IVF-ICSI: intracytoplasmic sperm microinjection

The sperm microinjection or ICSI is a process of in vitro fertilization (IVF) by which a sperm is microinjected directly into the interior of the ovule in order to obtain good quality embryos. Since it is a way to perform IVF, we often refer to this method as IVF-ICSI.

The main advantage of this technique is that it offers high success rates, which in many cases allow pregnancy to be achieved on the first attempt, even in the most severe cases of male factor sterility.

The fact that it is an IVF, with all the phases that implies, makes the price of a fertility treatment with ICSI is about 3000-5000 ?.

Below you have an index with all the points that we will discuss in this article.

Index

IVF-ICSI: intracytoplasmic sperm microinjection

1. What is an ICSI?
2. Differences between conventional IVF and IVF-ICSI
3. When is an ICSI done?
3.1. Azoospermia
3.2. Oligozoospermia
3.3. Astenozoospermia
3.4. Teratozoospermia
3.5. Combination of alterations in the semen
3.6. Other indications
4. IVF-ICSI step by step: phases of the process
4.1. Complementary techniques
5. Success rates and percentage of effectiveness
6. Possible risks
7. Price of the sperm microinjection
8. Questions from users
8.1. What is a PICSI?
8.2. When doing PGD, is it better to do conventional IVF or ICSI?
8.3. What is special about the IMSI?
8.4. Is ICSI effective with testicular biopsy?
8.5. After how many attempts of ICSI is pregnancy achieved?
8.6. Is sperm microinjection done in Social Security?
8.7. Why is ICSI not always done instead of conventional IVF?
9. Recommended reading

What is an ICSI?

ICSI comes from the acronym in English intracytoplasmic sperm injection, which means intracytoplasmic sperm injection.

This technique consists of choosing a sperm with good mobility and aspirating it inside a microinjection needle to later introduce it inside an ovule.

In this way, it seeks to ensure that the union of the female and male gametes occurs, that is, fertilization.

Differences between conventional IVF and IVF-ICSI

The main difference between artificial insemination and IVF is that, in the first, fertilization occurs inside the woman, without the need to extract the ovules. On the other hand, in the second, the ovules are extracted and fertilized in the laboratory to later transfer the embryo of better quality to the maternal womb.

ICSI and conventional IVF are similar assisted reproductive techniques that only differ in the way of introducing the sperm into the interior of the ovule:

IVF conventional the sperm itself that has to cross the barriers of the ovule to penetrate it. ICSI sperm is introduced into the ovum by a microneedle, directly and, therefore, is more complex than IVF.Intracytoplasmic sperm microinjection (ICSI)

Another difference is the price, because the greater technical complexity implies a slightly higher cost of the ICSI. However, in many clinics the price is the same for both procedures.

When is an ICSI done?

The appearance of the ICSI technique was a revolution to treat cases of sterility by severe male factor. In these situations, sperm microinjection is indicated because it is the therapeutic option that offers the best results for these patients.

However, this technique is also chosen in many couples who resort to IVF despite not having a severe male factor to ensure that fertilization occurs correctly.

Some of the most important indications are:

Azoospermia

This cause of infertility is due to the absence of sperm in the ejaculated semen. There are two main ways in which this occurs:

Obstructive azoospermia spermatozoa are not able to reach the rest of the seminal content by an obstruction in any of the spermatic channels. Although there is production, there is no expulsion of spermatozoa.Azoospermia secretory sperm fail to occur, since the problem is in the testicle, where they should be manufactured. Types of azoospermia

Oligozoospermia

It refers to poor semen quality due to lack of sperm concentration. According to the WHO (World Health Organization), an amount equal to or greater than 15 million sperm / ml of semen is recommended.

This cause of male infertility is also called oligospermia.

There are different degrees of oligospermia, being more severe the further away from the reference value. There are also many causes that can cause this alteration, such as varicocele, for example.

