Top-cited articles in andrology journals from 2013-2022: a bibliometric analysis.

Bibliometric analyses serve to identify influential articles that have shaped medical practice and fostered new research ideas. Over the past decade, research in andrology has witnessed exponential growth, with an increasing number of academic publications, collaborations, and research innovations. However, there is a lack of literature that has identified the top-cited andrology articles. We conducted a bibliometric analysis to identify the top 1000 citations in andrology journals, with a focus on the top funding agencies, authors, institutions, countries/regions, and journals. To perform this analysis, we identified the top-cited articles in andrology journals as indexed in the Web of Science Core Collection. From 2013 through 2022, we found a total of 9827 articles published in andrology journals. The top publishers included "Andrology," the "Asian Journal of Andrology," and "Andrologia." The top affiliations contributing to research include the Cleveland Clinic Foundation (269 publications), Egyptian Knowledge Bank (EKB) (265), and Shanghai Jiao Tong University (202). Funding was primarily provided by notable agencies such as the National Natural Science Foundation of China (905 grants), United States Department of Health Human Services (321), and National Institutes of Health (NIH USA) (317). The present bibliometric analysis highlights andrology research from 2013 through 2022, offering key insights into leading contributors, influential authors, prominent funding sources, and major trends in the field.

Misinterpretations of Significance Testing Results Near the P-Value Threshold in the Urologic Literature.

Background The outcome of a statistical test is to accept or reject a null hypothesis. Reporting a metric as "trending toward significance" is a misinterpretation of the p-value. Studies highlighting the prevalence of statistical errors in the urologic literature remain scarce. We evaluated abstracts from 15 urology journals published within the years 2000-2021 and provided a quantitative measure of a common statistical mistake-misconstruing the function of null hypothesis testing by reporting "a trend toward significance." Materials and methods We performed an audit of 15 urology journals, looking at articles published from January 1, 2000, to January 1, 2022. A word recognition function in Microsoft Excel was utilized to identify the use of the word "trend" in the abstracts. Each use of the word "trend" was manually investigated by two authors to determine whether it was improperly used in describing non-statistically significant data as trending toward significance. Statistics and data analysis were performed using Python libraries: pandas, scipy.stats, and seaborn. Results This study included 101,134 abstracts from 15 urology journals. Within those abstracts, the word "trend" was used 2,509 times, 572 uses of which were describing non-statistically significant data as trending toward significance. There was a statistically significant difference in the rate of errors between the 15 journals (p < 0.01). The highest rate of improper use of the word "trend" was found in Bladder Cancer with a rate of 1.6% (p < 0.01) of articles. The lowest rate of improper use was found in European Urology, with a rate of 0.3% (p < 0.01). Our analysis found a moderate correlation between the number of articles published and the number of misuses of the word "trend" within each journal and across all journals every year (r = 0.61 and 0.70, respectively). Conclusion The overall rate of p-value misinterpretation never exceeded 2% of articles in each journal. There is significance in the difference in misinterpretation rates between the different journals. Authors' utilization of the word "trend" describing non-significant p-values as being near significant should be used with caution.

S-nitrosylation of CSF1 receptor increases the efficacy of CSF1R blockage against prostate cancer.

Sustained oxidative stress in castration-resistant prostate cancer (CRPC) cells potentiates the overall tumor microenvironment (TME). Targeting the TME using colony-stimulating factor 1 receptor (CSF1R) inhibition is a promising therapy for CRPC. However, the therapeutic response to sustained CSF1R inhibition (CSF1Ri) is limited as a monotherapy. We hypothesized that one of the underlying causes for the reduced efficacy of CSF1Ri and increased oxidation in CRPC is the upregulation and uncoupling of endothelial nitric oxide synthase (NOS3). Here we show that in high-grade PCa human specimens, NOS3 abundance positively correlates with CSF1-CSF1R signaling and remains uncoupled. The uncoupling diminishes NOS3 generation of sufficient nitric oxide (NO) required for S-nitrosylation of CSF1R at specific cysteine sites (Cys 224, Cys 278, and Cys 830). Exogenous S-nitrosothiol administration (with S-nitrosoglutathione (GSNO)) induces S-nitrosylation of CSF1R and rescues the excess oxidation in tumor regions, in turn suppressing the tumor-promoting cytokines which are ineffectively suppressed by CSF1R blockade. Together these results suggest that NO administration could act as an effective combinatorial partner with CSF1R blockade against CRPC. In this context, we further show that exogenous NO treatment with GSNOR successfully augments the anti-tumor ability of CSF1Ri to effectively reduce the overall tumor burden, decreases the intratumoral percentage of anti-inflammatory macrophages, myeloid-derived progenitor cells and increases the percentage of pro-inflammatory macrophages, cytotoxic T lymphocytes, and effector T cells, respectively. Together, these findings support the concept that the NO-CSF1Ri combination has the potential to act as a therapeutic agent that restores control over TME, which in turn could improve the outcomes of PCa patients.

