GAF Management Special

Globozoospermia syndrome: An update

Tue, 07 Jan 2025 08:04:46 GMT

Article #61: Globozoospermia syndrome: An update.
Authors: Farzaneh Fesahat, Ralf Henkel, Ashok Agarwal
Andrologia, 2020. 52(2)
DOI: 10.1111/and.13459

Contributors for the Commentary: Hamid Kalantari, MSc (Iran), Karan Vadher, MSc
(UK), Jane Ezeukwu, MSc (Nigeria), Marjan Sabbaghian, PhD (Iran)

Commentary:

The article “Globozoospermia syndrome: An update” offers a clear and comprehensive review of globozoospermia, a rare cause of male infertility. Globozoospermia is characterized by round-headed sperm that lack an acrosome, a feature essential for fertilization. This review explores the origins and frequency of the condition, current diagnostic tests, and available treatment options.

Pathogenesis and Epidemiology:
The authors offer an easy-to-follow explanation of the structural abnormalities in globozoospermia, such as defects in the sperm’s cytoskeleton. They distinguish between two types of globozoospermia and discuss factors affecting its occurrence, which adds a useful perspective for understanding this condition.

Sperm Parameters and Diagnostic Approach:
The review covers sperm characteristics in men with globozoospermia, including sperm count, movement, and volume. The authors detail study findings on these parameters, which are helpful for diagnosis and treatment planning. Summary tables provide quick references for clinicians and researchers.

DNA/Chromatin Integrity and Sperm DNA Fragmentation:
This section is particularly informative on how DNA abnormalities in sperm, like poor chromatin structure and high DNA fragmentation, impact fertility. The authors stress that sperm DNA quality is crucial for successful reproduction.

Genetic Features:
The authors highlight the genetic basis of globozoospermia, noting the importance of certain genes (like DPY19L2) that contribute to the condition. They recommend genetic screening in populations with high rates of related marriages, where inherited forms of globozoospermia may be more common.

Fertilization Potential and Treatment:
The review explains that conventional ICSI techniques have limited success with globozoospermic sperm and suggests alternatives, such as calcium ionophores and recombinant PLC-zeta, to improve fertilization outcomes.

Conclusion:
The authors effectively summarize the need for new diagnostic and treatment options for globozoospermia. They emphasize how the condition impacts DNA quality and male fertility, making this review an invaluable resource for clinicians and researchers in reproductive medicine.

Take Home Message: Ashok Agarwal contributed this last item.
❖ Globozoospermia is characterized by round-headed sperm lacking an acrosome, which impacts the sperm’s ability to fertilize an egg.
❖ Genes like DPY19L2 are crucial, and genetic testing may be recommended in high risk populations, such as those with consanguineous marriages.
❖ Globozoospermic sperm often have high DNA fragmentation and poor chromatin packaging, reducing fertilization success.
❖ Conventional ICSI alone is less effective; alternative approaches like assisted oocyte activation (AOA) with calcium ionophores are often required.

In summary, globozoospermia faces three critical challenges: unclear genetic mechanisms despite links to genes like DPY19L2, limited treatment options with only moderate success in ICSI with Assisted Oocyte Activation, and inconsistent diagnostic
criteria for distinguishing between partial and total globozoospermia, complicating clinical diagnosis and management.

My Viewpoint on Globozoospermia syndrome
Hamid Kalantari responds to questions from Ashok

Q1. What are the primary morphological characteristics of globozoospermia?

Hamid Kalantari: Globozoospermia is primarily characterized by the presence of roundheaded spermatozoa with cytoskeleton defects around the acrosome, resulting in the absence of acrosomes.

Q2. How does globozoospermia differ between type I and type II in terms of sperm morphology?

Hamid Kalantari : Globozoospermia is classified into two subtypes: complete (type-I: 100% round-headed spermatozoa) and partial (type-II: >20% round-headed spermatozoa)

Q3. What is the estimated prevalence of globozoospermia among infertile men?

Hamid Kalantari: Globozoospermia is considered a rare condition with an estimated prevalence of less than 0.1% among infertile men.

Q4. What are the key differences in sperm parameters between globozoospermic men and normozoospermic controls?

Hamid Kalantari: The key differences are significant. Here are the primary distinctions:
• Sperm Concentration: Globozoospermic men often exhibit a lower sperm concentration than normozoospermic controls, although this difference may not always be statistically significant.
• Motility: Globozoospermic men exhibit a significant reduction in both total and progressive motility. Studies indicate that globozoospermic samples have notably lower sperm motility rates, with one study reporting a total motility of approximately 40%, compared to higher rates observed in normozoospermic controls.

• Morphology: Globozoospermic men typically have a very high percentage of spermatozoa with abnormal morphology, characterized primarily by round-headed sperm lacking acrosomes. In contrast, normozoospermic men exhibit a higher proportion of normally shaped sperm.
• Sperm DNA Integrity: Globozoospermic men have a higher rate of sperm with abnormal chromatin packaging and increased DNA fragmentation. For instance, the rate of CMA3- reacted spermatozoa (indicating protamine deficiency) is significantly higher in globozoospermic men (approximately 66%) compared to normozoospermic controls (around 21%).
• Apoptotic Spermatozoa: A higher percentage of apoptotic spermatozoa is observed in globozoospermic men, with studies reporting rates of around 17.6% versus 6% in normozoospermic controls. This suggests elevated sperm cell mortality and impairment in globozoospermic men.

Q5. How does the absence of an acrosome in globozoospermic spermatozoa affect fertility?

Hamid Kalantari: The absence of an acrosome in globozoospermic spermatozoa severely impairs fertility, as the acrosome is essential for fertilization. Without it, sperm cannot undergo the acrosome reaction or penetrate the zona pellucida, both of which are necessary for successful egg fertilization.

Q6. What role does sperm DNA fragmentation play in globozoospermia?

Hamid Kalantari: Studies have shown that globozoospermic spermatozoa (GS) often exhibit elevated levels of DFI, attributed to defects in chromatin packaging and protamine deficiency. Such high levels of DFI in GS can affect fertilization and embryo development.

While ICSI can bypass some barriers to fertilization, fragmented DNA in sperm can still negatively impact fertilization rates and subsequent embryo development. Although fertilization may occur, the quality of the resulting embryos can be compromised, leading to lower implantation rates and an increased risk of miscarriage.

Hamid Kalantari, MSc: Short Biography

Hamid Kalantari, MSc (Andrology)
Researcher, Department of Andrology, Reproductive
Biomedicine Research Center, Royan Institute for Reproductive
Biomedicine, ACECR, Tehran, Iran
Email: kalantary.hamid@gmail.com
ORCID: 0000-0002-2156-9517

Hamid Kalantari graduated with a Master's degree in Cell and Molecular Biology from the University of Tehran in Iran. He is a researcher in the Departmemt of Andrology at the Royan Institute since 2011. His research primarily focuses on the genetic aspects of infertility. Hamid has 13 publications,112 citations, and an h-index of 6 in Scopus (Oct 2024). He serves as a Research Assistant in the Global Andrology Forum.

My Viewpoint on Globozoospermia syndrome
Karan Vadher responds to questions from Ashok

Q1. How do environmental factors potentially contribute to the development of partial Globozoospermia?
Karan Vadher: Environmental factors such as exposure to endocrine-disrupting chemicals (e.g., phthalates and BPA), heavy metals (lead, cadmium, mercury), and particulate matter can disrupt hormonal balance, particularly testosterone, and cause oxidative stress, damaging sperm DNA and proteins. These disruptions impair sperm maturation, leading to morphological defects like partial Globozoospermia. Other contributors include radiation, lifestyle factors, and occupational exposure, which affect spermatogenesis and sperm quality. Mechanisms include hormonal disruption, cellular damage, interference with acrosome formation, and epigenetic modifications.

Q2. What are the current treatment strategies for patients with Globozoospermia undergoing assisted reproduction?
Karan Vadher: For patients with Globozoospermia undergoing assisted reproduction, the primary treatment strategies include ICSI and Intracytoplasmic Morphologically Selected Sperm Injection or IMSI. The IMSI offers higher magnification for better sperm selection.
Assisted Oocyte Activation (AOA) using calcium ionophores is often employed to enhance fertilization rates. Sperm selection techniques like Magnetic Activated Cell Sorting (MACS) and microfluidics can improve sperm quality before ICSI. In more severe cases, testicular sperm extraction methods, such as TESA, TESE, and Micro TESE, are the methods of choice.

Q3. What is the impact of Globozoospermia on conventional intracytoplasmic sperm injection (ICSI) outcomes?
Karan Vadher: Globozoospermia significantly impacts conventional ICSI outcomes, primarily resulting in low fertilization rates due to acrosome deficiency. Even with techniques like IMSI and AOA, poor or no embryo development is common, with high
embryo fragmentation and often no blastocyst formation. Additionally, Globozoospermia is associated with lower pregnancy and live birth rates, along with an increased risk of miscarriage.

Q4. How does sperm motility in globozoospermic patients compare to that in patients with other forms of male infertility?
Karan Vadher: In globozoospermic patients, sperm motility is often compromised compared to other forms of male infertility. The abnormal round-headed shape, absence of an acrosome, and disrupted cytoskeletal structure impair the sperm’s ability to swim effectively. While Globozoospermia primarily affects morphology, it also reduces progressive motility, which is crucial for successful fertilization.

Q5. What are the key findings from recent studies on semen parameters in Globozoospermia men?
Karan Vadher: Recent studies on Globozoospermia reveal that men with this condition display severe morphological abnormalities, with less than 1% normal sperm forms in complete cases and around 1% in partial cases. Sperm motility is often compromised due to the absence of the acrosome. Findings on semen volume and concentration vary across studies, showing mixed results. Additionally, globozoospermic patients have high sperm DNA fragmentation, which is linked to poor fertilization, impaired embryo development, and higher miscarriage rates.

Karan Vadher, MSc: Short Biography

Karan Vadher, MSc (Embryology)
Clinical Embryologist at London
Women’s Clinic, Bromley, London
UK); Chief Embryologist/IVF Lab
Quality Manager, Group of Candor IVF Center, Gujarat, India
Email: karan.embryologist@gmail.com
ORCID: 0009-0005-6625-6724

Karan Vadher is a HCPC (Health and Care Professions Council)Registered Clinical Embryologist working in UK and India. He has over six years of experience in the field of embryology. He is a member of Youth BRIGADE Committee in the Indian Society for Assisted Reproduction (ISAR) National Level (2024-2026) and a member of ACE and ESHRE. Karan has a special interest in male factor infertility, embryology and quality control in IVF lab. Karan serves as a Research Assistant in Global Andrology Forum.

My Viewpoint on Globozoospermia syndrome
Jane Ezeukwu responds to questions from Ashok

Q1. How does the presence of cytoplasmic droplets (CDs) around the nucleus impact sperm motility in globozoospermia?
Jane Ezeukwu: The presence of cytoplasmic droplets around the nucleus in globozoospermia significantly impacts sperm motility and is believed to contribute to impaired sperm motility. These cytoplasmic droplets may lead to sperm dysfunction due to abnormal positioning and retention within the cell, reducing its ability to move effectively.

Q2. What is the significance of coiled tails in globozoospermic spermatozoa?
Jane Ezeukwu: Coiled tails represent a morphological abnormality that affects sperm function. It is a structural defect and an important characteristic of globozoospermic spermatozoa. The sperm's ability to move is greatly reduced when the tail is coiled, and that impedes the sperm from swimming toward the egg for fertilization. This plays a significant role in the overall reduced fertility observed in men with globozoospermia.

Q3. How do WHO standards from different years affect the interpretation of semen parameters in globozoospermic patients?
Jane Ezeukwu: In globozoospermic patients, WHO standards and criteria for evaluating semen parameters have changed over time, and this has impacted the interpretation of these parameters. The WHO standards for sperm morphology have become more stringent over time. In the 1999 edition, criteria for normal sperm morphology were less strict, which allows for a broader definition of what constituted "normal." In contrast, the 2010 WHO edition introduced more stringent criteria, leading to a higher proportion of sperm being classified as abnormal. For patients with globozoospermia, these criteria result in a more severe diagnosis.
The 2010 WHO manual lowered reference limits for semen parameters like sperm concentration, motility, and morphology. As a result, semen samples previously considered to be normal under older standards might be classified differently under the updated criteria.

Q4. What are the implications of acrosome vesicle fusion defects in the pathogenesis of globozoospermia?
Jane Ezeukwu: As spermatogenesis proceeds, Golgi-derived vesicles merge to form the acrosome, an essential structure for the sperm. In globozoospermia, the acrosome fails to form due to improper fusion of Golgi-derived vesicles during spermatogenesis, this leads to the absence of a functional acrosome, which is essential for sperm to penetrate the egg. As
a result, sperm cannot undergo the acrosome reaction, causing severe impairment of fertilization capabilities as well as infertility. These defects worsen the functional impairment of globozoospermic sperm.

Q5. How does the round-headed morphology of spermatozoa in globozoospermia affect fertilization potential?
Jane Ezeukwu: The inability of the round‐headed spermatozoa to bind or penetrate the zona pellucida severely limits their ability to fertilize the egg, this is due to the lack of an acrosome which is crucial for penetrating the zona pellucida of the egg. It also impairs sperm motility and function which contributes to the reduced fertilization potential of globozoospermic spermatozoa.

Jane Ezeukwu, MSc: Short Biography

Jane Ezeukwu, MSc (Embryology)
Embryologist at Medison Specialist Women's Hospital,
Fertility Assyst, Lagos, Nigeria
Email: janedefrances@gmail.com
ORCID: 0009-0004-1727-1330

Jane Ezeukwu obtained B.Sc and M.Sc degrees in Human Anatomy. She worked as a research assistant at Dr. Akang’s Fertility and Andrology research lab in the Anatomy Department of the University of Lagos, Nigeria. Jane is an Embryologist at Medison Specialist Women's Hospital/ Fertility Assyst. Lagos. Nigeria. She is a member of the Clinical Embryologist Association of Nigeria. She serves as a Research Assistant at the Global Andrology Forum.

My Viewpoint on Globozoospermia syndrome
Dr. Marjan Sabbaghian responds to questions from Ashok

Q1. What are the main findings of electron microscopy studies on globozoospermic spermatozoa?

Dr. Marjan Sabbaghian: The key findings from these studies include

a) having round, acrosomeless heads due to the absence or malformation of the acrosome;

b) misshapen and irregular nucleus;

c) various flagellar defects, such as coiling of the flagellum around the head or midpiece; d) cytoplasmic droplets around the head and/or midpiece;

e)microtubules and fibrous sheath abnormalities.

Q2. How do the findings from transmission electron microscopy (TEM) studies contribute to the understanding of globozoospermia?

Dr. Marjan Sabbaghian: By using TEM studies, scientists can get a detailed look at the structural issues in sperm cells that cause globozoospermia. These studies reveal key problems like the missing acrosome, various shape defects, and irregularities in the cell’s cytoplasm. Understanding these abnormalities is essential for grasping how this condition affects male fertility.

Q3. What role do genetic factors play in the development of globozoospermia?

Dr. Marjan Sabbaghian: Globozoospermia is a syndrome with an autosomal recessive pattern of inheritance (both of the alleles must have mutations). Genetic factors play a major role in the development of globozoospermia.

The main genes involved are:

(1) DPY19L2 - Mutations in this gene are found in about 70% of globozoospermia cases. The DPY19L2 protein is involved in acrosome development and sperm head elongation;

(2) SPATA16 - Encodes a testis-specific protein localized to the Golgi apparatus and proacrosomal vesicles, playing a role in acrosomal enzyme sorting and modification.

(3) PICK1 - Involved in protein trafficking, including the acrosome. PICK1-deficient mice are infertile due to globozoospermia;

(4) ZPBP1 - Encodes an acrosomal protein. Heterozygous mutations have been found in some patients with abnormal sperm head morphology.

Q4. How do the structural defects in globozoospermic spermatozoa impact the success of ART procedures?

Dr. Marjan Sabbaghian: Globozoospermic sperm cells usually show significant structural issues, such as missing acrosomes and problems with the cytoskeleton around the nucleus.
The structural defects seen in globozoospermic spermatozoa present significant challenges for ART procedures, primarily due to their inability to fertilize oocytes naturally and their association with genetic abnormalities. However, advancements in ART techniques tailored for these patients show potential for improving reproductive outcomes.

Q5. What are the potential molecular mechanisms underlying the absence of acrosomes in globozoospermic spermatozoa?

Dr. Marjan Sabbaghian: The absence of acrosomes in globozoospermic spermatozoa is a complex phenomenon linked to various molecular mechanisms, primarily involving genetic mutations and defects in cellular processes during spermatogenesis. Here are the key mechanisms identified in the literature: Mutations in Specific Genes including SPATA16,GOPC, and VPS54. These genes are involved in vesicle transport from the Golgi apparatus, which is essential for acrosome biogenesis.

Q6. How do the classification of globozoospermia into type I and type II influence clinical management?

Dr. Marjan Sabbaghian: In summary, the classification of globozoospermia into Type I and Type II significantly influences clinical management strategies, particularly regarding the choice of assisted reproductive technologies and the need for genetic evaluations (e.g., the mutation in DPY19L2 gene). Understanding these distinctions help clinicians tailor treatment plans that optimize the chances of conception and address the specific needs of each patient.

Q7. What are the challenges in diagnosing globozoospermia using standard semen analysis?

Dr. Marjan Sabbaghian: Diagnosing globozoospermia through standard semen analysis is challenging due to the nature of the method and the specific characteristics of the condition.
These challenges include the inherently subjective characteristics of morphological evaluations, overlap with other conditions that make it difficult to pinpoint globozoospermia as the primary issue, inconsistencies in laboratory methodologies, and the rarity of the syndrome, which may lead to under-recognition in clinical settings. Consequently, a cautious approach is necessary, often requiring supplementary testing to confirm the diagnosis and guide effective treatment options.

Marjan Sabbaghian, MSc, PhD: Short Biography

Marjan Sabbaghian, MSc,Ph.D (Andrology)
Professor and Head of Andrology Laboratory
Department of Andrology, Reproductive Biomedicine
Research Center, Royan Institute for Reproductive
Biomedicine, ACECR, Tehran, Iran
Email: marjan.sabbaghian@gmail.com
ORCID: 0000-0001-9439-268X

Dr. Marjan Sabbaghian earned her Ph.D. in Biochemistry from the University of Tehran in 2009. She has been an Associate Professor and the Head of the Andrology Laboratory at the Royan Institute since 2011.

Dr. Sabbaghian is a member of the Proteomics Society of Iran. Her editorial contributions include serving as a Topic Editor for the Journal of Biomolecules (AprilAugust 2021) and Frontiers in Endocrinology (2023-present). In addition, she is the Section Editor for the Infertility section of the Urology Journal (January 2021-present) and an Associate Editor for Cell Journal (Yakhteh) since 2023.
Her research primarily focuses on the causes of male infertility, including abnormal sperm production or function due to genetic defects and sperm DNA fragmentation. Marjan is a proud member of the Global Andrology Forum.

Standardized Laboratory Procedures, Quality Control and Quality Assurance Are Key Requirements for Accurate Semen Analysis in the Evaluation of Infertile Male

Thu, 21 Nov 2024 14:01:02 GMT

Article #63: Standardized Laboratory Procedures, Quality Control, and Quality Assurance Are Key Requirements for Accurate Semen Analysis in the Evaluation of Infertile Male.
Authors: Ashok Agarwal et al; World J Mens Health 2022 Jan 40(1): 52-65
https://doi.org/10.5534/wjmh.210022

Contributors for the Commentary are Israel Maldonado (Mexico), Liliana
Ramirez (Mexico), Hamid Kalantari (Iran), Melissa M. Morales Berrocal
(Costa Rica), Mohamed Arafa (Qatar) and Daniela Delgadillo (Mexico)

Commentary:
As specialists dedicated to the field of male fertility assessment, we firmly believe that semen analysis is a cornerstone of evaluating reproductive potential. This comprehensive evaluation plays a crucial role in understanding sperm health, employing a series of standardized laboratory procedures that are essential for ensuring accuracy and reliability in diagnosing male infertility. Our commitment to this field drives us to emphasize the importance of analyzing key parameters such as sperm concentration, motility, morphology, and vitality, which collectively help identify potential fertility issues.
The advent of Computer-Assisted Sperm Analysis (CASA) systems has significantly transformed our approach to semen evaluation. These advanced technologies have revolutionized the way we assess sperm quality, enhancing precision and reproducibility while minimizing the subjectivity inherent in manual assessments. CASA systems enable rapid analysis of large sample volumes, allowing for in-depth evaluations of various sperm parameters, including advanced kinematic characteristics such as velocity, trajectory, and overall motility patterns. We believe that integrating CASA technology not only boosts diagnostic accuracy but also substantially reduces human error, ultimately contributing to improved patient outcomes and more informed clinical decision-making.

Moreover, the importance of standardized laboratory procedures cannot be overstated. Each step in the semen analysis process, from sample collection to final analysis, must adhere to specific protocols to ensure reliable and reproducible results. For instance, we recommend collecting semen samples after a recommended abstinence period of 2–7 days, as this timeframe is critical for obtaining accurate assessments of sperm parameters. Also, proper incubation of the samples at 37°C for 30–60 minutes allows for liquefaction, which is vital for accurately measuring sperm motility and concentration.

Macroscopic and microscopic evaluations are essential components of the semen analysis process. During the macroscopic assessment, we examine characteristics such as volume, viscosity, and pH. These parameters can provide immediate insights into potential issues affecting fertility. For instance, abnormal viscosity may indicate problems with seminal fluid composition, while variations in pH can signal underlying health concerns. Following this initial assessment, microscopic evaluation allows us to delve deeper into sperm characteristics, including motility (the ability of sperm to move), morphology (the shape and structure of sperm), and vitality (the percentage of live sperm in the sample).
In addition to these assessments, we highlight the vital role of Quality Control (QC) and Quality Assurance (QA) measures in maintaining the integrity of the analysis. Rigorous QC and QA protocols are essential for ensuring the accuracy and reliability of semen analysis results. This includes regular calibration of laboratory equipment, ensuring that all analytical instruments are functioning optimally, and providing accurate measurements. We advocate for competency assessments for laboratory personnel, as the expertise of the staff conducting the analyses is critical to producing reliable results. Furthermore, participation in external quality control programs allows laboratories to benchmark their performance agains t established standards, fostering continuous improvement and adherence to best practices. The significance of accurate reporting and interpretation of semen analysis results cannot be overstated, particularly in the context of male infertility. As clinicians and embryologists, we understand the emotional and psychological implications associated with infertility diagnoses. Therefore, we must approach the communication of results with sensitivity and clarity. Results must be contextualized within the patient’s clinical history, lifestyle factors, and other relevant medical information. This holistic approach enables us to provide meaningful insights into fertility potential and guides our recommendations for further evaluation or treatment.
Moreover, we recognize that semen analysis is not merely a standalone procedure but rather part of a comprehensive fertility evaluation. Often, male infertility is multifactorial, necessitating a thorough investigation that includes hormonal assessments, genetic testing, and possibly imaging studies. By integrating semen analysis with other diagnostic modalities, we can develop a more complete understanding of the underlying causes of infertility and tailor our interventions accordingly.
As we reflect on the advancements in the field, we are encouraged by the ongoing research and innovations aimed at enhancing semen analysis. For example, the development of novel biomarkers and non-invasive testing methods holds promise for improving the accuracy and efficiency of fertility assessments. These advancements may pave the way for more personalized approaches to male infertility treatment, ultimately empowering patients with better-informed choices regarding their reproductive health.

Israel Maldonado Rosas, BS, MSc: Short Biography

Israel Maldonado Rosas, BS, MSc
Owner and CEO
Scientific Director of Centro de Innovación
Tecnológica y Medicina Reproductiva (CITMER), Mexico City, Mexico
Email: imaldonado@citmer.mx
http://www.citmer.com
ORCID ID: 0000-0003-2765-6176

Israel Maldonado Rosas is the owner and CEO of the Centro de Innovación Tecnológica y Medicina Reproductiva (CITMER) in Mexico, which operates three IVF clinics located in Puebla, Monterrey, and Mexico City. He also serves as the Scientific Director of CITMER Research Center. A graduate in Biology from the Instituto Politécnico Nacional, Israelreceived specialized training as a Clinical Embryologist at the Instituto Valenciano de Infertilidad (IVI) in Valencia, Spain, in 2004. He further honed his skills through fellowships at the Kato Ladies Clinic in 2005 and 2007, and at the American Center for Reproductive Medicine in Cleveland, USA, in 2008. In 2016, he achieved board certification as a Clinical Embryologist by REDLARA. From 2016 to 2021, he served as an external faculty member in the International Training Program in Advanced Reproductive Techniques at the Cleveland Clinic’s American Center for Reproductive Medicine. Israel’s contributions to the field of embryology are widely recognized. In November 2020, he became the first Latin American embryologist to be honored by the American College of Embryology. An innovative researcher, he has authored over 26 scientific publications (h-index of 11 in Scopus) and 6 book chapters, showcasing his expertise in reproductive medicine. As the Founding Member of the GAF management team, Israel is a strong supporter of its mission, actively contributing to the advancement of andrology and reproductive health.

My Viewpoint on “Standardized Semen Analysis”
Dr. Israel Maldonado Rosas responds to questions from Ashok

Q1. What are the standardized protocols for semen collection and why are they crucial?

Dr. Maldonado: Standardized protocols for semen collection are essential for obtaining reliable results, particularly by ensuring the entire ejaculate is collected, as the initial fraction holds the highest sperm concentration. Patients should be given detailed instructions, including written guidelines, to support proper collection techniques. Recommended abstinence from ejaculation for 2 to 7 days before sample collection is vital, as this period optimizes semen parameters. The length of abstinence directly influences sperm concentration and motility—too short a period may result in a lower sperm count, while prolonged abstinence may lead to reduced sperm motility.
For sample collection, masturbation is the most common method; however, specialized condoms designed for semen collection during intercourse are also an option. To ensure sample integrity, patients are advised to use sterile containers and aim to collect the complete ejaculate. These standardized protocols, along with clear patient guidance, play a crucial role in ensuring accurate semen analysis results.

Q2. What are the standardized criteria for assessing sperm morphology according to WHO guidelines?

Dr. Maldonado: Sperm morphology assessment follows the WHO 6th edition guidelines, which define normal morphology as at least 4% of sperm exhibiting normal forms, based on the lower 5th percentile from a healthy population using strict Kruger’s criteria. Sperm morphology, vital for fertility, is evaluated through specific criteria. The head should be oval and smooth, with defined dimensions; the neck and midpiece must be of appropriate length and free from abnormalities; and the tail should be long and straight to ensure proper motility.

Common morphological abnormalities include round or irregularly shaped heads, multiple or coiled tails, and midpiece defects such as thickening or irregularities. These standardized assessments are crucial for diagnosing male infertility and guiding clinical decisions regarding assisted reproductive technology.

Q3. How do the different staining techniques used in semen analysis contribute to evaluating sperm morphology and vitality?

Dr. Maldonado: Typically, staining techniques such as Papanicolaou, and Diff-Quik are employed to evaluate sperm morphology, while eosin-nigrosin staining is used to assess sperm vitality, indicating the live/dead sperm ratio. The Diff-Quik stain specifically highlights sperm structures, including the head, midpiece, and tail, allowing for the visualization of morphological features such as size, shape, and abnormalities. In terms of vitality, eosin-nigrosin staining differentiates live sperm from dead ones; eosin stains dead sperm pink, while nigrosin provides a dark background for better visibility of live sperm, which remains unstained. This assessment is vital for understanding sperm functionality, enabling clinicians to distinguish between asthenozoospermia (decreased motility) and necrozoospermia (decreased vitality), facilitating accurate diagnosis and management of male infertility.

Q4. What is the significance of using computer-assisted semen analysis (CASA) systems in modern laboratories?

Dr. Maldonado: The implementation of Computer-Assisted Sperm Analysis (CASA) systems in andrology laboratories is vital for enhancing the accuracy and reliability of semen analysis, a key component in assessing male infertility. CASA systems improve inter and intra-observer consistency by providing precise, objective results, eliminating the subjectivity associated with manual assessments. They analyze sperm concentration, motility, and morphology rapidly, allowing for higher throughput in clinical settings and enabling the evaluation of more sperm, which increases diagnostic accuracy. Additionally, CASA systems can assess advanced parameters like sperm kinematics and motion characteristics, offering deeper insights into male fertility potential. The automated nature of CASA minimizes human errors common in manual analysis and integrates seamlessly with quality control programs to ensure the reliability and reproducibility of results. Overall, CASA systems significantly enhance the efficiency and effectiveness of semen analysis in clinical practice.

Q5. What protocols should be followed for post-vasectomy semen analysis to ensure accurate confirmation of azoospermia?

Dr. Maldonado: Post-vasectomy semen analysis is essential for confirming the success of the procedure, specifically the absence of sperm, known as azoospermia. This analysis ensures that the vas deferens are effectively blocked, preventing sperm from entering the ejaculate. For accurate confirmation of azoospermia, protocols should include collecting samples after a sufficient abstinence period of 2–7 days. Semen should be collected in a sterile container and incubated at 37°C for 30–60 minutes to allow liquefaction. Both macroscopic and microscopic evaluations must be performed, assessing volume, viscosity, pH, and sperm concentration. Centrifugation at 3,000g for 15 minutes is recommended to confirm the absence of sperm. Multiple samples should be analyzed at least 8–12 weeks post-surgery, to ensure consistent azoospermia confirmation.

Liliana Berenice Ramírez-Domínguez, BSc: Short Biography

Liliana Berenice RamírezDomínguez, BSc.
Clinical Embryologist and Scientific Coordinator,
CITMER Research Center

Mexico City, Mexico
Email: lramirez@citmer.mx
http://www.citmer.com
ORCID ID: 0000-0003-2351-0948

Liliana Ramírez is a Clinical Embryologist and Scientific Coordinator with over eight years of research experience, including 4+ years in human reproduction. As the research lead at Centro deInnovación Tecnológica y MedicinaReproductiva (CITMER), she has elevated the institution's profile through international congresses and publications. Her expertise spans assisted reproductive technologies, andrology techniques, and embryo culture optimization. A published author of research articles and book chapters, Liliana frequently presents at major reproductive meetings, including ESHRE and ASRM. She coordinates projects adhering to international standards while fostering national and global collaborations. A former research coordinator for the Global Andrology Forum, she remains a valued member of the organization.

My Viewpoint on “Standardized Semen Analysis”
Liliana Ramírez responds to questions from Ashok

Q1. What are the critical parameters evaluated in the macroscopic examination of semen?

Liliana: Macroscopic semen examination is essential for assessing male fertility, and evauating parameters like volume, liquefaction, pH, and appearance. Abnormalities can indicate various issues: high volume may suggest duct obstruction or androgen deficiency; delayed liquefaction may imply accessory gland dysfunction; acidic pH may indicate duct obstruction, while alkaline pH could signal inflammation or azoospermia, and abnormal coloration may point to infections or hematospermia.

Q2. What is the significance of sperm motility assessment in semen analysis?

Liliana: Sperm motility is a critical parameter in semen analysis, as it directly correlates with male fertility potential and provides significant diagnostic value in the evaluation of infertility. Low motility may indicate underlying conditions such as varicocele, infections, or lifestyle factors that could adversely affect reproductive health. Assessing sperm motility not only aids in diagnosing potential causes of infertility but also informs clinicians in selecting appropriate fertility treatments. Additionally, the motility assessment offers a strong predictive value for outcomes in assisted reproductive technologies, such as in vitro fertilization (IVF), thereby influencing pregnancy success rates.

Q3. How does the evaluation of seminal leukocytes contribute to diagnosing male infertility?

Liliana: Leukocytospermia may indicate various inflammation-related factors contributing to infertility, including conditions like varicocele, increased reactive oxygen species, and active infections. However, the presence of leukocytospermia must be evaluated meticulously, as it does not confirm bacterial infection on its own. A comprehensive assessment is required to determine if an underlying infection is present and to understand the implications for male fertility.

Q4. What are the implications of detecting anti-sperm antibodies in semen?

Liliana: The presence of anti-sperm antibodies typically results from a compromised blood testis barrier, which can impair sperm function, affecting motility, acrosome reaction, capacitation, and overall fertilizing potential. To address immunological-related infertility, treatment options such as corticosteroids and assisted reproductive technologies (ART) are recommended based on the patient’s history. These approaches aim to enhance sperm function and improve the chances of successful conception despite the presence of these antibodies.

Hamid Kalantari, MSc: Short Biography

Hamid Kalantari, MSc(Andrology)
Researcher, Department of Andrology, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
Email: kalantary.hamid@gmail.com
ORCID: 0000-0002-2156-9517

Hamid Kalantari graduated with a Master's degree in Cell and Molecular Biology from the
University of Tehran in Iran. He has been a researcher in the Department of Andrology at the Royan Institute since 2011. His research primarily focuses on the genetic aspects of infertility. Hamid has 13 publications, 112 citations, and an h-index of 6 in Scopus (Oct 2024). He serves as a Research Assistant in the Global Andrology Forum.

My Viewpoint on “Standardized Semen Analysis”
Hamid Kalantari responds to questions from Ashok

Q1. How does the duration of abstinence before semen collection affect the analysis?

Hamid: The World Health Organization (WHO) suggests an abstinence period of 2 to 7 days before semen analysis to ensure accurate results. This raises the question of how this interval affects the outcomes of semen analysis.
Short abstinence periods (1-2 days) improve sperm motility and viability by minimizing sperm aging and oxidative stress. However, this may lead to a lower total sperm count due to insufficient time for sperm accumulation. A moderate abstinence duration (3-4 days) strikes a balance between the quantity and quality of sperm, positively influencing semen parameters. In contrast, longer abstinence periods (5-7 days) result in increased sperm concentration but may negatively impact motility and viability, as extended abstinence can cause heightened stress and increase the risk of DNA damage. Despite following WHO recommendations, variability in semen analysis results persists. Therefore, accurately documenting the exact duration of abstinence in the report is crucial for healthcare providers to recommend suitable interventions.

Q2. Why is the rejection of certain semen specimens important, and what criteria are used?

Hamid: The rejection of certain semen specimens is crucial for maintaining the accuracy and reliability of semen analysis. Accepting poor-quality samples resulting from errors during collection can lead to misdiagnosis and unnecessary stress for patients. Criteria for rejection include contamination (e.g., presence of urine), inadequate volume due to improper collection methods, and delayed transportation of samples. For instance, if a patient’s semen sample is incomplete due to loss during ejaculation, the laboratory technician should inform the clinician. This proactive approach ensures that only highquality specimens are analyzed, preventing misinterpretation of results and providing proper guidance on sample collection for future submissions.

Q3. How is sperm vitality assessed, and why is it important?

Hamid: The assessment of sperm vitality involves two crucial methods used in clinical andrology laboratories: the hypo-osmotic swelling (HOS) test and staining with eosin and nigrosine dyes. The HOS test evaluates the osmoregulatory capacity of sperm membranes, while the staining technique identifies dead sperm cells with compromised membranes. Live sperm will exclude the dyes and appear clear, whereas dead sperm will take up the stains.
These methods are especially important when total motility is low (40%), as they help differentiate between live non-motile sperm and dead sperm. Understanding sperm vitality is essential for accurate diagnosis and effective management of male infertility.

Q4. How can laboratories ensure the reliability and reproducibility of semen analysis results?

Hamid: To ensure reliable semen analysis results, laboratories should (a) standardize procedures by following WHO guidelines and using automated systems, (b) implement quality control and assurance programs, and (c) provide regular training and competency evaluations for technicians.

Melissa Morales, MSc: Short Biography

Melissa Morales, MSc.
Clinical Embryologist, Laboratorio FIV, Hospital de las Mujeres, San José, Costa Rica.
Email: mmorales@evalabcr.com
ORCID ID: 0000-0002-9104-8514

Melissa Morales is a Medical Laboratory Scientist with a postgraduate degree in Andrology
at Instituto Nacional de Perinatología in 2016 and in Human Assisted Reproduction Techniques in 2018. She has been working as a Clinical Embryologist at the Costa Rican Social Security National IVF Laboratory since 2018. Melissa has researched topics such as advanced maternal age, male factor infertility, and genitourinary tract infections using molecular biology techniques, and animal models. Melissa is a proud member of the Global Andrology Forum.

My Viewpoint on “Standardized Semen Analysis”
Melissa Morales responds to questions from Ashok

Q1. How does quality control (QC) impact the accuracy of semen analysis?

Melissa: Quality control is essential in reducing errors by managing variations, enhancing reproducibility, facilitating staff training, and providing guidance during instances of alert values, thereby creating a safe laboratory environment. In andrology laboratories, the results are particularly vulnerable to variability due to the manual nature of analyses, making them heavily reliant on the analyst's experience. This reliance differs from conventional biomedical clinical laboratories. Therefore, it is critical to implement a stringent quality control program to ensure the accuracy and reliability of results.

Q2. What role does quality assurance (QA) play in semen analysis laboratories?

Melissa: While quality control is a vital tool for analysts in andrology laboratories, it must be integrated into a comprehensive quality management and assurance system to be truly effective. Such a system ensures that all processes align with defined standards, which are specifically tailored to the unique context and requirements of each laboratory. This holistic approach not only enhances the reliability and accuracy of test results but also fosters a culture of continuous improvement. By systematically monitoring and evaluating laboratory practices, staff can identify areas for enhancement, promote adherence to best practices, and ensure compliance with regulatory requirements, ultimately leading to better patient outcomes.

Q3. Why is sperm morphology important, and what methods are used?

Melissa: Sperm morphology enables the identification of the number of spermatozoa in a sample that is considered potentially competent. Furthermore, the morphological changes or alterations observed can complement genetic tests, aid in establishing a definitive diagnosis, and significantly influence clinical decision-making. This analysis is essential for determining the most appropriate assisted reproductive technology (ART) procedures for couples, such as intrauterine insemination (IUI), and in vitro fertilization (IVF).
Sperm morphology is assessed using smear and staining techniques, with Papanicolaou staining recommended for optimal visibility of all regions of the spermatozoon. However, commercially available stains like Diff-Quik are more practical and yield comparable results.

Q4. What is the relevance of biochemical markers in semen analysis?

Melissa: European guidelines on male infertility emphasize the importance of biochemical markers as part of an extended panel of tests to evaluate a patient’s andrological profile. These tests are crucial for classifying azoospermia as either obstructive or non-obstructive.
They are particularly relevant when infertility is suspected to have an infectious or inflammatory origin, such as in the case of Male Accessory Gland Infection (MAGI), as they assist not only in diagnosis but also in assessing the severity of the condition, such as differentiating prostatitis from prostatovesiculitis. Additionally, biochemical markers provide clinical utility in cases where the cause of infertility remains unknown, helping in a more comprehensive understanding of the underlying issues.

Q5. What are the impacts of environmental and lifestyle factors on semen analysis results?

Melissa: Environmental and lifestyle factors significantly impact semen analysis results. Obesity is linked to decreased semen quality and hormonal disruptions, which can impair fertility. Smoking contributes to a pro-inflammatory state in the reproductive system, leading to reduced sperm quality and motility. Additionally, exposure to environmental toxins, including heavy metals and endocrine disruptors, can adversely affect spermatogenesis and overall semen parameters. Recent meta-analyses have highlighted the negative effects of air pollution on sperm concentration and motility, suggesting that pollutants may directly harm sperm function. Overall, the observed decline in sperm quality over the past 50 years is likely associated with these environmental and lifestyle factors, rather than genetic causes.

Mohamed Arafa, MD, FECSM: Short Biography

Mohamed Arafa, MD, FECSM
Sr. Consultant Urology, ACC, Hamad Medical Corporation,
Doha, Qatar
Professor of Andrology & STDs, Cairo University, Cairo, Egypt
Email: mohamedmostafaarafa@gmail.com
ORCID ID: 0000-0003-0107-8857

Dr. Mohamed Arafa Omar Yamani graduated with an MD in Andrology from the Department of Andrology and sexually transmitted diseases at Cairo University, Egypt in 2004. He has been a faculty in the department since 2004. He moved to Hamad Medical Corporation in 2011 and has risen to the rank of Senior Consultant in Andrology in the Department of Urology since 2020. He was appointed as a Professor of Andrology at Cairo University in 2022. Arafa is an Adjunct Assistant Prof in Urology at Weill Cornell Medical CollegeQatar. He has authored or co-authored 108 publications, has over 3,000 citations, and has an h-index of 26 (Scopus, Nov 2024). His research focuses on male infertility and sexual dysfunction, including genetic, medical, and surgical therapies. He earned a fellowship in sexual medicine from the European Committee of Sexual Medicine in 2012. Prof. Arafa is a former Guest member of GAF Management and a proud member of the Global Andrology Forum.

Challenges in the Management of Nonobstructive Azoospermia

Thu, 14 Nov 2024 03:09:41 GMT

Article #62: Challenges in the Management of Nonobstructive Azoospermia.
Authors: Megan McMurray and Nicholas N. Tadros
This invited article is part of a new book “Current and Future Advances in Male Infertility: A Compendium for Clinicians and Researchers” - Edited by the GAF Experts and authored by the GAF members. The Editors are GAF members: Prof. Ramadan Saleh, Prof. Florence Boitrelle, and Dr. Rupin Shah, publisher: Springer-Nature, Published July 2024.
https://doi.org/10.1007/978-3-031-62648-7

Contributors for the Commentary are from Turkey: Baris Altay, MD,
Mustafa Emre Bakircioğlu, MD, Arif Kalkanli, MD, Coskun Kaya, MD,
Sadik Gorur, MD, Mustafa Gurkan Yenice, MD

Commentary:

Infertility nearly affects 1 in 6 North American couples, with male factor infertility seen in half of cases. It is known that several factors play a role in male infertility. Azoospermia which is defined as the absence of mature sperm in the ejaculate, is estimated to affect 1.9% of the general population and 10-20% of men with fertility problems. Two types of azoospermia have been identified. In nonobstructive azoospermia (NOA), it occurs due to deterioration in spermatogenesis. But, in obstructive azoospermia (OA) there are occlusions in the ductal system or ejaculatory system.
Numerous factors are implicated in NOA. It is mainly classified as pre-testicular (hypogonadotropic hypogonadism) or testicular (spermatogenic failure). Hypogonadotropic hypogonadism (HH) may be congenital (Kallmann syndrome, Prader Willi syndrome, and Laurence-Moon syndrome) or acquired (trauma, tumors, or radiation of hypothalamus/pituitary gland, exogenous steroids or androgens, including testosterone replacement therapy, anabolic steroids, and certain pituitary, adrenal, or testicular tumors). Spermatogenic failure (SF) may occur because of some genetic abnormalities such as Klinefelter syndrome, Y chromosome microdeletions or cryptorchidism, varicocele, prior infection (e.g., mumps orchitis), gonadotoxic exposures (chemotherapy agents, radiation exposure), and testicular trauma or ischemia (e.g., testicular torsion, injury from prior surgery).
In the initial evaluation, the patient should be questioned about his fertility history and a thorough physical exam must be performed. Azoospermia is diagnosed via a semen analysis, preferably with two concordant semen analyses obtained at least 1 month apart, showing a total absence of spermatozoa, even in the centrifuged pellet. Semen volume, FSH and LH levels, and physical exam findings should aid in differentiating between OA and NOA. Men with OA can have low semen volume (<0.5–1 mL) and normal FSH levels, while men with NOA will have normal semen volume and may have an abnormal FSH level. Small testis volume may be a sign of NOA, while the absence of vasa deferentia or enlarged proximal epididymis would indicate underlying OA. After the diagnosis of NOA is made, hormonal evaluation should be obtained to differentiate between HH and SF. Low FSH, low LH, and low testosterone levels are seen in HH. In contrast, SF is characterized by high/normal FSH and LH and low/ normal testosterone. Treatment of NOA varies according to the cause. HH can often be managed successfully
with hormonal therapy. This condition is characterized by impaired spermatogenesis due to decreased pituitary LH production causing decreased testicular testosterone production. Therefore, management focuses on stimulating ITT production. hCG is the primary medication used in this setting, as it directly stimulates LH receptors on Leydig cells to increase testosterone production. After testosterone levels have normalized, FSH supplementation is commonly added to the hCG regimen to further stimulate spermatogenesis. In men on anabolic steroids or testosterone replacement therapy, the first step is discontinuation of all such hormones. Spermatogenic recovery after discontinuation of exogenous testosterone is variable.
In spermatogenic failure, hormonal therapy is controversial. The use of hormonal therapy before testicular sperm extraction (TESE) in men with SF is commonly utilized despite a lack of supporting evidence, particularly in men with idiopathic SF.
In patients with NOA and clinically significant varicocele, varicocelectomy can be considered. 43.9% of patients with NOA were found to have sperm in postoperative semen analysis after varicocelectomy, and this was significantly higher in patients with hypospermatogenesis compared to maturation arrest and Sertoli cell-only syndrome. Varicocelectomy has also a positive effect on sperm retrieval and pregnancy rates, but this difference is not statistically significant.
In NOA patients, There are several techniques were described for sperm extraction including testicular sperm aspiration (TESA), conventional testicular sperm extraction (cTESE), and microdissection testicular sperm extraction (micro-TESE or mTESE). It was shown that cTESE was 2.0 times more likely to have successful sperm retrieval compared to TESA. Compared to cTESE, mTESE is generally believed to have improved the SRR in men with NOA. SRRs increased from 45% with cTESE to 63% with mTESE and found that mTESE was 1.5 times more likely to have successful sperm retrieval compared to cTESE.
There are several areas of investigation that may aid in the diagnosis and management of NOA in the future. Detailed genetic evaluation such as karyotyping for chromosomal translocations and next-generation sequencing may be useful in delineating the etiology of azoospermia. Predictive modeling and artificial intelligence may be used to help predict successful sperm retrieval in men with NOA.

REFERENCES
1. Agarwal A, Mulgund A, Hamada A, Chyatte MR. A unique view on male infertility around the globe. Reprod Biol Endocrinol. 2015;13(1) https://doi.org/10.1186/s12958-015-0032-1.
2. Olesen IA, Andersson AM, Aksglaede L, et al. Clinical, genetic, biochemical, and testicular biopsy findings among 1,213 men evaluated for infertility. Fertil Steril. 2017;107(1):74–82. e7. https://doi.org/10.1016/j.fertnstert.2016.09.015.
3. Schlegel PN, Sigman M, Collura B, et al. Diagnosis and treatment of infertility in men: AUA/ASRM guideline part I. Fertil Steril. 2021;115(1):54–61.https://doi.org/10.1016/j.fertnstert.2020.11.015.
4. Tharakan T, Corona G, Foran D, et al. Does hormonal therapy improve sperm retrieval rates in men with non-obstructive azoospermia: a systematic review and meta-analysis. Hum Reprod Update. 2022;28(5):609–28. https://doi.org/10.1093/humupd/dmac016.
5. Tharakan T, Salonia A, Corona G, Dhillo W, Minhas S, Jayasena C. The role of hormone stimulation in men with nonobstructive azoospermia undergoing surgical sperm retrieval. J Clin Endocrinol Metab. 2020;105(12) https://doi.org/10.1210/clinem/dgaa556.
6. Esteves SC, Miyaoka R, Roque M, Agarwal A. Outcome of varicocele repair in men with nonobstructive azoospermia: systematic review and meta-analysis. Asian J Androl. 2016;18(2): 246–53. https://doi.org/10.4103/1008-682X.169562.
7. Bernie AM, Mata DA, Ramasamy R, Schlegel PN. Comparison of microdissection testicular sperm extraction, conventional testicular sperm extraction, and testicular sperm aspiration for nonobstructive azoospermia: a systematic review and meta-analysis. Fertil Steril.2015;104(5):1099–103.e1-3.https://doi.org/10.1016/j.fertnstert.2015.07.1136.
8. Punjani N, Kang C, Lamb DJ, Schlegel PN. Current updates and future perspectives in the evaluation of azoospermia: a systematic review. Arab J Urol.2021;19(3):206–14.https://doi.org/10.1080/2090598x.2021.1954415.

Baris Altay, MD, FECSM, FEBU: Short Biography

Baris Altay, MD, FECSM,FEBU
Professor of Urology
Department of Urology
Ege University, Izmir, Turkey
ahmetbaris.altay@yahoo.com
Orcid ID: 0000-0002-3101-8022

Professor Baris Altay has been with the Urology Department at Ege University since 2009 and also serves as a consultant urologist at the university’s IVF Center. His clinical focus lies in male infertility and erectile dysfunction. An accomplished researcher, Professor Altay has authored over 54 articles in SCI-indexed journals, with a Scopus h-index of 16 and 955 citations as of November 2024.
He serves as a reviewer for Andrologia and Urology Research and Practice. Professor Altay has been certified as a Fellow of the European Board of Urology (FEBU) since 2003 and as a Fellow of the European Committee of Sexual Medicine (FECSM) since 2016. He served as President of the Turkish Andrology Society from 2020 to 2021 and has been the Vice President of the Turkish Urology Society since 2022. Baris is an active member of ESSM, EAA, and ESAU, and a proud member of the Global Andrology Forum, where he serves as a Guest Member of the GAF Management team.

My Viewpoint on “Challenges in the Management of NOA”
Dr. Mustafa Emre Bakircioğlu responds to questions from Ashok

Q1. What is the definition of non-obstructive azoospermia (NOA)?
Dr. Bakırcıoğlu: The definition of non-obstructive azoospermia is simply testicular sperm
production failure and, depending on semen analysis, the total absence of spermatozoa
after the search of centrifuged pellet. However, the accurate diagnosis of azoospermia can
be problematic according to WHO recommendations and almost 24% of cryptozoospermic
men are misdiagnosed as azoospermia.
Q2. How does NOA differ from obstructive azoospermia (OA)?
Dr. Bakırcıoğlu: The medical history and physical examination (the normal volume of testis,
epidydimal enlargement, absence of vas deferens) are the essentials to differentiate
obstructive azoospermia from NOA. In semen analysis, decreased ejaculate volume and
normal serum levels of FSH and total testosterone are the signs of obstructive azoospermia.
However, in rare cases, testis biopsy is the only way to differentiate NOA from OA ( Normal
testis volume, Normal FSH (<7 IU/mL), and normal ejaculate volume (>1.5 mL).
Q3. What are the two main classifications of NOA based on the anatomical location of
the underlying problem?
Dr. Bakırcıoğlu: The two main classifications of non-obstructive azoospermia (NOA) based
on the anatomical location of the underlying problem are:
a. Pre-testicular NOA (Hypogonadotropic Hypogonadism - HH): This refers to a
hormonal abnormality from the hypophysis gland that prevents the stimulation of
spermatogenesis.

b. Testicular NOA (Spermatogenic Failure): This occurs when the testes themselves
have an issue with producing sperm despite proper hormonal stimulation.
Q4. What are the common causes of hypogonadotropic hypogonadism (HH) leading to
NOA?
Dr. Bakırcıoğlu: Common causes of hypogonadotropic hypogonadism (HH) leading to nonobstructive azoospermia (NOA) include congenital conditions such as Kallmann syndrome,
Prader-Willi syndrome, and Laurence-Moon syndrome, as well as acquired factors like
trauma to the pituitary or hypothalamus, tumors affecting these areas, radiation exposure,
the use of exogenous steroids or androgens (e.g., testosterone replacement therapy,
anabolic steroids), and tumors of the pituitary, adrenal, or testicular glands.
Q5. List some genetic conditions associated with spermatogenic failure (SF) in NOA.
Dr. Bakırcıoğlu: Genetic conditions associated with spermatogenic failure (SF) in nonobstructive azoospermia (NOA) include Klinefelter syndrome, XYY syndrome and Y
chromosome microdeletions, the most common form is AZFc deletions. These genetic
abnormalities can disrupt normal sperm production, leading to spermatogenic failure.
Q6. How is NOA managed in men with Klinefelter syndrome?
Dr. Bakırcıoğlu: Men with Klinefelter syndrome (KS) have a chance to become genetically
father with sperm recovery from testis by MicroTESE operation and using testicular sperm
intracytoplasmic sperm injection technique. Some studies showed the benefit of hormonal
therapy in men with KS who have low serum testosterone levels. In a study, sperm recovery
success was significantly higher in men with KS who had a better response to hormonal
therapy compared to no response to hormone treatment and remained with low
testosterone levels.
Q7. What predictors are associated with successful TESE in Klinefelter syndrome?
Dr. Bakircioğlu: Aging is negatively affected in men with KS. However, hormonal levels of
FSH, LH, and total testosterone levels did not predict successful sperm recovery. Although
the total testis volume of the men with KS did not show any difference between sperm
positive and negative groups, the patients who have decreased left testis volume have poor
prognosis. Q3. What roles do machine learning algorithms play in predicting the success
of therapeutic procedures in andrology?
Q8. What is the recommended management approach for men with NOA and androgen
excess due to anabolic steroid use?
Dr. Bakircioğlu: The duration of anabolic steroid use negatively affects spermatogenic
recovery in men with NOA. Longer use of steroids is associated with a decreased probability
of recovery, as prolonged suppression of spermatogenesis can lead to irreversible damage
in some cases. The longer the duration of use, the less likely full spermatogenic recovery
will occur.
Q9. How does the duration of anabolic steroid use affect spermatogenic recovery in
NOA?
Dr. Bakircioğlu: The duration of anabolic steroid use negatively affects spermatogenic
recovery in men with NOA. Longer use of steroids is associated with a decreased probability
of recovery, as prolonged suppression of spermatogenesis can lead to irreversible damage
in some cases. The longer the duration of use, the less likely full spermatogenic recovery
will occur.

Mustafa Emre Bakircioğlu, MD: Short Biography

M. Emre Bakircioğlu, MD
Andrology Consultant Sensart Clinic, Associate Professor Istanbul, Turkey
E-mail: emre@emrebakircioglu.com
https://orcid.org/0000-0003-2411-9703

Dr. Mustafa Emre Bakircioğlu earned his MD from CerrahpasaMedical School, Istanbul University, and completed his Urology residency at Haydarpaşa Numune Hospital inIstanbul. He subsequentlyundertook a research fellowship inErectile Dysfunction and Neurourology at the Department of Urology, University of California, San Francisco, USA.
University of California, San Francisco, USA. Dr. Bakircioğlu is an active member of multiple professional organizations, including the AUA, EUA, ASRM, ESHRE, EAA, and SSMR. As of November 2024, his publication record on Scopus includes 30 articles, 1,330 citations, and an h-index of 19. Emre is also a proud member of the Global Andrology Forum.

My Viewpoint on “Challenges in the Management of NOA”
Dr. Arif Kalkanli responds to questions from Ashok

Q1. How is azoospermia diagnosed through semen analysis?

Dr. Kalkanli: Azoospermia is the condition in which no spermatozoa are found in semen analysis. For a definitive diagnosis, spermatozoa should not be detected in a semen analysis performed at least one month apart. The recommended method to distinguish absolute azoospermia from cryptozoospermia is to centrifuge the semen at 3,000 rpm for 15 minutes and perform a comprehensive pellet microscopic examination with phase contrast optics at ×200 magnification. In this method, a small amount of sperm that can potentially be used for intracytoplasmic sperm injection can be detected.

Q2. What are the key physical exam findings that help differentiate between OA and NOA?

Dr. Kalkanlı: In men with azoospermia, small testicular volume, abnormal secondary sexual characteristics, testicular masses, unilateral or bilateral absence of testicles, gynecomastia, and varicocele may support non-obstructive azoospermia. Absence of vas deferens or enlarged proximal epididymis may indicate underlying obstructive azoospermia.

Q3. What hormonal levels are indicative of hypogonadotropic hypogonadism in NOA?

Dr. Kalkanli: Assessing levels of four hormones is indispensable in the diagnosis of hypogonadotropic hypogonadism, which occurs as a result of inadequate stimulation of the testicles by the hypothalamic-pituitary-gonadal axis. These include low LH, low FSH, and low testosterone levels, as well as prolactin levels within normal limits.

Q4. When is karyotyping and Y chromosome microdeletion analysis recommended in the evaluation of NOA?

Dr. Kalkanli: Chromosomal abnormalities show a 10-fold higher incidence in men with severe oligozoospermia (spermatozoa <5 million/mL) or azoospermia compared to the general population. Men with azoospermia are at highest risk. Karyotype analysis and Y chromosome microdeletion analysis should be performed on all azoospermia patients.

Q5. What is the significance of the azoospermia factor (AZF) microdeletions on the Y chromosome in NOA?

Dr. Kalkanli: Y deletions are detected in 8-12% of azoospermic patients. AZFc deletions are most common (65-70%). AZFb, AZFb+c, and AZFa+b+c deletions are less common (25-30%).
AZFa deletions are the rarest type (<5%). Complete deletion of the AZFa region is associated with Sertoli Cell Only Syndrome, and complete deletion of the AZFb region is associated with spermatogenic arrest. In complete deletions of the AZFa and AZFb regions, the sperm retrieval rate with mTESE is close to zero. Therefore, TESE is not recommended in these patients. AZFc region deletions may result in a phenotypic spectrum ranging from azoospermia to oligozoospermia. In cases of AZFc microdeletions, 50-75% sperm can be obtained with mTESE.

Q6. What is the role of hormonal therapy in the management of men with hypogonadotropic hypogonadism (HH)?

Dr. Kalkanli: Since the insufficiency of the hypothalamo-pituitary-testicular axis reduces adequate testosterone secretion from the testicles, all stages of spermatogenesis and spermiogenesis are disrupted in HH patients. The use of analogues of gonadotropins expected to be released from the pituitary can increase the levels of intratesticular testosterone and restart spermatogenesis. The high success rate after treatment indicates that hormonal therapy has a critical role in hypogonadotropic hypogonadism patients.

Q7. What medications are commonly used in hormonal therapy for HH, and how do they work?

Dr. Kalkanli: Gonadotropins (LH and FSH) are missing in HH patients; therefore the goal of treatment is to replace these hormones. hCG (an LH analogue) can stimulate Leydig cells and increase testosterone levels. Adding FSH analogues to the treatment after increasing testosterone levels will initiate spermatogenesis. Various formulations of FSH are available, including menopausal (hMG), urinary FSH (uFSH), highly purified FSH (FSH-HP), and recombinant FSH (rFSH).

Q8. What is the expected success rate of spermatogenesis after hormonal therapy in men with HH?

Dr. Kalkanlı: After hormonal therapy, 63% to 95% of patients with HH have sperm in their ejaculate. The pregnancy rate after hormone therapy is between 51 - 83%. Also, the duration of gonadotropin therapy is an important factor in the success rate.

Q9. How does testicular volume impact the response to hormonal therapy in men with HH?

Dr. Kalkanlı: Larger initial testicular volume is a good prognostic indicator for response to gonadotropin therapy in men with hypogonadotropic hypogonadism.

Q10. Why might hormonal therapy be controversial in the management of spermatogenic failure (SF) in NOA?

Dr. Kalkanlı: Hormonal therapy in men with NOA is controversial. There is no high level of evidence that either gonadotropin therapy or other hormonal treatments (estrogen receptor modulators or aromatase inhibitors) can improve spermatogenesis. Also, the use of a combination of these therapies in men with NOA has no strong evidence.

Arif Kalkanli, MD: Short Biography

Arif Kalkanli, MD
Associate Professor of Urology.
Department of Urology, Taksim Education and Research
Hospital, Istanbul, Turkey.
E-mail: arifkalkanli@gmail.com
ORCID: 0000-0001-6509-4720

Dr. Arif Kalkanli graduated from the Faculty of Medicine at Dicle University in Diyarbakir, Turkey, in 2007 and completed his residency at Taksim Education and Research Hospital in Istanbul in 2015. He went on to complete a fellowship in Andrology at the Istanbul University Faculty of Medicine. Dr. Kalkanli is an active member of the European Association of Urology (EAU) Men's Sexual and Reproductive Health Working Group and serves on the EAU Men's Sexual and Reproductive Health Guidelines committee. As of November 2024, his Scopus publication record includes 24 articles, 128 citations, and an h-index of 7. Arif is also a proud member of the Global Andrology Forum.

My Viewpoint on “Challenges in the Management of NOA”
Dr. Coskun Kaya responds to questions from Ashok

Q1. What is the role of testicular sperm extraction (TESE) in the management of NOA?

Dr. Kaya: The majority of patients with NOA require the retrieval of testicular sperms for intracytoplasmic sperm injection (ICSI) as the only necessary treatment. The introduction of sperm retrieval techniques, especially TESE, and assisted reproductive technologies, such as ICSI, has provided many men with the chance of fathering a child that is genetically theirs and techniques like TESE have also significantly changed how NOA is managed.

Q2. What are the different techniques of sperm extraction mentioned in the chapter?

Dr. Kaya: Both approaches are based on a similar set of principles. The main difference is that the urologist operates with a microscope in a micro-TESE procedure, which enables the surgeon to enhance the probability of identifying spermatozoa. An experienced urologist can easily differentiate the tubules that are larger or “healthier looking” than the atretic and thin tubules via this microscope technique.

Q3. How does microdissection testicular sperm extraction (micro-TESE) differ from conventional TESE?

Dr. Kaya: MRI is nowadays used upfront for prostate biopsies. AI makes risk stratification possible; this implies that MRI images can be interpreted better making the need for prostate biopsies lower. Even with the nowadays performed transperineal prostate biopsies; it remains an invasive diagnostic test that comes with certain risks. By using AI and more accurately picking the patients that need to be biopsied, this potential risk of biopsy will be minimized.

Q4. What are the potential histopathologic findings in testicular biopsy of men with NOA?

Dr. Kaya: Biopsies carry the risk of bleeding and infection. Therefore, fully utilizing the biopsied tissue is critical in relieving the patient’s burden, avoiding a second biopsy, and assisting in clinical diagnosis. Furthermore, even after a testicular biopsy, the histopathologist may offer no conclusion because of the disrupted cell structure in the tissue, due to tissue quality, or other reasons. Following the collection of testicular samples in line with the specified methodology; the histological features of NOA are mainly classified into hypospermatogenesis, maturation arrest, and Sertoli cell only. In hypospermatogenesis, germ cells of all stages of spermatogenesis are present but with a relative paucity in numbers. In maturation arrest, spermatogenesis is incomplete and halts at primary or secondary spermatocyte (early) or spermatid (late) stages. Therefore, mature spermatozoa are usually absent. Sertoli cell-only Syndrome is characterized by a complete loss of germinal epithelium. It should be noted that it is common for men with NOA to present mixed histological patterns. Interstitial fibrosis, inflammation, testicular dysgenesis, and/or atrophy could be reported as histopathologic findings in testicular biopsy.

Q5. What factors may predict the success of sperm retrieval during TESE?

Dr. Kaya: The success rates of these procedures vary depending on the underlying cause. A thorough diagnostic workup is crucial in identifying the underlying cause of NOA. In addition, some factors affect fertility in men with NOA. The etiology of NOA, history of orchidopexy or previous failed TESE attempts, having Y-chromosome microdeletions and the type of deletions, type of the testicular pathology, the FSH-Inhibin B-testosterone levels, and the surgeon’s experience could all have a role in the prediction of the success of TESE. By contrast, the predictive role of age, obesity, and testicular volume is very limited.

Q6. What is the likelihood of spontaneous sperm recovery in men with NOA after varicocelectomy?

Dr. Kaya: The current evidence regarding the effectiveness of a varicocelectomy for men with NOA and clinical varicocele is limited and of very low certainty. The likelihood of spontaneous sperm recovery in men with NOA after varicocelectomy varies depending on several factors, including the presence and severity of the varicocele, testicular histopathology, and baseline hormonal levels. Men who have these conditions should be counseled carefully. The success of the operation should lead to the expectation of a spontaneous pregnancy. For realistic expectations, it should be made very clear that thisvoperation aims to find sperm in the ejaculate or during TESE.

Q7. What are the potential adverse effects of hormonal therapy in the treatment of NOA?

Dr. Kaya: The alteration of hormonal balance, the conversion of testosterone to estrogen, the systemic distribution of exogenous hormones to the whole body, water and salt retention, immune responses, and skin reactions are the main underlying mechanisms resulting from the adverse effects of hormonal therapy in men with NOA. A man who will begin to use hormonal treatment should be well-counseled before the treatment about the possible adverse effects and these should be monitored during the pre-and post-treatment period.

Q8. How might the timing of hypogonadism onset influence the outcome of hormonal therapy?

Dr. Kaya: If hypogonadism occurs before puberty, it can interfere with the development of the hypothalamic-pituitary-gonadal (HPG) axis, leading to more severe impairments in testicular function. In such cases, the response to hormonal therapy might be less favorable because the foundational development of the testicular and reproductive systems has been compromised. If hypogonadism develops after puberty, the HPG axis and testicular function have usually matured, so the impairment might be less severe. Hormonal therapy in these men might be more successful in restoring spermatogenesis because the foundational
development was already complete, and the testicular environment may be more responsive to hormonal stimulation. So, in cases of early-onset hypogonadism, more aggressive or combined treatment strategies might be necessary, while in late-onset cases, standard hormonal therapy may suffice.

Q9. What are the recommendations for ART in men with NOA who have completed hormonal therapy?

Dr. Kaya: Sperm retrieval combined with ICSI is the only option for men with NOA to impregnate their partner. However, given the uncertainty of sperm acquisition and the suboptimal sperm retrieval success rates in NOA males, the ideal position would be to optimize spermatogenesis and hence increase the chances of successful sperm recovery.
Although it is generally believed that empirical medical treatment is ineffective in men with spermatogenic failure, there might be a potential role for pharmacotherapy for men with NOA. The goals are to induce the recovery of sperm in the ejaculate or improve surgical sperm retrieval rates. During the treatment, hormone measurements (serum FSH, LH, estradiol, total testosterone, free testosterone, SHBG, and 17-hydroxy-progesterone levels) and liver enzymes (patients taking aromatase inhibitors) should be performed every three to four weeks. Semen analysis is carried out three months after the treatment commences and then every four weeks for over three months in patients who continue the therapy. Also, infertile men should try to conceive spontaneously during treatment. In the first year of treatment, a semen analysis should be performed and, depending on the results, ART should be started if the sperm concentration is <1 × 106/mL or wait until the second year of treatment to achieve spontaneous pregnancy if the sperm concentration is >5 × 106/Ml. In the absence of a pregnancy within two years, regardless of sperm count, the use of ART is recommended.

Q10. What is the role of salvage hormonal therapy in men with NOA who failed initial TESE?

Dr. Kaya: The testicular biopsy pathology of the first TESE may be important in determining the indication for salvage hormone therapy. This treatment modality could be used in men with NOA except those who have Sertoli cell-only syndrome. However, the type or administration method of this has not been defined in the literature. Typically, salvage hormonal therapy is administered for several months before a repeat TESE is attempted. This allows sufficient time for the hormonal modulation to potentially improve spermatogenesis. In addition, a micro-TESE should be preferred after the failure of any type of TESE.

Coşkun Kaya, MD, FEBU: Short Biography

Coşkun Kaya, MD, FEBU
Associate Professor, University of Health Sciences Eskisehir City HPRH Chief of Urology Department, Eskisehir, Türkiye
E-mail: coskun_kaya2008@yahoo.com
coskun.kaya@sbu.edu.tr
ORCID ID: 0000-0002-7445-2304

Dr. Coskun Kaya obtained his medical degree from the Ankara University Faculty of Medicine in 2008 and completed his urology residency at Eskisehir Osmangazi University Faculty of Medicine in 2013. His current research interest is in the development of machine learning models in andrology. He is a member of the Turkish Urology Association, and the Turkish Andrology Society. He served as the head of the local organization committee of the 23rd National Andrology Congress organized in Eskisehir, Türkiye in May 2024. As of November 2024, his publication record on Scopus includes 54 articles, 397 citations, and an h-index of 12. Coskun is also a proud member of the Global Andrology Forum.

My Viewpoint on “Challenges in the Management of NOA”
Dr. Mustafa Gürkan Yenice responds to questions from Ashok

Q1. What is the overall success rate of achieving pregnancy after hormonal therapy in men with HH?

Dr. Yenice: Different hormonal treatments, especially gonadotropins, can be preferred in the treatment of patients with HH. When different predictive factors are taken into account, pregnancy rates have been determined as 50%-85%.

Q2. How does the presence of a clinically apparent varicocele impact the success of varicocelectomy in men with NOA?

Dr. Yenice: Varicocele can be observed in men with NOA and varicocele at rates up to 44%. It has been observed that the rate of sperm detection is higher in postoperative semen analysis after varicocelectomy, especially in those with hypospermatogenesis. Pregnancy can be achieved in these patients using spontaneous or assisted reproductive techniques at different rates. While higher SRR rates are detected after surgery, there is no clear statistical data regarding pregnancy rates. Therefore, it would be appropriate to make a patient-based decision on this controversial issue, taking into account partner-related factors.

Q3. What is the role of brain MRI in the evaluation of NOA, particularly in men with suspected hypothalamic-pituitary axis abnormalities?

Dr. Yenice: Although brain MRI is not routine, it can be performed especially in men with hyperprolactinemia and to exclude the diagnosis of cranial tumors.

Q4. How do SERMs and aromatase inhibitors play a role in the management of idiopathic SF in NOA?

Dr. Yenice: Aromatase inhibitors prevent the negative feedback on gonadotropin release by preventing the conversion of testosterone to estradiol in peripheral tissues. SERMs downregulate negative feedback on the hypothalamic-pituitary-gonadal axis by competitively inhibiting estrogen receptors in the hypothalamo-pituitary region, thereby increasing the secretion of LH and FSH.

Q5. What are the potential outcomes of TESE in men with different histopathologic findings (e.g., Sertoli cell-only syndrome, maturation arrest)?

Dr. Yenice: Testicular histopathology has the most important role in predicting the success rates of mTESE. SRR rates are 70-100% in hypospermatogenesis, 25-85% in late maturation arrest, 25-40% in early maturation arrest, and 20-40% in Sertoli cell-only syndrome. Salvage TESE and surgical experience have effects on these rates.

Q6. What is the current evidence supporting the use of aromatase inhibitors in men with idiopathic SF in NOA?

Dr. Yenice: Aromatase inhibitors are quite safe drugs that improve hormonal and semen parameters by increasing endogenous testosterone production. However, prospective randomized controlled trials are lacking in this regard. Existing studies are contradictory and there are no definitive protocols regarding the duration, dose, or type of treatment.

Q7. Why might GnRH therapy be considered impractical for some patients with NOA?

Dr. Yenice: GnRH can be administered in a pulsatile manner, but it is expensive, and administered every 2 hours is impractical for most patients. Another factor that makes it not preferred is that the success rates are similar to those of HCG +/- FSH therapy.

Q8. What are the challenges in establishing definitive protocols for hormonal therapy in men with idiopathic NOA?

Dr. Yenice: In general, there is limited evidence regarding the use of hormone therapy before sperm retrieval in patients with idiopathic NOA. When the literature is reviewed, studies show different treatment protocols and durations, different follow-up periods, and TESE surgeons with different experiences. In addition, idiopathic NOA patients have unique and multifactorial problems (age, partner, comorbidities, etc.) that cause difficulties in establishing definitive protocols for hormonal therapy.

Q9. How do the 2020 American Urological Association (AUA) guidelines approach the use of hormonal therapies in NOA?

Dr. Yenice: The 2020 American Urological Association (AUA) guidelines recommend informing men with NOA that there is limited data on SERMS, aromatase inhibitors, and gonadotropin therapies.

Q10. What are the limitations of current research on the hormonal management of NOA?

Dr. Yenice: Despite the physiological rationale for hormonal therapy, there is a lack of convincing evidence and no definitive protocols regarding the duration, dose, or type of hormonal therapy. When looking at studies investigating the effect of hormone therapy on SRR, most studies are not randomized or prospective. SRR results are influenced by surgical and embryological factors, type of surgery, and experience. In addition, another prognostic factor for sperm retrieval surgery is the histopathological subtype, but most studies did not report data on this confounding variable or compare markers of testicular function.

Coşkun Kaya, MD, FEBU: Short Biography

Mustafa Gürkan Yenice, MD
Associate Prof. in Urology
Urology & Andrology Clinic
Bakırkoy Dr. Sadi Konuk Education and Training Hospital, İstanbul, Turkey
Email: yenicegurkan@gmail.com
ORCID ID:0000-0002-5813-3565

Dr. Mustafa Gürkan Yenice received his MD from the University of Marmara Medical School and completed his urology residency at the University of Trakya. He went on to complete a fellowship in Andrology at the University of Istanbul's Department of Andrology, with a specialized focus on male sexual and reproductive health.
Dr. Yenice is currently practicing at the Urology & Andrology Clinic of Bakırkoy Dr. Sadi Konuk Education and Training Hospital. He is an active member of the Turkish Urology Association, the Turkish Andrology Society, and the European Urology Association. As of November 2024, his Scopus record includes 25 articles, 146 citations, and an h-index of 8. Mustafa is also a proud member of the Global Andrology Forum.

Sperm DNA Fragmentation: A New Guideline for Clinicians

Sat, 14 Sep 2024 04:09:37 GMT

Article #59: Sperm DNA Fragmentation: A New Guideline for clinicians.
Authors: Agarwal, A, et al, World J Mens Health 2020 Oct 38(4): 412-471
https://doi.org/10.5534/wjmh.200128

Contributors: Ahmed Ragab, MD (Egypt), Khaled Almekaty, MD
(Egypt), Moheiddin Alghobary, MD (Egypt)

Commentary:
This narrative review represents a state-of-the-art guide for physicians on sperm DNA fragmentation (SDF), including its mechanism, types of SDF tests, indications of testing, and management of high SDF levels. Herein, we provide a comprehensive summary of the article to enhance the understanding of SDF and its implications on male fertility.

Mechanisms of SDF: Sperm DNA fragmentation (SDF) primarily arises from underlying mechanisms such as defective maturation, abortive apoptosis (testicular), and oxidative stress (post-testicular) (1). In addition, clinical factors such as age (2), varicocele (3), genitourinary infection (4), obesity (5), diabetes (6), and environmental factors such as heat exposure, environmental toxins, radiation, smoking, and diet can all lead to raised SDF (7).

