Intra Cytoplasmic Sperm Injection is one of the most important techniques in IVF. Nevertheless, with the kind of craze young prospective embryologists have in ICSI has made it a centerpiece of embryology. Whenever we have seen trainees do this procedure, micromanipulator alignment is the first thing to be mastered followed serially by sperm immobilization and ending with oocyte injection. In this process, ICSI is inculcated and hands-on experience is completed. These three parts sum up the technique but there are still two more aspects to the same to be imbibed practically apart from knowing the science behind the same.

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ICSI machine introduction and ICSI Dish preparation are added elements to learning ICSI. In machine introduction, we make the trainees get acquainted with nuts and bolts of the micro manipulating system. The process to know the machine is imperative in understanding the way it works which also is taken seriously as without the machine knowledge, progressing ahead is difficult if not impossible. But when we talk about making ICSI dishes, the task is observed thoroughly by the trainees but seldom pondered much about. However, ICSI can be a hindrance if the dish preparation is half baked or not done properly. And when we look at this prospect of four cases or above, the making of dishes can be a rate-determining step to handle the monumental work. Dish preparation is very simple, easy, and requires no prominent skill but alertness. The step comprises a dish (a specialized ICSI dish), culture or paraffin oil, HEPES media, and PVP. These ingredients make the dish and each of the components have specific usage. The plastic dish serves as the base, the media is for harboring the oocyte, (Polyvinylpyrrolidone) PVP is used for catching the sperm and the oil is for overlaying the drops made in the dish. The overlaying oil has many functions including preventing evaporation of the drops, maintaining the homeostasis, and preventing the pollution by VOC (Volatile Organic Compounds) and sustaining sterility.

Although there is no time frame to make an ICSI dish, it should not require more than two to five minutes to make them. The dish ideally has to be preheated and the preparation is better done at 37 degrees inside the Laminar Air Flow. The usage of PVP may be a subject of debate regarding their toxicity but it’s challenging to immobilize a sperm without the viscous solution. The most ambiguous perspective of making the dish is the pattern of the drops. The design can vary from person to person and I have seen innumerable artworks but two approaches are broadly applied. In the first case scenario, if the sperm count and the morphology is good, we can just make one PVP drop with media droplets. Taking both the gametes, we can simultaneously inject oocytes with sperm selection. In the second scenario, if the sperm count and the morphology is poor, it will overexpose the oocytes as we scramble to find sperm. Here, we can make a dish with two PVP droplets which facilitate the pre-selection of sperm in one and creating a reservoir in the second. Subsequently, oocytes can be added, and then injection can be completed. The dishes can be made using the micropipette with sterile tips or a 1ml BD syringe or any other sterile option available.

ICSI can be hampered if the dish making is not up to the mark. For example, the PVP droplet must be ideally flat to help us immobilize the sperm at the base of the dish and trap it. Flattening the droplet will reduce the number of sperm layers to a few. If not flattened, it may cause hindrance. Adding a minimal number of sperm is the key too as adding a high number can result in overcrowding and lack of clarity or space to select the correct sperm. Adding too many sperm can cause frustrations especially if there are more cases in a day. Other problems can be making big droplets (8-10ul is sufficient) or making drops but taking a lot of time to add oil or simply making the droplets at the edge of the dish. At times, sufficient oil is not added and media droplets may not be entirely submerged. PVP at room temperature and oil preheated to 37 degrees is a prerequisite and sometimes that is taken for granted.

Dish preparation may not be one of the main parts of the whole procedure but is a connecting link. Although making dishes is a reflex action, it is essential to maintain alertness and oversight in the same. And it may undoubtedly make or break the speed and the efficiency of the ICSI procedure!

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