ICSI for non-male infertility: from ineffectiveness to gender bias?

Intracytoplasmic sperm injection (ICSI) is currently being abused as it is also frequently employed in the absence of a frank male cause of infertility. There is growing and robust evidence showing that the use of ICSI should be limited to couples with male infertility. For all other causes of infertility, the procedure does not increase the chance of live birth, may increase malformations in newborns and requires more resources than conventional IVF. In addition, the use of ICSI may impact the sex ratio at birth, favouring female infants. Even if this effect may not be targeted as a gender biased procedure, it should be seen as a wake-up and warning call. It reminds us that ICSI is a ‘non-natural’ invasive technique that circumvents natural sperm selection mechanisms. Overall, a policy of indiscriminate use of ICSI is not justified and a plea is made for a return to a higher use of conventional IVF. Fear about failed fertilization or the use of preimplantation genetic testing for aneuploidies may represent barriers to the need to lower ICSI use and should be overcome.