Types of SDF tests: Sperm DNA fragmentation (SDF) can be assessed by various tests, including sperm chromatin structure assay (SCSA) (8), Comet assay (9), TUNEL (10), and sperm chromatin dispersion (SCD) (11). However, the TUNEL assay is the most widely utilized due to its accuracy and reliability. The lack of consensus on specific cut-off values for predicting fertility outcomes underscores the complexity of integrating these tests into clinical practice (12). Additionally, the interplay between oxidative stress and SDF highlights the need for a comprehensive approach to male fertility assessment, as no single test can fully capture the multifaceted nature of sperm health (13).

I ndications of SDF testing: Sperm DNA fragmentation (SDF) testing is recommended for patients experiencing unexplained infertility (14), recurrent pregnancy loss (15), recurrent ART failure (16), and clinical varicocele (17) with normal conventional semen analysis, particularly before embarking on assisted reproductive technology (ART) trials, as well as for those exposed to lifestyle and environmental risk factors (18). This approach is supported by extensive research and clinical guidelines aimed at improving reproductive outcomes.

1. Natural conception
The integrity of sperm DNA is essential for successful fertilization and early embryonic development. High SDF significantly reduces the natural pregnancy rate, as evidenced by many studies (19-21).
2. Assisted reproductive technology outcomes

The evidence suggests that sperm DNA integrity plays a significant role in ART
outcomes (19, 20). The current review analyzed the available evidence and concluded that elevated SDF is associated with a decreased pregnancy rate with intrauterine insemination (IUI) and in vitro fertilization (IVF) and an increased miscarriage rate
following both IVF and intracytoplasmic sperm injection (ICSI).
3. Varicocele
Varicocele is a significant correctable cause of male infertility. The available literature suggests that varicocele repair significantly improves SDF and reproductive outcomes, regardless of the type of surgical technique, SDF test type, or the baseline SDF value. However, more studies are needed to confirm these findings and to determine the optimal management for these men. Men with palpable varicocele and normal conventional semen analysis are a clear indication for SDF testing, as the sperm analysis is normal and a functional test should be imposed, especially before varicocele repair or commencing ART treatment (22, 23).
4. Recurrent pregnancy loss
There is strong evidence that links recurrent pregnancy loss to elevated SDF. This has been proven irrespective of the type of SDF test used (24).
5. Idiopathic and unexplained male infertility
Unexplained infertility means infertility of the couple despite an unremarkable fertility assessment. Of them, 20% proved to have significantly high SDF. Idiopathic infertility means abnormality in one or more semen parameters but without identifiable cause. Those also proved to have significantly higher SDF as compared to normal controls (14, 25).
6. High-risk patients
Lifestyle and environmental factors (physical, chemical, and biological) proved to correlate with significantly high oxidative stress levels, eventually leading to SDF and poor reproductive outcomes. Understanding these associations is crucial for developing strategies to improve the fertility potential of these patients (18, 26, 27).

Management of elevated SDF: This review uniquely describes a road map for the management of high SDF. Firstly, treatment should be directed to identifiable causes such as varicocele (28), genital tract infection (29), and risk factor modification such as cessation of smoking (30) and weight reduction (31). Another way is recurrent ejaculation (32), which may reduce SDF and improve pregnancy rates in ICSI. Moreover, antioxidants can alleviate OS (33) but should be used cautiously to avoid reductive
stress. Another approach would be using testicular sperm for ICSI (34), which may reduce SDF despite surgical risks and concerns about aneuploidy. Lastly, advanced sperm selection techniques like MACS (35) and IMSI (36) can be used to super-select sperm with lower SDF levels.

Pros and cons of SDF testing: Sperm DNA fragmentation (SDF) testing has the advantage of exploring and assessing male fertility on a molecular and functional basis in contrast to conventional semen analysis. This is particularly helpful in difficult cases such as unexplained infertility (14), recurrent pregnancy loss (15), clinical varicocele (37) with normal sperm analysis, and patients with recurrent ART failure (16). On the other hand, SDF testing faces a lot of limitations, such as the absence of universally accepted cut-off values, its reliability in clinical practice needs more research, test-to-test, and interpersonal variability are also limiting factors, and lastly, the cost of the test can be a burden, especially in developing countries (12,26).

References cited in the commentary:
1. Muratori, M., Marchiani, S., Tamburrino, L., & Baldi, E. (2019). Sperm DNA fragmentation: mechanisms of origin. Genetic Damage in Human Spermatozoa, 75-85.
2. Pino, V., Sanz, A., Valdés, N., Crosby, J., & Mackenna, A. (2020). The effects of aging on semen parameters and sperm DNA fragmentation. JBRA assisted reproduction, 24(1), 82.
3. Goldstein, M., & Eid, J. F. (1989). Elevation of intratesticular and scrotal skin surface temperature in men with varicocele. The Journal of Urology, 142(3), 743-745.
4. Pratap, H., Hottigoudar, S. Y., Nichanahalli, K. S., Rajendran, S., & Bheemanathi, H. S.(2019). Sperm DNA integrity in leukocytospermia and its association with seminaladenosine deaminase. Journal of Human Reproductive Sciences, 12(3), 182-188.
5. Pearce, K. L., Hill, A., & Tremellen, K. P. (2019). Obesity-related metabolic endotoxemia is associated with oxidative stress and impaired sperm DNA integrity. Basic and clinical andrology, 29, 1-9.
6. Karimi, J., Goodarzi, M. T., Tavilani, H., Khodadadi, I., & Amiri, I. (2012). Increased receptor for advanced glycation end products in spermatozoa of diabetic men and its association with sperm nuclear DNA fragmentation. Andrologia, 44, 280-286.
7. Baskaran S, Cho CL, Agarwal A. Role of sperm DNA damage in male infertility assessment. In: Rizk B, Agarwal A, Sabanegh ES Jr, editors. Male infertility in reproductive medicine:diagnosis and management. Boca Raton: CRC Press; 2019;205.
8. Simon, L., Aston, K. I., Emery, B. R., Hotaling, J., & Carrell, D. T. (2017). Sperm DNA damage output parameters measured by the alkaline Comet assay and their importance.Andrologia, 49(2), e12608.
9. Sharma, R. K., Sabanegh, E., Mahfouz, R., Gupta, S., Thiyagarajan, A., & Agarwal, A. (2010). TUNEL as a test for sperm DNA damage in the evaluation of male infertility. Urology,76(6), 1380-1386.
10.Fernández, J. L., Muriel, L., Rivero, M. T., Goyanes, V., Vazquez, R., & Alvarez, J. G. (2003). The sperm chromatin dispersion test: a simple method for the determination of sperm DNA fragmentation. Journal of andrology, 24(1), 59-66.
11.Evenson, D. P. (2013). Sperm chromatin structure assay (SCSA®). Spermatogenesis: methods and protocols, 147-164.
12.Santi, D., Spaggiari, G., & Simoni, M. (2018). Sperm DNA fragmentation index as a promising predictive tool for male infertility diagnosis and treatment management meta analyses. Reproductive biomedicine online, 37(3), 315-326.
13.Homa, S. T., Vassiliou, A. M., Stone, J., Killeen, A. P., Dawkins, A., Xie, J., ... & Ramsay, J. W. (2019). A comparison between two assays for measuring seminal oxidative stress and their relationship with sperm DNA fragmentation and semen parameters. Genes, 10(3), 236.
14.Oleszczuk, K., Augustinsson, L., Bayat, N., Giwercman, A., & Bungum, M. (2013). Prevalence of high DNA fragmentation index in male partners of unexplained infertile couples. Andrology, 1(3), 357-360.
15.Ribas-Maynou, J., García-Peiró, A., Fernandez-Encinas, A., Amengual, M. J., Prada, E., Cortes, P., ... & Benet, J. (2012). Double stranded sperm DNA breaks, measured by Comet assay, are associated with unexplained recurrent miscarriage in couples without a female factor
16.Larson, K. L., DeJonge, C. J., Barnes, A. M., Jost, L. K., & Evenson, D. P. (2000). Sperm chromatin structure assay parameters as predictors of failed pregnancy following assisted reproductive techniques. Human reproduction, 15(8), 1717-1722.
17.Mohammed, E. E. M., Mosad, E., Zahran, A. M., Hameed, D. A., Taha, E. A., & Mohamed, M.A. (2015). Acridine orange and flow cytometry: which is better to measure the effect of varicocele on sperm DNA integrity? Advances in urology, 2015(1), 814150.
18.Pacey, A. A. (2010). Environmental and lifestyle factors associated with sperm DNA damage. Human Fertility, 13(4), 189-193.
19.Spanò, M., Bonde, J. P., Hjøllund, H. I., Kolstad, H. A., Cordelli, E., Leter, G., & Danish First Pregnancy Planner Study Team. (2000). Sperm chromatin damage impairs human fertility. Fertility and sterility, 73(1), 43-50.
20.Zini, A. (2011). Are sperm chromatin and DNA defects relevant in the clinic? Systems biology in reproductive medicine, 57(1-2), 78-85.
21.Borges Jr., E., Zanetti, B. F., Setti, A. S., Braga, D. P. D. A. F., Provenza, R. R., & Iaconelli Jr., A. (2019). Sperm DNA fragmentation is correlated with poor embryo development, lower implantation rate, and higher miscarriage rate in reproductive cycles of non–male factor infertility. Fertility and sterility, 112(3), 483-490.
22.Zini, A., & Dohle, G. (2011). Are varicoceles associated with increased deoxyribonucleic acid fragmentation? Fertility and sterility, 96(6), 1283-1287.
23.Kim, K. H., Lee, J. Y., Kang, D. H., Lee, H., Seo, J. T., & Cho, K. S. (2013). Impact of surgical varicocele repair on pregnancy rate in subfertile men with clinical varicocele and impaired
semen quality: a meta-analysis of randomized clinical trials. Korean Journal of Urology, 54(10), 703-709.
24.Halim, B., & Lubis, H. P. (2016). The association between sperm DNA fragmentation and idiopathic early recurrent pregnancy loss. KnE Medicine, 55-63.
25.Saleh, R. A., Agarwal, A., Nada, E. A., El-Tonsy, M. H., Sharma, R. K., Meyer, A., ... & Thomas Jr., A. J. (2003). Negative effects of increased sperm DNA damage in relation to seminal oxidative stress in men with idiopathic and male factor infertility. Fertility and sterility, 79, 1597-1605.
26.Komiya, A., Kato, T., Kawauchi, Y., Watanabe, A., & Fuse, H. (2014). Clinical factors associated with sperm DNA fragmentation in male patients with infertility. The scientific world journal, 2014(1), 868303.
27.Radwan, M., Jurewicz, J., Polańska, K., Sobala, W., Radwan, P., Bochenek, M., & Hanke, W. (2016). Exposure to ambient air pollution: does it affect semen quality and the level of reproductive hormones? Annals of human biology, 43(1), 50-56.
28.Sun, X. L., Wang, J. L., Peng, Y. P., Gao, Q. Q., Song, T., Yu, W., ... & Dai, Y. T. (2018). Bilateral is superior to unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: a prospective randomized controlled study. International Urology and Nephrology, 50, 205-210.
29.Gallegos, G., Ramos, B., Santiso, R., Goyanes, V., Gosálvez, J., & Fernández, J. L. (2008). Sperm DNA fragmentation in infertile men with genitourinary infection by Chlamydia trachomatis and Mycoplasma. Fertility and sterility, 90(2), 328-334.
30.Boeri, L., Capogrosso, P., Ventimiglia, E., Pederzoli, F., Cazzaniga, W., Chierigo, F., ... & Salonia, A. (2019). Heavy cigarette smoking and alcohol consumption are associated with impaired sperm parameters in primary infertile men. Asian journal of andrology, 21(5), 478-485.
31.Samavat, J., Cantini, G., Lotti, F., Di Franco, A., Tamburrino, L., Degl’Innocenti, S., ... & Luconi, M. (2018). Massive weight loss obtained by bariatric surgery affects semen quality in morbid male obesity: a preliminary prospective double-armed study. Obesity surgery, 28, 69-76.
32.Agarwal, A., Gupta, S., Du Plessis, S., Sharma, R., Esteves, S. C., Cirenza, C., ... & Sabanegh, E. (2016). Abstinence time and its impact on basic and advanced semen parameters. Urology, 94, 102-110.
33.Stenqvist, A., Oleszczuk, K., Leijonhufvud, I., & Giwercman, A. (2018). Impact of antioxidant treatment on DNA fragmentation index: a double‐blind placebo‐controlled randomized trial. Andrology, 6(6), 811-816.
34.Arafa, M., AlMalki, A., AlBadr, M., Burjaq, H., Majzoub, A., AlSaid, S., & Elbardisi, H. (2018). ICSI outcome in patients with high DNA fragmentation: Testicular versus ejaculated spermatozoa. Andrologia, 50(1), e12835.
35.Zhang, H., Xuan, X., Yang, S., Li, X., Xu, C., & Gao, X. (2018). Selection of viable human spermatozoa with low levels of DNA fragmentation from an immotile population using density gradient centrifugation and magnetic‐activated cell sorting. Andrologia, 50(1), e12821.
36.Bradley, C. K., McArthur, S. J., Gee, A. J., Weiss, K. A., Schmidt, U., & Toogood, L. (2016). Intervention improves assisted conception intracytoplasmic sperm injection outcomes for patients with high levels of sperm DNA fragmentation: a retrospective analysis. Andrology, 4(5), 903-910.
37.Blumer, C. G., Fariello, R. M., Restelli, A. E., Spaine, D. M., Bertolla, R. P., & Cedenho, A. P. (2008). Sperm nuclear DNA fragmentation and mitochondrial activity in men with varicocele. Fertility and Sterility, 90(5), 1716-1722.

My Viewpoint on a New SDF Guideline for Clinicians
Dr. Ahmed Ragab responds to questions from Ashok

Q1. What are the primary mechanisms underlying sperm DNA fragmentation (SDF)?

Dr. Ragab: This entails endogenous and exogenous mechanisms. Endogenous mechanisms include defective sperm maturation and abortive apoptosis. Exogenous sources include varicocele, infection, hormonal imbalances, lifestyle risk factors (e.g., smoking, alcoholism), and environmental factors such as pollution and ionizing radiation. All these factors may cause sperm DNA damage via increased OS.

Q2. How does oxidative stress contribute to sperm DNA fragmentation?

Dr. Ragab: OS can lead to sperm DNA damage by altering the chemical structure of the DNA and inducing sperm apoptosis. Exploring more details on a molecular basis, OS can lead to lipid peroxidation by-products, particularly malondialdehyde (MDA) and 4-hydroxynonenal (4HNE), which can introduce DNA adducts such as 8-hydroxy-2’-deoxyguanosine (8-OHdG) and 1, N2-thioguanine. On the other hand, direct oxidative damage to DNA bases results in the formation of adducts, particularly at sites with poor protamine shielding. OS further activates the mitogen-activated protein kinase (MAPK) pathway, thereby impairing maturation and promoting apoptosis.

Q3. What are the clinical implications of sperm DNA fragmentation in male infertility?

Dr. Ragab: The integrity of sperm DNA is essential for successful fertilization, embryonic development, natural and assisted pregnancy, and live birth. High SDF proved to significantly reduce fertilization rate, natural pregnancy rate, IUI, and IVF outcomes. Moreover, high SDF proved to increase the incidence of recurrent pregnancy loss (RPL). However, it seems that the ICSI outcome is not significantly affected by SDF. However, these conclusions need more well-designed studies for confirmation.

Q4. How does age influence the levels of sperm DNA fragmentation??

Dr. Ragab: Previously, reproductive outcomes were thought to be affected by maternal, not paternal, age. Recently, after extensive research on SDF, it seems that SDF increases with age, starting in reproductive years and doubling between 20 and 60 years of age. This association may be due to higher exposure to OS, defective sperm chromatin packaging, and disordered apoptosis that occurs with aging.

Q5. What role does varicocele play in increasing sperm DNA fragmentation?

Dr. Ragab: Clinical varicocele was reported to significantly elevate SDF levels through high OS in the seminal plasma. Some studies found that men with varicocele have significantly higher levels of SDF as compared to healthy controls. Moreover, varicocele repair (VR) is associated with a reduction in SDF. Many studies and meta-analyses proved the positive effect of VR on the level of SDF and reproductive outcomes after surgery.

Q6 How do genitourinary infections contribute to increased sperm DNA fragmentation?

Dr. Ragab: Genitourinary infections and leukocytospermia can elevate SDF via OS-mediated mechanisms and consequently negatively affect fertility. Antibiotic therapy has been reported to be effective in treating infection-induced elevated SDF levels. Moreover, empirical antibiotic therapy for leukocytospermia may improve natural pregnancy rates.

Q7. What lifestyle factors are associated with increased sperm DNA fragmentation?

Dr. Ragab: Lifestyle and environmental factors that can induce SDF include obesity, sedentary life, cigarette smoking, alcohol consumption, electromagnetic waves, particularly from cell phones, environmental pollution, etc.

Q8. How does obesity influence sperm DNA fragmentation?

Dr. Ragab: Obese men have higher levels of OS and SDF as compared to normal controls. The proposed mechanisms include increased scrotal temperature, hormonal imbalance (aromatization of testosterone to estradiol leading to T/E2 imbalance), and lastly, chronic systemic inflammation. Indeed, studies have shown significant improvement in SDF and overall fertility with weight loss.

Q9. What are the common extrinsic factors that cause sperm DNA fragmentation?

Dr. Ragab: Sperm DNA fragmentation (SDF) can be caused by common extrinsic factors such as heat exposure, smoking, environmental pollutants, and chemotherapeutics.

Q10. How is sperm DNA fragmentation linked to assisted reproductive techniques (ART) outcomes?

Dr. Ragab. The evidence suggests that high SDF levels are linked to reduced pregnancy rates and increased miscarriage rates in both intrauterine insemination (IUI) and in vitro fertilization (IVF) procedures. Despite some conflicting findings regarding the predictive value of SDF testing methods, the overall consensus indicates that elevated SDF negatively impacts ART outcomes.

Ahmed Ragab, M.B.B.Ch, MSc, MD: Short Biography

Ahmed Ragab, MBBCh, MSc, MD (Andrology)
Associate Professor Department of Andrology, Sexual
Medicine & STIs Beni-Suef University Hospital & Faculty of Medicine
Beni-Suef, Egypt
Email: drahmedragab1981@gmail.com
ORCID ID: 0000-0001-7875-0352

Dr. Ahmed Ragab is an Associate Professor at the Department of Andrology, BeniSuef Faculty of Medicine in Egypt, specializing in male infertility, sexual medicine, and STIs. He graduated from the Faculty of Medicine, Cairo University, Beni-Suef branch, got his MSc in Dermatology and Andrology and then his M.D. in Andrology from Cairo University. Dr. Ragab's main focus is microsurgical procedures for male infertility, particularly for azoospermic males. He has several international publications in this field. He is a member of professional societies and actively participates in teaching and training medical students and residents in andrology. Lastly, Ahmed is a proud member of the Global Andrology Forum.

My Viewpoint on a New SDF Guideline for Clinicians
Dr. Khaled Almekaty responds to questions from Ashok

Q1. What are the different types of DNA damage that can occur in sperm?

Dr. Almekaty: Sperm DNA damage can be single-strand or double-strand beaks. The type of damage can be classified on a molecular basis into mismatched bases, abasic sites, base modifications (oxidation, alkylation, deamination), adducts and intrastrand crosslinks, and pyrimidine dimmers.

Q2. What are the clinical indications for testing sperm DNA fragmentation?

Dr. Almekaty: SDF testing is indicated in patients with unexplained infertility, recurrent pregnancy loss (RPL), repeated ART failure, palpable varicocele with apparently normal semen analysis, and in patients exposed to lifestyle risk factors and pollution.

Q3. How does oxidative stress (OS) cause DNA damage in spermatozoa?

Dr. Almekaty: OS can occur in the seminal tract and can contribute to SDF through the following possible mechanisms: (i) activation of the mitogen-activated protein kinase (MAPK) pathway, thereby impairing maturation and promoting apoptosis; (ii) activation of caspases and endonucleases leading to defective chromatin packaging and sperm maturation; (iii) also, OS can indirectly enhance SDF through lipid peroxidation by-products, which can introduce DNA adducts; (iv) Moreover, OS can directly damage DNA bases, resulting in the formation of adducts, particularly at sites with poor protamine shielding.

Q4. What are the consequences of increased sperm DNA fragmentation on embryo development?

Dr. Almekaty: SDF can negatively affect natural pregnancy rates. Moreover, it has a detrimental effect on ART outcomes. The literature suggests a negative impact of high SDF on IUI and IVF but not ICSI outcomes. Some studies also mentioned a “delayed effect” of high SDF in the form of recurrent pregnancy loss (RPL) despite initial successful fertilization and embryo formation. Of note, DSBs negatively impact fertility outcomes, affecting embryo kinetics, implantation rates, and recurrent miscarriages in couples without a female factor, while SSBs do not significantly impact these aspects. Nonetheless, higher levels of SSBs are inversely related to the natural pregnancy outcome.

Q5. How does oxidative stress activate apoptotic pathways in spermatozoa?

Dr. Almekaty: This can occur by 2 possible mechanisms; first, OS can activate the MAPK pathway. Second, activation of caspases and endonucleases leads to defective chromatin condensation. Both mechanisms eventually lead to abortive apoptosis and defective maturation.

Q6. What are the advantages and drawbacks of sperm DNA fragmentation testing?

Dr. Almekaty: SDF testing has the advantage of exploring and assessing male fertility on a molecular and functional basis, in contrast to conventional semen analysis, which lacks such analysis. It can help in the assessment of unexplained infertility, recurrent pregnancy loss (RPL), clinical varicocele with normal semen analysis, and recurrent ART failure. On the other hand, SDF testing faces a lot of limitations, such as the absence of universally accepted cut-off values, its reliability in clinical practice needs more research, test-to-test, and interpersonal variability are also limiting factors, and lastly, the cost of the test can be a burden, especially in developing countries.

Q7. How do environmental toxins contribute to sperm DNA fragmentation?

Dr. Almekaty: Environmental toxins in the air, soil, and water can lead to high SDF. For example, air pollution, heavy metals, occupational toxins, and even electromagnetic waves, particularly from cell phones, all can lead to OS and high SDF. Some studies suggested that the level of SDF depends on proximity and duration of exposure to environmental factors, which makes sense.

Q8. What is the impact of smoking on sperm DNA fragmentation?

Dr. Almekaty: Cigarette smoking enhances SDF due to the toxic effects of many tobacco metabolites such as nicotine, cadmium, lead, and benzopyrene.

Q9. How does defective germ cell maturation lead to sperm DNA fragmentation?

Dr. Almekaty: This can occur through several pathways: 1) abnormal activity of the topoisomerase II enzyme, inadequate protamination, and DNA damage inflicted by endonucleases and mutagens during spermiogenesis. 2) OS, during sperm transport through the epididymal passage. The latter is the rationale upon which some authors recommend the use of testicular rather than ejaculated in patients with high SDF and repeated ART failure.

Q10. What roles do reactive oxygen species (ROS) play in sperm DNA fragmentation?

Dr. Almekaty: Maintaining the balance of ROS in the seminal environment is of crucial importance for sperm vitality and for “within normal” physiological processes such as apoptosis and capacitation. An overproduction of ROS can lead to deleterious effects on sperm DNA integrity. ROS can alter DNA integrity in the sperm nucleus by inducing singleor double-strand DNA breaks, base modifications, chromatin cross-linking, etc. Moreover, spermatozoa have limited defense mechanisms against ROS-induced DNA damage in contrast to the ova, which can correct itself.

Khaled Mohamed Hafez Almekaty, M.B.B.Ch, MSc, MD: Short Biography

Khaled Mohamed Hafez Almekat, MD
Lecturer and consultant of uro-andrology

Urology department, Tanta University, Egypt
E-mail: dr.khaledhafez@yahoo.com
ORCID ID: 0000-0002-9815-7035

Dr. Khaled Mohamed Hafez Almekaty is a lecturer and consultant in uro-andrology at Tanta University, Egypt. He earned his MD in Urology in 2019, following an M.Sc. in Urology in 2011 and an M.B.,Ch.B. in 2006, all from Tanta University. Dr. Almekaty completed a clinical fellowship at the andrology unit of University College London Hospital, UK from 2015-17, where he gained hands-on experience in male infertility and penile implants under the supervision of renowned experts Profs. Suks Minhas and David Ralph. He specializes in andrology, male infertility, penile prosthetics, and reconstructive surgeries. Dr. Almekaty is well-published in andrology and male infertility and serves as a reviewer for several academic journals. He is an active participant in both local and international conferences and workshops in his field. Lastly, Khaled is a proud member of the Global Andrology Forum.

My Viewpoint on a New SDF Guideline for Clinicians
Dr. Moheiddin Alghobary responds to questions from Ashok

Q1. How can interventions to reduce sperm DNA fragmentation improve fertility outcomes?

Dr. Alghobary: Elevated SDF can be treated by many strategies: 1. Recurrent ejaculation, which can reduce SDF and improve pregnancy rates in ICSI. 2. Antioxidant therapy, which may reduce OS in infertile men but should be used cautiously as its overuse can lead to reductive stress. 3. Lifestyle modification, such as weight loss dietary control, and cessation of smoking may improve SDF, but evidence is scarce. 4. VR significantly reduces SDF and boosts fertility. 5. Advanced sperm selection, e.g., MACS and IMSI, can select sperm with lower SDF. 6. Lastly, using testicular sperm for ICSI can improve outcomes for high SDF, despite surgical risks and concerns about aneuploidy.

Q2. What are the limitations of conventional semen analysis in predicting male fertility potential?

Dr. Alghobary: In fact, about 15% of infertile patients have an apparently normal semen analysis. This means that having a normal semen analysis cannot exclude subfertility. So, think that societies and communities dealing with and treating fertility should consider introducing alternative tests that can assess sperm function, such as SDF testing, for a better diagnosis of male subfertility and improved decision-making on management plans.

Q3. How does sperm DNA fragmentation affect natural conception rates?

Dr. Alghobary: Sperm DNA integrity is essential for successful fertilization and early embryo development. High SDF significantly reduces the likelihood of natural conception, as evidenced by various studies. Research indicates that SDF is associated with reduced cleavage rates and can lead to the halting of embryonic development after the second cleavage stage. Furthermore, DNA damage in spermatozoa can affect the health and wellbeing of offspring.

Q4. What is the relationship between sperm DNA fragmentation and male accessory gland infections?

Dr. Alghobary: Genitourinary infections, leading to leukocytospermia, can elevate ROS production and SDF, negatively affecting fertility. Antibiotic therapy has been reported to be effective in treating infection-induced elevated SDF levels. Moreover, empirical antibiotic therapy for leukocytospermia may improve natural pregnancy rates.

Q5. How do chemotherapeutic agents influence sperm DNA fragmentation?

Dr. Alghobary: Onco-fertility is a very important and interesting field that has been extensively explored in recent years. The use of chemotherapy is based on the suppression of rapidly dividing cells, and as everyone knows, spermatogonia is a very good example of these cells. Thus, it is strongly recommended to do sperm banking before embarking on chemotherapy and tumor treatment. I think the mechanism by which chemotherapeutic agents lead to sperm DNA damage is by their direct antimitotic properties and also by enhancing OS in the seminal plasma, eventually leading to sperm DNA damage and defective maturation.

Q6. What is the role of the MAPK pathway in sperm DNA fragmentation?

Dr. Alghobary: The MAPK pathway has a critical role in regulating cell survival and death mechanisms. The activation of the MAPK pathway by OS leads to an increase in p53 and caspase 3 expression while decreasing bcl-2 levels, eventually resulting in impaired maturation and promotion of apoptosis.

Q7. How does advanced paternal age contribute to sperm DNA fragmentation?

Dr. Alghobary: SDF increases with age, starting in reproductive years and doubling between the ages of 20 and 60 years. This association has been attributed to higher exposure to OS, defective sperm chromatin packaging, and disordered apoptosis that occurs with aging.

Q8. What are the strengths, weaknesses, opportunities, and threats (SWOT) associated with sperm DNA fragmentation testing?

Dr. Alghobary:

A) Strengths: SDF testing can be more beneficial than conventional semen analysis in particular clinical situations, such as unexplained infertility, recurrent pregnancy loss (RPL), and clinical varicocele with normal semen analysis;

B) Weaknesses: the absence of universally accepted cut-off values and only moderate evidence is available to support its use;

C) Threats: the absence of strong evidence to support its use and the relatively high cost of the test;

D) Opportunities: further studies are essential to clarify the clinical implications of SDF testing and to explore effective treatment of high SDF.

Q9. How does oxidative stress-mediated apoptosis result in sperm DNA fragmentation?

Dr. Alghobary: OS activates the mitogen-activated protein kinase (MAPK) pathway, increasing p53 and caspase 3 expression and reducing bcl-2, thereby impairing maturation and promoting apoptosis.

Q10. What are the recommended clinical scenarios for performing sperm DNA fragmentation testing?

Dr. Alghobary: The recommended clinical scenarios for performing SDF include patients with unexplained infertility, recurrent pregnancy loss (RPL), clinical varicocele with apparently normal semen analysis, a negative ART outcome, and patients exposed to lifestyle risk factors and environmental toxicants.

Moheiddin Fakhry Alghobary, M.B.B.Ch, MSc, MD: Short Biography

Moheiddin Fakhry Alghobary, MD
Professor and Head of Dermatology, Andrology and
STDs Department, Faculty of Medicine, Mansoura University, Egypt
E-mail: moheiddin_alghobary@yahoo.com
ORCID ID: 0000-0002-3198-2209

Dr. Moheiddin Alghobary graduated from Mansoura Faculty of Medicine and began his career as aresident in Dermatology andAndrology in 1993. He earned both his MSc and MD in Dermatology and Andrology, with a primary focus on Andrology throughout his academic and clinical work. Dr. Moheiddin has publications in prestigious international journals, including the Journal of Sexual Medicine, Sexual Medicine Reviews, Andrology, Andrologia, and Journal of Urology. Dr. Moheiddin is an active member of the Egyptian Society of Andrology (ESA) and serves on its Editorial Board. His main areas of interest include sexual medicine, drug therapy for premature ejaculation and erectile dysfunction, and male infertility. Moheiddin is a proud member of the Global Andrology Forum.

Regenerative Therapy in Erectile Dysfunction: A Survey on Current Global Practice Trends and GAF Expert Recommendations

Mon, 09 Sep 2024 03:06:25 GMT

Article #58: “Regenerative Therapy in Erectile Dysfunction: A Survey on Current Global Practice Trends and GAF Expert Recommendations”.
Authors: Manaf Al Hashimi, Germar-M Pinggera, Taymour Mostafa, Amarnath Rambhatla, Rupin Shah, Eric Chung, et al., World J Mens Health Published online Jul 12, 2024, https://doi.org/10.5534/wjmh.240086

Contributors: Aleksei Ryzhkov, MD, PhD (Russia), Safar Gamidov, MD,
PhD (Russia), Vladlen Petrishchev, MD (Russia), Taras Shatylko, MD,
PhD (Russia)

Commentary:

One of the major achievements in the treatment of erectile dysfunction (ED) over the past few decades has been the introduction of phosphodiesterase type 5 inhibitors (PDE5i) into clinical practice in 1998. Their high efficacy, combined with accessibility and safety, has allowed PDE5i to take a leading position in the arsenal of ED treatment methods. There is perhaps nothing more convenient than taking a pill before sexual intercourse (or a daily dose) to achieve a quality erection. However, this therapy does not help all patients and has its drawbacks. Many patients do not wish to be tied to taking pills and aim to restore normal physiological erection. Great hopes in this direction are placed on the rapidly developing methods of regenerative therapy (RT) for the treatment of erectile dysfunction, which include the use of platelet-rich plasma (PRP), stem cell therapy (SC), and low-intensity shockwave therapy (LiSWT).

In this innovative study, for the first time, the real clinical experience of practicing specialists in applying regenerative medicine methods for treating ED is analyzed based on a survey. The results of a survey involving 479 practicing urologists and andrologists from 62 countries revealed that only 34% of them use regenerative therapy methods in treating ED. The most commonly used method was LiSWT, applied by 74.8% of respondents, followed by intracavernosal PRP injections (18.4%) and SC injections (3.7%). Interestingly, only 38.7% of respondents use RT methods as a first-line therapy for ED; most consider it appropriate to employ RT only when standard therapeutic approaches are unsatisfactory (61.3%). RT methods are rarely used as monotherapy for ED (17.8%); they are more often combined with other therapeutic options (82.2%), predominantly with PDE5i.

Patient satisfaction with the use of RT for ED treatment was rated as moderate by most respondents (50.3%). Only 24.5% of surveyed specialists noted that over 50% of patients achieved objective improvement and were fully satisfied with the treatment. The clinical effect of RT application develops in 93.3% of cases within six months after treatment and lasts from 3 to 12 months for more than half of patients (56.5%). An assessment of the influence of age and severity of ED on RT outcomes showed that better results are observed in middle-aged patients with moderate erectile dysfunction.

An analysis of clinical guidelines from professional societies revealed that many of them (including Russian clinical guidelines for erectile dysfunction) indicate the possibility of routine LiSWT application for ED treatment with certain limitations. At the same time, most societies oppose the use of cell therapy methods (PRP and SC) outside clinical trials.

Based on the results of this study, an analysis of recommendations from professional societies, available literature data, and clinical experience from GAF experts, nine recommendations for the application of RT in ED treatment have been formulated.

1. RT should not be considered the standard of care for treating ED and should be offered to patients with informed consent according to its current limitations.
2. RT appears to be more effective in patients with vasculogenic ED compared to other types of ED.
3. RT appears to be most effective in men with mild-to-moderate ED.
4. Young and middle-aged males appear to derive the most benefits from RT for the treatment of ED.
5. RT can be used in combination with other ED treatment modalities or as a solo treatment in males for whom standard treatments have failed, or who wish to try and regain natural erections.
6. A limited proportion of patients treated with RT for ED report satisfaction with treatment.
7. Current evidence is unclear as to the duration of significant improvement in erectile function after RT.
8. Although RT is associated with high short-term safety and minimum adverse effects, the long-term safety of RT is still unidentified.
9. Currently, there is more evidence to support the efficacy of low-intensity shock wave therapy compared to other modalities of RT.

The application of regenerative therapy (RT) has opened a new chapter in the treatment of erectile dysfunction (ED), offering pathogenesis-directed therapeutic approaches for this condition. Low-intensity shockwave Therapy (LiSWT), being the most well-studied method of RT, has demonstrated its efficacy and safety in several large-scale studies and has already found widespread use in clinical practice. Subsequent analysis of the accumulated clinical experience will help refine and standardize LiSWT protocols and identify patient categories for whom this therapeutic modality is most justified.

In contrast, the efficacy and safety of cell-based therapy methods (Platelet-Rich Plasma (PRP) and Stem Cells (SCs)) have not been sufficiently studied, limiting their application outside clinical research settings. High-quality studies with extended follow-up periods are necessary to establish the role of PRP and SCs in the treatment of ED.

My Viewpoint on the Regenerative Therapy in Erectile Dysfunction
Dr. Aleksei Ryzhkov, MD responds to questions from Ashok

Q1. What are the most common types of regenerative therapies currently used for erectile dysfunction (ED)?

Dr. Ryzhkov: The primary types of regenerative therapy in the treatment of erectile dysfunction include intracavernosal injection of platelet-rich plasma (PRP), intracavernosal stem cell (SC) therapy, and low-intensity shockwave therapy (LISWT). Among these, LISWT has gained the most traction in clinical practice. Numerous studies and meta-analyses have confirmed its effectiveness and safety. In contrast, the safety and clinical efficacy of intracavernosal injections of PRP and SCs have not been thoroughly studied; therefore, these methods should only be employed within the framework of clinical trials.

Q2. How does low-intensity shock wave therapy (LISWT) work in the context of treating ED?

Dr. Ryzhkov: LISWT is believed to induce microtrauma to cavernous tissue, promoting the release of vascular endothelial growth factor (VEGF), stromal cell-derived factor 1 (SDF-1), and various other chemokine proteins. These factors act on the endothelium, stimulating neovascularization and improving penile hemodynamics. Enhanced blood flow in the cavernous bodies positively impacts erection quality. Studies conducted on animal models have shown significant improvements in penile hemodynamics and even a reversal of pathological changes in the cavernous bodies induced by diabetes following LISWT treatment.

Q3. What are the primary indications for the use of regenerative therapies in ED?

Dr. Ryzhkov: Regenerative therapy is suitable for men who prefer not to pursue symptomatic treatment and wish to restore natural erections. It is also advisable for men for whom standard therapy with phosphodiesterase type 5 (PDE5) inhibitors has been ineffective. In such cases, regenerative therapy can be combined with PDE5 inhibitors to enhance outcomes.

Q4. How effective is platelet-rich plasma (PRP) therapy in treating ED compared to traditional methods like PDE5 inhibitors?

Dr. Ryzhkov: Currently, no direct studies are comparing the effectiveness of PDE5 inhibitors with PRP therapy. However, a recent meta-analysis by Haotian Huang (2024) indicated that after 1, 3, and 6 months of PRP treatment, the International Index of Erectile Function (IIEF-5) scores increased by 4.05, 3.73, and 3.92 points, respectively. In contrast, a metaanalysis by JinQiu Yuan (2013) found that IIEF scores improved by 5.92 to 8.07 points with PDE5 inhibitors, depending on the specific agent used. This suggests that PDE5 inhibitors may be more effective for treating erectile dysfunction.

Q5. What are the safety concerns associated with the use of stem cell (SC) therapy for ED?

Dr. Ryzhkov: The primary concerns regarding stem cell therapy involve the potential transformation of stem cells into malignant cells, which could lead to tumor development.

The proangiogenic, anti-apoptotic, and immunomodulatory properties of stem cells may act as tumor promoters in this context. However, published research findings on human applications do not support these concerns and demonstrate an excellent safety profile for this therapy (Mohamad Abou Chakra, 2024). Conversely, evidence shows that after one month of cultivation, 45.8% of mesenchymal stem cells can spontaneously transform into malignant cells (Røsland, G.V., 2009). Thus, the safety of this therapy remains a topic of debate, underscoring the need for further in vivo and in vitro studies to resolve this contradiction.

Q6. What patient populations are most likely to benefit from regenerative therapies for ED?

Dr. Ryzhkov: Current research findings indicate that regenerative therapy is more effective in young and middle-aged men with mild to moderate vasculogenic erectile dysfunction. In my practice, I always initiate treatment with regenerative therapy (LISWT) for young and middle-aged men experiencing mild erectile dysfunction. This approach has allowed over half of my patients to regain erectile function and avoid the need for PDE5 inhibitors.

Aleksei Ryzhkov, MD, PhD: Short Biography

Aleksei Ryzhkov, MD, PhD,
Assoc. Professor of Urology and Andrology
Department of Urology & Nephrology
Yaroslavl State Medical University, Yaroslavl, Russia
E-mail: 1129682@gmail.com
ORCID ID: https://orcid.org/0000-0001-7919-9830

Dr. Aleksei Ryzhkov is an Associate Professor at Yaroslavl State Medical University. He graduated from the University in 2007 and completed his residency in Urology in 2009. To
further enhance his expertise, he pursued fellowships at the Belgrade Center for Urogenital Reconstructive Surgery in Belgrade, Serbia; Zeisigwaldkliniken Bethanien in Chemnitz, Germany; and at both the University of Florence and the University of Rome in Italy. His research and clinical work primarily focus on surgical (mainly microsurgical) andrology, addressing conditions such as varicocele, obstructive azoospermia, erectile dysfunction, Peyronie's disease, and premature ejaculation. He has published over 40 articles in Russian scientific journals and is the author of one patent for an invention. Aleksei is a proud member of the Global Andrology Forum.

My Viewpoint on the Regenerative Therapy in Erectile Dysfunction
Dr. Safar Gamidov responds to questions from Ashok

Q1. How do patient outcomes with regenerative therapies compare to outcomes with conventional ED treatments?

Dr. Gamidov: It is impossible to compare those modalities as they are essentially different. Most PDE5 inhibitors and prostaglandin injections are better suited for situational use and offer no long-term benefits. A daily tadalafil regimen provides some sense of independence to the patient, as the drug intake is not required to be chronologically tied to sexual intercourse, but organic ED persists once the patient stops this therapy. Penile implants are effective, but the patient forgoes any hope of natural erections following this treatment. Regenerative therapy is unique as it provides a potential long-term solution for organic ED.

Q2. What are the current limitations in the clinical application of stem cell therapy for ED?

Dr. Gamidov: I think that the clinical use of stem cell therapy is limited primarily by its cost. Of course, there are other issues, such as safety and ethics, but they seem secondary. If stem cell therapy was more affordable, robust clinical trials providing safety outcomes could have already been performed. As for the ethical problems, a reliable source of autologous stem cells would be a good solution for most of them.

Q3. How does the combination of PRP and LISWT compare to the use of either therapy alone in treating ED?

Dr. Gamidov: A combination of different regenerative therapies looks promising, considering that their modes of action complement each other. A hypothesis behind shockwave therapy states that it induces microtrauma leading to a release of growth factors.
Resulting reparation and angiogenesis could be greatly augmented by an addition of signal molecules from an «external» source. However, I am convinced that PRP is a lesser form of regenerative therapy when compared to stem cell therapy.

Q4. What is the role of regenerative therapy in managing patients with refractory ED who do not respond to PDE5 inhibitors?

Dr. Gamidov: Non-responders to PDE5 inhibitors are a complex group of patients. Regenerative therapy works well for refractory arteriogenic ED, but with neurogenic ED one should be somewhat less optimistic. Existing regenerative modalities are useless, however, in veno-occlusive ED and for extensive corporal fibrosis.

Q5. What are the long-term outcomes of patients treated with regenerative therapies for ED?

Dr. Gamidov: We are far from being able to completely cure ED with regenerative therapies, but they provide a response that may last up to 12 months after treatment, according to some sources. However, their relative safety means that therapy may be repeated with a schedule tailored to the patient’s needs.

Q6. How does regenerative therapy address the underlying pathophysiology of ED rather than just the symptoms?

Dr. Gamidov: Release of cellular growth factors induced by regenerative therapy stimulates tissue repair, vascular growth, and, probably, nerve fiber remyelination. This leads to a general improvement in erectile response rather than a short-term symptomatic response. However, it is well known that regenerative modalities and symptomatic treatment complement each other.

Q7. What are the most promising sources of stem cells for ED treatment?

Dr. Gamidov: Embryonic cells are truly pluripotent and thus most promising from a purely scientific point of view, but their use is associated with numerous ethical issues. Perinatal stem cells would be acceptable if a hypothetical patient had them collected and preserved in a cryobank soon after birth. But it would be wiser to use those cells in case of a lifethreatening condition rather than ED. So, all things considered, autologous induced pluripotent stem cells remain the best option, though their reprogramming techniques require further refinement.

Q8. How does the efficacy of adipose-derived stem cells compare to bone marrowderived stem cells in the treatment of ED?

Dr. Gamidov: We don’t have robust data to answer this question yet. Adipose-derived stem cells are easier to obtain. They can be harvested in larger volumes. However, bone marrow stem cells may provide more growth factors necessary to induce tissue repair and improve corpora cavernosa vascularity. We need more clinical data on this issue.

Safar Gamidov, M.D., Ph.D: Short Biography

Safar Gamidov, MD, PhD.
Professor and Head, Department of Urology and Andrology
V.I. Kulakov National Medical Research Center, Moscow,
Russia
E-mail: safargamidov@yandex.ru
ORCID ID: 0000-0002-9128-2714

Professor Safar Gamidov is the head of the andrology and urology department at V.I.Kulakov National Medical Research Center in Moscow. He is a well-known academician and clinician specializing in andrology, reproduction, and reconstructive urology. Besides other clinical achievements, he was the first clinician in Russia to introduce Professor Gamidov has been a lead investigator for many clinical trials in the field of urology and is actively engaged in education, and teaching andrology to doctors from Russian-speaking countries. He is a respected member of the Russian Society of Urologists. Lastly, Safar is a proud member of the Global Andrology Forum.

My Viewpoint on the Regenerative Therapy in Erectile Dysfunction
Dr. Vlad Petrishchev responds to questions from Ashok

Q1. What are the potential risks of using unregulated or non-standardized PRP preparations in clinical practice?

Dr. Petrishchev: PRP is not considered a standard treatment, and the method used to prepare it is a significant source of variability. While clinical studies so far have not reported major complications, PRP is biologic but not subject to the same regulatory scrutiny as most other biologic products. Additionally, the vast majority of PRP treatments are offered off-label.

Q2. How do animal model studies inform the potential clinical utility of stem cell therapy for ED?

Dr. Petrishchev: Existing clinical trials suggest that stem cell therapy for ED has the potential to improve erectile function and may be a safe and effective treatment option. The primary mechanism behind SCT’s ability to improve erectile function is likely due to paracrine effects, with engraftment and cellular differentiation playing an ancillary role.
Larger and more rigorous clinical trials are needed to confirm these findings and to determine the optimal dosage, timing, and delivery methods of stem cell therapy for ED.

Q3. What are the current challenges in standardizing LISWT protocols for ED treatment?

Dr. Petrishchev: Shockwave devices vary in manufacturer, energy capacity, and shockwave delivery. Shockwaves may be delivered in a pinpoint manner, linear manner, or in a linear tissue-coverage manner. Data is limited due to a lack of long-term results and a small sample size. Future studies with larger cohorts and standardized protocols are needed to better delineate the long-term efficacy and feasibility of LISWT as a recommended treatment option for patients with mild to moderate ED.

Q4. What are the expert recommendations for patient selection when considering regenerative therapies for ED?

Dr. Petrishchev:

a) RT appears to be more effective in patients with vasculogenic ED compared to other types of ED,

b) RT appears to be most effective in men with mild-tomoderate ED, and

c) young and middle-aged males appears to derive the most benefits from RT for the treatment of ED.

Q5. How does the combination of regenerative therapies with traditional ED treatment influence patient satisfaction?

Dr. Petrishchev: According to the survey, RT is quite often used in combination with other ED treatments. Most commonly used are inhibitors, vacuum erection devices, intracavernosal alprostadil, or others. Approximately half of the respondents from the group utilizing RT (82 out of 163, 50.3%) indicated that their patients exhibited moderate satisfaction with the effectiveness of RT. Combination treatment with LISWT and once daily tadalafil led to a 20% higher rate of patients achieving MCID three months after treatment compared to LISWT alone. “RT can be used in combination with other ED treatment modalities or as a solo treatment in males for whom standard treatments have failed, or who wish to try and regain natural erections”.

Q6. What are the potential benefits of using regenerative therapies in patients with ED secondary to diabetes?

Dr. Petrishchev: Diabetic peripheral neuropathy and ED is a common complication of diabetes, affecting approximately 50% of diabetic individuals. By stimulating nerve regeneration, addressing the underlying causes of the disorder, and alleviating symptoms, RT and stem cell therapy for diabetic peripheral neuropathy have the potential to alter the management of this debilitating illness. One of its most significant advantages is its ability to regenerate damaged nerves. The intracavernous injection of SC to treat ED appears straightforward and logical with the proposed regenerative effect is achieved by either secreting growth factors locally via a paracrine mechanism or by migration to the major pelvic ganglia, to promote the propagation and differentiation of resident progenitor cells and encouraging the recovery of injured tissue.

Q7. What regulatory challenges exist in bringing regenerative therapies for ED to mainstream clinical practice?

Dr. Petrishchev: Regulatory and political practices vary across Europe and globally. Currently, the existing guidelines from relevant societies lack precise instructions for practitioners regarding RT in ED, primarily due to limited research and its classification as low evidence. The majority of professional societies' guidelines advise against using SC or PRP therapies outside of clinical trials.

Vlad Petrishchev, MD, MD: Short Biography

Vlad Petrishchev, MD
Andrologist Center of Reproduction “NovaClinic”

Moscow, Russia.
E-mail: petrishevv@mail.ru
ORCID ID: 0009-0008-6726-1199

Dr. Vladlen Petrishev , is aurologist, andrologist, at the Center of Reproduction“NovaClinic”, Moscow, Russia. Hehas been working as anandrologist in IVF clinics formore than 25 years. Hisresponsibilities include thediagnostics and treatment of male infertility, includingconservative and surgicalapproaches Additionally, his theresponsibilities include organization of effective interactionbetween gynecologists and andrologists at the stage of
treatment of infertile couples using ART. His scientific interests are focused on studying the causes of non-obstructive azoospermia (NOA), in particular, the search for predictors of successful sperm retrieval in men with NOA. Vlad is a proud member of the Global Andrology Forum.

My Viewpoint on the Regenerative Therapy in Erectile Dysfunction
Dr. Taras Shatylko responds to questions from Ashok

Q1. How important is patient education in managing expectations regarding the outcomes of regenerative therapies for ED?

Dr. Shatylko: Patient education is crucial. Patient-targeted sources of information on regenerative therapies may be commercially driven and unreliable, shaping unrealistic expectations. Even evidence-based articles require proper interpretation, which requires medical education and probably some experience in research. It is up to the physician to describe the possible benefits and risks of regenerative therapy to the patient to avoid disappointment. Integrity is the key here.

Q2. What are the ethical considerations surrounding the use of experimental regenerative therapies in ED?

Dr. Shatylko: First of all, ED is not a life-threatening condition. Second, there are reliable non-experimental methods to improve patients’ quality of life, such as PDE5 inhibitors and penile implants. That is why the ethical «window of opportunity» for regenerative therapies is so narrow. Moreover, even though most regenerative modalities are experimental, those experiments are rarely sponsored by investors or industry, and treatments are usually paid for by patients themselves out of pocket or, sometimes, through insurance. I think it’s also an important ethical problem.

3. How does the global adoption of regenerative therapies for ED vary by region and healthcare infrastructure?

Dr. Shatylko: Region and healthcare infrastructure do not seem to be the defining factors here. Most respondents in the survey were not aware of any specific regulations regarding regenerative therapies in their countries. Until the ambiguous status of regenerative therapies is resolved through clinical research, we can’t expect these treatments to be fully adopted regardless of region or country.

Q4. What is the current status of clinical trials investigating regenerative therapies for ED?

Dr. Shatylko: There are ongoing clinical trials on regenerative therapies for ED, but one could expect more research activity on such an intriguing topic. Shockwave and PRP therapies are more widely studied because there are fewer ethical limitations. Unfortunately,some published clinical trials provide disappointing results.

Q5.How does the cost-effectiveness of regenerative therapies compare to traditional treatments for ED?

Dr. Shatylko: Cost-effectiveness is not a strong point of regenerative therapies. Symptomatic treatment is relatively cheap with many generic formulations available. Penile implantation is costly (though semi-rigid devices are less expensive), but provides a radical lifelong solution for ED. Regenerative therapies, offering no guaranteed results and sometimes requiring repeated sessions, have no discernible benefit over traditional modalities.

Q6. What is the role of growth factors and cytokines in the efficacy of PRP therapy for ED?

Dr. Shatylko: Growth factors, cytokines, and other biologically active molecules are essential in mediating the effect of PRP on penile tissues. The composition of PRP defines its efficacy. However, currently, it’s hard to standardize it. Probably, stem cells would be a better source of growth factors for the treatment of ED and other conditions.

Q7. How does regenerative therapy potentially influence the natural course of erectile dysfunction?

Dr. Shatylko: We hope that regenerative therapy can reverse some functional and histological changes in cavernous tissues that lead to ED, thus affecting the natural course of this condition. It is obvious, however, that existing modalities can do so only in mild and moderate cases of ED. For example, corporal fibrosis is unlikely to be ameliorated by shockwave therapy, PRP, or stem cells.

Q8. What are the expert consensus guidelines on the use of regenerative therapies for ED based on current evidence?

Dr. Shatylko: Global Andrology Forum offers expert consensus guidelines which are separated into 9 statements. GAF states that regenerative therapy should not be considered the standard of care for patients with erectile dysfunction, though young men with mild-tomoderate vasculogenic ED may benefit from it. Understandably, GAF recommendations state that we need more evidence yet for many aspects of the clinical use of regenerative therapies.

Q9. What are the future directions for research and development in regenerative therapies for ED?

Dr. Shatylko: The most important future direction for regenerative therapy is the refinement of extracting reprogrammed pluripotent stem cells. We need reliable non-embryonic sources of stem cells to shake off the associated ethical limitations, and then we need to make basic research and clinical trials more affordable. PRP and stem cell products provide a powerful
cocktail of cytokines and growth factors. The next step would be to identify the exact molecules that define their efficacy, isolate them, and study them as separate drug candidates.

Taras Shatylko, MD, PhD: Short Biography

Taras Shatylko, MD, PhD
V.I. Kulakov National Medical Research Center, Moscow,
Russia
E-mail: dialectic.law@gmail.com
ORCID ID: 0000-0002-3902-9236

Dr. Taras Shatylko is a urologist at V.I. Kulakov National Medical Research Center (Moscow, Russia). Currently, he is working on a doctoral thesis that explores the role of surgery in improving male reproductive function. His teaching activity covers general urology, andrology and urooncology. He is a frequent speaker at urological conferences in Russia and abroad. Dr. Shatylko is also a reviewer for medical journals and a member of the editorial board for “Andrology and genital surgery” (Russia). His clinical interests include andrology, general urology, and oncology. Taras is a proud member of the Global Andrology Forum.

Sperm DNA fragmentation and infertility: a narrative review

Fri, 06 Sep 2024 16:04:37 GMT

Article #57: “Sperm DNA fragmentation and infertility: a narrative review.
Authors: Imad Ziouziou, Amarnath Rambhatla, Rupin Shah, Ashok Agarwal World Journal of Urology (2024) 42:408 [Published online July 11, 2024]
https://doi.org/10.1007/s00345-024-05090-2

Contributors: Prof. Ahmed El-Sakka (Egypt), Assoc. Prof. Ayman Rashed
(Egypt), Prof. Maged Ragab (Egypt)

Commentary:
The study of Sperm DNA fragmentation and infertility represents a significant revolutionary factor in addressing a new possible etiology of male factor infertility (MFI) (1). As the complexity of MFI diagnosis continues to grow, and the need for multidimensional tools to uncover the etiology of MFI, the importance of this timely paper which provides a practical understanding of the role of sperm DNA fragmentation (SDF) in the management of male infertility is mandated (1).

SDF is increasingly recognized as a significant biomarker for assessing male infertility. High levels of DNA fragmentation in sperm are associated with lower fertilization rates, poor embryo quality, and increased risk of miscarriage. (2)

Three main mechanisms are involved in the process of SDF which include defective maturation, abortive apoptosis, and elevated OS from intrinsic or extrinsic factors. Defective maturation and abortive apoptosis occur during spermatogenesis in the testes and OS from ROS usually affects sperm in the post-testicular male excurrent ductal system (3). Various causes of ROS with its consequences include infection, inflammation, leucocytes, smoking, alcohol, radiation, toxic chemicals, diseases of the male reproductive accessory gland, genital tract inflammation, varicocele, testicular torsion, or cryptorchidism. (4)

The exact mechanism of SDF during spermatogenesis is not fully known. However, apoptosis, protamination failure, and the excess of reactive oxygen species (ROS) which results in lipid peroxidation, with its impact on sperm motility are the main causes of SDF (5). The chromatin is highly compacted and tightly packed in mature sperm, primarily through the replacement of histones with protamines. Elevated SDF represents its impact with poor histone-chromatin transition, affecting the protection of sperm DNA integrity (6).

The WHO has acknowledged the significance of SDF testing in evaluating male fertility by including it in their latest semen analysis guidelines. While organizations such as ASRM and ESHRE have not fully endorsed routine SDF testing, they recommend it in cases of unexplained infertility, recurrent pregnancy loss, repeated IVF failures, and in men with risk factors like varicocele or smoking (7).

Several methods are available to measure SDF, such as the TUNEL (Terminal deoxynucleotidyl transferase dUTP nick end labeling assay), SCSA (Sperm Chromatin Structure Assay), SCD (Sperm Chromatin Dispersion or Halo Test), and Comet assay. Each method has its advantages and limitations, and the choice of test may impact clinical decision-making (8). Standardization of SDF testing across laboratories is crucial for improving the reliability, comparability, and clinical utility of SDF assessments in male infertility. This can be achieved by developing uniform testing protocols, establishing consensus on thresholds, and quality control measures, and integrating standardized practices into clinical guidelines. (9)

Therapeutic interventions for sperm DNA fragmentation include lifestyle modifications, antioxidant supplementation, hormone therapy, varicocele repair, and assistedreproductive technologies. All these measures could alleviate DNA fragmentation and improve male fertility potential. The choice of treatment depends on the underlying causes of DNA damage and the severity of the condition (9). Future research on SDF in male infertility should focus on developing more accurate and sensitive SDF assays, investigating the underlying molecular mechanisms of SDF, the role of SDF in emerging fields like epigenetics and intergenerational effects, exploring novel pharmacological and therapeutic interventions to reduce SDF levels and improve fertility outcome (10).

Take Home Message:

SDF testing is increasingly required in the evaluation and treatment of MFI, which is why more research is necessary to standardize SDF testing and its reliability, and clear guidelines for its use in clinical practice are urgently needed. Although, most of the guidelines and the published studies agreed that the level of evidence and grade of recommendations for indications and therapeutic interventions for sperm DNA fragmentation relied upon good quality and well-designed studies; some of the recommendations are based on poorer quality studies (retrospective, case series, expert opinion). Finally, this narrative review highlighted the importance of SDF and emphasized its role in achieving successful reproductive outcomes.

References:
1. Ziouziou I, Rambhatla A, Shah R, Agarwal A. Sperm DNA fragmentation and infertility: a narrative review. World J Urol. 2024 Jul 11;42(1):408.
2. Agarwal A, Rana M, Qiu E, AlBunni H, Bui AD, Henkel R: (2018) Role of oxidative stress, infection and inflammation in male infertility. Andrologia 50(11):e13126. https://doi.org/10.1111/and.13126
3. Agarwal A, Majzoub A, Baskaran et al (2020) Sperm DNA fragmentation: a new guideline for clinicians. World J men’s Health 38(4):412–471.

4. Szabó A, Váncsa S, Hegyi et al (2023) Lifestyle-, environmental-, and additional health factors associated with an increased sperm DNA fragmentation: a systematic review and meta-analysis. Reproductive Biology Endocrinology: RB&E 21(1):5.
5. Finelli R, Leisegang K, Kandil H, Agarwal A (2022) Oxidative stress: a comprehensive review of biochemical, molecular, and genetic aspects in the Pathogenesis and management of Varicocele. World J men’s Health 40(1):87–103.
6. González-Marín C, Gosálvez J, Roy R. Types, causes, detection and repair of DNA fragmentation in animal and human sperm cells. Int J Mol Sci. 2012 Oct 31;13(11):14026-52. doi:10.3390/ijms131114026.
7. Chua, S. C., Yovich, S. J., Hinchliffe, P. M., & Yovich, J. L. (2023). The sperm DNA fragmentation assay with SDF level less than 15% provides a useful prediction for clinical pregnancy and live birth for women aged under 40 years. Journal of Personalized Medicine, 13(7).

8. Agarwal, A., Cho, C., Majzoub, A., & Esteves, S. (2017). The Society for Translational Medicine: clinical practice guidelines for sperm DNA fragmentation testing in male infertility. Translational Andrology And Urology, 6(Suppl 4), S720-S733. doi:10.21037/tau.2017.08.06
9. Agarwal, A., Farkouh, A., Saleh, R., Hamoda, T. A. A. A. M., Harraz, A. M., Kavoussi, P., Arafa, M., Salvio, G., Rambhatla, A., Toprak, T., Gül, M., Phuoc, N. H. V., Boitrelle, F., Birowo, P., Ghayda, R. A., Cannarella, R., Kuroda, S., Durairajanayagam, D., Zini, A., … Le, T. V. (2023). Controversy and consensus on indications for sperm DNA fragmentation testing in male infertility: A global survey, current guidelines, and expert recommendations. World Journal of Men’s Health, 41.https://doi.org/10.5534/wjmh.22028
10. Farkouh, A., Saleh, R., Shah, R., & Agarwal, A. (2023). Sperm DNA fragmentation in male infertility: From bench to bedside. In Arab Journal of Urology (Vol. 21, Issue 4).https://doi.org/10.1080/20905998.2023.2278200

Ahmed I. El-Sakka, MBChB, MSc, MD: Short Biography

Ahmed I. El-Sakka, MD
Professor of Urology, Department of Urology
Faculty of Medicine, Suez Canal University, Ismailia, Egypt
Email: aielsakka@yahoo.com
ORCID ID: 0000-0001-8671-5952

Prof. Ahmed El-Sakka graduated from medical school, completed his residency-training program in Urology and Andrology, and obtained master’s and doctorate degrees in Urology from Suez Canal University, Ismailia, Egypt. He was trained as a fellow at the Department of Urology, University of California San Francisco. Prof. ElSakka holds several positionsincluding Chief of the UrologyDepartment and Dean Faculty of Medicine at Suez Canal University. He is the former President of the Middle East Society for Sexual Medicine, President section of Andrology at the Egyptian Urological Association, and Vice President of the Egyptian Society for Sexual Medicine and Surgery.
His list of publications includes over 170 original papers, review articles, and book chapters in addition to participation in more than 300 national and international conferences and meetings. He is also a member of the editorial board of several international journals and a member of numerous medical associations and societies. He has 107 publications, 2,746 citations, and an h-index of 31 according to Scopus (Sep’ 2024). Dr. El-Sakka is a proud member of the Global Andrology Forum.

My Viewpoint on the SDF and infertility
Dr. Ahmed El-Sakka responds to questions from Ashok

Q1. What are the primary mechanisms leading to sperm DNA fragmentation (SDF) during spermatogenesis?

Dr. El-Sakka: The exact mechanism of SDF during spermatogenesis is not fully known. However, apoptosis, protamination failure, and the excess of reactive oxygen species (ROS) which results in lipid peroxidation, with its impact on sperm motility are considered to be the main causes of SDF. Post-testicular mechanisms that result in the elevation of OS leading to the elevation of SDF. When the level of ROS is high then OS occurs. This results in lipid peroxidation which is toxic to DNA and ultimately damaging to cellular components that negatively affect fertility.

Q2. What are the clinical implications of elevated sperm DNA fragmentation in male infertility?

Dr. El-Sakka: Several interesting studies have reported that high SDF can act in a way as a barrier to male fertility. SDF levels are also affected by many factors like varicocele, obesity, unexplained infertility, idiopathic infertility, testicular cancer, and aging in men. SDF was categorized into viable and non-viable depending upon its impact on natural fertility in

normozoospermic males, in viable SDF males, spermatozoa showed the ability to fertilize but later failed in good embryo development, whereas non-viable SDF males are not able to initiate fertilization.

Q3. How does sperm DNA fragmentation affect natural pregnancy rates and ART outcomes?

Dr. El-Sakka: Basically, the elevated SDF contributes to male infertility, and its association with reduced natural conception and ART outcomes is almost the same. The rate of natural pregnancy is affected by DNA damage. The correlation between the SDF index and Pregnancy outcome was investigated by several studies, and was concluded that 20-30%, decreases the chance of natural pregnancy. A negative correlation was found between SDF and sperm motility in couples with recurrent spontaneous abortion. However, there is controversy on the clinical implications of SDF with contradictory findings reported amongst the SRMAs conducted on the effect of DNA fragmentation on natural pregnancy rates and ART outcomes.

Q4. What are the indications for SDF testing in the evaluation of male infertility?

Dr. El-Sakka: Several indications for SDF testing in the evaluation of male infertility were reported by different societies i.e. AUA, EAU, and others in addition to different published studies.
• Men with unexplained or idiopathic male infertility.
• Couples experiencing recurrent pregnancy loss.
• Infertile couples before initiating or after failure of IUI or IVF.
• Couples with recurrent miscarriage following ICSI
• Other indications such as Men with clinical varicocele or modifiable lifestyle risk factors were also reported.

All the guidelines and the published studies agreed that the level of evidence and grade of recommendations for such indications relied upon good quality and well-designed studies.
However, some of the recommendations are based on poorer quality studies (retrospective, case series, expert opinion).

Q5. How does varicocele repair influence sperm DNA fragmentation levels?

Dr. El-Sakka: Varicoceles have been consistently associated with increased SDF and immature chromatin, leading to infertility. One possible cause for poor semen quality and quantity is scrotal hyperthermia or heat stress, causing oxidative stress in varicocele males. Varicocele repair can improve OS, decrease ROS, increase antioxidants, and ultimately better natural pregnancy as well as ART outcomes. Varicocelectomy reduced SDF, improved sperm concentration, progressive motility, and morphology difference thus was considered as a treatment during abnormal DNA fragmentation index.

Ayman S. Rashed, MBChB, MSc, MD, PhD: Short Biography

Ayman S. Rashed, MD, PhD
Assoc. Professor of Urology and Andrology
Department of Urology/ Andrology

October 6th University, Cairo, Egypt
E-mail: aymanrashed@msn.com
ORCID id: 0000-0003-1994-2228

Dr. Ayman S. Rashed is a Professor of Urology and Andrology and the former Chair of Urology at the 6th of October University in Cairo, Egypt. Dr. Rashed was a Clinical Fellow at the Urology and Andrology Department of Klinikum Grosshadern, Ludwig Maximillian University in Munich, Germany, and at Justus Liebig University in Giessen, Germany, 1997-2000. He earned his MD and PhD in Urology and Andrology in 2004. In addition to his academic and clinical roles, Dr. Rashed is the President of the “Male Infertility” committee section of the Egyptian Urological Guidelines, where he plays a pivotal role in shaping national standards for the treatment of male infertility. His contributions to the field are further evidenced by his extensive participation as a speaker at numerous local, regional, and international conferences on Urology and Andrology. Renowned as one of the highest-volume Micro-TESE and microsurgery surgeons, Dr. Rashed is sought after for training by urologists and andrologists from Egypt and other Arabian countries. Dr. Rashed is a proud
member of the Global Andrology Forum.

My Viewpoint on the SDF and infertility
Dr. Ayman S. Rashed responds to questions from Ashok

Q1. What is the role of lifestyle and environmental factors in increasing sperm DNA fragmentation?

Dr. Rashed: Lifestyle and environmental factors play significant roles in increasing sperm DNA fragmentation (SDF), contributing to male infertility. Many lifestyle factors, such as smoking, excessive alcohol consumption, poor diet, heat exposure, lack of exercise, and chronic mental stress, lead to oxidative stress. This results in an imbalance between reactive oxygen species (ROS) and antioxidants in the body, causing damage to sperm DNA. Mitigating these lifestyle and environmental factors by adopting a healthy diet, regular exercise, avoiding smoking and alcohol consumption, reducing exposure to environmental toxins, and managing stress can help lower sperm DNA fragmentation and improve fertility.

Q2. How do different SDF measurement techniques compare in terms of reliability and clinical applicability?

Dr. Rashed: Different sperm DNA fragmentation (SDF) measurement techniques vary in reliability, sensitivity, and clinical applicability. Here's a comparison of the most commonly used methods:

1. TUNEL (Terminal deoxynucleotidyl transferase dUTP nick end labeling) Assay:
• Reliability: The TUNEL assay is highly reliable and sensitive. It directly labels DNA breaks as either single- or double-strand breaks. It can also be used for both fresh and frozen samples.
• Clinical applicability: Due to its accuracy, TUNEL is widely used in research and clinical settings.

2. SCSA (Sperm Chromatin Structure Assay):
• Reliability: SCSA is also considered reliable, particularly for its ability to measure DNA denaturation, a sign of chromatin instability. It has a standardized protocol, and a large number can be tested. It can be used for fresh and frozen samples.
• Clinical Applicability: SCSA is one of the most standardized tests frequently used in clinical practice. It is highly reproducible and provides quick results.

3. Comet assay:
• Reliability: The comet assay is sensitive and allows for directly detecting single- and double-strand DNA breaks. It can also detect specific types of DNA damage and be used in cases with marked oligozoospermia.
• Clinical Applicability: Though very sensitive, it is less commonly used in routine clinical settings due to its complexity, less standardization across laboratories, only done on fresh samples, Inter-observer variability, time-consuming, and technically demanding.

4. SCD (Sperm Chromatin Dispersion) Test:
• Reliability: Although the SCD test is simpler, easier to perform, and requires minimal equipment, commercial kits are available and less expensive. However, it is somewhat less reliable than TUNEL and SCSA.
• Clinical Applicability: Commonly used in clinical practice due to its simplicity and low cost.

In Summary:

❖ Best for Research: TUNEL and Comet assays are preferred in research due to their high sensitivity and detailed insights into DNA damage.
❖ Best for Clinical Use: SCSA and SCD tests are more commonly used in clinical practice because they balance accuracy with ease of use and costeffectiveness.
❖ Each method has strengths and limitations, and the choice of test often depends on the clinical context, available resources, and patient-specific needs. Multiple tests may be used together for a comprehensive assessment.

Q3. What are the recommended SDF thresholds for clinical decision-making in ART?

Dr. Rashed: Sperm DNA fragmentation (SDF) thresholds are crucial for clinical decisionmaking in assisted reproductive technologies (ART) such as IVF and ICSI. These thresholds help determine the likelihood of successful fertilization, embryo development, and pregnancy outcomes. While certain SDF thresholds have been suggested for clinical decision-making, the exact cut-off points are still debated, and their application can vary depending on the clinical context (e.g., natural conception vs. ART)

Recommended SDF Thresholds:

A. General ART thresholds:
• 20-30%: An SDF level within this range is generally considered a critical threshold.
Above 30% are associated with significantly reduced pregnancy rates and increased miscarriage rates. This threshold is widely used in clinical practice to guide decisions regarding ART techniques.
• 15-20%: Values below 15-20% are typically associated with better ART outcomes, including higher successful fertilization and pregnancy rates.

B. IVF/ICSI-specific thresholds:
• ICSI: An SDF level above 30% is often considered for ICSI. However, due to the direct injection of a single sperm into the egg, ICSI can sometimes overcome the negative impact of high SDF. Still, a higher SDF may lead to poorer embryo quality and lower pregnancy rates even with ICSI.
• IVF: A lower SDF is preferred for standard IVF. If SDF exceeds 20-25%, couples may be counseled to consider ICSI instead of IVF to improve their chances of success.

C. Male infertility cases:
• In cases of unexplained infertility or recurrent pregnancy loss, a more conservative threshold of around 15-20% may be applied. Higher SDF levels in these cases may prompt more aggressive interventions, such as the use of testicular sperm retrieval (which often has lower SDF) combined with ICSI. Also, surgical treatment of clinical varicocele should be considered even with ICSI intention.

D. Testicular vs. ejaculated sperm:
• In cases where SDF is high in ejaculated sperm, clinicians might consider using testicular sperm for ART since testicular sperm typically exhibit lower DNA fragmentation levels. This approach is advantageous in severe male factor infertility or recurrent ART failures.

Q4. How does sperm DNA fragmentation correlate with recurrent pregnancy loss?

Dr. Rashed: Sperm DNA fragmentation (SDF) has been increasingly recognized as a significant factor in recurrent pregnancy loss (RPL). RPL is generally defined as two or more consecutive miscarriages, and while various factors can contribute to RPL, SDF has emerged as a crucial male-related factor.
Correlation Between SDF and RPL:

A. Increased miscarriage rates:
• High SDF can lead to impaired embryo development, resulting in pregnancy loss. The DNA integrity in sperm is vital for successful fertilization and the subsequent development of a healthy embryo.

B. Impact on embryo quality:
• High SDF can result in poor-quality embryos that fail to implant properly or have abnormal development, leading to early pregnancy loss. Embryos with fragmented sperm DNA are more likely to experience cell division errors and chromosomal abnormalities, which can result in miscarriage.
• Clinical studies have consistently shown that men whose partners experience RPL tend to have higher SDF levels compared to men whose partners have successful pregnancies. For instance, a meta-analysis found that men with high SDF are nearly twice as likely to be involved in cases of RPL.

Q5. What is the significance of SDF in unexplained and idiopathic male infertility?

Dr. Rashed:
A. Unexplained male infertility:
• In many cases of unexplained infertility, standard semen parameters appear normal.
However, these parameters do not assess the genetic integrity of the sperm. Elevated SDF can be present despite normal semen analysis, indicating underlying DNA damage that could impair fertility.
• Men with unexplained infertility often have higher SDF levels compared to fertile men, suggesting that sperm DNA damage may be a hidden factor contributing to infertility.
• High levels of SDF can negatively impact fertilization rates, embryo development, and ultimately, pregnancy outcomes. Sperm with fragmented DNA may fertilize an egg, but the resulting embryo might fail to develop properly, leading to failed implantation or early miscarriage.

B. Idiopathic male infertility:
• In cases of idiopathic infertility, where no clear cause is identified after thorough evaluation, SDF testing provides valuable diagnostic information. It can help identify men at risk of poor reproductive outcomes due to sperm DNA damage.
• Elevated SDF levels in idiopathic infertility cases may prompt the consideration of advanced reproductive techniques, such as ICSI or the use of testicular sperm, which often have lower DNA fragmentation levels.

Q6. What are the limitations of current SDF testing methodologies?

Dr. Rashed: While SDF testing provides valuable insights into sperm DNA integrity, its clinical application is hindered by limitations such as lack of standardization, technical complexity, and challenges in interpretation. Ongoing research and efforts to standardize testing protocols are essential to improve the reliability and utility of SDF tests in clinical practice. Here are some of the key limitations:

A. Lack of standardization:
• Variation in Protocols: Different laboratories often use varying protocols and thresholds for SDF testing, leading to inconsistent results and comparability of SDF test results across different clinical settings.
• Different Assay Techniques: There are multiple SDF assays, each with its methodology, sensitivity, and specificity. The results obtained from one method may not correlate perfectly with those from another, complicating the interpretation and clinical decisionmaking.

B. Technical complexity:
• Requirement for Specialized Equipment: This limits accessibility and increases the cost of testing.
• Need for Technical Expertise: If the tests are not conducted under optimal conditions, the results can be variable.

