Debate: Are We Limiting the Potential of Oocytes by Not Using ICSI for All? - ICSI for Some

Abstract

Intracytoplasmic sperm injection (ICSI) was invented nearly thirty years ago and the first pregnancies in Australia were obtained at the Queen Elizabeth Hospital in the University of Adelaide’s Reproductive Medicine Program. Since then, ICSI has become the predominant method of fertilisation for IVF in cycles in Australia and in many parts of the world used for 100% of all cycles. While its value for male factor infertility, IVM egg fertilisation and injection into previously frozen eggs have been validated, the use of ICSI for non-male-factor infertility remains controversial and unproven. Given the significant concerns about the potential effects of ICSI on the health of children conceived by this method, a debate about its use in an excessive number of IVF cycles is warranted. The first randomised control trial of ICSI versus standard IVF fertilisation for unexplained infertility occurred more than twenty years ago and showed a lower ongoing pregnancy rate for those who received the ICSI form of fertilisation. Despite this evidence, ICSI continued to grow in prevalence across Europe, North America, the Middle East, Asia, and Australia for non-male factor infertility. Significant cohort studies started to emerge from the US and from Europe that showed either no benefit from ICSI for unexplained infertility, or indeed harm, in terms of ongoing pregnancy rates. This year we published in The Lancet, a randomised control trial where couples with unexplained infertility and a normal total sperm count and motility were randomised to receive either ICSI or standard IVF as a fertilisation method. No significant benefit of using ICSI was found with respect to ongoing pregnancy or live birth. The potential health benefits to the child and the cost effectiveness of the treatment weigh against the routine use of ICSI in the presence of normal sperm. Other cohort studies show that there is no benefit of ICSI for low egg numbers, advanced maternal age, or preimplantation genetic diagnosis. Examination of the use of ICSI across Australia, shows enormous variations between states and within the same state. It is clear, that members of the Society have very heterogeneous view of the use of ICSI and my intention in this talk is to encourage everyone to be more critical of its use when there is no sperm abnormality. I would encourage clinicians to use the normal natural processes of sperm selection which occur in routine IVF without sperm injection.