ArticlePDF Available

Comparison of strategies to reduce sperm DNA fragmentation in couples undergoing ICSI

Authors:
Sandro Esteves at Androfert
Sandro Esteves
  • Androfert
Ashok Agarwal at Cleveland Clinic
Ashok Agarwal
Ahmad Majzoub at Hamad Medical Corporation
Ahmad Majzoub
Download full-text PDF
Read full-text
Download citation
Content uploaded by Sandro Esteves
Author content
All content in this area was uploaded by Sandro Esteves on Sep 06, 2020
Content may be subject to copyright.
Transl Androl Urol 2017;6(Suppl 4):S570-S573tau.amegroups.com© Translational Andrology and Urology. All rights reserved.
We read with interest the commentary by Drs. Jan Tesarik and
Maribel Galán-Lázaro (1) regarding the recently published
practice recommendations for sperm DNA fragmentation
(SDF) testing based on clinical scenarios by Agarwal et al. (2).
Drs. Tesarik and Galán-Lázaro advocate the use of
SDF testing in all cases of fertility problems based on the
potentially dangerous implications of damaged DNA to
both natural and assisted conception. Notwithstanding,
the authors recognize that certain clinical scenarios pose
a higher risk to the couple, and therefore contributed
an algorithm to guide clinicians in ordering the test and
managing affected men (depicted in Table 1 and Figure 1 in
their article).
As the reader will see by examining their proposed
algorithm, two techniques for deselecting sperm with
damaged DNA, namely, motile sperm organelle morphology
examination (MSOME) and physiologic ICSI (PICSI) using
hyaluronic acid-selected spermatozoa, received a signicant
amount of attention. In this article, we discuss the existing
laboratory strategies to remove sperm with damaged DNA
for use in association with intracytoplasmic sperm injection
(ICSI).
To our knowledge, there is only one study that compared
interventions aimed at selecting sperm populations with
better DNA integrity for use with ICSI (3). In this report,
Bradley et al. retrospectively evaluated 448 ICSI cycles from
couples whose male partners had high levels of SDF. Sperm
injections were performed with either ejaculated sperm or
testicular sperm. In the ejaculated sperm group, the authors
applied interventions to reduce SDF including IMSI,
PICSI, and frequent ejaculation, and compared outcomes
with a control group of ‘no intervention’. They also
compared the results of ICSI using ejaculated sperm with
and without intervention to testicular sperm (Testi-ICSI),
and found higher live birth rates (P<0.05) with Testi-ICSI
(49.8%) than IMSI (28.7%) and PICSI (38.3%). The lowest
live birth rates (24.2%) were achieved when no intervention
was carried out to select sperm with intact DNA (P=0.020).
Notably, the utilization rate, calculated as the proportion
of embryos available for transfer or cryopreservation per
zygotes, was significantly higher among men subjected to
ICSI with testicular sperm than ejaculated sperm (54.7% vs.
43.8%). This study adds to the existing evidence suggesting
an advantage of testicular sperm in preference over
ejaculated sperm for ICSI to selected men with conrmed
high SDF in semen. Unfortunately, this study did not
provide data on the magnitude of SDF reduction after each
intervention modality.
However, studies examining the effectiveness of
laboratory strategies to reduce SDF do exist. Shortening
the ejaculatory abstinence, repeated ejaculation, and density
centrifugation, alone or combined, have shown to provide
a reduction in the proportion of sperm with damaged DNA
ranging from 22% to 47% (4-7). Likewise, swim-up has
yielded a reduction of about 35% in the proportion of DNA
damaged sperm (7,8). On the contrary, techniques such
as magnetic cell sorting (MACS), PICSI and IMSI have
brought about conicting results; while some studies have
Editorial
Comparison of strategies to reduce sperm DNA fragmentation in
couples undergoing ICSI
Sandro C. Esteves1, Ashok Agarwal2, Ahmad Majzoub3
1ANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, SP, Brazil; 2American Center for
Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA; 3Department of Urology, Hamad Medical Corporation, Doha, Qatar
Correspondence to: Sandro C. Esteves. Director, ANDROFERT, Andrology and Human Reproduction Clinic, and Collaborating Professor, Division
of Urology, UNICAMP, Av. Dr. Heitor Penteado 1464, Campinas, SP, 13075-460, Brazil. Email: s.esteves@androfert.com.br.
Response to: Tesarik J, Galán-Lázaro M. Clinical scenarios of unexplained sperm DNA fragmentation and their management. Transl Androl Urol
2017;6:S566-9.
Submitted Mar 10, 2017. Accepted for publication Mar 10, 2017.
doi: 10.21037/tau.2017.03.67
View this article at: http://dx.doi.org/10.21037/tau.2017.03.67
573
S571
Translational Andrology and Urology, Vol 6, Suppl 4 September 2017
Transl Androl Urol 2017;6(Suppl 4):S570-S573tau.amegroups.com© Translational Andrology and Urology. All rights reserved.
found reduction in SDF rates by applying these techniques,
others have failed to show any benefit (9-13) (Table 1).
