For many years sperm epigenetics has been a focus of studies hoping to identify novel mechanisms that drive infertility and offspring health abnormalities. This effort has yielded many exciting prospects but to date no direct and firm mechanistic pathways have been fully elucidated. This is largely a result of the unique nature of the mature sperm that is reflected in the distinct epigenetic signatures that are found therein. This unique landscape makes traditional approaches for understanding mechanisms difficult. However, the utility of sperm epigenetic marks in the prediction of specific reproductive outcomes is becoming clearer. While the mechanisms that explain the biological underpinnings of some of the associations between sperm epigenetics and reproductive health have yet to be elucidated, the value that these marks offer in prediction of various reproductive outcomes is becoming clearer.

The definition of epigenetics has been redefined in the last decades and today is generally accepted as the study of heritable factors, other than DNA base pair coding, that regulate gene expression. In this chapter, we briefly review the main epigenetic factors that exist in spermatozoa (e.g., histone and chromatin modifications, DNA methylation, and noncoding RNAs [ncRNAs]) and underline the associations and effects of aging, adiposity, and some lifestyle and environmental factors on the sperm epigenome. In conclusion, further work needs to be done to establish whether the changes of sperm epigenome triggered by aging, adiposity, diet, and smoking can have not only implications for the reproductive health but also for the future offspring.

Spectacular progress in the therapeutic management of patients with severe male infertility was obtained with the implementation of intracytoplasmic sperm injection (ICSI) and has opened avenues to treating previously untreatable cases of infertility. However, it must be recognized that in the vast majority of ICSI cycles, the selection of the spermatozoon followed by the intracytoplasmic injection is done very quickly at low magnification and without detection possibilities for potential pathological morphological anomalies of spermatozoa. Strong correlations between sperm morphological characteristics and male fertility have been demonstrated. Thus, it seems reasonable to implement optimized non-invasive sperm selection techniques in ART based on morphological ’normalcy’ of spermatozoa. Almost 20 years ago, ’motile-sperm organelle morphology examination’ (MSOME) was introduced by Bartoov et al. Using Nomarski differential interference contrast optics (DIC) an improved three-dimensional view of the head and midpiece became available. This chapter will describe different aspects of sperm selection by morphology.

Intracytoplasmic sperm injection (ICSI) was first described in 1992 as the ultimate tool for treating couples plagued by male factor infertility. Since then, it has become the most prevalent assisted reproductive technology (ART) treatment in the world, due to its incredible versatility and expanding cohort of indications for use. ICSI requires both a dedicated laboratory setup and knowledgeable and skilled embryologists in order to competently treat infertile couples. In this chapter, we will briefly describe the procedure, indications, required equipment and proper protocol in order to achieve reliable ICSI results and maintain consistent clinical outcome.

Piezo-ICSI is one of the intracytoplasmic sperm injection (ICSI) techniques using a piezo-actuator. This technique requires the use of a drive unit, a micropipette with a blunt-ended tip and an operation liquid. Piezo-ICSI can be applied for sperm immobilization, opening of the zona pellucida without oocyte deformation, and to semi-automatically break the oolemma membrane without the need for aspiration of cytoplasm into the injection pipette. The piezo-ICSI process is stable and easy and can contribute to standardizing the ICSI technique. In this chapter, we describe the set-up and protocol of piezo-ICSI for human oocytes.

Sperm motility is an important factor for successful fertilization and embryo development. If a patient presents only immotile sperm in the ejaculate or in a testicular sample, a viability test can help to identify among the immotile sperm those that are viable and suitable for intracytoplasmic sperm injection (ICSI). Different sperm viability tests have been introduced, and if they are applied properly, there is a good chance for successful treatment.

The preparation of a clean, highly motile sperm sample is an important part of a successful in vitro fertilization (IVF) program. Preparing sperm samples for IVF is also one of the first skills taught to junior embryologists and can help set both the tone and standard for how the remainder of their embryology training will occur. In addition to training junior embryologists on how to manipulate and process the sperm sample, it is also crucial that they are taught the importance of good quality control, correctly labelling and sample identification, proper documentation, and problem-solving skills. The purpose of this brief chapter is to help identify how to help train a junior embryologist to prepare sperm for IVF, rather than simply provide protocols for sperm preparation.

