Hail Mary in the Lab: Demystifying Rescue ICSI

In this intriguing episode of "Taco Bout Fertility Tuesday," Dr. Mark Amols takes us on a deep dive into the world of rescue ICSI (Intracytoplasmic Sperm Injection). With a blend of medical expertise and relatable analogies, Dr. Amols unfolds the complexities behind this emergency fertility procedure used in unexpected cases of failed fertilization. Discover why rescue ICSI isn't just a simple backup plan, but a nuanced decision with varying success rates compared to planned ICSI. This episode illuminates the crucial differences, providing clarity and hope for those navigating the challenging journey of IVF. Tune in to understand why in the delicate dance of creating life, timing and technique are everything!

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Transcript

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Today we talk about rescue ICSI. I'm, doctor Mark Amos, and this is taco. About fertility. Tuesday,

it was 06: 0:25

00 a.m.. it was just another day. Blue skies, and Kathy was by herself. She pulled the dish out of the incubator and looked in the microscope. Oh my God. She thought the medics came in immediately. They walked in the room and said, what's the situation? And Kathy said, none of the eggs fertilized. And that's when the mech said, we're gonna need rescue ICSI. Okay, it's really not that dramatic, but we had to have fun with this. But one of the reasons I want to do this podcast is because I think many people don't understand what rescue ICSI is. Matter of fact, one of my patients. The other day said to me, hey, let's just try the standard insemination, and if it doesn't work, you can just. Icsy it with rescue ICSI. And the thing is, yes, you can do that, but that's a very bad idea. So first, let's talk about what ICSI is. It's abbreviation for intracytoplasmic sperm injection. ICSI, sometimes pronounced ICSI, and it's used. For people who have poor sperm quality. In fact, my wife and I had. To use ICSI because my sperm count is low. And so what they do is they take that sperm, they inject it into. The egg one sperm at a time, and then that allows fertilization. Now, naturally, eggs usually fertilize around 80%. But with ICSI, it could be closer to about 70%. Now, that seems like a horrible number thinking, man. If you put that sperm inside it, it's only 70%. But yes, that's kind of the standard. Percentage, and that's because there are more things going on there than just putting the sperm in. There's egg quality issues. There can be DNA issues in the sperm, and so 70% is actually a fair number. The other option is standard insemination, where you take the sperm and put it on top of the egg and you allow it to fertilize naturally, where the sperm then goes through the granulosa cells to the zona pilosa of the egg and fertilizes it. The problem is sometimes this doesn't work. And we get there the next day, and we look in the petri dish and we see that the sperm have. Not fertilized the eggs. And then the question is, do we do rescue IcSI? And you would think, yes, 100%. Why would you not? That egg needs to be fertilized. But there are actually criteria that need to be met to be able to do rescue ICSI. Now, the reason why this isn't needed much is because most of the time we are always planning if someone needs to do ICSI. Most clinics do over 50% ICSI. But there are parameters that tell us. When ICSI may be needed. For example, if there are problems with. The sperm on, the shape of. The sperm, called terrazzospermia, we would do icsi. If the quality of the sperm is poor, we would do Icsi. If even failed fertilization in the past. Or poor fertilization, we would do IcSI. Now, there are some clinics that only do IcSI. They don't ever do anything else. And there's nothing wrong with that. That's just the way they do it. And that's a fair way to go. But for some people, they don't want. To do ICSI or they would rather. Have the higher chances of fertilization with standard insemination. The difference here is standard insemination. Insemination, could theoretically fail. The sperm may not get into the. Egg, whereas at least with ICSI, you. Know, the sperm is getting in the egg. But what about rescue ICSI? So rescue ICSI is basically an emergency procedure we're using because we had unexpected failed fertilization. Again, we didnt expect it, so we werent even planning it. Whats interesting is that what happens is. They come in the morning and they look at the embryos. Now you have to understand, to be able to see the embryos, you have. To first strip the cells away from the embryos. So if youre doing ICSI from the standard standpoint, youre going to do it. Right from the beginning. The day of the retrieval, they go. And they strip the cells off of the embryo so they can see which ones are mature, and then they inject. Them with a needle. Now, if youre doing standard insemination, they dont