When should ICSI be used?

IVF (ART) FormICSI: What is it?

ICSI (Intra Cytoplasmic Sperm Injection) is a technique used in many in vitro fertilization treatments. It involves fertilizing an egg by microinjecting a single sperm.

ICSI was designed to treat cases of male infertility such as oligospermia (low sperm concentration), asthenozoospermia (low sperm motility), or teratozoospermia (low sperm morphology), among others. Its application is determined by the gynecologist, andrologist, or embryologist, based on the seminal characteristics. It is also indicated in cases of unexplained infertility or previous fertilization failures.

With ICSI, the chances of transferring at least one embryo are 95%. The pregnancy rate per cycle is approximately 46%, depending on the woman's age and the number of embryos transferred. This rate may increase if the transfer is deferred. This pregnancy rate is reduced to 28% if the patient is over 40 years old, although these results improve when the transfer is deferred. The steps of ICSI are the same as those of classic IVF.

The only difference lies in the timing of oocyte fertilization:

1. Controlled ovarian stimulation: the patient receives hormonal medications to promote the maturation of a high number of eggs during the same cycle. Continuous ultrasound monitoring is performed to assess follicular development;
2. Ovarian or follicular puncture: this is a simple surgical procedure, performed under light anesthesia and lasting about 30 minutes. The gynecologist aspirates the liquid content of the ovarian follicles, where the eggs are located, through the vagina;
3. Decumulation: in the laboratory, the liquid obtained by puncture is analyzed to detect the eggs. After a resting period, the cells surrounding the oocytes are removed. This is a crucial step before performing ICSI. In the case of classic IVF, it will be performed the following day, as these cells are necessary for fertilization to occur;
4. Sperm collection and preparation: sperm is generally obtained by masturbation and prepared for fertilization. The preparation procedure is known as sperm capacitation and involves separating high-quality sperm from the sample for use in assisted reproductive treatment. In some cases, masturbation does not allow for sperm retrieval. Attempts will then be made to obtain sperm through testicular biopsy or epididymal aspiration;
5. Sperm microinjection: a sperm is selected, aspirated using the microinjection needle, and introduced into the egg, awaiting fertilization, i.e., the fusion of the genetic material of the two gametes;
6. Embryo culture: after fertilization, the embryos are left to continue their development in the incubator;
7. Endometrial preparation: the patient must receive progesterone orally or vaginally so that her endometrium is receptive and in optimal condition for embryo implantation;
8. Embryo transfer: depending on the quality of the embryos, the embryo(s) to be transferred to the mother's uterus are selected. This is a very simple technique that takes only a few minutes and does not require anesthesia. Using a thin catheter inserted through the vagina, the embryos are deposited at the bottom of the uterus, awaiting implantation in the endometrium and the beginning of pregnancy;
9. Embryo freezing: good-quality embryos that are not transferred will be cryopreserved for use in subsequent cycles;

When to use ICSI?

ICSI is performed when the sperm shows alterations, either in its motility or morphology (oligozoospermia, asthenozoospermia, teratozoospermia, cryptozoospermia, etc.) and the sperm is not able to penetrate the egg membrane to fertilize it on its own as occurs naturally.

ICSI can also be a solution when the male partner has few sperm, for example after a biopsy or testicular puncture (TESE, MESE). It is also a recommended technique in cases where the egg has difficulty fertilizing and/or we have a low ovarian reserve and in cases of previous fertilization failures.

This assisted reproductive method is also applied when frozen sperm must be used to fertilize the egg. For example:

• When the man has undergone a vasectomy and wishes to become a father using sperm frozen before the operation. Or because at some point in his life, he had to freeze his sperm because he underwent chemotherapy or radiotherapy;
• When sperm donation must be used because it is cryopreserved;

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Controversy over ICSI

In principle, there are no contraindications as such, but ICSI would not be indicated in cases of azoospermia, where a previous testicular biopsy informs us of the absence of sperm.

Furthermore, ICSI is a technique that presents few risks and complications:

• Multiple pregnancies in 14% of pregnancies achieved. The risk of this abuse is evident: it is a danger to the mother due to the weight of a multiple pregnancy and a danger to the children due to poor development or perinatal mortality. In Israel, there was even a case where a woman who had six embryos transferred, all of which implanted, had to undergo two abortions when the pregnancy was well advanced. Teams concerned with the transfer of surplus embryos transfer as many embryos as possible. Forty percent of IVF deliveries are by cesarean section and prematurity is well established;
• Severe ovarian hyperstimulation syndrome (1% of patients), which occurs mainly in patients under 30 or in patients with polycystic ovary syndrome. This risk can be mild, moderate, or severe. This is a potentially life-threatening syndrome, characterized by large ovaries (five to six centimeters in case of mild hyperstimulation) that tend to rupture, which can lead to intraperitoneal hemorrhage, hydrothorax, and thromboembolic phenomena. Then there are the dangers related to oocyte retrieval techniques, which include the risks of any surgical intervention and general anesthesia;
• Possible psychological effects, resulting from repeated failures. There is a danger to the health of women, leading in some cases to suicide: the psychological effect of the failure of the technique due to the disproportion between the expectations proposed by the doctors and the harsh reality;

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