Sperm Viability Selection for Immotile Sperm in ICSI: A Systematic Review and Meta-Analysis

Sperm Viability Selection for Immotile Sperm in ICSI: A Systematic Review and Meta-Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Sperm Viability Selection for Immotile Sperm in ICSI: A Systematic Review and Meta-Analysis Yasmin Magdi, Salah Elbashir, Ayman Rashed, Ayatallah Elhadidy, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8961164/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract S — Situation: Immotile or poorly motile sperm presents a significant clinical challenge in intracytoplasmic sperm injection (ICSI), prompting the use of adjunctive sperm viability selection techniques to optimize reproductive outcomes. P — Purpose: This study aimed to evaluate the effectiveness and safety of sperm viability selection methods for improving reproductive and neonatal outcomes in patients with immotile or poorly motile sperm undergoing ICSI. A — Approach: We conducted a systematic review and meta-analysis of controlled studies published in English between January 1990 and April 2025, identified through PubMed, Cochrane Library, Scopus, and Web of Science, comparing sperm viability selection techniques versus standard ICSI without viability selection. R — Results: Across included studies (13 studies), sperm viability selection was associated with a higher live birth rate compared with control (risk ratio [RR] 1.19; 95% confidence interval [CI], 1.05–1.36; P = 0.009; I²=6.6%), with subgroup analysis demonstrating greater improvement with theophylline use (RR 1.45; 95% CI, 1.09–1.92; P = 0.01; I²=66.4%). Results showed favorable secondary outcomes including increased clinical pregnancy rates and no observed increase in adverse neonatal or obstetric events. C — Conclusion: Sperm viability selection techniques were associated with improved live birth and pregnancy outcomes without an apparent increase in adverse perinatal events, although the certainty of evidence was low to very low. R — Relevance: These findings support consideration of sperm viability selection as an adjunct in ICSI for immotile or poorly motile sperm while underscoring the need for rigorously designed trials to inform evidence-based reproductive practice and guideline development. Registration: The protocol was prospectively registered on PROSPERO: CRD420251017288. Sperm viability Immotile sperm Hypo-osmotic test theophylline tail flexibility test azoospermia complete asthenozoospermia Figures Figure 1 Figure 2 What does this study add to the clinical work? There is evidence to support the beneficial effect of sperm viability selection in improving of live birth rate without adverse effect on neonatal and obstetric outcomes. Introduction Sperm vitality, usually assessed by motility, plays a central role in successful fertilization during intracytoplasmic sperm injection (ICSI) [ 1 ], where the embryologist must identify and select a viable spermatozoon for microinjection. Absence or severe impairment of sperm motility is common in men with azoospermia, which represent 1–2% of the male population and up to 15% of infertile men [ 2 ]. Complete absence of motile sperm in the ejaculate has been estimated to occur in approximately 1 in 5000 men [ 3 ]. Complete or severe absence of sperm motility has negative impact on success rates of ICSI treatment [ 4 ], which in turn is associated with psychological and emotional distress [ 5 ]. Various sperm viability selection techniques have been developed and incorporated into clinical practice to overcome this challenge. These includes chemical motility stimulates, hypo-osmotic swelling test (HOST), laser assisted selection and sperm tail flexibility test. In many assisted reproduction centers, these methods are applied to identify viable spermatozoa before considering alternative strategies, including sperm donation, oocyte cryopreservation, or repeat surgical sperm retrieval in pursuit of motile sperm [ 4 ]. As a result, viability selection techniques have become widely utilized as laboratory add-ons in ICSI cycles involving immotile or poorly motile sperm [ 4 ]. Despite their widespread use, robust evidence supporting the effectiveness and safety of these techniques remains lacking. Available studies are characterized by heterogeneity in design, variability in selection methods, and relatively small sample sizes, leading to inconsistent findings. Safety concerns are particularly relevant for chemical motility stimulants; experimental data from animal models have suggested potential embryotoxic effects following sperm exposure to agents such as pentoxifylline [ 6 ], although appropriate washing procedures prior to injection may mitigate this risk [ 7 ]. Non-chemical methods such as HOST and the sperm tail flexibility test avoid pharmacologic exposure but are limited by longer procedural time, operator dependency, and the possibility of false-positive viability assessment. Laser-assisted selection, while potentially effective, raises additional concerns regarding its invasive nature and the theoretical risk of sperm damage [ 1 ]. Given these uncertainties and absence of evidence from systematic reviews, a comprehensive synthesis of the available evidence is warranted. Therefore, we conducted a systematic review and meta-analysis to evaluate the effectiveness of sperm viability selection methods in improving reproductive outcomes in ICSI cycles involving immotile or poorly motile sperm and, critically, to assess their safety with respect to obstetric and neonatal outcomes. By quantitatively integrating existing data, this study aims to provide clinicians and patients with evidence-based guidance to inform decision-making in this challenging clinical scenario. Materials and Methods Registration, reporting, and patient and public involvement This systematic review and meta-analysis adhered to established reporting standards of MOOSE (Meta-analysis Of Observational Studies in Epidemiology) [ 8 ] and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [ 9 ] guidelines. The study protocol was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD420251017288). As this was a systematic review, no direct involvement of patients or members of the public was undertaken. Search strategies and eligibility criteria Eligibility criteria were defined according to the Population–Intervention–Comparison–Outcome (PICO) framework, and the detailed search strategy is provided in Supplemental Appendix S1. Two independent reviewers (Y.M. and S.E.) systematically searched PubMed, Cochrane Library, Scopus, and Web of Science for studies published from January 1990 to April 2025; the start date was selected to reflect the introduction of ICSI in 1992. The search was restricted to English-language articles comparing viability-based sperm selection techniques for immotile sperm with unselected sperm in couples undergoing ICSI, using predefined search terms outlined in Supplemental Appendix S1. We scrutinized the reference lists of included studies and relevant reviews to identify any additional articles. We further checked other websites manually to capture any other eligible studies ( https://www.semanticscholar.org/ ) ( https://researchrabbitapp.com/home ) ( https://www.connectedpapers.com ). The search strategy was developed and reported in accordance with the PRISMA-S (Preferred Reporting Items for Systematic Reviews and Meta-Analyses – Literature Search Extension) guidelines. Inclusion and exclusion criteria After manual duplicate removal, two independent investigators (S.E and Y.M) assessed titles and abstracts. Disagreements were solved by discussion with third reviewer (A.ED). A random sample of 2% of excluded studies was checked independently by two reviewers (Y.M and A.R) to ensure the accuracy of exclusion process. Full-text articles were subsequently evaluated for eligibility by two independent reviewers (Y.M. and S.E.), and discrepancies were resolved by consultation with a third reviewer (A.ED.). Studies were included if they met the following criteria: (i) involved patients undergoing ICSI using immotile or severely poorly motile sperm; (ii) applied an assisted sperm viability selection method for immotile sperm; (iii) included a comparison group in which untreated sperm were used for ICSI; (iv) were published as original, full-text articles in English; and (v) were randomized controlled trials (RCTs), cross-sectional studies, or prospective or retrospective comparative studies (cohort or case–control) reporting quantitative data on predefined embryological, clinical, neonatal, or obstetric outcomes. Studies were excluded if assisted viability selection methods were applied to sperm samples with normal motility or to retrograde ejaculates. In addition, reviews, commentaries, opinion pieces, letters, editorials, case reports, case series, animal studies, and conference abstracts were excluded. Data extraction A standardized data extraction spreadsheet was developed and pilot tested by Y.M. and A.ED. prior to formal use. Two reviewers (S.E. and A.E.) independently extracted data on study characteristics, including design, participant population, assisted sperm viability selection techniques, reported outcomes, and quantitative effect estimates. All extracted data were subsequently cross-checked by two senior reviewers (Y.M. and A.ED.) to resolve discrepancies and ensure completeness and accuracy of the dataset. Integrity check, risk of bias, and overall certainty of evidence assessments The integrity of included studies was assessed using the REAPPRAISED criteria, and studies raising serious concerns regarding data reliability were excluded following consensus among four reviewers (Y.M., A.ED., S.E., and A.E.). Prior to formal risk-of-bias assessment, the design of each included study was carefully reviewed and verified. When study design was mislabeled or unclear, three reviewers (S.E., A.H., and A.ED.) independently reclassified the design of the eligible studies to ensure methodological accuracy. For assessing the design of RCT, we followed the Cochrane definition ( https://handbook-5-1.cochrane.org/chapter_6/box_6_3_a_cochrane_definitions_and_criteria_for_randomized.htm ; and https://epoc.cochrane.org/sites/epoc.cochrane.org/files/uploads/SURE-Guides-v2.1/Collectedfiles/source/glossary.html ). Any disagreements were resolved by a fourth investigator (Y.M.), who made the final determination and reviewed the classification of all eligible studies to ensure methodological accuracy and consistency. Two investigators (S.E and A.E) appraised the quality of included studies independently using Joanna Briggs Institute (JBI) Checklists [ 11 ]. Discrepancies were discussed with third reviewer (Y.M) until agreement was achieved. According to assessment criteria, eligible studies were classified as 'low', 'high' or 'unclear' risk of bias. Two independent reviewers (Y.M and A.ED) assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework, according to the Cochrane GRADE handbook guidelines [ 12 ]. This included outcome-level assessment of risk of bias, inconsistency, indirectness, imprecision, and other biases (e.g. publication bias or observational study design). Disagreements were solved by discussion. Outcome measures The primary outcome was live birth rate, defined as live birth beyond 20 weeks of gestation. Secondary outcomes included embryological, pregnancy and neonatal outcomes, as defined elsewhere [ 13 ]. Quantitative analysis Statistical analyses were performed using the Cochrane Collaboration Review Manager Software (Rev-Man version 5.4.1) and a Web-Based Tool [ 14 ]. We reported the results using risk ratios (RRs) for dichotomous outcomes or mean difference (MD) for continuous outcomes, and with associated 95% confidence intervals (CIs). Heterogeneity was assessed for all outcomes using the I 2 test [ 15 ], Q test and tau-squared values. We analyzed data using a fixed effect model for non-significant heterogeneity and a random effect model for significant heterogeneity between studies. To assess the conclusiveness and robustness of the primary outcome, we used trial sequential analysis. We maintained an overall 5% risk of type I error, with a risk of type II error of 20%, at a power of 80%. We used a relative risk reduction of 20%. We considered subgroups in our analyses by method of viability sperm selection. A P <.05 was considered statistically significant. We first analyzed all included studies for