| Intracytoplasmic Sperm Injection |
Treatment for Severe Male Infertility
Male factor infertility affects 40% of couples. In the past, these men had no alternative except adoption. In the last twelve years, ICSI (Intracytoplasmic
Sperm Injection) has revolutionized treatment for severe sperm defects. This allows the direct injection of a single sperm into an oocyte to achieve
fertilization, with sperm that otherwise would not penetrate the oocyte.
East Coast Infertility and IVF performed the first ICSI procedure in Monmouth and Ocean Counties in 1995. Over the past seven years we have consistently
surpassed the national delivery averages for ICSI. Success has also occurred with the use of sperm obtained from the testicle or epididymis. These
treatment cycles require prior performance of TESE (Testicular Sperm Extraction) or MESA (Microscopic Epididymal Sperm Aspiration).
Male factor infertility has historically been one of the most difficult to treat causes of infertility. In the past ten years the diagnosis and treatment of severe
sperm defects has been revolutionized by advances in ICSI (Intracytoplasmic Sperm Injection). This technique was initially developed in Belgium and is
performed in conjunction with IVF (In Vitro Fertilization) to fertilize the oocytes (eggs). It allows the direct injection of a single sperm into an oocyte to
achieve fertilization, with sperm that otherwise would not penetrate the oocyte. Initial success rates led to a 26% pregnancy rate per cycle while some
centers have achieved pregnancy rates of 35% or higher. As the technique has improved the limitations of success has become the age of the woman,
which effects "oocyte quality", rather than the sperm factor problem. Success has also occurred with the use of sperm obtained from the testicle or
epididymis. These treatment cycles require prior performance of TESE (Testicular Sperm Extraction) or MESA (Microscopic Epididymal Sperm Aspiration).
Severe male factor fertility defects have as a common denominator the inability of the sperm to fertilize the oocyte. The diagnosis is often made by
evaluation of sperm parameters such as density, motility and morphology. Nonetheless, this also needs to be suspected in cases where the man has not
previously achieved a conception and the woman partner has no diagnosed fertility problems. Even normal appearing sperm may have molecular level
defects in the sperm head or sperm surface that does not allow fertilization to occur. In rare instances men with prior documented fertility may develop
sperm defects due to new diseases such as hypothyroidism, hemochromatosis, hyperprolactinemia, pituitary tumors, severe stress or trauma. Occasionally,
men may have intermittent descent and retraction of the testicles leading to alternating periods of fertility. Diagnosis of this fertility failure can be very
difficult. Strict sperm morphology assessments (Kruger morphology) as well as oocyte penetration tests (hamster egg penetration and the hemizona assay)
have only slightly improved the predictability of sperm fertilization. One, unfortunately, cannot rely on their results completely to decide definitively whether
ICSI will be required. A physician needs to carefully review all aspects of the couple’s condition in order to decide whether ICSI will be beneficial in a
particular case.
ICSI is performed on the day of the oocyte retrieval. After the oocytes are obtained, from a woman undergoing an IVF oocyte retrieval, they are fertilized
with sperm. Usually, natural insemination is performed by placing sperm from the male partner in a petri dish containing the oocytes. With ICSI the oocytes
are first cleansed of all the surrounding cells and the sperm are separately prepared. A special microscope with robotic microscopic manipulators is then
utilized. An individual sperm is "captured" in a fine glass needle, while the oocyte is gently held with a suction "holder." The needle is then inserted into the
oocyte (its cytoplasm) and released. The oocytes are then maintained in culture and evaluated the next day for fertilization.
Fertilization success rates can vary greatly depending upon the quality of the oocytes as well as other factors. The range is normally 30%-70%, but there
can rarely be total fertilization failure. Implantation and subsequent pregnancy rates are actually slightly higher than the rates for other causes of infertility.
Statistically the offspring are normal. There are, however, theoretical concerns regarding the possible introduction of infectious agents or foreign genetic
material into the oocyte by this technique.
Men with complete azoospermia (no sperm) can also be helped by this technique. First the underlying cause of azoospermia needs to be established.
Obstructive problems, such as absent vas deferens or scarring of the vas deferens, can be treated by MESA. In this technique a urologist performs a
surgical procedure where sperm are obtained from the epididymis (prior to the blocked area) and transferred to our laboratory. The sperm are
cryopreserved (frozen) and subsequently thawed when the oocytes are available. Cryopreservation of MESA obtained sperm does not decrease the
success of the treatment. Performance of TESE is necessary if the man has no sperm in the epididymis or if the cause of azoospermia is testicular failure
rather than obstruction. This technique requires urologic surgery in which a small portion of testicle tissue is removed. This tissue is then explored for
immature sperm that can then be utilized for ICSI. Success with TESE is limited by the quality of the sperm and cryopreservation of the TESE obtained
sperm seems to decrease the success.
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