Fertilisation Rate Archives - Fertility Fact Checker

How environmental toxins can impact your IVF cycle

It seems we can’t avoid environmental toxins. Being aware of this and where possible reducing your exposure is one step you can take to improve the chances of creating your little family.

You’ve modified your diet, significantly cut down on alcohol and well, smoking was never your thing anyway. The next thing you might be wondering is about toxins and the potential impact that has on egg and sperm quality and the little embryo about to implant. If you believe the news environmental toxins are EVERYWHERE but do they really matter or is it yet another, hippie fad?

Call them toxins, environmental contaminants, chemical contaminants or environmental toxicants, the synthetic chemicals that we come across in our daily living seem to be linked more and more to declining fertility in ‘normal’ populations and poorer outcomes in the IVF world. These chemicals have been linked to all sorts of conditions including cancers, neurological conditions and even mental health conditions. For the purposes of your upcoming IVF cycle we are most concerned with link to a decline in fertility and poorer IVF outcomes.

Endocrine Disruptors Explained

Environmental contaminants are often referred to as being ‘endocrine disruptors’ as they can interfere with the bodies endocrine, or hormone, system and more specifically in this instance with estrogen. The chemicals do this by either mimicking how estrogen works, blocking its use or simply just interfering with the way it is made or controlled (National Institute of Environmental Health Sciences). Regardless of the exact mechanism, they are preventing the normal functioning of our endocrine system from happening and this has the potential to adversely impact on our fertility and IVF success.

Endocrine disrupting contaminants are in many different substances (both natural and man-made) with some of the main ones being certain pharmaceuticals, dioxin and dioxin-like compounds, DDT and other pesticides, and plasticizers such as bisphenol A and phthalates.

Endocrine disruptors have been given a bit of attention recently and are thought to be so important as they can travel vast distances both through air and up the food chain (1) meaning that their impact can be wide reaching. The two ‘plasticizers’ have particularly been topical recently and are further discussed here (though pesticides and other contaminants are also of importance and should be reduced where possible).

Ive heard of it… but what is BPA?

Bisphenol A, or BPA, is a substance that was primarily used in the manufacturing of plastics (which is why it is called a ‘plasticizer’. It is still often used in the lining of tin cans and in some plastic drink bottles and is even used on the coating of til receipts that is then absorbed through our skin when handling the receipt (2).

There have been small studies that have been conducted analyzing the levels of BPA in the blood of women undergoing IVF and it has been found that the higher the levels of BPA the lower the fertilization rates (3). Other studies have also shown that for women doing IVF, those with higher levels of BPA in their blood had lower numbers of eggs, less mature eggs and lower rates of fertilization (2).

Now there are two things to be mindful of when getting your morning coffee – too much caffeine AND BPA from the cash register receipt!

BPA is found in many plastic containers and coatings and although the studies are small, at times contradictory and inconclusive, where possible it does seem like it is beneficial to limit the amount of BPA that you come into contact with (despite studies from the United States Food and Drug Administration saying that the level of BPA that is absorbed in day to day activities is within safe limits). This would include looking out for BPA free plastic containers (preferably glass containers because who knows what they are replacing the BPA with in other plastics), being mindful of which brands of tinned food that you eat (as BPA is often in the coating) and avoiding drinking water from plastic bottles. Oh and if you work in retail try and reduce the amount of receipt handling you do – just to be safe.

…and phthalates?

Phthalates are a group of chemicals that are used to make plastics more flexible and harder to break (Center for Disease Control; CDC). They are also used to in anything that is fragranced which is why they are found in many personal care products including perfumes, soaps, deodorants, hair sprays and even nail polishes! This is together with the hundreds of products including flooring, adhesives, detergents, lubricating oils, automotive plastics, plastic clothes such as raincoats and sometimes children’s toys, plastic packaging and medical tubing. It seems, phthalates are everywhere!

