Novel technologies for selecting the

best sperm for in vitro fertilization

and intracytoplasmic sperm injection
Denny Sakkas, Ph.D.
Boston IVF, Waltham, Massachusetts

The increasing focus on developing new tools to more accurately diagnose and select individual sperm before intracytoplasmic sperm
injection will allow us to counsel and treat couples with greater condence and efciency. Current sperm selection techniques are based
on the premise that if an ejaculated spermatozoon has cleared spermatogenesis with the correct morphology and/or membrane prop-
erties then it is most likely normal. Techniques that are designed to prepare a clean normal sperm population or that assist in selecting
an individual normal spermatozoon are currently being investigated. The use of techniques, including density-gradient preparation,
electrophoretic separation, microuidics, high-magnication sperm morphology selection, and hyaluronic acid binding, is discussed.
The research evidence that supports the interrelated developmental and genetic integrity of the
selected sperm, particularly sperm DNA damage and clinical outcome evidence are presented. Use your smartphone
(Fertil Steril 2013;99:10239. 2013 by American Society for Reproductive Medicine.) to scan this QR code
Key Words: Sperm selection, ICSI, male infertility, sperm morphology and connect to the
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O
ne of the most dramatic techno- niques that we use introduce gametes The success of ICSI has surprised
logical breakthroughs in assis- into the genetic pool that would have many; however, concerns are still prev-
ted reproduction technologies a lower chance to participate in natural alent. A recent study examining more
(ART) was the introduction of intracyto- fertility. Numerous follow-up studies than 300,000 births from a South Aus-
plasmic sperm injection (ICSI) in the have failed to show any major concerns tralian registry concluded that the in-
early 1990s (1). After numerous attempts regarding ICSI offspring. In some of the creased risk of birth defects associated
to successfully treat male factor infertil- major follow-up reports conducted by with IVF was no longer signicant after
ity through epididymal aspirations (2), Belgian authors, they found that in 8- adjustment for parental factors. The
zona dissection, and injection of multi- year-old ICSI children pubertal staging risk of birth defects associated with
ple sperm into the perivitelline space was similar between ICSI and spontane- ICSI remained increased, after multi-
(3), only the use of ICSI provided preg- ously conceived (SC) children. Neuro- variate adjustment, although the possi-
nancy rates that were equivalent to those logic examination also failed to show bility of residual confounding could
in routine in vitro fertilization (IVF). important differences between ICSI and not be excluded (6).
The use of ICSI is sometimes thought SC children. ICSI children did not require Some concern over the use of
to defy the basic evolutionary paradigm more remedial therapy or surgery or hos- poorer-quality sperm are warranted,
of survival of the ttest, which was pitalization than SC children. However, but we are yet to dene adequately
coined in the late 1800s. Although its a major congenital malformation was what is present in a spermatozoon
meaning has been challenged and experienced in 15/150 compared with that may adversely impact fetal out-
changed it is evident that many of the 5/147 SC children (P< .05) (4). Further come. Conversely, numerous groups
techniques we currently use in ART do follow-up showed that ICSI and SC chil- are now working on methodologies to
not adhere to this phrase. In particular, dren show similar cognitive and motor try and select normal spermatozoa
it could be argued that many of the tech- development up to the age of 10 years (5). so as to limit the possibility of an ad-
verse outcome after ICSI.
Received October 1, 2012; revised December 11, 2012; accepted December 14, 2012; published online
January 26, 2013.
D.S. has nothing to disclose.
Reprint requests: Denny Sakkas, Ph.D., Boston IVF, 130 Second Avenue, Waltham, Massachu-
setts 02451 (E-mail: dsakkas@bostonivf.com). POORER-QUALITY SPERM
What is a poor-quality spermatozoon?
Fertility and Sterility Vol. 99, No. 4, March 15, 2013 0015-0282/$36.00
Copyright 2013 American Society for Reproductive Medicine, Published by Elsevier Inc.
In a normal human ejaculate there are
http://dx.doi.org/10.1016/j.fertnstert.2012.12.025 well over 40 million spermatozoa, but

