ICSI Intra-cytoplasmic sperm injection

• Introduction

  Intracytoplasmic sperm injection (ICSI) is performed as part of your in vitro fertilization (IVF) procedure. It is a process in which an embryologist injects a single sperm into the cytoplasm (centre) of each egg. After the embryologist fertilizes the egg with the sperm, he or she will observe the egg over the next day or so. If fertilization occurs and the embryo matures properly, a doctor can transfer it into your uterus. Your doctor may recommend ICSI as part of your IVF procedure to treat many causes of infertility, especially when there is a problem with the sperm, such as low motility (movement) or a low sperm count. ICSI is especially useful in cases where the sperm cannot penetrate the egg or if the sperm is abnormally shaped. This treatment has been revolutionary in treating male factor infertility cases.

• The ICSI Timeline

  In a normal ovulation cycle, one egg matures per month. The goal of an ICSI cycle is to have many mature eggs available, as this will increase your chances of success with treatment. In order for there to be more than one egg available, stimulation of the ovaries needs to occur. It's important to note that the eggs being stimulated would have grown or died that month, so stimulating the ovaries does not deplete eggs for the future. This is a common question that patients ask, so rest assured.

• Step one: Stimulation of the ovaries

  In the stimulation phase of an ICSI cycle, you will use injectable medications for approximately 8 to 14 days to stimulate the ovaries to produce eggs. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH), both produced naturally within the body, comprise the medications. During this phase, you will come into the clinic approximately 7 to 8 times for morning monitoring, which allows the team to track the progress of your cycle and adjust medication dosages as needed. The trigger injection is the final step in the stimulation phase of treatment. Depending on your individual protocol, you will either have a human chorionic gonadotropin (hCG) or a buserelin trigger. This injection helps the developing eggs complete the maturation process and sets ovulation in motion. Timing is very important here, as the doctor must perform the egg retrieval prior to the expected time of ovulation.

• Step two: Egg retrieval

  A doctor will perform your egg retrieval procedure at Glasgow Royal Fertility Clinic. On the morning of your egg retrieval, a doctor will meet with you before the procedure to review your protocol. You will also meet with an anesthetist, who will review your medical history and will administer the intravenous fluid you will receive prior to the start of the procedure to induce sleep. 

  Obtaining the sperm: If you are using a fresh sperm sample, a member of the embryology team will come to accept the sample. If you are using a frozen sperm sample or donor sperm collected previously, the embryologist will verify those details with you. Our andrology laboratory will wash and prepare the sperm, so that the healthiest sperm are brought together with the eggs for fertilization (after the doctor performs the egg retrieval).

  Obtaining the eggs: The egg retrieval itself takes about 20 to 30 minutes. During the procedure, the doctor will guide a needle into each ovary to remove the egg-containing fluid in each follicle. The doctor utilises an ultrasound during the procedure to see where to guide the needle. Recovery will take about 30 minutes and you will be able to walk out on your own. It's important that a responsible adult drive you home after the procedure, as it is unsafe to drive after receiving anaesthesia. The person who is driving you will not need to stay at our clinic during your procedure—he or she should anticipate coming back to the clinic after approximately 3 hours.

• Step three: Fertilisation

  After the egg retrieval, the embryologist will prepare the eggs and sperm. For PGD the embryologist will inject one single sperm into each mature egg under a microscope. PGD is therefore possible with very few sperm.

• Step four: Embryo development

  Embryo development begins after fertilization. After initial fertilisation the embryos will be placed within our Embryoscopes which enables them to continue to develop completely undisturbed. An embryologist examines each developing embryo over the course of the following 5 to 6 days. The goal is to see progressive development, with a two- to four-cell embryo on day 2 and a six- to eight-cell embryo on day 3. After the eight-cell stage, rapid cell division continues and the embryo enters into what is called the blastocyst stage at day 5 or 6. It is your doctor’s goal to transfer the highest-quality embryo(s) to give you the greatest chance of success.

