To ICSI or not to ICSI

Intracytoplasmic sperm injection (ICSI) is an assisted reproductive technology (ART) used to treat sperm-related infertility problems. ICSI is used to enhance the fertilization phase of in vitro fertilization (IVF) by injecting a single sperm into a mature egg.
Under high-power magnification, a glass tool (holding pipet) is used to hold an egg in place. A microscopic glass tube containing sperm (injection pipet) is used to penetrate and deposit one sperm into the egg. After culturing in the laboratory overnight, eggs are checked for evidence of fertilization. After incubation, the eggs that have been successfully fertilized (zygotes) or have had 3 to 5 days to further develop (zygotes or blastocysts) are selected. Two to four are placed in the uterus using a thin flexible tube (catheter) that is inserted through the cervix. The remaining embryos may be frozen (cryopreserved) for future attempts.

Intracytoplasmic sperm injection (ICSI) is used to treat severe male infertility, as when little or no sperm are ejaculated in the semen. Immature sperm collected from the testicles are usually unable to move about and are more likely to fertilize an egg through ICSI. It is also helpful when the sperm is poorly shaped, it allows the embroyologist to pick the best sperm to fertilize the egg with.

Some couples choose to try ICSI after repeat in vitro fertilization has been unsuccessful. In the United States, about half of IVF procedures are currently performed using ICSI technology. Myself I find this absolutely crazy, why would couples not want to ICSI, why would you want to take the risk of eggs not fertalizing? I just do not get that!!

ICSI is also used for couples who are planning to have genetic testing of the embryo to check for certain genetic disorders. ICSI uses only one sperm for each egg, so there is no chance the genetic test can be contaminated by other sperm.

There has been some studies that show that using ICSI gives you a slightly higher change of having identical twins, but there is not enough evidence to support that quite yet.

So, we will be doing ICSI, we have to, with John's sperm which is poorly shaped and the potential that my eggs are too hard, that would make natural fertilization more difficult. So whatever the risks, I feel the benefits outweigh the risks.

Thanking God every day!

When I go back and read the posts that John has posted I literally get tears in my eyes. John and I are getting ready to celebrate four years together. It was four years ago on March 4th that John and I met and if someone had told me four years ago that I was going to move to Vegas and meet my husband within the first three months that I was here I would have told them they were nuts!

As much as I hate going through this fertility roller coaster I feel it has brought John and I closer together. John and I had a whirlwind before we got married, we moved in with each other pretty quick and then were engaged and married all fairly quickly, so I really like we are really getting to know each other and learning what the other is really made of. You really see a persons true personality when they are hurting. I have seen John cry and scream over this journey and he has seen me do the same. But in the end I we push on and we will succeed and we will be parents.

It was so funny the other night we were sitting at dinner at a casual dining restaurant that we go to all the time and I starting talking about IVF, and all the stuff that goes into it. ICSI, assisted hatching, PGD, PIO, and so on. His face was priceless he looked scared to death! Then I starting talking about twins and how wonderful it would be to have twins and what a blessing it would be. He looked very nervous at that time. As much as having twins would be a blessing I do think it would be difficult, can you imagine two of everything?!

John is always supportive and is my rock through all this, but I think the IVF talk was too much. I pretty much told him that I would just tell him when he needed to show up at the doctors office, and I think he is happier that way. Poor guy! I don't expect him to understand everything, that is my job! John is the type of person that wants to be shown two things and he will pick from there, so maybe I should show him two embryos and let him pick the ones he likes! HAHA
But my point is ladies, your husbands don't have to involved in every aspect of infertility in order to support you! It's just not their thing!

IUI's a new interesting study!

I found this article interesting because having been told that IVF with ICSI is out best option due to having boardeline sperm morohology issues. The age old question is where is the cut off line between doing IUI and doing IVF, most fertility specalists will say to do at least 3 IUI's before moving to IVF, while others say with certain criteria do not even try and IUI, do not pass go, do not collect $200, GO STRAIGHT TO IVF. This article takes men with a strict morphology of 5% and below and 5% and above and tests the pregnancy rate of both groups.

Normally multiplying the total motile sperm count by the percent of normal sperm determined by strict morphology (TM×SM) may be a significant predictor of pregnancy when sperm morphology is less than 5%, according to a new study by Texas researchers. It as been said that with a less then 5% morphology there is a harder time achieveing pregnancy.

It has been suggested that in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) may be the best treatment option for couples with less than 5% normal sperm strict morphology. Wanting to investigate whether the 5% threshold or the TM×SM was a significant predictor of intrauterine insemination (IUI) success, researchers looked at infertile couples undergoing IUI at their institution between November 1995 and December 2007. Their findings suggest that TM×SM may be helpful in selecting couples who are not suitable for IUI.

Females that were excluded from the study had an age greater than 40 years, history of endometriosis, tubal factor, or history of previous IVF or use of donor sperm. A total of 237 couples were included in the study. The investigators determined total motile sperm counts for each of the initial semen analyses and used the Kruger strict morphology criteria to calculate the percentage of total normal sperm, then multiplied to get the TM×SM.

The overall cumulative pregnancy rate was about 30%. Mean female age, mean strict morphology, mean TMC, and mean TM×SM in both the pregnant and nonpregnant groups were similar. The pregnancy rate was 24% in couples with strict morphology less than 5% (about 45% of the cohort) compared with a pregnancy rate of 34% in couples with strict morphology of 5% or more. The difference was not statistically significant.