C. Biological variability:
• Sperm Heterogeneity: Sperm samples are inherently heterogeneous, with varying levels of DNA fragmentation among different sperm cells within the same ejaculate. This variability can lead to sampling bias and may affect the accuracy of the test results.
• Temporal Variability: SDF levels can fluctuate over time due to factors such as illness, stress, or environmental exposures. A single test may not accurately reflect a man’s longterm sperm DNA integrity.

D. Challenges in clinical interpretation:
• Uncertain Clinical Thresholds: While certain SDF thresholds have been suggested for clinical decision-making, the exact cut-off points are still debated.
• Limited Predictive Value: Although high SDF is associated with poorer reproductive outcomes, the predictive value of SDF testing is still limited.

E. Cost and accessibility
• Expense: SDF testing can be expensive, especially when using more advanced methods like TUNEL or SCSA, making it less accessible to some patients.
• Availability: Not all fertility clinics or labs offer SDF testing, limiting access to this diagnostic tool for many patients.

F. Limited evidence in specific populations

• Understudied Populations: Most SDF research has focused on men with known infertility issues, leaving gaps in knowledge regarding the role of SDF in fertile men or populations with specific reproductive challenges, such as older men or those with chronic illnesses.

Q7. How does sperm DNA fragmentation relate to sperm chromatin structure abnormalities?

Dr. Rashed: Sperm DNA fragmentation (SDF) and sperm chromatin structure abnormalities are closely related aspects of sperm quality that contribute to male infertility. Both involve issues with the integrity and packaging of genetic material within sperm, and their interplay can significantly affect reproductive outcomes.

Relationship Between SDF and Sperm Chromatin Structure Abnormalities:
A. Chromatin packaging and SDF:
• Chromatin Structure: In mature sperm, chromatin is highly compacted and tightly packed, primarily through the replacement of histones with protamines. This tight packing protects the DNA from damage and ensures its integrity during fertilization.
• Abnormal Chromatin Packaging: When chromatin is not properly compacted, it becomes more vulnerable to damage from various factors, such as oxidative stress. Poor chromatin packaging is often associated with incomplete histone-to-protamine transition, leading to areas of the sperm DNA being less protected and more prone to fragmentation.

B. Oxidative stress and DNA damage:
• Role of Oxidative Stress: ROS can cause breaks in the DNA strands, particularly when chromatin is loosely packed, and the DNA is exposed.
• Correlation with SDF: Studies have shown a strong correlation between poor chromatin structure and increased levels of SDF. Sperm with abnormal chromatin structure often exhibit higher levels of DNA fragmentation.

C. Implications for fertility:
• Impact on Sperm Function: Abnormal chromatin structure and elevated SDF can impair sperm function, including its ability to fertilize an egg and support embryo development.

Maged M. Rageb, MBChB, MSc, MD: Short Biography

Maged M. Ragab, MD
Professor of Urology and Andrology
Department of Urology
Faculty of Medicine Tanta University, Tanta, Egypt
E-mail: maged.elsayed@med.tanta.edu.eg
ORCID: 0000-0003-4790-3322

Prof. Maged Ragab has been a Professor of Urology and Andrology at Tanta University, Egypt since 2017. An accomplished academic and clinician, Dr. Ragab earned his M.B.Ch.B. in Medicine and Surgery in 1993, followed by an M.Sc. in Urology in 1998 and a prestigious M.D. degree in Urology in 2015 from Tanta University. He further honed his expertise during his tenure as a Clinical Fellow of Urology at Washington Univ. School of Medicine between 2000 and 2002. Dr. Ragab leads the Andrology Unit at Tanta University’s School of Medicine. He serves as the Secretary of the Erectile Dysfunction section ofthe Egyptian Urological Association. Furthermore, he has been instrumental as Vice President of the Male Infertility section in the development of the Egyptian Urological Guidelines for their 1st and 2nd editions. Dr. Ragab is an active committee member of the Middle East Society for Sexual Medicine (MESSM). He has organized and conducted numerous male infertility training programs across Egypt over the past five years, sharing his knowledge and clinical skills. Dr.Ragab has 25 publications, 420 citations, and an h-index of 12 according to Scopus (Sep’ 2024). Lastly, Maged is a proud member of the Global Andrology Forum.

My Viewpoint on the SDF and infertility
Dr. Maged Ragab responds to questions from Ashok

Q1. What are the recommendations for SDF testing by various fertility societies?

Dr. Ragab: The WHO has acknowledged the significance of SDF testing in evaluating male fertility by including it in their latest semen analysis guidelines. While organizations such as ASRM and ESHRE have not fully endorsed routine SDF testing, they recommend it in cases of unexplained infertility, recurrent pregnancy loss, repeated IVF failures, and in men with risk factors like varicocele or smoking. (Chua et al., 2023).

Q2. How do single-strand and double-strand DNA breaks differ in their impact on fertility?

Dr. Ragab: Sperm DNA fragmentation can occur as either single-strand breaks (SSBs) or double-strand breaks (DSBs). DSBs are more severe and high levels are associated with reduced pregnancy rates and increased risk of miscarriage. (Agarwal, Barbăroșie, et al.,2020).

Q3. What are the potential therapeutic interventions to reduce sperm DNA fragmentation?

Dr. Ragab: Therapeutic interventions for sperm DNA fragmentation include lifestyle modifications, antioxidant supplementation, hormone therapy, varicocele repair, and assisted reproductive technologies. The choice of treatment depends on the underlying causes of DNA damage and the severity of the condition. (Agarwal et al., 2023).

Q4. What is the role of apoptosis in the development of sperm DNA fragmentation?

Dr. Ragab: Apoptosis may play a role in sperm DNA fragmentation. Apoptosis plays a critical role in sperm DNA fragmentation (SDF) by eliminating damaged sperm cells. Some germ cells escape this programmed elimination process and undergo maturation. These are then identified as defective spermatozoa, associated with high levels of DNA damage and contributing to male infertility. Understanding and targeting these abortive apoptotic pathways may offer therapeutic potential for improving male reproductive health.(Sakkas et al., 1999).

Q5. What are the future research directions for understanding the role of SDF in male infertility?

Dr. Ragab: Future research on SDF in male infertility should focus on developing more accurate and sensitive SDF assays, investigating the underlying molecular mechanisms of SDF, the role of SDF in emerging fields like epigenetics and intergenerational effects, exploring novel pharmacological and therapeutic interventions to reduce SDF levels and improve fertility outcome. (Farkouh et al., 2023).

Global Practice Patterns in the Evaluation of Non-Obstructive Azoospermia: Results of a World-Wide Survey and Expert Recommendations

Thu, 29 Aug 2024 16:45:20 GMT

Article #56: “Global Practice Patterns in the Evaluation of Non-Obstructive Azoospermia: Results of a World-Wide Survey and Expert Recommendations”
Authors: Shah R, et al. World J Mens Health World J Mens Health Published online Apr 4, 2024

https://doi.org/10.5534/wjmh .230333

Contributors: Sidney Glina, MD (Brasil), Dr. Rafael Favero Ambar, MD (Brasil), and Edson Borges Junior, MD, PhD (Brasil)

Commentary:

Non-obstructive azoospermia (NOA)is the most challenging diagnosis for the andrologist and the infertile male patient. Medical treatment is often disappointing, because there is no established diagnosis (idiopathic) in many cases, and assisted reproduction techniques are expensive and not always universally accessible. Furthermore, many diagnostic and treatment modalities remain a matter of debate and there is a lack of guidelines among academic societies.

In this comprehensive survey, the authors examined global practices in managing NOA patients, comparing them against professional society guidelines (AUA/ASRM, EAU, EAA) and expert recommendations from Global Andrology Forum (GAF) members. Conducted between July and September 2022, the survey utilized a 56-item questionnaire to assess NOA diagnosis and management practices among 367 participants from 49 countries, 3analyzed through a Delphi process. The current paper presents findings from the initial 21 questions, focusing on survey demographics and NOA evaluation approaches. The 336 responses came from 49 countries, providing an expanded view of the practices used by doctors (mostly responders) in the diagnosis and treatment of NOA.

Most azoospermia cases were non-obstructive and linked to primary hypogonadism (hypergonadotropic hypogonadism or testicular failure). Various congenital, environmental, iatrogenic, and acquired conditions can cause testicular failure and NOA, though the clinical relevance of a varicocele associated with NOA remains unclear.

The majority of respondents’ practices aligned with guidelines recommending a second semen sample if the initial examination shows an absence of spermatozoa. Most considered an interval of 11 to 29 days between semen analyses ideal, with 22.9% citing three months, reflecting a full cycle of spermatogenesis.

Serum FSH, LH, and total testosterone were the most commonly evaluated hormones in NOA patients. Studies have shown significant differences in these hormone levels between men with NOA and OA. However, serum total testosterone levels may not accurately reflect functional testosterone availability due to variations in serum sexhormone binding globulin (SHBG) levels, influenced by conditions like metabolic syndrome, thyroid disorders, pituitary disease, chronic liver disease, prostate cancer, nephrotic syndrome, estrogen use, anticonvulsants, and steroids. In such cases, calculating free testosterone after SHBG assay is recommended. Additionally, serum estradiol should be measured in obese men, and serum prolactin should be tested if decreased sexual desire and erectile dysfunction are present.

Patients with azoospermia or severe oligospermia have a higher likelihood of genetic abnormalities. The survey indicated the need for karyotyping and Y chromosome microdeletion testing in NOA patients, aligning with guidelines and common practices among respondents. Notably, 27% of respondents recommended Kal1 gene testing for X-linked Kallmann Syndrome, a common cause of congenital hypogonadotropic hypogonadism often associated with anosmia or severe hyposmia. Genetic counseling is crucial, and a significant proportion of respondents offer it. However, there is probably a need of a better understanding among the attending physicians of how and when some genetic testing should be performed because almost 1/5 of the respondents routinely perform CFTR gene mutation testing in patients with NOA although CFTR gene 4mutation does not cause NOA. According to GAF expert members, CFTR gene mutation testing should be performed only in cases of vas aplasia or congenital obstruction, particularly in regions with high CFTR mutation carrier prevalence.

Categorizing azoospermia into OA or NOA is vital due to differing management strategies. In most cases, clinical and laboratory results suffice for diagnosis. In this survey, 45.1% of participants did not perform diagnostic testicular biopsy routinely. GAF experts suggest that testicular biopsy should not precede therapeutic testicular sperm extraction (TESE) and should be recommended only in specific cases where serum FSH and LH levels and testicular volumes are normal, combined with surgical sperm retrieval. However, it is important to consider that obstructive azoospermia caused by an epididymal obstruction occurs with normal testis volume, normal FSH, and testosterone levels and that a definitive diagnosis that allows reconstruction through vaso-epididymal anastomosis is only possible during scrotal surgical exploration. Imaging plays a minor diagnostic role.

The survey revealed that 66.4% of respondents agreed that normal serum FSH predicts a higher chance of sperm retrieval by conventional TESE (cTESE) or microdissection TESE (mTESE).

Shah et al. concluded that global clinical practices, literature evidence, and recommended guidelines for NOA diagnosis were generally congruent. However, significant disparities in practices highlighted the need for evidence-based, international consensus guidelines to standardize NOA evaluation and address gaps in professional recommendations.

Take Home Message
Accurate diagnosis of NOA necessitates a comprehensive clinical and laboratory evaluation, including genetic testing and hormonal profiling. While definitive preoperative predictors for successful sperm retrieval are lacking, normal FSH levels, testicular volume, and specific histopathological findings suggest higher success rates. Genetic counseling with karyotype and Y microdeletion testing is advised for all NOA patients. Diagnostic testicular biopsy is not routinely required for differentiating NOA from OA. Personalized patient management plans, advanced diagnostic techniques, interdisciplinary collaboration, and ongoing research are essential for optimizing care and improving outcomes for NOA patients.

Sidney Glina, MD: Short Biography

Sidney Glina, MD, PhD

Professor and Head of Urology Division,

Centro Universitário Faculdade de Medicina do

ABC, Santo André, SP, Brasil

E-mail: glinas@terra.com.br

ORCID ID: 0000-0002-9053-5046

Dr. Sidney Glina is a renowned Brasilian urologist specializing in sexual and reproductive medicine, with a career spanning several decades. He graduated from the Faculdade de Medicina da Universidade de São Paulo in 1977 and completed his residency in General Surgery and Urology at the

Hospital das Clínicas of the same university from 1978 to 1983. In 1983, he further specialized in Male Infertility through a research fellowship under the late Dr. Anthony Thomas Jr. at the Cleveland Clinic Foundation in Ohio, USA. A leader in his field, Dr. Glina co-founded and currently directs the andrology section of PROJETO ALFA, an Assisted Reproduction laboratory in São Paulo. His contributions extend beyond clinical practice; he served as Editor of the International Brazilian Journal of Urology from 2012 to 2019 and now holds the title of Editor-Emeritus. Dr. Glina also led the International Society of Sexual Medicine as President from 2000 to 2002 and the Brazilian Society of Urology from 2006 to 2007. With over 200 published papers in indexed journals, his work has significantly influenced the field. He continues to practice in São Paulo, Brazil.

My Viewpoint on the Global Practice Patterns in the Evaluation of NOA

Dr. Sidney Glina responds to questions from Ashok

Q1. What are the expert recommendations for preoperative biochemical or clinical variables that predict positive sperm retrieval in NOA patients?

Dr. Glina: There are no preoperative biochemical or clinical variables that definitively predict positive sperm retrieval in patients with NOA. However, normal FSH, normal testicular volume, a history of sperm in the ejaculate, and favorable histopathology predict higher chances of sperm retrieval.

Q2. Which histopathological findings are associated with higher chances of sperm retrieval in NOA?

Dr. Glina: Testicular histopathology with hypospermatogenesis predicts higher chances of sperm retrieval in patients with NOA.

Q3. What are the common practices regarding the use of diagnostic testicular biopsy in NOA patients?

Dr. Glina: Although testicular histology is a good, maybe the best, predictor of successful surgical sperm retrieval in NOA patients it should not be done routinely as a diagnostic test, but only combined with therapeutic TESE.

Q4. How do expert recommendations derived through a Delphi consensus compare to international practice guidelines for NOA?

Dr. Glina: Although the Delphi consensus presents limitations, such as a limited number of physicians and countries participants, it provides a comprehensive perspective of real-life global practices. Also, this survey showed that although there is a congruity between global clinical practices, evidence in the literature, and professional society recommendations, there are several areas where guidelines are not available and clinical practices differ from the recommendations.

Q5. What are the limitations of current guidelines for the evaluation and management of NOA?

Dr. Glina: There are several topics on the diagnosis and management of NOA where there are no available guidelines.

Q6. What are the main predictors of successful sperm retrieval during conventional and microdissection TESE?

Dr. Glina: Normal FSH, normal testicular volume, a history of sperm in the ejaculate, and favorable histopathology predict higher chances of sperm retrieval.

Q7. What are the identified gaps in knowledge and areas needing further research in the evaluation and management of NOA?

Dr. Glina: Besides a better understanding of the etiology of idiopathic NOA, further research is needed on the possible medical treatment of NOA and the identification of predictors of sperm finding on surgical testicular retrieval.

Rafael Ambar, MD: Short Biography

Rafael Favero Ambar, MD
Consultant, Urology Division of Centro Universitario Faculdade de Medicina do ABC Andrology Group at Ideia Fertil Institute of Reproductive Medicine Sao Paulo, Brasil

E-mail: rf.ambar@gmail.com

ORCID id: 0000-0002-3496-2895

Dr. Rafael Ambar is a young Brasilian urologist specializing in male infertility and sexual disorders. He further advanced his expertise as a visiting researcher at the Cleveland Clinic's American Center for Reproductive Medicine, where he honed his research skills and contributed to significant scientific projects (Nov 2019 to Mar 2020). Currently, Dr. Ambar plays a pivotal role in the Andrology Group within the Urology Department at the Medical School of ABC in Brazil. He is also a key member of the andrology team at Instituto Ideia Fertil, one of Latin America's foremost reproductive clinics. He leads the Male Infertility Section of the Brasilian Society of Urology and serves as Vice-Coordinator of both the Penile Surgery section at ABEMSS and the Andrology fellowship program at IAMSPE.

My Viewpoint on the Global Practice Patterns in the Evaluation of NOA

Dr. Rafael Favero Ambar responds to questions from Ashok

Q1. What are the most common hormone tests ordered for diagnosing NOA?

Dr. Ambar: The most commonly ordered hormones are FSH, LH, and testosterone. Prolactin and estradiol might be useful in selected cases.

Q2. How do physical examination findings contribute to differentiating between obstructive azoospermia (OA) and NOA?

Dr. Ambar: During the physical examination, the reproductive urologist should determine if the patient has vas deferens agenesia, evaluate testes size, as well as secondary sexual characteristics.

Q3. What genetic tests are most frequently requested for patients suspected of having NOA?

Dr. Ambar: Karyotype and Y chromosome microdeletions should be requested in NOA

cases.

Q4. How is a definitive diagnosis of azoospermia typically confirmed?

Dr. Ambar: The definitive diagnosis is obtained by a testicular biopsy. However, in clinical practice, serum FSH levels higher than 7.6 mIU/mL and a testicular long axis less than 4.6 cm suggest NOA

Q5. What is the role of testicular histology in predicting the success of testicular sperm extraction (TESE) in NOA patients?

Dr. Ambar: Although there are conflicting results in medical literature, it is commonly accepted that histopathology with hypospermatogenesis predicts higher chances of sperm retrieval. On the other hand, histopathology showing SCO is related to an unsuccessful sperm extraction.

Q6. How do serum testosterone levels impact the diagnosis and management of NOA?

Dr. Ambar: Isolated serum testosterone level is not significant to diagnosis, as it may be impacted by several conditions. Concerning clinical management, testosterone levels are of importance to determine, together with gonadotropin levels, if hormonal stimulation therapy is needed.

Q7. What are the common criteria used to differentiate between OA and NOA based on semen tests?

Dr. Ambar: The volume and the presence of fructose are the most important parameters to differentiate between OA and NOA.

Edson Borges Junior, MD, PhD: Short Biography

Edson Borges Junior, MD, PhD
Medical Director – Fertgroup Medicina Reprodutiva General Coordinator, Instituto Sapientiae Sao Paulo, Brasil

E-mail: edson@fertility.com.br

ORCID: 0000-0002-4971-1925

Dr. Edson Borges Junior graduated in Medicine from the State University of Campinas, Brasil in 1984, with residencies in General Surgery and Urology. He earned his first PhD in Urology in 2005 at the Universidade Federal de Sao Paulo (UNESP) and the second PhD in Gynaecology in 2007 at the Botucatu Medical School from Universidade Estadual Paulista "Júlio de Mesquita Filho (UNESP). He has been serving as the Scientific Director of the Fertility Medical Group for 32 years and is currently the Medical Director of FERTGROUP, a corporation of 10 Assisted Reproduction laboratories in Brasil with over 160 partner or affiliated doctors. Edson has published extensively and is a prominent figure in the Brasilian urology and assisted reproduction societies.

My Viewpoint on the Global Practice Patterns in the Evaluation of NOA

Dr. Edson Borges Junior responds to questions from Ashok

Q1. How does the serum FSH level influence the management of NOA?

Dr. Borges: Elevated serum FSH levels indicate testicular failure and impaired spermatogenesis. However, there is no direct relationship between serum FSH levels and the possibility of obtaining testicular sperm.

Q2. What are the global trends in the use of karyotype analysis and Y chromosome microdeletions testing for NOA?

Dr. Borges: Despite these tests being considered mandatory in the investigation of non-obstructive azoospermia, they are still not adequately requested by urologists and physicians who treat male infertility. We need to increase the knowledge of these professionals so that these tests are more widely ordered.

Q3. How do clinical practices differ from professional society recommendations in the management of NOA?

Dr. Borges: Limited knowledge of the causes and treatment options for NOA leads to limitations in the clinical investigation, including both andrological examination and laboratory and hormonal tests. This simplification in the approach often hinders or delays the proper guidance of these patients.

Q4. How does the history of sperm in the ejaculate influence the approach to sperm retrieval in NOA patients?

Dr. Borges: A history of the presence of sperm in the ejaculate indicates a better prognosis for the recovery of testicular sperm. This suggests that spermatogenesis was present at some point.

Q5. How does the testis volume correlate with the likelihood of successful sperm retrieval in NOA?

Dr. Borges: Testicular volume has no direct correlation with the possibility of sperm recovery, regardless of the etiology of NOA.

Testicular Sperm Extraction for Men with Cryptozoospermia – Are We Jumping the Gun

Mon, 12 Aug 2024 14:35:16 GMT

Article #55: “Testicular Sperm Extraction for Men with Cryptozoospermia – Are We Jumping the Gun”
Authors : Andrian Japari, Baris Altay, Wyns Christine, Selahittin Cayan, Ramadan Saleh, Rupin Shah and Ashok Agarwal.

ARAB JOURNAL OF UROLOGY, Published online: 12 Jun 2024, https://doi.org/10.1080/20905998.2024.2367333

Contributors: Logan Hubbard, MD (USA), Sindhuja Srinivasan, MBBS,vMSc, PhD (India), and Omer Raheem, MD (USA)

Commentary:
The short review by Japari et al elegantly addresses the challenging issue of managing and treating men with cryptozoospermia, specifically exploring whether ICSI outcomes differ between using ejaculated sperm and testicular sperm.

Traditionally, cryptozoospermia is often characterized by the absence of sperm in the ejaculate on routine testing, with sperm being detected only after centrifugation. This condition, which affects over 8% of men with infertility, shares many causes with azoospermia, such as varicoceles, hormonal imbalances, genetic issues, gonadotoxic or testosterone exposure, environmental factors, and even testicular damage. When cryptozoospermia is diagnosed, addressing modifiable factors like lifestyle changes, weight management, varicocele repair, and hormonal corrections should be considered as an initial treatment option. If these measures prove ineffective, ICSI can be a valuable treatment option.

Men with cryptozoospermia often face challenges with sperm collection, quality, and quantity in the ejaculate, ultimately leading to the common recommendation of combining surgical sperm retrieval (SSR) with ICSI. Contemporary research studies, including well-conducted meta-analyses, have often debated whether ejaculated sperm or testicular sperm leads to better fertilization, clinical pregnancy rates, and overall outcomes. Ejaculated sperm might be preferred due to its maturity and ease of collection. However, using ejaculated sperm presents potential drawbacks such as difficulties in sample collection, increased oxidative stress (resulting in higher sperm DNA fragmentation), and the need for centrifugation, all of which can negatively impact fertilization and clinical pregnancy rates. Conversely, SSR has emerged as an effective method, by directly obtaining testicular sperm that helps avoid these abovementioned issues. Nonetheless, potential surgical complications such as testicular damage leading to subsequent hypogonadism, psychological stress, an increased chance of being unable to retrieve sufficient sperm, and significant costs necessitate adequate counseling, discussion, and documentation before SSR.

To address these uncertainties, Japari et al. conducted a narrative review analyzing nine high-quality studies from 2013 to 2023. The review finds that there is no clear evidence conclusively favoring either testicular or ejaculated sperm. Some studies suggest the benefits of testicular sperm, such as lower sperm DNA fragmentation, better implantation rates, improved embryo quality, and fewer canceled ART cycles. However, findings are often unclear on critical outcomes like live birth and pregnancy rates.

Variability in results may be attributed to limitations in the studies, such as unaccounted female factor infertility, differences in ovarian stimulation protocols, and insufficient sperm for morphological selection in performing ICSI.

Given these gaps in the literature, future research should include a well-designed randomized trial comparing ejaculated versus testicular sperm with fertilization, live birth, and clinical pregnancy rates as endpoints, with a special focus on controlling for other factors such as female factor infertility. These additions would provide clearer guidance on this issue and inform current clinical practice.

Main Takeaways:
1. Address modifiable risk factors and lifestyle changes for cryptozoospermia before resorting to costly and invasive ART options.
2. There is no definitive consensus on whether testicular or ejaculated sperm is superior for pregnancy and live birth rates.
3. SSR may be considered in cases where:
❖ The patient cannot provide a specimen
❖ Cryopreservation is not possible
❖ Suitable sperm is not available on the day of egg retrieval

❖ There has been a prior ICSI failure with ejaculated sperm

❖ Elevated sperm DNA fragmentation is present

My Viewpoint on the TESE for Men with Cryptozoospermia
Dr. Logan Hubbard responds to questions from Ashok

Q1. What are the primary etiological factors associated with cryptozoospermia?

Dr. Hubbard: The etiologic drivers of cryptozoospermia are numerous and can share many features with causes of azoospermia. These causative factors can often be subcategorized into hormonal (hypo- and hypergonadotropic hypogonadism), genetic (Klinefelter syndrome, and Y chromosomal abnormalities), and factors causing direct damage to the testicles (varicoceles, surgery, trauma, chemoradiation, endocrine disrupting chemicals).

Q2. What are the current global practices regarding the use of preimplantation genetic testing in NOA patients?

Dr. Hubbard: In cases where fertilization is achieved with sperm from NOA patients with a background of Klinefelter syndrome or AZF microdeletion, PGT may be suggested. In the majority of Klinefelter syndrome, chromosomal aneuploidy is not a concern when sperm is retrieved. On the other hand, in cases of AZFc deletion, there is a very high possibility that the trait will be inherited if a male child is born. Counseling is strongly recommended, and whether to perform PGT largely depends on the social background and the preferences of the couple.

Q3. What are the benefits and risks associated with surgical sperm retrieval (SSR) in cryptozoospermic patients?

Dr. Hubbard: Surgical sperm retrieval (SSR) has demonstrated benefits in situations of elevated sperm DNA Fragmentation (SDF), and situations where obtaining ejaculated specimens is unreliable (the patient is unable to produce a specimen, or suitable sperm is
unable to be found on the day of egg retrieval). Certain benefits to assisted reproductive techniques (ART) exist – such as lower canceled cycle rates, and implantation rates – while other metrics such as live birth rates and pregnancy rates remain controversial. Despite these benefits, there are clear risks to SSR including surgical and anesthetic complications, tubular damage with consequent fibrosis hypogonadism, psychological duress from undergoing a procedure, and a significant financial burden to some patients.

Q4. What are the psychological and financial implications for patients undergoing SSR?

Dr. Hubbard: Male factor infertility in general carries with it a known psychological burden. A study of 300 men with disaggregated infertility found men undergoing urologic procedures were seven times more likely to experience significant infertility-related stress. Failed TESE procedures were found to lower patient self-esteem, add to familial stress, and even precipitate affective symptoms. These drawbacks are all compartmentalized from the financial burden of infertility treatment where studies have shown 47% of those surveyed reported financial strain due to infertility treatments, and 46% had management options limited due to expense. Both percentages are likely underestimations.

Q5. Why is it important to analyze multiple semen samples before deciding on SSR for cryptozoospermic patient?

Dr. Hubbard: ICSI is often the treatment of choice for men with crypotozoospermia. However, in instances when rare and motile ejaculated sperm can be identified, ICSI can be performed using these samples and surgery can potentially be avoided. Analyzing multiple samples can improve the likelihood of finding rare motile sperm suitable for ICSI. Furthermore, a recent study found that the use of multiple ejaculated samples over a short period had no adverse effect on sperm concentration and improved motility on the day of planned mTESE with a live birth rate of 36%.

Q6. What are the potential complications of SSR, and how can they be minimized?

Dr. Hubbard: The complications of SSR include standard surgical risks such as bleeding, infection, and damaging local structures. Although rates of complications vary somewhat by SSR procedure, each carries a risk of intratesticular hematoma formation, tubular damage, microcalcifications, hyalinosis, testicular atrophy, and hypogonadism. In addition to proper patient counseling and selection, the use of mTESE may help reduce complications versus other surgical techniques. mTESE has lower intratesticular hematoma rates, and fibrosis rates, though with similar rates of testosterone recovery on long-term follow-up.

Q7. How can lifestyle modifications and medical treatments improve sperm quality in cryptozoospermic patients?

Dr. Hubbard: Many lifestyle factors are directly correlated with decreased semen parameters and sperm integrity. Correction of obesity, excessive drinking, smoking, and drug use can generate improvements in ejaculate volume, SDF, and hormonal parameters. Similarly, an improved diet can decrease SDF and positively affect sperm parameters. Electromagnetic radiation (in the form of cellular devices and computers) can increase SDF and reduce anti-oxidative activities. Stress can affect sperm motility and viability, in addition to suppressing the hypogonadal pituitary-gonadal axis. Couples should try to minimize their exposure to these factors, which could help improve their chances of conceiving, and reduce the need for costly and invasive therapies.

Q8. What are the key considerations for reproductive specialists when counseling cryptozoospermic patients about their treatment options?

Dr. Hubbard: First and foremost, patients should be counseled regarding the correction of modifiable risk factors and lifestyle changes that can be made to improve their fertility before discussing ART. Their options of using either ejaculated sperm or SSR with ICSI should be thoroughly discussed including the risks and benefits of both choices. Patients who cannot provide a specimen, or suitable sperm is not available at the time of egg retrieval, instances where cryopreservation is not possible, there is elevated SDF or couples with prior ICSI failures should be considered for and counseled on SSR. Otherwise, patients can be advised that there is no definitive consensus as to whether testicular or ejaculated sperm is superior for pregnancy and live birth rates.

Q9. What future research is needed to better understand and manage cryptozoospermia in infertile men?

Dr. Hubbard: The field at large is lacking a well-designed randomized trial comparing ejaculated versus testicular sperm including measuring fertilization outcomes, live birthrates, and clinical pregnancy rates. Accounting for the etiology of patients with cryptozoospermia, and consideration of female factor fertility (age, ovarian reserve, ovarian stimulation protocols) is vital to providing clearer evidence that can ultimately answer unresolved questions in this ongoing debate.

Logan C. Hubbard MD, MS: Short Biography

Logan C. Hubbard MD, MS
Clinical Academic Assistant Professor
Department of Urology, Andrology, Men’s Health, & Reconstruction
University of Minnesota, Minneapolis, MN, USA
E-mail: lchubbard13@gmail.com
ORCID ID: 0000-0002-0115- 6870

Dr. Logan C. Hubbard is an Assistant Professor of Urology specializing in male infertility, sexual medicine, and reconstruction at the Department of Urology, University of Minnesota, Minneapolis, MN, USA. Before his academic appointment, Dr. Hubbard attended the University of Southern California where he earned a Bachelors in Biological Sciences, and Masters in Global Medicine. Dr. Hubbard then traveled to Philadelphia to attend Thomas Jefferson Medical College and earned his medical degree there in 2018. He completed residency in Texas at Houston Methodist, followed by a fellowship at Henry Ford in Detroit focused on andrology, infertility, and reconstruction. Dr. Hubbard’s early research includes oncology, endourology, andrology, and men’s health encompassing functional imaging trials and BPH. His current research includes management and diagnosis of azoospermia, management of azoospermia after failed microTESE, as well as work in male sexual dysfunction and penile prosthetics. Dr. Hubbard has over 15 publications with 54 citations and an h-index of 3.0.

My Viewpoint on the TESE for Men with Cryptozoospermia
Dr. Srinivasan responds to questions from Ashok

Q1. What is cryptozoospermia and how is it diagnosed?

Dr. Srinivasan: Cryptozoospermia is a term applied when there is no sperm seen on a wet mount of a semen sample, but sperm are identified in the pellet of a semen sample centrifuged at 3000g for 15 minutes. Centrifugation is the key step in differentiating
between azoospermia and cryptozoospermia when no sperms are seen in a fresh wet mount preparation. Interestingly, the term cryptozoospermia is not mentioned in the sixth edition of the WHO manual for Semen analysis and we use the definition of it as mentioned in the fifth edition.

Q2. How does intracytoplasmic sperm injection (ICSI) help in managing infertility in cryptozoospermic patients?

Dr. Srinivasan: In infertile patients with cryptozoospermia, ICSI is the only choice for fertilization. Since the overall number of sperm is low in cryptozoospermic patients, it is important to cryopreserve multiple samples before the ovum pick-up procedure to have a sufficient number of morphologically normal sperm for ICSI.

Q3. What are the advantages and disadvantages of using ejaculated sperm for ICSI in cryptozoospermic patients?

Dr. Srinivasan: The main advantage of using ejaculated sperm for ICSI is its availability without an invasive procedure. Depending on the number of oocytes retrieved, if more sperm is required, a second sample can be requested from the male partner. The major disadvantage of ejaculated sperm is the non-availability of morphologically normal sperm for selection and high DNA fragmentation.

Q4. How does sperm DNA fragmentation (SDF) impact the outcomes of ICSI in cryptozoospermic patients?

Dr. Srinivasan: Patients with cryptozoospermia often have higher levels of DNA fragmentation. However, there may not always be enough sperm to accurately diagnose high DNA fragmentation using tests like Sperm Chromatin Dispersion (SCD) or TUNEL in patients with cryptozoospermia. In these cases, several groups have tried using testicular sperm in the place of or in addition to using ejaculated sperm to overcome the effect of high DNA fragmentation, although there is not enough evidence to support this. In my experience, when performing ICSI in cryptozoospermic patients, other factors like morphology of available sperm, and number of expected oocytes have to be borne in mind to adequately counsel patients before performing testicular biopsy for use in ICSI.

Q6. How do the outcomes of ICSI with ejaculated sperm compare to those with testicular sperm in terms of fertilization, pregnancy, and live birth rates?

Dr. Srinivasan: Several individual studies have shown contradictory evidence for the use of testicular sperms over ejaculated sperms and vice versa in terms of fertilization, pregnancy, and live birth. However, two meta-analyses have confirmed that using testicular sperms over ejaculated sperms does not increase the fertilization rate but increases the pregnancy and live birth rates when DNA fragmentation is high in ejaculated sperms.

Sindhuja Srinivasan, MBBS, MSc (Clinical Embryol), PhD: Short Biography

Sindhuja Srinivasan, MBBS, MSc, PhD
Consultant Senior Embryologist, Lab in charge, Chennai, India
e-mail: namboori1990@gmail.com
ORCID id: 0000-0002-0714-8804

Dr. Sindhuja Srinivasan is a Senior Embryologist and Lab Director at the Department of Fertility Medicine, Gleneagles Health City, Chennai, Tamil Nadu, India. She has completed her Bachelor in Medicine and Surgery (MBBS) from Chettinad Medical College India after which her passion for Embryology led her to complete a Master's degree in Clinical Embryology at Sri Ramachandra University, Chennai, India. She served as a Lecturer in Clinical Embryology, at the Department of Reproductive Medicine and Surgery, Sri Ramachandra Medical College between 2016 to 2022. Her ongoing research includes the area of ovarian stem cells. She is also a certified quality assessor for IVF labs.

Omer Raheem MD, MSc, MCh Urol, MRCSI, FACS: Short Biography

Omer Raheem MD, FACS
Staff Urologist, Director of Men’s Health, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
E-mail: o merraheem@gmail.com
ORCID: 0000-0001-6117-116X

Dr. Omer Raheem is a Staff Physician within the Surgical Subspecialties Institute at Cleveland Clinic Abu Dhabi. He is an American Board-certified urologist specializing in men’s sexual health, male infertility, andrology, male genitourinary prosthetics, and reconstruction. Before joining Cleveland Clinic Abu Dhabi, Dr. Raheem worked as an Associate Professor of Urology and Director of the Men’s Health Clinic in the Section of Urology, Department of Surgery at the University of Chicago Medicine, Chicago, USA.
Dr. Raheem completed his residency in Urology at the University of California, San Diego, US, and his fellowship in Men’s Health and Genitourinary reconstruction at the University of Washington, Seattle, US. He has published over 150 peer-reviewed articles and nine book chapters. He is an Associate Editor of Sexual Medicine Reviews, Sexual Medicine and Video Journal of Sexual Medicine, the official journals of the Sexual Medicine Society of North America as well as Associate Editor of the Journal of Urology Open Plus and Online Content Associate Editor of the Journal of Urology, the official journals of the American Urologic Association.

Global Practice Patterns and Variations in the Medical and Surgical Management of Non-Obstructive Azoospermia: Results of a World-Wide Survey, Guidelines and Expert Recommendations

Wed, 07 Aug 2024 10:53:02 GMT

Article #55: “Global Practice Patterns and Variations in the Medical and Surgical Management of Non-Obstructive Azoospermia: Results of a World-Wide Survey, Guidelines and Expert Recommendations”
Authors: Amarnath Rambhatla, Rupin Shah, Imad Ziouziou, Priyank Kothari, et al. World J Mens Health World J Mens Health Published online Apr 4, 2024
https://doi.org/10.5534/wjmh.230339

Contributors: Eric Chung (Australia), Koji Chiba (Japan), Hisanori
Taniguchi (Japan), and Akira Tsujimura (Japan)

Commentary:

There is a lack of societal guidelines and ongoing controversies regarding non obstructive azoospermia (NOA) management. The experts from the Global Andrology Forum (GAF) have conducted the largest survey on the real-world medical and surgical management of NOA by reproductive experts. This global survey provides a valuable and comprehensive perspective on global practices in NOA and highlights the diverse practice patterns and the need for evidence-based international consensus guidelines.
A total of 367 participants from 49 countries completed the 56-question online survey. Specifically of interest are the questionnaires and expert recommendations relating to surgical sperm retrieval (SSR) in the settings of hormonal therapy and those with genetic conditions as well as the role of testicular biopsy and varicocele repair (VR).

There is no international consensus on the treatment regimen for NOA cases secondary to exogenous testosterone therapy. Exogenous testosterone should not be used for men with NOA who are still interested in testicular sperm retrieval and future fertility. Instead, selective estrogen receptor modulators, aromatase inhibitors, or human chronic gonadotropins can be used to raise testosterone levels without compromising spermatogenesis although the exact dose and formulation remain debatable. Hormonal therapy for 3 to 6 months was suggested before SSR with the SSR rate reported as high as 50.0% by the respondents. While microdissection testicular sperm extraction (mTESE) is the most efficient procedure for sperm retrieval in men with NOA, the proportion of surgeons performing mTESE is relatively low. The wide range of SSR rates reported by the survey participants can be explained by the heterogeneous nature of patients with NOA (age, location, testicular size, hormonal levels, etiology), and variations in surgeon experience and techniques. In patients with Klinefelter syndrome, the SSR rates were quoted between 20%–60% and it has been shown that surgeons’ expertise and high volume mTESE centers may have better success rates.

The presence of AZF deletions can significantly impact SSR and the chance of finding sperm in men with Y chromosome AZFc microdeletion remains reasonable although proper counseling should be undertaken regarding the transmission of the AZF deletion to the male offspring. On the other hand, it is advisable not to consider sperm retrieval in the settings of a complete deletion of AZFa and AZFb given the likelihood of severe spermatogenesis impairment. To date, testicular biopsy and mapping remain controversial. While this approach can be more cost-effective since the histopathological outcome can guide subsequent fertility management, testicular biopsy is not considered standard of care by most guidelines. Nonetheless, sending a testicular biopsy for histopathology during SSR may be reasonable to determine the subsequent prognosis if no sperm is identified in the sample or in men with risk factors for testicular malignancy such as cryptorchidism or intratesticular microlithiasis. Similarly, the role of VR in men with NOA remains controversial as is reflected in the divergent practice patterns and the limited concrete evidence. The decision to perform VR in cases of NOA is a shared decision between the physician and the couple after a detailed discussion of the risks and benefits, likely guided by parameters such as testicular volume, FSH level,female partner’s age, testicular

histology if available, and overall fertility status.

To our knowledge, this is the first global survey for NOA and addresses important issues for clinicians. The results demonstrate a diverse range of practices in the medical an surgical management of NOA and underscore the need for evidence-based international consensus guidelines to ensure the highest standard of care for all patients. It is important to acknowledge the great variations in the findings among the respondents which reflect the locoregional expertise, access to technology, and financial aspects in NOA management. Comparing contemporary expert global practices against available international practice guidelines, the “expert recommendation” section can clarify the current best practices of NOA management based on global practices, society guidelines, and available evidence from the literature.

Take Home Message
Contributing author: Ashok Agarwal, Director, Global Andrology Forum, Moreland Hills, OH, USA

1. Microdissection Testicular Sperm Extraction (mTESE) as the Preferred Technique: mTESE remains the superior technique for sperm retrieval in men with NOA, particularly in those with small testicular volume, high FSH levels, or a history of testicular injury. Most guidelines and expert opinions recommend mTESE as the first-line approach when available.

2. Significance of Testicular Biopsy: Performing a testicular biopsy during surgical sperm retrieval (SSR) is essential for establishing a histological diagnosis, assessing the prognosis for future sperm retrieval attempts, and detecting conditions like intratubular germ cell neoplasia in situ (GCNIS), which could pose a high risk for testicular cancer.

3. Gene Therapy and CRISPR/Cas9 as Emerging Therapies : Gene therapy, particularly using CRISPR/Cas9 technology, shows potential for treating NOA caused by genetic defects. However, its clinical application requires further research to determine safety and efficacy.

4. Controversy in Varicocele Repair: While varicocele repair (VR) is considered for improving sperm retrieval in NOA patients, the evidence supporting its efficacy is limited. Specialists should counsel patients that while VR might increase the chances of sperm appearance in the ejaculate, the quality of evidence remains poor, and results may take up to 12 months.

5. Heterogeneity in Global Practices: There is significant variability in the global management of NOA, with practices often differing from established guidelines. This underscores the need for evidence-based international consensus guidelines to standardize care and improve outcomes.

Eric Chung, MBBS, FRACS: Short Biography

Eric Chung, MBBS, FRACS
Professor of Surgery, the University of Queensland,
Clinical Director, the AndroUrology
Centre for Sexual, Urinary and Reproductive Excellence
Brisbane, QLD Australia
E-mail: ericchg@hotmail.com
ORCID ID: 0000-0003-3373-3668

Eric Chung, MBBS, FRACS, a renowned reproductive urologist, is a Professor of Surgery at the University of Queensland, Brisbane, and Macquarie University Hospital, Sydney. As Clinical Director of the AndroUrology Centre for Sexual, Urinary, and Reproductive Excellence, Eric has made significant strides in understanding and treating male sexual dysfunctions, including Peyronie's disease, erectile dysfunction, and testosterone deficiency. He has authored over 193 peerreviewed articles and has an h-index of 33 and 2,694 citations on Scopus (July 2024). Eric holds leadership positions and serves on various committees. His contributions to medicine and academia have been recognized with multiple awards and honors. Eric’s dedication to andrological research and education secured him a coveted position on the GAF Management Council. As a key advisor, he reviews, writes, and edits research manuscripts and book chapters, and advises the senior management on new
ideas, projects, and global surveys

My Viewpoint on the GAF Global Survey on Medical and Surgical Management of NOA
Dr. Koji Chiba responds to questions from Ashok

Q1. What factors influence the decision to perform mTESE simultaneously with oocyte retrieval versus performing it with cryopreservation?

Dr. Chiba: Considering the sperm retrieval rate in mTESE, there are not a few cases where ICSI cannot be performed even when oocytes are retrieved, and performing mTESE simultaneously with oocyte retrieval may impose unnecessary invasion on the wife. On the other hand, fresh sperm may have a better effect on ICSI results, since sperm can receive a certain amount of damage from freezing and thawing. In cases planning to use donor sperm if sperm could not be retrieved, or with a strong expectation of sperm retrieval (e.g. in cases of AZFc deletion), mTESE simultaneously with oocyte retrieval is more likely to be proposed.

Q2. What are the current global practices regarding the use of preimplantation genetic testing in NOA patients?

Dr. Chiba: In cases where fertilization is achieved with sperm from NOA patients with a background of Klinefelter syndrome or AZF microdeletion, PGT may be suggested. In the majority of Klinefelter syndrome, chromosomal aneuploidy is not a concern when sperm is retrieved. On the other hand, in cases of AZFc deletion, there is a very high possibility that the trait will be inherited if a male child is born. Counseling is strongly recommended, and whether to perform PGT largely depends on the social background and the preferences of the couple.

Q3. How does the use of ultrasound to identify the most vascularized areas in the testis impact the success rates of sperm retrieval in NOA?

Dr. Chiba: There is currently no firm evidence supporting the use of imaging techniques to improve the success of sperm retrieval. However, in a situation where the sperm retrieval rate for mTESE is not satisfactory, it is hoped that new techniques to be developed to identify the foci where sperm is present.

Q4. How does the use of ultrasound to identify the most vascularized areas in the testis impact the success rates of sperm retrieval in NOA?

Q5. What are the recommended waiting periods before proceeding to mTESE after a failed conventional TESE?

Dr. Chiba: Depending on the extent of the invasion to the testes caused by cTESE, tissue damage due to subcapsular hematomas and other factors may persist for around six months. On the other hand, a prolonged waiting period can impact the age factors of the couple. Therefore, it is reasonable to propose mTESE after about 6 months. However, if the initial cTESE was minimally invasive, it might be acceptable to perform mTESE after approximately three months.

Q6. How do the practices of using fine-needle aspiration (FNA) before mTESE vary among clinicians?

Dr. Chiba: Performing FNA before mTESE may provide the possibility of obtaining sperm that can be used for ICSI and may provide helpful information on the location to be explored for mTESE. However, FNA is not a completely non-invasive procedure and there are concerns about certain damage to the testicular parenchyma, such as hematoma or inflammation. Only a few doctors perform FNA before mTESE, and some question its usefulness, while others even argue that it harms later mTESE. At present, there is a lack of enough evidence to suggest that FNA should be recommended in many NOA cases before mTESE.

Q7. What are the challenges in establishing evidence-based international consensus guidelines for the management of NOA?

Dr. Chiba: Management of NOA is complex because of the variety of its pathologies. In addition, there may be differences due to racial biological differences and differences in the social structure surrounding healthcare. If the management of NOA can be viewed from a global perspective through surveys, as was done in this study, it should be useful to establish evidence-based international consensus guidelines for the management of NOA.

Q8. How does the geographical distribution of respondents impact the reported practice patterns in NOA management?

Dr. Chiba: There are certain differences in testicular pathology between races, accessibility to healthcare, and the costs covered by healthcare insurance from country to country. These factors could have a significant impact on the management of NOA. Due to these factors, the geographical distribution of respondents may influence the outcome of the NOA practice pattern.

Q9. What are the expert recommendations for hormonal therapy before SSR in NOA patients based on the Delphi process?

Dr. Chiba: The evidence in favor of hormonal therapy to increase SSR in patients with NOA is still low and it is not a routine treatment. However, some patients may benefit from hormonal therapy as it may increase SSR. Further detailed research to determine which patients and which treatments may increase SSR is expected to advance and be applied clinically in the future.

Koji Chiba, MD, PhD: Short Biography

Koji Chiba, MD, PhD
Associate Professor
Department of Urology,
Kobe University Graduate School of Medicine, Hyogo, Japan
e-mail: kchiba@med.kobeu.ac.jp
ORCID id: 0000-0001-5575-0667

Dr. Koji Chiba graduated from Kobe University School of Medicine in 2001 and is welltrained in the Department of Urology, Kobe University Hospital, and its affiliated hospitals. After completing his general training, he subspecialized at Kobe University Graduate School of Medicine in andrology practice, including male infertility and LOH syndrome. He got a Ph.D. degree from Kobe University for his publication on basic research on spermatogenesis in 2011. He was at the Center for Reproductive Medicine, Baylor College of Medicine as a research fellow from 2014 to 2015. Koji is currently practicing andrology in addition to general urology at Kobe
University Hospital.

My Viewpoint on the GAF Global Survey on Medical and Surgical Management of NOA
Dr. Hisanori Taniguchi responds to questions from Ashok

Q1. What are the cutoff levels for FSH that predict positive SSR outcomes?

Dr. Taniguchi: At this time, there is no definitive cutoff value of FSH that predicts a positive SSR outcome for NOA patients. In other words, there is no evidence that FSH levels are not appropriate for mTESE for NOA patients. If a NOA patient shows an FSH level of around 8-9 IU/L, the physician should consider hypospermatogenesis or late spermatocyte arrest before TESE.

Q2. How does the management of NOA differ in patients with Klinefelter syndrome?

Dr. Taniguchi: The difference in management between patients with Klinefelter syndrome (KS) and those without KS is the management after TESE. Testicular volume in patients with KS often tends to be smaller and tends to have lower testosterone levels before TESE. Therefore, the physician should pay close attention to testosterone levels after TESE. However, there are no definitive criteria for testosterone levels during this period. Because low testosterone levels are associated with anemia, osteoporosis, and diabetes, the physician should explain to patients with KS preoperatively the possible complications that low testosteronemia can cause. It should also be explained that in some cases, testosterone replacement therapy may be recommended postoperatively.

Q3. What are the benefits and limitations of microsurgical varicocelectomy in improving sperm retrieval rates in NOA patients?

Dr. Taniguchi: As discussed in the main manuscript, there is limited evidence to support varicocelectomy in patients with NOA. Most varicocelectomy is undergone for cases that expect sperm appearance in the ejaculate and improve sperm retrieval such as a relatively normal FSH level (<10 IU/L) or relatively smaller ipsilateral testis. However, the appearance of sperm in the ejaculate may avoid surgery (mTESE), and improvement in sperm quality after varicocelectomy may improve fertility rates. In the case of varicocelectomy, the physician should explain the side effects of the surgery and the extended duration of treatment, especially in older couples.

Q4. What are the current recommendations for managing NOA due to exogenous testosterone use?

Dr. Taniguchi: Discontinuation of exogenous testosterone is strongly recommended. Alternatives include oral clomiphene citrate or hCG injections. Some patients present with NOA due to testosterone administration. There are cases in which discontinuation of
testosterone administration alone can be expected to restore spermatogenesis 3 months or later after discontinuation.

Hisanori Taniguchi, MD, PhD: Short Biography

Hisanori Taniguchi, MD,PhD
Associate Professor
Department of Urology and Andrology, Kansai Medical
University Hospital Osaka, Japan
e-mail: taniguhi@hirakata.kmu.ac.jp
ORCID id: 0000-0002-7404-0369

Dr. Hisanori Taniguchi is a clinical urologist at the Department of Urology and Andrology, Kansai Medical University, Hirakata, Osaka, Japan. He graduated from the Kansai Medical University in 2003 and was trained in the Department of Urology and Andrology, Kansai Medical University Hospital, and its affiliated hospitals. After completing his general training, he subspecialized in andrology practice, including male infertility, erectile dysfunction, and LOH syndrome. He got a Ph.D. degree from Kansai Medical University for his publication related to testosterone production. He had been at Memorial Sloan Kettering Cancer Center as a clinical investigator in 2017. He is currently practicing andrology actively in addition to general urology at Kansai Medical University Hospital. Dr. Taniguchi has published 69 research articles in peer-reviewed journals, has 475 citations, and has an h-index of 11 according to Scopus.

My Viewpoint on the GAF Global Survey on Medical and Surgical Management of NOA
Prof. Akira Tsujimura responds to questions from Ashok

Q1. How do different global practices approach the treatment of normogonadotropic, hypogonadotropic, and hypergonadotropic hypogonadism in NOA patients?

Dr. Tsujimura: The most ideal case for hormonal treatment before performing TESE for NOA is hypogonadotropic hypogonadism. Normal gonadotropism should be considered next, while hypergonadotropic hypogonadism, which is most common in NOA, is performed the least frequently. Recently, there have been reports that when sperm cannot be extracted after the first mTESE, hormone therapy can be used before the second mTESE attempt even for hypergonadotropic hypogonadism, and hormone therapy can be considered if the patient wishes. In any case, the most important factor to consider should be FSH.

Q2. What is the impact of varicocele repair on the appearance of sperm in the ejaculate in NOA patients?

Dr. Tsujimura: There is no uniformity in the response to NOA patients with varicocele. The EAU guideline suggests that the ejaculated sperm emergence rate with varicocele repair is 20.8% to 55.0% for NOA patients with varicocele, but in actual clinical practice, the rate seems to be a little lower. Even if varicocele repair does not result in the appearance of ejaculated sperm, the fact that the sperm retrieval rate by TESE is improved by varicocele repair is also supportive of recommending varicocele before TESE.

Q3. How does the variability in hormonal therapy recommendations reflect the quality of evidence available for treating NOA?

Dr. Tsujimura: The unequivocal evidence is the avoidance of testosterone administration. There is uniformity in the notion that the benefit of hormonal therapy is limited, at least not routinely. No one strongly recommends hormonal treatment, although there are differences in the recommendations. It is desirable to establish what should be recommended through analysis of a large number of cases in the future.

Q4. What are the common predictors of successful sperm retrieval in NOA patients undergoing SSR?

Dr. Tsujimura: Various factors have been analyzed, including testicular size, FSH, age, and others, but the factors that predict successful sperm retrieval are not clear. Some centers have attempted to improve sperm retrieval rates by performing preoperative ultrasound examinations, but their usefulness is skeptical. The most significant predictive factor is probably the preoperative examination of testicular tissue. In this sense, some centers perform preoperative FNA. However, it is not yet a standard procedure, and its usefulness is not yet sufficient.

Q5 . What are the key differences between obstructive and non-obstructive azoospermia in terms of etiology and management?

Dr. Tsujimura: The most common congenital form of obstructive azoospermia is congenital bilateral absence of the vas deferens (CBAVD), while the most common acquired form is infection of the epididymis or prostate gland. Many cases of non-obstructive azoospermia are congenital, including chromosomal and genetic abnormalities such as Klinefelter syndrome and Y-chromosome microdeletions. However, some cases are acquired as a result of chemotherapy or radiation therapy as well as post-mumps orchitis. In obstructive cases, reproductive tract surgical reconstruction is the treatment of choice; however, considering the wife's age and other factors, the patient may proceed to TESE-ICSI. In non-obstructive cases, there is no alternative but to hope for sperm retrieval with TESE-ICSI.

Q6. How does the lack of clear guidelines affect the management of NOA across different regions?

Dr. Tsujimura: In NOA, the only way to have a baby in any region is TESE-ICSI. However, there is still no certainty about the technical procedure of TESE. There is also no uniform treatment strategy for NOA associated with varicocele. In addition, the usefulness of hormonal therapy before TESE is also unclear, and its implementation varies from region to region. Accumulation of evidence and enhancement of treatment are desirable.

Q7. What is the role of hormonal therapy in the management of NOA, and how do different guidelines view its efficacy?

Dr. Tsujimura: Regarding hormone therapy before TESE for NOA, the EAU guidelines are negative, and the AUA/ASRM guidelines recommend that patients be informed that there are some effective cases of hormone therapy before TESE. Although the guidelines are not clear and recent meta-analyses have not always confirmed the benefit, many cases are treated with hormone therapy before TESE.

Q8. How effective is mTESE compared to cTESE for sperm retrieval in NOA?

Dr. Tsujimura: It is generally believed that mTESE increases the sperm retrieval rate compared to cTESE. However, there are no reliable comparative studies of the two techniques, and mTESE is not always the only technique used. mTESE is given only a weak
recommendation in the EAU guidelines, as the sperm retrieval rates of mTESE and cTESE are similar in several reports. Some centers continue to perform mTESE if no sperm is identified after cTESE. Nevertheless, mTESE is most commonly performed from the beginning in a real-world setting.

Akira Tsujimura, MD, PhD: Short Biography

Akira Tsujimura, MD, PhD
Professor of Urology
Department of Urology,
Juntendo University Urayasu Hospital
Urayasu, Chiba, Japan
E-mail: atsujimu@juntendo.ac.jp
ORCID: 0000-0002-3821-5184

Prof. Akira Tsujimura graduated from the Hyogo Medial College in 1988 and was well trained in the Department of Urology, at Osaka University Hospital and its affiliated hospitals. After finishing general training, he has been working on erectile dysfunction, male infertility, and prostate disease at Osaka University Graduate School of Medicine. He got a Ph.D. degree for the publication of andrology and biochemistry area in 1998. He had been at New York University Medical School as a research fellow from 1998 to 2000. Moreover, he has made remarkable achievements in male infertility, erectile dysfunction, and prostate research. He moved to Juntendo University in 2014 and now is working at the Department of Urology, Juntendo University Urayasu Hospital. Akira is the President of the Japan Society of Andrology, Vice President of the Japan Society for Reproductive Medicine, and the Vice President of the Japanese Society for Sexual Medicine. He has published about 320 research articles, has a citation count of 5,232,
and an h-index of 37 according to Scopus (Aug 2024).

Effectiveness of, and Satisfaction with, a Microsurgical Testicular Sperm Extraction Knowledge and Skills Masterclass for a World-Wide Audience

Mon, 05 Aug 2024 03:12:42 GMT

Article #53: “Effectiveness of, and Satisfaction with, a Microsurgical Testicular Sperm Extraction Knowledge and Skills Masterclass for a World-Wide Audience”
Authors: Walid El Ansari, Mohamed Arafa, Merilyn Lock, Rupin Shah, Ashok Agarwal, World J Mens Health 2024 Jul 42(3): 574-586
https://doi.org/10.5534/wjmh.230195

Contributors: Edoardo Pozzi, MD (USA, Italy), Murat Dursun, MD

(Turkey), Mustafa Kadihasanoglu, MD (Turkey)

Commentary:

The study on microsurgical testicular sperm extraction (mTESE) training masterclass represents a significant milestone in addressing the critical need for specialized training in mTESE on a global scale (1). As the complexity of male factor infertility (MFI) management continues to row, so does the imperative for highly skilled practitioners capable of performing procedures like mTESE (2). This paper highlights the effectiveness of a novel online masterclass and underscores several key issues in contemporary andrology education and practice (1). First and foremost, the author’s innovative approach to delivering a comprehensive mTESE masterclass through a hybrid model deserves commendation (1). Combining didactic lectures with interactive case discussions has created a learning environment that bridges the gap between theory and practice - a crucial aspect often overlooked in traditional medical education (1). The Global Andrology Forum's (GAF) utilization of technology to reach a worldwide audience is particularly noteworthy, as it democratizes access to specialized knowledge that was previously confined to select institutions. The study's findings of broad, deep, and inclusive learning outcomes across various participant demographics are encouraging (1). However, they also reveal a concerning baseline deficiency in mTESE knowledge and skills among practicing andrologists (1). This gap in expertise, highlighted by the fact that 57% of participants had no prior mTESE training, raises important questions about the current state of andrology residency programs and continuing medical education globally (1). As such, 55% of the participants who stated that they had received mTESE training reported that they achieved this through the watched videos (1). This indicates the necessity of using standardized training materials (surgery videos) and a need for expanded practical training sessions (1). Moreover, the differential improvement observed among participants - with those having less experience and lower self-rated skills showing greater relative gains - points to the potential of such masterclasses in rapidly upskilling the andrology workforce (1). This is particularly crucial in addressing disparities in male infertility care across different healthcare settings and geographical regions.

While the authors should be commended for their rigorous evaluation of the masterclass's impact, future iterations could benefit from long-term follow-up to assess knowledge retention and, more importantly, the translation of learned skills into clinical practice. Additionally, the development of standardized, competency-based assessment tools for mTESE proficiency could further improve the value of such educational initiatives. The near-universal satisfaction reported by participants underscores the need for high-quality, accessible training in advanced andrological techniques. However, it also highlights a worrying lack of similar educational opportunities in the field. As such, this study serves as a call to action for professional societies and academic institutions to invest in developing and scaling up similar programs. In conclusion, the GAF authors have not only demonstrated the efficacy of their mTESE masterclass but have also outlined the urgent need for a paradigm shift in andrology education. Their work challenges the andrology community to reimagine how we train the next generation of specialists and upskill current practitioners. As we move forward, it will be crucial to build upon this model, integrating hands-on training components and engaging in emerging technologies like virtual reality to further enhance learning outcomes (3). The GAF's initiative marks an important step towards standardizing and elevating the quality of male infertility care worldwide. It is now incumbent upon the broader andrology community to answer this call and work collaboratively to ensure that every practitioner has access to the knowledge and skills necessary to offer patients the highest standard of care, regardless of their geographical location or practice setting.

References:

1. El Ansari W, Arafa M, Lock M, Shah R, Agarwal A. Effectiveness of, and satisfaction with, a microsurgical testicular sperm extraction knowledge and skills masterclass for a world-wide audience. World J Mens Health. 2024 Jul;42(3):574–86.

2. Schlegel PN. Testicular sperm extraction: microdissection improves sperm yield with minimal tissue excision. HumReprod. 1999 Jan 1;14(1):131–5.

3. Cacciamani GE, Chen A, Gill IS, Hung AJ. Artificial intelligence and urology: ethical considerations for urologists and patients. Nat Rev Urol. 2024 Jan;21(1):50–9.

Edoardo Pozzi, MD 1,2,3,4 , Murat Dursun, MD 5,4, Mustafa Kadihasanoglu, MD 6,4

Desai Sethi Urology Institute, Miller School of Medicine, University of Miami, Miami, FL, USA;
University Vita-Salute San Raffaele, Milan, Italy;
Division of Experimental Oncology/Unit of Urology,
Global Andrology Forum, Moreland Hills, OH, USA; URI; IRCCS Ospedale San Raffaele, Milan, Italy;
University of Istanbul, Faculty of Medicine, Department of Urology, Section of Andrology, Istanbul, Turkey;
Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Department of Urology, Istanbul, Türkiye

Authors ORCID:

Edoardo Pozzi: 0000-0002-0228-7039

Murat Dursun : 0000-0001-9115-7203

Mustafa Kadihasanoglu : 0000-0001-5109-5319

Corresponding Author:

Edoardo Pozzi, M.D.

Desai Sethi Urology Institute

Miller School of Medicine

University of Miami, Miami, FL, USA

Email: exp1710@miami.edu

Take Home Message

Contributing author: Ashok Agarwal, Director, Global Andrology Forum, Moreland Hills, OH, USA

Significant Knowledge Improvement: The masterclass markedly improved participants' mTESE knowledge and skills, with pre-quiz scores increasing from an average of 13.7 to 17.1 post-quiz. This improvement was consistent across various demographic and professional backgrounds, demonstrating the comprehensive and effective nature of the training.

Broad and Inclusive Impact: The enhancement in knowledge was broad, covering 19 out of 24 quiz questions, and inclusive, with all participants showing improvements regardless of their demographics or professional attributes. Notably, those with less prior experience or lower self-rated skills saw the most significant gains.

High Satisfaction: Participants reported extremely high satisfaction levels (98% to >99%) with the masterclass, highlighting the quality and relevance of the content, which included didactic lectures and case discussions led by international experts in male infertility management.

Global Andrology Forum's Effective Model: The success of this masterclass showcases the effectiveness of the Global Andrology Forum's model for online and hybrid educational activities. This model can be adopted by other organizations aiming to enhance specialist training in andrology and related fields.

My Viewpoint on mTESE Masterclass for a World-Wide Audience

Dr. Edoardo Pozzi responds to questions from Ashok

Q1. What is the primary advantage of mTESE over conventional testicular sperm extraction (TESE) in non-obstructive azoospermia (NOA) patients?

Dr. Pozzi: The primary advantage of mTESE over conventional TESE in NOA patients is its superior safety and efficacy profile, with significantly reduced overall testicular tissue damage. This advantage resides in the microdissection technique used in mTESE, which allows for a more precise and targeted approach to sperm retrieval by minimizing excisional damage (mainly on Leydig cells). Moreover, through mTESE it is possible to identify areas more likely to contain sperm (dilated tubules), minimizing unnecessary tissue removal. Lastly, it is important to note that while mTESE is generally considered safer than conventional TESE, it is not without risks. Potential complications can include scrotal hematoma, abscesses, infections, and potential long-term impairment of testicular function. Additionally, there are concerns about the procedure's impact on hormonal function. The tissue excision during mTESE may lead to temporary or long-term hormonal dysfunction, affecting testosterone production, circulating total testosterone levels, follicle-stimulating hormone levels, and luteinizing hormone levels. These hormonal changes can potentially disrupt the homeostasis of the hypothalamic-pituitary-gonadal axis. Evidence is still controversial on this specific topic.

Q2. How do patient characteristics, such as age and testicular volume, influence the success rate of mTESE?

Dr. Pozzi: Patients’ characteristics may play a crucial role in men undergoing mTESE. Specifically, age has a somewhat controversial role in patients with NOA. As such, current evidence has not definitively established a specific age cutoff for paternal age and sperm retrieval outcomes in mTESE procedures. However, some studies suggest that increased paternal age may negatively affect sperm retrieval rates, particularly in patients with certain genetic conditions such as Klinefelter syndrome. The same holds true for testicular volume.

Q3. What are the key predictors of successful sperm retrieval in mTESE?

Dr. Pozzi: This is a million-dollar question. Many studies have attempted to answer and find reliable predictors for sperm retrieval in men undergoing mTESE for NOA. As such, key predictors of successful sperm retrieval in mTESE for men with NOA primarily involve hormonal markers. Anti-Müllerian hormone (AMH) has emerged as the most promising predictor, with lower serum AMH levels and a lower AMH/testosterone ratio associated with higher chances of successful sperm retrieval. AMH has shown consistent results across multiple studies and is considered a “reliable” biomarker for predicting positive sperm retrieval outcomes.

The follicle-stimulating hormone has been extensively studied, but its predictive value remains controversial. Some studies suggest that higher preoperative FSH levels may be associated with successful sperm retrieval, while others have found no significant correlation. Inhibin B (InhB) has also been investigated as a potential predictor. Lower baseline InhB levels have been associated with positive sperm retrieval in some studies. However, its role as a predictor is not firmly established, and more comprehensive research is needed to confirm its utility. It is important to note that the predictive value of these hormones can vary depending on the specific etiology of NOA. The complexity and heterogeneity of NOA cases make it challenging to establish definitive predictors. Additionally, factors such as patient age, testicular volume, and the surgeon's expertise may also influence mTESE outcomes.

Q4. How does the experience and training of the surgeon impact the outcomes of mTESE procedures?

Dr. Pozzi: The experience and training of the surgeon significantly impact the outcomes of mTESE procedures. Surgeons with specialized training in reproductive health, particularly those who have completed fellowships focused on male infertility, certainly achieve higher sperm retrieval rates. This is due to their advanced knowledge of testicular anatomy and their ability to identify subtle differences in seminiferous tubules that may contain sperm. Surgical volume is another critical factor. Surgeons who regularly perform mTESE procedures surely demonstrate better outcomes compared to those who perform them infrequently.

Q5. What are the potential complications associated with mTESE, and how can they be minimized?

Dr. Pozzi: mTESE can lead to several potential complications, despite being considered safer than conventional TESE and generally a very safe operation. These include scrotal hematoma, abscesses, infections, and potential long-term impairment of testicular function. Of particular concern is the procedure's impact on hormonal function, which may result in temporary or long-term hormonal dysfunction affecting testosterone production. To minimize these complications, several factors are crucial. First, the surgeon's experience and training play a significant role. Surgeons with specialized training in reproductive health and high surgical volumes tend to achieve better outcomes with fewer complications. Their expertise allows for more precise identification of sperm-containing tubules, minimizing unnecessary tissue removal and reducing the risk of hormonal disruption.

Edoardo Pozzi, MD: Short Biography

Edoardo Pozzi, MD 1,2

1.Desai Sethi Urology Institute, University of Miami

Miami, FL, USA

2.Division of Experimental

Oncology/Unit of Urology, Urological Research Institute (URI)

Università Vita-Salute San

Raffaele, Milan, Italy

IRCCS Ospedale San Raffaele, Milan, Italy

Email: pozzi.edoardo@hsr.it

ORCID: 0000-0002-0228-7039

Dr. Edoardo Pozzi works in Urology at Vita-Salute San Raffaele University, Milan, Italy. He graduated with honors and special mention from the English-language Medicine and Surgery program at the same university in 2019. During his final year of studies, he completed a research fellowship at the Andrology Department of University College London Hospital (UCLh) in London. After obtaining his license to practice clinically in the United States, Edoardo is doing a fellowship at the University of Miami, Desai Sethi Urology Institute. In Miami, he is involved in clinical/surgical activities and research in the uro-andrological field. He has authored over 90 scientific publications in indexed international journals, as well as six chapters in the uro-andrological field. He serves as Associate editor of the International Journal of Impotence Research (Springer Nature) and as a reviewer for several important scientific journals, including Human Reproduction, Fertility & Sterility, Andrology, and the Journal of Sexual Medicine.

My Viewpoint on mTESE Masterclass for a World-Wide Audience

Dr. Murat Dursun responds to questions from Ashok

Q1. How do hormonal treatments, such as those involving follicle-stimulating hormone (FSH), improve mTESE outcomes?

Dr. Dursun: The use of exogenous gonadotropins is known to be effective in azoospermic patients with hypogonadotropic hypogonadism. However, although studies on pre-surgical hormonal treatment in men with idiopathic non-obstructive azoospermia (NOA) are promising, there is still insufficient data to recommend it as a routine treatment. In studies, it has been suggested that increasing intratesticular testosterone (ITT), especially in those with low ITT, can enhance spermatogenesis and improve the success of sperm retrieval. Increased follicle-stimulating hormone (FSH) serum levels resulting from treatment can

also stimulate spermatogenesis. Various treatment options for this purpose include human chorionic gonadotropin (hCG) and/or FSH, as well as selective estrogen receptor modulators.

Q2. What role do molecular biomarkers and noncoding RNAs in seminal plasma play in predicting mTESE success?

Dr. Dursun: It has been shown that seminal plasma (SP) can be a rich source of non-invasive biomarkers, including tissue-specific RNAs and proteins. Therefore, SP biomarkers could be used to predict the success of sperm retrieval. MicroRNAs, long non-coding RNAs, circRNAs, tRNA-derived small RNAs (tsRNAs), Anti-Mullerian hormone (AMH), inhibin B, and certain metabolites have been studied as seminal plasma biomarkers to predict the success of sperm retrieval in men with NOA. However, the current evidence is not sufficient to allow the routine use of these biomarkers.

Q3. How does the use of advanced imaging techniques, like multiphoton microscopy, enhance the identification of active spermatogenesis during mTESE?

Dr. Dursun: mTESE is the first choice for sperm retrieval in men with NOA. However, there are difficulties in distinguishing between seminiferous tubules with normal and abnormal spermatogenesis. Some advanced imaging techniques, such as multiphoton microscopy (MPM), Raman spectroscopy (RS), and full-field optical coherence tomography (FFOCT), have been developed to make this distinction and potentially increase the success of sperm retrieval. However, these methods have not yet entered clinical use and remain at the experimental stage.

Q4. What are the key intraoperative factors that influence the success of mTESE in patients with NOA?

Dr. Dursun: In patients with non-obstructive azoospermia, success in sperm retrieval is enhanced by the seminiferous tubule structure and microscopy. It is known that the sperm retrieval rate with mTESE is 1.5 times higher than with the conventional method. Additionally, as the calibration of seminiferous tubules increases, the sperm retrieval rate also increases. As a surgical method, longitudinal tunical incision followed by intratunical longitudinal and transverse slicing yields higher sperm retrieval rates.

Q5. How do outcomes of salvage mTESE compare to initial mTESE procedures in patients who have previously failed TESE?

Dr. Dursun: The sperm retrieval rate with the first mTESE is around 50%. Therefore, in about h alf of the patients, sperm is not found, and salvage micro-TESE is needed. Studies have reported sperm retrieval rates with salvage mTESE ranging from 12% to 79%. Identifying parameters that affect success in salvage surgery can reduce TESE complications that may lead to potential tissue loss. A meta-analysis showed that younger age, lower levels of FSH and LH, smaller testicular volume, and histopathologically diagnosed hypospermatogenesis are associated with higher success rates in salvage micro-TESE surgery.

Murat Dursun, MD, FEBU: Short Biography

Murat Dursun, MD, FEBU

Associate Professor

Section of Andrology,

Department of Urology,

Faculty of Medicine,

University of Istanbul, Turkey

e-mail: murat.dursun@istanbul.edu.tr

ORCID id: 0000-0001-9115-7203

Dr. Murat Dursun is an Associate Professor at the University of Istanbul, Faculty of Medicine, Department of Urology, Section of Andrology. He graduated from the University of Istanbul in 2008 and completed his Urology residency at Okmeydani Training and

Research Hospital in 2014. Dr. Dursun has been a Fellow of the European Board of Urology (FEBU) since 2014. He is a member of the Turkish Association of Urology, the Turkish Association of Andrology, and the Global Andrology Forum. To enhance his knowledge and experience, he completed a three-month fellowship at Charité – Universitätsmedizin Berlin in 2022. His research

and clinical activities focus on male infertility, male sexual function (including erectile dysfunction, priapism, and Peyronie’s disease), and prostatic diseases (BPH, prostate cancer). He has published over 60 articles on PubMed, with 657 citations, and has an h-index of 16 in Scopus.

My Viewpoint on mTESE Masterclass for a World-Wide Audience

Dr. Mustafa Kadihasanoglu responds to questions from Ash ok

Q1. What are the best practices for training and skill development in mTESE for reproductive surgeons?

Dr. Kadihasanoglu: The appropriate assessment of potential patients and the effective implementation of the mTESE procedure necessitate a wide range of knowledge and abilities. A surgeon's experience and training are essential for a successful sperm retrieval procedure in mTESE, as there are significant learning curves involved. This makes proper training for the procedure especially important. A successful mTESE training program should incorporate both case discussions and didactic lectures. The program comprises a sequence of didactic lectures that commence with an overview of the mTESE technique's anatomy and tips and tricks. The lectures conclude with an array of tactics, strategies, and pearls that are intended to optimize mTESE outcomes in diverse clinical scenarios. Case studies of varied, complex non-obstructive azoospermia cases are presented after these didactic lectures. These cases represent the challenging conditions and heterogeneous, contentious situations that the andrology team may encounter when managing non-obstructive azoospermia.

Q2. How does the presence of conditions like Klinefelter syndrome affect the likelihood of successful sperm retrieval through mTESE?

