The ethics of ICSI – Intra Cytoplasmic Sperm Injection

ICSI for unexplained infertility

I felt pretty well versed and comfortable in the ethical debate behind IVF, well, so I thought until we came across ICSI.  Intra-Cytoplasmic Sperm Injection (ICSI) was recommended by our doctor because we have been diagnosed with unexplained infertility.  She explained that this procedure is worth trying because in our case of unexplained infertility there could be a chance that there may be something in the fluid surrounding my eggs preventing fertilisation.  ICSI overcomes this potential problem by injecting a sperm directly into the egg, avoiding the fluid.  It is important to note that with unexplained infertility there could be many other reasons unknown to us why we have not been able to get pregnant yet; we just can’t pinpoint the exact cause at this moment.  By performing ICSI (for a few thousand dollars more) it slightly increases our chances of success.  I have been looking into the evidence behind unexplained infertility and ICSI and the jury is out on whether it is worth while or not.  Despite the mixed reports on the internet, I trust our doctor, and as our fertility clinic is attached to a medical school I like to think that they are up to date on these things.

I hadn’t thought much about ICSI previously because Chris’s sperm is pretty good, I didn’t think it was on the table.  So I hadn’t read much about the procedure.  As I began to read up on the procedure, I started to think more about the ethics and morality of it.  Selecting the ‘best looking sperm’…is it any different to selecting the ‘best looking egg or embryo’ as would be the case for normal IVF?  And so I decided to look into it a bit more to understand what ICSI really is, and the considerations for and against this artificial reproductive technology procedure.

This post is just me putting ideas out there and exploring the issues, I do not necessarily agree with everything written here.  I may have been unintentionally selective or biased in some of my arguments, there are probably many more arguments for and against ICSI, so please feel free to comment and add at the bottom of my post.

What is ICSI?

ICSI – Intra Cytoplasmic Sperm Injection is an in-vitro fertilisation procedure that has been in use since 1992.  Fertilisation is achived by the direct injection of a single sperm into the cytoplasm of the egg.  The sperm can be extracted from fresh or frozen ejaculate, as well as being extracted directly from the testes (yikes, sorry guys, doesn’t sound fun at all).  The egg is prepared to facilitate penetration of the sperm.  The preparation of the egg includes enzymatic treatment and micro dissection of the cells which surround the egg.  Injecting the sperm bypasses the normal interaction it would have with the egg upon first encounter.  The deliberate selection of sperm for the procedure involves an assessment of selection criteria including: size, form and mobility of the sperm.  Despite the selection criteria, there is no guarantee that the sperm is actually ‘normal’ and therefore, there is no guarantee that fertilisation will occur.  It is even possible to select X or Y sperm to select gender, but only few fertility clinics offer gender selection for when it is necessary to avoid a known genetic disorder being passed.  I have also read about some fertility clinics offering gender selection if the family has one child already, and they want to ‘complete the family’ by selecting the opposite gender of its sibling.  This totally blows my mind.  After the sperm is injected into the egg, the egg is placed in an incubator and checked the next day for fertilisation.  If fertilisation is successful, the embryo is left for 2 or 3 days and then a decision is made whether to transfer the embryos back into the woman’s uterus for the next stage implantation.

Statistically speaking, there is evidence that ICSI slightly increases the pregnancy rate (but not statistically significant) compared to normal IVF.  The spontaneous abortion rate with ICSI is slightly lower, but this maybe as a result of the younger age of the mothers and the absence of female-related infertility.  The frequency of multiples is about the same (probably because the policies for number of embryos transferred remains the same).  The statistics for randomised trials of normal IVF v ICSI show that there is no significant difference.  Some researchers suggest that ICSI should only be reserved for the use of severe male factor infertility.  However, the use of ICSI is on the rise and becoming the new normal as infertility clinics like to reduce the risk of failure for the patient.  I can understand why that little extra % chance all adds up.

Ethical and moral considerations of ICSI – the arguments pro and against.

All ethical debates relating to IVF still apply to ICSI.  But ICSI may be considered effectively as a further layer of ethical debate  because we are potentially further ‘messing with nature’ by selecting one single sperm.  Often Pre-Implantation Genetic Diagnosis (PGD) will be part of ICSI, where there is a screening of cells of pre-implantation embryos for the detection of chromosonal disorders before an embryo transfer.  We are not doing PGD.  This can also add a further level for debate.

