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Reproductive outcomes of testicular versus ejaculated sperm for intracytoplasmic sperm injection among men with high levels of DNA fragmentation in semen: systematic review and meta-analysis

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Sandro C. Esteves, M.D., Matheus Roque, M.D., Cara K. Bradley, Ph.D., Nicolás Garrido, Ph.D.



To compare sperm DNA fragmentation (SDF) levels between testicular and ejaculated sperm and to evaluate outcomes of intracytoplasmic sperm injection (ICSI) with the use of testicular (Testi-ICSI) versus ejaculated (Ejac-ICSI) sperm in nonazoospermic men with high SDF.

Systematic review and meta-analysis.

Not applicable.

Normo- and oligozoospermic men with high levels of SDF in semen subjected to Testi-ICSI or Ejac-ICSI.

Summary mean difference (MD) and odds ratio (OR) were calculated with the use of an inverse variance model and fixed- or random-effects models, respectively.
Main Outcome Measure(s)

Primary outcomes were SDF levels, clinical pregnancy rates (CPRs), and live birth rates (LBRs). Secondary outcomes were fertilization and miscarriage rates.

Five studies involving 143 patients provided paired SDF rates for testicular and ejaculated sperm, revealing lower SDF in testicular sperm (MD −24.58%). Four studies involving 507 cycles and 3,840 oocytes reported clinical outcomes of Testi-ICSI and Ejac-ICSI. Fertilization rates were not different between sperm sources, but a trend to lower rates was observed with Testi-ICSI. CPRs were higher for Testi-ICSI than for Ejac-ICSI, as were LBRs, whereas miscarriage rates were reduced with Testi-ICSI.

Testicular sperm have lower levels of SDF than ejaculated sperm, with Testi-ICSI for high post-testicular SDF men improving reproductive outcomes compared with Ejac-ICSI. Infertile couples may benefit from Testi-ICSI if male partners have confirmed high SDF in the ejaculate.