The Needle in the Egg: Should You Choose ICSI?

ICSI—also known as intracytoplasmic sperm injection—sounds complicated, but it’s one of the most powerful tools in modern IVF. In this episode of Taco Bout Fertility Tuesday, Dr. Mark Amols breaks down what ICSI really is (hint: it’s the ‘needle in the egg’), when it’s a game-changer, and when it might just be an unnecessary add-on. From male factor infertility to frozen eggs, genetic testing, and even rescue ICSI, you’ll learn exactly when this treatment makes sense and when it doesn’t—so you can make the right choice for your journey.

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Transcript

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Today we talk about, a big question that comes up in almost every IVF cons. Should I do ixy? Im Dr. Mark Amols, and this is Taco about Fertility Tuesday. Whether you're in the middle of an IVF cycle, or maybe you're going to be going to an IVF cycle at some point, there's going to be the question of should you do ixsi? Now, for some clinics, this is optional. For other clinics, they make everyone do icsc. And the question is, should you do it? Is actually really worth it? And when is it just an extra add on? Well, let's start first with what is ici? Icsi. ICSI stands for Intracytoplasmic Sperm Injection. Thats a mouthful, but the idea is pretty simple. Instead of putting sperm with thousands of sperm on top of the egg, instead we pick one sperm and we inject it directly into the egg. Now, what'interesting is this isn't something that has been around for a long time. Matter of fact, in 1992 was the first time it was performed in a successful IVF cycle. Interesting enough, thats when I met my wife. Unbeknownst, to us, we were going to have fertility problems, specifically my sperm. And if it wasnt for ICI being created when we met each other, we wouldnt have kids. So thank you, Dr. Palermo. But whats interesting is ICSI isnt just for people who have low sperm count. There are other times you would use it. For example, ache freezing wouldn'even be possible if there was an ii. And that's because when you freeze eggs for future use, the eggs zonallsa, which is a shell on the outside, will actually harden. And so there'be really very little wa for the sperm to get into with natural fertilization. So without icsi, we wouldn't even be able to freeze eggs. Which is pretty profound thinking. How many people freeze eggs now? And it wouldn't be possible because you wouldn't be able to fertilize them later. Another situation where ICSE is going to be needed is in what's called PGTM M, which stands for Monogenetic Disorders. In that situation, you don't want to have a lot of sperm around the eggs because when you go to take a biopsy of the embryoator, those sperm are still stuck in the zone of pelluszida. They're kind of just left over from earlier. And so when you take that biopsy, you could actually get some of those sperm and could cause the results to be inconclusive or potentially unable to differentiate between real disease and possible contamination. So clearly ICSI is very important. It is something that has changed our field tremendously. But ICSI was developed for severe malactor. But this is common. Sometimes something made for something can be used for other things. Just like ivf. IVF was made for women who had block fallopian tubes. Whereas now a lot of IVF is done for other reasons. But as ICSI has grown and is used for more than just malactor, the real big question is should everyone be using excc? And the answer is very simple. No. And thats where the guidelines help. Now when we look at the American Society of Reproductive Medicine, also known as asrm, there are some clear cut cases where ICSIA is absolutely recommended. So the first one is going to be male factor infertility. Anytime the sperm count is going to be low or the sperm are not moving very well or theres concern thats not going to be able to penetrate the egg due to lets say very low morphology, like 0 or 1%, which is the shape of the sperm. Saying that only 1% of the sperm have that perfect shape, then ICSI is going to be used and it will be a game changer. The other situation would be whenever you attieve sperm a lot of people don't realize but when you retrieve sperm from the testicle, the amount of sperm you get is actually very minimal. So you cannot do artificial inseminations. You must do something like IVF because you're going to need ICSI to inject the spermmin due to the small quantity of sperm you have. Now the other two areas that we talked about were one was PGTM M that's a situation where you'looking for a disease in a stray sperm could contaminate the sample and would not lead to clean results and potentially the results wouldt be reliable. So its a common time to use ICSI when youre doing pgtm. The other situation we talked about was frozen eggs. Frozen eggs tend to have a harder outer shell and so ICHIA allows us then to inject the sperm in to allow people to have success with their frozen eggs. Another situation thats absolutely supported by the ASRM is a prior fertilization failure. Meaning when you go through IVF and they put the sperm on top of the eggs, if none of them fertilize, then ICSIA is going to be recommended next time because there'obviously some type of issue between the sperm and the egg that prevented it from fertilizing. Theres this saying Once ICSI always ICSI meaning if you'had Felvefert and youve used IY youE just going to always do it again. Youe not going to expect the sperm to somehow be better. Think of it like my Arizona Cardinals. I love them, but I expect theyre never going to really get better. So Im eventually going to die before they get a championship. Thats how we look at sperm. Once its'done bad, we just assume its always