The Sixth Edition of the WHO Manual for Human Semen Analysis: A Critical Review and SWOT Analysis

3.0 T diffusion tensor imaging and fiber tractography of the testes in nonobstructive azoospermia

PURPOSE

To assess the role of 3.0 T Diffusion Tensor Imaging (DTI) and Fiber Tractography (FT) of the testes in the work-up of nonobstructive azoospermia (NOA).

METHODS

This prospective study included consecutive NOA men and controls. A 3.0 T scrotal MRI was performed, including DTI. The testicular apparent diffusion coefficient (ADC) and fractional anisotropy (FA) were calculated. FT reconstructions were created. The Kruskal-Wallis test, followed by pairwise comparisons, assessed differences in testicular ADC and FA between NOA histologic phenotypes (group 1: hypospermatogenesis; group 2: maturation arrest; and group 3: Sertoli cell-only syndrome) and normal testes. The Mann-Whitney-U test compared ADC and FA between NOA testes with positive and negative sperm retrieval. Visual assessment of the testicular fiber tracts was performed. Fiber tracts fewer in number, of reduced thickness, disrupted and/or disorganized were considered "abnormal". Chi-square tests and binary logistic regression analysis assessed variations in testicular fiber tracts morphology.

RESULTS

Twenty-nine NOA men (mean age: 39 ± 5.93 years) and 20 controls (mean age: 26 ± 5.83 years) were included for analysis. Higher ADC (p < 0.001) and FA (p < 0.001) was observed in NOA testes compared to controls. Differences in FA were found between groups 1 and 3 (0.07 vs 0.10, p = 0.26) and groups 2 and 3 (0.07 vs 0.10, p = 0.03), but not between groups 1 and 2 (p = 0.66). An increase in FA was observed in NOA testes with Sertoli cell-only syndrome compared to hypospermatogenesis and maturation arrest. FA was higher in NOA testes with negative results for the presence of sperm compared to those with positive results (0.09 vs 0.07, p = 0.006). FT showed "abnormal" fiber tracts in NOA testes (p < 0.001).

CONCLUSION

3.0 T DTI and FT provide an insight into deranged spermatogenesis in NOA testes.

Retinoic Acid Regulates Spermiogenesis Via Hoxb1 and Shh Signaling in Testicular Germ Cells

Retinoic acid (RA) regulates all four major events in spermatogenesis; spermatogonial differentiation, meiotic entry, spermiogenesis, and spermiation. For the pre-meiotic phase, Sertoli cells are the source of RA and for the post-meiotic phase, pachytene spermatocytes are the source of RA. While the entire spermatogenic process is regulated by RA, how each of these phases is regulated by RA remains completely unknown. Homeobox B1 (Hoxb1) has two retinoic acid response elements (RARE) upstream and downstream of the gene. In this study, we investigated if RA facilitates spermatogenesis by its action on Hoxb1. The expressions of the Hoxb1 and Sonic hedgehog (Shh) genes were analyzed in the post-natal mouse testes and the testicular localizations of Hoxb1, Shh and Gli1 were analyzed by immunohistochemistry in the adult rat testis. To delineate the signaling mechanisms, Hoxb1 expression was altered in vitro and in vivo using retinoic acid and miR-361-3p. Finally, the levels of miR-361-3p and HOXB1 were analyzed in infertile human sperm samples. Hoxb1 and Shh gene expressions were found to be low in the testis of post-natal Swiss mice of 7, 14, 28, 35, and 60 days, after which the expressions of both spiked. Immunohistochemistry in the adult mouse testis showed the expressions of Hoxb1, Shh, and Gli1 in the elongating spermatids. Exposure of GC2 cells to RA and in vivo IP RA injection upregulated Hoxb1 and Shh signaling in the testis with increased expressions of Shh, Gli1, and Hdac1. Retinoic acid administration in Swiss mice compromised sperm production and reduced epididymal sperm count. The analysis of infertile human semen samples revealed an increased level of HOXB1 and a decreased level of miR-361-3p as compared to fertile controls. We conclude that retinoic acid regulates late stage of spermatogenesis (spermiogenesis) by affecting Hoxb1 and Shh signaling.

The prevalence of abnormal semen parameters in male partners of women with anovulatory polycystic ovarian syndrome: a retrospective case-control study

PURPOSE

Polycystic ovary syndrome (PCOS) is the leading cause of anovulatory infertility, often requiring ovarian stimulation in affected women attempting to conceive. Male partner semen quality and shared lifestyle factors can significantly impact reproductive outcomes. However, current international guidelines lack evidence-based recommendations on the necessity and timing of semen analysis for the fertility management of anovulatory PCOS women.

METHODS

In a retrospective case-control study, semen analysis results of male partners of 187 anovulatory PCOS women scheduled for ovarian stimulation were analyzed and compared to a control group of 76 male partners of women with bilateral tubal occlusion.

RESULTS

The prevalence of semen analysis results with at least one parameter classified as "borderline" and "pathological" among male partners of women with PCOS eligible to undergo ovarian stimulation was 51.3% and 22.5%, compared to 44.7% and 13.2% in the control group, respectively (p = 0.027). In the PCOS group, male body mass index (odds ratio, OR 1.478, p < 0.001), and smoking status (OR 6.228, p < 0.001) were significant predictors of pathological sperm test results, while no association was observed with any female characteristics (p > 0.05).

CONCLUSION

The high frequency of pathological sperm analysis results provides lacking epidemiological data on semen quality in this population, emphasizing the critical need for early male fertility evaluation prior to ovarian stimulation in PCOS women. Moreover, our findings indicate that the risk prediction for abnormal semen quality cannot be based on the female's data.

Sperm DNA Fragmentation: Unraveling Its Imperative Impact on Male Infertility Based on Recent Evidence

Male factors may be present in up to 50-70% of infertile couples and the prevalence of male infertility accounts for 20-30% of infertility cases. Understanding the mechanisms and causes behind male infertility remains a challenge, but new diagnostic tools such as DNA fragmentation might aid in cases where the routine semen analysis is insufficient. DNA fragmentation, which refers to damages or breaks of the genetic material of the spermatozoa, is considered one of the main causes of male infertility due to impaired functional capability of sperm. The aim of the present narrative review is to investigate and enlighten the potential correlation between DNA fragmentation and male infertility parameters such as the seminal profile and the reproductive outcomes. Comprehensive research in PubMed/Medline and Scopus databases was conducted and 28 studies were included in the present review. Fourteen studies provided data regarding the impact of DNA fragmentation and seminal parameters and showed a correlation of significantly lower sperm count, lower concentration, motility, and abnormal morphology with an increased DNA fragmentation index (DFI). Similarly, 15 studies provided data regarding the impact of DFI on reproductive outcomes. Two studies showed higher aneuploidy rates with higher DFI values, and seven studies showed significantly lower pregnancy rates and live birth rates with higher DFI values. Ultimately, the studies included in this review highlight, collectively, the importance of measuring sperm DFI in the assessment of male infertility. Further studies are needed to explore the effectiveness of interventions aiming to reduce DFI levels.

The Andrological Landscape in the Twenty-First Century: Making Sense of the Advances in Male Infertility Management for the Busy Clinicians

Male infertility represents a significant global problem due to its essential health, social, and economic implications. It is unsurprising that scientific research is very active in this area and that advances in the diagnostic and therapeutic fields are notable. This review presents the main diagnostic advances in male infertility, starting from the changes made in the latest WHO Manual of semen analysis and discussing the more molecular aspects inherent to "omics". Furthermore, the usefulness of artificial intelligence in male infertility diagnostics and the latest advances in varicocele diagnosis will be discussed. In particular, the diagnostic path of male infertility is increasingly moving towards a personalized approach to the search for the specific biomarkers of infertility and the prediction of treatment response. The treatment of male infertility remains empirical in many regards, but despite that, advances have been made to help formulate evidence-based recommendations. Varicocele, the most common correctable cause of male infertility, has been explored for expanded indications for repair. The following expanded indications were discussed: elevated sperm DNA fragmentation, hypogonadism, orchalgia, and the role of varicocele repair in non-obstructive azoospermia. Moving forward with the available data, we discussed the stepwise approach to surgical sperm retrieval techniques and the current measures that have been investigated for optimizing such patients before testicular sperm extraction. Finally, the key points and expert recommendations regarding the best practice for diagnosing and treating men with infertility were summarized to conclude this review.

Orchiopexy: one procedure, two diagnoses - different male infertility outcomes

ABSTRACT

Infertility, affecting one in six couples, is often related to the male partner's congenital and/or environmental conditions or complications postsurgery. This retrospective study examines the link between orchiopexy for undescended testicles (UDT) and testicular torsion (TT) in childhood and adult fertility as assessed through sperm analysis. The study involved the analysis of semen samples from 7743 patients collected at Soroka University Medical Center (Beer Sheva, Israel) between January 2009 and December 2017. Patients were classified into two groups based on sperm concentration: those with concentrations below 5 × 10 6 sperm per ml (AS group) and those above (MN group). Medical records and surgical histories were reviewed, categorizing orchiopexies by surgical approach. Among 140 individuals who had undergone pediatric surgery, 83 (59.3%) were placed in the MN group and 57 (40.7%) in the AS group. A higher likelihood of being in the MN group was observed in Jewish compared to Arab patients (75.9% vs 24.1%, P = 0.006). In cases of childhood UDT, 45 (78.9%) patients exhibited sperm concentrations below 5 × 10 6 sperm per ml ( P < 0.001), and 66 (76.7%) had undergone unilateral and 18 (20.9%) bilateral orchiopexy. Bilateral orchiopexy was significantly associated with lower sperm concentration, total motility, and progressive motility than unilateral cases ( P = 0.014, P = 0.001, and P = 0.031, respectively). Multivariate analysis identified UDT as a weak risk factor for low sperm concentration (odds ratio [OR]: 2.712, P = 0.078), with bilateral UDT further increasing this risk (OR: 6.314, P = 0.012). Jewish ethnicity and TT diagnosis were associated with a reduced risk of sperm concentrations below 5 × 10 6 sperm per ml. The findings indicate that initial diagnosis, surgical approach, and ethnicity markedly influence male fertility outcomes following pediatric orchiopexy.

