Until the 90’s, males with very low counts (less than 5 million per ml) or poor quality sperms had no hope of fathering THEIR OWN GENETIC children. This problem was surmounted by the new breakthrough of ICSI, which took place in Brussels and Belgium in 1992.
Since then, many such patients have fathered a child. We started our own ICSI programmed in 1998-99 and have performed till date more than 10,000 cycles with success rate of 40 to 50%/CYCLE, which is comparable to the best units in the world.
In ICSI, all the steps are similar to the procedure of IVF, except the step of fertilization. Normally in IVF, one egg is mixed with 200,000 sperms and one of the sperms fertilizes the egg on its own. In contrast, in ICSI, each egg is held and injected with a single live sperm. This micro-fertilization is done with the help of a machine called the Micro manipulator. The procedure can be categorized into 11 steps as discussed below.
Thus the procedure consists of:
- Controlled Ovarian stimulation with drugs (GnRH) Analogues and Gonadotrophins to produce many eggs.
- Monitoring of follicles and egg development with the aid of Vaginal Sonography and serial Estradiol hormone estimation.
- Administration of HCG injection, (Human Chorionic Gonadotrophins) when atleast two leading follicles are 18 mm in diameter.
- Oocyte or egg retrieval under short general anesthesia, 35 to 36 hours after HCG injection.
- Identification and isolation of eggs in the laboratory.
- Sperm collection and processing in the lab. In case of Azoospermia (no sperms in the semen) the sperms are collected directly from the testes with the procedures of PESA/MESA/TESE or TESA.
- stripping of the cumulusof the eggs in the laboratory with the help of an enzyme called HYALURONIDASE. Placement of eggs into small droplets of culture media under oil.
- Placement of sperms into small droplets of PVP under oil. Immobilization of the sperm with a micro injection needle (Diameter of 7 microns) and aspiration of the immobile sperm into the needle after crushing the tail portion of the sperm).
- Holding the egg with a holding pipette and injection of the immobilized sperm into the held egg. Placement of these eggs into the incubator for 2 to 5 days.
- Embryo formation 2 to 5 days after fertilization.
- Embryo transfer of good quality embryos back to the womb, after 2 (four cell embryo), 3 (six-eight cell embryo) or 5 (Blastocyst stage) days after egg removal.
- Males with severe sperm factors such as low count (less than 5 million), very poor motility or high degree of abnormal sperms. Males with Azoospermia, where there is no sperm present in the semen. The Azoospermia may be of the obstructive type where there is production of sperms in the testis but blockage of the conduction system, which brings the sperm out into the semen. Alternately, the Azoospermia may be of the non-obstructive type, where there is a failure of the testes to produce sperms. Nowadays, in both these types of Azoospermia, sperms can be
isolated directly from the testis by Testicular Biopsy.
- Retrieval Techniques of PESA/TESA/TESE and subsequently, ICSI can be performed on the following cases: • Males with sperm anti-bodies.
- Males with Ejaculated Dysfunction due to Spinal Chord injury or malfunction such as Quadriplegics or Paraplegics.
- Patients with Retrograde Ejaculation (ejaculation of the sperm into the urinary bladder) who fail to become pregnant with IUI.
- Patients where fertilization has failed with In-Vitro Fertilization.
- In our Clinic, we also believe in doing ICSI on patients who have had previous history of Tuberculosis or Endometriosis, as we believe it gives better fertilization rates than standard IVF (this is a personal experience not supported by international literature).
- Nowadays, some units are advocating routine ICSI for all patients, including those with normal sperm counts. We do not believe in such practice as we feel that pregnancy should be achieved with minimum handling of the gametes outside the body. If the sperm count is good enough for fertilization with IVF, we will not do ICSI. However, if a particular patient has a sperm count, which is in the grey-zone area, then we may subject half the eggs to IVF and half the eggs to ICSI.
- Our success rates for ICSI are in the region of 40 to 50% in both Azoospermia and Non-Azoospermia patients.