ArticlePDF Available

Abstract and Figures

Semen analysis is the oldest and most commonly used surrogate parameter for male fertility. Like all other clinical laboratory tests, semen analysis should be under strict internal and external quality control. WHO has pioneered standardisation and quality control of semen analysis. The external Quality Control Program of the German Society of Andrology (QuaDeGA) is based on WHO guidelines and since 2011 participation in ring trials is compulsory for all laboratories performing semen analysis in Germany. However, many laboratories fail to follow these guidelines so that it remains unclear whether the wide scatter of results from ring trials is caused by protocol failures or is inherent to semen analysis. In order to resolve this question we performed a survey among 624 participants and received valid answers from 256 (42.5%). The answers revealed that many laboratories lack basic equipment such as mixers, vortex, positive displacement pipettes and appropriate microscopes, do not use the recommended improved Neubauer chamber for counting, use inappropriate staining methods and do not evaluate sufficient sperm. Most surprisingly, 23% of the laboratories apply no internal quality control and these have a higher failure rate than those with internal control (28 vs 8%). Laboratories performing more than 20 semen analyses per month score better than those with lower sample frequency. Strict observation of WHO guidelines and more intensive teaching and practical training of technicians appear to be the most important measures to improve results. Until better agreement of results within and between laboratories is achieved, arguing over normal reference and threshold values remains a secondary problem.
Content may be subject to copyright.
306
External Quality Control of Semen Analysis
Reveals Low Compliance with WHO Guidelines
E. Nieschlag, T. Pock, B. Hellenkemper,
QuaDeGA (Quality Control Programme of the German Society of Andrology)
Introduction
In 2011 the German Federal Medical
Board (BÄK) integrated semen analy-
sis into its compulsory external quality
control program for medical laboratories
[1]. Since then all laboratories perform-
ing semen analysis for human medi cal
purposes are obliged to partici pate twice
yearly in ring trials (“Ringversuche”) to
obtain a certificate as a pre-requisite for
charging patients or insurances for se-
men analysis. The BÄK guidelines re-
quire participating laboratories to use
methodology as described in the current
World Health Organization (WHO). Lab-
oratory Manual for the Examination and
Processing of Human Semen. At the pre-
sent time this is the 5th edition of WHO
Manual [2] for which a German transla-
tion has been published [3]. The Quali-
ty Control Programe of the German So-
ciety of Andrology ( QuaDeGA GmbH)
was licensed by the BÄK as official Ref-
erence Institution to conduct the compul-
sory ring trials.
QuaDeGA was established in 2002 and
had performed ring trials on a voluntary
basis until 2011. Before participation be-
came mandatory in 2011 250 laborato-
ries had taken part in this external quality
control program. Since then the number
has increased to over 700 (Fig. 1).
While the number of participants in the
programme has amost tripled since it
became compulsory, over the years the
Youden plots continued to result in broad
windows and the rate of obtaining the cer-
tificate has remained around 80 % with
only a small tendency for improvement
(Fig 2). In an attempt to find out why the
failure rate remains high, we conducted a
survey among the participants asking for
details of their laboratory techniques, es-
pecially in regard to guidelines provided
by the WHO Manu al [2, 3].
Received: October 12, 2017; accepted after revision: October 26, 2017 (responsible Editor: Prof. H. Behre, Halle)
From the Center of Reproductive Medicine and Andrology, University Hospital Münster, Germany
Correspondence: Univ.-Prof. em. Dr. med. Dr. h.c. Eberhard Nieschlag, FRCP, Center of Reproductive Medicine and Andrology, Domagkstraße 11, D-48149 Münster,
e-mail: Eberhard.Nieschlag@ukmuenster.de
Semen analysis is the oldest and most commonly used surrogate parameter for male fertility. Like all other clinical laboratory tests, semen analysis should
be under strict internal and external quality control. WHO has pioneered standardisation and quality control of semen analysis. The external Quality Control
Program of the German Society of Andrology (QuaDeGA) is based on WHO guidelines and since 2011 participation in ring trials is compulsory for all labora-
tories performing semen analysis in Germany. However, many laboratories fail to follow these guidelines so that it remains unclear whether the wide scatter
of results from ring trials is caused by protocol failures or is inherent to semen analysis. In order to resolve this question we performed a survey among 624
participants and received valid answers from 256 (42.5%). The answers revealed that many laboratories lack basic equipment such as mixers, vortex, posi-
tive displacement pipettes and appropriate microscopes, do not use the recommended improved Neubauer chamber for counting, use inappropriate staining
methods and do not evaluate sufficient sperm. Most surprisingly, 23% of the laboratories apply no internal quality control and these have a higher failure
rate than those with internal control (28 vs 8%). Laboratories performing more than 20 semen analyses per month score better than those with lower sam-
ple frequency. Strict observation of WHO guidelines and more intensive teaching and practical training of technicians appear to be the most important meas-
ures to improve results. Until better agreement of results within and between laboratories is achieved, arguing over normal reference and threshold values
remains a secondary problem. J Reproduktionsmed Endokrinol_Online 2017; 14 (6): 306–10.
