Intra Cytoplasmic Sperm Injection (ICSI) is a laboratory procedure developed to help infertile couples undergoing in vitro fertilization (IVF) due to male factor infertility.ICSI a form of micromanipulation, involves the injection of a single sperm directly into the cytoplasm of a mature egg(oocyte0 using a glass needle(pipette).IVF-E.T, ICSI-E.T and related procedures require the following steps:
1. Patients Selection,
2. Pre-cycle Evaluation,
3. Ovulation Induction and Monitoring,
4. Egg Retrieval,
5. Sperm Processing,
6. In-Vitro Fertilization,
7. Embryo Transfer,
8. Post Transfer Management,
9. Cryo Preservation,
A complete evaluation of fertility factors (these are egg, sperm and uterine cavity) is important prior to considering IVF-E.T technique.
Tubal Disease Patients with tubal blockage or severe pelvic adhesionsor who have not conceived after tubal surgery are good candidates for IVF-E.T technique.
Moderate to severe Male Factor- The ability to treat sperm in the laboratory by various techniques, along with the ability to concentrate large numbers of motile sperm around eggs makes IVF-E.T a potential treatment for couples whose infertility is due to poor semen quality.
Endometriosis- As endometriosis often results in pelvic anatomy distortion and adhesion, the IVF-E.T technique procedure allows the egg and sperm to meet and fertilize in an environment free of endometriomas and be transferred directly into the uterus.
Immunologic infertility - IVF-E.T technique allows fertilization outside the body, away from the destructive actions of anti-sperm antibodies.
Unexplained infertility that has not responded to other types of therapy. IVF-E.T has successfully treated such couples. IVF-E.T can demonstrate the ability of the sperm to fertilize eggs become to growing embryos. Rarely, unexplained infertility may be due to defects in gamete funtion.
To achieve good success rate, need a meticulous evaluation of three factors(egg, sperm and uterine cavity) that contribute to a favourable outcome with IVF-E.T.
While age affects this parameter, the first of these is the women's ability to respond to fertility drugs. Measurements of FSH and Estradiol on the third day of the menstrual cycle help us estimate a women's ability to produce extra eggs in response to fertility drugs. In general women with high FSH levels and/or early high estradiol are more resistant to ovarian stimulation.
The second factor to evaluate is the uterine environment. it is recommended that the women undergo a one-time office hysteroscopy prior to beginning a IVF-E.T procedure. The hysteroscopy allow us to inside the uterine cavity and make sure there are no fibroids, polyps or scar tissue that could interfere with implantation. If the women have had a recent hysterosalpinogram(HSG) and the uterine cavity appears normal, the hysteroscopy can be waived. Also women undergoing IVF-E.T should have the length of their uterus carefully measured, in order to accomplish a traumatic embryo transfer later on.
Cervical cultures are taken before commencing treatment. Organisms such as urea plasma have been associated with poor reproductive outcome and poor embryonic growth in the laboratory.Finally the uterine lining is evaluated prior to ovulation using a sonogram. Certain patterns of uterine lining development especially when the lining is thin are associated with poor pregnancy rates. These sub-optimal patterns can sometimes be improved with estradiol supplementation.
The third factor is the male factor. This requires a semen analysis; in addition sperm antibodies are measured in both partners. High levels of sperm antibodies can interfere with fertilization with in the laboratory, and special techniques are employed to correct this problem. Couples undergoing IVF-E.T are screened for syphilis, hepatitis and HIV patients who have major medical, surgical or psychological problems are required to be treated before starting cycle. In addition to the above medical evaluation, couples contemplating IVF-E.T are informed of the availability of a counsellor. The counsellor is fimiliar with emotional impact of infertility and infertility treatments and can help the couple deal with this important aspect of their care.
IVF-E.T success rates depend upon the numbers of eggs, fertilized eggs and good quality embryos available for transfer. Additionally, the egg retrieval must be carefully timed so as to retrieve mature eggs.To accomplish these two goals, ovulation induction medications and careful monitoring are employed. In most cases, The long protocol(one of ovarian stimulation regimens) is selected and the women begins with intramuscularly injection decapeptyl depot 3.75mg(triptorelin 3.75mg) in their leutal phase, in other words after ovulation has occurred. Starting injection triptorelin does not have to be on an exact day? We usually give the injection a week before (usually 21 day of menses) of the upcoming treatments cycle. If patient have very short or very long menstrual cycles, we may adjust the day for injection. Sometimes , we actually need to give some outside progesterone in order to allow us to start decadently. This harmone prevents premature ovulation.
After menses occurs, prior to starting the ovarian stimulation, we select a day for Down Check, a sonogram is done to make sure there are no ovarian cysts, and a blood estradiol level and a progesterone level is measured to make sure that everything is in control. On a specified day the women begins injections of Gonadotropins(Gonal-F from SERENO-Switzerland, or Recagon from ORGANON-Ireland), according to a schedule that is provided by the clinic. When triptorelin is used, the ovaries remain quiescent until stimulation drugs are started. We arbitrarily call the first day of Gonadotropin administration cycle-Da1. IN order to monitor a patient's response to these drugs, Sonograms and serum estradiol levels are performed on day6, day8 and day10. These help us to determine, when the eggs are ready for collection.
Once the follicles(containing the eggs) are ready, the patient stops taking triptorelin and Gonadotropins. About 36 hours prior to the anticipated egg retrieval, the patients takes an injection of Human Chronic Gonadotropin(Hcg). This hormone replaces the women's normal LH surge, and is necessary for a final maturation of the eggs so that they can be fertilized.
