Should ICSI be recommended routinely in patients with four or fewer oocytes retrieved?

Comparison of outcomes between intracytoplasmic sperm injection and in vitro fertilization inseminations with preimplantation genetic testing for aneuploidy, analysis of Society for Assisted Reproductive Technology Clinic Outcome Reporting System data

OBJECTIVE

To evaluate whether insemination via intracytoplasmic sperm injection (ICSI) provides any benefit over in vitro fertilization (IVF) insemination for nonmale factor infertility with respect to preimplantation genetic testing (PGT) results and pregnancy outcome.

DESIGN

Retrospective cohort study of the Society for Assisted Reproductive Technology database.

SETTINGS

US-based fertility clinics reporting to the Society for Assisted Reprodcutive Technology.

PATIENTS

Patients undergoing IVF or ICSI inseminations in nonmale factor PGT for aneuploidy cycles.

INTERVENTION

In vitro fertilization vs. ICSI inseminations.

MAIN OUTCOME MEASURES

Primary outcomes were the percentage of embryos suitable for transfer and live birth rates (LBRs). Secondary outcomes included subgroup analysis for embryos suitable for transfer on cycles from patients ≥35-year-old vs. <35-year-old, ≤6 oocytes retrieved vs. >6 oocytes retrieved, and unexplained infertility. Additionally, gestational age at delivery and birth weight between IVF and ICSI inseminations were evaluated.

RESULTS

A total of 30,446 nonmale factor PGT diagnoses for aneuploidy cycles were evaluated, of which 4,867 were IVF inseminations and 25,579 were ICSI inseminations. Following exclusion criteria and adjustment for any necessary confounding variables, no significant differences existed in embryos suitable for transfer between IVF and ICSI treatment cycles, 41.6% (40.6%, 42.6%) vs. 42.5% (42.0%, 42.9%), respectively, or in LBRs, 50.1% (37.8, 62.4%) vs. 50.8% (38.5%, 62.9%), respectively.

CONCLUSION

There were no significant differences in the rates of embryos suitable for transfer and LBRs between IVF and ICSI inseminations in nonmale factor cycles undergoing PGT for aneuploidy.

Secretomes from Conventional Insemination and Intra-Cytoplasmic Sperm Injection Derived Embryos Differentially Modulate Endometrial Cells In Vitro

Conventional Insemination (CI) and Intra-Cytoplasmic Sperm Injection (ICSI) are routinely used insemination methods in clinical Assisted Reproductive Technologies (ART) settings. However, the existing data on the developmental competence and implantation potential of CI and ICSI derived embryos are not unequivocal. This prospective study on 23 patients undergoing ART treatment explored whether the secretomes of CI- and ICSI-derived embryo differentially alter the expression of integrins (αv and β3 integrin) and MUCIN-1 (MUC-1) in a human endometrial epithelial cell line (Ishikawa). Immunocytochemical data demonstrated that the secretome of CI-derived top quality (GI) embryos induced higher (p < 0.05) expression of ɑv β3 compared to sibling ICSI derived G1 embryos in Ishikawa cells. Though, relative levels of the transcript for MUC-1, anti-adhesion molecule did not show a significant difference between the study groups, immunocytochemical analysis demonstrated significantly (p < 0.0001) higher expression of MUC-1 in cells treated with ICSI-derived embryo secretome, compared to that treated with CI -derived embryo secretome. These results suggest that secretomes from CI and ICSI embryos differentially modulate the endometrial cells in vitro. This hints at differences in the ability of CI- and ICSI- derived embryos to alter endometrial profile.

Comparing reproductive outcomes between conventional in vitro fertilization and nonindicated intracytoplasmic sperm injection in autologous embryo transfer cycles: a Society for Assisted Reproductive Technology Clinic Outcome Reporting System Study

Objective

To compare clinical outcomes between nonindicated intracytoplasmic sperm injection (ICSI) and conventional insemination.

Design

Autologous cycles performed from 2014-2017 were identified, excluding frozen oocyte cycles. Outcomes were compared between conventional insemination (in vitro fertilization [IVF]) and nonindiated ICSI and analyzed separately for fresh, frozen-thawed preimplantation genetic testing (PGT) and frozen-thawed non-PGT cycles.

Setting

US-based fertility clinics reporting to the Society for Assisted Reproductive Technology.

Participants

A total of 187,520 patients underwent 318,930 cycles, 57,516 (18.0%) using conventional IVF and 261,414 ICSI (82.0%).

Interventions

Intracytoplasmic sperm injection, with or without indications (male factor, prior fertilization failure or any PGT [2012 recommendations]/single-gene PGT [2020 recommendations]).

Main Outcome Measures

Odds ratios (ORs) for live birth rates and clinical pregnancy rates were calculated after multivariable adjustment for maternal age, body mass index, infertility etiologies, prior IVF births, and number oocytes retrieved.

Results

Intracytoplasmic sperm injection was indicated in 151,627 (58.0%) of cycles according to 2012 American Society for Reproductive Medicine Practice Committee recommendations, and 108,895 (41.7%) according to 2020 recommendations. In multivariable models, nonindicated ICSI among fresh cycles was associated with reduced odds of completing a blastocyst-stage transfer (OR, 0.72; 95% confidence interval [CI] [0.7, 0.75]; P<.001), resulting in reduced odds of live birth (OR, 0.80; 95% CI [0.78, 0.83]; P<.001). Among completed fresh transfers, clinical pregnancy and live birth rates were comparable between nonindicated ICSI and IVF. Nonindicated ICSI in frozen-thawed cycles with PGT and without PGT was associated with comparable live birth and clinical pregnancy rates with IVF in multivariable models.

Conclusion

Nonindicated ICSI was associated with reduced blastocyst availability in fresh cycles compared with IVF, leading to lower live birth rates. Outcomes from completed transfers were clinically comparable.

Intracytoplasmic sperm injection vs. in-vitro fertilization in couples in whom the male partners had a semen analysis within normal reference ranges: An open debate

During recent decades, the application of intracytoplasmic sperm injection has increased considerably worldwide, especially in couples with non-male factor infertility. However, several studies analyzing the broad use of intracytoplasmic sperm injection, even in cases with a normal semen analysis, have collectively demonstrated no benefits compared to conventional in-vitro fertilization. Currently, there is insufficient evidence to support the intracytoplasmic sperm injection technique vs. in-vitro fertilization in cases of poor ovarian response or a low number of oocytes collected, or in patients with advanced maternal age. Since the intracytoplasmic sperm injection technique is more operator-dependent and invasive, its use should only be recommended in cases of male-factor infertility. There is some evidence showing that intracytoplasmic sperm injection is linked with an increased risk of birth defects. Albeit this evidence is limited, and currently it is not possible to draw a firm conclusion on these concerns, we do believe that these risks should be rigorously investigated. Thus, this review aims to clarify the debate on the application of the intracytoplasmic sperm injection procedure, as compared to standard in-vitro fertilization, in those assisted reproductive technology cycles without a clear male factor infertility. Furthermore, we try to clarify whether intracytoplasmic sperm injection would result in a higher live birth rate than in-vitro fertilization, in couples with non-male factor infertility.

