interpreting semen analysis results

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  • Interpreting Semen Analysis

    Results

    Sandro C. Esteves, MD, PhD

    ANDROFERT, Campinas, Brazil

    Reproductive Andrology S urgery Workshop IIReproductive Medicine Unit - J ahra Hospital - Kuwait 2014

  • Contents

    Semen analysis overview

    WHO reference values

    Implications to clinical management

    Proposal of a new report template

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  • Semen analysis is the most used biomarker to predict fertility potential

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  • Routine Semen Analysis

    Physical characteristics of ejaculate

    Sperm count

    Sperm motility

    Sperm morphology

    Sperm vitality

    Leukocyte count

    Additional tests (fructose, etc)

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  • Standardization Pre-analytical

    Analytical

    Post-analytical

    Quality ControlCertification, Validation

    Reference valuesWHO Manual

    Where to do it?

    Esteves, 5

  • Pre-analyticalInstructions for collection

    Rejection criteria

    Abstinence period

    AnalyticalStandard operating procedures

    Post-analyticalReport

    Is the lab good enough?

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  • ANDROFERTandrofert.com.br

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    WHO Manual: it is free!

  • 1980 1987 1992 1999

    Volume (mL) ND 2 2 2

    Sperm count (106/mL) 20-200 20 20 20

    Total sperm count (106) ND 40 40 40

    Motility(%) 60 50 50 50

    Progressive motility (%) 2 25% 25% (a) 25% (a)

    Vitality (%) ND 50 75 75

    Morphology (%) 80,5 50 30 (14)*

    Leukocytes (106/mL) < 4.7 < 1.0 < 1.0 < 1.0

    *Strict criteria (Tygerberg)

    WHO Reference Values2010

    1.5

    15

    39

    40

    32% (a+b)

    58

    4*

    1.0

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  • Urology 2012; 79(1):16-22

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  • How the references were obtained

    1953 specimens Recent fathers (Time-to-Pregnancy ; TTP) 12 mo. Data extracted from 5 studies Laboratories with QC Morphology by Krugers method

    Cooper TG, Noonan E, von Eckardstein S, Auger J, Baker H, Behre H, Haugen

    T, Kruger T, Wang C, Mibzvo MT, Vogelsong K

    World Health Organization reference values for human semen characteristics.

    Hum Reprod Update 16: 231-245, 2010.

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  • Percentile

    5% 50%* 95%

    Volume (mL) 1.5 3.7 6.8

    Count (x106/mL) 15.0 73.0 213.0

    Total count (x106) 39.0 255.0 802.0

    % Motile 40 61 78

    % Progressive motility 32 55 72

    % Normal (Kruger) 4 15 44

    % Alive 58 79 91

    Cooper et al: World Health Organization reference values for human semen characteristics.

    Hum Reprod Update 16: 231-245, 2010Esteves, 12

    How the references were obtained

  • Critical Appraisal of the WHO New Reference Values for Human Semen and Impact on

    Diagnosis and Treatment of Subfertile Men

    Esteves, Zini, Aziz et al, Urology, in press

    Columbia

    USA

    Melbourne

    Australia

    Turku

    Finland

    Oslo

    Norway

    Edimburgh

    UK

    Paris

    France

    Copenhagen

    Denmark

    Esteves, 13

  • WHO 2010: What changed?

    Percentile 5 to determine lower cutoff limits Strict (Kruger) morphology Single specimen per individual

    Method

    Recent fathers (known TTP)

    Selection bias

    Studied population

    Esteves et al. Critical Appraisal of the WHO New Reference Values for Human Semen and Impact on

    Diagnosis and Treatment of Subfertile Men. Urology 2012; 79(1):16-22.

    Esteves, 14

  • How do the new references impact clinical management?

    Referral

    Treatment

    ART

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  • Parameters Patient

    Volume (mL) 2,3

    Count (106/mL) 16,5

    Progressive motility (%) 40

    Vitality(%) 65

    Morphology (%) 9

    Referral Deferment

    References

    1999 2010

    2 1.5

    20 15

    50 32

    75 58

    (14) 4

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  • 987 couples with infertility

    duration > 12 months

    Esteves, Int Braz J Urol 2014

    53% reclassification

    due to morphology

    Semen Analysis Report

    Esteves, 17

    Abnormal results as per

    WHO 1999

    38.7%

    Redefined as

    Normal as per WHO 2010

  • Cause of infertility in up to 35% men

    Guidelines recommendation: Palpable (clinical)

    Abnormal semen analysis results

    Male Infertility Best Practice Policy Committee - AUA, 2004;

    European Association of Urology. Guidelines on Male Infertility, 2010.

    Varicocele Treatment

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  • 87.8

    49.937.4

    62.9 56 55.6

    8.4 7.3 6.1

    No varicocele Grade 2 Varicocele Grade 3 Varicocele

    Adolescents with and without Varicocele

    Count (million/mL) Progressive motility (% a+b) Morphology (%)

    Mori et al. Does varicocele grade determine extent of alteration to

    spermatogenesis in adolescents? Fertil Steril 90: 1769-1773, 2008.

    P=0.003 P

  • ICSIIVF & IUI

    ART

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  • Semen analysis alone should not be used to counseling or treatment indication

    Semen characteristics that discriminate fertile from infertile men not well defined

    Biological variability

    Not account for sperm dysfunctions

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  • History taking, physical examination, endocrine profile and laboratory sperm function testing are minimum standards

    Esteves, et al 2011; 2012; 2014

    Male infertility evaluation goes far beyond a simple semen analysis

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  • Reporting: proposal for a new template

  • Thank You

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