Sperm DNA fragmentation testing in male infertility work-up: are we ready?

We read with interest the guideline proposed by Agarwal and colleagues (1) on clinical utility of sperm DNA fragmentation (SDF) testing. The Authors stated that, despite the clear association between SDF and male fertility, the clinical implication of SDF is poorly understood. So, the aim of the guideline was to underline the actual indications of SDF testing and also to explain the management of patients with increased SDF. To achieve this purpose, the Authors examined original and review articles concerning the significance of SDF testing and arranged their manuscript into two main sections: in the first part they described the current tests for SDF evaluation, underlining their basic principles as well as the main advantages and disadvantages; in the second part they performed an evidence-based analysis of the utility of SDF tests under specific clinical scenarios, commonly found by urologists and reproductive specialists. In particular, in the clinical scenario #1 varicocele was analyzed: Agarwal and colleagues stated that SDF testing may allow to better select varicocelectomy candidates among patients with clinical varicocele and borderline to normal sperm characteristics. In clinical scenario #2 the authors considered the unexplained infertility, suggesting performing SDF testing in couples with recurrent spontaneous abortion (RSA) or before starting intrauterine insemination (IUI). Clinical scenario #3 described the relationship between SDF and assisted reproduction techniques (ART), recommending the SDF analysis in patients with recurrent ART failures. Finally, in clinical scenario #4 the influence of lifestyle risk factors on male fertility was considered, suggesting offering SDF testing to infertile men with evidence of this kind of exposure, in order to underline an eventual sperm DNA damage and/or to monitor the patient’s response to treatment.