Dr. Kadihasanoglu: A congenital trisomy of male sex chromosomes, Klinefelter syndrome (KS) is typified by the presence of one or more extra X chromosomes and manifests phenotypically as hypergonadotropic hypogonadism and testicular failure. KS accounts for approximately 10% of patients with secretory azoospermia and is the most common chromosomal abnormality in infertile individuals. The majority of KS patients are infertile and have secretory azoospermia. The successful spermatozoa recovery (SSR) from the seminiferous tubules has also been made possible by the presence of focal spermatogenesis in KS patients. KS patients have tubular sclerosis and atrophy, complete and incomplete germ-cell aplasia, and complete and incomplete maturation arrest. In comparison to unsuccessful sperm retrieval cases, several patient characteristics were found to be associated with SSR cases. According to multiple studies, there is a substantial correlation between SSR and reduced age, shorter infertility times, lower FSH levels, higher T levels, larger testicular volumes, and the presence of 46 XY spermatogonia.

Q3. What are the long-term outcomes for patients who undergo mTESE in terms of sperm retrieval rates and subsequent fertility treatments?

Dr. Kadihasanoglu: The sperm retrieval rates and associated clinical outcomes for patients with various causes of non-obstructive azoospermia have not been reported by a systematic study. The average sperm retrieval rates are between 40-60% in several studies. Men with cryptorchidism had an excellent chance of having their sperm recovered during a m-TESE procedure, according to earlier studies. The most significant genetic cause of male infertility is Y chromosome microdeletions, and in these NOA patients, AZFc represents over 60% of all AZF microdeletions. Since these men usually have sperm in their testes, many studies

advise TESE for patients with AZFc microdeletion. The average sperm retrieval rates for these patients are between 40-73.3%. In terms of clinical outcomes, the patients with AZFc microdeletion had the lowest rates of fertilization and clinical pregnancy among all patients.

Clinical pregnancy and live birth rates near 50% were achieved with the current mTESE method for KS patients.

Q4. How does the use of surgical magnification (e.g., operating microscope) impact the efficacy of mTESE?

Dr. Kadihasanoglu: The focal sperm-producing regions of the testis are not identified during the standard TESE technique's blind execution until the tissue has been removed from the patient. Before their removal, sperm-containing areas in testicular tubules are identified through microdissection. Direct examination of each seminiferous tubule allows for the identification of spermatogenically active regions within the testicle. The basic idea behind this method is straightforward: seminiferous tubules with multiple developing germ cells rather than just Sertoli cells will probably be larger and more opaque than tubules that are not producing sperm. mTESE using surgical magnification is associated with improved sperm retrieval for men with NOA over that achieved with previously described biopsy techniques. Magnification—particularly with an operating microscope—has been

shown to make it possible to see seminiferous tubules, which are larger and more likely to contain spermatozoa.

Q5. What strategies can be employed to improve patient selection for mTESE to maximize the chances of successful sperm retrieval?

Dr. Kadihasanoglu: Proper assessment of prospective patients and effective implementation of the mTESE procedure require a broad range of knowledge and skills. These include understanding testicular histology, hormonal and genetic testing, testicular

ultrasound, semen analysis, and physical examination. Proficiency in these areas enhances patient evaluation, history-taking, and investigation selection and interpretation. With the necessary expertise, selecting the right patients can significantly increase the chances of successful sperm retrieval.

Mustafa Kadihasanoglu, MD, FEBU, FACS: Short Biography

Mustafa Kadihasanoglu,

MD, FEBU, FACS

Associate Professor Department of Urology, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey

E-mail: m.kadihasanoglu@iuc.edu.tr

ORCID: 0000-0001-5109-5319

Dr. Mustafa Kadıhasanoğlu is an Associate Professor in the Department of Urology at Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey. He did a general surgery rotation at Heidelberg University and worked as a research fellow at the Technical University of Munich. At Vanderbilt University (USA), he completed a research fellowship in endourology and minimally invasive treatments. He has published over 60 scientific articles in SCIE journals and given over 100 presentations. He is the section editor of BMC Urology journal and the Editor-in-chief of Comprehensive Medicine. He holds the European and Turkish Urology Board Certificates and is a member of board of examiners of European Board of Urology. Mustafa is a Fellow of the American College of Surgeons (FACS) and an active member of the ISSM and the ESSM.

Mustafa is a member of the board of the Turkish Society of Andrology and an active member of several professional societies including the GAF. He is pursuing a PhD at Istanbul University Aziz Sancar Institute of Experimental Medicine's molecular medicine doctorate program.

Sperm Vitality and Necrozoospermia: Diagnosis, Management, and Results of a Global Survey of Clinical Practice

Sun, 07 Jul 2024 01:12:15 GMT

Article #52: “Sperm Vitality and Necrozoospermia: Diagnosis, Management, and Results of a Global Survey of Clinical Practice”

Authors: Ashok Agarwal et al. World J Mens Health 2022 Apr 40(2): 228-242

https://doi.org/10.5534/wjmh.210149

Contributors: David Penning, MD, Salima Daoud, MD, Tan V. Le, MD, Jesus Fernando Solorzano Vazquez, MD, and Abheesh Varma Hegde, MS, MCh Urol

Commentary:

This paper provides an overview of sperm vitality testing methods and necrozoospermia management in infertile men. It also discusses the results of a global survey about necrozoospermia management practices.

Briefly about Sperm Vitality:

In the latest 6th edition of the WHO Laboratory Manual for examination and processing of human semen (2021), sperm vitality assessment is mainly recommended if the total motility is less than 40%. It enables one to distinguish between immotile dead or alive sperm.

The prevalence of necrozoospermia among infertile men is estimated at 0.2 – 0.4%. In semen samples with poor motility, testing vitality is important as it helps clinicians search for etiology such as genital tract infection, oxidative stress, epididymal pathology, and structural defects of the flagellum. A well-conducted medical examination should be performed, and sperm DNA fragmentation (SDF) testing can have an added value in this context.

And Now about the Analysis:

Two methods based on the evaluation of sperm membrane integrity are available: one by dye exclusion (Eosin-Nigrosin staining or EN staining) or another by hypo-osmotic swelling (HOS test).

Dead cells have damaged plasma membranes allowing entry of the dye: spermatozoa with red or dark pink heads are considered dead, whereas white heads are considered alive. However, tested sperm can no longer be used for ART procedures.

The HOS test presumes that only cells with live membranes can indeed swell in hypotonic solutions. This test is useful when staining of sperm must be avoided, for instance, if ICSI is performed in the lab using fresh sperm. Alternate techniques such as pentoxifylline or theophylline test, mechanical and laserassisted immotile sperm selection, etc. are also available; testicular sperm is the ultimate option in the absence of viable ejaculated sperm.

Take Home Message:

The difference between asthenozoospermia (pathological decrease in sperm motility) and necrozoospermia (pathological decrease in sperm vitality) is important in directing further investigation and management of infertile patients.

Eosin-Nigrosin staining is a simple and reliable test if both internal and external quality controls are met. The management of necrozoospermia includes appropriate clinical examination, investigation of the underlying causes, and frequent ejaculation. In the absence of an obvious etiology, selection techniques of viable sperm during ART can overcome the problem in most cases, such as the HOS test to perform ICSI using freshly ejaculated sperm. Particular attention should be paid to the development of international guidelines for clinicians to harmonize the management of necrozoospermia worldwide.

Summary:

Sperm vitality staining is a valuable tool for analyzing semen samples with low motility. It can help pinpoint treatable conditions affecting fertility and guide decisions about sperm selection for ICSI in cases of complete immotility. Additionally, this test might be beneficial for patients with low live sperm counts when combined with DNA fragmentation testing. (Contributor: Ashok Agarwal)

My Viewpoint on Sperm Vitality and Necrozoospermia

Dr. David Penning responds to questions from Ashok

Q1. What are the common causes and risk factors associated with necrozoospermia?

Dr. Penning: Here are some common causes and risk factors associated with a high percentage of dead sperm in the semen: infections, alcohol, and drug use, unhealthy diet, radiation and chemotherapy, genitourinary infections, hormonal disorders, long periods of abstinence, advanced paternal age, anti-sperm antibodies, early testicular cancer. These factors can occur individually or in combination, however, the exact cause of necrozoospermia can vary from person to person.

Q2. Why is it important to rule out false results due to contamination or improper semen sample collection?

Dr. Penning: It allows for accurate diagnosis, as false results can lead to misdiagnosis and inappropriate treatment. It helps avoid unnecessary stress and anxiety by preventing unwarranted concerns about infertility and promotes a cost-effective approach by minimizing additional costs through accurate initial testing.

Q3. How does necrozoospermia correlate with sperm DNA fragmentation (SDF), and what are the clinical implications?

Dr. Penning: In cases of necrozoospermia, there is often a high level of sperm DNA fragmentation. For severe necrozoospermia associated with high levels of SDF, antioxidant therapy may be indicated to lower SDF levels, potentially improving semen parameters. In cases of total motility loss, some authors have suggested the use of testicular sperm which may be associated with lower levels of SDF.

David Pening, MD, PhD trainee: Short Biography

David Pening, MD, PhD trainee

OB-GYN Department ULB - Université Libre de Bruxelles

H.U.B. - Hôpital Universitaire de Bruxelles

CUB Hôpital Erasme, Belgium

Email: david.pening@ulb.be

ORCID ID: 0000-0002-7221-4361

Dr. David Pening graduated as an Obstetrician Gynaecologist in 2018 from the ULB School of Medicine, Brussels. He did the training in Fertility Clinic at CRG, UZ Brussel for 1 year. His clinical and research interests are focused on Andrology, as he graduated in Andrology from CHU Lille in 2021. He is currently PHU at CUB – Erasme Hospital, Fertility Clinic. Dr Pening is a member of several scientific societies namely the Royal College of the French Gynaecologists & Obstetricians (CRGOLFB), the French Society of Andrology (SALF), the American Society of Andrology (ASA), the Network for Young Researchers in Andrology (NYRA), and the Belgian Society for Reproductive Medicine (BSRM) as a Board Member. He has co-authored 5 papers (h-index: 3, citation count: 24) and serves as a reviewer for several international journals dealing with reproductive medicine.

My Viewpoint on Sperm Vitality and Necrozoospermia

Dr. Salima Daoud responds to questions from Ashok

Q1. What are the primary differences between sperm vitality and sperm viability assessments?

Dr. Daoud: These are two different methods to evaluate the health of sperm in a semen sample. Vitality refers to whether sperm are alive regardless of their motility. It can be evaluated by a dye exclusion method such as the eosin staining test, where the dead cells uptake the eosin dye due to perforation in their membrane, but it does not consider the functional capacities of the cell. Viability on other hand assesses the physiological functions of living sperm. The HOS test assesses the functional integrity of the sperm plasma membrane under osmotic stress and is therefore used as a viability test.

Q2. Why is the eosin-nigrosin (E-N) stain commonly used for sperm vitality testing, and what are its limitations?

Dr. Daoud: The E-N stain is a simple, rapid, inexpensive, and efficient vitality test and has therefore been implemented as a routine test in laboratories. Its major limitation is linked to its toxicity for the sperm, which prevents its use in ART.

Q3. How should a laboratory handle and prepare a semen sample for accurate sperm vitality testing?

Dr. Daoud: According to the WHO manual, sperm vitality testing should be performed no later than an hour after ejaculation to avoid a decrease in vitality due to dehydration or a temperature change. Procedure steps should be performed according to WHO recommendations, such as evaluating at least 200 spermatozoa and considering the partially stained cells as alive.

Q4. What are the recommended procedures for ensuring quality control in sperm vitality testing?

Dr. Daoud: Good staff training and controlling sources of variation in sperm vitality testing are highly important. Adherence to the WHO recommendations is necessary to achieve accurate and reproducible results. Internal quality controls should be routinely performed to assess errors and inter-operator variability. Quality control charts are useful to monitor results daily. Participation in external quality controls quarterly or biannually is recommended. Control vitality slides should be prepared by reference laboratories and results should be within ±2 standard deviation of the mean. Corrective action must be undertaken if the results of internal or external quality controls are outside control limits.

Salima Daoud, MD: Short Biography

Salima Daoud, MD

Associate Professor, Laboratory of Histology, Embryology & Reproductive Biology Faculty of Medicine, Sfax University, Tunisia

Email: daoud_salima@medecinesfax.org

ORCID ID: 0000-0003-4330-7363

Dr. Salima Daoud graduated from The Faculty of Medicine of Sfax in 2007. After finishing her internship in Tunisian and French University hospitals, she joined the Laboratory of Histology, Embryology, and Reproductive Biology, Faculty of Medicine of Sfax, in Tunisia, where she currently serves as an Associate Professor. Dr. Daoud is actively involved in preand post-graduate medical education. She is vice director of medical education at her institution. She is also a member of the Tunisian College of Histo-embryology and the 'Association Tunisienne des Embryologistes Tunisiens' (ATME). Her research interests focus on male infertility, reproductive toxicology, and AI-based tools for reproductive biology. Dr. Daoud has co-authored 8 papers (h-index: 4, citations: 63) and serves as a reviewer for several international journals dealing with reproductive medicine.

My Viewpoint on Sperm Vitality and Necrozoospermia

Dr. Tan V. Le responds to questions from Ashok

Q1. What management strategies are recommended for patients diagnosed with necrozoospermia?

Dr. Le: Management strategies for necrozoospermia include lifestyle changes such as diet and exercise, antioxidant therapy, frequent ejaculation to remove dead sperm from the ejaculatory ducts and assisted reproductive techniques like intracytoplasmic sperm injection (ICSI) using testicular sperm extraction (TESE) if viable sperm cannot be found in the ejaculate.

Q2. How can frequent ejaculation improve sperm vitality in cases of prolonged epididymal storage?

Dr. Le: Frequent ejaculation helps reduce the accumulation of dead or damaged sperm by continuously clearing the epididymis, which can prevent the negative effects of prolonged sperm storage. This can enhance the overall quality and vitality of sperm by ensuring that fresher sperm is available in the ejaculate.

Q3. What are the current global practices in sperm vitality testing and management of necrozoospermia, based on the survey results presented in the article?

Dr. Le: Current global practices include routine sperm vitality testing using eosin-nigrosin staining or hypo-osmotic swelling tests, and the management of necrozoospermia through lifestyle modifications, antioxidant supplementation, and ART such as ICSI with TESE. There is a focus on improving diagnostic accuracy and individualizing treatment plans based on specific patient needs.

Q4. What are the key indicators for recommending sperm vitality testing in routine andrology laboratory practice?

Dr. Le: Genital tract infections can lead to necrozoospermia with direct damage to the sperm by microorganisms, the effect of inflammatory mediators, and alteration of the genital tract environment. Also, an infection can cause DNA damage by ROS and the production of neutrophils.

Q5. What are the potential benefits of using antioxidants in the treatment of patients with necrozoospermia and high sperm DNA fragmentation?

Dr. Le: Antioxidants can reduce oxidative stress, which is a significant factor in sperm cell damage and DNA fragmentation. The use of antioxidants may improve sperm vitality, motility, and overall sperm quality, potentially enhancing the outcomes of ART procedures. They can also help reduce the percentage of sperm with DNA fragmentation, improving the chances of successful fertilization and healthy embryo development.

Tan V. Le, MD: Short Biography

Tan V. Le, MD

Andrologist Department of Andrology Binh Dan Hospital Ho Chi Minh City, Vietnam

E-mail: drlevutan@gmail.com

ORCID ID: 0000-0003-1766- 7453

Dr. Tan V. Le is a Vietnamese Urologist and Andrologist with a strong clinical background and a growing interest in clinical research, particularly in the areas of sexual dysfunction and male infertility. After graduating from Pham Ngoc Thach Medical University in Ho Chi Minh City in 2009, he completed his residency at the Urology Department of the University of Medicine and Pharmacy in Ho Chi Minh City starting in 2010. In 2018, Dr. Le served as a research fellow at the Urology Department of Tulane Medical University in Louisiana, USA, under the supervision of Professor Wayne Hellstrom. He is passionate about collaborating with and learning from andrologists worldwide to enhance his expertise. Dr. Le is affiliated with the Department of Andrology at Binh Dan Hospital and the Department of Urology and Andrology at Pham Ngoc Thach University of Medicine in Ho Chi Minh City, Vietnam. His research credentials include a total of 30 publications, an h-index of 9, and 224 citations.

My Viewpoint on Sperm Vitality and Necrozoospermia

Dr. Vazquez responds to questions from Ashok

Q1. How does the hypoosmotic swelling (HOS) test work, and why is it important for assessing sperm viability?

Dr. Vazquez: The HOS test is a diagnostic method used to evaluate the functional integrity of the sperm plasma membrane. Sperm with intact cell membranes will swell in response to the hypo-osmotic conditions because water enters the cell. The degree of swelling is observed under the microscope. Sperm with tail swelling are considered to have functional cell membranes. Here lies its importance as an assessment of membrane function, and indication of fertility potential. It is beneficial in cases of complete asthenozoospermia, where all sperm are immotile, to select viable sperm for ICSI.

Q2. How does testicular hyperthermia contribute to necrozoospermia, and what are its sources?

Dr. Vazquez: Hyperthermia contributes to necrozoospermia by dysregulating the production of heat shock proteins and heat shock factors, leading to abnormal germ cell apoptosis. The sources of hyperthermia can be local, such as in varicocele and obesity, or general, such as prolonged heat exposure from kitchens, ovens, or sitting on bicycles, as well as conditions like fever and hyperthyroidism.

Q3. What are the benefits and limitations of using the HOS test in selecting viable sperm for ICSI?

Dr. Vazquez: HOS can be used to select viable sperm for ICSI in cases of necrozoospermia with absolute asthenozoospermia. The sperm with vitality can be identified by adding them for less than 5 minutes in a hypoosmotic solution. They should then be rinsed with culture media and prepared to be injected by ICSI. It is noteworthy that in frozen sperm straws, cryopreserved samples may show spontaneous swelling from the freeze-thaw process.

Q4. How do genital tract infections affect sperm vitality, and what are the mechanisms involved?

Dr. Vazquez: Genital tract infections can lead to necrozoospermia with direct damage to the sperm by microorganisms, the effect of inflammatory mediators, and alteration of the genital tract environment. Also, an infection can cause DNA damage by ROS and the production of neutrophils.

Jesus Fernando Solorzano Vazquez, MD: Short Biography

Jesus Fernando Solorzano Vazquez, MD

Gynecologist and Obstetrician, Reproductive Medicine Specialist, Medical Coordinator in CITMER Mexico City, Mexico

e-mail: dr.solorzanobr@gmail.com fsolorzano@gmail.com

ORCID: 0000-0003-4354-8351

Dr. Jesús Fernando Solorzano Vázquez is a Gynecologist and Reproductive Medicine specialist at CITMER Mexico City, Mexico. Dr. Solorzano obtained his medical degree from University of Guanajuato in 2008. He completed his Gynecology and Obstetrics degree at University of Guadalajara in 2013 and finally got his degree in Reproductive Medicine Biology from National Autonomous University of Mexico 2015. Dr. Solórzano is focused on Male Infertility in his clinical practice and is interested in research in this field. He has published 6 research papers in peer-reviewed journals, has 19 citations, and has an h-index of 2 according to Scopus.

My Viewpoint on Sperm Vitality and Necrozoospermia

Dr. Hegde responds to questions from Ashok

Q1. What is the significance of differentiating between asthenozoospermia and necrozoospermia in clinical practice?

Dr. Hegde: The movement of a sperm is considered proof of vitality. However, in asthenozoospermia, the sperm is alive but not motile. Necrozoospermia is a pathological decrease in sperm vitality. It is important to differentiate these two entities to direct further investigation and treatment in infertile patients. The causes for necrozoospermia are numerous and treatment is directed toward the etiology.

Q2. What are the clinical implications of having a sperm motility rate below 40% and how does it guide further testing?

Dr. Hegde: Sperm motility rate below 40% needs assessment for sperm vitality (necrozoospermia) to differentiate between necrozoospermia and asthenozoospermia. This has consequences in clinical approach and management. The next automatic step should be an E-N test that detects dead sperms. The sperms used for this test cannot be used for ART.

Q3. What role do anti-sperm antibodies play in causing necrozoospermia?

Dr. Hegde: The anti-sperm antibodies are usually produced in the genital tract due to alteration of the blood-testis barrier. These are known to affect the motility of the sperm and could cause necrozoospermia.

Q4. How should clinicians approach the management of necrozoospermia in patients with idiopathic causes?

Dr. Hegde: Upto 20% of patients could have idiopathic necrozoospermia. Repeated ejaculations are known to improve both sperm motility and vitality. (60 minutes, 12 hours, or 24 hours after initial ejaculation). Drug treatments are usually ineffective. Modification of sperm processing methods such as utilizing magnetic activated cell sorting (MACS), incubation of sperms with glycerophospholipids, density gradient centrifugation followed by a swim-up procedure, and adding antioxidants like ethylene diamine tetraacetic acid (EDTA), catalase, vitamin E, ellagic acid, alpha-lipoic acid, and L carnitine to the sperm preparation medium could improve sperm vitality. In severe necrozoospermia, vitality testing needs to be done before initiating ICSI. Surgical sperm retrieval using micro TESE can be done in case of nerozoospermia that cannot be corrected otherwise.

Abheesh Varma Hegde, MS, MCh Urol: Short Biography

Dr. Abheesh Varma Hegde

Assistant Professor Department of Urology and Renal Transplantation Father Muller Medical College Mangalore, India

Email: abhi.vhegde@gmail.com

ORCID 0000-0002-2524-6889

Dr. Abheesh Hegde is a Consultant Urologist and Andrologist and an Assistant Professor at the Dept of Urology, Father Muller Medical College, Mangalore, India, a tertiary care hospital with a Urology residency program. He also serves as a visiting Consultant at rural centers around Mangalore, where no urological services are provided. He received his general surgery training at St John's Medical College, Bangalore, and MCh Urology from Topiwala National Medical College, Mumbai. Dr. Hegde is a member of several international Urological societies, including ISSM, SIU, Endourological Society, AUA, and EAU. He has been academically active throughout his career, winning multiple awards from regional, national, and international urology societies. He has presented over 30 papers at conferences and is a regular training faculty member at these events. Dr. Hegde has authored 16 publications (3 PubMed indexed), 6 book chapters, and has an h-index of 1, and a citation count of 1 according to Scopus.

Effects of Varicocele Repair on Sperm DNA Fragmentation and Seminal Malondialdehyde Levels in Infertile Men with Clinical Varicocele: A Systematic Review and Meta-Analysis

Sun, 23 Jun 2024 11:34:36 GMT

Article #51: “Effects of Varicocele Repair on Sperm DNA Fragmentation and Seminal Malondialdehyde Levels in Infertile Men with Clinical Varicocele: A Systematic Review and Meta-Analysis”

Rossella Cannarella et al. World J Men’s Health 2024 Apr 42(2): 321-337

https://doi.org/10.5534/wjmh.230235

Contributors: Dr. Fahmi Bahar (Indonesia), Dr. Gianmaria Salvio, (Italy), and Dr. Murat Gul (Turkey)

Commentary:

Nowadays, varicocele represents one of the most insidious challenges for the modern andrologist. Despite the mare magnum of publications, with nearly 2,000 articles published between 1988 and 2020 (Agarwal et al, 2022), the management of the infertile patient with varicocele, especially when not accompanied by frank sperm abnormalities, still appears unclear. Indeed, today as yesterday, we face a timeless dilemma: “To treat or not to treat, that is the question”. It turns out that around 15% of men experiencing the above situation, based on Sperm DNA Fragmentation (SDF) examination results, show severe sperm DNA damage, which may explain the difficulty in achieving pregnancy in their spouses (Agarwal & Allamaneni, 2005). Varicocele causes damage to sperm DNA presumably through oxidative stress (OS), and Malondialdehyde (MDA) levels can serve as a direct indicator of OS. Therefore, varicocele repair (VR) is expected to improve fertility in infertile men - at least in part - by decreasing OS and ultimately lowering SDF and MDA levels. Surprisingly, the efficacy of VR in mitigating these parameters remains ambiguous. A pioneering systematic review and metaanalysis embark on a journey to unravel this enigma.

Employing an exhaustive search across multiple databases, Cannarella et al. (2023) meticulously curated 29 studies encompassing 1,491 infertile men. Their analysis uncovered a compelling narrative: VR induces a significant reduction in SDF (SMD – 1.125, p<0.0001), alongside a noteworthy decrease in seminal MDA levels (SMD –2.450, p=0.001). Strikingly, this reduction in SDF persisted across varied surgical techniques and testing methodologies, affirming the robustness of their findings.

We believe that these findings not only contribute to the existing body of evidence but also hold the potential to influence professional societies' practice recommendations. They advocate for varicocele repair as a viable strategy to improve SDF and ameliorate seminal OS in infertile men, potentially reshaping clinical approaches and enhancing outcomes in male infertility management. However, as indicated by the global survey conducted by Agarwal et al., three main barriers commonly expressed by clinicians worldwide regarding SDF testing exist - high cost, lack of insurance coverage, and limited availability of the test. Moreover, when discussing SDF testing, there is no universal cutoff standard, and there are no official guidelines from professional associations regarding its implementation in daily practice (Agarwal et al, 2024).

Take Home Message: Contributing author - Ashok Agarwal

Varicocele repair (VR) significantly reduces sperm DNA fragmentation (SDF) and seminal malondialdehyde (MDA) levels, indicating improved sperm quality and reduced oxidative stress in infertile men. The effectiveness of VR is consistent across different surgical techniques, highlighting its general efficacy. These findings support the use of VR in clinical practice to enhance sperm quality and potentially improve reproductive outcomes. This meta-analysis emphasizes the importance of considering SDF and oxidative stress markers in managing male infertility and endorses VR as a beneficial intervention for men with high SDF due to varicocele.

My Viewpoint on the Effects of Varicocele Repair on SDF and OS

Dr. Fahmi Bahar responds to questions from Ashok

Q1. How might the reduction in oxidative stress markers like MDA influence male reproductive health post-VR?

Dr. Bahar: As we all know, it is estimated that one of the adverse effects of varicocele is the generation of oxidative stress, which can affect the quality and quantity of sperm. One common marker used in this regard is Malondialdehyde (MDA), where varicocelectomy can decrease MDA levels, thus resulting in better male reproductive health post-operation.

Q2. Does varicocele grade or severity influence the outcomes of VR in terms of SDF and MDA levels?

Dr. Bahar: Based on the clinical experience I encounter daily, generally, the more severe the degree of varicocele a person has, the better the improvement in parameters postoperation, and the decrease in the percentage of SDF (sperm DNA fragmentation) and MDA levels will be. As long as it is estimated that varicocele is indeed the only sole cause in those patients.

Q3. What are the clinical implications of the high heterogeneity observed in studies analyzing SDF and MDA levels post-VR?

Dr. Bahar: In this SRMA (Systematic Review and Meta-Analysis), a high heterogeneity index (above 50%) was found, thus a random-effects model approach was employed. Additionally, meta-regression and subgroup analysis were used, indicating the significance of Varicocelectomy in reducing SDF and MDA levels.

Q4. How could the findings from this study affect current guidelines on the management of varicoceles in infertile men?

Dr. Bahar: The findings of this study can serve as a reference for professional organizations to include the assessment of SDF and MDA levels as routine examinations in cases of varicocele. Subsequently, they may recommend varicocelectomy if increased levels of MDA and SDF are found.

Q5. Is there evidence to support routine SDF testing in men with palpable varicoceles before considering VR?

Dr. Bahar: According to the results of this study, which found a decrease in SDF levels before and after varicocelectomy, the assessment of SDF can be suggested as a routine examination for men with palpable varicocele to strengthen the indication for surgical intervention.

Fahmi Bahar, MD: Short Biography

Fahmi Bahar, MD Andrologist,

Andrology Section Siloam Palembang Hospital Jakarta, Indonesia

E-mail: dr.fbw.st@gmail.com

ORCID ID: https://orcid.org/0000-0002- 7027-9436

Dr. Fahmi Bahar is a distinguished andrologist currently practicing at Siloam Sriwijaya Hospital in Palembang, Indonesia. In addition to his clinical work, he contributes to academia as a guest lecturer at the Medical Faculty of Muhammadiyah Palembang University. Dr. Bahar earned his medical degree from Sriwijaya University, where he studied from 2005 to 2011. He further specialized in andrology at Airlangga University, completing his studies between 2017 and 2020. His scholarly contributions include 11 publications, with an H-index of 3 and 45 citations. Beyond his academic and clinical roles, Dr. Bahar is an active member of several professional organizations. These include the Global Andrology Forum, the Indonesian Association of Andrologists, the Indonesian Association of Sexologists, and the Indonesian Association for In Vitro Fertilization.

My Viewpoint on the Effects of Varicocele Repair on SDF and OS

Dr. Gianmaria Salvio responds to questions from Ashok

Q1. How significant is the reduction in sperm DNA fragmentation (SDF) after varicocele repair (VR) in infertile men with clinical varicocele?

Dr. Salvio: The reduction in SDF after varicocelectomy certainly appears to be statistically significant, but its clinical significance needs to be demonstrated. VR is accompanied by an average reduction of about 1% in SDF (SMD -1.125, 95 % confidence interval [CI] -1.410, - 0.840; p<0.0001), but it should be kept in mind that the magnitude of the effect may be affected both by the technique used for VR (non-surgical approaches might result in better results than surgical approaches) and by the method of measuring DNA fragmentation. It has also been observed from previous meta-analyses that infertile subjects have higher levels of SDF than fertile controls, but it is not known what minimum improvement is sufficient to achieve an increase in pregnancy rate. Therefore, no firm conclusions can yet be drawn, although the present study suggests that VR may indeed result in a benefit in terms of sperm DNA quality.

Q2. What changes in seminal malondialdehyde (MDA) levels are observed after VR, and what does this indicate about oxidative stress in these patients?

Dr. Salvio: VR is accompanied by a significant reduction in seminal MDA levels. It is derived from peroxidation of polyunsaturated fatty acids and its expression correlates directly with the oxidative state of the medium in which it is measured. Specifically, the reduction in seminal MDA suggests an important VR-related oxidative stress reduction effect, which may accompany improved fertility, as suggested by the observation that most infertility risk factors act through increased oxidative stress on spermatozoa.

Q3. Are the improvements in SDF and MDA levels after VR consistent across different surgical techniques?

Dr. Salvio: The effects of VR on MDA levels were analyzed in a total of 6 studies: surgical approaches (microsurgery in all) were evaluated in 4 studies and nonsurgical approaches in 2 studies. Although the small number of studies does not allow for subgroup analysis, the effect of VR appears overall positive and does not appear to be significantly different among the different types of procedures.

Q4. How does the effectiveness of microsurgical varicocele repair compare to nonmicrosurgical inguinal approaches in reducing SDF?

Dr. Salvio: From the present study, it appears that nonsurgical approaches may lead to a more pronounced decrease in SDF levels. By the way, it should be kept in mind that nonsurgical approaches were considered in only 4 studies, whereas micro-surgical approaches were evaluated in 13 studies. Therefore, no firm conclusions can be drawn.

Q5. What are the implications of these findings for the future management of male infertility associated with varicocele?

Dr. Salvio: The present meta-analysis confirms the beneficial effects of VR in infertile men. Since SDF and oxidative stress seem to play a pivotal role in male infertility (especially in idiopathic male infertility), but no clear cut-offs for normal or pathological SDF and MDA are currently available, more studies are needed to establish the ideal goal of improvement that should be reached to obtain clinical benefits and to improve pregnancy rate and live birth rate in infertile couples.

Gianmaria Salvio, MD: Short Biography

Gianmaria Salvio, MD, PhD

Assistant Professor Endocrinology Clinic of Ancona, Polytechnic University of Marche, Ancona, Italy

E-mail: gimmy133@hotmail.com

ORCID ID: https://orcid.org/0000-0001-9290- 5699

Dr. Gianmaria Salvio obtained his medical degree from the Polytechnic University of Marche in Ancona in 2013, graduating with the highest honors. He specialized in Endocrinology and Metabolic Diseases at the University of Padua, completing his training in 2019. During his residency, he also trained at the andrology unit at Careggi Hospital in Florence, earning the title of male genital tract sonographer from the European Academy of Andrology. In 2023, he achieved a PhD in Human Health from the Polytechnic University of Marche. From 2022 to 2024, Dr. Salvio worked as an endocrinology specialist at the Ancona University Hospital. Since March 2024, he has been a fixed-term researcher type B. He is an active member of the Italian Society of Andrology and Medicine of Sexuality (SIAMS), the European Academy of Andrology (EAA), and the Italian Society of Endocrinology (SIE). Dr. Salvio has held several positions within these organizations, including Regional Coordinator for SIAMS from 2021 to 2023 and member of various committees. Dr. Salvio has published 49 articles, received 565 citations, and holds an Hindex of 14 (Scopus).

My Viewpoint on the Effects of Varicocele Repair on SDF and OS

Dr. Murat Gul responds to questions from Ashok

Q1. What role do seminal oxidative stress markers play in evaluating the success of VR?

Dr. Gul: Seminal oxidative stress markers like malondialdehyde (MDA) levels can provide valuable insights into the success of varicocele repair (VR) in improving sperm quality. A systematic review and meta-analysis found that VR significantly reduced seminal MDA levels in infertile men with clinical varicocele, indicating reduced oxidative stress2. However, the search results do not directly address the role of oxidative stress markers in evaluating VR outcomes.

Q2. How might these findings influence the decision-making process for urologists treating men with infertility related to varicocele?

Dr. Gul: The findings that VR improves conventional semen parameters like sperm concentration, motility, and morphology in infertile men with varicocele12 can influence urologists' decision-making process. The significant improvements in semen quality provide evidence to support VR as a treatment option for male infertility related to varicocele. However, the search results do not discuss how these findings specifically impact urologists' decision-making.

Q3. Given the reductions in SDF and MDA, should VR be considered a preventive strategy for future fertility issues in men diagnosed with varicocele?

Dr. Gul: The search results do not directly address whether VR should be considered a preventive strategy for future fertility issues in men diagnosed with varicocele. While VR reduces sperm DNA fragmentation and oxidative stress markers2, more research is needed to determine if these improvements translate to preventing future fertility problems in men with varicocele.

Q4. Are there specific patient profiles (e.g., age, duration of infertility, varicocele severity) that particularly benefit from VR in terms of improvements in sperm quality?

Dr. Gul: The search results do not provide specific patient profiles that particularly benefit from VR in terms of sperm quality improvements. The meta-analyses included infertile men with clinical varicocele but did not stratify results based on age, duration of infertility, or varicocele severity. Further research is needed to identify patient characteristics that predict the greatest improvements in sperm parameters following VR.

Q5. What further research is needed to clarify the mechanisms by which VR improves sperm parameters and oxidative stress markers in men with varicocele?

Dr. Gul: To clarify the mechanisms by which VR improves sperm parameters and oxidative stress markers, future research should investigate:

The time course of changes in semen quality and oxidative stress after VR
The relationship between improvements in specific semen parameters and oxidative stress markers
The impact of VR on other markers of sperm function and DNA integrity
The role of varicocele grade and duration in modulating the effects of VR on sperm and oxidative stress
In summary, while VR significantly improves conventional semen parameters and reduces oxidative stress in infertile men with varicocele, more research is needed to fully elucidate the mechanisms and identify patient profiles most likely to benefit from this treatment

Murat Gul, MD: Short Biography

Murat Gul, MD, FEBU

Associate Professor Department of Urology, Selcuk University School of Medicine, Konya, Turkey

E-mail: drmuratgul@hotmail.com

ORCID ID: https://orcid.org/0000-0002- 6657-6227

Dr. Murat Gül earned his Doctor of Medicine degree and completed his urology residency at Selçuk University Faculty of Medicine in Turkey. After practicing as a urologist for three years, he completed a one-year Andrology Fellowship at the University of Copenhagen's Reproductive Biology Laboratory. From 2022 to 2023, Dr. Gül was a Visiting Professor in Andrology and Reconstructive Urology at the University of Turin, Italy. Since 2021, he has been an Associate Professor in the Department of Urology at Selçuk University. Dr. Gül has been an associate member of the European Society of Urology Sexual and Reproductive Health Guidelines Panel since 2019. He is active in the European Urology Young Urologists Working Group on Men's Health and the European Society for Sexual Medicine Committee on Male Sexual Health and Dysfunction. His scientific and clinical interests focus on male infertility and sexual dysfunction. Dr. Gül has published over 100 articles in international journals, receiving 1800 citations, and holds an H-index of 18. He is an editor for several international journals, including IJIR, Frontiers in Urology, and JUS.

Sixth edition of the World Health Organization laboratory manual of semen analysis: Updates and essential takeaway for busy clinicians

Mon, 17 Jun 2024 22:33:27 GMT

Article #50: “Sixth edition of the World Health Organization laboratory manual of semen analysis: Updates and essential takeaway for busy clinicians”

Authors: Eric Chung, Widi Atmoko, Ramadan Saleh, Rupin Shah & Ashok Agarwal. Arab Journal of Urology https://doi.org/10.1080/20905998.2023.2298048

Contributors: Dr. Vineet Malhotra (India), and Dr. Krishna C Mantravadi (India)

*Commentary:

Semen analysis (SA) is still considered the gold standard and is a preliminary step in a couple’s fertility journey. This basic screening of semen helps the clinical team plan further steps. However, while SA is the first investigation, it has several limitations and is not yet standardized enough to predict the time to conception or determine the best choice of assisted reproduction for overcoming infertility. Over the past few decades, scientists have developed six editions of the WHO manual to help standardize the evaluation of infertile men. The 6th edition, published in 2021, is the current version. In addition to basic semen analysis, it provides information on sperm preparation, cryopreservation, and quality control and assurance.

The new 6th Edition presents revised reference values for basic semen parameters. These values are based on data from fertile men in the 5th Edition, released in 2010, and five additional studies published between 2010 and 2020. This revision attempts to address a limitation in the 5th Edition, where reference values were skewed towards specific geolocations. However, the reference limits suggested by the WHO (World Health Organization 2021) come from a very mixed group of men and should not be mistaken for definitive limits between fertility and infertility. The new WHO manual emphasizes the development of decision limits, which are more significant than those from a mixed population.

A significant change from the previous 5th Edition is the abandonment of fixed reference values. The 6th Edition specifies that the 5th centile values are only one way to interpret SA results and that using the 5th centile alone is insufficient to diagnose male infertility.

The 6th Edition aims to optimize SA procedures by providing detailed steps and a methodological sequence for test execution. It also introduces new sperm tests for assessing sperm DNA fragmentation (SDF) and seminal oxidative stress (OS), while discontinuing obsolete tests like human cervical mucus evaluation.

Some adjustments have been made regarding basic semen parameters. The evaluation of semen odor has been added, noting that "urine or putrefactive odors may be of clinical interest," although standardizing this parameter is challenging due to its subjective nature.

Regarding sperm motility, the 6th Edition re-adopts the distinction of progressive motility into two categories (grades a and b). This categorization, which includes fast progressively motile, slow progressively motile, non-progressively motile, and immotile (grades a, b, c, and d, respectively), was last used in the 4th Edition. It is surprising that this distinction is included in the 6th Edition without recent studies (post-2010) demonstrating its utility in andrology or routine diagnosis.

For evaluating sperm count, semen dilutions have been simplified, but 200 spermatozoa per replicate should be counted. In the past, observing 0–4 spermatozoa per field at ×400 magnification (or 0–16 spermatozoa per field at ×200 magnification) could provide enough indication for concentration assessment, with concentrations reported as less than 2 × 10^6/mL. This method has been revised in the 6th Edition. Now, evaluating low sperm concentrations (<2 × 10^6/mL) requires more precision, acknowledging that errors in counting small numbers of spermatozoa can be significant. Ensuring that examined aliquots represent the entire ejaculate and conducting enough observations to reduce random variability is essential.

To achieve acceptable performance, thorough in-house training is necessary. Basic medical laboratory standards require regular internal quality control to monitor interand intra-personal variability. Each laboratory should also participate in an external quality assessment (EQA) scheme. Proper interpretation of semen examination results depends on reference limits.

In the 6th Edition, sperm vitality assessment is recommended when total sperm motility is below 40%. Notably, terms like "normozoospermia," "asthenozoospermia," "necrozoospermia," and "teratozoospermia" are not used in this edition. These terms have been removed because reference thresholds alone are meaningless; multiple criteria must be applied to diagnose male infertility. While this approach is correct, clinicians may find the absence of reference values confusing. They may need to rely on other literature sources, which can be time-consuming and challenging. Consequently, clinicians might continue using the 5th centile values from the 5th Edition, designed to compare fertile and infertile men with a criterion of time to pregnancy ≤12 months.

Advanced Examination:

The 6th Edition introduces the SDF assay as an extended semen assessment that can be requested in specific clinical scenarios, although it does not provide guidance on testing indications or address test result variability across different SDF assays. The manual offers a detailed outline of the technical aspects of these tests and some guidance on interpreting the results. However, it lacks discussion on the indications and clinical application of these test results.

The extensive data on human semen in the 6th Edition provide valuable insights into the global management of male infertility. Expanding our knowledge and understanding of different aspects of human semen will optimize the care of infertile men and improve the reproductive outcomes of infertile couples. However, the lack of reference values for basic and advanced semen examinations in this edition might limit its global utilization, leading clinicians to continue using the older 5th Edition for patient management.

Note: The above commentary has been lightly edited for better flow.

Take Home Message: Contributing author - Ashok Agarwal

The 6th Edition of the WHO manual on semen analysis introduces updated reference values, emphasizes the inadequacy of fixed thresholds for diagnosing male infertility, and includes new tests for sperm DNA fragmentation (SDF) and seminal oxidative stress (OS). It provides detailed methodologies, stresses quality control, and re-adopts progressive motility distinctions. Obsolete tests are removed, and subjective semen odor evaluation is added. Terms like "normozoospermia" are eliminated to encourage a comprehensive diagnostic approach. These changes are supposed to improve the accuracy and usefulness of semen analysis in assessing male infertility.

However, the 6th Edition leaves several unresolved questions: the lack of clear indications for new tests like SDF and OS, variability in SDF test results without specified cut-offs, and inadequate guidelines for integrating advanced tests into clinical practice. Additionally, the subjectivity of semen odor measurement complicates standardization, and removing terms like "normozoospermia" could confuse clinicians.

My Viewpoint on Updates in WHO Sixth Edition Manual for Semen Analysis

Dr. Vineet Malhotra responds to questions from Ashok

Q1. What are the implications of categorizing progressive sperm motility into rapid and slow, and how does this affect clinical practice?

Dr. Malhotra: Classification of sperm motility has been reclassified into the older method of rapid and slow progressive as it has been a favored method of grading sperm quality for use in assisted reproduction based on these parameters. Most fertility centers use rapid progressive sperms for better outcomes.

Q2. In what ways does the sixth edition emphasize the limitations of using the 5th percentile values of basic semen parameters alone to diagnose male infertility?

Dr. Malhotra: The limitations of using the 5th centile as the threshold for determining male subfertility alone have been questioned. It is proposed that using such values should be done in conjunction with other clinical and laboratory findings. However, it is still necessary to use them as useful references guiding treatment.

Q3. What new genetic and chromatin assessments are included in the extended examination of semen, and how should clinicians approach the lack of precise guidance on their indications?

Dr. Malhotra: The 6th edition includes sperm genetic testing including chromosomal abnormalities detection, gene mutations, chromatin evaluation, sperm DNA fragmentation testing, and the testing of leukocytes, antibodies, immature germ cells, indices of multiple sperm defects, and biochemical assessment of accessory organ function. FISH testing has been described to detect chromosomal abnormalities though there is a lack of clarity for usage in clinical practice.

Q4. How does the sixth edition address the variability and challenges associated with sperm DNA fragmentation (SDF) testing, and what are the recommended methods for evaluating SDF?

Dr. Malhotra: The recommended tests for SDF testing in the 6th edition include TUNEl, sperm chromatin dispersion assay, and acridine orange flow cytometry. However, no cutoff values have been described and the manual recommends all labs to have their controls to create individual lab reference ranges.

Q5. What is the clinical significance of including seminal oxidative stress testing in the advanced examination category, and how can this guide treatment decisions in cases of idiopathic or unexplained infertility?

Dr. Malhotra: The 6th edition considers Semen ROS testing in advanced semen examination as a research-based and emerging technology. Excessive semen ROS is found to affect all aspects of sperm fertilizing potential in various medical conditions including varicocele, leukocytospermia, diabetes, and obesity. It is also useful in predicting good embryo cleavage and blastocyst quality. It may be useful, especially in men with idiopathic or unexplained infertility where intervention may result in better clinical outcomes (e.g. large varicocele with normal semen parameters)

Vineet Malhotra, MBBS, MS, MCh Urology: Short Biography

Vineet Malhotra, MD, MCh Urol

Director and Head Urology and Andrology VNA Hospital, New Delhi, India

Drvineet7@gmail.com

Dr Vineet Malhotra is a Senior Consultant Uro-andrologist with a special interest in Prosthetic Uro-andrology. He received his training at the prestigious Muljibhai Patel Urological Hospital, Nadiad, Gujrat, India under the mentorship of Professor Rupin Shah between 2003-2006. He is currently the Secretary of the Andrology Section of the Urological Society of India. He has published 14 research articles in peer-reviewed journals, has received 76 citations, and an h-index score of 5.

My Viewpoint on Updates in WHO Sixth Edition Manual for Semen Analysis

Dr. Krishna Mantravadi responds to questions from Ashok

Q1. What are the key differences between the fifth and sixth editions of the WHO manual regarding the classification of semen examinations?

Dr. Mantravadi: As per the 6th edition following classifications have changed:

Q2. How does the new manual address the inclusion of data from previously underrepresented geographical areas, and what impact does this have on the reference values?

Dr. Mantravadi: The new 6th Edition presents revised reference values of basic semen parameters based on the combined data of fertile men from the previous 5th Edition, released in 2010, and 5 additional studies published between 2010 and 2020, thereby attempting to address a limitation noted in the 5th Edition due to skewing of the reference values towards normality of specific geolocations. However, the reference limits suggested by the WHO (World Health Organization 2021) come from a very mixed group of men and should therefore not be mistaken for true limits between fertility and infertility.

Q3. How has the assessment of sperm motility and vitality been updated in the sixth edition, and what are the clinical indications for these tests?

Dr. Mantravadi : The following are the clinical indications for vitality tests in the laboratory:

Necrozoospermia
Very poor motility or no motility
Suspected chronic genital tract infection
On Surgically retrieved testicular sperm

Q4. What are the recommended procedures for semen collection, transport, and laboratory assessment as per the sixth edition, and why are these steps critical for accurate semen analysis?

Dr. Mantravadi: To avoid exposure of the semen to fluctuations in temperature and to control the time between collection and analysis, it is recommended that the sample be collected in a private room close to the laboratory. Ideally, investigations should commence within 30 minutes after collection, but at least within 60 minutes. Individual exceptions can of course be necessary, and each individual should be given proper advice on possibilities and risks. If not collected in the proximity of the laboratory, transport must not allow the sample temperature to go below 20 °C or above 37 °C. If the patient for any reason must collect the ejaculate at another place, the specimen container should be kept close to the body under the clothes – for instance, in the armpit – during transport and should be delivered to the laboratory preferably within 30 minutes after collection and at least no longer than 50 minutes after collection.

Q5. What have been included or removed from the advanced examinations of semen in the sixth edition, and how might these changes impact the research and clinical evaluation of male infertility?

Dr. Mantravadi: Obsolete tests such as the human oocyte and human zona pellucida binding and the hamster oocyte penetration tests have been removed. The research tests in this edition include the assessment of reactive oxygen species and oxidative stress, membrane ion channels, acrosome reaction, and sperm chromatin. Computer-assisted sperm analysis (CASA) has been rewritten to describe the principles of CASA and its use as a research technology. In addition, emerging new methods using sperm movement or changes in light may constitute the basis for measuring sperm motility without the need for a microscope. The addition of these advanced examinations will aid in a comprehensive assessment of semen and improve the predictive power of WHO basic semen analysis in medically assisted reproduction. This will in turn shorten the time to pregnancy and avoid unnecessary use of assisted reproductive technologies.

Krishna Mantravadi, MBBS, MCE: Short Biography

Dr Krishna Mantravadi, MBBS, MCE (Monash University, Australia)

Scientific Head, Department of Clinical Embryology, Oasis Center for Reproductive Medicine, Hyderabad, Telangana, India.

E-mail: krishna@oasisindia.in

ORCID: https://orcid.org/0000- 0001-7642-6743

Dr. Krishna Mantravadi is a Clinical Embryologist with a keen interest in Andrology and Men’s health. At Oasis Fertility Center in India, his main areas of work are cryobiology, invitro maturation of oocytes, Andrology & men’s health. Currently, he is working on employing newer techniques to improve the success rates of IVF in PCOD and recurrent IVF failure cases. Dr. Mantravadi has published 73 research articles in peer-reviewed journals, has 38 citations, and has an h-index of 3 according to Scopus.

An In-Depth Bibliometric Analysis and Current Perspective on Male Infertility Research

Tue, 04 Jun 2024 16:16:36 GMT

Article #49: “An In-Depth Bibliometric Analysis and Current Perspective on Male Infertility Research”

Authors: Baskaran et al. World J Mens Health 2021 Apr 39(2): 302-314

https://doi.org/10.5534/wjmh.180114

Contributors: Dr. Keerti Singh (Barbados), Dr. Kavindra Kesari, (Finland), and Dr. Ranjit Vishwakarma (India)

*Commentary:

Baskaran S. et al., in their comprehensive bibliometric analysis of male infertility, employed a novel Funnel Model and reported a 265% increase in male infertility research from 1998 to 2017. The study highlighted a significant focus on testicular cancer, obesity, metabolic syndrome, and azoospermia, with relatively less attention given to erectile dysfunction and unexplained male infertility. An increasing trend in assisted reproductive technology (ART) research was also noted. The study projected a future trend towards integrated omics and ART research, emphasizing the need for improved diagnostic and treatment strategies in male infertility.

Key takeaways from this research:

• Research interest: Over the past two decades, there has been significant research interest in testicular cancer, obesity, Metabolic Syndrome (MetS), and azoospermia.

• Testicular cancer: The incidence of testicular cancer has doubled in the last three decades, especially in industrialized countries. This rise correlates negatively with semen parameters and fertility, particularly alarming among younger males.

• Obesity and MetS: These conditions have public health implications and negatively impact male fertility. Mechanisms and treatment options remain poorly understood.

• Erectile dysfunction (ED): Publication trends indicate a growing concern about ED and its importance in male infertility over the past decade.

• Unexplained male infertility (UMI): Despite fewer publications, there has been a significant increase in articles on UMI in the past two decades. This condition is poorly understood and clinically challenging, but research interest is growing.

• Genomics and advanced techniques: There has been a significant increase in genomics publications in the past two decades, along with a growing interest in proteomics, transcriptomics, and metabolomics. However, there are limitations due to the shortage of advanced techniques and sophisticated instruments, as well as limited accessibility and applied knowledge.

The Reviewer's (Keerti, Kavindra, and Ranjit) Viewpoint on Current Literature on Male Infertility:

The exponential growth in research publications on male infertility underscores the need for bibliometrics as a comprehensive tool for analyzing publication trends. This approach offers succinct analyses, uncovers the latest trends, and provides vital statistics for future research. Scientometrics mainly uses the Scopus database and includes literature from regional journals, thereby it can present diverse viewpoints on specific topics.

Key Topics in Male Infertility Research:

• Testicular Cancer, Obesity & Metabolic Syndrome (MetS), and Unexplained Male Infertility (UMI): These remain major clinical concerns with significant research focus.

• Erectile Dysfunction (ED): Fewer publications focus on ED, possibly because many EDrelated studies address sexual dysfunction. However, there has been a recent surge in ED research, likely due to increased awareness and acceptance of male sexual health issues.

Trends and Challenges:

• The global education of male infertility scientists and clinicians, along with the dissemination of scientific literature, has improved perceptions and highlighted the equal contributions of male and female factors to infertility.

• Idiopathic Male Infertility (IMI): Treating IMI is challenging, with many cases showing no improvement and often receiving empirical treatments. Understanding its multifactorial etiology has engaged more researchers, leading to in-depth studies on gene mutations and molecular defects. Significant progress is being made with genome-wide proteomics and transcriptomics technologies.

Current Gaps and Future Directions:

• Up to 40% of infertile males fall under the category of IMI, with idiopathic oligospermia accounting for 20% of cases. A critical unanswered question is, "Why is there a lack of new drugs for treating idiopathic oligospermia?" The role of the FDA and pharmaceutical agencies is crucial in approving and introducing new treatments with proven efficacy for IMI.

Global Collaboration and Policy Implications:

• There is a growing trend of collaborative global publications from international research consortia and intraregional collaborations. This addresses research capacity building and disparities in publication rates among regional indigenous universities, and lower-middle- and high-income countries.

• Future priorities should include investment in R&D, policy development, and insurance coverage for male infertility. This comprehensive approach will ensure continued progress in understanding and treating male infertility, ultimately benefiting patients worldwide.

*The commentary has been lightly edited for clarity and conciseness by Ashok Agarwal.

Take Home Message: Contributing author - Ashok Agarwal

Reproductive clinicians should prioritize screening for testicular cancer, obesity, MetS, and azoospermia due to their significant impact on male infertility. They should be aware of emerging omics technologies for comprehensive diagnostics and stay informed on advances in ART. Address ED and UMI with the latest research insights, emphasizing evidence-based and collaborative care.

My Viewpoint on Bibliometric Analysis on Male Infertility

Dr. Keerti Singh responds to questions from Ashok

Q1. What has been the most rapidly growing sub-area of male infertility research in the past 20 years?

Dr. Singh: Bibliometric analysis by Baskaran et al revealed that testicular cancer, obesity & metabolic syndrome, and azoospermia were the most rapidly growing sub-areas of male infertility research in the past 20 years. Some other areas of rapid growth include hypogonadism, lifestyle changes, and varicocele.

Q2. How has the research on testicular cancer influenced the overall understanding of male infertility?

Dr. Singh: Testicular cancer emerged as a hot topic in the field of male infertility and the topic of “Testicular Germ Cell Tumors (TGCT)” has the maximum number of articles in the Journal of Urology in the past 20 years. The incidence of testicular cancer has doubled in the past 30 years, distinctly in industrialized nations. It had a negative correlation with semen parameters and male fertility. The escalating trend of testicular cancer amongst young males is of significant concern.

Q3. What correlations exist between obesity, metabolic syndrome, and male infertility according to recent studies?

Dr. Singh: Obesity, Metabolic Syndrome (MetS) and azoospermia received greater research interest in the past two decades. Obesity and MetS negatively impact male fertility and have ascended as significant public health concerns. The recent decade saw a leap in their prevalence, moreover, there were poorly understood links between underlying mechanisms and treatment options in these areas.

Q4. How has the focus on azoospermia evolved over the years in terms of research and clinical approach?

Dr. Singh: Azoospermia was a common finding as observed in approximately 15% of male infertility cases and therefore received a significant spotlight. ART is the most effective treatment option available in this regard and a sharp rise in ART research in the past 20 years is clearly understood. Omics and mechanistic genomics research are at the forefront of identifying molecular events leading to non-obstructive azoospermia and also in developing biomarkers.

Q5. Why have areas like erectile dysfunction and unexplained male infertility received less attention compared to other aspects of male infertility?

Dr. Singh: There are fewer publications on erectile dysfunction (ED) probably due to EDrelated publications contributing more on sexual dysfunction topics. Understanding the pathophysiology and treatment of Unexplained male infertility (UMI) can be challenging and frustrating due to its poorly understood multifactorial etiology. The majority of the cases show no improvement, and most cases are treated empirically. This could be a likely reason for lowered research interest in UMI.

Keerti Singh, MD: Short Biography

Keerti Singh, MD, MS Anatomy

Lecturer, Department of Preclinical & Health Sciences The University of the West Indies, Cavehill Campus, Barbados Department of Surgery, Queen Elizabeth Hospital, St Michael, Barbados

E-mail: keerti.singh@cavehill.uwi.edu

ORCID ID: http://orcid.org/0000-0001- 7532-1229

Dr. Keerti Singh is a lecturer in Anatomy at the Department of Preclinical and Health Sciences, Faculty of Medical Sciences, UWI Cave Hill, Barbados, and a Senior House Officer in Surgery at Queen Elizabeth Hospital, Barbados. Her research interests include Gross and Clinical Anatomy, Embryology, Andrology, Reproductive Medicine, and Medical Education. Dr. Singh has 1179 citations and an H-index of 13. She is an active researcher with the Global Andrology Forum and a member of numerous professional organizations, including the American and British Association of Clinical Anatomists, ESHRE, and ISAR, and holds leadership roles in the Barbados Association of Medical Practitioners and Optimist International.

My Viewpoint on Bibliometric Analysis on Male Infertility

Dr. Kavindra Kesari responds to questions from Ashok

Q1. What mechanistic insights have recent studies provided regarding the pathophysiology of male infertility?

Dr. Kesari: In the past few years, the pathophysiology of male infertility mainly depends on lifestyle factors i.e. radiation, obesity, smoking, stress, etc. The mechanistic insights in the study through the funnel model explore the pathogenesis, prognosis, and diagnosis of various infertility scenarios and advancements in assisted reproductive technology (ART).

Q2. How do prognostic and diagnostic studies enhance the management of male infertility?

Dr. Kesari: The explanation of prognostic and diagnostic studies through the funnel model on male infertility research significantly increased in parallel over the last 20 years. In particular, several factors of lifestyle choices (smoking, drinking alcohol, and taking certain medications) can lower sperm counts, and sperm motility and affect testosterone levels, where such tools as prognostic and diagnostic may play an important role in managing the male fertility pattern.

Q3. What role do genomic studies play in advancing the diagnosis and treatment of male infertility?

Dr. Kesari: Genomics was the first omics tool used to detect and screen genetic abnormalities. The changes in micronuclei, DNA damage, and oxidative damage may be common causes influenced by several chemical, physical, and biological exposures. The field of genomics has significantly expanded over the past 20 years towards detecting diseases associated with male infertility.

Q4. What advancements have been made in proteomics that aid in the identification of biomarkers for male infertility?

Dr. Kesari: Proteomic techniques have provided insight into sperm function and dysfunction by enabling the identification of essential proteins and pathways involved in spermatogenesis, sperm maturation, and fertilization. Introducing mass spectrometry in the proteomic study provides great possibilities for biomarker detection through the comparison of protein expression profiles between normal samples and disease-affected ones.

Kavindra Kesari, PhD: Short Biography

Kavindra K. Kesari Ph.D. (India), Postdoc (Finland)

Professor (Environmental Toxicology) Chandigarh University, Punjab, India

Senior Visting Researcher Aalto University, Espoo, Finland

Email: kavindra_biotech@yahoo.co.in kavindra.kesari@aalto.fi

ORCID ID: 0000-0003-3622-9555

Dr. Kavindra Kesari is a Professor at the University Center for Research and Development, Chandigarh University, Punjab, India. Previously, he served as a Senior Scientist at the University of Helsinki and Aalto University in Finland. He is also a Commissioner at the International Commission on the Biological Effects of Electromagnetic Fields (ICBE EMF), USA, and a Visiting Research Fellow at INTI International University, Malaysia. Dr. Kesari earned his Ph.D. in Biotechnology in India, completing fellowships at Jawaharlal Nehru University, New Delhi. His current research focuses on the effects of radiation exposure on male reproduction, utilizing advanced spectroscopic techniques. With over 150 scientific publications, 30 book chapters, and 7 books, Dr. Kesari has presented at over 40 national and international meetings. His h-index is 41 on SCOPUS, with 4400 citations as of March 2024. He has received several awards and research grants. He has supervised numerous master's and doctoral students. Dr. Kesari also serves on international committees and as an editorial board member and reviewer for prestigious journals.

My Viewpoint on Bibliometric Analysis on Male Infertility

Dr. Ranjit Vishwakarma responds to questions from Ashok

Q1. How are metabolomic approaches being integrated into male infertility research and clinical practice?

Dr. Vishwakarma: Metabolic studies aim to identify and characterize metabolic biomarkers associated with male infertility in biological samples like semen, blood, and urine. Metabolic profiles of fertile and infertile can be compared to identify dysregulated metabolic pathways associated with impaired spermatogenesis, sperm function, or reproductive dysfunction. The metabolite composition of sperm cells can be analyzed to identify metabolites associated with sperm viability, motility, and DNA integrity and hence assess fertility status. Treatment response can be assessed, optimized, and tailored to individual patients by tracking the changes in metabolic profiles.

Q2. What impact does assisted reproductive technology (ART) research have on the treatment outcomes of male infertility?

Dr. Vishwakarma: ART has a significant impact on male infertility. IVF and ICSI have revolutionized the chances of conception of infertile couples. Research involving improving ART protocols, laboratory techniques, and patient selection has progressively improved ART outcomes. Donor sperm is a boon for couples with severe male infertility and genetic disorders. These sperms are utilized using ART techniques for successful pregnancies. Improvement in cryopreservation technique has improved the storage and viability of sperms and brings flexibility to the timing of IVF.

Q3. What emerging technologies are showing promise for future diagnostics and therapeutic strategies in male infertility?

Dr. Vishwakarma: Single-cell analysis helps researchers study individual sperm cells providing insights into its functions and abnormalities. Stem cell therapy regenerates damaged testicular cells or differentiates stem cells into sperm cells, thus offering treatment options for non-obstructive azoospermia. Nanoparticle technology is being investigated to deliver drugs to testes and enhance sperm functions. Omics technology is innovative and promising to provide a comprehensive understanding of male infertility at the molecular level.

Q4. How can findings from this bibliometric analysis guide future research priorities and funding in male infertility?

Dr. Vishwakarma: This bibliometric analysis shows the areas of male infertility which are less explored. These areas can be prioritized and funded to increase future research. Trends in publications can be analyzed to find new areas of study or developments in technology. Opportunities for international collaboration in male infertility research can be found by analyzing the affiliations and collaborations of the authors.

Ranjit Vishwakarma, MBBS, DNB General Surgery, DrNB Urology: Short Biography

Ranjit Vishwakarma, MBBS, DNB General Surgery, DrNB Urology

Junior Consultant, Department of Urology and Andrology, Lilavati Hospital and Research Center, Mumbai, India

Email: ranjitkarma@gmail.com

ORCID ID: 0000-0002-6784-2830

Dr. Ranjit Vishwakarma completed his Urology residency at Lilavati Hospital and Research Centre in Mumbai. He then served as a Senior Resident at Grant Medical College and Sir JJ Groups of Hospitals in Mumbai for a year. Ranjit did a fellowship in Andrology and Reconstructive Surgery at the Lyx Institute in Madrid, Spain. He has actively participated in several local and national conferences through posters, papers, and video presentations. His video on the "Stepwise approach for sperm retrieval technique" earned accolades from the Mumbai Urological Society. As a dynamic and dedicated Urologist, Dr. Vishwakarma specializes in andrology and microscopic surgery. He is also deeply committed to research and scientific publishing, a member of GAF, and an Active Researcher in Team 5.

Isolated teratozoospermia: revisiting its relevance in male infertility: a narrative review.

Fri, 24 May 2024 00:46:01 GMT

Article #48: “Isolated teratozoospermia: revisiting its relevance in male infertility: a narrative review.”

Authors: Widi Atmoko, Missy Savira, Rupin Shah Eric Chung, Ashok Agarwal

Transl Androl Urol 2024;13(2):260-273

https://tau.amegroups.org/article/view/121952/html

Contributors: Dr. Marlon Martinez (Philippines), Dr. Chu Ann Chai,

(Malaysia), and Prof. Christopher Ho (Malaysia)

Commentary:

Semen analysis, despite its flaws and shortcomings, is still considered the cornerstone in the initial evaluation of men with poor productive potential. Sperm morphology remains an essential component of this examination. Any value below the lower reference limit set by the most recent sixth edition of the World Health Organization (WHO) is termed teratozoospermia. Based on available data, there is conflicting evidence on the influence of isolated teratozoospermia on reproductive outcomes and no consensus on its management.

In this current manuscript, the authors performed a comprehensive literature search from the database on PubMed regarding the impact of isolated teratozoospermia on male reproductive potential. A total of 81 original articles and 7 systematic reviews and meta-analyses were included in forming this narrative review. Atmoko et. al. concluded that future studies should be conducted to arrive at definitive recommendations on the assessment and treatment of men with isolated teratozoospermia.

Kruger et. al., as early as 1986, established a reliable and reproducible classification of sperm morphology that was used as an indicator for assisted reproductive technology (ART). Based on the classification, teratozoospermia has been associated with poor fertilization and pregnancy outcomes after ART. Significant changes in the classification had been observed including the continued lowering of the threshold value. Although the criteria are more precise and descriptive, not all are controversial. There is an inherent variability and subjectivity in intra and inter laboratory assessment of sperm morphology, underscoring the complexity of fertility assessment. Hence, standard ization, quality control, and training of personnel should be given priority to improve evaluation.

There is no available guideline for the management of isolated teratozoospermia as most of the studies did not address this condition. In addition, there is limited data on the effective therapeutic options for isolated teratozoospermia. There are conflicting reports on the prognostic value of sperm morphology on natural conception, intrauterine insemination (IUI), in vitro fertilization (IVF), and intracytoplasmic injection (ICSI).

Traditionally, couples are counseled to undergo IVF/ICSI once diagnosed with such sperm abnormality. Couples with isolated teratozoospermia should be advised to undergo a trial of natural conception or IUI before proceeding with IVF/ICSI. This is a more cost-effective viable option for these infertile couples. From a personal standpoint, these treatment options can be offered in men with normal other semen parameters and the absence of pathologic female factors. The absence of complete globozoospermia and primary ciliary dyskinesia allows couples a trial of natural conception. There are some reports that reproductive outcomes are similar in men with isolated teratozoospermia, even in extremely low sperm morphology, compared to men with normal morphology who underwent IUI. There is no clear consensus in the literature on whether ART improves the outcome in men with isolated teratozoospermia as pieces

of evidence showed contradictory results.

Management of isolated teratozoospermia should directly treat the etiology. Infertile men should be treated based on their overall clinical scenario including female factors. These include lifestyle modification, avoidance of occupational hazard exposure, and varicocelectomy. While medical therapies such as antioxidants show promise in certain cases, more research is needed to validate their efficacy and inform clinical practice. The predictive value of isolated teratozoospermia on reproductive outcomes is still a matter of debate. This can be due to its association with sperm DNA fragmentation and reactive oxygen species leading to oxidative stress. The SWOT analysis highlighted recommendations on the strength of the more well-defined sperm morphology in the sixth WHO laboratory manual of semen examination, and the limitation of the lack of evidence on the treatment of isolated teratozoospermia, warranting further research to provide a stronger evidence base.

In summary, Atmoko et al offer a thorough examination of isolated teratozoospermia from a molecular, morphology, and clinical aspect, at the same time highlighting its implication for male infertility diagnosis and treatment. This underscores the scarcity of the currently available evidence and emphasizes the need for further studies to strengthen recommendations.

Take Home Message: Contributing author - Ashok Agarwal

Isolated teratozoospermia, characterized by abnormal sperm morphology with normal counts and motility, has conflicting consequences for male infertility. While it is linked to DNA damage and oxidative stress, its impact on fertility outcomes and assisted

reproductive technology remains unclear. Further research is essential to clarify its clinical significance and treatment options.

My Personal Viewpoint on Isolated Teratozoospermia

Dr. Marlon Martinez responds to questions from Ashok

Q1. What is the clinical significance of isolated teratozoospermia in male infertility according to recent studies?

Dr. Martinez: There are contradicting results on the impact of isolated teratozoospermia in infertile men. Some consider the evaluation of sperm morphology as a non-reliable indicator of male fertility potential as this is poorly correlated with reproductive outcomes.

In addition, other studies showed that the results of assisted reproduction were not mainly determined by isolated teratozoospermia. Future, high-quality studies should be conducted to arrive at a definitive conclusion about the role of isolated teratozoospermia in men with poor reproductive outcomes.

Q2. How does isolated teratozoospermia affect the outcomes of assisted reproductive technologies (ART) like IUI and IVF?

Dr. Martinez: The presence of isolated teratozoospermia is not a contraindication for a trial of natural conception or IUI before proceeding with higher forms of assisted reproduction. Even in men with severely impaired sperm morphology, some studies showed no significant difference in reproductive outcomes in couples who underwent IUI. Similar results were observed in couples who underwent IVF and ICSI showing no significant decrease in the probability of pregnancy. Although the use of IMSI, density gradient centrifugation, and magnetic-activated cell sorting can result in the identification of mature and viable sperm.

Q3. What are the key genetic and environmental factors associated with isolated teratozoospermia?

Dr. Martinez: Genetic causes and environmental factors can contribute to male infertility. Morphological sperm defects on the head, mid-piece, and tail due to genetic etiologies can be observed especially in men with a mutation of the AURKC gene. Other defects, like globozoospermia, cannot proceed with oocyte activation even after ICSI. Other gene mutations and deletions were reported to affect the fertilizing ability of the sperm. Exposure to smoking, alcohol, type of underwear, body mass index, cannabis, infection, and other environmental factors can lead to abnormal sperm morphology. However, other studies showed a non-significant association with these factors.

Q4. How does the presence of isolated teratozoospermia correlate with sperm DNA damage and oxidative stress?

Dr. Martinez: Overproduction of reactive oxygen species was found to be elevated among sperm with abnormal morphology. Men with isolated teratozoospermia have elevated sperm DNA fragmentation due to oxidative stress compared to those without abnormalities. This can result in lower fertilization, implantation, pregnancy, and live birth rates. However, other reports showed a correlation of sperm DNA damage with isolated asthenozoospermia rather than isolated teratozoospermia.

Q5. What are the implications of various sperm morphology assessment methods on the diagnosis of isolated teratozoospermia?

Dr. Martinez: Different laboratories and personnel are using their own classification and sperm morphological assessment which can lead to varying results. It is important to use the classification proposed by the latest edition of the manual for semen analysis released by WHO in 2021. This will make the evaluation universal and can be accepted globally.

Marlon P. Martinez, MD: Short Biography

Marlon P. Martinez, MD

Urologist, Section of Urology

Department of Surgery

University of Santo Tomas Hospital,

Manila, Philippines

E-mail: okahraman_1989@hotmail.com

ORCID: 0000-0002-1191-8154

Dr. Marlon Martinez is a urologist with a strong academic and professional background. He obtained his medical degree from the Faculty of Medicine and Surgery at the University of Santo Tomas (UST) in the Philippines in 2007. Dr. Martinez completed his urology residency training at UST Hospital in 2014. In pursuit of advanced knowledge and specialized skills, Dr. Martinez undertook post-residency training in male infertility. He completed both basic and advanced microsurgery training in the United States. Dr. Martinez has published 23 research articles in peer-reviewed journals, has 435 citations, and an h-index of 8 according to Scopus.

My Personal Viewpoint on Viewpoint on Isolated Teratozoospermia

Dr. Chu Ann Chai responds to questions from Ashok

Q1. Are there effective treatment options available for men diagnosed with isolated teratozoospermia?

Dr. Chai: Unfortunately, there are currently no detailed guidelines for the treatment of isolated teratozoospermia, and the evidence on its management remains limited. The two most discussed approaches are varicocelectomy and antioxidant therapy. Although the evidence supporting varicocelectomy for isolated teratozoospermia is weak, a considerable number of experts (41.1%) tend to recommend it, as indicated by the global varicocele survey. Among antioxidants, L-carnitine has shown promising outcomes, but stronger evidence is needed, especially for patients with isolated teratozoospermia without varicocele.

Q2. How does isolated teratozoospermia impact natural pregnancy rates compared to other forms of male infertility?

Dr. Chai: The impact of severe or moderate teratozoospermia on natural pregnancy rates remains uncertain, as does its suitability as a contraindication for IUI or IVF. Belloc et al. conducted a study involving 1,084 men with isolated sperm defects. The authors observed a stronger correlation between sperm DNA damage and isolated asthenozoospermia than with isolated teratozoospermia.

Q3. What are the strengths, weaknesses, opportunities, and threats (SWOT analysis) identified in current research on isolated teratozoospermia?

Dr. Chai: Strengths: The molecular pathophysiology of teratozoospermia involves sperm DNA damage, apoptotic alterations, overproduction of oxidative stress, and reduced antioxidant function. Additionally, the criteria for defining sperm morphology in the sixth WHO laboratory manual of semen examination are now more precise, clear, and descriptive.

Weaknesses: Conflicting data exists regarding the correlation of isolated teratozoospermia with fertility outcomes after assisted reproductive technology (ART), and limited studies provide low-quality evidence on the treatment of this condition

Opportunities: Future research should focus on providing stronger evidence regarding the use of assisted reproductive technology (ART), particularly intrauterine insemination (IUI), for isolated teratozoospermia. Additionally, there is a need to establish evidence on the benefits of antioxidants in treating this condition, improve the quality assessment of sperm morphology, and strengthen the evidence for the benefits of varicocelectomy in patients with clinical varicocele and isolated teratozoospermia, especially concerning pregnancy and live birth outcomes.

Threats: The sixth edition of the WHO Manual for the Laboratory Examination and Processing of Human Semen has eliminated the use of reference thresholds to distinguish semen abnormalities. Given the limited prevalence of isolated teratozoospermia, obtaining high-quality evidence remains challenging. Until the clinical significance of isolated teratozoospermia for fertility outcomes is definitively established, the importance of seeking treatment remains a matter of debate .

Q4. How do different sperm morphology classifications influence the clinical management of isolated teratozoospermia?

Dr. Chai: Differences in the classification of sperm morphology result in significant variations in diagnostic interpretation. Assessing morphology is inherently subjective, leading to challenges in achieving standardization and consistent, reproducible findings.

Q5. What future research directions are suggested by the study to better understand and manage isolated teratozoospermia?

Dr. Chai: To gain deeper insights into isolated teratozoospermia management, the authors recommended investigating sperm DNA fragmentation (SDF) in patients with this condition. Additionally, they proposed studying the clinical efficacy and risk-benefit analysis of assisted reproductive techniques (ART) specifically within the context of isolated teratozoospermia.

