Microfluidic-based sperm sorting & analysis for treatment of male infertility

Advancements in differentiation between sperm cells and epithelial cells for efficient forensic DNA analysis in sexual assault cases

Most of the sexual assault casework samples are of mixed sources. Forensic DNA laboratories are always in the requirement of a precise technique for the efficient separation of sperm and non-sperm DNA from mixed samples. Since the introduction of the differential extraction technique in 1985, it has seen significant advancements in the form of either chemicals used or modification of incubation times. Several automated and semi-automated techniques have also adopted the fundamentals of conventional differential extraction techniques. However, lengthy incubation, several manual steps, and carryover over non-sperm material in sperm fraction are some of the major limitations of this technique. Advanced cell separation techniques have shown huge promise in separating sperm cells from a mixture based on their size, shape, composition, and membrane structure and antigens present on sperm membranes. Such advanced techniques such as DEParray, ADE, FACS, LCM, HOT and their respective pros and cons have been discussed in this article. As current-day forensic techniques should be as per the line of Olympic slogan i.e., faster, higher, stronger, the advanced cell separation techniques show a huge potential to be implemented in the casework samples.

Sperm Preparation with Microfluidic Sperm Sorting Chip May Improve Intracytoplasmic Sperm Injection Outcomes Compared to Density Gradient Centrifugation

Does sperm preparation using the FERTILE PLUS™ Sperm Sorting Chip improve fertilization rates, blastocyst formation, utilization, and euploidy rates in patients undergoing intracytoplasmic sperm injection (ICSI), compared with density gradient centrifugation (DGC)? A single-cohort, retrospective data review including data from 53 couples who underwent ICSI cycles within a 12-month period. For each couple, the two closest, consecutive cycles were identified, where one used the standard technique of sperm preparation (DGC) and the subsequent used FERTILE PLUS™, therefore, couples acted as their own controls. Paired samples t-test was used to compare means for the outcomes (fertilization, blastocyst formation, utilization, and euploidy rates). Binary logistic regression analysis assessed the relationship between female age, the presence of male factor infertility, and euploidy rates. Blastocyst, utilization, and euploidy rates were significantly higher for cycles using FERTILE PLUS™ compared to DGC (76% vs 56%, p = 0.002; 60% vs 41%, p = 0.005, and 40% vs 20%, p = 0.001, respectively). Although there was an increase in fertilization rates for cycles using FERTILE PLUS™, this was not significant (72% vs 68%, p = 0.449). The euploidy rates of females ≤ 35 years were significantly increased when the FERTILE PLUS™ sperm preparation method was used, compared to the older age group (OR 2.31, p = 0.007). No significant association was found between the presence or absence of male factor infertility and euploidy rates between the two cycles. This study provides tentative evidence that the FERTILE PLUS™ microfluidic sorting device for sperm selection can improve blastocyst formation, utilization, and euploidy rates following ICSI in comparison to the DGC method.

Microfluidics as an emerging paradigm for assisted reproductive technology: A sperm separation perspective

Millions of people are subject to infertility worldwide and one in every six people, regardless of gender, experiences infertility at some period in their life, according to the World Health Organization. Assisted reproductive technologies are defined as a set of procedures that can address the infertility issue among couples, culminating in the alleviation of the condition. However, the costly conventional procedures of assisted reproduction and the inherent vagaries of the processes involved represent a setback for its successful implementation. Microfluidics, an emerging tool for processing low-volume samples, have recently started to play a role in infertility diagnosis and treatment. Given its host of benefits, including manipulating cells at the microscale, repeatability, automation, and superior biocompatibility, microfluidics have been adopted for various procedures in assisted reproduction, ranging from sperm sorting and analysis to more advanced processes such as IVF-on-a-chip. In this review, we try to adopt a more holistic approach and cover different uses of microfluidics for a variety of applications, specifically aimed at sperm separation and analysis. We present various sperm separation microfluidic techniques, categorized as natural and non-natural methods. A few of the recent developments in on-chip fertilization are also discussed.

Microfluidic chip as a promising evaluation method in assisted reproduction: A systematic review

The aim of assisted reproductive technology (ART) is to select the high-quality sperm, oocytes, and embryos, and finally achieve a successful pregnancy. However, functional evaluation is hindered by intra- and inter-operator variability. Microfluidic chips emerge as the one of the most powerful tools to analyze biological samples for reduced size, precise control, and flexible extension. Herein, a systematic search was conducted in PubMed, Scopus, Web of Science, ScienceDirect, and IEEE Xplore databases until March 2023. We displayed and prospected all detection strategies based on microfluidics in the ART field. After full-text screening, 71 studies were identified as eligible for inclusion. The percentages of human and mouse studies equaled with 31.5%. The prominent country in terms of publication number was the USA (n = 13). Polydimethylsiloxane (n = 49) and soft lithography (n = 28) were the most commonly used material and fabrication method, respectively. All articles were classified into three types: sperm (n = 38), oocytes (n = 20), and embryos (n = 13). The assessment contents included motility, counting, mechanics, permeability, impedance, secretion, oxygen consumption, and metabolism. Collectively, the microfluidic chip technology facilitates more efficient, accurate, and objective evaluation in ART. It can even be combined with artificial intelligence to assist the daily activities of embryologists. More well-designed clinical studies and affordable integrated microfluidic chips are needed to validate the safety, efficacy, and reproducibility. Trial registration: The protocol was registered in the Open Science Frame REGISTRIES (identification: osf.io/6rv4a).

Methods and Measures for Investigating Microscale Motility

Motility is an essential factor for an organism's survival and diversification. With the advent of novel single-cell technologies, analytical frameworks, and theoretical methods, we can begin to probe the complex lives of microscopic motile organisms and answer the intertwining biological and physical questions of how these diverse lifeforms navigate their surroundings. Herein, we summarize the main mechanisms of microscale motility and give an overview of different experimental, analytical, and mathematical methods used to study them across different scales encompassing the molecular-, individual-, to population-level. We identify transferable techniques, pressing challenges, and future directions in the field. This review can serve as a starting point for researchers who are interested in exploring and quantifying the movements of organisms in the microscale world.

Microfluidics: The future of sperm selection in assisted reproduction

BACKGROUND

Obtaining functional sperm cells is the first step to treat infertility. With the ever-increasing trend in male infertility, clinicians require access to effective solutions that are able to single out the most viable spermatozoa, which would max out the chance for a successful pregnancy. The new generation techniques for sperm selection involve microfluidics, which offers laminar flow and low Reynolds number within the platforms can provide unprecedented opportunities for sperm selection. Previous studies showed that microfluidic platforms can provide a novel approach to this challenge and since then researchers across the globe have attacked this problem from multiple angles.

OBJECTIVE

In this review, we seek to provide a much-needed bridge between the technical and medical aspects of microfluidic sperm selection. Here, we provide an up-to-date list on microfluidic sperm selection procedures and its application in assisted reproductive technology laboratories.

