Ep 88: ICSI (Intracytoplasmic Sperm Injection) with Dr. Matthew Lederman at RMA
Fertility Forward Episode 88
We often hear questions about ICSI (Intracytoplasmic Sperm Injection) and its role in fertility. So to answer them, today we are joined by Reproductive Endocrinologist and Infertility Specialist Dr. Matthew Lederman, who operates from the new RMA of New York clinic in Westchester. Dr. Lederman explains what ICSI is and how it can help to improve fertilization rates in male-factor infertility. Tuning in you’ll hear what three parameters they look at when doing a semen analysis and how ICSI differs from traditional IVF. We cover the role of ICSI when there is no sperm in the ejaculate, why they do the ICSI for patients who are having PGT (Preimplantation Genetic Testing), and the role of PGT in the success rates of fertilization. You’ll also hear why ICSI is used to fertilize eggs that have been frozen, what ZyMōt is, and how it works, as well as insight into the prevalence of unexplained infertility issues. For some fascinating insights from an empathetic expert on all things ICSI, tune in today!
Rena: Hi everyone. We are Rena and Dara and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients, because knowledge is power and you are your own best advocate.
Rena: We are so excited to welcome back to Fertility Forward today, one of our amazing, amazing recurring guests, Dr. Matthew Lederman, a reproductive endocrinologist at RMA of New York. And he is coming to us today from a brand new RMA office in Mount Kisco, correct?
Dr. Lederman: Correct. Yeah. We opened a brand new office in November. We partnered with CareMount to create a new office and lab called RMA of New York at CareMount and the office opened up November of 2021 and it's a full service lab now servicing, trying to bring everything that's in the City, outside of the City to service, you know, the greater Hudson Valley area, Westchester, you know, and beyond to try and, you know, improve fertility access and patients no longer have to go into the City and think they're, you know, more convenient.
Dara: How wonderful is that?
Rena: Wonderful. Yeah, it's amazing that you're expanding access to care and providing such great care out there.
Dara: And I think especially, you know, for, for a lot of people, I think just the act of having to commute, especially more, early morning to get blood work and to meet with their doctor. How nice is that? That now there's one less thing to have to add to, you know, as a potential stressor in the game.
Dr. Lederman: Yeah. And you know, stress is a big part of the fertility journey and it's really hard to find someone who's not stressed. Everyone, anyone we're seeing in the office, there's some level of stress, you know what they're going through. Even, you know, women who are considered, you know, freezing eggs, they're still stressed because they haven't met the partner. And they're doing that as a preventive measure. So everyone is stressed. And, you know, trying to, you know, improve access is a way of alleviating the stress a little bit. So where in the past, you know, patients would go to our, you know, we still have our office in White Plains, they would go to White Plains but anyone undergoing an egg retrieval, they had to go into the City. You know, now that's all done at, you know, we still have our White Plains office. Now patients, the retrieval, egg retrieval, or embryo transfer, you know, is done in, you know, the Mount Kisco office. All the monitoring, you know, the early ultrasounds blood work is done in the White Plains, Mount Kisco office, you know, we're open on weekends. So just really trying to, you know, make it easier and serve our patients, you know, by, you know, bringing, you know, fertility service, you know, in the, you know, in the backyard, not literally in the backyard, but just really in their neighborhood. And, you know, it's, it's a stressful process enough, we're trying to, you know, you know, de-stress and make it, you know, easier and improve access to them
Dara: The way I'm seeing it also is coming into the City, especially a lot of people who were born and raised in that neighborhood or people who have, you know, worked in the City and then, you know, decide to, to move afterwards. There's definitely a slower- paced, calmer, the way I would see it, I'm like, I think that's a great idea to, you know, I think there's an added bonus too that there, you know, you're looking at beautiful scenery and more greenery. So I, I think that's also a bonus,
Dr. Lederman: Definitely a different pace, you know, in the suburbs to the city.
Rena: Sure. So I'm so happy to have you on today also to talk about ICSI, because I know that's something so many of our patients, in the City, Westchester, everywhere always ask about. People always wanna know, why did my doctor do ICSI? Why didn't my doctor do ICSI? What is ICSI?
