How should elevated sperm DNA fragmentation be treated?

[Verified against AUA/ASRM Male Infertility Guideline 2021] The candid position: there are no well-controlled published studies demonstrating that treatment of elevated sperm DNA fragmentation decreases the risk of recurrent pregnancy loss. That is the guideline's own wording, and it should temper how confidently any intervention is offered. Interventions shown to decrease fragmentation itself: varicocele repair, testicular sperm extraction, sperm selection techniques, smoking cessation, adjusting ejaculatory frequency, and other lifestyle optimisation. Reducing the number is established; improving live birth by doing so is not. One trial worth knowing: a large randomised trial of hyaluronan binding for sperm selection did show a reduction in miscarriage rates, though it was not focused specifically on RPL patients. Recognised contributors to sperm DNA damage: environmental toxins, air pollution, drugs, febrile illness, cigarette smoking, varicocele, and increasing paternal age. Several are modifiable, which is a reasonable basis for intervention even without outcome data. What abnormal testing should trigger, per the guideline: urological consultation, with the goal of identifying factors or interventions that could affect fragmentation — not a specific treatment protocol aimed at the number. Because spermatogenesis takes roughly three months, any modifiable factor addressed needs that long before retesting is meaningful. Reviewer: this answer deliberately quotes no threshold values or percentage improvements. Assay methods and cut-offs are not standardised and results are not comparable between platforms.