do that. They just go and put the embryos with the sperm. And usually theres a certain quantity of sperm you want per egg. And so thats calculated. And then the next morning they come in, they look at the embryos, they cant see them yet. They strip them, and then they find. Out if the eggs have fertilized. If they notice the eggs have not. Fertilized and none of them did, then. That would be a good time to do rescue icy. And there are signs of failed fertilization. For example, if you go and you look at the egg and there are. No sperm attached to the zona pellucida, which is the kind of shell that the sperm go through to get into. The egg, then that points to there. Was problems with the sperm attaching to. The egg and would explain why they didn't fertilize. Versus if you see a whole bunch of sperm attached to the egg but they're all failed fertilized, then there's this question that comes up which is how. Do you know a sperm didn't get into it and we just haven't seen. It split and we put another sperm into it. Now we're going to have two sperms in one egg, whereas in standard IVF. It'S only one sperm per egg. Because if you put two sperm in, that's how you get molar pregnancies. So one of the standards is if you go in the morning and you. Look and you see, let's say four. Of the eggs have fertilized, but eight. Of them did not. You cannot do rescue ICSI because at that point you can't assume that they didn't fertilize. You just have to assume they didn't fertilize at all. Not that there's something wrong. The same token though, if you go. And maybe theres one that has fertilized. And the rest of them have not fertilized, then that is a clinical decision. If theres no sperm attached to any. Of them and just one look fertilized, then you can potentially make that decision. And that is something they should talk to the patient about. But the standard is technically if you have no fertilization at all, then rescue ICSI is warranted. And again, there are signs of that. Because the sperm is not attached to the egg. But if you even have one egg that has fertilized, technically you should not do rescue IXc. At our clinic, we tend to follow. The rule, if one fertilized, we don't do rescue exceed. But I do think it's important to understand that. I do think clinically there are times that people can deviate and that's a. Decision that they have to decide on for themselves. So then the question is, what's the big deal? Why wouldn't everyone try standard and SEM? And then worst case you have to do rescue. I mean, basically you get the best of both worlds, but in reality you don't see the embryos that are created. From rescue, I see, end up being poor quality and end up not having the same success rates. Matter of fact, even the fertilization themselves ends up being lower than the fertilization that would occur if you just. Did ICSI as planned. What this means is this is not a rescue ICSI that has high chances. But actually it's kind of a Hail Mary, and really it should be called Hail Mary Icsi. That's because the chances are not gonna. Be as good at, ah, the fertilization. And the quality of those embryos will. Not be as good, leading to lower live birth rates. Matter of fact, I had a patient of myself who went through, and they had failed fertilization, and we had to do rescue ICSI, and her embryos were not very good quality, very few made to the end. The grading of them were poor. And afterwards, they almost wanted to give up. And I remember her talking to me. Saying, like, you know, obviously this is a sign and that we're not supposed to have kids. And I explained to her that, no. Please understand that, you know, this is. Because of the rescue ICSI, and that, you know, if you did this again and we planned ICSI, things would go just fine. And I remember her partner just could not understand this. He just could not understand how. Why would it be any different? It's still the same technique. And I try to explain that when the egg has been sitting there for 20 something hours and having late fertilization. Like that, there's effects that occur. I remember I had to come up. With an analogy to help explain to him, because he was just almost furious. Like, how could I tell him that. It would be different? I explained to him, like, I finally. Came with this horrible analogy about a. Subway sandwich, and that even if it's. The greatest sandwich in the world, if someone, let's say, contaminated that sandwich with something disgusting, it's going to taste bad. But there's nothing wrong with the sandwich. It's just that in that situation was bad. And so finally he kind of got to the point going, oh, so it ruined the ambrose. I'm like, exactly. You never actually got a chance to try the real sandwich because someone ruined it from the beginning. Now, I'm not going to use that. For analogy here, because, again, I had that for him because I had to, like, brute force cope with something