Association Between MitoScore, BMI, and Body Fat Percentage as a Predictive Marker for the Outcome of In-Vitro Fertilization (IVF).

Background Infertility is defined as the inability to establish a pregnancy within 12 months of regular and unprotected sexual intercourse. In response to these problems, assisted reproductive techniques (ARTs) have made profound impacts on the therapeutic management of infertility. However, in-vitro fertilization (IVF) success rates are confounded by several internal and external factors. A relatively new approach to embryo assessment is known as MitoScore (Igenomix, Miami, USA). As a result, we sough to evaluate whether MitoScore can help in predicting in IVF outcomes, and to assess the relationship between MitoScore, BMI, and body fat percentage in determining the success of ARTs. Methods Using retrospective cohort, a study population consisting of 166 women aged 26-43 who were undergoing ART with pre-implantation genetic testing for aneuploidy (PGT-A) was assessed to determine if MitoScore, BMI, and body fat percentage impacted IVF outcomes. Results MitoScore, BMI, and body fat percentage were significantly lower in pregnant women as compared to non-pregnant women. Furthermore, MitoScore was correlated with subclasses of IVF outcomes (delivery, biochemical pregnancy, and spontaneous abortion) and was found to be positively correlated with BMI in patients with biochemical pregnancies. Conclusion Our findings suggest that MitoScore, BMI, and body fat percentage could act as critical parameters in determining the success of ART. However, the association between MitoScore, BMI, and body fat percentage does not appear to be a significant confounding factor to determine pregnancy outcome at this stage. Still, many factors need to be considered to establish the correlation reliably.

Consumption of a Healthy Plant-based Diet is Associated With a Decreased Risk of Erectile Dysfunction: A Cross-sectional Study of the National Health and Nutrition Examination Survey.

OBJECTIVE: To investigate the association between the plant-based content of diet and erectile dysfunction in men from the National Health and Nutrition Examination Survey (NHANES). METHODS: We collected de-identified information from the NHANES database on demographics, comorbidities, diet, and erectile dysfunction (ED). Exclusion criteria were age <20 or >70 years, incomplete plant-based diet index information, history of prostate cancer, or other missing information. Using the food frequency questionnaire, an overall plant-based diet index (PDI) and healthful plant-based diet index (hPDI) were developed. A higher score on the PDI and hPDI is indicative of greater consumption of plant-based foods. RESULTS: A total of 2549 men were analyzed, of those 1085 (42.6%) have good erectile function and 1464 (57.4%) have some degree of ED [usually have erections 521 (20.4%), sometimes have erection 690 (27.1%), or never have erections 253 (9.9%)]. The median age and BMI were 54 [41-64] years and 28.8 [25.5-32.6] kg/m2, respectively. The median PDI and hPDI were 50 [46-54] and 50 [45-56], respectively. In multivariable adjusted logistic regression analysis, hPDI was negatively associated with ED (OR = 0.98, 95% CI: 0.96-0.99; P = .001). There was no association between PDI and ED. CONCLUSION: In a well characterized national database, we showed that a healthful plant-based diet is associated with less chance of having erectile dysfunction. Whether interventions with a plant-based diet will improve erectile function remains to be studied.

Authorship Gender Composition in Urology Literature From 2015 Through 2020.