all outcomes. Then we conducted a sensitivity analysis for the primary outcome considering only studies with immotile sperm in control group. Results Databases and other websites search retrieved 393 studies. After duplicate removal, 294 studies were screened for title and abstract, and then 33 were screened for full-text eligibility (Fig. 1, for PRISMA). After exclusions for various reasons, presented in Fig. 1, we checked 17 studies for integrity. We excluded one study [ 16 ] after integrity check, and included only 16 [ 17 – 32 ] studies from 11 countries for the final analysis. Description of the included studies The characteristics of included studies are presented in (Table 1). The systematic review ultimately included sixteen eligible studies (2 RCT and 14 cohort studies). All included studies were written in English and published between 1996 and 2024. One study totaling 198 ICSI cycles used sperMagic medium for motility initiation [ 17 ], three studies totaling 982 ICSI cycles used theophylline [ 19 , 25 , 27 ], five studies totaling 682 ICSI cycles used pentoxifylline [ 20 , 24 , 26 , 30 , 31 ], two studies used laser-based sperm selection totaling 209 ICSI cycles [ 21 , 22 ], four studies totaling 328 used HOST [ 23 , 28 , 29 , 32 ], and one study totaling 66 ICSI cycles used mechanical touch technique [ 18 ]. Overall, the quality of included studies varied from low to high risk of bias according to JBI checklists. Among the 16 studies assessed, 7 were of low, 4 moderate, and 5 high risk of bias, as presented in supplemental table 1. Live Birth Across of 13 studies [ 17 – 23 , 25 , 27 , 29 – 32 ] with 2076 patients, sperm viability selection was associated with higher live birth rate compared to control (RR 1.19; 95% CI, 1.05–1.36; P = 0.009; low-quality evidence), Fig. 2A. The total number of patients for our primary outcome, live birth, was robust as suggested by the Z curve (Figure, 2C). The Q test and the I 2 index found minimal heterogeneity for the live birth outcome ( P = 0.38, I 2 = 6.6%). The funnel plot of our primary outcome, live birth rate, was suggestive of a publication bias, Fig. 2B. The Egger's test supports the presence of funnel plot asymmetry (intercept 1.35; 95% CI, 0.58–2.13; t = 3.419; p = 0.006). We further analyzed the rate of live birth according to the method of sperm viability selection used. For sperMagic and Mechanical touch technique methods, subgroup analysis was not applicable because each method was evaluated only once in one study. The use of theophylline revealed a statistically significant higher live birth rate compared to untreated sperm (RR 1.45; 95% CI, 1.09–1.92; P = 0.01; I 2 =66.4%; 3 studies with 813 patients). No improvement in the rate of live birth was observed using other methods, including pentoxifylline (RR 1.00; 95% CI, 0.79–1.27; P = 0.98; I 2 =0%; 3 studies with 531 patients), laser assisted selection (RR 1.35; 95% CI, 0.96–1.88; P = 0.08; I 2 =0%; 2 studies with 285 patients) and HOST (RR 1.18; 95% CI, 0.75–1.88; P = 0.48; I 2 =0%; 3 studies with 188 patients). A sensitivity analysis for studies evaluating patients with no motility in sperm samples for both sperm viability selection group and control group (5 studies with 984 patients) confirmed the same findings of improved rate of live birth (RR 1.26; 95% CI, 1.01–1.57; P = 0.042; I 2 = 0%) after using sperm viability selection compared to untreated immotile sperm. Pregnancy Outcomes We found improvement on the rates of clinical pregnancy (15 studies, 2315 patients, low-quality evidence) [ 17 – 21 , 23 – 32 ] and ongoing pregnancy (3 studies, 264 patients, very low-quality evidence) [ 24 , 28 , 30 ] after using sperm viability selection compared to untreated sperm. We found no increase on the rate of multiple pregnancy between both groups (5 studies, 1201 patients, very low-quality evidence) [ 17 , 19 , 25 , 27 , 31 ], Supplementary figure-1. Heterogeneity ranged from minimal to moderate for pregnancy outcomes, as suggested by the Q test and the I 2 index (clinical pregnancy P = 0.08, I 2 = 36.2%; ongoing pregnancy P = 0.2, I 2 = 36.7%; multiple pregnancy P = 0.97, I 2 = 0%). Data for implantation rate [ 17 – 21 , 23 , 25 – 28 , 30 , 31 ] (12 studies, 3728 transferred embryos, very low quality evidence) did not detect difference between both groups (RR 1.05; 95% CI, 0.94–1.17; P = 0.4; I 2 = 24.9%). Data from two studies with 388 patients [ 17 , 31 ] found no difference on the rate of ectopic pregnancy between both groups (RR 0.35; 95% CI, 0.04–3.54; P = 0.38; I 2 =0%, very low quality evidence). The funnel plot suggested potential publication bias for pregnancy outcomes, except for multiple and ectopic pregnancies. Embryological outcomes For embryological outcomes, the rates of fertilization, cleavage, top-quality day-3 embryos and blastocyst formation did not improve using sperm viability selection methods compared to control. The rate of top-quality blastocyst was significantly higher in viability sperm selection group compared to control group. The quality of evidence for all embryological outcomes is very low. We used random effects model for all embryological outcomes due to significant heterogeneity, Supplementary figure-1. The funnel plots for all embryological outcomes did not support the presence of potential publication bias. Neonatal and obstetrics outcomes There was no significant difference in birth weight (MD -0.2; 95% CI, -0.59-0.19; P = 0.3, I 2 =67.4%; 4 studies; very low-quality evidence), sex ratio (RR 1.19; 95% CI, 0.96–1.46; P = 0.11; I 2 =29.3%; 2 studies; very low-quality evidence) and birth defects (RR 0.18; 95% CI, 0.02–1.36; P = 0.09; I 2 =0%; 6 studies; very low quality evidence), supplementary figure-1. We found no differences between both groups in gestational age (MD -0.05; 95% CI, -0.24-0.14; P = 0.63; I 2 =45.5%; 4 studies; very low-quality evidence) and cesarean section (RR 0.73; 95% CI, 0.5–1.06; P = 0.1; I 2 = 0%; 2 studies; very low-quality evidence), supplementary figure-1. Discussion Although sperm viability selection techniques for immotile sperm are now widely implemented across in vitro fertilization laboratories [ 4 ], their clinical benefits and potential risks remain uncertain. Pooled estimates indicate that, among patients with severe male factor infertility undergoing ICSI with immotile sperm, the use of viability selection methods was associated with a higher live birth rate compared with ICSI performed using unselected sperm. However, this finding should be interpreted cautiously considering the low overall certainty of the available evidence. While ICSI has revolutionized the management of severe male factor infertility, patients with absent or markedly impaired sperm motility continue to experience suboptimal reproductive outcomes. Furthermore, concerns have been raised regarding a potentially increased risk of neonatal morbidity related to both underlying paternal factors and assisted reproductive techniques [ 33 , 34 ]. Accordingly, developing adequate, optimized programs during ICSI treatment is crucial considering not only effectiveness but also safety outcomes on offspring and mothers. In our analysis, the overall risk of adverse neonatal and obstetric outcomes appeared comparable between viability selection and control groups. Nonetheless, the number of studies reporting these safety endpoints was limited, restricting the precision of these estimates. Robust, adequately powered studies are needed to further evaluate short-term safety outcomes, and long-term follow-up data on children conceived following sperm viability selection remain urgently required to fully establish the safety profile of these interventions. The use of adjunctive interventions, commonly referred to as “add-ons,” has become increasingly prevalent in reproductive medicine. These interventions are often costly and have generated ethical and professional debate because of limited or insufficient high-quality evidence supporting their effectiveness and safety [ 5 ]. The development of robust, evidence-based guidance for add-ons is therefore essential to support informed decision-making by clinicians and patients throughout the fertility treatment journey [ 5 ]. Sperm viability selection, also described as artificial sperm activation, has been addressed by the European Society of Human Reproduction and Embryology (ESHRE) Add-ons Working Group, which recommends its use in cases of primary or secondary total asthenozoospermia but not for routine application [ 35 ]. However, these recommendations are largely based on heterogeneous primary studies with limited certainty of evidence. Findings from our systematic review and meta-analysis suggest that sperm viability selection for immotile sperm in ICSI cycles may improve live birth outcomes without increasing short-term adverse neonatal or obstetric risks compared with unselected sperm. Nevertheless, given the low overall quality of available evidence, the use of sperm viability selection should remain restricted to carefully selected cases with absent or severely impaired motility until further high-quality studies provide more definitive conclusions. Sperm viability methods of immotile sperm offer reliable selection of competent viable sperm with the highest fertilization potential available for injecting oocytes [ 4 ]. However, no evidence or consensus is available to recommend a preferred and effective method. In our subgroup analyses, the use of theophylline was associated with an increased live birth rate compared with unselected sperm. In contrast, no statistically significant difference in live birth was observed when immotile sperm were selected randomly or through the hypo-osmotic swelling test (HOST), laser-assisted selection, or pentoxifylline-based activation. For other evaluated techniques, the available data were insufficient to permit meaningful conclusions. It is important to recognize that several manual selection methods are highly operator-dependent, and outcomes may be influenced by the embryologist’s expertise, potentially introducing subjective bias and inter-operator variability. Chemical activation with theophylline, which induces sperm motility, may reduce reliance on technical skill in identifying viable immotile sperm. Compared with pentoxifylline, theophylline has a longer half-life, which may contribute to its sustained stimulatory effect [ 36 ]. Nevertheless, these findings must be interpreted with caution, as the overall certainty of evidence is limited by small sample sizes, methodological heterogeneity, and a scarcity of well-designed randomized controlled trials. There are numerous strengths to our review. To our knowledge, this is the first meta-analysis to assess the effectiveness and safety of sperm viability selection for ICSI patients with immotile sperm. The inclusion of a large cumulative sample size, together with follow-up extending to live birth in most studies, enhanced statistical power and contributed to the robustness of the pooled estimates. We applied a rigorous and comprehensive methodological approach to ensure systematic identification and inclusion of eligible observational and comparative studies, enabling assessment of the totality of available evidence and identification of persisting knowledge gaps. Methodological quality was evaluated using the revised Joanna Briggs Institute (JBI) critical appraisal tools, which are particularly appropriate for non-randomized study designs [ 37 ]. In addition, the integrity of included studies was assessed using the REAPPRAISED checklist to minimize the risk of incorporating untrustworthy or unreliable data into the evidence synthesis [ 10 ]. Several notable limitations should be considered when interpreting our findings. First, our meta-analysis included only two RCT while the remaining studies were cohort. Therefore, the results are affected by unmeasured confounding factors. However, heterogeneity ranged from low to moderate for most outcomes, which may reflect minimal effect of potential confounding factors on outcomes. Second, evidence of publication bias was identified for the primary outcome of live birth, warranting cautious interpretation of the magnitude of effect. Third, the limited number of studies reporting neonatal and obstetric outcomes restricts the precision and reliability of conclusions regarding safety. Fourth, inconsistencies in the definition and composition of control groups across eligible studies represent an additional limitation; however, sensitivity analyses excluding studies that included motile sperm in the control group yielded comparable results, supporting the robustness of the main findings. Taken together, these limitations underscore the urgent need for well-designed, adequately powered randomized controlled trials with clearly defined populations and standardized outcome reporting to validate the role of sperm viability selection in clinical practice. This review highlights the importance of strengthening the evidence base to better understand the implications of sperm viability selection on ICSI effectiveness and safety outcomes. Conclusions There is little evidence to support the beneficial effect of sperm viability selection in improving of live birth rate without adverse effect on neonatal and obstetric outcomes. The results should be interpreted with caution due to the very low to low quality of evidence. Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials No new data was created in this study. All data utilized are publicly accessible and can be provided by the author, upon reasonable request. Competing interests Y.M. has nothing to disclose. S.E. has nothing to disclose. A.R has nothing to disclose. A.E. has nothing to disclose. A.ED. has nothing to disclose. Funding The study received no funding. Authors' contributions Y.M: Conceptualization, Writing – original draft, review & editing, Software, Methodology, Investigation, Formal analysis, Data curation, critical revision and supervision. S.E: Conceptualization, Writing – review & editing, Methodology. A.R: Conceptualization, Writing – review & editing, Methodology. A.H: Writing – review & editing, Methodology. A.ED: Methodology, Data curation, critical revision, Writing – review & editing. All authors contributed to interpreting the findings, revising and editing the article. All authors approved the final version before submission. Acknowledgements The authors would like to thank Professor Khalid Saeed Khan for his valuable educational videos and advice through his YouTube channel that helped us to perform this study with the highest integrity standards in all steps. This work was presented at the 31 th annual international conference of the Egyptian Fertility and Sterility Society and won the Best Innovation in Fertility Award. In preparing this manuscript, the author(s) used artificial intelligence tools in order to enhance the clarity of writing and check spelling and grammar. Prior to submission, the author(s) reviewed the content edited by AI and took full responsibility for the content of the submitted manuscript. 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Fertil Steril 75:480–484. https://doi.org/10.1016/s0015-0282(00)01762-3 Griveau J-F, Lobel B, Laurent M-C et al (2006) Interest of pentoxifylline in ICSI with frozen-thawed testicular spermatozoa from patients with non-obstructive azoospermia. Reprod Biomed Online 12:14–18. https://doi.org/10.1016/s1472-6483(10)60974-1 Dong J, Yin M, Wu L et al (2024) Pregnancy and neonatal outcomes of ICSI using pentoxifylline to identify viable spermatozoa in patients with frozen-thawed testicular spermatozoa. Front Endocrinol 15:1364285. https://doi.org/10.3389/fendo.2024.1364285 Casper RF, Meriano JS, Jarvi KA et al (1996) The hypo-osmotic swelling test for selection of viable sperm for intracytoplasmic sperm injection in men with complete asthenozoospermia. Fertil Steril 65:972–976. https://doi.org/10.1016/s0015-0282(16)58271-5 Rumbold AR, Sevoyan A, Oswald TK et al (2019) Impact of male factor infertility on offspring health and development. Fertil Steril 111:1047–1053. https://doi.org/10.1016/j.fertnstert.2019.05.006 Coates A, Hesla JS, Hurliman A et al (2015) Use of suboptimal sperm increases the risk of aneuploidy of the sex chromosomes in preimplantation blastocyst embryos. Fertil Steril 104:866–872. https://doi.org/10.1016/j.fertnstert.2015.06.033 ESHRE Add-ons working group, Lundin K, Bentzen JG et al (2023) Good practice recommendations on add-ons in reproductive medicine†. Hum Reprod Oxf Engl 38:2062–2104. https://doi.org/10.1093/humrep/dead184 Ebner T, Shebl O, Mayer RB et al (2014) Healthy live birth using theophylline in a case of retrograde ejaculation and absolute asthenozoospermia. Fertil Steril 101:340–343. https://doi.org/10.1016/j.fertnstert.2013.10.006 Van Wely M, Hastings JM, Tarlatzis BC, Wang R (2025) Bias busters: using the right risk-of-bias tools. Hum Reprod Update. https://doi.org/10.1093/humupd/dmaf016 Table 1 Table 1: Characteristics of included studies Author and year Location Time period Study design Intervention Control Outcomes assessed Funding source Number of ICSI cycles Sperm Assisted selection method or agent Main Finding 1 Gu et al., 2018 China March 1, 2015 to January 31, 2016 Prospective cohort study Patients with sperm from TESE or absolute asthenozoo spermia and no motility detected after search, where SperMagic media was used to induce motility. Patients with sperm from TESE or absolute asthenozoo spermia and motility detected after search The rates of fertilisation, cleavage, implantation, pregnancy, live birth and neonatal out comes The study was funded by the National Natural Science Foundation of China (31401069, 31271596 and 81222007), Major State Basic Research Development Program of China (973 Program) (2012CB944901) and Natural Science Foundation of Hunan Province of China (2017JJ2327 198 SperMagic medium Data showed no improvement in the embryological or clinical outcomes after using SperMagic media for cases with complete absence of motility as compared to control group of untreated sperm. Neonatal outcomes were also similar between both groups. 2 Sandi‑Monroy et al., 2019 Germany August 2012 to January 2018 Retrospective cohort study Patients with immotile sperm, either TESE or ejaculated, where SpermMobil was used to induce motility. Patients with immotile sperm, either TESE or ejaculated. Fertilization rate, clinical outcomes, obstetric and perinatal outcomes No fund was received. 815 Theophylline Higher fertilization rate and lower miscarriage rate were detected after using theophylline, without adverse effects on obstetric and perinatal outcomes. 3 Aizer et al., 2021 Israel Between January 2013 and December 2019 Retrospective cohort study Patients undergoing ICSI with immotile testicular sperm with addition to pentoxifiline to induce motility/ Patients undergoing ICSI using motile testicular sperm. The rates of fertilization, top-quality embryos, cumulative clinical pregnancy, gestational sacs, implantation rate and cumulative live birth. Not reported 148 Pentoxifylline Although lower cumulative clinical pregnancy and cumulative live birth was detected in cases with immotile testicular sperm, even after addition of pentoxifiline as compared to motile sperm, it remains effective before counselling for donor spermatozoa or cryopreserving oocytes for future consideration. 4 Chen et al., 2021 China June 2014 to June 2018 Retrospective cohort study Azoospermic patients underwent ICSI with immotile sperm. Viable sperm were selected using Laser. Azoospermic patients underwent ICSI with immotile sperm. Pregnancy, implantation, miscarriage and live birth rate. Perinatal and neonatal outcomes were measured. The Guangxi National Science Foundation (Grant No. 2018JJB140142), projects grant from the Self Raised Foundation of Guangxi Health Commission (Project #Z20170777 and #Z20180078) and a project grant from the Research Foundation of Guangxi Medical and Health (Project# S2020056) supported this work. 132 cycles Laser-based sperm selection The rates of embryological, clinical, perinatal and neonatal outcomes were comparable between both groups. 5 Aktan1 et al., 2004 Turkey November 2002 and August 2003 Prospective cohort study Patients with immotile sperm, either ejaculated or testicular, where laser was used to select viable immotile sperm. Patients with immotile sperm, either ejaculated or testicular and underwent conventional ICSI. The rates of fertilization, cleavage, pregnancy and take-home baby rate. Not reported 77 patients Laser-based sperm selection Higher fertilization and cleavage rates were achieved after selection of viable immotile sperm for ICSI using laser, as compared to ICSI with immotile sperm without selection. 6 Kovac ˇic et al., 2006 Slovenia Between 1999 and 2003 Retrospective cohort study-Historical control Patients underwent ICSI using testicular sperm with complete immotile sperm, where Pentoxifylline was used to induce motility Patients underwent ICSI using testicular sperm with complete immotile untreated sperm. The rates of fertilization, blastulation, clinical pregnancy, miscarriage, ongoing pregnancy and livebirth. Not reported 77 Pentoxifylline Using pentoxifylline for cases underwent ICSI with immotile sperm improved fertilization rate as compared to untreated immotile sperm. Both groups were comparable for blastulation rate and clinical outcomes. 7 Cakira et al., 2024 Turkey June 2011 and July 2023 Retrospective sibling-oocytes cohort study Oocytes injected s with immotile sperm samples either ejaculated or testicular (fresh or frozen). oocytes injected with few motile sperm detected in the samples of the same population of intervention group. The rates of fertilization rate, implantation rate, live birth rate. Obstetric and neonatal outcomes were measured. No fund was received 203 cycles HOST Embryological, clinical and neonatal outcomes were comparable between immotile-HOS-positive sperm and motile sperm for fresh samples. For frozen-thawed samples, significantly lower fertilization and blastocyst formation rates were observed in with immotile-HOS-positive sperm compared to motile sperm. However, the rates of clinical, obstetric, and neonatal outcomes were similar. 8 Wober et al., 2015 Austria Two-year period Prospective cohort study Patients underwent ICSI with fresh TESE, where immotile sperm was treated with theophylline. Patients underwent ICSI with fresh TESE and have motile sperm in their samples. The rates of fertilization, blastulation, implantation, pregnancy, and live birth. Not reported 63 patients/102 cycles Theophylline The use of ready to use theophylline is effective and safe for patients with immotile testicular sperm. 9 de Oliveira et al., 2004 Spain July 2001-May 2002 Retrospective cohort study Patients underwent ICSI using immotile sperm of either fresh or frozen TESE samples. The flexibility and shape of sperm tail were assessed as an indicator of viability prior ICSI Patients underwent ICSI using motile sperm of either fresh or frozen TESE samples. The rates of fertilization, cleavage, implantation, pregnancy and take baby home. Not reported 61 patients/66 cycles Mechanical touch technique Mechanical touch technique is effective in selection of immotile sperm in patients undergoing ICSI using testicular sperm. Data showed similar rates of fertilization, cleavage, implantation, pregnancy and take baby home achieved using mechanical touch technique for selection of immotile sperm as compared to motile sperm of TESE samples. 10 Terriou et al., 2000 France Not reported Prospective cohort study Patients with complete immotile sperm from either fresh or frozen epididymal or testicular spermatozoa. The samples were treated with pentoxifylline before ICSI. Patients with spontaneously motile spermatozoa without treatment from either fresh or frozen epididymal or testicular spermatozoa. The rates of fertilization, cleavage, pregnancy and implantation Not reported 159 Pentoxifylline Although no significant improvements were detected after adding pentoxifylline in fertilization, cleavage and pregnancy rates, pentoxifylline efficiently initiated motility. 11 Ebner et al., 2011 Austria Between January and October 2010 Prospective sibling-oocytes cohort study Patients underwent ICSI treatment with frozen-thawed TESE. Sperm were treated with theophylline prior ICSI. Patients underwent ICSI treatment with frozen-thawed TESE. ICSI was performed with untreated sperm. The rates of fertilization, cleavage, blastulation, top-quality cleaved embryos and blastocysts. The rates of clinical pregnancy, implantation and livebirth were measured. Not reported 65 patients Theophylline Using theophylline for stimulation motility of TESE samples after thawing was effective and significantly improved the rates of fertilization and blastulation. It also improved clinical pregnancy and implantation and livebirth rates. 