Since the first successful birth in 1992, Intracytoplasmic sperm injection (ICSI) has become a widely used treatment for overcoming male factor infertility issues. The procedure has helped many couples realize their dreams of parenthood.

Dr. Jamie M. Knopman, Director of Fertility Preservation at CCRM New York discusses ICSI with Dreaming of Baby.

Daniela: Good afternoon, Dr. Knopman, and welcome to Dreaming of Baby! It’s a pleasure to have you with us today and we’re looking forward to discussing Intracytoplasmic Sperm Injection (ICSI) with you. Before we start our discussion, it would be great if you could introduce yourself to our readers as well as tell us a little about your work.

Dr. Jaime M. Knopman: Sure! My name is Jaime Knopman and I am a fertility specialist. I practice in NYC. I take care of both patients who are trying to get pregnant and struggling with infertility, as well as patients who hope to become pregnant in the future (fertility preservation).

What is Intra-cytoplasmic sperm injection (ICSI)?

Daniela: Great, thank you for this introduction. To start off, what is ICSI?

Dr. Jaime M. Knopman: We use a lot of abbreviations in fertility medicine. And because we talk fast it can be hard to understand what we are saying. ICSI stands for intra-cytoplasmic sperm injection. ICSI is a procedure that is performed in the IVF laboratory by an embryologist. ICSI came on to the IVF “scene” in 1992.

When is ICSI used?

Daniela: In the case of a couple trying to conceive, when is ICSI used? What are the issues that lead to the need for this procedure?

Dr. Jaime M. Knopman: ICSI was developed for men with poor sperm quality and quantity. Low sperm count, sperm motility, and abnormal morphology can be indications for ICSI. Abnormal morphology (shape of sperm) has been linked to poor fertilization. Therefore, some clinics will recommend ICSI for men with poor sperm morphology.In IVF, fertilization can be achieved through one of two ways: insemination or ICSI. With insemination, the embryologist will drop about 50,000 sperm on an egg. They will come back 18 hours later to see how many eggs were fertilized. Although the sperm is given a major head start (aka dropped on the egg) it still has to achieve fertilization itself. For some sperm, this “head start” is not enough. They not only need close proximity to the egg but also need to be physically injected into the egg to achieve fertilization. However, ICSI is no longer just used in cases of severe male factor infertility. We now also use it in cases of previous poor fertilization after IVF and/or genetic testing of embryos.

Charles: It is my understanding that ICSI can be used even with extremely low sperm counts. How much impact would you say ICSI has had on the fertility industry in terms of improving the chances of conceiving?

Dr. Jaime M. Knopman: It is a game changer for men with poor sperm quality. Fertilization can be achieved in places where it previously seemed impossible.

Dr. Knopman:”[ICSI] is a game changer for men with poor sperm quality. Fertilization can be achieved in places where it previously seemed impossible.

Charles: How frequently is ICSI used in IVF and what conditions are the most likely to result in the use of ICSI?

Dr. Jaime M. Knopman: The rise in both male factor infertility, as well as the genetic testing of embryos, has led to a significant increase in the use of ICSI. Because the indications have broadened, we see its use a lot more.

Daniela: Is ICSI used even for a first round of IVF – that is when there has been no history of prior poor fertilization?
Dr. Jaime M. Knopman: It can be if the sperm parameters are markedly reduced and both the fertility doctor and the urologist think it is indicated, OR when the couple is going to be doing PGS (genetic testing) of embryos.

The ICSI process

Daniela: So for the couple seeking fertility treatment, what does the ICSI process look like?

Dr. Jaime M. Knopman: The fertility doctor will assess the couple’s medical history and fertility factors and decide if ICSI is needed. If it is needed, then we will alert the lab and after the eggs are retrieved they will be prepared for ICSI. Only mature eggs can undergo ICSI; the cells surrounding the egg are removed ~ 3h after they are retrieved and then ICSI is performed on the mature eggs.

Charles: So to recap on ICSI, we are effectively injecting sperm directly into the egg?

Dr. Jaime M. Knopman: Correct!

How much does ICSI cost?

Charles: Does using ICSI increase the cost and can all clinics provide this service?

Dr. Jaime M. Knopman: It is slightly more expensive than regular insemination (so like an increase of ~ 1,000 dollars). All clinics can perform ICSI but like any IVF treatment, not all ICSI is created equal. A lot of success (aka how many eggs fertilize) has to do with the quality of the lab and the embryologist.

Are there risks associated with ICSI?

Charles: Is there any known risk to the egg when injecting the sperm directly into it?

Dr. Jaime M. Knopman: Unfortunately, there is risk to everything that you do in medicine. No procedure has a benefit without a risk. That is why we always weigh the risk and benefit ratio before we perform the procedure. That being said, in a good quality lab, the risk to damaging the egg while performing ICSI is small.

Charles: Understood; you shared earlier that ICSI came into play in 1992, has there been any improvements or is it still pretty much the same procedure as it was in 1992?

Dr. Jaime M. Knopman: The principles are still the same but like any procedure, as time passes, there are always improvements.

How effective is ICSI?

Daniela: Looking into pregnancy outcomes, how effective is ICSI?

Dr. Jaime M. Knopman: Fertilization rates are generally higher after ICSI is performed. The more embryos you have the better the chance of pregnancy!

Dr. Knopman: “Fertilization rates are generally higher after ICSI is performed. The more embryos you have the better the chance of pregnancy!”

When should ICSI not be used?

Charles: You have been a wonderful guest today, I do have one final question: in which situations would you advise against the use of ICSI? To be more specific, I am asking with regards to a situation where ICSI may seem like the right choice but isn’t.

Dr. Jaime M. Knopman: If your partner has good (normal) sperm parameters and you are not doing genetic testing of the embryos it is not necessary.

On a final note…

Daniela: We now have a very good overview of ICSI, thank you, Dr. Knopman. On a final note, what would be that one piece of advice you’d give a couple or individual concerned about their fertility and parenthood prospects?

Dr. Jaime M. Knopman: Don’t give up! While the whole process can be daunting and you may have never thought (or wanted) to be sitting across from a fertility doctor, if you hang in there and are willing to go down any fertility path, we can ensure that we will help you achieve your dream of being a parent.

Daniela: Thank for the insight you have shared with us today, Dr. Knopman. It’s been a pleasure speaking with you!

Dr. Jaime M. Knopman: You too! Have a great day.


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