title: Improving ICSI: A review from the spermatozoon perspective.
abstract: Intracytoplasmic sperm injection (ICSI) is the most frequently applied method for fertilization making the process of identifying the perfect spermatozoon fundamental. Herein we offer a critical and thorough presentation on the techniques reported regarding (i) handling and preparing semen samples, (ii) identifying and 'fishing' spermatozoa, and (iii) improving key factors, such as motility for a successful ICSI practice. These approaches are suggested to make the process easier and more effective especially in atypical and challenging circumstances. Furthermore, we present an epigrammatic opinion-where appropriate-based upon our collective experience. Techniques such as intracytoplasmic morphologically selected sperm injection, hyaluronic binding, polarized light microscopy, and annexin V agent identification for comparing sperm cells and their chromatin integrity are analyzed. Moreover, for the demanding cases of total sperm immotility the use of the hypoosmotic swelling test, methylxanthines, as well as the option of laser assisted immotile sperm selection are discussed. Finally, we refer to the employment of myoinositol as a way to bioreactively improve ICSI outcome for oligoasthenoteratozoospermic men. The diversity and the constant development of novel promising techniques to improve ICSI from the spermatozoon perspective, is certainly worth pursuing. The majority of the techniques discussed are still a long way from being established in routine practices of the standard IVF laboratory. In most cases an experienced embryologist could yield the same results. Although some of the techniques show great benefits, there is a need for large scale multicenter randomized control studies to be conducted in order to specify their importance before suggesting horizontal application. Taking into consideration the a priori invasive nature of ICSI, when clinical application becomes a possibility we need to proceed with caution and ensure that in the pursuit for innovation we are not sacrificing safety and the balance of the physiological and biological pathways of the spermatozoon's dynamic.
  
  
  BACKGROUND
  ICSI: intracytoplasmic sperm injection; IVF: in vitro fertilization; PGD: reimplantation genetic diagnosis; IVM: in vitro maturation; HCV/HIV: hepatitis C virus/human immunodeficiency virus; IMSI: intracytoplasmic morphologically selected sperm injection; DGC: density gradient centrifugations; S-U: swim-up; ART: assisted reproduction technology; IUI: intrauterine insemination; PVP: polyvinylpyrrolidone; HA: hyaluronic acid; MSOME: motile sperm organelle morphology examination; ZP: zona pellucida; MACS: magnetic activation cell sorting; HOST: hypo-osmotic swelling test; TESE: testicular sperm extraction; MMP: mitochondrial membrane potential; OAT: oligoasthenoteratozoospermic.
authors.affiliation: a Department of Physiology, Medical School, National and Kapodistrian University of Athens , Athens , Greece.|b Assisted Conception Unit, 2nd Department of Obstetrics and Gynecology , Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens , Athens , Greece.
authors.forename: Mara
authors.initials: M
authors.lastname: Simopoulou
authors.affiliation: b Assisted Conception Unit, 2nd Department of Obstetrics and Gynecology , Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens , Athens , Greece.
authors.forename: Laertis
authors.initials: L
authors.lastname: Gkoles
authors.affiliation: b Assisted Conception Unit, 2nd Department of Obstetrics and Gynecology , Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens , Athens , Greece.
authors.forename: Panagiotis
authors.initials: P
authors.lastname: Bakas
authors.affiliation: b Assisted Conception Unit, 2nd Department of Obstetrics and Gynecology , Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens , Athens , Greece.
authors.forename: Polina
authors.initials: P
authors.lastname: Giannelou
authors.affiliation: b Assisted Conception Unit, 2nd Department of Obstetrics and Gynecology , Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens , Athens , Greece.
authors.forename: Theodoros
authors.initials: T
authors.lastname: Kalampokas
authors.affiliation: c Centre for Human Reproduction , Genesis Hospital , Athens , Greece.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Pantos
authors.affiliation: a Department of Physiology, Medical School, National and Kapodistrian University of Athens , Athens , Greece.
authors.forename: Michael
authors.initials: M
authors.lastname: Koutsilieris
mesh_terms: D017304:Annexin A5 / Q000378:metabolism; D002843:Chromatin / Q000378:metabolism; D003470:Culture Media; D005260:Female; D006801:Humans; D006820:Hyaluronic Acid / Q000502:physiology; D008297:Male; D020554:Sperm Injections, Intracytoplasmic / Q000592:standards*; D013084:Sperm-Ovum Interactions; D013094:Spermatozoa / Q000378:metabolism / Q000502:physiology*
chemical_list: D017304:Annexin A5; D002843:Chromatin; D003470:Culture Media; D006820:Hyaluronic Acid
keywords: ART; ICSI; fertilization; infertility; spermatozoon