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Controversy and Consensus on Indications for Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey,
Ashok Agarwal1,2, Ala'a Farkouh1, Ramadan Saleh3
1Global Andrology Forum, American Center for Reproductive Medicine, Moreland Hills, OH, USA.
Insights
Sperm DNA fragmentation (SDF) testing is increasingly used globally for male infertility, but practices vary widely. This study surveyed experts to establish clear indications for SDF testing and guide clinical decisions.
Area of Science:
- Reproductive Medicine
- Andrology
- Clinical Diagnostics
Background:
- Sperm DNA fragmentation (SDF) testing is a significant addition to male infertility diagnostics, as outlined in the WHO manual.
- Elevated SDF is linked to various conditions and risk factors, necessitating identification of men who would benefit from testing.
Purpose of the Study:
- To investigate global clinical practices and indications for SDF testing.
- To compare current practices with professional society guidelines and evidence.
- To formulate expert recommendations for SDF testing indications.
Main Methods:
- A global online survey of clinicians managing male infertility was conducted, adhering to CHERRIES checklist criteria.
- Survey responses were analyzed and compared against existing professional society guidelines and scientific evidence.
- The Delphi method was employed to achieve consensus on expert recommendations.
Main Results:
- The survey included 436 experts from 55 countries, revealing diverse SDF testing practices.
- Approximately 75% of respondents test SDF for unexplained infertility, 39% for recurrent pregnancy loss, and 62.2% for smokers.
- Nearly 70% of experts assess SDF before assisted reproductive technologies (ART), with recurrent ART failure being a common indication.
Conclusions:
- Global practices for SDF testing in infertile men are varied, highlighting a need for standardized guidelines.
- There is a notable lack of comprehensive recommendations from professional societies regarding SDF testing.
- Expert-derived recommendations are proposed to assist clinicians in making informed decisions about SDF testing.
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.
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