ICSI’s Role in Addressing Male Reproductive Issues
Global fertility experts call for urgent action on declining sperm quality and male reproductive health
Global fertility experts are calling for coordinated international action to investigate the underlying causes of male infertility and declining sperm quality.
The International Federation of Fertility Societies, known as the IFFS, has warned that the non-selective use of intracytoplasmic sperm injection, or ICSI, may have unintentionally slowed scientific progress in understanding why male reproductive function is declining.
ICSI is a form of assisted reproductive treatment in which an embryologist injects a single sperm directly into an egg. It has transformed treatment for severe male-factor infertility and helped millions of people pursue parenthood.
However, experts are concerned that its growing use in cases where there may not be a clear medical indication could mean that the underlying causes of poor sperm quality are not always investigated thoroughly enough.
What is ICSI and how does it treat male infertility?
ICSI was developed in the early 1990s as a treatment for severe male-factor infertility. The technique can allow fertilisation to take place even when sperm numbers are very low or when sperm have difficulty moving or penetrating an egg naturally.
It may be recommended when:
- A man has a very low sperm count
- Sperm movement or shape is significantly affected
- Previous IVF treatment has resulted in failed or poor fertilisation
- Surgically retrieved sperm are being used
- There are certain complex male-factor fertility concerns
ICSI has undoubtedly been a major breakthrough in reproductive medicine. However, it helps sperm fertilise an egg without necessarily addressing why the sperm abnormality developed.
Has ICSI reduced investigation into the causes of male infertility?
IFFS President Dr Marcos Horton said ICSI had been extraordinary for patients, particularly where severe sperm abnormalities are present.
However, he warned that its clinical success may have reduced the urgency to investigate the biological, medical, lifestyle and environmental factors associated with poor sperm quality.
“ICSI has been extraordinary for patients, especially where a severe abnormality is present, but it may also mean we are overlooking the underlying biological and environmental factors driving poor sperm quality,” said Dr Horton.
“The Federation is uniquely positioned to unite these voices, and we are now preparing a coordinated global effort to address the decline in male reproductive health.”
The concern is not that ICSI should no longer be used. Instead, specialists want greater focus on identifying the causes of male infertility alongside providing assisted reproductive treatment.
Why declining sperm quality is a wider health concern
Poor sperm parameters may sometimes be associated with broader health concerns rather than existing solely as an isolated fertility problem.
Declining sperm quality may be linked with metabolic, hormonal or cardiovascular conditions, making male infertility relevant to both reproductive medicine and public health.
Dr Horton said the lack of scientific progress in understanding male reproductive decline should therefore be considered a wider health issue.
A fertility assessment may provide an important opportunity to examine a man’s general health, including hormonal function, weight, lifestyle, medical history and potential environmental exposures.
Treating infertility symptoms without finding the cause
Professor Bart Fauser, former co-editor-in-chief of the IFFS journal Global Reproductive Health and a leading reproductive medicine specialist, said the success of ICSI may have unintentionally diverted attention from the reasons male fertility is declining.
“ICSI has been a remarkable breakthrough, but it has also diverted attention away from the fundamental question of why male fertility is declining,” said Professor Fauser.
“We have treated the symptoms brilliantly, but we have not addressed the underlying causes – and that must now change.”
For patients, this means fertility treatment should ideally be accompanied by a proper investigation of potential male-factor infertility rather than relying solely on assisted conception techniques to overcome it.
What causes poor sperm quality?
Male infertility can have many possible causes, and in some cases no clear explanation is found.
Factors that may affect sperm production or function include:
A standard semen analysis looks at factors such as sperm concentration, movement and shape. Depending on the results, further tests or referral to a reproductive urologist, andrologist or endocrinologist may be appropriate.
What action is the IFFS calling for?
The IFFS is calling for a more coordinated approach to male infertility, including closer collaboration between fertility specialists and other areas of healthcare.
Its recommendations include:
Integrated male fertility care pathways
The IFFS wants clearer and more coordinated referral pathways between fertility clinics, urology, endocrinology, andrology and primary care.
This could help ensure that men with abnormal semen results receive an appropriate medical assessment rather than being directed immediately towards fertility treatment alone.
Better long-term health follow-up
Experts are calling for stronger long-term medical follow-up for men with poor sperm parameters.
Monitoring wider health could help identify associated hormonal, metabolic or cardiovascular concerns and improve understanding of how reproductive health relates to health across the life course.
Greater investment in male infertility research
The IFFS says more research funding is needed to investigate the biological, genetic, medical and environmental factors that may be driving declining semen quality.
This includes understanding the potential effects of pollution, endocrine-disrupting chemicals, lifestyle, chronic illness and other environmental exposures.
Stronger international collaboration
The Federation is working with the International Society of Andrology, or ISA, to explore a joint international statement and an online summit.
The aim is to establish shared global priorities for male infertility research, prevention, diagnosis and clinical care.
New global initiatives on male reproductive health
The IFFS and ISA are already collaborating on a free male infertility webinar series designed to increase professional education and discussion.
A dedicated pre-congress course is also planned for the IFFS World Congress in Brisbane in 2027.
Plans for an international online summit are being explored, with the intention of bringing together fertility doctors, andrologists, urologists, researchers, policymakers and patient representatives.
Male fertility should be treated as part of overall health
Professor Fauser stressed that male fertility should not be viewed only as a person’s ability to conceive at a particular moment.
“Male fertility should be recognised as part of overall health across the life course. It is not simply a measure of reproductive capability at a single moment in time.”
This represents an important shift in how male infertility is discussed.
Rather than considering an abnormal semen analysis only as a barrier to conception, experts want it to be recognised as a possible signal that further medical investigation may be needed.
What does this mean for people having fertility treatment?
For couples and individuals undergoing IVF, the message is not that ICSI is unsafe or ineffective. It remains an essential treatment for many cases of male-factor infertility.
However, patients may wish to ask their clinic:
- Why is ICSI being recommended in our case?
- Is there a clear male-factor indication?
- Has the cause of the abnormal semen result been investigated?
- Would a reproductive urologist or andrologist referral be helpful?
- Should hormonal, genetic or general health tests be considered?
- Could any lifestyle or environmental factors be contributing?
- How will male reproductive health be followed after treatment?
Patients should receive clear information about why a treatment has been recommended and whether further male fertility investigations may be appropriate.
Looking beyond ICSI to understand male infertility
Research has raised concern about long-term declines in sperm concentration, although findings vary by population, geography and study design.
ICSI has given many people with severe male infertility the opportunity to build a family. Its success is one of reproductive medicine’s greatest achievements.
But experts now argue that the next major challenge is to look beyond fertilisation itself and understand why increasing numbers of men may be experiencing poor reproductive health.
Treating male infertility and investigating its underlying causes should not be competing priorities. Both are essential to improving fertility treatment, protecting men’s wider health and supporting future generations.
The IFFS represents more than 50 national fertility societies around the world and is now calling for unified international leadership on this increasingly important issue.
