What is it?
Intracytoplasmic sperm injection (ICSI) is a form of in vitro fertilisation (IVF) in which a single sperm is injected directly into an egg. It was developed to provide treatment for couples with infertility due to problems in the man following the realisation that conventional IVF did not help in these situations. After many years of trying the first ICSI baby was eventually born in Belgium in 1992.
Who is it for?
ICSI was originally designed to help men with poor sperm quality including those with low counts, slow moving sperm and abnormal sperm. It is also now used for men with antibodies against their own sperm and where previous IVF treatment resulted in poor or failed fertilisation. The law as it currently stands in the UK allows any woman below the age of 55 years to have ICSI treatment. Most licensed units however have their individual eligibility criteria and typically restrict treatment to women below the age of 40 years and to couples in proven stable relationships.
How is it regulated?
The Human Fertilisation and Embryology Authority (HFEA) regulates ICSI treatment in the UK. The HFEA was established in 1991 and it licenses clinics to offer this treatment, monitors the treatment, and regulates research that involves human eggs, sperm and embryos (fertilised eggs). It publishes an annual guide of clinics that offer ICSI treatment and couples can obtain copies of this by ringing 0207 377 5077.
How is ICSI performed?
ICSI treatment involves a complex series of procedures:
- Initial assessment – this includes an interview with both partners as well as general and pelvic examinations of the woman. Blood tests are performed to determine the woman’s hormone levels, rubella status, blood count and blood group, as well as screening for infections (including HIV, syphilis and hepatitis) in both partners. The man’s sperm sample is examined to determine the sperm count, movement, normal forms and presence of antibodies. Some units require all men having this treatment to have their chromosomes tested. A swab from the vagina may also be taken from the woman to check for infection.
- Counselling of the couple – counselling can be helpful to the couple in understanding the treatment and should be available in any unit. Although not a compulsory requirement for treatment to proceed, couples are encouraged to utilise the opportunity of counselling.
- Stimulation of the ovaries – ICSI treatment proceeds in cycles where ‘controlled ovarian stimulation’ has taken place to increase the yield of eggs. Stimulation is achieved using two types of medicines, one to suppress the ovaries so that the woman does not ovulate before it is desirable and the other to stimulate development of many eggs. These medicines may be given as tablets, nasal puffs, or injections and may be started at any time during the menstrual cycle. Pelvic ultrasound scans and/or blood hormone (oestrogen) tests are used to monitor the woman’s response to stimulation. Stimulation continues until the eggs are mature enough to be collected at which time another hormone injection is given to ripen them.
- Collection of the eggs – putting a needle through the vagina and into the ovaries under ultrasound control and sucking gently is the usual method used for collecting the eggs. General anaesthesia or sedation (pain-relieving medicines) is used for the procedure. The eggs may sometimes be collected by laparoscopy (telescopic examination of the inside of the abdomen and pelvis). The number of eggs that are collected varies from one woman to another depending on their response to stimulation. Most women will be able to return home on the day this procedure is performed.
- Injection of eggs with sperm – the man will be required to produce a sperm sample by masturbation on the day of the egg recovery. A three-day period of abstinence from sexual intercourse or masturbation is advised to ensure the sperm are of good quality. The sperm is washed in a special fluid to select out the best qualities ones and the eggs are cleaned of all the cells that are on their outside. A single sperm is then injected into the center of each mature egg. The eggs are left overnight and by the next morning it is clear how many of them have fertilised.
- Replacement of embryos into the womb – the culmination of ICSI treatment is the replacement of embryos into the womb. This is usually done two days after the egg recovery but may sometimes be done one, three or five days after, depending on the practice in the unit providing the treatment. The embryos are gently sucked into a soft small tube that is passed up the neck and almost to the top of the womb into which they are gently injected. This does not usually require any anaesthetic or sedation. The number of embryos that are replaced each time depends on the regulations in the country concerned. The maximum number that can be replaced each time in the UK is three, but two are usually replaced to reduce the chance of multiple pregnancies (twins and triplets).
- Afterwards – following replacement of the embryos women are advised to take things easy, but there is usually no need to take time off work. Hormone injections or pessaries (vaginal tablets) are given afterwards to help the development of the embryo. If the treatment is not successful, a period will usually begin between 7 and 14 days after the replacement. Women who have not had a period by this time will usually have urine or blood tests to detect an early pregnancy and if this is positive, an ultrasound scan may be performed three weeks later for confirmation.
- ICSI treatment – involves a long process that may take up to 6 weeks from start to finish and even longer to know if it has been successful or not. Appreciation of and adequate preparation for this will help couples cope with the often rigorous demands of the treatment schedules.
How successful is it?
The technique of ICSI has made it possible for many couples to fulfill their hopes of having children. The chance of ICSI succeeding is improved in younger women (less than thirty years old), following previous pregnancies and in couples whose difficulty with conceiving has only been short lasting. ICSI success is measured by pregnancy and life birth rates and these vary widely across the world.
The average chance of a couple achieving a life birth from any one cycle of ICSI treatment in the UK is about 2 in 10. This varies widely from 4 in 10 in the some units to 1 in 10 in others. The average chance for each couple however goes up to about 6 in 10 after four cycles of treatment. The HFEA guide provides a useful source of information for couples and family doctors may be able to help in selecting appropriate units.
What can go wrong?
About 3 out of 4 women will complete this treatment without any difficulties or problems. Some common difficulties or problems include:
- Poor response to stimulation – this may affect up to 1 in 10 women. It causes the development of very few or no eggs at all and may lead to cancellation of cycles.
- Excessive response to stimulation – this can result in a condition called ‘ovarian hyperstimulation syndrome’ that affects up to 1 in 10 women. It is fortunately mostly mild. It causes pain and bloating of the tummy, vomiting, shortness of breath and tiredness. Admission to hospital may occasionally be needed for treatment. Very severe cases may become life threatening, but this is rare.
- Injuries during egg recovery – the needle used for the egg recovery may cause injury to the organs in the pelvis (such as the bladder, intestines, and blood vessels), but this is very rare.
- Pelvic infection – this can occur following egg recovery and may result in pelvic pus collection. It causes the woman to become ill with fever and tummy pain. Antibiotics are used to treat this and formed pus may need to be drained by surgery.
- Abnormalities in babies – it is now clear that babies that are born following ICSI treatment have a slightly increased chance of having birth abnormalities or problems with their chromosomes.
Human Fertilisation and Embryology Authority (HFEA) 30 Artillery Lane London E1 7LS Tel. 0207 377 5077
PROGRESS Campaign for Research into Reproduction 140 Gray’s Inn Road London WC1X 8AX