ICSI (Intracytoplasmic Sperm Injection/Micro Injection)

The intracytoplasmic sperm injection (ICSI) is another possible IVF treatment. It is used when the man's sperm quality is very low.

The female eggs are extracted by puncture and then fixed under a special microscope with the help of a retaining pipette. One single sperm is injected in to each egg, using very fine micro-manipulation equipment. This is a very delicate procedure performed by highly skilled Embryologist under a microscope.

The ICSI, also known as microinjection, copies the natural procedure of a sperm's penetration of the egg cell. Using this method 50 - 70% of extracted eggs are fertilised. After 3 to 5 days the embryo transfer takes place. The pre- treatment of the patient is the same as in an IVF. The difference is that the sperm is not mixed with the egg cells in the laboratory, instead the sperm is injected into the egg.

This procedure overcomes many barriers to fertilisation which can include failed fertilisation from repeated use of conventional IVF, severe male factor infertility, very low sperm counts and/or motility(less than 10 million sperm per millilitre), high number of morphologically abnormal sperm, utilisation of surgically retrieved sperm, use of frozen sperm when limited in number and quality.

The ICSI treatment is applied in the following cases :
when the number of sperm is limited (less than 10 million sperm per millilitre) an earlier attempt at fertilisation has been unsuccessful ("null fertilisation") when there are morphological abnormal sperms: if the sperm's head doesn't have the correct shape to allow it to penetrate and so fertilise the egg.

Utilisation of surgically retrieved sperm, When there is no sperm in the semen sample. Use of frozen sperm when limited to number and quality. The first human pregnancy with ICSI was reported in 1992 and since this time thousands of babies have been born as a result of the ICSI procedure, providing many couples with hope previously not available.

If the ejaculate does not contain any sperm or the sperm found are not suitable for egg fertilization. TESA is a method to extract sperm cells from the testicles, after a urologist has confirmed that the chances of collecting sperm in that way are considerable. The procedure is carried out by andrologist under local anesthesia. In TESA a small tissue sample is collected from the testicles by using a thin needle/ by a small cut on the testicular surface, and the sample is immediately examined in the laboratory. Sometimes a single sperm sample is not enough and sperm cells must be extracted from the other testicles as well. Whereas in MESA, the sample is collected from the epididymal tissue. The gathered sperms are subsequently used in connection with ICSI for egg fertilization and /or frozen for future use.

There is a risk that no live sperm cells are found that can be used. In this case, the possibility of using donor sperm should be considered.

Male Infertility Screening Tests

Screening tests and other diagnostic tests for severe male infertility :

  • Genetic testing (chromosomal)
  • Microdeletion
  • Nuclear chromation fragmentation
  • Hormonal screens
  • Cystic Fibrosis screening

IVM : (In vitro maturation)

IVM also known as a natural cycle or minimal stimulation, IVM patients undergo a procedure whereby immature eggs are retrieved from the ovaries and matured in the laboratory in only one or two days. Eggs that reach maturity in the lab are then fertilized with sperm using the Intracytoplasmic Sperm Injection(ICSI) procedure. After the eggs are fertilized, the embryos are grown in the laboratory for two to five days before being transferred to the mother’s womb.

IVM of human oocytes was first demonstrated in 1965 by R. G. Edwards. The first human birth resulting from an oocyte matured in vitro occurred in 1991. Since that time, many modifications and refinements have been made to the process of IVM in an effort to improve the efficiency and ultimately the outcomes of the technique. To date, there have been approximately 500 live births worldwide as a result of IVM.

At present, there are three broad patient categories for which IVM might represent a viable alternative to traditional hormonal stimulation of the ovaries and subsequent in vitro fertilization(IVF).

Women with polycystic ovarian syndrome,(PCOS), who are at significant risk of severe ovarian hyperstimulation syndrome(OHSS) – these women represent a population which tends to be exquisitely sensitive to the medications required for ovarian stimulation in typical IVF protocols. Because IVM entails retrieving immature oocytes, little or no stimulation of the ovaries is required which virtually eliminates the risk of OHSS.

The second patient category which stands to benefit from IVM for reasons mentioned above is the group of women who have undergone IVF previously and developed ovarian hyperstimulationsyndrome(OHSS).

Finally, women who have received a cancer diagnoses and need fertility preservation prior to receiving chemotherapy are candidates for IVM. These patients could benefit from this technology as it would decrease the amount of hormones to which they are exposed as well as decrease the amount of time necessary between diagnosis and the initiation of treatment

Typically the IVM process requires minimal to no hormonal stimulation of the ovaries. An initial ultrasound is performed to determine if ovarian cysts are present early in the woman’s natural cycle. Several days later, a follow-up ultrasound will be performed to assess follicular and endometrial development. Once a follicle reaches an appropriate size, the patient undergoes a procedure where the immature eggs are retrieved and then matured in the laboratory in only one or two days.

The eggs are then fertilized with sperm using Intracytoplasmic Sperm Injection(ICSI). After the eggs are fertilized, the embryos are grown in the laboratory for two to five days before being transferred to the mother’s womb.

In 2009, the Cochrane Collaboration performed an exhaustive review of all known trials (published and unpublished) involving IVM in order to specifically compare live birth outcomes from IVM to that of IVF.

The result was that there was no study identified which was deemed suitable to adequately compare the two techniques. Therefore, data evaluating IVM success rates are limited to prospective and retrospective observational studies.

Generally speaking, in these observational studies, maturation rates of retrieved immature oocytes tend to be 60 – 70%, fertilization rates (generally by ICSI) 65 – 75%, implantation rates around 10%. and clinical pregnancy rates 20 – 30%. Particular note should be made that due to the lower implantation rates associated with IVM, most studies report replacing more embryos on average than is currently recommended by ASRM guidelines for patient age.

IVM technologies are still evolving and the technique is still considered experimental. IVM appears to offer some clear advantages over traditional IVF in some selected patient populations. However, before IVM becomes standard of care, continued investigation is warranted in order to ensure its safety and efficiency.

Because IVM does not require hormonal stimulation, this process requires fewer ultrasounds and blood test, However, because the IVM process does require an additional two to three lab days.patients will save the most by eliminating medications.

Cryopreservation of Oocytes and Embryos :

Cryopreservation is a method that has been developed for long term storage of cells and tissues and their subsequent use.

It is possible to cryopreserve embryos, oocytes(eggs), semen and ovarian or testicular tissue in liquid nitrogen.There are two methods of freezing that can be used – slow programmable freezing and flash-freezing process known as Vitrification.

Embryo freezing: slow freezing is not being used now
Spare embryos or eggs of good quality can be frozen and stored for future use. In case of failed IVF treatment in the first cycle, these preserved eggs offer a second chance of success without the need for ovarian stimulation and egg collection. The freeze method we use is called vitrification.

Vitrification : is the thecnique that has changed the face of cryopreservation
Vitrification is an ultra rapid embryo freezing method.Vitrification is a process of converting something into glass like solid free of any crystal formation.Like for blastocyst, by adding cryoprotectant,water can be cooled until it hardens like glass with out any ice crystals forming.

We have been using vitrification for a number of years and believe its a superior method of freezing with our own results showing significant improvements in pregnancy outcomes.