Home » IVF#2 » To ICSI or Not to ICSI?

To ICSI or Not to ICSI?

During IVF#1, we went in blind, not knowing what the outcome would be for fertilization. The embryologist recommended we fertilize 2/3 of our eggs using ICSI and 1/3 via conventional IVF.

For those of you who aren’t familiar with these terms, conventional IVF is when they place the eggs and sperm together in the Petri dish and let fertilization happen on its own.
This allows the stronger sperm to fertilize, and the normal eggs to be fertilized.

ICSI, which stands for intracytoplasmic sperm injection is when the embryologist selects which sperm he/she deems to be the “the best”, and then manually injects that single sperm into the egg to fertilize it. There is a different kind of selection here, as it is based purely on the embryologist’s observations of morphology and motility. Less natural selection here, as the race to the egg and process of penetrating the zona pellucida (shell of the egg) is bypassed. Potentially, crappy sperm and crappy egg can fertilize and be fertilized by ICSI, however, if you suffer from fertilization failure (hard to penetrate eggs or sperm that can’t dissolve the shell) ICSI can make a positive difference.

These were our results from last year’s IVF:

IMG_6086

Now, the grades of these embryos were all very good, except for one which was fair. The “best looking” embryos were ICSI fertilized. We don’t know which ones were chromosomally normal, but know that the pregnancy (and subsequent miscarriage) in July/August/September was of a chromosomally normal female embryo.

Since egg retrieval is coming up next week, we have to decide how we want to fertilize our eggs. I want last year’s IVF to be a learning opportunity. The embryologist thinks we could do all conventional IVF since we did have fertilization occur properly this way. Conventional IVF also allows natural selection of normal eggs and normal sperm as well. Overall live birth outcomes are the same whether you do IVF or ICSI, even if IVF yields less embryos.

This compares the use of ICSI over Conventional IVF in several different causes of infertility, and finds that ICSI is only beneficial in cases of male factor infertility.

IMG_6084

Right now we’re leaning toward 100% IVF, but our RE thinks we should still do some ICSI, without giving a real reason. He says it depends on our numbers on retrieval day. We are not naive to the fact that doing ICSI means they can charge $1250 more.

And then there’s this, which seems to say that there’s little to no risk from doing ICSI, so why not do it.

Another factor is that we are not using the same anonymous sperm donor as last IVF, so it is unknown how well this sperm will fertilize our new batch of eggs. But seeing as how our sperm is coming from a sperm bank, we can assume the motility counts are decent.

I would love your feedback and experience as we make this decision.

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44 thoughts on “To ICSI or Not to ICSI?

  1. Obviously, so much of this depends on factors beyond our control, but this was my personal experience: We used ICSI on all of our eggs. Out of 16 eggs, 10 were mature and 9 of the 10 fertilized. From the fertilized eggs, 5 embryos were frozen on day 5, and 2 more were frozen on day 6, giving us a total of 7 from only 9 fertilized eggs. If I had it to do over again, I would go the ICSI route again.

    • Thanks for sharing. It looks like ICSI worked out really well for you girls. I’m torn. I wish we knew more about why none of IVF #1’s embryos worked out. I feel like there’s just not enough data in my case.

  2. My personal experience has been so much better with ICSI. I think you would always doubt yourself if you did all IVF and had low fertilization. Just my opinion. Xo

  3. I believe, perhaps out of my unwillingness to admit defeat, that my old clinic, possible poor lab and poor stimulation to be the reason for my total failure with round 1 ivf. In round 2, we did icsi, because the doc blamed my eggs despite me having twice been successful in two au naturel IUIs. Out of 9 eggs, 5 were mature, and 5 fertilized via icsi and made it to day 5 (though it was ultimately a fail too, with zero to freeze). Tough call. The stubborn in me wants to try a combo next time, if we go back down that road again.

    • Thanks for sharing. What basis did the doc have for blaming your eggs (other than the failure)? What stimulation protocol did they use with you each time? I know everyone is different, which is what drives me nuts sometimes. It’s so tough to know, isn’t it?

      • Yes it’s so tough to know. He jumped to that conclusion after zero fertilized with normal IVF because of how many IUIs I’ve done (2 BFPs out of 14 IUIs). He said my eggs are probably just difficult to fertilize, but didn’t have anything more concrete to add. I, on the other hand, believe (again my unwillingness to accept his theory and admit that my eggs are the issue) that the timing was the bigger culprit.

        For my first pregnancy, it took 2 real tries at IUI (the 3rd try was clearly just too far past ovulation). The second took 7 tries, BUT I was still breastfeeding baby #1 so I think maybe my hormones were just a bit out of sorts still. After my mc, we switched to that shitty clinic where we did 4 more triggered IUIs (2 w/o drugs, 2 w/femara). 3 were triggered at around 18mm, and one at 23mm (probably too late). I think that considering how early in my cycle the triggers & IUIs were compared to when my natural LH surge ever took place, that 18mm was just too immature for me. This theory is shared by my new RE, who agreed that we should try to wait until around 20mm to trigger.

        In IVF #1 we did antagonist protocol, with low doses of puregon 100ui & menopur 75ui, got 15 eggs but only 5 were mature (zero fert). IVF #2 we did short protocol, again with low dose of puregon 75ui (increased to 100ui for last 4-5 stim days) & menopur 75 ui. The goal this time was to get fewer, better quality eggs. Only 9 were retrieved and only 5, again, were mature. 100% fertilized.

