Intracytoplasmic sperm injection

Intra-cytoplasmic sperm injection (ICSI) is where individual morphologically normal sperm are immobilized and injected into a mature oocyte that has had its surrounded cumulus and corona cells removed. An inverted microscope with a heated stage and micromanipulating equipment (Fig. 46.7) is used. The oocyte is carefully positioned using a holding pipette under gentle suction, a very sharp glass injecting pipette is slowly inserted to rupture the oolemma and the immobilized sperm injected into the oocyte with a very small volume of the medium. The injecting pipette is then carefully removed and the oocyte incubated under the usual stringent laboratory conditions.

INDICATIONS

• Severe male factor including azoospermia and subsequent surgical sperm retrieval, either by MESA, TESE, PESA etc.

• Severe oligo-asthenoterato-zoospermia.

• Poor or total non-fertilization from previous IVF cycles.

• Preimplantation Genetic diagnosis cycles.

Most IVF units would have approximately 40 to 60% of their total IVF cycles using ICSI. Studies have been performed to see whether ICSI improves pregnancy rates with normal sperm parameters but there has not been any improvement shown by the routine use of ICSI [11].

RESULTS

Pregnancy rates of 36.5% per transfer are reported [12] with live birth rates of 30.4% per transfer based on over 28,800 cycles.

SAFETY

ICSI has been in clinical use since 1991 and all the results of the follow-up studies are generally reassuring. The current recommendations are that any male who has sperm parameters that require ICSI should be offered screening for karyotype as well as cystic fibrosis screening. Some centres also advocate the use of Y chromosome microdeletion screening, although this is not routinely offered. Cystic fibrosis screening is essential in cases of azoospermia, particularly if it is related to the condition of congenital bilateral absence of the vas deferens, as a significant proportion of these patients will be carriers of the cystic fibrosis mutations. Being a carrier does not preclude them being treated as a couple, but the female partner is then offered screening, and if she also is found to be a carrier, then they should be referred for consideration of IVF-ICSI with PGS.

If all the above results are normal, then the patients should be counselled carefully that there is a slight increase in genetic abnormalities of the offspring. Most of these abnormalities are thought to be minor and the major

Table 46.2 (a) Live births per transfer and singleton live births per transfer for assisted reproductive technology procedures performed among women who used freshly fertilized embryos from their own eggs, by patient's age — United States, 2002. (b) Live Births per Transfer for ART Cycles Using Fresh Embryos from Own and Donor Eggs, by ART Patient's Age, 2002

Table 46.2 (a) Live births per transfer and singleton live births per transfer for assisted reproductive technology procedures performed among women who used freshly fertilized embryos from their own eggs, by patient's age — United States, 2002. (b) Live Births per Transfer for ART Cycles Using Fresh Embryos from Own and Donor Eggs, by ART Patient's Age, 2002

Gynaecology Clinic

35-37

41-42

35-37

41-42

70 60 50 40

70 60 50 40

Intersex Organs
25 27 29 31 33 35 37 39 41 43 45 Art patient's age (years)

- Live births per transfer (donor eggs)

Live births per transfer (own eggs)

congenital malformation rate is generally thought to be similar to that of the general population.

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