Chu Ann Chai, MD: Short Biography

Chu Ann Chai

M.D, MSurg (UM), FRCS (Urol, Glgw)

Consultant Urologist, Senior Lecturer

University Malaya Medical Center

Department of Surgery, Urology Unit

Kuala Lumpur, Malaysia

E-mail: chaichuann@yahoo.com

ORCID ID: 0000-0001-8915-3617

Dr. Chu Ann Chai is a Consultant Urologist who completed his fellowship in Andrology and Urology at the prestigious NHS Lothian in Edinburgh, Scotland. Dr. Chai has made significant strides in the field of male infertility, particularly through the establishment of a combined Uro-Gynae Male Infertility service and microTESE surgery at the University of Malaya. In addition to his clinical achievements, Dr. Chai is an active participant in various international urological societies and educational groups. His roles include Fellow of Andrology and Urology, NHS Lothian, Edinburgh, Scotland, Trainer, and Faculty Member, Asian Urological Surgery Training & Education Group (AUSTEG), Faculty Member, International Alliance of Urolithiasis (IAU), Faculty Member, Asian Urological Society of Endoluminal & Technology (AUSET), Member, Global Andrology Forum, and CCriSP Instructor, Royal College of Surgeons (Eng). Dr. Chai has authored 22 research articles indexed on PubMed, which have collectively received 436 citations, earning him an h-index of 8 on Scopus.

My Personal Viewpoint on Viewpoint on Isolated Teratozoospermia

Dr. Christopher Ho Chee Kong responds to questions from Ashok

Q1. How reliable are current sperm morphology criteria from the WHO in predicting fertility outcomes in men with isolated teratozoospermia?

Dr. Chris Ho: Sperm morphology is a poor predictive value for fertility outcomes because it is very subjective and difficult to standardize across the globe.

Q2. What are the current controversies and debates surrounding the clinical management of isolated teratozoospermia?

Dr. Chris Ho: There are conflicting results regarding isolated teratozoospermia and fertility outcomes after ART. Limited studies are showing a correlation between isolated teratozoospermia and natural pregnancy. There is no clear evidence whether severe or moderate teratozoospermia compromises chances of natural pregnancy, or whether it is a contra-indication for IUI or IVF. One study found that isolated teratozoospermia was more common in fertile than infertile males. Currently, there are no guidelines for the treatment of isolated teratozoospermia.

Q3. How do apoptotic alterations in sperm cells relate to isolated teratozoospermia?

Dr. Chris Ho: Patients with teratozoospermia had a higher proportion of spermatozoa with late-stage apoptosis, and there was a substantial correlation between the frequencies of atypical sperm forms and apoptotic biomarkers. A diminished seminal antioxidant capacity was also considered a vital component of the mechanism in sperm cell death-mediated DNA breaks among teratozoospermic semen.

Q4. What role might antioxidants play in the management of isolated teratozoospermia?

Dr. Chris Ho: Antioxidants (L-carnitine, vitamin C, and vitamin E) could significantly improve sperm morphology and SDF rates (33% vs. 29%, after 6 months of treatment among men with isolated teratozoospermia and clinical varicocele. L-carnitine has also been shown to be the best antioxidant to improve sperm morphology among idiopathic male infertility cases. Unfortunately, there are no controlled trials on the role of antioxidants in men with isolated teratozoospermia without varicocele. Further studies are needed before antioxidants can be recommended for these patients.

Q5. Are there specific clinical or lifestyle interventions recommended for men with isolated teratozoospermia to improve their reproductive health and fertility outcomes?

Dr. Chris Ho: Lifestyle factors, including age when starting a family, nutrition, weight management, exercise, psychological stress, cigarette smoking, recreational and prescription drugs use, alcohol and caffeine consumption, environmental and occupational exposures, preventative care, and other behaviors are modifiable and be associated with infertility. However, there is a lack of good evidence to recommend any specific clinical lifestyle interventions for isolated teratozoospermia.

Prof Christopher Ho Chee Kong, MD, MS, MRCSEd, MBU (Cert), MFSTEd, FAMM, FICS (USA), FRCS (Urol)(Glasg), FECSM, FRCSEd, FACS: Short Biography

Christopher Ho Chee Kong, MD, MS, MRCSEd

Consultant Urologist, Oriental

Melaka Straits Medical Centre

Department of Surgery, Taylor's

University, Subang Jaya, Malaysia

Email: chrisckho2002@yahoo.com

ORCID ID: 0000-0002-8757-6867

Prof. Dr. Christopher Ho Chee Kong is an Adjunct Professor in the School of Medicine, at Taylor's University, and a Consultant Urologist at Oriental Melaka Straits Medical Centre. Formerly, a Professor of Surgery and Urology at Universiti Kebangsaan Malaysia (UKM), he has a notable career in both academia and clinical practice. Prof. Ho is actively involved in several prestigious organizations: Member of the International Consultation of Urological Diseases (ICUD), the Vice President of the Malaysian Society of Andrology and the Study of the Aging Male (MSASAM), Senior Vice President of the College of Surgeons Malaysia, Vice Chair of the International Society for Sexual Medicine Communications Committee, Committee Member of the Asian Society of Men’s Health and Andrology (AMSHA) and also a Fellow of the Royal College of Surgeons of Edinburgh (FRCSEd), and Glasgow FRCS (Urol)(Glasg), European Committee of Sexual Medicine (FECSM), International College of Surgeons (FICS), European Committee of Sexual Medicine (FECSM), American College of Surgeons (FACS) and Academy of Medicine Malaysia (FAMM). He is also a Member of the Faculty of Surgical Trainers Edinburgh (MFSTEd), Société Internationale d'Urologie (SIU), Examiner for the Membership of the Royal College of Surgeon (MRCS) exam, tutor for the Edinburgh Surgical Sciences Qualification (ESSQ), Director of Andrology Special Interest Group for the Malaysian Urology Association. Prof. Ho has published over 155 peer-reviewed

journal articles, with 870 citations and an h-index of 15. He has authored seven books on men's health and serves on the editorial boards of 10 journals, including the Investigative and Clinical Urology Journal and SIU journal. Additionally, he is a reviewer for 24 journals, an examiner for the Membership of the Royal College of Surgeons (MRCS) exam, and a tutor for the Edinburgh Surgical Sciences Qualification (ESSQ). As Director of the Andrology Special Interest Group for the Malaysian Urology Association, he continues to contribute significantly to the field of urology and men's health.

Impact of Varicocele on Testicular Oxidative Stress and Sperm Parameters in Experimental Animals: A Systematic Review and Meta-Analysis.

Tue, 07 May 2024 15:30:43 GMT

Article #48: “Impact of Varicocele on Testicular Oxidative Stress and Sperm Parameters in Experimental Animals: A Systematic Review and Meta-Analysis.”

Authors: Giorgio Ivan Russo, et al.

World J Men’s Health Published online Feb 7, 2024

https://doi.org/10.5534/wjmh.230260

Contributors: Oğuzhan Kahraman, MD (Turkey), Emrullah Sogutdelen, MD (Turkey) and Ranjit Vishwakarma, MBBS, DNB (India)

Commentary:

Varicocele is recognized as the most common correctable cause of male infertility. The mechanism by which varicocele contributes to infertility remains a subject of debate. Testicular tissue is highly prone to oxidative stress as it consumes a significant amount of oxygen. Reactive oxygen species (ROS) are known to cause harm to cellular structures and deoxyribonucleic acid (DNA).

Russo et al. conducted a systematic review and meta-analysis (SRMA) to explore the impact of varicocele on testicular oxidative stress markers and sperm parameters in experimental animal models with and without varicocele. An extensive literature review spanning the last 20 years was performed using the PubMed and Scopus databases. Out of 76 articles identified, only six met the criteria for inclusion in the current SRMA. Despite the heterogeneity of the data, findings indicated that levels of Malondialdehyde (MDA) and sperm DNA fragmentation (SDF) were significantly elevated, while sperm vitality and motility were notably reduced in animal models with varicocele.

The SRMA highlighted that, although based on a limited number of studies, there is high-quality evidence suggesting that ROS, leading to increased lipid peroxidation and elevated MDA levels—a marker of this process—are heightened in animal models with varicocele. The escalation in oxidative stress may result in DNA damage and adversely affect sperm motility and vitality.

There is an ongoing debate on varicocele repair in male infertility. In daily practice, only patients with clinical varicocele and abnormal sperm parameters are treated. Varicocelectomy may reverse sperm DNA damage and improve sperm parameters. Greater improvement is seen in higher-grade varicoceles. There is a controversy in the treatment of varicocele patients with elevated SDF and normal sperm parameters. If the female ovarian reserve is good, after discussing the possible delay for assisted reproductive techniques, varicocelectomy is advised.

The current literature reveals a gap in evidence concerning the relationship between the duration of varicocele, the associated level of oxidative stress, and changes in sperm parameters. Additionally, there is a notable scarcity of data on pregnancy and live birth rates, which are essential outcomes in fertility research.

My Personal Viewpoint on an Online Educational Model in Andrology

Dr. Oğuzhan Kahraman responds to questions from Ashok

Q1. What specific changes in malondialdehyde (MDA) levels were observed in the testes of varicocele-affected animals compared to controls?

Dr. Kahraman: Malondialdehyde levels were significantly elevated in the testis of varicocele-affected animals.

Q2. How did varicocele influence total sperm count and motility in the experimental animals?

Dr. Kahraman: The total sperm count, and motility were significantly reduced in the varicocele-affected animals.

Q3. What significant findings were noted in sperm DNA fragmentation (SDF) levels in animals with varicocele?

Dr. Kahraman: Sperm DNA fragmentation was significantly increased in the varicocele-affected animals.

Q4. What role does oxidative stress play in the pathophysiology of varicocele-induced testicular damage according to the study?

Dr. Kahraman: The exact mechanism of testicular damage by oxidative stress (OS) is not fully understood, although excess heat and hypoxia have been postulated. Inadequate production of heat shock proteins, which are involved in responding to heat stress, leads to increased sperm protein denaturation, apoptosis, and male infertility.

Q5. How might the findings of increased oxidative stress markers in varicocele-affected animals relate to human clinical scenarios?

Dr. Kahraman: There is still an ongoing debate about the relationship between varicocele and infertility in humans. Animal studies provide sufficient evidence of the detrimental effects of varicocele on sperm functions mediated by OS. The beneficial effects of varicocele repair could be mediated through the reduction of OS.

Oğuzhan Kahraman, MD: Short Biography

Oğuzhan Kahraman, MD, FEBU

Assistant Professor of Urology

Dept. of Urology, Faculty of Medicine, Baskent University

Konya, Turkiye

E-mail: okahraman_1989@hotmail.com

ORCID: 0000-0003-3691-8617

Dr. Oğuzhan Kahraman completed both his undergraduate and urology residency at Hacettepe University. He fulfilled his mandatory government service at Dr. Sami Ulus Teaching Hospital and is now a consultant urologist at Baskent University Konya Hospital. Dr. Kahraman serves as the Secretary of the Hypogonadism and Prostate Diseases Working Group within the Andrology Working Group of the Society of Urological Surgery in Turkey (SUST) and is the Podcast project manager for SUST (Uropod). His academic contributions include 12 original articles, 3 book chapters, and 1 edited book, with a Scopus h-index of 6 and 70 citations. Oğuzhan is committed to research and scientific publishing, a member of GAF, and an Active Researcher in Team 5.

My Personal Viewpoint on Varicocele and Testicular Oxidative Stress

Dr. Emrullah Sogutdelen responds to questions from Ashok

Q1. Given the study’s findings on sperm parameters, what are the potential impacts of varicocele repair on fertility outcomes?

Dr. Emrullah: Depending on the data from selected articles, total sperm count, sperm vitality, sperm motility, and sperm DNA fragmentation have been investigated. These are the potential parameters for fertility outcomes. However, all these parameters are not the only parameters for fertility, pregnancy, and live birth rates mentioned in the limitation parts of the article.

Q2. What does the study suggest about the importance of early detection and management of varicocele in preserving male reproductive health?

Dr. Emrullah: The exact mechanism of pathogenesis of oxidative stress in experimental animals with varicocele is not fully understood despite excess heat exposure and hypoxia that have been postulated. Varicocele is thought to increase testicular temperature, secondary to the increase in heat shock proteins and their impact on sperm protein denaturation, apoptosis, and male infertility. So, the earlier detection and management of varicocele may impact the preservation of male fertility.

Q3. How might the study's insights into oxidative stress and sperm health inform counseling and treatment strategies for infertile men with varicocele?

Dr. Emrullah: Hypoxia in patients with varicocele leads to a decrease in oxygen partial pressure and the presence of hypoxia in the testicular microenvironment triggers changes in the expression of various hypoxia-related factors and genes, subsequently impacting the testicular microenvironment. In the study, the detrimental impact of oxidative stress on sperm function and sperm DNA fragmentation clearly demonstrated in the animal models with varicocele.

Q4. Given the study's demonstration of testicular oxidative stress in varicocele, what are the implications for adolescent and young adult males?

Dr. Emrullah: The hypoxia-inducible factor-1 (HIF-1) is generated in response to tissue hypoxia and is expressed in germ cells. HIF-1 binds to vascular endothelial growth factor (VEGF) and plays a crucial role in mitigating the damage caused by tissue hypoxia. Depending on the germ cell maturation in adolescent or young adult males, they are relatively much more susceptible to oxidative stress and its detrimental effects.

Q5. How do the study's findings on the effects of varicocele on sperm vitality and motility align with or differ from previous research in the field?

Dr. Emrullah: The results of the current study suggest that varicocele-induced testicular damage is mediated by oxidative stress. Previous studies including infertile men with clinical varicocele showed significant improvement in postoperative semen parameters, including sperm concentration, total sperm count, progressive sperm motility, total sperm motility, and normal sperm morphology. Therefore, the positive effects of varicocele repair on sperm parameters could be mediated through a reduction of testicular/seminal oxidative stress.

Emrullah Sogutdelen, MD: Short Biography

Emrullah Sogutdelen, MD, FEBU

Associate Professor in Urology

Bolu Abant Izzet Baysal University, Medical School

Department of Urology

Bolu, Turkey

E-mail: esdelen@gmail.com

ORCID ID: 0000-0002-1454-5672

Dr. Emrullah Sogutdelen serves as an Associate Professor and consultant urologist at Izzet Baysal Education and Research Hospital in Bolu, Turkey. He completed both his medical degree and urology residency at Hacettepe University School of Medicine, graduating in 2010 and completing his residency in 2016, respectively. A member of the Association of Urological Surgery since 2012, Dr. Sogutdelen is also active within the European Urology Association. His contributions to urology include over 25 scholarly articles, with an h-index of 9. He has made national and international conference presentations and authored several book chapters. Presently, he is the co-leader of Research Team 5 in the Global Andrology Forum (GAF).

An online educational model in andrology for student training in the art of scientific writing in the COVID-19 pandemic.

Thu, 02 May 2024 14:57:40 GMT

Article #47: “An online educational model in andrology for student training in the art of scientific writing in the COVID-19 pandemic.”

Authors: Ashok Agarwal, Kristian Leisegang, Manesh Kumar Panner Selvam, et al.

Andrologia, Published: 2021, DOI: 10.1111/and.13961

Contributors: Sulagna Dutta, PhD (UAE), and

Haitham Elbardisi, MD (Qatar)

Preamble:

The authors of this article discuss an innovative online mentorship program developed by the American Center for Reproductive Medicine (ACRM) during the COVID-19 pandemic. This first-of-its-kind initiative, designed to train students in scientific writing and research methodologies relevant to andrology, effectively adapted to pandemic constraints. Prof. Ashok Agarwal, the former director of ACRM, now the Research Director of the Global Andrology Forum (GAF), spearheaded this innovative and adaptive educational model, demonstrating exceptional foresight and leadership in challenging times.

Commentary:

This 6-week-long program focused on five core pillars of Andrology Research: scientific writing, scientific methodology, understanding plagiarism, soft skills development, and basic Andrology knowledge. The study aimed to evaluate the outcomes of this mentorship program, structured around scientific writing projects and one-on-one mentorship, complemented by weekly online meetings, lectures, and assessments. The effectiveness of the program was gauged through mentee surveys and showed significant improvement in all criteria related to the core pillars.

The study demonstrates the feasibility and success of an online mentorship model in providing comprehensive training in scientific writing and research methodologies in Andrology. The program's innovative approach allowed for continued research training during the COVID-19 pandemic, offering a template for future online educational models in specialized fields.

Take Home Message:

This article underscores the importance of adapting educational models to maintain the continuity of scientific training during unprecedented challenges like the COVID-19 pandemic. It highlights the effectiveness of the ACRM Online Mentorship Program in enhancing the Mentee’s understanding of scientific writing, research methodologies, and essential soft skills in Andrology, thereby contributing significantly to the field of Reproductive Medicine Research.

Key Takeaways: Contributor of this section: Ashok Agarwal, USA

The ACRM Online Mentorship Program significantly improved mentee development in andrology research and scientific writing during the COVID-19 crisis.
The program was structured around five core pillars: scientific writing, scientific methodology, understanding plagiarism, developing soft skills, and basic andrology knowledge.
The mentorship utilized a one-on-one expert mentorship approach, which included weekly formative assessments and online meetings with experts, enhancing personalized learning and engagement.
Mentees reported a marked improvement in skills related to scientific writing, from grammar to understanding scientific methodologies, and the application of plagiarism awareness in their work.
The final assessment of the mentees was comprehensive, incorporating both quantitative rubrics and qualitative feedback, which guided the mentees toward preparing their manuscripts for publication.

My Personal Viewpoint on an Online Educational Model in Andrology

Dr. Sulagna Dutta responds to questions from Ashok

Q1. How did the COVID-19 pandemic impact traditional andrology education and necessitate the shift to an online educational model?

Dr. Dutta: The COVID-19 pandemic led to significant disruptions in traditional educational systems, including the suspension of in-person teaching in andrology. This challenge necessitated a swift transition to an online educational model to maintain continuity in educational and training programs. The American Center for Reproductive Medicine (ACRM) responded to these challenges by developing an inaugural ACRM Online Mentorship Program, designed to support and continue the education of students in the field of andrology. The shift to an online model was driven by the need to adapt to the restrictions imposed by the pandemic while ensuring that educational objectives and the quality of training were maintained.

Q2. What are the five core pillars of andrology research emphasized in the ACRM Online Mentorship Program, and why are they considered critical for scientific writing and research in andrology?

Dr. Dutta: The ACRM Online Mentorship Program emphasized five core pillars of andrology research: scientific writing, scientific methodology, understanding plagiarism, development of soft skills, and basic knowledge of andrology. These pillars are critical for scientific writing and research in andrology because they collectively provide a comprehensive foundation necessary for conducting high-quality research. Scientific writing and methodology are essential for generating and reporting research findings accurately. Understanding plagiarism is crucial for maintaining ethical standards. Soft skills, such as communication and time management, are vital for collaborative research efforts, while a solid foundation in andrology ensures that research is grounded in relevant and current scientific knowledge.

Q3. How does the program address the challenge of teaching practical and laboratory skills in an online format?

Dr. Dutta: The ACRM Online Mentorship Program adapted to the challenge of teaching practical and laboratory skills in an online format by focusing on scientific writing projects, regular online meetings including expert lectures, formative assessments, and a student-centered approach. Although the program could not replicate hands-on laboratory experiences directly, it emphasized the development of scientific literacy, critical analytic skills, and understanding of research methodologies, which are foundational to practical and laboratory skills in andrology. The program utilized a range of digital tools and platforms for interactive learning and engagement.

Q4. What methodologies were employed in the program to ensure mentees' understanding and avoidance of plagiarism in scientific writing?

Dr. Dutta: To ensure mentees' understanding and avoidance of plagiarism in scientific writing, the program employed several methodologies, including focused training on plagiarism through lectures and the incorporation of plagiarism analysis in weekly written submissions. Mentees received education on the importance of originality in research, the use of similarity index reporting to detect potential plagiarism, and discussions on how to avoid unintentional plagiarism. These methodologies provided mentees with the knowledge and tools to recognize, understand, and avoid plagiarism in their scientific writing.

Q5. How does the program assess the development of soft skills among mentees, and why are these skills important in medical research and practice?

Dr. Dutta: The program assessed the development of soft skills among mentees through weekly assessments conducted by mentors, focusing on qualities such as punctuality, initiative, attention to detail, critical thinking, self-organization, and effective communication. Soft skills are important in medical research and practice because they enhance teamwork, improve communication with peers and mentors, and facilitate the management of research projects. By assessing and developing these skills, the program aimed to prepare mentees for the collaborative and interdisciplinary nature of medical research and practice, ensuring they are well-equipped to contribute effectively in professional settings.

Sulagna Dutta, PhD: Short Biography

Sulagna Dutta, PhD

Assistant Professor

School of Life Sciences

Manipal Academy of Higher Education

Dubai, UAE

Email: sulagna_dutta11@yahoo.com

ORCID id: https://orcid.org/0000-0002-7893-5282

Dr. Sulagna Dutta is a Physiologist with >150 research publications and a current Scopus h-index of 29. Dutta is a Faculty at the School of Medicine, Manipal Academy of Higher Education, Dubai, UAE. She has earned her PhD in Physiology, with specialization in Immunology from the University of Calcutta, India. She has also pursued a Research Internship in Reproductive Medicine from the American Center for Reproductive Medicine (ACRM), Cleveland Clinic, USA. Sulagna has more than 12 years of experience in teaching and research in India, Malaysia, and the UAE. Her research interests include immunology, reproductive physiology, and infertility. She has been ranked among the Top 2% of Scientists in the world by Stanford University since 2020.

My Personal Viewpoint on an Online Educational Model in Andrology

Dr. Haitham Elbardisi responds to questions from Ashok

Q1. In what ways did the program adapt its teaching strategies to accommodate the online format and ensure engagement and effective learning?

Dr. Haitham: The program adapted its teaching to an online format by developing a collaborative model with clear outcomes, focusing on scientific processes, and providing real-time feedback. It emphasized interactive learning over lectures and fostered a partnership between mentors and students to enhance knowledge assembly and application.

Q2. How does the ACRM Online Mentorship Program facilitate the development of basic andrology knowledge among its participants?

Dr. Haitham: The ACRM program (while under the leadership of Prof. Ashok Agarwal) was a platform that brought together high-caliber clinicians and researchers from around the world. Through this platform, junior medical students and doctors have the opportunity to interact with seasoned professionals, which is otherwise difficult to achieve. The seniors provided an exceptional opportunity to teach basic and advanced research skills and guide the summer interns through the process of publishing their first real-time research in peer-reviewed journals. The ACRM thus served as an excellent platform for knowledge sharing and learning.

Q3. What were the significant outcomes and mentee developmental improvements reported in the study, and how do these outcomes compare to traditional in-person education methods?

Dr. Haitham: Throughout the course schedule, regular assessments were conducted starting from enrolment until the exit from the program. These assessments can be divided into four categories: formative assessment, final assessment (presentation and writing assignments), soft skills assessment, and surveys (weekly and final exit surveys). The online survey was reviewed and approved by the Institutional Review Board (IRB) of Cleveland Clinic.

The outcome of the assessments was remarkable, and there was excellent online engagement. The virtual colloquium meeting was rated very good, and the majority of mentees strongly agreed or agreed with each statement. They found the learning objectives to be clear and meticulously organized. Finally, the pre-and post-program questionnaires showed significant improvement in the mentees' skills in all five core outcomes.

Q4. How does the one-on-one expert mentorship in the ACRM program enhance the learning outcomes in scientific writing and methodology for mentees?

Dr. Haitham: The one-on-one mentorship provided the mentee with an exceptional opportunity to receive guidance from experts on planning and collaboratively writing scientific manuscripts. This consisted of didactic lectures, followed by explanations and a step-by-step writing, and reviewing process.

Q5. What future implications and recommendations does the study suggest for the integration of online educational models in medical and scientific training programs, particularly in the field of andrology and reproductive medicine?

Dr. Haitham: A good online education setup allows learners to connect with expert mentors in andrology, offering valuable content, which is vital since such experienced researchers are rare.

Haitham Elbardisi, MD: Short Biography

Haitham Elbardisi, MD

Senior Consultant in Urology and Andrology

Department of Urology

Hamad Medical Corporation

Doha, Qatar

Email: elbardisi@gmail.com

ORCID id: 0000-0003-3902-7924

Dr. Haitham Elbardisi is a Senior Consultant in Urology and Andrology at Hamad Medical Corporation (HMC), Doha, Qatar, and serves as an Associate Professor at both Weill Cornell Medicine-Qatar and Qatar University. His expertise lies in Male Infertility and advanced microsurgical techniques. He has significantly contributed to the medical field as a founding member of a center of excellence at HMC, a pioneering institution in Andrology and Male Infertility care for Qatar and the wider Middle East region. Between 2010 and 2021, Haitham, as Associate Program Director, led the Urology residency to its ACGME accreditation in 2013 — a first for a program outside the U.S. He also launched the Andrology fellowship program at HMC, mentoring a diverse group of local and international fellows. His research endeavors are as impactful as his clinical work. Focusing on the nuances of patient care, his research addresses critical issues in varicocelectomy, NOA, ICSI, and the genetics of male infertility. He has secured four major grants from HMC and the Qatar National Research Funds (QNRF), fueling advances in the understanding and treatment of male reproductive health. Haitham has a distinguished academic career with 58 original PubMed-indexed articles, a citation count of 1116, and an h-index of 17 (source: Scopus).

The Impact of Single- and Double-Strand DNA Breaks in Human Spermatozoa on Assisted Reproduction

Sun, 14 Apr 2024 16:07:35 GMT

Article #46: “The Impact of Single- and Double-Strand DNA Breaks in Human Spermatozoa on Assisted Reproduction”

Authors: Ashok Agarwal, Catalina Barbarosie, Rafael Ambar, Renata Finelli, International Journal of Molecular Sciences, 2020, 21, 3882

doi:10.3390/ijms21113882

CAPSULE

Contributors: Carlo Giulioni, MD (Italy), and

Nikolaos Sofikitis, MD, PhD (Greece)

Commentary:

The integrity of sperm DNA represents a prerequisite for successful fertilization, optimal embryonic quality, and the development of healthy offspring. Male and female pronuclei development and extrusion of the second polar body are normally followed by zygotic divisions and further early embryonic development. Abnormalities in sperm DNA, due to the "late paternal effect," disrupt zygotic transcription impeding embryonic implantation. Various sperm DNA defects, including sperm DNA fragmentation (SDF), mitochondrial damage, and Y-chromosome microdeletions, may result in single- or double-strand breaks.

Methods to diagnose sperm DNA strand breaks (SDF) are available. Compromised sperm DNA compaction during spermatogenesis, involving protamine assembly, increases susceptibility to DNA damage, negatively affecting the final sperm reproductive capacity. Abortive apoptosis may lead to double-strand DNA breaks (DSBs). Oxidative stress, an imbalance between reactive oxygen species (ROS) and antioxidants, directly damages DNA causing SDF.

Diagnostic tests, such as TUNEL, SCSA, SCD (Halo test), Comet assay, and γH2AX immunodetection, employ diverse methodologies and yield variable outcomes. While the Comet assay distinguishes between single- and double-strand DNA breaks, γH2AX specifically identifies DSBs. It is essential to note that the outcome of these tests may not directly correlate, and the results are not easily comparable.

The section further examines the association between sperm DNA single-strand breaks (SSBs) and DSBs with their consequences on various reproductive outcomes, especially in assisted reproductive technology (ART). Limited evidence exists regarding the specific impact of SSBs and DSBs on ART outcomes. Several studies suggest a negative correlation between SSBs and fertilization rates. In fact, higher SSB percentages are associated with lower fertilization rates in in vitro fertilization (IVF). Additionally, elevated SSB profiles correlate with reduced implantation rates.

Conversely, intracytoplasmic sperm injection (ICSI) procedures may provide an alternative method to overcome the impact of sperm DNA damage on male reproductive capacity. DSBs exhibit a more pronounced negative influence on reproductive outcomes than SSBs. Evidence suggests that ICSI, involving the selection of sperm based on optimal motility and morphology, may partially overcome the consequences of sperm DNA damage compared to IVF trials.

Overall, DSBs appear to have a more substantial negative impact on reproductive outcomes than SSBs. This may be attributable to the separation of paternal and maternal DNA in early embryo development, limiting the probability of DSBs repair. The influence of sperm DNA damage is less pronounced with ICSI, where embryologists selectively choose spermatozoa, inadvertently favoring those with lower sperm DNA fragmentation rates due to the sperm selection method. In male germ cell development, DNA repair mechanisms operate until the third week of spermatogenesis, after which sperm DNA undergoes compaction and repair processes are downregulated.

However, concerning sperm genomic integrity, the oocyte can effectively repair paternal SSBs and DSBs when sperm DNA damage is below 8%. Male germ cells lack molecular mechanisms for single-strand break repair but employ base excision repair (BER) mechanisms during spermatid stages. For DSB repair, mechanisms include homologous recombination (HR) and non-homologous end joining (NHEJ), with an alternative NHEJ pathway active in spermatids, particularly in the absence of classical NHEJ components.

In conclusion, sperm DNA damage, affecting one or both strands, leads to a lower ability of the sperm nucleus to fertilize the female gamete and to trigger zygotic cleavage and early embryonic development appropriate to complete the implantation process with a subsequent normal fetal development. Current tests vary, with only the Comet assay distinguishing SSBs and DSBs. Repair potential decreases after early spermatogenesis, impacting reproductive outcomes. The role of ICSI in overcoming male infertility when high percentages of spermatozoa, with abnormalities in DNA, are present, needs further studies to be supported unequivocally.

Key Takeaways (Carlo and Nikolaos):

Over the past 20 years, there has been a stable trend of ART and male infertility publications. Most of the research focused on the conventional approach compared to advanced techniques. More research will be needed for advanced techniques, particularly as it can be a salvage procedure for a few severe male infertility cases that still want to have a biological child. Azoospermia has been the most reported clinical scenario, but up until now, many controversies still exist. With the golden era of Andrology, more research can be done to fill the gap in the literature and improve the care for infertile men.

My Personal Viewpoint on Diagnostic Value of Advanced Semen Analysis

Dr. Carlo Giulioni and Prof. Nikolaos Sofikitis respond to questions by Ashok

Q. 1. How do single-strand breaks (SSBs) and double-strand breaks (DSBs) in sperm DNA specifically impact fertilization rates and embryonic development in the context of assisted reproductive technology (ART)?

A 1: Single-strand breaks (SSBs) and double-strand breaks (DSBs) in sperm DNA have been recognized as significant factors affecting fertilization rates and embryonic development, particularly in the context of assisted reproductive technology (ART). SSBs and DSBs can compromise the integrity of paternal genetic material transmitted to the oocyte during fertilization, with a significant association with an increased risk of chromosomal abnormalities and genomic instability within the developing embryo. Furthermore, SSBs and DSBs in sperm DNA may activate cellular pathways involved in apoptosis or senescence, further compromising embryo viability. These cellular responses to DNA damage can disrupt normal embryonic development and contribute to reduced implantation rates and increased rates of pregnancy loss in ART cycles.

The exact mechanisms by which SSBs and DSBs influence fertilization rates and embryonic development in the context of ART are unclear. However, sperm DNA damage exerts detrimental effects on reproductive outcomes by compromising the integrity and functionality of paternal genetic material transmitted to the embryo.

Q 2. What are the limitations of current diagnostic methods for detecting sperm DNA fragmentation (SDF), and how do these limitations affect the interpretation of test results in clinical practice)?

A 2. The contemporary diagnostic approaches for discerning sperm DNA fragmentation (SDF) possess several inherent limitations, which impinge upon the accurate interpretation of test outcomes within clinical settings. Firstly, one notable constraint lies in the diversity of methodologies employed across diagnostic platforms. Discrepancies in sample preparation techniques, assay protocols, and result quantification methodologies among laboratories render comparisons between studies challenging, thereby compromising the establishment of standardized diagnostic thresholds and benchmarks for clinical interpretation. Secondly, the lack of consensus regarding the optimal threshold for categorizing SDF levels as pathological further complicates the interpretation of test results. Divergent cutoff values across studies contribute to ambiguity in clinical decision-making, as clinicians grapple with discerning between normal and abnormal sperm DNA integrity. Moreover, the absence of universally accepted guidelines exacerbates the challenge of implementing consistent diagnostic criteria. Furthermore, inherent biological variability in sperm DNA fragmentation poses a significant obstacle to accurate diagnosis. SDF levels exhibit natural fluctuations within individuals over time. Finally, current diagnostic methods often lack the capability to discern the underlying causes of elevated SDF levels, thereby limiting their clinical relevance. Consequently, the absence of mechanistic insights hampers targeted interventions and personalized treatment strategies, thereby constraining the clinical utility of diagnostic tests for SDF.

Q 3. Considering the repair mechanisms for sperm DNA damage, how does the oocyte's capacity to repair paternal SSBs and DSBs influence the selection of sperm for ART procedures, particularly ICSI?

A3. The capacity of the oocyte to repair paternal single-strand breaks (SSBs) and double-strand breaks (DSBs) in sperm DNA significantly influences the selection of sperm for Assisted Reproductive Technology (ART) procedures, notably Intracytoplasmic Sperm Injection (ICSI). ART techniques such as ICSI bypass natural selection processes that typically occur during natural conception.

Unlike somatic cells, sperm lacks the cytoplasmic machinery required for DNA repair. Consequently, the oocyte's ability to repair DNA damage in sperm becomes a critical determinant in ensuring the genomic integrity of the resulting embryo.

The differential capacity of the oocyte to repair paternal SSBs and DSBs influences sperm selection strategies during ART procedures, especially ICSI. While the oocyte can partially repair DNA lesions, excessive sperm DNA damage can overwhelm its repair machinery, leading to impaired embryonic development, increased miscarriage rates, and potential long-term health consequences for offspring. Consequently, various sperm selection techniques have been developed to identify and isolate sperm with intact DNA, such as sperm DNA fragmentation assays and advanced sperm selection methods based on DNA integrity. By selecting sperm with minimal DNA damage, ART clinics aim to optimize embryo quality and improve reproductive outcomes for couples undergoing fertility treatments.

Q4. Given the evidence suggesting a more pronounced negative impact of DSBs over SSBs on reproductive outcomes, what future research directions are critical for improving ART success rates in cases of significant sperm DNA damage?

A4. The discernible evidence indicating a heightened detrimental influence of Double Strand Breaks (DSBs) compared to Single Strand Breaks (SSBs) on reproductive outcomes underscores the imperative for delineating pivotal future research trajectories aimed at enhancing the success rates of Assisted Reproductive technology (ART) in instances marked by substantial sperm DNA impairment. Several critical avenues for future investigation emerge in this context.

Primarily, comprehensive elucidation of the mechanistic underpinnings governing the divergent impact of DSBs vis-à-vis SSBs on reproductive outcomes constitutes a fundamental research imperative. This necessitates in-depth exploration into the distinct molecular pathways and cellular processes implicated in the repair mechanisms of DSBs and SSBs within the context of sperm DNA damage. Moreover, prospective research endeavors should prioritize the development and validation of refined diagnostic modalities capable of accurately discerning the extent and nature of sperm DNA damage, with a particular emphasis on distinguishing between DSBs and SSBs.

Furthermore, there exists a compelling imperative to explore innovative therapeutic strategies aimed at mitigating the adverse effects of DSBs on sperm function and fertility outcomes. In this regard, the exploration of pharmacological agents targeting key molecular effectors involved in the repair and mitigation of DSBs holds significant therapeutic potential. Concurrently, the integration of emerging biotechnological approaches such as genome editing technologies may offer novel avenues for the precise manipulation and correction of DNA lesions, thereby ameliorating sperm DNA integrity and enhancing ART success rates.

Carlo Giulioni, MD: Short Biography

Carlo Giulioni, MD

Urology consultant

Urology Unit

Casa di Cura Villa Igea

Ancona, Italy

E-mail: carlo.giulioni9@gmail.com

ORCID ID: 0000-0001-9934-4011

Dr. Carlo Giulioni is a distinguished urologist and andrologist, specializing in male fertility and minimally invasive surgical techniques. After graduating with distinction in Medicine and Surgery in 2017, he pursued a specialization in Urology and Andrology. In 2022, he undertook a Fellowship program focusing on robotic and laparoscopic procedures at Clinique Saint Augustin, Bordeaux (France). His residency program was completed with honors in 2023. Throughout his academic journey, Carlo Giulioni has dedicated his research efforts to areas such as male infertility, uro-oncology, and endourology. Carlo has been a member of the Global Andrology Forum and serves as the co-leader of its Research Team 3 under the leadership of Dr. Rossella Cannarella. Currently, he works as a consultant at Casa di Cura Villa Igea, located in Ancona, Italy.

Nikolaos Sofikitis, MD, Ph.D., D.M.Sci: Short Biography

Nikolaos Sofikitis, MD, PhD Professor and Chair of Urology

Department of Urology

Ioannina University School of Medicine,

Ioannina, Greece

Email: v.sofikitis@hotmail.com

ORCID id: 0000-0003-1528-4029

Professor Nikolaos Sofikitis graduated from the Athens University School of Medicine in 1986, he then embarked on an illustrious career that spans decades and continents. He earned his first Ph.D. diploma in 1993 from the Graduate School of Athens University School of Medicine and secured a second Ph.D. from the Graduate School of Tottori University School of Medicine, Yonago, Japan, the same year. Between 1989 and 1993, he contributed to the field of urology as a teacher at Tottori University School of Medicine, before transitioning into roles such as Assistant Lecturer and Director of the Reproductive Physiology Unit within the same department, positions he held until 2000. His academic journey also took them to the United States, where he served as a Research Instructor at Tulane University School of Medicine and as an Assistant Professor at Cornell University Medical Center. In 2001, he was board-certified as a urologist in Greece and since then, has been the Professor and Chair of the Department of Urology at Ioannina University School of Medicine in Greece. His leadership and expertise were further recognized through his role as the Chair of the European Section of Andrological Urology (ESAU) of the European Association of Urology from 2016 to 2024 and as a board member for various prestigious European urology programs. He has published extensively and has 262 research articles in PubMed-indexed journals; a citation count of 561 and an h-index of 39 (source: Scopus). Niko is a member of the Global Andrology Forum.

Male Infertility: New Developments, Current Challenges, and Future Directions

Fri, 05 Apr 2024 05:50:08 GMT

Article #45: “Male Infertility: New Developments, Current Challenges, and Future Directions”

Authors: Murat Gül, Giorgio Ivan Russo, Hussein Kandil, Florence Boitrelle, Ramadan Saleh, Eric Chung, Parviz Kavoussi, Taymour Mostafa, Rupin Shah, Ashok Agarwal

World J Men’s Health Published online Jan 2, 2024

https://doi.org/10.5534/wjmh.230232

CAPSULE

Contributors: Charalampos Konstantinidis, MD (Greece), and

Ryan Smith, MD (United States)

Commentary:

Introduction: This review addresses gaps in our knowledge, discusses new diagnostic methods/therapies/potential targets for new therapies, and provides insights for future research and therapy areas.

Towards a better understanding of the etiopathogenesis of male infertility: Factors to consider in spermatogenic aberration-male infertility, include anatomic etiologies such as varicoceles etc., environmental, genetic, inflammatory, infective, drug-induced/hormonal disorders. New diagnostic assessments that assess fertilization competent sperm are needed.

Male infertility diagnostics:

1. The 6th edition of the WHO manual for semen analysis

Its novelty is the absence of recommended SA reference values.
It does not detail all the new tests available for genetic and epigenetic diagnosis.
In the research section (advanced SA) it lists some tests to assess seminal OS.
It highlights the inherent limitations of semen analysis and the need for better adjunct tests.

2. Use of artificial intelligence in sperm analysis: While AI holds promise, it encounters challenges like patient care autonomy, cost, ethical concerns etc. There’s a concern of providing false reassurance without a complete formal SA.

3. Home testing of semen: The FDA has approved many at-home sperm testing products including SpermCheck®, YO®, and Trak®. These have improved access but have limitations compared to an andrology lab assessment.

4. Whole genome testing: It’s believed whole exome sequencing (WES) will be replaced by whole genome sequencing (WGS).

5. Epigenetic markers: Many epigenetic markers have been considered in assessing the presence of active spermatogenesis among NOA patients. For instance, ESX1 transcript. 396, 395, and 378 microRNAs.

6. Seminal proteomics: Studying the seminal plasma approach supports the management of male infertility, since this method’s rich in protein biomarkers.

7. Radiomics: The extraction of numerical values from radiological images offers a more comprehensive analysis beyond the simple visual capacity.

Relationship between a male’s fertility status and general health: Besides fertility therapies, general health issues must be considered and dealt with

Personalized medicine and male infertility: Personalized medicine (stem cell/gene therapy/nanoparticle drug delivery) is on the rise.

Male fertility preservation: Different techniques of sperm cryopreservation have been used for ICSI. However, a series of epigenetic modifications may occur secondary to cryopreservation, including changes in mRNA expression.

Future of stem cells in male infertility: Strategies to restore fertility for pre-pubertal boys include spermatogonial stem cell transplantation (SSCT), testicular tissue engraftment, and in vitro spermatogenesis.

The art of ART: ARTs have become the gold standard in medically assisted reproductive medicine.

AI for andrological surgeries: AI (through the use of ML models) can predict surgery outcomes.

The future of andrologists: The role of the andrologist is to expand with international initiatives already underway (Global Andrology Forum-GAF etc.).

Conclusions: The development of genetic testing, the use of epigenetic markers, seminal proteomes, radiomics, advancements in male fertility preservation tools, future application of AI, all, provide hope for various kinds of infertility cases and patients with cancer.

Key Takeaways: Contributor: Ashok Agarwal

The most important takeaways from this article for reproductive physicians are:

The field of male infertility is undergoing significant advancements through the integration of technology and innovative diagnostic methods. Advanced diagnostics, including genetic and epigenetic testing, seminal proteomics, and radiomics, are being increasingly used in trying to solve the complex etiology of male infertility, leading to personalized and more effective treatment options. Innovations in fertility preservation, such as cryopreservation of single or rare sperm and successful freezing of spermatozoa from testicular tissue, offer unimaginable hope to cancer patients at risk of treatment-induced infertility, ensuring their chance for future parenthood. Moreover, the application of AI in predicting treatment outcomes, sperm selection, and diagnosing infertility marks a move towards precision medicine. All these promising advances have the potential to enhance clinical decision-making and improve treatment success rates – however, the jury is out!

My Personal Viewpoint on New Developments in Male Infertility

Dr. Charalampos Konstantinidis responds to the questions by Ashok Agarwal

Q1: What are the latest advancements in the diagnostics and treatment of male infertility highlighted in recent decades?

A1: During the last decades advanced sperm manipulation techniques for improved assisted reproductive technologies, surgical procedures for sperm retrieval, and novel tests of sperm function have been developed offering more opportunities for parenthood in infertile couples.

Q2. How does seminal oxidative stress testing contribute to the management of male infertility?

A2: Although antioxidant supplements are used to improve sperm quality it is important to check the oxidation-reduction potential and in case of an imbalance, we can add or stop antioxidant factors.

Q3. What is the role of sperm DNA fragmentation testing in evaluating male infertility, and how does it impact treatment decisions?

A3: In case of unexplained inability of natural conception, varicocele, failure of ART and exposition to lifestyle/environmental risk factors, DNA fragmentation testing may suggest a contributing infertility factor suggesting treatment options such as varicocelectomy or anti-oxidation supplements.

Q4. In what ways do genetic and epigenetic tests advance our understanding and treatment of male infertility?

A4: In many cases of NOA, genetic and epigenetic tests may explain the condition and predict the presence of spermatogenesis in testicular biopsy.

Q5. How can artificial intelligence and personalized medicine be integrated into the management of male infertility?

A5: Artificial intelligence can analyze complex predictive models and provide treatment algorithms to improve sperm quality or for sperm retrieval. Personalized medicine is the future not only for infertility issues but for many conditions that genetic factors are contributing.

Q6. What are the ethical considerations in the use of advanced reproductive technologies for male infertility, including donor insemination and surrogacy?

A6: I believe that every person has the right to parenthood. Under that prism, ART can be helpful. Donor insemination and surrogacy can be an option in case the infertile couple makes this decision.

Charalampos Konstantinidis, MD, PhD, FEBU, FECSM: Short Biography

Charalampos Konstantinidis, MD

Head of Urology and Neuro-Urology Unit, National Rehabilitation Center

Ilion, Athens, Greece

Staff Member, Urology Department, General Hospital "Asklepieio Voulas"

Vasileos Paulou 1, 16673, Voula, Athens, Greece

E-mail: konstantinidischaralampos@yahoo.comORCID ID: 0000-0002-4689-6899

Dr. Charalampos Konstantinidis , a University of Patra medical graduate (1996), completed his Urology training in 2004 and became a Fellow of the European Board of Urology (FEBU) in 2005. His post-graduate journey included clinical fellowships in Germany, Serbia, and Austria, focusing on genito-urinary reconstructive surgery and neuro-urology. Since 2006, he has served as a Urology consultant at the National Rehabilitation Center of Athens. An active GAF member, Dr. Konstantinidis holds memberships in several national and international urological and scientific societies. He is a prolific speaker with over 260 lectures and has contributed to more than 300 presentations globally. His publications include 30 international and over 35 Greek articles, along with chapters in 8 books related to functional urology. Google Scholar cites him 422 times, with an h-index of 11 and an i10-index of 13.

My Personal Viewpoint on New Developments in Male Infertility

Dr. Ryan Smith responds to the questions by Ashok Agarwal

Q1. How does the introduction of novel sperm selection techniques for intracytoplasmic sperm injection (ICSI) improve outcomes?

A1. Over the past 30 years, the use of ICSI has rapidly increased and accounts for a preponderance of IVF cycles worldwide. This has included couples without severe male factor infertility in hopes that it might increase fertilization success. Studies now suggest that this is incorrect and therefore novel sperm selection techniques are an area seeing exponential growth in reproductive medicine.

Q2. Discuss the significance of telemedicine in the field of reproductive urology and male infertility.

A2. The COVID-19 pandemic resulted in the rapid adoption of telemedicine, including within reproductive urology. While challenges and limitations remain, telemedicine is here to stay in the assessment of male infertility. One may anticipate that we will likely see guiding principles surrounding telemedicine adopted into male infertility guidelines in the future.

Q3. How does the management and treatment of male infertility benefit from the development of andrology as an independent specialty?

A3. Advances in both the diagnostic assessment and treatment of male infertility have grown exponentially as the science has evolved. The role of the reproductive urologist has become more subspecialized as has the subspecialty training. Current guidelines reflect the complexity and prevalence of male infertility, recommending that couples undergo a concurrent evaluation and men with an abnormal semen analysis should be evaluated by a male reproductive expert.

Q4. What are the implications of recent research on environmental, genetic, and lifestyle factors affecting male fertility for clinical practice?

A4. The impacts of environmental and lifestyle factors on male infertility are likely underestimated. While difficult to quantify on an individual level, technology and diagnostic advancements may make this possible in the future. Environmental toxins and lifestyle factors have been implicated in the worldwide decline in semen parameters.

Q5. How is the understanding of microbiome's role in male infertility evolving, and what are the potential therapeutic interventions?

A5. While more research needs to be done, it is established that semen has its own microbiome. Several studies suggest that bacterial imbalances may impact sperm count and quality. The gut microbiome may similarly play a role in male fertility and research continues to elucidate these associations.

Q6. What are the current challenges and future directions in the surgical procedures for sperm retrieval?

A6. Promising technologies to assist in sperm identification at the time of sperm retrieval continue to evolve. One area is within the ability to identify sperm at the time of microTESE or ideally, to better assess the probability of sperm identification prior to the procedure. Unfortunately, access to care and costs for these procedures remain barriers to many couples receiving these necessary treatments.

Ryan Smith, MD: Short Biography

Ryan P. Smith, M.D.

Associate Professor of Urology

Male Reproductive Medicine and Surgery

Men's Health | UVA Health

University of Virginia

Email: margianaria@gmail.com

ORCID id: 0000-0002-3880-9740

Dr. Ryan P. Smith , Associate Professor of Urology at the University of Virginia, specializes in Male Reproductive Medicine and Surgery. A graduate and resident alumnus of the same university, he further honed his expertise with a fellowship at Baylor College of Medicine under Dr. Larry Lipshultz. Since joining the University of Virginia faculty in 2013, Ryan has held several leadership roles, including Co-Director of the Andrology Fellowship, Urology Residency Program Director, and Medical Student Clerkship Director. Recognized for his contributions, he has been a CREST Scholar with the American Society of Reproductive Medicine and a traveling scholar for key reproductive societies, besides serving on their boards. In practice, Ryan divides his time between UVA Health and Virginia Fertility & IVF, offering him extensive insight into fertility care. His research primarily focuses on male infertility and sperm-egg interactions. Ryan has over 50 PubMed indexed research articles to his credit with 1,437 citations and an h-index of 20 (source: Scopus, March’ 2024).

Diagnostic value of advanced semen analysis in evaluation of male infertility

Sun, 24 Mar 2024 23:51:17 GMT

Article #44: “Diagnostic value of advanced semen analysis in evaluation of male infertility”

Authors: Cătălina Barbăroșie, Ashok Agarwal, Ralf Henkel

Andrologia. 2020;00:e13625.

https://doi.org/10.1111/and.13625

CAPSULE

Contributors: Donny Eka Putra, MD (Indonesia), and

Ria Margiana, MD (Indonesia)

Commentary:

Advanced semen analysis goes beyond the basic parameters assessed in a standard semen analysis. It includes additional test that can provide information about etiology of male infertility and prediction the reproductive success in couples trying to have spontaneous pregnancy or couples undergoing assisted reproductive technologies (ART). These advanced tests offer a more detailed analysis of sperm function and quality, including oxidative stress (OS), and sperm DNA fragmentation (SDF). The present article summarizes diagnostic value of advanced semen analysis, including most commonly used sperm function tests, along with assays used to assess OS and SDF in order to make comprehensive view of male reproductive health.

A critical gain of sophisticated semen evaluation is that it may evaluate male infertility in greater depth and nuance, so that a more precise and individualized diagnosis is viable, which may bring about customized therapeutic regimens that enhance patients' prognoses. However, A crucial downside is the heightened rate and intricacy of those methodologies compared to standard semen analysis.

From a clinical view, the medical integration of superior semen analysis has an awesome capacity for reinforcing diagnoses and remedies aimed at male infertility by identifying the root causes of infertility. Furthermore, modern strategies are integrated to fill the gaps left using traditional semen evaluation, providing physicians with a complete toolkit to realize the complexities of male reproductive health. Thirdly, the supply emphasizes the importance of standardization and continuous studies in advanced semen evaluation to set up typically identified procedures and reference ranges. This is critical for ensuring consistent and dependable consequences across different laboratories.

There are popular sperm function tests available: sperm capacitation and acrosome reaction, sperm zona pellucida binding test, hypo-osmotic swelling test, and anti-sperm antibody test. Additionally, sperm quality can be assessed by SDF test as well as tests that measure reactive oxygen species (ROS), OS, and oxidation-reduction potential (ORP). All these tests can help identify specific problems that could affect male fertility that might not be apparent from basic semen analysis. However, there are some limitations to these advanced tests. First, there are not standardized methodologies of these advanced tests yet. Second, the interpretation with these tests requires expertise and analyzed by qualified healthcare professional experienced in male fertility assessment. Third, not all healthcare facilities or fertility clinics offer advanced semen analysis, due to cost and availability of specialized equipment.

In the era of invitro fertilization (IVF), the role of advanced semen analysis became prominent. While providing detailed information about sperm quality and function, aiding the selection of the best sperm for injection, it is not always a definitive predictor for IVF success. The other factors, including female factors fertility status and embryology labs expertise, also play important role in IVF success.

Considering the importance diagnostic values of advanced semen analysis and their downsides, the clinician should interpret and integrate these essentials information with other clinical assessment (medical history, physical examination, hormone test, and other fertility evaluation) to design individualized treatment strategies.

Key Takeaways:

The article by Barbăroșie et al. underscores the importance of integrating advanced semen analysis techniques into the evaluation of male infertility. Advanced semen analysis provides detailed insights into male fertility, assessing parameters beyond basic count and motility, such as sperm morphology, OS, and DNA integrity, crucial for diagnosing and treating infertility. Incorporating these advanced analyses can significantly improve the diagnostic accuracy and treatment outcomes for male infertility cases. This approach allows for a deeper understanding of male reproductive health, enabling clinicians to tailor more effective treatment strategies for patients facing infertility challenges.

My Personal Viewpoint on Diagnostic Value of Advanced Semen Analysis

Dr. Donny Eka Putra and Ria Margiana responds to the questions by Ashok Agarwal

1. Could you share your personal views on the role of sperm function tests in male infertility diagnostics?

Dr. Eka Putra: In my daily practices, I do sperm function tests for patients who had unexplained fertility issues or inconclusive basic standard semen analysis. Because many patients can access information from the internet now, they often come to doctor and want answers to their “WHY” questions. In my opinion, sperm function tests should be integrated in daily practices for urologist or andrologist who concern in individualized treatment for male infertility. Even in the era of assisted reproductive techniques, we need “the super- selective sperm” to achieve the best outcome.

2. Is there a specific sperm function test that you trust and recommend to your patients, and could you provide insight into why you favor this test?

Dr. Eka Putra: I would recommend Sperm DNA fragmentation test, as well as hypo-osmotic swelling test and antisperm antibodies. Only these test are available in my practice.

3. What are your perspectives on the potential of new sperm function tests in the future?

Dr. Eka Putra: I think the integration of Artificial Intelligence (AI) using algorithm to sperm function test data analysis and interpretation, can offer more accurate predictions of fertility outcomes.

Donny Eka Putra, MD: Short Biography

Donny Eka Putra, MD

Urology Consultant

Head of Urology Department, Dr. Dradjat Prawiranegara Hospital

Clinical staff, Faculty of Medicine Universitas Indonesia

Jakarta, Indonesia

E-mail: donnyputra8@gmail.com

ORCID ID: https://orcid.org/0000-0002-

Dr. Donny Eka Putra serves as a Consultant Urologist at the Department of Urology, Dr. Dradjat Prawiranegara Hospital in Serang, Indonesia, where he distinguishes himself with a cum laude in his specialty. Donny plays a pivotal role within the Indonesian medical community as an active member of the Indonesian Society of Genitourinary Reconstruction and currently leads the Urology Department at Dr. Dradjat Prawiranegara Hospital. His commitment to service extends to his position as Head of Community Service at InaUA and his membership in the Society of Genitourinary Reconstructive Surgeons. Beyond his clinical and leadership roles, Dr. Donny is involved in research, contributing as an active researcher with Team #3 in the Global Andrology Forum. His contributions highlight his dedication to advancing urological care and research.

Ria Margiana, MD, MBiomed, PhD: Short Biography

Ria Margiana, MD, MBiomed, PhD

Lecturer, Department of Anatomy, Faculty of Medicine, Universitas Indonesia

Jakarta, Indonesia

Email: margianaria@gmail.com

ORCID id: https://orcid.org/0000-0002-6747-0117

Dr. Ria Margiana is a prominent lecturer of Anatomy in the Department of Anatomy, Universitas Indonesia, in Jakarta, Indonesia. Her academic journey commenced with a medical degree from the Faculty of Medicine at Brawijaya University. She furthered her specialization and pursued a doctoral program in biomedical sciences at the University of Indonesia. Ria is a member of ASPIRE and IFAA. As a dedicated member of the Global Andrology Forum (GAF), she plays a vital role in GAF's research team 1. Her academic output includes 161 publications, resulting in 963 citations, with an h-index of 13. Dr. Margiana's contributions to the field exemplify her commitment to research and education in biomedical sciences.

Causes and Consequences of Sperm Mitochondrial Dysfunction.

Wed, 13 Mar 2024 01:10:48 GMT

Article #43: “Causes and Consequences of Sperm Mitochondrial Dysfunction.”

Authors: Damayanthi Durairajanayagam, Dipty Singh, Ashok Agarwal, and Ralf Henkel,

Andrologia, 2021;53(1): e13666. DOI: 10.1111/and.13666

CAPSULE

Contributors: Georgia Kakourou, MSc, PhD (Greece), and

Athanasios Zachariou, MD, PhD (Greece)

Commentary:

Prelude:

The article by Durairajanayagam et al. (2021) discusses the multifunctional role of mitochondria. It provides a comprehensive overview of mitochondrial origin, structure, function, and dynamics, including the unique features of mitochondrial DNA (mtDNA), before exploring their involvement in sperm function and male fertility. Mitochondria are involved in the generation of energy in the form of ATP, the regulation of homeostasis, apoptosis, and signaling through reactive oxygen species (ROS), while, particularly relevant to sperm function, mitochondria provide energy for processes like sperm motility, hyperactivation, capacitation, acrosome reaction, and fertilization.

Main Highlights:

a) defects in mitochondrial ultrastructure in ejaculated sperm impact sperm motility and integrity and are associated with asthenozoospermia.
b) oxidative stress, triggered by mitochondrial ROS generation, damages sperm, leading to apoptosis, resulting in loss of motility and oxidative DNA damage (oxidative stress is discussed in management special reports #29 and #35),
c) mitochondrial membrane potential is correlated with sperm quality (motility and DNA integrity); sperm with low mitochondrial membrane potential (MMP) exhibit lower quality and fertilization rates during in vitro fertilization.
d) alterations in sperm mitochondrial DNA copy number and mtDNA variants, single nucleotide polymorphisms and haplogroups impact semen quality, reduce sperm functionality and lower odds of fertilization in an ART setting.
e) other factors, like varicocele and exposure to electromagnetic fields, further exacerbate mitochondrial dysfunction, affecting sperm metabolism.

The authors suggest that addressing mitochondrial dysfunction can be crucial for improving the management of male infertility.

Our Insight:

Mitochondria have generally been investigated as crucial players in reproduction. The potential utility of mtDNA copy number and integrity as a biomarker of sperm quality must overcome challenges in the variability of methodologies used and the variability of mitochondrial characteristics among individuals. In the context of preimplantation genetic testing, mtDNA quantification has been investigated on trophectoderm cells obtained by embryo biopsy for nearly ten years as a marker of implantation potential, performed alongside embryo aneuploidy testing to improve ART success, but with contradicting results. With regards to male infertility, mtDNA variants may lead to or be associated with reduced sperm motility, function, and impaired fertilization. Mitochondrial replacement therapy has also been employed in the field of assisted reproduction as a means to avoid the transmission of mtDNA disease but also as an add-on to fertility treatment, mainly to improve oocyte quality in women with difficulties conceiving. Despite clinical application, there seems insufficient evidence to support the benefit of this approach in achieving pregnancy.

It is anticipated that incorporating a combination of the above-mentioned mitochondria-related biomarkers (for example, measurement of mitochondrial abundance, morphology, mitochondrial membrane potential, generation of ATP, and ROS production) in the assessment of sperm health may provide a more comprehensive evaluation of male fertility, particularly in cases where traditional assessments yield inconclusive results. As research progresses, the above may become of clinical use. Other ongoing research areas may involve sperm epigenetics (please refer to management special report #25) and the potential crosstalk between sperm

mitochondria and non-coding RNAs in the nuclear genome. Finally, future studies may also consider using techniques for editing the mitochondrial genome.

Future Research:

The authors propose areas of future research which need to be explored. These include understanding the mechanisms and implications involved in the selective degradation of paternal mitochondria in the preimplantation embryo, elucidating the limited ability of spermatozoa for DNA repair, and the impact of advancing age and the mechanisms involved in sperm ageing.

Final Thoughts:

This article has been very inspiring, defining new research aims and underlining the need to achieve a deeper molecular understanding of the role of mitochondria in reproduction. This will support targeted and tailored interventions for improving the management of male infertility. Improved management may include advances in reproductive assessment for early identification of infertile males, personalized treatment (e.g. use of antioxidants), suitable ART protocols and laboratory conditions, depending on the mitochondrial dysfunction. Our advancing knowledge will eventually support better counselling for infertile couples.

Key Takeaways: (Contributor: Ashok Agarwal)

The article highlights mitochondria's crucial role in sperm functionality and its link to male infertility, stressing the importance of mitochondrial health for sperm motility, DNA integrity, and overall semen quality. It suggests that assessing mitochondrial membrane potential could improve infertility diagnoses. However, unresolved issues remain, including the mechanisms of paternal mitochondrial DNA elimination, sperm's DNA repair capacity, mitochondrial DNA's role as a fertility marker, aging's impact on fertility, and the diagnostic potential of mitochondrial characteristics, indicating a need for further research in this sphere.

My Personal Viewpoint on Sperm Mitochondrial Dysfunction:

Dr. Georgia Kakourou responds to the questions by Ashok Agarwal

Q1: How does mitochondrial dysfunction contribute to asthenozoospermia and affect sperm motility and integrity?

A1: Sperm mitochondrial dysfunction contributes to asthenozoospermia largely due to the insufficient production of energy, which is needed for a functioning flagellum. Mitochondrial dysfunction may also lead to increased production of ROS affecting the structural and functional integrity of the sperm tail and midpiece and may also trigger apoptosis, reducing sperm count and overall sperm quality. In practice, spermatozoa from individuals with asthenozoospermia indicate reduced sperm movement, reduced mitochondrial membrane potential (MMP), defects in mitochondria ultrastructure and higher rates of apoptosis compared to fertile controls.

Q2. What is the impact of mitochondrial DNA (mtDNA) mutations, deletions, and variations on male fertility and semen quality?

A2: Variations in mtDNA (point mutations, rearrangements, duplications, deletions) may impact semen quality/function due to:

1) compromised energy production (mtDNA partially encodes for OXPHOS-related proteins)

2) increased ROS production

3) abnormalities in spermatogenesis, affecting sperm count, morphology and quality.

Higher levels of mtDNA variations have been detected in infertile patients of varying phenotypes (e.g. asthenozoospermia, oligoasthenozoospermia, obstructive azoospermia), while mtDNA integrity has been correlated to sperm fertilization rate. Studies have also associated elevated mtDNA copy number with poor sperm quality.

Q3. How does oxidative stress, induced by mitochondrial reactive oxygen species (ROS) generation, lead to sperm apoptosis and DNA damage?

A3: Mitochondrial ROS generation can initiate a cascade of events leading to

1) lipid peroxidation, that damages the structural integrity of the sperm membrane,

2) oxidation of proteins within the sperm causing structural and functional alterations,

3) excessive DNA damage

4) mitochondrial dysfunction.

These collectively contribute to the release of pro-apoptotic factors and the activation of the intrinsic apoptotic pathway. The release of cytochrome c from damaged mitochondria activates caspases, leading to programmed cell death and DNA fragmentation, overall compromising sperm quality and fertility.

Q4. In what ways does mitochondrial membrane potential (MMP) serve as an indicator of sperm quality and fertility potential?

A4: Mitochondrial Membrane Potential (MMP) serves as an indicator of sperm quality by reflecting the functional status of mitochondria. High MMP levels indicate efficient energy production, which is crucial for optimal sperm motility and functionality. Healthy mitochondria with an intact MMP indicate better resistance to oxidative stress and mitochondrial dysfunction. Additionally, MMP is linked to mitochondrial DNA integrity and fertilization potential, making it a valuable marker for assessing fertility and overall sperm health (count, morphology, motility, and viability).

Q5. How do alterations in mitochondrial function affect ATP production and its consequences for sperm function, including capacitation and the acrosome reaction?

A5: Sperm mitochondria provide energy in the form of ATP. ATP supports the required changes in sperm plasma membrane composition and functionality during capacitation, as well as fusion of the sperm plasma membrane and the outer acrosomal membrane and subsequent release of enzymes to facilitate penetration of the oocyte, during the acrosome reaction. Mitochondria also produce ROS, which are involved in the above processes. When mitochondria are dysfunctional, ATP levels are reduced, while elevated levels of ROS become harmful (oxidative stress) and further impair mitochondrial function, exacerbating ATP depletion and negatively impacting sperm function and competence.

Georgia Kakourou, MSc, PhD: Short Biography

Georgia Kakourou, MSc, PhD

Molecular Biologist-Geneticist

National and Kapodistrian University of Athens

Laboratory of Medical Genetics,

Choremio Research Laboratory, St. Sophia’s Children’s Hospital

Athens, Greece

E-mail: gkakourou@med.uoa.gr

ORCID: https://orcid.org/0000-0002-6244-1923

Dr. Georgia Kakourou is a Molecular Biologist-Geneticist, working in Preimplantation Genetic Testing diagnostics since 2002, and currently a clinical scientist and Scientific Associate at the Laboratory of Medical Genetics of the University of Athens (UoA), Greece. She obtained her MSc and PhD in Human Genetics from University College London, UK and between 2002‐2009 worked at the “UCL Centre for PGD” undertaking mainly PGT for monogenic disorders. Since then, she continues to be involved in PGT at UoA, as well as studies and activities in the field of reproductive genetics. Since 2013, she has been actively involved in the Steering Committee of the Special Interest Group “Reproductive Genetics” of the European Society of Human Reproduction and Embryology (ESHRE) as a member, deputy, coordinator, past-coordinator, and currently basic science officer. She has academic teaching and research activities at UoA and serves as a reviewer for several journals in the reproductive genetics field.

My Personal Viewpoint on Sperm Mitochondrial Dysfunction

Dr. Athanasios Zachariou responds to the questions by Ashok Agarwal

Q1: What are the implications of mtDNA copy number variations and integrity for assessing male fertility?

A1: The integrity of mtDNA is crucial for assessing male fertility due to its impact on sperm motility. Mutations, deletions, and duplications in mtDNA can compromise semen quality, leading to asthenozoospermia or oligoasthenozoospermia. Sperm motility is directly correlated with the functionality of oxidative phosphorylation (OXPHOS) pathways, which are partially encoded by mtDNA. Higher levels of deleted mtDNA have been observed in spermatozoa with poor motility and morphology leading to reduced sperm functionality and lower odds of fertilization in an ART setting.

Q2. How does the mitochondrial genome differ from the nuclear genome, and what are the clinical implications of these differences for male infertility?

A2: The mitochondrial genome differs from the nuclear genome in several ways. Firstly, mitochondrial genes are solely inherited from the mother and don't adhere to Mendelian inheritance. Secondly, while the mitochondrial genome typically maintains homoplasmy, heteroplasmy can exist within a cell. Thirdly, the mutation rate of mitochondrial DNA is considerably higher than that of nuclear DNA. These distinctions have clinical implications for male infertility as mutations in mitochondrial DNA can impact sperm function and fertility potential, contributing to male infertility issues.

Q3. What role does the selective degradation of paternal mitochondria play in the fertilization process and the maintenance of mtDNA homoplasmy?

A3: The selective degradation of paternal mitochondria in the fertilized egg ensures maternal inheritance of mtDNA, maintaining homoplasmy. This process, coupled with oogenesis-related mechanisms like replication from a single or very few template mtDNA, establishes homoplasmy in the oocyte. By reducing mtDNA copy number, the variability inmtDNA transmission is minimized, preventing the accumulation of mutated genomes and potential mitochondrial dysfunction.

Q4. How does the environment, including exposure to electromagnetic fields and varicocele, influence mitochondrial function and male fertility?

A4: The environment, including exposure to electromagnetic fields and varicocele, can influence mitochondrial function and male fertility by inducing oxidative stress. Both factors can lead to increased mitochondrial ROS production in spermatozoa, resulting in lipid peroxidation, impaired sperm motility, and DNA damage. Additionally, varicocele has been associated with under expression of essential mitochondrial proteins, contributing to metabolic dysregulation and sperm dysfunction.

Q5. What future research directions are proposed for understanding the role of mitochondria in sperm function and male fertility, and how might these findings translate into clinical practice?

A5: Future research directions include investigating mechanisms of paternal mitochondrial genome transmission and degradation, exploring spermatozoa's DNA repair response to oxidative stress, and assessing mtDNA integrity as a biomarker of sperm quality. These findings may translate into clinical practice by potentially utilizing sperm mitochondrial characteristics as biomarkers for sperm function and fertilizing capacity.

Athanasios Zachariou, MD, PhD: Short Biography

Athanasios Zachariou, MD, PhD, FEBU

Assistant Professor

Urology Department

Ioannina University

Ioannina, Greece

Email:

ORCID: https://orcid.org/0000-0002-5287-4450

Dr. Athanasios Zachariou is an Assistant Professor in the Urology Department of Ioannina University. He is the President of the Coordinating Committee of Andrology and Infertility of the Hellenic Urological Association. He holds a master’s degree in “Management of Health Units” (Open University of Cyprus, 2014) and a PhD degree from Aristotle University of Thessaloniki (2004), specialized on neurourology and the functional urology of the lower urinary tract. Athanasios has been a Fellow of the European Board of Urology (FEBU) since 1998. He is a board member of the EAU Section of Outpatient and Office Urology (ESUO), an ex-officio board member of the EAU Section of Female and Functional Urology (ESFFU), and an associate member of the European Section of Andrological Urology (ESAU). He has been awarded for his research work eight times (four times at European Urology Conferences). His research and clinical activity focus on male infertility, male and female sexual function, and the pathophysiology of the lower urinary tract system.

Sperm DNA Fragmentation: A New Guideline for Clinicians

Mon, 26 Feb 2024 06:00:23 GMT

Article #42: “Sperm DNA Fragmentation: A New Guideline for Clinicians”.

Authors: Ashok Agarwal et al.

World J Men’s Health 2020 Oct 38(4): 412-471

https://doi.org/10.5534/wjmh.200128

CAPSULE

Contributors: Ahmad Motawi, MD, PhD, FECSM (Egypt), and

Charalampos Thomas, MD, MSc, PhD, FECSM (Greece)

Commentary:

Despite the technological advances, conventional semen analysis is still the corner stone of infertile men evaluation, but it has limitations in predicting male fertility potential and the outcome of assisted reproductive technology. A normal semen analysis does not rule out infertility in some patients. About 15% of them have normal results.

Sperm DNA Integrity is crucial for fertilization, embryo development and ART outcomes. Many studies have reported a link between SDF and male infertility. So far not only we do not have a routine assessment of Sperm DNA Fragmentation (SDF) but also it isn’t recommended by professional organizations as standard practice.

This article provides a thorough overview on SDF types and methods of assessment, emphasizing on the impact they have in diagnosis and treatment of male infertility. By using clinical scenarios, the authors provide helpful paradigms of implementation of all the current knowledge, and they concluded by performing a SWOT analysis of SDF testing evaluating 4 parameters: Strength-Weakness-Opportunities and finally Threats in order to understand the advantages and drawbacks for the clinical utility of SDF in specific clinical scenarios regarding male infertility.

SDF could originate from either endogenous or primary mechanisms such as defective maturation and abortive apoptosis occurring within the testis, or by oxidative stress throughout the male reproductive tract, or exogenous clinical and environmental risk factors as obesity, smoking, varicocele via increased intratesticular temperature, environmental pollution, exposure to heavy metals or even electromagnetic waves. Any type of DNA damage can be observed, including loss of base, bases mismatch or modifications, single strand (SSB) or double strand breaks (DSB), which induces SDF thus compromising natural conception or ART outcomes.

Numerous techniques have been described, in order to assess SDF, such as tests that label the broken ends of the DNA strands, as TUNEL, SCSA and SCD. However, these tests cannot tell the difference between single-strand breaks (SSBs) and double-strand breaks (DSBs) in the DNA. The two-tailed Comet assay is the only test that can do that. Another test that is recently developed is the γH2AX test, which specifically detects DSBs in sperm DNA.

So, what test should someone order when male infertility is under investigation? The authors have provided detailed tables, comparing the techniques in terms of pregnancy outcome, clinical cut-offs, sensitivity, and specificity among other parameters. Alongside they offer a list of men/couples who will benefit the most from an SDF testing, including men with varicocele, couples with recurrent pregnancy loss, idiopathic and unexplained male infertility, or high-risk patients among others. They also provide suggestions in management of men with high SDF, including oral antioxidants, infections treatment, varicocelectomy, life-style changes, short ejaculatory abstinence, methods of sperm processing and preparation and even the use of testicular sperm for ICSI in some cases.

The authors gave an example of 4 clinical cases that visualize the whole concept, where they provide clinical paradigms of diagnostic workflow and treatment methods.

Finally, the study provided expert recommendations on SDF assessment with SWOT analysis on the clinical utility of sperm SDF testing in specific male infertility scenarios.

1. Strengths:

SDF testing can be a valuable additive in specific clinical scenarios, such as inability of natural conception, idiopathic infertility, varicocele, RPL, ART failure and exposition to lifestyle/environmental risk factors.
Interventions such as recurrent ejaculation, oral antioxidants, varicocelectomy in clinical varicocele, treatment of GU infections, advanced sperm selection techniques for ICSI or using testicular sperm have been proved efficient in alleviating high SDF in clinical practice in terms of improving fertility.

2. Weaknesses:

By far, the greatest limitation is the lack of a definitive cut-off value above which a sample is considered anomalous.
Lack of strong recommendation upon the use of SDF in everyday practice.

3. Opportunities:

The authors have highlighted the need for further, well designed studies to enhance our understanding of the clinical use of SDF.

4. Threats:

International societies such as EAU and AUA do not recommend SDF testing as a routine for the evaluation of male infertility due to lack of sufficient high-quality evidence supporting data.
However, emerging data from upcoming research will probably provide sufficient data for the justification of performing SDF testing as routine.
SDF cost has to be considered, since it may not be reimbursed by health systems around the globe. However, what may the cost be, please take into consideration how useful it may be in terms of improving the outcome of treatment and the impact on the overall treatment cost.

Take Home Message: (contributor: Ashok Agarwal)

Sperm DNA integrity is critical for successful fertilization and the development of healthy offspring. Damage to sperm DNA can significantly impact both natural and assisted reproductive outcomes.
Various clinical and environmental factors can negatively affect sperm DNA integrity, including lifestyle choices and exposure to toxins, underscoring the importance of a comprehensive evaluation of male fertility beyond traditional semen analysis.
The article underscores the utility of SDF testing in certain clinical scenarios, such as unexplained infertility, recurrent pregnancy loss, and prior to assisted reproductive techniques, to better inform treatment strategies and improve outcomes.
Despite the availability of several assays for assessing sperm DNA damage, there is a lack of consensus on standard cut-off values for predicting reproductive outcomes, highlighting the need for further research and standardized guidelines.
The article emphasizes a multidisciplinary approach to the management of male infertility, incorporating SDF testing alongside other diagnostic tools to tailor interventions more effectively and improve the chances of achieving pregnancy.