VOL. 99 NO. 4 / MARCH 15, 2013 1023

MALE INFERTILITY
when spermatogenesis is compromised a greater percentage
of sperm in the ejaculate begin to show a range of abnormal-
ities. These include membrane, mitochondrial, centriolar,
nuclear, and chromosomal anomalies. How can one select
spermatozoa to eliminate these anomalies? Given that the
object is to isolate live spermatozoa, the approaches used
have been based on looking at morphology or a membrane
property. A major approach in the discovery of sperm bio-
chemical markers, independently from sperm concentration
and motility in the semen, is based on the recognition that
there are objective markers of sperm function that focus on
elements of spermatogenesis and spermiogenesis that are
abnormal in the process of sperm development from sper-
matogonium to spermatozoa. The basis of this approach is
that if an ejaculated spermatozoon has cleared spermatogen-
esis with the correct morphology and/or membrane proper-
ties, then it is most likely normal. Huszar et al. (7) have
worked on this basis in rst identifying cytoplasmic retention
as an abnormal morphologic feature and nally progressing
through many years' work to develop the hyaluronic acid
(HA)binding assay, which will be discussed subsequently.
DIFFERENT TYPES OF EJACULATED
SPERMATOZOA
When spermatozoa arrive in the ejaculate, they have progressed
through spermatogenesis and traversed through the male
reproductive tract uids. The result can be a population of sper-
matozoa that is heterogeneous regarding quality. Major mech-
anisms of inducing abnormalities in spermatozoa during either
the production and/or the transport of sperm cells can include:
1) apoptosis or anomalies during the process of spermatogene-
sis; 2) DNA strand breaks produced during the remodeling of
sperm chromatin during the process of spermiogenesis; 3)
post-testicular DNA fragmentation induced mainly by oxygen
radicals during sperm transport through the seminiferous tu-
bules and the epididymis; 4) DNA fragmentation induced by
endogenous caspases and endonucleases; 5) DNA damage
induced by radio and chemotherapy; and 6) DNA damage in-
duced by environmental toxins (8).
Many of the diagnostic techniques available can assess
whether some of these abnormalities have occurred, but
they fail to proactively allow for the selection of spermatozoa
before treatment. For example, one area of sperm structure
that has generated increasing interest in sperm assessment
is that of the sperm nuclear DNA/chromatin structure. In
1980, Evenson et al. (9) published a manuscript in Science ti-
tled Relation of mammalian sperm chromatin heterogeneity
to fertility. Their study used ow cytometry measurements of
heated sperm nuclei to reveal a signicant decrease in resis-
tance to in situ denaturation of spermatozoal DNA in samples
from bulls, mice, and humans of low or questionable fertility
compared with others of high fertility. They showed that there
were changes in sperm chromatin conformation that were re-
lated to the diminished fertility. They then went on to suggest
that ow cytometry of heated sperm nuclei could provide
a new and independent determinant of male fertility.
In addition to that original methodology, numerous tests
have been developed for the analysis of sperm nuclear DNA
1024
fragmentation (8). These tests include TdT-mediated dUTP
nick-end labeling (10), Comet (11), chromomycin A3
(CMA3) (12), in situ nick translation (13, 14), DNA breakage
detectionuorescence in situ hybridization (15), sperm
chromatin dispersion test (SCD) (16), and sperm chromatin
structure assay (SCSA) (17, 18). A recent meta-analysis (19)
concluded that sperm DNA damage is associated with a signif-
icantly increased risk of pregnancy loss after IVF and ICSI. The
protocol of analysis may, however, prove to be more impor-
tant, because it was shown that the sperm DNA fragmentation
values of the actual aliquots used for IVF insemination were
signicantly correlated with pregnancy outcome (20). This is
in sharp contrast to the results reported by Bungum et al.
(21), where no correlation was found between sperm DNA
fragmentation values in the samples used for IVF, as measured
by the SCSA test, and pregnancy outcome. Overall, some con-
troversy still remains about the utility of these tests (22).
It is important to note that in general, patients requiring
ICSI will present with higher levels of sperm DNA damage
(Fig. 1). In techniques such as IVF or ICSI, where a lot of the
natural selection and sperm competition is bypassed, it be-
comes more important to remove or isolate DNA damaged
sperm for treatment. To date, no sperm test can directly gauge
the degree of sperm DNA damage in a single sperm and isolate
it, so we are forced to examine surrogate markers that may re-
ect sperm DNA damage or other detrimental sperm qualities.
SELECTING THE BEST SPERM
The strategy to select the best sperm or to eliminate those that
are abnormal from the population can be performed with the
use of various approaches. The population of sperm as a whole
can be prepared or individual sperm can be isolated. The ap-
proaches published to date reect the following strategies to
select or deselect sperm largely on the basis of morphology
or membrane characteristics.
Morphologic Characteristics
The use of morphologic characteristics is familiar to embryol-
ogists, because they have routinely used morphology to select
embryos. Morphology has also been a key characteristic in
assessing spermatozoa during semen analysis. A recent rean-
alysis of semen parameters showed that men whose partners
had a time to pregnancy of %12 months had semen volume
1.5 mL (range 1.41.7 mL), total sperm number 39 million
per ejaculate (range 3346 million), sperm concentration 15
million per mL (range 1216 million/mL), vitality 58% (range
55%63%), progressive motility 32% (range 31%34%); total
(progressive nonprogressive) motility 40% (range 38%
42%); morphologically normal forms 4.0% (range 3.0%
4.0%). Semen quality of the reference population was superior
to that of the men from the general population and normo-
zoospermic men (23).
Although the World Health Organization and Kruger
strict criteria have been used for many years in routine
sperm assessment, ICSI has been generally practiced by se-
lecting sperm at a cursory level by the technician. In 2001,
Bartoov et al. (24) reported a high-magnication technique
for selecting normal spermatozoa before ICSI. The selection
VOL. 99 NO. 4 / MARCH 15, 2013