Dr. Lederman: So ICSI, you know, stands for intracytoplasmic sperm injection and it's a embryology procedure that's actually been around for quite some time. It's been around since I, you know, I think it's 1992, so now 30 years. So it's, you know, been around for a while. And it was initially, you know, developed, you know, to treat, you know, you know, mild, severe sperm factor fertility. When we do an infertility evaluation, we, you know, the, you know, the male partner that we'll check a semen analysis. We’re looking at three parameters, you know, the concentration, which is the number of sperm, the motility, which is the percent of sperm that swim or move. And what's called the morphology, which is the shape of the sperm. And it actually, most sperm are misshapen. So ICSI was first developed to treat severe cases of male factor infertility when the concentration was very low, when the motility was very low, when the morphology is very low. So, you know, when you do IVF, you could, you know, there's two ways of inseminating the eggs - standard insemination. We take one egg, a bunch of sperm, let fertilization occur on its own or ICSI, which is when you inject one sperm into the egg. All right? So when you have cases of very low numbers, ICSI helps improve fertilization rates. So it brings the fertilization rates up to almost 80%, high 70, even 80%. And it helps with fertilization. Cause if you did, you had a severe sperm issue and you did the old standard insemination, you tend to get lower fertilization rates.
Rena: Okay. So let me just stop you there for one second. So ICSI basically means that you're ensuring that the sperm fertilizes the egg. So is that right?
Dr. Lederman: Well, there's no, you know, when you do ICSI, you know, there's no guarantee of fertilization.
Rena: Or you're making sure it gets to the right place?
Dr. Lederman: What you’re doing, you're directly injecting the sperm into the egg. And that's what's really needed when you have a moderate to severe sperm issue. Because when you have those moderate to severe sperm issues with standard insemination, which you just take one egg, put a bunch of sperm on top of it, let fertilization occur on its own. They don't fertilize as well. They have much lower fertilization rates. So ICSI helps improve it. You know, other indications, you know, for ICSI is that someone who say did IVF before with, you know, standard insemination and they had poor fertilization rate or no fertilization rates, you know, so ICSI helps improve that. ICSI is also used for, you know, sometimes when couples are doing IVF infertility, there may be no sperm in the ejaculate and there could be no sperm in the ejaculate because there could be an obstruction. So the sperm are not getting to the ejaculate. And in order to get the sperm, you have to do a testicular biopsy, which is done by a urologist, where they biopsy the testes and that sperm can then undergo ICSI. Okay? Or there's no sperm and it's not an obstruction. Sometimes there's so few sperm in order to only in order to get the sperm to be used, you have to biopsy the testes. That's done by a urologist who specializes in male fertility. And then you use that sperm, you know, it can then go undergo ICSI.
Rena: Well OK. I'm glad you explained it like that because I have a lot of patients who I, I think they always think ICSI is like the, be all end, all they'll say, but I did ICSI. I don't understand why it didn't work. And so how you explained it as well, it doesn't ensure fertilization. It just makes sure that the sperm gets to the right place. But then what happens from there, ICSI is not in charge of that. And so I think a lot of times people have sort of these sort of unrealistic expectations and they'll think like ICSI is it. That's it. And then when it doesn't work, they, it, they really don't understand.