There are also concerns about the longer duration of sperm
incubation at 37 degrees Celsius with these procedures,
which may itself increase SDF. Additionally, IMSI and
MACS relies on the availability of expensive equipment and
skilled technician. Recent studies with ICSI have indicated
no signicant differences in fertilization, pregnancy, quality
of embryos, implantation rates, miscarriage rates and live
birth rates in samples prepared with or without MACS,
IMSI and PICSI, although the evidence is not unequivocal
(reviewed by Rappa et al.) (14). Notably, these methods
have been applied to an unselected population of men
undergoing ART regardless of SDF rates. It is possible that
strict inclusion criterion of only men with high SDF may
avoid diluting the effect size of some of these techniques, a
hypothesis that deserves further investigation.
In addition to the laboratory strategies to identify and
remove sperm with SDF, the use of testicular sperm in
preference over ejaculated sperm for ICSI has also been
attempted. In this regard, few studies have examined SDF
in ejaculated and testicular sperm of men with confirmed
high SDF in the neat ejaculate (15-17). Interestingly, the
relative reduction in SDF ranged from 66% to 80%, thus
markedly greater than the techniques discussed above. It is
therefore of no surprise that the study of Bradley et al. have
found higher live birth rates with Testi-ICSI than IMSI and
PICSI (3). Nevertheless, the synergistic effect of combining
techniques to select sperm populations with better DNA
integrity, such as short ejaculatory abstinence and PICSI/
IMSI, or testicular sperm and IMSI, is yet to be studied.
Equally important is to evaluate the economic advantage
of these interventions. Differences in specific costs per
procedures may differ between clinics and countries, as well
as the availability of instrumentation and skilled workforce,
all of which need to be taken into considerations in a cost-
effectiveness analysis.
The study of Esteves et al. has shown that the number
needed to treat (NNT) by testicular compared to ejaculated
sperm to obtain an additional live birth per fresh transfer
cycles was 4.9 (95% CI: 2.8–16.8) (15). In other words,
if we need to treat about five patients with Testi-ICSI to
Table 1 Summary of the effect on sperm DNA fragmentation (SDF) reduction using different strategies
Method SDF Relative reduction SDF assay Study
Short abstinence 25% SCD Gosálvez et al., 2011;
22% TUNEL Agarwal et al. 2016
Gradient centrifugation 22%–44%* SCD Gosálvez et al., 2011
56.6% SCD Xue et al., 2014
Swim-up 33.3% SCD Parmegiani et al., 2010
38.1% SCD Xue et al., 2014
MACS 26.7% TUNEL Tsung-Hsein et al., 2010
None TUNEL Nadalini et al., 2014
PICSI 67.9% SCD Parmegiani et al., 2010
None SCSA Rashki Ghaleno et al., 2016
IMSI 78.1% TUNEL Hammoud et al., 2013
None SCD Maettner et al., 2014
Testicular sperm 79.7% SCD Esteves et al., 2015
79.6% TUNEL Greco et al., 2005
66.5% TUNEL Moskovtsev et al., 2010
*Combined with frequent ejaculation and short ejaculatory abstinence. MACS, Magnetic-activated cell sorting; PICSI, ‘Physiologic
ICSI’ with hyaluronic acid (HA) binding assay; IMSI, Intracytoplasmic morphologically selected sperm injection; TUNEL, terminal
deoxyribonucleotide transferase-mediated dUTP nick-end labeling) assay; SCD, sperm chromatin dispersion test; SCSA: sperm chromatin
structure assay.
S572 Esteves et al. Strategies to reduce SDF in the context of ICSI
Transl Androl Urol 2017;6(Suppl 4):S570-S573tau.amegroups.com© Translational Andrology and Urology. All rights reserved.
obtain an additional live birth, it means we could avoid one
out of ve oocyte pick-ups. It would also be interesting to
investigate the effect of the laboratory techniques discussed
above using NNT calculations.
Lastly, although the existing interventions can be overall
useful to remove sperm with DNA damage, none of them
can get rid of 100% damaged sperm (18) (see Table 1). A
technique that applies a neutral dye capable of identifying
damaged and non-damaged sperm is currently not available.
Consequently, research efforts should be made to find
methods to analyze live sperm and select those with intact
chromatin for ICSI. Given the clear association between
DNA damage and pregnancy outcomes, any laboratory
method or therapeutic strategy to minimize SDF should
be considered as an attempt to improve the sperm capacity
for promoting normal embryo development and healthy
offspring. However, due to the paucity of high-quality
evidence, physicians and their patients should be aware of
not only the possible advantages but also the limitations of
these interventions.
Acknowledgements
None.
Footnote
Conicts of Interest: The authors have no conicts of interest
to declare.
References
1. Tesarik J, Galán-Lázaro M. Clinical scenarios of
unexplained sperm DNA fragmentation and their
management. Transl Androl Urol 2017;6:S566-9.
2. Agarwal A, Majzoub A, Esteves SC, et al. Clinical
utility of sperm DNA fragmentation testing: practice
recommendations based on clinical scenarios. Transl
Androl Urol 2016;5:935-50.
3. Bradley CK, McArthur SJ, Gee AJ, et al. Intervention
improves assisted conception intracytoplasmic sperm
injection outcomes for patients with high levels of sperm
DNA fragmentation: a retrospective analysis. Andrology
2016;4:903-10.
