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Intracytoplasmic sperm injection
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==Procedure== ICSI is generally performed following a transvaginal oocyte retrieval procedure to extract one or several oocytes from a woman. In ICSI IVF, the male partner or a donor provides a sperm sample on the same day when the eggs are collected.<ref>{{cite web | url=http://www.testtubebabyprocess.com/2016/12/icsi-ivf.html | archive-url = https://web.archive.org/web/20170603174338/http://www.testtubebabyprocess.com/2016/12/icsi-ivf.html | archive-date = 3 June 2017 | title = ICSI IVF or (Intracytoplasmic sperm injection In vitro fertilization) | work = Test Tube Baby Process }}</ref> The sample is checked in the lab, and if no sperm is present, doctors will extract sperm from the epididymis or testicle. The extraction of sperm from epididymis is also known as percutaneous epididymal sperm aspiration (PESA) and extraction of sperm from testicle is also known as testicular sperm aspiration (TESA). Depending on the total amount of spermatozoa in the semen sample, either low or high, it can be just washed or capacitated via swim-up or gradients, respectively. [[File:ICSI Procedure.jpg|thumb|240x240px|A medical animation still showing the ICSI procedure.]] The procedure is done under a [[microscope]] using multiple micromanipulation devices ([[micromanipulator]], [[microinjectors]] and [[micropipettes]]). A holding pipette stabilizes the mature [[oocyte]] with gentle suction applied by a microinjector. From the opposite side a thin, hollow glass micropipette is used to collect a single sperm, having immobilised it by cutting its tail with the point of the micropipette. The oocyte is pierced through the [[oolemma]] and the sperm is directed into the inner part of the oocyte (cytoplasm). The sperm is then released into the oocyte. The pictured oocyte has an extruded [[polar body]] at about 12 o'clock indicating its maturity. The polar body is positioned at the 12 or 6 o'clock position, to ensure that the inserted micropipette does not disrupt the spindle inside the egg. After the procedure, the oocyte will be placed into cell culture and checked on the following day for signs of [[fertilization]].<ref>{{cite web |title=ICSI treatment- Nanditapalshetkar |url=https://nanditapalshetkar.in/icsi/ |website=nanditapalshetkar}}</ref> In contrast, in natural fertilization sperm compete and when the first sperm penetrates the oolemma, the oolemma hardens to block the entry of any other sperm. Concern has been raised that in ICSI this sperm selection process is bypassed and the sperm is selected by the embryologist without any specific testing. However, in mid-2006 the FDA cleared a device that allows embryologists to select mature sperm for ICSI based on sperm binding to [[hyaluronan]], the main constituent of the gel layer ([[cumulus oophorus]]) surrounding the oocyte. The device provides microscopic droplets of hyaluronan hydrogel attached to the culture dish. The embryologist places the prepared sperm on the microdot, selects and captures sperm that bind to the dot. Basic research on the maturation of sperm shows that hyaluronan-binding sperm are more mature and show fewer DNA strand breaks and significantly lower levels of [[aneuploidy]] than the sperm population from which they were selected. A brand name for one such sperm selection device is PICSI.<ref>{{cite web|url=http://www.prweb.com/releases/2006/07/prweb407895.htm|archive-url=https://web.archive.org/web/20081206081721/http://www.prweb.com/releases/2006/07/prweb407895.htm|url-status=dead|archive-date=December 6, 2008|title=New Sperm Selection Technology for Assisted Reproductive Technology (ART) Cleared by FDA}}</ref> A recent clinical trial showed a sharp reduction in miscarriage with embryos derived from PICSI sperm selection.<ref name="pmid23203216">{{cite journal | vauthors = Worrilow KC, Eid S, Woodhouse D, Perloe M, Smith S, Witmyer J, Ivani K, Khoury C, Ball GD, Elliot T, Lieberman J | display-authors = 6 | title = Use of hyaluronan in the selection of sperm for intracytoplasmic sperm injection (ICSI): significant improvement in clinical outcomes--multicenter, double-blinded and randomized controlled trial | journal = Human Reproduction | volume = 28 | issue = 2 | pages = 306–314 | date = February 2013 | pmid = 23203216 | pmc = 3545641 | doi = 10.1093/humrep/des417 }}</ref> 'Washed' or 'unwashed' sperm may be used in the process. Live birth rate are significantly higher with progesterone to [[luteal support|assist implantation]] in ICSI cycles.<ref name=van-der-Linden2011>{{Cite journal | vauthors = Van der Linden M, Buckingham K, Farquhar C, Kremer JA, Metwally M | title = Luteal phase support in assisted reproduction cycles | doi = 10.1093/humupd/dms017 | journal = Human Reproduction Update | volume = 18 | issue = 5 | pages = 473 | year = 2012 | doi-access = free | hdl = 2066/98072 | hdl-access = free }}</ref> Also, addition of a [[GNRH agonist]] has been estimated to increase success rates.<ref name=van-der-Linden2011/><ref>{{cite journal | vauthors = Kyrou D, Kolibianakis EM, Fatemi HM, Tarlatzi TB, Devroey P, Tarlatzis BC | title = Increased live birth rates with GnRH agonist addition for luteal support in ICSI/IVF cycles: a systematic review and meta-analysis | journal = Human Reproduction Update | volume = 17 | issue = 6 | pages = 734–740 | year = 2011 | pmid = 21733980 | doi = 10.1093/humupd/dmr029 | doi-access = free }}</ref> Ultra-high magnification sperm injection (IMSI) has no evidence of increased live birth or miscarriage rates compared to standard ICSI.<ref>{{cite journal | vauthors = Farquhar C, Marjoribanks J | title = Assisted reproductive technology: an overview of Cochrane Reviews | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | issue = 8 | pages = CD010537 | date = August 2018 | pmid = 30117155 | pmc = 6953328 | doi = 10.1002/14651858.CD010537.pub5 }}</ref> A new variation of the standard ICSI-procedure called Piezo-ICSI uses small axial mechanical pulses (Piezo-pulses) to lower stress to the cytoskeleton during zona pellucida and oolemma breakage.<ref>{{cite web | url = https://www.eshre.eu/Education/Calendar-Campus-events/Top-quality-in-micro-manipulation/Programme?dayid=169 | vauthors = Sakkas D | title = New styles of ICSI | date = 18 May 2019 | location = Gent, Belgium | publisher = European Society of Human Reproduction and Embryology (ESHRE) | work = ESHRE-Workshop: Top quality in micromanipulation: everything you always wanted to know about ICSI and embryo biopsy }}{{Dead link|date=September 2024 |bot=InternetArchiveBot |fix-attempted=yes }}</ref> The procedure includes specialized Piezo actuators, microcapillaries, and filling medium to transfer mechanical pulses to the cell membranes.<ref>{{cite web | url = http://www.eppendorf.com/appnote395 | vauthors = Costa-Borges N, Mestres E, Vanrell I, García M, Calderón G, Stobrawa S | title = Intracytoplasmic Sperm Injection (ICSI) in the Mouse with the Eppendorf PiezoXpert®: How to Increase Oocyte Survival Rates After Injection | work = Application Note | publisher = Eppendorf AG | location = Hamburg }}</ref> The Piezo technique itself was for example established for animal ICSI and animal ES cell transfer.
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