Drawbacks of the current practice

tau.amegroups.com © Translational Andrology and Urology. All rights reserved. Dr. Cunha-Filho, in his commentary on the practice recommendations by Agarwal et al. (1), described the current status of sperm DNA fragmentation (SDF) testing. He discussed the pitfalls of the current practice in using intracytoplasmic sperm injection (ICSI) in bypassing male factors on one hand, while elaborating on the current limitations of SDF testing on the other (2). The remarkable evolution of assisted reproductive techniques (ART) in the past three decades has significantly impacted the field of clinical andrology (3). In the era of ICSI, workup of female partner remains important because she has to go through the ART procedure and pregnancy. Tremendous attention invested in improving embryo quality and pregnancy outcome after ART had led to significant advancement in recent years (4). In contrast, the role of semen analysis as the one-and-only “cornerstone” from the male perspective remained unchanged. Despite the revision of World Health Organization (WHO) criteria for semen analyses, little has been changed except more focus on strict morphology (5). Interest in sperm function tests, including hemizona assay and hamster oocyte penetration test, have disappeared as none of the tests have been widely studied clinically. The increasing use of ICSI in managing couples with severe male factors (6) renders semen analysis a screening test merely for the presence or absence of sperm in an ejaculate. The value of proper male evaluation is overlooked since ICSI possibly gives the couple a baby without explaining the nature or cause of underlying male infertility. The success and advancement of ART is obvious. However, the live birth rate utilizing ICSI as the treatment of male factor infertility is around 30% only (7). A comprehensive male partner evaluation and correction of male infertility factors is essential in improving the outcome. The author (Dr. Cunha-Filho) brought up the important message of “over-indication of ICSI”. In fact, the use of ART for male subfertility has been recently reviewed by Cochrane database. The systematic review illustrated the fact that the use of ART in male subfertility is often not supported by evidence, the choice of ART and cutoff value of semen parameters are largely unknown. Further, most of the studies reviewed in the Cochrane review suffered from major methodological flaws (8). Semen analysis provides information on the functional status of the genital tract in general and reflects the status of seminiferous tubules, epididymis, and accessory sex glands. It is the most widely used biomarker to predict and often taken as a surrogate measure of male reproductive potential (9). However, up to 40% of infertile men have semen parameters within the reference ranges (10,11). The ability of semen analysis in discriminating infertile from fertile men is questionable. The use of semen analysis is further hindered by the intra-individual and interlaboratory variations. It was reported that within-subject variability over a 10-week follow up ranged from 10.3% to 26.8% and the sperm concentration showed the highest variation (12). Similarly, high inter-laboratory coefficient of variation of 34% for sperm concentration, 20% for sperm motility, and 70% for strict sperm morphology has been reported (13). Since the introduction of WHO criteria for semen analysis in 1980, the manual was revised several times and the latest version, the fifth edition came out in 2010. It is the first time semen analysis results from fathers Editorial