Key words: Quality Control Program of the German Society of Andrology, QuaDeGA, semen analysis
Figure 2. Development of total number of participants and the percentage of those
obtaining a certificate from ring trial 20/2011 to 31/2017.
Figure 1. Participants in the QuaDeGA program 2002–2016 (ring trial 1–30).
J Reproduktionsmed Endokrinol_Online 2017; 14 (6)
External Quality Control of Semen Analysis Reveals Low Compliance with WHO Guideline
307
Methods
Ring trials
The QuaDeGA program has been de-
scribed in previous publications [4, 5]
and the reader is referred for details to
these publications. In short, QuaDeGA
carries out external quality control tri-
als twice a year, consisting of two fixed
sperm preparations (sample A and B).
These samples allow for the measure-
ment of sperm concentration as well as
for preparation and staining of a smear
for the assessment of morphologically
normal forms. Film sequences of two dif-
ferent native semen samples are provid-
ed on the QuaDeGA platform for analy-
sis of sperm motility. Each participant in-
serts the results on the online platform.
For the three parameters (1) sperm con-
centration, (2) normal morphology and
(3) progressive motility medians of the
values obtained by those laboratories
indicating that they adhere strictly to
WHO guidelines the 2.5 and 97.5 per-
centiles are used to construct Youden
plots (Fig. 3). Those participants whose
results for all parameters lie within the
Youden plot windows receive certificates
of passing the external quality control. In
addition, QuaDeGA provides a ranking
for each result indicating whether results
lie within the Youden plot (rank 1), or
whether a systematic (rank 2) or a non-
systematic (rank 3) or a random error
(rank 4) has been noted.
Method used for the Survey
A questionnaire comprising 35 items
concerning technical and methodologi-
cal details of semen analysis as per-
formed in the individual laboratories was
drafted in German and sent electronical-
ly to participants using the online sur-
vey platform SurveyMonkey (Registered
trade mark). The 624 participants in the
ring trial 30/2016 in Germany, Austria
and Switzerland were addressed, and a
deadline of 3 weeks was set for return-
ing answers. The questions are not de-
scribed here in detail as their content
becomes evident from the results in the
next section.
Results
Responders
273 answers were received of which 256
(93.8%) could be evaluated. Data were
saved and summarized by the online
platform for further analysis. The 256
laboratories represent 42.5 % of those
who had received the questionnaire and
reflected the spectrum of participating
laboratories (andrologists, urologists,
ART centers, general clinical laborato-
ries, hospitals, university clinics and pri-
vate surgeries). Data were saved for fur-
ther analysis with Microsoft Excel.
In order to find out whether the respon-
ders were biased concerning their per-
formance in the ring trials tests, their re-
sults in run 30/2016 were compared with
those from the non-responders. While
83% of the 624 addressed participants
had received a certificate, 86% of the
256 responders and 82% of the 359 non-
responders had received certificates, in-
dicating that there was no significant
difference in performance between re-
sponders and non-responders. As not all
responders answered all questions, the
number of replies varies from question
to question. On average 7% of the ques-
tions were not answered.
Availability of the WHO Manu-
al, Lab equipment and Tech-
niques
When asked whether the WHO Manu-
al was available in the individual labora-
Figure 3. QuaDeGA ring trial 30/2016: Youden plots for sperm parameters in samples A and B of 663 participants constructed from medians of the WHO compliant participants (2.5
to 97.5 percentiles).
J Reproduktionsmed Endokrinol_Online 2017; 14 (6)
External Quality Control of Semen Analysis Reveals Low Compliance with WHO Guideline
308
tory, 93% answered “Yes”. When asked
whether they followed WHO guidelines
for the individual parameters, 93% an-
swered “Yes” for sperm concentration,
94% for motility and 90% for morpho-
logy.
However, when asked for the available
basic equipment in their laboratory, 28%
had no Vortex (or comparable mixing de-
vice), 45% no simple counting aid and
34% no laboratory counter. Of 254 an-
swering laboratories 36% used a phase
contrast microscope and 22% a high-
quality light microscope; the rest used
medium (33%) or standard (9%) mi-
croscopes not considered sufficient by
WHO guidelines.
Only 38.2% used the WHO recommend-
ed diluent, 23.1% no diluent and the re-
maining 38.7% used either NaCl, water
or other media.
Only 59% of 249 laboratories used the
WHO recommended improved Neu-
bauer chamber for counting sperm. 27%
used the Makler chamber, and the re-
maining 14% various but not recom-
mended chambers.
Only 55 of 256 laboratories (22%) used
the WHO recommended positive dis-
placement pipettes for concentration. All
49 laboratories using the correct cham-
ber and correct pipettes achieved rank 1,
while only 93% of those using the cor-
rect chamber, but incorrect pipettes, and
95% of those using Makler chambers
achieved rank 1 (Fig. 4).
Only 55% of 256 labs used the WHO
recommended Papanicolaou, Shorr or
DiffQuik staining method (Fig. 5). The
61 of 244 (25%) laboratories evaluating
more than 200 sperm cells achieved the
best results.