OBJECTIVE: To describe the current landscape of first and last female authorship in urology journals relative to the journals' impact factor. We hypothesized that women would have a smaller proportion of publications in journals with higher impact factors. METHODS: Eighteen urology journals were divided into groups based on impact factor accordingly: from 33.2 to 6.2 were classified as high (European Urology, Nature Reviews Urology, The Journal of Urology, BJU International, Prostate Cancer and Prostatic Diseases, and The Journal of Sexual Medicine), from 5.8 to 5.0 as medium (Asian Journal of Andrology, European Urology Focus, Sexual Medicine Reviews, Bladder Cancer, Prostate and World Journal of Urology), and from 4.8 to 2.2 as low (Urologic Oncology, Journal of Endourology, Neurourology and Urodynamics, Urology, Journal of Pediatric Urology and Female Pelvic Medicine & Reconstructive Surgery). A computer script was designed using Python to search PubMed and record first and last author of publications between 2015 and 2020. Gender was determined by Gender-Api (https://gender-api.com). Names with an accuracy of <90% were excluded. Type of peer-review and scope of each journal were also analyzed. Statistical analysis was performed using Matlab. RESULTS: A total of 37,413 first and 28,414 last authors were identified during the study period. Overall, women represented 21% (8,029/37,413) of first and 15% (4,232/28,414) of last authors. Women were significantly less published in high impact journals compared to both medium and low impact journals (P <.001 in all). Among all journals, articles with female first authors were more likely to have a female last author (OR: 2.72, CI: 2.5-2.9, P <.001). Subspecialty journals had more female last authors than general journals (P <.05), and female representation increased if reviews were double-blinded (P <.001). Over the last 6 years, there has been a significant increase in female senior authorship among all journals (P = .045). CONCLUSION: The proportion of female authorship was significantly lower in higher impact urology journals. While the underlying cause is likely multifactorial, this finding highlights a gender discrepancy that may impact women's ability to achieve career goals in academic medicine when compared to their male counterparts.

Medical Malpractice Lawsuits Involving Urology Trainees.

OBJECTIVE: To distinguish the various characteristics of medical malpractice lawsuits involving trainees to prevent future litigation. METHODS: LexisNexis, an online legal research database containing legal records from the United States, was retrospectively reviewed for malpractice cases involving urology interns, residents, or fellows from January 1, 1988 to December 31, 2020. RESULTS: A total of 16 cases were included, of which 7 (43.8%) involved urological allegations while 9 (56.2%) involved non-urological allegations. 5 of the cases consisting of non-urological adverse outcomes led to mortality. Procedural error was claimed in 12 (75.0%) cases, negligence in 7 (43.8%), delayed evaluation in 6 (37.5%), lack of informed consent of procedure or complications in 5 (31.2.%), failure to pursue treatment in 4 (25.0%), inexperienced trainee in 2 (12.5%), failure to supervise trainee in 2, lack of informed consent of trainee involvement in 1, incorrect diagnosis in 1, and prolonged operative time in 1 case. CONCLUSION: Malpractice education, careful supervision, awareness during perioperative care, and detailed communication between patients and physicians should be highlighted in training programs to improve patient outcomes and mitigate risk of future malpractice.

Current Treatment Modalities Targeting Tumor Microenvironment in Castration-Resistant Prostate Cancer.

Prostate cancer (PCa) is responsible for significant cancer-related morbidity and mortality following local treatment failure in men. The initial stages of PCa are typically managed with a combination of surgical resection and/or androgen deprivation therapy (ADT). Unfortunately, a significant proportion of PCa continues to progress despite being at castrate levels of testosterone (<50 ng/dl), at which point it is coined castration-resistant prostate cancer (CRPC). In recent years, many novel therapeutics and drug combinations have been created for CRPC patients. These include immune checkpoint inhibitors, chemokine receptor antagonists, steroidogenic enzyme inhibition, and novel tyrosine kinase inhibitors as well as combinations of drugs. The selection of the most appropriate therapy depends on several factors like stage of the disease, age of the patient, metastasis, functional status, and response towards previous therapies. Here, we review the current state of the literature regarding treatment modalities, focusing on the treatment recommendations per the American Urological Association (AUA), recent clinical trials, and their limitations. An accurate and reliable overview of the strengths and limitations of PCa therapeutics could also allow personalized therapeutic interventions against PCa.

Association between low testosterone and anaemia: Analysis of the National Health and Nutrition Examination Survey.