4. Gosálvez J, González-Martínez M, López-Fernández
C, et al. Shorter abstinence decreases sperm
deoxyribonucleic acid fragmentation in ejaculate. Fertil
Steril 2011;96:1083-6.
5. Agarwal A, Gupta S, Du Plessis S, et al. Abstinence time
and its impact on basic and advanced semen parameters.
Urology 2016;94:102-10.
6. Gosálvez J, de la Torre J , López-Fernández C, et al. DNA
fragmentation dynamics in fresh versus frozen thawed plus
gradient-isolated human spermatozoa. Syst Biol Reprod
Med 2010;56:27-36.
7. Xue X, Wang WS, Shi JZ, et al. Efcacy of swim-up
versus density gradient centrifugation in improving sperm
deformity rate and DNA fragmentation index in semen
samples from teratozoospermic patients. J Assist Reprod
Genet 2014;31:1161-6.
8. Parmegiani L, Cognigni GE, Bernardi S, et al. ‘Physiologic
ICSI’’, Hyaluronic acid (HA) favors selection of
spermatozoa without DNA fragmentation and with normal
nucleus, resulting in improvement of embryo quality.
Fertil Steril 2010;93:598-604.
9. Tsung-Hsien Lee, Chung-Hsien Liu, Yang-Tse Shih, et
al. Magnetic-activated cell sorting for sperm preparation
reduces spermatozoa with apoptotic markers and improves
the acrosome reaction in couples with unexplained
infertility. Hum Reprod 2010;25:839-46.
10. Nadalini M, Tarozzi N, Di Santo M, et al. Annexin V
magnetic-activated cell sorting versus swim-up for the
selection of human sperm in ART: is the new approach
better then the traditional one? J Assist Reprod Genet
2014;31:1045-51.
11. Rashki Ghaleno L, Rezazadeh Valojerdi M, Chehrazi M,
et al. Hyaluronic acid binding assay is highly sensitive to
select human spermatozoa with good progressive motility,
morphology, and nuclear Maturity. Gynecol Obstet Invest
2016;81:244-50.
12. Hammoud I, Boitrelle F, Ferfouri F, et al. Selection of
normal spermatozoa with a vacuole-free head (x6300)
improves selection of spermatozoa with intact DNA
in patients with high sperm DNA fragmentation rates.
Andrologia 2013;45:163-70.
13. Maettner R, Sterzik K, Isachenko V, et al. Quality
of human spermatozoa: relationship between high-
magnication sperm morphology and DNA integrity.
Andrologia 2014;46:547-55.
14. Rappa KL, Rodriguez HF, Hakkarainen GC, et al. Sperm
processing for advanced reproductive technologies: Where
are we today? Biotechnol Adv 2016;34:578-87.
15. Esteves SC, Sánchez-Martín F, Sánchez-Martín P, et al.
Comparison of reproductive outcome in oligozoospermic
men with high sperm DNA fragmentation undergoing
intracytoplasmic sperm injection with ejaculated and
S573
Translational Andrology and Urology, Vol 6, Suppl 4 September 2017
Transl Androl Urol 2017;6(Suppl 4):S570-S573tau.amegroups.com© Translational Andrology and Urology. All rights reserved.
testicular sperm. Fertil Steril 2015;104:1398-405.
16. Greco E, Scarselli F, Iacobelli M, et al. Efcient treatment
of infertility due to sperm DNA dmage by ICSI with
testicular spermatozoa. Hum Reprod 2005;20:226-30.
17. Moskovtsev SI, Jarvi K, Mullen JB, et al. Testicular
spermatozoa have statistically signicantly lower DNA
damage compared with ejaculated spermatozoa in patients
with unsuccessful oral antioxidant treatment. Fertil Steril
2010;93:1142-6.
18. Gosálvez J, Lopez-Fernandez C, Fernandez JL, et al.
Unpacking the mysteries of sperm DNA fragmentation:
ten frequently asked questions. J Reprod Biotechnol Fertil
2015;4:1-16.
Cite this article as: Esteves SC, Agarwal A, Majzoub A.
Comparison of strategies to reduce sperm DNA fragmentation
in couples undergoing ICSI. Transl Androl Urol 2017;6(Suppl
4):S570-S573. doi: 10.21037/tau.2017.03.67
... The advantages and disadvantages of the various sperm selection techniques are presented in Table 5 [112,[114][115][116][118][119][120][121][122][123][124][125][126][127][128][129][130][131][132][133][134][135][136]. However, it should be underlined that the randomized clinical trials conducted to report on the effectiveness of these techniques did not focus strictly on men with elevated SDF, thus robust evidence is lacking on the effect of advanced sperm selection on this specific group of patients. ...
... Provide better results in reducing SDF [123], since sperm with fragmented DNA tend to present vacuoles and ultra-morphological alterations. ...
... Requires the use of expensive equipment [123]. Several reports show no clinical benefits, probably because its use is not focused on the right population of patients [133,136]. ...
