ICSI (Intracytoplasmic Sperm Injection)

Medically reviewed by Dr Manjushree Boob, MD, DNB, FICMCH, FICOG — Infertility & IVF Consultant

What it is

Intracytoplasmic sperm injection (ICSI) is a laboratory technique used inside an IVF cycle. Instead of leaving the sperm to find and penetrate the egg on its own, the embryologist picks up one single sperm in a glass needle far finer than a hair and places it directly into the centre of the egg, watching through a microscope at high magnification.

That is the whole difference. Everything else in the cycle is the same as ordinary IVF: hormone injections to grow several eggs, a short procedure to collect them, fertilisation in the laboratory, and an embryo placed back into the uterus a few days later.

Here is how I usually explain it in the consulting room. In conventional IVF, we put the eggs and the prepared sperm together in a dish and let nature do the rest — it is a fair race, and the sperm still has to swim, attach and break through the egg’s outer shell. ICSI skips the race entirely. If the sperm cannot make that journey, we carry it there.

Who needs it

• Severe male-factor infertility — very low sperm count, poor movement, or a high proportion of abnormally shaped sperm.
• Azoospermia, where there is no sperm in the ejaculate but sperm can be retrieved surgically from the testis (TESA, PESA, micro-TESE).
• Previous failed fertilisation in a conventional IVF cycle, where eggs were collected but very few or none fertilised.
• Frozen or surgically retrieved sperm, where numbers are limited and nothing can be wasted.
• Very few eggs collected, so that each one matters and we do not want to leave fertilisation to chance.
• When eggs are being used after freezing, since the shell of a thawed egg often behaves differently.
• When genetic testing of embryos is planned, because stray sperm sticking to the outside of the egg can contaminate the test result.
• Unexplained infertility with repeated failure of simpler treatments such as IUI.

“My reports are all normal. Why has ICSI been suggested to me?” Sometimes it is a precaution rather than a diagnosis. If only three or four eggs are expected, or a previous cycle produced eggs that never fertilised, we may not want to gamble on a normal-looking semen report. A report tells us about the sperm in a sample. It cannot tell us whether that sperm can actually get into an egg. If we are not convinced ICSI adds anything for you, we will say so — it is not a step that should be added to every cycle by default.

How it is done

Ovarian stimulation. Daily hormone injections for about ten to twelve days encourage several follicles to grow together instead of the single egg you would produce naturally. Ultrasound scans and blood tests every few days tell us when they are ready.

Trigger and egg retrieval. A final injection matures the eggs. About thirty-four to thirty-six hours later, the eggs are collected through the vagina using a fine needle guided by ultrasound — no cut, no stitch. It takes roughly fifteen to thirty minutes.

Sperm preparation. The semen sample given on the same day is washed and concentrated so that the healthiest, most active sperm are separated out. If sperm has to be retrieved from the testis, that small procedure is done alongside, or the frozen sample from an earlier retrieval is thawed.

The injection itself. Each egg is stripped of the cells surrounding it and examined; only mature eggs can be injected. The embryologist immobilises one chosen sperm, draws it into a very fine glass needle, holds the egg steady with a suction pipette, and passes the needle through the shell and the membrane to release the sperm inside. This is repeated egg by egg.

Culture and transfer. The next morning we check which eggs have fertilised. The embryos are grown in the incubator for two to five days, and the best one — occasionally two — is placed into the uterus through a soft catheter. Extra good-quality embryos are frozen for later. Sometimes we deliberately freeze everything and transfer in a calmer, later cycle.

Anaesthesia, duration and hospital stay

The egg retrieval is done under short general anaesthesia or deep sedation and takes about fifteen to thirty minutes. You come in fasting that morning and go home the same day, usually within four to six hours, once you have eaten and passed urine comfortably.

The ICSI procedure itself happens in the laboratory, not on you — it takes the embryologist a few minutes per egg, and you are not involved in it at all.

The embryo transfer needs no anaesthesia. It feels much like a smear test, takes about ten to fifteen minutes, and you rest for a short while afterwards before going home.

Sperm retrieval for men, when needed, is a short day-care procedure under local or brief general anaesthesia, with the man going home the same day.

Recovery

Day 1 after egg retrieval. Expect crampy discomfort like a period, mild bloating and a little spotting. Simple painkillers are enough. Eat normally, drink well, and rest at home.

The first week. The bloating usually settles over a few days. Most women are back at work in one to two days. Avoid strenuous exercise, heavy lifting and intercourse until we tell you otherwise, particularly if many eggs were collected — the ovaries stay enlarged and tender for a while. If an embryo transfer is done in the same cycle, it usually falls within this week; there is no need for bed rest afterwards, and lying flat for days does not improve the outcome.

Weeks 2 to 4. The pregnancy test is done about two weeks after the transfer. This is the hardest part of the whole treatment for most couples, and no amount of preparation makes the waiting comfortable. Continue the hormone support exactly as prescribed and do not stop it on your own, even if you see spotting.

By six weeks. If the test is positive, an early scan confirms the pregnancy and its location. If it is negative, we sit down and go through the cycle honestly — how the eggs responded, how many fertilised, how the embryos looked — and decide what should change next time, or whether a frozen embryo from this cycle can be used.

Call us straight away for severe abdominal pain, rapidly increasing bloating, breathlessness, reduced urine output, vomiting or fever after the retrieval.

Why ICSI rather than conventional IVF

In conventional IVF, thousands of prepared sperm are placed around each egg and one of them fertilises it unaided. That works well when the sperm are healthy and plentiful. It works badly when they are not.

