Controversy and consensus on the management of elevated sperm DNA fragmentation in male infertility: A global survey, current guidelines, and expert recommendations

Purpose Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition. Materials and Methods An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method. Results A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4–6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated. Conclusions This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians

conjugens

Primula conjugens (Greene) A.R. Mast & Revealgyroselle des montagnesslim-pod shootingstarPrairie BluffK. McFadyenS. facing, grassy slope; Arctostaphylos uva-ursi providing substantial ground cover2215Erigeron compositus, Potentilla sp., Townsendia sp., Sedum sp., Achillea millefolium, Arctostaphylos uva-ursi>75Abundant throughou

sororia

Arnica sororia Greenearnica parenteTwin arnicaCastle FallsT. ChisholmMeadow near Castle Falls1329 mLomatium triternatum, Allium textile, Lupinus sericeus, Heuchera cylindrica, Calochortus apiculatus, Geum triflorum, Senecio integerrimus, Collinsia parviflora, Achillea millefolium, Cerastium arvense, Eriogonum flavum, Lithospermum ruderale, Toxicoscordion venenosum, Anemone patens, Penstemon confertus, Juncus balticus, Amelanchier alnifoliaCommonNear clearing of wooded meado

conjugens

Primula conjugens (Greene) A.R. Mast & Revealslim-pod shootingstargyroselle des montagnesPrairie BluffK. McFadyenS. facing, grassy slope; Arctostaphylos uva-ursi providing substantial ground cover2215Erigeron compositus, Potentilla sp., Townsendia sp., Sedum sp., Achillea millefolium, Arctostaphylos uva-ursi>75Abundant throughou

Giuditta e altre eroine bibliche tra Rinascimento e Barocco. Orizzonti di senso e di genere, variazioni, riscritture. Atti del Seminario di Studio (Padova, 10-11 dicembre 2007)

Il volume presenta l'attraversamento interdisciplinare del tema di Giuditta tra Quattro e Seicento. Sulla sua valenza figurativo-simbolica, sulla sua fruizione nell\u2019ambito dei diversi generi letterari in uno dei periodi cruciali della sua multiforme fortuna italiana hanno finito per interrogarsi pressoch\ue9 in esclusiva i relatori intervenuti (storici, musicologi, studiosi della letterarura e delle arti figurative), attraendo all\u2019eroina anche l\u2019accostamento alla serie delle altre figure bibliche che, a partire da Ester, in Italia e in Europa, tra Rinascimento e Barocco, con lei si accompagnarono. Un\u2019esplorazione a queste ultime dilatata, ma tutta incentrata sul duplice motivo della violenza e della seduzione di cui in primis Giuditta si fa nel contesto europeo esemplarmente latrice tra Sei e Novecento, \ue8 stata affidata al Colloque international et interdisciplinaire \uabEntre violence et s\ue9duction: Judith et autres h\ue9ro\uefnes bibliques dans l\u2019Europe des xive-xviiie si\ue8cles\ubb tenutosi a Parigi nei giorni 8-10 dicembre 2008, i cui Atti sono ora in corso di pubblicazione per le edizioni parigine del Centre Interuniversitaire de Recherche sur la Renaissance Italienne (CIRRI)

Global prevalence, treatment, and prevention of hepatitis B virus infection in 2016: a modelling study

Background: The 69th World Health Assembly approved the Global Health Sector Strategy to eliminate viral hepatitis by 2030. Although no virological cure exists for hepatitis B virus (HBV) infection, existing therapies to control viral replication and prophylaxis to minimise mother-to-child transmission make elimination of HBV feasible. We aimed to estimate the national, regional, and global prevalence of HBsAg in the general population and in the population aged 5 years in 2016, as well as coverage of prophylaxis, diagnosis, and treatment. Methods: In this modelling study, we used a Delphi process that included a literature review in PubMed and Embase, followed by interviews with experts, to quantify the historical epidemiology of HBV infection. We then used a dynamic HBV transmission and progression model to estimate the country-level and regional-level prevalence of HBsAg in 2016 and the effect of prophylaxis and treatment on disease burden. Findings: We developed models for 120 countries, 78 of which were populated with data approved by experts. Using these models, we estimated that the global prevalence of HBsAg in 2016 was 3·9% (95% uncertainty interval [UI] 3·4–4·6), corresponding to 291 992 000 (251 513 000–341 114 000) infections. Of these infections, around 29 million (10%) were diagnosed, and only 4·8 million (5%) of 94 million individuals eligible for treatment actually received antiviral therapy. Around 1·8 (1·6–2·2) million infections were in children aged 5 years, with a prevalence of 1·4% (1·2–1·6). We estimated that 87% of infants had received the three-dose HBV vaccination in the first year of life, 46% had received timely birth-dose vaccination, and 13% had received hepatitis B immunoglobulin along with the full vaccination regimen. Less than 1% of mothers with a high viral load had received antiviral therapy to reduce mother-to-child transmission. Interpretation: Our estimate of HBV prevalence in 2016 differs from previous studies, potentially because we took into account the effect of infant prophylaxis and early childhood vaccination, as well as changing prevalence over time. Although some regions are well on their way to meeting prophylaxis and prevalence targets, all regions must substantially scale-up access to diagnosis and treatment to meet the global targets. Funding: John C Martin Foundation. © 2018 Elsevier Lt