In very severe cases, we speak of cryptospermia or cryptozoospermia, which refers to sperm concentrations below 100,000 sperm / ml of semen.

Astenozoospermia

Also called asthenospermia, it is a problem that measures the quality of the sperm according to their mobility. As stipulated by the WHO, is considered astenozoospermia when the number of progressive sperm or displacement is less than 32%.

In addition, the total percentage of mobile sperm should exceed 40%.

ICSI due to mobility problems of sperm

Teratozoospermia

Teratozoospermia or teratospermia refers to an alteration in the morphology of sperm. According to Kruger's criterion, if these are abnormal in more than 85% of the sample of ejaculate, it is considered a cause of male sterility, so that the patient would be recommended ICSI treatment in case of wanting to get paternity.

According to the WHO criteria, a semen sample is considered to be teratozoospermic when it has more than 96% of the abnormal sperm in its morphology.

Combination of alterations in the semen

In addition to the aforementioned seminal alterations, it is possible to detect several altered parameters in the same semen sample.

Thus, we can find cases of:

Oligoastenospermiaproblems in the concentration and mobility.Oligoteratospermia alteration of the concentration and morphology.Astenoteratospermiaas mobility and morphology are altered.Oligoastenoteratozoospermiaproblems of mobility, morphology and sperm concentration.

Other indications

ICSI is also recommended in men who have had a vasectomy and men with an infectious disease (HIV, hepatitis, etc.).

Another common case of application of ICSI is the case of men with frozen semen after undergoing oncological treatment (radiotherapy or chemotherapy) or because it is impossible to obtain an ejaculate under normal conditions.

Regarding female infertility, the causes for which they usually resort to an ICSI technique are less numerous. These are cases in which a low number of oocytes have been obtained after ovarian puncture due to low ovarian reserve, oocytes with thickened zona pellucida or when there is poor oocyte quality.

However, it is a controversial topic, since many specialists defend that, in cases where the ovules are more delicate, it is more advisable to perform a conventional IVF because it is more physiological and, therefore, less aggressive for the oocytes.

IVF-ICSI step by step: phases of the process

The steps to follow in an ICSI are the same as for conventional IVF, the only difference is at the time of the insemination of the oocytes as we will see below:

Controlled ovarian stimulation: the patient receives hormonal medication to promote the maturation of a high number of quality ovules in the same cycle. Follicular development will be continued to study the follicular development.
Ovarian or follicular puncture: when the control ultrasound indicates that the follicles are of a size close to ovulation, the puncture is scheduled. It is a simple surgical procedure, performed under mild anesthesia and lasting about 30 minutes. In it, the gynecologist is vacuuming, vaginally, the liquid content of the follicles, where are the ovules.
Decumulation: in the laboratory, the liquid obtained in the puncture is analyzed in search of the ovules. After a time of rest, they are decumulated, that is to say, the cells they may have around them are removed. It is an essential step before carrying out the ICSI. In the case of conventional IVF, it will be done the next day, since these cells are necessary for fertilization to occur.
Collection and preparation of semen: sperm is usually obtained by masturbation and is prepared for fertilization. The preparation procedure is known as sperm capacitation and consists of separating high-quality sperm from the sample for use in the treatment of assisted reproduction. There are some cases in which masturbation does not allow sperm to be obtained, so we will try to obtain them by means of a testicular biopsy or aspiration of the epididymis.

Stages of the ICSI process

Sperm microinjection: a sperm is chosen, aspirated with the microinjection needle and introduced into the ovum, waiting for fertilization to occur, that is, the fusion of the genetic material of both gametes.
Embryo culture: after fertilization, the embryos are allowed to continue their development in the incubator. The incubators maintain optimal conditions of temperature, light and humidity for embryonic growth.
Endometrial preparation: the patient must be administered, orally or vaginally, progesterone to ensure that the endometrium is receptive and in the best conditions for embryo implantation to occur.
Embryo transfer: the embryo or embryos (a maximum of 3 in Spain) that are to be transferred to the maternal womb are selected based on embryo quality. This is a very simple technique that lasts a few minutes and does not require anesthesia. Using a thin catheter inserted into the vagina, embryos are deposited in the fundus waiting to be implanted in the endometrium and start pregnancy.
Embryo freezing: good quality non-transferred embryos will be cryopreserved for use in later cycles.

