Real-time artificial intelligence-assisted rare-sperm searching: a prospective, multi-centre, paired sister-oocyte pilot study

Research question In severe male-factor infertility, does real-time artificial intelligence (AI)-assisted sperm searching reduce search time and increase sperm recovery compared with unassisted searching, and does its use affect downstream embryology outcomes? Design Prospective, multi-centre, within-patient paired split-dish pilot study (January 2024-September 2025). Matched dishes containing processed testicular tissue or semen from poor-prognosis non-obstructive azoospermic (NOA) or severe oligozoospermic patients (n=40) were searched with and without AI assistance. Primary outcomes were time per sperm and time per dish, reported as medians (IQR) because distributions were skewed and included zero values. Secondary outcomes were sperm recovered per dish and, in the subset with oocytes injected from both conditions, fertilisation and utilisable embryos per mature oocyte injected. Results Median time per dish decreased from 35.80 minutes (IQR 27.85-44.75) to 21.80 minutes (IQR 18.00-29.88) with AI assistance (p<0.0001; 40 paired comparisons). Median sperm recovered per dish increased from 0.00 (0.00-3.50) to 0.75 (0.00-5.00) (p<0.0001). In 18 patients where sperm were found with both methods, median time per sperm decreased from 10.85 minutes (6.95-38.65) to 5.50 minutes (2.27-11.00) (p=0.001). ICSI proceeded using sperm identified only with AI assistance in 8/40 cases. In a small subset of patients with oocytes injected from both conditions (12 paired patients), an exploratory analysis showed the median fertilisation rate increased from 0.0% (0.0-43.8) to 36.7% (21.2-63.9) (p=0.039), and utilisable embryos per MII increased from 0.00 (0.00-0.15) to 0.21 (0.15-0.31) (p=0.02). Conclusions AI-assisted sperm localisation reduced search time and increased sperm recovery in paired within-patient comparisons. Embryology findings from a small subset are exploratory and require larger studies to confirm.