Concerns About Icsi

A concern in considering the use of suboptimal spermatozoa for ICSI is the potential for transmitting the genetic abnormalities responsible for male infertility (4, 5, 7, 10, 29, 36-41). Despite this, ICSI is accepted as the only therapeutic option for patients with congenital absence of the vas deferens, associated with a gene deletion labeling these individuals as carriers of cystic fibrosis (42, 43). Similarly, infertile patients with Kartagener's syndrome or other ciliary dyskinesia that renders spermatozoa immotile may transmit this condition to their offspring. In these cases, genetic screening and patient counseling is crucial, and preimplantation genetic testing as well as prenatal evaluation should be considered.

Liebaers et al. (44) reported only 1% of sex chromosomal anomalies after ICSI, and in our ICSI program (n = 2190) there was a 1.8% incidence of congenital abnormalities compared to 3.0% in babies born as a result of standard IVF and compared to 3.6% in

Table 5.5. In Vivo Evolution and Pregnancy Outcome of Embryos Generated by ICSI

No. No. of Complications in Pregnancy Evolution

Table 5.5. In Vivo Evolution and Pregnancy Outcome of Embryos Generated by ICSI

No. No. of Complications in Pregnancy Evolution

Embryos replaced

12,176

Embryonic sacs implanted

3,116 (25.6%)

144 anembryonic sacs

Implanted embryos displaying a

2,786 (22.9%)

150 vanishing; 15 ectopics; 199 miscarriages; 100

fetal heartbeat

selective reductions; 30 therapeutic abortions

Remaining fetal heartbeats at

2,230 (18.3%)

23 fetal demises

20 wks gestation

Live offspring delivered

2,207 (18.1%)

17 neonatal mortalities

Surviving offspring

2,190 (18.0%)

*Percentages indicate proportion of embryos.

*Percentages indicate proportion of embryos.

Table 5.6. Incidence of Congenital Abnormality in Relation to the Insemination Technique

ICSI

IVF

Cycles

3,828

3,399

Offspring delivered

2,190

1,865

Newborns with major malformations

23 (1.0%)

30 (1.6%)

Newborns with minor malformations

17 (0.8%)

24 (1.3%)

Total malformations

40 (1.8)*

54 (2.9)*

*C2, 2 x 2, 1 df; Difference in congenital malformations between ICSI and IVF, P < 0.05.

*C2, 2 x 2, 1 df; Difference in congenital malformations between ICSI and IVF, P < 0.05.

the general population (45). Thus, our data agree with conclusions from other programs (46-48) that the incidence of fetal abnormalities after ICSI is no higher than that after natural conception and standard IVF, despite the fact that it often involves suboptimal spermatozoa (39). As already mentioned, there is, of course, a reason to be concerned that the problems that necessitated recourse to ICSI in some cases (e.g., astheno-, oligo-, and azoospermia) could emerge in the male children (49, 50).

Finally, more needs to be known about the ongoing development of children conceived by ICSI, who are being studied to assess both their physical and psychological progress. Bowen et al. (51) have reported that although most children conceived by ICSI are normal, there may be a small delay in development of ICSI children at 1 year compared to those conceived by routine IVF or naturally. However, neither ICSI (n = 201) nor IVF (n = 131) children had any slower mental development than 1283 Dutch children of the same age conceived naturally, nor did they have a slower mental development than the general population (52, 53). However, larger studies need to be conducted to be able to draw definitive conclusions.

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