Question 54. Who needs ICSI, and how can my reproductive endocrinologist be certain that I need it?

So as you may recall from Question 53, ICSI is that crazy technique that involves taking a sperm and inserting it into the egg to induce fertilization.....hard to believe that it works but there you have it.

Sometimes it is not that easy to figure out who needs ICSI and who doesn't. I have a nice couple that first came to me a few years ago with mild male factor infertility as the apparent cause. Ultimately they decided to pursue Natural Cycle IVF and were successful on the 2nd attempt of Natural Cycle IVF with ICSI. We used ICSI as they had no previous pregnancies and there was some mild male factor. We have tended to err on the side of ICSI with Natural Cycle IVF as there is only 1 egg and if we don't get fertilization then the cycle is a bust....

In any case, following delivery of a healthy baby from that first NC IVF cycle they returned last year for another round of NC IVF. However, we just couldn't get them pregnant. Several cycles ended in failed fertilization in spite of ICSI. They had no interest in any treatment other than NC IVF as they had moral/philosophical issues with the fertilization of multiple eggs.

So for NC IVF cycle #6, I made the bold recommendation to defer ICSI and go with just IVF. We got a nice egg, it fertilized, it grew, I did the ET of a perfect blastocycst and they are currently pregnant with Baby #2. Was it the IVF without ICSI that did it? Was it just a good egg? Was it the fact that DrG had been off that weekend and was well-rested for a Monday morning ET? Who knows? I am just glad that their persistence paid off.....

Another example of having to treat individuals and not applying cookie-cutter protocols to yoru patients....

So with all that said, here is the latest excerpt from our 100 Questions and Answers about Infertility book. Don't forget to respond to the poll so I can understand who besides my Mother reads this blog....


54. Who needs ICSI, and how can my reproductive endocrinologist be certain that I need it?


Most couples undergoing treatment with IVF do not require ICSI. The most common indication for ICSI is male factor infertility associated with an abnormal semen analysis. Thereore, men with unproven fertility whose sperm count, motility, or morphology is suboptimal are appropriate candidates for IVF with ICSI to ensure fertilization of the ova.

Another common indication for ICSI is unexplained infertility. In these couples, neither the man nor the woman has any apparent fertility-related problems. Their diagnostic evaluation is entirely normal, yet infertility exists. In such couples, traditional IVF may result in fertilization failure in 20-40% of IVF cycles. By using ICSI, the eggs are “forced” to fertilize, and the pregnancy rates are usually high. Fertilization rates with ICSI are usually 60-80% depending upon egg and sperm factors.

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To Tweet or not to Tweet..that is the question...

Although I am not an early adopter of technology, I am not a Luddite either. I have written this blog for a couple of years now and I think that at least 3 other people (besides my Mother) read my posts. I have usually focused on questions from our book on infertility but have commented on a range of other topics ranging from Princeton's epic win over Hahvahd at Yale earlier this year that secured an NCAA invitation for the men's basketball team to the reasons that some clinics fail to offer Natural Cycle IVF and so on.

I am now trying to figure out where Twitter fits into my approach to helping patients. Honestly, I am not really sure what the answer is to that question. I certainly have no plans to end up with a Weinergate type situation and I have had the experience of hitting "reply all" instead of just "reply" on email so I am aware of how embarrassing these miscues can be....

So in order to best serve my loyal base of almost 10 readers, I am asking for you to take about 45 seconds out of your busy days to participate in an anonymous survey about this blog. There is no way for me to identify you, nor do I have any desire to do so. I guess you can always tell me that you were the one who said that you think I should give up medicine and start selling Amway but I leave that to your discretion.

So please help me out here and as they say in Chicago: "Vote early and vote often!"

Click here to go to Survey Monkey and take the Poll. Thanks!

DrG

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Question 53: What is ICSI, and how does it differ from IVF?

In medical school at Duke I took a class in reproductive physiology taught by Dr. Patricia Saling. She was very engaging lecturer and the class was very interesting. During the class we had to memorize the sequence of events that included the fusing of the egg and sperm membranes, the release of the enzymes in the sperm acrosome and a bunch of other steps that I no longer remember. The possibility that you could get a baby from ramming a sperm into the middle of the egg with a micro-injector was just laughable....I would have flunked the class if I suggested it! So when the Belgium group reported on their experience with ICSI at the 1993 ASRM meeting in Boston no one could really believe it....seemed nutty. Yet here we are nearly 20 years later and ICSI seems totally banal! Hard to believe....

More on ICSI in the coming posts but here is today's Question of the Day from 100 Questions and Answers about Infertility, 2nd Edition.

53. What is ICSI, and how does it differ from IVF?

In routine IVF, eggs are placed in a laboratory dish in culture media together with prepared sperm. The eggs and sperm are allowed to spontaneously fertilize overnight. The fertilized eggs then develop and in the incubator until the embryo transfer procedure, which is usually performed 3 to 5 days after the egg retrieval.

Intracytoplasmic sperm injection (ICSI) differs from IVF in that each egg is individually injected with a single sperm using a tiny needle under microscopic guidance (Figure 4). The resulting embryo is then cultured similarly to an embryo produced in a non-ICSI IVF treatment.

ICSI was initially introduced by the IVF team working at the Brussels Free University in Belgium. At that time, assisted fertilization was being attempted through the insertion of the sperm under the eggshell (zona pellucida). The Belgian group took the extra step of injecting the sperm not only under the eggshell but actually into the middle of the egg itself. The first ICSI pregnancies were reported in 1992. Since then, tens of thousands of children have been born as a result of this unique procedure.

Both ICSI and non-ICSI IVF have similar pregnancy rates and outcomes. The embryos produced by either method should not be considered to be superior to those created with the other. ICSI is simply a method to ensure that the egg is fertilized. ICSI is a safe and proven IVF method that does not increase the likelihood that the child conceived in this way will have a birth defect.

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