1. The document discusses sperm DNA fragmentation (SDF), including its origin during spermatogenesis, various etiologies, and methods of assessment. 2. It reviews correlations between SDF and semen parameters as well as clinical outcomes like fertility and pregnancy loss, finding inconsistent relationships. 3. The clinical utility of SDF testing is examined for conditions like infertility, predicting assisted reproduction outcomes, and recurrent miscarriage, though evidence is mixed depending on testing methodology. The document concludes that more evidence is needed before recommending routine SDF testing.

1. Clinical utility of sperm DNA
fragmentation tests
Aboubakr Elnashar
elnashar53@hotmail.com
Benha University Hospital, Egypt
2016
Aboubakr Elnashar

2. CONTENTS
1. Origin of SDF
2. Etiology of SDF
3. Assessment of SDF
4. Correlation with semen parameters
5. Correlation with clinical parameters
6. Clinical utility of SDF tests
7. How to decrease SDF?
 Conclusion
7Aboubakr Elnashar

3. 1. ORIGIN OF SDF
(Marin et al, 2012)
 First line:
Spermiogenesis*/or spermatogenesis
A breakdown in keys of cell system:
-Apoptosis
-DNA repair
-Chromatin remodelin
 Second line:
• Increase radical oxygen species
• Failure of antioxidant defense system during transport
through male reproductive tract
*conversion of round spermatid to elongated spermatid
Aboubakr Elnashar

4. 2. ETIOLOGY OF SDF
(Evgini et al, 2014)
I. Primary Testicular Factors
1. Abnormal germ cell apoptosis
2. Advanced paternal age
3. Exposure to gonadotoxins
4. Sperm protamine deficiency
5. High level of ROS
II. Extratesticular Factors
1. Smoking
2. Radiation
3. Chemotherapy
4. Genital tract inflammation
5. Testicular hyperthermia
6. Varicocele
Aboubakr Elnashar

5. 3. ASSESSMENT OF SDF
TestPrincipleMethod
TUNEL
ISNT
Incorporation of probes
at the site of damage
Direct
SCSA
SCD
Comet
Susceptibility of DBs to
denature in acid
solution
Indirect
Aniline blue
Toluidine blue
Incorporation of probes
to nuclear proteins
Chromatin
incorporation
(Feijo and Esteves, 2014)
Aboubakr Elnashar

6. Aboubakr Elnashar

7. Normal= 10
Fragmented= 4
SDFI= 4X100/10+4
=28.5%
normal
normal
normal
normal
normal
normal
normal
normal
normal
fragmented
fragmented
fragmented
fragmented
normal
≥30: male infertility
15-30: RM.
≤15: Excellent to Good fertility potential
Aboubakr Elnashar

8. 4. CORRELATION BETWEEN SEMEN
PARAMETERS & SDF
Sperm quality:
(sperm concentration, motility, vitality and morphology)
an inverse correlation
(Lo´pez et al, 2013; Evgini et al, 2014; Komiya et al, 2014)
No significant correlation
(Lin et al, 2008; Xia et al, 2005; Karydis , 2005).
Aboubakr Elnashar

9. Controversy may be attributed to:
1. Variability in the methods used for SDF testing
2. Variability in the methodology and criteria
applied in the analysis of conventional semen
parameters
3. Quality control in semen parameters testing:
rarely mentioned in semen analysis studies
Aboubakr Elnashar

10. Sperm viability
(Samplaski et al, 2015)
(measured by eosin-nigrosin assay)
correlates strongly with SDF.
If viability ≤50%: SDF was ≥ 30%
If viability ≥75%: SDF was ≤30%
If sperm viability≥75%, or ≤ 30%: SDF testing not
necessary.
{SDF testing is more expensive than vitality testing}
Aboubakr Elnashar

11. 5. CORRELATION BETWEEN CLINICAL
PARAMETERS & SDF
(Evgini et al, 2014)
SDF showing correlations with
1. Fertilization rates
2. Embryonic development
3. Implantation
4. Pregnancy
5. Abortion rates
6. Congenital anomalies of the offspring
Aboubakr Elnashar

12. 6. CLINICAL UTILITY OF SDF TESTS
British Fertility Society, 2013
Testing of SDF shows much promise both as
diagnostic test for male infertility and
prognostic test for ART outcomes.
SDF closely associated with fertility outcomes:
Negative relationships with:
fertilization, embryo quality, implantation
Positive relationships with:
miscarriage and childhood diseases.
Aboubakr Elnashar

