In situations where the number or quality of sperm is insufficient to allow fertilization in a dish, individual sperm may be injected into eggs by means of intracytoplasmic sperm injection (ICSI). The use of ICSI has expanded the application of in vitro fertilization to include serious male subfertility, previously untreatable by other means. ICSI may be performed with ejaculated sperm or with sperm that have been retrieved from a man's testicles (or epididymus) by a minor surgical procedure performed by a urologist .	Photo Slideshow: A Look Inside IVF
Whereas several hundred thousand sperm are required for standard insemination in a petri dish, only one sperm per egg is required for ICSI. The sperm used for ICSI may be retrieved on the day of the egg retrieval. Alternatively, frozen sperm obtained from previous collection procedures may be used.

In addition to those situations where the number of sperm is low, ICSI is also used when the quality of sperm is sub-optimal. Common examples include problems with sperm movement (motility) or sperm structure (morphology). These sperm characteristics may be recognized on standard semen analysis testing.

Further indications for ICSI may be discovered by means of more technical sperm evaluations. Currently, we employ a duo of tests known as SCSA which measure DNA fragmentation and stainability to identify men who might benefit from ICSI. We also consider ICSI in cases of poor fertilization during prior IVF attempts and when a low number of eggs are retrieved.

An egg undergoing sperm insertion (ICSI)

Why don't we perform ICSI on every case?
The reason goes far beyond the additional cost to the patient. Worldwide experience suggests that ISCI leads to a 1% increase in the incidence of birth defects among the offspring beyond the 3-5% incidence seen with natural reproduction.

Critics argue that this increase stems from the use of poorer quality sperm found in many of the men involved with the procedure. Others believe that the process of penetrating the egg with a needle might disrupt internal architecture of the egg, leading to defects in the division/separation of whole chromosomes or the imprinting of individual genes. In light of this information we enthusiastically employ ICSI in those situations where we feel the technique greatly improves a couple's chances to succeed, but avoid it when it there is no obvious reason to use it.