What is PICSI, how does it differ from ICSI, and does it raise pregnancy chances? ESHRE, Cochrane and HFEA assessments, risks and doctor questions.
PICSI (physiological ICSI) is an add-on laboratory practice in which, before microinjection, sperm are selected by their property of binding to a surface containing hyaluronic acid. According to a current assessment prepared for Europe, it is not recommended for routine clinical use; the update of a review has also shown no difference in live birth, or found the possibility of a very small increase. This result does not mean that the method does harm; it means that there is no basis for routine use. You decide together with your doctor whether it will be considered in your own situation.
Is PICSI a fertilisation method separate from ICSI?
In ICSI the embryologist selects a sperm cell and places it inside the egg. PICSI is not a separate fertilisation method; it is an extra step within ICSI concerning which sperm will be selected. Egg collection, embryo development and transfer continue in the same way as the flow in an ICSI cycle.
What does selecting sperm with hyaluronic acid aim at?
The assumption on which the method rests is this: sperm that bind to hyaluronic acid are more mature and have better DNA integrity. The aim is for selection to be made accordingly. The assessment text on this subject mentions studies reporting a relationship between low binding scores and weaker sperm quality; however, the value of binding for predicting fertilisation and pregnancy is limited. That is, although the mechanism looks logical, it has not been shown that this is reflected in the treatment outcome.
In which group of patients has PICSI been researched?
According to the regulator in the United Kingdom, PICSI has been researched only in ICSI done because of a male factor. No benefit has been shown in treatments without a male factor. For this reason, if PICSI has been recommended to a couple whose sperm results are normal, it is sensible to ask the reason.
Is PICSI necessary in every treatment?
The assessment on this subject mentions studies suggesting benefit in some subgroups, such as older women and men with abnormal sperm DNA damage. These studies are not strong enough to distinguish which group of patients would benefit. For this reason PICSI being considered is the preference of your doctor and of you rather than a proven necessity.
Does PICSI increase the chance of live birth and pregnancy?
The update of a review compared ICSI done with sperm selected with hyaluronic acid with standard ICSI. No difference in live birth was found, or the possibility of a very small increase was reported; the reliability of this evidence is low. No difference was seen in clinical pregnancy either. The regulator in the United Kingdom also reports that medium- or high-quality evidence has not shown a benefit in terms of live birth.
Does PICSI reduce the risk of miscarriage?
A decrease in miscarriage has been seen in some studies, and a current review also speaks of a possible decrease. However, the reliability of this finding is low. The regulator in the United Kingdom also emphasises that the findings on miscarriage are a secondary, not a primary, outcome and should therefore be regarded as less reliable. Consequently, to say "PICSI reduces miscarriage" would go beyond what the evidence available says.
Why is PICSI not recommended for routine use?
The current assessment on this subject recommends neither the hyaluronic acid binding test nor physiological ICSI for routine clinical use. The regulator in the United Kingdom, for its part, classifies PICSI in the lowest category in terms of live birth in ICSI with a male factor; this classification means that medium- or high-quality evidence has not shown a benefit. This classification does not mean that harm has been reported. A classification could not be made regarding reducing miscarriage in older women and was left uncertain. Different assessments meet at the same point: there is no basis to argue for routine use.
Which risks continue when PICSI is applied?
The selection is made on the semen sample in the laboratory; the regulator in the United Kingdom has not reported any additional health risk. The current assessment on this subject also states that no safety problem has been shown. On the other hand, this does not mean an assurance for every individual; the risks of ICSI itself, for example the possibility of the egg being damaged during the procedure, continue in a cycle with PICSI.
Could a separate fee be requested for PICSI?
Whether a separate charge is requested for this practice varies with the centre carrying out the treatment. For couples who bear the cost of treatment themselves, it is also possible to consider several standard cycles instead of a single cycle with an unproven add-on. The worry "if I do not have it done, my chance will fall" is very natural; knowing the limits of the evidence can help you weigh this worry.
Are PICSI, IMSI, MACS and embryo glue the same thing?
No. IMSI looks at the shape of the sperm under high magnification, MACS rests on separating sperm thought to be damaged, and PICSI uses binding to hyaluronic acid. The evidence for each of the three is assessed separately, and the state of one cannot be transferred to the others. The medium containing hyaluronic acid used during embryo transfer, mostly called "embryo glue", is not related to sperm selection; it is at a stage after fertilisation, and the current assessment on this subject places it in the "recommended" category. It should not be thought that PICSI is in the same category. PICSI selects sperm; it does not test the genetic structure of the embryo.
What questions can you ask your doctor?
- What is the finding in my sperm results that brings PICSI up?
- What do you expect this practice to change in my situation?
- Is anything left missing in my plan if it is not done?
- Is there a separate charge, and if so what does it cover?
- How does this step appear in the information and consent document?
Frequently Asked Questions
Does it work in a man with sperm DNA damage?
The current assessment on this subject does not recommend the routine use of the sperm DNA damage test, and the predictive value of the test is uncertain. Because there is no independent study of sufficient size, it cannot be said that PICSI removes DNA damage or is the solution.
What does this review say about other sperm selection methods?
The update of the same review finds the results even more uncertain for methods other than hyaluronic acid; in most of these comparisons no effect could be shown. The authors do not see evidence that would take any advanced selection technique into routine use.
Could the evidence change in the future?
Yes, it could. The researchers state that better-quality studies are needed before routine recommendations are given, and report that there are ongoing studies that have not yet concluded. Today's assessments therefore reflect not a final word but the level of knowledge on a particular date; it is sensible to talk about the current situation with your doctor.
If PICSI is not done, is ICSI applied incompletely?
No. PICSI is not a separate fertilisation method; it is a step added to the sperm selection stage of ICSI. You can ask your doctor the reasoning for the recommendation in your situation.
Does the binding of sperm to hyaluronic acid predict pregnancy for certain?
No. The value of binding for predicting fertilisation and pregnancy is limited. It has not been shown that the assumption on which the method rests is reflected in the treatment outcome.
Is PICSI necessarily needed if the sperm results are normal?
No. PICSI has been researched only in ICSI done because of a male factor. Because no benefit has been shown in treatments without a male factor, you can ask the reason for its being recommended to you.
Does PICSI definitely increase the likelihood of live birth?
No. In the review update, no difference was found, or the possibility of a very small increase was reported; the reliability of the evidence is low. Medium- or high-quality evidence has not shown a benefit either.
Do the studies reporting a decrease in miscarriage give a definite result?
No. The reliability of this finding is low. In addition, the fact that the findings on miscarriage are a secondary outcome means they need to be interpreted more cautiously.
Does not being recommended routinely mean PICSI is harmful?
No. The absence of a basis for routine use does not mean that harm has been reported. That no safety problem has been shown is not an assurance for every individual either.
Does PICSI remove the risk of the egg being damaged during the procedure?
No. The risks of ICSI itself continue in a cycle with PICSI too; the possibility of the egg being damaged during the procedure is one of them.
Does PICSI test the genetic structure of the embryo?
No. PICSI selects sperm. It is not a test that assesses the genetic structure of the embryo.
Are PICSI and embryo glue the same practice?
No. PICSI is used in sperm selection. The transfer medium containing hyaluronic acid relates to the stage after fertilisation and is assessed differently; the recommendation category of one cannot be transferred to the other.
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