12 El-Nour et al., 2001 Saudi Arabia September 1997 and July 1999 Randomized controlled study Patients underwent ICSI with immotile sperm, either ejaculated or testicular sperm, where sperm was selected based on HOS viability test Patients underwent ICSI with immotile sperm, either ejaculated or testicular sperm, where ICSI was done with untreated immotile sperm. The rates of fertilization, cleavage, embryo quality, pregnancy, and implantation rates Not reported 30 cycles HOST No statistical significance was observed between groups in terms of fertilization, cleavage, quality of embryos, pregnancy and implantation rates. 13 Sallam et al., 2005 Egypt January 2002 and August 2004 Randomized controlled study Patients underwent ICSI with TESE and no motility was detected. HOS was used to detect viability. Patients underwent ICSI with TESE and no motility was detected. Sperm selection was based on their morphology. The rates of fertilization, top quality embryos, pregnancy and ongoing pregnancy. Not reported 79 patients HOST Data showed significant improvement in the rates of fertilization, pregnancy and ongoing pregnancy rates after the use of HOS to select viable immotile sperm for ICSI, as compared conventional selection of immotile sperm based on their morphology. 14 Griveau et al., 2006 France January 2000 to December 2004 Retrospective cohort study Patients underwent ICSI with frozen testicular sperm and showed no motility after thawing and pentoxifylline was used to induce motility Patients underwent ICSI with frozen testicular sperm and showed motility after thawing The rates of Fertilization, implantation, pregnancies, livebirth and newborn malformations Not reported 108 Pentoxifylline The study reported significant decrease in fertilization rate with the use of pentoxifylline compared to control group. 15 Dong et al., 2024 China April 2013 to June 2021 Retrospective cohort study Patients underwent ICSI with testicular sperm (TESA), where pentoxifylline was used to induce motility. Patients underwent ICSI with testicular sperm (TESA. Clinical outcomes including, biochemical pregnancy, clinical pregnancy, implantation, miscarriage, ectopic pregnancy, multiple pregnancy and live birth rates. Neonatal outcomes, including birth defect, birth weight, gestational age, preterm birth, and early-neonatal death. The study was funded by the National Natural Science Foundation of China (Grant No. 81971448). 341 patients with testicular sperm (190 patients after propensity score matching) Pentoxifylline No significant differences were detected in clinical or neonatal outcomes after using pentoxifylline for patients underwent ICSI with testicular sperm, as compared to untreated sperm. 16 Casper et al., 1996 Canada Not reported Nonrandomized, sequential cohort study Patients with complete immotile sperm in ejaculates, where HOS was used for selection of viable sperm. Patients with complete immotile sperm in ejaculates, where sperm was randomly injected. Fertilization, cleavage, clinical pregnancy, miscarriage and live birth. Not reported 13 patients/ 16 cycles HOST Based on preliminary results, selection of immotile sperm using HOS may improve fertilization and cleavage rates, compared to random selection. Note: HOST= hypo-osmotic swelling test, ICSI= intracytoplasmic sperm injection, TESA= testicular sperm aspiration, TESE = testicular sperm extraction. Additional Declarations The authors declare no competing interests. Supplementary Files 1SuppFigureOverallresults.pdf Overall results AppendixS1.docx Appendix S1-PICO SuppTable1.docx Table S1- Critical appraisal of eligible cohort studies Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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legend\u003c/p\u003e","description":"","filename":"fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8961164/v1/2dedb453cfa86dfb295b2941.jpg"},{"id":104399362,"identity":"228a5074-78e7-4d8b-80e8-8ca28b3d99e3","added_by":"auto","created_at":"2026-03-11 12:05:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":356409,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8961164/v1/330407294401823e3b4041e2.jpg"},{"id":104407810,"identity":"ae9fd1ec-61fa-407a-b23e-3c44b04530e1","added_by":"auto","created_at":"2026-03-11 12:40:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1635949,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8961164/v1/349d674f-9047-4abd-aec2-e61d99bff901.pdf"},{"id":104399490,"identity":"8138f879-8810-4e4e-869a-a4a5a85f554c","added_by":"auto","created_at":"2026-03-11 12:06:21","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1096669,"visible":true,"origin":"","legend":"\u003cp\u003eOverall results\u0026nbsp;\u003c/p\u003e","description":"","filename":"1SuppFigureOverallresults.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8961164/v1/53212759427978d6c0ce939a.pdf"},{"id":104398870,"identity":"5a7ad196-4266-4cb3-9c94-2b96131f2e0c","added_by":"auto","created_at":"2026-03-11 12:04:04","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":24094,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix S1-PICO\u003c/p\u003e","description":"","filename":"AppendixS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8961164/v1/c815b49e2bfc7b9d3e5aaa55.docx"},{"id":104399551,"identity":"803af97e-c0af-492b-8d66-7483ae03450e","added_by":"auto","created_at":"2026-03-11 12:06:37","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":26614,"visible":true,"origin":"","legend":"\u003cp\u003eTable S1- Critical appraisal of eligible cohort studies\u0026nbsp;\u003c/p\u003e","description":"","filename":"SuppTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8961164/v1/f04c039bac572d33915737f3.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eSperm Viability Selection for Immotile Sperm in ICSI: A Systematic Review and Meta-Analysis\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"What does this study add to the clinical work?","content":"\u003cp\u003eThere is evidence to support the beneficial effect of sperm viability selection in improving of live birth rate without adverse effect on neonatal and obstetric outcomes.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eSperm vitality, usually assessed by motility, plays a central role in successful fertilization during intracytoplasmic sperm injection (ICSI) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], where the embryologist must identify and select a viable spermatozoon for microinjection. Absence or severe impairment of sperm motility is common in men with azoospermia, which represent 1\u0026ndash;2% of the male population and up to 15% of infertile men [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Complete absence of motile sperm in the ejaculate has been estimated to occur in approximately 1 in 5000 men [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Complete or severe absence of sperm motility has negative impact on success rates of ICSI treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], which in turn is associated with psychological and emotional distress [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVarious sperm viability selection techniques have been developed and incorporated into clinical practice to overcome this challenge. These includes chemical motility stimulates, hypo-osmotic swelling test (HOST), laser assisted selection and sperm tail flexibility test. In many assisted reproduction centers, these methods are applied to identify viable spermatozoa before considering alternative strategies, including sperm donation, oocyte cryopreservation, or repeat surgical sperm retrieval in pursuit of motile sperm [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. As a result, viability selection techniques have become widely utilized as laboratory add-ons in ICSI cycles involving immotile or poorly motile sperm [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite their widespread use, robust evidence supporting the effectiveness and safety of these techniques remains lacking. Available studies are characterized by heterogeneity in design, variability in selection methods, and relatively small sample sizes, leading to inconsistent findings. Safety concerns are particularly relevant for chemical motility stimulants; experimental data from animal models have suggested potential embryotoxic effects following sperm exposure to agents such as pentoxifylline [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], although appropriate washing procedures prior to injection may mitigate this risk [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Non-chemical methods such as HOST and the sperm tail flexibility test avoid pharmacologic exposure but are limited by longer procedural time, operator dependency, and the possibility of false-positive viability assessment. Laser-assisted selection, while potentially effective, raises additional concerns regarding its invasive nature and the theoretical risk of sperm damage [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven these uncertainties and absence of evidence from systematic reviews, a comprehensive synthesis of the available evidence is warranted. Therefore, we conducted a systematic review and meta-analysis to evaluate the effectiveness of sperm viability selection methods in improving reproductive outcomes in ICSI cycles involving immotile or poorly motile sperm and, critically, to assess their safety with respect to obstetric and neonatal outcomes. By quantitatively integrating existing data, this study aims to provide clinicians and patients with evidence-based guidance to inform decision-making in this challenging clinical scenario.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eRegistration, reporting, and patient and public involvement\u003c/h2\u003e \u003cp\u003eThis systematic review and meta-analysis adhered to established reporting standards of MOOSE (Meta-analysis Of Observational Studies in Epidemiology) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] guidelines. The study protocol was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD420251017288). As this was a systematic review, no direct involvement of patients or members of the public was undertaken.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSearch strategies and eligibility criteria\u003c/h3\u003e\n\u003cp\u003eEligibility criteria were defined according to the Population\u0026ndash;Intervention\u0026ndash;Comparison\u0026ndash;Outcome (PICO) framework, and the detailed search strategy is provided in Supplemental Appendix S1. Two independent reviewers (Y.M. and S.E.) systematically searched PubMed, Cochrane Library, Scopus, and Web of Science for studies published from January 1990 to April 2025; the start date was selected to reflect the introduction of ICSI in 1992. The search was restricted to English-language articles comparing viability-based sperm selection techniques for immotile sperm with unselected sperm in couples undergoing ICSI, using predefined search terms outlined in Supplemental Appendix S1. We scrutinized the reference lists of included studies and relevant reviews to identify any additional articles. We further checked other websites manually to capture any other eligible studies (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.semanticscholar.org/\u003c/span\u003e\u003cspan address=\"https://www.semanticscholar.org/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://researchrabbitapp.com/home\u003c/span\u003e\u003cspan address=\"https://researchrabbitapp.com/home\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.connectedpapers.com\u003c/span\u003e\u003cspan address=\"https://www.connectedpapers.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The search strategy was developed and reported in accordance with the PRISMA-S (Preferred Reporting Items for Systematic Reviews and Meta-Analyses \u0026ndash; Literature Search Extension) guidelines.\u003c/p\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eAfter manual duplicate removal, two independent investigators (S.E and Y.M) assessed titles and abstracts. Disagreements were solved by discussion with third reviewer (A.ED). A random sample of 2% of excluded studies was checked independently by two reviewers (Y.M and A.R) to ensure the accuracy of exclusion process.