SEARCH METHOD

A literature search was performed in Web of Science, PubMed, and Scopus to select papers reporting microfluidic sperm selection using the keywords: microfluidic sperm selection, self-motility, non-motile sperm selection, boundary following, rheotaxis, chemotaxis, and thermotaxis. Papers published before March 31, 2023 were selected.

OUTCOMES

Our results show that most studies have used motility-based properties for sperm selection. However, microfluidic platforms are ripe for making use of other properties such as chemotaxis and especially rheotaxis. We have identified that low throughput is one of the major hurdles to current microfluidic sperm selection chips, which can be solved via parallelization.

CONCLUSION

Future work needs to be performed on numerical simulation of the microfluidics chip prior to fabrication as well as relevant clinical assessment after the selection procedure. This would require a close collaboration and understanding among engineers, biologists, and medical professionals. It is interesting that in spite of two decades of microfluidics sperm selection, numerical simulation and clinical studies are lagging behind. It is expected that microfluidic sperm selection platforms will play a major role in the development of fully integrated start-to-finish assisted reproductive technology systems.

Qualified sperm selection based on the rheotaxis and thigmotaxis in a microfluidic system

Microfluidic systems with the ability to mimic the female reproductive tract (FRT) and sperm features have emerged as promising methods to separate sperm with higher quality for the assistant reproductive technology. Thereby, we designed and fabricated a microfluidic system based on FRT features with a focus on rheotaxis and thigmotaxis for passive sperm separation. In this regard, four various geometries (linear, square, zigzag, and sinusoidal) were designed, and the effect of rheotaxis and thigmotaxis were investigated. Although separated sperm in all microchannels were 100% motile, non-linear geometries were more effective than linear geometry in the term of separating the progressive sperm with high quality. In the presence of upstream flow, periodical changes in the slope of walls (in non-linear geometries) give rise to the periodical facing sperm with a high flow rate in the middle of microchannels, which was a reason for the high quality of separated sperm. However, because of sharp corners in the square and zigzag microchannels that create dead zones with a lack of upstream flow, which is noticeable via simulation results, these geometries have obstacles against sperm swimming toward the outlet, which was proved by image analysis. The sinusoidal geometry showed the highest enhancement level of the designed geometries compared to the linear geometry. Separated sperm exhibited 34.7% normal morphology, 100% motility, and 100% viability in the sinusoidal geometry. Therefore, the periodic change in the position of sperm from one wall to another wall can be a strategy for separating sperm with high quality.

Graphical abstract

In the present study, we used a microfluidic system for studying the combined effects of thigmotaxis and rheotaxis for sperm separation process to achieve the successful Assisted reproductive technology (ART). The designed PDMS-based microfluidic system had four various geometries, including linear, square, zigzag, and sinusoidal. The functionality of separated sperm was evaluated by sperm tracking (ImageJ), motility assay (CASA software), and morphology assay (Papanicolaou ultrafast staining). Probing various geometries revealed 100% motility. In non-linear geometries, sperm's periodic detachment from the walls gave rise to the periodic interaction with the high flow velocity in the center of the channel, resulting in the separation of high-quality sperm with progressive motility. The collected data proved the influence of thigmotaxis on the quality of separated sperm. Morphologically improvement in separated sperm from the sinusoidal geometry was significant than others, which means the sinusoidal structure would be the best candidate for the sperm separation process.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13534-023-00294-8.

Only the Best of the Bunch-Sperm Preparation Is Not Just about Numbers

In this Seminar, we present an overview of the current and emerging methods and technologies for optimizing the man and the sperm sample for fertility treatment. We argue that sperms are the secret to success, and that there are many avenues for improving both treatment and basic understanding of their role in outcomes. These outcomes encompass not just whether treatment is successful or not, but the wider intergenerational health of the offspring. We discuss outstanding challenges and opportunities of new technologies such as microfluidics and artificial intelligence, including potential pitfalls and advantages. This article aims to provide a comprehensive overview of the importance of sperm in fertility treatment and suggests future directions for research and innovation.

Controversy and Consensus on the Management of Elevated Sperm DNA Fragmentation in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

PURPOSE

Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition.

MATERIALS AND METHODS

An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method.

RESULTS

A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4-6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated.

CONCLUSIONS

This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians.

Stain-Free Sperm Analysis and Selection for Intracytoplasmic Sperm Injection Complying with WHO Strict Normal Criteria

This multi-center study evaluated a novel microscope system capable of quantitative phase microscopy (QPM) for label-free sperm-cell selection for intracytoplasmic sperm injection (ICSI). Seventy-three patients were enrolled in four in vitro fertilization (IVF) units, where senior embryologists were asked to select 11 apparently normal and 11 overtly abnormal sperm cells, in accordance with current clinical practice, using a micromanipulator and 60× bright field microscopy. Following sperm selection and imaging via QPM, the individual sperm cell was chemically stained per World Health Organization (WHO) 2021 protocols and imaged via bright field microscopy for subsequent manual measurements by embryologists who were blinded to the QPM measurements. A comparison of the two modalities resulted in mean differences of 0.18 µm (CI -0.442-0.808 µm, 95%, STD-0.32 µm) for head length, -0.26 µm (CI -0.86-0.33 µm, 95%, STD-0.29 µm) for head width, 0.17 (CI -0.12-0.478, 95%, STD-0.15) for length-width ratio and 5.7 for acrosome-head area ratio (CI -12.81-24.33, 95%, STD-9.6). The repeatability of the measurements was significantly higher in the QPM modality. Surprisingly, only 19% of the subjectively pre-selected normal cells were found to be normal according to the WHO2021 criteria. The measurements of cells imaged stain-free through QPM were found to be in good agreement with the measurements performed on the reference method of stained cells imaged through bright field microscopy. QPM is non-toxic and non-invasive and can improve the clinical effectiveness of ICSI by choosing sperm cells that meet the strict criteria of the WHO2021.

Design of a gradient-rheotaxis microfluidic chip for sorting of high-quality Sperm with progressive motility

Assisted reproductive technology (ART) is an important invention for the treatment of human infertility, and the isolation of high-quality sperm with progressive motility is one of the most critical steps that eventually affect the fertilization rate. Conventional sperm separation approaches include the swim-up method and density gradient centrifugation. However, the quality of isolated sperm obtained from both approaches can still be improved by improving sorted sperm motility, minimizing the DNA fragmentation rate, and removing abnormal phenotypes. Here, we report a Progressive Sperm Sorting Chip (PSSC) for high-quality sperm isolation. Based on the rheotaxis behavior of sperm, a gradient flow field is created in the chip for progressive sperm sorting. Clinical experiment results for 10 volunteers showed that greater than 90% of isolated sperm exhibit high motility (> 25 μm/s), high linearity (0.8), and a very low DNA fragmentation rate (< 5%). In addition, the whole process is label and chemical free. These features aid in gentle sperm sorting to obtain healthy sperm. This device uniquely enables the selection of high-quality sperm with progressive motility and might be clinically applied for infertility treatment in the near future.

