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• W3045692799 abstract "Intracytoplasmic sperm injection (ICSI), developed in the early 1990s, had become a routine part of in vitro fertilization (IVF) treatment at most assisted reproductive technology (ART) clinics by the late 1990s. Originally developed for severe male factor infertility, ICSI has assumed a role in treatment for many additional indications, including mild male factor infertility, history of failed fertilization, and unexplained infertility. However, at some clinics ICSI is used for additional indications—it may even be used in lieu of standard insemination for all cases. These changes have led to a marked increase in the overall use of ICSI as a proportion of all ART cycles (1Boulet S.L. Mehta A. Kissin D.M. Warner L. Kawwass J.F. Jamieson D.J. Trends in use of and reproductive outcomes associated with intracytoplasmic sperm injection.JAMA. 2015; 313: 255-263Crossref PubMed Scopus (159) Google Scholar). Use of ICSI for conditions other than severe male factor infertility has raised questions about both the safely and the efficacy of this technique. Early studies of the success rates and safety of ICSI demonstrated that its live-birth rates were comparable to those of IVF (ART using standard insemination). Although ICSI is essentially safe, it has resulted in some minor increases in congenital abnormalities in the resulting children. Many of the studies have concentrated on cases of severe male factor infertility, and subsequent study showed that male factor infertility itself was likely a major contributor to the abnormalities found (2Esteves S.C. Roque M. Bedoschi G. Haahr T. Humaidan P. Intracytoplasmic sperm injection for male infertility and consequences for offspring.Nat Rev Urol. 2018; 15: 535-562Crossref PubMed Scopus (46) Google Scholar). Nevertheless, the question remains as to whether IVF and ICSI outcomes are comparable in cases where the indication for ICSI is either less severe male factor infertility or other infertility diagnoses. This is an important question because if there is no advantage to using ICSI or if ICSI introduces additional risk, then the justification for using it in place of standard insemination is not clear. The study by Liu et al. (3Liu L. Wang H. Li Z. Niu J. Tang R. Obstetric and perinatal outcomes of intracytoplasmic sperm injection versus conventional in vitro fertilization in couples with non-severe male infertility.Fertil Steril. 2020; 114: 792-800Scopus (2) Google Scholar) in this month’s issue of Fertility and Sterility addresses this question by presenting data comparing IVF and ICSI outcomes and evaluating these outcomes according to a variety of individual diagnoses. Although initial studies on ICSI outcomes were primarily targeted at pregnancy and live-birth rates, gestational age, birth weight, and congenital abnormalities, outcome studies in recent years have also focused on adverse pregnancy effects as well as other indicators of infant health. The pregnancy abnormalities studied have included rates of gestational diabetes and hypertension, placental abnormalities, and postpartum hemorrhage. Studies of child health have included birth height, small and large for gestational age, incidence of macrosomia, and need for hospitalization in a neonatal intensive care unit (NICU) after delivery. The paper by Liu et al. (3Liu L. Wang H. Li Z. Niu J. Tang R. Obstetric and perinatal outcomes of intracytoplasmic sperm injection versus conventional in vitro fertilization in couples with non-severe male infertility.Fertil Steril. 2020; 114: 792-800Scopus (2) Google Scholar) evaluates these outcomes for 18,962 standard IVF cycles as compared with 2,937 ICSI cycles in an overall population without severe male factor infertility. The study also partitions outcomes into subgroups of the population divided by indication, including mild or moderate oligoasthenozoospermia (OA), non–male factor infertility, advanced maternal age, unexplained infertility, and low oocyte yield. The study by Liu et al. (3Liu L. Wang H. Li Z. Niu J. Tang R. Obstetric and perinatal outcomes of intracytoplasmic sperm injection versus conventional in vitro fertilization in couples with non-severe male infertility.Fertil Steril. 2020; 114: 792-800Scopus (2) Google Scholar) is a retrospective analysis of outcomes that excluded severe male factor infertility, mixed IVF/ICSI cycles, cycles with preimplantation genetic testing, and women who had underlying medical conditions including chronic hypertension and diabetes, uterine abnormalities, and recurrent abortion. Consistent with earlier studies, the authors demonstrated no differences in pregnancy or live birth (4Grimstad F.W. Nangia A.K. Luke B. Stern J.E. Mak W. Use of ICSI in IVF cycles in women with tubal ligation does not improve pregnancy or live birth rates.Hum Reprod. 