• Users Online: 255
  • Print this page
  • Email this page

 
Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 3  |  Page : 125-131

Sperm DNA fragmentation does not affect the clinical outcomes in the cumulative transfers of an ICSI cycle along with blastocyst transfers in couples with normozoospermic male patients


1 Department of Reproductive Medicine and Surgery, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh; Department of Biotechnology, Sri Venkateswara University, Tirupati, Andhra Pradesh, India
2 Department of Biotechnology, Sri Venkateswara University, Tirupati, Andhra Pradesh, India
3 Department of Reproductive Medicine and Surgery, Sri Aurobindo Institute of Medical Sciences, Indore, Madhya Pradesh, India

Date of Submission10-Dec-2021
Date of Decision27-Feb-2022
Date of Acceptance28-Mar-2022
Date of Web Publication31-May-2022

Correspondence Address:
K V Saritha
Department of Biotechnology, Sri Venkateswara University, Tirupati, Andhra Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2305-0500.346090

Rights and Permissions
  Abstract 

Objective: To know whether sperm DNA fragmentation (SDF) affects the clinical outcomes in the cumulative transfers of an intracytoplasmic sperm injection (ICSI) cycle along with blastocyst transfers in couples with normozoospermic males.
Methods: The study included 252 couples who underwent their first ICSI cycles along with blastocyst transfer and whose male partner semen samples were normozoospermic according to the World Health Organization 2010 criteria. All the couples were classified into two groups based on the SDF: the low SDF group (SDF≤30%, n=162) and the high SDF group (SDF>30%, n=90). Clinical as well as laboratory outcomes were correlated between the two groups. Sperm DNA fragmentation was assessed on the post-wash semen samples by acridine orange test. The main outcome measures were the live birth rate and miscarriage rate.
Results: A significant decrease in the live birth rates was observed in the high SDF group compared to the low SDF group in fresh embryo transfer cycles (P<0.05). However, no significant difference was observed in the clinical outcomes either in the frozen embryo transfer cycles or in the overall cumulative transfer cycles (P>0.05). No significant difference was observed in the laboratory outcomes between the two SDF groups. A remarkable decrease in sperm motility was observed in the high SDF group compared to the low SDF group (P<0.05).
Conclusions: Sperm DNA fragmentation does not affect the clinical outcomes in the cumulative transfers of an ICSI cycle along with blastocyst transfers in couples with normozoospermic males.

Keywords: Sperm DNA fragmentation; Intracytoplasmic sperm injection; ICSI; Live birth rates; Blastocyst transfer; Cumulative transfers


How to cite this article:
Repalle D, Saritha K V, Bhandari S. Sperm DNA fragmentation does not affect the clinical outcomes in the cumulative transfers of an ICSI cycle along with blastocyst transfers in couples with normozoospermic male patients. Asian Pac J Reprod 2022;11:125-31

How to cite this URL:
Repalle D, Saritha K V, Bhandari S. Sperm DNA fragmentation does not affect the clinical outcomes in the cumulative transfers of an ICSI cycle along with blastocyst transfers in couples with normozoospermic male patients. Asian Pac J Reprod [serial online] 2022 [cited 2022 Jun 27];11:125-31. Available from: https://www.apjr.net/text.asp?2022/11/3/125/346090




  1. Introduction Top


Infertility affects around 15% of couples of reproductive age[1]. Male factor infertility is estimated to be 40%-50% of infertility cases around the globe, defined by the alteration of at least one of the standard semen parameters recognized by the World Health Organization (WHO)[2]. However, standard semen parameters may not predict the fertility potential of males as around 15% of the infertile men have normal semen parameters according to the WHO reference ranges. Traditional semen analysis cannot predict sperm abnormalities at the DNA level, which may be the reason for the male factor infertility[2].