Molecular characterization of DNAH6 and ATPase6 (Mitochondrial DNA) genes in asthenozoospermia patients in the northern region of India

BACKGROUND

Male infertility due to spermatogenesis defects affects millions of men worldwide. However, the genetic etiology of the vast majority remains unclear. The present study was undertaken to assess the association of DNAH6 and ATPase6 genes in asthenozoospermia patients in the northern region of India.

METHODS

A total of 60 semen samples were collected for the study, of which 30 were from the case group and 30 were from the control group. The semen samples for the case group (asthenozoospermia) and control groups were collected from IVF and Reproductive Biology Centre, Maulana Azad Medical College, New Delhi. Sperm count and motility were classified as per World Health Organization (WHO 2021) protocol. A total genomic DNA was extracted as per the stranded TRIZOL method with little modification.

RESULTS

In-vitro molecular characterizations of DNAH6 and ATPase6 genes in both groups were checked by Polymerase Chain Reaction (PCR). The 675 bp and 375 bp amplicons were amplified using PCR for ATPase6 and DNAH6 genes. Our study results showed a significant (P ≤ 0.05) null deletion of DNAH6 and ATPase6 genes in asthenozoospermia patients as compared to the control. We found the significant null deletion of DNAH6 in case 45.0%, and the control group was 11.7%. However, in the case of APTase6, it was 26.7% and 10.0%, respectively.

CONCLUSIONS

Our study concluded that the presence of DHAH6 and ATPase6 genes had a significant impact on male infertility.

Longitudinal trends and correlation between autism spectrum disorder prevalence and sperm quality parameters (2000-2024): a comprehensive statistical analysis

Introduction

Over the past few decades, there has been growing concern about the concurrent trends of increasing Autism Spectrum Disorder (ASD) prevalence and declining sperm quality. These trends represent significant public health challenges that warrant thorough investigation of their underlying causes and implications.

Objectives

The primary objectives of this study are to analyze trends in ASD prevalence and sperm quality parameters from 2000 to 2024, assess the statistical significance and effect size of these trends, explore potential correlations between ASD prevalence and sperm quality parameters, and identify significant predictors among sperm quality parameters that influence ASD prevalence.

Methods

This study employed a longitudinal approach using multiple regression, time series analysis, ANOVA, Principal Component Analysis (PCA), hierarchical clustering, logistic regression, and cross-correlation analysis. Data on ASD prevalence were sourced from the CDC Autism and Developmental Disabilities Monitoring Network, while sperm quality data were collected from various published studies.

Results

The findings reveal significant negative associations between ASD prevalence and sperm quality parameters such as sperm concentration and motility, suggesting that better sperm quality is linked to lower ASD rates. Conversely, parameters like sperm DNA fragmentation (SDF), volume of ejaculate, pH level, and semen viscosity show positive associations with ASD prevalence, indicating higher values in these parameters correlate with higher ASD rates.

Conclusion

The study highlights the importance of maintaining reproductive health to potentially mitigate ASD risk and calls for further research to elucidate the underlying mechanisms driving these trends. These findings support the hypothesis that reproductive health factors play a crucial role in ASD etiology and suggest potential biological markers for assessing ASD risk.

A 2-step remote TUNEL approach for sperm DNA fragmentation assessment. Analysis in donors and patients

OBJECTIVES

Infertility is a disease of the male or female reproductive systems. Male reproductive workup is based on routine semen analysis, although of limited value. The 2021 WHO Manual incorporated Sperm DNA Fragmentation (SDF) assessment, and highlighted the need for individual laboratories to define suitable thresholds. This study aimed to present an alternative to address this issue, determine an SDF cut-off value with fertile donors, and characterize SDF in a patient cohort and their relationship with semen parameters.

STUDY DESIGN

A service unit was established to remotely perform TUNEL assay in a 2 step-process. Semen samples were received at andrology laboratories, subjected to routine semen analysis (WHO, 2010), partially processed and transported to the service unit for SDF evaluation. Using this setting, studies were done in fertile donors (n = 15) to define the cut-off value, and in men undergoing infertility workup (n = 318).

RESULTS

A cut-off value of 9.17 % was determined with the fertile donor cohort. With this cut-off, a 64.46 % abnormal SDF incidence was determined in the patient cohort. SDF negatively correlated with sperm number, vitality and motility, and positively with abnormal morphology and male age (P < 0.05). TUNEL-positive cases depicted lower sperm quality and higher male age (P < 0.05). A similar abnormal SDF incidence was determined among patients with semen abnormalities. Asthenozoospermic and ≥40 years patient samples depicted higher (P < 0.05) SDF than those of the general population. SDF incidence was also high in normozoospermic patients.

CONCLUSIONS

Using a 2-step remote approach with a standardized procedure and an SDF cut-off value established with fertile donors, high SDF incidence in semen samples depicting normal and abnormal quality were identified in men consulting for infertility, highlighting the relevance of its evaluation as part of the male fertility workup.

Innovative Approach for Human Semen Quality Assessment Based on Volatilomics

The volatilome profile of some biofluids (blood, urine, and human semen) identified by Solid-Phase Microextraction-Gas Chromatography/Mass Spectrometry (SPME-GC/MS) and collected from young men living in two high-pollution areas in Italy, i.e., Land of Fires and Valley of Sacco River, have been coupled to sperm parameters obtained by spermiogram analysis to build general multiple regression models. Panels of volatile organic compounds (VOCs) have been selected to optimize the models and used as predictive variables to estimate the different sperm quality parameters (sperm cell concentration, total and progressive motility/immotile cells, total/head/neck/tail morphology anomalies, semen round cell concentration). The results of the multiple linear regression models based on the different subgroups of data joining VOCs from one/two or three biofluids have been compared. Surprisingly, the models based on blood and urine VOCs have allowed an excellent estimate of spermiogram values, paving the way towards a new method of indirect evaluation of semen quality and preventive screening. The significance of VOCs in terms of toxicity and dangerousness was discussed with the support of chemical databases available online.

Incidence and Causes of Tubal Occlusion in Infertility: A Retrospective Cohort Study

Background and Objectives: Fallopian tubal pathology is a primary risk factor for female infertility, with simple proximal disease and proximal disease extending more distally being more common than pure distal occlusion. Proximal tubal occlusion is often attributed to ascending events, such as pelvic inflammatory disease. Conversely, while distal occlusion can also be attributable to ascending pelvic inflammatory disease, it can also have a pelvic origin, such as through endometriosis and ruptured appendicitis. The aim of this study was to identify certain causes of infertility and their association with tubal occlusion. The focus was on the location of tubal occlusion, uni- versus bilateral occlusion, and other causes of infertility, including male factors. Methods: In a retrospective study cohort study, 373 women aged between 18 and 40 years, treated from 1 January 2017 to 31 December 2022, were included. Fallopian tube patency was tested using either hysterosalpingography, hysterosalpingo-contrast sonography, or laparoscopic chromopertubation. Results: In total, 95 of 373 women (25.5%) revealed at least one occluded tube, with unilateral occlusion being more common than bilateral occlusion (60/95, 63.2% vs. 35/95, 36.8%). The majority of tubal occlusions occurred proximally (86.2%). According to the adjusted multivariate regression models, the presence of hydrosalpinx (odds ratio, OR, 13.323, 95% confidence interval, CI: 2.679-66.253, p = 0.002), myomas (OR 2.108, 95%CI: 1.008-4.409; p = 0.048), and an abnormal sperm test result of the male partner (OR 2.105, 95%CI: 1.156-3.833; p = 0.015) were statistically significant associated factors for tubal occlusion. Conclusions: Fallopian tube patency testing is still of major relevance in fertility evaluation. The presence of uterine myomas, hydrosalpinges, and a male factor significantly increase the risk.

Advanced Sperm Selection Techniques for Assisted Reproduction

Male infertility accounts for approximately 40% of infertility cases. There are many causes of male infertility, including environmental factors, age, lifestyle, infections, varicocele, and cancerous pathologies. Severe oligozoospermia, cryptozoospermia, and azoospermia (obstructive and non-obstructive) are identified as severe male factor infertility, once considered conditions of sterility. Today, in vitro fertilization (IVF) techniques are the only treatment strategy in cases of male factor infertility for which new methodologies have been developed in the manipulation of spermatozoa to achieve fertilization and increase success rates. This review is an update of in vitro manipulation techniques, in particular sperm selection, emphasizing clinical case-specific methodology. The success of an IVF process is related to infertility diagnosis, appropriate choice of treatment, and effective sperm preparation and selection. In fact, selecting the best spermatozoa to guarantee an optimal paternal heritage means increasing the blastulation, implantation, ongoing pregnancy and live birth rates, resulting in the greater success of IVF techniques.

