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Doctor explaining and giving a consultation to a patient on the ethics of ICSI

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Intracytoplasmic sperm injection (ICSI): Ethical and medical considerations

Intracytoplasmic sperm injection (ICSI) represents a giant leap forward for the field of fertility and especially for those struggling with male-factor infertility. But what is the cost of this advancement? Are there any ethical considerations, and how might the use of ICSI affect future offspring? Let’s examine the facts surrounding ICSI and explore the potential disadvantages of its use.

Key takeaways

  •  ICSI has given hope to couples worldwide since its inception in the early 1990s.
  •  It involves injecting a single sperm cell into the egg cytoplasm, bypassing the need for good-quality sperm and a high sperm count.
  •  There are several disadvantages when using ICSI, including increased risk of twins and triplets.
  • Ethical considerations are associated with using ICSI as it allows people to pass on genetic material that may result in future genetic issues for their offspring.

What’s the history of ICSI? 

A vast number of people come up against fertility issues that impact their ability to conceive a child naturally. Typically, millions of healthy sperm are required to successfully reach, penetrate, and fertilize an egg, but several issues can impair the sperm’s ability to do this successfully. One of these issues is sperm count. If you do not have sufficient sperm in your ejaculate, they are unlikely to reach their destination. ICSI transformed fertility treatment because rather than needing millions, only a few single sperm cells are required to succeed. This has given hope to people worldwide with various reasons for not having sperm, such as genetic causes or lifestyle factors.

ICSI was first developed at Vrije Universiteit Brussel in 1990, followed by the first pregnancy using ICSI in 1991, thanks to the efforts of Dr. Gianpiero Palermo. In January 1992, the first successful ICSI birth occurred. ICSI was introduced in 1993 as an option for couples who had previously failed to conceive successfully through conventional in vitro fertilization (IVF) where male-factor infertility was the underlying cause. It was a huge development for couples with a complete and unexplained fertilization failure and gave hope to many who had exhausted all previous options. Since then, it has gained worldwide popularity and is now used in the fertilization of thawed and donor oocytes (immature egg cells), as well as in pre-implantation genetic testing.

Overview of the ICSI process

ICSI is carried out in fertility treatment centers using the following procedure:

1. A mature egg or eggs are removed from the partner with ovaries following hormone treatment, in the same way as during IVF.

2. A semen sample is obtained from the partner with testes, either from ejaculate or via a sperm retrieval procedure if normal ejaculation is not possible.

3. A specialist fertility doctor will use a microneedle to immobilize and retrieve a single sperm cell from the sample.

4. This very thin needle will be inserted carefully through the egg’s outer shell and into the cytoplasm. 

5. The single sperm is injected into the cytoplasm.

6. A waiting game begins to see if fertilization takes place over the next 24 hours.

7. If successful, the embryo is implanted into the uterus to allow the rest of the pregnancy to follow.

 Who might use ICSI?

ICSI is particularly useful for people who have low sperm motility or a low sperm count. Poor or declining sperm quality may result in too few sperm reaching the egg or leaving them unable to penetrate its outer layer to enter the cytoplasm, where fertilization occurs. Some people also suffer from azoospermia — a lack of sperm in the ejaculate. This may happen if someone has had a vasectomy, was born without a vas deferens (this is the duct that normally transports sperm into the urethra for ejaculation), or if they have suffered from infections that led to scarring around these tissues, blocking the sperm’s normal pathway. This is known as obstructive azoospermia.

Non-obstructive azoospermia is more common and usually associated with one or both testicles not producing any sperm. This may mean donor sperm is required for successful ICSI and fertilization.

A fertility specialist may also recommend ICSI if the sperm quality on the day of egg collection is insufficient for successful IVF.

ICSI success rates

ICSI does not guarantee fertilization every time, but it does appear to vastly improve the odds for couples where there are factors affecting sperm quality and quantity. Around 60–80% of injected eggs will be fertilized, meaning ICSI is as successful as conventional IVF, with comparable pregnancy rates.

ICSI costs

ICSI is often carried out as part of conventional IVF these days and is usually covered by any insurance that also covers IVF treatment. Without insurance, the cost can range from $800 to $2,500 — depending on where the procedure is performed, if sperm retrieval is also necessary, and if it is alongside other procedures such as thawing if the sperm samples have been in freezer storage.

Potential disadvantages of ICSI

With all the above positives, it is clear to see why ICSI is so popular and used so widely. However, we need to consider the potential issues associated with this means of assisted reproductive technology.

There is an increased likelihood of damage to the egg and embryo as a result of ICSI compared to IVF or normal fertilization. This is due to the the injection method, but the risk is very small.

As with IVF, there is a greater chance of conceiving twins or triplets, and parents pregnant with multiples often face more complications in pregnancy and childbirth. There is also a substantial extra cost of bringing up more than one planned baby.

There are slightly higher chances of congenital disabilities occurring in ICSI pregnancies compared to normal pregnancies. However, this is rare.

How using ICSI may affect the future offspring

Although many of the specific causes of male-factor infertility remain unknown, it is estimated that around 50% of cases may be due to contributing genetic factors. There are currently over 30 known genetic diseases that can affect male-factor fertility. In days gone by, people with these conditions would have had to face a future without children of their own, and while that would have been a painful reality, it also created a natural barrier to the hereditary transmission of such genetic illnesses. 

ICSI has allowed people faced with these genetic issues to become biological parents, increasing the likelihood of them passing their conditions onto their offspring. It’s, therefore, essential to consider the impact of these issues before undertaking ICSI, especially with regard to the effect on any future children.

Pre-implantation genetic screening (PGD) is an option for people concerned about passing on genetic conditions, but one study found most prospective parents will opt to have ICSI even if a genetic defect is detected if it means they can have children of their own. This study involved men who had a microdeletion in the azoospermia factor (AZF) region, which causes severe male-factor infertility.

The moral consequences of these decisions should not be taken lightly.

Some genetic illnesses, such as cystic fibrosis, can impact life expectancy. Many people with cystic fibrosis do not live past the age of 40. Therefore, before ICSI is undertaken, the impact of their early death on their prospective children should be considered carefully.

Ethical considerations for ICSI

A study in the journal Nature Genetics estimated that if 90% of men that are infertile through genetic causes fathered children through ICSI, the rate of male-factor infertility due to this reason alone could increase to 6.7% within ten generations. It highlighted the importance of considering the impact of passing on these genes and health issues to future generations.

In some ways, there is now “gender justice,” as one paper called it — as infertile men now have the option to become parents, which was previously only a reality for women with fertility issues when IVF came along. However, some would consider ICSI as a form of “treating one person for another person’s condition.” In other words, the woman is being treated for the man’s infertility. This raises some moral questions: the same paper asked if this takes us a step closer to “babies on demand” and cloning.

It is clear there are issues that need deep discussion when considering ICSI, and it is not without its ethical issues; however, for most couples who are struggling to conceive, ICSI represents a beacon of hope.

Other ways to improve fertility

ICSI is one option open to couples who are trying to conceive (TTC) when there are issues with sperm quality and quantity. There are many other ways you can improve your sperm, which are worth considering before going down the expensive route of IVF and ICSI. These include making lifestyle changes and supplementing your diet with science-backed nutrients that are essential for healthy sperm production.  

A good place to start is to check your sperm health by carrying out a semen analysis. Legacy has an at-home kit you can use to do this in the comfort of your own home. Click here for more details. If you want to learn more about the various lifestyle changes that can impact your sperm health, click here to read more on the subject. This page will take you to relevant information about supplementation that could be a useful addition to your diet while TTC.

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