Add-ons in the ART Lab: Part 1

Data from European countries in the year 2015 showed that ICSI was used in an increasing rate of 71.2% of treatment cycles. The same trend has also been reported in the United States, South America and Asian countries. Interestingly, the largest indication for ICSI has been for couples with non-male factor infertility.

The rationale for using ICSI in couples with non-male factor infertility is based on an assumption that ICSI might avoid unexpected total fertilization failure and increase the number of embryos available. Over the last 20 years, ICSI has been widely implemented in clinical practice without a solid evidence from RCTs.

Most retrospective data showed that ICSI did not appear to significantly reduce total fertilization failure in couples with non-male factor infertility, even in women with a small number of oocytes due to poor ovarian response, yet there were data showed different results. Recent large RCT showed that, in general, ICSI for non-male factor infertility did not improve live birth rate compared to conventional IVF.

Yet, many specific indications of ICSI for non-male factor ART have been discussed with limited supporting data. Reassuring data for the safety of ICSI have been reported. The difference in ICSI experience and the preference for ICSI in many IVF centers around the world will keep the use of ICSI for non-male factor infertility popular.

In the future, the use of ICSI might be more restricted in some areas or countries. On the other side, the trend of using ICSI for non-male indications will keep going on. ICSI will still be the most common method of insemination in ART anyway, with the reassuring safety. And ICSI is no more an “add-on”, it is a part of modern ART practice.

Sperm samples are known to have a complex heterogeneity. Swim up and density gradient centrifugation which are the current methodologies for sperm preparation are based on sperm motility and they are not efficient methods to select higher quality sperm. New methods have been developed that are based on sperm characteristics correlated to fertilization ability and quality of the spermatozoa to support embryonic development. Advanced sperm selection techniques are meant to improve the chance that structurally intact and mature sperm with high DNA integrity are selected for fertilization. The aim is therefore to identify sperm preparation and selection techniques that can improve sperm genetic integrity, fertilization capacity, embryo development, clinical outcomes and prove to be safe. In this lecture, the current methodologies of sperm preparation in a clinical setting are described along with the advanced sperm selection techniques. The effectiveness and safety of these techniques on ART outcomes is examined to identify the sperm selection techniques that can be incorporated into routine clinical practice.