Controversy and Consensus on the Management of Elevated Sperm DNA Fragmentation in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations
Article
Full-text available
  • May 2023
Purpose: Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition. Materials and Methods: An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method. https://doi.org/10.5534/wjmh.230008 4 www.wjmh.org INTRODUCTION An estimated 180 million couples or more are affected by infertility globally, with the male factor contributing to almost 50% of cases [1]. Male infertility has a complex nature and can be caused by a vast array of disorders. Besides some systematic illnesses or iatrogenic complications, any condition that can affect the male reproductive system including anatomical or functional anomalies, hormonal instabilities, and genetic or immunologic disorders can cause male infertility [2]. The assessment of male infertility relies primarily on conventional semen analysis. However, it is believed that semen analysis alone is insufficient to predict male fertility potential [3], as 15% of infertile men have normal semen parameters [4]. For this reason, new tests have been proposed to assess the functional competence of spermatozoa, including sperm DNA fragmentation (SDF) testing, which has been included and highlighted as a promising biomarker in the Sixth Edition of the World Health Organization (WHO) Laboratory Manual for the Examination and Processing of Human Semen [5]. Sperm DNA integrity is an important factor that can have a direct impact on male fertility potential [6] and sperm DNA strand breaks have been negatively correlated with fertilization rates in couples suffering from unexplained infertility [7]. Furthermore, impaired sperm DNA integrity can have adverse impacts on assisted reproductive technology (ART) success [8]. Different approaches have been suggested to lower SDF. Antioxidants play a key role in maintaining redox balance by scavenging reactive oxygen species (ROS) and have been shown to benefit infertile men with elevated SDF [9,10]. Short ejaculatory abstinence [11], weight loss [12,13], and using testicular sperm for intracytoplasmic sperm injection (ICSI) [14,15] are among other approaches that have been shown to reduce SDF. Recently, Agarwal et al [16] suggested a treatment algorithm using the available evidence in the literature that included the following strategies to lower SDF: recurrent ejaculation, antioxidants, lifestyle modification, control of infection/inflammation, varicocele repair (VR), and sperm processing and preparation. Despite the many different approaches for lowering SDF that have been investigated, there is a lack of standardization on clinical grounds. This can mainly be attributed to the scarcity of professional society recommendations that specifically address the management of infertile men who are found to have elevated SDF. As such, it is important to determine the current worldwide practices related to the treatment of elevated SDF and how clinicians approach such cases, and whether they are in line with the current evidence and recommendations. To ensure adequate management of infertile men, a unified, evidence-based, and patientcentered approach to those found to have elevated SDF is crucial. Therefore, the aims of this study are: 1) To investigate the global practices related to the Results: A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4–6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated. Conclusions: This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians.
View
... One more suggested line of treatment is the use of surgically retrieved testicular spermatozoa as an alternative of epididymal sperm. The motive to use testicular sperm is to minimize sperm with fragmented nDNA and acquire specimens with better mtDNA for use with in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) procedures [22,49,101]. However, latest evidence suggests the exact opposite, indicating epididymal sperm to be superior to testicular sperm for ICSI outcome [81,83]. ...
... In this way, spermatozoa can be selected by visualizing morphology under conditions not possible with normal laboratory equipment. Subtle morphologic abnormalities become visible under this high magnification (66006) that cannot be seen under normal high power objectives (4006), permitting the embryologist to select better sperm for ICSI fertilization [22,96,100,101]. Other ways to upgrade sperm nDNA include enhanced preparation techniques. ...
... Very recently, a novel sperm selection assay has been proposed to select viable sperm free of chromosomal anomalies for use with ICSI. Sperm hyaluronic acid (HA) binding has demonstrated the ability to isolate mature, viable sperm with unreacted acrosomal status, without damaging the specimen [22,51,101,103]. One principle of this assay lies in the expression of the chaperone protein HspA2; in spite of its pivotal role in meiosis, HspA2 levels have become physiological and biochemical markers of sperm maturation [22,101,104]. ...
Sperm DNA Links from Sperm to Ovum to Implant Genetic Changeability: an Overview
Article
  • Apr 2018
Sperm DNA disintegration is known to cooperate male fertility. The data bring about that sperm DNA cleavage can be competently treated with orally administered antioxidant during a relatively short moment period. It is an accepting thought that the two types of DNA become visible to be distinctive and autonomously packaged molecules; though, investigation has established the symbiotic nature of these structures in contributing to male infertility. Data should continue to be gathered to ascertain strong correlation between conventional semen examination parameters and sperm DNA integrity; this information remains contentious and inadequate in clinical practice until certain novel techniques for the diagnosis and treatment of sperm DNA can be established. Rather more modern technology should be employed to associate such information into practical clinical awareness. This overview compiles certain specific reports pertaining to studies on sperm DNA physiology, biochemistry and molecular biology to provide further new insights into establishing hypothesis that sperm DNA integrity is both enormously fragile and remarkably significant for male fertility. Keywords: Apoptosis; Male infertility; Sperm DNA
View
... Therefore, patients with extremely high DFI may benefit less from these techniques. Similar to our conclusion, Esteves et al. after reviewing the literature concluded that none of the sperm selection techniques could completely eliminate the DNA fragmented spermatozoa (38). Lepine et al., in their meta-analysis, reported that it is still not clear whether advanced sperm selection strategies will likely improve the live birth rate. ...