\u003c/p\u003e \u003cp\u003eFull-text articles were subsequently evaluated for eligibility by two independent reviewers (Y.M. and S.E.), and discrepancies were resolved by consultation with a third reviewer (A.ED.). Studies were included if they met the following criteria: (i) involved patients undergoing ICSI using immotile or severely poorly motile sperm; (ii) applied an assisted sperm viability selection method for immotile sperm; (iii) included a comparison group in which untreated sperm were used for ICSI; (iv) were published as original, full-text articles in English; and (v) were randomized controlled trials (RCTs), cross-sectional studies, or prospective or retrospective comparative studies (cohort or case\u0026ndash;control) reporting quantitative data on predefined embryological, clinical, neonatal, or obstetric outcomes.\u003c/p\u003e \u003cp\u003eStudies were excluded if assisted viability selection methods were applied to sperm samples with normal motility or to retrograde ejaculates. In addition, reviews, commentaries, opinion pieces, letters, editorials, case reports, case series, animal studies, and conference abstracts were excluded.\u003c/p\u003e\n\u003ch3\u003eData extraction\u003c/h3\u003e\n\u003cp\u003eA standardized data extraction spreadsheet was developed and pilot tested by Y.M. and A.ED. prior to formal use. Two reviewers (S.E. and A.E.) independently extracted data on study characteristics, including design, participant population, assisted sperm viability selection techniques, reported outcomes, and quantitative effect estimates. All extracted data were subsequently cross-checked by two senior reviewers (Y.M. and A.ED.) to resolve discrepancies and ensure completeness and accuracy of the dataset.\u003c/p\u003e\n\u003ch3\u003eIntegrity check, risk of bias, and overall certainty of evidence assessments\u003c/h3\u003e\n\u003cp\u003eThe integrity of included studies was assessed using the REAPPRAISED criteria, and studies raising serious concerns regarding data reliability were excluded following consensus among four reviewers (Y.M., A.ED., S.E., and A.E.).\u003c/p\u003e \u003cp\u003ePrior to formal risk-of-bias assessment, the design of each included study was carefully reviewed and verified. When study design was mislabeled or unclear, three reviewers (S.E., A.H., and A.ED.) independently reclassified the design of the eligible studies to ensure methodological accuracy.\u003c/p\u003e \u003cp\u003eFor assessing the design of RCT, we followed the Cochrane definition (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://handbook-5-1.cochrane.org/chapter_6/box_6_3_a_cochrane_definitions_and_criteria_for_randomized.htm\u003c/span\u003e\u003cspan address=\"https://handbook-5-1.cochrane.org/chapter_6/box_6_3_a_cochrane_definitions_and_criteria_for_randomized.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e; and \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://epoc.cochrane.org/sites/epoc.cochrane.org/files/uploads/SURE-Guides-v2.1/Collectedfiles/source/glossary.html\u003c/span\u003e\u003cspan address=\"https://epoc.cochrane.org/sites/epoc.cochrane.org/files/uploads/SURE-Guides-v2.1/Collectedfiles/source/glossary.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Any disagreements were resolved by a fourth investigator (Y.M.), who made the final determination and reviewed the classification of all eligible studies to ensure methodological accuracy and consistency.\u003c/p\u003e \u003cp\u003eTwo investigators (S.E and A.E) appraised the quality of included studies independently using Joanna Briggs Institute (JBI) Checklists [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Discrepancies were discussed with third reviewer (Y.M) until agreement was achieved. According to assessment criteria, eligible studies were classified as 'low', 'high' or 'unclear' risk of bias.\u003c/p\u003e \u003cp\u003eTwo independent reviewers (Y.M and A.ED) assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework, according to the Cochrane GRADE handbook guidelines [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This included outcome-level assessment of risk of bias, inconsistency, indirectness, imprecision, and other biases (e.g. publication bias or observational study design). Disagreements were solved by discussion.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcome measures\u003c/h2\u003e \u003cp\u003eThe primary outcome was live birth rate, defined as live birth beyond 20 weeks of gestation. Secondary outcomes included embryological, pregnancy and neonatal outcomes, as defined elsewhere [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQuantitative analysis\u003c/h3\u003e\n\u003cp\u003eStatistical analyses were performed using the Cochrane Collaboration Review Manager Software (Rev-Man version 5.4.1) and a Web-Based Tool [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. We reported the results using risk ratios (RRs) for dichotomous outcomes or mean difference (MD) for continuous outcomes, and with associated 95% confidence intervals (CIs). Heterogeneity was assessed for all outcomes using the \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e test [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], Q test and tau-squared values. We analyzed data using a fixed effect model for non-significant heterogeneity and a random effect model for significant heterogeneity between studies. To assess the conclusiveness and robustness of the primary outcome, we used trial sequential analysis. We maintained an overall 5% risk of type I error, with a risk of type II error of 20%, at a power of 80%. We used a relative risk reduction of 20%.\u003c/p\u003e \u003cp\u003eWe considered subgroups in our analyses by method of viability sperm selection. A \u003cem\u003eP\u003c/em\u003e\u0026lt;.05 was considered statistically significant. We first analyzed all included studies for all outcomes. Then we conducted a sensitivity analysis for the primary outcome considering only studies with immotile sperm in control group.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDatabases and other websites search retrieved 393 studies. After duplicate removal, 294 studies were screened for title and abstract, and then 33 were screened for full-text eligibility (Fig.\u0026nbsp;1, for PRISMA). After exclusions for various reasons, presented in Fig.\u0026nbsp;1, we checked 17 studies for integrity. We excluded one study [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] after integrity check, and included only 16 [\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] studies from 11 countries for the final analysis.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDescription of the included studies\u003c/h2\u003e \u003cp\u003eThe characteristics of included studies are presented in (Table\u0026nbsp;1). The systematic review ultimately included sixteen eligible studies (2 RCT and 14 cohort studies). All included studies were written in English and published between 1996 and 2024. One study totaling 198 ICSI cycles used sperMagic medium for motility initiation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], three studies totaling 982 ICSI cycles used theophylline [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], five studies totaling 682 ICSI cycles used pentoxifylline [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], two studies used laser-based sperm selection totaling 209 ICSI cycles [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], four studies totaling 328 used HOST [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and one study totaling 66 ICSI cycles used mechanical touch technique [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the quality of included studies varied from low to high risk of bias according to JBI checklists. Among the 16 studies assessed, 7 were of low, 4 moderate, and 5 high risk of bias, as presented in supplemental table 1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLive Birth\u003c/h2\u003e \u003cp\u003eAcross of 13 studies [\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] with 2076 patients, sperm viability selection was associated with higher live birth rate compared to control (RR 1.19; 95% CI, 1.05\u0026ndash;1.36; P\u0026thinsp;=\u0026thinsp;0.009; low-quality evidence), Fig.\u0026nbsp;2A. The total number of patients for our primary outcome, live birth, was robust as suggested by the Z curve (Figure, 2C). The Q test and the I\u003csup\u003e2\u003c/sup\u003e index found minimal heterogeneity for the live birth outcome (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.38, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;6.6%). The funnel plot of our primary outcome, live birth rate, was suggestive of a publication bias, Fig.\u0026nbsp;2B. The Egger's test supports the presence of funnel plot asymmetry (intercept 1.35; 95% CI, 0.58\u0026ndash;2.13; t\u0026thinsp;=\u0026thinsp;3.419; p\u0026thinsp;=\u0026thinsp;0.006).\u003c/p\u003e \u003cp\u003eWe further analyzed the rate of live birth according to the method of sperm viability selection used. For sperMagic and Mechanical touch technique methods, subgroup analysis was not applicable because each method was evaluated only once in one study. The use of theophylline revealed a statistically significant higher live birth rate compared to untreated sperm (RR 1.45; 95% CI, 1.09\u0026ndash;1.92; P\u0026thinsp;=\u0026thinsp;0.01; I\u003csup\u003e2\u003c/sup\u003e =66.4%; 3 studies with 813 patients). No improvement in the rate of live birth was observed using other methods, including pentoxifylline (RR 1.00; 95% CI, 0.79\u0026ndash;1.27; P\u0026thinsp;=\u0026thinsp;0.98; I\u003csup\u003e2\u003c/sup\u003e =0%; 3 studies with 531 patients), laser assisted selection (RR 1.35; 95% CI, 0.96\u0026ndash;1.88; P\u0026thinsp;=\u0026thinsp;0.08; I\u003csup\u003e2\u003c/sup\u003e =0%; 2 studies with 285 patients) and HOST (RR 1.18; 95% CI, 0.75\u0026ndash;1.88; P\u0026thinsp;=\u0026thinsp;0.48; I\u003csup\u003e2\u003c/sup\u003e =0%; 3 studies with 188 patients).\u003c/p\u003e \u003cp\u003eA sensitivity analysis for studies evaluating patients with no motility in sperm samples for both sperm viability selection group and control group (5 studies with 984 patients) confirmed the same findings of improved rate of live birth (RR 1.26; 95% CI, 1.01\u0026ndash;1.57; P\u0026thinsp;=\u0026thinsp;0.042; \u003cem\u003eI\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%) after using sperm viability selection compared to untreated immotile sperm.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePregnancy Outcomes\u003c/h2\u003e \u003cp\u003eWe found improvement on the rates of clinical pregnancy (15 studies, 2315 patients, low-quality evidence) [\u003cspan additionalcitationids=\"CR18 CR19 CR20\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and ongoing pregnancy (3 studies, 264 patients, very low-quality evidence) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] after using sperm viability selection compared to untreated sperm. We found no increase on the rate of multiple pregnancy between both groups (5 studies, 1201 patients, very low-quality evidence) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], Supplementary figure-1. Heterogeneity ranged from minimal to moderate for pregnancy outcomes, as suggested by the Q test and the I\u003csup\u003e2\u003c/sup\u003e index (clinical pregnancy \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.08, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;36.2%; ongoing pregnancy \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.2, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;36.7%; multiple pregnancy \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.97, I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%).\u003c/p\u003e \u003cp\u003eData for implantation rate [\u003cspan additionalcitationids=\"CR18 CR19 CR20\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] (12 studies, 3728 transferred embryos, very low quality evidence) did not detect difference between both groups (RR 1.05; 95% CI, 0.94\u0026ndash;1.17; P\u0026thinsp;=\u0026thinsp;0.4; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;24.9%). Data from two studies with 388 patients [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] found no difference on the rate of ectopic pregnancy between both groups (RR 0.35; 95% CI, 0.04\u0026ndash;3.54; P\u0026thinsp;=\u0026thinsp;0.38; I\u003csup\u003e2\u003c/sup\u003e =0%, very low quality evidence). The funnel plot suggested potential publication bias for pregnancy outcomes, except for multiple and ectopic pregnancies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eEmbryological outcomes\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eFor embryological outcomes, the rates of fertilization, cleavage, top-quality day-3 embryos and blastocyst formation did not improve using sperm viability selection methods compared to control. The rate of top-quality blastocyst was significantly higher in viability sperm selection group compared to control group. The quality of evidence for all embryological outcomes is very low. We used random effects model for all embryological outcomes due to significant heterogeneity, Supplementary figure-1. The funnel plots for all embryological outcomes did not support the presence of potential publication bias.