Human sperm cooperate to transit highly viscous regions on the competitive pathway to fertilization

Human sperm compete for fertilization. Here, we find that human sperm, unexpectedly, cooperate under conditions mimicking the viscosity contrasts in the female reproductive tract. Sperm attach at the head region to migrate as a cooperative group upon transit into and through a high viscosity medium (15-100 cP) from low viscosity seminal fluid. Sperm groups benefit from higher swimming velocity, exceeding that of individual sperm by over 50%. We find that sperm associated with a group possess high DNA integrity (7% fragmentation index) - a stark contrast to individual sperm exhibiting low DNA integrity (> 50% fragmentation index) - and feature membrane decapacitation factors that mediate sperm attachment to form the group. Cooperative behaviour becomes less prevalent upon capacitation and groups tend to disband as the surrounding viscosity reduces. When sperm from different male sources are present, related sperm preferentially form groups and achieve greater swimming velocity, while unrelated sperm are slowed by their involvement in a group. These findings reveal cooperation as a selective mode of human sperm motion - sperm with high DNA integrity cooperate to transit the highly viscous regions in the female tract and outcompete rival sperm for fertilization - and provide insight into cooperation-based sperm selection strategies for assisted reproduction.

High-DNA integrity sperm selection using rheotaxis and boundary following behavior in a microfluidic chip

Rheotaxis, as one of the main natural guidance mechanisms in vivo, has been used in microfluidics to separate motile sperm. However, the lack of DNA integrity assessment and the inability to separate the cells in a specific reservoir have been the main limitations for the practical application of most of the devices using rheotaxis for sperm separation. Here, we present a microfluidic chip that can separate highly motile sperm using their inherent rheotaxis and boundary-following behavior in a network of boomerang-shaped microchannels. The device design is informed by our FEM simulation results to predict sperm trajectories. Experimental results demonstrate the device's performance to separate over 16 000 motile sperm in under 20 min, sufficient for droplet-based IVF. Separated cells are classified into two motility groups, highly motile (swimming speed > 120 μm s^-1) and motile (swimming speed < 120 μm s^-1). The device selects sperm with over 45%, 20%, and 80% improvement in motility, the number of highly motile sperm, and DNA integrity, respectively, suggesting promising potential for applications in assisted reproduction.

The efficacy of novel centrifugation-free sperm selection (Io-Lix) on sperm parameters and ICSI reproductive outcomes

RESEARCH QUESTION

What is the effect of a novel non-centrifugation method (Io-Lix) of sperm selection on sperm parameters and intracytoplasmic sperm injection (ICSI) reproductive outcomes?

DESIGN

This pilot study elevated the capacity of the Io-Lix sperm selection protocol to improve sperm parameters (concentration, motility and sperm DNA fragmentation) of the neat ejaculate. Once established, the reproductive outcomes of Io-Lix selected spermatozoa were used for autologous and donor oocyte ICSI programmes and their efficacy compared with those using conventional swim-up.

RESULTS

Io-Lix sperm selection resulted in lower sperm concentration yield (P < 0.001) and sperm DNA fragmentation (P < 0.001) but higher sperm motility (P < 0.001) when compared with spermatozoa in the neat ejaculate. When compared with swim-up sperm selection the Io-Lix protocol resulted in a 14.7% (P = 0.028) increase in pregnancy rate and 16.3% (P = 0.047) reduction in miscarriages in the autologous ICSI programme. A similar comparison of sperm selection procedures employed for a donor oocyte ICSI programme showed no difference in terms of their respective reproductive outcomes.

CONCLUSIONS

The Io-Lix sperm selection protocol resulted in improved pregnancy rate and reduction in miscarriage when applied to autologous ICSI, which was attributed to a reduction in the proportion of spermatozoa with DNA damage post-selection. A similar finding was not apparent in the donor oocyte programme, which may be associated with the capacity of the donor oocyte to repair sperm DNA post-syngamy.

Microfluidic sperm sorting improves ICSI outcomes in patients with increased values of Double-Strand Breaks in sperm DNA

BACKGROUND

Delays in embryo kinetics, implantation failures in ICSI treatments and recurrent miscarriages have been associated with high values of Double-Strand Breaks (DSB) in sperm DNA. While conventional methods for semen preparation have been shown to be inefficient reducing DSB values, Microfluidic Sperm Sorting (MSS) devices are promising tools to reduce this damage.

OBJECTIVE

To study the clinical utility of an MSS device in ICSI treatments when the male partner presents increased DSB values, as compared to the use of conventional methods based on sperm motility.

METHODS

This retrospective cohort study included 28 infertile couples undergoing ICSI treatments. Only couples where the male partner presented increased values of DSB were included. DSB values were evaluated in semen samples by the Neutral Comet assay. Couples performed a first ICSI cycle using conventional methods for semen preparation (Density Gradients and Swim-up) and a second ICSI cycle using the ZyMōt™ICSI (formerly named FertileChip®) microfluidic device. Embryology and clinical outcomes were compared between ICSI cycles.

RESULTS

Semen parameters and the number of obtained and fertilized oocytes did not show differences between ICSI rounds. Clinical outcomes were statistically better when MSS was used: the biochemical pregnancy rate increased 28.31%; the clinical pregnancy rate increased 35.56% and the number of live births increased 35.29%, as compared to the first ICSI cycle in this group of patients.

CONCLUSIONS

The ZyMōt™ICSI microfluidic device improved the reproductive outcomes in couples where the male partner presented increased DSB values, when compared to the use of conventional semen preparation techniques.

Evaluation Of The Clinical Results Of Using Microfluidic Channel System For Sperm Selection In IVF Cycles In Patients With Low Sperm Concentration

Objective: Microfluidic channel system (MAC), a new generation method, gives the chance to select better quality spermatozoa with lower DNA fragmentation indices. This study evaluated the treatment results in patients who underwent ICSI-ET due to the MAC technique's male factors. Methods: Sakarya University ART Center carried out this retrospective study. Patients with 35 male factor indications were included in our study. In these patients, swim-up (SU) was used in the first of two consecutive IVF cycles, and the MAC sperm preparation technique was used in the second. Our study compared fertilization, quality embryo counts, implantation after fresh embryo transfer, pregnancy rates, fifth-day embryo, and frozen embryo numbers. Results: Fertilization rate was higher in the MAC group than in the SU group (P=0.009). The number of 3rd and 5th Day Grade 1 embryo in the MAC group was statistically higher than in the SU group (p=0.000 for both parameters). The number of quality embryos frozen on day 5 was higher in the MAC group than in the SU group (P=0.000). Conclusions: It is thought that MAC application does not make a statistically significant contribution on implantation and pregnancy in IVF cycles performed due to the malefactor. However, it may positively affect fertilization rate and embryo quality. In addition, we think that it increases the number of embryos frozen at the end of the cycle, and for this reason, the MAC technique may provide positive benefits to IVF treatments.