I will start with what I have found regarding the pros of ICSI, and other Artificial Reproductive technologies, followed by the against arguments…

Pro ICSI: The right to procreate.  To want a child is probably the most legitimate need in the world.  The right to found a family is one of the most important human rights as declared in the Universal Declaration of Human Rights (948, Article 16.1)  ICSI enables and supports this right.

Pro ICSI : Genetically related offsping. Before ICSI was possible, couples with male infertility would likely have resorted to donor sperm, or due to religious or personal beliefs would have rejected the use of a donor and remain childless.  With ICSI, it is possible for couples to have a child that is genetically related to them that previously was not possible.

Pro ICSI: Reducing the risks to the couple. If natural IVF was chosen over ICSI the woman may be unnecessarily putting herself at increased risk, physically and mentally for both partners.  For instance, if natural IVF were to fail first time round, ICSI may have prevented failure.  There are no guarantees, but as a couple puts themselves through multiple rounds of IVF, the physical and mental stresses increase, including the financial burden.

Against ICSI: The risks to the child itself.  There is much debate about the use of ICSI in male infertility and associated genetic abnormalities.  Chris does not have male infertility, so the risk of genetic abnormality is supposedly lower.  But the case for natural selection is negated with ICSI, there is no competition as would be with natural fertilisation, the chosen sperm may be a factor in genetic malformation.  There is also a risk of choosing a sperm that is immature and may interfere with the process of genetic imprinting and could result in growth retardation and functional disorders.  However, there has been little evidence to support these concerns.  Having said there is little evidence, ICSI has been around only since 1992, so children born from ICSI have not reached far into their adulthood and so studies are limited on the long term health related issues of ICSI born children.  Not to say the least, that the long term generation effects of ICSI on the population overall are not well understood and are only theorised.  For example, will infertility be passed? In itself, will ICSI simply contribute to further medicalising in the future?

Against ICSI: Multiple Embryos.  With IVF, to give a couple the best chance for a pregnancy multiple embryos are produced, grown, and then implanted into the uterus.  Some embryos may be discarded if they aren’t of good enough quality to present a healthy chance of pregnancy.  ICSI increases the likelihood for the generation of surplus embryos.  For some people, each embryo represents a life and so the disposal of embyros is considered in the same light as abortion.

I found one eloquent and well articulated argument that explains why some people are against multiple embryos “Where doubt exists on the level of fact, the integrity of conscience requires that the presumption be in favour of the life.  There is a classic example, if a hunter hears a rustling noise in the bushes, and is unsure whether it is a deer or another human being, he must assume it is a human being until such time as he can establish that it is not.  Similarly we may accept the argument that there is scientific uncertainty as to the precise moment when an individual human life begins.  That uncertainty, however, does not remove the obligation of care and respect for what certainly has the potential to become, and may already be, a distinct human individual.”

Against ICSI: Human Error. I have read about people worried about sperm/eggs getting mixed up in the laboratories.  We learned that sperm is dyed a certain colour for each patient so there is no confusion – this was why Chris’s sperm was purple!!  But to err is human after all and so are we potentially increasing the risk for a morally complex problem?

Chris's purple sperm

Chris’s purple sperm

Partial ICSI – overcoming some of the issues at hand?  Partial ICSI is where some of the eggs are left to fertilise ‘naturally’ in the petri dish as with normal IVF, and the rest of the eggs are injected with individually selected sperm as ‘back up insurance’, just in case normal fertilisation does not occur naturally.

There are many different valid and understandable viewpoints about assisted reproductive technologies like IVF and ICSI.  I am the type of person who respects others’ viewpoints and tries to understand as much as possible all sides of an argument.  I am an analyst by profession so I like to think I am good at that.  We have decided to do IVF and ICSI knowing these issues.  I just hope that others can equally respect our decision for IVF and ICSI.  But I now feel suitably versed to think about some of the important ethical and moral issues surrounding these artificial reproductive technologies.