Internal Quality Control
The WHO manual considers it manda-
tory that all laboratories perform inter-
nal quality control and the BÄK provid-
ed Excel tables for this purpose which
can be obtained from QuaDeGA upon
request. However, only 35% perform
their internal quality control by using
these tables, while 42% use other pro-
grams for internal quality control. Sur-
prisingly 23% of the 244 laboratories
answering this question used no inter-
nal quality control. While 92% of those
practicing internal quality control ob-
tained a certifi cate, only 74% of those
without internal quality control reached
that goal.
Frequency of Semen Analysis
Investigating the impact of the number of
semen analyses on the results of the indi-
vidual laboratories, it became clear that
those laboratories performing more than
20 semen analyses per month obtain cer-
tificates to a higher proportion than those
laboratories with fewer than 20 semen
samples (Fig. 6).
Discussion
Despite a battery of sophisticated sperm
function tests, semen analysis remains
the basic standard investigation to as-
sess male fertility and infertility. Semen
analy sis plays a central role in the work-
up of the infertile couple, but it is also
important in toxicological, ecological
and epidemiological studies. Recent-
ly, semen parameters were even found
to reflect general health and – as a bio-
marker – to predict life expectancy [6].
5% 3%
2% 2%
93%
100%
95%
100%
98%
96%
94%
92%
90%
88%
WHO compliant Chamber WHO compliant /
but different pipee
Makler chamber
n = 49 n = 132 n = 66
Rank 1 Conc.
Rank 2 Conc.
Rank 3 Conc.
Figure 4. Impact of counting chambers and pipettes on determination of sperm concentrations (from 247 responses) as
reflected by results from ranking. Left: using improved Neubauer chamber and positive displacement pipettes; middle:
using improved Neubauer chamber, but no positive displacement pipettes; right: using Makler chamber.
Papanicolaou
Shorr
DiffQuik
Others
0% 10% 20% 30% 40% 50% 60% 70%
45%
37%
4%
14%
Figure 5. Different stainings used by 257 laboratories for sperm morphology. Green: WHO compliant; red: Not WHO
recommended.
J Reproduktionsmed Endokrinol_Online 2017; 14 (6)
External Quality Control of Semen Analysis Reveals Low Compliance with WHO Guideline
309
In the light of this eminent role of semen
parameters, it is surprising that semen
analysis has long escaped quality assur-
ance programs which are an obligatory
exercise for all other measurements in
the medical laboratory. Even the WHO
manual (1st edition 1980) was not over-
ly concerned with external quality con-
trol, and it was only in the 4th edition in
1990 that a small paragraph was dedicat-
ed to this topic. The 5th edition of 2010
[2, 3] expanded external quality control
into a chapter. In parallel, several nation-
al and international external quality con-
trol programs have been developed in
order to improve the validity and inter-
labora tory comparability of results. In
a few countries participation in external
quality control programs became legal-
ly obligatory, and in Germany health in-
surances will not refund costs for semen
analysis without a valid certificate from
the quality control reference institution
issued to the investigating laboratory.
Nevertheless, some sceptics continue to
doubt the value of quality control and the
adherence to generally accepted guide-
lines in order to guarantee reliable and
reproducible results for sperm counts,
motility and morphology [7, 8]. Others
question the predictive value of sperm
parameters in terms of chances for con-
ception and pregnancy [9–13]. However,
this remains an elusive discussion as
long as the suggested and largely accept-
ed guidelines are not strictly followed.
With its manual, WHO provides such
guidelines which have been accepted as
the international standard, although they
remain not undisputed.
As long as participation in an external
quality control program for semen analy-
sis was voluntary , we recognized that
only 8% of laboratories participating in
the QuaDeGA program adhere strictly to
the WHO manual [5], and other external
quality control schemes reported a simi-
lar low adherence to WHO guidelines
[14–16]. Since external quali ty con-
trol and use of WHO guidelines became
compulsory in Germany over 90% of
labs claim to adhere to WHO guidelines,
but as our current survey has shown, in
reality the proportion of WHO followers
is much lower. This failure to adhere to
the guidelines ranges from inappropriate
equipment and techniques to the lack of
internal quality control. Until this situa-
tion changes and uniform methodology
is used, it will be impossible to judge the
value of quality control programs and the
predictive value of semen parameters as
such. The high failure rate in obtaining
the certificate by those not performing
internal quality control, and high suc-
cess rates of those using proper counting
chambers and pipettes, provide visible
examples of how adherence to guidelines
can impact results positively. Also the
impact of different staining techniques
on the evaluation of sperm morphology
has been well documented, as not only
the chemicals used for coloring, but also
the osmolarity of the solutions strong-
ly influence sperm appearance and pre-
dispose to divergent results. In order to
overcome this problem, use of only one
staining technique to be used in all labo-
ratories has been suggested [17, 18], but
the editors of the WHO manual could not
agree to such a strict requirement.
Only if all participants adhere to the
same technical template, can the mag-
nitude of an adherence problem of
semen analysis be properly assessed. It
is a fact that since the first discovery of
sperm under the microscope of Anthony
Leeuwen hoek in 1678, semen analysis
has remained a subjective method de-
pending on the training and the skills of
64
44
61
23
64
16
8
3
32
90
80
70
60
50
40
30
20
10
0
1-10 Semen
analysis
11-20 Semen
analysis
21-50 Semen
analysis
51-100 Semen
analysis
>100 Semen
analysis
Passed Failed
Figure 7. Performance in QuaDeGA ring trial 30/2016 with 663 laboratories divided into three groups of 221 each
according to time of starting participation between 2002 and 2016.
