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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, Ashok, Hamoda, Taha Abo-Almagd Abdel-Meguid, Kavoussi, Parviz, Saleh, Ramadan, Zini, Armand, Arafa, Mohamed, Harraz, Ahmed M., Gul, Murat, Karthikeyan, Vilvapathy Senguttuvan, and others. (2023) Controversy and consensus on the management of elevated sperm DNA fragmentation in male infertility: A global survey, current guidelines, and expert recommendations. The World Journal of Men's Health, 41 (4). Article Number 809. ISSN 2287-4208. E-ISSN 2287-4690. (doi:10.5534/wjmh.230008) (KAR id:101147)

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Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition.

Materials and Methods

An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method.


A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4–6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated.


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. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians.

Item Type: Article
DOI/Identification number: 10.5534/wjmh.230008
Uncontrolled keywords: Pharmacology (medical); Urology; Psychiatry and Mental health; Public Health; Environmental and Occupational Health; Health Policy; Aging; Reproductive Medicine
Subjects: Q Science
Q Science > QH Natural history > QH301 Biology
Divisions: Divisions > Division of Natural Sciences > Biosciences
Funders: University of Kent (
SWORD Depositor: JISC Publications Router
Depositing User: JISC Publications Router
Date Deposited: 05 May 2023 13:29 UTC
Last Modified: 04 Oct 2023 15:11 UTC
Resource URI: (The current URI for this page, for reference purposes)
Farkouh, Ala’a:
Agarwal, Ashok:
Hamoda, Taha Abo-Almagd Abdel-Meguid:
Kavoussi, Parviz:
Saleh, Ramadan:
Zini, Armand:
Arafa, Mohamed:
Harraz, Ahmed M.:
Gul, Murat:
Karthikeyan, Vilvapathy Senguttuvan:
Durairajanayagam, Damayanthi:
Rambhatla, Amarnath:
Boitrelle, Florence:
Chung, Eric:
Birowo, Ponco:
Toprak, Tuncay:
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Cannarella, Rossella:
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