FIGURE 1
The proportion of 95 men with >20% (dark gray) and <20% (light
gray) of their spermatozoa being positive for sperm DNA damage
as assessed by the TdT-mediated dUTP nick-end labeling assay in
relation to a sperm count of (A) <20 million/mL and (B) >20
million/mL.
Sakkas. Selecting the best sperm for IVF and ICSI. Fertil Steril 2013.
of spermatozoa with normal nuclei was shown to improve
the pregnancy rate with ICSI. They went on to verify this
technique by performing ICSI using morphologically
normal sperm, selected at >6,000 times magnication, in
couples with repeated ICSI failures. Sixty-two couples,
with at least two previous consecutive pregnancy failures
after ICSI underwent a single ICSI trial preceded by mor-
phologic selection of spermatozoa with normal nuclei. Fifty
of these couples were matched with couples who underwent
VOL. 99 NO. 4 / MARCH 15, 2013
Fertility and Sterility
a routine ICSI procedure at the same IVF center and ex-
hibited the same number of previous ICSI failures. The
matching study revealed that the pregnancy rate after mod-
ied ICSI was signicantly higher than that of the routine
ICSI procedure (66% vs. 30%). Antinori et al. (25) conducted
a prospective randomized study to assess the advantages of
intracytoplasmic morphologically selected sperm injection
(IMSI) over the conventional ICSI procedure in the treat-
ment of patients with severe oligoasthenoteratozoospermia.
IMSI was based on a preliminary motile sperm organellar
morphology examination under 6,600 high magnica-
tion. A total of 446 couples with at least two previous diag-
noses of severe oligoasthenoteratozoospermia, 3 years of
primary infertility, the woman aged %35 years, and an un-
detected female factor were randomized to IVF microinse-
mination treatments: ICSI (n 219; group 1) and IMSI (n
227; group 2). A comparison between the two different
techniques was made in terms of pregnancy, miscarriage,
and implantation rates. The data showed that IMSI resulted
in a higher clinical pregnancy rate (39.2% vs. 26.5%;
P .004) than ICSI when applied to severe male infertility
cases. Despite their initial poor reproductive prognosis, pa-
tients with two or more previous failed attempts beneted
the most from IMSI in terms of pregnancy (29.8% vs.
12.9%; P .017) and miscarriage (17.4% vs. 37.5%) rates.
A recent meta-analysis demonstrated no signicant
difference in fertilization rate between ICSI and IMSI groups
(26). However, signicantly improved implantation (odds
ratio [OR] 2.72, 95% condence interval [CI] 1.504.95)
and pregnancy (OR 3.12, 95% CI 1.556.26) rates were
observed in IMSI cycles. Moreover, the results showed a sig-
nicantly decreased miscarriage rate (OR 0.42, 95% CI
0.230.78) in IMSI cycles compared with ICSI cycles. The
meta-analysis concluded that IMSI not only signicantly
improves the percentage of top-quality embryos and im-
plantation and pregnancy rates, but also signicantly re-
duces miscarriage rates compared with ICSI. However,
a weakness of this meta-analysis was the variable study
characteristics (26). A recent prospective trial also con-
cluded that IMSI may improve IVF success rates in severe
male factor infertility patients (27).
The traits of the morphologically selected sperm have also
been investigated and reviewed by Nadalini et al. (28), who
concluded that morphologically selected sperm with normal
nuclear shape appear to maintain sperm DNA integrity. Over-
all, the use of IMSI appears to be promising (28). Some draw-
backs are present, however, particularly the belief that it is
a complicated technique that can not be routinely performed
and it can take a long time to identify the sperm under high
magnication. Finally, some recent data question the routine
use of IMSI. Montjean et al. (29) have reported that the acro-
some reaction is correlated with a highly signicant decrease
in the presence of vacuoles without signicantly modifying
sperm nuclear condensation and morphology (Bartoov crite-
ria). Those authors concluded that sperm vacuoles are associ-
ated with acrosomal and capacitation status and appear to be
a reection of normal sperm physiology. An interesting aside
of this technique is also the possible skew in selection of X-
bearing sperm (30).
1025
MALE INFERTILITY
Preparing a Whole Sperm Sample
A seemingly milder technique that prepares a sperm popula-
tion has been reported by Aitken et al. (31). Briey, this sep-
aration system consists of a cassette where the semen is
introduced into one chamber, a current is applied, and within
seconds a puried suspension of spermatozoa is collected
from the adjacent chamber. The spermatozoa collected in
the adjacent chamber all show good count, viability, motility,
and improvement in morphology and DNA integrity. Some
pregnancies have been reported with the use of this system,
and a clinical trial showed that membrane-based electropho-
resis was as effective as density-gradient centrifugation in
preparing sperm for IVF and ICSI, although it had the added
benet of being signicantly faster (31). Optimized modica-
tions have recently been described that indicated more
benets compared with conventional density-gradient centri-
fugation technologies (32).
Another technology that could aid in the preparation of
sperm populations is microuidics (33, 34). Microuidic
technology has been used in numerous biologic applications
