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Recent Advances and Controversies in Diagnosing and Treating Male Infertility

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Recent Advances and Controversies in Diagnosing and Treating Male Infertility Faculty Opinions Faculty Reviews 2020 9:(22) Recent advances and controversies in diagnosing and treating male infertility Rafael F. Ambar 1,2,3 Neel Parekh 1 Ashok Agarwal 1* 1 American Center for Reproductive Medicine, Cleveland Clinic, Cleveland, OH, USA 2 Urology Department of Faculdade de Medicina do ABC - FMABC/Andrology Group at Ideia Fertil Institute of Human Reproduction, Santo André, SP, Brazil 3 Hope Clinic – Fertility Center, Sao Paulo, SP, Brazil Abstract Interest in male infertility has increased, as it plays an important role in up to 50% of couples struggling with infertility, which is an estimated 48.5 million couples globally. Despite recent advances, diagnosing and treating male infertility remain a significant clinical challenge owing to complex multifactorial pathways and the diversity of treatment options. This review will assess current controversial topics on male infertility such as the use of home-based semen testing, management of subclinical varicocele, and recent advances in the field of sperm proteomics. Keywords Home-based sperm testing, Male Infertility, Sperm DNA fragmentation, Proteomics, Varicocele Peer Review The peer reviewers who approve this article are: 1. Larry I. Lipshultz, Scott Department of Urology, Baylor College of Medicine, 6624 Fannin Street, Suite 1700, Houston, TX 77030, USA Competing interests: No competing interests were disclosed. 2. Sidney Glina, Department of Urology, Centro Universitario em Saude do ABC, Santo André, Brazil Competing interests: In June 2020 Sidney Glina published a systematic review on intracytoplasmic sperm injection (https://pubmed.ncbi.nlm.nih.gov/32648379/) with the authors of this Faculty Review (Rafael F. Ambar, Ashok Agarwal, Neel Parekh). 3. Marcelo Vieira, Urology Department, ALFA Clinic, São Paulo, Brazil Competing interests: In May 2019 Marcelo Vieira published an article on Male Oxidative Stress Infertility (https://pubmed.ncbi.nlm.nih.gov/31081299/) with the authors of this Faculty Review (Ashok Agarwal and Neel Parekh). 4. Filipe Tenorio, Department of Surgery, Universidade Federal de Pernambuco, Rua Guilherme Salazar, n 150, apt 601E, Recife, PE, ZIP 52061-275, Brazil; Instituto de Medicina Integral Prof. Fernando Figueira, Rua dos Coelho, 300, Coelhos, Recife, PE, ZIP 50070-902, Brazil Competing interests: No competing interests were disclosed. Faculty Opinions Faculty Reviews 2020 9:(22) *Corresponding authors: Ashok Agarwal ([email protected]) Competing interests: The authors declare that they have no competing interests. Grant information: The authors declare that no grants were involved in supporting this work. Copyright: © 2020 Agarwal A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite this article: Ambar RF, Parekh N and Agarwal A. Recent advances and controversies in diagnosing and treating male infertility. Faculty Reviews 2020 9:(22) https://doi.org/10.12703/r/9-22 Published: 10 Dec 2020, Faculty Reviews 9:(22) https://doi.org/10.12703/r/9-22 Faculty Opinions Faculty Reviews 2020 9:(22) Introduction assay7. Nonetheless, many of these products only assess fertil- Infertility affects roughly 48.5 million couples around the ity potential by measuring sperm concentration, which is only globe1, and male factor infertility may play a role in up to 50% one aspect of the semen analysis. A recent study tested a new of cases, being solely responsible in 20% of cases2. The con- smartphone-based sperm test on its ability to provide motile tinuous search for methods to improve fertility outcomes in sperm concentration. The authors report that the YO Home Sperm infertile couples, combined with evidence of decline in semen Test (Figure 1) can add motility information to the analysis with quality among young healthy men worldwide, has increased a high level of accuracy and precision, allowing it to be a rea- the focus on male infertility1,3. With this expanded interest, sonable option for screening purposes8. The lack of evaluation many new studies have been directed towards male infertility, of other parameters such as morphology, volume, and pH are with an exponential growth in the number of publications4. clear limitations of these methods, but the user-friendly plat- forms and ease of access that these smartphone-based devices In this review article, the most current and significant advances provide are useful tools in appropriately selected cases8. In 2019, in this field will be addressed, focusing on home semen testing, a small and easily portable device integrating autofocus optical a better understanding of