In my daily fertility practice, while trying to help couples to conceive, I’ve noticed a trend lately. Patients are less interested in using high levels of “assisted reproduction” to have children. In particular, they would like to avoid in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), the Cadillac of all techniques. Even before they meet me, they have decided against it. Not all couples, mind you, but certainly more than before.
Briefly, IVF-ICSI is a busy month for women. It involves stimulating them with daily, injectable hormones during the first half of the menstrual cycle to generate more eggs than normal within the ovary. Ovulation of eggs is induced by injection of a second hormone, which is closely followed by egg retrieval using needle aspiration under anesthesia. Retrieved eggs are then stripped of their cell coats in a dish and a single sperm is individually injected into each egg by an embryologist. The criteria for choosing sperm are: good looking and hopefully moving. Eggs then become embryos in a Petri dish and are transferred back to the female reproductive tract three to five days later, depending on how they develop. Extra embryos can be frozen for future use. A pregnancy test is obtained two weeks later.
As a male fertility specialist whose practice mantra has been “treat the male, cure the disease,” I find this trend very interesting. Assisted reproduction is almost always an option for couples, but I have spent a good deal of time publishing research showing that classic male infertility treatments such as varicocele repair and vasectomy reversal are very cost-effective ways to conceive compared to more expensive techniques like IVF-ICSI. On the other hand, these techniques are the only option for many men with azoospermia, or the absence of ejaculated sperm, and I am glad that it exists for this.
I wrote down what patients said when I asked them why IVF-ICSI is not an option on the table for them and here are some of the responses:

  • “It seems pretty invasive and unnatural.”
  • “Isn’t it relatively new?” (IVF is 32 years old, ICSI is 18 years old)
  • “Who selects the sperm?” (Since it is not God or Darwin)
  • “Wasn’t ICSI developed as an experimental mistake?” (Yes)
  • “How do we know that those are our eggs and our sperm? (Rare)
  • “It’s only a single try at having children.” (Maybe two)
  • “Isn’t there an issue with higher birth defects and syndromes in babies” (Very likely)
  • “Are our children going to be infertile?” (Unknown)
  • “We’d prefer to have the hope of trying every month at home.”
  • “IVF-ICSI is too expensive”

What I think is happening is that as IVF-ICSI is being offered to consumers more often than ever (currently 1-2% of U.S. babies are born from these techniques), patients are becoming better educated about the technology and are making more informed, personal choices. My gut also says that good, old-fashioned sex has a strong following among infertile couples as a way to conceive. In the words of Woody Allen in Annie, “that was the most fun I’ve ever had without laughing.”