for miniaturization and simplication of laboratory
techniques. Initial studies seeking to apply microuidic
technology to sperm preparation showed promising results.
They reported that the use of a microuidic device, designed
with two parallel laminar ow channels which preferentially
separate motile spermatozoa into a separate outlet, increased
sperm motility in a sample from 44% to 98% and morphology
from 10% to 22% (33). This area is now progressing with
numerous publications examining adaptations to microuidic
chambers that will allow sperm selection (34). Similarly to
electrophoretic separation technology, the removal of
centrifugation has the potential to limit some of the
iatrogenic preparation problems described earlier. These
technologies may also prove to be useful in isolating motile
spermatozoa from oligozoospermic samples, even with high
amounts of nonmotile gamete and/or nongamete cell
contamination. Centrifugation and classic sperm preparation
techniques can not, however, be overlooked, because they
have been shown to limit the amount of abnormal sperm cells
in the nal sperm preparation (35, 36). Novel approaches that
limit centrifugation will allow us to avoid the iatrogenic
failures of IVF that could be associated with sperm
preparation techniques (37). In addition, little effort has been
concentrated on improving sperm handling media so that
antioxidants and other protectants could improve or maintain
the overall functional parameters of spermatozoa (38).
Deselection of Apoptotic Spermatozoa
In the early 1990s we revealed that some ejaculated sperm
exhibit apoptotic marker proteins (39); the mechanisms be-
hind this remain unknown. We are, however, well aware
that spermatozoa that exhibit apoptotic marker proteins on
their membranes are most likely abnormal and more likely
to be associated with increased DNA damage, poor morphol-
ogy, cytoplasmic retention, and numerous other abnormal
traits. The presence of apoptotic proteins, such as Fas, phos-
phatidylserine, Bcl-XL, p53, etc., in ejaculated sperm has
since been veried by many independent studies (4043).
1026
The origin of these sperm and why and how they either
avoid apoptosis or the reason they express apoptotic
proteins remains to be investigated (44). Their presence has
generated some interest in using the characteristic to isolate
positive and negative expressing spermatozoa. One novel
and promising technique is with the use of annexin V
conjugated microbeads. The use of magnetic-activated cell
sorting has been shown to remove spermatozoa with phos-
phatidylserine externalization (marker of apoptosis) and to
produce a higher-quality nonapoptotic sperm fraction. A sim-
ilar hypothesis could be used to remove sperm expressing
other apoptotic marker proteins, or sperm expressing different
apoptotic marker proteins could be deselected sequentially.
Removal of these spermatozoa which failed to be excluded
by the apoptotic machinery or have an abnormal membrane
protein expression would theoretically benet sperm selec-
tion. This technique is showing promise in some trials, but
it has yet to be tested in larger randomized trials (45, 46).
SELECTION OF SINGLE SPERMATOZOON FOR
ICSI
Microscope Based
Another microscope-based technology that is showing prom-
ise is one that analyzes birefringence in the sperm head.
Gianaroli et al. (47) recently performed a prospective random-
ization including 71 couples with severe male factor infertility
and performed ICSI with the use of polarized light for sperm
selection, which permitted analysis of the pattern of birefrin-
gence in the sperm head, which putatively allows selection of
acrosome-reacted spermatozoa. They found no effect on the
fertilizing capacity and embryo development of selected
sperm, but the implantation rate was higher in oocytes
injected with reacted spermatozoa (39.0%) than in those
injected with nonreacted spermatozoa (8.6%). They concluded
that spermatozoa that have undergone the acrosome reaction
seem to be more prone to supporting the development of viable
ICSI embryos. It has also been show that a relationship exists
between DNA damage and sperm head birefringence (48).
A novel methodology that could be adapted to a micro-
scope is based on the use of Raman spectroscopy (49, 50).
This technique can noninvasively distinguish the DNA
packaging and protamine content between normal and
abnormal cells (51). In one descriptive study, it was shown
that the relative protein content per cell and DNA
packaging efciency are distributed over a relatively wide
range for sperm cells with both normal and abnormal
shapes (51). Their ndings indicate that single-cell Raman
spectroscopy could be a valuable tool in assessing the quality
of sperm cells.
Finally, a historically tried technique may also prove to be
useful for selecting sperm under the microscope. Stanger et al.
(52) recently reported that the hypo-osmotic swelling test
(HOST) can identify individual spermatozoa with minimal
DNA fragmentation and concluded that its application may
be a valuable tool in the routine identication and selection
of viable DNA-intact individual spermatozoa for ICSI. Given
that HOST has been used for identifying testicular- and
epididymal-recovered spermatozoa for many years, it may
VOL. 99 NO. 4 / MARCH 15, 2013
 Fertility and Sterility