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eNeonatal and obstetrics outcomes\u003c/h2\u003e \u003cp\u003eThere was no significant difference in birth weight (MD -0.2; 95% CI, -0.59-0.19; P\u0026thinsp;=\u0026thinsp;0.3, I\u003csup\u003e2\u003c/sup\u003e =67.4%; 4 studies; very low-quality evidence), sex ratio (RR 1.19; 95% CI, 0.96\u0026ndash;1.46; P\u0026thinsp;=\u0026thinsp;0.11; I\u003csup\u003e2\u003c/sup\u003e =29.3%; 2 studies; very low-quality evidence) and birth defects (RR 0.18; 95% CI, 0.02\u0026ndash;1.36; P\u0026thinsp;=\u0026thinsp;0.09; I\u003csup\u003e2\u003c/sup\u003e =0%; 6 studies; very low quality evidence), supplementary figure-1. We found no differences between both groups in gestational age (MD -0.05; 95% CI, -0.24-0.14; P\u0026thinsp;=\u0026thinsp;0.63; I\u003csup\u003e2\u003c/sup\u003e =45.5%; 4 studies; very low-quality evidence) and cesarean section (RR 0.73; 95% CI, 0.5\u0026ndash;1.06; P\u0026thinsp;=\u0026thinsp;0.1; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%; 2 studies; very low-quality evidence), supplementary figure-1.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough sperm viability selection techniques for immotile sperm are now widely implemented across in vitro fertilization laboratories [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], their clinical benefits and potential risks remain uncertain. Pooled estimates indicate that, among patients with severe male factor infertility undergoing ICSI with immotile sperm, the use of viability selection methods was associated with a higher live birth rate compared with ICSI performed using unselected sperm. However, this finding should be interpreted cautiously considering the low overall certainty of the available evidence.\u003c/p\u003e \u003cp\u003eWhile ICSI has revolutionized the management of severe male factor infertility, patients with absent or markedly impaired sperm motility continue to experience suboptimal reproductive outcomes. Furthermore, concerns have been raised regarding a potentially increased risk of neonatal morbidity related to both underlying paternal factors and assisted reproductive techniques [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Accordingly, developing adequate, optimized programs during ICSI treatment is crucial considering not only effectiveness but also safety outcomes on offspring and mothers. In our analysis, the overall risk of adverse neonatal and obstetric outcomes appeared comparable between viability selection and control groups. Nonetheless, the number of studies reporting these safety endpoints was limited, restricting the precision of these estimates. Robust, adequately powered studies are needed to further evaluate short-term safety outcomes, and long-term follow-up data on children conceived following sperm viability selection remain urgently required to fully establish the safety profile of these interventions.\u003c/p\u003e \u003cp\u003eThe use of adjunctive interventions, commonly referred to as \u0026ldquo;add-ons,\u0026rdquo; has become increasingly prevalent in reproductive medicine. These interventions are often costly and have generated ethical and professional debate because of limited or insufficient high-quality evidence supporting their effectiveness and safety [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The development of robust, evidence-based guidance for add-ons is therefore essential to support informed decision-making by clinicians and patients throughout the fertility treatment journey [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSperm viability selection, also described as artificial sperm activation, has been addressed by the European Society of Human Reproduction and Embryology (ESHRE) Add-ons Working Group, which recommends its use in cases of primary or secondary total asthenozoospermia but not for routine application [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. However, these recommendations are largely based on heterogeneous primary studies with limited certainty of evidence. Findings from our systematic review and meta-analysis suggest that sperm viability selection for immotile sperm in ICSI cycles may improve live birth outcomes without increasing short-term adverse neonatal or obstetric risks compared with unselected sperm. Nevertheless, given the low overall quality of available evidence, the use of sperm viability selection should remain restricted to carefully selected cases with absent or severely impaired motility until further high-quality studies provide more definitive conclusions.\u003c/p\u003e \u003cp\u003eSperm viability methods of immotile sperm offer reliable selection of competent viable sperm with the highest fertilization potential available for injecting oocytes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, no evidence or consensus is available to recommend a preferred and effective method. In our subgroup analyses, the use of theophylline was associated with an increased live birth rate compared with unselected sperm. In contrast, no statistically significant difference in live birth was observed when immotile sperm were selected randomly or through the hypo-osmotic swelling test (HOST), laser-assisted selection, or pentoxifylline-based activation. For other evaluated techniques, the available data were insufficient to permit meaningful conclusions.\u003c/p\u003e \u003cp\u003eIt is important to recognize that several manual selection methods are highly operator-dependent, and outcomes may be influenced by the embryologist\u0026rsquo;s expertise, potentially introducing subjective bias and inter-operator variability. Chemical activation with theophylline, which induces sperm motility, may reduce reliance on technical skill in identifying viable immotile sperm. Compared with pentoxifylline, theophylline has a longer half-life, which may contribute to its sustained stimulatory effect [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Nevertheless, these findings must be interpreted with caution, as the overall certainty of evidence is limited by small sample sizes, methodological heterogeneity, and a scarcity of well-designed randomized controlled trials.\u003c/p\u003e \u003cp\u003eThere are numerous strengths to our review. To our knowledge, this is the first meta-analysis to assess the effectiveness and safety of sperm viability selection for ICSI patients with immotile sperm. The inclusion of a large cumulative sample size, together with follow-up extending to live birth in most studies, enhanced statistical power and contributed to the robustness of the pooled estimates.\u003c/p\u003e \u003cp\u003eWe applied a rigorous and comprehensive methodological approach to ensure systematic identification and inclusion of eligible observational and comparative studies, enabling assessment of the totality of available evidence and identification of persisting knowledge gaps. Methodological quality was evaluated using the revised Joanna Briggs Institute (JBI) critical appraisal tools, which are particularly appropriate for non-randomized study designs [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In addition, the integrity of included studies was assessed using the REAPPRAISED checklist to minimize the risk of incorporating untrustworthy or unreliable data into the evidence synthesis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral notable limitations should be considered when interpreting our findings. First, our meta-analysis included only two RCT while the remaining studies were cohort. Therefore, the results are affected by unmeasured confounding factors. However, heterogeneity ranged from low to moderate for most outcomes, which may reflect minimal effect of potential confounding factors on outcomes. Second, evidence of publication bias was identified for the primary outcome of live birth, warranting cautious interpretation of the magnitude of effect. Third, the limited number of studies reporting neonatal and obstetric outcomes restricts the precision and reliability of conclusions regarding safety. Fourth, inconsistencies in the definition and composition of control groups across eligible studies represent an additional limitation; however, sensitivity analyses excluding studies that included motile sperm in the control group yielded comparable results, supporting the robustness of the main findings.\u003c/p\u003e \u003cp\u003eTaken together, these limitations underscore the urgent need for well-designed, adequately powered randomized controlled trials with clearly defined populations and standardized outcome reporting to validate the role of sperm viability selection in clinical practice. This review highlights the importance of strengthening the evidence base to better understand the implications of sperm viability selection on ICSI effectiveness and safety outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThere is little evidence to support the beneficial effect of sperm viability selection in improving of live birth rate without adverse effect on neonatal and obstetric outcomes. The results should be interpreted with caution due to the very low to low quality of evidence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo new data was created in this study. All data utilized are publicly accessible and can be provided by the author, upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eY.M. has nothing to disclose. S.E. has nothing to disclose. A.R has nothing to disclose. A.E. has nothing to disclose. A.ED. has nothing to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eY.M:\u003c/strong\u003e\u0026nbsp;Conceptualization, Writing – original draft, review \u0026amp; editing, Software, Methodology, Investigation, Formal analysis, Data curation, critical revision and supervision. \u003cstrong\u003eS.E:\u003c/strong\u003e Conceptualization, Writing – review \u0026amp; editing, Methodology. \u003cstrong\u003eA.R:\u003c/strong\u003e Conceptualization, Writing – review \u0026amp; editing, Methodology. \u003cstrong\u003eA.H:\u003c/strong\u003e Writing – review \u0026amp; editing, Methodology. \u003cstrong\u003eA.ED:\u0026nbsp;\u003c/strong\u003eMethodology, Data curation, critical revision, Writing – review \u0026amp; editing.\u0026nbsp;All authors contributed to interpreting the findings, revising and editing the article. All authors approved the final version before submission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Professor Khalid Saeed Khan for his valuable educational videos and advice through his YouTube channel that helped us to perform this study with the highest integrity standards in all steps. This work was presented at the 31\u003csup\u003eth \u0026nbsp;\u003c/sup\u003eannual international conference of the Egyptian Fertility and Sterility Society and won the Best Innovation in Fertility Award.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn preparing this manuscript, the author(s) used artificial intelligence tools in order to enhance the clarity of writing and check spelling and grammar. Prior to submission, the author(s) reviewed the content edited by AI and took full responsibility for the content of the submitted manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNordhoff V (2015) How to select immotile but viable spermatozoa on the day of intracytoplasmic sperm injection? An embryologist\u0026rsquo;s view. Andrology 3:156\u0026ndash;162. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/andr.286\u003c/span\u003e\u003cspan address=\"10.1111/andr.286\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanken EJ, Greenberg DR, Nam CS et al (2025) The use of immotile testicular sperm for in vitro fertilization/intracytoplasmic sperm injection: what are the outcomes? 