• Step five: Embryo transfer

  The embryo transfer is a simple procedure that only takes about 5 minutes to complete. There is no anaesthesia or recovery time needed. When your nurse arranges your transfer, she will notify you and provide instructions on when to arrive and how to prepare. You need to have a full bladder for the procedure as a full bladder ensures good visualization of the lining of the uterus and proper placement of the embryos. It's important to drink the specific amount of liquid recommended 30 to 40 minutes ahead of time. You will review your cycle with the doctor and the number of embryos recommended for transfer. Upon entering your procedure room, the embryologist will again confirm your last name and the number of embryos for transfer. The embryologist will load the transfer catheter in the embryology lab with the embryo(s) and then the doctor will insert the catheter into the uterus and push the embryo through with a small amount of fluid. An external abdominal ultrasound provides visual guidance via a monitor to the doctor throughout the procedure. Once the doctor transfers the embryo, he or she will slowly remove the catheter. Since the embryo is invisible to the naked eye, the embryologist will then examine the catheter under a microscope in the lab to ensure that the catheter did indeed release the embryo. The nurse will give you instructions for the following 2 weeks until it's time for the pregnancy test.

• Step six: The pregnancy test

  Two weeks after the embryo transfer, you will perform a pregnancy test. This test is frequently called a "beta" because it measures the beta chain portion of the hCG hormone emitted by the developing embryo. We let you do this test in the privacy of your own home using a urinary pregnancy test and you then let us know the outcome so we can plan the next steps.

1. What can be done to improve sperm quality?

   • Sperm quality on the day of egg retrieval is often related to what happened in the male’s body 3 months ago. This is because sperm development takes 3 months. Listed below are guidelines to help ensure the semen specimen is of the best possible quality.
   • A fever of 38.5 degrees centigrade or higher within 3 months prior to ART treatment may adversely affect sperm quality. Sperm count and motility may appear normal, but fertilization may not occur. If you become sick during the IVF cycle, please notify the GRFC nurse, and take paracetamol to keep your temperature below 38.5 degrees centigrade.
   • Discontinue alcohol and cigarette use before and during IVF treatment. Do not use any “recreational”/illegal drugs.
   • If any prescription medication has been taken during the last 3 months, notify the GRFC nurse.
   • Do not sit in hot tubs, spas, jacuzzis, or saunas during or 3 months prior to the IVF cycle.
   • Do not begin any new form of endurance exercise during or 3 months prior to the IVF cycle. Physical activity at a moderate level is acceptable and encouraged.
   • Avoid all testosterone and Androstenedione/Androstanediol hormone containing supplements. Do not take any gym supplements
   • Tell your infertility doctor if you have ever had genital herpes, or suspect you may have been exposed to genital herpes in the past. Also tell your doctor if you have pre lesion symptoms, develop a lesion, or have healing lesions before or during the ART cycle.
   • Refrain from ejaculation for 2-3 days, but not more than 5 prior to collecting the semen sample for the IVF cycle. The GRFC nurse will provide you with your specific instructions from the Andrologist.

    

2. What is happening while I wait for my pregnancy test- The Two Week Wait

   For most patients who undergo fertility treatment, the two-week wait before you have your beta (pregnancy test) can seem like an eternity. Each day seems longer than the last, and the question “Am I pregnant?” goes through your mind hundreds of times a day. One becomes hyper-aware of your body’s every sensation. We all sympathize and wish there was some medical way to make the time shorter or easier for you. So we gathered some questions from our community, ran them by our nurse educators, and came up with some answers to your pressing two-week wait questions.

3. What is the two-week wait?

   The two-week wait is the period of time between the end of your fertility treatment cycle and beta hCG urine test – the test that determines whether or not you’re pregnant. It takes about two weeks from the time a fertilized egg implants in the uterine wall to start emitting enough of the hormone hCG (human chorionic gonadotropin) to be detected by a urine test. We sometimes call the test a “beta” because the test actually measures a beta chain portion of the hCG hormone molecule and is officially named a ‘beta HCG “ test.

4. What is happening to my body during the two-week wait?

   During this time, you may feel as if you are about to start your period. Your body has been through a lot and the medications you’re taking are designed to promote the optimal environment for pregnancy. You may experience some cramping, spotting or light bleeding, abdominal bloating, fatigue, and breast tenderness. While you may be slightly alarmed to experience some of these symptoms, they are normal and do not signify that you are or are not pregnant. Please note, if after your treatment you feel excessive bloating, shortness of breath, chest pain, or lower abdominal pains, you may have ovarian hyperstimulation and should call your clinical team immediately.

