IVF or ICSI: What is the best way to fertilize an egg?

IVF vs ICSI, which is better? Couples faced with male infertility are often given many options for fertility treatment. Learn what’s best.

Intracytoplasmic sperm injection (ICSI, pronounced “Ik-see”) was designed as a treatment for male factor infertility, but these days it has many different indications.  ICSI involves injection of a single sperm into an egg that has been harvested for the purpose of in vitro fertilization (IVF).

The first baby born from ICSI was in 1992 and since that time ICSI has revolutionized the treatment of infertility worldwide. Currently, ICSI is used in 60 to 100% of IVF cycles, depending on which area of the world you have your fertility treatment.

Infertility affects about one in six couples, and male factor is the single most common cause. There are many different problems that can affect a man’s sperm, some of these are genetic, but in most cases the cause is never determined. If the sperm count is low (oligozoospermia) or they do not swim well (asthenozoospermia) then the sperm will not be able to make it through the woman’s uterus and fallopian tube to reach the egg for fertilization. Abnormally shaped sperm (teratozoospermia) may have trouble swimming and/or penetrating the shell of the egg.

Before the availability of ICSI, standard IVF was used for more than 10 years. Standard IVF means that a woman’s eggs are stimulated with hormones and then harvested from the ovaries and placed in a dish (in vitro is Latin for ‘within the glass’). More than one hundred thousand sperm are then ‘sprinkled’ on each egg and the dish is placed in an incubator. This means that the sperm must compete for the egg and fertilization occurs in a similar way to what happens in a woman’s body. When the sperm count is not perfect however, standard IVF can result in a very low number of eggs being successfully fertilized. From there, the resulting embryos (egg + sperm = embryo) do not all develop normally, and furthermore every normal embryo does not lead to a healthy pregnancy. I tell patients that it takes a lot of eggs just to make one successful embryo!

ICSI means that instead of hoping the sperm makes it into the egg on its own, an embryologist would pick the healthiest looking sperm from a sample and inject it directly into the egg. To say it simply, with ICSI the sperm doesn’t have to swim or break through the eggshell, it just has to show up inside the egg. It is not currently possible to test the DNA inside the sperm to make sure it is normal before using it, so the embryologist chooses based on appearance. Even sperm with abnormal shapes (morphology) can be used to create a healthy baby. The packaging of the sperm does not necessarily reflect its genetic potential. In men who have no sperm at all in the ejaculate (azoospermia) a surgical procedure can be used to extract sperm directly from the epididymis or testicle (TESE or microTESE) which can be used for ICSI.  Fertility clinics must be highly specialized to offer this procedure. Using the techniques of microTESE and ICSI, azoospermic men (who prior to 1992 would not have been able to have a genetically-related child) are now able to have a family.

Embryologists require years of training and experience to properly perform ICSI. An anti-vibration table keeps the micromanipulation tools steady while the sperm is suctioned into a tiny needle and then injected through the egg’s shell (oolemma). Factors that can affect the success of embryos beyond this point include a woman’s age, egg quality, and sperm DNA quality.

A 2012 committee opinion from the American Society for Reproductive Medicine (ASRM) concluded that ICSI is best used for male factor infertility, frozen eggs, couples with previous failed fertilization and preimplantation genetic testing.

ICSI is considered to be safe for the couple and the resulting child. There have been over a million babies born from IVF worldwide. The earliest babies are now into adulthood and having children themselves.  The large majority of studies on IVF suggest that infertility itself, rather than the process of IVF, is largely the cause of adverse outcomes after fertility treatment.  But, this does not account for all birth defects.

Babies born from men with very low sperm counts who required ICSI may have a 1 – 2% increase in birth defects, which includes future low sperm counts in the male babies. The most significant risk factor for birth defects after IVF is actually pregnancy with multiple babies (twins, triplets, etc). The good news is that this is preventable. Worldwide, clinics are working to reduce the number of embryos transferred at once, in order to lessen this risk. It is important to keep in mind that human biology is never perfect. Birth defects occur in more than 3% of all pregnancies, even when they are naturally conceived.