Comparison of the Efficiency of Magnetic-Activated Cell Sorting (MACS) and Physiological Intracytoplasmic Sperm Injection (PICSI) for Sperm Selection in Cases with Unexplained Infertility
Article
Full-text available
  • Jul 2022
Background: The cases with unexplained infertility may have an abnormality in their sperm chromatin structure. Sperm selection methods can be used to separate sperm with low DNA fragmentation. The purpose of this study was to compare the efficacy of physiological intracytoplasmic sperm injection (PICSI) with magnetic-activated cell sorting (MACS) in assisted reproductive techniques in cases with unexplained infertility. Methods: The semen samples were collected from couples with unexplained infertility. After semen analysis and sperm DNA fragmentation (SDF) evaluations, samples were prepared with swim-up method. The rates of SDF in different fractions including raw semen (n=20), swim-up (n=20), only motile sperm after swim-up (swim-up selection) (n=20), MACS sperm selection (n=20), only motile sperm after MACS (MACS selection) (n=20), and PICSI sperm selection (n=16) were evaluated. Also, the main sperm characteristics and fine morphology of sperm suspension after MACS were assessed. Statistical analysis was performed using GraphPad Prism. The p<0.05 was considered statistically significant. Results: DNA fragmentation index (DFI) values in PICSI and MACS groups were significantly reduced as compared to the swim-up group. The rate of this reduction was more pronounced in MACS (58.20±13.02) than PICSI (36.57±15.52) group. Also, our results showed that MACS resulted in decreased sperm motility, with no alteration in their fine morphology. Conclusion: MACS was found to be more efficient in reduction of SDF rates than PICSI. However, none of the sperm selection techniques can not totally eliminated the spermatozoa with DNA fragmentation in the final sperm sample.
View
... Another study evaluated the ability of swim-up technique and density gradient centrifugation to remove single-and double-strand DNA damage. The results showed that both are equally efficient in eliminating spermatozoa containing double-strand DNA damage and sperm with highly damaged (degraded) DNA and that density gradient centrifugation is more efficient than swim-up technique in selecting spermatozoa that are free from single-strand DNA damage [74]. Other methods such as the morphologically (IMSI) or physiologically (PICSI) selected sperm for ICSI and magnetic cell sorting have selected sperm with lower SDF for use in ICSI with variable efficiency [75,76]. ...
Best Practice Guidelines for Sperm DNA Fragmentation Testing
Chapter
  • Jan 2020
The field of male infertility has witnessed many advancements in the past few decades that have refined our understanding of the sperm contribution to conception. The extent of sperm DNA fragmentation is currently believed to play a key role on fertilization and embryogenesis making it an important test of sperm function. This belief has triggered many scientists to explore SDF testing in clinical practice. Many tests can assess DNA damage directly through dyes and probes or indirectly though measuring the denaturation of DNA. Regardless of the method used, SDF testing is gaining popularity and is extensively investigated to evaluate its value in the management of male infertility. Recent publication of clinical practice guidelines on the utility of SDF testing has provided a strong evidence-based approach to the utilization of this test by fertility specialists. This chapter aims at exploring the evidence highlighting the significance of SDF testing in clinical practice.
View
... The effects of reduction in the proportion of sperm with damaged DNA after DGC and swim-up have been reported by a number of studies. However, the results were inconclusive and the implication on ICSI outcomes remains unclear [48]. Supplementation of culture media with antioxidant may improve ICSI outcomes by scavenging excessive production of ROS. ...
The Role of Interventions to Reduce Oxidative Stress and Improve Sperm DNA Integrity Before ICSI
Chapter
  • Jan 2020
In the era of assisted reproductive techniques where intracytoplasmic sperm injection (ICSI) may overcome the most severe form of male infertility, sperm with severe function defect may bypass the natural selection process and achieve clinical pregnancy and live birth. The risk of injecting DNA-damaged sperm into oocyte during ICSI is increasingly recognized with the understanding of oxidative stress (OS)-induced sperm DNA fragmentation (SDF) in the pathogenesis of male subfertility. Emerging evidence reveals the negative impact of poor sperm DNA integrity on ICSI outcomes, particularly miscarriage rate. The invention of various OS and SDF assays, on one hand, allows the investigation of potential treatment strategies in the alleviation of OS and SDF. On the other hand, presence of effective treatment is essential in further substantiating the role of laboratory assays in clinical practice. Several interventions including the use of sperm with short ejaculatory abstinence, oral antioxidant therapy, varicocele repair, advanced sperm selection techniques, and the use of testicular sperm have been explored. Most of these strategies have proven their efficacy in reducing OS and SDF significantly. However, clinical application of the techniques remains less clear due to limited clinical trials in the literature. Although improved ICSI outcomes have been observed in a number of retrospective and prospective studies, the treatment strategies should be utilized with caution in view of the lack of randomized study at the moment.
View
... In contrast, the DG method is based on the capacity of motile spermatozoa to sediment in higher density medium when centrifuged within different layers of medium of different density 15 . Both techniques serve to recover a fraction of spermatozoa of higher quality than the initial pool in terms of factors including DNA integrity 17 , though the quality of the spermatozoa in terms of DNA damage and ROS production seems to be better for the swim-up procedure 18 . However, despite these effective sperm preparation methods, the efficiency of ICSI remains relatively low. ...
