Sperm DNA fragmentation for the evaluation of male infertility: clinical algorithms

tau.amegroups.com © Translational Andrology and Urology. All rights reserved. We acclaim the commentary written by Mirzazadeh and Sadri-Ardekani on our article addressing the clinical utility of sperm DNA fragmentation testing by Agarwal et al. (1). The authors’ contribution is a valuable addition to the clinical debate surrounding this important topic. The authors have not only acknowledged the role of SDF testing in the evaluation of infertile men, but also offered sound algorithms that should further clarify the indications for SDF testing in patients with varicocele, unexplained infertility, recurrent miscarriage, recurrent intrauterine insemination (IUI) and in vitro fertilization (IVF) failure, and recurrent miscarriage after intracytoplasmic sperm injection (ICSI). We thank the authors for their useful addition, and we aim to further elucidate their views in this reply and suggest some changes to their proposed algorithms. Mirzazadeh and Sadri-Ardekani admitted that despite the current recommendations by the American Urological Association (AUA) (2), American Society for Reproductive Medicine (ASRM) (3) and European Association of Urology (EAU) (4) which generally endorse against the routine use of SDF in the clinical evaluation of infertile men, they still believe that SDF testing plays a significant role in clinical decision making. In fact, clinical recommendations are looked at as best practice statements that aim to guide clinicians on evidence-based approach for management. In this sense, with further research and development into a particular field of medicine, a constant update to the clinical recommendations is periodically required. To this end, numerous studies exploring the effects of SDF on male fertility have been published lately. Good quality studies reporting a significant detrimental relationship between SDF and clinical varicocele (5-7), unexplained infertility (8,9), and outcomes of assisted reproductive treatments (ART) (10-12) were published recently highlighting the need for further updates in the clinical recommendations of the abovementioned societies. Mirzazadeh and Sadri-Ardekani have pointed out that our practice recommendations contained extensive information on the various laboratory tests used for SDF measurement suggesting that such a discussion may be more applicable for laboratory specialists than clinicians. We disagree with their view on this point as we feel that this information is crucial for clinicians interpreting the SDF results. The main preventing barring widespread adoption of the SDF test is the fact that a variety of SDF test modalities exist results in a misunderstanding of the exact DNA damage that each method tests and the difficulty in recognizing an agreed upon threshold for the SDF abnormality. Therefore, the clinician ordering the SDF test needs to be well acquainted with the method that was performed on his patient to accurately interpret the test result. The authors have provided an algorithm on the clinical utility of SDF in varicocele patients. While we agree with the authors that this should clarify the intended message, we have modified their algorithm by incorporating the clinical grade of the varicocele (Figure 1). Perhaps there isn’t a topic in the field of male infertility that was investigated more that varicocele (13). Clinical varicocele is recognized as the most common surgically reversible cause of male infertility. Editorial