Intracytoplasmic sperm injection versus conventional in vitro fertilization in unexplained infertility

Area of Science:

• Reproductive Medicine
• Infertility Treatment
• Assisted Reproductive Technology

Background:

• Unexplained infertility affects a significant portion of couples seeking fertility treatments.
• Intracytoplasmic sperm injection (ICSI) and conventional in vitro fertilization (cIVF) are primary assisted reproductive technologies.
• Comparative effectiveness and cost-effectiveness of ICSI versus cIVF in unexplained infertility require further elucidation.

Purpose of the Study:

• To compare the cumulative live birth rate (CLBR) and cost-effectiveness of ICSI versus cIVF.
• To evaluate secondary outcomes including fertilization rates, miscarriage rates, and embryo utilization.
• To assess the impact of preimplantation genetic testing for aneuploidy (PGT-A) on these comparisons.

Main Methods:

• Retrospective cohort study utilizing data from the Society for Assisted Reproductive Technology (SART) Clinic Outcomes Reporting System.
• Inclusion of patients with unexplained infertility undergoing their first autologous retrieval cycles (January 2017-December 2019) with linked embryo transfers through December 2021.
• Outcomes adjusted for patient age, BMI, oocytes retrieved, follow-up length, and clinic-specific ICSI utilization rates.

Main Results:

• No significant difference in CLBR was observed between ICSI and cIVF, both with and without PGT-A.
• ICSI cycles without PGT-A showed a higher miscarriage rate, while rates were similar with PGT-A.
• ICSI resulted in a lower ratio of two pronuclear (2PN) oocytes per oocyte retrieved, with no significant difference in embryo transfer or cryopreservation rates per 2PN.
• Total fertilization failure was higher in cIVF (4%) compared to ICSI (1.1%).
• ICSI incurred substantial additional costs compared to cIVF, estimated at over $11 million annually without PGT-A and over $9 million annually with PGT-A.

Conclusions:

• Routine use of ICSI in patients with unexplained infertility is not supported by the current evidence.
• The additional cost associated with ICSI does not translate into improved cumulative live birth rates.
• Conventional IVF remains a cost-effective primary treatment option for unexplained infertility.