Stem Cells and Organs-on-chips: New Promising Technologies for Human Infertility Treatment

Having biological children remains an unattainable dream for most couples with reproductive failure or gonadal dysgenesis. The combination of stem cells with gene editing technology and organ-on-a-chip models provides a unique opportunity for infertile patients with impaired gametogenesis caused by congenital disorders in sex development or cancer survivors. But how will these technologies overcome human infertility? This review discusses the regenerative mechanisms, applications, and advantages of different types of stem cells for restoring gametogenesis in infertile patients, as well as major challenges that must be overcome before clinical application. The importance and limitations of in vitro generation of gametes from patient-specific human-induced pluripotent stem cells (hiPSCs) will be discussed in the context of human reproduction. The potential role of organ-on-a-chip models that can direct differentiation of hiPSC-derived primordial germ cell-like cells to gametes and other reproductive organoids is also explored. These rapidly evolving technologies provide prospects for improving fertility to individuals and couples who experience reproductive failure.

Sperm selection techniques in cattle: Microfilter device versus conventional methods

Microfluidics and microfilter devices have been developed to mimic the characteristics of the female reproductive tract, minimizing the risk of sperm damage. This study aimed to compare the use of a microfilter device versus conventional methods for sperm selection used in in vitro fertilization (IVF). For selecting spermatozoa, the pooled samples were processed in a microfilter device, swim-up and mini-Percoll gradient. Kinematic and morphometric parameters, vitality and DNA damage were analysed before and after sperm selection. After selection, 10,000 motile spermatozoa per oocyte were used in IVF drops. Embryos were assessed at three (cleavage rate) and seven (blastocyst rate) days post-IVF. Results of sperm kinematic parameters including average path velocity, velocity straight line, curvilinear velocity, linearity, lateral head displacement with the microfilter device were superior to density gradient (p < 0.05), but similar to swim-up method. Likewise, sperm DNA damage was significantly reduced using the microfilter device and swim-up method. Regarding the total sperm recovery rate post selection, results with the microfilter device (17.64%) and mini-Percoll gradient (18.27%) were higher than with swim-up method (6.52%). However, the cleavage and blastocyst rates were the lowest using the microfilter device. In conclusion, sperm selection using the microfilter device and swim-up method can improve kinematic parameters, although the mini Percoll gradient was the most efficient method for embryo production.

A Review of the Impact of Microfluidics Technology on Sperm Selection Technique

Sperm sorting procedures depend on centrifugation processes. These processes produce oxidative stress and cell damage that are undesirable for in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes because they affect fertilization and implantation chances. The microfluidic sperm selection technique has shown promise in this area. It can create a platform for isolating and manipulating good-quality sperm cells using diverse triggers such as mechanical factors, chemical agents, and temperature gradients. Furthermore, microfluidic platforms can direct sperm cells for IVF or sperm sorting by utilizing an approach that is passive or active. In this review, we explain the use of microfluidics technologies for sorting and arranging sperm cells for different purposes. We also discuss the use of microfluidics technology in selecting and assessing sperm parameters and how it affects male infertility.

Management of male factor infertility: position statement from the Italian Society of Andrology and Sexual Medicine (SIAMS) : Endorsing Organization: Italian Society of Embryology, Reproduction, and Research (SIERR)

PURPOSE

Infertility affects 15-20% of couples and male factors are present in about half of the cases. For many aspects related to the diagnostic and therapeutic approach of male factor infertility, there is no general consensus, and the clinical approach is not uniform.

METHODS

In the present document by the Italian Society of Andrology and Sexual Medicine (SIAMS), endorsed by the Italian Society of Embryology, Reproduction, and Research (SIERR), we propose evidence-based recommendations for the diagnosis, treatment, and management of male factor infertility to improve patient and couple care.

RESULTS

Components of the initial evaluation should include at minimum medical history, physical examination, and semen analysis. Semen microbiological examination, endocrine assessment, and imaging are suggested in most men and recommended when specific risk factors for infertility exist or first-step analyses showed abnormalities. Full examination including genetic tests, testicular cytology/histology, or additional tests on sperm is clinically oriented and based on the results of previous investigations. For treatment purposes, the identification of the specific cause and the pathogenetic mechanism is advisable. At least, distinguishing pre-testicular, testicular, and post-testicular forms is essential. Treatment should be couple-oriented, including lifestyle modifications, etiologic therapies, empirical treatments, and ART on the basis of best evidence and with a gradual approach.

CONCLUSION

These Guidelines are based on two principal aspects: they are couple-oriented and place high value in assessing, preventing, and treating risk factors for infertility. These Guidelines also highlighted that male infertility and in particular testicular function might be a mirror of general health of a man.

Does Choosing Microfluidics for Sperm Sorting Offer an Advantage to Improve Clinical Pregnancies in Donor Egg Recipients?

Background:

Microfluidics (MF), an advanced sperm sorting technology results in the extraction of spermatozoa with higher DNA integrity and lower DNA damage compared to existing conventional sperm sorting methods.

Aims:

The aim of the present study is to assess the efficiency of MF and to isolate the best spermatozoa for intracytoplasmic sperm injection (ICSI) over the density gradient (DG) technique.

Study Setting and Design:

We recruited couples who choose the oocyte donation programme for this study to eliminate confounding factors associated with oocyte quality.

Materials and Methods:

Sperm was processed by MF (n = 180) and DG (n = 151). ICSI was performed and positive pregnancy, miscarriage and clinical pregnancy rates were compared.

Statistical Analysis:

All variables were analysed using Graph Pad Prism 5. The unpaired two-tailed t-test was used to assess the significance. A value of P < 0.05 was considered statistically significant.

Results:

There was no significant difference in pregnancy rates between the groups. However, a clear demarcation is seen in terms of clinical pregnancy rates, where the DG group achieved higher clinical pregnancies (91.7%) compared to the MF group (80.7%). Further, we compared miscarriage rates and biochemical pregnancies, and found a significantly higher miscarriage and biochemical pregnancy rate in the MF group (14.5% and 4%, respectively) compared to the DG group (6% and 1%, respectively).

Conclusions:

Based on the available literature, we anticipated a higher clinical pregnancy rate with MF compared with conventional processing. Our results show MF does not have any add-on positive effect on clinical pregnancy rate.

Antibody-Conjugated Magnetic Beads for Sperm Sexing Using a Multi-Wall Carbon Nanotube Microfluidic Device

This study proposes a microfluidic device used for X-/Y-sperm separation based on monoclonal antibody-conjugated magnetic beads, which become positively charged in the flow system. Y-sperms were selectively captured via a monoclonal antibody and transferred onto the microfluidic device and were discarded, so that X-sperms can be isolated and commercially exploited for fertilization demands of female cattle in dairy industry. Therefore, the research team used monoclonal antibody-conjugated magnetic beads to increase the force that causes the Y-sperm to be pulled out of the system, leaving only the X-sperm for further use. The experimental design was divided into the following: Model 1, the microfluid system for sorting positive magnetic beads, which yielded 100% separation; Model 2, the sorting of monoclonal antibody-conjugated magnetic beads in the fluid system, yielding 98.84% microcirculation; Model 3, the sorting of monoclonal antibody-conjugated magnetic beads with sperm in the microfluid system, yielding 80.12% microcirculation. Moreover, the fabrication microfluidic system had thin film electrodes created via UV lithography and MWCNTs electrode structure capable of erecting an electrode wall 1500 µm above the floor with a flow channel width of only 100 µm. The system was tested using a constant flow rate of 2 µL/min and X-/Y-sperm were separated using carbon nanotube electrodes at 2.5 V. The structure created with the use of vertical electrodes and monoclonal antibody-conjugated magnetic beads technique produced a higher effective rejection effect and was able to remove a large number of unwanted sperm from the system with 80.12% efficiency.