Similarly to BPA we can ingest phthalates by, for example, eating food that has been in contact with the plastic containers it has been heated in or particularly in the case of cosmetics and personal items, absorbing them through our skin. You can even breathe in phthalates. Once the phthalates are in our body, they are metabolised into metabolites are are then excreted in urine.

Reduce your exposure to phthalates by only using phthalate free makeup and toiletries.

It is by analyzing the metabolites in our urine that researchers are able to quantify how much phthalates a person has been exposed to and make comparisons to various outcomes, such as, the success of an IVF cycle. Before we look at IVF specifically, there is a significant body of research that has been done in animals implicating phthalates with poorer reproductive outcomes and also linking phthalates to an increase in oxidative stress in our body (particularly researched in men and pregnant women).

From what I have seen though, whilst it seems increasingly undeniable that the influence of phthalates negatively impacts our IVF cycles the hard human evidence demonstrating its impact in women is still coming. However, a study in 2016 (4) reported that when analyzing the metabolites found in the urine of women undergoing IVF the higher the amounts of metabolite DEHP and DiDP found, the lower the number of eggs produced and number of mature eggs produced. Additionally, an increased presence of the metabolites DiNP and DiDP were associated with lower fertilization rates. This ultimately led the researchers to conclude that higher levels of DEHP ultimately led to lower clinical pregnancy and live birth rates.

Whilst having high amounts of phthalates in your blood (and urine) isn’t going to be the only factor to make or break your cycle, or even be the major factor, it may be at the very least a significant risk factor and is certainly worth reducing your exposure where possible.

It should be noted though that not all studies support this. For example in 2017 a paper was published (5) that indicated that male, but not female, urinary concentrations of phthalates influenced blastocyst quality and another study reported that even though metabolite MEHP and MBP where found in follicular fluid and urine of females doing IVF these were not associated with the usual IVF outcomes (which may include things like egg quality, number, fertilization rates etc).

As we have already stated though, regardless of the evidence being somewhat inconclusive, there does seem to be enough evidence to suggest that it is worthwhile reducing your exposure to endocrine disruptors as much as possible.

So, how do we do this?

Throw out the plastic storage containers in your house and investing in either glass or stainless steel. Watch out for plastic recycling codes 3, 6 and 7 as these may contain endocrine disruptors. Particularly avoid reheating your food in plastics as when the plastic is heated the integrity of the plastic is changed making it easier for the transfer of phthalates to your food.
Try not to use cling film and other products to wrap your food in. Paper bags for sandwiches may seem like a throwback to the fifties but its at least worth a try. So is aluminum foil.
Use ‘natural’ cosmetics products available such as those from Nourished Life (this is an Australian website but there are others in the US). Or if this proves to be cost prohibitive looking for products that are ‘phthalate free’ (and their derivatives). This can be tricky and they can hide so it pays to do your research as sometimes the name can be somewhat ‘hidden’. Remember products that have added fragrances nearly always contain phthalates so looking for ‘fragrance free’ is worth a try also.
Beware of the scented candle! They may also be a source of phthalates.
Reducing chemical cleaners in your home. I have recently started using ‘Enjo’ and although expensive and at times does take a little more work the benefits of not having harsh chemical cleaners make it worthwhile.
Try eating organic. Non organic vegetables can often contain residue pesticides which although not directly discussed here can also be endocrine disruptors. Additionally, non organic meat can contain remnants of hormones and antibiotics given to the animals which then passes up the food chain to us.
Limit handling til receipts!
Stick as much as possible to unprocessed foods and avoid canned foods (unless you know that the lining of tins are BPA free).
Being aware of the environment you are in. For example, trying to avoid places where you know lots of air freshener or scented candles are used or if you have laid new carpet, for example, ensure it has been aired out as much as possible before you move back in.

For more practical ways to reduce your exposure to chemicals to increase your chances of IVF success, have a look at Eat Think Grow.