going to be bad. Now its'not unreasonable. If lets say youve did something to correct the sperm and you want to go back to standard insemination where you just put the sperm on top of the eggs, its not unreasonable. Talk to your doctor. But what I would tell you is if you'ever had Felford, pretty much every time in the future, no matter with another clinic, you should be recommended continue with icy. So those are pretty clear indications of when XCE should be done. But where is XCC debated? Well, per the ASRM routine, ICSI in non male factor cases doesnt improve fly birth rates. So what this is saying is that clinics who do it all the time, no matter what, technically shouldn't be doing that because it doesn't benefit the patient. Matter of fact, it even kind of lowers your chances a little bit because standard insemination usually does have a better fertilization rate than icsi. Matter of fact, I'm astonished how some clinics make everyone do exc and then also make you pay several thousand dollars for it. At our clinic we do give the patient a choice, but there are times will tell them they need to do XC in that we would not recommend doing standard insemination. Now it doesn't make these clinics wrong who require everyone to do exceed. There is a reason why they do that and that reason is because it lowers the risk of failed fertilization, which really is one of those rare things that can happen. But when it does, it's devastating. Imagine you're someone who's coming from, let's say another country and you come to the States to do ivf, maybe for someone like gender selection and you go through and the sperm looks good. They do standard stem. Nothing fertilizes. When you think about that, think of everything you had to do to come to that clinic, come to another country and nothing fertilized. Thats the reason some people will do ICI for everyone. Now I dont think you need to. I think you can look at the situation and determine who are the best ones that have it. It doesnt mean I cant be wrong. I have been wrong before. But What I'm saying is that there are situations that just kind of make sense to do exam. So, for example, let's say you've been together for 10 years and you can't find anything wrong and you haven't got pregnant. Technically you shouldn't do icc. However, I'm going to recommend ICC every time. Why? Because I don't have a reason for why you aren't getting pregnant. And so in my mind, I'm wondering, could there be some type of issue with fertilization? Now, you don't have to jump in all the way and say, okay, we're going to do ICI. You could say, well listen, let's do 70% ICSI and 30% traditional. That way we can figure out if there is a problem with the fertilization. Another situation is going to be where there's very few sperm. So, for example, I'm not saying that there's not enough sperm. What I'm saying is that let's say your partner had cancer and you have one VI sperm left. Technically you can just thaw that sperm and do it as standard insemination. But you dont get a lot of tries. Theres not endless supply of that sperm now because it was frozen prior to their cancer treatment. So in that situation, I would recommend ICI because I would want to use a little bit of the sperm by chipping some of it off, doing ivf, and then you can do multiple, multiple cycles. Now, for most clinics, when they are not doing ICI as a standard, what they'll do is they'll usually do a small SEME analysis on the day of to verify there isn't something wrong with the sperm. Just because your sperm has been good on prior semen analyses does not mean on the day of the retrieval that you can't have a bad day. We do that same thing. And then the other thing we do is we do a morphology test. If we notice one of those are wrong, then what we'll do is switch you over to ICSI as long as you'consented for us to do that. When I've had patients put no XE and I know they need it, I will talk to them and say, listen, we will not do icsi, but I highly recommend you do it because I'm concerned or not going to have fertilization and I've had patients say, nope, we don't want to do icsi. And just, like I suspected, their fertilization was poor. So the point there is, talk to your doctor. Theyve seen a lot of these cases. And so if you are at a clinic that does allow you to choose, it'very important to talk to them. Dont listen to me, Dont listen to some facebook post or some other group. Talk to your doctor because they know your situation best. Now the next topic is what happens when it doesn't fertilize. You probably heard you could do rescuexy and so if you can rescue it and do exc, why do you need to even try exeing to begin with? Well, that's a great question. Because if that was true and you can just do rescuexc and you could help any egg that didn't fertilize, no one would start with icsi. The problem is rescue ICSI is not as good as doing the icy. Meaning if we could take 10 eggs and those 10 eggs are exactly identical and one of them you did ICI from the beginning, the other 10 you did ICSI after they filled fertilization. What you would find is the ones that you did after feled fertilization will do much poore. When I say poor, I'm not talking about lower fertilization. I mean the quality of the embryos will be poorer. The pregnancy rates when you do implantation will be poorer. The grating of the embryos will probably be lower. It might be called rescue ixy, but really it should be called Hail Mary ICI because in reality you're already in a bad situation and now you're just trying to turn a bad situation into an okay situation. So the point of that is never rely on standard and SEM because you think you can always do rescue icy. Rescue xe is a Hail Mary. If you need xi, you do it from the beginning. So lets bring this all together. Lets talk about the pros and the cons. So the pros of ICI 1 its going to solve fertilization problems and male factor causes. 