IVF and ICSI – should it be used for ‘male factor’ couples only?

Now some countries will use ICSI standards 100% of all cycles will be ICSI. The UK tends to be about 50-50. If the sperm parameters are good and it’s your first cycle or you’ve had previously good fertilization, there’s absolutely no need to do ICSI as standard. It should only be used in poor patients with a male factor infertility or where they’ve had a previous cycle and have not had very good fertilization with IVF.

Over the years, while at the beginning, ICSI was used for the treatment of male infertility cases only. Over the years, we have expanded its use for normal-spermic for men that have had a previous fertilization failure after conventional IVF or for even for the cases of low number of oocytes or low quality of the oocytes in order to maximize the chances for fertilization and embryo transfer. However, when it comes to the use of ICSI instead of IVF for non-male infertility cases, for normal-spermic men, the clear value and the benefit is still debatable with the exception only of the cases where they have a previous fertilization failure after conventional IVF.

The decision to do ICSI (Intracytoplasmic Sperm Injection) or conventional IVF depends on many factors. Nowadays the ICSI treatment is more used, but that does not mean that we have poor results with conventional IVF. The factors that can indicate one treatment or another are several, the quality of the sperm (since if we have a poor sample it would not be used for conventional IVF). Age of the patient, the number of eggs collected (if there are few oocytes, ICSI is recommended), previous cycles performed.Sometimes if we have a good number of oocytes and the sperm is suitable for IVF, we can do half and half and it will serve as a diagnosis, this is done when a first cycle is performed.

Absolutely because the evidence does not suggest any benefit and year on year national data from the United States shows that when you use it unnecessarily (when the sperm is fit for purpose) you end up with worse outcome than if you just use IVF and also you save yourself few hundred pounds – the extra fees that people get for ICSI.

The answer is no. The situation nowadays is completely different from when the ICSI method was invented. With the growing age of the couples going into fertility treatment, it’s not only the male factor but also the number and quality of retrieved eggs. So nowadays it is recommended to perform ICSI always at each fertilization on all eggs, even with full normal sperm.

Intracytoplasmic Sperm Injection is recommended for couples who have been diagnosis with male infertility issues such as low sperm count, low sperm motility or for example, abnormal morphology, also if there is a an anti-sperm antibody test alternated or for couple who have experienced poor or low/none fertilization rate using standard IVF. However, recently I have to say that ICSI has been utilized also in non-male factor cases for instance in women that retrieved a few oocytes or ones that choose to to undergo pre-implantation genetic tests for aneuploidy.

It depends as of course if you have a low semen count and low motility, the possibility of fertilisation is reduced. So by opting for IVF where the sperm is in contact with the oocytes, the possibility of fertilisation is lower, only because you have less sperm and they are less motile. When sperm count and motility is lower than the recommended thresholds, it is important to choose ICSI as an option.

Infertility can be caused by the female or the male factor; most of the time, we see cases where both sides are at play. Male factor infertility can be caused by, for example, issues with sperm, such as low motility or DNA fragmentation. Female factor infertility can be caused by many more reasons, such as low egg quality due to ageing, congenital issues, or others.

In both cases, IVF and ICSI can help. What, however, is the difference between them? During IVF, we allow the sperm to naturally fertilize the egg, while during the ICSI procedure, an embryologist selects a single sperm and directly injects it into the oocyte. The latter option is especially recommended for women of advanced age, even if the sperm quality is perfect. This is because, during ICSI, embryologists perform certain tests to make sure the best possible sperm is selected. ICSI is then a fertilization method that allows patients of all types to generate a good quality embryo.

In Vitro Fertilization (IVF) is the most common type of assisted reproductive technology (ART). It’s a laboratory procedure that involves retrieving eggs from a woman’s ovaries and fertilizing them with sperm to produce embryos. Once fertilized, a limited amount of embryos is transferred into the recipient’s uterus so that they can continue developing naturally inside.

The insemination of the oocytes can be carried out with conventional fertilization methods or by using Intracytoplasmic Sperm Injection (ICSI). Conventional IVF consists of culturing the eggs with a certain amount of sperm – around 100,000 sp/ml. Conversely, ICSI only uses a single, pre-selected sperm, which is directly injected into the cytoplasm of a mature egg.

Conventional IVF fertilization was traditionally the method of choice when treating couples suffering from non-male factor infertility. However, the use of ICSI has increased dramatically in all treatment scenarios, as it helps avoid total fertilization failure due to unknown causes. Today, we use ICSI exclusively in all of our cases.

On the day of the egg retrieval, the mature eggs we obtain can be fertilized using conventional IVF or the ICSI technique. Conventional IVF is simply combining sperm with eggs in a laboratory. The ICSI method involves the embryologist selecting a single sperm with a fine glass needle and injecting it directly into the egg. Differences in the fertilization rates depend on the quality of eggs and sperm – right now, embryologists largely prefer the ICSI route. In certain circumstances, ICSI should be the only method employed. These circumstances consist mainly of sperm defects, like oligo, astheno, teratozoospermia, or a combination of all of them. In these cases, ICSI should always be performed, as altered sperm quality has a major impact on the fertilization process. In severe cases, an additional technique for sperm selection, such as Fertile Chip, may be used before proceeding to ICSI.

Another indication for ICSI is when the sperm is obtained by testicular aspiration or biopsy, or in the case where frozen sperm is to be used. When using high valued sperm, we don’t want to take the risk of a possible fertilization failure. But what if the sperm quality is good? If there is a normal ovarian reserve, if no former treatments have been performed that indicate a future fertilization problem, or if the couple wishes to only use conventional IVF, we can accommodate that wish. The advantage of conventional IVF is that it’s easier and cheaper to perform, and fertilization takes place in a slightly more “natural” way.

In patients who have a limited ovarian reserve or highly valued eggs (for instance, in egg donation treatments), we always recommend ICSI. If the patients decide to perform a preimplantation genetic diagnosis of their embryos, now called PGT-A, we would recommend ICSI. The same is true for frozen egg cycles. Lastly, we always recommend ICSI over conventional IVF if we suspect previous fertilization failures.

In summary, the clearest indication for ICSI is a diagnosed male factor. Other scenarios in which it would be the recommended course of action are situations when a risk of fertilization failure is present or if we want to guarantee the highest fertilization rates. In clinical practice, almost all couples use ICSI; very few patients use conventional IVF or a combination of conventional IVF and ICSI.