13. Clinical indications for SDF tests
(Evgini et al, 2014)
1. Prolonged idiopathic male infertility
2. Advanced male age
3. Prolonged exposure to toxic environmental conditions
4. Cancer patients
5. Seminal parameters below the reference range
6. Varicocele
7. Repeated abortions
8. Low fertilization rate or bad quality embryos
9. Implantation failure
Aboubakr Elnashar

14. Semen analysis
Abnormal
SDF T
DFI≤30
ICSI
DFI≥30
Lifestyle, antioxidant
SDF T after 3 months
Normal+ Female factor
ICSIFailed
Aboubakr Elnashar

15. SDF T should be integrated in routine clinical
practice
(Evgini et al, 2014)
{Strong correlation with:
Several aspects of ART
Further consequences of offspring}
Aboubakr Elnashar

16. 1. Prediction of male fertility
increased SDF: reduced male fertility
(Simon, Lewis; 2011)
Aboubakr Elnashar

17. 2. Prediction of pregnancy outcome in IUI:
Conflicting
DFI ≥30%: lower PR
(Bungum et al, 2007)
Other studies
did not confirm the cutoff
No association
Aboubakr Elnashar

18. 3. Prediction of pregnancy outcome in IVF and
ICSI
low SDF: significantly higher LBR
(Osman et al,2015 MA)
SDF has a greater impact on IVF and ICSI in
reduced ovarian reserve
SDF testing of particular clinical significance in
reduced ovarian reserve
(Jin et al,2015)
Aboubakr Elnashar

19. Not confirmed.
(Coughlan et al, 2015; Zhang et al,2015 MA)
SDF: not associated with pregnancy outcome of
FET in IVF and ICSI.
(Ni et al, 2014)
Why conflicting results?:
{1. Significant differences between test
methodologies
2. Sperm preparation methods in interpreting the
data from SDF tests}
Aboubakr Elnashar

20. 4. Prediction of pregnancy outcome in IVF
SDF: modest but significant reduction in IVF. PR
(Zini et al, 2011, MA, Zhao et al, 2014 MA)
SDFI > 20%: significantly lower LBR in IVF
(Oleszczuk et al, 2016)
Aboubakr Elnashar

21. 5. Prediction of pregnancy outcome in ICSI
No statistically significant difference in LBR between
low and high SDFI
(Osman et al,2015 MA; Oleszczuk et al, 2016)
ICSI might be a preferred method of in vitro
treatment in cases with high SDFI.
Aboubakr Elnashar

22. Diagnostic value of SDF and sperm morphology
for predicting outcome of ICSI.
(Elnashar et al, 2016)
No statistically significant relationship between
SDF before and after semen processing and sperm
morphology and ICSI outcome.
Aboubakr Elnashar

23. 6. Prediction of pregnancy loss
 Significant association between SDF and
pregnancy loss after IVF or ICSI
(Zini, 2008, MA, Zhao et al, 2014 MA)
SDF was significantly increased in RM
(17.1% vs. 10.2%)
: possible causes of unexplained RM.
(ZidiJrah et al,2016)
In RM: 30% of men high levels of SDF
(SDFI>15%).
(Leach et al, 2015)
Miscarriage was significantly increased for SDFI >
40%
(Oleszczuk et al, 2016)
Aboubakr Elnashar

24. 7. HOW TO DECREASE SDF
 Avoid iatrogenic SDF
(Esteves, 2013)
1. Short abstinence (1day) and serial ejaculation
(Pons et al, 2013)
2. Instruct patients to deliver specimens 1-2h
before ART
3. Process specimens as soon as possible
4. Keep specimens at room Temp using
appropriate culture media
5. Incubation time after processing should not
exceed 4h
6. Thaw cryopreserved specimens just before
performing ART
Aboubakr Elnashar

25.  Decrease SDF
1. Oral antioxidant
2. Life style modifications:
stop smoking and wt loss
3. Identify and treat underlying condition:
GTI and varicocele
4. Consider TESA-ICSI
{SDF is significantly lower in testicular specimens
compared with ejaculated one}.
TESA-ICSI is an effective option in oligozoospermia and
high ejaculated SDF.
(Esteves et al, 2015)
Aboubakr Elnashar

26. CONCLUSION
(ASRM, 2013)
There is insufficient evidence to recommend the
Routine use of SDF testing in evaluation
and treatment of infertile couple
{level C}
?????????
For diagnostic test
1. Results must be reproducible
2. Applicable to a given patient
3. Change management of patient
Aboubakr Elnashar

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