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Question 55. My husband and I were told by one RE that we needed ICSI, but another RE says that we don’t. What should we d

Posted Sep 19 2011 9:54pm
So if you have read the survey results you are aware that most readers like the clinical vignettes that I post to illustrate points of interest. ICSI really is an amazing procedure. It really should not work and yet we have hundreds of thousands of babies born after IVF/ICSI and some clinics do only ICSI and never do just plain IVF....

This year I had a returning patient. She and her husband had been successful with Natural Cycle IVF with ICSI. We did ICSI because they had unexplained infertility and his sperm parameters were slightly abnormal. Since they delivered a healthy baby after the second NC IVF, we thought that this should be a no-brainer.

However, that is not how it worked out. We kept getting tripped up. Almost all possible outcomes were experienced from no fert to embryo arrest. But the couple had absolutely no desire to try regular IVF. They were uncomfortable with many aspects of stimulated IVF and only wanted to try NC IVF.

Finally, on the 6th NC IVF since delivering I suggested that we try no ICSI as sperm quality looked OK. Guess what? Beautiful egg, normal fert, beautiful blast and now an ongoing pregnancy.

So was it doing IVF and not ICSI that made the difference or was it just time for them to have success....who knows.

This case demonstrates the difficulties we face in advising patients. Sometimes the decisions are clear cut but sometimes logic seems to depart. Patients want clear cut decisions and advice but as physicians we should be careful to reconsider all options if success is eluding us...

So as we keep working our way through all 100 Questions here is today's Question of the Day
55. My husband and I were told by one RE that we needed ICSI, but another RE says that we don’t. What should we do?

ICSI is accepted as a standard treatment option for infertile couples with severe male factor infertility. In most clinics, approximately 50% to 90% of the eggs that are injected with sperm using ICSI will fertilize normally. Some eggs do not survive after injection with the sperm and subsequently degenerate.

The criteria regarding what constitutes severe male factor infertility, however, vary from clinic to clinic. One the one hand, some clinics use ICSI for all (or nearly all) patients based on the theory that assisted fertilization is better than no fertilization at all. Most clinics employ ICSI based upon specific sperm parameters. In general, ICSI is employed in cases where the semen analysis reveals abnormalities related to sperm count (less than 20 million/mL), sperm motility (less than 50% are motile), or sperm morphology (less than 30% have a normal shape). ICSI should also be considered in couples with no previous evidence of fertilization or a history of failed fertilization with a prior IVF attempt. ICSI must be used in cases of sperm obtained from the testicle or epididymis in men with azoospermia. Some clinics use ICSI in all cases of IVF with frozen donor sperm.

Not all cases are clear-cut, for example, in our clinic we often perform an IVF/ICSI split if sperm parameters are normal but the couple have no previous pregnancies. That is, the eggs that are collected during the oocyte retrieval phase are divided between normal fertilization and ICSI. If some component of male factor infertility is present, splitting the eggs between ICSI and IVF may reveal whether the sperm can actually fertilize an egg. If the eggs fail to fertilize with IVF but fertilize normally with ICSI, then the logical conclusion would be that the sperm is incapable of fertilizing the egg with IVF alone. Couples with unexplained fertilization failure with IVF may have a problem with the sperm, the egg, or both. In such cases a repeat cycle of IVF using ICSI will usually yield good fertilization results and, ideally, a pregnancy.
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