The World Journal of Men's Health (Oct 2023)

Controversy and Consensus on the Management of Elevated Sperm DNA Fragmentation in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

  • Ala’a Farkouh,
  • Ashok Agarwal,
  • Taha Abo-Almagd Abdel-Meguid Hamoda,
  • Parviz Kavoussi,
  • Ramadan Saleh,
  • Armand Zini,
  • Mohamed Arafa,
  • Ahmed M. Harraz,
  • Murat Gul,
  • Vilvapathy Senguttuvan Karthikeyan,
  • Damayanthi Durairajanayagam,
  • Amarnath Rambhatla,
  • Florence Boitrelle,
  • Eric Chung,
  • Ponco Birowo,
  • Tuncay Toprak,
  • Ramy Abou Ghayda,
  • Rossella Cannarella,
  • Nguyen Ho Vinh Phuoc,
  • Fotios Dimitriadis,
  • Giorgio I. Russo,
  • Ioannis Sokolakis,
  • Taymour Mostafa,
  • Konstantinos Makarounis,
  • Imad Ziouziou,
  • Shinnosuke Kuroda,
  • Marion Bendayan,
  • Raneen Sawaid Kaiyal,
  • Andrian Japari,
  • Mara Simopoulou,
  • Lucia Rocco,
  • Nicolas Garrido,
  • Nazim Gherabi,
  • Kadir Bocu,
  • Oguzhan Kahraman,
  • Tan V. Le,
  • Christine Wyns,
  • Kelton Tremellen,
  • Selcuk Sarikaya,
  • Sheena Lewis,
  • Donald P. Evenson,
  • Edmund Ko,
  • Aldo E. Calogero,
  • Fahmi Bahar,
  • Marlon Martinez,
  • Andrea Crafa,
  • Quang Nguyen,
  • Rafael F. Ambar,
  • Giovanni Colpi,
  • Mustafa Emre Bakircioglu,
  • Ralf Henkel,
  • Hussein Kandil,
  • Ege Can Serefoglu,
  • Abdullah Alarbid,
  • Akira Tsujimura,
  • Alireza Kheradmand,
  • Christina Anagnostopoulou,
  • Angelo Marino,
  • Aram Adamyan,
  • Birute Zilaitiene,
  • Cevahir Ozer,
  • Edoardo Pescatori,
  • Paraskevi Vogiatzi,
  • Gian Maria Busetto,
  • Giancarlo Balercia,
  • Haitham Elbardisi,
  • Hamed Akhavizadegan,
  • Hesamoddin Sajadi,
  • Hisanori Taniguchi,
  • Hyun Jun Park,
  • Israel Maldonado Rosas,
  • Mohamed Al-Marhoon,
  • Mohammad Ali Sadighi Gilani,
  • Naif Alhathal,
  • Germar-Michael Pinggera,
  • Priyank Kothari,
  • Nasser Mogharabian,
  • Sava Micic,
  • Sheryl Homa,
  • Sara Darbandi,
  • Tran Quang Tien Long,
  • Wael Zohdy,
  • Widi Atmoko,
  • Marjan Sabbaghian,
  • Wael Ibrahim,
  • Ryan P. Smith,
  • Christopher Chee Kong Ho,
  • Jean de la Rosette,
  • Ahmed I. El-Sakka,
  • Mirko Preto,
  • Cătălina Zenoaga-Barbăroșie,
  • Saad Mohammed Abumelha,
  • Aykut Baser,
  • Kaan Aydos,
  • Liliana Ramirez-Dominguez,
  • Vijay Kumar,
  • Teng Aik Ong,
  • Tiago Cesar Mierzwa,
  • Ricky Adriansjah,
  • Saleem A. Banihani,
  • Kasonde Bowa,
  • Shinichiro Fukuhara,
  • Marcelo Rodriguez Peña,
  • Mohamad Moussa,
  • Umut Çağın Ari,
  • Chak-Lam Cho,
  • Nicholas N. Tadros,
  • Muhammet Rasit Ugur,
  • Edouard Amar,
  • Marco Falcone,
  • Frederic Romain Santer,
  • Arif Kalkanli,
  • Keshab Kumar Karna,
  • Kareim Khalafalla,
  • Ranjit B. Vishwakarma,
  • Federica Finocchi,
  • Carlo Giulioni,
  • Erman Ceyhan,
  • Gökhan Çeker,
  • Chadi Yazbeck,
  • Osvaldo Rajmil,
  • Mehmet Yilmaz,
  • Baris Altay,
  • Trenton L. Barrett,
  • Kay Seong Ngoo,
  • Shubhadeep Roychoudhury,
  • Gianmaria Salvio,
  • Haocheng Lin,
  • Ates Kadioglu,
  • Massimiliano Timpano,
  • Tomer Avidor-Reiss,
  • Lukman Hakim,
  • Puneet Sindhwani,
  • Giorgio Franco,
  • Rajender Singh,
  • Filippo Giacone,
  • Mikhail Ruzaev,
  • Raghavender Kosgi,
  • Nikolaos Sofikitis,
  • Ayad Palani,
  • Gokhan Calik,
  • Deniz Kulaksız,
  • Davor Jezek,
  • Manaf Al Hashmi,
  • Panagiotis Drakopoulos,
  • Huda Omran,
  • Sofia Leonardi,
  • Ciler Celik-Ozenci,
  • Nur Dokuzeylül Güngör,
  • Jonathan Ramsay,
  • Toshiyasu Amano,
  • Emrullah Sogutdelen,
  • Gede Wirya Kusuma Duarsa,
  • Koji Chiba,
  • Sunil Jindal,
  • Missy Savira,
  • Luca Boeri,
  • Edson Borges,
  • Deepak Gupte,
  • Fatih Gokalp,
  • Guadalupe Hernández Hebrard,
  • Suks Minhas,
  • Rupin Shah

DOI
https://doi.org/10.5534/wjmh.230008
Journal volume & issue
Vol. 41, no. 4
pp. 809 – 847

Abstract

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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.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.

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