2016; 31: 2750-2755Crossref PubMed Scopus (21) Google Scholar), or in pregnancy or child outcomes between IVF and ICSI in the overall ART population. The strength of the study, however, is in the subdivision of the population according to diagnosis. Although the numbers in some of the categories were rather small, this subdivision permitted the direct comparison of a full variety of outcomes within each group. Among pregnancy outcomes the only significant differences were minor alterations in singleton and twin rates between IVF and ICSI for the category of non–male factor infertility, with the singleton rate being elevated and multiple rate being reduced after use of ICSI. When pregnancy and delivery outcomes were evaluated for the different diagnoses, the only difference seen was a reduction in infant need for neonatal intensive care among those with moderate OA. Whether this difference will be repeated in larger prospective studies remains to be determined. Use of ICSI provides a clear advantage for cases of severe male factor infertility and for cases of prior failed fertilization of unexplained origin, where fertilization rates are compromised without its use. But the question has remained as to what role the use of ICSI plays in situations in which the procedure is being employed for other indications (5Palermo G.D. Neri Q.V. Rosenwaks Z. To ICSI or not to ICSI?.Semin Reprod Med. 2015; 33: 92-102Crossref PubMed Scopus (49) Google Scholar). If use of ICSI is no more efficacious and conveys no additional benefit for the health of mother or child over the use of IVF, then there is no apparent advantage to using it. If success rates were higher or risks of neonatal abnormalities were lower with it, then using it would be justified; however, without this improvement, ICSI adds increased effort on the part of the laboratory and increased cost to the patients with no advantage. In the study by Liu et al. (3Liu L. Wang H. Li Z. Niu J. Tang R. Obstetric and perinatal outcomes of intracytoplasmic sperm injection versus conventional in vitro fertilization in couples with non-severe male infertility.Fertil Steril. 2020; 114: 792-800Scopus (2) Google Scholar), there was no improvement in these parameters for non–male factor infertility patients. There was additionally also no improvement for cases of mild or moderate OA with the possible exception of a minor reduction in the moderate but not the mild OA group in the incidence of NICU admission. It is not clear from the data why NICU admission should be elevated in the moderate OA group, so this is an observation that should be explored further. One of the most widely discussed diagnostic categories for use of ICSI has been unexplained infertility (5Palermo G.D. Neri Q.V. Rosenwaks Z. To ICSI or not to ICSI?.Semin Reprod Med. 2015; 33: 92-102Crossref PubMed Scopus (49) Google Scholar). However, even in this category the data from Liu et al. (3Liu L. Wang H. Li Z. Niu J. Tang R. Obstetric and perinatal outcomes of intracytoplasmic sperm injection versus conventional in vitro fertilization in couples with non-severe male infertility.Fertil Steril. 2020; 114: 792-800Scopus (2) Google Scholar) demonstrate that the pregnancy and live-birth rates per woman in her first cycle were no better for ICSI than for IVF. Similarly, no advantage in maternal or child health outcomes was obtained for this group. The study did not evaluate whether these cycles resulted in similar numbers of good-quality embryos, so it is possible that more eggs were fertilized and more embryos frozen in the ICSI cycles as compared with the IVF cycles, which in turn could mean that cumulative rates of pregnancy and birth improved among the ICSI cases for this diagnostic category. Because the cumulative delivery outcomes were not evaluated in this study, this possibility has yet to be determined. Nevertheless, cases with low oocyte yield, another diagnostic category, had no improvement in pregnancy or live-birth rates for ICSI as compared with IVF. There was similarly no improvement for women with advanced maternal age. The study by Liu et al. (3Liu L. Wang H. Li Z. Niu J. Tang R. Obstetric and perinatal outcomes of intracytoplasmic sperm injection versus conventional in vitro fertilization in couples with non-severe male infertility.Fertil Steril. 2020; 114: 792-800Scopus (2) Google Scholar) has provided a substantial advance in our understanding of the value of using ICSI for ART cases for indications other than severe male factor and fertilization failure, the indications for which it was developed. Their data show no significant advantage to use of ICSI compared with IVF for a number of diagnostic categories. This in turn provides us with important data to support the use of standard insemination practices rather than ICSI for a majority of ART cases. The authors should be commended for addressing this important question. Obstetric and perinatal outcomes of intracytoplasmic sperm injection versus conventional in vitro fertilization in couples with nonsevere male infertilityFertility and SterilityVol. 114Issue 4PreviewTo determine whether intracytoplasmic sperm injection (ICSI) is associated with improved outcomes compared with conventional in vitro fertilization (IVF) for patients with nonsevere male factor infertility. Full-Text PDF" @default.
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• W3045692799 title "When do we use intracytoplasmic sperm injection?" @default.
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