There is an androgen effect on haematopoiesis; however, the effect of low testosterone in anaemia has not been fully studied. In this study, we aim to explore the association of total serum testosterone, low testosterone (≤300 ng/dl), haemoglobin concentration and prevalence of anaemia in a nationally representative sample of men. We analysed data from the NHANES III database, and men between the age of 18-80 years of age were selected. We defined anaemia as haemoglobin ≤13.5 ng/dl and low serum testosterone as ≤300 ng/dl. After analysing 5,888 men, it was shown that those with anaemia had a higher prevalence of low serum testosterone (32.3%) compared to those without anaemia (24.1%) (p < .001), and in multivariable-adjusted analysis, it was shown that low testosterone was significantly associated with anaemia (OR = 1.44; 95% CI: 1.17-1.78; p = .001). Our findings suggest that men with low serum testosterone have a higher risk of anaemia, and there is a positive association between serum testosterone and serum Hb. Further prospective studies need to be performed to confirm our findings.

Impact of Plant-Based Diet on PSA Level: Data From the National Health and Nutrition Examination Survey.

OBJECTIVE: To determine the potential association between plant-based dietary content and PSA levels among men enrolled in the National Health and Nutrition Examination Survey (NHANES). METHODS: Data on demographics, diet, and PSA levels was acquired from the NHANES database. Plant-based diet index (PDI) and healthful plant-based diet index (hPDI) were calculated using food frequency questionnaires. A higher score on PDI and hPDI indicates higher consumption of plant foods or healthy plant foods, respectively. Multivariable-adjusted logistic regression analysis was performed to determine the association between elevated PSA, clinical variables, demographics, and plant-based diet indices. RESULTS: A total of 1399 men were included in the final cohort. Median age of participants was 54 [46-63] years. Median PSA level was 0.9 [0.6-1.5] ng/dL, and 69 (4.9%) men had a PSA level ≥4 ng/dL. Although there was no association between elevated PSA and PDI, on multivariable analysis patients with higher consumption of healthy plant-based diet (high hPDI scores) had a decreased probability of having an elevated PSA (OR = 0.47, 95% CI: 0.24-0.95; P = .034). CONCLUSION: There is a significant association between increased consumption of a healthy plant-based diet and lower PSA levels. This finding may be incorporated into the shared-decision making process with patients to promote healthier lifestyle choices to reduce the likelihood of prostate biopsy and potential treatment-related morbidity.

COVID-19 vaccine hesitancy linked to increased internet search queries for side effects on fertility potential in the initial rollout phase following Emergency Use Authorization.

The Emergency Use Authorization (EUA) of the COVID-19 vaccine on December 11, 2020 has been met with hesitancy for uptake with some citing potential impacts on future fertility. We hypothesised that irrespective of sex, fertility-related queries would markedly increase during the 48 days following EUA of the coronavirus vaccine. We sought to objectively identify trends in internet search queries on public concerns regarding COVID-19 vaccine side effects on fertility that might impact vaccine uptake. We used Google Trends to investigate queries in Google's Search Engine relating to the coronavirus vaccine and fertility between 10/24/2020 and 1/27/2021. The five most queried terms were identified as: 'COVID Vaccine Fertility', 'COVID Vaccine and Infertility', 'COVID Vaccine Infertility', 'COVID Vaccine Fertility CDC', and 'COVID 19 Vaccine Infertility' with an increase of 710.47%, 207.56%, 264.35%, 2,943.7%, and 529.26%, respectively, all p < .001. This study indicates that there was an increase in online COVID-19 vaccine-related queries regarding fertility side effects coinciding with the Emergency Use Authorization (EUA) on December 11, 2020. Our results objectively evidence the increased concern regarding the vaccine and likely demonstrate a major cause for hesitancy in vaccine uptake. Future studies and counselling with patients should be undertaken to help mitigate these concerns.

Evaluation of SARS-CoV-2 in Human Semen and Effect on Total Sperm Number: A Prospective Observational Study.