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Fertil Steril 104:866\u0026ndash;872. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.fertnstert.2015.06.033\u003c/span\u003e\u003cspan address=\"10.1016/j.fertnstert.2015.06.033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eESHRE Add-ons working group, Lundin K, Bentzen JG et al (2023) Good practice recommendations on add-ons in reproductive medicine\u0026dagger;. Hum Reprod Oxf Engl 38:2062\u0026ndash;2104. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/humrep/dead184\u003c/span\u003e\u003cspan address=\"10.1093/humrep/dead184\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEbner T, Shebl O, Mayer RB et al (2014) Healthy live birth using theophylline in a case of retrograde ejaculation and absolute asthenozoospermia. Fertil Steril 101:340\u0026ndash;343. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.fertnstert.2013.10.006\u003c/span\u003e\u003cspan address=\"10.1016/j.fertnstert.2013.10.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Wely M, Hastings JM, Tarlatzis BC, Wang R (2025) Bias busters: using the right risk-of-bias tools. Hum Reprod Update. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/humupd/dmaf016\u003c/span\u003e\u003cspan address=\"10.1093/humupd/dmaf016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 1","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"904\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 904px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Characteristics of included studies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eAuthor and year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eTime period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eStudy design\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eIntervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eControl\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eOutcomes assessed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eFunding source\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNumber of ICSI cycles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eSperm Assisted selection method or agent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eMain Finding\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eGu et al., 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eMarch 1, 2015 to January 31, 2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eProspective cohort study\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients with sperm from TESE or absolute asthenozoo spermia and no motility detected after search, where SperMagic media was used to induce motility.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients with sperm from TESE or absolute asthenozoo spermia and motility detected after search\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eThe rates of fertilisation, cleavage, implantation, pregnancy, live birth and neonatal out comes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eThe study was funded by the National Natural Science Foundation of China (31401069, 31271596 and 81222007), Major State Basic Research Development Program of China (973 Program) (2012CB944901) and Natural Science Foundation of Hunan Province of China (2017JJ2327\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e198\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eSperMagic medium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eData showed no improvement in the embryological or clinical outcomes after using SperMagic media for cases with complete absence of motility as compared to control group of untreated sperm. Neonatal outcomes were also similar between both groups.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eSandi‑Monroy et al., 2019\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eGermany\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eAugust 2012 to January 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eRetrospective cohort study\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients with immotile sperm, either TESE or ejaculated, where SpermMobil was used to induce motility.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients with immotile sperm, either TESE or ejaculated.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eFertilization rate, clinical outcomes, obstetric and perinatal outcomes\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNo fund was received.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e815\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eTheophylline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eHigher fertilization rate and lower miscarriage rate were detected after using theophylline, without adverse effects on obstetric and perinatal outcomes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eAizer et al., 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eIsrael\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eBetween January 2013 and December 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eRetrospective cohort study\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients undergoing ICSI with immotile testicular sperm with addition to pentoxifiline to induce motility/\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients undergoing ICSI using motile testicular sperm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eThe rates of fertilization, top-quality embryos, cumulative clinical pregnancy, gestational sacs, implantation rate and cumulative live birth.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ePentoxifylline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eAlthough lower cumulative clinical pregnancy and cumulative live birth was detected in cases with immotile testicular sperm, even after addition of pentoxifiline as compared to motile sperm, it remains effective\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ebefore counselling for donor spermatozoa or cryopreserving oocytes for future consideration.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eChen et al., 2021\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eJune 2014 to June 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eRetrospective cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eAzoospermic patients underwent ICSI with immotile sperm. Viable sperm were selected using Laser.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eAzoospermic patients underwent ICSI with immotile sperm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003ePregnancy, implantation, miscarriage and live birth rate.\u0026nbsp;Perinatal and neonatal outcomes were measured.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eThe Guangxi National Science Foundation (Grant No. 2018JJB140142), projects grant from the Self Raised Foundation of Guangxi Health Commission (Project #Z20170777 and #Z20180078) and a project grant from the Research Foundation of Guangxi Medical and Health (Project# S2020056) supported this work.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e132 cycles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eLaser-based sperm selection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eThe rates of embryological, clinical, perinatal and neonatal outcomes were comparable between both groups.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eAktan1 et al., 2004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eTurkey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eNovember 2002 and August 2003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eProspective cohort study\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients with immotile sperm, either ejaculated or testicular, where laser was used to select viable immotile sperm.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients with immotile sperm, either ejaculated or testicular and underwent conventional ICSI.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eThe rates of fertilization, cleavage, pregnancy and take-home baby rate.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e77 patients\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eLaser-based sperm selection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eHigher fertilization and cleavage rates were achieved after selection of viable immotile sperm for ICSI using laser, as compared to ICSI with immotile sperm without selection.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eKovac ˇic et al., 2006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eSlovenia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eBetween 1999 and 2003\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eRetrospective cohort study-Historical control\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients underwent ICSI using testicular sperm with complete immotile sperm, where Pentoxifylline was used to induce motility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients underwent ICSI using testicular sperm with complete immotile untreated sperm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eThe rates of fertilization, blastulation, clinical pregnancy, miscarriage, ongoing pregnancy and livebirth.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ePentoxifylline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eUsing pentoxifylline for cases underwent ICSI with immotile sperm improved fertilization rate as compared to untreated immotile sperm. Both groups were comparable for blastulation rate and clinical outcomes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eCakira et al., 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eTurkey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eJune 2011 and July 2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eRetrospective\u0026nbsp;sibling-oocytes cohort study\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eOocytes injected s with immotile sperm samples either ejaculated or testicular (fresh or frozen).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003eoocytes injected with few motile sperm detected in the samples of the same population of intervention group.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eThe rates of fertilization rate, implantation rate, live birth rate. Obstetric and neonatal outcomes were measured.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNo fund was received\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e203 cycles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eHOST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eEmbryological, clinical and neonatal outcomes were comparable between immotile-HOS-positive sperm and motile sperm for fresh samples. For frozen-thawed samples, significantly lower fertilization and blastocyst formation rates were observed in with immotile-HOS-positive sperm compared to motile sperm. However, the rates of clinical, obstetric, and neonatal outcomes were similar.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eWober et al., 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eAustria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eTwo-year period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eProspective cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients underwent ICSI with fresh TESE, where immotile sperm was treated with theophylline.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients underwent ICSI with fresh TESE and have motile sperm in their samples.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eThe rates of fertilization, blastulation, implantation, pregnancy, and live birth.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e63 patients/102 cycles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eTheophylline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eThe use of ready to use theophylline is effective and safe for patients with immotile testicular sperm.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003ede Oliveira et al., 2004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eSpain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eJuly 2001-May 2002\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eRetrospective cohort study\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients underwent ICSI using immotile sperm of either fresh or frozen TESE samples. The flexibility and shape of sperm tail were assessed as an indicator of viability prior ICSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients underwent ICSI using motile sperm of either fresh or frozen TESE samples.