Should ICSI be used for all IVF Cycles?

Just fewer than 5% of all couples undergoing in vitro fertilization (IVF) have successful egg and sperm retrieval, see positive results on sperm quality tests, and then experience failed IVF because fertilization fails to occur.  For some reason, the sperm just can’t crack the outer shell of the egg, called the zona pellucida.  Unfortunately the best test for this failure to fertilize is IVF.  A single cycle of IVF costs roughly $10,000; many couples are understandably upset when it fails before any embryos are even created.  A failed IVF cycle is an expensive way to find out you have a fertilization problem!

A relatively new procedure, called intracytoplasmic sperm injection (ICSI) eliminates the possibility of failed fertilization.  Instead of placing sperm and egg inside a lab dish and allowing fertilization to occur, a single sperm is injected directly into the cytoplasm of an egg.  Forcing fertilization ensures that embryos will be created, and eliminates the possibility of failure at this stage.

In most clinics ICSI is used as an added procedure to a second cycle of IVF, when the first cycle fails due to a lack of fertilization.  It can also allow men with extremely low sperm production to use their own sperm for IVF.  Additional costs for ICSI often range between $2,000 and $2,500, depending on the size of the clinic, the quality of its lab, and how often the clinic performs the procedure. 

The big debate among fertility specialists is whether or not to use ICSI for all IVF cycles.  If it eliminates the possibility for almost 5% of IVF patients to experience failure, then why not use ICSI all the time? 

The answers have to do more with human nature than with medicine.  ICSI is a relatively new technique, and for many smaller clinics it is outside of the lab’s comfort zone.  All labs are comfortable doing IVF, but not as many routinely do ICSI.  As a result, their procedures are less efficient so their costs are higher, and the cost is passed on to the patient.  Some doctors also worry about the possibility of increased birth defects associated with ICSI.  Several major studies conducted around the world have found no higher incidence of chromosomal abnormalities in embryos created with ICSI than IVF.  Quite simply, ICSI marks a significant change in the standard protocol for reproductive technology, and people (even doctors) are resistant to change.

So if your clinic hasn’t embraced the change, where does that leave you?  Talk to your doctor about the possibility of fertilization failure, and ask about the additional cost for having ICSI done with IVF.  Some clinics are so good at the procedure, it is standard for everyone, at no extra cost to patients.  Other clinics will charge additional fees. 

ICSI is more effective and just as safe as IVF, so the question is really about cost.  Fertilization failure could mean a wasted cycle of IVF, which means more money and more time.  ICSI may require additional cost in the beginning, but could result in pregnancy with one cycle instead of many.  Talk to your doctor, find out how often they perform ICSI and the costs, and then do the math!  ICSI may be a good investment.