Viscoelastic Particle Focusing and Separation in a Spiral Channel

As one type of non-Newtonian fluid, viscoelastic fluids exhibit unique properties that contribute to particle lateral migration in confined microfluidic channels, leading to opportunities for particle manipulation and separation. In this paper, particle focusing in viscoelastic flow is studied in a wide range of polyethylene glycol (PEO) concentrations in aqueous solutions. Polystyrene beads with diameters from 3 to 20 μm are tested, and the variation of particle focusing position is explained by the coeffects of inertial flow, viscoelastic flow, and Dean flow. We showed that particle focusing position can be predicted by analyzing the force balance in the microchannel, and that particle separation resolution can be improved in viscoelastic flows.

Lower reactive oxygen species production and faster swimming speed of human sperm cells on nanodiamond spin-coated glass substrates

The sperm selection stage is what assisted reproductive technologies have in common and is crucial as it affects the success of the treatment cycle. The employment of microfluidic platforms for sperm selection has emerged showing promising results. In microfluidic platforms, sperm cells encounter micro-confined environments meanwhile having contact with channel walls and surfaces. Modification of contact surfaces using nanoparticles leads to the alteration of surface characteristics which in turn affects sperm behavior especially motility which is an indicator for sperm health. In this article, we present the results of investigating the motility parameters of sperm cells in contact with surface-modified glass substrates using nanodiamond particles. The results show that the sperm swimming velocities are significantly improved within the range of 12%-52% compared to the control surface (untreated). Reactive oxygen species production is also decreased by 14% justifying the increase in swimming speed. Taken together, bonding these modified surfaces to sperm selection microfluidic devices could enhance their efficiency and further improve their outcomes offering new solutions to patients facing infertility.

The Future of IVF: The New Normal in Human Reproduction

Increased demand for in vitro fertilization (IVF) due to socio-demographic trends, and supply facilitated by new technologies, converged to transform the way a substantial proportion of humans reproduce. The purpose of this article is to describe the societal and demographic trends driving increased worldwide demand for IVF, as well as to provide an overview of emerging technologies that promise to greatly expand IVF utilization and lower its cost.

The influence of the female reproductive tract and sperm features on the design of microfluidic sperm-sorting devices

Although medical advancements have successfully helped a lot of couples with their infertility by assisted reproductive technologies (ART), sperm selection, a crucial stage in ART, has remained challenging. Therefore, we aimed to investigate novel sperm separation methods, specifically microfluidic systems, as they do sperm selection based on sperm and/or the female reproductive tract (FRT) features without inflicting any damage to the selected sperm during the process. In this review, after an exhaustive studying of FRT features, which can implement by microfluidics devices, the focus was centered on sperm selection and investigation devices. During this study, we tried not to only point to the deficiencies of these systems, but to put forth suggestions for their improvement as well.

Advancements in Microfluidic Systems for the Study of Female Reproductive Biology

The female reproductive tract is a highly complex physiological system that consists of the ovaries, fallopian tubes, uterus, cervix, and vagina. An enhanced understanding of the molecular, cellular, and genetic mechanisms of the tract will allow for the development of more effective assisted reproductive technologies, therapeutics, and screening strategies for female specific disorders. Traditional 2-dimensional and 3-dimensional static culture systems may not always reflect the cellular and physical contexts or physicochemical microenvironment necessary to understand the dynamic exchange that is crucial for the functioning of the reproductive system. Microfluidic systems present a unique opportunity to study the female reproductive tract, as these systems recapitulate the multicellular architecture, contacts between different tissues, and microenvironmental cues that largely influence cell structure, function, behavior, and growth. This review discusses examples, challenges, and benefits of using microfluidic systems to model ovaries, fallopian tubes, endometrium, and placenta. Additionally, this review also briefly discusses the use of these systems in studying the effects of endocrine disrupting chemicals and diseases such as ovarian cancer, preeclampsia, and polycystic ovarian syndrome.

Curved ratchets improve bacteria rectification in microfluidic devices

We study how bacteria rectification in microfluidics devices can be optimized by performing experiments with eight ratchets of different shape and size. Results show that curved ratchets perform best and that their radius of curvature influences how well they perform, as it affects the time bacteria spend on the ratchet surface. We find that the optimal bacterial ratchet is a 60μm radius semicircle witch 15μm concavities. We also show that the angle at which bacteria leave the ratchets can play an important role in their efficiency. Lastly, we reproduce our experimental conditions in a simple numerical simulation to confirm our findings.

Role of the sperm, oocyte, and embryo in recurrent pregnancy loss

Disorders affecting the sperm, oocyte, or embryo may cause a significant fraction of spontaneous miscarriages and cases of recurrent pregnancy loss (RPL). Altered chromosomal integrity of sperm and oocytes, which is highly dependent of the age of the mother, represents a major cause of miscarriage and in turn RPL. Avoiding transfers of abnormal embryos is possible with preimplantation genetic testing for aneuploidies. Chromosomal anomalies may also be caused by structural rearrangements of one or several chromosomes in either parents, a finding encountered in 12% of couples with RPL, including in those who have had one or several healthy babies. More than 40% of these chromosomal rearrangements are identifiable on regular karyotypes. When abnormal findings are made, preimplantation genetic testing for monogenic disorders allows selection of disease-free embryos. Finally, asymmetric inactivation of the X chromosome has been found more commonly in women with RPL, but no specific treatment is currently available.

