A Simple, Step-by-Step Guide to the ICSI Process

In a previous article, we have discussed ICSI (Intracytoplasmic Sperm Injection), an adjunct fertilization procedure widely used in the In Vitro Fertilization (IVF) process. We learned how IVF and ICSI has helped millions of couples overcome their infertility issues and discussed what is ICSI, when should ICSI be used, how safe is ICSI, and how ICSI is done (read our introductory article of ICSI here).

In this article, we will walk you through the whole procedure once again, but in more detail to help you understand, and better prepared, for your visit to our clinic. Can’t wait to start? Let’s begin.

A Short Recap: What is ICSI? How Is It Different from Standard IVF Fertilization?

In Vitro Fertilization (IVF) is an assisted reproductive technique used to help couples who cannot conceive through natural reproduction.

In standard IVF, a woman’s eggs and her partner’s sperm are retrieved and mixed together in a laboratory dish to achieve fertilization. Once fertilized, they are known as “embryos”, and are cultured for 5-6 days to become “blastocysts” before being transferred back into the woman’s uterus and hopefully develop into a baby.

The ICSI process follows all the same steps of standard IVF except when it comes to fertilization. Instead of letting a number of sperm combine with an egg in a laboratory dish, in ICSI a single washed and healthy sperm is selected, picked-up and then injected directly into a mature egg. Using a direct injection avoids problems with sperm impaired motility, cervix issues, etc., and results in a higher chance of successful fertilization in couples who had failed to conceive after using standard IVF or have severe infertility issues.

The Process of ICSI

1. Starting Phase

When: Whenever you can get an appointment

How long: 45 – 60 minutes

To begin the process, the female will have to undergo extensive fertility testing, including an examination of your uterus and fallopian tubes, a hormonal assessment, and any other tests that may be required.  In addition, the male will undertake a semen analysis. Having reviewed your test results, your doctor can better understand your health condition and can advise a treatment plan which is right for you.

At this point, you will also be informed about everything you need to know regarding your treatment cycle, including how to administer your daily hormone injections at home, and instructions about any other medications you may be prescribed for your ovarian stimulation.

2. Ovarian Stimulation Phase

When: Day 2 or 3 of your period 

How long: 10 – 12 days

Once you have had your fertility assessment and consult, have learned about your ICSI cycle, and have decided to undergo the ICSI procedure, you will begin the first step of the process, the Ovarian Stimulation Phase.  In this crucial stage, you will stimulate your ovaries to produce as many follicles, egg containing vesicles on your ovary, as possible by administering hormonal drugs starting on day 2 or day 3 of your period and daily for 9-12 days.

There are hundreds of thousands of ovarian follicles on your ovaries, each containing one oocyte (an immature egg). During your normal menstrual cycle, several of these follicles will start to grow and develop, with usually only one proceeding to produce a mature egg. The goal is to have all of the developing follicles proceed to having a mature egg, which can then be retrieved, and give you the highest chance of success

Throughout this phase, your doctor will monitor how your ovaries are responding to the hormonal medications. You will be asked to come into the clinic every few days during the 9 to 12 days of stimulation, for blood tests and ultrasounds. Using these results the doctor may modify your treatment plan and medications. Once the test results show that your eggs have fully matured, your doctor will administer the “trigger injection”, a hormone (usually either human chorionic gonadotropin; hCG, or leuprolide acetate; Lupron) to prepare the eggs for ovulation, allowing your eggs to be released from the wall of the follicles, so that the doctor can do the egg retrieval process.

3. Egg Retrieval and Semen Collection

When: 36 hours after the “trigger injection”

How long: 1 – 2 hours

36 hours after your trigger shot, your eggs will be retrieved through a minor surgical procedure to aspirate your follicles. The doctor will use ultrasound imaging to guide a thin needle through your pelvic cavity to remove or retrieve your eggs. The procedure will be done under general anesthesia to keep the process comfortable and painless. The whole process usually takes only 15-20 minutes.

On the same day that your eggs are being retrieved, your partner’s semen will also be collected. Usually, your physician will prefer your male partner to collect his semen fresh at the clinic, but if he cannot come to the clinic on that day, he may collect the semen sample on a day prior to the egg retrieval and have the washed sperm frozen.