Figure 6. Impact of number of semen analyses per lab and month on awarding the certificate based on answers from
218 participants.
11% 18% 26%
250
200
150
100
50
0
1–221 222–443 444–663
2001–2011 2011–2013 2014–2016
Cerficate
No cerficate
J Reproduktionsmed Endokrinol_Online 2017; 14 (6)
External Quality Control of Semen Analysis Reveals Low Compliance with WHO Guideline
310
the investigator. As most semen analy-
ses are performed by medical laboratory
technicians it is deplorable that at most
of their schools semen analysis is not in-
cluded in their curriculum and most un-
dergo training on the job when confront-
ed with semen analysis. Therefore post-
graduate semen analysis courses are of
utmost importance for improvement of
this situation [13]. In addition, participa-
tion in external quality control programs
has an educational effect on its own [19],
as demonstrated by an increasing rate of
obtaining certificates with the duration
of participating in the QuaDeGA ring tri-
als (Fig. 7). In support of stricter use of
guidelines, journals should request proof
of proficiency by the laboratories sub-
mitting data from semen analysis [20].
Furthermore it is astonishing that despite
30 years of computer-assisted semen
analysis (CASA) research, semen anal-
ysis remains a subjective method. Al-
though technology has advanced to the
extent that individual human faces can be
identified among thousands of subjects, it
remains a puzzle why sperm at low con-
centrations cannot be differentiat ed ex-
actly from debris and sperm morphology
cannot be recognized accurately by elec-
tronic means. Hopefully, once the neces-
sary technology has been develop ed,
all quality control problems will be re-
solved – or not, if it should then become
evident that reproducibility and interlabo-
ratory comparability of results from se-
men analysis depend on other factors in-
trinsic to the object under investigation.
Acknowledgements
The authors gratefully acknowledge co-
operation with Dr. T. J. Panholzer for
maintaining the QuaDeGA platform at
the Institute for Medical Biometry, Epi-
demiology and Information Technolo-
gy of the University Medicine Mainz,
as well as language editing of the manu-
script by Susan Nieschlag MA.
Conflict of Interest
The authors are employed part-time
by the Quality Control Programme
of the German Society of Andrology
( QuaDeGA GmbH).
References:
1. BÄK. Richtlinie der Bundesärztekammer zur Qualitäts-
sicherung laboratoriumsmedizinischer Untersuchungen:
Ejakulatuntersuchungen. Dt Ärztebl 2011; 108: 2298–304.
2. World Health Organization (WHO). Laboratory manual for the
examination and processing of human semen. 5th Edition,
Geneva, 2010.
3. WHO Laborhandbuch zur Untersuchung und Aufarbeitung des
menschlichen Ejakulates. Übersetzt von Nieschlag E, Schlatt S,
Behre HM, Kliesch S (Hrsg.) unter Mitarbeit von Bongers R,
Gottardo F, Greither T, Hellenkemper B, Nieschlag S, Nordhoff V,
Schalkowski M, Zitzmann M. 5. Auflage, Springer Heidelberg,
2012.
4. Cooper T, Hellenkemper B, Nieschlag E. External Quality
Control for Semen Analysis in Germany - Qualitätskontrolle der
Deutschen Gesellschaft für Andrologie (QuaDeGA). The First 5
Years. J Reprod Med Endocrinol 2007; 4: 331–5.
5. Mallidis C, Cooper TG, Hellenkemper B, Lablans M, Ückert F,
Nieschlag E. Ten years’ experience with an external quality con-
trol program for semen analysis. Fertil Steril 2012; 98: 611–6.
6. Latif T, Kold Jensen T, Mehlsen J, Holmboe SA, Brinth L, Pors
K, et al. Semen quality as a predictor of subsequent morbidity:
A Danish cohort study of 4,712 men with long-term follow-up.
Am J Epidemiol. 2017; 279:1–8.
7. Tomlinson MJ. Uncertainty of measurement and clinical value
of semen analysis: has standardisation through professional
guidelines helped or hindered progress? Andrology 2016;
4:763–70.
8. Jequier AM. Is quality assurance in semen analysis still really
necessary? A clinician’s viewpoint. Hum Reprod 2005; 20: 2039–
42.
9. Van Der Steeg JW, Steures P, Eijkemans MJC, Habbema JDF,
Hompes PGA, Kremer JAM, et al. Role of semen analysis in
subfertile couples. Fertil Steril 2011; 95:1013–9.
10. Cooper TG, Noonan E, von Eckardstein S, Auger J, Baker
HWG, Behre HM, et al. World Health Organization reference
values for human semen characteristics. Hum Reprod Update
2009; 16: 231–45.
11. Van Geloven N, Van Der Veen F, Bossuyt PMM, Hompes PG,
Zwinderman AH, Mol BW. Can we distinguish between infertili-
ty and subfertility when predicting natural conception in couples
with an unfulfilled child wish? Hum Reprod 2013; 28: 658–65.
