10 1016@j Fertnstert 2019 05 016

REFLECTIONS
(4 h before cumulus cells removal and 1–3 h before ICSI) in the

Sperm DNA fragmentation to absence of oxygen. These stressing conditions might indeed
predict embryo development, have compromised the possibility of the oocytes to cope
with SDF, as it happens for normozoospermic samples that
implantation and miscarriage: when exposed to prolonged incubation periods might suffer
still an open question from higher SDF rates.
In conclusion, due to the limitations of the present study,
Male factor infertility is responsible for approximately half of further prospective investigations are still needed to outline
all causes of infertility. In the last decade, more attention has the predictivity of SDF tests in unexplained infertility, recur-
been given to sperm DNA fragmentation (SDF) as a potential rent pregnancy loss and repeated implantation failure cases,
cause of unexplained infertility. The increased DNA damage as well as to highlight whether reduced outcomes might be
in spermatozoa from men with oligozoospermia seems to be imputed to SDF per se. Until such evidence is produced, the
associated with both a reduced chance of natural conception recommendations of the Practice Committee of the American
and an increased risk of early pregnancy loss (1). Neverthe- Society for Reproductive Medicine are still valid: there is still
less, the role of SDF during in vitro fertilization cycles where insufficient evidence to recommend the routine use of sperm
intracytoplasmic sperm injection (ICSI) is adopted is still un- DNA integrity tests for diagnosis and treatment of infertile
clear. A consequence mainly imputable to the heterogeneous couples (5).
nature of the studies conducted in terms of both women
characteristics and assays adopted to evaluate SDF (2, 3). To Laura Rienzi, B.Sc., M.Sc.a
date, four tests have been implemented: the comet assay Rossella Mazzilli, M.D.a,b
(single cell gel electrophoresis), the TUNEL test (terminal Filippo Maria Ubaldi, MDa
a
deoxyuridine nick and labeling assay), the SCSA (sperm G.en.e.r.a. Centre for Reproductive Medicine; and
b
chromatin structure assay) and the SCD test (sperm Andrology Unit, Department of Clinical and Molecular
chromatin dispersion) (2). Medicine, University of Rome ‘‘Sapienza’’, Sant'Andrea
The study conducted by Borges and colleagues (4) aimed Hospital, Rome, Italy
at investigating the influence of SDF on the outcomes of https://doi.org/10.1016/j.fertnstert.2019.05.016
in vitro fertilization cycles in couples undergoing ICSI in
the absence of male factor infertility. They used the SCD You can discuss this article with its authors and other
(Halo test), whose strength is an easy implementation. How- readers at
ever, it is subject to a large inter-observer variability which https://www.fertstertdialog.com/users/16110-fertility-
might interfere with the reproducibility of the results. The au- and-sterility/posts/48679-28241
thors performed a sample size analysis powered to detect a
difference in the embryo quality, which is also a subjective
parameter and an odd primary outcome, that does not repre-
sent a valuable clinical information per se. Moreover, only REFERENCES
day 5 blastocysts were accounted, both single and double em- 1. Jungwirth A, Giwercman A, Tournaye H, Diemer T, Kopa Z, Dohle G, et al.
bryo transfers were performed, and it is unclear which embryo European Association of Urology guidelines on Male Infertility: the 2012 up-
date. Eur Urol 2012;62:324–32.
selection strategy was adopted. The authors conclude that
2. Agarwal A, Majzoub A, Esteves SC, Ko E, Ramasamy R, Zini A. Clinical utility
SDF R30% is associated with poor embryo development,
of sperm DNA fragmentation testing: practice recommendations based on
lower implantation and higher miscarriage rates. However, clinical scenarios. Transl Androl Urol 2016;5:935–50.
it is unclear how this threshold has been defined and vali- 3. Cissen M, Wely MV, Scholten I, Mansell S, Bruin JP, Mol BW, et al. Measuring
dated, but most importantly inter- and intra-operators corre- sperm DNA fragmentation and clinical outcomes of medically assisted
lation coefficients in the evaluation of SDF and of embryo reproduction: a systematic review and meta-analysis. PLoS One 2016;11:
quality are missing. This fault largely limits the reproduc- e0165125.
4. Borges E Jr, Zanetti BF, Setti AS, Paes de Almeida FBD, Provenza RR,
ibility and possible generalization of these results, especially
Iaconelli AJ. Sperm DNA fragmentation is correlated with poor embryo devel-
since the SDF is not associated with ICSI outcomes when opment, lower implantation rate and higher miscarriage rate in reproductive
treated as a continuous variable. cycles of non-male factor infertility. Fertil Steril 2019.
Lastly, an important procedural concern relies on the pro- 5. Practice Committee of the American Society for Reproductive. The clinical
longed incubation (5–7 h) of the oocytes before insemination utility of sperm DNA integrity testing: a guideline. Fertil Steril 2013;99:673–7.
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(4 h before cumulus cells removal and 1–3 h before ICSI) in the

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