When to consider ICSI?

ICSI is a specially useful embryological technique for treatment of male infertility and repeated IVF failure. ICSI is now very much a standard procedure being sued in well over half of all treatment cycles in India.

What is ICSI?

ICSI is now a well-established microinjection technique which has helped thousands of infertile men to overcome issues with sperm parameters. It is also useful in cases of fertilisation failures with repeated IVF cycles. The technique evolved in 1990’s in Belgium and since then has become established as one of the biggest discoveries in the management of infertility. Presently more than 50% IVF cycles in India and up to 63% IVF cycles in USA are ICSI cycles.

How is ICSI different IVF?

ICSI is mainly an embryological process. The process of ovarian stimulation, egg retrieval and embryo transfer remains the same as in IVF (described above). The male partner provides a semen sample on the same day by masturbation. Alternatively, sperms retrieved surgically from testis (in case of obstructive / un-obstructive azoospermia) or sperm that has been previously cryopreserved can also be used. So, technically the number of sperms required is only as many as the number of eggs that can be fertilised.

The eggs are also processed differently for ICSI, as they are first cleaned in order to clean them and remove the debris and outer cumulus cells. The eggs are screened for maturity under a microscope and the mature ones are selected for micro-manipulation or ICSI. One carefully selected sperm is injected into each selected egg using a micro-manipulator under high magnification microscope. Later the fertilised eggs are placed in the incubator and allowed to grow.

Who benefits from ICSI? Who are potential candidates for ICSI?
  • ICSI benefits all mainly men with low sperm count , poor motility or morphology
  • In cases with surgically retrieved sperms like MESA, TESA, TESE, where this is the only tool to fertilise the egg.
  • In pts with recurrent fertilisation failure with IVF.
  • In patients undergoing preimplantation genetic diagnosis.
What are various risks associated with ICSI?

ICSI revolutionised the treatment of male factor infertility enabling even males with nil sperm count to father their own genetic child. It is a fairly safe procedure. But, some studies have indicated a marginal increase in risk of congenital malformations in the offspring (six per thousand births compared to two per thousand births in general population). But it still remains to be proven if the real cause of the higher incidence of congenital malformations in such children is ICSI or just a transmission of genetic abnormalities from the male with severe sperm abnormalities.

Contact Dr Parul Katiyar for more information about ICSI and treatment of infertility.

Looking beyond Semen Analysis as a marker for Male Fertility

Its often difficult to pin down the real cause of male infertility as the assessment of the male partner remains restricted to semen analysis and a normal report is used to rule male factors out. Many of these incompletely evaluated men and couples can benefit from further investigation of the male partner, which not only helps start proper intervention for conception early on, but also saves lot of mental stress and stigma for the woman partner.

It’s a well-known fact that male factor contributes to a couple’s inability to conceive in up to 40% of all cases of infertility. In practice, however, the inability of a couple to conceive is still seen largely as a woman’s problem. In fact, one of the most common initial responses of the male partners that we come across when assessing them is that all “I am healthy and all my reports are good” and then the whole responsibility is shifted to the woman partner alone.

So, what does “my reports are all good” actually mean? This refers to normal semen parameters as noted on standard semen analysis. But then the real question is if a normal semen analysis report indeed rules out male factor infertility! Recently there has been a big debate on how good a good semen analysis report actually is and if it is an accurate indicator or predictor of a man’s fertility. Well, the simple answer is No, it is not!  And, even though semen analysis offers a good initial assessment of male partner, there is more to sperm health and function than what a standard semen analysis picks up. It is now 300 years since Leeuwenhook first identified sperms under the microscope, yet it seems that we have only just begun to intelligently evaluate the concept of male Infertility and till date semen analysis remains the cornerstone for evaluation of male fertility.

Sperm production in the testis is a lengthy and tedious process and any adverse influence during the sperm production or maturation process can lead to an adverse sperm health and/or quality. According to estimates, up to 10% of men having normal semen parameters can actually fail to conceive due to undetectable damage in the spermatozoa. These men can be infertile without actually being aware of it and are often classified as unexplained Infertility, unless they are further investigated properly. Therefore, it is very important that the evaluation of male partner is not limited to only semen analysis, and is combined with comprehensive history taking, clinical examination and relevant endocrine /genetic investigations.

The real shortcomings of semen analysis include its inability to predict the fertilization potential of the sperms and the overall functional health (DNA integrity) of the sperms. Thus there is an increasing awareness about the need of supplementary tests to evaluate male partner and look beyond only semen analysis to assess the male factor infertility.

The reasons for infertility in such men can be attributed to development of anti-sperm antibodies, which interfere with a sperm’s ability to fertilize the egg. These antibodies cannot be detected on routine semen analysis and we need specialized tests to detect them. Also, the tests to detect anti-sperm antibodies have been in existence for a long time but since there is no particular treatment for this condition, these tests have not gained a lot of acceptance in clinical evaluation of infertile men. However, since these men benefit from IVF or ICSI for conception, an early detection of anti-sperm antibodies helps in overall management of the couple.

Another very common, and often missed, cause of male factor infertility is damaged sperm DNA. As discussed in one of my earlier articles, DNA is the basic genetic material and any abnormality or alteration in the sperm DNA affects its fertility potential – not just for natural conception, but also for IUI and IVF treatment. Damage to sperm DNA can happen at any stage of its development, maturation or transport – starting from beginning of spermatogenesis till the time of ejaculation. A number of factors can cause high DNA fragmentation. These include lifestyle factors such as smoking, excessive drinking and drug abuse, advanced age, exposure to environmental toxins, varicocele and infections causing oxidative damage to DNA.

One more factor leading to male factor infertility is dysfunctional sperms, as a result of which the sperms  may not be able to fertilize the eggs naturally. All these causes of infertility may be present in men with normal semen parameters.

ICSI has helped numerous couples with male factor infertility with seemingly normal semen parameters conceive by injecting the sperm directly into the egg for fertilization. This technique helps bypass many of the shortcomings of the sperms, but also increases the risk of selecting defected sperms, which could then pass  onto the offspring.

There is a lot of research in the field of andrology to understand and improve the health of sperms. This can help in not just improving the diagnosis of infertility and reducing the burden of unexplained Infertility, but also devising directed therapies to improve outcome of fertility treatments.

I will write about what should be done for couples having unexplained infertility with the male partner having normal semen parameters on semen analysis.

For any questions, please write to me at ivfgurgaon@gmail.com.