Even though ICSI (intracytoplasmic sperm injection) seems to be safe it is unwise to use such a complicated treatment if there is a simpler solution. ICSI is also expensive, hardly surprising, given the cost of the equipment, the laboratory space required, and the fact that considerable time needs to be devoted to it by the embryologist. There are a number of possible alternatives that couples when undergoing IVF can elect to use.
It is quite common for couples to request that their eggs are split into two lots after collection so that half are collected treated by routine IVF, and the remainder fertilised using ICSI. They feel that they want to try ICSI only as a last resort, hoping to achieve natural fertilisation of sufficient eggs to create embryos for transfer. I personally think this reasonable. But the HFEA (Human Fertility and Embryology Authority) has ruled that patients must not have a naturally fertilised egg transferred at the same time as an ICSI fertilised egg. Their reason for this decision seems largely to be to collect data on the fate of ICSI embryos. If a pregnancy occurs after a ‘mixed transfer’, there is no way of knowing whether the pregnancy occurred as a result of the standard IVF or fertilisation by ICSI; this is still the case if a woman has twins. Many feel that the HFEA view is often too heavy-handed as it limits the freedom of individual patients without any really good reason. However, now transferring more than one embryo simultaneously is regulated because of the risk of multiple births.
Men with a reduced sperm count but who produce reasonably motile sperm can have the number of good sperm enriched. This used to be done by passing collected sperm through a filtering medium to concentrate the best ones. The most widely used fluid is a viscous solution called percoll. After filtration, the good sperm is placed in a tiny droplet of culture fluid. The collected egg is added to the droplet and, because the sperm is concentrated around the egg, there may be a greater chance of fertilisation. Since ICSI has been perfected, this technique is less frequently used.
There are a number of so-called adjuvants (pharmacological agents that modify the effect of other agents) that have been used to make sperm more active in the hope of making them more likely to fertilise an egg during IVF. The most commonly used drug used to be Pentoxifylline, another is caffeine. There is no doubt that these compounds increase sperm motility, but there is limited evidence to show that they also increase its fertilising capacity and trials have failed to demonstrate a better pregnancy rate resulting from their use.
Because the complex techniques to enhance fertilisation may not work, it may be worth considering using donor sperm and having it ready for when egg collection is made. This has become more difficult since donor sperm has become a scarce commodity, so arrangements need to be made some weeks in advance of IVF treatment; egg collection day is too late.
If donor insemination is being considered, it is wise for a couple to have counselling from an expert familiar with the issues associated with donor sperm – some clinics insist on this. It is essential to explore the family aspects of sperm donation and for both the man and the woman to review their feelings very carefully. Both partners must be completely satisfied that they would be prepared to accept donor sperm.
If a couple decides to use sperm donation as a back-up, a suitable donor should be found by an appropriate matching between a donor and the infertile male. Donor sperm can then be held in reserve in the IVF laboratory depending on the outcome of sperm aspiration. It must be pointed out that once any collected sperm has been mixed with the woman’s eggs, it will be too late to use donor sperm. One way around this is to separate the eggs and use some for IVF with ICSI and retain the rest for exposure to donor sperm. A number of units may offer this but it will reduce the total number of eggs available for embryo transfer.
The difficulty with ICSI is often the fact that even if the woman functions completely normally, the problem is entirely that of her partner. Even though most ICSI is still done using ejaculated sperm, the woman has to undergo the stress of extensive stimulation with drugs, the daily monitoring, the egg collection operation to collect the eggs, the embryo transfer and has the worry and the anxiety of waiting to see whether or not she is pregnant.
Remarkably, many women seem to prefer this. Others find it a very considerable strain. Some women feel that it gives them some kind of control over the whole process. I have found frequently that many women do everything to try and protect their male partner from the consequences of infertility, including taking over all the burdens associated with treatment. Nonetheless, this can put considerable strain on a relationship, and a substantial number of men feel very guilty about the effort that their partner has made on his behalf.
For all these reasons, it is extremely important for these issues to be carefully thrashed out before an IVF treatment. We strongly recommend that all patients considering ICSI treatment, or indeed any complex treatment for male infertility, seek careful advice and consult an experienced infertility counsellor.