My Personal Viewpoint on Diagnostic Value of Advanced Semen Analysis

Dr. Ahmed Motawi responds to questions by Ashok Agarwal

1. What is your personal philosophy on the use of SDF testing for male infertility?

Dr. Motawi : I believe that SDF testing would have more potential in the future in assessing male infertility, but for the time being I am not using it routinely for all patients. I reserve its use for selected case scenarios giving into consideration the lack of a gold standard technique and universally agreed upon cut-off value, in addition to the high cost and lack of well-trained technicians.

2. What are the common indications for ordering this test?

Dr. Motawi : I usually order SDF testing in a selected group of patients mainly idiopathic male infertility, recurrent pregnancy loss with normal female factor, repeated ART failure, presence of chronic reproductive tract infections and for the decision of varicocelectomy in patients with repeated normal semen analyses.

3. What is your preferred SDF test and why?

Dr. Motawi: My preferred SDF test is the halo test being simple to use, most widely available in labs, relatively low cost, about 75 USD in Egypt compared to other tests. However, if available and the patient can afford, I’ll use the two tailed TUNEL test as its more accurate and can differentiate between SS and DS breaks.

4. What is the approximate cost of this test in your country?

Dr. Motawi: Approximately 75-100 USD.

5. Are the results of SDF test of use in the clinical management of your patients?

Dr. Motawi: Yes, as mentioned above, in selected cases the decision to perform varicocelectomy in patients with normal semen analyses depends on SDF test results, the decision to go directly with ART or to wait and use antioxidants treatment first. Also, in resistant high SDF cases with repeated ICSI failure, I may opt to use testicular sperm.

Ahmad Motawi, MBBCH, MSc., MD, FECSM: Short Biography

Ahmad Motawi MD

Associate Professor,

Department of Andrology, Sexual medicine and STIs

Faculty of Medicine

Cairo University, Egypt

E-mail: a7madmotaw3@gmail.com

ORCID ID: https://orcid.org/0000-0003-0962-0604

Ahmed Tareq Motawi, MD is a Consultant Andrologist and Genital Surgeon in the Faculty of Medicine at Cairo University, Egypt. Member of European Academy of Andrology (EAA), International society for Sexual Medicine (ISSM), Middle East society for Sexual Medicine (MESSM), Egyptian Society of Andrology (ESA). He is an academician at the Faculty of Medicine, Cairo University and is currently working as an Associate Professor at the Department of Andrology, Sexual medicine and STIs. He is the Leader of research team 6 in the Global Andrology Forum. Dr. Motawi has a publication count of 8, citation count of 45, and h-index of 3 (source: Web of science)

My Personal Viewpoint on Diagnostic Value of Advanced Semen Analysis

Dr. Charalampos G. Thomas responds to questions by Ashok Agarwal

Q1. What is your personal philosophy on the use of SDF testing for male infertility?

Dr. Thomas: Extremely useful in diagnosing and treating male infertility.

Q2. What are the common indications for ordering this test?

Dr. Thomas: Azo-oligospermia, varicocele, repeated miscarriages, male infertility.

Q3. What is your preferred SDF test and why?

Dr. Thomas: Flow cytometry (more accurate) and HALO (good enough).

Q4. What is the approximate cost of this test in your country?

Dr. Thomas: 150-180 euros and 120 euros respectively

Q5. Are the results of SDF test of use in the clinical management of your patients?

Dr. Thomas : By all means!

Charalampos G. Thomas, MD, MSc, PhD, FECSM: Short Biography

Charalampos G. Thomas, MD

Consultant in Urology & Sexual Medicine

Head of Urology and Neuro-urology Unit, National Rehabilitation Center

General Hospital of Corinth

Athens, Greece

Email: babisthomas@yahoo.gr

ORCID id: https://orcid.org/0000-0003-0139-2221

Charalampos G. Thomas , MD is a urologist with a special interest in Sexual Medicine and functional urology. He is a consultant urologist in Corinth's General Hospital, where he runs both the department of Sexual Medicine & Reproduction and functional urology. He is also a Staff Member in Urology in the General Hospital "Asklepieio Voulas", Vasileos Paulou, in Athens. He is the treasurer of the Hellenic Urological Association (H.U.A) and the secretary of its section of Urodynamics Neurourology and Female Urology. He has also served as secretary of the Andrology and Infertility section of Hellenic Urological Association (HUA). Fellow of the European Board of Urology, Fellow of the European Committee of Sexual Medicine, Member of the Neurourology Promotion Committee of the International Continence Society (ICS), Board Member of the EAU Section of Functional Urology (ESFU), Associate Member of the EAU Section of Genitourinary Reconstructive Surgeons (ESGURS). Associate Member of the EAU Section of Andrological Urology (ESAU).

Comparative analysis of tests used to assess sperm chromatin integrity and DNA fragmentation

Tue, 13 Feb 2024 15:49:54 GMT

Article #41: “Comparative analysis of tests used to assess sperm chromatin integrity and DNA fragmentation”.

Authors: Sulagna Dutta, Ralf Henkel & Ashok Agarwal

Andrologia, Published: 28 May 2020, DOI: 10.1111/and.13718

https://doi.org/10.1111/and.13718

CAPSULE

Contributors: Sulagna Dutta (UAE), and Ralf Henkel, PhD (UK)

Preamble:

Traditional semen analysis, which evaluates parameters like sperm concentration, motility, and morphology, often falls short in pinpointing fertility issues, as these aspects can overlap between fertile and infertile men and fail to highlight deeper cellular or molecular dysfunctions in sperm. One crucial aspect of understanding male infertility is assessing sperm chromatin integrity, as it reveals subtle sperm defects that routine semen analysis might miss. Issues in chromatin condensation increase the susceptibility of sperm DNA to damage, making the evaluation of sperm chromatin integrity, through various methods like the SCSA, TUNEL, and SCD assays extremely important. These tests directly assess DNA fragmentation, while others like aniline blue and chromomycin A3 evaluate chromatin condensation quality.

The significance of chromatin integrity tests lies in their ability to identify specific causes of sperm dysfunction, thus enhancing the diagnosis and management of male infertility. They provide a comprehensive understanding of male fertility, crucial given the limitations of conventional semen analysis. Clinically, sperm DNA integrity is acknowledged as vital for human reproduction, and recent guidelines recommend Sperm DNA Fragmentation (SDF) testing in cases like infertile patients with varicocele, unexplained infertility, recurrent IVF failures, and those exposed to certain infertility inducers. Despite this, SDF tests are not universally endorsed in male infertility assessments.

Impaired sperm DNA integrity can result from factors like oxidative stress during spermatogenesis, leading to adverse outcomes like altered semen parameters, recurrent miscarriages, and reduced fertility. Various factors, including lifestyle, environmental exposures, and genetics, contribute to SDF. For assessing this damage, techniques like the TUNEL assay (the gold standard), SCD, Comet, SCSA assays, and the determination of 8-hydroxy-2-deoxyguanosine are used. These tests correlate the extent of sperm DNA fragmentation with other sperm characteristics and reproductive outcomes.

Commentary:

In this article, the authors emphasized the complexity and necessity of evaluating sperm chromatin integrity and sperm DNA fragmentation (SDF) in understanding male infertility and advocate for more standardized, comprehensive diagnostic approaches to enhance the accuracy and efficacy of treatments in male reproductive health.

SDF testing is facing challenges due to the usage of different assays, lack of standardization and significant variability between individuals and laboratories. This necessitates method revalidation and strict quality control. Differentiating between tests for SDF and chromatin condensation is vital, as these tests assess different, distinct sperm functions and aspects. The variety of DNA damages, each needing specific assays, complicates the correlation of results from different tests.

Concluding Remarks:

This article is another significant contribution from the Global Androgen Forum (GAF), emphasizing the importance of analyzing sperm chromatin integrity and DNA fragmentation as distinct functional features in understanding male infertility. It highlights that a differentiated analysis is not only pivotal in unraveling the mechanisms behind male infertility but also serves as a predictor of fertility outcomes in natural reproduction and assisted reproductive technologies (ART). The article points out that high SDF is a clinically recognized paternal-derived defect that can lead to repeated ART failures and miscarriages. It discusses the availability of various assays to evaluate sperm chromatin integrity and SDF, noting that each assay has its own set of advantages and limitations. Therefore, it's crucial to compare these tests carefully before selecting one, ensuring the most relevant information is obtained. Since there are different types of DNA damage (e.g. mismatched bases, abasic sites, base modifications) with sperm DNA fragmentation (DNA strand breaks) being the end point of one type of damage, the article also stresses the importance of identifying the actual causes of sperm DNA damage to provide appropriate therapeutic strategies. While cut-off values for SDF tests have been proposed, the authors suggest that they require further validation and a broader consensus within the scientific community. Overall, the article strongly supports including sperm DNA fragmentation assessments in the evaluation of infertile men, underscoring its critical role in the diagnosis and treatment of male infertility.

***************************************

Take Home Message: (Contributor: Ashok Agarwal)

Sperm DNA integrity is crucial for male fertility: Evaluation of sperm chromatin integrity and DNA fragmentation is vital for diagnosing and managing male infertility, given its significant impact on reproductive outcomes.
Conventional semen analysis is insufficient: Routine semen analysis does not provide information on sperm DNA integrity, necessitating the use of specialized tests to uncover subtle defects affecting fertility.
Various methods are available for assessment: Techniques such as the TUNEL assay, SCD (sperm chromatin dispersion) test, and SCSA (sperm chromatin structure assay) offer different degrees of diagnostic and prognostic capabilities for evaluating sperm DNA damage and chromatin condensation.
Choice of method matters: Each method has its specific advantages, limitations, and applications, making it important to select the most appropriate test based on clinical needs, personal experience and laboratory capabilities.
Clinical implications of sperm DNA damage: High levels of SDF are associated with decreased semen quality, reduced reproductive potential, and adverse ART outcomes, underscoring the need for inclusion of these assessments in male infertility workups.

My Personal Viewpoint on “Diagnostic Value of Advanced Semen Analysis”

Dr. Sulagna Dutta responds to the questions by Ashok Agarwal

Q1. Regarding our current emphasis on Sperm DNA Fragmentation (SDF) testing for male infertility, do you believe it is justified, exaggerated, or understated in the existing literature and scientific discussions?

Dr. Dutta : In current scientific literature and discussions, Sperm DNA Fragmentation (SDF) testing is understated. Considering the limited understanding of the molecular mechanisms behind idiopathic male infertility, increased knowledge about SDF and its various testing methods could significantly improve the diagnosis and assessment of male infertility.

Q2. Can you identify Sperm DNA Fragmentation (SDF) tests that are straightforward, provide accurate cutoff values, demonstrate reproducibility, have validated results in clinical trials, are extensively published, and are cost-effective?

Dr. Dutta: Tests like the Sperm Chromatin Structure Assay (SCSA), the TUNEL assay, and the Comet assay are noted for their reliability. These tests offer straightforward procedures, reproducibility, and have been validated in various clinical settings. However, cost-effectiveness and clear cutoff values vary, and more extensive publishing in clinical trials is needed for some.

Q3. What, in your opinion, are the three primary reasons behind the absence of a gold standard test for assessing sperm chromatin integrity? Additionally, could you share your preference for a specific SDF test and the reasons behind your choice?

Dr. Dutta: The three primary reasons behind the absence of a gold standard test for assessing sperm chromatin integrity can be:

Variability in Test Methodologies: Different SDF tests use varied techniques, leading to inconsistencies in results.
Lack of Universal Cutoff Values: There's no consensus on the threshold values for SDF levels that indicate fertility issues.
Complex Nature of Sperm DNA Damage: Sperm DNA damage is multifaceted, making it challenging to standardize a single test.

Preference for SDF Test: The TUNEL assay is favored for its balance of sensitivity and specificity. However, the choice often depends on the specific clinical context and available resources.

Q4. I'm curious about your perspective on the utilization of AI-based devices to interpret the results of SDF testing. How do you see this technology influencing the accuracy and efficiency of such assessments?

Dr. Dutta: With further improvisation of the AI technology, AI-based devices hold promise for enhancing the accuracy and efficiency of SDF test interpretations. These technologies can potentially standardize readings, reduce human error, and provide quicker, more reliable assessments.

Q5. Looking ahead, do you envision SDF testing becoming commonplace in the future, recognized by major professional societies in the field of male infertility? Your insights into the potential trajectory of SDF testing would be valuable.

Dr. Dutta: It is likely that SDF testing will become more mainstream in male infertility assessment, as understanding and technology improve. This likelihood increases if major professional societies acknowledge its significance, especially if future research and publications further establish the link between SDF levels, fertility outcomes, and testing methods, similar to our article under discussion.

Sulagna Dutta, PhD: Short Biography

Sulagna Dutta, PhD

Assistant Professor

School of Life Sciences

Manipal Academy of Higher Education

Dubai, UAE

sulagna_dutta11@yahoo.com

https://orcid.org/0000-0002-7893-5282

Dr. Sulagna Dutta is a Physiologist with >150 research publications and an h-index of 30 on Scopus. She is a Faculty at the School of Medicine, Manipal Academy of Higher Education, Dubai, UAE. She earned her PhD in Physiology, with specialization in Immunology from the University of Calcutta, India, and later pursued a Research Internship in Reproductive Medicine at the Cleveland Clinic, USA. Sulagna has over 12 years of experience in teaching and research in India, Malaysia, and UAE. Her research interests include immunology, reproductive physiology, and infertility. She is being ranked among the Top 2% Scientists in the world by Stanford University since 2020

My Personal Viewpoint on “Diagnostic Value of Advanced Semen Analysis”

Prof. Ralf Henkel responds to the questions by Ashok Agarwal

Prof. Henkel: I believe that sperm DNA fragmentation is an essential diagnostic parameter that should be tested in order to have a more complete analysis of the male fertilizing ability. My analyses show that even in the group of patients which are supposedly to be normal, the normozoospermic men, 27% of these men show elevated sperm DNA fragmentation. In the other patient groups, the percentage of patients with high sperm DNA fragmentation is even much higher (oligozoospermia: 24%; teratozoospermia: 53%; asthenozoospermia: 98%). Therefore, considering that this parameter is providing significant additional information for the patient and for the physician on how to treat and manage the patient, I would even recommend testing routinely for sperm DNA fragmentation. In addition, in order to shorten the time period from diagnosing the man until possible assisted reproduction, sperm DNA fragmentation testing should be done together with a test for seminal redox stress. The aim should be to diagnose and treat the man properly, rather than treating the sperm or using potentially defective sperm for ICSI attempts.

In summary, the scientometric analysis offers a thorough overview of the research in male infertility and ART, providing valuable insights for private andrologists to improve their practice and patient care.

Prof. Henkel: The SDF tests with the highest accuracy and reproducibility are tests that employ flow cytometry, namely the TUNEL assay or the sperm chromatin structure assay (SCSA). The other test systems such as COMET assay or Halosperm test have a higher inter-rater variability than the TUNEL or SCSA because they are analyzing a much smaller number of sperm and are manually evaluated. The advantage of the Halosperm test or similar tests, however, is that they are cheaper.

Prof. Henkel: In my opinion, reasons why there is still no generally accepted “gold standard test” for sperm DNA fragmentation are the lack of standardization and as a result of that different cut-off values. In addition, the cost factor seems to play a big role as not all laboratories can afford a flow cytometer and therefore rather perform a cheaper one which has a higher inter-observer variability.

Prof. Henkel: At the moment, AI is tested for tests such as the Halosperm test in order to improve reliability and reduce inter-observer variation. I would also see opportunities for the implementation of AI in novel test systems that could perhaps analyze the number of DNA strand breaks as a measure of the extend of the sperm DNA damage. Important is however, that such systems are getting cheaper, more standardized, and more accurate and reproducible.

Prof. Henkel: Yes, definitely. However, it will still take some time for medical societies to fully adopt sperm DNA fragmentation as a routine test.

Ralf Henkel, PhD: Short Biography

Ralf Henkel, PhD, Habil

Chief Scientific Advisor: LogixX Pharma, Reading, UK

Visiting Reader, Department of Metabolism, Digestion and Reproduction, Imperial College London, UK

ralf.henkel@logixxpharma.com

https://orcid.org/0000-0003-1128-2982

Prof. Ralf Henkel, a distinguished scientist, pursued his studies in Biology and Chemistry at Marburg, Germany. Following the completion of his PhD, he contributed to the fields of Dermatology and Andrology in Giessen, Germany. In 2004, he assumed the role of Professor at the Urology department in Jena, Germany and later served as the Head of the Department of Medical Bioscience at the University of the Western Cape in Cape Town, South Africa He currently holds the position of Extraordinary Professor at the same institution. Since June 2020, Ralf has been engaged with LogixX Pharma, UK. Prof. Henkel is also the Editor-in-Chief of Andrologia. Throughout his illustrious career, he has supervised 76 students, published over 300 articles, chapters, and books, and has an h-index of 46 on Scopus. His collaboration with Ashok Agarwal dates back to their time at the Cleveland Clinic, and since 2022, he has been a senior member of the Global Andrology Forum.

Male Oxidative Stress Infertility (MOSI): Proposed Terminology and Clinical Practice Guidelines for Management of Idiopathic Male Infertility

Thu, 01 Feb 2024 16:18:36 GMT

Article #40: “Male Oxidative Stress Infertility (MOSI): Proposed Terminology and Clinical Practice Guidelines for Management of Idiopathic Male Infertility”

Authors: Ashok Agarwal, et al.

World J Men’s Health 2019 Sep 37(3): 296-312, Published online May 8, 2019,

DOI: 10.5534/wjmh.190055

https://doi.org/10.5534/wjmh.190055

CAPSULE

Contributors: Kadir Böcü, MD (Turkey), and

Germar M. Pinggera, MD (Austria)

Preamble:

Oxidative stress (OS) is increasingly recognized as a major factor in male infertility. Seminal reactive oxygen species (ROS), produced by leukocytes or abnormal and immature spermatozoa, play a key role in this process. While small amounts of ROS are necessary for normal sperm function, excessive levels can lead to OS and disrupt fertility by damaging sperm membranes and DNA and potentially causing disease in offspring. Recent studies indicate that 30% to 80% of infertile men have high seminal ROS levels, a condition that might be treatable.

There's a lack of consensus on how to best measure OS in clinical settings, leading to the proposal of "Male Oxidative Stress Infertility" (MOSI) as a term for infertile men with abnormal semen characteristics and OS. This category could include many previously classified as having idiopathic infertility. Epidemiological studies suggest that OS might affect about 56 million infertile men globally, with two-thirds potentially falling under the MOSI category. The impact of OS in men with normal semen in couples with unexplained infertility is less clear, though some evidence suggests a higher prevalence of leukocytospermia in this group.

Conventional semen analysis, used for over a century to assess sperm quality, is now recognized as insufficient for accurately predicting male fertility due to its limitations, such as poor reproducibility and subjective results.

The emergence of the term "Male Oxidative Stress Infertility (MOSI)" represents a significant leap forward in the understanding and categorization of male infertility issues. It recognizes the substantial role that oxidative stress plays in impairing male reproductive functions and the need for a specific terminology to describe cases that have hitherto been marked as idiopathic due to a lack of identifiable cause.

The challenge with idiopathic male infertility has always been the diagnosis and management in the absence of a clear-cut underlying pathology. By introducing MOSI as a definitive term, the medical community may now have a more concerted direction for investigation and treatment. The classification of MOSI acknowledges the complex interplay between reactive oxygen species (ROS) and spermatozoa, which can lead to DNA damage, poor sperm quality, and ultimately, reduced fertility.

This article by GAF authors on the management of MOSI provides a much-needed framework for clinicians. These guidelines can standardize the approach to diagnosis, including the assessment of oxidative stress levels, lifestyle factors, and potential environmental or occupational exposures that could contribute to elevated ROS. Furthermore, the inclusion of antioxidant therapy as a management strategy could offer new avenues for treatment, especially in cases where traditional interventions have proven inadequate.

From a personal standpoint, this article serves a crucial function in the paradigm shift of observing and managing male reproductive health. The formulation of the term MOSI itself showcases an innovative approach to a condition that exists in swathes of the infertile male populace. In addition, the authors' advocacy for the implementation of oxidation-reduction potential (ORP) as a diagnostic modality shines light on the growing importance of biochemistry and reproductive toxicity in fertility studies.

Agarwal et al.'s efforts to underscore the adoption of ORP measurement techniques such as the MiOXSYS system to quantify seminal oxidative stress are particularly impressive. The predilection of this research team towards evidence-based treatment aligns closely with our own philosophical bearings toward clinical intervention.

Key Takeaways:

MOSI's introduction provides a more directed investigative and treatment approach.
This practical guideline for MOSI may help to standardize diagnosis, integrate antioxidant therapy, and address interdisciplinary management.
Recognition of the delicate balance in addressing oxidative stress versus antioxidant defense is vital for treatment efficacy.
The proposed terminology and guidelines could potentially lead to precision management, reducing idiopathic cases and empowering both clinicians and patients.
Success is contingent upon acceptance within the broader medical community and effective translation into clinical practice.

*************************************

Final Remarks:

In idiopathic male infertility, the diagnosis of MOSI serves as a key therapeutic target. Pinpointing oxidative stress allows for the effective implementation of antioxidant regimens, enhancing sperm quality and function. This strategy holds promise for improving ART success rates and enables the development of personalized treatment protocols for cases of unexplained infertility. MiOXSYS is a promising technology, however, its adoption as a diagnostic tool for seminal ORP is limited by cost, affecting its wider application in clinical practice. (Contributor: Ashok Agarwal)

My Personal Viewpoint on Male infertility in a MOSI setting

Dr. Kadir Böcü responds to the questions by Ashok Agarwal

Q1. What is your personal view on the significance of the MOSI diagnosis in the management of idiopathic male infertility?

Dr. Böcü: In my practice dealing with male infertility, I frequently come across cases where there's no clear explanation for the condition—termed idiopathic infertility. However, most of these cases are characterized by high levels of oxidative stress. High oxidative stress, a concept rooted in evidence-based medicine, usually affects the DNA within sperm and has been identified as a significant factor contributing to male infertility. I find that determining the imbalance between the body's creation of reactive oxygen species (ROS) and its ability to counteract these with antioxidants is crucial in tailoring treatment for individuals.

Examining MOSI from a standpoint rooted in evidence-based medicine is quite revealing when addressing idiopathic male infertility. Evaluating the oxidative stress in these patients could uncover previously hidden issues, offering new directions for their treatment.

Q2. What are the three main causes for the diagnosis of MOSI in your patients?

Dr. Böcü: The main causes for the diagnosis of MOSI in my patients generally include:

Lifestyle factors such as smoking, excessive alcohol intake, and poor diet can increase oxidative stress.
Environmental toxins and exposure to pollutants enhance ROS production.
Varicoceles may impair scrotal thermoregulation and lead to a local increase in oxidative stress.

Q3. How do you diagnose patients with MOSI, and what are the three treatment choices (not including ART) that you offer to these patients in your practice?

Dr. Böcü: I can diagnose MOSI at a rate of 40-50% in my patients with idiopathic male infertility based on their oxidation-reduction potential (ORP) values.

For these patients with idiopathic male infertility where female factors and oxidative stress status are not present or unknown, I generally recommend three treatment choices that might include:

A. Lifestyle modifications: These include weight management, cessation of smoking, and limitation of alcohol intake, adopted as these changes can improve overall sperm quality.

B. Antioxidant therapy: Empirical use of antioxidants like vitamins E and C, Coenzyme Q10, or selenium might help reduce oxidative stress. Although commonly advised, recent studies suggest that indiscriminate use may not always be beneficial and should be personalized.

C. Varicocele repair: If a varicocele is present, surgical repair could potentially improve semen parameters and reduce oxidative stress.

On the other hand, in another group of idiopathic male infertility patients with normal ORP levels, I prefer off-label empirical hormonal treatment regimens aimed at inducing spermatogenesis, although the current literature is controversial.

Kadir Böcü, MD: Short Biography

Kadir Böcü, MD, FEBU

Assistant Professor in Urology

Niğde Ömer Halisdemir University Faculty of Medicine

Department of Urology, Niğde, Turkey

E-mail: drkadirbocu@gmail.com

ORCID ID: 0000-0003-4323-4037

Dr. Kadir Böcü

Dr. Kadir Böcü is a urologist with a focus on sexual medicine and men's health. He graduated from Necmettin Erbakan University School of Medicine in 2013 and completed his urology residency at Selcuk University School of Medicine in 2021. A member of the National Association of Urological Surgery since 2020. Dr. Böcü is active in the European Urology Association and has contributed significantly to the field through 13 articles, and numerous presentations at national and international forums. Currently, he is the leader of Research Team 13 in GAF.

My Personal Viewpoint on Male infertility in a MOSI setting

Dr. Germar M. Pinggera responds to the questions by Ashok Agarwal

1. What is your personal view on the significance of the MOSI diagnosis in the management of idiopathic male infertility?

Dr. Pinggera: As oxidative stress has been demonstrated to play a pivotal role in the etiology of male fertility, the introduction of the novel term MOSI represents a promising avenue. It offers the potential for clinicians to make more accurate diagnoses and treatments and for scientists to develop a structured foundation for a deeper understanding of the disease, facilitating comparable studies in the future.

2. Do you diagnose patients with MOSI (idiopathic + high OS) in your practice? If yes, then how do you treat them?

Dr. Pinggera: While classical microscopic semen analysis serves as an initial step in assessing male fertility status, it is essential to emphasize that it primarily adopts a descriptive approach, not comprehensively covering all aspects of male infertility. For numerous patients, supplementing semen analysis with the assessment of Male Oxidative Stress Infertility (MOSI) can significantly enhance diagnostic accuracy. Our experience suggests that the inclusion of MOSI evaluation provides a more discriminating tool for cases of unexplained male infertility.

In instances of elevated MOSI levels, the conventional empirical and somewhat off-label medical treatments for idiopathic male infertility, such as Selective Estrogen Receptor (SER) or hormonal therapies, may benefit from augmentation with antioxidative therapy over a span of several months.

3. What are the three main causes for the diagnosis of MOSI in your patients?

Dr. Pinggera: MOSI is indeed a critical issue in the realm of male reproductive health.

a. Oxidative Stress: OS occurs when there is an imbalance between reactive oxygen species (ROS) and the body's ability to detoxify them. High levels of ROS can damage sperm cells and affect their motility and DNA integrity, potentially leading to infertility. Various factors such as environmental toxins, smoking, and certain medical conditions can increase oxidative stress in the male reproductive system.

b. Antioxidant Deficiency: Antioxidants play a crucial role in neutralizing ROS and protecting sperm from oxidative damage. Inadequate intake of antioxidants through diet or lifestyle factors may lead to a deficiency, contributing to MOSI. Vitamin C, vitamin E, zinc, and selenium are examples of antioxidants that are important for male fertility.

c. Lifestyle and Environmental Factors: Modern lifestyles can also impact male fertility. Factors such as excessive alcohol consumption, smoking, exposure to environmental toxins (like pesticides or heavy metals), and sedentary habits can contribute to MOSI. Additionally, chronic stress and obesity may also have detrimental effects on sperm quality and fertility.

4. What are the three treatment choices (not including ART) that you will offer to patients with idiopathic male infertility (poor semen quality, no female factor, unknown OS status)?

Dr. Pinggera: When addressing idiopathic male infertility characterized by poor semen quality, no identified female factor, and unknown oxidative stress (OS) status, several treatment options could be considered, always, depending on the specific patient history and after addressing any underlying medical conditions that may contribute to his infertility. But, in general, to support any treatment options and to increase his therapeutic adherence, the knowledge of MOSI appears fundamental. Such patients can profit from lifestyle modifications and specific counselling like diet and nutritional optimization by adopting a balanced diet rich in antioxidants, vitamins, and minerals that support sperm health. In adipose men or those with primarily sedentary lifestyles exercise and weight management should be encouraged. Notwithstanding, smoking or alcohol abuse must be recommended before only advising for any pharmacological interventions by prescribing antioxidant supplements in mono or combination therapy.

Germar M. Pinggera, MD: Short Biography

Germar M. Pinggera, MD, LLM

Department of Urology

Innsbruck Medical University

Anichstrasse 35

6020- Innsbruck

Austria

Email: urologie.pinggera@gmail.com

ORCID id: 0000-0001-6463-2494

Dr. Germar-M. Pinggera is a renowned urologist and andrologist with a focus on men’s sexual health and male infertility as well urethral reconstructive surgery. He serves as the head of the Andrology & Male Infertility Unit in the department of Urology of the Medical University Innsbruck, Austria. He is certified as a Fellow of the European Committee of Sexual Medicine (FECSM). Dr. Pinggera also leads the Working Group of Andrology and Sexual Health for the Austrian Society of Urology and is since many years board member of the Austrian Endocrinologic Society (ÖGES). His expertise extends to being a reviewer for multiple international urological journals and organizing scientific congresses. He is involved in conducting clinical and scientific research as the principal investigator of several academic studies to discover novel therapeutic approaches. Dr. Pinggera's commitment to his field is further evidenced by his position as a full academician at the European Academy of Andrology (EAA). He is a senior member of the Global Andrology Forum (GAF) and serves as the Assistant Chairman on the GAFs Senior Advisory Board.

Is there plagiarism in the most influential publications in the field of andrology?

Fri, 19 Jan 2024 18:10:51 GMT

Article #39: “Is there plagiarism in the most influential publications in the field of andrology?”

Authors: S Baskaran, A Agarwal, MK Panner Selvam, R Henkel, D Durairajanayagam, K Leisegang, A Majzoub, D Singh, K Khalafalla.

Andrologia, 2019;51: e13405.

PMID: 31489696, https://doi.org/10.1111/and.13405

CAPSULE

Contributors: Bahadır Şahin, MD, (Turkey), and Taymour Mostafa, MD (Egypt)

Preamble:

Plagiarism is a crucial issue in scientific writing which can severely compromise the quality of publication. It ranges from simple discrepancies to significant duplication of manuscripts without suitable citation of the source article. However, despite the increased number of publications alerting us of the dangers of plagiarism and discussing the ethics of publications, there is no agreement on the permissible cut‐off level of plagiarism adopted by scientific journals, particularly in the field of Andrology.

In the current article, the authors selected one hundred of the most influential articles in the field of andrology, which were defined based on their publication score. From these 100 articles, 77 articles that authors have access to in full text were analyzed for their similarity index using the most common plagiarism detection software, iThenticate and Turnitin. The articles were classified according to their publication year (pre-2000 and post-2000), publication type (review articles vs. research articles), and their similarity index was then compared.

This analysis provided the following information:

The higher mean similarity index for the most influential andrology articles by Turnitin compared to iThenticate due to:

a. iThenticate compares the manuscript against over 60 billion web pages and 49 million articles from 800 scholarly publishers.
b. Turnitin undergoes scrutiny against its unparalleled database of >70 billion web pages, 1 billion student papers and 69 million articles from >1,700 publishers.

The higher similarity index for reviews than research articles speculating that:

a. Research articles are based on original research mostly for the first time reducing having elements of plagiarism.
b. Review articles summarize previously published findings from the literature rather than reporting new results.

A significantly higher level of similarity in articles published on/after the year 2000 compared to those published before explained by:

a. The tremendous growth in andrology research over the past few decades.
b. The increased journals dealing with many aspects of andrological sciences lately than before linked to the exponential increase in the number of available resources.
c. Advances in computer technology that facilitated scientific information such as; the internet (1991), and medical search engines such as PubMed (1996) and Scopus (2004).

The authors concluded that some level of reproducibility is unavoidable, particularly in subsections like materials and methods, which may pointedly overlap within specialized disciplines. With the advent and increasing use of plagiarism detection software by journals/publishers, there is a need for the development of similarity index guidelines to standardize acceptable levels of textual similarity for scientific publications.

Expert commentary:

The paper accurately acknowledges the notable surge in research and publications about andrology attributed to the growing interest in diverse areas of andrology such as:

The introduction of new revolutionized technologies like intracytoplasmic sperm injection (ICSI) for specific cases of infertility since 1992 and oral phosphodiesterase-5 inhibitors for cases of erectile dysfunction (since 1998).
New advances like regenerative therapies (RT), stem cells, platelet-rich plasma (PRP), and extra-corporeal shockwave therapy (ESWT) opened new scientific research possibilities that contributed to the growing literature. This technological progression is mirrored in the scientific literature, thereby increasing the scope for plagiarism, both unintentional and deliberate.
The advent of specialized andrological societies, including the Global Andrology Forum (GAF) since 2020, with numerous global surveys, special editions of specialized journals, and many andrological books released by international publishers, contributed to the rapid growth of literature in the field of andrology.
The growing utilization of artificial intelligence (AI) in various scientific fields, such as andrology, necessitates the development of fresh viewpoints in the execution and assessment of scientific research. The development of generative AI models and their widespread availability have significantly escalated plagiarism rates and ethical dilemmas in the field of medical research.

Additionally, Baskaran et al.'s analysis revealed an alarming trend of plagiarism, especially in review articles compared to research articles. This finding is significant as it sheds light on the nature of plagiarism, emphasizing the need for robust plagiarism detection and prevention strategies. Overall, the present study makes a valuable and important influence to the field of andrology. The authors not only brings attention to the problem of plagiarism in publications related to andrology but also establishes a foundation for future conversation and regulation regarding the preservation of the integrity of scientific research and publishing.

My Personal Viewpoint on Plagiarism in Andrology Articles

Dr. Bahadır Şahin responds to the questions by Ashok Agarwal

1. How do you deal with the issue of plagiarism in your own scientific writing and publications?

To prevent plagiarism in my scientific writing, I prioritize comprehensive citation of all references, employ plagiarism detection software, and uphold a strong commitment to originality in presenting research. Comprehending and valuing the rights of intellectual property are crucial, as is developing a practice of conscientiously recognizing the contributions of others.

2. What are the three main reasons for an increase in plagiarism these days?

Accessibility of Information: The internet offers convenient access to extensive amounts of information, which may lead some individuals to plagiarize without giving proper credit.

a. The imperative to publish: The prevailing "publish or perish" culture within academia exerts significant pressure on researchers to generate a greater number of papers, occasionally resulting in compromised ethical standards.
b. Inadequate awareness or comprehension: Occasionally, particularly among novice researchers, there exists a deficiency in comprehending the definition of plagiarism and the methods to prevent it.

3. What is your advice on the three things that GAF researchers can do to avoid falling victims of plagiarism?

a. Education and Training: Consistent instruction on research ethics and accurate citation practices can effectively minimize inadvertent plagiarism.
b. Utilizing plagiarism detection tools can aid in the early detection and resolution of potential issues during the research and publication process.
c. Encouraging a Culture of Integrity: Cultivating a setting that prioritizes innovation and ethical behavior in academic investigations will inherently deter plagiarism.

4. What will you consider an egregious case of plagiarism?

An egregious instance would involve the exact replication of significant sections of someone else's work, particularly crucial findings or data, without providing proper citation or recognition. This not only breaches ethical norms but also erodes the trust and integrity of the scientific community.

5. What actions would you advise against the authors or groups (in your institution or outside) who deliberately engage in plagiarism in the original research articles?

a. Institutional Review and Sanctions: The institution should undertake a comprehensive evaluation. If plagiarism is verified, it is necessary to consider suitable measures, such as retracting the papers, suspending the individual, or terminating their employment.
b. Inform professional or academic organizations to ensure wider knowledge and response.
c. Educational Remediation: In situations where there is a deficiency in comprehension, it is necessary to implement educational interventions to mitigate the likelihood of future instances.

Bahadır Şahin, MD: Short Biography

Bahadır Şahin, MD

Assistant Professor in Urology

Marmara University School of Medine

Urology Department, Andrology Division

İstanbul, Turkey

Email: drbahadirsahin@gmail.com

ORCID id: 0000-0002-4874-4178

Dr. Bahadır Şahin is an Assistant Professor of Urology at Marmara University School of Medicine, specializing in andrology since completing his residency. Born in Sivas, Turkey, he pursued medical education at Marmara University, graduating in 2009. Following a stint as a general practitioner, he completed his Urology Residency at the same university.

Dr. Şahin's career includes significant contributions to the field through research, international publications, and book chapters. He actively participates in andrology and uro-oncological societies in Turkey and is an active member and the Statistical Advisor of the Global Andrology Forum (GAF).

My Personal Viewpoint on Plagiarism in Andrology Articles

Prof. Taymour Mostafa responds to the questions by Ashok Agarwal

1. How do you deal with the issue of plagiarism in your scientific writing and publications?

Deep understanding of the subject background through several scientific resources before starting to write.

2. What are the three main reasons for an increase in plagiarism these days?

a. Lack of article writing skills, English writing skills, skills to search in scientific databases, and skills to use reference software.
b. Increased search data day by day due to the numerous publications.
c. Increased writing on a special subject numerously on a special item such as COVID-19 pandemic, artificial intelligence, antioxidants etc.

3. What is your advice on the three things that GAF researchers can do to avoid falling victims of plagiarism?

a. Attending the different comprehensive webinars held by GSF.
b. Deep understanding of the subject background through several scientific resources, before starting writing.

4. What will you consider an egregious case of plagiarism?

If complete paragraph(s) are copied from few papers.

5. What actions would you advise against the authors or groups (in your institution or outside) who deliberately engage in plagiarism in the original research articles?

In our institution, there is an obligation to submit each research article to the iThenticate plagiarism tool (with a report and stamp from official organizations) before submission to the promotion committee, grants, or awards. Otherwise, it is rejected.

Taymour Mostafa, MD MBBCh, MSC, DS: Short Biography

Taymour Mostafa, MD, MSc, DS

Professor, Department of Andrology

Sexology & STIs

Faculty of Medicine Cairo University

Cairo, Egypt

Email: taymour.mostafa@yahoo.com

ORCID id: 0000-0003-3627-0662

Prof. Taymour Mostafa is a highly accomplished Andrologist, graduating with top honors from the University of Cairo, Faculty of Medicine in 1978. A seasoned expert in Andrology and Sexual Medicine, with a career spanning decades, he is currently an Emeritus Professor of Andrology, Sexology & STIS at the University of Cairo School of Medicine, Cairo Egypt.

His research interests include male infertility, and sexual health. He has supervised 57 MSc, and 19 MD thesis projects and serves as a reviewer for most international peer-reviewed journals. He is affiliated with various prestigious international societies and has received multiple awards and honors. Dr. Mostafa has published over 200 peer-reviewed articles. Dr. Mostafa is a senior member of the Global Andrology Forum.

Introducing a NEW item: Expert Opinion

Expert Speaks on the “Plagiarism in Andrology Research”

Dr. Nicolás Garrido Puchalt (Spain) responds to the questions by Ashok Agarwal

1. What is your perspective on plagiarism in scientific research?

Scientific communication is the pillar that sustains the advancement of knowledge, allowing researchers to build on the basis generated by others, and therefore, any situation that jeopardizes the integrity of the information communicated must be prevented, discovered, and the perpetrator punished. The scientific community must have quality information that is certain and reliable, to enable progress.

Plagiarism, on the other hand, is a big word, encompassing a wide range of scenarios, from the indiscriminate copying of entire articles to moderate self-plagiarism by using own phrases and expressions, or even information from one's previous work, and whose consequences or sanctions must be proportionate to the problem generated. Plagiarism, per se, does not generate a problem of integrity of the information, but of who is attributed the merit of a work, result, or interpretation.

2. Have you encountered any incidents of plagiarism in your academic career?

Yes, of course, in the academic field, it is not unusual to find this type of circumstances, and in very different proportions, i.e. from small texts copied literally, which do not constitute a violation of the acceptable limits (both journals and universities are increasingly implementing plagiarism detection systems, which even measure the percentage of copied text, and identify the original source). Interestingly, acceptability thresholds may differ between institutions.

In my experience, it is much more frequent in student papers than in researchers and their submissions to scientific journals, where it is a much more controlled aspect. Moreover, I see ato decrease over the years, even though it is becoming increasingly difficult to write without resembling existing text, given the large amount of new information on each topic that is available every day.

3. How do you address plagiarism in your role as a journal editor?

There are available tools provided by the Editorials for each journal to filter out those papers with a significant percentage of copied text, that may vary among them. Then, if suspected plagiarism with already existing sources is found, there are nice guidelines from the COPE on how to act in this sense, that are internationally followed. See more information here. https://publicationethics.org/sites/default/files/plagiarism-submitted-manuscript-cope-flowchart.pdf

4. What are your three recommendations for GAF researchers to avoid plagiarism?

Plagiarism can be conscious, but it can also be unconscious. Obviously, the conscious is not acceptable, and in general, when referring to another work, even if a similar message is sent, the wording must be distinct enough to be considered original. Refrain from literally copying. To avoid the unconscious, which can originate from something as simple as using one's own texts, or writing sentences that contain expressions or comments that are very common in a field ("Infertility is a disease that affects 15% of the population of reproductive age..."), the recommendation is to identify it by using the multiple tools available online before submitting it to the corresponding journal. This might be a risk when writing reviews. Be original. Use your own words.

5. Could you share examples of egregious plagiarism cases you've come across?

Sure, cases where the whole paper tables and figures were already published by the same author on a previous paper about a different topic (this means not only plagiarism, but also data fabrication), cases where the University Final Master’s Thesis were done with ChatGPT from already existing sources, presenting more than 75% of plagiarized text, and also a paper where the references were provided as an image, copied from an existing book chapter, from which the text was also fully copied. Among others, I think these were the most extreme cases I’ve come across.

6. What is your advice on handling authors or groups engaged in deliberate plagiarism?

As described above, if deliberate plagiarism can be demonstrated, depending on what position I hold regarding them, the way I will respond would be different. If collaborating in a research/writing project, I would stop this collaboration. As a Journal Editor, seems obvious that the paper would not go through the revision process if detected beforehand, and the paper could be retracted if detected later. As a teacher, not accepting the student’s work and suspending the student.

7. What is your opinion on the use of AI Bots like ChatGPT in scientific research?

There are some nice papers out there on this topic. See RBM online, Altmae et al., 2023 “Artificial intelligence in scientific writing, a friend or a foe?”. Although I have no experience on this, I trust the authors concluding that can be a help in several aspects of scientific writing as organizing materials, creating some draft pieces, proofreading, etc. like in all creative writing, as it could be the case of screenwriters, book writers, etc.

We can also expect in the near future newer improved AI tools, in comparison with those nowadays available, since currently there are some significant limitations on their use.

8. What is your advice for GAF members who may be using the AI Bots in scientific writing?

The manuscript by Altmae et al. provides a thorough explanation of various limitations that authors employing AI bots for scientific writing must carefully consider. These limits include critical aspects that warrant attention during the preparation of any manuscript using such tools. Plagiarism stands out as a primary concern, given that the bot draws information from numerous pre-existing sources. Additionally, it is imperative to assess whether the bot aligns with the author's interpretation, scrutinize the completeness and relevance of the information chosen by the bot for analysis, and ensure that it resonates with the author's experience and knowledge.

9. What is your view on whether ChatGPT and similar Bots are a " Friend or Foe" of GAF researchers?

The Chat Bots if used cautiously can be of nice assistance for scientific writing, but so far, they cannot replace author’s knowledge, experience, and assess the need for major revision in a written article/ scientific report, as one may do with the work of a junior researcher in your team.

Nicolas Garrido, PhD: Short Biography

Nicolás Garrido Puchalt, PhD

Director, Research Administration, Research/Innovation, IVIRMA Global Research Alliance

IVI Foundation Director

Edificio Biopolo – Instituto de Investigación Sanitaria la Fe

Avenida Fernando Abril Martorell, 106 - Torre A, Planta 1ª

46026 Valencia

TL +34 963903305

IVI-RMA Global

Email: nicolas.garrido@ivirma.com

ORCID id: 0000-0001-8271-5218

Nicolas Garrido is the Director of IVI Foundation, and Director of Research Administration at IVI RMA Global, B.Sc. in Biology (University of Valencia) in 1997, followed by a Post-graduate Research Fellowship at the Department of Gynaecology, Heinrich-Heine University, Germany. He obtained his doctorate from the University of Valencia in 2001, Extraordinary Prize in 2002, and has a Master’s degree in Research Methodology: Design and Statistics in Health Sciences (Universitat Autònoma de Barcelon)) in 2009, in Science and Innovation Management in 2018 and in Project Management in 2020, (Universidad Politécnica de Valencia). Director of the Andrology Laboratory and Sperm Bank at the IVI University Institute in Valencia from 2000 until 2016, and IVI Teaching Program (2004-2017).

Nicolás was the Director of the Andrology Laboratory and Sperm Bank at the IVI University Institute in Valencia from 2000 till 2016 and led the IVI Teaching Program from 2004-2017. He is an Adjunct Professor at the University of Valencia, heading numerous research projects funded on male infertility, sperm physiology, sperm selection techniques, biomarkers of fertility, and statistics to measure ART success. He has authored 220 papers, 450 abstracts, and 80 chapters.

Nicolás serves as the Andrology Section Editor at RBM Online, past Associate Editor for Fertility and Sterility, and Ad Hoc Reviewer of many journals in the field. He was the Past Coordinator of ESHRE Special Interest Group for Andrology. Nicolás is a member of the GAF Statistical Expert Panel.

Expert Speaks on the “Plagiarism in Andrology Research”

Prof. Christine Wyns (Belgium) responds to the questions by Ashok Agarwal

1. What is your perspective on plagiarism in scientific research?

This is acceptable to a limited degree, as in materials and methods sections e.g. the description of a technical procedure such as IHC in papers coming from the same lab or even between labs that have used the same procedure; repeating a few sentences from another author if the original reference is correctly mentioned. However, it is unacceptable for results of original research.

2. Have you encountered any incidents of plagiarism in your academic career?

I have seen cases of self-plagiarism which is «text recycling» i.e. some authors publishing nearly the same text/part of text or/and sometimes same figures from results sections in their own papers. This aims at increasing paper numbers and citations and is probably linked to pressure of academic institutions for an increased visibility.

Concealment of original sources of ideas/concepts that are usually expressed in the discussion section using the same sentences as another author is another frequent occurrence but is not always intentional.

3. How do you address plagiarism in your role as a journal editor?

The risk of finding plagiarism in high impact journals is likely lower than in some other journals and I had so far not participated in the assessment of such cases.

a. Assessment should preferably be done on a case-by-case basis as it depends where the plagiarism is found. Indeed, a certain degree of similarity is acceptable in the Materials and Methods sections as the procedures often remain the same e.g. IHC, ICC and authors may then be asked to revise the text to minimize text recycling. As far as I know there is no threshold over which the level is considered unacceptable.
b. However, plagiarism found in a result section of an original research article is unacceptable as research results should only be published once.
c. Detection of plagiarism in accepted manuscripts is usually part of editorial checks and decisions on it are usually taken as an editorial team including an adjudicating editor. Authors could in certain circumstances see their manuscript rejected and be flagged for plagiarism.

4. What are your three recommendations for GAF researchers to avoid plagiarism?

Be an expert in the field where you publish as writing is easier when ideas and concepts are clear for the author as is the reasoning behind.

a. If it is a review, make your own outline on the subject, prepare a table on studies of interest with the main information/outcomes/limitations before starting the writing based on your own critical review.

b. If you repeat a small part of a manuscript in a discussion or introduction of a paper, always add the original reference you have used.

c. Avoid writing successively only conclusions/main outcomes taken from the included papers.

d. Avoid using parts of papers from other authors without referencing the original quotation and reproducing figures without the author’s permission.

5. Could you share examples of egregious plagiarism cases you've come across?

Self-plagiarism: authors use parts or the totality of their own publications when writing their next papers; this may include results from original research (even if slightly modified in its presentation)

Giving concrete examples presents the risk of disclosing the identity of specific groups or persons.

6. What is your advice on handling authors or groups engaged in deliberate plagiarism?

a. If the group is known to practice plagiarism, their paper should be uploaded in a software to detect plagiarism before acceptance.
b. If this was not done and plagiarism appeared at a later time, the decision needs to be taken based on what section of the paper is concerned but could lead to withdrawal in some cases.

7. What is your opinion on the use of AI Bots like ChatGPT in scientific research?

This is not acceptable as ChatGPT uses any source of information without reasoning behind it and thus it is scientifically not reliable.

8. What is your advice for GAF members who may be using the AI Bots in scientific writing?

It is not advisable to use it.

9. What is your view on whether ChatGPT and similar Bots are a "Friend or Foe" to GAF researchers?

They are foes. A recognized researchers should be able to write a scientific paper on his ow n.

Christine Wyns, MD, PhD: Short Biography

Christine Wyns, MD, PhD

Head of the Cliniques Universitaires Saint-Luc's

Gynaecology and Andrology Department

Medical Director of the Reproductive Tissue and Cell Bank

Professor at Université Catholique de Louvain (UCL)

Brussels, Belgium

Email: christine.wyns@saintluc.uclouvain.be

ORCID id: 0000-0002-6581-5003

Prof. Christine Wyns is a distinguished professional in the field of Medicine, specializing in Gynecology and Andrology. She earned her Doctorate degree in Medicine from the Catholic University of Louvain, Brussels, in 1993. Dr. Wyns furthered her expertise with degrees in Gynecology from the Catholic University of Louvain, Andrology from the University of Limoges, and Health and Biomedical Sciences from the Catholic University of Louvain. With a rich academic background, Dr. Wyns has served as the former Head of the Department of Gynecology and Andrology. Currently, she holds the position of Head of the IVF and Andrology units within the Department of Gynecology-Andrology, and serves as the Director of the Reproductive Tissue and Cell Bank at Cliniques Universitaires Saint Luc in Brussels, Belgium.

In addition to her clinical roles, Dr. Wyns is a Professor at the Catholic University of Louvain, Brussels, where she leads the research lab in Andrology (IREC, pole REPR) with a special focus on fertility preservation for prepubertal boys. Dr. Wyns has made significant contributions to the field, having served as the past-chair of the European IVF monitoring (EIM) steering committee-ESHRE. Her extensive body of work includes over 100 articles in medical journals and books, and she is a regular presenter at major international conferences and symposia.

Expert Speaks on the “Plagiarism in Andrology Research”

Prof. Ralf Henkel (United Kingdom) responds to the questions by Ashok Agarwal

1. What is your perspective on plagiarism in scientific research?

With increasing pressure on researchers to publish, plagiarism is a problem that must not be ignored. This problem is exacerbated by the pressure researchers experience in getting a job.

2. Have you encountered any incidents of plagiarism in your academic career?

Yes, as Editor-in-Chief for Andrologia, I have encountered plagiarism several times.

3. How do you address plagiarism in your role as a journal editor?

When a manuscript is submitted for publication, we automatically check for plagiarism and similarity with relevant software. Then, the report is checked to see where the similarity is. If whole paragraphs or sections are copied, the manuscript will be rejected outright. On the other hand, if there are only a few sentences plagiarized, the manuscript will be returned to the authors with relevant advice for significant revision. If we detect plagiarism after publication, the paper will be retracted.

4. What are your three recommendations for GAF researchers to avoid plagiarism?

a. Do not only take information from where you have seen it, verify it.
b. Paraphrase information and ALWAYS cite the relevant verified reference.
c. Be aware of self-plagiarism!

5. Could you share examples of egregious plagiarism cases you've come across?

I do not have relevant examples readily available.

6. What is your advice on handling authors or groups engaged in deliberate plagiarism?

If I find authors or groups who continue plagiarizing, they will be earmarked and blocked from publication. Relevant articles will then be retracted, and possible legal action will be considered.

7. What is your opinion on the use of AI Bots like ChatGPT in scientific research?

In my opinion, this is a huge problem as it makes plagiarism much easier. Therefore, plagiarism software such as Turnitin have implemented a feature that can identify AI generated text sequences. Authors will be informed accordingly and have to revise the

relevant sections with relevant references.

8. What is your advice for GAF members who may be using the AI Bots in scientific writing?

I would advise not to use AI bots at all. Science and scientific articles should reflect the intellectual ability of the writer/scientist and not of some AI bot. Not using these bots will also reduce the risk of plagiarizing other papers.

9. What is your view on whether ChatGPT and similar Bots are a "Friend or Foe" of GAF researchers?

As I said, I do not advise using these bots as science should reflect human ingenuity and creativity, not that of a machine.

Ralf Henkel, PhD: Short Biography

Ralf Henkel, PhD, Habil

Chief Scientific Advisor: LogixX Pharma, Reading, UK

Visiting Reader, Department of Metabolism, Digestion and Reproduction, Imperial College London, UK

Email: ralf.henkel@logixxpharma.com

ORCID id: 0000-0003-1128-2982

Since June 2020, Prof. Henkel has been engaged with LogixX Pharma, UK. Additionally, he serves as a Visiting Reader in the Department of Metabolism, Digestion, and Reproduction at Imperial College London, UK, and holds the title of Honorary Professor at Universidad Peruana Cayetano Heredia, Lima, Peru. Prof. Henkel is also the Editor-in-Chief of Andrologia.

Throughout his illustrious career, Prof. Henkel has supervised 76 students, published over 300 articles, chapters, and books, boasting an impressive h-index of 61. His collaboration with Ashok Agarwal dates back to their time at the Cleveland Clinic, and since 2022, he has been a senior member of the Global Andrology Forum.

Acknowledgement: Bahadir Sahin, Taymour Mostafa, Nicolas Garrido, Christine Wyns and Ralf Henkel contributed to this week’s Management Special. We are grateful for their generous support as senior members of the GAF.

The excessive use of antioxidant therapy: A possible cause of male infertility

Mon, 08 Jan 2024 14:50:52 GMT

The excessive use of antioxidant therapy: A possible cause of male infertility

Authors: Ralf Henkel, Inderpreet Singh Sandhu, Ashok Agarwal

Andrologia, 2019 Feb;51(1):e13162.
PMID: 30259539 DOI: 10.1111/and.13162

CAPSULE

Contributors: Akira Tsujimura, MD, PhD (Japan), and Edoardo S. Pescatori, MD (Italy)

Commentary by Prof. Akira Tsujimura:

(article: PMID: 30259539 DOI: 10.1111/and.13162)

In many developed countries, declining fertility has become a national problem, and interest in male infertility has increased over the years. The most common cause of male infertility is spermatogenesis dysfunction, especially for unknown causes (idiopathic). The European Urological Association guidelines for idiopathic male infertility and oligozoospermia state that the effects are not uniform, with some meta-analyses showing that antioxidant therapy improved conception and pregnancy rates, while others reported no improvement in semen findings after treatment. However, it is also true that reactive oxygen species and oxidative stress are closely related to various pathological conditions such as neurodegenerative diseases, aging, and male infertility. Therefore, in actual clinical practice, antioxidants have been used empirically in patients with idiopathic spermatogenesis dysfunction.

Antioxidants are available in a variety of formulations containing various concentrations of selected antioxidants. They are commercially available in the form of dietary supplements and are added to a variety of foods and teas. For male infertility, glutathione, vitamins C and E, carnitine, N-acetylcysteine, coenzyme Q10, selenium, and zinc are antioxidants commonly used as therapeutic agents. However, exact dosages and dosing regimens for these antioxidants are not clearly defined. Some of these substances on the market are in such high concentrations that they do not occur in nature, and there is concern about the side effects of overdose. In fact, the few studies that have evaluated antioxidant overdose and its associated side effects have found that the side effects of high dietary intake of antioxidant supplements vary. Taking selenium as an example, it has been reported that elevated seminal selenium concentrations (>80 ng/ml) are associated with decreased motility, azoospermia, and increased miscarriage rates. In fact, selenium concentrations between 40 and 70 ng/ml are considered optimal for productive reproduction (high pregnancy rates and low miscarriage rates). Furthermore, there is growing evidence that the antioxidant or antioxidant-promoting activity of antioxidants, even if they are of natural origin, is ultimately dependent on their concentration. In addition, because many antioxidant compounds act synergistically, treatment with antioxidants not only fails but may even be toxic.

The study by Henkel et al, addresses the "antioxidant paradox," in which high doses of antioxidant supplements damage cells with free radical substances and reiterates that antioxidant therapy for male infertility has clear benefits and risks.

My Personal Viewpoint on the use of antioxidants for male infertility:

1. When and why do you recommend antioxidant supplements to your patients? What is their diagnosis? (Agarwal)

Prof. Tsujimura : If I make a diagnosis of idiopathic spermatogenesis dysfunction after examination of the patient's semen, blood (hormone) tests, and the presence of varicocele, I suggest that the patient take antioxidants. However, I fully explain that there is no specific treatment for spermatogenesis dysfunction and that antioxidants are the drug of choice by process of elimination.

2. Comment on the kind of antioxidant supplements you recommend and in what dose and for how long? (Agarwal)

Prof. Tsujimura: These drugs are basically not covered by insurance in Japan, so I ask patients to purchase them themselves after explaining them to them. I recommend a combination of L-carnitine (750 mg), zinc (30 mg), astaxanthin (16 mg), coenzyme Q10 (90 mg), and vitamins C, E, and B12. The efficacy of these fixed-dose combinations is reported in Reproductive Medicine and Biology 19: 89-94, 2020. The minimum duration of administration is 3 months, and the maximum is about 1 year.

Commentary by Dr. Edoardo Pescatori:

(article: PMID: 30259539 DOI: 10.1111/and.13162)

Oxidative stress, defined as a disturbance in the balance between the production of reactive oxygen species (free radicals) and antioxidant defenses, it is acknowledged to be linked, among the others, to disturbances of male fertility. In men oxidative stress may be the result of several factors: wrong lifestyles (overweight/obesity, sedentary lifestyle, smoking, excessive alcohol intake, etc,), varicocele, radiation, exposure to environmental toxic agents. All these may negatively impact the spermio/spermatogenetic process, as witnessed also by altered values at sperm analysis and DNA fragmentation test. Accordingly, several antioxidant supplementations have been proposed, and are widely used, to hypothetically “treat” oxidative stress. The present paper by Henkel, Sandhu and Agarwal elegantly and comprehensively illustrates the potential risks of “too much” antioxidant supplementation, emphasizing the possibility to fall into the “antioxidant paradox”, where an excessive antioxidant load can induce a “reductive stress”, as dangerous as the oxidative stress.

This paper clearly shows how this area is controversial: Authors showed that, although several studies on antioxidant supplementations documented positive effects in clinically infertile men, many others have failed to show positive outcomes on semen parameters, and some have even reported negative outcomes in terms of increased sperm DNA fragmentation or chromatin decondensation.

Authors then explored the possible causes that might explain the present difficulty “to find the truth” about the correct antioxidant treatment: commercially available antioxidants are mostly a mixture of potentially active products, and the role of each specific one is difficult to assess; it would be desirable to know the actual individual redox level in each individual patient, but this is seldom, if ever, done. Authors emphasize the lack of a universally accepted method to test the bodily and seminal redox status. More: the normal seminal redox level is unknown and, consequently, no generally accepted cut‐off values are presently available.

Should the present scientific limits of above be overcome, ideally studies simultaneously evaluating the impact of specific antioxidant supplementations on sperm analysis, sperm DNA fragmentation and decondensation tests, stratified by individual bodily and seminal redox status, could answer many questions on the correct antioxidant treatment in the individual infertile man. Up to then, the role of the Andrologist is crucial in identifying all the potential causes of oxidative stress in each infertile man, to pursue correction of wrong lifestyle habits, with emphasis on a correct diet with natural antioxidants present in food, unlikely at risk of inducing a status of “reductive stress”.

My Personal Viewpoint on the use of antioxidants for male infertility:

1. What is your personal philosophy on the role of antioxidants for the treatment of infertility patients? (Agarwal)

Dr. Pescatori: The priority should be to identify the presence of potential treatable causes of oxidative stress (wrong lifestyle habits, varicocele, environmental causes), and address them. Only after having done so, to consider antioxidant supplementations.

2. When and why do you recommend antioxidant supplements to your patients? What is their diagnosis? (Agarwal)

Dr. Pescatori: I prescribe antioxidants in patients with not correctable risk factors of oxidative stress, and with altered test of sperm DNA fragmentation, besides sperm analysis. I consider antioxidants even more in the presence of recurrent pregnancy loss.

3. When will you prescribe antioxidants and in what dose and for how long? (Agarwal)

Dr. Pescatori: I prescribe antioxidants at the recommended (either scientific or Company) dose, I do not associate more antioxidants. My typical treatment cycle has a 3-month duration, and I request a follow-up visit with the outcomes of: sperm analysis, DNA fragmentation and decondensation tests.

Introducing a NEW item: Expert Opinion

Expert Speaks on the Role of Antioxidants in Male Infertility

Invited Expert: Professor Armand Zini

(article: PMID: 36102104 DOI: 10.5534/wjmh.220067)

Dr. Zini shared his viewpoint on a recent meta-analysis published by GAF researchers on the “Impact of Antioxidant Therapy on Natural Pregnancy Outcomes and Semen Parameters in Infertile Men” Agarwal et al, World J Men’s Health. 2023 Jan;41(1):14-48. Published online Sep 07, 2022. https://doi.org/10.5534/wjmh.220067

The etiology of male infertility is multifactorial and, in many cases the underlying mechanism is the excess production of semen reactive oxygen species (ROS) and oxidative stress. Abnormal semen ROS production is known to cause sperm dysfunction and sperm DNA damage resulting in reduced male fertility potential.

These observations have led clinicians to treat infertile men with antioxidant supplements. Although the mechanism of action of dietary supplements remains to be fully elucidated, in vitro studies have demonstrated that antioxidants can protect sperm function and sperm DNA integrity when spermatozoa are exposed to high levels of ROS. Moreover, most clinical studies have shown that dietary antioxidants can improve sperm function and DNA integrity in infertile men. However, a beneficial effect of these supplements on pregnancy and live birth rates has not been established. Additional work is required to determine the optimal antioxidant supplement and the effect of these agents on sperm parameters and reproductive outcomes.

Akira Tsujimura, MD, PhD: Short Biography

Akira Tsujimura, MD, PhD

Professor, Department of Urology Juntendo University Urayasu Hospital,

Urayasu, Japan

Email: atsujimu@juntendo.ac.jp

ORCID id: 0000-0002-3821-5184

Professor Tsujimura graduated from Hyogo Medical University in 1988 and has been a urologist in Japan for 36 years. After graduation, he started his clinical practice at Osaka University, where he has been conducting clinical and basic research with subspecialties in androgen-related areas such as male infertility, sexual dysfunction, late onset hypogonadism, and prostate diseases, as well as surgery for malignant tumors. He studied at New York University from 1998 to 2000, where he conducted basic research on the prostate.

Akira currently holds key positions in various Japanese andrological societies as the: President of Japan Andrology Society, Vice chairperson of Japan Society for Reproductive Medicine, and the Vice president of the Japanese Society for Sexual Medicine. He is also a member of a committee that prepares guidelines for reproductive medicine.

Edoardo S. Pescatori, MD: Short Biography

Edoardo S. Pescatori, MD

Specialist in Urology, Andrologist (European Academy of Andrology certification)

Affiliation: Andrology and Reproductive Medicine Unit, Next Fertility GynePro,

Bologna, Italy

Email: drjsp2912@gmail.com

ORCID id: 0000-0002-9326-5598

Dr. Pescatori graduated from Università di Medicina e Chirurgia, Padova (Italy) in 1986, and completed his Residency program in Urology in the same University, in 1991. He did two fellowships in the USA: in Urological Oncology (Cleveland Clinic Foundation, Cleveland – Ohio 1988-1989) and in Male Erectile Dysfunction (Boston University Medical School, Boston – Massachusetts. 1991-1992).

He has been involved in animal research with development of an original model of reflex erections and ejaculations in the rat (J. Urol., 149: 627-632, 1993), in clinical research, with several publications in International Journals, and in development of International Consensus Conferences. He is presently working as Andrologist performing diagnosis and treatment of male infertility and male sexual dysfunctions.

Armand Zini, MD, FRCSC: Short Biography

Armand Zini, MD, FRCSC

Professor of Surgery

Division of Urology, Department of Surgery, McGill University,

Montreal, Quebec, Canada.

OVO Fertility Clinic, Montreal, Quebec, Canada

Email: ziniarmand@yahoo.com

ORCID id: 0000-0002-2194-5578

Dr. Armand Zini is Professor of Surgery at McGill University and Head of the Division of Urology at St. Mary’s Hospital in Montreal. Armand is also the Director of Andrology Fellowship Program at McGill University in Montreal. Armand received his medical degree and completed urologic training at McGill University. He then completed a fellowship in male infertility at the New York Hospital-Cornell Medical Centre and The Population Council in New York.

His research interests include varicoceles, sperm retrieval techniques, sperm DNA fragmentation and the role of oxidative stress in male infertility. Dr. Zini has participated in several national and international guidelines committees on the management of male infertility and related disorders. He has published over 150 papers, 15 book chapters, and has co-edited 2 books on the role of sperm DNA damage in male infertility.

Acknowledgement: Akira Tsujimura, Edoardo Pescatori, and Armand Zini contributed to this week’s Management Special. We are grateful for their generous support as senior members of the GAF.

A systemic review and meta-analysis exploring the predictors of sperm retrieval in patients with non-obstructive azoospermia and chromosomal abnormalities.

Fri, 05 Jan 2024 15:14:07 GMT

A systemic review and meta-analysis exploring the predictors of sperm retrieval in patients with non-obstructive azoospermia and chromosomal abnormalities.

Authors: Majzoub A, Arafa M, Hailey H, Imperial J, Leisegang K, Khalafalla K, Agarwal A, Henkel R, Elbardisi H.

Andrologia. 2022;54:e14303.
https://onlinelibrary.wiley.com/doi/10.1111/and.14303

CAPSULE

Contributors: Vilvapathy Senguttuvan Karthikeyan, MD (India), and Sanjay Prakash Jayaprakash, MD (India)

This review collates available evidence from 53 articles and includes 2965 patients undergoing surgical sperm retrieval (SSR) for non-obstructive azoospermia (NOA) with chromosomal abnormalities. The review tries to identify predictors for a successful SSR.

Observations:

Klinefelter Syndrome (KS) was the most prevalent (75.5%) chromosomal disorder with a positive SSR rate of 38.63%

In KS patients, lower age, lower FSH & LH levels, higher testosterone levels were analyzed to be positive predictors of successful SSR (mean FSH: 36.8 IU/L). The mean testicular volume in men with KS was 3.4 ml. A larger testis size significantly predicted the overall success of SSR [OR 1.433, 95% CI 1.036– 1.983, p = 0.030) with no observable heterogeneity]. Age did not affect SSR outcome.

2. Y chromosome microdeletion was seen in 18.6%.

Men with AZFc microdeletion had a positive SSR of 41.95% and partial AZFc microdeletions had a SSR rate of 55.56% (Mean FSH: 17 IU/L; Mean testis volume 10.4 ml).
There were not enough predictors identified for SSR outcome in AZFc patients.

3. There have been successful SSR (33-100%) in men with chromosomal translocations and inversions; however, there were no consensus on the predictors of success.

Comments:

Contribution of KS (3-4%) and AZF mutations (7%) in infertile men is around 10%.; Incidence of KS (8-12%) and AZF (15%) put together, in men with NOA is around 25-27%.
The additional contribution of data from this SRMA gives an idea as to what proportion of men with NOA could have KS and AZF mutations. A plethora of genetic defects exist in men who test negative for these chromosomal abnormalities.
In men with NOA, there is a role for preimplantation genetic testing. In countries where genetic testing and gender selection are prohibited, given the low yield of men with chromosomal abnormalities, this also raises the need to routinely perform these two tests.
There has been a growing interest in genomic fertility analysis; these have diagnostic and therapeutic implications. It is too premature to discuss these newer panels due to cost and also the too little data available to support or refute its use. There is at least 50% more of additional information required to prognosticate the success rates of SSR, outcome of ICSI, clinical pregnancy rates and live birth rates.
In essence, this review adds little to existing knowledge of KS and AZF mutations in NOA. Though this manuscript shows prediction rates of SSR, it clearly does not give an idea of SSR in men in whom these panels are negative. In clinical practice, most men now have normal karyotype and AZF mutations leaving a big void in the understanding of genetics in NOA.

Limitations:

Most studies focused on SSR outcomes rather than prediction of success.
The analysis did not clearly mention the exact cut off FSH values or testis volume beyond which SSR had a predominantly negative outcome because this could be an important factor in counselling the patients.
SSR rates in both mosaic and non-mosaic variants of KS are different and could have been another component in this data.

Conclusions:

Results of this meta-analysis can guide clinicians to counsel NOA patients undergoing SSR based on clinical and laboratory parameters. Further evidence addressing the limitations and the role of additional genetic tests could be more useful in the future.

Vilvapathy Senguttuvan Karthikeyan,

MBBS, MS MRCS(Ed), MCh, FAIS, FECSM: Short Biography

Vilvapathy S. Karthikeyan , MBBS, MS, MRCS(Ed), MCh, FAIS, FECSM

Andro-Urologist

Apollo Hospitals, Greams Road, Apollo Fertility & Andromed, Chennai

Email: sengkarthik@live.com

ORCID id: https://orcid.org/0000-0002-0244-476X

Dr Karthikeyan is a Microsurgical Andrologist and Urologist focusing on Andrology and Men’s health practice. He is one of the few andrologists to routinely perform office evaluation of erectile dysfunction including office sildenafil test in Southern India. His special interests include prostatitis and scrotal content pain, fertility preservation, genetics in male infertility, oncosexology and regenerative therapy in andrology.

Dr Karthikeyan has received training in Miami, USA and New Delhi and has diploma in Male Infertility from Brazil, North Carolina, and Germany. He has served as an international and national faculty at Andrology conferences. He has 80+ publications in indexed medical journals and is the author of textbook chapters.

Sanjay Prakash Jayaprakash,

MBBS, MS(GS), DrNB (Uro), FMAS, FIAGES, FAMH: Short Biography

Sanjay Prakash Jayaprakash

MBBS, MS(GS), DrNB (Uro), FMAS, FIAGES, FAMH

Consultant Urologist and Microsurgical Andrologist

Asian Institute of Nephrology & Urology, Chennai, Tamil Nadu, India

Email: drjsp2912@gmail.com

ORCID id: https://orcid.org/0000-0001-8758-9441

Dr Sanjay Prakash J is a Urologist and fellowship trained Andrologist from India. He has good experience in treating male infertility and has performed multiple microsurgical sperm retrieval procedures and reconstructive procedures. His field of interest is in male sexual dysfunction with a special interest in prosthetic surgery.

Having completed a Fellowship in Advanced Andrology & Male Sexual Dysfunction from the Rajiv Gandhi University of Health Sciences in Karnataka, India. Sanjay is interested in research activities and is currently researching regenerative therapies for erectile dysfunction. He is an author of chapters for two textbooks and has published nearly 25 articles in indexed medical journals.

Acknowledgement: Vilvapathy Senguttuvan Karthikeyan and Sanjay Prakash Jayaprakash contributed to this week’s Management Special. We are grateful for their support as active members of the GAF.

Effectiveness and Satisfaction with a Microsurgical Testicular Sperm Extraction Knowledge and Skills Masterclass for a World-Wide Audience

Sat, 30 Dec 2023 15:27:11 GMT

Effectiveness and Satisfaction with a Microsurgical Testicular Sperm Extraction Knowledge and Skills Masterclass for a World-Wide Audience
Authors: Walid El Ansari, Mohamed Arafa, Merilyn Lock, Rupin Shah, Ashok Agarwal, World J Men’s Health, Published online Jan 2, 2024
https://doi.org/10.5534/wjmh.230195

CAPSULE

Contributors: Luca Boeri, MD (Italy), and Rupin Shah, MD (India)

Luca Boeri, MD: Non-obstructive azoospermia (NOA) is the cause of infertility for about 10% of infertile couples. In these cases, testicular sperm extraction (TESE) associated with intracytoplasmic sperm injection (ICSI) represents a possibility to father a child. TESE is a simple procedure associated with minimal adverse events, however, the success rate is only about 40-60% according to published data. Microsurgical TESE (mTESE) was introduced in 1998 and emerging data have shown that sperm recovery was higher after this procedure compared to conventional TESE. Nonetheless, the rate of sperm recovery is still wide (20 to 60%) and related to several clinical and histopathologic parameters. To this aim, it is important to identify the best candidate for mTESE procedures. Successful mTESE requires a breadth of knowledge and skills for the appropriate evaluation of potential patients and successful execution of the mTESE procedure. For example, clinicians should have a great knowledge of the clinical history of the patient, a correct understanding of the hormonal parameters, genetic testing, and ultrasound findings. Moreover, proper training in the procedure is also crucial as the surgeon’s training and experience are key factors for successful sperm retrieval in mTESE. Accurate training in couple’s infertility management and mTESE procedures is rare and not standardized in several countries. Based on these consideration the GAF group organized an online mTESE masterclass tailored for the andrology workforce worldwide to improve their knowledge of this important topic.

The masterclass was organized by GAF in collaboration with the Turkish Urology Association (TUA) during the annual TUA Symposium (13–16 March 2023). Five didactic lectures were delivered followed by presentations of four varied and difficult NOA cases. These were used as a platform for in-depth discussions employing different case scenarios to debate the topics and deliberate the management of each case through interactive dialogues between moderators, panelists, and participants. A pre-quiz was distributed 10 days before the masterclass to all registered participants. This quiz was designed to assess the participants’ mTESE knowledge and skills. Moreover, the same quiz was delivered after attending the masterclass to gauge the acquisition of learning attributable to the masterclass. Participants' satisfaction was also assessed.

Capsule

A total of 1,025 participants initially registered, of which 163 completed both the pre- and post-quiz and the questionnaire and were considered for further analysis. Participants’ age ranged from 20 to 70 years old, with more male participants than females. Most of the attendees had clinical backgrounds and worked in public hospitals. Most participants never/occasionally performed mTESE. Likewise, most did not receive mTESE training. Nearly half the participants self-rated their mTESE skills as low, while only a minority (11%) rated themselves as very high. Whilst about 83% of the participants emphasized their need for mTESE training and guidance, roughly half the participants declared that good mTESE training was either unavailable or available with difficulty.