The bottom line

Although the evidence to say that phthalates negatively influences IVF outcomes is not yet conclusive, there does seem to be a growing body of evidence to say that they are very likely to have at least some impact. Although it will be near impossible to ever completely eliminate your exposure to phthalates, BPA and other environmental toxins, given that your IVF cycle is potentially the most important thing to ever happen to you and you want to do all you can to support its success it wouldn’t hurt to eliminate reduce your exposure as much as possible whilst still living life. This includes eating organic, reducing use of nail polish hair spray and especially fragranced cosmetics and minimising food that has been inside plastic (especially plastic that has been heated such as in a microwave) containers. You know, while living in the 21^st century, juggling work and ultrasound appointments.

References

Younglai, E, Holloway, A, Foster, W. (2005). Environmental and occupational factors affecting fertility and IVF success. Human Reproduction Update, 11 (1) 43–57, doi:10.1093/humupd/dmh055
Ehrlich, S., Williams, P., Missmer, S., Flaws, J., Ye, X., Calafat, A., Petrozza, J., Wright, D. and Hauser, R. (2012). Urinary bisphenol A concentrations and early reproductive health outcomes among women undergoing IVF. Human Reproduction 27 (12) 3583–3592.
Fujimoto, V., Kim, D., vom Saal, F., Lamb, J., Taylor, J. & Bloom, M. (2011) Serum unconjugated bisphenol A concentrations in women may adversely influence oocyte quality during in vitro fertilization. Fertility and Sterility 95 (5) 1816 – 1819
Hauser, R., Gaskins, A,, Souter, I., Smith, K., Dodge, L., Ehrlich, S., Meeker, J., Calafat, A. and Williams, P. for the EARTH Study Team (2016). Urinary Phthalate Metabolite Concentrations and Reproductive Outcomes among Women Undergoing in Vitro Fertilization: Results from the EARTH Study. Environmental Health Perspectives 124 (6) 831- 839.
Wu, H., Ashcraft, L., Whitcomb B., Rahil, T., Tougias, E., Sites, C. and Pilsner, J. (2017). Parental contributions to early embryo development: influences of urinary phthalate and phthalate alternatives among couples undergoing IVF treatment. Human Reproduction 32 (1) 65- 73.

A spoonful of sugar… not exactly ‘delightful’ for IVF success

We have heard many, many times about the disastrous effects of sugar on our natural fertility. ‘Disastrous’ sounds quite dramatic, but it is the current bad thing in nutrition circles right? Sarah Wilson, ‘I Quit Sugar’ author, Pete Evans, general paleo champion and a whole host of trainer-slash-tv-show-celebrities will be back me up here.

And it seems rightfully so.

For natural fertility, sugar is frequently cited as being responsible for increasing inflammation (especially in women with endometriosis), altering hormone levels such as progesterone, estrogen and androgens and increasing insulin resistance which has its own collection of negative consequences.

Want 19 evidence based ways to improve YOUR IVF cycle? Click Here.

Not exactly helping the medicine that's going down. — **Not helping the medicine that’s going down.**

But what about the impact of sugar on IVF success? Unsurprisingly there is only an incredibly limited number of randomized control trials looking at the impact of sugar on IVF success rates. Is that because it’s generally understood that of course sugar negatively impacts IVF? If so, why isn’t that information fed to us (pardon the pun) in the fertility clinics in a very clear way? Or is it because there are no funding bodies willing to pay for such a trial? Or perhaps it’s thought to play very little of a role at all. Regardless of the reason the outcome is still the same. More evidence is needed.

For those of you who have read my free ebook (and those of you who haven’t, why not? Did I mention it was free?) you will know that I am a big believer that despite all the medications, medical procedures and laboratory techniques that IVF utilizes as ‘patients’ we are still active in that process. That is despite the fact that your body is about to be highjacked by all sorts of medications you still have control over what you eat, drink and the way you live your life.

That is NOT to say that if we have a bad cycle with skyrocketing estrogen, 50 antral follicles developing and only one lead follicle that eating the right food is going to save the day, but in a more moderate situation modifying diet and lifestyle factors have been shown to have a significant impact on IVF success rates (1). As we know Lady Luck also has her hand to play in the IVF cycle – so perhaps modifying those lifestyle factors can be considered a bit like buying extra lines in the lottery rather than just the standard ticket.