Good practice recommendations on add-ons in reproductive medicine†

STUDY QUESTION

Which add-ons are safe and effective to be used in ART treatment?

SUMMARY ANSWER

Forty-two recommendations were formulated on the use of add-ons in the diagnosis of fertility problems, the IVF laboratory and clinical management of IVF treatment.

WHAT IS KNOWN ALREADY

The innovative nature of ART combined with the extremely high motivation of the patients has opened the door to the wide application of what has become known as 'add-ons' in reproductive medicine. These supplementary options are available to patients in addition to standard fertility procedures, typically incurring an additional cost. A diverse array of supplementary options is made available, encompassing tests, drugs, equipment, complementary or alternative therapies, laboratory procedures, and surgical interventions. These options share the common aim of stating to enhance pregnancy or live birth rates, mitigate the risk of miscarriage, or expedite the time to achieving pregnancy.

STUDY DESIGN, SIZE, DURATION

ESHRE aimed to develop clinically relevant and evidence-based recommendations focusing on the safety and efficacy of add-ons currently used in fertility procedures in order to improve the quality of care for patients with infertility.

PARTICIPANTS/MATERIALS, SETTING, METHODS

ESHRE appointed a European multidisciplinary working group consisting of practising clinicians, embryologists, and researchers who have demonstrated leadership and expertise in the care and research of infertility. Patient representatives were included in the working group. To ensure that the guidelines are evidence-based, the literature identified from a systematic search was reviewed and critically appraised. In the absence of any clear scientific evidence, recommendations were based on the professional experience and consensus of the working group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 46 independent international reviewers. A total of 272 comments were received and incorporated where relevant.

MAIN RESULTS AND THE ROLE OF CHANCE

The multidisciplinary working group formulated 42 recommendations in three sections; diagnosis and diagnostic tests, laboratory tests and interventions, and clinical management.

LIMITATIONS, REASONS FOR CAUTION

Of the 42 recommendations, none could be based on high-quality evidence and only four could be based on moderate-quality evidence, implicating that 95% of the recommendations are supported only by low-quality randomized controlled trials, observational data, professional experience, or consensus of the development group.

WIDER IMPLICATIONS OF THE FINDINGS

These guidelines offer valuable direction for healthcare professionals who are responsible for the care of patients undergoing ART treatment for infertility. Their purpose is to promote safe and effective ART treatment, enabling patients to make informed decisions based on realistic expectations. The guidelines aim to ensure that patients are fully informed about the various treatment options available to them and the likelihood of any additional treatment or test to improve the chance of achieving a live birth.

STUDY FUNDING/COMPETING INTEREST(S)

All costs relating to the development process were covered from ESHRE funds. There was no external funding of the development process or manuscript production. K.L. reports speakers fees from Merck and was part of a research study by Vitrolife (unpaid). T.E. reports consulting fees from Gynemed, speakers fees from Gynemed and is part of the scientific advisory board of Hamilton Thorne. N.P.P. reports grants from Merck Serono, Ferring Pharmaceutical, Theramex, Gedeon Richter, Organon, Roche, IBSA and Besins Healthcare, speakers fees from Merck Serono, Ferring Pharmaceutical, Theramex, Gedeon Richter, Organon, Roche, IBSA and Besins Healthcare. S.R.H. declares being managing director of Fertility Europe, a not-for-profit organization receiving financial support from ESHRE. I.S. is a scientific advisor for and has stock options from Alife Health, is co-founder of IVFvision LTD (unpaid) and received speakers' fee from the 2023 ART Young Leader Prestige workshop in China. A.P. reports grants from Gedeon Richter, Ferring Pharmaceuticals and Merck A/S, consulting fees from Preglem, Novo Nordisk, Ferring Pharmaceuticals, Gedeon Richter, Cryos and Merck A/S, speakers fees from Gedeon Richter, Ferring Pharmaceuticals, Merck A/S, Theramex and Organon, travel fees from Gedeon Richter. The other authors disclosed no conflicts of interest.

DISCLAIMER

This Good Practice Recommendations (GPRs) document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and are based on the scientific evidence available at the time of preparation.ESHRE GPRs should be used for information and educational purposes. They should not be interpreted as setting a standard of care or bedeemedinclusive of all proper methods of care, or be exclusive of other methods of care reasonably directed to obtaining the same results.Theydo not replace the need for application of clinical judgement to each individual presentation, or variations based on locality and facility type.Furthermore, ESHRE GPRs do not constitute or imply the endorsement, or favouring, of any of the included technologies by ESHRE.

Intracytoplasmic sperm injection does not improve the outcome of IVF treatments in patients with advanced maternal age or low oocyte number: A randomized controlled trial

INTRODUCTION

Intracytoplasmic sperm injection (ICSI) was introduced to achieve fertilization in cases of severe male factor infertility. However, ICSI is often used in cases of non-male factor infertility, such as advanced maternal age or low oocyte number, but the clinical benefit of the method in these indications has not been proven.

MATERIAL AND METHODS

A prospective randomized study was conducted in a university clinic between 2018 and 2020. Patients with ≥40 years of age and/or ≤4 oocytes with non-sever male factor infertility were randomized into conventional IVF or ICSI groups. Fertilization rate, embryo quality, implantation, clinical pregnancy and live birth rates were compared.

RESULTS

A total of 336 IVF cycles (169 conventional IVF and 167 ICSI) were involved in the study. The fertilization rate was higher in the conventional IVF group compared to the ICSI group (IVF: 61.7%, ICSI: 53.4%, P=0.001). Embryo development and morphology did not show considerable difference between groups. Implantation, clinical pregnancy and live birth rate were 13.1%, 24.3% and 11.4% in the conventional IVF and 10.4%, 19.0%, 12.0% in the ICSI group. The differences were not significant. Subgroup analysis showed a significantly better clinical outcome following conventional IVF when advanced maternal age was accompanied by low oocyte number (Implantation: 11.7% vs 2.6%, P=0.027; Clinical pregnancy: 18.5% vs 4%, P=0.020).

DISCUSSION

A significantly higher fertilization rate, a tendency for higher clinical pregnancy rate was found in conventional IVF treatments compared to ICSI. When advanced maternal age was associated with low oocyte number, ICSI resulted in a substantially lower chance of fertilization and clinical pregnancy. These data suggest that ICSI offers no advantage over conventional IVF in terms of fertilization, embryo quality, implantation and pregnancy rates for couples with advanced maternal age or with low oocyte number.

The use of ICSI in ART: evidence for practice

This article reviews the evidence regarding the safety and efficacy of intra-cytoplasmic sperm injection (ICSI). It provides evidence-based clinical and laboratory guidelines and recommendations for use of ICSI within an assisted reproductive technology (ART) service. The guidelines address the evidence for the use of ICSI rather than conventional IVF (cIVF); the use of ART techniques supplementary to ICSI; and risks associated with ICSI. This article is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of management may be appropriate, taking into account the needs and medical history of the patient, available resources, and institutional or clinical practice limitations.

