Use of sperm DNA fragmentation testing and testicular sperm for intracytoplasmic sperm injection

Reproductive Outcomes of Different Sperm Selection Techniques for ICSI Patients with Abnormal Sperm DNA Fragmentation: a Randomized Controlled Trial

The aim of the study is to compare the reproductive outcomes of different sperm selection techniques: density gradient centrifugation (DGC), testicular sperm (Testi), physiological ICSI (PICSI), and magnetic-activated cell sorting (MACS) in abnormal sperm DNA fragmentation (SDF) ICSI patients. A randomized controlled trial included 302 patients with abnormal SDF undergoing ICSI where they were randomized into 4 groups: a control group of DGC (n= 72), Testi (n=73), PICSI (n=78), and MACS (n=79). Results showed no significant differences in the male age, female age, or SDF between the four groups. Testi group had significantly lower cleavage and blastulation rates compared to PICSI, DGC, or MACS groups (p =0.001). For the high-quality blastocysts, DGC and MACS groups had significantly higher rate than the Testi group (p =0.014). The highest pregnancy rate was scored for the PICSI group (69.6%), while the lowest pregnancy rate was scored for the DGC group (51.4%) with (p =0.025). The PICSI group showed a significantly higher implantation rate compared to the other groups (p =0.003). Regarding the ongoing pregnancy rate, the significant difference was observed between the PICSI (62.8%) and MACS (62%) vs. DGC (45.8%). Besides, no significant differences were found in the miscarriage rates between the four groups. In conclusion, PICSI and MACS along with DGC showed significant improvement in embryological and clinical outcome over testicular sperm or sperm processed by DGC alone in patients with abnormal SDFRegistration number: NCT04482517.

The Effect of Sperm DNA Fragmentation Index on the Outcome of Intrauterine Insemination and Intracytoplasmic Sperm Injection

CONTEXT

Elevated sperm DNA fragmentation index (DFI) is found to affect normal embryonic development, implantation and fetal development after intrauterine insemination (IUI), in vitro fertilization and intracytoplasmic sperm injection (ICSI). Estimation of DFI by terminal deoxynucleotidyl transferase-mediated fluorescent deoxy uridine nucleotide nick end labeling (TUNEL) assay was found to have a high predictive value for pregnancy after fertility treatments.

AIM

This study aims to find the effect of increased sperm DNA fragmentation by TUNEL assay on reproductive outcome after IUI and ICSI.

PRIMARY OBJECTIVE

To find the association of DFI and pregnancy rate in IUI and ICSI.

SECONDARY OBJECTIVES

To find the association of DFI with fertilization and implantation in ICSI. To find the association of DFI with miscarriage rate.

SETTINGS AND DESIGN

A prospective observational study performed at a tertiary care university teaching hospital.

SUBJECTS AND METHODS

105 male partners of infertile couple planned for IUI and ICSI underwent estimation of sperm-DFI by TUNEL assay. The treatment outcomes were compared between the DFI-positive (≥20%) and DFI-negative (<20%) groups.

STATISTICAL ANALYSIS USED

Statistical analysis was performed by SPSS version 17, Software. P < 0.05 was considered statistically significant.

RESULTS

The men with abnormal semen analysis were significantly higher in the DFI-positive group (77.15% vs. 22.85%). There was no significant difference in the pregnancy rate in IUI cycles (17.6% vs. 11.8%); but in the ICSI, the pregnancy rate was significantly reduced in the DFI-positive group (16.7% vs. 47.4%).

CONCLUSIONS

Elevated DFI significantly affects the pregnancy rate in ICSI cycles.

A Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis on the clinical utility of sperm DNA fragmentation testing in specific male infertility scenarios

Background

Sperm DNA fragmentation (SDF) is recognized as a leading cause of male infertility because it can impair the paternal genome through distinct pathophysiological mechanisms. Current evidence supports SDF as a major factor in the pathophysiology of several conditions, including varicocele, unexplained infertility, assisted reproductive technology failure, and environmental lifestyle factors, although the mechanisms involved have not been fully described yet. Measurement of the levels of DNA fragmentation in semen provides valuable information on the integrity of paternal chromatin and may guide therapeutic strategies. A recently published clinical practice guideline (CPG) highlighted how to use the information provided by SDF testing in daily practice, which triggered a series of commentaries by leading infertility experts. These commentaries contained an abundance of information and conflicting views about the clinical utility of SDF testing, which underline the complex nature of SDF.

Methods

A search of papers published in response to the CPG entitled “Clinical utility of sperm DNA fragmentation testing: practice recommendations based on clinical scenarios” was performed within the Translational Andrology and Urology (TAU) website (http://tau.amegroups.com/). The start and end dates for the search were May 2017 and August 2017, respectively. Each commentary meeting our inclusion criteria was rated as “supportive without reservation”, “supportive with reservation”, “not supportive” or “neutral”. We recorded whether articles discussed either SDF characteristics as a laboratory test method or clinical scenarios, or both. Subsequently, we extracted the particulars from each commentary and utilized the ‘Strengths-Weaknesses-Opportunities-Threats’ (SWOT) analysis to understand the perceived advantages and drawbacks of SDF as a specialized sperm function method in clinical practice.

Results

Fifty-eight fertility experts from six continents and twenty-two countries contributed commentaries. Overall, participants (87.9%; n=51) were supportive of the recommendations provided by the CPG on the utility of SDF testing based on clinical scenarios. The majority of participants made explicit remarks about both the clinical scenarios and SDF assays’ characteristics. Among ‘not supportive’ and ‘supportive with reservation’ participants, 75% (n=30/40) and 77.5% (n=31/40) expressed concerns related to technical limitations of SDF testing methods and clinical utility of the test in one or more clinical scenarios discussed in the CPG, respectively. The SWOT analysis revealed that the CPG provides a reasonable evidence-based proposal for integration of SDF testing in the routine daily practice. It also uncovered gaps of knowledge and threats limiting the widespread application of SDF in everyday practice, thus allowing the identification of opportunities to further refine SDF testing and its clinical utility.

Conclusions

The understanding of the role of SDF in male infertility requires an in-depth analysis of the multifactorial pathophysiological processes and the theories involved. The SWOT analysis allowed an objective evaluation of CPG on the clinical utility of SDF testing based on clinical scenarios and its accompanying commentaries written by global experts in all possible angles. Implementation of SDF testing in the clinic may not only increase the outcome of ART but more importantly improve the health of both fathers to be and resulting offspring.