In summary, the availability of ICSI has transformed the lives of many men whose sperm count would never otherwise have allowed them to have a baby of their own. In the hands of a highly experienced fertility clinic, ICSI is not harmful to the sperm or the egg and it can help couples get the maximum number of embryos during their IVF cycle. Although it was initially developed for male factor infertility, it now has many other indications to optimize fertilization.

Remember that every couple is unique and your fertility doctor can best advise you on whether standard IVF versus ICSI is the right decision for you.

What to Expect at a Fertility Clinic: Your first visit

A visit to the fertility clinic does not have to be a daunting experience. Here’s a brief overview about what to expect if you decide to visit a specialist.

A visit to the fertility clinic does not have to be a daunting experience. Many couples think they are responsible for figuring out the reasons for their lack of fertility on their own (or with Dr. Google’s help). A visit to the fertility clinic does not represent a failure in this regard – it’s actually just the opposite! Seeing a fertility doctor can help to ease the stress of trying to conceive by taking the burden of medical expertise off a couple’s shoulders. Ideally, this means you can get back to trying for a baby and spend less time thinking about trying for a baby!

Usually, a family doctor or gynecologist will make the referral to a fertility clinic on your behalf. Fertility doctors are specialists in women’s medicine (Obstetrics & Gynecology) with additional training on top of that (usually two or three years more) in Reproductive Endocrinology and Infertility. If it takes two to make a baby, they why are fertility doctors mainly gynecologists? It is because the female portion of fertility treatment is arguably more complex. There are specialists in male fertility (urologists) who work with fertility clinics when necessary.

Before your first visit each member of the couple will need to undergo some basic testing. Standard protocol dictates that the man and the woman will do basic blood testing for infectious diseases (HIV, hepatitis and syphilis). We also do some additional hormone blood tests for the woman (day 3 FSH and estrogen level) to test her egg number and make sure she is immune to chicken pox and rubella in preparation for pregnancy. Men are also asked to do a sperm test (semen analysis). Collecting a sample for a sperm test can be awkward in some circumstances.

Here are some tips to make things go smoothly.

Sometimes you can produce your sample at home: Our clinic operates in British Columbia and Alberta, in both of these provinces, outpatient laboratory or hospital-based sperm testing is covered by provincial insurance (so you do not have to pay out of pocket). The sperm sample has to be produced on your own (usually off-site) and then dropped off at the lab, ideally, within thirty minutes. Your doctor’s office or the lab should provide you with a sterile plastic cup to collect the sample. You can hold it close to the body on the way to the lab to keep it warm. You may need an appointment before dropping of the sample, so check with your local lab first.

A brief period of abstinence is important: The ideal duration of abstinence before collecting a sperm sample is two to five days, but even a shorter time between ejaculations should not decrease the sperm numbers. Even if you rush to the lab with your sample, it is common that the lab will take over an hour before processing the sample for analysis. This can have an impact on the sperm movement scores (motility), but your fertility doctor can usually tell if this is the case. Our fertility clinics offer the option to collect and analyze the sperm sample on-site at our specialized labs, but unfortunately healthcare does not cover this (cost is $100-250). Results of the sperm test are usually available within a week.

Plan to reserve at least 60 minutes for your visit: When you attend the first visit to the fertility clinic plan to be there for 30 – 60 minutes. It is best if both members of the couple can attend. The fertility doctor will go through a detailed history of the woman’s cycle, any previous pregnancies or miscarriages, past medical problems and medications. The man’s medical history is also important and you will both be asked about any health problems that may run in your families. It is important to disclose any medication, supplement or recreational drug use as these can have an impact on egg and sperm quality. Remember, your doctor is there to help and all information is completely confidential.

You can expect your fertility specialist to review the results of all of the tests you have done so far. He or she may perform an examination of the woman including an ultrasound of the uterus and ovaries. Further testing is often necessary before a final diagnosis can be made. This means that you will leave your first visit with a basic understanding of where you’re at, but you may not have a definitive plan for treatment yet. You should have a chance to ask questions and to describe your goals to your doctor and you should leave feeling like you are on the path to progress in your fertility journey. Sometimes one member of a couple feels really stressed out by trying for a baby and the other does not see things as being urgent.

Don’t worry, we get that. As I said, it takes two to make a baby and we’re here to help you both.