A microfluidic sperm-sorting device reduces the proportion of sperm with double-stranded DNA fragmentation

Sperm DNA fragmentation can be produced in one (ssSDF) or both (dsSDF) DNA strands, linked to difficulties in naturally achieving a pregnancy and recurrent miscarriages, respectively. The techniques more frequently used to select sperm require centrifugation, which may induce sperm DNA fragmentation (SDF). The objective of this study was to assess whether the microfluidic-based device FertileChip® (now ZyMot®ICSI) can diminish the proportion of sperm with dsSDF. First, in a blinded split pilot study, the semen of nine patients diagnosed with ≥60% dsSDF, was divided into three aliquots: not processed, processed with FertileChip®, and processed with swim up. The three aliquots were all analyzed using neutral COMET for the detection of dsSDF, resulting in a reduction of 46% (P < 0.001) with FertileChip® (dsSDF: 34.9%) compared with the ejaculate and the swim up (dsSDF: 65%). Thereafter, the FertileChip® was introduced into clinical practice and a cohort of 163 consecutive ICSI cycles of patients diagnosed with ≥60% dsSDF was analyzed. Fertilization rate was 75.41%. Pregnancy rates after the first embryo transfer were 53.2% (biochemical), 37.8% (clinical), 34% (ongoing) and the live birth rate was 28.8%. Cumulative pregnancy rates after one (65.4% of patients), two (27.6% of patients) or three (6.4% of patients) transfers were 66% (biochemical), 56.4% (clinical), 53.4% (ongoing) and the live birth rate was 42%. The selection of spermatozoa using Fertile Chip® significantly diminishes the percentage of dsSDF, compared with either the fresh ejaculate or after swim up. Its applicability in ICSI cycles of patients with high dsSDF resulted in good laboratory and clinical outcomes.

Recent Microfluidic Innovations for Sperm Sorting

Sperm selection is a clinical need for guided fertilization in men with low-quality semen. In this regard, microfluidics can provide an enabling platform for the precise manipulation and separation of high-quality sperm cells through applying various stimuli, including chemical agents, mechanical forces, and thermal gradients. In addition, microfluidic platforms can help to guide sperms and oocytes for controlled in vitro fertilization or sperm sorting using both passive and active methods. Herein, we present a detailed review of the use of various microfluidic methods for sorting and categorizing sperms for different applications. The advantages and disadvantages of each method are further discussed and future perspectives in the field are given.

Toward embryo cryopreservation-on-a-chip: A standalone microfluidic platform for gradual loading of cryoprotectants to minimize cryoinjuries

Embryo vitrification is a fundamental practice in assisted reproduction and fertility preservation. A key step of this process is replacing the internal water with cryoprotectants (CPAs) by transferring embryos from an isotonic to a hypertonic solution of CPAs. However, this applies an abrupt osmotic shock to embryos, resulting in molecular damages that have long been a source of concern. In this study, we introduce a standalone microfluidic system to automate the manual process and minimize the osmotic shock applied to embryos. This device provides the same final CPA concentrations as the manual method but with a gradual increase over time instead of sudden increases. Our system allows the introduction of the dehydrating non-permeating CPA, sucrose, from the onset of CPA-water exchange, which in turn reduced the required time of CPA loading for successful vitrification without compromising its outcomes. We compared the efficacy of our device and the conventional manual procedure by studying vitrified-warmed mouse blastocysts based on their re-expansion and hatching rates and transcription pattern of selected genes involved in endoplasmic reticulum stress, oxidative stress, heat shock, and apoptosis. While both groups of embryos showed comparable re-expansion and hatching rates, on-chip loading reduced the detrimental gene expression of cryopreservation. The device developed here allowed us to automate the CPA loading process and push the boundaries of cryopreservation by minimizing its osmotic stress, shortening the overall process, and reducing its molecular footprint.

Game-Changing Approaches in Sperm Sex-Sorting: Microfluidics and Nanotechnology

Simple Summary

Sexing of sperm cells, including the capacity to preselect the sex of offspring prior to reproduction, has been a major target of reproductive biotechnology for a very long time. The advances in molecular biology, biophysics, and computer science over the past few decades, as well as the groundbreaking new methods introduced by scientists, have contributed to some major breakthroughs in a variety of branches of medicine. In particular, assisted reproduction is one of the areas in which emerging technologies such as nanotechnology and microfluidics may enhance the fertility potential of samples of sex-sorted semen, thus improving the reproductive management of farm animals and conservation programs. In human medicine, embryo sex-selection using in vitro fertilization (IVF) and preimplantation genetic testing (PGT) is accepted only for medical reasons. Using sex-sorting before IVF would enable specialists to prevent sex-linked genetic diseases and prevent the discharge of embryos which are not suitable for transfer due to their sex.

Abstract

The utilization of sex-sorted sperm for artificial insemination and in-vitro fertilization is considered a valuable tool for improving production efficiency and optimizing reproductive management in farm animals, subsequently ensuring sufficient food resource for the growing human population. Despite the fact that sperm sex-sorting is one of the most intense studied technologies and notable progress have been made in the past three decades to optimize it, the conception rates when using sex-sorted semen are still under expectations. Assisted reproduction programs may benefit from the use of emergent nano and microfluidic-based technologies. This article addresses the currently used methods for sperm sex-sorting, as well as the emerging ones, based on nanotechnology and microfluidics emphasizing on their practical and economic applicability.

High efficiency rare sperm separation from biopsy samples in an inertial focusing device

Immotile and rare sperm isolation from a complex cell background is an essential process for infertility treatment. The traditional sperm collection process from a biopsy sample requires long, tedious searches, yet still results in low sperm retrieval. In this work, a high recovery, high throughput sperm separation process is proposed for the clinical biopsy sperm retrieval process. It is found that sperm have different focusing positions compared with non-sperm cells in the inertial flow, which is explained by a sperm alignment phenomenon. Separation in the spiral channel device results in a 95.6% sperm recovery in which 87.4% of non-sperm cells get removed. Rare sperm isolation from a clinical biopsy sample is performed with the current approach. The chance of finding sperm is shown to increase 8.2 fold in the treated samples. The achieved results highly support this method being used for the development of a rapid biopsy sperm sorting process. In addition, the mechanism was proposed and can be applied for the high-efficiency separation of non-spherical particles in general.

Reproductive Chances of Men with Azoospermia Due to Spermatogenic Dysfunction

Non-obstructive azoospermia (NOA), or lack of sperm in the ejaculate due to spermatogenic dysfunction, is the most severe form of infertility. Men with this form of infertility should be evaluated prior to treatment, as there are various underlying etiologies for NOA. While a significant proportion of NOA men have idiopathic spermatogenic dysfunction, known etiologies including genetic disorders, hormonal anomalies, structural abnormalities, chemotherapy or radiation treatment, infection and inflammation may substantively affect the prognosis for successful treatment. Despite the underlying etiology for NOA, most of these infertile men are candidates for surgical sperm retrieval and subsequent use in intracytoplasmic sperm injection (ICSI). In this review, we describe common etiologies of NOA and clinical outcomes following surgical sperm retrieval and ICSI.

Simplified sperm testing devices: a possible tool to overcome lack of accessibility and inconsistency in male factor infertility diagnosis. An opportunity for low- and middle- income countries

Background

Manual semen assessment (MSA) is a key component in a male’s fertility assessment. Clinicians rely on it to make diagnostic and treatment decisions. When performed manually, this routine laboratory test is prone to variability due to human intervention which can lead to misdiagnosis and consequently over- or under- treatment. For standardisation, continuous training, quality control (QC) programs and pricy Computer-Assisted Sperm Analysis (CASA) systems have been proposed, yet, without resolving intra- and inter-laboratory variability. In response, promising simplified sperm testing devices, able to provide cost-effective point-of-care male infertility diagnosis are prospected as a plausible solution to resolve variability and increase access to sperm testing.