In couples with SM less than 5%, the pregnant group had a significantly higher mean TM×SM compared with the nonpregnant group (3.7 million vs. 2.3 million). No pregnancies occurred in the 14 couples whose TM×SM was less than 0.29 million. Overall, TM×SM was the only significant predictor of pregnancy in couples with SM below 5%.

In laymans terms this study tells us not to look at strict morphology alone. You should also look at the total motile count and combine it with the strict morphology, said study investigator Ertug Kovanci, MD, assistant professor of obstetrics and gynecology at Baylor College of Medicine in Houston. “Sometimes IVF with ICSI is recommended just because the strict morphology is less than 5%. But we are saying that if the total motile count is good, you don't have to do IVF with ICSI [in these couples]. You can get away with IUIs.”

That is great news, because it could potentially lead to huge costs savings because IUI is both less invasive and less expensive. Obviously if continued IUI's are not successful then it is important to speak to your fertility specalist about moving forward to IVF with ICSI, but this study gives hope to those who have boarderline sperm morphology numbers. In our case, we were told go right to IVF with ICSI, but after some time and lots of vitamins John's sperm had improved and we now fit into the parameters to do IUI's and John has put up steller numbers at both of our IUI's. So things change, espiclly sperm. One thing to keep in mind with IUI's is the success rate is not as high as an IVF on one cycle, so it may take more then one cycle to achieve pregnancy, do not give up hope.
Best of luck to you!

The dreaded diagnosis: Unexplained

In the wonderful world of infertility there many different diagnosis's- we have been falling into the what I can the "dreaded" diagnosis of unexplained infertility. However there is some science behind the unexplained diagnosis.

Infertility is officially defined as the inability to conceive after one year of sexual intercourse without the use of any contraceptive methods. A systematic and standard evaluation of all couples with infertility usually involves three initial tests:

1. Confirmation of ovulation by History and lab tests.
2. An assessment of the fallopian tubes and the uterus by the use of an x-ray called Hysterosalpingogram (HSG).
3. An assessment of a semen analysis (SA).

If the results of these three tests are normal, and the couple has been trying to conceive for at least one year, the diagnosis of unexplained infertility is made. Of the patients seeking infertility treatment nearly 10 to 15 percent are diagnosed with unexplained infertility. What this means is that even though the initial tests we perform to evaluate ovulation, the fallopian tubes and SA are normal, this couple has difficulty conceiving due to some inefficiency in the process of conception.

Eventually most couples with unexplained infertility get pregnant. The problem may be an inefficiency that can be overcome with time and more attempts at conception. Most patients with unexplained infertility conceive within six to seven years. Perhaps a younger patient can afford the wait, but older patients may not have the luxury of time.

Now, I know that everyone is freaking out when I say six to seven years, now that seems like a really long time. I am 28 right now and my husband is 38 years old, so where I could afford to wait my husband cannot, its not that he couldn't physically have kids when he is older, but why would he want to be 44 when he could be 39? That is why I am so grateful that we have modern medical advances that can help speed up the procedure.

Unexplained Infertility may be a mystery since it assumes that in most cases we do not know what is the cause of infertility. In fact there is often something wrong at a more basic level. For example, it is possible that there is something wrong at the level of the gametes (egg & sperm) and their interaction with each other, or their interaction with the female reproductive organs.

It is also possible to have sperm that appear normal under a microscope,therefore causing the seman analysis to appear normal, however sometimes the sperm is not able to perform the function of fertilization adequately. Furthermore, one can have normal sperm but poor quality eggs that do not fertilize or fertilize at a lower than expected rate. If normal eggs and sperm meet, one can expect a fertilization rate between 60 to 90 percent. The outer shell of the egg, the Zona Pellucida, usually hardens after one sperm enters the egg. It is possible for the outer shell not to allow a sperm to enter, or allow too many sperm to enter the egg. Both these situations result in abnormalities that lead to infertility. There is where ICSI in conjuction with IVF is a miracle, because a single sperm is injected into a single egg causing a much hight fertilization rate.

Once an egg is fertilized, there is an 80 percent chance of cell division. The rate of division of the resulting embryo is also of significance. Usually 48 hours after fertilization, the embryo is between two to four cells (blastomeres). At 72 hours, they are usually between six to eight cells. After five days of growth, they are usually over 120 cells with a fluid cavity in the middle (Blastocyst). If a larger than expected percentage of embryos divide slowly or stop dividing at any stage, this can result in infertility. This is where IVF is helpful because the embroyos that have the correct number of cells are the ones that are transferred back into the uterus, therefore causing a higher probability that one will implant and cause a healthy pregnancy.

There can also be problems with normal attachment or implantation of the embryo once it reaches the uterine cavity. This can be due to the presence or absence of certain important factors needed for implantation at the level of the uterus or the embryo. The outer shell of the embryo can be too hard or thick and not allow hatching of the embryo out of its shell (Zona Pellucida). This can result in a lower chance of implantation. A genetic abnormality with the embryo can lead to infertility. The embryos suspected of having a higher chance of a genetic abnormality are embryos with a higher degree of cell fragmentation (abnormal looking cells in the embryo).

Although, an evaluation of the fallopian tubes, ovulation, and a SA are good initial screening tests, they do not identify all causes of infertility. Unexplained infertility therefore is not one specific diagnosis, but possibly a combination of one or many inefficiencies in the processes of conception.

If you are suffering from unexplained infertility, just remember that some things just take time, and eventually most couples suffering from unexplained infertility will go onto conceive. But remember that with all the medical interventions we can take the guesswork out of a lot of possible issues that you may be having, therefore giving you the best chance of getting and staying pregnant.