Cryopreservation of human spermatozoa offers male patients the option to preserve fertility prior to initiating cancer therapy, vasectomy or assisted reproductive technology (ART) treatment. Human sperm can be easily cryopreserved in liquid nitrogen and stored for years. A number of cryopreservation techniques and cryoprotectants have been investigated. To date, however, vapour-phase or programmed slow cooling using a glycerol/egg yolk buffer cryoprotectant has been the most widely applied sperm cryopreservation protocol. Sperm cryosurvival rates of 40% to 60% are generally achievable. However, in patients having low motility or low sperm number at the outset, cryopreservation and recovery of viable sperm can be more challenging. In such cases, freezing of single sperm or small numbers of sperm is emerging as a valuable tool. With this technique, intracytoplasmic sperm injection (ICSI) can be performed even in cases with only a few frozen spermatozoa.

Appropriate procedures must be documented that describe all the steps performed during an insemination of oocytes for in vitro fertilization (IVF). These procedures must be designed bothe to optimize the fertilization of oocytes and to prevent circumstances that increase the risk of introduction, transmission or spread of communicable diseases through the collection, preparation, culture and/or transfer of patients’ gametes and embryos.

Infertility due to azoospermia may be overcome by surgically retrieving sperm from the epididymis or testicle followed by in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) and embryo transfer. The nature of the azoospermia (obstructive (OA) versus non-obstructive azoospermia (NOA)), the surgical approach (percutaneous versus open) and the timing of the sperm retrieval relative to oocyte retrieval for IVF/ICSI (fresh versus frozen sperm) contribute to the success of sperm retrieval and the number of viable sperm that will be available for the IVF/ICSI procedure. The goal of the surgical team should be to maximize the recovery of mature, viable sperm for ICSI while minimizing patient risk and cost. The laboratory processing the samples must minimize post-recovery cell damage, preserve sample sterility and strive to optimize the efficiency of the surgery when possible by cryopreserving excess sperm for future IVF/ICSI procedures. Lastly, these teams must work together to optimize the ease of surgery coordination with the IVF procedure. The relevant procedures for sperm preparation from epidymal aspirates or testicular biopsies will be described in this chapter.

Spermatozoa have to be separated from seminal fluid to omit negative influences and to ensure best medically assisted reproduction (MAR) results. Several preparation techniques exist that can be used to enrich the best motile and morphologically normal spermatozoa: simple washing, swim-up (with or without washing step) and density gradient centrifugation. Every technique has its advantages and disadvantages, and also, the final attribution of the sample (e.g., usage for intrauterine insemination, in vitro fertilization or intracytoplasmic sperm injection) has to be taken into account. Simple washing is optimal for high sperm numbers in normozoospermic patients. Swim-up gives excellent results in normozoospermic and moderate oligoasthenoteratzoospermic (OAT) samples, and density gradient centrifugation is preferred if a sample is moderate to severe OAT. Epididymal aspirated samples can be prepared either by swim-up or by density gradient. Testicular sperm extraction samples have to be processed differently, as steps dissociating the tissue have to be executed first. Good-quality sperm preparation is a prerequisite for the highest success rates in MAR.

The concept of productive sexual continence was widespread in the nineteenth century. Writing on sexual health, medical and otherwise, agreed that excessive sexual activity involved a loss that threatened one’s health or wellbeing, though disagreed over how much was too much. And although suspicion of prolonged continence was common, many inferred that if sex lost something precious then continence must involve gain. The chapter begins with medicine, finding that productive continence was worked into thinking about the sexual body even as conceptions of sexuality and bodily function changed dramatically. It then looks at influential popular and intellectual genres to which a similar concept of continence was important: quack adverts, advice for young men, New Women literature, nineteenth-century Platonism, and the Oxford Movement. In this literature, unlike medical writing, the idea was often extended to women with the justification that sexual activity involved a loss of some spiritual or emotional quality rather than physical substance. It was a concept that would have been very difficult to avoid in the nineteenth century and would have been plausible to both men and women.

Sex. We walk the reader through why it matters to generate variation in a species. The mixing of genes from two sexes will be familiar to most readers as the reason for the uniqueness of each of us, right from the moment of conception. But we give insight on the other, less widely understood, ways that the differences between us come about. This leads to explanation of the early ‘conversations’ between the mother and her embryo that take place, and why they matter. We give some current and long-standing examples of mankind’s attempts to control conception or to encourage it, including the eugenic sterilisation agenda, artificial insemination and pregnancy termination after fetal sex determination. We explore one of the most hotly debated areas of medicine, assisted reproductive technologies, to which many people will relate. We encourage the reader to challenge the way they think about the preconception period, and consider why the responsibility seems to fall on girls and women, with its consequences for gender equality. This leads to the next chapter.