ICSI for non-male factor infertility: time to reappraise IVF?

Preamble:

Intracytoplasmic Sperm Injection (ICSI) emerged in 1992 as a revolutionary breakthrough in the field of assisted reproduction. Dr. Gianpiero D. Palermo, an Italian scientist, pioneered this technique at the Brussels Free University in Belgium. This groundbreaking procedure allows individuals and couples facing male infertility issues, such as low sperm count or poor sperm motility, to have a chance at parenthood. By directly injecting a single sperm into an egg, ICSI bypasses many barriers, offering hope where it might have been elusive. ICSI's precision and success rates transformed fertility treatment and has revolutionized assisted reproduction, granting countless families the precious opportunity to conceive and experience the joy of parenthood. (Contributor, Ashok Agarwal)

A. Introduction:

Since its inception in 1992, Intracytoplasmic Sperm Injection (ICSI) has become a prominent technique in Assisted Reproductive Technology (ART) centres worldwide. It’s popularity has led to a shift from conventional in vitro fertilization (cIVF) in many cases. This article delves into the various facets of ICSI's utilization, its advantages, disadvantages, and its applicability within the realm of ART.

B. Rising ICSI Utilization and Expansion Beyond Male Factor Infertility:

Recent studies indicate a substantial increase in ICSI usage, even in cases where male factor infertility is not the primary concern. The proportion of ICSI procedures has surged significantly, suggesting potential overuse beyond its intended applications. This emphasizes the importance of appropriate selection criteria for ICSI, particularly when male infertility is absent.

C. Pros and Cons of ICSI and cIVF

While ICSI is often regarded as having better fertilization rates, this advantage does not always translate to superior clinical outcomes. A thorough analysis reveals that ICSI may not consistently offer improved results compared to cIVF. The comparison of key parameters like fertilization rates, pregnancy rates, and live birth rates between ICSI and cIVF demonstrates variations across studies. The safety and effectiveness of ICSI remain areas of ongoing concern, with potential links to birth defects and chromosomal abnormalities.

D. ICSI Indications and Applications in Non-Male factor Infertility:

1. Previous cIVF Failures

ICSI's effectiveness shines when addressing previous fertilization failures following cIVF, especially cases involving total fertilization failure (TFF). Studies suggest that ICSI can yield more favorable outcomes when dealing with poor or failed fertilization after cIVF attempts.

2. Limited or Poor-Quality Oocytes

ICSI has been proposed as a strategy to improve fertilization outcomes when dealing with a limited number of oocytes or oocytes of suboptimal quality. Although research findings vary, certain studies suggest that ICSI might lead to enhanced fertilization rates in these situations.

3. Advanced Maternal Age

ICSI has been advocated as a preferred insemination method for older women with non-male factor infertility. However, the findings across studies are inconsistent, with some studies indicating comparable fertilization and live birth rates between ICSI and cIVF approaches.

4. Preimplantation Genetic Testing (PGT)

ICSI is specifically recommended for PGT cycles to minimize paternal contamination and mosaicism. Nonetheless, clinical data do not consistently support the superiority of ICSI over cIVF in PGT cycles, necessitating case-specific considerations.

5. Cryopreserved Oocytes

Due to the potential hardening of the zona pellucida, ICSI is generally favored for inseminating cryopreserved oocytes. However, the absence of direct comparisons between ICSI and cIVF in this context calls for further investigation.

6. Unexplained Infertility

While certain studies indicate higher fertilization rates with ICSI in cases of unexplained infertility, the translation to improved clinical pregnancy and live birth rates is not always observed. Hence, careful consideration of the necessity of ICSI is crucial.

E: Limitations and Practical Implications

ICSI's broad utilization may not consistently result in enhanced clinical outcomes. Factors like cost-effectiveness, safety concerns, and potential overuse should guide the selection between ICSI and cIVF. The concept of "Physiologic ICSI," involving refined techniques like hyaluronic acid-based sperm selection, presents an avenue for improved outcomes, yet practical considerations must be weighed against complexity and cost.

F: Conclusion

While ICSI has transformed ART, its perceived advantages should be evaluated against potential drawbacks. The choice between ICSI and cIVF should be based on evidence-based medicine, tailored to each couple's unique circumstances. Practitioners should remain vigilant, continually review emerging research, and prioritize the best interests of their patients.

Acknowledgment:

This commentary was co-authored by Dr. Hrishikesh Pai (India) and Dr. Sunil Jindal (India). We gratefully acknowledge the time and effort invested by them in summarizing this article.

Contributors:

Hrishikesh Pai, MD, FCPS, FICOG,

Prof of Reproductive Medicine D Y Patil University Navi Mumbai India

Medical Director Bloom IVF, Mumbai, India

President, Federation of OBGYN Societies of India, 2023

hdpai@hotmail.com

+919820057722

www.drhrishikeshpai.com