Dr. Lederman: Because there’s usually more to the story. So even in severe sperm cases, sometimes ICSI doesn't compensate for that. Or when you have a really bad egg factor that could also play a role. So there are other, you know, variables and you know, a lot of our patients when they're doing IVF, a lot of them undergo ICSI. And the reason for that, even if there's not a male factor infertility, most of our patients who are doing IVF, they’re undergoing PGT - we love these acronyms. So PGT stands for pre-implementation genetic testing. So these patients are dealing with the IVF. We're taking out the eggs, doing the ICSI, growing the embryos out. We're not putting it back right away. We're doing a biopsy and screening the embryos, that's the PGT, checking for chromosome abnormalities, things like down syndrome, which is trisomy 21, as well as numerous other chromosome abnormalities. Okay. And when you have chromosomally normal embryo, it improves, you know, it improves the implantation rate. So the implantation rate, you know what I usually tell my patients with a genetically tested embryo, so chromosomally normal, is about 60 to 70%. So it allows us transfer one embryo with high confidence. We're not transferring embryos that have no chance from the start or ones that are destined to miscarry. Doesn’t completely eliminate it, but it greatly reduces it. And when, if there are extra embryos, their own age, a couple knows what they have for the future, for future babies. Where age plays a role, the older you are, the harder to get that embryo. Once you have the embryo, it makes no difference how old you are. Screening makes everyone you go. And that's what a lot of our patients do and they do IVF, we screen a transfer, a single genetically screened embryos. And when you do, and the reason we do the ICSI is that theoretically, if you did standard insemination, you took one egg ,bunch of sperm. And then when you grow the embryos out, theoretically that when you would go to biopsy the embryo, the other sperm DNA could theoretically contaminate the biopsy specimen, the genetic testing. So, so that's why most, you know, that's why most of our patients, you know, we do the ICSI for that reason and almost all our patients who are doing IVF, they're doing that PGT, the genetic testing of the embryo. So therefore they undergo ICSI as a result.
Dara: Yeah. I would think the ICSI would be, especially if the numbers are much greater, I think it's, it's you said 70 to 80% success as opposed to maybe in the fifties or something of, of that line. That makes sense. But the other thing I have, my question is how do you know which sperm to take in terms of, is there a specific thing that you look for? Is it within a pool? Do you test them before? Or…
Dr. Lederman: It's a little tricky, you know, cause you can't really, there's not great testing for the sperm. There's no necessarily proven test. So what the, what the embryologist will do, they'll pick a sperm that's wiggling away, moving around and looks morphologically normal. So the morphologically normal looking sperm, that's moving around, there’s no other way to test it. There's some things out there like Zymot, which is a thing that, you know, we're looking at, which is where tries to pick out, you know, sperm that would be, have a lower what's called, you know, you know, DNA fragmentation. So that's a theory is that, you know, less, more fragmented sperm may not do as well. And this tries to sort sperm by DNA fragmentation, and then the embryologist could pick sperm that would have less fragmentation to therefore do the ICSI. It's still one of those things that are still being looked at. There's no real great way of, you know, picking the sperm other than just trying to pick out a sperm that looks normal and is, you know, moving around.
Rena: And what about the other procedure that, you know, I, I hear being thrown around - Zymot?
Dr. Lederman: So, you know, that's, you know what I do, you know, we're just alluding to, it's an, an ancillary procedure that tries to sort sperm by DNA fragmentation, you know, which is, there's a lot of controversies around it, around it, but the thought is, well, maybe if the sperm is less fragmented, less DNA fragments, okay? That the better outcomes, even though it's the, you know, the research around that still a, you know, work in progress and the Zymot is a way of separating sperm to have less fragmentation to then be used for the ICSI procedure. So it's one of those things that's still being looked into, you know, this, more of a story to come, but, you know, hopeful one day, maybe we'll figure out how to, you know, how to, how we better identify what sperm to use.
Dara: That's what I love about this field. That it's, it's forever changing, especially based on the research that's being done. But, but what's exciting is that there is new research, you know, every year, and we are seeing so many different changes. What I wanted to ask in terms of ICSI is, back to ICSI, is the prep-work the same in terms of the lead up?
Dr. Lederman: Well, it's, you know, you know, the day of the egg retrieval, the partner, you know, gives an ejaculate specimen, that's all the same, you know, that's all the same. And then, you know, in the lab, it's how it's processed, you know, so you process the sperm kind of the same way by the embryologist, but then it's what you do with a sperm, right? You know, whether or not, you know, like I said, most of our case involve ICSI, so that involves more work by the embryologist because you have to pick the sperm and then do the, you know, every egg you inject a single sperm, you know, so there's a lot more work done by the embryologist compared to the standard insemination. When they process sperm, they just combine the sperm and eggs in the dish. So there's actually less work from the embryologist in standard insemination, a lot more work when it comes to ICSI because if you get five eggs, you have to, you know, ICSI five eggs. If you get 25 or 30 eggs, they have to inject 25 or 30 eggs with a sperm.