12. Hamilton JAM, Cissen M, Brandes M, Smeenk JMJ, De
Bruin JP, Kremer JAM, et al. Total motile sperm count: A better
indicator for the severity of male factor infertility than the
WHO sperm classification system. Hum Reprod 2015; 30:
1110–21.
13. Barratt CLR, Björndahl L, Menkveld R, Mortimer D. ESHRE
special interest group for andrology basic semen analysis
course: A continued focus on accuracy, quality, efficiency and
clinical relevance. Hum Reprod 2011; 26: 3207–12.
14. Penn HA, Windsperger A, Smith Z, Parekattil SJ, Kuang
WW, Kolettis PN, et al. National semen analysis reference
range reporting: Adherence to the 1999 World Health Organiza-
tion guidelines 10 years later. Fertil Steril 2011; 95: 2320–3.
15. Björndahl L. Compliance with recommendations for reliable
semen analysis results – a matter of importance for patients
and scientific development. Andrology 2016; 4: 771–2.
16. Punjabi U, Wyns C, Mahmoud A, Vernelen K, China B,
Verheyen G. Fifteen years of Belgian experience with external
quality assessment of semen analysis. Andrology 2016; 4:
1084–93.
17. Gatimel N, Moreau J, Parinaud J, Léandri RD. Sperm mor-
phology: Assessment, pathophysiology, clinical relevance, and
state of the art in 2017. Andrology 2017; 1–18.
18. Meschede D, Keck C, Zander M, Cooper TG, Yeung CH,
Nieschlag E. Influence of three different preparation techniques
on the results of human sperm morphology analysis. Int J
Androl 1993; 16: 362–9.
19. Brüggemann, M. Qualitätssicherung laboratoriumsmedizini-
scher Untersuchungen. In: Jonitz G, Mansky T, Scriba PC (Hrsg).
Ergebnisverbesserung durch Qualitätsmanagement. Deutscher
Ärzteverlag, Köln, 2014; 109–114.
20. Carrell DT, De Jonge CJ. The troubling state of the semen
analysis. Andrology 2016; 4: 761–2.
J Reproduktionsmed Endokrinol_Online 2017; 14 (6)
... To determine whether semen assessments are robust throughout the world requires that there are standardized methods used by clinical and research laboratories. Such standardized methods certainly exist but a wealth of data show that semen assessments, for a variety of reasons such as lack of adherence to methods, can have poor reproducibility (Björndahl et al., 2016;Carrell & De Jonge, 2016;Barratt et al. 2017;Nieschlag et al. 2017). As a result, a patient categorized as subfertile in one lab has reasonable likelihood of being categorized as fertile in another laboratory and vice versa. ...
... For better compliance, long-acting FSH formulations have been proposed (i.e. corifollitropin alfa) in place of rhFSH (Nieschlag et al. 2017), which may improve patient satisfaction and compliance. ...
Article
Background In attempting to formulate potential WHO guidelines for the diagnosis of male infertility, the Evidence Synthesis Group noted a paucity of high-quality data on which to base key recommendations. As a result, a number of authors suggested that key areas of research/evidence gaps should be identified, so that appropriate funding and policy actions could be undertaken to help address key questions. Objectives The overall objective of this Consensus workshop was to clarify current knowledge and deficits in clinical laboratory andrology, so that clear paths for future development could be navigated. Materials and Methods Following a detailed literature review, each author, prior to the face-to-face meeting, prepared a summary of their topic and submitted a PowerPoint presentation. The topics covered were (a) Diagnostic testing in male fertility and infertility, (b) Male fertility/infertility in the modern world, (c) Clinical management of male infertility, and (d) The overuse of ICSI. At the meeting in Cairo on February 18, 2019, the evidence was presented and discussed and a series of consensus points agreed. Results The paper presents a background and summary of the evidence relating to these four topics and addresses key points of significance. Following discussion of the evidence, a total of 36 consensus points were agreed. Discussion The Discussion section presents areas where there was further debate and key areas that were highlighted during the day. Conclusion The consensus points provide clear statements of evidence gaps and/or potential future research areas/topics. Appropriate funding streams addressing these can be prioritized and consequently, in the short and medium term, answers provided. By using this strategic approach, andrology can make the rapid progress necessary to address key scientific, clinical, and societal challenges that face our discipline now and in the near future.
... Die hohe Diskrepanz der Bestimmungsergebnisse der Spermienkonzentrationen und -morphologie identischer Proben zwischen verschiedenen Laboratorien demonstriert die Notwendigkeit einer effektiven Qualitätskontrolle der Ejakulatanalyse (Neuwinger et al. 1990). Inzwischen wurden einige Maßnahmen ergriffen, um strikte Qualitätskontrollprogramme im Andrologielabor zu etablieren (Pacey 2009 (Cooper et al. 1999(Cooper et al. , 2002(Cooper et al. , 2007 und steigern die Vergleichbarkeit der Messungen unterschiedlicher Laboratorien (Mallidis et al. 2012;Nieschlag et al. 2017 ...