In almost all cases, egg retrieval is accomplished non-surgically using a vaginal ultrasound probe to guide a needle into the ovaries. The procedure does not require general anaesthesia and is performed with just simple intravenous sedation. An anaesthesiologist administers the sedation to maximise your comfort and safety. As a result, the experience is not painful and recovery is rapid.
Freshly ejaculated sperm must undergo biochemical and structural change called capacitation before they can fertilize an egg. In IVF-E.T sperm are capacitated in the laboratory and the motile and healthy sperms are isolated prior to inseminating the eggs.
In-Vitro Fertilization literally means "fertilization of glass". Follicular fluid removed from the ovaries is examined in our lab for presence of eggs. These are isolated and placed in cultures media where they are allowed to futher mature. A few hours later, portions of the processed sperms are placed around each egg. Only 50 to 100 thousand sperms are needed for each egg. This is why men with low sperm counts can often fertilize eggs in the lab.
The eggs and sperms are left to incubate together in a carefully controlled environment. Approximately 18 to 24 hours following insemination, the eggs are inspected under the microscope to determine how many have been successfully fertilized. These embryos will be kept in the laboratory as they continue to grow and develop until the moment of transfer.
The embryos are transferred via thin plastic tube through the cervix into the uterine cavity. They are then deposited in the upper part of the uterus and the catheter is withdrawn. This is generally a painless procedure and the patient remains immobile for 2 hours, after that she can go home.As the implementation will occur in the following few days, the patients are instructed to rest at home during this time after the transfer. Light activities allowed without stress and most sleepwell at night.
We usually transfer the embryos into the women's uterus two days after the egg retrieval. At this stage, the embryos have cleaved and contain 4 cells each. We usually transfer 3 to 5 embryos depending on the quality(grading) of the embryos.
During the follow-up phase, the women receives daily vaginal suppository of progesterone with the goal of enhancing implantation. 14 days after the embryo transfer, blood and urine pregnancy tests are performed. Rising blood levels of pregnancy, HCG, indicate that implantation has occurred. Confirmation of a clinical pregnancy is made by ultrasound about 2 weeks later.
Freezing extra embryos gives couples an additional opportunity to conceive without going through stimulation cycle and egg retrieval. The success rate with frozen/thawed embryo are improved when women uses hormone replacement instead of her natural cycle.Prior to thawing the embryos, an ultrasound assessment of the uterine lining is performed to make sure an adequate uterine environment is present. About half or two third of the frozen embryos survive the defrosting process.
The ICSI procedure is performed by using a technique called micromanipulation. Micromanipulation uses a special microscope, along with very small surgical tools, to pick up and handle one single sperm, injecting it directly into an egg.
The ICSI procedure can help you achieve IVF pregnancy success even when male infertility problems are an issue. If your male partner has experienced any of the following problems, talk to your doctor about ICSI:
• Absence of sperm in the semen, possibly caused by a blockage
• Low sperm count, poor sperm quality and/or abnormal sperm shape and movement
• Sperm unable to penetrate through the outer layer of your egg or production of antisperm antibodies
Have you tried IVF without success? If so, ask your doctor about ICSI and IVF success rates.
1. The mature egg is held with a specialized holding pipette.
2. A very delicate, sharp and hollow needle is used to immobilize and pick up a single sperm.
3. This needle is then carefully inserted through the zona (shell of the egg) and in to the center (cytoplasm) of the egg.
4. The sperm is injected in the cytoplasm and the needle is removed.
5. The eggs are checked the next morning for evidence of normal fertilization.
Fertilization rates for ICSI: Most IVF programs see that about 70-85% of eggs injected using ICSI become fertilized. We call this the fertilization rate, which is different from the pregnancy success rate.
Pregnancy success rates for in vitro fertilization procedures with ICSI have been shown in some studies to be higher than for IVF without ICSI. This is because in many of the cases needing ICSI the female is relatively young and fertile (good egg quantity and quality) as compared to some of the women having IVF for other reasons.
In other words, the average egg quantity and quality tends to be better in ICSI cases (male factor cases) because it is less likely that there is a problem with the eggs - as compared to cases with unexplained infertility. Some unexplained cases have reduced egg quantity and/or quality - which lowers the chances for a successful IVF outcome.
IVF with ICSI success rates vary according to the specifics of the individual case, the ICSI technique used, the skill of the individual performing the procedure, the overall quality of the laboratory, the quality of the eggs, and the embryo transfer skills of the infertility specialist physician.
Sometimes IVF with ICSI is done for "egg factor" cases - low ovarian reserve situations. This is when there is either a low number, or low "quality"of eggs (or both). In such cases, ICSI fertilization and pregnancy success rates tend to be lower.
• This is because the main determinant of IVF success is the quality of the embryos.
• The quality of the eggs is a crucial factor determining quality and viability of embryos.
In some cases, assisted hatching is done on the embryos prior to transfer, in order to maximize chances for pregnancy.
Unfortunately problems can occur during ICSI procedures. Here are some potential issues that could arise during the process:
• Your eggs may become damaged.
• The embryo might fail to grow after the fertilization.
• Some people speculate that the ICSI process might lead to higher rates of genetic defects compared to other fertility treatments. But, the birth defects most commonly associated with ICSI can usually be fixed with surgery.