Intra Cytoplasmic Sperm Injection (ICSI)

Until the 90's males with very low counts (less than 5 million per ml) or poor quality sperms had no hope of fathering children. This problem was surmounted by the new breakthrough of ICSI, which took place in Brussels, Belgium in 1992.

Since then, many such patients have fathered a child. We started our own ICSI programme in 1995-96 and have performed till date more than 800 cycles with success rate of 30 to 40%, 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 100,000 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 Micromanipulator.

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 the two leading follicles are 18mm in diameter.
• Oocyte or egg retrieval under short general anesthesia 35 to 37 hours after HCG injection.
• Identification and isolation of eggs in the laboratory.
• Sperm collection and processing in the lab. Incase of azoospermia (no sperms in the semen) the sperms are collected directly from the testis with the procedures of PESA/MESA/FTNB/TESE or TESA.
• Dissection of the eggs in the laboratory with the help of an enzyme called Hyloronetis. 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 (tail first).
• 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.

Indications :

• Males with severe sperm factors such as low count (less than 5 million), very poor motility or high degree of abnormal sperms.
• Males with azozoospermia, where there is no sperm present in the semen. The azozoospermia 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 testis to produce sperms. Nowadays, in both these types of azoospermia, sperms can be isolated directly from the testis, using the SPERM

Retrieval Techniques of PESA/TESA/TESE and subsequently, ICSI can be performed on

• 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 unit 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 are in the region of 30 to 40% in both azoospermia and non-azoospermia patients, which are comparable to the best in the world.

Concept

Similar to IVF, ICSI differs in the fertilization process. Unlike in IVF, where one egg is mixed with 1 lakh sperms, with fertilization taking place on its own, ICSI is a technique where each egg is held and injected with a single live sperm. This micro-fertilization is done with the help of a machine called the Micromanipulator. The procedure (anchor) can be categorised into 11 steps.

Indications for ICSI is a technique usually performed in males with:

• severely low sperm counts
• poor quality of sperms
• more… link as an anchor to the retrieval techniques of PESA/MESA etc, lower down in the content paras.

ICSI and Babies and Us

Pioneered in Brussels, Belgium in 1992, BabiesandUs brought the technique to India in 1995.

Since then, the institution has performed more than 800 cycles with a globally competent success rate of 30 to 40%.

In ICSI all the steps are similar to the procedure of IVF (procedure of IVF), except in fertilization.

Procedure

• 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 the two leading follicles are 18mm. in diameter.
• Oocyte or egg retrieval under short general anaesthesia, 35 to 37 hours after HCG injection.
• Identification and isolation of eggs in the laboratory.
• Sperm collection and processing in the lab. Incase of azoospermia (no sperms in the semen) the sperms are collected directly from the testis with the procedures of PESA/MESA/FTNB/TESE or TESA.
• Dissection of the eggs in the laboratory with the help of an enzyme called Hyloronetis Placement of eggs into small droplets of culture media under oil.
• Placement of sperms into small droplets of PVP under oil. Immobilisation of the sperm with a micro-injection needle (Diameter of 7 microns) and aspiration of the immobile sperm into the needle (tail first).
• 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.

Indications :

• low count (less than 5 million)
• very poor motility
• high degree of abnormal sperms.

Although ISCI is carried out among patients even with normal sperm counts, BabiesandUs believes that pregnancy should be achieved with a minimum handling of the gametes outside the body. If a particular patient has a sperm count that is in the grey-zone area, then we may subject half the eggs to IVF and half the eggs to ICSI.

• Males with azoospermia have no sperm present in the semen. The azoospermia may be of the obstructive type where there is production of sperms in the testis but a blockage in the conduction system disallows sperms to enter the semen. Alternately, the azoospermia may be of the non-obstructive type, where there is a failure of the testis to produce sperms. Fortunately, today, sperms can be isolated directly from the testis, using the Sperm Retrieval Techniques of PESA/TESA/TESE and subsequently, ICSI can be performed. BabiesandUs maintains a competent success rate of 30-40% in males with azoospermia.
• Males with sperm anti-bodies.
• Males with ejaculated dysfunction due to an injury to the spinal chord or in quadriplegics or paraplegics.
• Patients with retrograde ejaculation (ejaculation of the sperm into the urinary bladder) who fail to allow pregnancy under.
• Patients where In Vitro Fertilisation has proved to be unsuccessful.

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