International Journal of Clinical Obstetrics and Gynaecology

Aim: The aim of this study was to assess the option of recue ICSI in cases of Fertilisation Failure (FF) in order to salvage the IVF ET.

Material and Methods: This retrospective study was done in a tertiary care Assisted reproductive techniques centre of Armed Forces. Records were assessed to study the cases of fertilization failure. All those cases which had an obvious etiology for probable FF were excluded. Remaining cases where rescue ICSI was done were studied to assess its role.

Study design: Retrospective Observational study

Study location: A tertiary care ART centre in Armed Forces Hospitals

Study duration: Dec 2018 to Dec 2020

Subjects and selection method: All couples going IVF ET for various etiologies were studied for fertilization failure. Only cases with unexplained FF were studied to assess the role of rescue ICSI. Inclusion criteria

1. Normal BMI (in the range of 18.5 to 24.5 kg/m2)

2. Normal ovarian reserves (AMH above 1.0 ng/ml)

3. Conventional IVF used for fertilization

1. Male factor infertility

2. Prior fertilisation failures

3. Advanced maternal/paternal age (Below 40 yrs)

Procedure methodology: Records of all patients meeting the inclusion and exclusion criteria were studied

Stimulation protocol: Antagonist protocol was used universally for stimulation in our centre. Patients were started on Inj Recombinant Follitropin Alpha (Merck Pharmaceuticals) 1050 IU/1.75 ml powder with solvent for stimulation. Personalised Stimulation protocol was started based on Age, BMI, Ovarian volume, AMH and previous stimulation data if any. Inj Ovurelix containing Citrorelix 0.25 mg from Sun Pharmaceuticals was started as antagonist on evidence of sufficient endogenous Estrogen production. Namely ultrasounds follow up showing follicular size reaching 12mm or endometrial thickness more than 6mm. On adequate stimulation with a cohort of at least 4 follicles of size 18mm, trigger was given with inj Ovitrelle 250 mcg (Contains Recombinant Choriogonadotropin Alpha,250 mcg, Merck Ltd)) and ovum pickup was done after 36-40h. Conventional Insemination was done only if post wash specimen shows a sperm concentration of more than 20 million/ml with more than 50% grade 4 motility. After denudation metaphase 2 mature oocyte without two Pronuclei stage were reassessed after 2h to rule out delayed fertilization. Those m2 oocytes which failed to fertilize were provided rescue. ICSI was done using micromanipulation disposable Injecting and holding needles from Vitromed, with bend angle of 30 degree. The holding needle had an inner diameter of 20 micro meters and injecting needle had an inner diameter of 5 micrometer. The freshly prepared semen sample was taken in PVP media under oil overlay and ICSI performed in the standard way.

Results: The incidence of fertilization failure in our clientele was about 11%. Out of 415 cases, 45 patients had complete fertilization failure. Patients meeting our inclusion and exclusion criteria for FF were 23 cases. Most common cause of FF was unexplained infertility with mean duration of marriage as 9y 7mo.Overall 15% cases were due to poor ovarian reserve and with poor yield on OPU. Male factor infertility in spite of ICSI failed to fertilize in 6 cases. We obtained a fertilization rate of 41% with rescue ICSI and on further growth 56% reached 4 cell stages. Off these 21 had minimal fragmentation. Those embryos which had minimal fragmentation and equal blastomere were allowed to grow and 6 of 73 fertilized oocyte reached 8 cell stage.

Conclusion The emergency rescue ICSI, in window of 18-20 hours can help salvage a cycle faced with complete fertilisation failure. It will reduce the physical and financial burden of IVF ET cycle to some extent. We conclude it is a viable option in a perplexing situation of complete fertilisation failure