Comparison of clinical outcomes between conventional in vitro fertilization and intracytoplasmic sperm injection in poor responders with only single oocyte retrieved

OBJECTIVE

To compare the clinical outcomes between conventional insemination (IVF) and intracytoplasmic sperm injection (ICSI) in poor responders with only a single oocyte retrieved.

MATERIALS AND METHODS

This is a retrospective case-control study. Couples who were treated with assisted reproductive technology (ART) with a single oocyte retrieved in Mackay Memorial Hospital from 1996 to 2016 were recruited. All data were categorized into three groups, according to their fertilization method and semen quality: group A, conventional insemination with non-male factor (IVF-NMF, n = 115), group B, ICSI with male factor (ICSI-MF, n = 30), and group C, ICSI with non-male factor (ICSI-NMF, n = 49).

RESULTS

No statistically significant difference was observed between IVF and ICSI groups in pregnancy outcomes, including the chemical or clinical pregnancy rate, miscarriage rate, and live birth rate. Similar fertilization rates per oocyte obtained were observed in IVF and ICSI patients, but significantly lower per mature oocyte in the ICSI group (IVF: 91.5%, ICSI-MF: 75.0%, ICSI-NMF: 77.8%). Although there is no statistical significance, the lower live birth rate is observed in group C than others (A:11.5%, B:25%, C:5%, p = 0.187).

CONCLUSION

In this study, pregnancy outcomes of conventional in vitro fertilization and ICSI in poor responders with only a single oocyte retrieved were similar. However, the fertilization rate of matured oocytes in ICSI groups is significantly lower than that in the IVF group, indicating that ICSI procedures might cause oocyte damage. Therefore, the choice of fertilization method should be based on semen quality. A randomized controlled trial should be performed to confirm our findings.

Impact of intracytoplasmic sperm injection in women with non-male factor infertility: A systematic review and meta-analysis

OBJECTIVE

The purpose of this study is to determine whether intracytoplasmic sperm injection (ICSI) is beneficial in patients with non-male factor infertility.

METHODS

This systematic review and meta-analysis included articles from inception to May 2022. Published studies of non-male factor infertile women undergoing ICSI or in vitro fertilization (IVF) included in PubMed, Embase, web of science, Wanfang Database, and CNKI were searched by computer, without language restrictions. A random-effect model was applied to calculate the risk ratios (RRs) and their 95% confidence intervals (CIs). Letters, case reports, and review articles including meta-analyses and expert opinions were excluded. The primary endpoints were laboratory outcomes and pregnancy outcomes. The Secondary endpoints were neonatal outcomes.

RESULTS

Six randomized controlled studies and 20 retrospective cohort studies met the inclusion criteria. In meta-analytic forest plots, compared with IVF, those who received ICSI treatment were not different in fertilization rate (RR = 0.99, 95% CI [0.90-1.09], P = 0.88), total fertilization failure rate (RR = 1.30, 95% CI [1.17-1.45], P < 0.00001), and good quality embryo rate (RR = 0.94, 95% CI [ 0.86-1.02], P = 0.15), clinical pregnancy rate (RR = 0.84, 95% CI [0.70-1.01], P = 0.06), live birth rate (RR = 0.89, 95% CI [0.77-1.03], P = 0.13), miscarriage rate (RR = 1.06, 95% CI [0.78-1.43], P = 0.71), preterm neonatal delivery rate (RR = 0.92, 95% CI [0.67-1.26], P = 0.61), and low neonatal weight rate (RR = 1.13, 95% CI [0.80-1.61], P = 0.48). However, the implantation rate of IVF was better than ICSI (RR = 0.77, 95% CI [0.64-0.93], P = 0.005). In the subgroup analysis of the live birth rate of fresh embryo transfer, IVF performed in those ≥35 years had a higher live birth rate (RR = 0.82, 95% CI [0.78-0.83], P < 0.001).

CONCLUSION

The findings of this study indicate that ICSI is not superior to IVF in the treatment of infertility related to non-male factors. In order to confirm this result, more high-quality clinical studies are needed.

Opportunities and Limits of Conventional IVF versus ICSI: It Is Time to Come off the Fence

Conventional IVF (c-IVF) is one of the most practiced assisted reproductive technology (ART) approaches used worldwide. However, in the last years, the number of c-IVF procedures has dropped dramatically in favor of intracytoplasmic sperm injection (ICSI) in cases of non-male-related infertility. In this review, we have outlined advantages and disadvantages associated with c-IVF, highlighting the essential steps governing its success, its limitations, the methodology differences among laboratories and the technical progress. In addition, we have debated recent insights into fundamental questions, including indications regarding maternal age, decreased ovarian reserve, endometriosis, autoimmunity, single oocyte retrieval-cases as well as preimplantation genetic testing cycles. The “overuse” of ICSI procedures in several clinical situations of ART has been critically discussed. These insights will provide a framework for a better understanding of opportunities associated with human c-IVF and for best practice guidelines applicability in the reproductive medicine field.

ICSI in non-male factor infertility patients does not alter metabolomic signature in sibling embryos as evidenced by sensitivity enhanced nuclear magnetic resonance (NMR) spectroscopy

Intracytoplasmic sperm injection (ICSI) was developed to overcome male factor infertility, however, there recently has been an increasing trend in ICSI usage irrespective of the etiology, demonstrating an overuse of this insemination technique. There is a limited knowledge on the behaviour of ICSI derived embryos in non-male factor infertility patients. Metabolomic assessment of preimplantation embryos in conjunction with morphological evaluation can provide better understanding of embryonic behaviour. Hence, this study was undertaken to explore if there are any metabolomic differences between IVF and ICSI derived sibling day-5 blastocysts from non-male factor infertility patients. This prospective study included nineteen couples with non-male factor infertility undergoing Assisted Reproductive Technology. The sibling oocytes retrieved from each patient were randomly assigned to two groups and inseminated either by IVF or ICSI. Spent culture media (SCM) in which embryos were cultured up to day 5 were collected and investigated using sensitivity enhanced NMR based metabolite profiling utilizing high resolution (800 MHz) NMR equipped with cryogenically cooled micro-coil (1.7 mm) probe. The metabolomic signature between IVF and ICSI derived sibling blastocysts was assessed. A significant reduction in the concentrations of pyruvate, citrate, glucose and lysine were observed in both IVF and ICSI sibling embryos compared to medium control (P< 0.05–0.001). Further, histidine and valine level was found lower in ICSI embryos compared to medium control (P<0.05) during 96 hours of in vitro culture. Notably, between IVF and ICSI SCM, no significant difference in the concentration of the metabolites was found. Our results suggest that ICSI in non-male factor does not alter the SCM metabolomic signature during 96 hours of embryonic development.

Physical activity and sperm quality: influence in sperm donors

PURPOSE

To ascertain whether physical activity (PA) is associated with better sperm quality in sperm donors.