Understanding seminal plasma in male infertility: emerging markers and their implications

Infertility affects a significant proportion of the reproductive-aged population, with male-associated factors contributing to over half of the cases. However, current diagnostic tools have limitations, leading to an underestimation of the true prevalence of male infertility. While traditional semen parameters provide some insights, they fail to determine the true fertility potential in a substantial number of instances. Therefore, it is crucial to investigate additional molecular targets responsible for male infertility to improve understanding and identification of such cases. Seminal plasma, the main carrier of molecules derived from male reproductive glands, plays a crucial role in reproduction. Amongst its multifarious functions, it regulates processes such as sperm capacitation, sperm protection and maturation, and even interaction with the egg's zona pellucida. Seminal plasma offers a non-invasive sample for urogenital diagnostics and has shown promise in identifying biomarkers associated with male reproductive disorders. This review aims to provide an updated and comprehensive overview of seminal plasma in the diagnosis of male infertility, exploring its composition, function, methods used for analysis, and the application of emerging markers. Apart from the application, the potential challenges of seminal plasma analysis such as standardisation, marker interpretation and confounding factors have also been addressed. Moreover, we have also explored future avenues for enhancing its utility and its role in improving diagnostic strategies. Through comprehensive exploration of seminal plasma's diagnostic potential, the present analysis seeks to advance the understanding of male infertility and its effective management.

Low human sperm motility coexists with sperm nuclear DNA damage and oxidative stress in semen

BACKGROUND

Low sperm motility, one of the common causes of male infertility, is associated with abnormal sperm quality. Currently, important sperm/semen biomarkers are sperm chromatin status and oxidation‒reduction potential (ORP) in semen. Because the association between sperm motility and these biomarkers is still not fully clarified, our study was designed to verify the distribution and risk of sperm DNA fragmentation (SDF) and oxidative stress in semen in asthenozoospermic men.

MATERIALS AND METHODS

This study was carried out on discharged sperm cells of asthenozoospermic men (isolated asthenozoospermia or coexisted with reduced sperm number and/or morphology), nonasthenozoospermic men (reduced total sperm count and/or sperm morphology) (experimental groups) and normozoospermic men (proven and presumed fertility) (control group). Basic semen analysis was evaluated according to the 6th edition of the World Health Organization manual guidelines. SDF was assessed using the sperm chromatin dispersion test, while static(s) ORP in semen was measured by means of a MiOXSYS analyser.

RESULTS

The men from the asthenozoospermic group had lower basic semen parameters than those from the control and nonasthenozoospermic groups. In men with poor sperm motility SDF and sORP, prevalence and risk for > 20% SDF (high level of DNA damage) and for > 1.37 sORP (oxidative stress) were significantly higher than those of control and nonasthenozoospermic subjects. The risk for sperm DNA damage and oxidative stress in asthenozoospermic men was over 10-fold higher and almost 6-fold higher than those in control subjects and almost or over 3-fold higher than those in nonasthenozoospermic men.

CONCLUSIONS AND DISCUSSION

Poor human sperm motility coexisted with low basic sperm quality. Sperm DNA damage and oxidative stress in semen were much more frequent in asthenozoospermia. These abnormalities can decrease the sperm fertilizing capability under both natural and medically assisted reproduction conditions. Thus, in asthenozoospermia, the evaluation of sperm chromatin status and oxidation-reduction potential in semen is justified and inevitable, and the appropriate antioxidant therapy can be suggested.

Effect of electroacupuncture on total motile sperm count and sperm motility

Background

Approximately 50% of infertility cases are attributed to male factors. Acupuncture has long been employed as a complementary therapy to enhance male infertility treatment outcomes. This study aimed to assess the impact of electroacupuncture (EA) therapy on sperm motility and TMSC in male infertility patients.

Design and methods

This randomized clinical trial involved 30 male infertility patients divided into 2 groups. Consecutive sampling was utilized among men diagnosed with infertility at the Fertility Clinic Sekar, Dr. Moewardi General Hospital, Surakarta. Both groups underwent assessments of sperm motility and TMSC before and after the intervention. The first group received Coenzyme Q, while the second group received Coenzyme Q + EA.

Results

The Qoenzyme Q + EA group exhibited no significant difference in motility levels before treatment, with an average motility of 41.40% ± 13.33 and a TMSC level of 33.59 × 106 ± 27.91. Post-treatment, motility remarkably increased by 56.40% ± 11.78, and the TMSC level rose by 78.63 × 106 ± 58.38 in the Qoenzyme Q + EA group. Conversely, the Qoenzyme Q pre-treatment group had an average motility of 48.07% ± 15.77 and a TMSC level of 30.20 × 106 ± 34.82. After Coenzyme Q treatment, a significant decrease in motility by 42.80% ± 18.03 and TMSC level by 28.22 × 106 ± 15.16 was observed.

Conclusion

Combining Coenzyme Q + EA had a more significant impact on sperm motility and TMSC levels than Coenzyme Q alone. These findings underscore the differential effects of Coenzyme Q + EA and Coenzyme Q on sperm motility and TMSC levels, suggesting potential therapeutic implications for male reproductive health. Future studies with larger sample sizes are warranted to validate and expand upon these results.

Enhancing Intracytoplasmic Sperm Injection Outcomes With Zeta Sperm Selection: A Case Report

Sperm morphology significantly influences the fertilization capacity of male germ cells. Morphological abnormalities are frequently associated with an overproduction of reactive oxygen species (ROS), leading to further sperm damage and subsequent infertility. This case study examines a couple facing infertility, with male factor infertility identified as the primary issue, characterized by teratozoospermia and a high DNA fragmentation index (DFI). The objective was to assess the efficacy of zeta potential (ZP) as a sperm sorting technique for intracytoplasmic sperm injection (ICSI) in patients showing high DNA fragmentation. A 34-year-old male with abnormal sperm parameters underwent ICSI using the ZP technique for sperm separation, while his 28-year-old female partner received ovarian stimulation. This intervention resulted in the development of two good-quality blastocysts, resulting in a successful embryo transfer (ET) and a positive pregnancy outcome. Previous attempts using conventional assisted reproductive technologies (ART), including in vitro fertilization (IVF), followed by ICSI and ET, as well as other sperm selection methods, were not successful. The ZP-based approach demonstrated significant benefits by selecting spermatozoa with optimal parameters, such as negative membrane potential, thereby enhancing the success rate. This case emphasizes the advantages of personalized treatment strategies in managing male infertility and highlights the potential of advanced sperm sorting techniques in improving fertility outcomes.

Impact of COVID-19 on sperm quality and the prostaglandin and polyamine systems in the seminal fluid

BACKGROUND

The implications of SARS-CoV-2 infection on male fertility remain largely unknown. Besides their well-known pro- and anti-inflammatory actions, prostaglandins and polyamines are present in semen, where they play key roles in sperm quality.

OBJECTIVES

To analyze semen parameters, oxidative profile and the seminal fluid prostaglandin and polyamine systems in samples collected from individuals without coronavirus disease 2019 diagnosis and men who recovered from coronavirus disease 2019.

MATERIALS AND METHODS

This study compared semen collected from men without positive coronavirus disease 2019 diagnosis with samples obtained from individuals 1-6 months and 7-30 months post SARS-CoV-2 infection. Semen parameters, thiobarbituric acid reactive substances, cyclooxygenase 2 expression by fluorescence immunocytochemistry and immunoblotting, prostaglandin levels by enzyme immunoassay, ornithine decarboxylase activity by a radioactive assay, and polyamine and acetylated polyamine levels by thin-layer chromatography were assessed.

RESULTS

In both groups of semen samples from coronavirus disease 2019 recovered men, sperm vitality, total and progressive sperm motility, and putrescine levels were significantly decreased when compared with samples from the uninfected group. In contrast, lipid peroxidation, leukocyte-associated cyclooxygenase 2 expression, and prostaglandin D2 levels were higher in semen from coronavirus disease 2019 recovered men than in samples from uninfected individuals. While sperm concentration and morphology, ornithine decarboxylase activity, and N-acetylputrescine levels were statistically diminished in semen obtained up to 6 months after coronavirus disease 2019 recovery, these parameters remained unchanged when samples were collected 7-30 months after coronavirus disease 2019 recovery. Coronavirus disease 2019 vaccination did not show negative effects on any of the parameters evaluated.

DISCUSSION AND CONCLUSION

Our work provides insights into the detrimental impact of coronavirus disease 2019 on several sperm parameters, in some cases, even more than a year after SARS-CoV-2 infection, which would be accompanied by alterations in the seminal fluid prostaglandin and polyamine profiles. Therefore, future treatments targeting the prostaglandin and polyamine pathways in coronavirus disease 2019 recovered men could lead to a successful reinstatement of semen parameters.

