Intracytoplasmic sperm injection today: a personal review.

There no longer seem to be any categories of male factor infertility that cannot be treated with intracytoplasmic sperm injection (ICSI). Even for men with azoospermia caused either by obstruction or by germinal failure, ICSI may be performed successfully. The only failures will be in azoospermic men who have neither spermatozoa nor spermatids retrievable from the testis, but these men comprise a small percentage of the cases with severe male factor. The source of the spermatozoa and the cause of the sperm defect appear to have no effect on the success of the procedure, whether the spermatozoon is epididymal, fresh or frozen, testicular, ejaculated, or from the testicles of men with severe defects in spermatogenesis. Maturation arrest, Sertoli cell-only, cryptorchidism, chemotherapy and mumps do not appear to have a major impact on the pregnancy rate. Of all the factors studied in couples where the male is severely infertile or azoospermic, the only factor that seems to matter (as long as spermatozoa are retrieved) is the age of the wife and, to a considerably lesser extent, her ovarian reserve. Extensive genetic and paediatric follow-up studies of ICSI pregnancies have revealed no increased risk of congenital malformation (2.6%), no increased risk of de-novo autosomal abnormalities, and a 1.0% risk of sex chromosomal abnormalities. These results are very reassuring, but point to the need for careful counselling of couples with male infertility.