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Intracytoplasmic sperm injection (ICSI) is very similar to conventional IVF in that gametes (eggs and sperm) are collected from each partner, the difference being in the method of achieving fertilisation.
ICSI refers to the laboratory procedure where a single sperm is picked up with a fine glass needle and is injected directly into each egg . It is carried out in the laboratory by experienced embryologists using highly specialised equipment. Candidates to potentially benefit from ICSI include:
➥ Low sperm count
➥ Abnormal sperm or low sperm motility
➥ Sperm retrieved surgically from the epididymis (MESA/PESA) or the testes
➥ Sperm retrieved from urine or following electro-ejaculation
➥ High levels of antibodies in the semen
➥ Previous fertilisation failure using conventional IVF
The ICSI procedure fertilizes about 50 to 80 percent of eggs but fertilization isn’t guaranteed even when a sperm is injected into the egg. Once fertilization happens, the success rate for a couple using IVF-ICSI is same as a couple using conventional IVF.
In most cases involving male factor, a conventional ICSI procedure is usually performed where an expert embryologist examines the sperms using a microscope with magnification up to 400x and selects the normal motile sperms. However, in cases where the sperm samples are extremely low or highly abnormal, the selection of sperms may be done through IMSI or Intracytoplasmic Morphological Sperm Injection, an improved variation of ICSI.
IMSI is a technique that uses a high-powered microscope with magnification up to 6,000x to examine the sperms. The magnified digitally enhanced images of the sperm allow the embryologist to detect any structural alterations and abnormality that are otherwise hard to locate with conventional methods. This helps in the selection of the quality sperms with the most normal morphology for fertilization.
Azoospermia is a condition where there are no sperm at all in a man’s ejaculated semen and there can be various reasons for this. Sperm production and delivery involves a system of tubes within the male reproductive system. Azoospermia can be caused by an abnormality or blockage in the epididymis or the vas deferens – referred to as obstructive azoospermia. In these cases, sperm are being produced in the testes, they just can’t get out in the semen. Sometimes however, sperm production in the seminiferous tubules does not occur at all or is happening at such a low level that sperm are not detectable in the ejaculate – referred to as non-obstructive azoospermia.
This procedure is done under local anesthesia and is usually coordinated with their female partner’s egg retrieval. A needle is inserted in the testicle and tissue/sperm are aspirated. TESA is performed for men with obstructive azoospermia (s/p vasectomy). Occasionally, TESA doesn’t provide enough tissue/sperm and an open testis biopsy may be then needed.
This also makes use of the same needle and syringe technique as in TESA but in the needle is put directly into the epididymis.
TESE involves making a small incision in the testis and examining the tubules for the presence of sperm. It is either done as a scheduled procedure or is coordinated with their female partner’s egg retrieval. TESE is usually performed under sedation or local anesthesia. The sperms obtained are usually cryopreserved for future IVF/ICSI.
MESA is performed in the operating room under general anesthesia using an operating microscope. The sperms relieved are usually cryopreserved for future IVF/ICSI. MESA allows for an extensive collection of mature sperm as compared to aspiration techniques. It is the preferred method of retrieval for men with congenital bilateral absence of the vas deferens as it does not impact steroid production of the testis.
MicroTESE is performed in the operating room with general anesthesia under an operating microscope. It is carefully coordinated with the female partner’s egg retrieval, and is performed a day before the egg retrieval. This allows for each partner to be there for the other’s procedure. Patients frequently have donor sperm backup in case sperms are not found in the male partner. MicroTESE has significantly improved sperm retrieval rates in azoospermic men, and is a safer procedure since less testicular tissue is removed.
Ovulation induction uses hormonal therapy to stimulate multiple egg development and release, or ovulation. The choice of drug to be used is decided as per individual patient profile & diagnosis so as to achieve the maximum number of eggs. Subsequently, monitoring is done with blood tests & serial ultrasounds.
