Intra-Cytoplasmic Sperm Injection (ICSI) - Information For Patients Saint Mary's Hospital

Saint Mary’s Hospital
     Department of Reproductive Medicine

     Intra-Cytoplasmic Sperm
     Injection (ICSI)
     Information For Patients

INS/DRM/CLI/018 V5/01/11/2013

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Contents                                         Page

What is ICSI and why is it necessary?             4

Which couples require ICSI?                       5

How is ICSI carried out?                          5

How successful is ICSI?                           6

What risks are associated with ICSI treatment?    7

Chromosomal abnormalities                         7

What happens if my chromosome test shows a
rearrangement?                                    8

Birth Defects                                     8-9

Developmental delays                              9

                                3

What is ICSI and why is it necessary?
Intra-cytoplasmic sperm injection (ICSI) refers to the technique
of injecting a single sperm into the centre (cytoplasm) of the
egg. In natural conception a large number of sperm surround
the egg and many attach to the outside, but only one sperm
penetrates and fertilises each egg. In IVF we mimic nature by
adding a large number of sperm to the dish containing the egg.
When fertilisation does not occur, it is usually because the sperm
cannot attach to or penetrate the egg. This can be because of a
fault with either sperm or egg. When abnormal fertilisation
occurs, it is usually because more than one sperm has entered
the egg.
ICSI overcomes problems of failed or abnormal fertilisation by
placing a single sperm directly in the centre of the egg. Any
problems with ICSI arise because this one sperm may not be the
‘right’ one, or because the injection procedure damages the
egg.
ICSI is relatively new and as such should still be regarded as
experimental.

                                 4

Which couples require ICSI?
Currently we are using ICSI in couples with reduced semen
counts or where there is reduced sperm motility, in which the
risk of fertilisation failure is increased, and also those who have
previously had very low or no fertilisation in an IVF cycle.
ICSI is likely to be the treatment of choice if the sperm is sub-
optimal.
We also use ICSI in the following situations:
• Reduced fertilisation rate after conventional IVF: less than
  40% normal fertilisation with at least 4 mature eggs
  collected.
• Failed fertilisation after conventional IVF.
• Use of surgically retrieved sperm.
• Patients who have had ICSI in previous IVF cycles should
  continue to have ICSI in future cycles.

How is ICSI carried out?
Except for the method of fertilisation, every other aspect of
your treatment cycle is identical for ICSI and conventional IVF,
including hormonal stimulation, egg recovery, producing the
sperm sample and embryo replacement.
On the day of ICSI, the embryologist carefully removes the outer
(cumulus) cells from each egg, using an enzyme normally
produced by sperm. This enables the embryologist to see inside
the egg using a high powered microscope and assess if the egg
is ‘mature’. All eggs can be inseminated by IVF, but only mature
eggs can be used in ICSI. In most treatment cycles,
approximately 80% of eggs are mature. The sperm are prepared
as normal for IVF. The embryologist then picks out individual
live sperm, of normal appearance and injects one into each egg,
using a special glass needle (see diagram on page 6).

                                 5

After ICSI the eggs are returned to the incubator overnight and
checked for fertilisation the following morning, as for
conventional IVF.

How successful is ICSI?
Approximately 6 out of every 10 eggs will fertilise successfully
by ICSI, similar to IVF. The reasons for ICSI fertilisation not being
100% successful include:
• Immature eggs cannot be injected.
• Some eggs may be damaged by the injection procedure.
  This appears to be related to the properties of the inner egg
  membrane.
• Even when injected directly into the egg, many sperm are not
  capable of ‘activating’ the egg.
Following successful fertilisation, embryo development is similar
for ICSI and IVF. Following embryo transfer, pregnancy rates are
similar to IVF. Many clinics report higher success rates for ICSI
compared to IVF, but this is only because the women having ICSI
are more fertile.

                                  6

What risks are associated with ICSI treatment?
ICSI offers the opportunity of success for couples who could not
achieve it otherwise. However, it is still a relatively new
technique and was not preceded by long term animal studies, as
is usually required for new medical techniques or drugs.
It is known that abnormal sperm production, as is the case in
men with very low sperm count or absent sperm in the
ejaculate, can be associated with genetic defects in the male.
As ICSI bypasses the normal processes of sperm ‘selection’ and
fertilisation, these genetic defects may be transmitted to the
children.
It is also possible that the egg may be damaged by the injection
procedure. Theoretically, this can result in damage to the
resulting embryo if the damaged egg is fertilised normally.
Although the great majority of babies born by ICSI appear to be
normal, the full implications of treatment will not be known for
many years, and you should be aware of the possible risks of
this procedure as detailed below. For further information please
see our main Patient Information booklet.

Chromosomal abnormalities
Men with very low sperm counts are more likely to have a
rearrangement of their chromosomes – known as a balanced
translocation (approximately 3–5%). This will be discussed with
you in clinic and a blood test can be arranged if this is the case.
Many of these rearrangements involve the chromosomes
responsible for sex determination (XX for women and XY for
men). If there is a rearrangement, this can lead to a
chromosome abnormality in any baby conceived. Many men
with low sperm counts will have a small deletion of their Y
chromosome, that is, a tiny genetic fragment may be missing.
This will not be found in routine chromosome testing. This
deletion may be passed on to a baby boy and may cause him to
have a lowered sperm count when he grows up.

                                 7

What happens if my chromosome test shows a
rearrangement?
• If an abnormality is found, the chance of a pregnancy is less.
• The abnormality may increase your chance of miscarriage and
  there may be implications for any child conceived.
• The child may be unaffected, it may display the same
  abnormality as its father or it may inherit an abnormality,
  which will affect the child more than the father.
• If an abnormality is found in your chromosomes this would
  be discussed with you in detail by one of our genetics
  counsellors.

Birth defects
The evidence on whether or not babies born after IVF or ICSI
treatment have a greater risk of birth defects is not yet
completely clear. More studies are needed in order to gain
further insight into these possible effects.
In 2005, a major European review of children born after ICSI
and IVF (followed up until 5 years of age) found that so-called
major birth defects involving the heart, lungs, musculoskeletal
or gastrointestinal systems, were present in about 2% of
naturally conceived offspring, 4% of children conceived by
routine IVF, and in 6% of children conceived after ICSI. A
substantial proportion of the abnormalities in the ICSI children
were problems in the development of the urinary or genital
organs, especially in boys. However, all of them were
correctable by surgery and they were found to be caused by
genetic factors from the father, rather than a result of the ICSI
procedure itself.

                                 8

Minor birth defects were present in about 20% of naturally
conceived offspring, 31% of children conceived by routine IVF,
and in 29% of children conceived after ICSI. Minor anomalies
are those which do not in themselves have serious medical,
functional or cosmetic consequences for the child. More recent
studies reported no difference in the risk for any anomaly or
specific anomalies after different types of IVF technologies
including ICSI.

Developmental delays
Some research papers concerning follow up of small numbers of
ICSI children suggest possible developmental delay in some
children conceived using the ICSI technique. This has not been
found in ongoing follow up studies in the UK and Europe.
Treatment will not be refused based on the results of above
tests or if a couple declines the offer of testing.
If you have any questions you feel need answering we would be
pleased to do this when you next attend clinic.
ICSI is relatively new and as such should still be regarded as
experimental.

                                9

Own notes/questions

                      10

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                                11

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   TIG 125/13 Produced November 2013 Review Date November 2015 (SF Taylor CM14401)