PURPOSE: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has created a surge of research to help better understand the breadth of possible sequelae. However, little is known regarding the impact on semen parameters and fertility potential. We sought to investigate for presence of viral RNA in semen of men with SARS-CoV-2 infection and to evaluate its effect on semen parameters in ejaculate. MATERIALS AND METHODS: We prospectively recruited thirty men diagnosed with acute SARS-CoV-2 infection using real-time reverse transcriptase polymerase chain reaction (RT-PCR) of pharyngeal swab specimens. Semen samples were collected from each individual using mailed kits. Follow-up semen samples were done with mailed kits or in-person in office setting. Semen analysis and PCR was performed after samples were received. RESULTS: Thirty semen samples from recovered men were obtained 11-64 days after testing positive for SAR-CoV-2 infection. The median duration between positive SAR-CoV-2 test and semen collection was 37 days (interquartile range [IQR]=23). The median total sperm number (TSN) in ejaculate was 12.5 million (IQR=52.1). When compared with age-matched SARS-CoV-2(-) men, TSN was lower among SARS-CoV-2(+) men (p=0.0024). Five men completed a follow-up sperm analysis (median 3 months) and had a median TSN of 18 million (IQR=21.6). No RNA was detected by means of RT-PCR in the semen in 16 samples tested. CONCLUSIONS: SARS-CoV-2 infection, though not detected in semen of recovered men, can affect TSN in ejaculate in the acute setting. Whether SARS-CoV-2 can affect spermatogenic function long-term remains to be evaluated.

Exogenous testosterone replacement therapy versus raising endogenous testosterone levels: current and future prospects.

Testosterone replacement therapy is an important treatment option for men with low testosterone and symptomatic hypogonadism. Various formulations of exogenous testosterone replacement therapy exist, including oral, buccal, intramuscular, transdermal, subdermal, and nasal preparations. However, exogenous testosterone replacement therapy is a double-edged sword, posing risks to fertility due to negative feedback mechanisms on the hypothalamic-pituitary-gonadal (HPG) axis, which is the main regulator of testosterone production and spermatogenesis in males. Alternative pharmacologic therapies are being used to increase endogenous testosterone levels while attempting to preserve fertility and function of the HPG axis. These include selective estrogen receptor modulators, gonadotropins, and aromatase inhibitors. This review focuses on overviewing and comparing the currently available methods of exogenous testosterone replacement therapy, alternative treatments to increasing endogenous testosterone, and novel treatments that are currently under investigation to normalize testosterone levels while preserving the function of the HPG axis. In conclusion, reports suggest that, though Testosterone replacement therapy is an important way to restore testosterone levels and reduce symptoms associated with low testosterone, it is often difficult to decide which treatment to select for patients with testosterone deficiency. Several factors need to be considered to decide on optimal therapy option for the patient which include but are not limited to safety, efficacy, cost-effectiveness, dosing flexibility, and side effects. Alternative approaches which aim to improve endogenous testosterone production and preserve fertility are promising but still are at their initial stages of development. Ultimately, patient-centered decision making is paramount to appropriate treatment selection.

A Systematic Review of Artificial Intelligence in Prostate Cancer.

The diagnosis and management of prostate cancer involves the interpretation of data from multiple modalities to aid in decision making. Tools like PSA levels, MRI guided biopsies, genomic biomarkers, and Gleason grading are used to diagnose, risk stratify, and then monitor patients during respective follow-ups. Nevertheless, diagnosis tracking and subsequent risk stratification often lend itself to significant subjectivity. Artificial intelligence (AI) can allow clinicians to recognize difficult relationships and manage enormous data sets, which is a task that is both extraordinarily difficult and time consuming for humans. By using AI algorithms and reducing the level of subjectivity, it is possible to use fewer resources while improving the overall efficiency and accuracy in prostate cancer diagnosis and management. Thus, this systematic review focuses on analyzing advancements in AI-based artificial neural networks (ANN) and their current role in prostate cancer diagnosis and management.

The association between plant-based content in diet and testosterone levels in US adults.

PURPOSE: To evaluate the association between the plant-based content of diet and serum testosterone levels in men from the national health and nutrition examination survey (NHANES) database. MATERIALS AND METHODS: Data on demographics, diet, and testosterone levels was acquired from the NHANES database. Using the food frequency questionnaire, an overall plant-based diet index (PDI) and a healthful plant-based diet index (hPDI) was developed. A higher score on PDI and hPDI indicates higher consumption of plant foods. RESULTS: A total of 191 participants were included, average age was 45 (30-60) years and average total testosterone level was 546.7 ± 254.7 ng/dL. The mean PDI and hPDI were 50.4 ± 6 and 50.8 ± 7.2, respectively. On multiple linear regression analysis, BMI and age significantly contribute to testosterone levels (p < 0.05); however, neither of the diet indexes significantly predicted serum testosterone levels (PDI: p = 0.446; and hPDI: p = 0.056). CONCLUSIONS: In a well characterized national database, the plant-based diet index is unable to predict testosterone levels. Plant-based food content in diet is not associated with serum testosterone levels.