Newer techniques have been developed to know the sperm at the molecular level. Sperm DNA fragmentation (SDF) assessment by acridine orange test is one of the tests that assess the integrity of the sperm DNA based on the susceptibility of the DNA to denaturation[3]. The acridine orange stain differentiates the sperm with normal double-stranded DNA (green fluorescence) and abnormal denatured or single-stranded DNA (orange-red fluorescence) with the help of metachromatic shift properties of the stain[4],[5]. Acridine orange test is a simple and affordable test for the assessment of DNA integrity in infertile men[4],[5]. Clinical assessments of SDF need to be performed on the total motile fraction of sperm rather than raw ejaculate sperm by acridine orange test, as the raw semen carries a huge number of degenerated and dead sperm with damaged DNA[6].

The mature spermatozoa does not possess the capacity to repair their DNA as transcription and translation are halted. However, oocytes can repair SDF to some extent depending on the oocyte quality[7],[8]. Age swaps the gene expression patterns in cumulus cells which are essential for oocyte quality[9]. In mature human oocytes, genes involved in cell cycle regulation, oxidative stress, and DNA repair are all affected by female age[10]. Hence, female age is one of the crucial factors affecting oocyte quality[11]. The study is mainly aimed to know whether SDF affects the clinical outcomes in the cumulative transfers of an intracytoplasmic sperm injection (ICSI) cycle along with blastocyst transfers in couples with normozoospermic males.


  2. Materials and methods Top


2.1. Study population

A total of 252 couples whose male partners’ semen samples were normozoospermic according to WHO 2010 criteria, undergoing their first ICSI cycles along with blastocyst transfers between February 2017 and December 2019 were included in this study. Patients with altered semen parameters on the day of oocyte pickup, patients with life-threatening diseases, ICSI with vitrified/thawed oocytes, donor oocytes, preimplantation genetic testing, cryopreserved sperm, were excluded from this study.

The causes of infertility were an ovarian factor in 48, tubal factor in 46, endometriosis in 23, polycystic ovary syndrome in 25, unexplained in 45, and mixed in 65 patients. All the patients of ICSI cycles were categorized into two groups based on the SDF rates[3]: 1) the low SDF group (SDF ≤30%, n=162) and 2) the high SDF group (SDF >30%, n=90). Clinical as well as laboratory outcomes were correlated between the two groups.

2.2. Controlled ovarian stimulation

In all patients, controlled ovarian stimulation was attained by recombinant follicle-stimulating hormone (r-FSH) (Recagon, MSD; Gonal-F, Merck) or human menopausal gonadotropin (HMG) (Gynogen, Sanzyme; Materna HMG, Emcure) starting from day 3 of the cycle. The pituitary function was suppressed either by gonadotrophin-releasing hormone (GnRH) agonists (Luprorin, Intas) in long stimulation protocol or GnRH antagonists (Cetrorelix Acetate, Emcure) in antagonist stimulation protocol. Recombinant human chorionic gonadotropin (r-HCG) (Ovidrel, Merck) was administered when three or more follicles reached a diameter of ≥17 mm, and appropriate serum estradiol values were detected. Transvaginal oocyte retrieval was performed 35 h post trigger with HCG [Figure 1].
Figure 1: Flowchart of controlled ovarian stimulation procedure.

Click here to view


2.3. Embryo transfers

In patients for fresh embryo transfer, after oocyte retrieval micronized progesterone was administered daily vaginally (Crinone 8% gel, Merck.) and intramuscularly (Hald 100 mg, Intas) on alternate days till the pregnancy test was confirmed negative or continued for another 3 months if the pregnancy test was positive. Patients with optimum endometrial lining and thickness (>7 mm) on the day of ovulation trigger underwent fresh embryo transfer, otherwise transfers were canceled.

In patients for frozen embryo transfer, oral estradiol valerate (Evadiol, Intas) was used in a step-by-step increasing dose pattern for the preparation of endometrium. Endometrial lining and thickness were observed regularly prior to embryo transfer. Patients with optimum endometrial lining and thickness (>7 mm) underwent embryo transfer, otherwise transfers were canceled. Micronised progesterone (Crinone 8% gel, Merck) was administered daily vaginally and intramuscularly (Hald 100 mg, Intas) on alternate days and continued till the pregnancy test was confirmed negative or continued for another 3 months if the pregnancy test was positive.

