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

S — Situation: Immotile or poorly motile sperm presents a significant clinical challenge in intracytoplasmic sperm injection (ICSI), prompting the use of adjunctive sperm viability selection techniques to optimize reproductive outcomes. P — Purpose: This study aimed to evaluate the effectiveness and safety of sperm viability selection methods for improving reproductive and neonatal outcomes in patients with immotile or poorly motile sperm undergoing ICSI. A — Approach: We conducted a systematic review and meta-analysis of controlled studies published in English between January 1990 and April 2025, identified through PubMed, Cochrane Library, Scopus, and Web of Science, comparing sperm viability selection techniques versus standard ICSI without viability selection. R — Results: Across included studies (13 studies), sperm viability selection was associated with a higher live birth rate compared with control (risk ratio [RR] 1.19; 95% confidence interval [CI], 1.05–1.36; P = 0.009; I²=6.6%), with subgroup analysis demonstrating greater improvement with theophylline use (RR 1.45; 95% CI, 1.09–1.92; P = 0.01; I²=66.4%). Results showed favorable secondary outcomes including increased clinical pregnancy rates and no observed increase in adverse neonatal or obstetric events. C — Conclusion: Sperm viability selection techniques were associated with improved live birth and pregnancy outcomes without an apparent increase in adverse perinatal events, although the certainty of evidence was low to very low. R — Relevance: These findings support consideration of sperm viability selection as an adjunct in ICSI for immotile or poorly motile sperm while underscoring the need for rigorously designed trials to inform evidence-based reproductive practice and guideline development. Registration: The protocol was prospectively registered on PROSPERO: CRD420251017288.