Its not just monkey business

So back to sugar and IVF.

It wasn't a winner. And I don't know why I had a lotto ticket from 2009 in my purse. — Removing some of the ‘luck’ from an IVF cycle.

Like I said, there is insufficient information examining the exact impact of sugar on IVF success. Interestingly though in 2014 a study conducted on rhesus monkeys was completed (2). I know, a human study would have been preferable but don’t we share over 90% of the same DNA with primates?

What the scientists did was get a group of monkeys and divide them into two separate groups. Over a period of six months one group was given extra sugar in their diet and the other group was not. I know, try and suspend that part of your brain that is telling you this is a step back for animal rights.

They then did a stimulated cycle, very similar to that of an IVF cycle and compared the outcomes of the monkeys that were given sugar against those that were not. What they found was that when they did an egg collection, after six months of eating extra sugar, although overall the number of eggs collected was similar between the two groups, significantly less mature eggs were able to be collected in monkeys that had been given extra dietary sugar versus those that were not (18.5% of eggs were mature in the sugar group versus 86% mature in the non-sugar group). It is believed the sugar interfered with how the eggs were able to mature. This is obviously concerning as fertilisation and production of a viable embryo is not possible without eggs first developing to maturation. And because I know you are thinking it, the extra sugar that these primates were taking wasn’t even that high with researchers reporting that it was in fact the equivalent of less than half of what most women in the U.S. would consume.

Although this is only a small, elementary study completed in monkeys it is one of the first to particularly look at the direct relationship between sugar and IVF cycle outcomes. It is therefore absolutely worth noting and women undergoing IVF could do worse than to simply reduce the amount of sugar they intake.

A human study this time

Another study was also done (3), this time in humans, looking at the relationship between carbohydrate intake (and as we know, sugar is a simple form of a carbohydrate), protein intake and IVF outcomes. Although this was only a small study – only twelve women participated, so yes, there is plenty of room for these results to be skewed – they found huge differences when women aged 35 or younger and with a BMI of 26.5 or less modified these two food groups.

After being unsuccessful for one of their IVF cycles, these women waited at least two months before commencing another cycle. In between these IVF cycles the women focused on reducing their carbohydrate intake and increasing their protein intake (these women had dietary support and were guided on how to do this) and found that blastocyst formation increased significantly as did clinical pregnancy rates – from 16% to a whopping 83%.

All in all, this led the authors to summarise that

Seemingly young healthy patients with poor embryo development can possibly increase the percentage of blastocyst formation by increasing their daily intake of protein and lowering their daily carbohydrate intake 2 months prior to their IVF cycle. – Russell et al 2012

And for ladies over 35…

Sugary donuts: High in carbohydrate, low in protein. Just bad all round.

Dr Russell repeated this kind of study on 120 ladies who were aged 36 and 37. As reported by Kate Johnson for Medscape, these ladies were categorised depending on whether their diet consisted of high amounts of protein (over 25% of their food intake) or low amounts of protein (under 25%). It was found that ladies who were in the ‘high protein’ group had better rates of blastocyst formation (64% vs 34%), clinical pregnancy rates (66% vs 32%) and the holy grail of IVF treatments, live birth rates (58% vs 11%) .

Additionally, when protein was greater than 25% coupled with carbohydrate being less then 40% the clinical pregnancy rate skyrocketed to 80%. I think that is AMAZING.

Dr Russell concedes that although from the data presented here it seems as if a high protein, low carbohydrate (and that includes sugars) diet is the way to go, the underlying mechanisms is unknown. Is it the actual grains that causes this change or is it another factor such as a possible inflammatory effect of gluten (have a look at my post on gluten if you haven’t already)?

