It is high time for clinical application of sperm DNA fragmentation testing

tau.amegroups.com © Translational Andrology and Urology. All rights reserved. We read with interest the commentary by Drs. Basar and Kahraman (1). The authors provide a comprehensive review of sperm DNA fragmentation (SDF) from etiologies and assisted reproduction outcomes to treatment strategies. We wish to further elaborate the discussion on the use of SDF testing in managing varicocele. Varicoceles can be found in 35–50% and up to 69–81% of men with primary infertility and secondary infertility, respectively (2,3). It is considered the most commonly identifiable and surgically correctable male infertility factor. However, controversies continue to plague the studies designed to answer the clinical question related to the effect of varicocele repair on improvement in semen parameters and pregnancy rates. Results from systematic review and meta-analyses were divided and have led to more confusion (4-6). These conflicting results are the main contributing factor to the vague and inconsistent guidelines on the diagnosis and treatment of varicoceles from various professional societies including the American Society for Reproductive Medicine (ASRM) (7), American Urological Association (AUA) (8) and European Urological Association (EAU) (9). Although most professional society guidelines agree on varicocele repair in patients with clinical varicocele and impaired semen parameters, however, they fail to settle the debate of varicocele treatment. Despite the fact that repair of subclinical varicocele is generally not recommended by guidelines and metaanalyses, there are reports suggesting potential role of treatment for subclinical varicocele (10). The possible benefit of simultaneous repair of subclinical varicocele with a contralateral clinical varicocele has also been recognized (11,12). On the other hand, repair of clinical varicocele does not necessarily lead to desirable outcome. Recent data support an association between grade of clinical varicocele and improvement in semen parameters after repair. Several studies consistently reported a significant difference in semen parameter outcomes after repair of highvs. low-grade varicocele. The total motile sperm count after varicocelectomy improved by 128% in men with grade 3 varicoceles compared with a mere 21% and 27% in men with grade 2 and 1 varicoceles respectively (13). Takahara et al. also demonstrated the relationship between clinical grading of varicocele and post-varicocelectomy increase in sperm density. There was an improvement in sperm density of 38 (±36) × 10/mL for large varicocele compared to 3 (±18) × 10/mL improvement in small varicocele (14). As a result, the dichotomous classification of clinical and subclinical varicocele in decisions to proceed with surgical repair may be flawed. Similarly, the use of abnormal semen parameters in treatment decision may not be ideal. The revised lower reference limits for semen analyses by the World Health Organization (WHO) in 2010 (15) re-categorized previously abnormal men as normal and may leave this Editorial