Clinical UM Guideline
|Subject:||Intracytoplasmic Sperm Injection (ICSI)|
|Guideline #:||CG-SURG-35||Current Effective Date:||10/06/2015|
|Status:||Revised||Last Review Date:||08/06/2015|
This document addresses the use of intracytoplasmic sperm injection (ICSI) during an infertility treatment cycle, allowing couples with male factor infertility to attain live birth rates, similar to those achieved with in vitro fertilization (IVF) using conventional methods of fertilization.
Note: Please see the following related document for additional information:
A maximum of three cycles of ICSI per attempted pregnancy is considered medically necessary in covered individuals who meet ANY of the following criteria:
Note: Two semen analyses are required prior to categorization of the male infertility. A comprehensive semen analysis must be completed prior to infertility treatment cycles.
Not Medically Necessary:
More than three cycles of ICSI per attempted pregnancy is considered not medically necessary.
ICSI is considered not medically necessary when the criteria above are not met including, but not limited to all of the following:
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|89280||Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes|
|89281||Assisted oocyte fertilization, microtechnique; greater than 10 oocytes|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
The American Society of Reproductive Medicine (ASRM) (2015) defines infertility as the inability to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse. Male infertility is defined as the inability to ejaculate or an insufficient number of sperm. Work-up for the diagnosis of infertility should include a comprehensive medical, reproductive, and family history and a physical exam. Laboratory testing and diagnostic evaluation may also be appropriate with emphasis on a systematic, expeditious manner and the least invasive method for diagnosis of infertility.
According to the National Institutes of Health (NIH), approximately one in six couples has difficulty conceiving. It is estimated that male infertility is a factor in about 30–40% of these cases. The most common cause for infertility in men is an enlarged mass of veins in the spermatic cord within the scrotum. The spermatic cord is made up of veins, arteries, lymphatic vessels, nerves, and the duct that carries sperm from the testes to the seminal vesicles.
Normal semen parameters established by the World Health Organization (WHO) are as follows:
Severe male factor infertility is defined by any of the following semen analysis parameters:
ICSI is a potential component of IVF cycle; this alternate technique has expanded treatment options for male infertility, allowing previously infertile couples to conceive. The procedure is completed under a microscope using a microscopic glass needle to inject a single sperm directly into the egg. Once the egg is fertilized, it is transferred to the female partner's uterus. ICSI is used for individuals who have very poor semen quality or lack of sperm in the semen caused by an obstruction or testicular failure. In some cases, sperm may be surgically extracted from the testicles or epididymis for this procedure.
According to the Society for Assisted Reproductive Technology (2008)
If a woman gets pregnant naturally, there is a 1.5% to 3% chance that the baby will have a major birth defect. The chances of birth defects after ICSI are rare. Certain conditions that have been associated with the use of ICSI (Beckwith-Wiedemann syndrome, Angelman syndrome, hypospadias, or sex chromosome abnormalities) are thought to occur in far less than 1% of children conceived using this technique. Some of the problems that caused your infertility may be genetic. Therefore, boys conceived with the use of ICSI may have infertility issues as adults.
Smith and colleagues (2010) reported results from a prospective fertility cohort study of 408 couples undergoing cycle based treatment in the United States. The authors concluded that cycle-based fertility treatments offer clinically significant increases in the pregnancy rate, however, this benefit does not persist indefinitely. "Couples not achieving a pregnancy with medications alone after two cycles or intrauterine insemination (IUI) after three cycles may be best counseled to pursue a higher level of infertility treatment. Those failing IVF after two cycles may want to consider other treatment strategies, such as donor sperm, donor egg, or further modifications in the IVF or ICSI protocol because additional cycles seem less likely to increase reproductive success as much as earlier cycles."
A 2012 committee opinion of the American Society of Reproductive Medicine and Society for Assisted Reproductive Technology stated that ICSI is a safe and effective treatment for male factor infertility. The document also stated that ICSI for unexplained fertility, low oocyte yield and advanced maternal age does not improve clinical outcomes. Their opinion included a statement that ICSI may be beneficial for individuals undergoing IVF with preimplantation genetic testing (PGT), fertilization after in vitro matured oocytes and cryopreserved oocytes. The authors concluded that the use of ICSI is a safe and effective therapy for the treatment of male factor infertility; currently there is no data to support the routine use of ICSI for non-male factor infertility.
Azoospermia: Lack of live spermatozoa in the semen; classified as obstructive or nonobstructive depending on whether cause is blockage of the tubules or ducts.
Intracytoplasmic sperm injection (ICSI): A fertility treatment that is used to treat sperm related problems by injecting a single sperm into a mature egg. The fertilized egg is then placed in a woman's uterus or fallopian tube.
Oligospermia: Decreased number of spermatozoa in the semen.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Intracytoplasmic sperm injection (ICSI)
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Revised||08/06/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified medically necessary abbreviation. Discussion and Websites sections updated.|
|Reviewed||08/14/2014||MPTAC review. Websites updated.|
|New||08/08/2013||MPTAC review. Initial document development.|