Before you start throwing out all the pastas, breads and cookies from your pantry remember that changing your diet when imminently about to commence an IVF cycle is not necessarily about weightloss (you don’t want to drastically alter your weight without your fertility doctor being aware of it as it may change your medication regime) but is about making sure you are eating the optimal foods to assist in the production of healthy eggs and ensuring that there is a healthy environment to welcome any little embryos. The women in these studies also had help from nutritionists to help them get their balance just right. Likewise, before you make any drastic changes to your diet it would be prudent for you also to get this type of advice – or even just speak about it with your doctor or fertility nurse. In the meantime though, it is safe to say that I would definitely rethink that afternoon Mars Bar.

References

Gormack, A., Peek, J., Derraik, J., Gluckman, P., Young, N. & Cutfield, W. (2015) Many women undergoing fertility treatment make poor lifestyle choices that may affect treatment outcome. Human Reproduction, 30 (7) 1617–1624
Chaffin, C., Latham, K., Mtango, N., Midic, U. & VandeVoort, C. (2014) Dietary Sugar in Healthy Female Primates Perturbs Oocyte Maturation and In Vitro Preimplantation Embryo Development. Endocrinology 155 (7)
Russell, J., Abboud, C., Williams, A., Gibbs, M., Pritchard, S. & Chalfant, D. (2012) Does changing a paitents dietary consumption of proteins and carbohydrates impact blastocyst and clinical pregnancy rates from one cycle to the next? Fertility and Sterility. Sup 47 O-153.
http://www.medscape.com/viewarticle/803821

ICSI IVF… What Is It About?

For some ICSI is just that next step down the fertility path when traditional IVF fails. For others their clinic ONLY fertilises eggs by using ICSI and there is no way around it. One thing is apparent though and that is that ICSI is gaining ground on IVF and becoming more and more common. Here are some answers to those common questions regarding ICSI.

What is ICSI?

ICSI, pronounced ‘ick-see’ stands for intra-cytoplasmic sperm injection. It is when the embryologist selects one sperm from the semen sample that has been provided and this single sperm is then injected directly into the egg. There are different methods and techniques that the embryologist can use to select the best sperm such as using an extra high magnification microscope or putting the sperm into substances that mature sperm then bind to and then picking one of these. For the purposes of this article we will just lump all these different methods together (as is mostly done in the literature).

There are strict rules set by various overseeing bodies that dictate which sperm is suitable for ICSI. For example sperm must be mature and of a particular size and shape. This is reassuring as it again attempts to ensure that only healthy, mature sperm are injected – though if they weren’t healthy, mature sperm the egg probably wouldn’t fertilise rather than having adverse outcomes for your baby.

Although it is a different procedure ICSI comes under the umbrella of IVF and sometimes your lab might interchange the term ICSI with IVF.

ICSI is different to IVF, which as you are likely to know is where the egg and the sperm are placed together in a dish and the sperm are left to their own devices to penetrate the shell of the egg and fertilise the egg that way. As a new patient in the fertility world IVF can seem a little bit more natural then ICSI because at least some sort of natural selection is taking place, right? That is in traditional IVF the best sperm still has to win at the end of the day, albeit in a manufactured environment. On top of injections and ‘harvesting’ your eggs ICSI can seem like yet another intervention.

Why is ICSI used?

ICSI has been traditionally used when there is significant male factor infertility and we can’t really go further without first briefly touching on sperm count. You might remember that the normal sperm count in a healthy man is around 40 million per ‘go’ (or ejaculate in case I wasn’t clear). Don’t forget though that sheer numbers is not enough and the sperm themselves need to be healthy with good motility, that is the need to have the ability to move around and get to where they need to and good morphology, meaning that they look the part with one tail and one head, for example. When a semen sample is provided, the embryologist will prepare the sperm, taking out all these stragglers leaving behind only the best of the best. Or as I have heard one consultant say SAS sperm.

Low Sperm Count

It has previously been mentioned that in instances of male factor infertility if the SAS sperm count is greater than 10 million it might be worth attempting IUI, if the count is between 5 – 10 million try IVF and anything less than this just use ICSI as the likihood of fertilisation without it would be relatively low. It is in these very low sperm counts that ICSI was first intended.