2 essentially you need to use it anytime youre using surgical procedures to retrieve the sperm. 3 if you'doing something like pgtm, it helps keep the genetic testing accurate because it prevents contamination from other sperm. 4 When it comes to freezing eggs, it allows us to fertilize the eggs with a high success which makes an egg freezing possible. And number five, it can prevent repeat heartbreaks if you have fertilization failures in the past. Now lets talk about the cons. But one of them is extra cost. At our clinic we actually don't charge that much. It's about 500 dolars,$600 wearge for ICSI. But there are clinics that can charge 2,000, $3,000. And like I said, it actually surprises me when they force you to do it how they can force you to pay. Now that's me on my soapbox. Obviously people have to charge for what they have to charge, but it's just something that's always bugged me at my clk on the first time we did it, they did this, I thought it was frustrating and had to pay for something that we didn't even have the choice to use. Now technically I have bad sperm, so we have to use it regardless. One of the other cons of using ICSI is theres technically slightly more manipulation of the egg. You know, we get worried about things like embryo biopsies where were taking three cells from like 100 cells. But when you think about it, youre sticking a needle into one cell. If that cell dies, its over. If you take three cells from an embryo that has 100 cells, that embryos is can be fine. So we give so much concern to biopsies because we think and they're like pulling the cells out. In reality, ICSI can be very dangerous. And for some patients who have very fragile eggs, theyggs can actually die at the time of fertilization or even the next day we come back and then they die. So there is some manipulation of the egg that could potentially hurt your eggs. And so that's why you don't want to do it just to do it. The third thing when it comes to cons is going to be there's actually no benefit when the sperm and the eggs are normal. So we have normal sperm factor. There's no other reason like you haven't been TR them for 10 years, then using ieed doesn't really benefit to and as I said, you could technically say it might be a, this benefit because your fertilization rate would be lower. Whereas ice is around 70% and standard inseminations closer to 80. So that takes us to the final point and that is the question we asked from the beginning. Should you choose ICSI if it's one of those five reasons we talked about male factor sperm that's been retrieved through surgery, they're doing genetic testing such as pgtm. You're using frozen eggs or you've had fill fertilization? Absolutely. In the situation where you don't have any problems, should you do it just to prevent not getting fertilization? Well, that could be a costly mistake. I'm not going toa lie. If I'm traveling across state to a clinic and let's say I'm only getting one shot at this. I may not want to take the risk and say yeah, I want to do ici, but I'm someone who's older who might have fragile egs, maybe I don't have that many eggs and I have no reason to do ic. As scary as it may sound, it would be better to do standard fertilization because remember, complete failed fertilization is very uncommon. So unless some of those situations for when you should do ICXI are known and none of those apply, the routine use of ICXSI is improen to make a difference and ASRM doesn't recommend it for everyone. That doesn't mean you can't do it. And that's why I go back to the point talk to your doctor. When I am trying to make that decision I'm looking at it from multiple perspectives. Not just is it needed because of criteria but I'm looking at the whole picture. How long have they been trying? Has that person ever had proven fertility? Well if the guy sperm is perfect but I found out the last three partners he's had never got pregnant. I'm going to be worried about something and even something as simple as just coming from another country. When I have someone coming from another country I almost always do exceed because why? Because if it fails it's tremendously going to be a problem. They have to come all the way back from another country just to be able to do IVF with us. So for me it makes sense in that situation, even if it's just a minor issue to push them towards icy. That's the reason we make it just a very substantial cost because we don't want anyone not to do it because of cost but we also don't want people just to do it to do it. If you're at one of those clinics that makes everyone do it, ask them why they recommend it for you. I can guarantee you they have a reason and thats the point. Always talk to your doctor. ICSI is one of the most powerful tools we have in modern fertility treatment but it isnt a one size fits all solution. Hopefully this episode is able to help you determine if that solution is for you. And if you think it isnt t or it is talk to your doctor and they may agree or they may disagree and their reasoning may be right but you need to talk to them. If you found this episode helpful, please tell your friends about it. Tell another friend who might be going through the same thing but always tell people about us. Give us a five star review on your favorite medium and as always, keep coming back. I had several people send me messages to tbft@newirectionfertility.com about some future episodes, which I'm going to be putting together. Thank you for that. And I encourage others to do it as well. I can assure you, if you're questioning something, someone else is too. I look forward to talking to you again next week. on Talk About Fertility Tuesday.