be a safe and easy technology that is ready to adopt. Bassiri
et al. (53) recently showed that HOST can be used to identify
spermatozoa with traits of apoptosis, abnormal head mor-
phology, nuclear immaturity, or membrane damage.
Sperm Binding to Hyaluronic Acid
Another technique that uses the concept of selecting sperma-
tozoa that have undergone normal spermatogenesis is the
HA-binding assay. During human spermiogenesis, spermatids
experience alterations in the plasma membrane that involve
the appearance of HA-binding sites. Human sperm that bind
to HA exhibit attributes similar to that of zona pellucida
bound sperm, including minimal DNA fragmentation, normal
shape, and low frequency of chromosomal aneuploidies (54).
In 2005, Jakab et al. (55) reported that selection of HA-bound
spermatozoa signicantly decreased the percentage of sperm
showing both apoptotic marker proteins and aneuploidies. It
was proposed that the clinical use of HA-bound sperm would
improve overall ICSI results.
A number of studies have now indicated that HA-bound
sperm selected for the ICSI procedure may lead to increased
implantation rates. In one such study, Parmegiani et al. (56)
showed that in 293 couples treated with HA-ICSI versus 86
couples treated with conventional ICSI (historical control
group), all outcome measures (fertilization, embryo quality,
and implantation and pregnancy rates) were the same or
improved in the HA-bound sperm group. The implantation
rate was increased from 10.3% in conventional ICSI to
17.1% in the HA group. A clinical trial assessing the same
technology by Worillow et al. (57) has also shown that clin-
ical pregnancy rates are improved when using HA-selected
sperm compared with conventional ICSI. Furthermore, HA
binding can be used as a diagnostic semen analysis platform
before treatment. In a recent study from a multicenter clin-
ical trial, Worillow et al. (57) have shown that when patients
with <65% binding efciency are prescreened and selected
before ICSI, their success rates tend to be slightly improved
with the use of this technology, particularly regarding preg-
nancy loss. HA patients with a HA-binding score of %65%
demonstrated an implantation rate of 37.4% compared with
30.7% for control subjects [n 63 vs. 58; P>.05]. In addi-
tion, they reported a clinical pregnancy rate in patients ran-
domized to the HA group of 50.8% compared with 37.9% for
those randomized to the control group (n 63 vs. 58;
P>.05). Most striking for the HA patients with a HA binding
score of %65%, a statistically signicant reduction in their
pregnancy loss rate to 3.3% was observed, versus 15.1% in
control subjects [n 73 vs. 60; P .021]. In contrast, Tarozzi
et al. (58) reported that the application of HA was not useful
in the context of the limited use of oocytes under Italian
law, although their study has been contradicted by Parme-
giani et al. (56). Interestingly, using two different types of

