is ICSI really the answer?

It’s incredible how many couples are told that ICSI is the answer to poor sperm quality. Yet really, it’s not actually a solution!

This is a classic example of how men (and couples) aren’t being supported and given the correct information on how they can improve their sperm. ICSI is often held up as solution to poor sperm quality when actually there are other things that could and should be considered first.

First of all, let’s just explain the difference between ICSI and IVF.

IVF is where the sperm and an egg are put together in a dish and left to get on with it in an incubator overnight. With this method the sperm still need to swim and find the egg and it’s a case of the best sperm wins. Where the sperm are strong and healthy then this method makes sense if things haven’t been happening naturally.

ICSI is a lot more advanced where a high-powered microscope is used to allow embryologists to place a single sperm inside the egg. There is a whole lot more that happens to the sperm before this in terms of the sperm being cleaned up and washed so that embryologists can choose the “best” sperm but in a nutshell this is what happens. Clinics will opt for this method when the sperm are less mobile, poorly shaped or there just aren’t many of them.

In both instances the couple get the phone call the next day to see how many eggs have fertilised because even putting the sperm inside the egg doesn’t guarantee success.

A very well known Andrologist once said “ICSI was the death of Andrology”. Andrology being the study and treatment of male infertility. ICSI often attempts to bypass any fertility issues on the man’s side rather than actually trying to establish what’s going on.

Within the UK we have a system that is very much geared towards investigating female fertility and then pushing couples towards IVF through a gynaecologist (a female reproductive specialist) as the answer. A man will be offered a semen analysis and that is all. If his sample comes back below range then IVF or ICSI is seen as the answer.

What this inevitably means is that a couple head off down the IVF road getting further and further into tests and treatment with very little further testing for the man. The fertility clinics offer ICSI as the solution to poor male fertility and the man doesn’t get looked at again unless there are multiple failed cycles or recurrent miscarriages.

It seems absolutely bonkers that we are sending couples into expensive and emotionally challenging treatments without proper testing that has fully assessed both parts of the equation and then offering a “solution” that really doesn’t look at the root cause of the problem.

ICSI is certainly very well indicated in many cases and it’s a phenomenal treatment but it really shouldn’t be the first line of attack if a man has poor quality sperm. Much as the sperm will get cleaned up and an embryologist will choose a good looking sperm you’re still choosing from a less than optimal bunch, surely it makes sense to try and improve things so that you can choose the best from a good bunch or potentially even avoid any intervention at all.  

If we rewind any couple’s fertility investigations and take them back to the very first semen analysis, there are several options to consider at this point before being referred to IVF if a man’s results have come back sub optimal.

A semen analysis is a good first step but actually a very basic assessment of a man’s fertility. There is so much more that could be offered to a man that might help explain a poor semen analysis result such as:

  • Infection screening
  • Diet and lifestyle profile
  • Ultrasound
  • Hormone profile
  • DNA fragmentation

Even a simple physical examination might show something that could be causing the problem.

Typically, none of this happens for the man early on and not consistently even after recurrent IVF / ICSI failure.

If you’re a couple who are already heading into the realm of fertility tests then I would urge you to consider getting a full male fertility assessment done before you get pushed down the IVF / ICSI route. Many male fertility issues are actually fixable or at very least can be improved upon but only if you know what’s going on. You wouldn’t go into a marathon without training and getting some decent trainers so why would you go into IVF without doing all you can to improve the sperm?

There is no doubt that for many couples by the time they end up at a fertility clinic time is not on their side and once they’ve been through several failed treatment cycles it feels too late in the day to go back and reassess the sperm. Therefore, ICSI seems like the sensible option but really if the right tests and investigations were done in the first place then time, expense and heartache could have been avoided.

So our advice to any couple would always been to try and get as well informed and thoroughly tested on the man’s side before you progress to IVF. We know that 40% of fertility issues sit with the man yet we don’t investigate them properly. ICSI really isn’t a magic bullet for poor sperm quality. It is a useful adjunct to treatment, but you’ve always got to try and find out what’s causing poor sperm quality first and deal with that if you can.

Further testing can be hard to find however things are changing and at testhim we're helping creat that change. There is more to follow on that very soon but a good first step is to find an Andrologist who can run advanced tests for you.