Materials and methods

A throughout literature research for semen testing, sperm analysis, smart-phone assisted semen analysis, ‘at-home’ semen testing, male infertility, infertility in developing countries, infertility in low- and middle-income countries (LMIC) and quantitative sperm analysis was performed. A total of 14 articles, specific to ‘at-home’ simplified sperm assessment, were included to treat the core subject.

Results

Continuous training and consistent QC, are sine qua none conditions to achieve accurate and comparable MSA. Compliance does not rule-out variability, nevertheless. Emerging simplified sperm assessment devices are an actual alternative to resolve the lack of standardisation and accessibility to sperm analysis. YO ® , SEEM ® , and ExSeed ® are commercially available, user-friendly smartphone-based devices which can accurately measure volume, sperm concentration (millions/ml) and total motile sperm count. More broadly, by cost-effectiveness, availability, accuracy and convenient application, these devices could effectively select patients for first-line artificial reproduction treatments such as intrauterine insemination.

Conclusions

Accuracy and cost-effectiveness make smart-phone based sperm testing devices a practical and realistic solution to overcome variability in MSA. Importantly, these tools represent an actual opportunity to standardise and improve male subfertility diagnosis and treatment, especially in LMIC. However, before clinical application is possible, guidelines, further testing with special attention on accuracy in washed sperm, availability, cost-benefit and reliability are required.

Sperm selection during ICSI treatments reduces single- but not double-strand DNA break values compared to the semen sample

PURPOSE

To detect a possible bias in sperm DNA fragmentation (SDF) testing when performed on semen samples or on those few spermatozoa selected for Intracytoplasmic Sperm Injection (ICSI) treatments.

METHODS

A multimethodological analysis of Single- and Double-Strand DNA Breaks (SSB and DSB, respectively) was performed through the Neutral Comet, the Alkaline Comet, the Sperm Chromatin Dispersion (SCD) and the Terminal deoxynucleotidyl transferase dUTP Nick End Labelling (TUNEL) assays. SDF was evaluated in (i) semen samples from 23 infertile patients (not achieving pregnancy or suffering recurrent miscarriage); (ii) samples after a Swim-up and (iii) spermatozoa microselected for ICSI (ICSI-S).

RESULTS

The analysis of 3217 ICSI-S revealed a significant reduction of SSB values compared to the Ejaculate and the Swim-up samples. On the contrary, DSB values were not reduced after any sperm selection method. The No-pregnancy group presented poorer semen parameters and higher SSB values. The Recurrent miscarriage group presented better semen parameters but also higher DSB values.

CONCLUSION

The analysis of SDF on semen samples may not be fully representative of those few spermatozoa selected for ICSI. Since oxidative stress impairs sperm motility and causes SSB, selecting a motile sperm may intrinsically imply choosing a sperm not affected by this damage. DSB have an enzymatic origin which does not affect motility, making it difficult to select a sperm without this damage. Therefore, ICSI treatments could be effective in patients presenting high SSB values. Patients presenting high DSB values should expect bad ICSI results if this damage is not reduced through other specific methods.

FertDish: microfluidic sperm selection-in-a-dish for intracytoplasmic sperm injection

The selection of high quality sperm is critical for intracytoplasmic sperm injection (ICSI), a prevalent assisted reproduction technology. However, standard selection methods are time-consuming and fail to recover the most viable sperm, thereby limiting the ICSI success rate. Microfluidics enables rapid selection of viable sperm in a manner representing in vivo processes, however, existing platforms lack clinical applicability. Here, we present FertDish, which integrates the clinically established ICSI Petri dish with a film featuring an array of sperm-selecting microchannels for selection of sperm directly from semen. The FertDish format mimics the clinician-familiar ICSI dish setup, and provides rapid (<10 min) single stage sperm preparation that circumvents standard labour-intensive multi-stage sperm processing steps. Tests with human donor and patient semen samples show that FertDish enables the selection of a high quality sperm sub-population, featuring improvements in DNA fragmentation index of more than 91% (donor) and 74% (patient) versus raw semen and 50% (donor) and 63% (patient) versus standard methods, and a distribution of more than 97% sperm with viable and high level DNA. The FertDish enables a high sperm recovery rate (>3.3 × 105 sperm per mL), and is readily adaptable to the clinical workflow with potential to improve ICSI outcomes.

Microfluidic sperm selection yields higher sperm quality compared to conventional method in ICSI program: A pilot study

An appropriate preparation technique, should be capable of isolating highquality spermatozoa for intracytoplasmic sperm injection (ICSI). The aim was to assess sperm quality parameters, DNA integrity, embryo development, and clinical outcomes using a practical and accessible Microfluidic Sperm Sorting (MSS) technique. A total of 95 ICSI cases performed using sperm samples were prepared with our MSS (group 1) or by Direct Swim Up (DSU; control) method (group 2). Both sperm quality parameters and sperm DNA fragmentation (SDF) were compared between the groups. DNA fragmentation was assessed using Sperm Chromatin Dispersion (SCD) test and fine morphology was assessed using Motile Sperm Organelle Morphology Examination (MSOME). Embryo development and clinical outcomes were compared between the groups. In the MSS group, progressive motility and the fraction of Class I sperm morphology sperm were significantly higher compared to DSU group (P < 0.01 and P < 0.001, respectively). Moreover, the rates of DNA fragmentation and immotile spermatozoa were significantly lower in MSS when compared to DSU group (P < 0.001). Also, higher rates of high-quality embryo formation (P < 0.001), implantation (P = 0.04) and pregnancy (P = 0.05) were achieved in the MSS compared to DSU groups. The MSS technique proved to be a noninvasive, disposable, easy to use, and inexpensive method for separation of high-quality spermatozoa. Both laboratory parameters and clinical outcomes were improved with application of MSS for neat sperm collection in ICSI.AbbreviationsICSI: Intracytoplasmic Sperm Injection; MSS: Microfluidic Sperm Sorting; Sperm DNA Fragmentation (SDF); SCD: Sperm Chromatin Dispersion; MSOME: Motile Sperm Organelle Morphology Examination; DGC: Density Gradient Centrifugation; DSU: Direct Swim Up; ROS: Reactive Oxygen Species; ART: Assisted Reproducetive Technology.

An automated instrument for intrauterine insemination sperm preparation

Sperm preparation is critical to achieving a successful intrauterine insemination and requires the processing of a semen sample to remove white blood cells, wash away seminal plasma, and reduce sample volume. We present an automated instrument capable of performing a sperm preparation starting with a diluted semen sample. We compare our device against a density gradient centrifugation by processing 0.5 mL portions of patient samples through each treatment. In 5 min of operating time, the instrument recovers an average of 86% of all sperm and 82% of progressively motile sperm from the original sample while removing white blood cells, replacing the seminal plasma, and reducing the volume of the sample to the clinically required level. In 25 min of operating time, density gradient centrifugation recovers an average of 33% of all sperm and 41% of progressively motile sperm. The automated instrument could improve access to IUI as a treatment option by allowing satellite doctor’s offices to offer intrauterine insemination as an option for patients without the clinical support required by existing methods.

