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

Intracytoplasmatic Sperm Injection (ICSI) is currently abused, being frequently employed also in the absence of a frank male cause of infertility. However, there is growing and robust evidence showing that ICSI should not be used for unexplained infertility and mild male factor. The procedure does not increase the chance of live birth, may increase newborns malformations and requires more resources than conventional In Vitro Fertilization (IVF). In addition, the use of ICSI may impact the Sex Ratio at birth, favoring females. Even if this effect may not be targeted as a gender bias 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 we plea for a return to a higher use of conventional IVF. Fear about failed fertilization, or the use of PGT-A may represent barriers to the need to lower ICSI use and should be overcome.