METHODS

A prospective case-control study was designed in an IVF center setting. A total of 207 sperm donation candidates from a relatively small geographical area were included in the study with no intervention. Donor candidates were subjected to conventional sperm analysis according to WHO criteria. Moreover, they answered a standardized questionnaire regarding their last week PA (IPAQ), with PA expressed in metabolic equivalents (METs)-min/week. Donors were classified into 4 groups: low, moderate, high and very high PA. Specific sports were included in the questionnaire. Semen samples from 43 accepted donors were used in artificial insemination by donor (AID) and IVF. The fertilization rates (FR) and pregnancy rates (PR) were studied.

RESULTS

Semen volume, sperm concentration, progressive spermatozoa, non-progressive spermatozoa, total motile progressive spermatozoa and sperm morphology were similar in the four PA groups. No correlation between various semen parameters studied and METs was found. Running or cycling > 1 h/week did not influence sperm parameters. The AID PR was similar in the different PA groups. However, in IVF the mean donor FR was significantly higher in the high PA group and in the very high PA group.

CONCLUSIONS

No detrimental effect was associated with PA, or even very high PA, regarding conventional sperm parameters. Moreover, a better FR was associated with high and very high PA in IVF cycles, which merits more studies.

Effectivity of conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) when male factor is absent: a perspective point of view

An objective and individualized approach of in vitro fertilization techniques tends to decrease costs and improve the experience of infertile couples during treatment. The use of available technologies to diagnose and treat infertility based on scientific evidence seems to be the best practice, which is the guideline that motivates this review on the available techniques for laboratory oocyte insemination. Conventional IVF, the pioneering technique, was initially used in the treatment of tubal obstruction infertility, successfully expanding the treatment of infertile couples presenting with several other factors. However, it was less effective in cases of severe male factor infertility. Intracytoplasmic sperm injection, which was developed in 1992, proved to be the method of choice for treating couples with severe male factor infertility. Since then, it has been increasingly used regardless of the infertility factor. This review discusses the effectiveness of conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) when the male factor is absent in all aspects, as technical and clinical outcomes, associated risks, adjustments for using with other technologies and costs. Finally we discuss the advantages and disadvantages of each one, with all aspects reviewed.

In vitro fertilisation (IVF) versus intracytoplasmic sperm injection (ICSI) in patients without severe male factor infertility: study protocol for the randomised, controlled, multicentre trial INVICSI

INTRODUCTION

Over the last decades, the use of intracytoplasmic sperm injection (ICSI) has increased, even among patients without male factor infertility. The increase has happened even though there is no evidence to support that ICSI results in higher live birth rates compared with conventional in vitro fertilisation (IVF) in cases with nonmale factor infertility. The lack of robust evidence on an advantage of using ICSI over conventional IVF in these patients is problematic since ICSI is more invasive, complex and requires additional resources, time and effort. Therefore, the primary objective of the IVF versus ICSI (INVICSI) study is to determine whether ICSI is superior to standard IVF in patients without severe male factor infertility. The primary outcome measure is first live birth from fresh and frozen-thawed transfers after one stimulated cycle. Secondary outcomes include fertilisation rate, ongoing pregnancy rate, birth weight and congenital anomalies.

METHODS AND ANALYSIS

This is a two-armed, multicentre, randomised, controlled trial. In total, 824 couples/women with infertility without severe male factor will be recruited and allocated randomly into two groups (IVF or ICSI) in a 1:1 ratio. Participants will be randomised in variable block sizes and stratified by trial site and age. The main inclusion criteria are (1) no prior IVF/ICSI treatment, (2) male partner sperm with an expected count of minimum 2 million progressive motile spermatozoa following density gradient purification on the day of oocyte pick up and (3) age of the woman between 18 and 42 years.

ETHICS AND DISSEMINATION

The study will be performed in accordance with the ethical principles in the Helsinki Declaration. The study is approved by the Scientific Ethical Committee of the Capital Region of Denmark. Study findings will be presented, irrespectively of results at international conferences and submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04128904. Pre-results.

ICSI Does Not Improve Live Birth Rates but Yields Higher Cancellation Rates Than Conventional IVF in Unexplained Infertility

Objectives: Unexplained infertility has been one of the indications for utilization of intracytoplasmic sperm injection (ICSI). However, whether ICSI should be preferred to IVF for patients with unexplained infertility remains an open question. This study aims to determine if ICSI improves the clinical outcomes over conventional in vitro fertilization (IVF) in couples with unexplained infertility.

Methods: This was a retrospective cohort study of 549 IVF and 241 ICSI cycles for patients with unexplained infertility at a fertility center of a university hospital from January 2016 and December 2018. The live birth rate and clinical pregnancy rate were compared between the two groups. Other outcome measures included the implantation rate, miscarriage rate, and fertilization rate.

Results: The live birth rate was 35.2% (172/488) in the IVF group and 33.3% (65/195) in ICSI group, P = 0.635. The two groups also had similar clinical pregnancy rates, implantation rates, and miscarriage rates. The fertilization rate of IVF group was significantly higher than that of ICSI group (53.8 vs. 45.7%, P = 0.000, respectively). Sixty-one and 46 patients did not transfer fresh embryos in IVF and ICSI cycles, respectively. Patients with IVF cycles had lower cancellation rates than those with ICSI (11.1 vs. 19.1%, P = 0.003, respectively).

Conclusion: ICSI does not improve live birth rates but yields higher cancellation rates than conventional IVF in the treatment of unexplained infertility.

Comparison of in vitro fertilisation/intracytoplasmic sperm injection on live birth rates in couples with non-male factor infertility and advanced maternal age

PURPOSE

To determine if the use of ICSI in women of advanced maternal age with non-male factor infertility increases chances of live birth.

METHODS

Retrospective data analysis of 10 years of cycle data from a single Australian IVF clinic (Repromed). First cycle patients only of an advanced maternal age (≥ 35 years) with non-male factor infertility utilising standard IVF or ICSI insemination and having at least three oocytes collected at egg pick up were assessed for live birth following transfer of single genetically unscreened blastocyst (N = 577). Subanalysis of clinical pregnancy, miscarriage, fertilisation, embryo utilisation rate and having a blastocyst for transfer were considered. Unadjusted, covariate adjusted and propensity score weighted analysis were performed.

RESULTS

The use of standard IVF insemination in women ≥ 35 years with non-male factor infertility increased the chance of a live birth compared with ICSI insemination (unadjusted OR = 2.72, 95% CI [1.78, 4.17]; adjusted OR = 2.64, 95% CI [1.64, 4.27] and weighted OR = 2.26, 95% CI [1.72, 2.98] 31% vs 14%). All other outcomes (fertilisation rate, embryo utilisation, blastocyst for embryo transfer and miscarriage rate) were unaffected.

CONCLUSION

In couples with advanced maternal age and non-male factor infertility, standard IVF insemination appears to increase the chance of a live birth compared with ICSI. As such, the results of this study support the use of routine IVF as the preferred insemination technique for older women in non-male factor infertility. However, future randomised controlled trials are still required to assess this policy.

Obstetric and perinatal outcomes of intracytoplasmic sperm injection versus conventional in vitro fertilization in couples with nonsevere male infertility

OBJECTIVE

To determine whether intracytoplasmic sperm injection (ICSI) is associated with improved outcomes compared with conventional in vitro fertilization (IVF) for patients with nonsevere male factor infertility.