5. Will I be taking medications during this time?

   Yes. Most patients need to continue to take progesterone supplements in order to produce the same levels of hormones that would occur in early stages of pregnancy.

6. Can I continue my normal day-to-day activities during the two-week wait?

   We tell all of our patients to be cautious during their first five days after their treatment. We recommend that you refrain from strenuous physical activities as well as sexual activities during that time as they may cause uterine contractions that might impair the implantation process. There is also a greater risk during that time of ovarian issues arising since, for many patients, the ovaries are still slightly enlarged at that point. After those first few days, you can to start light aerobic activities such as yoga, swimming , moderate walking and swimming, and lightweight training on stairmaster or elliptical trainers – activities that can get their heart rate up, but are not demanding, impact on their bodies like jogging or impact aerobics or treadmills.

7. Do I need to adjust my diet during this time?

   No special diet is required, but we recommend that you start making nutritional choices as if you’re already pregnant. This means eating well balanced meals, no sushi or other raw or undercooked meats, avoiding high-mercury fish and soft cheeses, no alcohol, and continuing to take a preconception supplement. Click here to learn about the difference between preconception and prenatal vitamins.

8. Can I travel during the two-week wait (or thereafter if pregnant)?

   We prefer that patients avoid travelling for the first few days post-treatment, primarily so that you are close to our centre for examination should any problems develop. This is also true during and following the time of your pregnancy testing and ultrasound. Early pregnancy complications such as hyper stimulation, bleeding or pain can occur and we would want you near our team here for care. In addition, the rigours of travel, time zone changes, luggage, etc. leave you vulnerable to complications. Before you schedule to travel during this period of time, check with your nurse and team to see if this is at all advisable.

9. What levels of hCG will determine if I’m pregnant?

   Any positive level of beta hCG indicates a pregnancy has started (unless the test is done to early following an HCG trigger injection). We will then have you come in for ultrasounds usually between 6-7 weeks to determine if the embryo continues to develop into a fetus. At about 8+ weeks, GRFC will refer you back to your local antenatal clinic to continue your antenatal care.

10. If I am pregnant, how do you ‘count’ how far along we are?

    As soon as it is determined that you are pregnant, we revert to the Obstetrical counting / dating system. This is done to avoid using one set of dates from the time of an IUI or IVF versus another set of dates used by obstetricians. The doctors determine pregnancy dating to be from the last menstrual period, at least 2 weeks prior to ovulation. Obviously, we often know more about when ovulation may have occurred than usually they do, but for convention we add two weeks to our dates to conform with the obstetric team. As an example, if we know when ovulation was triggered and an IUI or IVF was performed, your beta might be two weeks thereafter. If it is positive, the obstetrician would say you are FOUR weeks pregnant, not two, and therefore so do we. You first early pregnancy ultrasound is usually scheduled for you between 6-7 weeks Gestational Age. That is actually only 4-5 weeks from your IUI or embryo transfer. You just saved two weeks off the length of the 40 week pregnancy!!

11. What are my next steps if I’m not pregnant?

    If you aren’t successful, your nurse will advise you to stop your medications. You will have the opportunity to talk with your doctor to review the past cycle and make a decision together about your next steps.

12. How long after a failed cycle can I do another cycle?

    While your doctor will determine the timing of a new cycle, it’s not always necessary to take time off between cycles unless otherwise directed. Many of our patients are able to begin their next treatment cycle immediately and for many a cycle of rest is recommended.

13. Do you have any BMI or age limits to treatment?

    We want to ensure that you have the best possible chance of having a healthy pregnancy, and so we adhere to British Fertility Society Guidelines on an upper body mass index limit of 35 kg/m2. 

    For those women who need to lose weight, we recommend the Counterweight Plus scheme which has been endorsed by the NHS.

    For women using their own eggs we treat up to the age of 50 years old but you need to fully appreciate the very low likelihood of success with advanced maternal age. For women using an egg donor, it is 50 years.

Fees

We are delighted to be able to offer ICSI as a treatment package with a single cost from the moment you decide to pursue treatment. Our full price list can be found here for download, but below is a summary of what the ICSI package includes. At any time, if you have any questions about the fees, please contact us as soon as possible on 0141 956 0509 to speak to a member of staff.