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eThe rates of fertilization, cleavage, implantation, pregnancy and take baby home.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e61 patients/66 cycles\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eMechanical touch technique\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eMechanical touch technique is effective in selection of immotile sperm in patients undergoing ICSI using testicular sperm. Data showed similar rates of fertilization, cleavage, implantation, pregnancy and take baby home achieved using mechanical touch technique for selection of immotile sperm as compared to motile sperm of TESE samples.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eTerriou et al., 2000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eProspective cohort study\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients with complete immotile sperm from either fresh or frozen epididymal or testicular spermatozoa. The samples were treated with pentoxifylline before ICSI.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients with spontaneously motile spermatozoa without treatment from either fresh or frozen epididymal or testicular spermatozoa.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eThe rates of fertilization, cleavage, pregnancy and implantation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ePentoxifylline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eAlthough no significant improvements were detected after adding pentoxifylline in fertilization, cleavage and pregnancy rates, pentoxifylline efficiently initiated motility.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eEbner et al., 2011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eAustria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eBetween January and October 2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eProspective sibling-oocytes cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients underwent ICSI treatment with frozen-thawed TESE. Sperm were treated with theophylline prior ICSI.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients underwent ICSI treatment with frozen-thawed TESE. ICSI was performed with untreated sperm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eThe rates of fertilization, cleavage, blastulation, top-quality cleaved embryos and blastocysts. The rates of clinical pregnancy, implantation and livebirth were measured.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e65 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eTheophylline\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eUsing theophylline for stimulation motility of TESE samples after thawing was effective and significantly improved the rates of fertilization and blastulation. It also improved clinical pregnancy and implantation and livebirth rates.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eEl-Nour et al., 2001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eSaudi Arabia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eSeptember 1997 and July 1999\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eRandomized controlled study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients underwent ICSI with immotile sperm, either ejaculated or testicular sperm, where sperm was selected based on HOS viability test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients underwent ICSI with immotile sperm, either ejaculated or testicular sperm, where ICSI was done with untreated immotile sperm.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eThe rates of fertilization, cleavage, embryo quality, pregnancy, and implantation rates\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e30 cycles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eHOST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eNo statistical significance was observed between groups in terms of fertilization, cleavage, quality of embryos, pregnancy and implantation rates.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eSallam et al., 2005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eEgypt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eJanuary 2002 and August 2004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eRandomized controlled study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients underwent ICSI with TESE and no motility was detected. HOS was used to detect viability.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients underwent ICSI with TESE and no motility was detected. Sperm selection was based on their morphology.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eThe rates of fertilization, top quality embryos, pregnancy and ongoing pregnancy.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e79 patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eHOST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eData showed significant improvement in the rates of fertilization, pregnancy and ongoing pregnancy rates after the use of HOS to select viable immotile sperm for ICSI, as compared conventional selection of immotile sperm based on their morphology.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eGriveau et al., 2006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eFrance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eJanuary 2000 to December 2004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eRetrospective cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients underwent ICSI with frozen testicular sperm and showed no motility after thawing and\u0026nbsp;pentoxifylline was\u003c/p\u003e\n \u003cp\u003eused to induce motility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients underwent ICSI with frozen testicular sperm and showed motility after thawing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eThe rates of Fertilization, implantation, pregnancies, livebirth and newborn malformations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ePentoxifylline\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eThe study reported significant decrease in fertilization rate with the use of pentoxifylline compared to control group.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eDong et al., 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eApril 2013 to June 2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eRetrospective cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients underwent ICSI with testicular sperm (TESA), where\u0026nbsp;pentoxifylline\u0026nbsp;was used to induce motility.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients underwent ICSI with testicular sperm (TESA.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eClinical outcomes including, biochemical pregnancy, clinical pregnancy, implantation, miscarriage, ectopic pregnancy, multiple pregnancy and live birth rates. Neonatal outcomes, including birth defect, birth weight, gestational age, preterm birth, and early-neonatal death.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eThe study was funded by the National Natural Science Foundation of China (Grant No. 81971448).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e341 patients with testicular sperm (190 patients after propensity score matching)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003ePentoxifylline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eNo significant differences were detected in clinical or neonatal outcomes after using pentoxifylline for patients underwent ICSI with testicular sperm, as compared to untreated sperm.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003eCasper\u0026nbsp;et al., 1996\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003eCanada\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eNot reported\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eNonrandomized, sequential cohort study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003ePatients with complete immotile sperm in ejaculates, where HOS was used for selection of viable sperm.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003ePatients with complete immotile sperm in ejaculates, where sperm was randomly injected.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003eFertilization, cleavage, clinical pregnancy, miscarriage and live birth.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003eNot reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e13 patients/ 16 cycles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;HOST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003eBased on preliminary results, selection of immotile sperm using HOS may improve fertilization and cleavage rates, compared to random selection.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 904px;\"\u003e\n \u003cp\u003eNote: HOST= hypo-osmotic swelling test, ICSI= intracytoplasmic sperm injection, TESA= testicular sperm aspiration, TESE = testicular sperm extraction.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Al-Yasmeen Fertility and Gynecology Center","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sperm viability, Immotile sperm, Hypo-osmotic test, theophylline, tail flexibility test, azoospermia, complete asthenozoospermia","lastPublishedDoi":"10.21203/rs.3.rs-8961164/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8961164/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eS — Situation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImmotile or poorly motile sperm presents a significant clinical challenge in intracytoplasmic sperm injection (ICSI), prompting the use of adjunctive sperm viability selection techniques to optimize reproductive outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eP — Purpose:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to evaluate the effectiveness and safety of sperm viability selection methods for improving reproductive and neonatal outcomes in patients with immotile or poorly motile sperm undergoing ICSI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA — Approach:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a systematic review and meta-analysis of controlled studies published in English between January 1990 and April 2025, identified through PubMed, Cochrane Library, Scopus, and Web of Science, comparing sperm viability selection techniques versus standard ICSI without viability selection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eR — Results:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcross included studies (13 studies), sperm viability selection was associated with a higher live birth rate compared with control (risk ratio [RR] 1.19; 95% confidence interval [CI], 1.05–1.36; P = 0.009; I²=6.6%), with subgroup analysis demonstrating greater improvement with theophylline use (RR 1.45; 95% CI, 1.09–1.92; P = 0.01; I²=66.4%). Results showed favorable secondary outcomes including increased clinical pregnancy rates and no observed increase in adverse neonatal or obstetric events.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC — Conclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSperm viability selection techniques were associated with improved live birth and pregnancy outcomes without an apparent increase in adverse perinatal events, although the certainty of evidence was low to very low.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eR — Relevance:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese findings support consideration of sperm viability selection as an adjunct in ICSI for immotile or poorly motile sperm while underscoring the need for rigorously designed trials to inform evidence-based reproductive practice and guideline development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol was prospectively registered on PROSPERO: CRD420251017288.\u003c/p\u003e","manuscriptTitle":"Sperm Viability Selection for Immotile Sperm in ICSI: A Systematic Review and Meta-Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 14:12:40","doi":"10.21203/rs.3.rs-8961164/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f3682f87-3d91-473c-a7fe-9fb0eb88867f","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-27T14:12:40+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 14:12:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8961164","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8961164","identity":"rs-8961164","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}