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Editorial
. 2021 Nov-Dec;47(6):1250-1258.
doi: 10.1590/S1677-5538.IBJU.2020.1004.

Best urological practices on testing and management of infertile men with abnormal sperm DNA fragmentation levels: the SFRAG guidelines

Sandro C Esteves  1   2   3 , Armand Zini  4 , Robert Matthew Coward  5
Affiliations
Editorial

Best urological practices on testing and management of infertile men with abnormal sperm DNA fragmentation levels: the SFRAG guidelines

Sandro C Esteves et al. Int Braz J Urol. 2021 Nov-Dec.
No abstract available

PubMed Disclaimer

Conflict of interest statement

None declared.

Figures

Figure 1
Figure 1. Sperm DNA fragmentation tests.
A) Sperm Chromatin Dispersion test (SCD): Sperm sample of a patient with varicocele presenting with elevated SDF. Open arrowheads indicate sperm with halos of dispersed chromatin representing a normal DNA molecule with no fragmented DNA. Black arrowheads indicate sperm with small or absent halos of dispersed chromatin, representing sperm with fragmented DNA. Arrows in indicate sperm with no halos at all, fragmented-degraded DNA. B) Alkaline Comet assay under fluorescence microscopy: Sperm sample of a patient exhibiting elevated sperm DNA fragmentation (SDF). Several comets are shown, which represent sperm with DNA fragmentation. The longer and brighter the ‘Comet’ tail, the more fragmentation is present. Open arrow: spermatozoon with DNA fragmentation. White arrow: spermatozoon with a hardly visible ‘Comet’ tail, representing a cell with minimal DNA fragmentation. As the Comet test measures the amount of damage in each cell, it is rare to find a perfect spermatozoon with 0% damage, even from fertile donors. C) TUNEL Assay: Visualization of sperm DNA damage using terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL). Digoxigenin-dUTP was incorporated into DNA breaks using a terminal transferase that was detected using anti-digoxigenin-FITC (green color). TUNEL+ represents sperm presenting DNA damage. Slides were counterstained with propidium iodide (red color). TUNEL- represents sperm free of DNA breaks. D) Sperm Chromatin Structure Assay (SCSA): Test data (SCSA Diagnostics, Brookings, USA). Left panel (top box): raw data from a flow cytometer showing each of 5.000 sperm as a single dot on a scattergram. Y-axis = green fluorescence with 1.024 gradations (channels) of DNA stainability (intact double-stranded DNA). X-axis = red fluorescence with 1.024 gradations of red fluorescence (single-strand DNA). Axes shown are 1.24/10. The line at Y = 75 marks the upper boundary of DNA staining of normal sperm chromatin; above that line are sperm (dots) with partially uncondensed chromatin allowing more DNA stainability. The bottom left corner shows gating out of seminal debris. Middle panel: Raw data from the left panel are converted by SCSAsoft software (or equivalent) to red/red+green fluorescence. This transforms the angled sperm display in the left panel to a vertical pattern that is often critical for accurately delineating the percentage of sperm with fragmented DNA. Y-axis = total DNA stainability vs. X-axis = red/red+green fluorescence (DFI). Right panel: Frequency histogram of data from middle panel showing computer gating into %DFI and Mean DFI. Bottom box: SCSAsoft software calculations of the mean of two independent measures of mean and standard deviation (std dev) of median DFI, %DFI, and %HDS (high DNA stainability). Modified from: Esteves SC, Zini A, Coward RM, Evenson DP, Gosálvez J, Lewis SEM, Sharma R, Humaidan P. Sperm DNA fragmentation testing: Summary evidence and clinical practice recommendations. Andrologia. 2020 Oct 27:e13874. Epub ahead of print. This is an open-access article distributed under the Creative Commons Attribution License. The license permits unrestricted use, distribution, reproduction in any medium, remixing, transformation, and building upon the material for any purpose provided the original work is properly cited.
Figure 2
Figure 2. A Pictorial summary of the recommendations for sperm DNA fragmentation testing and possible management in couples with elevated sperm DNA fragmentation.
IUI: intrauterine insemination; IVF: in vitro fertilization; ICSI: intracytoplasmic sperm injection; RPL: recurrent pregnancy loss. Reprinted from: Esteves SC, Zini A, Coward RM, Evenson DP, Gosálvez J, Lewis SEM, Sharma R, Humaidan P. Sperm DNA fragmentation testing: Summary evidence and clinical practice recommendations. Andrologia. 2020 Oct 27:e13874. Epub ahead of print. This is an open-access article distributed under the Creative Commons Attribution License. The license permits unrestricted use, distribution, reproduction in any medium, provided the original work is properly cited.
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References

    1. 1. Samplaski MK, Smith JF, Lo KC, Hotaling JM, Lau S, Grober ED, et al. Reproductive endocrinologists are the gatekeepers for male infertility care in North America: results of a North American survey on the referral patterns and characteristics of men presenting to male infertility specialists for infertility investigations. Fertil Steril. 2019; 112:657-62. - PubMed
    1. 2. Esteves SC, Miyaoka R, Agarwal A. An update on the clinical assessment of the infertile male. Clinics (Sao Paulo). 2011; 66:691-700. Erratum in: Clinics (Sao Paulo). 2012; 67:203. - PMC - PubMed
    1. 3. Esteves SC. Clinical relevance of routine semen analysis and controversies surrounding the 2010 World Health Organization criteria for semen examination. Int Braz J Urol. 2014; 40:443-53. - PubMed
    1. 4. Krawetz SA. Paternal contribution: new insights and future challenges. Nat Rev Genet. 2005; 6:633-42. - PubMed
    1. 5. Esteves SC. Are specialized sperm function tests clinically useful in planning assisted reproductive technology? Int Braz J Urol. 2020; 46:116-123. - PMC - PubMed

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