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- Original Article -
Sperm DNA damage in men from infertile couples
Juris Erenpreiss1, Saad
Elzanaty2,3, Aleksander Giwercman2
1Andrology Laboratory, Riga Stradins University, LV-1007 Riga, Latvia
2Reproductive Medicine Centre, Scanian Andrology Centre, Malmö University Hospital, Malmö SE 205 02, Sweden
3Department of General Surgery, Urology Section, Kristianstad Central Hospital, Kristianstad SE 291 85, Sweden
Abstract
Aim: To investigate the prevalence of high levels of sperm DNA damage among men from infertile couples with both
normal and abnormal standard semen parameters.
Methods: A total of 350 men from infertile couples were assessed.
Standard semen analysis and sperm chromatin structure assay (SCSA) were carried out.
Results: Ninety-seven men (28% of the whole study group) had a DNA fragmentation index (DFI) > 20%, and 43 men (12%) had a DFI > 30%.
In the group of men with abnormal semen parameters
(n = 224), 35% had a DFI > 20%, and 16% had a DFI > 30%,
whereas these numbers were 15% and 5%, respectively, in the group of men with normal semen parameters
(n = 126). Men with low sperm motility and abnormal morphology had significantly higher odds ratios (ORs) for having a DFI
> 20% (4.0 for motility and 1.9 for morphology) and DFI > 30% (6.2 for motility and 2.8 for morphology) compared
with men with normal sperm motility and morphology.
Conclusion: In almost one-third of unselected men from
infertile couples, the DFI exceeded the level of 20% above which, according to previous studies, the
in vivo fertility is reduced. A significant proportion of men with otherwise normal semen parameters also had high sperm DNA
damage levels. Thus, the SCSA test could add to explaining causes of infertility in cases where semen analysis has not
shown any deviation from the norm. We also recommend running the SCSA test to choose the appropriate assisted
reproductive technique (ART). (Asian J Androl 2008 Sep; 10: 786_790)
Keywords: infertility; sperm DNA damage; sperm chromatin structure assay; semen quality
Correspondence to: Dr Juris Erenpreiss, Andrology Laboratory, Riga Stradins University, LV 1007 Riga, Latvia.
Tel: +371-2947-1361 Fax: +371-6733-1739
E-mail: jerenpreiss@gmail.com
Received 2008-02-18 Accepted 2008-04-16
DOI: 10.1111/j.1745-7262.2008.00417.x
1 Introduction
Sperm chromatin structure and DNA integrity are
known to have a crucial influence on reproductive
outcomes [1_7], including fertilization and embryonic
transplantation rates in assisted reproductive technique (ART)
procedures [6_9]. It has been suggested that, in
contrast to standard semen parameters, which do not act as
powerful discriminators between fertile and infertile men
[10], sperm DNA damage assessment yields better
prognostic value. It has been shown that fecundity starts to
decrease when sperm DNA damage, expressed as the DNA fragmentation index (DFI) in sperm chromatin
structure assay (SCSA), exceeds 20% [4, 5]. Above a
threshold of 30%, chances for fertilization are close to zero,
either by means of natural conception [4, 5] or
intrauterine insemination (IUI) [6, 7]. This shows that the DFI
possesses a high predictive value for male infertility in vivo (both natural and IUI fertilization). In addition, it
has been suggested that in cases with a DFI > 30%,
intracytoplasmic sperm injection (ICSI) should be the
method of choice [7] because a high DFI is not
associated with a decreased success rate in ICSI procedures, in
contrast to IUI and in vitro fertilization (IVF) [6, 7, 11].
Infertile men are reported to have a higher fraction of
sperm with chromatin defects and DNA breaks than
fertile controls [12_14]. Sperm DNA damage assessment
has been recommended as a complementary test in male
infertility work-up by some authors [11, 15]. However,
it is still unclear whether sperm DNA damage
assessment should be introduced as a routine test in infertile
men or only applied in selected cases. There are few
studies addressing the issue of prevalence of high levels
of sperm DNA damage among infertile men. Such
prevalence was reported to be 17% when the 30% DFI
threshold was used [12], and 58% using the 24% DFI
threshold [13]. The latter threshold was chosen because all
fertile men in that particular study showed a DFI below
this level. In addition, there are conflicting data whether
infertile men with normal standard semen parameters have
increased levels of sperm DNA damage that could explain the infertility of the couple. Although some studies
have shown increased sperm DNA damage (DFI > 24%)
in 40% of these men [13, 14], other studies reported that
infertile men with normal semen parameters infrequently
(8%) have a DFI > 30% [12], or fail to
show increased sperm DNA damage levels among infertile men with
normal conventional semen parameters, as compared to
fertile donors [16].
