Should we do intracytoplasmic sperm injection (ISCI)?

With more and more Ovally patients undergoing IVF, we’ve been focusing on how to best support you and ensure you’re fully informed to make treatment decisions that are right for you. Intracytoplasmic sperm injection (ICSI) is often a part of IVF that isn’t discussed much in doctor’s appointments. It is a fertilization technique that has been used during in vitro fertilization (IVF) since the early 1990s. A single sperm cell is selected and injected directly into an egg. ICSI stands in contrast to conventional in-vitro fertilization, when a mature egg is combined with a sample consisting of many sperm, allowing natural fertilization to take place. Many fertility clinics, particularly in the US, now use ICSI for any IVF procedure, or recommend and charge an extra ~$1.7k on average for ICSI to be performed. That’s why we dove into the research to identify when it’s advantageous to use ICSI, and what potential risks or downsides there are to consider.

When is it advantageous to do ICSI?

ICSI was designed to increase fertilization rates when there are issues with the sperm, i.e., in cases of ‘male factor infertility’. ICSI seems to be the most effective in those cases, though differentially so: While patients with azoospermia (without motile sperm) need to use ICSI, and patients with a low concentration of sperm typically benefit from ISCI by increasing fertilization rates, patients with sperm morphology (issues with the size or shape of the sperm’s head, midsection, or tail) don’t necessarily benefit from ICSI over conventional IVF.
If there’s no male factor infertility present, there does not seem to be a benefit of doing ICSI over conventional in-vitro fertilization. While ICSI might still slightly increase fertilization rates in those cases, post-fertilization outcomes such as implantation rates and birth rates are not better than for a conventional IVF procedure.
Some doctors may tell you that it’s necessary to use ICSI in order to perform pre-implantation genetic screening (PGS), a technique used to identify chromosomal abnormalities in embryos by taking a few cells from a developing embryo and performing a genetic analysis. However, the data do not show that ICSI embryos have higher rates of chromosomal normality or higher birth rates compared to embryos created through conventional IVF.
If you’re trying to screen for specific diseases using pre-implantation genetic diagnosis (PGS), some doctors and researchers argue that it’s important to use ICSI for fertilization to get the most accurate genetic read. However, others have shown no misdiagnoses or contamination issues in genetic analyses of embryos that were created through conventional IVF vs. ICSI. More research is required on this question.


What are potential risks or downsides of ICSI vs. conventional IVF?

There are risks and potential downsides to using ICSI. One risk is to damage the egg as the sperm is injected into it. This only happens in a small percentage of cases (~5% of eggs at good labs) and is likely worth it if the expected fertilization rate improves significantly with ICSI in cases of male factor infertility. Without male factor infertility, the risk of egg damage likely isn’t worth it.
There has been an ongoing debate about an increase in birth defects and urological issues (e.g., lower testosterone levels) in babies born from IVF using ICSI vs. conventional IVF. However, potential negative effects are not consistent across studies, and underlying fertility issues, such as male factor infertility, could play a role in explaining some of the defects and issues.


What do I do as a patient?

We suggest you discuss the use of ICSI or natural IVF with your doctor prior to undergoing your IVF or embryo freezing cycle. Your doctor may know of even more recent, yet-to-be published research and of a particular reason for why ICSI or conventional IVF may be beneficial in your case. We recommend the following questions as a starting point.
– Do we have male factor infertility based on our test results?
– If so, what about the sperm is showing concerning results? Its motility? Concentration? Morphology?
– Would you recommend using conventional IVF or ICSI? Why?
– What are the risks of using ICSI in our case?
– What are the benefits of using ICSI?
– Would you recommend we go through genetic testing on our embryos?
– To what extent do you think the benefits of ICSI would outweigh the risks in our case (e.g., a significantly higher fertilization rate)?
– What is the incremental cost of performing ICSI vs. conventional IVF?
See our list of other questions to ask prior to IVF treatment in this previous post.

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