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Intra-Cytoplasmic Sperm Injection (ICSI)

Just as IVF revolutionized the treatment of female-caused infertility, Intra-cytoplasmic sperm injection (ICSI) was introduced as a major breakthrough in the treatment of male-caused infertility in which a single sperm is directly injected into the body (cytoplasm) of the egg. It is especially useful for patients where the male partner has a very low sperm count (oligozoospermia), poor sperm motility (asthenozoospermia) or too many abnormal sperms (teratozoospermia). Also, in men with obstructive azoospermia (zero sperm counts because of some obstruction in the ducts), sperm can be directly retrieved from the upper part of the testis called the epididymis (PESA-percutaneous epididymal sperm aspiration) and in cases of non-obstructive azoospermia, sperm can be retrieved directly from the testis (TESA – testicular sperm aspiration) and used for ICSI, thus helping them to have their own biological offspring without resort to a donor sperm.

More recently, we perform microsurgical testicular sperm aspiration using microscopes and multiple biopsies especially in cases of testicular failure with very small testes or high FSH levels (indicating testicular failure) and obtain sperm which are capable of fertilization.

When is ICSI Used?

ICSI helps the following patients:

  • Azoospermia (zero sperm count).
  • Oligozoospermia (low sperm counts).
  • Asthenozoospermia (poor sperm motility).
  • Teratozoospermia (too many abnormal sperms).
  • Retrograde ejaculation (sperm are retrieved from the urine bladder).
  • Anejaculation (sperm are retrieved using a special machine called electroejaculator).
  • Failed fertilization at conventional IVF.
  • Unexplained Infertility.
  • Wife's age > 37, eggs having a thick outer coat (zona).

Screening / Ovarian stimulation / Egg collection – these are done in the same way as described in the IVF section

How is ICSI done?

This procedure is very specialized, and requires a great deal of skill on the part of the scientist. We have a dedicated Embryologist just for ICSI who is available at the centre at all times and all days of the year. Special microscopes and micromanipulation equipment are required for this skilled procedure. To put it in perspective, an egg is approximately one-tenth of a millimetre across! The egg is gently held with a suction pipette (on the left in the picture below) while a sperm is picked up with a microinjection needle, and deposited in the cytoplasm of the egg after piercing the tough egg shell. By doing this, several barriers to the sperm have been removed, and fertilization usually follows. The day after injection, we can tell whether fertilization has taken place if there are two small spheres (pronuclei) visible in the egg. If fertilization is successful, the pre-embryo (zygote) is allowed to divide several times in culture medium in the laboratory, before it is transferred to the uterus or fallopian tube. Any "spare" good embryos resulting from the procedure can be frozen for more attempts later.

Steps Involved in ICSI

The mature egg is held with a specialized holding pipette.

A very delicate, sharp and hollow needle is used to immobilize and pick up a single sperm.

This needle is then carefully inserted through the zona (shell of egg) and into the cytoplasm of the egg.

The sperm is injected into the cytoplasm and the needle carefully removed. The eggs are checked the next morning for evidence of normal fertilization.

Success Rate

ICSI has similar success rate to IVF (about 50-60 % of embryo transfer procedures produce a clinical pregnancy). The success rates might look marginally lower than conventional IVF but this is due to the fact that you are dealing with a more difficult group of patients with compromised sperm quality in the ICSI group. Frozen embryo transfers after ICSI also have a similar success rate to those after IVF (about 60%). These results vary with female age resulting in a substantial fall in pregnancy rates in women over the age of 38.

What About Babies Born By ICSI

At the current moment, available research suggests that ICSI and IVF born children are normal. There is no increased risk of any anomalies or developmental delays in offspring born from these techniques. Stray reports which appear in the press may be related to children born from these techniques in the older age group which is at a higher risk for such anomalies (age related and not technique related). There are follow-up studies of children from Australia and Belgium until the age of 15 and beyond and they conclusively show that there is no increased risk of any abnormality in children born through IVF & ICSI as compared to normal born children. Whatever reports might have appeared were in women who were above the age of 35 and had IVF pregnancies using their own eggs. The point of the matter is that these women would have had similar outcomes even with natural pregnancies and the abnormalities were more likely due to the advanced age of the mother rather than the techniques of IVF & ICSI.

How to minimize your stay in Mumbai?

Please enquire about availability of injections/tablets as follows – Leuprolide acetate (brands – Lupride, lupron, luprdex, lupronin), Busaralin acetate (brands – Suprefact, Busarlin), Triptorelin acetate (brands – Decapeptyl) or any other GnRH agonist. Also, enquire for availability of oral contraceptive (birth control) pills (common brands – ovral L, novelon, femilon, triquilar, duoluton-L, ovral G, diane) Depending upon whether injections or tablets are available you can inform us and we may ask you to follow one of the following protocols.

Long protocol – Begin InjLupride / Busarlin 0.5 ml subcut once daily from 21st day of periods (counting from 1st day of periods) – take for 15-20 days – to be continued until arrival in Mumbai after a minimum of 15 injections (arrival on the first Friday after 15th injection). To be continued during (menstruation) periods. Procedure would be completed in 20 days after arrival.

Short protocol – Begin tablets of Norethisterone acetate 5 mg twice a day from day 20 of your periods. This has to be taken for a minimum of 7 and maximum of 14 days. We would ask you to take the last tablet on any Sunday and arrive on the following Friday after that. This would ensure that you get your periods a day before arrival so that we can begin injections immediately. Your stay in Mumbai would be for 20 days after arrival.

If flight (Visa) / train bookings are possible at short notice: Begin tab progynova (estradiol valerate) 2mg twice a day from the 25th day of the periods – Then wait for your next period. Arrive in Mumbai on the 2nd, 3rd, 4th, 5th or latest 6th day of periods. Make sure that you keep taking the pills even during your menstruation and until you meet DrJatin. This kind of programming helps us to begin injections for IVF as soon as you arrive without having to waste time waiting for periods to start.

Note : Details about ovarian stimulation protocols, embryo transfer, blastocyst transfer, embryo vitrification (freezing) and reasons for failure are same as in section on In vitro fertilization (IVF)

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