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

Fertil Steril. 2017 Sep;108(3):456-467.e1. doi: 10.1016/j.fertnstert.2017.06.018.


Objective: 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.

Design: Systematic review and meta-analysis.

Setting: Not applicable.

Patient(s): Normo- and oligozoospermic men with high levels of SDF in semen subjected to Testi-ICSI or Ejac-ICSI.

Intervention(s): 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.

Result(s): 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.

Conclusion(s): 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.

Keywords: Semen; intracytoplasmic sperm injection; male infertility; sperm DNA fragmentation; testicular sperm.

Publication types

  • Comparative Study
  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Adult
  • DNA Fragmentation
  • Ejaculation*
  • Female
  • Humans
  • Infertility / epidemiology*
  • Infertility / therapy*
  • Male
  • Pregnancy
  • Pregnancy Outcome / epidemiology*
  • Sperm Injections, Intracytoplasmic / methods
  • Sperm Injections, Intracytoplasmic / statistics & numerical data*
  • Sperm Retrieval / statistics & numerical data*
  • Testis / metabolism*
  • Treatment Outcome
  • Young Adult