Other notes and interesting references

On a side note, I found an interesting statement as I was researching that I wanted to share with you, it is about IVF and women’s rights in general.  Mary Anne Warren, (a philosophy professor who wrote a lot about abortion and criteria for personhood) wrote:

“If women’s right to reproductive autonomy means anything, it must mean that we are entitled to take some risks with our physical and psychological health, in the attempt to either have or not have children.  Neither abortion nor many forms of contraception are entirely safe, but women sometimes reasonably judge that the alternatives are even less desirable.  Having a wanted child can be as important a goal as avoiding an unwanted birth.”

Other references which discuss some of the more interesting medical facts than I am not willing to describe in my blog as I am not a medical professional or just interesting…

Potential Health Risks Associated to ICSI: Insights from Animal Models and Strategies for a safe procedure, Front Public Health. 2014. 2: 241.  Accessible here:

Ethics of Intracytoplasmic Sperm Injection: proceed with care, Wert, G.M., Human reproduction, 1998 vol 13 (1)  Accessible here:

Dealing with uncertainties: ethics of prenatal diagnosis and preimplantation genetic diagnosis to prevent mitochondrial disorders, Human reproduction update,  2008, vol 14 (1), Accessible here:

Ethical issues in Assisted Reproductive Technologies, a presentation by Effy Vayena:

Ethical issues arising from the use of Assisted Reproductive Technologies, Dickens, B.M., Accessible here:

The $$$ lowdown

I have created a new page on my site that sums up all the costs of our infertility journey so far.  I will keep this up to date as much as possible…I have copied the text from it and pasted it below (or here is the link to the page)

We are very lucky that our medical insurance includes coverage for the treatment of infertility, including IUI and IVF.

We are being open and honest about these costs because it is important for people to understand the difference having insurance coverage can make.  Only 15 states in the US make it mandatory for insurance providers to cover infertility treatment, and even some of those are extremely limited.  There is much debate on whether infertility should be covered as an essential health benefit.  There are many campaigns ongoing to change state law in this regard (

There is definitely a lot to be said about the psychology and stress to infertile couples over spending this vast amount of money if they do not have insurance coverage for infertility.  Chris and I find this process stressful enough as it is without the added burden of the actual cost.  I cannot even begin to imagine what it would be like without coverage.  At each stage of our journey we have had to get approval from our insurance company and with having an ‘unexplained’ diagnosis we have always been nervous that they will not cover us.  However, we have been fortunate so far. Fingers crossed they will cover our IVF too.

Item Full cost Insurance covered? Final cost to us
Ovulation Kit (pack of 20) x3 $70.00 No $70.00
Pregnancy Tests (various types) x4 $85.00 No $85.00
Basal Thermometer x1 $13.00 No $13.00
Pre-seed Lubricant x1 $24.00 No $24.00
Chris blood tests $572.00 Yes $10.25
Dani blood tests $560.00 Yes $14.43
Reproductive Endocrinologist Consulting Fees (Doctor visits) x3 $340.00 Yes $5.85
Ultrasounds x4 $900.00 Yes $71.72
Anti-biotics for HSG $15.97 Yes $1.60
Sperm Analysis $110.00 Yes $1.53
HSG $835.00 Yes $29.18
Letrozole x3 $8.53 Yes $0.86
Ovidrel x3 $371.16 Yes $37.11
IUI x3 $765.00 Yes $36.81
Sperm Wash x3 $320.00 Yes $16.80
Progesterone suppositories x3 $147.00 No $147.00
Running Total* $5,136.66   $565.14

A note about our healthcare insurance.  We pay a 10% co-pay for each bill of the ‘in-network’ cost, not necessarily 10% of the whole cost.  Our current infertility clinic (or ‘provider’ as it is also called) is ‘in-network’ so we get extremely preferable rates; for example our new doctor visit it was $190.00, our insurance paid $0, so we paid $0.  This is because our insurance company has negotiated these types of ‘bulk’ discounts in advance with our provider.

Choosing an ‘out of network’ provider can increase overall costs.  There is one other fertility clinic in our area we could have chosen, but is out of network.  It was something we considered, but we went on recommendation and did not think too much about this at the beginning.

Currently my insurance premium is ~$500 a month, plus my employer contributes ~$1100 a month, this covers both Chris and I for all medical expenses including dental and optical.

*As of 10th May 2015