Sperm selection in IVF: the long and winding road from bench to bedside

Spermatozoa wage battle to conquer fertilization but the traits needed to succeed remain elusive. The natural advantageous qualities that enable only a few selected sperm cells to reach the site of fertilization remain unknown. Although in vitro fertilization (IVF) facilitates the job of spermatozoa, a universally acceptable means of sperm selection is yet to be developed. No objective or reliable sperm quality indicators have been established and sperm selection is, to a great extent, based on subjective qualitative evaluation. The best method for sperm selection in IVF presents several challenges: intrinsic sperm qualities cannot be evaluated and the ideal endpoint for these studies is debatable. An ideal method for sperm selection in ART should be noninvasive and cost-effective, and allow the identification of high-quality spermatozoa and yield better outcomes in terms of pregnancy and live birth rates. This narrative review included 85 papers and focused on the new available methods and technologies that might shed some light on sperm selection in IVF. It discusses the available data on microfluidic devices, omics profiling, micronuclei studies, sperm plasma membrane markers, and other techniques, such as Magnetic Activated Cell Sorting (MACS), Raman micro-spectroscopy, and artificial intelligence systems. The new techniques herein reviewed offer fresh approaches to an old problem, for which a definite solution has yet to cross the bridge from bench to IVF clinics around the world, since clinical usefulness and application remain unproven.

Sperm selection strategies and their impact on assisted reproductive technology outcomes

The application of assisted reproductive technologies (ART) has revolutionised the treatment of human infertility, giving hope to the patients previously considered incapable of establishing pregnancy. While semen analysis is performed to access whether a sample has an adequate number of viable, motile and morphologically normal sperm cells able to achieve fertilisation, sperm selection techniques for ART aim to isolate the most competent spermatozoon which is characterised by the highest fertilising potential. Based on the semen analysis results, the correct sperm selection technique must be chosen and applied. In this review, different sperm selection strategies for retrieving spermatozoa with the highest fertilising potential and their impact on ART outcomes are discussed. In addition, advantages and disadvantages of each method and the best suited techniques for each clinical scenario are described.

Sperm Extraction in Obstructive Azoospermia: What's Next?

For men with obstructive azoospermia, several surgical sperm retrieval techniques can facilitate conception with assisted reproductive technology. The evolution of both percutaneous and open approaches to sperm retrieval has been affected by technological innovations, including the surgical microscope, in vitro fertilization, and intracytoplasmic sperm injection. Further modifications to these procedures are designed to minimize patient morbidity and increase the quality and quantity of sperm samples. Innovative technologies promise to further ameliorate outcomes by selecting the highest quality sperm. Although various approaches to surgical sperm retrieval are now well established, several advancements in sperm selection and optimization are being developed.

Towards a better testicular sperm extraction: novel sperm sorting technologies for non-motile sperm extracted by microdissection TESE

Non-obstructive azoospermia (NOA) is the most severe form of male factor infertility. It is characterized by a lack of spermatogenesis in the seminiferous tubules. Microdissection testicular sperm extraction (microTESE) has significantly improved testicular sperm retrieval rates compared to conventional techniques for NOA. Following testicular biopsy, the sperm is usually non-motile and contained within seminiferous tubules requiring extensive laboratory processing to find individual sperm sufficient for artificial reproductive technologies (ART). Current techniques include mechanical and enzymatic processing which is time-consuming and often damaging to sperm. We review novel techniques that may help improve sperm retrieval rates after microTESE including microfluidics (dielectrophoretic cell sorting, spiral channel sorting, and pinched flow fractionation), fluorescence-activated cell sorting (FACS), and magnetic-activated cell sorting (MACS).

A treatment approach for couples with disrupted sperm DNA integrity and recurrent ART failure

OBJECTIVE

To test a novel method to select spermatozoa with high chromatin integrity.

DESIGN

Specimens with high sperm chromatin fragmentation (SCF) were selected by density gradient selection (DGS) and microfluidic sperm sorting (MSS).

SETTING

Academic medical center.

PATIENT(S)

Ejaculates from consenting men were processed by DGS/MSS. Couples underwent ICSI cycles with spermatozoa processed by DGS/MSS. Clinical outcomes were evaluated after embryo transfer.

INTERVENTION(S)

SCF was measured by TUNEL. ICSI with spermatozoa selected by DGS and MSS was performed.

MAIN OUTCOME MEASURE(S)

Fertilization, embryo implantation, and pregnancy outcomes were compared between DGS and MSS.

RESULT(S)

A total of 23 men had an average SCF of 20.7 ± 10%. After DGS and MSS, the SCF was 12.5 ± 5% and 1.8 ± 1%, respectively. In couples who underwent ICSI, the average SCF was 28.8 ± 9%, which fell to 21.0 ± 9% after DGS and 1.3 ± 0.7% after MSS. Four couples underwent 11 ICSI cycles with DGS and achieved one (25%) pregnancy that resulted in pregnancy loss. In four subsequent ICSI cycles with MSS, an ongoing clinical pregnancy rate of 50% was achieved. Five additional couples underwent 12 cycles of ICSI with DGS. After preimplantation genetic testing for aneuploidy, 30.3% of the embryos were euploid. One pregnancy was achieved, resulting in pregnancy loss. With MSS, 31.5% of the embryos were euploid and 4 couples obtained a pregnancy. Finally, sixteen couples underwent 20 ICSI cycles solely with MSS at our center. Of these couples, 8 had failed 13 ICSI cycles with DGS elsewhere. These couples achieved an overall implantation of 34.5% (10/29) and a pregnancy rate of 58.8% (10/17).

CONCLUSION(S)

Microfluidic selection yielded spermatozoa with optimal genomic integrity and improved chances of obtaining a euploid conceptus.

Does a microfluidic chip for sperm sorting have a positive add-on effect on laboratory and clinical outcomes of intracytoplasmic sperm injection cycles? A sibling oocyte study

The most recent technologies for sperm sorting involve microfluidics. However, the most important question whether their use is of any advantage in terms of laboratory and clinical IVF/ICSI outcomes still remains controversy. In this study, we aimed to investigate whether a microfluidic sperm sorting device (Fertile Plus^® ) has a positive add-on effect on laboratory and clinical outcomes. Sibling oocytes of 81 patients were assigned to two sperm sorting groups including swim up and Fertile Plus^® . All embryos were cultured until day 5/6. Fertilisation, embryo quality and blastocyst development were assessed as primary outcomes among 81 patients; clinical pregnancy, implantation and live birth rates were analysed as secondary outcomes as a subgroup analysis due to transfer cancellations. No statistically significant differences were found between groups in terms of all outcomes analysed in laboratory and clinical terms (p > .05 for all). The results of this study suggest that sorting spermatozoa through Fertile chip does not improve laboratory outcomes significantly and does not seem to have a positive contribution to clinical outcomes.