ICSI use doubles despite lack of improved outcomes

The use of intracytoplasmic sperm injection (ICSI) doubled between 1996 and 2012 compared with conventional in vitro fertilization (IVF) despite a lack of improved reproductive outcomes, according to a recent study one male infertility expert called “important work” that informs current practice.

For the study, which was published in JAMA (2015; 313:255-63), first author Sheree L. Boulet, DrPH, MPH, of the Centers for Disease Control and Prevention, Atlanta, and colleagues assessed national trends and reproductive outcomes of fresh IVF cycles (embryos transferred without being frozen) associated with the use of ICSI compared with conventional IVF. The authors used data on fresh IVF and ICSI cycles reported to the U.S. National Assisted Reproductive Technology Surveillance System during 1996-2012.

Of the 1,395,634 fresh IVF cycles from 1996 through 2012, 908,767 (65.1%) used ICSI and 499,135 (35.8%) reported male factor infertility. Among cycles with male factor infertility, ICSI use increased from 76.3% to 93.3%; for those without male factor infertility, ICSI use increased from 15.4% to 66.9%.

During 2008-2012, male factor infertility was reported for 35.7% of fresh cycles. In the absence of male factor infertility, ICSI use was associated with small but statistically significant decreases in implantation, pregnancy, live birth, multiple live birth, and low birth weight rates compared with conventional IVF.

“Although such differences may be a function of the large sample size and thus not clinically relevant, our findings suggest that use of ICSI may improve fertilization rates but not implantation or pregnancy rates in the setting of unexplained infertility, advanced maternal age, and low yield,” the authors wrote.

Next: Dr. Hotaling discusses study's implications

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In an email, James M. Hotaling, MD, MS, of the University of Utah Health Care, Salt Lake City, discussed the study’s implications with Urology Times.

“At first glance, this article seems to imply that ICSI is overused with little benefit to pregnancy rates, particularly in cases without a male factor,” said Dr. Hotaling, who was not involved with the research.

“Some of the increase in ICSI is undoubtedly due to cases of severe male factor infertility where testicular sperm extraction [TESE] and microTESE facilitate obtaining sperm from men that can only be used for ICSI; however, most of the increased use of ICSI derived from non-male factor cycles, without a significant improvement in live birth rate in these couples.

“While we can conclude that the increased use of ICSI is, in part, due to an increased recognition that 50% of infertility is due to male factors, the trend of increased use of ICSI without a significant benefit to couples without male factor (where IVF is a viable option) is concerning, particularly since we are just beginning to understand the complex epigenetic implications of embryo culture and do not yet fully understand the epigenetic and genetic consequences for offspring of using ICSI versus IVF.

“This is important work that informs our practice and also showcases what can be done when outcomes are tracked on a national level,” Dr. Hotaling said.

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