from all of these studies the key results were that for

ICSI vs PICSI success rates for live births were 25% for ICSI and between 24.5-31% for PICSI

The miscarriage rates from this low quality data showed that PICSI may reduce miscarriage rates from 7% in ICSI vs 3-6% in PICSI.

The author came to this conclusion:

“The evidence suggests that sperm selected by hyaluronic acid binding may have little or no effect on live birth or clinical pregnancy but may reduce miscarriage.”

The second study was a medium sized study of 2772 couples who were split 1381 in PICSI group and 1371 in ICSI. It had no conflicts of interest and was funded by the National Institute for Health Research Efficacy and Mechanism Evaluation Programme.

The reason that it was funded, is that ICSI unlike natural fertilisation IVF cycles doesn’t stop dysfunctional sperm entering the egg. They wanted to explore whether by trying to improve the quality of sperm selected via PICSI the live birth rates could be improved. It didn’t explicitly look at miscarriage rates but has inferred some results from the trial.

The link provided takes you to the full text, which is an interesting read if you are scientifically minded, however is quite heavy.

Ultimately it found that:

Live Birth Rates: ICSI – 25.2% | PICSI – 27.2%

Clinical Pregnancy Rate: ICSI – 35.7% | PICSI – 35.2%

Miscarriages Rate: ICSI – 7% | PICSI – 4.3%

They concluded as the Cochrane one did that it didn’t improve Live Birth rates however, it may reduce miscarriage rates, however, they require a larger trial to validate. 

Are there any risks associated with PICSI?

The are no additional specific risks between PICSI and ICSI, however all the risks associated with ICSI and IVF are still there. These include damage to embryo as ICSI is an invasive procedure for the embryo.

So, should I get PICSI as part of my IVF treatment?

Understanding all of this should help you make informed consent about your fertility treatment options when it comes to IVF add-ons.

From reading the evidence coupled with the fact that the HFEA website rates this treatment as red leads us to conclude that this is not an effective IVF treatment add-on.

The treatment cost is on average £240 in addition to the ICSI treatment.

We believe the additional cost of treatment vs the benefits are just not balanced and as such can’t recommend this treatment option.

The only possible time that it might be useful, and this is purely as a peace of mind option, is if you have had multiple rounds of IVF that have specifically ended in miscarriage and as a couple your partner has sever male factor infertility. We must emphasise however, that this option does not have enough scientific evidence to be certain of any improved outcome.

 

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