Impact of artificial oocyte activation with calcium ionophore on ICSI outcomes using surgically retrieved spermatozoa: A comprehensive analysis

Background: Intracytoplasmic sperm injection (ICSI) is an effective technique for addressing male infertility. However, fertilization challenges persist, particularly with spermatozoa obtained through testicular sperm procedures. Objectives: This study evaluates the impact of artificial oocyte activation (AOA) on ICSI outcomes using surgically retrieved spermatozoa (motile, immotile, fresh, and frozen), including results from vitrified-warmed embryo transfers and investigating potential improvements in clinical outcomes. Materials and Methods: A retrospective analysis was conducted on 73 testicular sperm extraction (TESE)–ICSI cycles involving 57 patients. Outcomes were compared between AOA and non-AOA groups using a sibling oocyte model. Results: Fertilization rates were similar between AOA and non-AOA groups (53.2% vs. 52.3%). However, AOA showed a non-significant increase in TQE rates (64.4% vs. 54.7%, p = 0.067). Cumulative live-birth rates were comparable between AOA (19.3%) and non-AOA (21.6%) groups (p = 0.77). Notably, AOA significantly enhanced TQE rates when used with fresh spermatozoa (65.9% vs. 49.4%, p = 0.026) and non-progressive/immotile spermatozoa (72.7% vs. 51.1%, p = 0.031), yet had minimal effect with motile spermatozoa. There were no significant differences in embryo development timings between the groups. Obstetric and neonatal outcomes were comparable in-between groups, supporting the safety of AOA in this setting. Discussion: AOA appears to positively influence ICSI outcomes when using fresh and non-progressive/immotile spermatozoa. While the overall morphokinetics of embryo development were not affected, the improvement in TQE rates highlights AOA's potential in enhancing embryo quality. The consistent trends toward higher clinical pregnancy and live-birth rates further support its clinical utility. Conclusion: The study demonstrates that AOA significantly improves TQE rates, without negatively impacting overall morphokinetics or obstetric and neonatal outcomes. While the results suggest AOA's potential for specific subsets of male factor infertility cases, further research is needed to confirm its long-term safety and efficacy before broader clinical applications.