2.4. Semen analysis and processing

Patients were advised to collect semen samples in sterile, non-toxic containers by masturbation after sexual abstinence of 2-3 days. After 30 min of liquefaction, samples were evaluated for count, motility, and morphology according to WHO 2010 criteria[2]. Semen samples were prepared by two-layer density gradient (V-Grad 80%-40%, Vitromed, Germany) centrifugation for ICSI. The post-wash sample was used for SDF evaluation by acridine orange test.

2.5. Acridine orange test

The SDF was assessed by the acridine orange test method[4]. Smears with 10 μL of post-wash samples were prepared and air-dried. Carnoy’s solution (methanol: Glacial acetic acid, 3:1 vol/vol) was used in fixing the slides overnight. The staining solution was prepared daily from the stock solution of acridine orange (1 g/L in distilled water, stored in dark at 4 °C) in the mentioned ratio of 10 mL of stock solution, 40 mL of 0.1 M citric acid, and 2.5 mL of 0.3 M Na2HPO47H2O and pH adjusted to 2.5. Slides were stained with the above stain for 5 min and rinsed in distilled water and covered with coverslips.

SDF was assessed using a fluorescence microscope (Olympus C × 31, Japan) under oil at ×1 000. Sperms with green fluorescence indicate normal intact DNA, whereas orange indicates fragmented sperm[4],[12]. At least 400 spermatozoa were assessed in each slide of the replicates to calculate the average SDF. Slides were fixed on the very same day of ICSI and SDF was evaluated on next day using the acridine orange test. One highly skilled and trained andrologist evaluated all the slides for consistency and to prevent interpersonal variability. Each stained slide was observed right away after staining to reduce the variation of fluorescence intensity.

2.6. ICSI

Oocytes recovered were incubated in culture media (Onestep, Vitromed, Germany) for 1-2 h before denudation by hyaluronidase enzyme (Hyadase 80IU, Vitromed) at 37 °C with 6% CO2, 5% O2 and the rest N2. All the ICSI procedures were performed by a highly-skilled embryologist according to Palermo et al[13]. A morphologically normal sperm was selected and immobilized in polyvinylpyrrolidone (7%, Vitromed). The immobilized sperm was aspirated tail-first into the injection pipette and injected into the oocyte by aspirating a little cytoplasm before releasing the sperm into the oocyte. 16-18 h post ICSI, the appearance of two pronuclei with a second polar body extrusion was noted to evaluate the fertilization. The obtained embryos were cultured till day 5 post- ICSI for embryo transfer or vitrification.

2.7. Embryo grading

Day 5 blastocysts were graded according to Gardner et al[14]. Expansion of the blastocysts was graded as 3-6, and trophectoderm, and inner cell mass were graded as A, B, and C. Expansion of blastocyst was graded as follows: 3-full blastocyst, 4-expanded, 5-hatching, and 6-hatched. Whereas for trophectoderm: grade A-trophectoderm with many cells forming a cohesive epithelium; grade B-trophectoderm with few cells forming a loose epithelium and grade C-trophectoderm with very few cells. Similarly, for inner cell mass, grade A-tightly packed inner cell mass with many cells; grade B-loosely grouped inner cell mass with many cells and grade C-inner cell mass with very few cells. A blastocyst with an expansion of more than grade 3 and trophectoderm and inner cell mass with grade A or B was considered a good quality blastocyst.

2.8. Clinical follow-up

On day 5, one or two embryos were transferred using a soft catheter (Cook, Australia). Serum β HCG was observed after 14 days of the transfer to confirm the pregnancy test positive. An intrauterine sac with the presence of a fetal heartbeat was considered a clinical pregnancy. Miscarriage was defined as a pregnancy loss after detection of an intrauterine pregnancy by ultrasound before 20 weeks. The live birth rate was calculated as the presence of a live birth (either single or multiple live births) after an embryo transfer cycle.

2.9. Statistical analysis

The statistical analysis was executed in the Statistical Package for the Social Sciences (SPSS, IBM) for windows version 26.0. Categorical variables like clinical outcomes between groups were shown as proportions and scrutinized using Chi-square test. Characteristics of patients between groups were shown as continuous variables which were represented as mean±standard deviation (mean±SD) and scrutinized using the unpaired t-test. Multivariable analysis was performed using logistic regression for clinical outcomes to predict the effect of SDF on clinical outcomes in ICSI cycles of couples whose male partners’ semen samples were normozoospermic. Statistical significance was set at P<0.05.