Sperm selection by thermotaxis improves ICSI outcome in mice
Article
Full-text available
  • Feb 2018
The ejaculate is a heterogeneous pool of spermatozoa containing only a small physiologically adequate subpopulation for fertilization. As there is no method to isolate this subpopulation, its specific characteristics are unknown. This is one of the main reasons why we lack effective tools to identify male infertility and for the low efficiency of assisted reproductive technologies. The aim of this study was to improve ICSI outcome by sperm selection through thermotaxis. Here we show that a specific subpopulation of mouse and human spermatozoa can be selected in vitro by thermotaxis and that this subpopulation is the one that enters the fallopian tube in mice. Further, we confirm that these selected spermatozoa in mice and humans show a much higher DNA integrity and lower chromatin compaction than unselected sperm, and in mice, they give rise to more and better embryos through intracytoplasmic sperm injection, doubling the number of successful pregnancies. Collectively, our results indicate that a high quality sperm subpopulation is selected in vitro by thermotaxis and that this subpopulation is also selected in vivo within the fallopian tube possibly by thermotaxis.
View
Unraveling the Impact of Sperm DNA Fragmentation on Reproductive Outcomes
Article
  • Dec 2023
In recent years, there has been a growing interest in identifying subcellular causes of male infertility, and sperm DNA fragmentation (SDF) research has been at the forefront of this focus. DNA damage can occur during spermatogenesis due to faulty chromatin compaction or excessive abortive apoptosis. It can also happen as sperm transit through the genital tract, often induced by oxidative stress. There are several methods for SDF testing, with the sperm chromatin structure assay, terminal deoxynucleotidyl transferase d-UTI nick end labeling (TUNEL) assay, comet assay, and sperm chromatin dispersion test being the most commonly used. Numerous studies strongly support the negative impact of SDF on male fertility potential. DNA damage has been linked to various morphological and functional sperm abnormalities, ultimately affecting natural conception and assisted reproductive technology outcomes. This evidence-based review aims to explore how SDF influences male reproduction and provide insights into available therapeutic options to minimize its detrimental impact.
View
Sperm DNA Fragmentation: Treatment Options and Evidence-Based Medicine
Chapter
  • Mar 2020
Sperm DNA fragmentation testing has been recognized as an important additive evaluation tool for examining male fertility potential. This is because SDF can significantly influence fertilization, embryogenesis, and live birth rate. Several indications for SDF testing have been recently recognized. Once detected, the SDF level can aid the clinician in making sound decisions in attempting to normalize the SDF value and improve a man’s fertility status. Treatments such as frequent ejaculations, treatment of infection, avoidance of risk factors, antioxidant therapy, varicocelectomy, sperm selection, and use of testicular sperm for intracytoplasmic sperm injection have been utilized with promising results.
View
Klinefelter Syndrome
Chapter
  • Mar 2020
Klinefelter syndrome (KS) is the most common X chromosome abnormality encountered in men with infertility. The classic form 47,XXY accounts for 80–90% of cases. An error of nondisjunction during gametogenesis provides the extra X chromosome in KS men. The various karyotype variants of KS share the same features of hypergonadotropic hypogonadism but present with more distinct physical, medical and psychological features than the classic form. Spermatogenesis appears to be intact during infancy up to the prepubertal period; however, it progressively declines during adulthood. Learning and behavioural challenges are frequent at an earlier age, while androgen deficiency and infertility are usually encountered at an advanced age. Testosterone replacement therapy is the cornerstone to address hypogonadism to enhance the quality of life and prevent the long-term complications of the androgen-deficient state. Intracytoplasmic sperm injection (ICSI) is a major breakthrough in the treatment of infertility, particularly in KS men. Sperm can be found in the ejaculate in patients with KS and can be used for assisted reproductive technology. However, microdissection testicular sperm extraction (TESE) is the mainstay procedure of choice for sperm retrieval for ICSI, as most KS men present with non-obstructive azoospermia. This procedure provides significantly superior overall outcomes compared to other sperm retrieval techniques. Although men with sex chromosomal abnormalities have a low risk of producing offspring with the same abnormalities after ICSI, genetic counselling should be performed in a multidisciplinary approach to enhance the quality of life and overall health status of KS men.
View
Adverse effects of paternal obesity on the motile spermatozoa quality
Article
Full-text available
Growing evidence suggests that paternal obesity may decrease male fertility potential. During infertility treatment with intra-cytoplasmic sperm injection (ICSI), a morphologically normal motile spermatozoon is injected into a mature egg, when possible. However, sperm motility and morphology per se do not reflect the sperm molecular composition. In this study, we aimed to assess the quality of motile spermatozoa in the context of obesity by analysing their conventional and molecular characteristics as well as their ability to promote early embryonic development. A prospective study was conducted on 128 infertile men divided into three groups: 40 lean, 42 overweight, and 46 obese men. Conventional sperm parameters (concentration, motility and morphology) and sperm molecular status (chromatin composition and integrity, 5-methycytosine (5-mC) and 5-hydroxycytosine (5-hmC) contents and oxidative stress level) were analysed on raw semen and/or on motile spermatozoa selected by density gradient or swim-up techniques. Morphokinetic analysis of the embryos derived from ICSI was performed using the Embryoviewer software. Our results showed that the motile sperm-enriched fraction from obese men exhibited higher levels of retained histones (p<0.001), elevated percentage of altered chromatin integrity (p<0.001), and decreased contents of 5-hmC (p<0.001), and 5-mC (p<0.05) levels as compared to that from lean men. Importantly, there were no statistically significant correlations between these molecular parameters and the percentages of morphologically normal motile spermatozoa. Regarding embryo morphokinetics, the CC1 (p<0.05) and CC3 (p<0.05) embryonic cell cycles were significantly delayed in the cleavage embryos of the obese group as compared to the embryos of the lean group. Our data is of particular interest because, besides demonstrating the negative impacts of obesity on motile spermatozoa molecular composition, it also highlights the possible risk of disturbing early embryonic cell cycles kinetics in the context of paternal obesity.