Previous Zero Fertilisation Rate

In addition to the reason of having low sperm count, another reason that ICSI might be used is if you have previously completed a cycle where there was zero fertilisation. This can happen in 10 – 20% of couples (Chen et al as cited in 1). Instead of having to live that one again, your embryologists may recommend that you skip plain old IVF and head straight to ICSI in order to give the egg and sperm the best chance to meeting and the egg fertilising. Remember though, that just because the sperm has been injected right into the egg, a little something special still has to happen and it doesn’t automatically guarantee fertilisation. It can in some instances improve it though which is why some clinics opt for ICSI as standard, though other clinics believe that with normal, healthy sperm ICSI is just not required and with mother nature not actually intending for a needle to necessarily be shoved in her eggs side they are quite possibly correct.

Rescue ICSI

ICSI may also be performed in ‘rescue’ situations. That is when traditional IVF has been attempted but no fertilisation has occurred after a certain amount of time. In this case the embryologist will inject the egg with sperm in an attempt to make it easier for fertilisation to occur. When rescue IVF is needed research shows that the sooner it is done the better. One small study shows that fertilisation rates for rescue ICSI performed after 6 hours has a fertilisation rate of 70%, compared with only 48% when rescue ICSI was performed after 22 hours (1). This 70% fertilisation rate is in line with the general fertilisation rates of standard IVF (Nagy et al as cited in 1) so this is a very good outcome. The 6 hour rescue ICSI, as opposed to 22 hour rescue ICSI also has better implantation, pregnancy and live birth rates. It should be noted that in some instances clinics do not always like to practice rescue ICSI due to the risk of more than one sperm being inserted into the egg and the complications this can cause (though there are ways technician can try and see if an egg has fertilised to reduce this from happening, for example by looking at the polar body of an egg, so this doesn’t happen very often).

Extra Testing or Surgical Collection

ICSI can also be recommended if you are planning on doing embryo testing or if sperm has needed to be collected surgically through means such as Percutaneous Epididymal Sperm Aspiration (PESA), Micro-Epididymal Sperm Aspiration (MESA) or Testicular Sperm Extraction (TESE).

Does ICSI cause higher rates of birth defects?

Generally speaking, the news is good. It seems that if you are comparing IVF to ICSI there is no correlation between the use of ICSI over IVF and birth defects.

This was recently covered in a metaanalysis completed by some researchers in Europe (2). They reassuringly found that there was no difference between ICSI conceived babies and IVF conceived babies and this has also been reported elsewhere (3).

Although this study is getting a little old now (Bonduelle et al 2003, as cited in 3) research was also done assessing children’s development at two years of age which is a welcome study to have given that a lot of research stops following the babies at birth. By completing standardised testing it was found that at two years the psychomotor and cognitive development of children were the same irrespective of whether the child was conceived using IVF or ICSI.

The Centre for Disease Control reports nearly 70,000 ICSI cycles were completed in America in the year 2012. This is a number that has been steadily increasing since the introduction of ICSI and we can be forgiven for thinking that there may be some safety in numbers. With all the checks and scrutiny that IVF clinics are rightfully held to, if ICSI was causing an increase in children with birth defects it would have come to light by now. And with the first ICSI babies being conceived in the early 90’s, this provides around 25 years of longitudinal data to have had scrutinised.

There was one study however, that again studied babies born following ICSI conception or IVF conception (4). They found that ICSI babies generally were at higher risk of preterm birth and lower gestational weight and age (even accounting for the fact they were born earlier). It seems though that ICSI babies were more likely to be part of multiples which could very well account for this outcome as when they assessed just singletons the ICSI babies were no longer at a disadvantage. This was only one very small study however with flaws in its own methodology, but in the interests of presenting both sides of the story, I mention it briefly.

