Second ejaculation: a simple, cost free mechanism to deal with high sperm DNA fragmentation

Abstract

High sperm DNA fragmentation is a controversial subject. However, many physicians test for DNA fragmentation and feel it is important. If high, methods of dealing with DNA fragmentation include testicular sperm aspiration, Anexin sperm wash and ICSI. These procedures add cost, pain after surgery and are of undetermined value. Sperm DNA fragmentation is felt to occur in the epididymis while waiting to be expelled. This study was undertaken to determine if a second ejaculation 3-hours after the first could improve sperm DNA fragmentation, by limiting time in the epidydimis. A prospective cohort study where males were requested to wait 3-days without an ejaculation at which point a semen analysis and DNA fragmentation was performed and repeated 3-hours latter on a 2nd specimen. 112 subjects underwent the two semen analysis protocol as part of the fertility evaluation. All ejaculations were performed at the fertility center. DNA fragmentation was evaluated using the halo test. Data was compared by intra-subject t-test. Data is presented as % or mean±SD. Power analysis suggested ≥73 subjects were required for an 80% power and an alpha of 5% with a 2 unit mean difference with SD of 6 units. High DNA fragmentation is >35%. Male age was 36±7 years (range 29-65). DNA fragmentation decreased from 34.6±19.4 to 23.7±16.0% (p<0.0001) in the 1st and 2nd specimen respectively. Average percentage improvement 23%±30%. Among subjects with high fragmentation 22/49 (45%) failed to improve into the normal range. Regarding subjects with initial DNA fragmentation>35%, comparison of 1st and second 2nd fragmentation were 52±16% & 36±17% (p<0.0001), respectively. Greatest improvement was 97%-28% DNA fragmentation. 7/112 had worse DNA fragmentation in the second specimen and of those only 2 fell above the normal range, both with a first specimen above the normal range as well. Among semen parameters volume went from 3.1±3.3ml to 1.9±0.8ml, p=0.0001, concentration from 41±39 to 32±31 million/ml, p=0.001 & progressive motility increased from 57±21% to 60±21%, p=0.06. In none of the cases where total motile sperm count was greater than 5 million did the quality of the second semen specimen convert the subject to ICSI. The first 10 subjects had both 1st and 2nd DNA fragmentation confirmed with the TUNEL assay and equivalent improvements were seen r=0.97 (p<0.05), this was not continued due to cost assumed by the clinic. High DNA sperm fragmentation can often be managed with a second ejaculation 3 hours after the first. Changes in sperm quality are not clinically significant and none of the ICSI specimens from ejaculation 1 would have required ICSI based on the ejaculation 3 hours latter. 55% improve into the normal range. Therefore, a second ejaculation represents a safe, cost free mechanism to deal with this issue in many patients.