... Die Ringversuchsteilnehmer, die mit ihren Messwerten für die Progressivmotilität, Morphologie und Konzentration innerhalb des Zielbereichs liegen, erhalten ein Zertifikat über das Bestehen der Qualitätskontrolle. Nur Laboratorien mit einem gültigen Zertifikat können die Kostenerstattung durch die Krankenkassen in Anspruch nehmen.Ungefähr 700 Laboratorien aus dem In-und Ausland nehmen regelmäßig am QuaDeGA-Programm teil(Nieschlag et al. 2017).Die Dokumentation der Ejakulat-(und Hormon-) Parameter erfolgt idealerweise in einem standardisierten Befundbogen mit mehreren Spalten, in den die Ergebnisse der Ejakulatuntersuchungen zu verschiedenen Zeitpunkten eingetragen werden können (Tab. 2). ...
Chapter
Die Untersuchung des Ejakulates dient der Diagnostik und Prognose der männlichen Fertilität. Ob Spermatozoen vorhanden sind, in welcher Anzahl und in welchem Zustand (vital, beweglich, morphologisch normal), sind nützliche Indikatoren, die die Funktion des Hodens, des Nebenhodens und der akzessorischen Geschlechtsdrüsen widerspiegeln und Informationen über die Qualität des beim Koitus übertragenen Samens liefern. Da die Variabilität des Ejakulates ein und desselben Mannes von Tag zu Tag hohen Schwankungen unterliegt, ist die Anwendung standardisierter Methoden für die Gewinnung und Quantifizierung der Komponenten des Ejakulates und der Charakteristika der Spermatozoen notwendig, um eine objektive Interpretation der gewonnenen Daten zu erlauben. Die wichtigsten Tests zur Ejakulatanalyse sowie die Terminologie und Referenzwerte werden hier entsprechend der 6. Ausgabe des WHO-Laborhandbuchs für die Untersuchung und Aufbereitung des menschlichen Ejakulates (2021) beschrieben.
... In general, the literature reports a global lack of conformance to the WHO recommendations and poor compliance with the standardized protocols for semen analysis (Björndahl et al., 2016). To date, published data have focused on the conformance of laboratories who perform a semen analysis in a clinical setting and the subsequent clinical implications of a non-standardized semen analysis (Riddell et al., 2005;Punjabi et al., 2016;Nieschlag et al., 2017;Zuvela and Matson, 2020). Currently, there is no quantification of the level of adherence of research studies, which report the results of a basic semen analysis, according to WHO recommendations. ...
Article
Full-text available
STUDY QUESTION Do publications that involve the interpretation of the results of a basic semen analysis, published in Human Reproduction and Fertility & Sterility between 2011 and 2020, give sufficient evidence in their methodology to demonstrate that they followed the technical methods recommended in the fifth edition of the World Health Organization (WHO) laboratory manual, entitled WHO Laboratory Manual for the Examination and Processing of Human Semen (WHO5)? SUMMARY ANSWER Evidence of methodological agreement of studies with the WHO5 recommendations was low, despite 70% of papers stating that they followed WHO5 recommendations. WHAT IS KNOWN ALREADY A basic semen analysis is currently an integral part of infertility investigations of the male, but method standardization in laboratories remains an issue. The different editions of the WHO manual for the basic semen analysis (WHO1–6) have attempted to address this by providing increasingly rigorous methodological protocols to reduce experimental error. However, to what extent these methods are followed by studies that involve the interpretation of the results of basic semen analysis remains unknown. STUDY DESIGN, SIZE, DURATION A survey of the technical methods used to perform a basic semen analysis was conducted on studies published in two leading reproduction journals (Human Reproduction and Fertility & Sterility) between 2011 and 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS The literature search was performed on the electronic databases PUBMED and MEDLINE Ovid between January 2021 and March 2021. The MeSH terms included in the search were ‘sperm concentration’ OR ‘sperm motility’ OR ‘sperm morphology’ OR ‘sperm vitality’ OR ‘male fertility’ AND ‘human spermatozoa’ NOT ‘animals’. A total of 122 studies were available for analysis. MAIN RESULTS AND THE ROLE OF CHANCE In total, 70% of the studies cited WHO5 in their methods section. Of the remaining studies, 10% cited the fourth edition of the WHO laboratory manual (WHO4), 7% cited both WHO4 and WHO5, 1% cited the third edition of the WHO laboratory manual (WHO3), and 12% did not cite the WHO at all. Overall methodological agreement with WHO5 recommendations was poor, with the main reason for this lack of agreement being that the research studies did not disclose specific details of the technical methods and equipment used. LIMITATIONS, REASONS FOR CAUTION In the case of studies that did not disclose any specific technical methods that they used, we did not attempt to contact these authors and so were unable to confirm the agreement between their technical methods and WHO5 recommendations. WIDER IMPLICATIONS OF THE FINDINGS Our findings suggest there is an urgent need to develop strategies to address standardization in reporting the results of a semen analysis for publication. This is particularly timely given the recent publication of WHO6 and ISO standard 23162 for the basic examination of human semen. STUDY FUNDING/COMPETING INTEREST(S) There was no funding for this project. C.L.R.B., as an employee of the University of Dundee, serves on the Scientific Advisory board of ExSeed Health (from October 2021, financial compensation to the University of Dundee) and is a scientific consultant for Exscientia (from September 2021, financial compensation to the University of Dundee). C.L.R.B. has previously received a fee from Cooper Surgical for lectures on scientific research methods outside the submitted work (2020) and Ferring for a lecture on male reproductive health (2021). C.L.R.B. is Editor for RBMO. TRIAL REGISTRATION NUMBER N/A.