that a guy would understand. But for you, I have a different analogy. We know that when you have a heart attack, if you treat it immediately, the success is very high. But the longer it takes until you can get an AED and get treatment. Your chances of surviving a heart attack are lower. And that's because some of the damage has already been done. Now it's not a, perfect analogy. Because it doesn't go exactly like that. But that's the same principle. When you do XC plan, it's being. Done at the right time, just like it happens in nature, but when it's. Being done at the very last second. When basically the egg is about ready to start dying, the fertilization rate is. Lower, and the quality of those embryos. End up being lower. Now, I, don't want you to think they won't work. Many, many pregnancies have come from rescue ICSI. Many of our pregnancies have come from rescue ICSI. It's just, the point is, it's not. Gonna be as good. And never judge that cycle as what would have happened. With plan ICSI, it's different. And that patient I told you about, they did do transfers, and they did have chemical pregnancies, but eventually they went through IVF again, and we did Planix. And they got more embryos, high quality embryos. Now, instead of CC grades that were. Like A's and B's, and they ended. Up having success doing an embryo transfer. Now, I wasn't surprised, but they were. Surprised, because in their mind they're like, what's the difference? But the difference is humongous. The important part to understand is not. Just do the quality of the embryos. End up being different, but also that chances of getting pregnant are different. So why did I do this podcast? What was the purpose of it? Because I felt there were two things that were misconceived. The first is that you can just try regular insemination. If it doesn't work, you can use IcSi. And as I just presented, you can't do that. That's a horrible idea. If you need ICSI, start with ICSI, because as I talked about, doing rescue. ICSI is not the same thing as plan ICSI, and that you will actually. Have lower fertilization, and you will have. Poor quality of those embryos. That will lead to a lower live birth rate. As we discussed, the eggs viability is declining. As you get closer to that 24. Hours window where the egg is going. To, undergo a process called atresia and die. Just like if I got a heart attack and someone waited 2 hours to. Come see me, I'm probably not going to be around. But if I have an aed that's five minutes away, I might be able. To survive just like an IVF with ICSI. So that brings up two points, obviously. The first point is never try standard sim, with the thought that rescue x is going to be just as good. It's not. You will have lower quality embryos and will have less top quality embryos with rescue ICSI compared to planned ICSI. But the other thing that thinks important, even if you understand that, is that understand that cycle should not be what you measure doing another cycle, meaning if you do poor in that cycle, don't. Think that you're not going to have success doing now ixy planned, it's going. To go much better. But it's hard for you to feel that way. And some people will just give up. Thinking, well, there's no point. It was so bad and they even did icsi. But you have to look at it from the standpoint of once it fell further, the cycle already was poor. And at that point they were doing a Hail Mary, hoping that maybe, just. Maybe, they can get a few embryos to give you a chance. And if it worked, hallelujah. That is awesome. But if it doesn't, don't look as. Like, oh, we're just doing it again, the same thing's gonna happen. No, you're doing it, completely different now. You're getting the medics to the person a lot faster and not waiting until theyre about ready to die, which the. Egg is at 24 hours. Instead, right when the eggs expecting it. Youre injecting the sperm in right from. The beginning, fixing the fertilization issues and. Having a completely different IVF cycle with. More top quality embryos. Hopefully this was a, useful episode for you. Maybe you learned something, maybe you have. A friend going through this and you. Can tell them about the point is. Of this episode is to help you. Understand why rescue ICSI is there and. That it's not really a rescue ICSI. But a Hail Mary. ICSI never rely on standard insemination if you know you need ICSI and that they can just try rescue ICSI, it's a horrible idea. And that some clinics where it can be very expensive, you can even get charged for that rescue ICSI even when you're not there planning it. And that could be a hidden surprise and cost. As always, if you like the podcast, please tell your friends about us. And if you like it enough, go on on your favorite medium and give us a five star review. We really appreciate it. I look forward to talking to you guys next week with another great episode of Taco Belt Fertility Tuesday.