In terms of pre-post quiz scores, a significant improvement was seen after attending the masterclass. Clinicians had significantly higher scores in the pre-quiz, however, this difference became insignificant in the post-quiz. Importantly, participants with non-clinical backgrounds improved relatively more than those with clinical backgrounds. Of note, all participants enhanced their mTESE knowledge and skills after the masterclass regardless of their sex, professional background, experience, practice type, past mTESE training, and initial pre-masterclass self-rated skills in performing mTESE. Participants’ satisfaction with the webinar’s topics, quality, clinical relevance, and content was very high, ranging from 98% to above 99%.

In conclusion, the GAF masterclass on mTESE was extremely appreciated and useful for improvement in theoretical and practical skills. Such improvements were characterized by learning that was broad, deep, highly significant, inclusive, and differential. Participants who most needed mTESE knowledge and skills were the precise ones who improved the most, namely non-clinical practitioners with ≤5 years of experience serving in public practice, as well as clinical practitioners with low self-rated mTESE performance.

Rupin Shah: In March 2023 a unique, global, online workshop on the practical aspects of mTESE was presented by senior GAF members in a format that included lectures, operative videos, and multiple case discussions. The urgent need for such training was highlighted by the fact that there were over 1000 registrants for the symposium. The demographic data confirmed that the majority of those attending the symposium were the ones who most needed it, and that almost 100% of participants felt benefited from attending the symposium.

This paper provides details of the topics covered as well as a detailed analysis of the participants – their demographics, their pre and post symposium knowledge levels, and the various steps implemented to make the symposium optimally useful, and to document the resultant gain in knowledge. This paper will be a useful guide for anyone planning any educational activity related to this subject.

Take Home Message:

Mastering micro-TESE demands precise surgical skills due to its delicate nature, necessitating extensive training in microsurgical techniques. Surgeons often seek specialized training to work alongside experienced mentors to develop proficiency in this intricate procedure. However, such training is hard to come by in many countries and when available could be expensive. The surgery involves navigating tiny testicular structures under high-powered microscopes, identifying sperm-containing areas, and minimizing tissue damage risks. Even for skilled clinicians, micro-TESE doesn’t guarantee the retrieval of viable sperm in every case. The success rate can be affected by factors like the underlying cause of infertility, the quality of testicular tissue, and the expertise of the surgeon. Furthermore, the success of mTESE requires the services of laboratory specialists (and a state-of-the-art cryopreservation laboratory), with excellent skills in identifying, isolating, and freezing rare sperm. Ethical counseling for potential outcomes is crucial. Continuous learning and staying updated on microsurgical advancements are vital for excellence. Virtual masterclass training offers a viable solution due to limited availability of specialized training. (Contributor: Ashok Agarwal, USA)

Luca Boeri, MD, PhD, FEBU: Short Biography

Luca Boeri, MD, PhD, FEBU

Department of Urology

Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico

Milan, Italy

Email: dr.lucaboeri@gmail.com

ORCID id: 0000-0003-0040-784X

Dr. Luca Boeri is a dedicated Urologist and Andrologist at Milan's Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico. He earned his medical degree from the University Vita Salute San Raffaele and underwent residency at the University of Milan, complemented by a research fellowship at Mayo Clinic (Rochester, MN, USA). Dr. Boeri's expertise lies in male infertility and sexual dysfunction, leading the microsurgery team in andrology at his hospital.

Recently, he completed a PhD focusing on the immune tolerance of infertile and fertile men. He contributes actively to the European Association of Urology (EAU) Guidelines for Sexual and Reproductive Health and holds memberships in various national and international societies, including the Italian Society of Urology, Italian Society of Andrology, and International Society for Sexual Medicine. With over 180 peer-reviewed publications and book chapters, Dr. Boeri remains deeply engaged in advancing urological and andrological research.

Rupin Shah, MD: Short Biography

Rupin Shah, MBBS, MS, MCh (Urol)

Department of Urology & Andrology

Lilavati Hospital & Research Centre

Mumbai, India

Email: drrupinshah@gmail.com

ORCID id: 0000-0002-7868-5949

Dr. Rupin Shah , a Urologist specializing in Andrology, focuses on male infertility and impotence. He practices as a Microsurgeon and Consultant Andrologist at the Lilavati Hospital & Research Centre, Mumbai and holds distinction as India's first urologist trained abroad in Andrological microsurgery.

Rupin’s notable contributions include pioneering impotence surgery, earning recognition with the President’s prize from the International Society of Impotence Research. He developed the widely used Shah penile prosthesis, receiving acclaim with the Dr. B C Roy Award for advancing Andrology in India. With numerous publications and academic roles, he serves as a Senior Advisor and member of the Core Management of the Global Andrology Forum.

Acknowledgement: Luca Boeri and Rupin Shah contributed to this week’s Management Special. We are grateful for their outstanding support as active members of the GAF.

Standardized Laboratory Procedures, Quality Control and Quality Assurance Are Key Requirements for Accurate Semen Analysis in the Evaluation of Infertile Male

Wed, 27 Dec 2023 16:49:19 GMT

Standardized Laboratory Procedures, Quality Control and Quality Assurance Are Key Requirements for Accurate Semen Analysis in the Evaluation of Infertile Male

Authors: Agarwal et al, World J Mens Health 2022 Jan 40(1): 52-65

pISSN: 2287-4208 / eISSN: 2287-4690

https://doi.org/10.5534/wjmh.210022

CAPSULE

Contributors: Ivan Hoffmann, MD (Germany), Safar Gamidov, MD (Russia), and Israel Maldonado, MS (Mexico)

Semen analysis is an essential and fundamental test for evaluating male fertility potential. Semen analysis is performed according to the current World Health Organization (WHO) criteria manually or automatedly with computer-aided sperm analytical system (CASA). emen analysis requires performance of highest quality, reliability, and accuracy as it contributes to the decision making of management and treatment of infertile couples. The workflow of semen analysis is divided into 3 phases: pre-analytical, analytical and postanalytical. Each phase implements particular steps that should be monitored. Each laboratory is required to establish quality indicators for laboratory equipment, standard operating procedures (SOP) and testing personnel and its surveillance. Quality control (QC) and quality assurance (QA) are important tools of the quality management system (QMS) that intends to achieve reproducible results.

QC monitors the accuracy and precision of a particular test or procedure whereas the purpose of the QA is the overall surveillance to ensure quality of procedures in a lab. The QMS defines quality indicators of all phases of the workflow of semen analysis and monitors the processes in order to meet this quality indicators. Both external and internal quality control (EQC and IQC) are important to evaluate quality in a laboratory. The IQC checks all critical points during the work routine to minimize the variability of an existing procedure within the laboratory. The EQC evaluates the laboratory performance by an external agency that commonly sends the same sample to different laboratories and compares the results of participating laboratories. It is essential to review, interpret and comment on the data collected by QC. The implementation of QA requires frequent and well-planned independent audits. Results of the audits must be reported. Reports must include any incident, error or deviation from the expected quality standard, its detailed description and record compliance, deficiencies and corrective actions taken.

CASA systems are automated or semi-automated instruments of semen analysis. The aim is to provide more precise results in a faster way than manual semen analysis. There are different CASA systems available using different mathematical algorithms. It is important to ensure that devices provide reliable results. Whether the semen analysis is manual or automated, its results significantly impact the management of an infertile couple. For example, there are patterns suggestive of seminal tract obstruction when surgical treatment could be indicated. Taken together, semen analysis and clinical data can be used to distinguish cases of male infertility associated with varicocele, metabolic syndrome, oxidative stress etc. By assessing these factors clinical andrologists should be able to determine whether the patient has indications of medical or surgical treatment, or the couple should proceed to ART right away. Semen analysis is a cornerstone of this decision-making process which places great responsibility on laboratory staff. According to the Code of Federal Regulations (42 CFR 493), Andrology labs need documented policies and procedures for a robust quality assurance (QA) program. Adherence to these standards, crucial for CLIA certification, ensures accurate, timely, and reliable test results. Maintaining staff competency, proper documentation of QA activities, and using standardized, reproducible methods are pivotal to guarantee high-quality outcomes in Andrology laboratories.

Summary: Understanding the principles and techniques for collecting and analyzing semen samples is crucial in clinical practice and infertility management. Strict quality control in andrology testing ensures consistent and reliable results. Accrediting agencies mandate proficiency test participation for reproductive labs conducting moderate to high complexity tests. Familiarity with normal semen parameter ranges and definitions of abnormal categories is vital for interpreting laboratory findings in

clinical settings.

Take Home Message:

Relying solely on manual semen analysis for infertile males poses challenges due to its subjectivenature, potential for variability among technicians, limited parameters assessed, time-consumingprocess, dependency on skilled personnel, inconsistencies in reporting, and the risk ofinaccuracies due to human error. Integrating automated or AI-based systems can help overcome these challenges by providing more consistent, comprehensive, and efficient assessments.

(Contributor: Ashok Agarwal, USA)

Ivan Hoffmann, MD: Short Biography

Ivan Hoffmann, MD

Urologist/ Andrologist

Center for Reproductive Medicine and Andrology

University Clinic Halle (Saale)

Munster, Germany

Email: ivan.hoffmann@outlook.de

ORCID id: 0009-0007-6102-2376

Dr. Ivan Hoffmann is a distinguished urologist and andrologist practicing at both the University Clinic Halle and the Infertility Clinic Hoffmann in Berlin. He earned his medical degree from Charite Medical University in Berlin and underwent residencies at several prestigious institutions, including the University Clinic Halle, Military Hospital Berlin, and University Clinic Gießen. His primary focus within the field lies in infertility.

In addition to his background in urology and andrology, Dr. Hoffmann is currently pursuing a second residency in Gynecology and Obstetrics at the University Clinic Halle, broadening his expertise in reproductive health.

Dr. Hoffmann's contributions extend beyond clinical practice. He serves as the secretary of the German Society of Andrology (DGA) since 2018, actively engaging in shaping and advancing the field of andrology in Germany. Furthermore, he maintains active memberships in international societies such as the European Association of Urology and the European Academy of Andrology, reflecting his commitment to staying updated with global advancements in his field.

Safar Gamidov, MD: Short Biography

Safar Gamidov, MD, PhD

Professor and Head of Andrology and Urology Department,

V.I. Kulakov National Medical Research Center, Moscow, Russia

Email: safargamidov@yandex.ru

ORCID id: 0000-0002-9128-2714

Dr. Safar Gamidov holds the prestigious position of the Head of Andrology and Urology Department at the V.I. Kulakov National Medical Research Center in Moscow, Russia. His expertise involves male infertility, sexual dysfunction, and urethral stricture disease, making him a leading figure in these fields.

Dr. Gamidov is recognized as a pioneer in several advanced surgical techniques, notably penile prosthesis surgery, surgical sperm retrieval, and seminal tract reconstruction within Russia. His groundbreaking contributions have significantly impacted the landscape of these specialized surgical procedures.

Apart from his clinical achievements, Dr. Gamidov is actively engaged in research and is a sought-after speaker at both national and international conferences. His extensive knowledge and expertise make him a frequent invitee to share insights and advancements in the field of andrology and urology.

In addition to his clinical and research endeavors, Professor Gamidov plays a pivotal role in education. He conducts a distinctive andrology course at Sechenov University and mentors’ postgraduate students, contributing significantly to the education and training of future professionals in this field.

Israel Madonado Rosas, MS: Short Biography

Israel Maldonado Rosas, BS, MSc.

Chief Embryologist,

CEO and Scientific Director CITMER - ART Clinics and Research Center Mexico city, Mexico.

Email: imaldonado@citmer.mx

ORCID id: 0000-0003-2765-6176

Israel Maldonado Rosas, MS. , is a prominent figure in the field of Assisted Reproductive Technology (ART) and serves as the owner and CEO of the renowned ART Clinic named the "Center of Technological Innovation and Reproductive Medicine" (CITMER) in Mexico. CITMER operates three IVF clinics situated in Puebla, Monterrey, and Mexico City, offering specialized reproductive health services.

Israel's academic background includes a degree in Biology from the Instituto Politecnico Nacional. He pursued extensive training in Clinical Embryology at prestigious institutions worldwide, including the Instituto Valenciano de Infertilidad in Valencia, Spain, the Kato Ladies Clinic in Tokyo, Japan, and the American Center for Reproductive Medicine in Cleveland, USA.

With board certification as a Clinical Embryologist from the REDLARA since 2016, Israel holds substantial expertise in his field. His contributions extend beyond clinical practice, with a notable research focus reflected in over 26 publications in peer-reviewed articles and book chapters.

Israel Maldonado Rosas also holds a distinguished position as a Guest Member of the GAF Management Council, emphasizing his commitment and involvement in the broader landscape of reproductive medicine.

Acknowledgement: Ivan Hoffmann, Safar Gamidov, and Israel Maldonado contributed to this week’s Management Special.

We are grateful for their exceptional support as active members of the GAF.

Scientific landscape of oxidative stress in male reproductive research: A scientometric study

Fri, 22 Dec 2023 17:56:01 GMT

Scientific landscape of oxidative stress in male reproductive research: A scientometric study
Authors: Agarwal et al, Free Radical Biology and Medicine 156 (2020) 36-44
https://doi.org/10.1016/j.freeradbiomed.2020.05.008

Preamble:

Briefly about the oxidative stress:
Oxidative stress occurs when reactive oxygen species (ROS) surpass the body's natural antioxidant defenses, leading to damage in cell components like lipids, proteins, and DNA. This imbalance is linked to male infertility, especially in cases involving poor lifestyle choices (smoking, obesity, alcohol, inadequate diet), aging, varicoceles, infections, mobile phone radiation, and environmental pollutants. In male infertility, ROS can harm sperm production, motility, and genetic material. Studies confirm ROS as a significant factor in infertility and recurrent miscarriages, highlighting the importance of assessing ROS levels and overall antioxidant capacity in managing repeated pregnancy loss.

And now about the scientometrics analysis:
Scientometric analysis offers an objective view of scientific knowledge. It quantifies articles by year, authors, affiliations, journals, and countries, revealing emerging trends and productive entities across scientific, social, and economic domains, unlike bibliometric research.

CAPSULE

Contributors: Lucia Rocco (Italy), and Gokhan Calik, MD (Türkiye)

The scientometric study explores oxidative stress (OS) in male reproductive health using Scopus data from 1941 to 2018. It highlights OS trends, key publications, and major contributors. The United States, India, and Italy were prominent publishers, with collaborative success driving research. OS was recognized as a significant cause of male infertility, particularly in the US.

Journals like Fertility and Sterility, Andrologia, and Human Reproduction were highly productive. Sperm anomalies and varicoceles were major topics, peaking in the 1981-1990 and 2011-2018 periods. Detection techniques focused on chemiluminescence and antioxidant assessment, with chemiluminescence notably reliable and reproducible for ROS measurement. Limitations include sample quantity required.

ORP measurement emerged as an alternative technique, with thresholds for abnormal semen quality and infertility. Validation across diverse scientific backgrounds is needed. Prognostic/diagnostic studies surged in the last decade, indicating OS's increasing relevance in male infertility pathologies. OS presents an avenue for exploring conditions like idiopathic infertility and potentially using antioxidant treatments, urging exploration of novel diagnostic techniques.

Personal perspectives
The advent of Scientometric analysis introduces a powerful quantitative approach, offering insights not only into male infertility but potentially across broader infertility domains. This innovative research avenue not only guides researchers but also sets a benchmark for clinicians worldwide, paving the way for the integration of new scientific technologies in understanding and addressing infertility. Its utility extends beyond male fertility, promising a broader impact in diverse areas of reproductive health.

Take Home Message:
Extensive research on oxidative stress (OS) in male fertility from 1941 to 2018 emphasizes its pivotal role. The US, India, and Italy led contributions. Key journals and topics like sperm issues and varicoceles evolved over time. Chemiluminescence and antioxidant assessment stood out in OS detection, but ORP measurement needs wider validation. Recent studies highlight OS's growing relevance in male infertility. The quantitative results from this study signals OS as a key area for investigating complex conditions and potential treatments. (Contributor: Ashok Agarwal, USA)

Lucia Rocco, PhD: Short Biography

Lucia Rocco, PhD
Associate Professor in “Biology and Techniques of Reproduction”
University of Campania “Luigi Vanvitelli”
Dept of Environmental, Biological and Pharmaceutical Sciences and Technologies
Caserta, Italy
Email: Lucia.ROCCO@unicampania.it
ORCID id: 0000-0001-6250-4798

Dr. Lucia Rocco is an Associate Professor in the Dept of Environmental, Biological and Pharmaceutical Sciences and Technologies at the University of Campania, Caserta, Italy.
She has over 30 years of research experience in various fields as Genetic Ecotoxicology, Animal and Human Cytogenetics, and Molecular Cell Biology. Evaluation of genotoxic effects induced by environmental pollutants, such as nanoparticles alone and in combination with heavy metals or endocrine disrupting chemicals (EDCs); cytogenetics using conventional and molecular (cytogenomic) techniques; analysis of chromosomal alterations also in relation with human fertility and/or subfertility. She also has a strong theoretical and practical background in experimental planning and data analysis.

Lucia is the Principal Investigator in Reproductive Biology and Genotoxicity Research Laboratory at University of Campania “Luigi Vanvitelli”, DiSTABiF, Caserta, Italy. She has 65 publications to her credit, 1495 citations and an h-index of 22.

The main publications and research interests of Prof. Rocco can be accessed at this link:
https://www.scopus.com/authid/detail.uri?authorId=56249592100

Gokhan Calik, MD, MD: Short Biography

Gokhan Calik, MD, FEBU
Asst. Prof. of Urology
Dept. Of Urology
Istanbul Medipol University
Faculty of Medicine
Istanbul, Türkiye
E-mail: gcalik@medipol.edu.tr
ORCID id: 00000002 9976 9666

Dr. Gokhan Calik is currently working in the subsection of Uro-andrology in his department. He is the co-investigator of various national/international urology research projects such as BEPS (Benign Prostate Hyperplasia Surgery - Ejaculation Preservation Study) and myBPHcare by the Société Internationale d’Urologie (SIU). He is also the administrator of the online data management system (turconline.com) of the Turkish Urological Research Collaboration group. Gokhan serves as a co-team leader in GAFs Research Team 4 under Prof. Wael Zohdy.

Acknowledgement: Lucia Rocco and Gokhan Calik contributed to this week’s Management Special. We are grateful for their excellent support as active members of the GAF.

Sperm DNA fragmentation in male infertility: From bench to bedside

Sun, 17 Dec 2023 03:36:19 GMT

“Sperm DNA fragmentation in male infertility: From bench to bedside”.
Authors: Ala’a Farkouh, Ramadan Saleh, Rupin Shah & Ashok Agarwal
Arab Journal of Urology, Published online: 12 Nov 2023, DOI: 10.1080/20905998.2023.2278200
https://doi.org/10.1080/20905998.2023.2278200

Preamble:
Sperm DNA fragmentation (SDF) is a molecular sperm abnormality that can have detrimental impact on male reproductive potential. There has been a growing interest in SDF globally, both in clinical applications and research output. In fact, SDF testing was included as an extended sperm function test in the latest edition of the WHO laboratory manual for the examination and processing of human semen. The pathogenesis of SDF is attributable to several intrinsic and extrinsic factors that culminate in oxidative stress, abortive apoptosis, and defective sperm chromatin maturation. Many investigators have examined specific risk factors or etiologies that lead to increased SDF and impaired male fertility potential. Similarly, many studies have investigated methods to counteract these factors and reduce SDF or select spermatozoa that contain lower SDF levels.

In the past couple of years, the Global Andrology Forum (GAF) has gained a leadership in the andrology field in terms of research output on SDF, publishing several clinically relevant reviews, book chapters, clinical practice guidelines, global surveys, and metaanalyses. From personal experience of being involved in many of these projects, I noticed a very large amount of literature published on SDF but noticed a large gap in the quantity and quality of evidence pertaining to certain aspects, including some etiologies, certain
treatments, or certain testing methods. For example, many well designed and controlled studies have investigated the detrimental impact of SDF on assisted reproduction, including outcomes such as clinical pregnancy and miscarriage rates. In fact, many authors have published high quality systematic reviews and meta-analyses to further highlight these findings. However, studies on how to improve the outcomes of these assisted reproductive techniques when SDF is present in the male partner are lacking, with only few observational or small experimental studies available. Furthermore, one commonly highlighted theme in the published literature is the variability of SDF testing techniques and a lack of standardized cut-off and interpretation of the available SDF assays. This may create confusion to both researchers and clinicians and provide further challenges when attempting to combine or interpret data.

As GAF continues to publish on SDF global practices and up-to-date high-quality evidence, this short review presents the most recent evidence in a concise and straightforward manner, providing answers to important clinical questions.

CAPSULE

Contributors: Ala’a Farkouh, MD (USA), and Taha Hamoda, MD (Saudi Arabia)

SDF refers to single or double strand breaks of sperm DNA -triggered by several factors such as oxidative stress- that can eventually negatively impact the reproductive outcomes. Different testing technologies and lacking a universally accepted cut-off or reference values cloud the scene in both research and clinical practice. The presented GAF’s article concisely reviews the clinical indications of SDF testing, summarizes different testing techniques, and outlines the management options for elevated SDF.

Among many reputable scientific bodies heavily engaged in SDF research, the GAF is currently actively and efficiently leading the world-wide research on both SDF testing and management. The GAF has enriched the literature with numerous publications that may change the rules of the game.

Future Reflections:
When asked the question “What did you learn from working on the SDF global survey project?” My answer was “We need to do more research.” The future of SDF research is limitless, with many pertinent laboratory and clinical questions that need answers. Basic science research may focus on further understanding the pathogenesis at a molecular level. Observational studies may delineate and provide strong evidence on certain risk factors or etiologies that lead to elevated SDF. Laboratory research may standardize the SDF assays, allowing uniform analysis, reporting, and interpretation. Interventional studies and randomized controlled trials can provide the basis for evidence-based medicine when managing infertile couples with elevated SDF in the male partner.

Take Home Message:

The novelty of Sperm DNA Fragmentation (SDF) lies in its specific focus on genetic integrity. Unlike many other diagnostic markers that primarily assess sperm count, motility, or morphology, SDF evaluates the structural integrity of DNA within sperm cells. This focus on genetic quality provides unique insights into male fertility issues, directly linking to embryo quality, pregnancy success rates, and miscarriage risks. SDF serves as a predictive marker, guiding treatment decisions and interventions aimed at addressing underlying genetic factors affecting fertility outcomes in ways that no other markers could do. Integrating SDF testing into routine assessments offers a more personalized approach, potentially improving fertility outcomes through targeted interventions and treatment modifications. (Contributor: Ashok Agarwal, USA)

Ala’a Farkouh, MD: Short Biography

Ala’a Farkouh, MD
Researcher
Department of Urology
Loma Linda University Health
Loma Linda, CA, USA

Dr. Farkouh is a physician from Jordan and pursuing a career in Urology. He graduated from the University of Jordan in 2019 and worked in the Department of Surgery, King Hussein Cancer Center (KHCC), Jordan as a transitional resident for two years. He has been working with the Global Andrology Forum since 2020 and has published several projects, including reviews, book chapters, abstracts, original research, and global surveys.

He joined the Department of Urology at Loma Linda University in California in 2022 as a fulltime researcher working on benchtop research, basic research, clinical research, and physician safety research with a heavy focus on endourology. He aims to pursue a Urology residency in the United States, aiming to merge his clinical expertise and training with his demonstrated research acumen and strong analytical skills.

Taha Abdel-Meguid Hamoda, MD: Short Biography

Taha Abdel-Meguid Hamoda, MD
Professor/Consultant in Urology and
Andrology
Department of Urology
King Abdulaziz University
Jeddah, Saudi Arabia
E-mail: tahaaboalmagd@yahoo.com
ORCID: 0000-0002-8070-4088

Dr. Taha Hamoda is a Professor/Consultant in Urology and Andrology at the King Abdulaziz University, Jeddah, Saudi Arabia. He is an Honorary Professor of Urology/Andrology at Minia University, El Minia, Egypt. Taha is a senior member of the Global Andrology Forum and a former member of GAFs Core Management Council.

He has published over 100 peer reviewed publications and 12 books contributions. He holds a US patent for an invented surgical technique (2020) and is a member of several national and international scientific societies and associations. Taha serves as an expert reviewer for several high impact journals in urology and andrology and has served as a reviewer for the EAUs Clinical Guidelines on Male Infertility

https://kingabdulaziz.academia.edu/TahaAbdelmeguid

Acknowledgement: Ala’a Farkouh and Taha Hamoda contributed to this week’s Management Special. We are grateful for their exceptional support as active members of the GAF.

A Novel Approach to Improving the Reliability of Manual Semen Analysis: A Paradigm Shift in the Workup of Infertile Men

Mon, 11 Dec 2023 10:27:17 GMT

A Novel Approach to Improving the Reliability of Manual Semen Analysis: A Paradigm Shift in the Workup of Infertile Men”.
Authors: Christopher Douglas, Neel Parekh, Linda G. Kahn, Ralf Henkel, Ashok Agarwal World J Men’s Health 2021 Apr 39(2): 172-185
https://doi.org/10.5534/wjmh.190088

Preamble: This article explores standard male fertility evaluation, focusing on challenges in conventional semen analysis (SA). SA is globally accepted as the primary test in assessing male fertility. SA has been a contentious issue among fertility researchers for a considerable period. Its subjective nature has led to criticism regarding the interpretation by clinicians and the assessment variability among lab technicians. The absence of standardized protocols and inherent individual variations have made the test highly error prone. Consequently, doubts have emerged about its accuracy and efficiency, prompting the need for consistent implementation of quality control programs. These programs aim to mitigate the considerable variability in assessing most variables of conventional SA.

Capsule: Contributors: Hussein Kandil, MD (UAE), Dongsuk Kim, MD, PhD (South Korea)
The intricacies and challenges faced while assessing semen parameters using SA has a more profound implication when it comes to clinical practice, as seen for instance during the process of deciding between IUI, versus IVF/ICSI which is a decision that is based upon the total motile sperm count.
Because of the aforementioned factors, over the last decade, there has been constant trial of coming about with new techniques and technologies that would more accurately assess male fertility. There has been a shift towards a computerized technology, as with the computer assisted semen analysis (CASA), which was aspired to offer higher accuracy in assessing male fertility, overcoming the shortcomings of conventional SA, but unfortunately, this has come about with the cost of increased price and concerns regarding the technological calibration.

Further innovations involved the emergence of home-based kits to assess male fertility, which probably have alleviated the issues of privacy and have found some degree of appreciation by the end users, like patients who had concerns with undergoing lab based testing. The current devices only measure sperm concentration or motility, leading to inaccurate and unreliable results. Evaluating sperm DNA fragmentation, crucial for sperm function and male fertility, lacks standardized testing methods. Moreover, the different available assays and techniques for SDF testing vary, raising concerns about their cost. Due to these issues, DNA fragmentation testing hasn't emerged as a reliable alternative to semen analysis (SA) for assessing male fertility. Although physiological levels of oxidative stress (OS) are required for sperm function, OS derived from excess of oxidants or a deficiency in antioxidants can disrupt the homeostasis of the redox system and can be associated with sperm DNA damage compromising male fertility. Chemiluminescence is widely used in the measurement of seminal ROS, but it has several limitations including inability to measure ROS in frozen samples, requiring a large semen volume and low reliability in the presence of ROS producing leukocytes in semen. The total antioxidant capacity (TAC) assay, which measures the antioxidant concentration only in the seminal fluid cannot evaluate the enzymatic antioxidants or individual antioxidants in the entire ejaculate and is not cost effective. Measuring the oxidation-reduction potential (ORP) is an innovative tool used in identifying a single direct marker of male factor infertility. ORP measured via Male Infertility Oxidative System (MiOXSYS) predicts abnormal semen parameters with high sensitivity and specificity, in short time (<5 minutes) and is simple to perform, cost effective, highly reliable, requiring little training and only 30 uL of sample. The MiOXSYS overcomes many of the challenges however, it cannot be used in cases of severe oligozoospermia (≤1×106 sperm/mL) or azoospermia. When it comes to the test’s accuracy, ROC curve analysis resulted in a cut off value of 1.36 mV/106 sperm/mL, which could differentiate between normal and abnormal semen samples with a high sensitivity, specificity, and positive and negative predictive value. Further multi-center study with 2,092 men of diverse ethnicity from nine institutions located in seven countries showed that an ORP cutoff value of 1.34 mV/106 sperm/mL could reliably distinguish between normal and abnormal semen quality with 98.1% sensitivity, 40.6% specificity, 94.7% positive predictive value, and 66.6% negative predictive value (area under the curve [AUC] = 0.765)

Take Home Message:
Various methods have emerged for male fertility assessment, but challenges remain. Manual semen analysis methods measuring sperm concentration, motility or morphology are unreliable. Innovations like computerized analysis are hampered by cost and calibration issues. Home-based kits address privacy concerns but lack comprehensive testing. Sperm DNA fragmentation testing lacks standardized methods, hindering its reliability. MiOXSYS shows promise in detecting abnormalities in redox status but has limitations in severe cases. Establishing an ORP cutoff value offers potential, but more diverse studies are needed for accurate semen quality distinction. Despite advancements, a unified, comprehensive approach remains elusive in assessing male fertility. (Contributor: Ashok Agarwal, USA)

Meet the Contributors:
Hussein Kandil, MBBCh, FACS, MBA: Short Biography

Hussein Kandil, MBBCh, FACS,
MBA
Urologist/ Andrologist
Fakih IVF Fertility Center
Abu Dhabi, UAE
Email: hkandil@gmail.com
ORCID: 0000-0002-5549-3274

Dr. Hussein Kandil is a urologist specialized in male reproductive and sexual medicine. He currently runs the male reproductive unit at Fakih IVF Fertility Center in Abu Dhabi (UAE) and is the andrology section Coordinator at the Arab School of Urology. He obtained his urology diploma from Balamand University in affiliation with the division of urology at St. George Hospital University Medical Center, Lebanon. His residency included training at the urology divisions of Pontoise Regional Hospital and Lens Teaching Hospital (France). This was followed by a traveling Fellowship in Andrology at the University of Illinois at Chicago (USA), with clinical training in male reproductive and microsurgical treatments. Further, he earned the Fellowship of the American College of Surgeons (FACS). Later, he graduated with Distinction earning a master’s degree in business administration (MBA) from the University of Strathclyde, UK. During his years of practice, he was among the first to perform microdissection TESE for patients with non-obstructive azoospermia in Lebanon. Dr. Hussein Kandil authored male infertility books and coauthored several book chapters in the field of male infertility. His area of expertise includes the microsurgical techniques in andrology including micro-dissection TESE and microsurgical varicocele ligation, in addition to the management of male reproductive endocrine disorders.

Dongsuk Kim, MD, PhD: Short Biography

Dongsuk Kim, MD., PhD
Associate Professor, Urologist,
Andrologist
Department of Urology, Fertility Center,
CHA Gangnam Medical Center
CHA University, 650-9 Yeoksam-dong,
Seoul 135-081, South Korea
E-mail: dskim100@cha.ac.kr
ORCID: 0000-0001-7350-0303

Dr. Dongsuk Kim is a urologist with subspecialty of male infertility. He has obtained a Medical Degree from Yonsei University Medical school in Seoul. He finished the postgraduate studies at Yonsei University, and then completed a PhD degree from the Yonsei University in Seoul, Korea.
Dr. Kim did his Urology Residency at Severance Hospital and Urologic Fellowship at Severance Hospital of Yonsei University in Seoul. He is now serving as an Associate Professor of Urology in fertility center of CHA Gangnam Medical Center, CHA University, South Korea.
He is specially interested in male infertility, male fertility preservation in cancer patients and male sexual dysfunction. He is actively working as a member of the Korean Urologic Association, Korean Society for Sexual Medicine and Andrology, and Korean Society of Reproductive Medicine.
His clinical research in male infertility is supported by the National Research Foundation of Korea.

Acknowledgement: Hussein and Dongsuk contributed to this week’s Management Special.

We are grateful for their excellent support as active members of the GAF.

The Sixth Edition of the WHO Manual for Human Semen Analysis: A Critical Review and SWOT Analysis

Sat, 02 Dec 2023 04:26:41 GMT

The Sixth Edition of the WHO Manual for Human Semen Analysis: A Critical Review and SWOT Analysis.
Authors: Boitrelle F, Shah R, Saleh R, Henkel R, Kandil H, Chung E, Vogiatzi P, Zini A, Arafa M, Agarwal A.
Life (Basel). 2021 Dec 9;11(12):1368.

DOI: 10.3390/life11121368 .

Preamble: Understanding Sperm Epigenetics
Epigenetics in male infertility involves changes that impact gene activity without altering the DNA sequence. For instance, DNA methylation modifications can affect sperm quality. Histone alterations during spermatogenesis impact the packaging of genetic material in sperm. Dysregulation of non-coding RNAs, like miRNAs, can lead to sperm function issues. These epigenetic changes can influence male fertility, affecting sperm function and potentially impacting fertility outcomes.

CAPSULE

Contributors: Christopher Ho, MD (Malaysia), Widi Atmoko, MD (Indonesia)

Semen analysis is a mainstay for initial evaluation among infertile men. Proper preparation, assessment, and interpretation are mandatory to avoid misdiagnosis or unnecessary treatment. After around 10 years since the last edition, the WHO released its newest sixth edition manual of semen examination and processing. The present article reviews the Sixth Edition of the WHO Manual for Human Semen Analysis,
including a thorough analysis of strengths, weaknesses, opportunities, and threats (SWOT)

What the 5th edition lacked; this 6th edition attempted to improve on. It includes adding new data from fertile men in Southern Europe, Asia, and Africa to increase the representativeness of all geographical areas. Nevertheless, there is still no representation from Saharan Africa or South America. This 6th edition also
acknowledges that the 5th percentile values of basic semen parameters alone are insufficient for accurate diagnosis of male infertility. However, this created a lack of reference threshold or decision internals to replace the 5th percentiles.

The manual introduces an updated laboratory technical guide on semen analysis, including comprehensive step-by-step procedures. For instance, it adopts the earlier classification of sperm motility, adds semen odor examination, and a detailed assessment of lower sperm concentrations. Some recommendations on quality control and quality assurance that can help guide optimum laboratory performance are provided in the manual.

In addition, sperm DNA fragmentation (SDF) and fluorescence in situ hybridization (FISH) are also introduced as extended tests of semen. SDF is considered the most discussed and promising addition in male infertility workup. Despite the introduction of SDF as an extended examination, there is still a lack of indication, criteria for interpretation and cut-off threshold values. Despite sufficient data saying otherwise, the 6th edition still considers oxidative stress (OS) tests as specialized and mainly research based procedures in the advanced test section.

The problem that can arise is that there are too many technical details and a lack of reference values in this 6th edition, which may put off clinicians from reading it. The lack of reference values may drive clinicians to use the 5th edition instead. More importantly, clinicians should consider multiple factors, such as the patient's clinical status and female factors in fertility assessment to provide a thorough diagnosis.

The changes in the sixth edition of the WHO manual of human semen examination and processing have offered a great understanding of how to carry out a proper semen analysis. However, there is room for updates and improvement. This review by GAF authors rightfully said that future research may help overcome weakness in this 6th edition to help produce a better edition in the future, especially with the help of SWOT analysis.

Considering that clinicians must evaluate the strengths and drawbacks of the existing manual and reach a reasonable decision specific to each patient's situation, the review has completely analyzed and broken down the gist of the 6th edition so eloquently that it is an excellent supplement for busy clinicians who do not have the time to sieve through too many pages of jargon.

Christopher Ho Chee Kong, MD, MS, MRCSEd, MBU (Cert), MFSTEd, FAMM, FICS (USA), FRCS (Urol)(Glasg), FECSM, FRCSEd, FACS: Short Biography

Prof. Christopher Ho Chee Kong
Consultant Urologist,
Oriental Melaka Straits Medical Centre
Adjunct Professor, School of Medicine,
Taylor’s University
Kuala Lumpur, Malaysia

Prof. Dr. Christopher Ho Chee Kong is an Adjunct Professor in the School of Medicine, Taylor's University and Consultant Urologist at Oriental Melaka Straits Medical Centre. He was previously Professor of Surgery and Urology at Universiti Kebangsaan Malaysia (UKM).

Chris is a member of the International Consultation of Urological Diseases (ICUD), the Vice President for the Malaysian Society of Andrology and the Study of the Aging Male (MSASAM), Senior Vice President of the College of Surgeons Malaysia, Vice Chair of the International Society for Sexual Medicine Communications Committee, Committee Member of the Asian Society of Men’s Health and Andrology (AMSHA) and also a Fellow of the Royal College of Surgeons of Edinburgh (FRCSEd), and Glasgow FRCS (Urol)(Glasg), European Committee of Sexual Medicine (FECSM), International College of Surgeons (FICS), European Committee of Sexual Medicine (FECSM), American College of Surgeons (FACS) and Academy of Medicine Malaysia (FAMM).

He is also a Member of the Faculty of Surgical Trainers Edinburgh (MFSTEd), Société Internationale d'Urologie (SIU), Examiner for the Membership of the Royal College of Surgeon (MRCS) exam, tutor for the Edinburgh Surgical Sciences Qualification (ESSQ), Director of Andrology Special Interest Group for the Malaysian Urology Association.

He has published over 155 publications in peer reviewed journals as well as 7 book chapters on issues in Men’s Health. He is also a member of the Editorial Board of 10 journals (including the Investigative and Clinical Urology journal, SIU journal) and a reviewer for more than 24 journals.

Widi Atmoko, MD, FECSM, FICS: Short Biography

Widi Atmoko, MD
Andro-Urology Consultant
Cipto Mangunkusumo Hospital, Faculty
of Medicine Universitas Indonesia
Head of Urology Dept
Universitas Indonesia Hospital
Head of Uro-Nephrology Cluster,
Kencana Cipto Mangunkusumo Hospital
Jakarta, Indonesia

Dr. Widi Atmoko is a consultant urologist at the Department of Urology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia. He earned his medical degree and specialty with cumlaude distinction and is now pursuing a Doctoral degree from the same university. In 2020, he became a certified Andro-urologist consultant, and in 2023, he was recognized as a Fellow by the European Committee of Sexual Medicine.

Dr. Atmoko is the President of the Indonesian Society of Andrological Urology, Head of the Urology Department at Universitas Indonesia Hospital, and Head of Uronephrology Cluster at Kencana Dr. Cipto Mangunkusumo Hospital. Beyond these roles, he has been actively involved in other key positions, including the Head of Information, Technology, and Public Relations at InaUA, a member of SIU Academic Committee for the Sexual and Reproductive Section, and editorial board member of Video Journal of Sexual Medicine. Additionally, he serves as one of the research team leaders in the Global Andrology Forum.

Dr. Atmoko's contributions include over 60 scientific articles and chapters in reputable journals and books. His accomplishments are backed by several research grants and his selection for international fellowship and observership programs from esteemed organizations.

Dr. Widi serves as the Leader of Research team 7.

Acknowledgement: Chris and Widi contributed to this week’s Management Special. We are grateful for their outstanding support over the years.

Sperm epigenetics landscape: correlation with embryo quality, reproductive outcomes, and offspring’s health

Mon, 20 Nov 2023 01:58:48 GMT

Sperm epigenetics landscape: correlation with embryo quality, reproductive outcomes, and offspring’s health.

Authors: Garrido N, Boitrelle F, Saleh, R, Durairajanayagam D, Colpi G, Agarwal A, Panminerva Medica

2023 June;65(2):166-78.
DOI: 10.23736/S0031-0808.23.04871-1

CAPSULE

Contributors: Nicolás Garrido, PhD (Valencia, Spain) and Sezgin Gunes, PhD (Samsun, Turkiye)

Various mechanisms govern epigenetic control in sperm, encompassing DNA methylation, histone modifications, and non-coding RNAs. These mechanisms play a pivotal role in cyclic DNA methylation changes, toggling specific genes on or off. In infertile males, some of these mechanisms are altered, compromising the maintenance of the necessary epigenetic pattern for optimal sperm function.

Proper methylation of both specific and imprinted paternal genes significantly influences sperm quality. During spermatogenesis, sperm chromatin undergoes modifications, replacing about 90-95% of histones with smaller protamines, compacting the paternal genome.

Non-coding RNAs like miRNAs, siRNAs, and piRNAs contribute to the transcriptional inactivation of spermatozoa. Aberrations in these processes can lead to fertilization issues, hindered embryo development, poorer outcomes in assisted reproductive technologies (ART), and health problems in offspring, despite normal semen parameters. Moreover, these factors can be transmitted to the offspring during meiosis.

Environmental and lifestyle factors such as alcohol consumption, diet, physical activity, and smoking can contribute to incorrect epigenetic markers, impacting sperm function and potentially affecting the health of future generations.

Discovering clinically significant epigenetic biomarkers has the potential to enhance the diagnosis of male fertility issues and facilitate the creation of precise treatments. This is because the epigenetic profile can be altered similarly to how external environmental factors affect it. Advancements in analytical technologies are providing fresh insights and a deeper comprehension of the epigenetic terrain, aiming to refine diagnoses and tailor therapies more effectively.

Take home message:

The available data indicates a connection between sperm epigenetic patterns and male fertility, as well as potential health risks for offspring. However, before implementing diagnostic tests or therapies based on this, more studies with proper design and adequate power are required to confirm and translate these findings into real-world applications.

Commentary:

Various techniques measure epigenetic changes in human spermatozoa from infertile men:

DNA Methylation Analysis: Uses bisulfite sequencing or methylation-specific PCR toassess DNA methylation patterns in specific gene regions.
Histone Modification Analysis: Investigates alterations in histone proteins through chromatin immunoprecipitation (ChIP) assays.
Non-Coding RNA Profiling: Examines levels of regulatory non-coding RNAs (miRNAs, piRNAs) influencing gene expression.
Epigenome-wide Association Studies (EWAS): Analyzes genome-wide epigenetic changes using high-throughput sequencing or microarrays.

These tests identify and quantify sperm epigenetic changes linked to male infertility. However, commercial epigenetic tests for human sperm are not yet available in clinical settings. While ongoing research explores epigenetic modifications in sperm, translating this into routine diagnostic tests is in the early stages. (Contributor: Ashok Agarwal, Director, Global Andrology Forum)

Nicolás Garrido: Short Biography

Dr. Nicolás Garrido
Director, Research Administration,
Research/Innovation, IVIRMA Global
Research Alliance
IVI Foundation Director
Edificio Biopolo – Instituto de
Investigación Sanitaria la Fe
Avenida Fernando Abril Martorell, 106 -
Torre A, Planta 1ª
46026 Valencia
IVI-RMA Global

Nicolás serves as the Section Editor of Male Infertility at RBM Online, past Associate Editor for Fertility and Sterility, and Ad Hoc Reviewer of many journals in the field. He was the Past Coordinator of ESHRE Special Interest Group for Andrology.

Nicolás is a member of the GAF Statistical Expert Panel.

Sezgin Gunes, PhD: Short Biography

Professor Sezgin Gunes
Chair of Department of Medical Biology
and Molecular Genetics
Faculty of Medicine
Teaching fellow in Department of
Multidisciplinary Molecular Medicine
Graduate Institute
Ondokuz Mayis University, Atakum
55139 Samsun, Turkiye

Sezgin Gunes is a senior medical biologist and a Professor of Molecular Genetics at Ondokuz Mayis University, Turkiye. She teaches molecular biology and genetics courses and the biology of reproductive systems and genetics of cancer to the medical faculty students, M.Sc., and PhD students.

Sezgin is actively involved in the supervision of postgraduate students. Her experience is based on clinical diagnostic and the basic science arenas. Her special research interests are on genetic and epigenetic mechanisms underlying common human diseases, especially male infertility and urological and gynecological malignancies.

Sezgin has over 100 peer-reviewed articles and book chapters in international academic books.

Dr. Sezgin serves as the Co-leader of Research team 10 and as Co-leader in Research Training cell.

Acknowledgement: Nicolás and Sezgin contributed to this week’s Management Special.
We are grateful for their remarkable support over the years.

Pushing the Boundaries for Evidenced-Based Practice: Can Online Training Enhance Andrology Research Capacity Worldwide? An Exploration of the Barriers and Enablers - The Global Andrology Forum

Fri, 10 Nov 2023 02:41:54 GMT

“Pushing the Boundaries for Evidenced-Based Practice: Can Online Training Enhance Andrology Research Capacity Worldwide? An Exploration of the Barriers and Enablers - The Global Andrology Forum”.
El Ansari W, Arafa M, Shah R, Harraz A, Shokeir A, Zohdy W, Savira M, Agarwal A; Global Andrology Forum., World J Mens Health. 2023 Aug 9. doi: 10.5534/wjmh.230084. Epub ahead of print. PMID: 37635339.
https://doi.org/10.5534/wjmh.230084

Preamble: What is RCB?
Research capacity building (RCB) in healthcare professions involves enhancing individuals' and institutions' abilities to conduct, disseminate, and apply high-quality research. It includes training healthcare professionals in research methodologies, fostering a research culture, providing resources, mentorship, and organizational support. RCB aims to strengthen evidence-based practices, improve patient outcomes, and contribute to advancements in healthcare knowledge and innovation. (contributor: Ashok Agarwal)

Contributors: Hiva Alipour, DVM, PhD (Aalborg, Denmark) and Mohamed Arafa, MD (Doha, Qatar)

This scientific article discusses a research capacity building (RCB) webinar that was designed and implemented specifically for andrology practitioners worldwide. The study aimed to assess the impact of the webinar on attendees' research knowledge, as well as explore the barriers and enablers to RCB among this group.

The webinar consisted of two sessions on research design and systematic review/meta analysis, delivered by experienced urology and andrology professors. A total of 237 participants attended the webinar, with 184 completing a survey assessing their research knowledge before and after the webinar, satisfaction with the webinar, and barriers and enablers to research.

The results showed that the most common motivators for research among the attendees were to publish scientific papers and develop research abilities or new skills.

The most common barriers to research were the lack of training in research and research software, and the lack of time for research. Overall, satisfaction with the webinar was high, with 86.3% to 88.4% of participants reporting favorable ratings for the various aspects of the webinar. Furthermore, the study found significant improvements in participants' research knowledge after attending the webinar. The total scores for the pre- and post-webinar quiz significantly increased, as well as the scores for the study design and systematic review/meta-analysis sessions.

Overall, the findings suggest that the webinar was effective in enhancing andrology practitioners' research knowledge and skills. The study highlights the importance of addressing barriers and providing opportunities for training and mentorship to promote research capacity building among healthcare professionals in the andrology field.

Key Points:
1. A research capacity building webinar was conducted for andrology practitioners worldwide, aiming to assess the impact on their research knowledge and identify barriers and enablers to research in this group.

2. The webinar consisted of sessions on research design and systematic review/meta analysis, with experienced professors delivering the content. A total of 237 participants attended the webinar, and 184 completed a survey evaluating their research knowledge, satisfaction, and barriers and enablers to research.

3. Motivations for research among attendees included publishing scientific papers and developing research abilities, while barriers included lack of research training and software knowledge, as well as limited time for research. Overall, satisfaction with the webinar was high, and significant improvements were observed in participants' research knowledge after attending the webinar.

Hiva Alipour: Short Biography
Hiva Alipour graduated as a Doctor of Veterinary Medicine (D.V.M.) from Urmia IA University (Urmia, Iran) in 2009 before joining the "Royan Institute for Reproductive and Regenerative Medicine" (Tehran, Iran), where he established and set up the "Sperm Biology Lab" from the ground up and continued to manage and spearhead the research in this lab until 2013.

He then moved to Denmark to continue his education and was awarded the doctorate degree (Ph.D.) by the "Faculty of Medicine at Aalborg University (Aalborg, Denmark)" for his studies on "The advanced examination and functional biology of sperm in relation to abstinence time and composition of seminal plasma" in 2017. He has since served as a Postdoctoral fellow and Assistant Professor at the same university where he currently holds a position as an Associate Professor at the "Laboratory of Regenerative Medicine."
Through his collaboration with the industry since 2015, acting as a Scientific Consultant and specialist for several pharmaceutival and medical-device companies, he has made a significant contribution to the optimization of "Computer Aided Sperm Analysis" (CASA) and the integration of "advanced (functional) semen analysis" in clinical practice. Dr. Alipour has delivered over 40 invited lectures, workshops, and training sessions on his expert field of sperm quality and CASA, at international conferences, meetings, research institutes, and industrial corporations worldwide.

He is currently involved as topic editor, guest editor, or reviewer for several International Journals dealing with Regenerative and Reproductive Medicine, Assisted Reproduction, Andrology, and Theriogenology. He has been recognized as a member of the scientific board of the "annual International Royan Congress on Reproductive Biomedicine" and the panel of Juries for "The Royan international award" since 2010. Hiva Alipour is currently a Guest Member of GAF management.

Dr. Alipour is actively involved in teaching and research in the field of medicine with a focus on reproduction and ART. His research has encompassed different aspects of male fertility involving the spermatozoa's biology, functional quality, and fertilization potential as affected by seminal metabolomic profiles, microbiota, and environmental factors. His most recent studies focused on the potential role of sperm quality in recurrent miscarriage.

Hiva Alipour (DVM, PhD,)
Associate Professor
Department of Health Science and Technology
Laboratory of Regenerative Medicine,
Faculty of Medicine, Aalborg University,
Aalborg, Denmark

GAF Affiliation:
Leader of Research Team# 12
Member, Guest Management

Mohamed Arafa, MD: Short Biography

Dr Mohamed Arafa graduated from Cairo University Medical School in 1996. After he finished his internship in Kasr ALAini Hospital, Cairo University, he joined the Andrology Department, Cairo University where he did his residency and fellowship training in Andrology. He then joined the faculty in the Andrology Department, Cairo University, where he is now a Professor. Since 2011 he is working as Senior Consultant Urology/Andrology and Male Infertility, Hamad General Hospital, Qatar. He is appointed as Adjunct Assistant Professor of Urology, Weill Cornell medicine – Qatar.

During his profession in Andrology Dr Arafa has shown great interest in Andrology and male infertility diagnosis and treatment. He has respectable experience in Andrology laboratory procedures, including routine and advanced semen analysis and sperm cryopreservation. His surgical skills extend to cover all Andrology surgeries, especially microsurgical procedures (testicular biopsy, varicocelectomy, vasoepididymostomy and vasovasostomy).

Dr Arafa is a reviewer for several International Journals dealing with Andrology. He was an Ordinary Director in the Middle East Society of Sexual Medicine (MESSM) Board of Directors and the Chief Editor of MESSM Newsletter. He is a fellow of the Multidisciplinary Joint Committee on Sexual Medicine and has recently been licensed as a Clinical Sexologist, Therapist Association Certification, Miami, Florida, USA.

The research activities of Dr Arafa include more than 150 published articles in international peerreviewed journals and many book chapters. His research covers all domains of Andrology mainly genetics and proteomics of male infertility, oxidative stress in semen, sexual dysfunctions, and late-onset hypogonadism.

Mohamed Arafa is a Guest Member of GAF management.

Dr. Mohamed Arafa
Professor of Andrology, Faculty of Medicine,
Cairo University, Cairo, Egypt
Sr. Consultant in Male Infertility and
Andrology, Hamad Medical Corporation

Doha, Qatar

Adjunct Professor of Urology, Weill Cornell
Medical College, Doha, Qatar
Email: mohamedmostafaarafa@gmail.com

Oocytes evaluation and in-vitro fertilization/intra cytoplasmic sperm injection outcomes

Tue, 07 Nov 2023 03:11:16 GMT

“Oocytes evaluation and in-vitro fertilization/intra cytoplasmic sperm injection outcomes”,

Minasi MG, Anagnostopoulou C, Boitrelle F, Vogiatzi P, Sallam H, Saleh R, Colpi G, & Agarwal A. (2023), Panminerva medica, 65(2), 179–187.

https://doi.org/10.23736/S0031-0808.23.04838-3

Preamble: Maternal age occupies a central position in the realm of intrinsic factors. With a global shift toward delayed childbearing, the advancing median age of conception has become a prominent contributor to infertility. The article underscores that as women age, there is a noticeable decline in the competence of their oocytes. Ovarian aging emerges as a critical player in this narrative, exerting a profound influence on oocyte quality. Its adverse ramifications cascade down, affecting embryo development, implantation, and the genetic constitution of the ovum and, consequently, the embryo. Besides ovarian aging, the review enumerates internal factors that affect oocyte competence including obesity, lifestyle choices, and pathologies such as PCOS and endometriosis. It additionally emphasizes the impact of external factors to oocyte quality such as ovarian stimulation protocols, handling, and environmental conditions.

CAPSULE
Contributors: Christina Anagnostopoulou, MSc (Athens, Greece) and Israel Maldonado Rosas, MS (Mexico City, Mexico)

The article provides an insightful exploration of the escalating global prevalence of infertility, coinciding with the surging demand for assisted reproductive technology (ART). As the cornerstone of this reproductive revolution, oocyte (egg) quality assumes paramount significance. In ART, the quality of oocytes plays an instrumental role in determining the success or failure of fertility treatments. This article unravels the intricate web of factors that converge to shape oocyte quality, encompassing both intrinsic and extrinsic influences.

Drawing attention to the multifaceted evaluation of oocyte quality, the article scrutinizes the traditional morphological criteria extensively. It accentuates that the morphological assessment of cumulus-oocyte complexes, oocyte size and shape, and the presence of cytoplasmic markers, such as vacuoles and smooth endoplasmic reticulum (SER) clusters, remains the bedrock of oocyte evaluation. However, it clearly conveys the existence of an ongoing debate surrounding the predictive value of these morphological markers. While some aberrations have been correlated with suboptimal treatment outcomes, their reliability remains a subject of ongoing research.

Venturing beyond morphological assessments, the article delves into cutting-edge methods for evaluating oocyte quality. Metabolomic analysis, gene expression profiling, and the measurement of oxygen consumption emerge as powerful tools in the quest for more nuanced and accurate indicators of oocyte competence. These innovative techniques peer deeper into the metabolic and genetic machinery of oocytes, potentially unraveling hidden facets of their quality.

Recommendations
While acknowledging the current limitations in oocyte quality evaluation, the article charts a course for the future. It articulates the imperative of conducting large-scale studies that encompass a spectrum of factors, including patient-specific parameters and laboratory conditions. This holistic approach is envisioned as the path to refining predictive models and creating a more accurate classification system for oocyte quality.

Postscript
In summary, the article accentuates the pivotal role of oocyte quality assessment in the landscape of ART. It underscores the ongoing research endeavors aimed at refining the accuracy of evaluation methods. The fusion of traditional morphological scoring with modern cytoplasmic and molecular predictors holds the promise of yielding a more comprehensive classification system for oocyte quality. Such advancements bear the potential to revolutionize ART outcomes, offering renewed hope and possibilities to couples with fertility issues.

Christina Anagnostopoulou: Short Biography
Christina Anagnostopoulou obtained her BSc in 2000 and her MSc in 2003 from the National and Kapodistrian University of Athens, Greece. In the following years, she has received further training in the field of assisted reproduction in Aberdeen, UK and in Cleveland, USA. Overall, she has more than 20 years of experience in clinical embryology while working in several IVF labs.

Christina is an ESHRE Certified Senior Clinical Embryologist since 2012. From 2011 until 2019 she was an invited faculty for ART training at the Cleveland Clinic’s Center for Reproductive Medicine. Her research interests include clinical embryology, andrology, preimplantation genetic diagnosis, and genetics. She has been a frequent invited speaker at national and international conferences and has published several articles in scientific journals.

Christina Anagnostopoulou, BSc, MSc

Senior Clinical Embryologist
Reproductive Medicine Unit – EmbryoART,
Leto Maternity Hospital, Athens Greece
E-mail: anagnostc@gmail.com

Acknowledgement: Christina and Israel contributed to this week’s Management Special. We are grateful for their remarkable support over the years.

Israel Rosas Maldonado: Short Biography

The Renaissance of Male Infertility Management in the Golden Age of Andrology

Wed, 25 Oct 2023 08:36:09 GMT

“The Renaissance of Male Infertility Management in the Golden Age of Andrology”,

Aldo E. Calogero, Rossella Cannarella, Ashok Agarwal, Taha Abo-Almagd Abdel-Meguid Hamoda, Amarnath Rambhatla, Ramadan Saleh, Florence Boitrelle, Imad Ziouziou, Tuncay Toprak, Murat Gul, Tomer Avidor-Reiss, Parviz Kavoussi, Eric Chung, Ponco Birowo, Ramy Abou Ghayda, Edmund Ko, Giovanni Colpi, Fotios Dimitriadis, Giorgio Ivan Russo, Marlon Martinez, Gokhan Calik, Hussein Kandil, Gianmaria Salvio, Taymour Mostafa, Haocheng Lin, Hyun Jun Park, Nazim Gherabi, Nguyen Ho Vinh Phuoc, Nguyen Quang, Ricky Adriansjah, Sandro La Vignera, Sava Micic, Damayanthi Durairajanayagam, Ege Can Serefoglu, Vilvapathy Senguttuvan Karthikeyan, Priyank Kothari, Widi Atmoko,
Rupin Shah (2023), pISSN: 2287-4208 / eISSN: 2287-4690, World J Men’s Health
Published online Jan 5, 2023, https://doi.org/10.5534/wjmh.220213

Preamble: In a clinical context, "renaissance" signifies a period of revival and remarkable progress in a specific field or discipline. It often involves the introduction of advanced technologies, innovative therapies, and a surge in scientific knowledge. Understanding and embracing such renaissances is crucial for the clinicians to provide the best care and stay at the forefront of their field. (Contributor: Ashok Agarwal)

CAPSULE
Contributor: Dr. Jonathan Ramsay, London, UK
This is a very helpful review article. The historical details are both interesting and compelling, and the look to the future based upon our current understanding also gives us all considerable pause for thought and of course enterprise.

The starting point of this review is all about the ‘assisted reproductive technology effect’ (the ART effect). This is a relegation of men to the role of sperm donors and, if this is male factor, this of course causes even more emasculation to the patients. We start from a new concept that male infertility is in fact a disease, and the global burden of disease study shows quite clearly that this disease is increasing at 0.291% per annum. If indeed we did, which we do not, regard male fertility as a disease, this would be headline news, but such statistics should be handled carefully by doctors and especially by journalists. Any topic which is global, behavioural, societal, economic and has both sexual and gender implications, is an easy target for both the media and for journalism. Not surprisingly, the terms ‘spermageddon’ and ‘sperm apocalypse’ have been coined and can cause considerable unnecessary alarm in our patients.

So, the current renaissance in andrology is certainly timely, but professionals need to manage this popularism with care. The apparent reduction in fecundity worldwide must be a marker of declining fertility – amongst many other societal changes – but this should be the stimulus to consider research, rather than allowing or facilitating too much speculation.

But clearly there is sufficient circumstantial evidence to convict environmental factors, and particularly endocrine disruptors, in the overall picture of declining sperm counts and declining fecundity.

Extended andrological tests and a more cooperative approach between andrologists and gynaecologists have revealed, not surprisingly, the obvious conclusion that 50% of the problem (not, as was traditionally quoted, 30%) relates to male factors, but female reproductive physiology has also changed; an earlier menarche means an earlier menopause and societal changes have meant that more women are delaying their attempts at first conception to after their thirtieth birthday.

The established association of male infertility and subfertility to men’s health is beginning to be accepted, but whilst doctors are beginning to be on board with this we are still a long way from believing, let alone knowing, that an abnormal semen analysis is indeed a surrogate marker of men’s health.

I would certainly agree that andrology is beginning to emerge from the Middle Ages, in which ART was acknowledged wrongly to be the only ‘treatment’ for male fertility. A ‘solution’ in 25% of cases, yes, but no, not a ‘treatment’.

If a renaissance starts with a new awareness, then we have reached that point, but enlightenment – the next phase – can only result from new inventions. The measurement of sperm DNA fragmentation (SDF) and its clear relationship to oxidative stress has been an important invention. Microsurgical testicular sperm retrieval is an invention to facilitate the ‘solution’ but still falls short of a treatment.

There have however been two important areas of renaissance which I think can be regarded as enlightenment, because in both cases ART may be avoided. The first is varicocele, which as an effective treatment of male fertility has been recently and conclusively reinvented. Acceptance of the validity of varicocele treatment has been aided by better diagnosis – varicocele measurement – and better fertility measurement by DNA fragmentation. The second is the now accepted role of lifestyle changes, diet and nutrition. Once again, the role of improved diagnostics, SDF, and measurement of levels of oxidative stress have been instrumental in demonstrating the benefits of these more personal interventions.

But true ‘enlightenment’ can only be realized by more sophisticated genetic diagnostics because we cannot measure the epigenome. The recent confirmation of the complete Y-chromosome structure, and probably the use of AI to interrogate the genome, will be pivotal to our understanding of the currently unexplained.

Therefore, we look forward to enlightenment, which will continue to explain what is currently unexplained, but is desperately sought by urologists, andrologists, nutritionists and patients alike. Only when we have a proper genetic explanation will we be able to intercept, and possibly even to modify such cases by CRISP/Cas9, such cases.

In conclusion, the Age of Renaissance will only move to enlightenment when we can explain and treat nonobstructive azoospermia, rather than trying to find solutions only relying on sperm retrieval and ART.

Dr. Jonathan Ramsay, FRCS(Eng),
MS(London), FRCS(Urol)
Andrology Dept, Hammersmith Hospital,
Imperial College Healthcare NHS Trust
London, UK
Email: jwa.ramsay@hotmail.com
https://jonathanramsay.co.uk/

Acknowledgement: Dr. Jonathan Ramsay contributed to this week’s Management Special.
We are grateful for his remarkable support over the years.

Impact of Antioxidant Therapy on Natural Pregnancy Outcomes and Semen Parameters in Infertile Men: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Tue, 17 Oct 2023 02:31:32 GMT

Impact of Antioxidant Therapy on Natural Pregnancy Outcomes and Semen Parameters in Infertile Men: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Authors: Agarwal A, Cannarella R, Saleh R, Harraz AM, Kandil H, Salvio G, Boitrelle F, Kuroda S,
Farkouh Ala’a, Rambhatla A, Zini A, Colpi G, Gül M, Kavoussi P, Hamoda TA, Ko E, Calik G, Toprak
T, Pinggera GM, Park HJ, Ghayda RA, Minhas S, Busetto GM, Bakırcıoğlu ME, Kadioglu A, Chung
E, Russo GI, Calogero AE, Ambar RF, Jayasena CN, Shah R.
World J Men’s Health. 2023 Jan;41(1):14-48. English. Original Article. Open Access
Published online September 7, 2022. https://doi.org/10.5534/wjmh.220067

Preamble:

Idiopathic originated male factor infertility plays a significant role in one third of the couples. This systematic review and meta-analysis, conducted by Agarwal et al, consisted of 45 randomized controlled trials with the largest number in the literature, including 4332 infertile men treated with antioxidants (AOX) or no treatment/placebo. The authors found that AOX therapy significantly increased spontaneous pregnancy by 1.97 times higher, and sperm parameters including sperm concentration, motility and normal sperm morphology also increased significantly after AOX therapy, compared to placebo or no treatment. However, this meta-analysis found no significant effect on live birth rate or miscarriage rates post-AOX therapy.

CAPSULE:

This review would be important for clinicians, and for the infertile couples to know that it is sometimes not possible to conceive naturally, and spontaneous pregnancy and sperm parameters might be increased with some kind of medical therapy such as AOX. Therefore, AOX might a) obviate the need for assisted reproductive technology (ART), b) downsize the level of ART needed to bypass idiopathic male factor infertility, and c) increase spontaneous pregnancy rates in couples who want to conceive naturally.

Previous systematic review and meta-analyses clearly demonstrated that high levels of semen reactive oxygen species are associated with sperm dysfunction, sperm DNA damage and reduced male reproductive potential. The latest Cochrane database review showed statistically significant increases in the spontaneous pregnancy (2.97 times) and live birth rates (1.79 times) among sub-fertile men using AOS treatment. Therefore, this current article reinforces the Cochrane review’s findings by reporting significant increases in pregnancy rates and sperm parameters with the AOX treatment. Furthermore, in addition to previous SRMAs, for the first time, this study showed AOX treatment significantly increased seminal total antioxidant capacity (TAC) and significantly decreased seminal MDA levels, compared to controls.

Of the 45 RCTs, 6 reported outcomes of AOX therapy or no treatment after varicocele repair. Another aspect of this study, which is very important, is to demonstrate significant effect of AOX therapy on spontaneous pregnancy and sperm parameters, regardless of presence of varicocele and/or varicocele repair.

Recommendations:

Based on the findings of this article, clinicians should suggest AOX therapy to improve sperm parameters and spontaneous pregnancy rates. In the future, we need more qualified prospective, randomized, placebo-controlled trials to clarify duration, contents, and dosage of the AOX regimens for defining which AOX would be the best to achieve the highest improvement in sperm parameters, pregnancy, and live birth rates in men with idiopathic infertility.

Contributors Profile:

Selahittin Çayan, MD, FECSM
Professor of Urology
University of Mersin School of Medicine
Department of Urology,
Director of Andrology Unit and Mal Reproductive Laboratory
33343-Mersin, Turkey
selcayan@mersin.edu.tr

An Expert Opinion on the 2023 Antioxidants meta-analysis by Agarwal et al:
Adriano Fregonesi, MD, PhD, Campinas, Brazil

Agarwal et al.'s comprehensive review and meta-analysis provide important insights into the possible benefits of antioxidant therapy for male infertility. My own experience is consistent with the study's findings, indicating improvements in sperm parameters and pregnancy outcomes. The use of rigorous methods and the inclusion of 60 randomized controlled trials lend credibility to the research.

Certain limitations, however, must be acknowledged. The moderate to low evidence quality raises questions regarding the results' reliability. The absence of data on miscarriage and stillbirth, as well as a thorough investigation of potential side effects, generates gaps in our understanding of the treatment's safety and effectiveness. The study's failure to address the variation in antioxidant categories, doses, and durations employed among trials affects the interpretation of results. In addition, the study's insufficient investigation of the root causes of male infertility is a missed chance to fully grasp the issue's multifaceted nature.

Nonetheless, despite these limitations, the study offers valuable insights and paves the way for further research to determine the precise impact, optimal agents, and dosages required for effective treatment in male infertility.

Short biography of Prof. Fregonesi:
Adriano Fregonesi, MD, PhD obtained his medical degree from the University of Campinas, São Paulo, Brazil. He completed residency in urology at the same institution. Additionally, he undertook fellowships at UCLA in 1996 and UCSF in 1999. He currently serves as the Head of the Urology Department at the University of Campinas and holds the position of Associate Professor of Urology at the Faculty of Medicine in Jundiaí, both in Brazil. Dr. Fregonesi is an active member of several professional associations, including the Brazilian Society of Urology, American Urological Association, European Association of Urology, and International Society of Sexual Medicine.

Adriano Fregonesi, MD, PhD
Head Department of Urology
Faculty of Medical Sciences,
Universidade Estadual de Campinas, UNICAMP
Sao Paulo, Brazil
GAF Member
adriano.fregonesi@gmail.com

ICSI for non-male factor infertility: time to reappraise IVF?

Mon, 02 Oct 2023 21:52:04 GMT

ICSI for non-male factor infertility: time to reappraise IVF?

Sallam H, Boitrelle F, Palini S, Durairajanayagam D, Parmegiani L, Jindal S, Saleh R, Colpi G, Agarwal A.,

Panminerva Med. 2023 Jun;65(2):159-165. Epub 2023 May 16.

doi: 10.5534/wjmh.230084 . PMID: 37635339.

Preamble:

Intracytoplasmic Sperm Injection (ICSI) emerged in 1992 as a revolutionary breakthrough in the field of assisted reproduction. Dr. Gianpiero D. Palermo, an Italian scientist, pioneered this technique at the Brussels Free University in Belgium. This groundbreaking procedure allows individuals and couples facing male infertility issues, such as low sperm count or poor sperm motility, to have a chance at parenthood. By directly injecting a single sperm into an egg, ICSI bypasses many barriers, offering hope where it might have been elusive. ICSI's precision and success rates transformed fertility treatment and has revolutionized assisted reproduction, granting countless families the precious opportunity to conceive and experience the joy of parenthood. (Contributor, Ashok Agarwal)

A. Introduction:

Since its inception in 1992, Intracytoplasmic Sperm Injection (ICSI) has become a prominent technique in Assisted Reproductive Technology (ART) centres worldwide. It’s popularity has led to a shift from conventional in vitro fertilization (cIVF) in many cases. This article delves into the various facets of ICSI's utilization, its advantages, disadvantages, and its applicability within the realm of ART.

B. Rising ICSI Utilization and Expansion Beyond Male Factor Infertility:

Recent studies indicate a substantial increase in ICSI usage, even in cases where male factor infertility is not the primary concern. The proportion of ICSI procedures has surged significantly, suggesting potential overuse beyond its intended applications. This emphasizes the importance of appropriate selection criteria for ICSI, particularly when male infertility is absent.

C. Pros and Cons of ICSI and cIVF

While ICSI is often regarded as having better fertilization rates, this advantage does not always translate to superior clinical outcomes. A thorough analysis reveals that ICSI may not consistently offer improved results compared to cIVF. The comparison of key parameters like fertilization rates, pregnancy rates, and live birth rates between ICSI and cIVF demonstrates variations across studies. The safety and effectiveness of ICSI remain areas of ongoing concern, with potential links to birth defects and chromosomal abnormalities.

D. ICSI Indications and Applications in Non-Male factor Infertility:

1. Previous cIVF Failures

ICSI's effectiveness shines when addressing previous fertilization failures following cIVF, especially cases involving total fertilization failure (TFF). Studies suggest that ICSI can yield more favorable outcomes when dealing with poor or failed fertilization after cIVF attempts.

2. Limited or Poor-Quality Oocytes

ICSI has been proposed as a strategy to improve fertilization outcomes when dealing with a limited number of oocytes or oocytes of suboptimal quality. Although research findings vary, certain studies suggest that ICSI might lead to enhanced fertilization rates in these situations.

3. Advanced Maternal Age

ICSI has been advocated as a preferred insemination method for older women with non-male factor infertility. However, the findings across studies are inconsistent, with some studies indicating comparable fertilization and live birth rates between ICSI and cIVF approaches.

4. Preimplantation Genetic Testing (PGT)

ICSI is specifically recommended for PGT cycles to minimize paternal contamination and mosaicism. Nonetheless, clinical data do not consistently support the superiority of ICSI over cIVF in PGT cycles, necessitating case-specific considerations.

5. Cryopreserved Oocytes

Due to the potential hardening of the zona pellucida, ICSI is generally favored for inseminating cryopreserved oocytes. However, the absence of direct comparisons between ICSI and cIVF in this context calls for further investigation.

6. Unexplained Infertility

While certain studies indicate higher fertilization rates with ICSI in cases of unexplained infertility, the translation to improved clinical pregnancy and live birth rates is not always observed. Hence, careful consideration of the necessity of ICSI is crucial.

E: Limitations and Practical Implications

ICSI's broad utilization may not consistently result in enhanced clinical outcomes. Factors like cost-effectiveness, safety concerns, and potential overuse should guide the selection between ICSI and cIVF. The concept of "Physiologic ICSI," involving refined techniques like hyaluronic acid-based sperm selection, presents an avenue for improved outcomes, yet practical considerations must be weighed against complexity and cost.

F: Conclusion

While ICSI has transformed ART, its perceived advantages should be evaluated against potential drawbacks. The choice between ICSI and cIVF should be based on evidence-based medicine, tailored to each couple's unique circumstances. Practitioners should remain vigilant, continually review emerging research, and prioritize the best interests of their patients.

Acknowledgment:

This commentary was co-authored by Dr. Hrishikesh Pai (India) and Dr. Sunil Jindal (India). We gratefully acknowledge the time and effort invested by them in summarizing this article.

Contributors:

Hrishikesh Pai, MD, FCPS, FICOG,

Prof of Reproductive Medicine D Y Patil University Navi Mumbai India

Medical Director Bloom IVF, Mumbai, India

President, Federation of OBGYN Societies of India, 2023

hdpai@hotmail.com

+919820057722

www.drhrishikeshpai.com

New Paragraph

Sunil Jindal MS, DNB, MNAMS

Scientific Director and Andrologist

Jindal Hospital & Fertility Institute, Meerut and Delhi, India

Honorary Professor, Venkateshwara Inst of Medical Science & Univ.

President Elect Delhi ISAR & Delhi IAGE

drsunilkjindal@gmail.com

http://jindalhospital.org

How to select healthy sperm for intracytoplasmic sperm injection in samples with high sperm DNA fragmentation?

Wed, 27 Sep 2023 14:22:03 GMT

How to select healthy sperm for intracytoplasmic sperm injection in samples with high sperm DNA fragmentation?

Authors: Garrido et al.

Panminerva Medica 2023 June;65(2):148-58
DOI: 10.23736/S0031-0808.23.04870-X

Preamble:

Selection of ICSI-viable sperm: a challenge?
High sperm DNA fragmentation (SDF) negatively impacts natural fertility and assisted reproduction conditions. It reduces fertilization rates, implantation, pregnancy, and live birth rates in in-vitro fertilization (IVF). Although SDF has no adverse impact on fertilization or pregnancy rates in intracytoplasmic sperm injection (ICSI), it is correlated with poor embryo quality and a higher risk of miscarriage. Techniques like magneticactivated cell sorting, intracytoplasmic morphologically selected sperm injection, physiologic ICSI, and microfluidic sperm sorters are used to select sperm with intact DNA for ICSI.
ICSI treatment is mainly optimized by the prior spermatozoa selection with intact DNA. However, long-term complications like sperm DNA fragmentation are unclear due to defective packaging during spermiogenesis, apoptosis, and oxidative stress. Sperm preparation procedures can reduce SDF rates, increasing spermatozoa with normal chromatin structure.

CAPSULE:

This article reviews several methods used in sperm selection in cases with high SDF to be used in ART techniques.