ICSI removes the three barriers that stop weak sperm: swimming to the egg, binding to its outer shell, and pushing through it. Only one living sperm per egg is needed, which is why men with extremely low counts, or with sperm retrieved surgically in tiny numbers, can still father a child. It also gives a far more predictable answer than sitting through a second cycle hoping fertilisation will happen this time.

The other side of it, stated plainly: ICSI is an extra laboratory step with an extra cost, it bypasses natural sperm selection, and it does nothing at all for egg quality or implantation. For a couple with good sperm parameters, conventional IVF gives comparable results without that extra intervention. Adding ICSI to every case is convenient for the laboratory, not necessarily better for the patient. Our IVF and fertility department page describes where each approach fits.

Risks and complications

• Failure of fertilisation, even with ICSI, in a small proportion of cycles.
• Damage to some eggs during injection, which is why not every egg collected becomes an embryo.
• Ovarian hyperstimulation syndrome (OHSS) — an over-response to the hormone injections causing bloating, fluid collection and, rarely, a serious illness needing admission. Modern protocols and freezing all embryos have made severe OHSS much less common.
• Bleeding, infection or injury to nearby structures during egg retrieval. Uncommon, but real.
• Multiple pregnancy if more than one embryo is transferred, which carries higher risks for both mother and babies — one reason single embryo transfer is preferred wherever possible.
• Ectopic pregnancy, which can occur despite the embryo being placed inside the uterus.
• Miscarriage, at roughly the rate expected for the woman’s age.
• Genetic considerations — certain causes of severe male infertility can be inherited by a son, which is why we advise genetic testing before ICSI in specific situations.
• The emotional and financial strain of a cycle that does not work. This deserves to be counted as a risk, because it is the one couples feel most.

Alternatives

Timed intercourse or ovulation induction remains reasonable for younger couples with mild problems and open tubes.

IUI (intrauterine insemination) places washed sperm directly into the uterus. It is far cheaper and simpler, and worth trying when the sperm count and motility are only mildly reduced. It is not useful for severe male-factor infertility.

Conventional IVF without ICSI is appropriate when sperm parameters are adequate and there is no history of failed fertilisation.

Medical and surgical treatment for the man — treating a hormone deficiency, an infection, or a varicocele — sometimes improves the semen parameters enough to avoid ICSI, or at least to improve the sperm available for it. Lifestyle matters too: heat, smoking, alcohol and untreated diabetes all affect sperm.

Donor sperm is discussed when no sperm can be retrieved, or when repeated attempts have failed. It is a decision that needs time, counselling and privacy, and we never rush a couple into it.

Adoption is a legitimate and often overlooked path, and we are happy to talk about it without any pressure. You can also see all the procedures we perform if you would like an overview first, and our step-by-step guide to the IVF process, timeline and injections explains what a full cycle actually feels like.

What it costs

We have not published a fixed price range for ICSI, because a fertility cycle varies far more from couple to couple than a standard operation does, and a number quoted here would mislead more people than it helped. What we can be transparent about is what drives the cost:

• The stimulation protocol and the dose of hormones you need — this is usually the single largest variable, and it depends on your age, your ovarian reserve and how you have responded before.
• Whether sperm has to be retrieved surgically (TESA, PESA or micro-TESE) and whether it is used fresh or frozen.
• The number of eggs collected, since ICSI is performed egg by egg.
• Whether embryos are transferred fresh or frozen for a later cycle, and how many are frozen.
• Add-on laboratory steps such as assisted hatching, blastocyst culture or genetic testing of embryos, none of which are needed by everyone.
• Anaesthesia, day-care charges and any admission if a complication such as OHSS occurs.
• Pre-cycle investigations, and any corrective procedure such as a hysteroscopy before starting.
• Your insurance or TPA cover, which for fertility treatment is limited in most policies.

Please call us on +91-8668954915 for an itemised estimate for your own situation. We would much rather give you a real figure after seeing your reports than a comfortable one over the phone. Charges are subject to change without prior intimation, and deluxe or super-deluxe room categories, emergency admission and night or holiday procedures are charged higher.

Preparing for your ICSI cycle

• Bring every previous report you have — semen analyses, hormone profiles, scans, and notes from any earlier IVF or IUI cycle. Old records save both time and money.
• Both partners will need baseline blood tests, including infection screening, before the cycle starts.
• The man should abstain for two to five days before giving the sample, and avoid alcohol, smoking and hot baths in the weeks before.
• Start folic acid, and get your thyroid, diabetes and blood pressure properly controlled beforehand.
• Bring your weight into a healthier range if you can. It genuinely affects both the response to hormones and the chance of implantation.
• Learn the injection technique with our nurse before you go home with the medicines, and keep them stored exactly as instructed.
• Keep the scan and blood-test days free — they are frequent during stimulation and cannot be shifted.
• Arrange for someone to accompany you on the day of egg retrieval, since you must not drive after an anaesthetic.
• Plan two or three light days around the retrieval, and, if you can, some flexibility in the two weeks after the transfer.
• Ask us anything you are unsure of before starting. Once the injections begin, the cycle moves quickly.

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If you have been told that ICSI is your only option and you are not sure whether that is really true, bring your reports to the fertility team at Shubham Hi-Tech Hospital and Test Tube Baby Centre, Amravati. We will go through them with you, explain plainly what we think will work and what will not, and give you the time to decide. Call +91-8668954915 or get in touch here.

Disclaimer: This article is for general information only and is not a substitute for professional medical advice. Please consult a qualified doctor for guidance specific to your situation.