Therefore, the aim of this study was to investigate
the prevalence of sperm DNA damage in a large group
of infertile men with both normal and abnormal semen
parameters in order to elucidate whether SCSA analysis
can add to the information obtained by routine semen
analysis when explaining the causes of infertility.
2 Materials and methods
2.1 Materials
Unless otherwise stated, all chemicals were obtained
from Sigma Chemical (St. Louis, MO, USA).
2.2 Semen donors
This retrospective study involved 350 consecutive
male patients from infertile couples referred to the
Fertility Centre, Malmö University Hospital, Malmö, Sweden,
for fertility counselling during the period 2001_2004.
Infertility was defined as the inability to conceive after at
least 1 year. No information regarding female partners
was available for the study group.
2.3 Sperm quality measures
2.3.1 Standard semen parameter measurements
Samples were obtained by masturbation. Only one
ejaculate from each patient was obtained. The patients
were recommended 2_5 days of sexual abstinence,
although in each case the actual abstinence period was
noted. Samples were allowed to liquefy for 30 min.
Standard semen parameters (volume, concentration and
motility) were measured according to the World Health
Organization (WHO) guidelines [17]. Sperm
concentration was assessed using positive displacement pipettes
and an improved Neubauer hemocytometer. Sperm motility was graded into four groups: rapid progressive
motility, slow progressive motility, non-progressive
motility, or immotile sperm. Sperm morphology was
assessed after Papanicolaou staining following WHO
guidelines for the staining procedure. A level of
¡Ý 5% was regarded as the threshold for normal morphology.
Semen parameters were regarded as normal in men with
sperm concentration
¡Ý 20 × 106/mL, progressive
motility ¡Ý 50% and/or rapid progressive motility
¡Ý 25%, and a proportion of morphologically normal sperms
¡Ý 5%.
2.3.2 Sperm DNA damage assessment
Sperm DNA damage was evaluated by SCSA. The SCSA was applied following the procedure described
earlier, using staining with acridine orange (AO) [18, 19].
An aliquot of unprocessed semen (13_70 μL) was diluted
to a concentration of
1_4 × 106 sperm/mL with TNE
buffer (0.01 mol/L Tris-HCl, 0.15 mol/L NaCl, and
1 mmol/L ethylenediaminetetraacetic acid [EDTA], pH 7.4).
This cell suspension was treated with an acid detergent
solution (pH 1.2) containing 0.1% Triton X-100,
0.15 mol/L NaCl, and 0.08 mol/L HCl for 30s, then stained
with 6 mg/L purified AO (Polysciences, Warrington, PA,
USA) in a phosphate_citrate buffer (pH 6.0). Under these
experimental conditions, AO intercalated in
double-stranded DNA emits green fluorescence, and AO
associated with single-stranded DNA emits red fluorescence.
Thus, sperm chromatin damage can be quantified by flow
cytometry measurements of the metachromatic
shift from green (native, double-stranded DNA) to red
(relaxed, single-stranded DNA) fluorescence. Measurements were
stopped after measuring 10 000 spermatozoa using a
FACSort flow cytometer (Becton Dickinson, San Jose,
CA, USA). Adopting guidelines published by Evenson
et al. [18], the extent of DNA
denaturation was expressed in terms of the DFI, which is the ratio of red to total
(red plus green) fluorescence intensity, using SCSAsoft 1.0
software (SCSA Diagnostics, Brookings, SD, USA). For
the flow cytometer set-up and calibration, aliquots
were used from a normal human ejaculate sample retrieved
from the laboratory repository. All SCSA analyses were
carried out by one person.
2.4 Data analysis
The prevalence of patients with a DFI > 20% and a
DFI > 30% was calculated in the whole study group,
and separately in patients with normal and abnormal
standard semen parameters. The prevalence in groups was
compared using Fisher's exact test. Odds ratios for
having a high DFI (DFI > 20% and DFI > 30%) in men with
abnormal vs normal sperm concentration
(< 20 × 106/mL
vs.
¡Ý 20 × 106/mL), sperm motility (< 50% progressive
motility and < 25% rapid progressive motility
vs. ¡Ý 50% progressive motility or
¡Ý 25% rapid progressive motility), and morphology (< 5% normal forms
vs. ¡Ý 5% normal forms) were calculated using the logistic regression
analysis model, including abstinence time and age as potential
confounders. P < 0.05 were considered statistically
significant. Statistical analysis was carried out using
SPSS 15.0 software (SPSS, Chicago, IL, USA).
