Artificial oocyte activation in patients with fertilization failure using calcium ionophores: a meta-analysis on reproductive outcomes

To evaluate the clinical efficacy and safety of artificial oocyte activation using calcium ionophores on reproductive and perinatal outcomes in couples with a history of fertilization failure following ICSI.

A systematic search was conducted for English-language studies published between 2003 and 2025. Studies comparing AOA-treated groups using calcium ionophores versus non-treated ICSI controls were included. Subgroup analyses were performed based on study design, type of ionophore (ionomycin vs. calcimycin), and fertilization failure subtype (total vs. low fertilization). Risk of bias was assessed using Cochrane RoB 2 and ROBINS-I tools.

Twenty-one studies met inclusion criteria. ICSI-AOA using calcium ionophores was associated with an increased fertilization rate, clinical pregnancy rate, and live birth rate. Miscarriage rate was reduced. Subgroup analyses indicated that ionomycin was more effective than calcimycin in improving fertilization, and that benefits were also observed for total and low fertilization failure. No differences were found for perinatal characteristics or malformation rates. Risk of bias was moderate to high, and no evidence of publication bias was detected.

Calcium ionophore-mediated activation may enhance reproductive outcomes in ICSI cycles in patients with fertilization failure, without increasing miscarriage or adverse neonatal outcomes. Their selective use could prevent cycle cancellation and reduce the emotional and financial burden associated with repeated ICSI failures. However, given the variability in ionophore protocols and experimental design, further randomized studies are warranted to standardize dosing, timing, and indications before universal clinical adoption.