Chapter
Semen is analyzed for both diagnostic and prognostic purposes. Whether spermatozoa are present, in what numbers and in what condition (viable, motile, morphologically normal), are useful indicators that reflect testicular, epididymal, and accessory gland function and provide information on the quality of semen transferred at coitus. As variation in semen quality produced by the same man on different days is high, the use of standard methods for collecting and quantifying semen constituents and sperm characteristics is obligatory for an objective interpretation of the semen analysis result. The major semen analysis tests are described here along with the terminology and reference values provided by the sixth edition of the WHO Laboratory Manual for the Examination and Processing of Human Semen (2021).
Article
Backgrounds Despite a wide spectrum of contraceptive methods for women, the unintended pregnancy rate remains high (45% in the US), with 50% resulting in abortion. Currently, 20% of global contraceptive use is male‐directed, with a wide variation among countries due to limited availability and lack of efficacy. Worldwide studies indicate that >50% of men would opt to use a reversible method, and 90% of women would rely on their partner to use a contraceptive. Additional reasons for novel male contraceptive methods to be available include the increased life expectancy, sharing the reproductive risks among partners, social issues, the lack of pharma industry involvement and the lack of opinion makers advocating for male contraception. Aim The present guidelines aim to review the status regarding male contraception, the current state of the art to support the clinical practice, recommend minimal requirements for new male contraceptive development and provide and grade updated, evidence‐based recommendations from the European Society of Andrology (EAA) and the American Society of Andrology (ASA). Methods An expert panel of academicians appointed by the EAA and the ASA generated a consensus guideline according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system. Results Sixty evidence‐based and graded recommendations were produced on couple‐centered communication, behaviors, barrier methods, semen analysis and contraceptive efficacy, physical agents, surgical methods, actions before initiating male contraception, hormonal methods, non‐hormonal methods, vaccines, and social and ethical considerations. Conclusion As gender roles transform and gender equity is established in relationships, the male contribution to family planning must be facilitated. Efficient and safe male‐directed methods must be evaluated and introduced into clinical practice, preferably reversible, either hormonal or non‐hormonal. From a future perspective, identifying new hormonal combinations, suitable testicular targets, and emerging vas occlusion methods will produce novel molecules and products for male contraception.
Article
Research question: How do laboratories perform when assessing sperm motility with a 3-category system and interpreting results as per the fifth edition of the World Health Organization manual (WHO5), and will the use of a 4-category system as per the sixth edition of the WHO manual improve their performance? Design: Eighty video recordings of sperm samples were sent to over 200 laboratories spanning a 5-year period for the assessment of progressive motility. The results were reviewed relative to the all-laboratory trimmed mean (ALTM) in terms of the minimum and maximum values reported, the coefficient of variation and the proportion of laboratories indicating an abnormal result. A further 20 video recordings were sent over 1 year, with 6-11 laboratories per distribution adjusting to reporting rapid progressive motility using the 4-category system. Results: For the 3-category system, the videos covered a mean assessed progressive motility range of 12.0-81.1%. The mean difference between the minimum and maximum values per sample was 50.3% and the coefficients of variation were negatively correlated with the ALTM (r = -0.87, P < 0.00001). Progressive motility abnormality reporting formed a sigmoid curve, and the inflection point (50% of laboratories identifying an abnormality) gave an ALTM value of 32.01%. Preliminary results for laboratories using the 4-category system showed no performance improvement but the number of laboratories was small. Conclusions: Analytical variation can result in laboratories crossing the clinical cut-off of the lower reference limit for samples whose motility is close to the WHO5 lower reference limit, but is less important for samples with extreme values. The benefits of a 4-category motility system are yet to be shown.
Chapter
Die Betreuung des ungewollt kinderlosen Paares erfordert eine enge interdisziplinäre Zusammenarbeit und korrekte Diagnosestellung bei Mann und Frau. In ca. der Hälfte der Fälle finden sich Fertilitätsstörungen auf Seiten des Mannes, für die verschiedenste anlagebedingte sowie erworbene Faktoren ursächlich sein können. Nach ihrer Lokalisation lassen sich Störungen der Hoden, der ableitenden Samenwege und der akzessorischen Drüsen, der Samendeposition, Störungen des übergeordneten Hypothalamus-Hypophysen-Systems sowie Androgenrezeptor- und Enzymdefekte unterscheiden. Für die Einschätzung der männlichen Fertilität ist die Untersuchung des Ejakulates von zentraler Bedeutung, die andrologische Diagnostik darf sich jedoch keinesfalls hierauf beschränken. Ausführliche Anamnese, körperliche Untersuchung und skrotale Sonografie sind unverzichtbare Bestandteile des Basisprogramms, Hormonanalysen und weitere Zusatzuntersuchungen, wie z. B. eine humangenetische Diagnostik, werden bei Bedarf ergänzt. Als invasive Untersuchungsmethode ist die Hodenbiopsie bis heute nicht durch andere Verfahren zu ersetzen, insbesondere bei der Differenzialdiagnostik der Azoospermie.