2.10. Ethics approval statement

This study was approved by the Institutional Ethics Committee (No. SAIMS/IEC/2017/02/03). Written consent was obtained from all the couples.


  3. Results Top


3.1. Female patient characteristics between the low and high SDF groups

No significant difference was observed in the female age, number of oocytes retrieved, number of mature metaphase II oocytes, total FSH administered and peak estradiol levels at ovulation trigger between the low and high SDF groups except for the female body mass index (BMI) [Table 1].
Table 1: Female patient characteristics between the low and high SDF groups.

Click here to view


3.2. Embryological outcomes between the low and high SDF groups

Similarly, no significant difference was observed in the embryological outcomes like fertilization rates, cleavage rates, blastocyst rates, good quality blastocyst rates, and the number of embryo transfer cycles between the two SDF groups [Table 2].
Table 2: Embryological outcomes between the low and high SDF groups.

Click here to view


3.3. Male patient characteristics and semen parameters between the low and high SDF groups

No significant difference was observed in the male age and semen parameters like volume, count, and morphology between the two SDF groups. A significant difference was observed in the sperm motility (P<0.05) and SDF (P<0.001) rates between the two SDF groups [Table 3].
Table 3: Male patient characteristics and semen parameters between the low and high SDF groups.

Click here to view


3.4. Clinical outcomes between the low-SDF and high-SDF groups in the ICSI cycles of normozoospermic male patients

Clinical outcomes were compared between the low-SDF and high- SDF groups as shown in [Table 4]. A total of 165 patients underwent fresh transfers, 110 were in the low SDF group and 55 were in the high SDF group. A significant decrease in the live birth rate was observed in the high SDF group compared to the low SDF group (P=0.037). No significant difference was observed in the clinical pregnancy rate and miscarriage rate between the two groups. Out of the 171 frozen transfers, 103 were in the low SDF group and 68 were in the high SDF group. No significant difference was observed in the clinical outcomes. Similarly, no significant difference was observed in the clinical outcomes (calculated per transfer) of the overall cumulative transfers [Table 4]. No significant difference was observed in the cumulative pregnancy and cumulative live birth rates between the low and high SDF groups [Table 5].
Table 4: Clinical outcomes between the low and high SDF groups in the ICSI cycles of normozoospermic male patients.

Click here to view
Table 5: Clinical outcomes (calculated per patient) between the low and high SDF groups.

Click here to view


3.5. Multivariate logistic regression analysis to predict the effect of SDF on the clinical outcomes in ICSI cycles of normozoospermic male patients

In the multivariate analysis using logistic regression, SDF was a significant predictor of live birth rate and clinical pregnancy rate in the fresh embryo transfer cycles, however, not an independent predictor of clinical outcomes in the overall cumulative transfer cycles and frozen transfer cycles when adjusted for possible confounding factors [Table 6].
Table 6: Multivariate logistic regression analysis to predict the effect of SDF on the clinical outcomes in ICSI cycles of normozoospermic male patients.

Click here to view



  4. Discussion Top


Routine semen analysis has a salient role in the infertility evaluation of men. But, when it comes to sperm abnormalities at the DNA level it has a meager role. SDF is unfettered by normal semen analysis and has good diagnostic and prognostic capabilities for non-fertile men labeled as idiopathic men based on routine semen parameters[15],[16],[17].

In this study, the clinical and laboratory outcomes were correlated between the low and high SDF groups of ICSI cycles of normozoospermic male patients. The clinical outcomes like live birth rate were significantly decreased in the high SDF group of fresh embryo transfer cycles. However, the difference in the clinical outcomes was not observed in the frozen embryo transfer cycles and overall embryo transfer cycles. Various studies in the literature showed the negative effect of SDF on the clinical outcomes in the fresh embryo transfer cycles only[3],[18],[19]. A particular study showed the negative effect of SDF on the clinical outcomes in non-male factor infertility patients but those findings were also confined to fresh embryo transfers only[3]. Frozen embryo transfers were most preferred in recent times where clinics are opting for the freeze-all policies as they have comparable results with the fresh embryo transfers[20]. Cumulative transfers provide accurate success of the assisted reproductive techniques cycles as they include both fresh and frozen embryo transfers. The effect of SDF on the clinical outcomes should be correlated in cumulative transfers/overall transfers[21].