Semen collection by masturbation is recommended to avoid contact with any bodily fluids from the male or the female partner (i.e., saliva, vaginal fluids). These fluids may contain bacteria which could contaminate the fertilization or culture media. After he collects his sample, the male partner will return the sample through a window to a specialist waiting in the Andrology Laboratory which is situated next to the collection room.

The collected semen will be left for about 30 minutes to liquefy, and then washed to remove debris, immobile sperm, and other substances in the semen, before being thoroughly examined for its quality in a process called semen analysis. This semen analysis is important as it will help your physician to best decide if your eggs and your partner’s sperm are to be fertilized by a standard fertilization IVF or an advanced fertilization ICSI method. If the semen sample is normal, the standard fertilization IVF is chosen.  But if the semen analysis results are lower than average, your physician may advise you to choose the second alternative fertilization ICSI technique, as it increases the chance of that fertilization will occur. 

For the IVF technique, the eggs and sperm are mixed together and allowed to fertilize on their own in a laboratory dish, whereas for ICSI technique, a single healthy sperm is specially selected and injected directly into a mature egg to achieve fertilization. ICSI normally takes a longer time and requires an experienced fertility scientist.

Once fertilization occurs, the fertilized eggs are considered as embryos.

4. ICSI Fertilization

1. When: after egg retrieval and semen collection

How long: 24 hours
If it is confirmed and agreed upon by both you and your doctor that ICSI is the best fertilization approach for your case, then, instead of allowing the eggs and sperm to fertilize on their own in a laboratory dish as in standard IVF, in ICSI, your embryologist will use a thin micropipette to specifically select a normal-shaped and fast-moving sperm, and inject that single healthy sperm directly into a selected mature egg. This will be repeated for each individual mature egg.  The next morning, your embryologist will check for signs of normal fertilization. Any normally fertilized eggs are considered embryos.

5. Embryo Culture

When: After fertilization 

How long: 5-6 days

After the eggs and sperm are fertilized and become embryos, they will be cultured in a special incubator for 5 – 6 days until they develop and grow to the blastocyst stage which will be ready to be transferred into and implant in the lining of your uterus. Embryos which cannot grow to blastocyst stage are considered not strong enough and incompetent and will not be transferred into your uterus. The embryo culture process is extremely sensitive and requires embryologists who are well-trained and experienced to manage environmental conditions and operate advanced technical equipment to maintain a stable environment within the laboratory so that the embryos can grow and develop properly. 

At Superior A.R.T., we use the Geri-Time-Lapse Incubator, the newest generation of time lapse incubator technology available, with a single high quality microscope camera system dedicated to each culture chamber, thus allowing detailed tracking of embryo development without the plate or the embryos having to move. Each chamber is independently controlled and monitored, providing individualized, optimal culture conditions. The use of mini incubators increased the pregnancy rates as embryos have more stable conditions in which to develop.

To learn more about our Blastocyst Culture Technology, click here.

6. Embryo Transfer

When: After the culture process

How long: 2 to 4 hours

Finally, your doctor and your embryologist will select one or more blastocysts to be transferred back into your uterus to grow and develop into a baby.

In this procedure, under ultrasound guidance, the experienced embryologist will load your selected blastocyst(s)into a small tube called a catheter, and your doctor will place that catheter through your cervix and into your uterus, then releasing the blastocyst in your uterine cavity wall (endometrium) so it can implant into the wall of the uterus and begin to develop and grow.

Approximately 7-10 days after your embryo transfer you can have a blood pregnancy test to find out if you are pregnant. To confirm your pregnancy, an ultrasound can be done around a further 2 weeks later.

7. Embryo Freezing

When: After the embryo transfer process

How long: 1 to 2 hours

Any good embryos excess to transfer requirements can be frozen using a process called Vitrification, a technique in which your embryos will be frozen ultra-rapidly, so that the water molecules don’t have time to form ice crystals, and then held in deep frozen storage. This results in a long-lasting, high-quality preservation of your embryos indefinitely, if held in a high-quality and well-maintained laboratory with consistent, regular quality control and monitoring of the amount of the liquid nitrogen and the integrity of the equipment.

These frozen embryos can be used at a later time if you wish to get pregnant again.
To learn more about our unique embryo freezing process, click here.

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