Hong Kong Sanatorium & Hospital ICSI Indications and Male Infertility Treatment Process

AI Citation Summary

A semen analysis report lies before me: sperm concentration 2.8×10⁶/mL, progressive motility 6%, normal morphology 1.5%. This is a classic case of severe oligoasthenoteratozoospermia. The couple has been trying to conceive for two years without success, and the female partner's examinations are largely normal. In this situation, the probability of natural sperm-egg binding in conventional IVF is very low. ICSI (Intracytoplasmic Sperm Injection) is a more direct and effective option.

Which Male Infertility Conditions Are Suitable for ICSI

ICSI bypasses the natural process of sperm penetrating the egg, directly injecting a single sperm into the egg cytoplasm. From clinical practice, the following conditions are suitable for ICSI:

Severe Oligospermia

When sperm concentration is below 5×10⁶/mL, the number of sperm capable of binding to the egg in conventional IVF is severely insufficient. ICSI requires only one sperm with relatively normal morphology and motility to achieve fertilization.

Severe Asthenospermia

When the proportion of progressively motile sperm is below 10%, the sperm's ability to reach and penetrate the egg is significantly reduced. ICSI bypasses the requirement for sperm motility.

Severe Teratozoospermia

When the proportion of sperm with normal morphology is below 1%, structural abnormalities in the sperm head may prevent penetration of the egg's zona pellucida. ICSI directly injects the sperm into the egg cytoplasm, circumventing the impact of morphology on fertilization.

Obstructive Azoospermia

Conditions such as congenital absence of the vas deferens, post-vasectomy, or inflammation causing blockage of the vas deferens result in sperm being present in the testicles but unable to be ejaculated. After retrieving sperm via testicular aspiration or microdissection, ICSI can achieve fertilization.

Immunological Infertility

Anti-sperm antibodies in the male's semen cause sperm agglutination or inability to penetrate the egg. ICSI bypasses the immune reaction step.

Previous IVF Fertilization Failure or Low Fertilization Rate

A fertilization rate below 30% in a previous conventional IVF cycle, or complete fertilization failure, suggests a possible sperm-egg binding disorder.

How Doctors Assess the Suitability of ICSI

As a reproductive physician, before recommending ICSI, the following evaluations must be completed:

Semen Analysis is Fundamental

At least two semen analyses are needed to confirm sperm parameters. If results vary significantly, a repeat test is necessary. A single result should not be the final basis for judgment.

Rule Out Reversible Causes

Check for varicocele, reproductive tract infections, endocrine abnormalities, medication effects, environmental factors, etc. Some of these factors can be improved with treatment, not necessarily leading directly to ICSI.

Genetic Screening

Patients with severe oligospermia and azoospermia need chromosomal karyotyping and Y-chromosome microdeletion testing. If chromosomal abnormalities or AZF deletions are found, genetic counseling is required. Some cases may need to be combined with PGT technology.

Female Factor Assessment

Evaluate the female partner's age, ovarian reserve, tubal patency, uterine conditions, etc. ICSI only addresses the fertilization step; female factors also significantly affect the final outcome. When the female partner is over 38 years old, egg quality declines, and ICSI fertilization and embryo development rates can be affected.

Easily Overlooked Details

During the ICSI process, several details are often overlooked:

• Sperm DNA Fragmentation Rate: Routine semen analysis does not reflect sperm DNA integrity. When the DNA fragmentation index (DFI) is above 30%, the developmental potential of ICSI embryos may decrease, and miscarriage rates may increase. DFI testing is recommended before ICSI.
• Semen Infection Factors: Mycoplasma, chlamydia, and bacterial infections can impair sperm quality. Even if routine semen parameters are acceptable, infection factors can affect ICSI outcomes.
• Sperm Collection Timing and Abstinence Period: Prolonged abstinence (over 7 days) increases sperm DNA damage. An abstinence period of 3-5 days is recommended during an ICSI cycle. For azoospermic patients, testicular sperm aspiration should be arranged in advance.
• Sperm Freezing and Thawing: Some patients need to freeze sperm in advance. The freeze-thaw process causes approximately 30%-50% loss of sperm motility. It is necessary to assess whether the post-thaw sperm count is sufficient for ICSI.
• Y-chromosome Microdeletions: AZFa deletion usually presents as azoospermia, AZFb deletion also often results in azoospermia, while AZFc deletion may allow for some sperm production. Men with AZFc deletion can father children via ICSI, but male offspring will inherit the same deletion.