How defective spermatogenesis affects sperm DNA integrity.

Spermatogenesis is the essential process to maintain and promote male fertility. It is extraordinarily complex with many regulatory elements and numerous steps. The process involves several cell types, regulatory molecules, repair mechanisms and epigenetic regulators. Evidence has shown that fertility can be negatively impacted by reduced sperm DNA integrity. Sources of sperm DNA damage include replication errors and causes of DNA fragmentation which include abortive apoptosis, defective maturation and oxidative stress. This review outlines the process of spermatogenesis, spermatogonial regulation and sperm differentiation; additionally, DNA damage and currently studied DNA repair mechanisms in spermatozoon are also covered.

A systematic review and evidence-based analysis of ingredients in popular male testosterone and erectile dysfunction supplements.

The objective was to study available evidence for ingredients of popular over-the-counter testosterone and erectile dysfunction (ED) supplements. The top 16 male testosterone and 16 ED supplements in the USA were identified from the most popular online retailers: A1 Supplements, Amazon, Vitamin Shoppe, and Walmart. In total, 37 ingredients were identified and PUBMED online database was reviewed for randomized-controlled trials (RCT) studying their efficacy. Ingredients were categorized based on evidence quantity using an adapted version of the American Heart Association scoring system. In total, 16 ingredients from testosterone supplements and 21 from ED supplements were identified. Tribulus, Eurycoma longifolia, Zinc, L-arginine, Aspartate, Horny goat weed, and Yohimbine were most common. In all, 105 RCTs studying the identified ingredients were found. No whole supplement products have published RCT evidence. 19% of ingredients received an A grade for strong positive evidence with net positive evidence in two or more RCTs. In total, 68% received C or D grades for contradicting, negative, or lacking evidence. Overall, 69% of ingredients in testosterone supplements and 52% of ingredients in ED supplements have published RCT evidence. Many male supplements claim to improve testosterone or ED parameters; however, there is limited evidence, which should be considered when counseling patients.

A paradoxical decline in semen parameters in men treated with clomiphene citrate: A systematic review.

Clomiphene, a selective oestrogen receptor modulator, has been utilised in managing male sub-fertility since 1967. Numerous controlled and uncontrolled studies have been published regarding the efficacy of clomiphene citrate in male sub-fertility cohorts. Although the primary intention of treating men with clomiphene citrate is to improve sperm parameters and testosterone levels, some studies have reported paradoxical decline in semen parameters. The information available on decline in sperm parameters following treatment with clomiphene is sparse. We conducted a systemic review using PubMed, Embase, Cochrane Library and Scopus databases for original studies reporting adverse effects of clomiphene citrate therapy on sperm parameters. This systematic review includes 384 men from 11 different studies that reported adverse effects of clomiphene citrate therapy. Of the men included in these studies, 19%, 21%, 17% and 24% of clomiphene-treated men demonstrated a decrease in sperm count, concentration, motility and total motile sperm count respectively. In up to 17% of patients, deterioration of semen parameters did not recover following discontinuation of therapy. In the future, more studies should report on this aspect so the magnitude of this effect can be more clearly understood.

Sperm DNA Fragmentation: A New Guideline for Clinicians.

Sperm DNA integrity is crucial for fertilization and development of healthy offspring. The spermatozoon undergoes extensive molecular remodeling of its nucleus during later phases of spermatogenesis, which imparts compaction and protects the genetic content. Testicular (defective maturation and abortive apoptosis) and post-testicular (oxidative stress) mechanisms are implicated in the etiology of sperm DNA fragmentation (SDF), which affects both natural and assisted reproduction. Several clinical and environmental factors are known to negatively impact sperm DNA integrity. An increasing number of reports emphasizes the direct relationship between sperm DNA damage and male infertility. Currently, several assays are available to assess sperm DNA damage, however, routine assessment of SDF in clinical practice is not recommended by professional organizations. This article provides an overview of SDF types, origin and comparative analysis of various SDF assays while primarily focusing on the clinical indications of SDF testing. Importantly, we report four clinical cases where SDF testing had played a significant role in improving fertility outcome. In light of these clinical case reports and recent scientific evidence, this review provides expert recommendations on SDF testing and examines the advantages and drawbacks of the clinical utility of SDF testing using Strength-Weaknesses-Opportunities-Threats (SWOT) analysis.