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ICSI: How IVF Tackles Male Infertility

Jessica Joseph, RN, BSN, MHA
May 10, 2023
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Men who have infertility often face a devastating reality. Especially if their partner is diagnosed with unexplained infertility, meaning all her fertility testing came back normal. Usually, this means a woman may have to undergo IVF, involving hormone injections, anesthesia, and the surgical procedure of egg retrieval because her partner’s sperm parameters are abnormal.  Couples, before proceeding with IVF, may elect to explore what can be done to improve sperm parameters. Attempting to improve sperm parameters may enhance the chances of fertilization with IVF or natural conception.  In the case of IVF, intracytoplasmic sperm injection (ICSI) will further enhance fertilization rates, embryo implantation, successful pregnancy, and chances of live birth.


Causes of Male Infertility


Consultation with a reproductive urologist can help determine the underlying cause of abnormal sperm parameters and see if treatment can be done before undergoing IVF.  A reproductive urologist will perform a comprehensive intake that includes blood work, semen analysis, ultrasounds, genetic screening, and a medical history review.  A thorough medical history includes past surgeries, existing allergies, current medications, and chronic illness diagnoses.  


Underlying causes of male factor fertility can be due to:

  • Hormonal issues based on abnormal levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin. Hormone imbalance results in a decrease in sperm production.

  • Chromosomal issues or genetic problems, such as Klinefelter Syndrome, which can lead to male infertility.

  • Anatomical issues such as a varicocele, which is a dilated vein in the scrotum, that can prevent sperm production, movement, and transport.


Once a reproductive urologist establishes a root cause, a treatment plan (if possible) can be utilized before IVF treatment or natural conception.


Sperm Parameters

Male-related infertility is diagnosed when sperm parameters are within an abnormal range.  The three factors that play a role are sperm concentration, motility, and morphology.



The quantity of sperm is measured in two ways:

  1. The concentration, which is how much sperm is in one millimeter of semen

  2.  Sperm count, which is the total number of sperm in one sample  


According to the World Health Organization (WHO), the normal sperm concentration should be 15 million sperm per one milliliter of semen.  The reason why a high count is required is that statistically speaking, out of a million sperm, only one single sperm has a chance of reaching the egg for fertilization.



Sperm motility measures if the sperm can move adequately to reach the egg for fertilization in the woman’s reproductive tract. Andrologists (scientists who prepare and analyze sperm in a lab) consider 40% of motile sperm a good sample, and at least 32% need progressive motility, meaning moving in straight lines and large circles.



Morphology indicates the shape of the sperm.  Andrologists consider sperm normally shaped when it has an oval-shaped head, a midpiece commonly called the neck, and a long tail. However, most sperm are abnormally shaped, so a semen sample with 4% or higher normally shaped sperm is considered a good specimen.


Advanced Testing

Some labs can now test to ensure the sperm is genetically healthy.  This involves ruling out DNA sperm fragmentation, which is when the genetic material contained in the sperm is considered abnormal due to DNA damage.  Testing for DNA sperm fragmentation involves mailing the semen sample to an outside lab for evaluation.

DNA sperm fragmentation is caused by oxidative stress that can occur from:


  • Smoking cigarettes

  • Being exposed to endocrine-disrupting chemicals (EDCs)

  • Poor nutrition

  • Excessive alcohol intake

  • Certain medical conditions, such as diabetes, cancer, and obesity

  • Anatomical issues such as varicocele (enlarged veins in the testicles)


According to Fertility and Sterility, the ASRM guidelines indicate that DNA sperm fragmentation does not need to be done with an initial male fertility evaluation. However, this advanced testing may prove helpful in the following scenarios:


  • Normal semen analysis and unexplained infertility

  • Multiple failed IVF cycles

  • Repeated miscarriages



IVF can still be successful, even when men have abnormal sperm parameters if ICSI is performed. ICSI involves micromanipulation by an embryologist, which consists of isolating a single sperm and injecting it into the egg’s cytoplasm in the embryology lab. Based on ASRM data, ICSI procedures result in higher fertilization rates.


ICSI is generally indicated to overcome abnormal sperm parameters, including:

  • Azoospermia-low sperm count (less than 15 million)

  • Poor sperm morphology (less than 4% Krueger strict)

  • Poor sperm motility (less than 40% motile sperm)


ICSI is also indicated for people using:

  • Frozen eggs

  • Donor eggs

Men trying to conceive for four to five months or over the age of thirty can consider sperm testing at home along with men’s fertility supplements.   Lifestyle factors also play a crucial role in sperm health. If conservative interventions and lifestyle modifications have not helped, a reproductive urologist consult can also be done to ensure no underlying issues.



Babakhanzadeh E, Nazari M, Ghasemifar S, Khodadadian A. Some of the Factors Involved in Male Infertility: A Prospective Review. Int J Gen Med. 2020 Feb 5;13:29-41. doi: 10.2147/IJGM.S241099. PMID: 32104049; PMCID: PMC7008178.


Cooper  TG, Noonan  E, Von Eckardstein  S, Auger J, Baker HWG, Behre  HM, Haugen TB, Kruger T, Wang  C,  Mbizvo MT, Vogelsong KM. World Health Organization reference values for human semen characteristics, Human Reproduction Update, Volume 16, Issue 3, May-June 2010, Pages 231–245,



Xie P., Cheung S., Kocur, O.M. , Rosenwaks, Z., Palermo, G.D., Sperm DNA fragmentation: What have we learned so far? Fertility and Sterility. December 2021. 116 (6) 1491. doi: 10.1016/j.fertnstert.2021.09.029

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