View
View
Clinical utility of sperm DNA fragmentation testing: Practice recommendations based on clinical scenarios
Article
Full-text available
  • Dec 2016
Sperm DNA fragmentation (SDF) has been generally acknowledged as a valuable tool for male fertility evaluation. While its detrimental implications on sperm function were extensively investigated, little is known about the actual indications for performing SDF analysis. This review delivers practice based recommendations on commonly encountered scenarios in the clinic. An illustrative description of the different SDF measurement techniques is presented. SDF testing is recommended in patients with clinical varicocele and borderline to normal semen parameters as it can better select varicocelectomy candidates. High SDF is also linked with recurrent spontaneous abortion (RSA) and can influence outcomes of different assisted reproductive techniques. Several studies have shown some benefit in using testicular sperm rather than ejaculated sperm in men with high SDF, oligozoospermia or recurrent in vitro fertilization (IVF) failure. Infertile men with evidence of exposure to pollutants can benefit from sperm DNA testing as it can help reinforce the importance of lifestyle modification (e.g., cessation of cigarette smoking, antioxidant therapy), predict fertility and monitor the patient's response to intervention.
View
Comparison of reproductive outcome in oligozoospermic men with high sperm DNA fragmentation undergoing intracytoplasmic sperm injection with ejaculated and testicular sperm
Article
Full-text available
  • Oct 2015
Objective: To investigate the effectiveness of intracytoplasmic sperm injection (ICSI) using testicular sperm as a strategy to overcome infertility in men with high sperm DNA fragmentation (SDF). Design: Prospective, observational, cohort study. Setting: Private IVF centers. Patient(s): A total of 147 couples undergoing IVF-ICSI and day 3 fresh ETs whose male partner has oligozoospermia and high SDF. Intervention(s): Sperm injections were carried out with ejaculated sperm (EJA-ICSI) or testicular sperm (TESTI-ICSI) retrieved by either testicular sperm extraction (TESE) or testicular sperm aspiration (TESA). SDF levels were reassessed on the day of oocyte retrieval in both ejaculated and testicular specimens. Main outcome measure(s): Percentage of testicular and ejaculated spermatozoa containing fragmented DNA (%DFI) and clinical pregnancy, miscarriage, and live-birth rates. Result(s): The %DFI in testicular sperm was 8.3%, compared with 40.7% in ejaculated sperm. For the TESTI-ICSI group versus the EJA-ICSI group, respectively, the clinical pregnancy rate was 51.9% and 40.2%, the miscarriage rate was 10.0% and 34.3%, and the live-birth rate was 46.7% and 26.4%. Conclusion(s): ICSI outcomes were significantly better in the group of men who had testicular sperm used for ICSI compared with those with ejaculated sperm. SDF was significantly lower in testicular specimens compared with ejaculated counterparts. Our results suggest that TESTI-ICSI is an effective option to overcome infertility when applied to selected men with oligozoospermia and high ejaculated SDF levels.
View
Unpacking the mysteries of sperm DNA fragmentation: Ten frequently asked questions
Article
Full-text available
  • Aug 2015
Although it has been thirty years since publication of one of the most influential papers on the value of assessing sperm DNA damage, andrologists have yet to reach a general consensus about how to apply this seminal parameter to improve or predict reproductive outcomes. Studies that have attempted to establish a causal relationship between sperm DNA damage and pregnancy success have often resulted in conflicting findings, eroding the practitioner’s confidence to incorporate this phenomenon into their appraisal of fertility. In this review we have identified and answered ten important unresolved questions commonly asked by andrologists with respect to the relationship between sperm DNA damage and fertility. We answer questions ranging from a basic comprehension of biological mechanisms and external factors that contribute to increased levels of sperm DNA damage in the ejaculate to what type of DNA lesions we might be expect to occur and what are some of the consequences of DNA damage on early embryonic development. We also address some of the fundamental technical issues associated with the most appropriate measurement of sperm DNA damage and the need to attenuate the confounding impacts of iatrogenic damage. We conclude by asking whether it is possible to reduce elevated levels of sperm DNA damage therapeutically.
View
Clinical utility of sperm DNA fragmentation testing: practice recommendations based on clinical scenarios
Article
  • Jan 2016
Sperm DNA fragmentation (SDF) has been generally acknowledged as a valuable tool for male fertility evaluation. While its detrimental implications on sperm function were extensively investigated, little is known about the actual indications for performing SDF analysis. This review delivers practice based recommendations on commonly encountered scenarios in the clinic. An illustrative description of the different SDF measurement techniques is presented. SDF testing is recommended in patients with clinical varicocele and borderline to normal semen parameters as it can better select varicocelectomy candidates. High SDF is also linked with recurrent spontaneous abortion (RSA) and can influence outcomes of different assisted reproductive techniques. Several studies have shown some benefit in using testicular sperm rather than ejaculated sperm in men with high SDF, oligozoospermia or recurrent in vitro fertilization (IVF) failure. Infertile men with evidence of exposure to pollutants can benefit from sperm DNA testing as it can help reinforce the importance of lifestyle modification (e.g., cessation of cigarette smoking, antioxidant therapy), predict fertility and monitor the patient’s response to intervention.