Some other studies showed that SDF has no effect on clinical outcomes[22],[23],[24]. The contentious effect of SDF on the clinical outcomes is possibly due to the female factor. Female factor plays a major role in determining the effect of SDF on the clinical and laboratory outcomes, especially female age. As age decides the quality of oocytes, it has been observed that young females with good quality oocytes can reduce the negative effect of SDF on clinical outcomes[25],[26]. In this study, even though female patients included were between the ages of 21-42 years, the average age of females was 30 years; this may possibly be the reason for the no effect of SDF on the clinical outcomes in the overall transfers. Larger studies are needed to know the effect of SDF on clinical outcomes in cumulative transfers. Some other studies noted no significant difference in the clinical outcomes in the frozen embryo transfer cycles of the SDF groups, which is in corroboration with this study[27].

SDF was negatively correlated with sperm motility which is already mentioned in the literature[28]. Other parameters like sperm volume, count, and morphology were similar between the SDF groups. Female BMI was significantly higher in the high SDF group but that does not impact the clinical outcomes in this study. Many studies showed the effect of SDF on the miscarriage rate, but we did not find any difference in the miscarriage rates in any type of transfers either fresh or frozen and overall cumulative transfers maybe due to the younger female patient group[29]. A recent study concludes that SDF in the sample used for fertilization was not associated with embryological and clinical outcomes which are in corroboration with this study[28].

The strengths of the present study are its prospective nature, the clinical and embryological outcomes were evaluated on the actual sperm used in the ICSI, unlike other studies where the SDF assessment was done on the semen samples prior to the ICSI cycles and correlation to the clinical outcome were done at a later time. All the samples were fixed on the same day of ICSI and assessed for SDF on the consecutive day, which is also an important step as in many studies they used to freeze the semen sample and assess SDF later. Freezing and thawing procedures may also impart a certain amount of DNA fragmentation in the semen samples[30]. Acridine orange test is a simple method that can be performed in-house without any extra financial burden to the couples. We have minimized the confounding effect of type of transfer (fresh or frozen) by calculating the clinical outcomes separately for fresh, frozen, and overall cumulative transfers. Other possible confounding factors were also adjusted for the clinical outcomes in multivariate analysis.

The limitations of this study are a smaller sample size due to the inclusion of only ICSI cycles with normozoospermic samples and patients who underwent only day 5 blastocyst transfers. The acridine orange test method may not be robust like the sperm chromatin structure assay (SCSA) method but as mentioned earlier acridine orange test is a simple method and SDF can be evaluated technically similar to the SCSA method.

In conclusion, SDF does not affect the clinical outcomes in the cumulative transfers of an ICSI cycle along with blastocyst transfers in couples with normozoospermic males.

Conflict of interest statement

The authors declare that there is no conflict of interest.

Funding

The study received no extramural funding.

Authors’ contributions

Deepthi Repalle conceptualized and planned the design of the study, acquired the data, and drafted the manuscript. Saritha K.V. and Shilpa Bhandari assisted in writing the manuscript and refined the manuscript critically. All authors read and approved the final manuscript.



 
  References Top

1.
Agarwal A, Mulgund A, Hamada A, Chyatte MR. A unique view on male infertility around the globe. Reprod Biol Endocrinol 2015; 13: 37.  Back to cited text no. 1
    
2.
World Health Organization. WHO manual for the examination of human sperm and sperm cervical mucus interaction. 5th ed. Switzerland: WHO Press; 2010.  Back to cited text no. 2
    
3.
Borges E Jr, Zanetti BF, Setti AS, Braga DPAF, Provenza RR, Iaconelli A Jr. Sperm DNA fragmentation is correlated with poor embryo development, lower implantation rate, and higher miscarriage rate in reproductive cycles of non-male factor infertility. Fertil Steril 2019; 112(3): 483-490.  Back to cited text no. 3
    
