The use of ICSI in all cases of in-vitro conception

Sergio Oehninger1 and Roger Gosden

The Jones Institute for Reproductive Medicine, Department of Obstetrics and Gynecology, 601 Colley Avenue, Norfolk, Virginia 23507, USA

1 To whom correspondence should be addressed. e-mail: oehninsc{at}evms.edu

Dear Sir,

We are pleased that our article (Oehninger and Gosden, 2002Go) has stimulated a debate about the indications for ICSI and are grateful for the opportunity to respond to the letter of Drs Abu-Hassan and Al-Hasani who advocate general application of the technique. We do not rule out universal practice of ICSI in the light of new knowledge, especially based on prospective randomized clinical trials. Nevertheless, we stand by our assertion that it is unjustifiable on the basis of current evidence.

Based on present data, we estimate that ICSI should be indicated when male infertility is properly diagnosed based upon a state-of-the-art extended evaluation of the male partner (including the basic semen evaluation and sperm function testing) and also in cases with previous failed fertilization. Available prospective, randomized studies have demonstrated that it is not beneficial to perform ICSI in non-male infertility or unexplained infertility cases. Altogether, there are no data to suggest that ICSI should be performed in all cases of in-vitro conception (reviewed in Oehninger and Gosden, 2002Go). Consequently, to perform ICSI in all cases on a purely pragmatic basis appears to be a significant departure from the principles of evidence-based medicine.

Drs Abu-Hassan and Al-Hasani stated, "ICSI is a new method replacing an old one" and made an analogy to transvaginal ultrasound-guided oocyte retrieval replacing laparoscopic recovery. This is a comparison of apples and pears. Ultrasound-guided oocyte retrieval performed transvaginally is an easier, more efficient, less invasive and less expensive technique than a laparoscopy. Conversely, ICSI is a more invasive, more complex, and more expensive technique than standard insemination. It is only more efficient when indicated as mentioned above.

ICSI is a wonderful new therapeutic option, an extension of classical IVF. It has allowed for efficient treatment of previously considered poor prognosis cases. Furthermore, it has constituted the basis for acquisition of new knowledge related to human fertilization and genetics. However, it is an invasive technique that bypasses natural barriers to fertilization, raising concerns about disturbances of the fertilization and early embryogenesis processes. Although some of those concerns have been properly addressed, there are still questions that deserve answers derived from scientific unbiased studies.

Based on the evidence existing today, ICSI should not be extended to all IVF cases. ICSI should not be a surrogate to an embryology laboratory technique with poor insemination results. ICSI is here to stay and new indications should be adopted following studies demonstrating efficacy and safety. As a still relatively new technique that can have potential long-term impact on offspring, ICSI should remain under appropriate surveillance.

References

Oehninger, S. and Gosden, R.G. (2002) Should ICSI be the treatment of choice for all cases of in-vitro conception? No, not in light of the scientific data. Hum. Reprod., 17, 2237–2242.[Abstract/Free Full Text]





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