1.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
The World Journal of Men's Health 2023;41(4):809-847
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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