DESIGN

Retrospective cohort.

SETTING

University-affiliated reproductive endocrinology unit.

PATIENT(S)

Couples who received their first-cycle embryo transfer without severe oligoasthenozoospermia (OA) between January 2012 and December 2016 were included in this study.

INTERVENTION(S)

Six subgroup analyses were performed according to the proposed indications for the use of ICSI as follows: non-male factor infertility, advanced maternal age (≥38 years), unexplained infertility, low oocyte yield (≤6), mild OA, and moderate OA.

MAIN OUTCOME MEASURE(S)

Live birth rates and selected perinatal outcomes.

RESULT(S)

ICSI resulted in live birth rates similar to those achieved with IVF (41.68% vs. 44.31%). There were no significant differences in the incidences of gestational diabetes mellitus, hypertension disorder of pregnancy, placental previa, postpartum hemorrhage, cesarean delivery, fetal macrosomia, small for gestational age, large for gestational age, neonatal intensive care unit (NICU) admission, and congenital anomalies between the two groups. Subgroup analyses showed that ICSI resulted in a lower rate of NICU admission in couples with moderate OA.

CONCLUSION(S)

Our results suggested that routine use of ICSI for all causes of infertility did not result in better pregnancy and perinatal outcomes compared with conventional IVF in the first cycle. ICSI might be associated with a lower risk of NICU admission when used in couples with moderate OA. Large prospective studies are required to validate our current findings.

ALWAYS ICSI? A SWOT analysis

PURPOSE

Intracytroplasmatic sperm injection (ICSI) is a common procedure used to improve reproductive results, even among couples without male factor infertility. However, the evidence available is still uncertain on the possible advantages and deficiencies that this procedure may have in patients with no formal indication for ICSI.

METHODS

A SWOT (strengths, weaknesses, opportunities, threats) analysis examines the possible advantages and deficiencies of performing ICSI in these patients with no formal indication.

RESULTS

The evidence suggests that ICSI is not justified for non-male factor infertile couples requiring in vitro conception. One of the major strengths associated to the procedure is the virtual elimination of cases further complicated by total fertilization failure and a combination between IVF and ICSI on sibling oocytes has been advised in the literature. Greater technical difficulties, higher costs and performing an unnecessary invasive technique in some cases represent some of the weaknesses of the procedure, and questions regarding safety issues should not be ruled out.

CONCLUSION

Despite the widespread use of ICSI in patients without a formal diagnosis of male factor infertility, evidence demonstrating its effectiveness in this population is still lacking. Additional large and well-designed randomized controlled trials are needed to clarify definitive indications for ICSI in non-male factor infertility.

Intracytoplasmic sperm injection (ICSI) for non-male factor indications: a committee opinion

Intracytoplasmic sperm injection, while typically effective for overcoming low or absent fertilization in couples with a clear abnormality of semen parameters, is frequently used in combination with assisted reproductive technologies for other etiologies of infertility in the presence of semen parameters that meet the World Health Organization 2010 normative reference values. This committee opinion provides a critical review of the literature, where available, to identify situations where this may or may not be of benefit. This document replaces the previously published document of the same name, last published in 2012 (Fertil Steril 2012;98:1395-9).

Tobacco consumption is associated with slow-growing day-6 blastocysts

Objective

To investigate if there are any obvious clinical factors associated with delayed blastulation at day 6 (D6) compared with day 5 (D5).

Design

Monocentric observational cohort study from November 2012 to December 2018.

Setting

Tertiary-care academic medical center.

Patient(s)

A total of 941 women with an entire cohort of exclusively D5 blastocysts compared with 162 patients with a cohort of exclusively D6 blastocysts.

Intervention(s)

None.

Main Outcome Measure(s)

Clinical characteristics and data related to the ovarian stimulation protocols.

Result(s)

After univariate analysis, a significantly higher proportion of women who were active smokers was found in the D6 group compared with the D5 group (n = 22/162 [13.6%] vs. n = 82/941 [8.7%]). In addition, the women in the D6 group had a higher rank number of assisted reproductive technology (ART; total no. of ART cycles performed: 2.1 ± 1.4 vs. 1.6 ± 1.1) and a lower antral follicle count (AFC; 18.7 ± 11.3 vs. 22.2 ± 12.8). Moreover, fertilization with the use of intracytoplasmic sperm injection was used more frequently in the D6 group compared with the D5 group. Logistic regression analysis adjusted for confounders highlighted several independent predictors for reaching blastocyst stage at D6 rather than D5: being an active smoker, previous ART cycles, and a lower AFC.

Conclusion(s)

Obtaining an exclusively D6 blastocyst cohort is independently associated with women who are active smokers, previous ART cycles, and a lower AFC. These findings provide evidence, to be confirmed by further studies, that women who are active smokers could greatly benefit from smoking cessation before undergoing ART.

Reactive oxygen species in reproduction: harmful, essential or both?

The process of embryonic development is crucial and radically influences preimplantation embryo competence. It involves oocyte maturation, fertilization, cell division and blastulation and is characterized by different key phases that have major influences on embryo quality. Each stage of the process of preimplantation embryonic development is led by important signalling pathways that include very many regulatory molecules, such as primary and secondary messengers. Many studies, both in vivo and in vitro, have shown the importance of the contribution of reactive oxygen species (ROS) as important second messengers in embryo development. ROS may originate from embryo metabolism and/or oocyte/embryo surroundings, and their effect on embryonic development is highly variable, depending on the needs of the embryo at each stage of development and on their environment (in vivo or under in vitro culture conditions). Other studies have also shown the deleterious effects of ROS in embryo development, when cellular tissue production overwhelms antioxidant production, leading to oxidative stress. This stress is known to be the cause of many cellular alterations, such as protein, lipid, and DNA damage. Considering that the same ROS level can have a deleterious effect on the fertilizing oocyte or embryo at certain stages, and a positive effect at another stage of the development process, further studies need to be carried out to determine the rate of ROS that benefits the embryo and from what rate it starts to be harmful, this measured at each key phase of embryonic development.

ICSI does not improve reproductive outcomes in autologous ovarian response cycles with non-male factor subfertility

STUDY QUESTION

Does the method of fertilisation improve reproductive outcomes in poor ovarian response (POR) cycles when compared to all other ovarian response categories in the absence of male factor subfertility?

SUMMARY ANSWER

ICSI does not confer any benefit in improving the clinical pregnancy or live birth (LB) outcome in autologous ovarian response cycles in the absence of male factor subfertility when compared to IVF.

WHAT IS KNOWN ALREADY

ICSI is associated with an improved outcome when compared to IVF in patients with severe male factor subfertility.

STUDY DESIGN, SIZE, DURATION

A retrospective study involving 1 376 454 ART cycles, of which 569 605 (41.4%) cycles fulfilled the inclusion and exclusion criteria for all autologous ovarian response categories: 272 433 (47.8%) IVF cycles and 297 172 (52.2%) ICSI cycles. Of these, the POR cohort represented 62 641 stimulated fresh cycles (11.0%): 33 436 (53.4%) IVF cycles and 29 205 (46.6%) ICSI cycles.

