Controversy and Consensus on Indications for Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

Ashok Agarwal, Ala'a Farkouh, Ramadan Saleh, Taha Abo Almagd Abdel Meguid Hamoda, Ahmed M. Harraz, Parviz Kavoussi, Mohamed Arafa, Gianmaria Salvio, Amarnath Rambhatla, Tuncay Toprak, Murat Gül, Nguyen Ho Vinh Phuoc, Florence Boitrelle, Ponco Birowo, Ramy Abou Ghayda, Rossella Cannarella, Shinnosuke Kuroda, Damayanthi Durairajanayagam, Armand Zini, Christine WynsSelcuk Sarikaya, Kelton Tremellen, Taymour Mostafa, Ioannis Sokolakis, Donald P. Evenson, Ralf Henkel, Wael Zohdy, Eric Chung, Imad Ziouziou, Marco Falcone, Giorgio I. Russo, Manaf Al-Hashimi, Aldo E. Calogero, Edmund Ko, Giovanni Colpi, Sheena Lewis, Ege Can Serefoglu, Fahmi Bahar, Marlon Martinez, Quang Nguyen, Rafael F. Ambar, Mustafa Emre Bakircioglu, Hussein Kandil, Nasser Mogharabian, Marjan Sabbaghian, Hisanori Taniguchi, Akira Tsujimura, Hesamoddin Sajadi, Wael Ibrahim, Widi Atmoko, Paraskevi Vogiatzi, Sezgin Gunes, Mohammad Ali Sadighi Gilani, Shubhadeep Roychoudhury, Nur Dokuzeylül Güngör, Lukman Hakim, Ricky Adriansjah, Priyank Kothari, Sunil Jindal, Edouard Amar, Hyun Jun Park, Tran Quang Tien Long, Sheryl Homa, Vilvapathy Senguttuvan Karthikeyan, Birute Zilaitiene, Israel Maldonado Rosas, Angelo Marino, Edoardo Pescatori, Cevahir Ozer, Hamed Akhavizadegan, Nicolas Garrido, Gian Maria Busetto, Aram Adamyan, Mohamed Al-Marhoon, Haitham Elbardisi, Parisa Dolati, Mahsa Darbandi, Sara Darbandi, Giancarlo Balercia, Germar Michael Pinggera, Sava Micic, Christopher Chee Kong Ho, Mohamad Moussa, Mirko Preto, Cătălina Zenoaga-Barbăroșie, Ryan P. Smith, Raghavender Kosgi, Jean de la Rosette, Ahmed I. El-Sakka, Saad Mohammed Abumelha, Tiago Cesar Mierzwa, Teng Aik Ong, Saleem A. Banihani, Kasonde Bowa, Shinichiro Fukuhara, Luca Boeri, Yavuz Onur Danacıoğlu, Fatih Gokalp, Osama Mohamed Selim, Chak Lam Cho, Nicholas N. Tadros, Muhammet Rasit Ugur, Mehmet Serkan Ozkent, Peter Chiu, Arif Kalkanli, Kareim Khalafalla, Ranjit B. Vishwakarma, Federica Finocchi, Sotiris Andreadakis, Carlo Giulioni, Gökhan Çeker, Erman Ceyhan, Vineet Malhotra, Mehmet Yilmaz, Massimiliano Timpano, Trenton L. Barrett, Shannon Hee Kyung Kim, Sun Tae Ahn, Filippo Giacone, Ayad Palani, Gede Wirya Kusuma Duarsa, Ateş Kadıoğlu, Franco Gadda, Daniel Suslik Zylbersztejn, Kaan Aydos, Deniz Kulaksız, Deepak Gupte, Gokhan Calik, Keshab Kumar Karna, Panagiotis Drakopoulos, Aykut Baser, Vijay Kumar, Juan Manuel Corral Molina, Osvaldo Rajmil, Raphael H. Ferreira, Sofia Leonardi, Armen Avoyan, Emrullah Sogutdelen, Giorgio Franco, Jonathan Ramsay, Liliana Ramirez, Rupin Shah, Global Andrology Forum

Research output: Contribution to journalArticlepeer-review

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Abstract

Purpose: Sperm DNA fragmentation (SDF) testing was recently added to the sixth edition of the World Health Organization laboratory manual for the examination and processing of human semen. Many conditions and risk factors have been associated with elevated SDF; therefore, it is important to identify the population of infertile men who might benefit from this test. The purpose of this study was to investigate global practices related to indications for SDF testing, compare the relevant professional society guideline recommendations, and provide expert recommendations. 

Materials and Methods: Clinicians managing male infertility were invited to take part in a global online survey on SDF clinical practices. This was conducted following the CHERRIES checklist criteria. The responses were compared to professional society guideline recommendations related to SDF and the appropriate available evidence. Expert recommendations on indications for SDF testing were then formulated, and the Delphi method was used to reach consensus. 

Results: The survey was completed by 436 experts from 55 countries. Almost 75% of respondents test for SDF in all or some men with unexplained or idiopathic infertility, 39% order it routinely in the work-up of recurrent pregnancy loss (RPL), and 62.2% investigate SDF in smokers. While 47% of reproductive urologists test SDF to support the decision for varicocele repair surgery when conventional semen parameters are normal, significantly fewer general urologists (23%; p=0.008) do the same. Nearly 70% would assess SDF before assisted reproductive technologies (ART), either always or for certain conditions. Recurrent ART failure is a common indication for SDF testing. Very few society recommendations were found regarding SDF testing. 

Conclusions: This article presents the largest global survey on the indications for SDF testing in infertile men, and demonstrates diverse practices. Furthermore, it highlights the paucity of professional society guideline recommendations. Expert recommendations are proposed to help guide clinicians.

Original languageEnglish
Pages (from-to)575-602
Number of pages28
JournalWorld Journal of Men's Health
Volume41
Issue number3
Early online date10 Apr 2023
DOIs
Publication statusPublished - Jul 2023
Externally publishedYes

Keywords

  • Delphi method
  • DNA fragmentation
  • Male infertility
  • Practice guidelines
  • Sperm
  • Survey

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