The Effectiveness of Time in Treatment with Vitamin C and Broccoli Extract on Cadmium Poisoning in Mice: Histological Changes of Testicular Tissue and Cell Apoptotic Index

The growth rate of reproductive system disorders caused by heavy metals is undeniable. The effect of time and interfering compounds are also of paramount importance. The main objective of this study was to compare the effects of broccoli extract and vitamin C in the context of cadmium poisoning on various reproductive parameters in mice, with a specific focus on the influence of time. A total of one hundred and forty-four male mice were randomly assigned to six groups. The control (C) group received only water and a standard diet without any interventions. The Cd group received a single intraperitoneal dose of cadmium chloride at 1.5 mg/kg. The cadmium intervention groups were administered broccoli extract at dosages of 100 mg/kg (Cd + B100), 200 mg/kg (Cd + B200), and 300 mg/kg (Cd + B300), respectively. Additionally, the Cd + VC group was treated with cadmium and vitamin C at 200 mg/kg intraperitoneally for a duration of 28 days. At the end of each week (four stages), five animals were randomly chosen from each group. Epididymal sperm were subjected to analysis for sperm parameters, while testicular tissue sections were examined for histological studies, apoptosis index, and markers of oxidative stress. The influence of time on body and testis weight gain was notably significant in the Cd + B300 and Cd + VC groups (p = 0.001). In all groups, except for Cd + B100, there were marked increases in spermatogenic cell lines and the Johnson coefficient compared to the Cd group (p = 0.001). These changes were particularly pronounced in the Cd + VC and Cd + B300 groups with respect to time (p < 0.001). Furthermore, there was a discernible positive impact of time on sperm count in the high-dose broccoli and vitamin C groups, although this effect did not reach significance in terms of sperm motility and vitality. Over time, the levels of superoxide dismutase (SOD) and catalase (CAT) enzymes increased, while malondialdehyde (MDA) levels decreased in the Cd + VC, Cd + B200, and Cd + B300 groups (p = 0.001). The apoptosis index in testicular tissue reached its highest level in the Cd group and its lowest level in the Cd + B300 and Cd + VC groups during the fourth week (p < 0.05). Linolenic acid, indole, and sulforaphane were identified as the most potent compounds in broccoli during this intervention. Consequently, vitamin C and broccoli extract at a dosage of 300 mg/kg demonstrated significant enhancements in reproductive performance in cases of cadmium poisoning. Overall, the influence of time significantly amplified the process of spermatogenesis and sperm production, with no observable changes in sperm viability and motility.

Influence of Age, Obesity, Smoking, Sleep duration, and Sleep Quality on Concentration, Morphology, and Sperm Motility: A Cross-Sectional Study

BACKGROUND

Age, smoking, sleep duration, sleep quality, and obesity are risk factors that can affect the amount of sperm concentration, morphology, and motility. The aim of this study is to assess the lifestyle effects: of age, smoking, sleep duration, sleep quality, and obesity on the amount of concentration, morphology, and motility of sperm.

MATERIALS AND METHODS

The study utilized an analytical observational approach with a cross-sectional design. The study subjects comprised 70 male partners of infertile couples admitted to the Sekar Fertility Clinic at the Dr. Moewardi General Hospital between March and August 2022. The study assessed variables including age, body mass index (BMI), smoking status, sleep duration, sleep quality, sperm concentration, sperm morphology, and sperm motility. Furthermore, the data were analyzed using univariate, bivariate, and multivariate methods with SPSS 25 software.

RESULTS

The research findings demonstrate that obesity is significantly associated with abnormal sperm concentration [odds ratio (OR)=40.07, confidence interval (CI)=3.90-411.67, P=0.002]. Furthermore, moderate or heavy smoking is significantly associated with abnormal sperm concentration (OR=17.45, CI=1.83-166.15, P=0.013) and sleep quality with severe disorders (OR=5.73, CI=1.12-29.21, P=0.036). Moreover, obesity is significantly associated with abnormal sperm motility (OR=12.97, CI=2.66-63.15, P=0.002), while moderate or heavy smoking (OR=5.89, CI=1.23- 28.20, P=0.026) and poor sleep duration (OR=6.21, CI=1.43-26.92, P=0.015) also exhibit significant associations with abnormal sperm motility. However, no significant findings were observed regarding sperm morphology.

CONCLUSION

The findings of this study indicate that obesity, moderate or heavy smoking, and sleep quality have statistically significant effects on sperm concentration, while obesity, moderate or heavy smoking, and sleep duration have statistically significant effects on sperm motility. However, no statistically significant influence was observed on sperm morphology. Further research with larger sample sizes and more diverse populations is needed to validate these findings and explore other potential factors that may impact male fertility.

A brief history of technical developments in intracytoplasmic sperm injection (ICSI). Dedicated to the memory of J.M. Cummins

Intracytoplasmic sperm injection (ICSI) is an assisted reproductive technology for treatment of severe male infertility introduced into clinical practice in 1992. This review provides a brief history of the development of ICSI by acknowledging major developments in the field. The review addresses key developments in pre-clinical and early studies, how ICSI compares with in vitro fertilisation, long-term consequences, how the mechanistic approach to ICSI has changed in both manual and semi-automated approaches, and how sperm selection procedures are integrated into ICSI. From the beginnings using animal models in the 1960-1970s, the development of ICSI is a remarkable and transformative success story. Indeed, its broad use (70% of cycles globally) exceeds the need required for treating infertile males, and this remains a controversial issue. There remain questions around the long-term health impacts of ICSI. Furthermore, advances in automation of the ICSI procedure are occurring. An estimated 6million children have been born from the ICSI procedure. With further automation of sperm selection technologies, coupled with automation of the injection procedure, it is likely that the proportion of children born from ICSI will further increase.

High rate of isolated teratospermia in a population of fertile men and the questionable clinical utility of sperm morphology

Objective

To better understand the impact of sperm morphology on fertility by assessing sperm morphology in a population of known fertile men.

Design

A prospective cohort study.

Setting

Fertility center associated with the university.

Patients

Healthy men >18 years of age were recruited to provide one semen sample before a vasectomy appointment scheduled between March 2020 and November 2022. Patients were included in the study when they had at least one biologic child and no history of difficulty achieving pregnancy or fertility procedures.

Interventions

None.

Main Outcome Measures

Sperm morphology.

Results

A total of 68 patients (mean age 36.7 years) were included. Thirty-eight (55.9%) patients had 3% or lower normal sperm morphology, including two patients who had 0 normal morphology. The most common morphologic abnormalities were head-shaped defects (n = 59, 84.3%), followed by coiled tails (n = 14, 20.3%). Count, concentration, motility, and progressive motility were normal in >90% of patients.

Conclusions

More than half (55.9%) of fertile male patients had lower than normal sperm morphology in our study. The results of our study further question the clinical relevance of sperm morphology on fertility outcomes and when the current approach in assessing morphology is too strict.

Impact of Group vs Individual Embryo Culture Strategies on Blastocyst and Clinical Outcomes

Embryo culture is one of the most important steps in an assisted reproduction laboratory. Embryos can be cultured individually, one embryo per media drop, or in groups, culturing several embryos in the same media drop. Due to the controversy generated on this subject, we wondered which embryo culture method would have the best results in terms of quality and blastocyst formation rate. We designed a prospective randomized study comparing two different embryo culture strategies: group and individual embryo culture. The data were obtained from 830 embryos from 103 egg donation treatments. The zygotes were randomized into two groups: individual culture (group 1) or group culture (group 2). The embryos were cultured in 35-µl drops until day 5 when they were classified morphologically. We observed a significant increase in the blastocyst formation rate and in the usable embryo rate in individual culture on day 5 compared to group culture. However, good embryo quality (A/B blastocysts), implantation, and pregnancy rates were similar regardless of the type of embryo-culture. As a conclusion, individual culture may increase blastocyst formation rate and may benefit embryo quality on day 5. Our results support previous reports suggesting that individual culture could improve embryo development.

Histopathological evaluation of infertility: Lessons from laboratory rodents

Infertility is a growing challenge globally with emerging risk factors. There are effective laboratory tests to evaluate infertility in humans, nevertheless, some measures, especially histopathological evaluations, are invasive due to the pain inflicted when accessing the reproductive organs and obtaining samples; hence, their relevance may be limited in humans. However, these histopathological evaluations provide essential information on the etiopathogenesis of infertility and the likely mechanisms of action of potential therapeutic candidates. Also, non-invasive methods are available, such as the assay of testosterone in the blood and semen analysis, both of which are predictors of testicular functions. This review provides detailed information on the available histopathological investigations of infertility, such as qualitative and quantitative histopathological assessments of gonadal tissues, specific cell counts, and sperm morphology characterization, with a focus on the procedures, interpretation, and pathophysiological basis. Data from the literature revealed that histopathological examinations of the reproductive organs, as well as spermatozoa, are useful in understanding the pathogenesis of incident infertility. Histopathological evaluation may range from basic hematoxylin and eosin stains to some special stains. Also, histopathological findings (such as spermatogenic cells and planimetric variables, like seminiferous tubule diameter and theca cell and corpus luteum thickness) may be quantified and analyzed for comparison. Some skill is required for these investigations, which may be a limiting factor; however, they are important tools in translational medicine.

Spermbots and Their Applications in Assisted Reproduction: Current Progress and Future Perspectives

Sperm quality is declining dramatically during the past decades. Male infertility has been a serious health and social problem. The sperm cell driven biohybrid nanorobot opens a new era for automated and precise assisted reproduction. Therefore, it is urgent and necessary to conduct an updated review and perspective from the viewpoints of the researchers and clinicians in the field of reproductive medicine. In the present review, we first update the current classification, design, control and applications of various spermbots. Then, by a comprehensive summary of the functional features of sperm cells, the journey of sperms to the oocyte, and sperm-related dysfunctions, we provide a systematic guidance to further improve the design of spermbots. Focusing on the translation of spermbots into clinical practice, we point out that the main challenges are biocompatibility, effectiveness, and ethical issues. Considering the special requirements of assisted reproduction, we also propose the three laws for the clinical usage of spermbots: good genetics, gentle operation and no contamination. Finally, a three-step roadmap is proposed to achieve the goal of clinical translation. We believe that spermbot-based treatments can be validated and approved for in vitro clinical usage in the near future. However, multi-center and multi-disciplinary collaborations are needed to further promote the translation of spermbots into in vivo clinical applications.