View
Intervention improves assisted conception intracytoplasmic sperm injection outcomes for patients with high levels of sperm DNA fragmentation: A retrospective analysis
Article
  • May 2016
Sperm DNA fragmentation (SDF) is used in assisted reproductive technology (ART) programs as an indicator for sperm quality, although there is still a lack of consensus as to its clinical utility. In this retrospective study, we examined intracytoplasmic sperm injection (ICSI) outcomes of 1924 infertile patients who underwent SDF analysis using the sperm chromatin integrity test. ART patients were classified as having low [DNA fragmentation index (DFI) <29%] or high SDF (DFI ≥29%) and by whether or not an intervention [physiological intracytoplasmic sperm injection (PICSI), intracytoplasmic morphologically selected sperm injection (IMSI), testicular sperm extraction (TESE)/testicular sperm aspiration (TESA), frequent ejaculation] was performed. High SDF patients who did not have an intervention had a lower fertilization rate and poorer clinical outcomes from blastocyst transfers as compared with low SDF patients; the fertilization rate was 66.0% vs. 70.2% (p = 0.042), single embryo transfer (SET) fetal heart pregnancy rate was 28.5% vs. 45.2% (p = 0.042), and SET live birth rate was 24.9% vs. 40.6% (p = 0.060), respectively. Furthermore, high SDF patients who had an intervention had significantly improved blastocyst transfer outcomes, similar to those of low SDF patients; the SET live birth rate for high SDF intervention patients was 43.8% as compared with 24.9% for high SDF no intervention patients (p = 0.037) and 40.6% for low SDF patients (p = 0.446). Analysis of the three main intervention subgroups for high SDF patients revealed that TESE/TESA patients had the highest SET live birth rate; in comparison with 24.2% for high SDF patients who did not have an intervention, PICSI patients had 38.3% (p = 0.151), IMSI patients had 28.7% (p = 0.680), and TESE/TESA patients had 49.8% (p = 0.020). Our data suggest that SDF results indicate ICSI outcomes and that patients who have high SDF benefit from an intervention.
View
View
View
Hyaluronic Acid Binding Assay Is Highly Sensitive to Select Human Spermatozoa with Good Progressive Motility, Morphology, and Nuclear Maturity
Article
  • Nov 2015
  • GYNECOL OBSTET INVES
Objective: This study was performed to evaluate the correlation of hyaluronic acid binding assay (HBA) with conventional semen parameters, lipid peroxidation (LPO), intracellular reactive oxygen species (ROS), DNA fragmentation (DF), DNA maturity and mitochondrial membrane potential (MMP) level in human spermatozoa. Methods: The semen samples were obtained from 98 patients. The seminal plasma was separated for the study of LPO, and the pellet was employed for evaluation of intracellular ROS, DF, nuclear maturity (sperm chromatin structure assay) and MMP through flowcytometry. Results: The correlation and strength of HBA with respect to the studied parameters were estimated by the Pearson coefficient and multiple liner regression tests. While HBA indicated a positive correlation with progressive motility (β-coefficients = 0.449, p < 0.05) and normal morphology (β-coefficients = 2.722, p < 0.01), it had only negative relationship with DNA integrity (high DNA stain ability; β-coefficients = -0.517, p < 0.05). HBA also did not show any important correlation with other conventional and intracellular sperm parameters. Conclusions: The HBA is sensitive to morphological integrity, high progressive motility and nuclear maturation. Nonetheless, HBA is not a reliable test for prediction of sperm intracellular ROS, DF and MMP risks and healthy spermatozoa selection.
View
Efficacy of swim-up versus density gradient centrifugation in improving sperm deformity rate and DNA fragmentation index in semen samples from teratozoospermic patients
Article
  • Jul 2014
  • J ASSIST REPROD GEN
Purpose: To compare the efficacy of swim-up and DGC in improving sperm deformity and DNA fragmentation and to determine which method is better in teratozoospermic patients requiring artificial reproduction. Methods: The present study compared the effects of swim-up and density gradient centrifugation (DGC), the two most commonly used semen preparation methods, on sperm deformity rate and DNA fragmentation index (DFI) in semen samples from teratozoospermic patients. Results: The results demonstrated that both swim-up and DGC yielded a significantly lower sperm deformity rate and DFI in comparison to unprocessed whole semen, with DGC having more favorable results. Sperm deformity rate in unprocessed whole semen samples was significantly lower in the 20-29 age group than in the 40-49 age group, but no significant difference was observed in DFI between different age groups. There was no significant correlation between sperm deformity rate and DFI. Conclusions: Our findings suggest that enrichment of sperm with normal morphology and intact DNA in teratozoospermic patients could be achieved by both DGC and swim-up procedures, and that DGC is a better method.
View