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  » Infertility  »  Intracytoplasmic sperm injection - ICSI and IVF

Highly effective treatment for male factor infertility

What is ICSI?

ICSI involves injection of single sperm in to single eggs in order to get fertilization. First, the woman must be stimulated with medications and have an egg retrieval so that we can obtain several eggs in order to attempt in vitro fertilization.

The eggs are injected using specially designed microscopes, needles and micromanipulation equipment .

Who should be treated with intracytoplasmic sperm injection?

There is no "standard of care" in this field of medicine regarding which cases should have the ICSI procedure and which should not. Some clinics use it only for severe male factor infertility, and some use it on every case. The large majority of IVF clinics are somewhere in the middle of these 2 extremes. Our thinking has changed over time - we are now doing more ICSI (as a percentage of total cases) than in the past. Certainly, as we learn more about ways that we can help couples conceive, our thinking in this area will continue to evolve. Having said that, we are currently recommending in vitro fertilization (IVF) with ICSI for:

1. All couples with severe male factor infertility that do not want donor sperm insemination.

2. All couples with infertility with:

Sperm concentrations of less than 15-20 million per milliliter
OR
Sperm motility less than 35%
OR
Very poor sperm morphology (subjective - specific cutoff value not appropriate)

3. All couples having IVF who have had a previous cycle with no fertilization - or a low rate of fertilization (low percentage of mature eggs that are normally fertilized).

4. All couples having IVF who have a very low yield of eggs at the egg retrieval - our current cutoff is 5-6 (or less) eggs. In this scenario, ICSI is being used to try to get a higher percentage of eggs fertilized than with conventional insemination of the eggs (just mixing eggs and sperm together).

  How is ICSI performed?

1. The mature egg is held with a specialized holding pipette.

2. A very delicate, sharp and hollow needle is used to immobilize and pick up a single sperm.

3. This needle is then carefully inserted through the zona (shell of egg) and in to the cytoplasm of the egg.

4. The sperm is injected in to the cytoplasm and the needle carefully removed.

5. The eggs are checked the next morning for evidence of normal fertilization .
ICSI in progress
Needle with a sperm inside is advanced to the left
Shell of embryo has already been penetrated by needle
Membrane of egg (oolemma) is stretching and is about to break
Sperm head visible at tip of needle

Fertilization and pregnancy rates with ICSI

Fertilization rates for ICSI in most good IVF programs are about 60-85% of eggs injected.

Pregnancy rates for in vitro fertilization procedures with ICSI have been shown in some studies to be higher than for IVF without ICSI. This is because in many of the cases needing ICSI the female is relatively young and fertile (good egg quantity and quality ) as compared to some of the women having IVF for reasons other than male factor infertility. Another way to say this is - average egg quantity and quality is usually better in ICSI cases (male factor cases) because it is less likely that there is a problem with the eggs - as compared to cases with unexplained infertility in which there is more probability of a somewhat reduced egg quantity and quality (on the average, since some women in this group have egg related issues).

IVF with ICSI pregnancy rates vary according to the specifics of the individual case, the ICSI technique used, the skill of the individual performing the procedure, the overall quality of the laboratory, the quality of the eggs, and the embryo transfer skills of the physician performing that procedure. 

Sometimes ICSI is done for "egg factor" cases - low ovarian reserve situations. This is when there is either a low number of eggs, or lower "quality" eggs (or often both). In such cases, pregnancy rates are somewhat lower (as a group) since the main determinant of IVF success is the quality of the transferred embryos - and the quality of the eggs is a crucial determinant of the resulting embryo quality.

In some cases, assisted hatching might be done on the embryos prior to transfer, in order to maximize chances for pregnancy.