Clinical utility of sperm DNA

fragmentation tests Aboubakr Elnashar

Benha University Hospital, Egypt

Aboubakr Elnashar

CONTENTS 1. Origin of SDF

2. Etiology of SDF

3. Assessment of SDF

4. Correlation between semen parameters &

SDF

5. Correlation between clinical parameters &

SDF

6. Clinical utility of SDF tests

2013

2014

2015

Conclusion

6 Aboubakr Elnashar

1. ORIGIN OF SDF (Marin et al, 2012)

First line:

Spermiogenesis/or spermatogenesis

A breakdown in keys of cell system:

-Apoptosis

-DNA repair

-Chromatin remodelin

Second line:

• Increase radical oxygen species

• Failure of antioxidant defense system during transport

through male reproductive tract Aboubakr Elnashar

2. ETIOLOGY OF SDF (Evgini et al, 2014)

I. Primary Testicular Factors

1. Abnormal germ cell apoptosis

2. Advanced paternal age

3. Exposure to gonadotoxins

4. Sperm protamine deficiency

5. High level of ROS

II. Extratesticular Factors

1. Smoking

2. Radiation

3. Chemotherapy

4. Genital tract inflammation

5. Testicular hyperthermia

6. Varicocele Aboubakr Elnashar

3. ASSESSMENT OF SDF

Test Principle Method

TUNEL

ISNT

Incorporation of probes

at the site of damage

Direct

SCSA

SCD

Comet

Susceptibility of DBs to

denature in acid

solution

Indirect

Aniline blue

Toluidine blue

Incorporation of probes

to nuclear proteins

Chromatin

incorporation

(Feijo and Esteves, 2014)

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Normal= 10

Fragmented= 4

DFI= 4X100/10+4

=28.5%

normal

normal

normal

normal

normal

normal

normal

normal

normal

fragmented

fragmented

fragmented

fragmented

normal

≥30: male infertility

15-30: RM.

≤15: Excellent to Good fertility potential

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4. CORRELATION BETWEEN SEMEN

PARAMETERS & SDF

Majority of the studies:

an inverse correlation between SDF rate and sperm

quality (sperm concentration, motility, vitality and

morphology), irrespective of the age of the subjects (Lo´pez et al, 2013; Evgini et al, 2014)

A significant negative correlation between % of

morphologically normal spermatozoa and SDF

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5. CORRELATION BETWEEN

CLINICAL PARAMETERS & SDF

SDF showing correlations with

1. Fertilization rates

2. Embryonic development

3. Implantation

4. Pregnancy

5. Abortion rates

6. Congenital anomalies of the offspring (Evgini et al, 2014)

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6. CLINICAL UTILITY OF SDF TESTS

ASRM, 2013

5 questions

1. Does SDF test predict male fertility with natural

conception?

There is an association with increased SDF and

reduced fertility in men (Simon, Lewis; 2011)

Insufficient evidence (Level C) to use the test as a

predictor of fertility {cut-points have not been clearly

established and validated}

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2. Does SDF test predict pregnancy with IUI?

Conflicting

A Level II-1study showed a positive predictive value of the SCSA test with DFI ≥30% associated with a lower PR and LBR. (Bungum et al, 2007)

Other studies did not confirm the cutoff Another study found no association with DNA integrity and pregnancy with IUI.

Insufficient evidence (Level C) to recommend the

use of SDF tests to predict pregnancy with IUI.

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3. Is SDF predictive of pregnancy with in IVF?

Meta-analysis (Zini et al, 2011)

SDF was associated with a modest but significant.

reduction in IVF. PR

Insufficient evidence (Level C) to recommend

routine use of SDF testing for patients undergoing

IVF.

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4. Is SDF predictive of pregnancy with IVF and

ICSI?

A meta-analysis (Collins et al, 2008)

SDF was significantly associated with PR in

IVF/ICSI cycles.

Association was mild

Predictive ability was weak.

Test cut-offs were not clearly established.

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Meta-analysis [Zini et al, 2011]

No consistent relationship between SDF and embryo quality and/or development. The influence of SDF on embryo quality/development may be more significant in ICSI compared to IVF cycles.

Insufficient evidence (Level C) to recommend

routine DNA integrity testing for patients undergoing

IVF/ICSI.

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5. Is SDF predictive of pregnancy loss?

A meta-analysis (Zini, 2008)

significant association between SDF and pregnancy

loss after IVF or ICSI

Insufficient evidence (Level C) to recommend

routine DNA integrity testing to predict

pregnancy loss.

For diagnostic test

1. Results must be reproducible

2. Applicable to a given patient

3. Change management of patient

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II. British Fertility Society, 2013

Testing of SDF shows much promise both as

diagnostic test for male infertility and

prognostic test for ART outcomes.

SDF closely associated with fertility outcomes

including

Negative relationships with:

fertilization, embryo quality, implantation

Positive relationships with:

miscarriage and childhood diseases.

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III. Evgni et al, 2014: Clinical indications

for SDF tests 1.Prolonged idiopathic infertility

2.Low fertilization rate or bad quality embryos in

IVF

3. Implantation failure following IVF

4.Repeated abortions

5.Prolonged exposure to toxic environmental

conditions affecting fertility

6.Conventional seminal parameters found below

the reference range

7.Advanced male partner age

8.Varicocele patients

9.Cancer patients

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Semen analysis

Abnormal

SDF T

DFI≤30

ICSI

DFI≥30

Lifestyle, antioxidant

SDF T after 3 months

Normal+ Female factor

ICSI Failed

Due to its strong correlation with several aspects of ART

procedures and further consequences for the offspring: SDF T

should be integrated in routine clinical practice (Evgni et al, 2014)

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Osman et al, 2015: SR and MA

LBR increased significantly in couples with low SDF

compared with those with high SDF

After IVF and ICSI, men with low SDF had

significantly higher LBR

A sensitivity analysis: no statistically significant

difference in LBR between low and high SDF when

ICSI was used

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Conclusion

There is insufficient evidence to recommend the

routine use of SDF testing in evaluation and

treatment of infertile couple {level C}

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For diagnostic test

1. Results must be reproducible

2. Applicable to a given patient

3. Change management of patient

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