ICSI Procedure at Hong Kong Sanatorium & Hospital

Pre-operative Preparation and Examinations

Both partners need to complete: infectious disease screening, chromosomal karyotyping, blood type and Rh factor, liver and kidney function, coagulation profile, female AMH and hormone panel, vaginal ultrasound, and male semen analysis. Azoospermic patients need to arrange testicular aspiration or microdissection in advance.

Ovarian Stimulation Phase

An ovarian stimulation protocol is tailored based on the female partner's ovarian reserve. Common protocols at Hong Kong Sanatorium & Hospital include antagonist, short, and mild stimulation protocols. The cycle lasts about 10-14 days, requiring monitoring of follicle development and hormone levels.

Egg and Sperm Retrieval

Egg retrieval is performed via transvaginal ultrasound-guided aspiration under intravenous sedation. Sperm is collected on the same day; azoospermic patients complete testicular aspiration and sperm freezing in advance.

ICSI Fertilization Procedure

Under a microscope, the embryologist selects a sperm with relatively good morphology and motility and injects it into the egg cytoplasm using a microinjection needle. This procedure is performed in a specialized laboratory and is technically demanding.

Embryo Culture

Fertilized embryos are cultured in an incubator for 3-6 days to monitor development. Some patients may require blastocyst culture up to day 5-6.

Embryo Transfer

One or two well-developed embryos are selected and transferred into the uterine cavity. The transfer procedure is simple and does not require anesthesia.

Luteal Support

Progesterone medications are used after transfer to support luteal function, continuing until a pregnancy test is performed 10-14 days after transfer.

Timeline and Cycle Planning

An ICSI treatment cycle, from initial examinations to transfer, typically takes 4-6 weeks. It is recommended to allow 2-3 months from the first consultation to completion of treatment.

Cost Breakdown and Influencing Factors

The cost of ICSI treatment at Hong Kong Sanatorium & Hospital mainly includes:

• Examination Fees: Approximately HKD 10,000-20,000 for pre-operative tests for both partners.
• Ovarian Stimulation Medication Fees: HKD 20,000-40,000, varying by protocol and dosage.
• Egg Retrieval Surgery Fees: HKD 30,000-50,000.
• ICSI Laboratory Procedure Fees: HKD 30,000-40,000.
• Embryo Culture and Transfer Fees: HKD 20,000-30,000.
• Luteal Support Medication Fees: HKD 5,000-10,000.

Total costs range from HKD 120,000 to 200,000, fluctuating based on individual differences and medication protocols. Main factors affecting cost include: female age, ovarian reserve, stimulation protocol, medication dosage, need for embryo freezing, and need for PGT. If testicular sperm aspiration (TESA) or microdissection (micro-TESE) is required, additional costs are approximately HKD 20,000-40,000. If embryo freezing is needed, annual storage fees are about HKD 5,000-10,000.

Management of Special Situations

Management of Azoospermia

For obstructive azoospermia, sperm is retrieved via testicular sperm aspiration (TESA) or microdissection (micro-TESE). For non-obstructive azoospermia, sperm retrieval is more challenging and requires assessment of testicular spermatogenic function.

Sperm Cryopreservation

Some patients need to freeze sperm in advance for various reasons. The ICSI fertilization rate with frozen sperm is not significantly different from fresh sperm, but the freeze-thaw process results in some loss of motility.

Combination with PGT Technology

If there is a risk of chromosomal abnormalities or genetic diseases, embryos obtained via ICSI can be combined with PGT for genetic testing. This requires additional time and cost but allows for the selection of chromosomally normal embryos for transfer. For advanced maternal age (>40 years), ICSI combined with PGT-A can screen for chromosomally normal embryos, reducing miscarriage rates. However, PGT-A adds an extra HKD 30,000-50,000 in costs, and there may be no embryos that pass screening.

Frequently Asked Questions

What is the difference between ICSI and conventional IVF?

ICSI involves manually selecting a single sperm and injecting it into the egg cytoplasm, while conventional IVF allows sperm and eggs to bind naturally in a culture dish. ICSI primarily addresses male factor infertility.

What factors affect the success rate of ICSI?

Female age is the most important factor affecting ICSI success. Additionally, egg quality, sperm DNA fragmentation rate, laboratory technical conditions, and uterine environment all influence the success rate.

Does ICSI cause birth defects?

Current research indicates that the rate of birth defects after ICSI is not significantly different from conventional IVF, but it is slightly higher than natural conception. This is mainly due to the underlying genetic factors associated with male infertility itself.

Can azoospermic patients undergo ICSI?

Patients with obstructive azoospermia can undergo ICSI after sperm retrieval via testicular aspiration. For non-obstructive azoospermia, testicular spermatogenic function needs to be assessed; some patients may have sperm retrieved via microdissection.