PARTICIPANTS/MATERIALS, SETTING, METHOD

All cycles recorded on the anonymised Human Fertilisation and Embryology Authority (HFEA) registry database between 1991 and 2016 were analysed. All fresh cycles with normal sperm parameters, performed after 1998 were included: frozen cycles, donor oocyte and sperm usage, intrauterine insemination cycles, preimplantation genetic testing (PGT) for aneuploidies (PGT-A), PGT for monogenic/single gene defects (PGT-M), PGT for chromosomal structural arrangements (PGT-SR) cycles, where the reason for stimulation was for storage and unstimulated cycles were excluded.

MAIN RESULTS AND THE ROLE OF CHANCE

ICSI did not confer any benefit in improving the LB outcome when compared to conventional IVF per treatment cycle (PTC), when adjusted for female age, number of previous ART treatment cycles, number of previous live births through ART, oocyte yield, stage of transfer, method of fertilisation and number of embryos transferred in the POR cohort (adjusted odds ratio [a OR] 1.03, 99.5% confidence interval [CI] 0.96–1.11, P = 0.261) and all autologous ovarian response categories (aOR 1.00, 99.5% CI 0.98–1.02, P = 0.900). The mean fertilisation rate was statistically lower for IVF treatment cycles (64.7%) when compared to ICSI treatment cycles (67.2%) in the POR cohort (mean difference −2.5%, 99.5% CI −3.3 to −1.6, P &lt; 0.001). The failed fertilisation rate was marginally higher in IVF treatment cycles (17.3%, 95% binomial exact 16.9 to 17.7%) when compared to ICSI treatment cycles (17.0%, 95% binomial exact 16.6 to 17.4%); however, this did not reach statistical significance (P = 0.199). The results followed a similar trend when analysed for all autologous ovarian response categories with a higher rate of failed fertilisation in IVF treatment cycles (4.8%, 95% binomial exact 4.7 to 4.9%) when compared to ICSI treatment cycles (3.2%, 95% binomial exact 3.1 to 3.3%) (P &lt; 0.001).

LIMITATIONS, REASONS FOR CAUTION

The quality of data is reliant on the reporting system. Furthermore, success rates through ART have improved since 1991, with an increased number of blastocyst-stage embryo transfers. The inability to link the treatment cycle to the individual patient meant that we were unable to calculate the cumulative LB outcome per patient.

WIDER IMPLICATIONS OF THE FINDINGS

This is the largest study to date which evaluates the impact of method of fertilisation in the POR patient and compares this to all autologous ovarian response categories. The results demonstrate that ICSI does not confer any benefit in improving reproductive outcomes in the absence of male factor subfertility, with no improvement seen in the clinical pregnancy or LB outcomes following a fresh treatment cycle.

STUDY FUNDING/COMPETING INTEREST(S)

The study received no funding. C.M.B. is a member of the independent data monitoring group for a clinical endometriosis trial by ObsEva. He is on the scientific advisory board for Myovant and medical advisory board for Flo Health. He has received research grants from Bayer AG, MDNA Life Sciences, Volition Rx and Roche Diagnostics as well as from Wellbeing of Women, Medical Research Council UK, the NIH, the UK National Institute for Health Research and the European Union. He is the current Chair of the Endometriosis Guideline Development Group for ESHRE and was a co-opted member of the Endometriosis Guideline Group by the UK National Institute for Health and Care Excellence (NICE). I.G. has received research grants from Bayer AG, Wellbeing of Women, the European Union and Finox.

TRIAL REGISTRATION NUMBER

Not applicable.

Higher clinical pregnancy rate with in-vitro fertilization versus intracytoplasmic sperm injection in treatment of non-male factor infertility: Systematic review and meta-analysis

OBJECTIVE

To evaluate the evidence about in-vitro fertilization (IVF) versus intracytoplasmic sperm injection (ICSI) for the treatment of non-male factor infertility.

DATA SOURCES

Electronic databases searched using the following MeSH terms (Sperm Injection, Intracytoplasmic) AND (in Vitro Fertilisation) AND (Infertility).

METHODS OF STUDY SELECTION

All RCTs included infertile patients due to non-male factors underwent IVF or ICSI were considered for this meta-analysis. One-thousand twenty-two studies were identified of which 20 studies deemed eligible for this review.

DATA EXTRACTION

Three independent authors extracted the relevant data from included studies. The study outcomes were pooled in the form of relative risk (RR) and 95 % confidence interval (CI) using Mantel-Hansel method. The main outcome measures are the fertilization rate, the implantation rate, the clinical pregnancy rate (CPR), the total fertilization failure and the live birth rate.

RESULTS

Regarding the fertilization rate, the pooled estimate did not favour either IVF or ICSI group (RR = 0.94; 95 %CI [0.82, 1.07]; p = 0.34). However, IVF significantly increased the CPR than ICSI (RR = 1.28, 95 %CI [1.11, 1.49]; p = 0.001). The overall effect estimate did not favor either of two groups regarding the implantation rate (RR = 1.25, 95 % CI [0.92, 1.68], p = 0.15). Similarly, no difference between both groups regarding the live birth rate (RR = 1.08, 95 % CI [0.79, 1.49]; p = 0.62).

CONCLUSIONS

No difference between ICSI and IVF regarding fertilization rate per oocytes, implantation rate and live birth rate in the treatment of non-male factor infertility, while IVF has significantly higher clinical pregnancy rate and higher risk of total fertilization failure.

ICSI Versus Conventional IVF in Women Aged 40 Years or More and Unexplained Infertility: A Retrospective Evaluation of 685 Cycles with Propensity Score Model

This study compared the cumulative live birth rates following Intracytoplasmic sperm injection (ICSI) versus conventional in vitro fertilization (cIVF) in women aged 40 years or more and unexplained infertility. A cohort of 685 women undergoing either autologous conventional IVF or ICSI was retrospectively analyzed. The effects of conventional IVF or ICSI procedure on cumulative pregnancy and live birth rates were evaluated in univariate and in multivariable analysis. In order to reduce potential differences between women undergoing either IVF or ICSI and to obtain unbiased estimation of the treatment effect, propensity score was estimated. ICSI was performed in 307 couples (ICSI group), whereas cIVF was performed in 297 couples (cIVF group), resulting in 45 and 43 live deliveries, respectively. No differences were observed in morphological embryo quality, in the number of cleavage stage embryos, in the number of transferred embryos, and in the number of vitrified embryos. As for the clinical outcome, no differences were observed in pregnancy rate, cumulative pregnancy rate, live birth rate, cumulative live birth rate, and abortion rate. The present results suggest that ICSI is not associated with increased likelihood of a live birth for unexplained, non-male factor infertility, in women aged 40 years or more.

ICSI does not offer any benefit over conventional IVF across different ovarian response categories in non-male factor infertility: a European multicenter analysis

PURPOSE

To evaluate whether ICSI offers any benefit compared with IVF in different ovarian response categories in case of non-male factor infertility.