Effects of long and short ejaculatory abstinence on sperm parameters: a meta-analysis of randomized-controlled trials

Purpose

This study aimed to investigate the effects of ejaculatory abstinence on sperm parameters.

Methods

This analysis was registered in PROSPERO (CRD42023472124). We performed a search on PubMed using the following text terms: (("sperm parameters" OR "sperm analysis" [Mesh]) AND ("sperm DNA fragmentation" OR "DNA fragmentation" [Mesh]) AND ("sexual abstinence" [Mesh] OR "abstinence")) and an advanced search in Scopus using the terms ("sperm parameters" OR "sperm parameters" OR "DNA fragmentation") AND ("abstinence"). The sperm parameters that were investigated were sperm volume, total sperm motility, progressive sperm motility, sperm concentration, sperm morphology, and sperm DNA fragmentation (SDF). A two-day cut-off as a "short" or "long" abstinence period has been defined.

Results

Thirteen studies published between 2013 and 2022 were included in this meta-analysis. A total of 2,315 patients, ranging from 6 to 836 from each cohort, were enrolled in the study. We showed that longer abstinence time was associated with greater sperm concentration (mean difference [MD]: 8.19; p <0.01), sperm volume (MD: 0.96; p <0.01), and higher SDF (MD: 3.46; p <0.01), but lower progressive sperm motility (MD: -1.83; p <0.01). Otherwise, no statistically significant difference was observed in patients with longer vs. shorter abstinence times regarding total sperm motility (MD: -1.83; p = 0.06). Meta-regression analysis showed that days of abstinence were positively and linearly related to sperm concentration (slope: 3.74; p <0.01) and SDF (slope: 0.65; p = 0.044).

Conclusions

According to our data, short ejaculatory abstinence is associated with better sperm quality. Indeed, a higher percentage of progressive sperm motility and lower levels of SDF have been reported in a short abstinence cohort. In contrast, the long abstinence group reported a higher sperm concentration.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023472124.

The Influence of Lifestyle on Male Fertility in the Context of Insulin Resistance-Identification of Factors That Influence Semen Quality

Background: Male fertility is known to have been negatively influenced by the progress of civilization. Another condition whose incidence has been on the increase for the same reason is insulin resistance (IR). In addition, men increasingly often resign from the pursuit of active forms of leisure, preferring more sedentary ones. Considering these trends, this aim of this study was to investigate the relationships between lifestyle factors, insulin resistance, and male fertility in men with and without the condition. A further aim was to select those lifestyle factors that would make it possible to predict the level of male fertility, especially when IR is concerned. Methods: This study was performed in a group of 73 participants, divided into groups based on their insulin resistance status. Their physical activity, diet, perceived stress, sleep quality, libido level, and duration of sexual abstinence were assessed on the basis of a number of parameters, including indices proposed by the authors. In addition, relevant anthropometric measurements were taken and tests related to glucose metabolism and semen quality were carried out. On the basis of these data, statistical tests were performed to establish or disprove relationships between lifestyle choices and semen quality, as measured my sperm motility. Results: The results of this study highlighted the associations between a number of parameters, i.e., micronutrient and vitamin intake, diet quality, body composition, insulin resistance, and the duration of sexual abstinence, and semen quality, as measured by sperm motility. Significantly, the presence or absence of IR was linked to male fertility. A multivariate model was developed, incorporating parameters such as the Matsuda index, vitamin intake, and sexual abstinence duration, to predict motility scores. Conclusions: This study underscores the negative impact of modern civilization's lifestyle choices on male fertility. Notably, vitamin and mineral consumption, especially from antioxidant-rich diets like the Mediterranean diet, emerged as key modifiable factors affecting fertility. Routine diagnostics for insulin resistance in fertility-related interventions is recommended. This study also highlights the importance of considering sexual abstinence duration during semen collection for accurate diagnostic results. Future research should focus on validating the proposed multivariate model and exploring the effects of lifestyle modifications, particularly vitamin supplementation, on fertility outcomes in men, especially in the context of IR.

Effects of Reactive Oxygen and Nitrogen Species on Male Fertility

Significance: In recent decades, male fertility has been severely reduced worldwide. The causes underlying this decline are multifactorial, and include, among others, genetic alterations, changes in the microbiome, and the impact of environmental pollutants. Such factors can dysregulate the physiological levels of reactive species of oxygen (ROS) and nitrogen (RNS) in the patient, generating oxidative and nitrosative stress that impairs fertility. Recent Advances: Recent studies have delved into other factors involved in the dysregulation of ROS and RNS levels, such as diet, obesity, persistent infections, environmental pollutants, and gut microbiota, thus leading to new strategies to solve male fertility problems, such as consuming prebiotics to regulate gut flora or treating psychological conditions. Critical Issues: The pathways where ROS or RNS may be involved as modulators are still under investigation. Moreover, the extent to which treatments can rescue male infertility as well as whether they may have side effects remains, in most cases, to be elucidated. For example, it is known that prescription of antioxidants to treat nitrosative stress can alter sperm chromatin condensation, which makes DNA more exposed to ROS and RNS, and may thus affect fertilization and early embryo development. Future Directions: The involvement of extracellular vesicles, which might play a crucial role in cell communication during spermatogenesis and epididymal maturation, and the relevance of other factors such as sperm epigenetic signatures should be envisaged in the future.

Correlation of Dietary Macro- and Micro-Mineral Intake with Seminal Plasma Quality/Quantity and Oxidant/Antioxidant Status in Infertile Compared to the Normal Men: a Case-Control Study

Male infertility is a global public health issue, but studies on the correlation between the dietary components and sperm quality showed inconclusive results due to the heterogeneous population with different dietary habits and environmental stimuli. Herein, the correlation of dietary macro- and micro-mineral intake was evaluated with quality/quantity and oxidant/antioxidant status of seminal fluid in infertile compared to the healthy men. One hundred twenty men attending to the infertility clinic of Ayatollah Mousavi Hospital in Zanjan City were enrolled. Seminal fluid was extracted, and groups were categorized into the infertile (non-standard) and normal (standard) groups based on the WHO, 2020 criteria. Food frequency questionnaire was completed. Seminal malondialdehyde (MDA) and total antioxidant capacity (TAC) were measured by ELISA kit based on the manufacture's instruction. An independent sample t-test was used to determine differences between the two groups, and linear regression model was used to determine the effect of each dietary macro/micro mineral intake on these parameters. Adjusting for all parameters, dietary selenium increased 3.7-folds the seminal TAC level (p=0.04) and decreased sperm with non-progressive motility by 2.4-folds (p=0.04). Higher manganese intake increased the sperm count by 7.8-folds (p=0.005). Dietary copper decreased sperm vitality and increased sperm with slow motility (OR= -1.7, 95% CI= -59.8, -9.9; p=0.007). Dietary zinc (OR=1.24, p=0.01) and iron (OR=1.5, p=0.02) showed a positive effect on sperm vitality. None of macro and micro minerals showed a significant effect on the seminal MDA level. Daily intake of adequate amounts of micro and macro minerals improves sperm quality and increases the antioxidant capacity of the seminal fluid; however, copper showed a negative correlation that must be evaluated in future studies.

Are they functional hypogonadal men? Testosterone serum levels unravel male idiopathic infertility subgroups

PURPOSE

To evaluate total testosterone distribution in male idiopathic infertility.

METHODS

A retrospective, real-world case-control clinical study was conducted. Cases consisted of men evaluated for couple infertility, specifically those with alterations in semen parameters and normal gonadotropin levels, and after excluding all known causes of male infertility. Controls were male subjects who underwent semen analysis for screening purposes, without any abnormality detected. The total testosterone distribution was evaluated in cases and controls. Further analyses were performed subgrouping cases according to total testosterone reference threshold suggested by scientific societies (i.e., 3.5 ng/mL).

RESULTS

Cases included 214 idiopathic infertile men (mean age 38.2 ± 6.2 years) and controls 224 subjects with normozoospermia (mean age 33.7 ± 7.5 years). Total testosterone was not-normally distributed in both cases and controls, with positive asymmetric distribution slightly shifted on the left in cases. The rate of subjects with testosterone lower than 3.5 ng/mL was higher in cases (23.8%) than controls (4.5%) (p < 0.001). In cases with testosterone lower than 3.5 ng/mL, a significant direct correlation between testosterone and the percentage of normal morphology sperms was highlighted, also applying multivariate stepwise linear regression analysis (R = 0.430, standard error = 0.3, p = 0.020).

CONCLUSION

Although idiopathic infertile men show by definition altered semen analysis and gonadotropins within reference ranges, testosterone serum levels are widely variable in this population. Approximately a quarter of these patients present some sort of functional hypogonadism. Our data support the need to better classify idiopathic male infertility and total testosterone serum levels could be a supportive parameter in tracing the patient's therapeutic profile.

Evaluating the Use of Selective Serotonin Reuptake Inhibitors (SSRIs) and Male Infertility: A Critical Retrospective Study

Background: The use of selective serotonin reuptake inhibitors (SSRIs) has been associated with potential effects on male fertility, although the exact mechanisms are not fully understood. The aim of this study was to understand the relationship between SSRIs and male infertility; Methods: A retrospective chart review of Saudi males who were treated with SSRIs and attended an infertility clinic in KSMC was undertaken. The medical records of men from an infertility clinic were reviewed to screen the quality of the sperm parameters in patients taking SSRIs; Results: In total, 299 men were identified, of whom 29 (9.6%) were exposed to SSRIs, while 270 (90.4%) did not receive SSRIs, defined as the control infertile group. When comparing the mean ages, a notable disparity was observed between the control group of infertile men (34.2 ± 6.9 years) and the infertile group using SSRIs (41.5 ± 3.2 years) (p < 0.001). Regarding the sperm analysis and the use of SSRIs, the impact of SSRIs use showed no significant differences in sperm liquefaction (p = 0.1), motility (p = 0.17), viscosity (p = 0.16), or count (p = 0.069) with escitalopram, fluoxetine, or paroxetine use; Conclusions: Our study showed no significant difference in the sperm analysis between the SSRI and non-SSRI cohorts. However, the relationship between SSRI use and sperm count warrants further investigation and consideration in clinical practice.