4.
Repalle D, Chittawar PB, Bhandari S, Joshi G, Paranjape M, Joshi C. Does centrifugation and semen processing with swim up at 37 °C yield sperm with better DNA integrity compared to centrifugation and processing at room temperature? J Hum Reprod Sci 2013; 6: 23-26.  Back to cited text no. 4
    
5.
Ajina T, Ammar O, Haouas Z, Sallem A, Ezzi L, Grissa I, et al. Assessment of human sperm DNA integrity using two cytochemical tests: Acridine orange test and toluidine blue assay. Andrologia 2017; 49(10). doi: 10.1111/and.12765.  Back to cited text no. 5
    
6.
Liu DY, Liu ML. Clinical value of sperm DNA damage should be assessed in motile sperm fraction rather than whole ejaculated sperm. Fertil Steril 2013; 99(2): 367-371.  Back to cited text no. 6
    
7.
Marchetti F, Bishop J, Gingerich J, Wyrobek AJ. Meiotic interstrand DNA damage escapes paternal repair and causes chromosomal aberrations in the zygote by maternal misrepair. Sci Rep 2015; 5: 7689.  Back to cited text no. 7
    
8.
González-Marín C, Gosálvez J, Roy R. Types, causes, detection and repair of DNA fragmentation in animal and human sperm cells. Int J Mol Sci 2012; 13(11): 14026-14052.  Back to cited text no. 8
    
9.
Al-Edani T, Assou S, Ferrières A, Deutsch SB, Gala A, Lecellier CH, et al. Female aging alters expression of human cumulus cells genes that are essential for oocyte quality. Biomed Res Int 2014; 2014: 964614. doi: 10.1155/2014/964614.  Back to cited text no. 9
    
10.
Grøndahl ML, Yding Andersen C, Bogstad J, Nielsen FC, Meinertz H, Borup R. Gene expression profiles of single human mature oocytes in relation to age. Hum Reprod 2010; 25(4): 957-968.  Back to cited text no. 10
    
11.
Liang X, Mao Y, Wang Y, Liu S, Yan J. Female age affects the utility of sperm DNA fragmentation in predicting IVF and ICSI outcomes. Reprod Biomed Online 2019; 39(6): 955-962.  Back to cited text no. 11
    
12.
Erenpreiss J, Bars J, Lipatnikova V, Erenpreisa J, Zalkalns J. Comparative study of cytochemical tests for sperm chromatin integrity. J Androl 2001; 22: 4553.  Back to cited text no. 12
    
13.
Palermo GD, O’Neill CL, Chow S, Cheung S, Parrella A, Pereira N, et al. Intracytoplasmic sperm injection: State of the art in humans. Reproduction 2017; 154(6): F93-F110. doi: 10.1530/REP-17-0374.  Back to cited text no. 13
    
14.
Gardner DK, Lane M, Stevens J, Schlenker T, Schoolcraft WB. Blastocyst score affects implantation and pregnancy outcome: Towards a single blastocyst transfer. Fertil Steril 2000; 73(6): 1155-1158. doi: 10.1016/s0015-0282(00)00518-5.  Back to cited text no. 14
    
15.
Saleh RA, Agarwal A, Nelson DR, Nada EA, El-Tonsy MH, Alvarez JG, et al. Increased sperm nuclear DNA damage in normozoospermic infertile men: A prospective study. Fertil Steril 2002; 78(2): 313-318.  Back to cited text no. 15
    
16.
Erenpreiss J, Elzanaty S, Giwercman A. Sperm DNA damage in men from infertile couples. Asian J Androl 2008; 10(5): 786-790.  Back to cited text no. 16
    
17.
Tarozzi N, Bizzaro D, Flamigni C, Borini A. Clinical relevance of sperm DNA damage in assisted reproduction. Reprod Biomed Online 2007; 14(6): 746-757.  Back to cited text no. 17
    
18.
Simon L, Proutski I, Stevenson M, Jennings D, McManus J, Lutton D, et al. Sperm DNA damage has a negative association with live-birth rates after IVF. Reprod Biomed Online 2013; 26: 68-78.  Back to cited text no. 18
    
