Intracytoplasmic sperm injection

Male factors are the commonest single cause of infertility (1).

The technique of intracytoplasmic sperm injection (ICSI) has revolutionised the treatment of patients with moderate to severe oligoasthenoteratozoospermia and other sperm dysfunctions; it has also enabled treatment of patients with azoospermia (either resulting from non-obstructive or obstructive origin) via the surgical retrieval of testicular or epididymal spermatozoa

• it has been suggested that ICSI results in a slight, but significant, increased incidence of sex chromosomal abnormalities in children born as a result of ICSI (2).
• However a case-control study by AG Sutcliffe et al (3), of neurodevelopmental delay among children in their 2nd year of life who have been conceived via ICSI, showed no difference between the 2 groups. Also congenital abnormality rates were similar between the 2 groups - however there was a trend to a slightly higher incidence of congenital abnormalities (particularly of the genital tract) in children born to fathers with azoospermia
• ICSI has been used as a treatment option in non-male-factor infertility

NICE state that (4):

• consider ICSI
  • if the partner with male reproductive organs has abnormal semen parameters, taking into account the severity
  • if a previous in vitro fertilisation (IVF) treatment cycle has resulted in failed fertilisation or a very low fertilisation rate
• do not use ICSI for non-male factor fertility problems if the semen parameters are normal
• do not use intracytoplasmic morphologically selected sperm injection (IMSI) as an adjunct to ICSI
• do not use physiological intracytoplasmic sperm injection (PICSI) in preference to standard ICSI

The NICE committee noted (4):

“…The committee agreed that ICSI should not be used for non-male factor fertility problems. However, in line with the original 2004 recommendation on ICSI, the committee agreed that ICSI could be considered if previous standard IVF cycles have resulted in failed or very poor fertilisation. There was insufficient evidence on the effectiveness of intracytoplasmic morphologically selected sperm injection (IMSI) as an adjunct to ICSI in terms of improving live birth rate compared with standard ICSI, so the committee agreed that it should not be used, because it is unlikely to provide any benefit over standard ICSI. Evidence on physiological intracytoplasmic sperm injection (PICSI) showed no difference in rate of live births when compared with standard ICSI…”

Reference:

1. Carson SA, Kallen AN; Diagnosis and Management of Infertility: A Review. JAMA. 2021 Jul 6;326(1):65-76.
2. Bonduelle M et al (1999). Seven years of ICSI and follow-up of 1987 subsequent children. Huma Reprod, 14 (suppl), 243-64.
3. Sutcliffe AG et al (2001). Outcome in the second year of life after in-vitro fertilisation by intracytoplasmic sperm injection. Lancet, 357 (9274), 2080-4.
4. NICE. Fertility problems: assessment and treatment. Clinical guideline CG156. Published February 2013, last updated March 2026.