Interestingly some researchers hypothesise that it sometimes can be the reverse, that is children of IVF conceived births can fare worse off than ICSI (2). One theory of why this is is because IVF is used predominantly when the sperm is of sufficient quality and quantity, but there are still difficulties with fertility. This infers that it is due to maternal factors that infertility is experienced. That is IVF is traditionally used when there is female factor infertility and ICSI when there is male factor infertility. If this is the case and if there are slightly poorer outcomes for IVF babies, it would seem that it is more important to have a healthy mother producing good quality eggs which may be able to compensate in some way for poorer sperm quality. I should also stress that when comparing birth outcomes the researchers are generally looking at things like birth weight and gestational age and not major disabling defects, therefore if not totally ideal is most likely to be so insignificant to not change your decision to complete one procedure over another. Though like everything, your doctor will be the best person to walk you through the pros and cons.

Whilst we have established that there is no differerence between IVF conceived and ICSI conceived babies, in the course of researching I did find that it has been mentioned that ART babies in general have higher risk of birth defects. There are a number of possible reasons for this and one is that it may be that the reason couples have difficulty conceiving is the risk factor for the defect rather than the technology itself. Alternatively, it may be one or more then one of the steps involved in the IVF/ICSI process that causes this. For example it may be the medication used to stimulate cycles, growing embryos in a culture or transferring embryos into the uterus that possibly increases the risk of birth defects (though IUI is also included under the ART umbrella and in IUI the embryo is not created in the lab so this doesn’t necessarily explain it all).

These same researchers also suggests that babies that are the result of a frozen embryo transfer are generally at less risk of preterm birth and lower birth weight. This is good news for women who are already less then thrilled to be completing a frozen transfer due to the slightly lower success rates. It is suggested that this occurs because in frozen embryo cycles there is not the same amounts of medication being used and in the luteal phase (that is the phase after ovulation/ transfer) the hormones in your body more accurately reflect those in nature. But don’t worry fresh cycle ladies, there is some evidence that suggests that there is actually no relationship between the total dose of medication taken, number of eggs harvested and the health of your baby (this is low grade evidence though and further research is needed).

Remember, take all this with a pinch of salt and there is no point in getting concerned over this without discussing your individual situation with your doctor. Although when you are in the moment it may seem like the be all and end all, for example ART children are possibly more likely to have certain defects, the overall number of children experiencing these remain a very, very small number. It is up to you to determine what you are comfortable with but for most women the risk of not having a child far outweighs the relatively very small risk of a child with an abnormality. But again the exact numbers and percentage will vary according to your particular situation so it is best to discuss this with your clinic.

How much does ICSI cost?

Depending where in the world you live the cost of ICSI over IVF can be significant. Resolve, which is a leading information and support network for all things fertility related report that ICSI can cost up to an extra $1500 to the cycle for those women living in the United States of America. If you are in Australia, where there are already excellent Medicare rebates for IVF, the extra out of pocket expense for doing ICSI over IVF can be around $300 depending on your clinic.

References

1. Chen, C. & Kattera, S. 2003. Rescue ICSI of oocytes that failed to extrude the second polar body 6 h post-insemination in conventional IVF. Human Reproduction Vol.18, No.10 pp. 2118-2121

2. Pinborg A, Wennerholm UB, Romundstad LB, Loft A, Aittomaki K, Söderström-Anttila V, Nygren KG, Hazekamp J, Bergh C: Why do singletons conveived after assisted reproductive technology have adverse perinatal outcome? Systematic review and meta-analysis. Human Reproduction Update 2013, 19:87–104

3. Devroey, P. and Van Steirteghem. A. 2004. A review of ten years experience of ICSI. Human Reproduction Update, Vol.10, No.1 pp. 19±28, 2004

4. Nouri, K., Ott, J., Stoegbauer, L., Pietrowski, D., Frantal, S. and Walch, K. 2013 Obstetric and perinatal outcomes in IVF versus ICSI-conceived pregnancies at a tertiary care center – a pilot study. Reproductive Biology and Endocrinology 2013, 11:84