A perspective on sperm DNA fragmentation

tau.amegroups.com © Translational Andrology and Urology. All rights reserved. The paper on sperm DNA fragmentation by Ashok Agarwal et al. summarizes the currently available DNA fragmentation tests and discusses the role of sperm function tests in the intracytoplasmic sperm injection (ICSI) era (1). The authors have summarized the clinical utility of sperm DNA fragmentation test and have provided recommendations based on specific clinical practice scenarios. We, however, have reservations regarding the precise clinical utility of these sperm function tests. Semen analysis remains, even today in 2017, the single most important test in evaluating male infertility, despite its poor positive predictive value and even poorer negative predictive value. Nevertheless, numerous other tests, which have been introduced in the last 6 decades to complement, supplement, and replace semen analysis have proven to be even more inadequate. Semen analysis, as a routine part of infertility evaluation, was first introduced only in the early 20 century (2). Normal or reference semen values have never been convincingly established. The WHO Laboratory Manual for the Examination and Processing of Human Semen (5 edition, 2010) was the first attempt to standardize semen variables based on evidence. This approach is patchy, inadequate, and not representative of the world population (3). Much before the WHO 2010 manual, one of our PhD students, Dr. Kamaraj, worked to establish Nomo gram for fertility in South Indian men (4). The study conclusions were drastically different from WHO 1999-4 edition. There is no sperm concentration, motility, or morphology values, above which pregnancy is certain, nor below which pregnancy is impossible. The exceptions to this statement are absolute azoospermia, total asthenozoospermia, total teratozoospermia, or total necrozoospermia. Most of these are rare in occurrence. Even today, we do not know the sperm concentration or total sperm count necessary for in vivo conception. Donor insemination studies have clearly shown that in fertile women, conception is possible even with values as low as 2.5 million/mL of motile spermatozoa (5). Fertility, after all, is a joint effort of two people—man and woman. Sub-fertility of either of the partner may be compensated by normal or super fertility of the other (6).