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Lesson 2 of 6

What is ICSI?

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Natural & Conventional Insemination

During the course of natural insemination, sperm compete vigorously to fertilize a single egg. In the human body, this means each sperm swims through difficult conditions in the vagina, cervix, uterus and fallopian tubes, at a relative distance equivalent to a human swimming from Los Angeles to Australia. Less than 1% of the sperm ultimately arrive at the egg’s perimeter, and few are able to pierce its outer core.

During an IVF cycle, many clinics will fertilize the woman’s eggs using conventional fertilization (CI). In this case, an embryologist uses all of the eggs retrieved from the woman’s ovaries and surrounds each in a petri dish with carefully-prepared droplets of sperm to facilitate fertilization. CI requires skill and if you elect to do it, you will want to go to a clinic that does it routinely. The major fear with CI is that in roughly 0%-15% of cases, none (or very few) of the eggs fertilize. This is called Total Fertilization Failure (TFF) and is a devastating result for patients.

What is ICSI?

During IVF, when sperm cannot fertilize an egg using CI, doctors will recommend selecting a single sperm that looks promising (the methods here are incredibly crude) from a semen sample and injecting it directly into the egg. ICSI is microsurgery, and it’s the smallest procedure we do in medicine – by injecting one cell into another, we run the risk of doing real damage to the machinery of the egg, especially if the procedure is not done carefully.

Unlike with conventional insemination (CI), ICSI can only be performed on “mature eggs” which often means we’re excluding 20%–30% of the eggs we retrieve. Of the remaining eggs, a high quality laboratory should be able to fertilize 70%–80% (known as the “ICSI Fertilization Rate”). What happens to those mature eggs we cannot fertilize? Often about half of those are damaged in the ICSI process.

ICSI Fertilization Funnel

Embryologist Experience Is Important

Since ICSI is a procedure on the egg, the experience of the embryologist is important. Below you can see a study of how embryologist skill improves with practice.

While this study concluded after one year of training, it’s clear gains are still being made with every successive quarter.

As to be expected, embryologists and clinics have highly-variable rates of skill and success. However, over the course of time your embryologist and clinic should have a 70%–80% ICSI fertilization rates.

For whatever reason, some embryologists may struggle with fertilizing a certain patient’s eggs and so to defray risk, some larger clinics will subdivide each patient’s eggs amongst multiple embryologists. Generally speaking, we think this is a wise approach.

When choosing between conventional insemination (CI) or ICSI, take into account how experienced your clinic is with each. Insisting your clinic do CI when they do mostly ICSI (and are out-of-practice), or vice versa, may be counterproductive as it interrupts how they’re accustomed to handling treatment.

Pro Tips

  • Learn what percentage of procedures your clinic does with ICSI or CI. Factoring in where they have more experience may influence your decision
  • Ask your clinic what their ICSI Fertilization Rate is (70% of mature oocytes is respectable) and what percentage of eggs they damage in the process (10% or higher of mature oocytes is a negative sign)
  • Ascertain how your clinic’s lab does ICSI. If they work as a team and subdivide eggs amongst embryologists this can mitigate risk a single embryologist will scupper your chances