19.
Speyer BE, Pizzey AR, Ranieri M, Joshi R, Delhanty JDA, Serhal P. Fall in implantation rates following ICSI with sperm with high DNA fragmentation. Hum Reprod 2010; 25(7): 1609-1618.  Back to cited text no. 19
    
20.
Stormlund S, Sopa N, Zedeler A, Bogstad J, Prætorius L, Nielsen HS, et al. Freeze-all versus fresh blastocyst transfer strategy during in vitro fertilisation in women with regular menstrual cycles: Multicentre randomised controlled trial. BMJ 2020; 370: m2519. doi: 10.1136/ bmj.m2519.  Back to cited text no. 20
    
21.
Germond M, Urner F, Chanson A, Primi MP, Wirthner D, Senn A. What is the most relevant standard of success in assisted reproduction?: The cumulated singleton/twin delivery rates per oocyte pick-up: The CUSIDERA and CUTWIDERA. Hum Reprod 2004; 19(11): 2442-2444. doi: 10.1093/humrep/deh501.  Back to cited text no. 21
    
22.
Yang H, Li G, Jin H, Guo Y, Sun Y. The effect of sperm DNA fragmentation index on assisted reproductive technology outcomes and its relationship with semen parameters and lifestyle. Transl Androl Urol 2019; 8(4): 356-365.  Back to cited text no. 22
    
23.
Esbert M, Pacheco A, Vidal F, Florensa M, Riqueros M, Ballesteros A, et al. Impact of sperm DNA fragmentation on the outcome of IVF with own or donated oocytes. Reprod Biomed Online 2011; 23(6): 704-710.  Back to cited text no. 23
    
24.
Sun TC, Zhang Y, Li HT, Liu XM, Yi DX, Tian L, et al. Sperm DNA fragmentation index, as measured by sperm chromatin dispersion, might not predict assisted reproductive outcome. Taiwan J Obstet Gynecol 2018; 57(4): 493-498.  Back to cited text no. 24
    
25.
Meseguer M, Santiso R, Garrido N, García-Herrero S, Remohí J, Fernandez JL. Effect of sperm DNA fragmentation on pregnancy outcome depends on oocyte quality. Fertil Steril 2011; 95(1): 124-128.  Back to cited text no. 25
    
26.
Liang X, Mao Y, Wang Y, Liu S, Yan J. Female age affects the utility of sperm DNA fragmentation in predicting IVF and ICSI outcomes. Reprod Biomed Online 2019; 39(6): 955-962.  Back to cited text no. 26
    
27.
Ni W, Xiao S, Qiu X, Jin J, Pan C, Li Y, et al. Effect of sperm DNA fragmentation on clinical outcome of frozen-thawed embryo transfer and on blastocyst formation. PLoS One 2014; 9(4): e94956. doi: 10.1371/ journal.pone.0094956.  Back to cited text no. 27
    
28.
Green KA, Patounakis G, Dougherty MP, Werner MD, Scott RT Jr, Franasiak JM. Sperm DNA fragmentation on the day of fertilization is not associated with embryologic or clinical outcomes after IVF/ICSI. J Assist Reprod Genet 2020; 37(1): 71-76. doi: 10.1007/s10815-019- 01632-5.  Back to cited text no. 28
    
29.
Robinson L, Gallos ID, Conner SJ, Rajkhowa M, Miller D, Lewis S, et al. The effect of sperm DNA fragmentation on miscarriage rates: A systematic review and meta-analysis. Hum Reprod 2012; 27(10): 2908-2917.  Back to cited text no. 29
    
30.
Le MT, Nguyen TTT, Nguyen TT, Nguyen TV, Nguyen TAT, Nguyen QHV, et al. Does conventional freezing affect sperm DNA fragmentation? Clin Exp Reprod Med 2019; 46(2): 67-75. doi: 10.5653/ cerm.2019.46.2.67.  Back to cited text no. 30
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  2. Materials and...
  In this article
Abstract
1. Introduction
3. Results
4. Discussion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed218    
    Printed0    
    Emailed0    
    PDF Downloaded64    
    Comments [Add]    

Recommend this journal