TABLE 1

Summary of techniques reported to improve selection of the various problems encountered in a sperm sample.
High DNA High
Sperm selection technique Normal Oligo Astheno Terato damage ROS Comment
Sperm population preparation
Swim-up Density-gradient preparation preferred over
Density gradient swim-up for isolating better sperm
Electrophoretic separation May not be as useful for severe oligozoospermia
Microuidics but reduces iatrogenic effects associated with
sperm centrifugation
Apoptotic deselection May not be as useful for severe oligozoospermia
Surgical sperm retrieval
Testicular/epididymal biopsy Has been shown to be effective in patients with
high DNA damage in ejaculated sperm and
previous failures
Individual sperm selection
HA binding Promising clinical results but not effective when
man has very low count and/or poor motility
Birefringence Limited clinical results
IMSI Promising clinical results and more effective for
men with very low count and/or poor motility;
can be time consuming
HOST Effective for men with very low count and/or poor
or no motility; technique successfully used
historically for testicular biopsy patients
Experimental procedures
RNA-based selection Not yet proven clinically
Membrane peptides
Proteomic analysis
Raman
Note: Spermatogenesis can lead to the production of an ejaculate with normal count, motility, and morphology or with decreased count (oligo), poor motility (astheno) and poor morphology
(terato). In addition, spermatozoa with high levels of nuclear DNA damage and damage from ROS can be present. These sperm can be eliminated from a sperm preparation with the use of tech-
niques that are designed to eliminate them from the nal preparation, or they can be individually selected before ICSI. Based on the current literature (see text), the most effective techniques for
optimizing sperm selection in patients would be to perform an electrophoretic apoptotic sperm deselection or microuidic preparation followed by individual sperm selection for ICSI with the use of
high magnication (IMSI) or by selecting sperm whose membranes possess the hyaluronan receptor (HA binding). Men with very low sperm counts and/or very poor or no motility can be treated
directly with the use of IMSI or HOST. HA hyaluronic acid; HOST hypo-osmotic swelling test; IMSI intracytoplasmic morphologically selected sperm injection; ROS reactive oxygen species;
moderately effective; most effective.
Sakkas. Selecting the best sperm for IVF and ICSI. Fertil Steril 2013.

VOL. 99 NO. 4 / MARCH 15, 2013 1027

MALE INFERTILITY
commercial HA selection methods showed similar clinical
results (59).
FUTURE APPROACHES TO SPERM SELECTION
A number of new technologies are being developed that may
also serve the purpose of allowing better sperm selection be-
fore classic IVF or ICSI. Other molecular techniques may allow
the analysis of sperm populations in the future. For example,
DNA methylation patterns of key developmental genes have
been shown to differ in spermatozoa, which may affect
embryo development (60). Interesting results are also being
generated from proteomic (61) and RNA (62) analysis of
sperm, which will create a database for identifying key factors
implicated in defective sperm function and aid in both diag-
nosis and treatment. This approach may already be bearing
fruit: Enciso et al. (63) have recently presented evidence
that a novel peptide-based stain could be designed that is
capable of detecting DNA damage in individual sperm cells.
Evaluation of sperm DNA fragmentation with the use of
this peptide could eventually allow this approach to be ap-
plied to the selection or deselection of viable spermatozoa
with intact DNA for use in ICSI and/or IMSI.
CONCLUSION
The effect of the paternal genome on reproductive outcome is
denitely coming under more scrutiny. Although the evi-
dence is overwhelming in animal models, the effect of the pa-
ternal genome is less evident and possibly more subtle in the
human. ICSI and the use of compromised sperm populations is
denitely creating some concern regarding its effect on off-
spring. The overall results point to incremental improvements
in pregnancy rates when particular patients are selected for
treatment with the use of these technologies. As these novel
sperm selection methods are developed, the challenge will
be in choosing which patients to apply different strategies
for (Table 1). Some of these technologies will be more appli-
cable broadly, whereas others may suit only a specic subset
of patients. The increasing focus on developing new tools to
more accurately diagnose and select individual sperm before
ICSI will allow us to counsel and treat couples with greater
condence and efciency and to allay the fears that we are
passing on a compromised paternal genome when treating
men with the use of ART.
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