        This most recent IUI was also triggered, but 2 days after measuring 16mm … So I’m hoping they’ll have had the chance to become large enough to mature at trigger!

        Ttc sucks! I want a freaking “oops I’m pregnant!”

      • Thank you so much for sharing your details. I find it helpful. Your poor body has been put through so much. I guess in your case, the ICSI did allow for fertilization to happen, but in the end, none made it. The scientific research says that that is why ICSI is kind of a flash in the pan- it allows for greater fertilization, but in the end, the rate of live birth ends up the same, as it allows more abnormal embryos to make it to later stages of development. That’s why I’m so torn- do I want to have less embryos overall, or more embryos but less certainty that I’m putting in good ones?

        I hope this IUI is the one that works to get you that sibling for DD!

      • Thanks! I feel that I need to believe my body is capable to repeat what it’s already done, and that it will. It may take more time, but time vs. the process of an IVF…seems much more attractive right now. I feel the exact same way and am so not ready to attempt IVF again for that reason.

  4. Sounds like a lot of things to think about. I don’t have any words of wisdom or advice, just fingers crossed and positive thoughts headed your way as you both make a decision that’s right for your family and start the next cycle.

    • Very true. But it also means that not great sperm could fertilize a good egg, and vice-versa, causing a sneaky “decent” looking embryo, and then leading to miscarriage. I’m just so scared of miscarrying again, but I guess we will never know what caused both of DW’s and my miscarriages. Sorry, I’m just thinking out loud now. Thanks for your wisdom πŸ™‚

  5. All of the US clinics with the top stats have almost 100% ICSI rates. Just pick a state, find the clinic with the best numbers, and you’ll see it will be something like 95% ICSI on the SART data. It’s mandatory at my clinic. CCRM is at 91%.

    • Thanks for the info. It’s so tough making these decisions without enough data on our own case, and also without forthcoming information from our clinic. I appreciate the advice, and after more consideration, we’re leaning more towards 100% ICSI. Somehow reproductive technology seems so far behind in Canada compared to the States.

  6. Honestly, I think I would go with IVF all the way. There’s something to be said for part of a very unnatural process to still happen naturally. I totally understand the draw to ICSI, but I think in your case with a new donor and totally new IVF in general, and previous miscarriages, I’d go natural fertilization and instead opt for PGD. Is that and option for you?

    • Unfortunately they won’t do PGD for us. I’m not sure why, but the RE doesn’t think we need it – and therefore won’t “okay” for it to be done. It’s kind of messed up in Canada. Everything has to be signed off as medically necessary by the doctor in order to do anything.

      • I’ve never heard of that. This is not insured care – so there is no medically necessary threshold up cross. Our first IVFs were in Canada and we just had to pay for PGD not get a medically necessary assessment even though our RE at the time did not recommend it. That’s such utter BS. I’m sorry your RE is such a tool.

      • Yeah I argued with them, that we were willing to pay for it, but they said they wouldn’t do it because the RE didn’t think it was necessary. DW also thinks it’s too expensive, and that she’d rather take the chance of keeping having to do FETs. I’m a little more impatient and fearful of miscarrying, and would rather know that the embryos I’m transferring are normal. Ugh.

      • I tend to agree with your wife FWIW. With your immune issues PGD does not eliminate risk of loss. You would need a new clinic with real immune care to be sure that genetic testing was a key outstanding variable. I would spend the PGD money changing clinics to one that properly tests and treats immune issues instead if this cycle does not work. But I am truly truly truly hoping this is all moot because you will be and stay pregnant soon soon soon.

      • Thank you. I spent the morning googling “PGS normal but miscarriage”. Ugh. It seems like there are a lot of women with self-suspecting immune issues that their RE’s won’t address. At least this time I’m on the prednisone and Fragmin. Fingers crossed it works!

      • I know. Scary isn’t it? What dose of prednisone are you on again and when do you start it and the LMWH? Forgive me for not keeping these things straight in my mind. I can barely remember how to spell these days.

  7. Thank you for your blog entry on this subject..I just wrote a blog entry that asks the same questions. I’m currently on Day 4 of Stims in our first (and only, thanks to affordability) IVF cycle..I can’t remember if I told you, but we are also in Toronto, so understand your Canadian perspective! I am doing ICSI, as I have borderline moderately high FSH, so I’m a bit concerned my eggs may be a bit tough to fertilize. I understand your concerns though…I will never know if my eggs can be penetrated by sperm “naturally”..but as this is our only shot, I guess it doesn’t really matter. Good luck with everything.

  8. Good info in this post and comments. We had to icsi, ostensibly because of poor sperm. I wonder now if maybe we had fertilization because my crap eggs were meeting his crap sperm, but no one knew both parts were lacking, hmmmm…. Curious, what are you DW planning to do now that you’ve had a few days to consider?

    • We are leaning towards ICSI, because the risk of losing a good egg due to failed fertilization (last time we lost one of our IVF fertilized eggs due to double sperm fertilization) is kind of significant. If you think about how at my age, only 30-40% of our blastocysts are projected to be normal, losing a single good egg to fertilization failure is a big deal. Now, I would love to do PGS to eliminate embryos that make it to day 5 but are no good, but if you read the comments above, my RE doesn’t think I need it. It’s so tough, because I really am so scared of miscarrying again, and I worry that this fear is creating a bias for us to do conventional IVF. However, when eggs are such a difficult thing to extract, I don’t want any going to waste because they’re not fertilizing properly but could still be normal.

  9. Pingback: IVF#2: Day 1 Fertilization Report | Mama et Maman

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