title: Should we evaluate and treat sperm DNA fragmentation?
abstract: The clinical utility of sperm DNA fragmentation tests needs to be revisited in light of increasing evidence of detrimental effect of sperm DNA damage on reproductive outcomes.
  
  
  
  Current evidence supports the association between high sperm DNA fragmentation and poor outcomes with regards to natural conception and intrauterine insemination. The relationship between high sperm DNA fragmentation and impaired outcomes after in-vitro fertilization and intracytoplasmic sperm injection are more equivocal. However, recent studies indicate that poor sperm chromatin content is associated with an increased risk of early pregnancy loss after in-vitro fertilization and intracytoplasmic sperm injection. Several strategies are proposed to alleviate sperm DNA fragmentation and/or select sperm with higher quality chromatin content for assisted reproductive techniques. The intake of oral antioxidants, varicocele repair, use of recurrent ejaculations alone or combined with micromanipulation-based sperm selection techniques, and the use of testicular sperm for intracytoplasmic sperm injection have been attempted with promising results.
  
  
  
  Sperm DNA fragmentation tests provide clinically relevant information for natural conception and artificial reproduction independent of those derived from conventional semen parameters. The increasing knowledge of paternal factors on pregnancy outcome and the improvement in treatment strategies should prompt routine evaluation of sperm DNA fragmentation in infertile couples.
authors.affiliation: aAmerican Center for Reproductive Medicine, Cleveland Clinic, Cleveland, Ohio, USA bDivision of Urology, Department of Surgery, Kwong Wah Hospital, Yau Ma Tei, Hong Kong cANDROFERT, Andrology and Human Reproduction Clinic, Referral Center for Male Reproduction, Campinas, São Paulo, Brazil.
authors.forename: Ashok
authors.initials: A
authors.lastname: Agarwal
authors.forename: Chak-Lam
authors.initials: CL
authors.lastname: Cho
authors.forename: Sandro C
authors.initials: SC
authors.lastname: Esteves
mesh_terms: D053938:DNA Fragmentation; D005260:Female; D005306:Fertilization; D005307:Fertilization in Vitro; D006801:Humans; D007248:Infertility, Male / Q000175:diagnosis* / Q000235:genetics / Q000628:therapy*; D007314:Insemination; D008297:Male; D011247:Pregnancy; D011256:Pregnancy Outcome; D018873:Pregnancy Rate; D020554:Sperm Injections, Intracytoplasmic; D013094:Spermatozoa / Q000473:pathology*