Do you really need ICSI?

ICSI (intracytoplasmic sperm injection) is a successful treatment when there are male fertility problems, but it is often used more widely in fertility clinics – and some offer ICSI to many patients where there is no male factor problem at all. Now, new research presented at ESHRE (the European Society of Human Reproduction and Embryology) shows that there is no benefit to offering ICSI unless there is a male fertility issue.

ICSI was developed in the 1990s as a breakthrough treatment for men who would otherwise have had to use donor sperm to become a parent, but now it is used so often that twice as many ICSI cycles are carried out around the world as IVF cycles. In some countries all assisted conception cycles are ICSI.

This large study of almost 5000 patients in Belgium and Spain being treated with ICSI or IVF found there was no benefit to using ICSI where there was no male fertility problem. The results of the study were presented by Dr Panagiotis Drakapoulos from UZ Brussels, the Belgian centre where ICSI was developed more than 25 years ago. The study was a collaboration between the Brussels centre and 14 clinics in Spain.

The reason given for using ICSI is often that it is thought it results in a higher chance of fertilisation and more embryos, but this large study showed no overall difference in outcome using IVF or ICSI regardless of whether the female patients had large numbers of eggs (more than 15) or not so many (1-3) – so there is no rationale for using it to try to improve outcomes in cycles where there are just a few eggs.

The use of ICSI varies around the world, with the highest rates in many countries of Eastern and Mediterranean Europe. There is a slightly lower use in some Nordic countries, the UK and France. In its latest review of treatment trends in the UK, the HFEA reported that ICSI use ‘continued to increase until 2014, but it is now in decline, possibly due to clinical opinion that it’s not needed in all contexts of IVF’. 

This reflects the message from this study, which, according to Dr Drakapoulos, found ‘no justification for the use of ICSI in non-male factor infertility’. He added that the number of eggs retrieved ‘should not play any role in selecting the insemination method’. Dr Drakapoulos also highlighted the extra financial cost of ICSI over IVF.