Rena: Gosh, that must be the most delicate procedure.
Dr. Lederman: Yeah. You know that, you know, that usually happens a few hours after the egg retrieval is when, you know, the ICSI procedure would take place by the embryologist. And that's why it's very important to have, you know, to have embryologists who are very skilled in those, you know, those procedures because it's a very skilled, it's a skilled procedure.
Dara: Yeah. But that's nice to know that, you know, in terms of patients it's not requiring, you know, more effort or more medication that, you know, the procedure for the patients remains the same leading up to, to, you know, the, the IVF procedure.
Dr. Lederman: Yeah. There’s, there's no, no difference in the, you know, in the, the same way to get there, you know, and you know, for any, any, you know, nowadays what we see a lot of women who freeze their eggs and anyone who has frozen eggs, when we, when we thaw them, ICSI, you know, we always do ICSI to fertilize them they, they don't undergo the standard insemination because you know, those, the way they're frozen, they're more sensitive. The ICSI helps improve fertilization also in those cases and we're seeing a lot more women who froze their eggs in the past coming back and using them, whether it's for baby one or even baby two or baby three, you know, depends on how big of a family. So we always do ICSI when we use frozen eggs after they're unfrozen and thawed.
Rena: And what do you say last week we had on, I had two Dr. Bar-Chama from RMA and then another lovely urologist. And we were talking about Project AIM and this at home sperm tester. And we were talking all about sort of male factor fertility. So what do you say to patients who, you know, because so many times people say, oh, it's it's her fault or his fault. And you know, I always correct the language and say it's nobody's fault and fertility is a disease. So what would you say to a patient who was sort of like blaming the sperm or, or blaming, you know, the egg on treatment not working? How do you handle that?
Dr. Lederman: Well, you know, I think you hit it perfectly. It's no one's fault. A lot of times it's, you know, sometimes it's just a female factor, sometimes just a male factor. Sometimes it's, it's actually about 40% is a combination. It's both male and female. It can be a, you know, a sperm factor and an egg factor. It's very, it's, you know, it’s very common to have a combination of both that is the cause of, you know, the infertility, infertility, the ability to get pregnant. So a lot of times it is more than one factor. Sometimes there's tubal factor, egg factor and sperm factor.
Dara: Yeah. So, so many different
Rena: And it also can be unexplained too.
Dr. Lederman: You know, also a lot of times it's, you know, unexplained and sometimes it could get explained with time and sometimes it remains unexplained and you know, over 10% of, you know, infertility cases are unexplained and it, it drives couples crazy because you know, they, they're almost looking for a reason, you know, so they could say, all right, this is the cause. And it's more frustrating when you don't have a cause, you know? You know, we, we like answers and no one likes when you don't have an answer, unfortunately a lot of times you don't have an answer. Their young, ovarian testing is good. The flow seems open, the sperm is normal and sometimes even a mild sperm issue, like a mild morphology issue kind of falls under that unexplained category.
Rena: It's so hard. Yeah. And I think you sort of, it just really touched upon something that resonates with so many people that it's the unexplained that's so hard, you know, and I think that's what psychologically really difficult when you're saying, but everything looks good on paper, Right? I'm doing all the tests, I'm doing everything. Why is this not working? And it's very hard for people to wrap their heads around.
Dr. Lederman: Yeah. You know, everyone likes the answers and it's when you have an answer, but it, you know, in this field, you know, in medicine in general, sometimes you don't have an answer and you know, with, you know, fertility, you know, sometimes those answers get explained over time. You know, where that unexplained is, you know, sometimes they'll do IVF and they may not do as well, where they get a fair number of eggs. They, you know, they get fertilization, but they don't end up with a ton of genetically normal embryos to use. And you learn a lot by doing IVF because you see what happens in a dish. And sometimes that unexplained becomes an egg factor once you get that information.
