No benefit of ICSI over IVF in non-male factor infertility
Patients undergoing assisted reproduction for non-male factor infertility do not derive greater benefit from intracytoplasmic sperm injection (ICSI) over in vitro fertilization (IVF), according to a study presented at ESHRE 2019.
“There is no advantage of ICSI over IVF as insemination method for non-male factor infertility,” said study author Dr Panagiotis Drakopoulos from the Center for Reproductive Medicine, Brussels University Hospital, Brussels, Belgium, and colleagues. Ovarian response also has no part to play in selecting ICSI over IVF, he said.
Drakopoulos and co-authors analysed data of 4,891 patients from Belgium and Spain who had undergone their first cycle of ovarian stimulation for IVF or ICSI for non-male factor infertility between 2009 and 2014. Most patients underwent ICSI (n=4,227) compared with IVF (n=664). The patients were categorized into four groups based on their ovarian response: poor responders, 1–3 oocytes; suboptimal responders, 4–9 oocytes; normal responders, 10–15 oocytes; and high responders, >15 oocytes. There was no significant difference in type of insemination method between groups (p=0.35).
The mean fertilization rate – defined in this study as the ratio of two pronuclei oocytes over number of oocyte-cumulus complexes – did not significantly differ between patients who underwent ICSI and IVF (61 percent vs 60 percent; p=0.9). [ESHRE 2019, abstract O-228]
The number of embryos transferred or cryopreserved per fertilized oocyte also did not differ between patients who underwent ICSI and IVF (p=0.6, 0.13, 0.4, and 0.64 in poor, suboptimal, normal, and high responders, respectively).
After adjusting for confounders and ovarian response, ICSI did not lead to greater live birth rates (odds ratio [OR], 1.1, 95 percent confidence interval [CI], 0.9–1.3) or cumulative live birth rates* (OR, 1.06, 95 percent CI, 0.9–1.2) than IVF.
According to Drakopoulos, although ICSI was first developed as a treatment option for male factor infertility, the procedure is often used for all causes of infertility.
“This is based on the wrong assumption that ICSI could potentially increase fertilization rates and therefore, the number of embryos, especially in patients with a reduced fertility background. For example, ICSI is the first choice for fertilization in many centres in patients who respond mildly to ovarian stimulation and have few eggs retrieved. However, this is completely wrong. We don’t have evidence that supports the use of ICSI in [non-male factor infertility] cases,” he said.
“I think we have overestimated the effect of ICSI and have arrived at a situation of therapeutic illusion,” he said.
“The aim of our study was to evaluate whether ovarian response should affect the decision of the insemination method used in conventional ovarian stimulation. It’s clear from these results that the number of oocytes retrieved has no value in the selection of the insemination procedure in cases of non-male factor infertility,” said Drakopoulos. This establishes that ICSI has no benefit in patients with poorer ovarian response, he added.
Despite the possibility of bias associated with the retrospective design of the study, Drakopoulus hinted that these results may be practice-changing, though he recommended waiting for the results of an ongoing randomized study comparing IVF and ICSI in non-male factor infertility in Vietnam before making any solid conclusions.