METHODS

This is a retrospective multicenter analysis using individual patient data, conducted in 15 tertiary referral hospitals in Europe (1 center in Belgium and 14 in Spain). The study included the first cycle of all patients undergoing ovarian stimulation for IVF or ICSI in a GnRH antagonist protocol. Only patients having either IVF or ICSI for non-male factor infertility were included. Patients were divided into 4 groups based on their ovarian response as follows: group A, poor responders (1-3 oocytes); group B, suboptimal responders (4-9 oocytes); group C, normal responders (10-15 oocytes); group D, high responders (> 15 oocytes).

RESULTS

In total, 4891 patients were analyzed, of whom 4227 underwent ICSI and 664 IVF. There was no significant difference for the insemination method (ICSI vs. IVF) used among the different ovarian response categories: 87% vs. 13%, 87% vs. 13%, 86% vs. 14%, 84% vs. 16%, for groups A, B, C, and D, respectively, p value = 0.35. Mean fertilization rates and embryo utilization rates were comparable between IVF and ICSI in the whole cohort. Fresh and cumulative LBR did not differ significantly for IVF and ICSI in poor, suboptimal, normal, and high responders.

CONCLUSION

There is no advantage of ICSI over IVF as insemination method for non-male factor infertility, irrespective of the ovarian response. The number of oocytes retrieved has no value for the selection of the insemination procedure in case of non-male infertility.

Dielectrophoretic Microfluidic Device for in Vitro Fertilization

The aim of this work was to create a microfluidic platform that uses in vitro fertilization (IVF) and avoids unnecessary damage to oocytes due to the dielectrophoretic force manipulation of the sperms and oocytes that occurs in a traditional IVF operation. The device from this research can serve also to decrease medium volumes, as well as the cost of cell culture under evaporation, and to prevent unnecessary risk in intracytoplasmic sperm injection (ICSI). To decrease the impact and destruction of the oocyte and the sperm, we adopted a positive dielectrophoretic force to manipulate both the sperms and the oocyte. The mouse oocytes were trapped with a positive dielectrophoretic (p-DEP) force by using Indium Tin Oxide (ITO)-glass electrodes; the ITO-glass electrode chip was fabricated by wet etching the ITO-glass. The polydimethylsiloxane (PDMS) flow-focusing microfluidic device was used to generate microdroplets of micrometer size to contain the zygotes. The volume of the microdroplets was controlled by adjusting the flow rates of both inlets for oil and the DEP buffer. As a result, the rate of fertilization was increased by about 5% beyond that of the DEP treatment in traditional IVF, and more than 20% developed to the blastocyst stage with a low sperm-oocyte ratio.

Is there a reason to perform ICSI in the absence of male factor? Lessons from the Latin American Registry of ART

Study question

Does the use of ICSI offer any outcome advantage over IVF in patients with non-male factor infertility?

Summary answer

We did not find any outcome improvement that justifies the routine use of ICSI over IVF in non-male factor ART cycles.

What is already known

Since its introduction in Latin America, the use of ICSI has increased substantially, even among patients without male factor infertility. However, it is not clear whether ICSI provides an advantage over IVF in non-male factor infertility.

Study design size duration

A retrospective cohort study of fresh cycles performed in 155 ART clinics located in 15 Latin American countries between 2012 and 2014. Records were assessed for 49,813 ART cycles (39,564 ICSI and 10,249 IVF) performed in infertile couples who did not have male factor infertility. Student's t-test was used to analyze normally distributed data, Wilcoxon test to analyze non-normally distributed data, and Fisher's exact test for categorical data. Logistic regression was used to quantify the effect of ICSI on delivery rate, adjusting for age of female partner, number of oocytes inseminated, number of embryos transferred, and transfer at blastocyst stage as possible confounding factors. Poisson regression analysis was used to quantify the effect of ICSI on fertilization rate, adjusting for age of female partner.

Participants/materials setting method

Cycles with the diagnosis of male factor and use of cryopreserved semen and with a freeze-all strategy were excluded.

Main results and the role of chance

After correcting for age of female partner, number of oocytes inseminated, number of embryos transferred and transfer at blastocyst stage, we found that the use of ICSI was associated with a significant decrease in the odds of delivery compared to IVF (odds ratio 0.88, 95% CI 0.84 to 0.93; P < 0.0001).

Limitations reasons for caution

An important limitation of this study is the lack of randomization owing to its retrospective nature. This could result in selection bias, i.e. couples with the worst prognosis undergoing ICSI, or patients with a history of fertilization failure in IVF cycles undergoing ICSI. More than one cycle from the same couple may be included in the study.

Wider implications of the findings

The lack of an outcome benefit-and, indeed, a reduced likelihood of delivery-following ICSI in non-male factor infertile couples suggests that ICSI may not be the most appropriate clinical approach in these patients.

Study funding/competing interests

None.

Can calcium ionophore "use" in patients with diminished ovarian reserve increase fertilization and pregnancy rates? A randomized, controlled study

OBJECTIVE

To determine whether calcium ionophore solution can improve the fertilization rate in patients with diminished ovarian reserve whose partners have normal sperm parameters.

DESIGN

Between January 2014 and August 2014, patients with diminished ovarian reserve were randomized to make artificial oocyte activation with calcium ionophore solution.

SETTING

University hospital.

PATIENT(S)

A total of 296 patients who had diminished ovarian reserve and partners with normal sperm parameters were included in the study.

INTERVENTION(S)

Metaphase 2 oocytes were treated with calcium ionophore solution (GM508 Cult-Active) for 15 minutes just after intracytoplasmic sperm injection.

MAIN OUTCOME MEASURE(S)

Fertilization rate, implantation rate, clinical pregnancy rate, ongoing pregnancy rate.

RESULT(S)

Fertilization, implantation, pregnancy, and ongoing pregnancy rates for the calcium ionophore and control groups were 60.7% and 55.4%, 12.8% and 10.7%, 21% and 12.8%, and 10.9% and 6.1%, respectively.

CONCLUSION(S)

This is the first prospective, randomized, controlled study to analyze the effect of calcium ionophore solution on fertilization rate in patients with diminished ovarian reserve. We did not observe any differences in fertilization, clinical pregnancy, or ongoing pregnancy rates between the groups. We propose that fertilization ratios could not be increased by artificial oocyte activation via application of calcium ionophore solution in patients with diminished ovarian reserve.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02045914.

Embryonic development in human oocytes fertilized by split insemination

OBJECTIVE

To compare the laboratory outcomes of intracytoplasmic sperm injection (ICSI) and conventional insemination using sibling oocytes in poor prognosis IVF cycles where ICSI is not indicated.

METHODS

Couples undergoing IVF with following conditions were enrolled: history of more than 3 years of unexplained infertility, history of ≥3 failed intrauterine insemination, leukocytospermia or wide variation in semen analysis, poor oocyte quality, or ≥50% of embryos had poor quality in previous IVF cycle(s). Couples with severe male factor requiring ICSI were excluded. Oocytes were randomly assigned to the conventional insemination (conventional group) or ICSI (ICSI group). Fertilization rate (FR), total fertilization failure, and embryonic development at day 3 and day 5 were assessed.