Rena: I always tell people to look at it as a puzzle. And I always say nothing is ever a waste in this process because as you said, medicine and science is all about data points and information, right? And so everything that you do is a piece of your puzzle leading you to where you wanna go. And I know that it's so hard because it's your time, your money, your body, your emotions, but nothing is ever a waste because you're always, always collecting data points.
Dr. Lederman: Yeah. A lot more information. As you know, you know, some patient journeys are quicker than others and they have less data points, which is good because they've gotten pregnant, you know, quicker, you know, some are journeys are longer and you know, you take one step at a time, you get, as you, whatever information you learn throughout the process, you know, you know, we'll talk to one another and figure out a game plan, but you learn a lot, you know, there's a lot more data, data points. And sometimes, I mean, I hope there's not too many because that means a longer journey, but unfortunately some journeys are longer than others.
Rena: Well, you know what, Dr. Letterman, I think that's one of the reasons I so enjoy and, and I know Dara, too, enjoys working with you so much is because you have this empathy and compassion and you, you really understand that part for people. And so I always know that any patient with you, you, you have, you know, in addition to obviously the endocrinology background, just the compassion to understand, you know, how difficult this can be for people too.
Dr. Lederman: That's very sweet. It's a tough process. You know, know it's a tough journey and you know, it's not just myself, it's a whole team and it's really the team approach, you know, where, you know, there's, you know, the nurses, the coordinators from the clinicals drawing the blood, you know, to the nutrition aspect, aspect, you know, to, you know, Rena offering, you know, the fertility counseling, you know, it's a whole team approach to try and make a journey as best as possible, you know, cause it, you know, they’re rough journeys, it's a rollercoaster of a ride, you know, for, you know, many women where there's a lot of highs, I got 30 eggs, but they only end up with three embryos maybe that are genetically normal. You know, it's, it's an up and down and it requires a whole team to help them, guide them over the journey to try and make the process as stress free and as comforting as possible.
Rena: Sure. It takes a village,
Dr. Lederman: It takes a village. It does.
Rena: And we're so happy you've expanded yours in Westchester.
Dr. Lederman: Yes. You know, we're bringing the village outside the City and you know, to, you know, just make, you know, just make it easy and you know, and improve access and you know, we're growing, you know, and our plan is to, you know, to continue to grow and continue to make it easier, you know, and build a team, you know, you know, to treat, you know, patients who, who don't wanna go to the City and you know, where, you know, it's more convenient for them.
Rena: Well, we're so happy to have you and the expansion and you know, your wonderful team.
Dr. Lederman: Thank you.
Dara: And I appreciate you explaining ICSI for, for our listeners because it's, it's something that people do hear quite often, but it's not always, it explained with this much thought and really making it clear for our listeners today. So thanks for being on,
Dr. Lederman: Oh my pleasure. I truly enjoyed it. And thank you for having me.
Dara: Of course. So how we like to end, as you probably know by now, Dr. Lederman is with some words of gratitude for today. So what are you grateful for at this very moment?
Dr. Lederman: I'm grateful for having such a supportive family and an amazing team who I work with.
Rena: I love that. What about you, Dara?
Dara: I was gonna say family, too. Family and, and a support system, but now I'm gonna, I'm gonna steal from you, Dr. Lederman and let it lead to the people that I work with, to my patients, to the, you know, RMA team and to the support that my family gives to me every single day. What about you Rena?
Rena: Well, if my family's listening, which I don't think they listen to this, but if they, if they are, how can I not say family as well? You know, I'm super grateful also for my parents and my daughter, you know, I'm really lucky and cause it's just my daughter, my dog and myself, but my parents live five floors above me, which is really, really wonderful. We joke that we have a, like a brownstone, so super grateful for family also.
Dara: How nice. Thanks again, Dr. Lederman and we'll have you back on sooner rather than later.
Dr. Lederman: Thank you for having me again. It was my pleasure. Looking forward to joining you in the future.
Dara: Thank you so much for listening today and always remember: practice gratitude, give a little love to someone else and yourself, and remember - you are not alone. Find us on Instagram @fertility_forward and if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.