Phases of the process of an ICSI

Complementary techniques

In some cases, it may be necessary to use other techniques to achieve pregnancy or increase the chances of success, such as:

IVF-ICSI with testicular biopsy In patients with azoospermia, own sperm can be obtained through a biopsy of the testicle. In these cases, the technique of choice will be the ICSI.pICSI (physiological ICSI) by means of this technique, the sperm that are more likely to fertilize under physiological conditions, that is, in a natural way, can be separated.IMSI (intracytoplasmic injection of morphologically selected spermatozoa) ) allows to select spermatozoa with better morphology before microinjection. ICSI with annexin columns (MACS) allows the selection of non-apoptotic sperm, that is, of better quality. FIV-ICSI with PGD (preimplantation genetic diagnosis) thanks to the genetic analysis of a or several cells of the embryo, it is possible to select to transfer only embryos free of genetic diseases. Assisted hatching is to make a hole in the zona pellucida of the embryo to facilitate implantation. Although this technique is already in disuse in many laboratories, sometimes it is still done. Complementary techniques of ICSI

Success rates and percentage of effectiveness

The probability of success of this technique varies according to each particular case. Although there are many factors that can influence the rate of pregnancy through IVF, the age of the woman who undergoes treatment is one of the most influential.

An approximation of success rates according to age is as follows:

40% in women under 35 years old.
Between 27-36% in women from 35 to 37 years old.
Between 20-26% in women from 38 to 40 years old.
Between 10-13% in women over 40 years.

We must not forget that these rates are very general and that they can change not only depending on the case of sterility of each patient, but also of the reproductive center where we perform the treatment.

It must also take into account what data are analyzed when making statistics. For example, there are those who consider success a positive result of the pregnancy test and who speak of success only in case of birth of the child. Therefore, we must pay special attention when comparing the results of assisted reproduction treatments between different clinics.

If you want to know more about the success rates that are achieved with this technique, in this link you can get more information: ICSI results.

Possible risks

The main problems that may arise after treatment with ICSI are:

Ovarian hyperstimulation syndrome is a side effect of medication. It is due to the excessive response to hormonal treatment for ovarian stimulation. It can lead to discomfort, swelling, etc. However, nowadays, it occurs on a few occasions and practically never becomes serious. In this sense, the echographic controls during the stimulation are fundamental. Multiple pregnancies in the cycles in which two embryos are transferred, the probability of having a twin pregnancy is 6%. If three are transferred, the probability of having a twin pregnancy is 12% and having a triple is 3%. Currently, there are several studies focused on improving the selection of higher quality embryos to avoid having to transfer more than one. Therefore, the studies are aimed at improving the success rate of the transfer of a single embryo. Natural abortion is calculated to occur in 20-22% of cases. Most spontaneous abortions occur in the first weeks of pregnancy. Ectopic pregnancy occurs when the embryo implants in an extrauterine area. The statistic tells us that between 2 and 5 women out of 100 subjected to in vitro fertilization can have an ectopic pregnancy. In pregnancies conceived naturally, the probability is 1- 1.5%.

Price of sperm microinjection

The costs of an IVF-ICSI treatment, as with any technique of assisted reproduction, are variable and can vary between very different figures, depending on the center, the city and the needs of each infertility situation.

Some peculiarities, such as having to resort to the donation of ovules or spermatozoa, performing PGD or performing a testicular biopsy, can substantially change the price of the treatment.