Enhancing Fertility: A Case Report of the Frozen Platelet-Rich Plasma Therapy for Thin Endometrium and Poor Ovarian Reserve

A 33-year-old female patient was assessed for primary infertility due to thin endometrium and poor ovarian reserve (POR). The effectiveness of platelet-rich plasma (PRP) therapy was evaluated in terms of thickening the endometrium and enhancing implantation. The patient also had a history of four intrauterine inseminations and one intracytoplasmic sperm injection (ICSI), along with low anti-Müllerian hormone (AMH) and high follicle-stimulating hormone levels which showed POR. Gonadotropins are given to enhance follicular growth, while agonists and antagonists are given to prevent premature luteinizing hormone surge and suppress the top axis. During the first oocyte pick-up (OPU), five oocytes were retrieved. ICSI was done to make fertilization easier. On day 5, the embryos had degraded from their initial high quality. The patient was advised to undergo treatment with PRP. The endometrial thickness was significantly thicker, raising the chance of implantation. The second OPU was scheduled, resulting in the retrieval of 14 oocytes on the same day ICSI was performed. High-quality blastocysts (4AA) were produced and transferred during embryo transfer, and the patient tolerated the procedure well. The clinical success of the pregnancy outcome was confirmed by another beta-human chorionic gonadotropin test.

Cumulus matrix selection leads to isolation of spermatozoa with better motility, morphology, and lower DNA fragmentation

The objective of this study was to compare the motility, morphology, and levels of DNA fragmentation of spermatozoa subjected to conventional swim-up or cumulus matrix (CM) sperm selection. Semen samples were collected from 60 normozoospermic men at a private hospital between December 2021 and March 2022. After liquefaction, semen samples were separated into two portions - one part was subjected to conventional swim-up preparation and the remaining spermatozoa were subjected to CM selection. The CM was obtained by mechanical isolation from healthy donor oocytes. Semen analysis and evaluation of sperm were performed according to WHO 6th Edition Laboratory Manual and Kruger's strict criteria, respectively. Sperm DNA fragmentation (SDF, %) of the two preparations was evaluated using Halosperm G2 detection kit (Halotech, Madrid, Spain). Wilcoxon rank-sum test was used to compare the characteristics of spermatozoa obtained by the two preparations. Spermatozoa selected by CM showed significantly better rapidly progressive motility (43.5% vs. 30.6%, respectively, p<0.001), higher percentage of morphologically normal forms (14.0% vs. 9.0%, respectively, p<0.05), and lower levels of SDF (26.0% vs. 45.0%, p<0.05) in comparison to those prepared by conventional swim-up. Moreover, the incidence of multiple sperm defects was considerably lower in the samples that underwent CM selection compared to those that did not (30.0% vs. 49.0%, respectively, p<0.05).The selection by CM significantly increases sperm motility and reduces morphologically abnormal spermatozoa and DNA fragmentation rates in comparison to the conventional swim-up preparation. The application of this selection technique may increase chances of successful IVF outcomes.

Success in Parenthood: The In Vitro Maturation Breakthrough in Infertility

This case report revolves around a 37-year-old woman and her 39-year-old husband, who have been married for seven years and were seeking treatment for infertility. The husband has been diagnosed with asthenozoospermia for the past six years and has been on continued medication, and the woman has been diagnosed with polycystic ovarian syndrome (PCOS). To improve fertility outcomes, this case report enlightens the treatment and medical strategy for people with PCOS. Treatment included low-dose ovarian stimulation for the removal of immature eggs, and then in vitro maturation (IVM) of those oocytes was done. Later, intracytoplasmic sperm injection (ICSI) was performed to form the blast. The formed blasts were later cryopreserved till embryo transfer. This case report highlights the importance of preventing the risk of ovarian hyperstimulation syndrome (OHSS) in patients with PCOS.

Genome and Epigenome Disorders and Male Infertility: Feedback from 15 Years of Clinical and Research Experience

Infertility affects around 20% of couples of reproductive age; however, in some societies, as many as one-third of couples are unable to conceive. Different factors contribute to the decline of male fertility, such us environmental and professional exposure to endocrine disruptors, oxidative stress, and life habits with the risk of de novo epigenetics dysregulation. Since the fantastic development of new "omes and omics" technologies, the contribution of inherited or de novo genomes and epigenome disorders to male infertility have been further elucidated. Many other techniques have become available to andrology laboratories for the investigation of genome and epigenome integrity and the maturation and the competency of spermatozoa. All these new methods of assessment are highlighting the importance of genetics and epigenetics investigation for assisted reproduction pathology and for supporting professionals in counselling patients and proposing different management strategies for male infertility. This aims to improve clinical outcomes while minimizing the risk of genetics or health problems at birth.

Sperm morphology by strict criteria does not predict clinical pregnancy rate following intra-uterine insemination

Objective

To determine the impact of abnormal sperm morphology of the pre-washed semen sample on the day of intrauterine insemination (IUI) on clinical pregnancy rates (CPR).

Design

Cross sectional retrospective chart review.

Setting

Academic fertility center.

Patients

Couples undergoing (IUI) from May 2014 to March 2022.

Interventions

Sperm morphology, by strict criteria, on the pre-washed IUI sample.

Main outcomes Measures

To determine the association of sperm morphology with CPR.

Results

Semen analysis reports, including Kruger strict criteria for morphology from the pre-washed IUI sample, were reviewed for 1,059 cycles, comprising 825 total treated couples.Of the total 1,059 cycles,15.1% resulted in clinical pregnancy. When categorized by strict morphology ≥4% (normal morphology), (3%-2%) [mild-moderate teratozoospermia (TZS)], and ≤1% (severe TZS), the CPR was 16%, 13%, and 10%, respectively (p value 0.30). Early spontaneous miscarriage rate was 4% and when stratified by morphology ≥4% (3%-2%), and ≤1%, was 3%, 1%, and 0%, respectively (p value 0.20).In couples with isolated TZS, the pregnancy rate was 16% in the normal morphology group, 14% in the mild-moderate group, and 8% in the severe group. (p value 0.30).In the multivariate logistic regression, sperm morphology, mild/moderate TZS vs normal forms (OR = 0.99, 95% CI [0.94-1.1]), severe TZS vs normal forms (OR = 0.98, 95% CI [0.0.83-1.1]), was not a predictor of CPR. The Pre-wash TMSC (OR = 1.0, 95% CI [0.996-1.00]) was also not predictive of CPR.The only predictive factor of CPR in IUI was the PWTMSC (OR = 1.03, 95%CI [1.00-1.06).

Conclusions

The morphology of the pre-washed sample on the day of IUI did not find a difference in CPR, neither in miscarriage rate following IUI, in couples with normal or abnormal sperm morphology, including severe TZS.Mild, moderate, or severe TZS in the semen sample should not exclude couples to attempt an IUI procedure.

Aggressive sperm immobilization improves reproductive outcomes in patients with suboptimal semen parameters and previous ICSI fertilization failure

Intracytoplasmic sperm injection (ICSI) is the most effective procedure to resolve male infertility, enhancing overall fertilization and pregnancy outcomes. However, it is important to note that fertilization failure (FF) can still occur in a few cases after ICSI. This study aims to introduce a specialized technique of aggressive sperm immobilization for ICSI and evaluate its impact on reproductive outcomes in cases involving prior fertilization failure. All infertile couples with male partners having suboptimal semen samples and previous ICSI fertilization failure were evaluated using retrospective data from National Taiwan tertiary university hospital (NTUH) between January 2016 and February 2022. Fertilization failure in our study was defined as less than 30% fertilization rate (FR, the number of normally fertilized oocytes divided by the total number of injected mature oocytes). Data involving both standard (routine procedure) and aggressive sperm immobilization (SI) techniques during different ICSI cycles were included in this study. Standard and aggressive SI methods were performed by compressing the distal half tail of the spermatozoa ≦ 5 and 15 times prior to ICSI respectively. Generalized estimating equations analysis were applied to compare the clinical outcomes between two procedures. Overall, data from 23 infertile couples who had undergone 65 ICSI cycles (31 standard SI with low fertilization rate and 34 aggressive SI) were included in the study. The average FR in the ICSI cycles with standard SI and aggressive SI were 23.6 ± 23.1% and 49.5 ± 31.8 respectively (P = 0.0002). The majority of embryos were transferred at the day 3 stage, with an average number transferred of 2.6 ± 0.9 in the aggressive SI group and 1.9 ± 0.9 in the standard group. The number of embryos transferred per transfer cycle was higher in the aggressive SI (P = 0.015), whereas the number of good-quality embryos was similar between the two procedures (P = 0.44). There were one and seven live births from the standard SI cycles and aggressive SI cycles respectively. In conclusion, aggressive SI was associated with a significantly higher FR, resulting in more available embryos for transfer without compromising embryo quality. Therefore, this specialized technique improved pregnancy outcome among infertile couples with a previous ICSI-FF. It can be a safe, economic, and effective method to improve the assisted reproductive technologies outcomes for infertile patients affected by previous ICSI-FF.

