Should sperm DNA fragmentation testing be routinely used in assessing male infertility?

Semen analysis (SA) is the cornerstone for male infertility evaluation. Variations in sperm quantity and quality may make SA an unreliable decision-making tool in providing an insight of infertility (1). Consequently, efforts have been made to upgrade techniques of male fertility analysis. In recent times, primary investigative techniques have centered around assessing sperm capacity, sperm function, sperm morphology and sperm nucleus. Advances in the field of male infertility research have brought about strategies for assessing sperm chromatin quality and DNA fragmentation (2). Sperm DNA is a vital component of human conception as sperm DNA damage may affect various markers of conception including embryo quality, blastocyst development, implantation, pregnancy, and miscarriage (3). A recently published paper by Agarwal et al. presented guidelines of testing sperm DNA fragmentation (SDF), and discussed its usefulness as a diagnostic tool in male fertility evaluation in various clinical scenarios. Despite insufficient clinical evidence supporting the routine use of SDF in fertility evaluation, both the American Urological Association (AUA) and European Association of Urology (EAU) guidelines on male infertility acknowledge the importance of DNA fragmentation in spermatozoa (4). On the contrary, the Practice Committee of the American Society for Reproductive Medicine (ASRM), regardless of acknowledging the relationship between sperm DNA damage and other semen parameters, states that: ‘insufficient evidence exists to recommend sperm DNA integrity test as a routine test in the evaluation and treatment of the infertile couple’ (5). Testing methods for sperm DNA fragmentation