In any case and in a generalized way, the price of the ICSI is between ? 3,000 and ? 5,000. Generally, there is no distinction in the price for conventional IVF or ICSI, although there may be variation in some clinics depending on the method of fertilization applied.

In the ORG Assisted Reproduction Discount Section, thanks to our collaboration agreement with different clinics, you will find a great variety of ICSI treatments with a reduction in the price.

In addition, the first visit is free to better adapt to the needs and personal situation of each patient: Discount coupons in FIV-ICSI.

Typically, the cost of treatment does not include ovarian stimulation medication, so it is important to be well informed before starting the process. The cost of this medication will vary depending on the protocol indicated by the doctor. However, it is usually between 1000 and 1200 ?.

Another aspect to take into account when considering the cost of an ICSI is the personal situation in which each couple or person is. The treatment can result in success the first time or, on the contrary, having to repeat the cycles on more than one occasion. Therefore, depending on the degree of infertility and the attempts that are needed, the price may vary.

Questions from users

What is a PICSI?

The PICSI technique refers to what is known as physiological ICSI (phisiological ICSI in English). It is a form of sperm selection prior to introduction into the egg.

It is based on the ability of sperm to bind to hyaluronic acid, a substance that covers the ovules. To carry it out, a special plate is used in which there are some drops of a substance similar to hyaluronic acid that covers the ovules. Thus, the sperm capable of adhering to the plaque will be the highest quality and potential fertilization.

When doing PGD, is it better to do conventional IVF or ICSI?

When the pre-implantation genetic diagnosis (PGD) is going to be applied, the fertilization of the ovules is done through the ICSI method to avoid possible interferences in the PGD results.

In conventional IVF, many sperm that have tried to penetrate the ovule remain attached to the surface of the ovule and its genetic content can be dragged during the embryo biopsy performed in the PGD, which may alter the final result of this technique.

What is special about the IMSI?

IMSI means intracytoplasmic injection of morphologically selected sperm. It is an ICSI in which the microinjection sperm has been carefully selected based on its morphology. In order to select the sperm, the ICSI is performed under a high magnification microscope that allows to see in detail the morphological qualities of the sperm.

Therefore, the IMSI is an ICSI performed under a 6300 magnification microscope instead of the usual 400 magnifications of the ICSI.

Is ICSI effective with testicular biopsy?

It will depend on each case. If in the testicular biopsy it is possible to obtain at least one quality sperm for each ovule to be fertilized, the probability of success will be high. If, on the other hand, no live sperm are found in the biopsy, microinjection can not be performed.

After how many attempts of ICSI is pregnancy achieved?

There are those who achieve pregnancy on the first attempt and who need two, three, four or more attempts to finally achieve the desired pregnancy. There are many factors to consider and, therefore, it is not possible to establish a general number of attempts.

Some factors that influence are the quality of the ovules and spermatozoa, the embryonic quality, the cause of infertility and the state of the endometrium, among others.

Yes, currently, most assisted reproduction units have a microinjector and, therefore, apply the ICSI technique when necessary.

Why is ICSI not always done instead of conventional IVF?

The specialists in assisted reproduction always try to solve the problems of fertility approaching as much as possible to the naturalness of the reproductive process. In the conventional IVF technique, it is the sperm itself that reaches the ovule and penetrates it through its own means. On the other hand, in the IVF-ICSI, it is the professional who deposits the sperm directly inside the ovule. Therefore, IVF is closer to the natural process of pregnancy search.

In addition, in conventional IVF, there is natural selection of the sperm, which in ICSI is made by the specialist's criteria. If a sperm is able to fertilize the ovum on its own, this indicates that it is of good quality and, therefore, that it will most likely give rise to viable embryos.

On the other hand, at ICSI we go a step further and allow sperm with quality problems to be able to fertilize. For example, sperm with mobility problems but viable in other aspects naturally or through conventional IVF will not be able to fertilize the ovum but they will do so through ICSI.

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