Overcoming Infertility Challenges: A Case Report on the Management of Ovarian Endometriomas and Successful Pregnancy With Intracytoplasmic Sperm Injection and Platelet-Rich Plasma Perfusion

Endometriosis and infertility are clinically associated. The therapeutic approaches for endometriosis, whether medical or surgical, yield distinct outcomes for a woman's potential for achieving conception, whether through natural means or with the aid of assisted reproductive technology (ART). In this case report, a 29-year-old female and her 32-year-old partner, married for the last five years, sought assistance at our fertility clinic after having one failed in vitro fertilization (IVF) cycle. The patient had a history of dysmenorrhea and deep dyspareunia, suggesting the presence of an ovarian cyst. Transabdominal ultrasound and laparoscopy confirmed the existence of ovaries with adhesions and a chocolate cyst measuring 8 cm × 6 cm in dimensions. Cystectomy of ovarian endometriomas enhances the rate of spontaneous conception and reduces pain. Moreover, it has the potential to enhance the outcome of IVF. The successful outcome achieved through ART, specifically the intracytoplasmic sperm injection cycle, underscores the importance of technological advancements in overcoming infertile barriers. This case report exemplifies the personalized and innovative approaches available to couples undergoing fertility treatment.

Unravelling the epigenetic impact: Oxidative stress and its role in male infertility-associated sperm dysfunction

Male infertility is a multifactorial condition influenced by epigenetic regulation, oxidative stress, and mitochondrial dysfunction. Oxidative stress-induced damage leads to epigenetic modifications, disrupting gene expression crucial for spermatogenesis and fertilization. Paternal exposure to oxidative stress induces transgenerational epigenetic alterations, potentially impacting male fertility in offspring. Mitochondrial dysfunction impairs sperm function, while leukocytospermia exacerbates oxidative stress-related sperm dysfunction. Therefore, this review focuses on understanding these mechanisms as vital for developing preventive strategies, including targeting oxidative stress-induced epigenetic changes and implementing lifestyle modifications to prevent male infertility. This study investigates how oxidative stress affects the epigenome and sperm production, function, and fertilization. Unravelling the molecular pathways provides valuable insights that can advance our scientific understanding. Additionally, these findings have clinical implications and can help to address the significant global health issue of male infertility.

Relationship between dietary glycemic index and glycemic load and sperm-quality parameters in Iranian men: a cross-sectional study

BACKGROUND

Infertility is a major clinical problem with psychological, financial and medical costs. Male infertility has recently been linked to 50% of childless couples. It is worth mentioning that diet and its components can be manipulated and applied in counseling meetings of infertile men as a modifiable factor. The goal of this study was to determine the correlation of dietary glycemic index (GI) and glycemic load (GL) with sperm-quality parameters in Iranian men.

MATERIALS AND METHODS

In this cross-sectional study which was carried from Aug to Nov 2023, after excluding smokers, 322 men who were attending the IVF clinic of Ayatollah Mousavi Hospital for seminal analysis were enrolled. Dietary intake was completed by an expert dietitian through face-to-face interviews with a validated 168-item food frequency questionnaire (FFQ). In the present study, sperm-quality parameters, including motility, concentration, normal morphology, vitality, DNA fragmentation index (DFI), and chromatin maturation of sperm, were analyzed. The relationship between dietary GI and CL and these parameters was assessed.

RESULTS

Adjusting for the baseline variables, dietary GI and GL showed positive and negative associations with sperm progressive motility, respectively (p = 0.01 and p < 0.001). Higher dietary GI was associated with lower (p = 0.03); however, a higher dietary GL was associated with higher immotile sperm (p < 0.001). A higher dietary GI was associated with a 77% higher sperm count (p = 0.003). In contrast, higher dietary GL was associated with a lower count (p < 0.001). Higher dietary GI and GL were associated with higher and lower percentages of sperm with normal morphology by 70% and 40%, respectively (p < 0.001 in both). A higher dietary GL was associated with an increase in sperm vitality and DFI of 33% and 53%, respectively (p < 0.001). Higher dietary GI showed a significant negative effect on sperm DFI (p = 0.009). Dietary GI and GL showed significant positive and negative effects on SCMA, respectively (p = 0.002 and p < 0.001).

CONCLUSION

A diet with a higher GI showed beneficial effects on more parameters of sperm; however, higher dietary GL showed deleterious effects, except sperm vitality and SCMA. More studies are needed to obtain a concise result.

Updates in the pathophysiology of COVID-19 infection in male reproductive and sexual health: a literature review

This extensive comprehensive review explores the impact of the Coronavirus disease 2019 (COVID-19) pandemic on men's sexual and reproductive health. We conducted a literature review focusing on the possible pathophysiology by which severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) affects men's sexual and reproductive systems. We reviewed most of the studies that reported the impact of SARS-CoV-2 infection on the Testicular, Epididymal, Prostatic, and Penile tissue. Also, we focused on evaluating the SARS-CoV-2 infection on semen parameters and male reproductive hormones. Finally, we reviewed the COVID-19 vaccine's effect on male reproductive and sexual health. Findings revealed the adverse consequences of SARS-CoV-2 at cellular and organ levels on the male genital tract. However, the reported data are still controversial. The initial data regarding COVID-19 vaccination was promising promoted safety for men's reproductive and sexual health. We conclude this paper by offering recommendations to address these adverse consequences and potentially improve sexual and reproductive health among men in the post-COVID-19 pandemic era.

Associations between Sperm Epigenetic Age and Semen Parameters: An Evaluation of Clinical and Non-Clinical Cohorts

The well-documented relationship between chronological age and the sperm methylome has allowed for the construction of epigenetic clocks that estimate the biological age of sperm based on DNA methylation, which we previously termed sperm epigenetic age (SEA). Our lab demonstrated that SEA is positively associated with the time taken to achieve pregnancy; however, its relationship with semen parameters is unknown. A total of 379 men from the Longitudinal Investigation of Fertility and Environment (LIFE) study, a non-clinical cohort, and 192 men seeking fertility treatment from the Sperm Environmental Epigenetics and Development Study (SEEDS) were included in the study. Semen analyses were conducted for both cohorts, and SEA was previously generated using a machine learning algorithm and DNA methylation array data. Association analyses were conducted via multivariable linear regression models adjusting for BMI and smoking status. We found that SEA was not associated with standard semen characteristics in SEEDS and LIFE cohorts. However, SEA was significantly associated with higher sperm head length and perimeter, the presence of pyriform and tapered sperm, and lower sperm elongation factor in the LIFE study (p < 0.05). Based on our results, SEA is mostly associated with defects in sperm head morphological factors that are less commonly evaluated during male infertility assessments. SEA shows promise to be an independent biomarker of sperm quality to assess male fecundity.

Protamine 2 and phospholipase C zeta 1 are possible biomarkers for the diagnosis of male subfertility in frozen-thawed stallion semen

Subfertility is one of the main issues in horse breeding and the study of mRNAs in sperm might help in elucidating the reasons that lead to this diagnosis. The present study aims at assessing the differences in the expression of 10 potential candidate genes in stallions of different fertility. Frozen-thawed semen of 29 stallions was included. Each sample was classified into two groups according to pregnancy rates (PR) achieved with this semen: "good fertility" (GF; n = 17; PR ≥ 30 %) or "poor fertility" (PF; n = 12; PR <20 %). All stallions underwent a breeding soundness examination (BSE) before semen production and were only included into the semen cryopreservation program when raw semen characteristics at BSE met minimal requirements. Semen was cryopreserved following European Union regulations and all stallions met the respective health requirements. Each sample was assessed for concentration (NucleoCounter SP-100), motility (CASA), membrane functionality (SYBR-14/PI), mitochondrial membrane potential (JC-1), morphology (SpermacStain), acrosome integrity (SpermacStain), membrane integrity (HOS test) and chromatin integrity (Aniline blue). Sperm RNAs were extracted using the Direct-zol RNA Miniprep Kit (Zymo Research) and RT-qPCR was performed for each target gene. ACTB and RPL32 were included as reference genes (RGs) for normalization. For each variable of each group, mean, standard deviation and SEM were calculated. The difference in gene expression levels between the GF and PF group were analyzed using the Mann-Whitney U test and Spearman's rank correlation. Significant results were considered with p < 0.05. Sperm quality parameters did not differ significantly between the two groups except for concentration, that was significantly higher in GF (p = 0.043). In GF a positive correlation was identified for PRM1/PRM2 with r = +0.6, while PRM1/ACR (r = -0.495), PRM2/ZPBP (r = -0.645) and CRISP3/ACR (r = -0.551) were inversely correlated. In PF direct correlations were registered for PRM1/PRM2 (r = +0.629), PRM1/PRM3 (r = +0.657), PRM2/SPA17 (r = +0.685), SPA17/PLCZ1 (r = +0.786) and PRM3/ACR (r = +0.627). In the total sample (GF + PF), positive correlations were detected for PRM1/PRM2 (r = +0.625), PRM1/PRM3 (r = +0.368); PRM2/SPA17 (r = +0.465), SPA17/PLCZ1 (r = +0.637) and PLCZ1/ZAN (r = +0.587). Only two of the genes considered were differentially expressed in the 2 groups: PRM2 and PLCZ1, that were significantly (p < 0.05) overexpressed in the GF group. Stallions frozen-thawed semen with higher expression levels of PRM2 and PLCZ1 are more likely to belong to animals with a good pregnancy rate. Further studies are needed to investigate the role of sperm transcripts in male subfertility in stallions.