RESULTS

A total of 309 mature oocytes from 37 IVF cycles (32 couples) were obtained: 161 were assigned to conventional group and 148 to ICSI group. FR was significantly higher in the ICSI group compared to the conventional group (90.5% vs. 72.7%, P<0.001). Total fertilization failure occurred in only one cycle in conventional group. On day 3, the percentage of cleavage stage embryos was higher in ICSI group however the difference was marginally significant (P=0.055). In 11 cycles in which day 5 culture was attempted, the percentage of blastocyst (per cleaved embryo) was significantly higher in the ICSI group than the conventional group (55.9% vs. 25.9%, P=0.029).

CONCLUSION

Higher FR and more blastocyst could be achieved by ICSI in specific circumstances. Fertilization method can be tailored accordingly to improve IVF outcomes.

Live birth rates using conventional in vitro fertilization compared to intracytoplasmic sperm injection in Bologna poor responders with a single oocyte retrieved

PURPOSE

To compare reproductive outcomes following conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in poor responders fulfilling the Bologna criteria, with a single oocyte retrieved.

METHODS

The present retrospective study included 243 Bologna poor responders with a single oocyte retrieved, who were categorized into three groups, depending on the fertilization method and semen quality (IVF non-male factor-IVF/NMF n = 101; ICSI non-male factor ICSI/NMF n = 50; ICSI male factor-ICSI/MF n = 92).

RESULTS

In IVF/NMF, ICSI/NMF and ICSI/MF similar fertilization rates [65.3, 66, 58.7%, respectively], proportions of embryo formation [63.4, 60, 53.3%, respectively], proportions of good quality embryos [54.7, 56.7, 57.1%, respectively], implantation rates [8.9, 10, 8.2% respectively] and live birth rates per oocyte retrieval [5.0, 4.0, 3.3%, respectively] were observed. Degeneration rate of oocytes due to mechanical damage was significantly higher after ICSI in the ICSI/NMF and ICSI/MF groups (8 and 6.5%, respectively) compared to IVF/NMF (0%) (p = 0.02).

CONCLUSIONS

Conventional IVF and ICSI are associated with similar reproductive outcomes in poor responder patients with a single oocyte retrieved. Therefore, the choice of fertilization method should be based primarily on semen quality, in combination with the patient's previous history. A randomized controlled trial should be performed to confirm this study's findings that conventional IVF and ICSI have similar reproductive outcomes in poor responders.

Trends in use of and reproductive outcomes associated with intracytoplasmic sperm injection

IMPORTANCE

Intracytoplasmic sperm injection (ICSI) is increasingly used in patients without severe male factor infertility without clear evidence of a benefit over conventional in vitro fertilization (IVF).

OBJECTIVE

To assess national trends and reproductive outcomes for fresh IVF cycles (embryos transferred without being frozen) following the use of ICSI compared with conventional IVF with respect to clinical indications for ICSI use.

DESIGN, SETTING, AND POPULATION

Retrospective cohort study using data on fresh IVF and ICSI cycles reported to the US National Assisted Reproductive Technology Surveillance System during 1996-2012.

MAIN OUTCOMES AND MEASURES

Trends in ICSI use during 1996-2012 with respect to male factor infertility, unexplained infertility, maternal age 38 years or older, low oocyte yield, and 2 or more prior assisted reproductive technology cycles; reproductive outcomes for conventional IVF and ICSI cycles during 2008-2012, stratified by the presence or absence of male factor infertility.

RESULTS

Of the 1,395,634 fresh IVF cycles from 1996 through 2012, 908,767 (65.1%) used ICSI and 499,135 (35.8%) reported male factor infertility. Among cycles with male factor infertility, ICSI use increased from 76.3% (10,876/14,259) to 93.3% (32,191/34,506) (P < .001) during 1996-2012; for those without male factor infertility, ICSI use increased from 15.4% (4197/27,191) to 66.9% (42,321/63,250) (P < .001). During 2008-2012, male factor infertility was reported for 35.7% (176,911/494,907) of fresh cycles. Among those cycles, ICSI use was associated with a lower multiple birth rate compared with conventional IVF (30.9% vs 34.2%; adjusted relative risk [RR], 0.87; 95% CI, 0.83-0.91). Among cycles without male factor infertility (n = 317,996), ICSI use was associated with lower rates of implantation (23.0% vs 25.2%; adjusted RR, 0.93; 95% CI, 0.91-0.95), live birth (36.5% vs 39.2%; adjusted RR, 0.95; 95% CI, 0.93-0.97), and multiple live birth (30.1% vs 31.0%; adjusted RR, 0.93; 95% CI, 0.91-0.95) vs conventional IVF.

CONCLUSIONS AND RELEVANCE

Among fresh IVF cycles in the United States, ICSI use increased from 36.4% in 1996 to 76.2% in 2012, with the largest relative increase among cycles without male factor infertility. Compared with conventional IVF, ICSI use was not associated with improved postfertilization reproductive outcomes, irrespective of male factor infertility diagnosis.

Assisted hatching and intracytoplasmic sperm injection are not associated with improved outcomes in assisted reproduction cycles for diminished ovarian reserve: an analysis of cycles in the United States from 2004 to 2011

OBJECTIVE

To investigate the impact of intracytoplasmic sperm injection (ICSI) and assisted hatching (AH) on assisted reproductive technology (ART) outcomes in initial cycles with diminished ovarian reserve (DOR) as the primary diagnosis.

DESIGN

Retrospective cohort study of cycles from the Society for Assisted Reproductive Technology (SART) Clinic Outcome Reporting System database.

SETTING

Not applicable.

PATIENT(S)

A total of 422,949 fresh, nondonor, initial ART cycles of which 8,597 were diagnosed with only elevated FSH and 38,926 were diagnosed with only DOR according to the SART DOR categorization.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Live birth and clinical pregnancy rates.

RESULT(S)

ICSI and AH were associated with diminished odds of live birth in SART DOR-only cycles (adjusted odds ratio [AOR] 0.88, 95% confidence interval [CI] 0.81-0.96 for ICSI; AOR 0.77, 95% CI 0.71-0.84 for AH). No association between odds of live birth and either ICSI or AH in elevated FSH-only cycles was observed. The combination of ICSI and AH was associated with significantly lower odds of live birth in SART DOR-only cycles but not in elevated FSH-only cycles.

CONCLUSION(S)

In initial ART cycles for which the only indication relates to a diagnosis of DOR, AH and ICSI are not associated with improved live birth rates.

Intracytoplasmic sperm injection (ICSI) for non-male factor infertility: a committee opinion

Intracytoplasmic sperm injection, while typically effective for overcoming low or absent fertilization in couples with a clear abnormality of semen parameters, is frequently utilized in combination with assisted reproductive technologies for other etiologies of infertility in the presence of normal semen parameters. This committee opinion provides a critical review of the literature, where available, to identify situations where this may or may not be of benefit.