what is ICSI treatment and why might we need it?

What is ICSI treatment and why might we need it?

When Rachel and I were going through our infertility testing and into our IVF, I had been diagnosed with chronic prostatitis which had an impact upon my sperm, it had reduced the count and appeared to have had a further impact upon Sperm quality. We were told at the clinic that my sperm was borderline and that a decision would be made on the day if we need to have ICSI treatment. That’s great I thought, but what is ICSI? So from my research and speaking to those who went through it this is what I found.

ICSI or Intracytoplasmic Sperm Injection, is a process which injects the sperm directly into the egg to assist in fertilisation and has a similar success rate as normal IVF fertilisation methods. It is used for:

  1. If you have sperm issues including count, morphology, mortality and motility
  2. You need surgical sperm extraction
  3. You’re using frozen sperm
  4. You’re having PGS or PGD testing on the embryo

What is ICSI for IVF?

ICSI is a specialist form of IVF, it is mainly done for moderate-severe male infertility problems and multiple failed fertilisations in previous IVF cycles. The process is entirely done within the lab after egg retrieval and, as such, it doesn’t impact your experience of IVF.  For a detailed look on the normal IVF process check out our guide How does IVF Work

In regular IVF treatment protocols, the sperm and mature egg are placed into a dish with a medium and about 80% of eggs will be fertilised if there are no specific fertilisation problems.

The full ICSI procedure goes like this:

  1. A semen sample is produced into an appropriate container on the same day as the egg retrieval. This will be checked – If no sperm is present then it is likely you will have sperm directly extracted from the testicle or epididymis.
  2. Some clinics will wash the sperm, some will not, either works.
  3. The next part of the procedure is done fully under a microscope. The sperm are looked at and an appropriate sperm will be selected that is mobile, alive and has the right morphology.
  4. The embryologist will use a micropipette to hold and stabilise the mature egg. Using another separate micropipette, the selected sperm is immobilised by having its tail cut off.
  5. The egg is pierced through the cell membrane and the sperm head is directly injected into the centre mass of the egg. It is important not to damage the spindle(protein structure that divides the genetic material) in this process.
  6. The egg will then be placed in a cell culture medium and checked the next day for fertilisation.

The video to the right shows the procedure.

 

Why is ICSI done?

ICSI is normally suggested for severe male factor infertility which accounts for about 30% of all infertility diagnosis’ in couples. The specific areas that it will improve the success rates of IVF treatments are: –

  • Poor sperm motility also known as asthenozoospermia
  • Abnormal sperm morphology known as teratozoospermia
  • Very low sperm count known as oligospermia
  • Antibody’s around the sperm

The table to the right gives an overview of the main conditions which can be determined by a sperm analysis. I’m sure you’ll agree that pronouncing them will take a 3 year college degree alone.

 

These are the main reasons that ICSI is performed during IVF and has clear research and evidence to show that it improved pregnancy rates through IVF for those who have these infertility diagnoses. There are other specific reasons that ICSI may be suggested and used which are based in evidence, they are: –

  • If sperm have been frozen and the thawed sperm aren’t showing much signs of movement and activity.
  • Frozen eggs can cause a hardening of the zona pellucida which may make natural fertilisation harder.
  • You have already had multiple cycles of IVF cycles which have failed due to non-fertilisation of the eggs even though all the tests showed healthy eggs and sperm.
  • You have had preimplantation genetic screening or diagnosis

Some clinics may suggest using ICSI for the following reasons, however the evidence is not conclusive that it will have any positive impact on the chance of a successful pregnancy these include: –

  • Age of the mother – There is no evidence showing that ICSI improves normal fertilisation methods in IVF for those of a more advanced age.
  • Unexplained infertility – Even though the reason for unexplained fertility is unclear or undefined there is no evidence that using ICSI as a standard procedure for those with unexplained infertility improves overall fertilisation rates.
  • Minimal stimulation = low egg number – If stimulation during the IVF phase isn’t as effective as the clinic hoped and a low number of eggs are fertilised some like to offer ICSI as a tool to ensure fertilisation, however this is flawed logic, as the current research shows that in those without the above situations the fertilisation rates, pregnancy rates and live birth rates will be the same between ICSI and normal IVF fertilisation processes. (We actually only had a low number of eggs in our first cycle – however all fertilised through normal IVF method)
  • As a matter of course – Some clinics try to sell packages with no tests that include ICSI. It has been shown that in a random sample only 3% of people would have benefit so 97 people out of a 100 would be paying additional with no benefit and increased risks.

Who is ICSI treatment not right for?

We’ve already explored who ICSI is right for. ICSI isn’t right for most people without the issues explained within the previous section. One specific example is those that have had failed fertilisation in previous IVF cycles due to poor quality or immature egg’s. ICSI is very unlikely to help you even though it seems logical it might.

What is the success rate of ICSI treatment?

IVF treatment as a whole has the following success rates (remember these are total, so includes complex cases and conditions):

  • under 35: 29%
  • 35-37: 24%
  • 38-39: 17%
  • 40-42: 11%
  • 43-44: 4%
  • over 44: 3%.

Using ICSI where it is medically evidenced that it will improve your chances of fertilisation will bring the rates up to those of standard IVF procedures but will not increase the chances if there is no valid reason to have this procedure. The one area where ICSI does help is in the rates of fertilisation of those with the identified reasons in the why is ICSI done section where it brings fertilisation of eggs to similar levels found in normal IVF cycles for those without the identified fertility problems. For a more detailed look on success rates take a look at HFEA trends and statistics (extenal link)

Are there any risks with ICSI?

All the normal risks which come with IVF are still risks with ICSI. But ICSI also adds some additional risks. These include: –

  • ICSI is an invasive procedure and as such damage to the embryo can occur which can mean that it can become non-viable.
  • There is a slight increase (less than 1%) of birth anomalies and defects.
  • Due to the fact that a sperm which wouldn’t have been able to penetrate the egg naturally due to a defect there are tiny additional risk of sex chromosome abnormalities, Hypospadias (a birth defect in boys where the urethra opening is underneath the penis rather than on the tip), Angelman syndrome and Beckwith-Wiedemann syndrome
  • A very small chance that male infertility problems are inherited by a male child.
  • ICSI increases the chance of multiples in pregnancy which carry many additional risks.

Can I get ICSI on the NHS?

As discussed in our article on NHS funding and the postcode lottery of IVF in the UK. ICSI is no different, most trusts which offer IVF will offer ICSI where it is determined that the procedure will increase your chance of a successful IVF cycle – those things will be the elements discussed in sections above as they supported by evidence.

Should I get ICSI treatment

ICSI is a skilled job which means that in a private clinic it is quite expensive. Generally, packages that include ICSI start around £4,000 for a cycle not including medications and some appointments. Having researched other packages, it appears clinics add a £1,000 premium on for ICSI. This is quite a lot of money especially if you are needing multiple cycles.

Our opinion is that if you have any of the specific conditions mentioned in the why is IVF done and you are having your treatment privately then you should seriously consider ICSI as it is more likely you will end up with fertilised embryo’s to implant bringing your chance of pregnancy in-line with the standard IVF process. However if you don’t have these we certainly wouldn’t recommend ICSI as there is no evidence that it improves pregnancy rates, but it does add additional risk as such we don’t feel it’s worth it.

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