Frequency, morbidity and equity - the case for increased research on male fertility

Currently, most men with infertility cannot be given an aetiology, which reflects a lack of knowledge around gamete production and how it is affected by genetics and the environment. A failure to recognize the burden of male infertility and its potential as a biomarker for systemic illness exists. The absence of such knowledge results in patients generally being treated as a uniform group, for whom the strategy is to bypass the causality using medically assisted reproduction (MAR) techniques. In doing so, opportunities to prevent co-morbidity are missed and the burden of MAR is shifted to the woman. To advance understanding of men's reproductive health, longitudinal and multi-national centres for data and sample collection are essential. Such programmes must enable an integrated view of the consequences of genetics, epigenetics and environmental factors on fertility and offspring health. Definition and possible amelioration of the consequences of MAR for conceived children are needed. Inherent in this statement is the necessity to promote fertility restoration and/or use the least invasive MAR strategy available. To achieve this aim, protocols must be rigorously tested and the move towards personalized medicine encouraged. Equally, education of the public, governments and clinicians on the frequency and consequences of infertility is needed. Health options, including male contraceptives, must be expanded, and the opportunities encompassed in such investment understood. The pressing questions related to male reproductive health, spanning the spectrum of andrology are identified in the Expert Recommendation.

Implications of Progestin-Primed Ovarian Stimulation (PPOS) in a Patient With Diminished Ovarian Reserve (DOR) and Its In Vitro Fertilization (IVF) Outcome

In this case study, a 39-year-old woman pursuing treatment for secondary infertility at our infertility clinic was visited by her 42-year-old husband. The couple had a history of failed attempts, including two intrauterine insemination (IUI), two intracytoplasmic sperm injection (ICSI) cycles, and two miscarriages. Diminished ovarian reserve (DOR) was noted in the patient's medical profile. A gonadotropin-releasing hormone (GnRH) antagonist, cetrorelix acetate, was given to the patient at a daily dosage of 0.25 mg to treat their condition once the maturing follicle had grown to a diameter of 10 mm. Following the administration of the GnRH antagonist, the first oocyte pick-up (OPU) procedure was conducted. During this process, two oocytes were successfully retrieved. Subsequently, ICSI was performed to facilitate fertilization. However, during the fertilization check, it was observed that no pronuclear fertilization (PN) formations occurred, leading to a cessation of development. Following the initial failure, an ovarian stimulation strategy based on progestin priming was implemented. Progestin is administered using this technique to ready the endometrium for the implantation of the embryo. After the modified ovarian stimulation protocol, an additional beta-human chorionic gonadotropin (β-hCG) test was verified as a successful clinical pregnancy outcome.

A Case Report Based on a Holistic Approach to Improve Assisted Reproductive Technology (ART) Pregnancy Outcomes in a Patient With Thyroid Dysfunction

To address infertility in a 34-year-old woman with hypothyroidism, this case study investigated an integrated holistic therapy approach. The woman presented with primary infertility and sought treatment at an infertility centre in Maharashtra, India. She underwent thorough evaluations for infertility, revealing a history of hypothyroidism. The therapy strategy included a six-month course of 50 mg levothyroxine, along with yoga and yog nidra. The yoga interventions, incorporating techniques such as surya namaskar, kriyas, yoga asanas, and pranayama, proved beneficial for weight management, stress reduction, and overall well-being. The deep relaxation method known as yog nidra played a crucial role in achieving hormonal balance. After six months, the patient's body mass index (BMI) improved from 28 to 24, and the male partner's semen analysis showed results within normal limits. The patient's thyroid-stimulating hormone (TSH) levels also returned to the normal range. Further in-vitro fertilization (IVF) treatment, including a successful embryo transfer, resulted in a positive clinical pregnancy test. This research underscores the effectiveness of alternative therapies like yoga and meditation in conjunction with traditional medicine to address both the psychological and physiological components of infertility caused by hypothyroidism. The case suggests that an integrated approach like this could offer a comprehensive solution for infertile couples. However, for broader applicability, additional investigation and clinical validation are warranted.

Achieving Successful Pregnancy in a Patient With Ovarian Endometriosis Through Assisted Reproductive Technology (ART) Intervention: A Case Report

Endometriosis stands out as the predominant issue among gynecological disorders. Approximately 50% of women experiencing infertility have been observed to be affected by endometriosis. Growing evidence indicates that endometriomas, in isolation, might adversely affect ovarian physiology. Medications such as ethinyl estradiol and levonorgestrel have been found to contribute to the amelioration of ovarian cysts in women of reproductive age. Presently, there are limited alternatives available for addressing the infertility associated with endometriosis. The primary effective approaches for treatment still revolve around surgery and assisted reproductive technology for endometriosis-related infertility. This case study centers on the utilization of ethinyl estradiol and levonorgestrel in patients with ovarian endometrioma, leading to an enhancement in the likelihood of achieving a successful clinical pregnancy.

Insertional Variations of Human Endogenous Virus K6 and K11 in Normozoospermic Men

Male infertility is a multifactorial heterogeneous reproductive disorder in which genetic, epigenetic, and environmental factors play a role in the development of disease. Recent studies have shown that retrotransposon expression alterations may be related to impairment of spermatogenesis. Therefore, in this pilot study, we aimed to investigate whether HERV-K6 and HERV-K11 insertional variations have a role in idiopathic infertility among normozoospermic men. Genomic DNA isolated from the blood samples of 41 infertile normozoospermic and 45 fertile normozoospermic men were analyzed by inter-retrotransposon polymorphism polymerase chain reaction. HERV-K6 variation rates in the infertile and the fertile group were 0-58.3% and 0-53.4%, respectively. The variation rates of HERV-K11 were 0-75.0% in infertile and 0-77.8% in fertile men. The HERV-K6 and HERV-K11 insertion rates of the fertile group were higher than the infertile group (P < 0.0001 and P = 0.007, respectively). The findings of the study suggest that HERV-K6 and HERV-K11 retrotransposon insertion show variation among individuals, and their insertions might be associated with male infertility.

Effect of smoking on methylation and semen parameters

One type of epigenetic modification is genomic DNA methylation, which is induced by smoking, and both are associated with male infertility. In this study, the relationship between smoking and CHD5 gene methylation and semen parameters in infertile men was determined. After the MS-PCR of blood in 224 samples, 103 infertile patients (62 smokers and 41 non-smokers) and 121 fertile men, methylation level changes between groups and the effect of methylation and smoking on infertility and semen parameters in infertile men were determined. The results showed that there is a significant difference in the methylation status (MM, MU, UU) of the CHD5 gene between the patient and the control group, and this correlation also exists for the semen parameters (p < .001). The average semen parameters in smokers decreased significantly compared to non-smokers and sperm concentration was (32.21 ± 5.27 vs. 55.27 ± 3.38), respectively. MM methylation status was higher in smokers (22.5%) compared to non-smokers (14.6%). Smoking components affect the methylation pattern of CHD5 gene, and smokers had higher methylation levels and lower semen parameters than non-smokers, which can be biomarkers for evaluating semen quality and infertility risk factors. Understanding the epigenetic effects of smoking on male infertility can be very useful for predicting negative consequences of smoking and providing therapeutic solutions.

Outcomes comparison of testicular versus ejaculated sperm for intracytoplasmic sperm injection in infertile men with high DNA fragmentation: updated systematic review and meta-analysis

Background

The testicular sperm instead of ejaculated sperm for intracytoplasmic sperm injection (ICSI) in infertile men with high sperm DNA fragmentation (SDF) is a controversial topic. This updated systematic review and meta-analysis aims to evaluate whether couples with high level of SDF will benefit more from intracytoplasmic sperm injection with testicular sperm (Testi-ICSI) as compared to intracytoplasmic sperm injection with ejaculated sperm (Ejac-ICSI).

Methods

A systematic search was conducted according to PRISMA guidelines, using PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials (CENTRAL), encompassing studies from the earliest record until May 2022. We included studies analyzing comparative pregnancy outcomes of testicular versus ejaculated sperm for ICSI in infertile men with high DNA fragmentation. The risks of bias and certainty of evidence were assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, respectively.

Results

Eleven studies were included. Meta-analysis showed that SDF levels revealed a significant difference association [odds ratio (OR) =-25.81; 95% confidence interval (CI): -34.82, -16.81; I2=94%; P<0.00001] between testicular and ejaculated sperm. Compared with Ejac-ICSI, a non-significant tendency was observed for fertilization rates (FRs) in the Testi-ICSI group (OR =0.87; 95% CI: 0.67, 1.12; I2=81%; P=0.28). However, there was significant difference pointing to better outcomes for Testi-ICSI in clinical pregnancy rates (CPRs) (OR =2.36; 95% CI: 1.71, 3.24; I2=0%; P<0.00001), live birth rates (LBRs) (OR =3.10; 95% CI: 2.13, 4.51; I2=4%; P<0.00001) and miscarriage rates (MRs) (OR =0.28; 95% CI: 0.13, 0.60; I2=0%; P=0.001).

Conclusions

Results of this updated meta-analysis reveal that SDF rates are lower in testicular sperm than in ejaculated sperm and that Testi-ICSI is correlated with better clinical outcomes, including higher CPRs, higher LBRs, and lower MRs in infertile males with high SDF levels. Nevertheless, with the overall low to moderate quality of the studies, further well-designed controlled studies are required.