Why you may need ICSI


The longstanding misconception that women are responsible for most causes of infertility still persists up to today. Hard evidence, however, shows to the contrary that:

  • Combine male and female factors account for the majority of cases of infertility.
  • Exclusively male factor accounts for up to 30% of infertility cases.
  • And disorder of the spermatozoon accounts for the majority of the male related causes of infertility.

This is the first reason for asking the question “why you may need ICSI”

Up until recently the treatment of male infertility has been problematic, frustrating and unrewarding. Primarily, the cause of depressed sperm parameters is largely unknown. Secondly, it is inexplicable why millions of sperm is produced per ejaculate when fertilisation requires just one spermatozoon.

Recent advances in assisted reproductive technology (ART) have literally opened a brand new world in the management of male infertility. Abnormally low or absence of sperm in the ejaculate can no longer be regarded a “life sentence” to childlessness. Couples stricken by this dilemma now have genuine and palpable hope of having children of their own through the use of Intracytoplasmic Sperm Injection (ICSI). Palermo and colleagues first performed ICSI in Belgium in 1992. This highly rewarding treatment for male related infertility is now available at Paragon Fertility Centre. This is the second reason for asking the question “why you may need ICSI”

The key advantage of ICSI in requiring just a single sperm to fertilise the egg triggered the development of micro- surgical techniques to surgically collect or retrieve sperm from the testis or the sperm duct of men previously regarded as sterile. The single and only life line offered to the “so called sterile men” by the combination of ICSI and micro-surgical sperm retrieval is the third reason “why you may need ICSI” because just a handful of surgically removed sperm is all that is required to establish your fatherhood. The commonly used micro-surgical techniques are called PESA and TESA ( Percutaneous Epididymal Sperm Aspiration and Testicular Sperm Aspiration respectively).

This leaflet contains information on both ICSI and PESA & TESA.

What is ICSI?

ICSI is a highly technical procedure designed to insert a spermatozoon into the cytoplasm of the egg using specially designed micro glass tube or pipette. A highly trained embryologist aided by micro-manipulators performs the procedure under a sophisticated inverted microscope.

In the process a single sperm is drawn into the micro glass tube using specially designed micro-suction device. While on the opposite side of the microscope field, using a second micro-suction device the egg is held steady. Then using a micro injection system, the sperm is injected into the egg using the glass tube in which the sperm had earlier been drawn.



Who Needs ICSI?

ICSI is indicated for the following conditions:

  • Marked depression of semen parameters i.e. low total count, poor motility, severe abnormal forms.
  • Men with ejaculatory problems
  • Patients with anti-sperm antibodies
  • Sperm retrieved surgically from azoospermic(without sperm in the ejaculate) men
  • Problem with sperm binding to the egg and/or inability to penetrate the egg
  • Previous failed fertilisation
  • Poor quality donor sperm
  • Poor quality of cryo-preserved sperm
  • Patients with thick zona pellucida

ICSI allows a much higher fertilisation rate of approximately 50% of the eggs.

The Process

image004The sperm for use in ICSI procedures are obtained in exactly the same way as for IVF or may be obtained using micro-surgical techniques – PESA or TESA. The sperm is washed and prepared in a similar way as for IVF.

The eggs are retrieved in the standard way, after which the cells surrounding the egg are carefully removed. The eggs are then examined under the microscope for maturity and suitability for sperm injection.

The egg and the sperm are then placed under the sophisticated inverted microscope to which the micro-manipulators are attached. The mature egg called oocyte is identified by the presence of a Polar body underneath the enclosing membrane. The fastest swimming sperm with the best size and shape is identified and drawn into the fine injection pipette by the Embryologist. The sperm is then injected into the egg as previously described. The remainder of the process is similar to the standard IVF in respect of incubation of the injected eggs and transfer of the resulting embryos. The excess embryos not immediately transferred may be cryo-preserved (kept frozen) for later transfer.


Regardless of the cause of low or absent sperm in the ejaculate the real possibility of recovering a handful of sperm sufficient to carry out ICSI procedure is the key value of high precision micro-surgical techniques called PESA and TESA.

PESA (Percutaneous Epididymal Sperm Aspiration) means surgical recovery of sperm from the sperm reservoir duct located at the top of each testis.

TESA (Testicular Sperm Aspiration) means surgical recovery of sperm from the testis itself.

Both PESA and TESA are delicate high precision micro-surgical procedures that can be performed under either a local anaesthetic or light sedation. Rarely some men prefer to have a full general anaesthesia.


Who Needs Pesa & Tesa?
1. Men with azoospermia due to obstruction of the sperm duct as a result of one of the following conditions:

  • Inborn absence of the vas deferens
  • Following vasectomy
  • Blockage of vas deferens following sexually transmitted disease
  • Blockage of vas deferens and ejaculatory duct following trauma

2. Men with azoospermia due to failure of sperm production but have sperm producing islands in the testis.

3. Men with erectile dysfunction

How is the Pesa & Tesa Performed?

Both procedures require use of needles to perform precision and delicate surgery with minimal incision or cutting. In Pesa the sperm is obtained from the epididymis (sperm reservoir duct located on top of the testis) while in Tesa sperm is recovered from the testis itself.

Following treatment you would require firm and tight fitting pants to support the scrotum for about two to three days. We recommend bed rest as well as regular pain killers as you may experience some discomfort.

Surgically removed sperm are not fully motile and thus are incapable of fertilisation by conventional means but by using ICSI fertilisation can take place.

Please note surgical retrieval of sperm is usually done to coincide with the female partner’s egg collection so that the full IVF treatment is performed straight away. In some cases the sperm may not be found in the sample collected. Therefore it is important to discuss before hand the option of using donor sperm as a “back up measure”

On the other hand when a large quantity of sperm is collected surgically it may be advisable to have the sample frozen for later use. This option must also be discussed before hand with the doctor.


Concluding Remarks

ICSI combined with micro- surgical techniques of sperm recovery PESA and TESA have provided a major breakthrough in the management of male factor infertility. Whilst recognising the place of medical and surgical treatment in the management of male infertility, undeniably this particular combination of ART provides assurance that if conventional treatment fails or are deemed inappropriate, an effective assisted conception exist in ICSI and PESA or TESA.



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