October 1, 2022

IVF expert complains about unjustifiable use of ICSI around the world

Derides it as “Santa Claus in the fertility clinic”

The editor-in-chief of one of the world’s leading reproductive medicine journals has attacked the rising use of intracytoplasmic sperm injection (ICSI) for the treatment of infertility, following publication of the latest world report on assisted reproductive technologies (ART).

The report in Human Reproduction shows that while ICSI use has levelled off in some regions, its use is approaching 100% of assisted reproduction cycles in the Middle East and a few countries in other regions, despite the fact that ICSI was developed for the treatment of male infertility, which is a factor in around 40% of couples seeking fertility treatment. The world report covers the years 2008, 2009 and 2010 — the years for which the most recent data are available.

In a savage editorial entitled “Santa Claus in the fertility clinic”, to accompany the world report, Professor Hans Evers highlights the fact that in 2010 there were 220,000 in vitro fertilisation (IVF) treatments, but there were more than 455,000 ICSI treatments in the world. There was 1.4 times as much ICSI than IVF in Asia, twice as much in sub-Saharan Africa, just over twice as much in Europe, 2.7 times as much in North America, more than 6 times as much in Latin America and more than 60 times as much in the Middle East. (Statistics for the ICSI:IVF ratio for Australian and New Zealand were not available.)

He writes that doctors are guilty of over-estimating the effect of ICSI. “The majority of the patients who will get pregnant with intracytoplasmic sperm injection (ICSI) will also do so with IVF.”

Studies have shown that ICSI results in fewer live births than IVF when used for couples where male infertility is not the problem. “Intending to improve their patients’ pregnancy probability by preventing fertilization failure, well-meaning doctors actually decrease their chances. This has to stop. We have pledged to do no harm,” he writes.

Prof Evers says doctors will serve their patients best by making decisions based on the evidence, “not by playing Santa Claus and doling out nicely wrapped presents of unnecessary, ineffective and costly care.”

The authors of the ICMART report say that the reasons behind the high use of ICSI are not fully understood and are beyond the scope of their report. They write:

“Investigating why ICSI is a preferred fertilization technique in a number of countries, particularly in Latin America and the Middle East, is warranted.”  

The risk of birth defects with ICSI is small but statistically higher than with conventional IVF – which also has an elevated risk of birth defects. As well, using ICSI as a remedy for male infertility risks passing on infertility to the next generation.

The report shows wide variation in the use of ART between countries. Globally, ART use remained fairly constant, with 436 cycles per million of the population in 2008 and 474 cycles per million in 2010.

However, ART use ranged from 4,775 cycles per million in Israel (which had consistently the highest levels of access over the three years) to just 8 cycles per million in the Dominican Republic in 2010. In the same year there were almost 2,500 cycles per million in Australia and New Zealand, more than 900 per million in Europe, 570 cycles per million in North America, 150 cycles per million in Latin America and nearly 90 cycles per million in sub-Saharan Africa. 

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