oxidative stress (OS) and DNA dam- technology, artificial intelligence (AI) algorithms, electronic age testing, new directions in varicocele repair, and a review engineering, and a mechanical system was studied. The authors of the growing impact of proteomics. have shown that this mini CASA system is reliable and easy to use, providing data on sperm concentration, sperm motil- Recent advances in home-based male infertility tests ity, sperm progressive motility, and seminal pH9. Another recent The study of human reproduction has identified male factor article described the use of a smartphone-based device to assess infertility as an important disease that should not be neglected. advanced sperm tests such as the hyaluronic binding assay and However, approximately 30% of male partners do not undergo sperm DNA fragmentation by the Halosperm test10,11. The authors a complete evaluation prior to the utilization of assisted reported high correlation on the parameters analyzed when reproductive technology (ART)5. Men are more reluctant to compared to conventional analysis, although further tests are seek medical help and frequently struggle with providing a semen required for its validation. sample in a laboratory setting6. Furthermore, clinical conditions such as post-vasectomy reversal or patients undergoing chemo/ Despite the attractive advances in home-based devices, cau- radiotherapy, to name but a few, may require serial semen analy- tion should be taken in regard to patient selection, mainly ses, making patient compliance even more difficult. Therefore, in cases of self-testing, since it may lead to a false sense of home-based semen testing has been developed as a convenient security, potentially delaying medical evaluation. solution to these limitations. Advances and controversies on oxidative stress, Currently, there are several home-based semen analyzers DNA damage, and antioxidants approved by the U.S. Food and Drug Administration (FDA). Sperm DNA fragmentation (SDF) as well as its causes and These devices utilize microfluidics in association with smartphone impact on successful pregnancies are a frequently discussed technology, centrifugation technique, or an immunodiagnostic topic in the field of male infertility. The increased interest in the Figure 1. The Yo® Home Sperm Test Kit. A: Kit box and contents (clip, cups, slide, liquefaction powder, and transfer pipettes). B: assembled YO® clip with inserted testing slide. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©2020. All Rights Reserved. Faculty Opinions Faculty Reviews 2020 9:(22) use of sperm DNA fragmentation and OS testing for diagnos- concentration, total count, and motility in infertile men18. The tic or treatment purposes as well as recent evidence discussed results described above have also been validated in a larger, below led international societies (American Urological Asso- multicenter study, which included 2,092 infertile men, where ciation and European Association of Urology) to acknowledge an ORP of greater than 1.34 mV/106 was found to distinguish the importance of SDF levels in their guidelines12,13. In a novel patients with normal or abnormal semen quality19. The same approach, using scientometric analysis, Baskaran et al.14 showed group conducted a receiver operating characteristic (ROC) a linear increasing trend in the number of publications on SDF analysis and established a cutoff value of 1.42 mV/106 to and ART in the last few decades as well as a larger number of differentiate fertile from infertile semen groups20. publications concerning clinical scenarios related to SDF. In this section, the role of SDF and its association with OS will Assays of sperm DNA integrity are examples of advanced sperm be discussed regarding the diagnosis and treatment of male function tests that have been extensively investigated over the infertility. past decade21. Nevertheless, the variability among the different testing methods, such as terminal deoxynucleotidyl transferase Diagnosis dUTP nick end labeling (TUNEL), Comet, sperm chromatin Recent literature suggests that 30 to 80% of infertile men have structure assay (SCSA), and sperm chromatin dispersion (SCD), elevated seminal reactive oxygen species (ROS) levels. Fur- together with the uncertainty of the nature and type of DNA thermore, the negative effect of OS and sperm DNA damage damage delay the use of these assays on a routine basis. A recent on male fertility has also been demonstrated15,16. Therefore, in review article described the advantages and disadvantages of 2019, Agarwal et al. proposed the terminology “Male Oxidative the most common tests for DNA damage with the cutoff val- Stress Infertility” (MOSI) for patients with abnormal semen ues that have been described for each.
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