Contributors: Alayman Hussein, MBBCH, MSc, MD, AF (Egypt) and Cesar Rojas-Cruz, MD, FECSM (Germany)

Magnetic-activated cell sorting MACS for non-apoptotic spermatozoa:
This technique excludes apoptotic sperm cells which express phosphatidyl-serine in their membrane using a column filter and exposition to a magnetic field after addition of annexin V coated with metallic microparticles. The result is a ready to use sample rich in non-apoptotic sperm. Suggested indication is infertile patients with high SDF, more than 2 failed ICSI trials and/or more than 2 miscarriages with an unknown female factor. Multiple studies have shown heterogeneous results with the use of MACS. The accumulated evidence does not support its clinical use.

IMSI (intracytoplasmic morphologically selected sperm injection):
Conventionally sperm to be injected for ICSI are selected based on motility and typical morphology using 200x to 400x optical magnification. More than 2 decades ago and alternative approach using ultra high magnification (6000X) was described. It allows selection based on subcellular organelles such acrosome, post acrosomal lamina, mid piece mitochondria, tail, and nucleus. A correlation has been described with the presence of sperm vacuoles and SDF. A great body of research has not shown clinically relevant differences using this selection technique.

Physiological ICSI (PICSI):
Studies evaluating use of selected sperm with Hyaluronic acid for ICSI have improved embryo quality and live birth rates. Hyaluronan-selected sperm has lower levels of SDF and aneuploidy. Recent studies have shown a possible effect on miscarriage using this approach.

Microfluidics:
Trying to mimic the natural shape of female reproductive tract, different systems of chambers and filters are used for sperm selection. This technique avoids the detrimental effects of conventional centrifugation which has been related with higher levels of SDF and ROS in the pellets.
Microfluidic based sperm selection devices have shown reduced amounts of SDF. Clinical impact has been evaluated with conflicting results.

Electrophoresis:
Using a membrane based electrophoretic purification technique sperm with low SDF could be isolated. The impact in clinical results had been discouraging.

Birefringence:
Using an inverted microscope with high power differential interference contrast optics sperm can be assessed. A total pattern of human sperm head birefringence is associated with higher SDF.

Testicular vs Ejaculate sperm:
Testicular sperm has lower SDF compared with ejaculated sperm (ES). It has been reported in observational studies that improved ICSI outcomes with testicular sperm compared with ES. TESE may be recommended for couples with repeated ICSI failures and high SDF, however, the quality of evidence is very low.

In conclusion, the current ability of these techniques to improve ICSI outcomes is suboptimal. Focused future research will probably give effective additional tools for the study and treatment of this subset of infertile couples with high SDF sperm.

Acknowledgment:
This commentary was co-authored by Professor Alayman Hussein (Egypt) and Dr. Cesar Rojas-Cruz (Germany).
We gratefully acknowledge the time and effort invested by them in summarizing this article.

Contributors profile:
Alayman Hussein, MBBCH, MSc, MD, AF
Professor and Chairman of Urology Department,
Minia University, Minia, Egypt
President of the Andrology Section of the Egyptian
Urological Association
www.alaymanclinic.com

Cesar Rojas-Cruz, MD, FECSM
Urologist/ Andrologist
Urology Department,
University of Rostock
Germany
www.cesarrojascruz.com

Time-lapse embryo monitoring: does it add to standard in-vitro fertilization/intracytoplasmic sperm injection?

Fri, 22 Sep 2023 10:37:23 GMT

Time-lapse embryo monitoring: does it add to standard in-vitro fertilization/intracytoplasmic sperm injection?

Authors: Minasi MG, Boitrelle F, Sallam H, Vogiatzi P, Parmegiani L, Saleh R, et al.

Panminerva Med 2023; 65:188-98.

DOI: 10.23736/S0031-0808.23.04837-1

CAPSULE: This commentary is a collaborative effort of Professor Christine Wyns (Brussels, Belgium) and Dr. Yoshiharu Morimoto (Osaka, Japan).

This paper underlines the evolution of time-lapse technology (TLT) in IVF translating from traditional incubators to incubators using built-in or not imaging systems to capture sequential images of the embryo during culture and allow the embryologist to closely monitor the embryonic development process in vitro without opening the incubator. Based on extensive morpho-kinetic data of the developing embryo various algorithms were developed and analyzed to help predict ART outcomes.

Technical parameters of several commercially available time-lapse systems (TLSs) such as type of illumination, single or grouped embryo culture and dishes, single or multiple planes of view and possibility or not to be used in conventional incubators are summarized in this paper.

This review further presents the current knowledge on TLT with regards to embryo blastulation and clinical outcomes:

❖ The possibility to discriminate between embryos with a higher likelihood to develop into a blastocyst was analyzed in multicentric studies, including thus different culture conditions and fertilization methods. Overall, these studies pointed to the need for further validation of the observations, although fastercleaving embryos seemed to have a better chance to reach the blastocyst stage.

❖ Among studies aiming to identify embryos with better clinical outcomes it was shown that euploid blastocysts developing after a morulation time of less than 80 hours post-insemination and having a high trophectoderm quality resulted in a significantly higher live birth rate, although in the specific culture conditions used.

❖ Meta-analyses including randomized controlled trials found controversial results on clinical outcomes when using TLSs versus conventional morphological assessment, most likely related to the high heterogeneity between studies, notably with regards to TLSs, culture conditions and day of embryo transfer.

❖ Two of the meta-analyses showed improvements in live birth rates and decreased miscarriage rates while one meta-analysis of ten RCTs concluded in the absence of a difference for ongoing pregnancy and live birth rates. Furthermore, the latest Cochrane published in 2019 did not find differences between use of TLSs or not in terms of live birth, clinical pregnancy, cumulative pregnancy, miscarriage, or

stillbirth rates.

❖ Based on a systematic review of 13 studies, none of the morpho-kinetic parameters appeared to be strongly associated with embryo ploidy and the current evidence is thus not in favor of using TLSs to select euploid embryos.

Besides some practical advantages of TLSs such as reduction in time spent by embryos outside the incubator conditions, a lower risk of human errors or collision of dishes, a reduced workload for lab technicians due to use of single-step media, need for fewer culture dishes and automation of embryo scoring, the authors point to laboratory team skills required to correctly position the embryos in the wells and to the need of some training for data interpretation. High costs related to purchase of the equipment, software and specific consumables are also highlighted.

Expert opinion:

❖ TLT allows to collect continuous and more accurate embryo evaluation by contrast to conventional fixed- timepoint microscopic observation.

❖ Aiming at a better embryo selection using TLT is in line with efforts to promote single embryo transfer but so far validated predictive morpho-kinetic criteria and algorithms that may allow improved clinical outcomes have not been identified.

❖ While it seems obvious that there is less disruption in culture conditions in TLSs, current recommendations are in favor of the need to have an internal lab validation of embryo morphokinetic parameters able to predict clinical outcomes, taking thus into account center specific culture conditions.

❖ Based on inconsistencies between available studies, discarding embryos based only on TLSs’ evaluation should currently be discouraged.

❖ Future efforts to obtain reliable and consistent data using TLT could be facilitated by the integration of artificial intelligence imaging diagnostic tools.

❖ Data collection and storage using TLT could promote data sharing and facilitate open science.

Acknowledgment: This commentary was co-authored by Professor Christine Wyns (Belgium) and Dr. Yoshiharu Morimoto (Japan). We gratefully acknowledge the time and effort invested in summarizing this article.

Christine Wyns, MD, PhD

Head of the Cliniques universitaires Saint-Luc's

Gynaecology and Andrology Department

Medical Director of the Reproductive Tissue and Cell Bank

Professor at Université Catholique de Louvain (UCL)

Brussels, Belgium

https://www.international-saintluc.be/en/medecin/professor-christine-wyns

Christine is a Guest Member of GAF Management, click here to see her profile:

https://www.globalandrologyforum.com/meet-the-managment-team

Yoshiharu Morimoto, M.D., PhD

Chief Exécutive Officer, IVF Japan

Chairman, Horac Grand Front Osaka Clinic

Osaka, Japan

www.ivfhorac.com

The GAF: Structure, Roles, Functioning and Outcomes: An Online Model for Collaborative Research

Sun, 17 Sep 2023 02:32:40 GMT

The GAF: Structure, Roles, Functioning and Outcomes: An Online Model for Collaborative Research.

Authors: Walid El Ansari, Missy Savira, Widi Atmoko, Rupin Shah, Florence Boitrelle, Ashok Agarwal, World J Men’s Health,

Published online pISSN:
2287-4208 / eISSN: 2287-4690, World J Men’s Health Published online Jul 27, 2023
https://doi.org/10.5534/wjmh.230101

Preamble:

The Global Andrology Forum (GAF) is an innovative pioneering initiative of international collaborative online andrology research and training organization. The concept of GAF was initially formulated in 2020 by Dr. Ashok Agarwal, as a response to the limitations and restrictions extended by the COVID-19 pandemic. In an unexpectedly very short period since its introduction to the world, the GAF has clearly inspired the reproductive professionals around the world with its vision and mission, sturdily constructed its

organization, solidified its structure, and finely developed its policies and procedures.

Currently, the GAF proudly incorporates close to 700 multidisciplinary members from different parts of the globe, with diverse experiences and expertise, to include novices as well as the most experienced and world-pronounced andrologists and scientists. The GAF has proved to be exceptionally productive with publications of dozens of original articles in high impact journals and several significant books and special issues. Further, many enthusiastic active researchers and research groups are currently conducting several other important ongoing research projects, that when published are expected to enrich the worldwide andrology literature and influence our practice.

The free of charge GAF membership offers many benefits to the members including -but not limited to- exposure to innovative concepts and new ideas, opportunities to participate in high-quality systematic reviews, meta-analyses, scientific articles, and book chapters, attending online meetings, and receiving training in various aspects of research, such as study design, research methodology, literature searches, and scientific writing. The GAF is welcoming all qualified individuals to apply for free membership (please refer to our official website for more information

(https://www.globalandrologyforum.com/welcome-a-member).

CAPSULE: GAF was launched in December 2021 as the first international collaborative online research group aiming to connect andrology professionals and scientists and to amalgamate multiple medical specialties and disciplines that share the common focus of male reproductive and sexual health. GAF members are from diverse specialties with urologists comprising the largest group (one third) followed by andrologists, researchers, in vitro fertilization (IVF) specialists, embryologists, and endocrinologists. Other specialties include immunology, biomedical engineering, product innovation, pediatrics, primary health care, public health, health care management, and genetics. Almost a third of the members are having >15 years of experience. GAF exerts continuous efforts in research and scientific publications, as these are key to the development and advancement of our understanding. GAF’s activities include online research, training, and webinars.

GAF outcomes include publishing of original scientific articles, state-of-the-art books, and Special issues of journals. GAF has published 29 original articles within one year of its creation, with authors from 48 countries spanning topics that included varicocele, sperm DNA damage, oxidative stress, semen analysis and male infertility, oocyte/embryo, and laboratory issues of assisted reproductive technique (ART) and male infertility evaluation.

This highlighted article is the first of a kind reporting the example of GAF research groups or consortiums, providing information on the membership characteristics, collaboratives, organizational configuration and hierarchy, management structure and as well as the scientific potential or actual achieved outcomes.

Future Reflection:

Soon after its launch, the GAF became the impetus driving advancement in the practice of andrology all over the world. The numerous benefits brought by conducting high quality research, generating consensus, and eliciting impeccable quality of evidence for treatments and practices (that will become gold standard) for the practicing physician – will reflect on the andrology current landscape and will forever change the future horizon. GAF also inspires other esteemed and prestigious bodies to establish connections and affiliations. The GAF seriously considers and welcomes future affiliations with other related bodies, societies, associations, organizations, federations, and groups in different parts of the world.

Apart from andrology, the GAF represents a successful positive example and a constructive model for other disciplines wishing to develop similar collaborative international online research and training groups.

Many contemplate that GAF is here to stay, but we are proud to say that GAF is here to reshape the field and practice of andrology.

Acknowledgment: This commentary was written by Professor Taha Hamoda, Jeddah, Saudi

Arabia and Minia, Egypt.

Does Varicocele Repair Improve Conventional Semen Parameters? A Meta-Analytic Study of Before-After Data

Mon, 11 Sep 2023 02:23:04 GMT

Does Varicocele Repair Improve Conventional Semen Parameters? A Meta-Analytic Study of Before-After Data.

Authors: Rossella Cannarella, Rupin Shah,
Taha Abo-Almagd Abdel-Meguid Hamoda. et al, World J Men’s Health, Published online Jun 22, 2023
https://doi.org/10.5534/wjmh.230034

Preamble:

Varicocele Repair: Necessary or unnecessary? An endless debate!! While varicocele is observed in approximately 15% of the general male population, this rate increases to 19% to 41% in primary male infertility and to 80% in secondary male infertility. Varicocele is accepted as the most common correctable cause of male infertility. However, fertility and non-fertility indications for varicocele repair have not been clearly defined and the debate is still ongoing. Some of these are the role of varicocelectomy in the treatment of infertile men with varicocele and azoospermia or those with subclinical varicocele, or in the management of infertile men with varicocele recurrence and predictive factors of outcome of varicocelectomy in infertile men.

The true benefit of varicocele repair on reproductive hormone levels, pregnancy and live birth rates is also controversial. However, the main problem here is that the effect of varicocele repair on semen parameters is still not fully understood. Therefore, this metaanalysis aimed to examine the effect of varicocele repair on conventional semen parameters. This unique research project lasted for about 24 months and could be easily called the most comprehensive meta-analysis to date in the world.

CAPSULE: This meta-analysis compared the different sperm parameters before and after varicocelectomy in 351 studies including more than 32,000 patients. The results showed significant improvement of semen parameters namely, semen volume, sperm concentration, total sperm count, total motile sperm count, progressive sperm motility, total sperm motility, and sperm morphology. By virtue of being the largest metaanalysis to date, comparing sperm parameters before and after varicocelectomy, this study validated the beneficial role of varicocelectomy in patients with male infertility.

Recommendation:

This meta-analysis provides strong support for the role of varicocele repair in infertile male with clinical varicoceles. Infertile patients with varicocele should be advised about the benefits of varicocelectomy due to strong evidence of improved semen parameters.

Acknowledgment: This commentary was co-written by Tuncay Toprak, MD and Ahmed M. Harraz,

MD and reviewed by Rupin Shah, MD.

A World-Wide, Innovative, Online Initiative to Bridge the Gaps in Research and Clinical Practice of Male Infertility and Sexual Health.

Sun, 03 Sep 2023 22:10:54 GMT

The Global Andrology Forum (GAF): A World-Wide, Innovative, Online Initiative to Bridge the Gaps in Research and Clinical Practice of Male Infertility and Sexual Health.

Agarwal A, Saleh R, Boitrelle F, Cannarella R, Hamoda TA, Durairajanayagam D, Harraz AM, Shah R.

World J Mens Health. 2022 Oct;40(4):537-542.

doi: 10.5534/wjmh.230084 . PMID: 36047074.

CAPSULE:

This editorial presents the GAF, its vision, missions, and organization. The GAF of which you are members was born in 2020 with the aim of conducting research of the highest quality in the field of andrology. It was formalized as the Global Andrology Forum in December 2021. Our work includes new systematic reviews and meta-analyses, scientometric studies and global surveys of clinical practice in andrology. GAF research studies integrate basic science and clinical practice, bridging the gap between researchers and clinicians. GAF also offers educational and academic activities, including scientific meetings, tutorials, online tests, and comprehensive training in research methodology. In addition, GAF strives to provide the best available research and clinical data to improve evidence-based practice in male sexual and reproductive health care, while maintaining a global perspective on the availability of health care and considering the diverse beliefs, value systems and preferences of patients. This editorial sums up who we are and who we will become, a global group of andrologists driven by a single vision: to make global andrology a science and medicine of excellence.

Acknowledgment:

Florence Boitrelle, MD, PhD, Professor Andrologist, Reproductive Biologist, Sexologist,

Biologie de la Reproduction - Andrologie – CECOS; CHI de Poissy Saint Germain en Laye, Université Paris-Saclay, UVSQ, INRAE, BREED, 78350, Jouy-en-Josas.

Male Infertility

Mon, 28 Aug 2023 01:53:55 GMT

Male Infertility
Authors: Agarwal et al, Lancet. 2021 Jan 23:397 (10271):319-33
https://doi.org/10.1016/S0140-6736(20)32667-2

Preamble:
Male Infertility 101
The inability to conceive has persisted as a problem for 8-12% of couples globally, with the sole male factor contributing to approximately 20-30% of infertility cases. The burden infertility imposes on couples is substantially significant, ranging from psychological, social, and even economic burden on patients. Alarmingly, evidence suggests that sperm count has declined over time, and male infertility is strongly associated with increased mortality risk and higher incidence of cancer. As plenty of diagnostic tests are available, interpretations are often imprecise and subjective. Thus, accurate diagnosis of male infertility may be a challenge for clinicians.

Epidemiology and Challenges in Comprehensive Evaluation

Creating a successful diagnosis of male infertility remains a challenge due to the multiple organs involved in the process of conception; whereas the classification of male infertility remains unchanged (primary or secondary); follow-up assessments should be conducted the same way regardless of the differential diagnosis. Throughout the years,several parameters have differed over time, namely in semen analysis, where the recommendations by WHO (2010) have lower reference limits compared to past editions due to the evidence from statistical analysis of semen parameters in fertile men in previous years. Furthermore, hormonal evaluation is a key tool in solidifying a diagnosis.

In men with azoospermia or severe oligozoospermia, the use of karyotyping is recommended by several professional bodies; EAU even extends their recommendations to include men with a sperm count of less than 10x106/mL and those with a history of recurrent spontaneous abortions, malformations, or intellectual disabilities. Additional evaluations such as sperm DNA fragmentation (SDF) testing may add to the bigger picture in diagnosing male infertility and a more comprehensive assessment of the overall fertility status than conventional semen parameters. However, currently, professional bodies such as AUA and ASRM do not recommend the routine use of SDF.

Current and Future Avenues of Male Infertility Management

Much like the evaluation aspect of treating male infertility, today's management options have several advancements, for example, in patients with azoospermia. However,the success rate of sperm retrieval in obstructive azoospermia is higher than in those with non-obstructive azoospermia (NOA). Finding heterogeneous patchy spermatogenesis during testicular biopsy may warrant the rationale for sperm retrieval in patients with NOA. In patients with varicoceles, the current understanding is that varicocele repair is recommended in men with clinical varicocele and abnormal semen parameters and less recommended to those who display normal semen analyses and/or subclinical varicoceles.
As for those with idiopathic male infertility, current recommendations include assisted reproductive technology or empirical medical therapy. The implementation of assisted reproductive technology has greatly facilitated couples with infertility; however, some couples still show poor outcomes despite the success of the techniques. Therefore, it should be noted that selecting the best sperm before intracytoplasmic sperm injection is of the utmost importance. Furthermore, the future in the diagnosis and management of male infertility lies with the integration of andrology and artificial intelligence; although still in its early stages, the possibilities of machine learning opening new doors in treating male infertility.

CAPSULE: Among 8–12% of infertile couples globally, a male factor contributes to approximately half of the cases. The etiology of male subfertility varies highly, ranging from congenital, acquired, or idiopathic factors which result in spermatogenesis impairment. As many health conditions can affect male fertility, a thorough assessment of patients to identify treatable or reversible lifestyle factors or medical conditions. Semen analysis remains the cornerstone for assessing male infertility. However, advanced diagnostic tests of sperm quality and function have been developed to improve accuracy. Assisted reproductive techniques have also substantially increased the ability of infertile couples to have biological children. A comprehensive overview of male infertility assessment and management, current controversies and future
directions were presented in the article.

Acknowledgment: Ponco Birowo, MD, Ph.D. is a Professor of Urology, Faculty of Medicine

Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Dr. Birowo
serves as a Guest member of the GAF Management.

Controversy and Consensus on the Management of Elevated Sperm DNA Fragmentation in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

Tue, 22 Aug 2023 17:31:02 GMT

Controversy and Consensus on the Management of Elevated Sperm DNA Fragmentation in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

Farkouh Ala’a, Agarwal A, et al, World J Mens Health. 2023;41:e48.

https://doi.org/10.5534/wjmh.230008

Preamble:
The assessment of male infertility relies primarily on conventional semen analysis. However, 15% of infertile men have normal semen parameters, and hence the semen analysis may be insufficient to detect all causes of male infertility. New tests are proposed to assess the functional competence of spermatozoa, including sperm DNA fragmentation (SDF) testing, which has been included and highlighted as a promising biomarker in the Sixth Edition of
the World Health Organization (WHO) Laboratory Manual for the Examination and Processing of Human Semen. Sperm DNA integrity is an important factor that can have a direct bearing on male fertility potential and sperm DNA strand breaks have been negatively correlated with fertilization rates in couples suffering from unexplained infertility and poorer outcomes during assisted reproductive treatments. Approaches such as offering antioxidants, short ejaculatory abstinence, weight loss, and using testicular sperm for intracytoplasmic sperm injection (ICSI) are demonstrated to benefit infertile men with elevated SDF. (Contributor: Zhongwei H, MBBS, PhD)

Briefly what is our vision:
To provide expert recommendations on the management of infertile men with elevated SDF based on the integration of best practices from available evidence in the literature, trendsi in global practices and current recommendations from professional society guidelines. (Contributor: Zhongwei H, MBBS, PhD)

Why do we do what we do?
The evidence from literature remains divided on the routine clinical use of sperm DNA fragmentation during male infertility assessment. Importantly, many professional societies recommended lifestyle modifications and antioxidant use for men with purported high sperm DNA fragmentation. Physiologically, men continuously produce spermatozoa and spermatogenesis occur on average every 70 days, therefore it is prudent to consider lifestyle modifications and antioxidant use to improve SDF. Hence, this clinical survey was done to understand globally about the clinical practices of professionals who provide care for men with fertility issues and the clinical impact of detecting SDF. The results of this survey offer novel information that will integrate with professional society guidelines and published evidence to provide sound clinical practice recommendations. (Contributor: Zhongwei H, MBBS, PhD)

Capsule:
A Reproductive Endocrinologist’s Viewpoint:
This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. A total of 436 experts from 55 different countries submitted responses to the survey on their practices for infertile men with elevated SDF. The majority of the experts recommend lifestyle modifications and prescribe empiric antioxidants. Most respondents will refer men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF for ART after 6 months’ failure of conservative and empiric medical management. However, for most questions, heterogenous practices were demonstrated - for example, duration of antioxidant treatments, other sperm selection techniques, indications for varicocele repair and testicular sperm extraction. Hence, this demonstrates the scarcity of professional society guidelines in this regard and this paper attempts to highlight the relevant evidence and offers expert recommendations to guide clinicians on management of infertile men who are detected to have elevated SDF. [Contributor: Zhongwei Huang, MBBS, PhD (Oxon) MRCOG (UK) is a Consultant in the Division of Reproductive Endocrinology and Infertility, Department of Ob-Gyn, National University of Singapore, Singapore]

A Reproductive Urologist’s Viewpoint:
Most if not all of us practicing clinical andrologists have differing views on elevated sperm DNA fragmentation (SDF) in terms of interpretation with regards to its predictive value of male infertility as well as its treatment options. A lot of patients who seek medical attention with regards to male infertility often request for SDF to be evaluated in addition to the runof-the-mill semen analysis. However, are there scientifically proven treatments or lifestyle modifications that can truly lower elevated SDF and if so, would lowering elevated SDF result in successful conception?

Can elevated SDF be contributed by the presence of varicoceles and would varicocele repair lower the elevated SDF to improve the chances of successful conception should the rest of the semen analysis parameters appear not to be affected? Does elevated SDF then become an indication for varicocele repair? What about reduced ejaculatory abstinence of 12-24 hours before attempting conception? Is that a recommended practice, knowing that this can result in additional stress to the couple and result in psychogenic erectile dysfunction in men due to performance anxiety?

This article gives a good overview of a global survey, current guidelines and ends off with expert recommendations regarding the controversy and consensus on the management of elevated SDF in male infertility. [Contributor: Ronny Tan, MBBS, MRCSEd, M Med (Surgery), FAMS (Urology), Advanced Urology Associates, Singapore]

Controversy and Consensus on Indications for Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

Mon, 14 Aug 2023 17:11:22 GMT

Controversy and Consensus on Indications for Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations.

World J Men’s Health World J Men’s Health (IF: 5.4; Q1). Apr 10, 2023.

https://doi.org/10.5534/wjmh.220282

Preamble:

Sperm DNA damage refers to the structural abnormalities or breaks within the genetic material of sperm cells. It arises from oxidative stress, environmental toxins, and lifestyle factors. Defective sperm maturation and impaired DNA repair mechanisms contribute to sperm DNA damage. The intriguing aspect of human sperm DNA damage lies in its potential to impact fertility, miscarriage rates, and offspring health, highlighting the importance of understanding and addressing this intricate biological phenomenon.

(Contributor: Agarwal, A)

Capsule:

Until recently, male fertility testing has been relatively unchanged since the mid-17th century when Anthony van Leeuwenhoek identified spermatozoa microscopically. It is well established that conventional semen parameters are the cornerstone of the male fertility evaluation, and they are, without question, of a great deal of importance. However, they are a crude assessment of a man’s fertility. A criticism is that they give no data on the functionality of the individual’s sperm. Functional testing of sperm as an adjunct to conventional semen analysis is crucial for higher levels of understanding of sperm function and its potential impacts on clinical outcomes. The sperm DNA fragmentation (SDF) assay is the only test of advanced semen analysis to have the level of data to support its use in clinical practice. Due to the large body of scientific evidence, this test has been included in professional society guideline statements. Although it is considered a useful adjunct, there is controversy about when it is indicated with the current viewpoint that it should not be tested on all infertile men.

The publication entitled “Controversy and Consensus on Indications for Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations ” explores when it is appropriate to obtain SDF testing. This study includes data from a survey of 436 experts from 55 countries to gain a global understanding of the appropriate use of SDF testing and practice patterns. The survey revealed that common indications for SDF testing worldwide include unexplained or idiopathic infertility, couples with recurrent pregnancy loss, men who are smokers, to help guide the need for varicocele repair, and prior to assisted reproductive technology in certain situations. Professional society guideline recommendations are also reviewed, and the lack of standardization is evident at this point among societies. (Contributor: Birowo, P)

Postscript:

As interest in SDF testing increases, it is essential to identify specific clinical scenarios where assessing the male partner's SDF status would significantly impact infertility management. Defining proper indications maximizes benefits while minimizing unfocused and excessive SDF testing among all infertile males. (Contributor: Agarwal, A)

Acknowledgment:

Ponco Birowo, MD, Ph.D.

Professor of Urology, Faculty of Medicine Universitas Indonesia

Cipto Mangunkusumo Hospital

Jakarta, Indonesia

Dr. Ashok Agarwal

Director of Research, Global Andrology Forum American Center for Reproductive Medicine Professor, Case Western Reserve University Emeritus Staff, Cleveland Clinic Foundation Associate Member, European Section of Andrological Urology, EAU President, Global Andrology Solutions, LLC Moreland Hills, OH United States

Antisperm Antibody Testing: A Comprehensive Review of Its Role in the Management of Immunological Male Infertility and Results of a Global Survey of Clinical Practices

Mon, 07 Aug 2023 17:21:07 GMT

Antisperm Antibody Testing: A Comprehensive Review of Its Role in the Management of Immunological Male Infertility and Results of a Global Survey of Clinical Practices. World J Men’s Health World J Men’s Health (IF: 5.4; Q1)

2022 Jul;40(3):380-398. doi: 10.5534/wjmh.210164 . Epub 2022 Jan 1.

Preamble:
The entity antisperm antibodies (ASA) is an enigma since it can be present in fertile males/couples. Controversy continues to exist regarding its actual purpose and clinical utility, especially in the current era of reproductive technology. While the presence of ASA may signal immunologic infertility, several factors such as types of ASA immunoglobulins, other semen parameters, and female factors can significantly alter egg fertilization rate. The GAF has taken the initiative to comprehensively review the current concept and clinical utility of ASA in the relatively sparse literature. Indeed, further research should be conducted to highlight the appropriate use of ASA testing
to optimize the management of infertile couples.

Capsule:
The article provides an overview of the causes of immunological male infertility, the clinical indications, and methods for antisperm antibody (ASA) testing, along with the results of a worldwide survey for the clinical application and management of antisperm antibody (ASA) testing in male infertility.

Spermatozoa are normally protected by the blood-testis barrier allowing them to remain undetectable to the male immune system, that would otherwise trigger a response against them. When the blood-testis barrier is breached or damaged due to injury or other pathologies, then antisperm antibodies (ASA) are formed that may affect sperm count, motility, vitality, capacitation, acrosome reaction and fertilizing potential of the spermatozoa. A varying prevalence of ASA has been reported in infertile men with percentages ranging from 2% to 15.6%, mainly due to variations in the applied thresholds to define the positive ASA test.

Referral for ASA testing often derives from certain indications from medical history or relevant findings during semen analysis, such as extensive agglutinations. According to the WHO guidelines, ASA testing can be either performed through direct testing for IgA/IgG by measuring the binding of immunobeads in the sperm surface, or through indirect testing by measuring sperm-specific immunoglobulins in sperm-free fluids such as seminal plasma. In the event of immunological infertility, management may include the prescription of corticosteroids to alleviate immunological response or the use of assisted reproductive technologies (ART) as sperm processing may remove
bounded antibodies.

The global online survey among experts revealed that there are reservations in ASA testing and its interpretation, but it remains widespread amongst clinicians for the diagnosis of immunological infertility, in the event of asthenozoospermia, agglutinations, or failed IUI/IVF and mostly performed by direct testing. Steroid administration to treat ASA positive cases is the most frequent approach, while many recommend Intrauterine insemination (IUI) and intracytoplasmic sperm injection (ICSI) as an alternate approach.

Recommendations:
ASA testing should be recommended in selected cases, based on suggestive clinical history and semen parameter outcomes, when the couple is trying for a natural pregnancy. However, if a couple is proceeding for IVF/ICSI, then there is no strong evidence to support ASA testing.

Postscript:
One interesting aspect of antisperm antibodies is their role in contraceptive vaccines for both males and females. However, developing contraceptive vaccines based on antisperm antibodies remains a complex and sensitive area of research. The main challenges include ensuring the safety and reversibility of the contraceptive effect, as well as addressing potential unintended immune reactions.

Acknowledgment: Pariskevi Vogiatzi, PhD (Greece), Eric Chung, MD (Australia) and Ashok Agarwal (Cleveland, USA) contributed to this summary piece.

Citation Errors in Scientific Research and Publications: Causes, Consequences, and Remedies

Mon, 31 Jul 2023 17:03:03 GMT

Citation Errors in Scientific Research and Publications: Causes, Consequences, and Remedies.

Agarwal et al, World J Men’s Health Published online Mar 15, 2023

https://doi.org/10.5534/wjmh.230001

CAPSULE: Data collected throughout the world through serious scientific research can in fact be considered a sort of "sanctuary" where Science, like a secular deity, bestows its gifts on those who honor it.

Therefore, the construction of this "sanctuary" requires strictly controlled, indisputable and up-to-date information (knowledge is constantly evolving).
This article covers key issues about the imperative of proper citations of scientific sources for every claim underlying any new research, and unequivocally demonstrates GAF's dedication to the "sanctity" of Science.

The Authors summarize the causes of all possible citation errors when a paper is in preparation: transcribing statements quoted in later documents omitting the original source, or quoted in older documents omitting more recent statements; self-citations that overlook more relevant statements by other Authors; unintentional distortion of the cited results or conclusions; referring only to abstracts or secondary sources in order to save time, or due to inaccessibility of the primary source; poor compliance with existing guidelines on Best Citation Practice, etc.

Of course, diagnosing citation errors is followed by an extensive list of remedies: a careful review of the manuscript, verifying that every single statement is supported by an adequate citation; an in-depth analysis of the full text of the original source; a systematic literature review with appropriate tools and software packages; express any personal opinion in an unambiguous form, etc.

Finally, the Authors remind readers that the technical guidelines for correct citation are available in the Publication Manual of the American Psychological Association, and that even the smallest citation errors can spread inaccuracies and half-truths that could even lead to a Chinese Whisper Game!

Acknowledgment: Giovanni M Colpi, MD (Lugano, Switzerland) contributed to this week’s management special.

Sperm DNA Fragmentation: A Critical Assessment of Clinical Practice Guidelines

Tue, 25 Jul 2023 16:54:46 GMT

Sperm DNA Fragmentation: A Critical Assessment of Clinical Practice Guidelines. World J Men’s Health Published online Apr 21, 2021, PMID: 33988000 PMCID:

PMC8761233, https://doi.org/10.5534/wjmh.210056

CAPSULE: This review compares and contrasts two independently published guidelines looking at sperm DNA fragmentation (SDF) testing and management of SDF for infertile couples. SDF has been associated with negative reproductive outcomes. Despite the mounting evidence in the literature, there is no consensus for SDF testing and management to assist infertile couples from our infertility societies. In fact, there have been conflicting recommendations from the European Society of Human Reproduction and Embryology (ESHRE), the European Academy of Andrology (EAA), the European Association of Urology (EAU), American Urological Association (AUA), and American Society for Reproduction (ASRM). Agarwal et al (2020) and Esteves et al (2020) separately published guidelines providing recommendations for SDF testing indications, appropriate assays, and management options. This article compared the recommendations from each guideline and sought to provide a combined consensus clinical practice guideline for infertility providers. Finally, the article summarized both guidelines in a well-designed table. The Venn diagram below shows unique and overlapping areas in the three main domains that were analyzed in the article. Despite some differences between the two guidelines, together, they provide extensive complementary evidence for the testing and treatment of SDF in infertile men. The 4 main assays (TUNEL, Comet, SCSA, and SCD) can provide valid and reliable SDF levels. Indications for testing include UMI or IMI, recurrent pregnancy loss, clinical varicocele, lifestyle risk factors, and for before or after failure of ART, including IUI and IVF. Management of elevated SDF includes lifestyle advice and modification, treatment of underlying conditions including varicocele or infection, use of ICSI in cases of persistently elevated SDF, and use of testicular sperm for failed ICSI. With the mounting evidence being provided by independent researchers, hopefully this will move our societies to provide consensus guidelines for testing and management of elevated SDF.

Acknowledgment: Edmund Ko, MD (Los Angeles, USA), Wael Zohdy, MD (Cairo, Egypt; currently in Mississauga, Canada), and Ashok Agarwal (Cleveland, USA) contributed to this week’s management special

Need for Training in Research Methodology Prior to Conducting Systematic Reviews and Meta-Analyses, and the Effectiveness of an Online Training Program: The Global Andrology Forum Model.

Thu, 20 Jul 2023 16:37:26 GMT

Need for Training in Research Methodology Prior to Conducting Systematic Reviews and Meta-Analyses, and the Effectiveness of an Online Training Program: The Global Andrology Forum Model.

Cannarella et al. World J Men’s Health. 2023 Apr;41(2):342-353.

doi: 10.5534/wjmh.220128 .

Epub 2023 Jan 1. PMID: 36593714; PMCID: PMC10042656.

Preamble:
In the era of evidence-based medical practice, systematic reviews, and meta-analyses (SRMAs) have great value in molding the clinical opinions and guiding practice recommendations. It is generally assumed that the authors of a SRMA are fully trained and qualified to carry out this type of research. Surprisingly, no study in the worldwide literature has specifically addressed this issue or answeredif a focused training of researchers involved in SRMAs may impact the quality of the SRMA. In this article, we describe a novel, online training program to train clinicians and researchers engaged in the conduct of SRMAs, document their level of skills prior to this training, and discuss the outcome of such a training.

Briefly, what is our vision?
The training and the experience of the researchers performing the SRMAs are usually not explained in the SRMAs' methodology, and this may be a source of bias. With the recent explosion of SRMAs, there is an increasing risk of poorly conducted studies being published and used for establishing clinical guidelines. Therefore, there is a need for a robust quality control of SRMAs by effective training of researchers in different steps of SRMAs. Optimizing the performance of the research team conducting an SRMAs will ensure the accuracy of all steps of the SRMA, and guarantee that the best available medical evidence is presented.

Why do we do what we do?
The Global Andrology Forum (GAF) is an international online scientific group established in 2021, is committed to conducting the highest quality research related to male reproductive and sexual health including SRMAs. While conducting SRMAs, the GAF realized that to avoid mistakes during the study, it is necessary to train the researchers rigorously. Hence, GAF developed a comprehensive online training program that focuses on all the steps of SRMA including the search of different databases, data acquisition and analysis and quality check of included studies.

Online Research: A fantasy or a fact?
The GAF is engaged in several SRMAs. A unique feature of our research group is that it is entirely online, which enables it to break free of geographical boundaries and engage many talented researchers from all over the world. Thanks to our large team we have been able to perform dozens of SRMAs with no limitations of time or language and verify each step in duplicate or triplicate. To further ensure that the research done by the GAF was of the highest quality, we provide online training in the various steps involved in conducting SRMAs and test the research knowledge and skills of our team.

Lastly, online research conducted in Andrology by GAF researchers is genuine and not a fantasy – this is proven by over two dozen original scientific publications in high impact journals in less than two years.

Online research may be a novel approach in medical field but there are several examples of such research in other fields. This research can be conducted entirely on an online platform without the need for a laboratory, expensive equipment, funding by government or private foundations or other type of resources. Some examples of online esearch are:

Scientometrics research: This analysis focuses on measuring and evaluating various indicators, such as publication output, citations, collaboration patterns, author productivity, journal impact factors, and research impact.
Social media research: This type of research involves collecting and analyzing data from social media platforms, such as Twitter, Facebook, and Instagram. This data can be used to study a variety of topics, such as public opinion, social movements, and consumer behavior.
Survey research: This type of research involves collecting data from a large number of people through surveys. Surveys can be conducted online, through the mail, or over the phone. This data can be used to study a variety of topics, such as public opinion, customer satisfaction, and the effectiveness of marketing campaigns.
Text mining: This type of research involves extracting and analyzing text data from a variety of sources, such as news articles, academic papers, and social media posts. This data can be used to study a variety of topics, such as trends in language use, the spread of misinformation, and the impact of social media on society.

CAPSULE: To the best of our knowledge, this is the first study demonstrating the need for training of the researchers involved in the conduct of SRMAs. Indeed, even well trained clinicians are often naïve in the methodology of SRMAs. Therefore, we advocate that all researchers performing an SRMA should undergo a comprehensive training that must cover each aspect of the SRMA methodology. Our article offers an example of an online training program that could be used to impart knowledge and skills to researchers performing high-quality SRMAs.

Acknowledgment: Ramadan Saleh, MD (Sohag, Egypt), and Ashok Agarwal (Cleveland, USA) contributed this week’s research summary.

Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

Fri, 14 Jul 2023 16:19:37 GMT

Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations
Authors: Shah R, Agarwal A, Kavoussi P, et al, World J Men’s Health Published 2023 Jan 41(1): 164-197
https://doi.org/10.5534/wjmh.220048

Preamble:
Varicocele and male infertility: a never-ending story!
Varicocele affects nearly 15% of the general male population and is diagnosed in 19% to 41% of primary male infertility and 80% of secondary male infertility cases. Varicocele is also considered the most common correctable cause of male infertility. However, the management of varicocele for fertility and non-fertility related indications is not clearly established and many areas of controversy remain. Current challenges in the management of infertile men
with varicocele include: 1) determining the true benefit of varicocele repair (VR) on seminal parameters, reproductive hormone levels, pregnancy and live birth rates; 2) predictive factors of the outcome of VR in infertile men; 3) the role of VR in the management of infertile men with varicocele and azoospermia or in those with subclinical varicocele; and the management of infertile men with varicocele recurrence.

In fact, considerable variation and controversy is expected in the worldwide practice patterns of varicocele management for different clinical situations.

Therefore, the aim of this study was to use a comprehensive online survey to determine the attitudes and practice patterns of clinicians worldwide in the management of varicocele in infertile men, thus identifying divergence and concurrence in global practice patterns, and to compare these with the latest international (American Urological Association/American Society for Reproductive Medicine [AUA/ASRM], European Association of Urology [EAU])
practice guidelines, and with evidence from systematic reviews and recent meta-analyses. Finally, to provide further clarity in each area of varicocele evaluation and management, an “Expert Opinion” has been provided based on the consensus of 16 highly experienced experts. This unique project lasted for 12 months and witnessed enormous contributions from 185 authors belonging to 40 countries.

Capsule:
The questionnaire used for this survey has been created from questions raised by a large, international group of clinicians, and thus reflects the real-life, practical concerns of physicians dealing with male infertility and varicocele. The survey responses represent the opinions and practices of 574 clinicians from 59 countries and reveal a marked diversity in all aspects of varicocele management. The survey highlights several areas where there is inconclusive data and the need for more research, and identifies numerous lacunae in the management guidelines issued by professional bodies (EAU, AUA, ASRM), which need to be addressed in future guidelines. Besides, this survey serves the useful purpose of allowing clinicians to compare their practices with those of their peers, and against recommended guidelines and the latest research findings, and thus rethink some of their own practices and clinical protocols.

Recommendation:
Clinicians dealing with varicocele and male infertility are invited to ponder over what they know, what they do, where they go wrong, and what they should do.

Acknowledgment: Ramadan Saleh, MD helped with this news item.

Comprehensive Analysis of Global Research on Human Varicocele: A Scientometric Approach

Fri, 07 Jul 2023 15:57:43 GMT

Comprehensive Analysis of Global Research on Human Varicocele: A Scientometric Approach

Authors: Agarwal et al, World J Men’s Health 2022 Oct 40(4): 636-652
https://doi.org/10.5534/wjmh.210202

Preamble:
Revealing the mystery of varicocele:
Varicocele has long been associated with male infertility. While significant progress has been made in understanding the role of varicocele in male infertility, there are still several gaps in our knowledge. Some of these gaps include: 1) the exact prevalence of varicocele and its impact; 2) predictive factors for infertility in men with varicocele; and 3) mechanisms of infertility. Future research addressing these gaps may help unravel mysteries that surround the relationship of varicocele and male infertility.

What is scientometrics analysis?
Scientometric analysis of published literature is a quantitative approach that involves the study of scientific publications to analyze various aspects of scientific research on a selected topic. It involves the use of bibliometric and citation analysis methods to examine patterns, trends, and relationships within a particular field or across multiple disciplines. This analysis focuses on measuring and evaluating various indicators, such as publication output, citations, collaboration patterns, author productivity, journal impact factors, and research impact. It offers insights into the growth and development of scientific knowledge, the influence and visibility of researchers and institutions, and the dissemination and impact of research findings. Scientometric analysis plays a vital role in assessing the scholarly impact of research, identifying emerging trends, and informing decision-making processes in academia, research institutions, funding agencies, and policy development.

Capsule:
The authors of this article analyzed the publication trends in varicocele research of over 33 years (between 1988 and 2020), exposing an increasing focus on various aspects. The initial studies focused on adolescent varicocele and laparoscopic repair, but later shifted towards impact of varicocele on male fertility potential, efficacy of microsurgical repair of varicoceles, and varicocele's association with factors like body mass index and seminal oxidative stress (OS). Few studies have explored the prevalence and risk factors of varicocele, and the impact of varicocele treatment on seminal OS and sperm DNA fragmentation. Additionally, there is a lack of research on reproductive outcomes with different assisted reproductive technologies and the paternity endpoint.

Recommendation:
To enhance varicocele research, collaboration between clinical and research institutions around the world is crucial, along with large-scale studies and long-term follow-ups. This collaborative approach could address important questions about the specific males affected by varicocele, the mechanisms underlying varicocele-induced damage, and improve clinical management practices globally.

Acknowledgment: Ramadan Saleh, MD reviewed this news item.

Relevance of Leukocytospermia and Semen Culture and Its True Place in Diagnosing and Treating Male Infertility

Sat, 01 Jul 2023 10:20:33 GMT

Relevance of Leukocytospermia and Semen Culture and Its True Place in Diagnosing and Treating Male Infertility
Authors: Sharma R, et al, World J Men’s Health, Published online Jun 9, 2021
https://doi.org/10.5534/wjmh.210063

Capsule: Leukocytospermia refers to the presence of an increased number of white blood cells (leukocytes) in semen. Normally, a small number of leukocytes can be found in semen samples, but when the concentration exceeds a certain threshold, it is considered leukocytospermia. Leukocytospermia can be significant in the context of male infertility for several reasons: 1) Infection: the presence of elevated white blood cells may indicate an underlying infection in the male reproductive tract, such as prostatitis, epididymitis, or seminal vesiculitis. These infections can impair sperm production, motility, and function, thereby affecting fertility; 2) inflammatory response: leukocytes play a crucial role in the body's immune response to infection or injury. However, excessive or sustained inflammation in the male reproductive tract can lead to the release of harmful substances, such as reactive oxygen species (ROS) and pro-inflammatory cytokines. These substances can damage sperm cells, impair their function, and reduce fertility; 3) oxidative stress: White blood cells produce ROS as part of their defense mechanism against pathogens. However, high levels of ROS can cause oxidative stress, which can negatively affect sperm quality and function. Oxidative stress can lead to DNA damage, lipid peroxidation, and alterations in sperm membrane integrity, all of which can contribute to male infertility; 4) antisperm antibodies: In some cases, leukocytospermia can trigger an immune response in which the body produces antibodies against sperm cells (antisperm antibodies). These antibodies can bind to sperm cells, impair their motility, and function, and interfere with fertilization. It's important to note that leukocytospermia alone does not directly indicate infertility, as it can be present in both fertile and infertile men. However, it serves as an indicator of potential underlying issues in the male reproductive system that may contribute to fertility problems. If leukocytospermia is suspected, further investigations, including semen culture, testing for inflammation markers, and evaluation for genital tract infections, should be conducted to determine the cause and appropriate treatment. Leukocytospermia is associated with high levels of ROS, leading to DNA damage and poor sperm quality. Detecting leukocytes in semen is important as they can indicate underlying inflammation or infection. Investigating leukocytospermia helps diagnose the cause of male infertility and is part of optimal management. The peroxidase staining test provides reliable results, although it's not the gold standard. While leukocytospermia doesn't predict a positive semen culture alone, resolving it can aid in managing infertility.

The new 6th edition of the WHO Laboratory Manual for the Examination and Processing of Human Semen: is it a step toward better standard operating procedure?

Fri, 30 Jun 2023 18:03:41 GMT

Article #9: The new 6th edition of the WHO Laboratory Manual for the Examination

and Processing of Human Semen: is it a step toward better standard operating

procedure?

Authors: Chung E, et al, Asian Journal of Andrology (2022) 24, 123–124

doi: 10.4103/aja2021118 ; published online: 07 January 2022

Preamble:

The preliminary release of the new 6th Edition of the WHO manual for public commentary has aroused significant scientific interest and criticism. The founding members of GAF was one of the very first group of experts (and scientific organizations) to critically review this Manual and wrote several editorial pieces in peer-review journals. This foresight and continued dedication to advancing the Andrology field by GAF is truly remarkable and speaks volumes regarding the influential role of GAF in the scientific community.

Briefly, a little about the WHO Laboratory manuals:

The WHO Laboratory Manual on semen analysis processing was first published in 1980 and in accordance with the International Organization for Standardization’s basic semen examination on specification and test methods. Over the last 4 decades, several editions have been released with scientific scrutiny despite incorporating new advances in semen analysis standard methods and new technologies in extended and advanced sperm parameters evaluation.

And now about the Sixth edition:

The new 6th Edition of the WHO manual aims to provide not only an update of the current methods and thresholds but also an insight into recent developments in semen examination, sperm preparation and cryopreservation, and quality control and assurance. One of the most notable changes in the new 6th Edition is the change in the definition of “abnormal ejaculates”. While the reference ranges and limits on various sperm parameters have been revised to remove the existing dichotomy between “fertile” and “infertile” men and Various sperm parameters have been revised accordingly to afford more generalization since male fertility should be viewed as a continuum of semen parameters in real life, and the fact that SA alone cannot predict fertility, pregnancy or its associated clinical outcomes given the multifactorial nature of fertilization process. Significant advances in scientific knowledge and state-of-art technologies have improved various aspects of functional assessment of male infertility, while advanced sperm selection methodologies have been updated or introduced, targeting especially the populations with poor reproductive prognosis in terms of natural conception and assisted reproductive technology.

Capsule:

It is important to understand that this WHO manual functions both as an aid as well as a foundation for human semen examination and processing but is not intended to replace actual clinical management of male infertility. Men with fertility risk factors or abnormal semen parameters should be referred to a male reproductive specialist for a full clinical evaluation, appropriate counselling, and evidence-based therapeutic interventions.

Acknowledgment: Eric Chung, MD authored the above news item. Thank you, Eric!

Artificial Intelligence in Andrology: From Semen Analysis to Image Diagnostics

Tue, 27 Jun 2023 09:52:50 GMT

Artificial Intelligence in Andrology: From Semen Analysis to Image Diagnostics (Newly published article)
Authors: Ramy Abou Ghayda, Rossella Cannarella, Aldo E. Calogero et al, World J Men’s
Health Published online Jun 15, 2023
https://doi.org/10.5534/wjmh.230050

Preamble: GAF management congratulates authors of this new article on AI in Andrology for an authoritative review of the hottest topic, introducing it for the first time in worldwide literature. The research for this review was another example of an exquisite teamwork involving over sixty authors (all GAF members), who worked cumulatively roughly for over a thousand hours spread out over a course of 12 months. This massive research campaign was led by Dr. Ramy Ghayda, Dr. Rossella Cannarella and Prof. Aldo Calogero – we thank them for their leadership. This manuscript then went through multiple rounds of review and revision and here before we forget, a special thanks is due to Prof. Wael Zohdy for his valuable feedback which allowed significant improvement in the final article.

Capsule: Artificial intelligence in medicine has gained momentum, benefiting various fields. In andrology and reproductive medicine, AI is being touted to play a valuable role in diagnosing male infertility, improving patient care, and enhancing research efficiency. Studies have shown that AI aids in objective selection of sperm, oocytes, and embryos, predicts surgical outcomes, assesses cost-effectiveness, develops robotic surgery, and supports clinical decision-making. AI algorithms can automate and enhance the analysis of sperm samples. The use of AI based semen analysis systems are already assisting in the diagnosis of male fertility issues and helping guide appropriate treatment options. Further integration of AI promises evidence-based breakthroughs and reshaping of andrology and reproductive medicine. However, despite these promises, only the time will truly tell the full potential and impact of AI in the field of Andrology.

2022 GAF Annual Report:
We are submitting for your reading and future reference a copy of our Annual Report for the past year. This report will be useful in explaining the multifarious activities of our organization: education, training, advanced research, and scientific publications. We hope that you will take the time to read about these activities and find something that may interest you to participate more actively. Just send us a simple email with your query to get started ( agarwal@globalandrology.org ). We welcome your participation.

Post-Vasectomy Semen Analysis: Optimizing Laboratory Procedures and Test Interpretation through a Clinical Audit and Global Survey of Practices

Mon, 26 Jun 2023 17:46:23 GMT

Article #8: Artificial Intelligence in Andrology: From Semen Analysis to Image
Diagnostics (Newly published article)
Authors: Ramy Abou Ghayda, Rossella Cannarella, Aldo E. Calogero et al, World J Men’s
Health Published online Jun 15, 2023
https://doi.org/10.5534/wjmh.230050

Preamble: GAF management congratulates authors of this new article on AI in Andrology for an authoritative review of the hottest topic, introducing it for the first time in worldwide literature. The research for this review was another example of an exquisite
teamwork involving over sixty authors (all GAF members), who worked cumulatively roughly for over a thousand hours spread out over a course of 12 months. This massive 4 research campaign was led by Dr. Ramy Ghayda, Dr. Rossella Cannarella and Prof. Aldo Calogero – we thank them for their leadership. This manuscript then went through
multiple rounds of review and revision and here before we forget, a special thanks is due
to Prof. Wael Zohdy for his valuable feedback which allowed significant improvement in
the final article.

Capsule: Artificial intelligence in medicine has gained momentum, benefiting various fields. In andrology and reproductive medicine, AI is being touted to play a valuable role in diagnosing male infertility, improving patient care, and enhancing research efficiency. Studies have shown that AI aids in objective selection of sperm, oocytes, and embryos, predicts surgical outcomes, assesses cost-effectiveness, develops robotic surgery, and supports clinical decision-making. AI algorithms can automate and enhance the analysis
of sperm samples. The use of AI based semen analysis systems are already assisting in the diagnosis of male fertility issues and helping guide appropriate treatment options. Further integration of AI promises evidence-based breakthroughs and reshaping of andrology and reproductive medicine. However, despite these promises, only the time will truly tell the full potential and impact of AI in the field of Andrology.

2022 GAF Annual Report:
We are submitting for your reading and future reference a copy of our Annual Report for the past year. This report will be useful in explaining the multifarious activities of our organization: education, training, advanced research, and scientific publications. We hope that you will take the time to read about these activities and find something that may interest you to participate more actively. Just send us a simple email with your query get started (agarwal@globalandrology.org). We welcome your participation.

A Global Survey of Reproductive Specialists to Determine the Clinical Utility of Oxidative Stress Testing and Antioxidant Use in Male Infertility

Sun, 18 Jun 2023 12:09:00 GMT

Global Survey of Reproductive Specialists to Determine the Clinical Utility of Oxidative Stress Testing and Antioxidant Use in Male Infertility.

Agarwal A, Finelli R, Selvam MK, Leisegang K, Majzoub A, Tadros N, Ko E, Parekh N, Henkel R, Durairajanayagam D, Colpi GM, Cho CL, Sallam HN, Park HJ, Saleh R, Micic S, Ambar RF, Zini A, Tremellen K, Alvarez JG, Palani A, Arafa M, Gava MM, Jindal S, Amar E, Kopa Z, Moein MR, Busetto GM, Sengupta P, Kavoussi P, Maldonado I, Fikri J, Borges E, Martinez M, Bojovic D, Rajmil O, Aydos K, Parekattil S, Marmar JL, Sefrioui O, Jungwirth A, PeÃ±a MG, Cordts EB, Elbardisi H, Mostafa T, Sabbaghian M, Sadighi Gilani MA, Morimoto Y, Alves MG, Spasic A, Kenic U, Ramsay J, Akande EO, Oumeziane A, Dozortsev D, Chung E, Bell EG, Allegra A, Tanos V, Fiadjoe M, Gurgan T, Abou-Abdallah M, Al-Rumaih H, Oborna I, Arab H, Esteves S, Amer M, Kadioglu A, Yuzko O, Korsak V, Shah R. A

World J Mens Health. 2021 Jul;39(3):470-488.

https://doi.org/10.5534/wjmh.210025

CAPSULE:

Capsule: The lack of clinical guidelines for AOX use restricts standardization in clinical protocols despite increasing attention. There is no consensus on regimen, dosing, or treatment length while the prescription practices vary globally. Our online survey evaluated the practice patterns of reproductive specialists regarding the clinical usefulness of OS tests and AOX prescriptions in male infertility. Despite low-quality scientific evidence, AOX is commonly used in treating infertile men. The reasons for low quality evidence range from: limited well-designed clinical trials with small sample sizes, inconsistent methodologies, variations in the types and doses of antioxidants studied, and lack of standardized outcome measures. Additionally, the existing studies may have methodological flaws or bias, leading to uncertainty in drawing definitive conclusions about the effectiveness of antioxidants in treating male infertility. The authors emphasize the need for clinical practice guidelines in AOX therapy for male infertility management.

. ..

Sperm Vitality and Necrozoospermia: Diagnosis, Management, and Results of a Global Survey of Clinical Practice

Sun, 18 Jun 2023 12:00:02 GMT

Sperm Vitality and Necrozoospermia: Diagnosis, Management, and Results of a Global Survey of Clinical Practice.

Agarwal A, Sharma RK, Gupta S, Boitrelle F, Finelli R, Parekh N, Durairajanayagam D, Saleh R, Arafa M, Cho CL, Farkouh A, Rambhatla A, Henkel R, Vogiatzi P, Tadros N, Kavoussi P, Ko E, Leisegang K, Kandil H, Palani A, Salvio G, Mostafa T, Rajmil O, Banihani SA, Schon S, Le TV, Birowo P, Ãeker G, Alvarez J, Molina JM, Ho CC, Calogero AE, Khalafalla K, Duran MB, Kuroda S, Colpi GM, Zini A, Anagnostopoulou C, Pescatori E, Chung E, Caroppo E, Dimitriadis F, Pinggera GM, Busetto GM, Balercia G, Elbardisi H, Taniguchi H, Park HJ, Maldonado Rosas I, de la Rosette J, Ramsay J, Bowa K, Simopoulou M, Rodriguez MG, Sabbaghian M, Martinez M, Gilani MA, Al-Marhoon MS, Kosgi R, Cannarella R, Micic S, Fukuhara S, Parekattil S, Jindal S, Abdel-Meguid TA, Morimoto Y, Shah R.
World J Mens Health. 2022 Apr;40(2):228-242.

https://doi.org/10.5534/wjmh.210149

CAPSULE:

Necrozoospermia, also known as necrospermia, is a condition characterized by the presence of a high percentage of non-motile or immotile sperm in semen. In normal circumstances, a certain percentage of sperm in semen should exhibit progressive motility to ensure successful fertilization. However, in necrozoospermia, a significant proportion of the sperm are non-motile, dead, or have impaired motility. The management of necrozoospermia involves addressing contributory factors, lifestyle modifications, and specific interventions based on the condition's severity. Avoidance of heat exposure, lifestyle changes, urogenital infection treatment, and correcting hyperthyroidism are initial management steps. Repeated ejaculations can improve sperm vitality affected by infrequent ejaculations and prolonged epididymal storage. Absolute asthenozoospermia should be differentiated from necrozoospermia by assessing sperm vitality. If a large proportion of live but immotile spermatozoa is present, structural defects in the flagellum may be indicated. Sperm vitality testing methods, such as E-N stain or HOS test, are recommended when total motility is below 40%. The HOS test can aid intracytoplasmic sperm injection (ICSI) by selecting viable spermatozoa. Activation substances such as pentoxifylline (PTX) or theophylline can improve sperm motility but require rinsing before injection. Testicular sperm extraction is recommended for absolute necrozoospermia.

Necrozoospermia correlates with sperm DNA fragmentation (SDF), emphasizing the need for SDF testing to determine nuclear integrity and guide treatment decisions. Antioxidants may be considered to reduce SDF in severe cases, but further research is needed. Our survey shows diverse vitality testing approaches and limited management strategies for necrozoospermia, underscoring the need for guidelines in this area.

Christine Wyns, MD, PhD

Head of the Cliniques universitaires Saint-Luc's

Gynaecology and Andrology Department

Medical Director of the Reproductive Tissue and Cell Bank

Professor at Université Catholique de Louvain (UCL)

Brussels, Belgium

https://www.international-saintluc.be/en/medecin/professor-christine-wyns

Sperm Morphology Assessment in the Era of Intracytoplasmic Sperm Injection: Reliable Results Require Focus on Standardization, Quality Control, and Training.

Sun, 11 Jun 2023 11:52:11 GMT

Sperm Morphology Assessment in the Era of Intracytoplasmic Sperm Injection: Reliable Results Require Focus on Standardization, Quality Control, and Training.
Agarwal A, Sharma R, Gupta S, Finelli R, Parekh N, Panner Selvam MK, Henkel R, Durairajanayagam D, Pompeu C, Madani S, Belo A, Singh N, Covarrubias S, Darbandi S, Sadeghi R, Darbandi M, Vogiatzi P, Boitrelle F, Simopoulou M, Saleh R, Arafa M, Majzoub A, Kandil H, Zini A, Ko E, Alvarez JG, Martinez M, Ramsay J, Jindal S, Busetto GM, Sallam H, Maldonado I, Anagnostopoulou C, Alves MG, Sengupta P, Gilany K, Evenson DP, Lewis SE, Gosalvez J, Ambar RF, Shah R.World J Mens Health. 2022 Jul;40(3):347-360.

https://doi.org/10.5534/wjmh.210054

CAPSULE:

This review aims to cover several key aspects related to the evaluation and management of sperm morphology. Firstly, it summarizes the standardized laboratory procedures necessary for an accurate assessment of sperm morphology, emphasizing the importance of consistent training and monitoring, as well as the use of an ocular micrometer for precise measurement of sperm dimensions. The review also highlights the significance of quality control (QC) and quality assurance (QA) in the laboratory assessment of sperm morphology, as they are crucial for reliable and dependable results, and play a role in laboratory accreditation. Furthermore, the association between abnormal sperm morphology, also known as teratozoospermia, and the outcomes of assisted reproductive technology (ART) is discussed. The review explores how abnormal sperm morphology can impact the success of ART procedures, emphasizing the importance of considering sperm morphology in the clinical management of infertile couples and their choice of ART. In conclusion, this comprehensive review underscores the importance of specialized laboratory skills, QC, and QA in evaluating sperm morphology. It highlights the need for accurate measurement techniques, prompt identification and rectification of errors, and the use of proficiency testing for reporting reliable results. Understanding sperm morphology is crucial in the clinical management of infertility and in making informed decisions regarding ART procedures.

...

Sperm DNA Fragmentation: A New Guideline for Clinicians

Sun, 11 Jun 2023 11:41:35 GMT

Sperm DNA Fragmentation: A New Guideline for Clinicians.,
Agarwal A, Majzoub A, Baskaran S, Panner Selvam MK, Cho CL, Henkel R, Finelli R, Leisegang K, Sengupta P, Barbarosie C, Parekh N, Alves MG, Ko E, Arafa M, Tadros N, Ramasamy R, Kavoussi P, Ambar R, Kuchakulla M, Robert KA, Iovine C, Durairajanayagam D, Jindal S, Shah R. World J Mens Health. 2020 Oct;38(4):412-471. https://doi.org/10.5534/wjmh.20012 8

CAPSULE:

This article focuses on the clinical significance of Sperm DNA Fragmentation (SDF) testing in the management of male infertility. It provides an overview of the underlying mechanisms and risk factors of SDF, as well as the different clinical tests associated with DNA fragmentation. The article also discusses the indications for SDF testing and presents case scenarios of male infertility with high SDF. SDF is known to negatively impact fertilization, embryo development, and the success of assisted

reproductive technologies (ART). Consequently, SDF testing is increasingly being used in the evaluation of male infertility. The causes of SDF can be endogenous, resulting from defective maturation and abortive apoptosis in the testes, or exogenous, stemming from clinical diseases, lifestyle factors, and environmental exposures. Although a universally agreed-upon cut-off value has not been established, a threshold of 20% is commonly considered to have good discriminative accuracy between fertile and infertile men.

The art icle identifies specific clinical scenarios where SDF testing is most beneficial, such as unexplained infertility, recurrent pregnancy loss (RPL), varicocele, patients opting for ART, and those with lifestyle or environmental risk factors. For patients with high SDF results, several therapeutic interventions can be implemented to improve their chances of conception. These include recurrent ejaculation, antioxidant therapy, lifestyle modifications, varicocelectomy (surgical treatment for varicocele), and advanced sperm selection techniques or testicular sperm for intracytoplasmic sperm injection (ICSI).

Overall, SDF testing plays a crucial role in assessing male infertility and can guide appropriate management strategies to enhance fertility outcomes in affected individuals.

The Use of Testicular Sperm for Intracytoplasmic Sperm Injection in Patients with High Sperm DNA Damage: A Systematic Review.

Sun, 28 May 2023 22:21:07 GMT

The Use of Testicular Sperm for Intracytoplasmic Sperm Injection in Patients with High Sperm DNA Damage: A Systematic Review.

Ambar RF, Agarwal A, Majzoub A, Vij S, Tadros NN, Cho CL, Parekh N, Borges E, Glina S.

World J Mens Health. 2021 Jul;39(3):391-398.

doi: 10.5534/wjmh.230084 . PMID: 32648379.

CAPSULE:

The use of testicular sperm with lower sperm DNA fragmentation (SDF) has been explored as a potential solution for unsuccessful ICSI cycles. However, it is important to critically evaluate the existing studies and understand the complex mechanisms of sperm DNA damage. While oxidative stress-induced DNA damage is commonly implicated, intratesticular alterations can also contribute to fragmented DNA in testicular sperm. Therefore, clinical management should prioritize strategies to lower SDF, rather than resorting to potentially harmful surgical sperm retrieval. Controlling exogenous factors, increasing ejaculation frequency, using antioxidants, and employing effective sperm selection methods can help reduce DNA fragmentation. While SDF may have little impact on ICSI pregnancy rates, it is associated with a higher miscarriage rate. However, these findings are based on heterogeneous studies using different SDF assays, making interpretation difficult. Most studies on testicular sperm and SDF have limitations, such as small sample sizes, lack of control groups, and inadequate reporting of live birth rates. Moreover, the mechanism of intratesticular DNA damage and its interaction with extratesticular pathways remain unclear. Further studies with rigorous designs, control groups, and appropriate outcomes are needed to determine the role of testicular sperm in non-azoospermic patients who have previously failed ICSI.

GAF Management Special

Globozoospermia syndrome: An update

Contributors for the Commentary: Hamid Kalantari, MSc (Iran), Karan Vadher, MSc (UK), Jane Ezeukwu, MSc (Nigeria), Marjan Sabbaghian, PhD (Iran)

Standardized Laboratory Procedures, Quality Control and Quality Assurance Are Key Requirements for Accurate Semen Analysis in the Evaluation of Infertile Male

Contributors for the Commentary are Israel Maldonado (Mexico), Liliana Ramirez (Mexico), Hamid Kalantari (Iran), Melissa M. Morales Berrocal (Costa Rica), Mohamed Arafa (Qatar) and Daniela Delgadillo (Mexico)

Challenges in the Management of Nonobstructive Azoospermia

Contributors for the Commentary are from Turkey: Baris Altay, MD, Mustafa Emre Bakircioğlu, MD, Arif Kalkanli, MD, Coskun Kaya, MD, Sadik Gorur, MD, Mustafa Gurkan Yenice, MD

Sperm DNA Fragmentation: A New Guideline for Clinicians

Contributors: Ahmed Ragab, MD (Egypt), Khaled Almekaty, MD (Egypt), Moheiddin Alghobary, MD (Egypt)

Regenerative Therapy in Erectile Dysfunction: A Survey on Current Global Practice Trends and GAF Expert Recommendations

Contributors: Aleksei Ryzhkov, MD, PhD (Russia), Safar Gamidov, MD, PhD (Russia), Vladlen Petrishchev, MD (Russia), Taras Shatylko, MD, PhD (Russia)

Sperm DNA fragmentation and infertility: a narrative review

Contributors: Prof. Ahmed El-Sakka (Egypt), Assoc. Prof. Ayman Rashed (Egypt), Prof. Maged Ragab (Egypt)

Global Practice Patterns in the Evaluation of Non-Obstructive Azoospermia: Results of a World-Wide Survey and Expert Recommendations

Contributors: Sidney Glina, MD (Brasil), Dr. Rafael Favero Ambar, MD (Brasil), and Edson Borges Junior, MD, PhD (Brasil)

My Viewpoint on the Global Practice Patterns in the Evaluation of NOA

Dr. Sidney Glina responds to questions from Ashok

My Viewpoint on the Global Practice Patterns in the Evaluation of NOA

Dr. Rafael Favero Ambar responds to questions from Ashok

My Viewpoint on the Global Practice Patterns in the Evaluation of NOA

Dr. Edson Borges Junior responds to questions from Ashok

Testicular Sperm Extraction for Men with Cryptozoospermia – Are We Jumping the Gun

Global Practice Patterns and Variations in the Medical and Surgical Management of Non-Obstructive Azoospermia: Results of a World-Wide Survey, Guidelines and Expert Recommendations

Effectiveness of, and Satisfaction with, a Microsurgical Testicular Sperm Extraction Knowledge and Skills Masterclass for a World-Wide Audience

Sperm Vitality and Necrozoospermia: Diagnosis, Management, and Results of a Global Survey of Clinical Practice

Effects of Varicocele Repair on Sperm DNA Fragmentation and Seminal Malondialdehyde Levels in Infertile Men with Clinical Varicocele: A Systematic Review and Meta-Analysis

Sixth edition of the World Health Organization laboratory manual of semen analysis: Updates and essential takeaway for busy clinicians

An In-Depth Bibliometric Analysis and Current Perspective on Male Infertility Research

Isolated teratozoospermia: revisiting its relevance in male infertility: a narrative review.

Impact of Varicocele on Testicular Oxidative Stress and Sperm Parameters in Experimental Animals: A Systematic Review and Meta-Analysis.

An online educational model in andrology for student training in the art of scientific writing in the COVID-19 pandemic.

The Impact of Single- and Double-Strand DNA Breaks in Human Spermatozoa on Assisted Reproduction

Male Infertility: New Developments, Current Challenges, and Future Directions

Diagnostic value of advanced semen analysis in evaluation of male infertility

Causes and Consequences of Sperm Mitochondrial Dysfunction.

Sperm DNA Fragmentation: A New Guideline for Clinicians

Comparative analysis of tests used to assess sperm chromatin integrity and DNA fragmentation

Male Oxidative Stress Infertility (MOSI): Proposed Terminology and Clinical Practice Guidelines for Management of Idiopathic Male Infertility

Is there plagiarism in the most influential publications in the field of andrology?

The excessive use of antioxidant therapy: A possible cause of male infertility

A systemic review and meta-analysis exploring the predictors of sperm retrieval in patients with non-obstructive azoospermia and chromosomal abnormalities.

Effectiveness and Satisfaction with a Microsurgical Testicular Sperm Extraction Knowledge and Skills Masterclass for a World-Wide Audience

Standardized Laboratory Procedures, Quality Control and Quality Assurance Are Key Requirements for Accurate Semen Analysis in the Evaluation of Infertile Male

Scientific landscape of oxidative stress in male reproductive research: A scientometric study

Sperm DNA fragmentation in male infertility: From bench to bedside

A Novel Approach to Improving the Reliability of Manual Semen Analysis: A Paradigm Shift in the Workup of Infertile Men

The Sixth Edition of the WHO Manual for Human Semen Analysis: A Critical Review and SWOT Analysis

Sperm epigenetics landscape: correlation with embryo quality, reproductive outcomes, and offspring’s health

Pushing the Boundaries for Evidenced-Based Practice: Can Online Training Enhance Andrology Research Capacity Worldwide? An Exploration of the Barriers and Enablers - The Global Andrology Forum

Oocytes evaluation and in-vitro fertilization/intra cytoplasmic sperm injection outcomes

The Renaissance of Male Infertility Management in the Golden Age of Andrology

Impact of Antioxidant Therapy on Natural Pregnancy Outcomes and Semen Parameters in Infertile Men: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

ICSI for non-male factor infertility: time to reappraise IVF?

How to select healthy sperm for intracytoplasmic sperm injection in samples with high sperm DNA fragmentation?

Time-lapse embryo monitoring: does it add to standard in-vitro fertilization/intracytoplasmic sperm injection?

The GAF: Structure, Roles, Functioning and Outcomes: An Online Model for Collaborative Research

Does Varicocele Repair Improve Conventional Semen Parameters? A Meta-Analytic Study of Before-After Data

A World-Wide, Innovative, Online Initiative to Bridge the Gaps in Research and Clinical Practice of Male Infertility and Sexual Health.

Male Infertility

Controversy and Consensus on the Management of Elevated Sperm DNA Fragmentation in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

Controversy and Consensus on Indications for Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

Antisperm Antibody Testing: A Comprehensive Review of Its Role in the Management of Immunological Male Infertility and Results of a Global Survey of Clinical Practices

Citation Errors in Scientific Research and Publications: Causes, Consequences, and Remedies

Sperm DNA Fragmentation: A Critical Assessment of Clinical Practice Guidelines

Need for Training in Research Methodology Prior to Conducting Systematic Reviews and Meta-Analyses, and the Effectiveness of an Online Training Program: The Global Andrology Forum Model.

Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

Comprehensive Analysis of Global Research on Human Varicocele: A Scientometric Approach

Relevance of Leukocytospermia and Semen Culture and Its True Place in Diagnosing and Treating Male Infertility

The new 6th edition of the WHO Laboratory Manual for the Examination and Processing of Human Semen: is it a step toward better standard operating procedure?

Artificial Intelligence in Andrology: From Semen Analysis to Image Diagnostics

Post-Vasectomy Semen Analysis: Optimizing Laboratory Procedures and Test Interpretation through a Clinical Audit and Global Survey of Practices

A Global Survey of Reproductive Specialists to Determine the Clinical Utility of Oxidative Stress Testing and Antioxidant Use in Male Infertility

Sperm Vitality and Necrozoospermia: Diagnosis, Management, and Results of a Global Survey of Clinical Practice

Sperm Morphology Assessment in the Era of Intracytoplasmic Sperm Injection: Reliable Results Require Focus on Standardization, Quality Control, and Training.

Sperm DNA Fragmentation: A New Guideline for Clinicians

The Use of Testicular Sperm for Intracytoplasmic Sperm Injection in Patients with High Sperm DNA Damage: A Systematic Review.

Contributors for the Commentary: Hamid Kalantari, MSc (Iran), Karan Vadher, MSc
(UK), Jane Ezeukwu, MSc (Nigeria), Marjan Sabbaghian, PhD (Iran)

Contributors for the Commentary are Israel Maldonado (Mexico), Liliana
Ramirez (Mexico), Hamid Kalantari (Iran), Melissa M. Morales Berrocal
(Costa Rica), Mohamed Arafa (Qatar) and Daniela Delgadillo (Mexico)

Contributors for the Commentary are from Turkey: Baris Altay, MD,
Mustafa Emre Bakircioğlu, MD, Arif Kalkanli, MD, Coskun Kaya, MD,
Sadik Gorur, MD, Mustafa Gurkan Yenice, MD

Contributors: Ahmed Ragab, MD (Egypt), Khaled Almekaty, MD
(Egypt), Moheiddin Alghobary, MD (Egypt)

Contributors: Aleksei Ryzhkov, MD, PhD (Russia), Safar Gamidov, MD,
PhD (Russia), Vladlen Petrishchev, MD (Russia), Taras Shatylko, MD,
PhD (Russia)

Contributors: Prof. Ahmed El-Sakka (Egypt), Assoc. Prof. Ayman Rashed
(Egypt), Prof. Maged Ragab (Egypt)