3 Results
Semen characteristics of the whole study group, and
for study groups with normal (n = 126) and abnormal
(n = 224) semen parameters, are given in Table 1. Men
with normal semen parameters had a significantly lower
DFI (13.0 ± 7.7) than men with abnormal semen
parameters (20.4 ± 12.5,
P < 0.001). Abstinence time, in
contrast to the age of the patient, was found to be a
significant confounder for the DFI (P = 0.015).
Ninety-seven men (28%) of the whole study group
had a DFI > 20%, and 43 men (12%) had a DFI > 30%.
There was a significantly larger proportion of men with
high DFI levels in the group with abnormal semen
parameters compared with the group with normal semen
quality, 35% vs. 15% for DFI > 20%
(P < 0.001), and 16%
vs. 5% for DFI > 30% (P = 0.002).
Odds ratios (ORs) for high DFI levels in men with
abnormal vs normal semen parameters are shown in
Table 2. Men with both low sperm motility and abnormal sperm
morphology had significantly higher ORs for showing
high DFI levels compared with men with normal sperm
motility and normal morphology.
4 Discussion
Our data indicate that almost one-third of men from
infertile couples, regardless of their standard semen quality
parameters, have sperm DNA damage at levels that have
been shown to have a negative impact on fecundity
(DFI >20%) [4, 5]. Furthermore, a DFI above 30 % was found
in 12 % of these men. Although association with couple
fecundity has been found for standard sperm parameters,
no clear cut-off levels for fertility or infertility have been
established [10, 20]. However, a number of studies have
shown that almost no conceptions in vivo occur when
the DFI exceeds the level of 30 % [4_7]. Thus, in a
significant proportion of males seeking clinical help for
infertility, SCSA can help by explaining the reason for
infertility.
Our data show that decreased sperm motility and
morphology is a significant predictive factor for high
sperm DNA damage. ORs for having high DNA damage were highest for diminished sperm motility, which is in
line with previous data, showing that DNA damage has
its strongest negative correlation with sperm motility
among all semen parameters [14, 21_23]. Oxidative stress
(reactive oxygen species [ROS] activity) damages cell
membranes and inhibits sperm motility, and this same
ROS activity likely causes sperm DNA fragmentation [3,
24]. However, even in men with normal sperm motility,
as well as other standard semen parameters, DFI levels
of more than 20% or 30% could be observed.
Apart from helping to explain the infertility problem
of a couple, SCSA analysis was previously shown to help
decision-making when an ART needs to be applied. It
has been shown that IUI procedures are unsuccessful in
men with DFI > 30% [6, 7]. Therefore, IVF or ICSI
should be used, with the latter yielding higher success
rates compared to IVF in these cases [6, 7, 11]. Sperm
DNA damage assessment in infertile couples can be
recommended to choose the most appropriate ART method,
even if a man has a normal standard semen analysis.
Although only 5% of these men, according to our data,
will show a DFI > 30% it is probably still feasible to use
SCSA to avoid IUI procedures with highly improbable
chances of success. The limitation of this study is the
lack of data for female partners from the infertile couples.
It is possible that if we limited the group of men with
normal semen parameters to those with partners without
fertility problems, the proportions of men with
DFI > 20% and DFI > 30% would be larger than 16% and 5%,
respectively, as in our unselected group.
In conclusion, the proportion of men with a high
DFI is greater among those with abnormal standard
semen parameters compared with those with normal
semen parameters, and an increased level of DFI is most
often found in men with astheno- and teratozoospermia.
However, in a significant proportion of men with
otherwise normal semen parameters, the DFI exceeded the
level of 20% above which, according to previous studies,
in vivo fertility is reduced. Thus, the SCSA test could
help to explain the causes of infertility in cases where
semen analysis has not shown any deviation from the
norm. Furthermore, because 16% of men with abnormal semen analysis, and 5% of men with normal semen
analysis, showed a DFI > 30% (in the group of men from
infertile couples unselected in regards to female factors),
sperm DNA damage assessment is important for choosing the most appropriate ART method. IUI procedures
should not be recommended when the DFI > 30%.
Acknowledgment
We wish to thank Ms Katarina Jepson, Mrs Ewa Askerlund, Mrs Cecilia Tingsmark, and Mrs Susane
Lundin for their technical assistance. We are also
grateful to Mr Roger Alston and Dr Jamie Honeychurch for
their help with English editing of the manuscript. The
study was supported by grants from the Swedish
Governmental Funding for Clinical Research, Swedish Research
Council (Grant No. K2005/72X-14545-03A), The Swedish Childhood Cancer Society (Grant No.
03/016), Swedish Cancer Society (Grant No.
4423), Gunnar Nilsson's Cancer Foundation, and Malmö University Hospital
Foundation for Cancer Research.
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