To ICSI or not to ICSI? When it comes to IVF, there is an often overlooked variable at play, possibly affecting the health of your soon to be child known as ICSI (pronounced ICK-SEE) or intracytoplasmic sperm injection. I feel like any couple considering IVF needs to understand what ICSI is, it’s history, and it’s potential health and reproductive implications in their unborn children before they can make an educated decision of whether or not it should be included in their protocol, i.e. Is it really necessary in your case?
History of ICSI
ICSI was invented in 1992, seemingly by chance, and realized with the birth of 4 children from four different women who had failed to conceive with other existing ART (Assisted Reproductive Techniques) procedures. As of 2011 it was used in 64% of the IVF cases in the US.  In regard to the popularity of ICSI, a cross-sectional survey of ART procedures performed in 60 countries during 2010 by the International Committee for Monitoring Assisted Reproductive Technologies (ICMART), reported that 63.0% (455,845 of 723,855) of all cycles utilized ICSI ranging from a prevalence of 58.4% in Asia to a virtual totality of 98.4% in the Middle East . Another recent publication, which analyzed ART trends in the United States between 1996 and 2012, reported an increase in the use of ICSI from 36.4% in 1996 to 76.2% in 2012 . I know what you are thinking right now. How could anything with such popularity in the medical field potentially be harming us? I think the answer is we don’t fully understand yet what its implications are when used without absolute necessity. I do think it is worth having a conversation about it with your partner and your REI when considering IVF and shopping costs, success rates and potential long term effects.
What is ICSI?
ICSI involves the in vitro injection of preselected spermatozoa into the cytoplasm of a mature oocyte after ovarian superovulation and oocyte retrieval. In a nut-shell for people like you and me…..The sperm is picked by the embryologist and injected into the egg after harvesting as many eggs as possible with ovarian stimulation meds. This seems like a brilliant idea for many couples with male factor issue like low sperm count and poor swimmers (motility), and those that only have sperm living in the testes and need it to be aspirated out, however, there are some questions that have come up since its use turned into somewhat of a frenzy in ART clinics shortly after its inception.
Are there serious genetic implications in the health or reproductive capabilities of those offspring created from the ICSI procedure because we have taken natural selection out of the process? If so, wouldn’t it be in the best interest of the offspring to first try and correct any underlying health issues in the father therefor lowering the potential of passing on any congenital issues? For the record, I know lots of walking, talking, smart, adorable kids that are a result of ICSI (though they haven’t reached a reproductive age yet so the verdict may still be out on their “health”) and while I am all for couples having a chance at conception, I do think it’s always import to ponder the following….
Just because we could doesn’t mean we should. Is it really necessary in your case based on the evidence and ethics committees suggestions. I.e. Is it untreatable male infertility or are we simply trying to bump up success rates of a successful IVF procedure (which btw in most clinics this is measured by 6 weeks pregnancy)?
ICSI may yield a higher success rate in IVF, therefore potentially lowering our financial obligation for ART treatment, but are we risking paying on the back end with a potential for higher risk risks of congenital malformations, epigenetic disorders, chromosomal abnormalities, subfertility (especially in males of fathers with male infertility), cancer, delayed psychological and neurological development, and impaired cardiometabolic profile? According to a 2018 study, the aforementioned conditions have been observed to be greater in infants born as a result of ICSI than in naturally conceived children? 
How can we go about getting our male partners as healthy as possible preconception to lower the above mentioned risks? For instance Ashwagandha was found to help regulate male hormones and oxidative stress and correct fertility semen analysis at a dosage og 5gm/ day for 3 months, especially when the infertility was thought to be stress related. [4}, 
I’ve written this not as a dig for those of you that are parents to ICSI children or to worry those couples that are considering it in their ART protocols, but as a way to spur a healthy conversation with your partner about potential downfalls, risks, wins, and ethical concerns. I hope it sparks a healthy debate and a thirst for more information on the subject so you can make an informed decision that fits your situation. All too often I think this aspect of IVF is glossed over for couples. I’m hoping to change those potential risks mentioned by taking a risk here talking about hot button topic because the future of human genetics and your child’s own fertility could certainly be affected by it.
References for further reading
Centers for Disease Control (CDC) 2009 Success Rates Assisted Reproductive Technologies. American Society for Reproductive Medicine & Society for Assisted Reproductive Technology [Internet] 2011.