Article
Full-text available
For over 30 years, sperm morphology assessment has been one of the most common tests in evaluation of fertility. This review examines the clinical relevance of sperm morphology assessment in the diagnosis of infertility and in assisted reproductive technology, as well as its analytical reliability. Publications on the pathophysiology, the analytical reliability of the test and its clinical relevance in diagnosis and in Assisted Reproductive Technology (ART) were evaluated. This review compared and discussed study methodologies and results, including patient characteristics, preparation, smear staining methods and classification systems. The assessment of the percentage of some abnormalities such as for example thin head, amorphous head, or bent or asymmetrical neck is of little clinical use, and their pathophysiology is not well explained as most are physiological traits. Some studies have highlighted correlations between the percentage of normal forms and functional sperm abnormalities, as well as correlations with ability to conceive in vivo and, in some situations, with the success of intra-uterine insemination (IUI) or conventional IVF. However, except in the case of some specific sperm defects (easy to detect with 99 or 100% of spermatozoa affected) and which are often linked to genetic disorders (globozoospermia, macrocephaly, decapitated sperm syndrome and fibrous sheath dysplasia), sperm morphology assessment has very poor sensitivity and specificity in the diagnosis of infertility. Moreover, there is very little evidence that indices of multiple sperm defects [sperm deformity index (SDI), teratozoospermia index (TZI), and multiple abnormalities index (MAI)] are relevant. Above all, many publications report a major lack of analytical reliability of this test, mainly in assessment of the details of sperm abnormalities. Many questions arise concerning how and when sperm morphology should be assessed, and how to interpret the thresholds of normal forms. Questions are raised on the real clinical impact of this test.
Article
Full-text available
Semen analysis is difficult to standardize, quality control and quality assurance are necessary to ensure that results are accurate and precise. This Belgian EQA survey over a 15-year period, involving 121 laboratories, attempted to reduce interlaboratory variability and at the same time, encouraged participating laboratories to implement correct techniques as advised by the WHO. Over the total period, the median coefficient of variation (CV) for sperm count, irrespective of the method used was 19.2%, while using improved Neubauer chamber resulted in a significantly (p < 0.001) lower median CV (14.4%). The overall median CV for rapid progressive motility was high (37.1%), but progressive motility (15.1%) and total motility (13.8%) were acceptable. Sperm morphology revealed a large variability in 79.4% irrespective of the staining procedures or evaluation criteria used. Participation in the Belgian EQA is on voluntary basis. Both, participation and implementation of the correct techniques should be made mandatory for accreditation and benefit of patient treatment. The existing Belgian EQA program should now be harmonized with other existing EQA schemes in Europe.
Article
Full-text available
The German external quality control programme for semen analysis (QuaDeGA) has distributed 20 QC samples in 10 distributions (two per year) over the last 5 years. Analysis of the results from all participants with respect to the methods used, changes in methods employed, fluctuations and improvement in results are presented. The number of participants rose from an initial 27 to 145 by distribution 10 and 18 centres dropped out. Most centres did not use WHO-recommended methods upon entry into the programme and few changed to them during their participation. Using the QuaDeGA ranking system as a measure of satisfactory performance, an overall improvement in semen analysis was observed with some centres reporting better and consistent results. In conjunction with changing to unified, WHO-recommended semen analysis protocols, participation in the QuaDeGA scheme is beneficial in improving semen analysis as judged by improved agreement with target values for semen variables.
Article
Semen quality is suggested to be a biological marker of long-term morbidity and mortality; however, few studies have been conducted on this subject. We identified 5,785 men seen for infertility in Frederiksberg Hospital, Denmark from 1977-2010, and 4,712 men were followed in the Danish National Patient Registry until first hospitalization, death or end of the study. We classified patients according to all hospitalizations and the presence of cardiovascular disease, diabetes, testicular and prostate cancer. We found a clear association between sperm concentration below 15 mill/mL and all-cause hospitalizations, 50% (95% CI: 1.4, 1.6) and cardiovascular disease, 40% (95% CI: 1.2, 1.6) compared to men with a concentration above 40 mill/mL. The probabilities for hospitalizations were also higher with a low total sperm count and motility. Men with a sperm concentration of 195-200 mill/mL were, on average, hospitalized for the first time seven years later compared to men with a sperm concentration of 0-5 mill/mL. Semen quality was associated with long-term morbidity and a significantly higher risk of hospitalization were found, in particular for cardiovascular diseases and diabetes mellitus. Our study supports the suggestion that semen quality is a strong biomarker of general health.
Article
This article suggests that diagnostic semen analysis has no more clinical value today than it had 25–30 years ago, and both the confusion surrounding its evidence base (in terms of relationship with conception) and the low level of confidence in the clinical setting is attributable to an associated high level of ‘uncertainty’. Consideration of the concept of measurement uncertainty is mandatory for medical laboratories applying for the ISO15189 standard. It is evident that the entire semen analysis process is prone to error every step from specimen collection to the reporting of results and serves to compound uncertainty associated with diagnosis or prognosis. Perceived adherence to published guidelines for the assessment of sperm concentration, motility and morphology does not guarantee a reliable and reproducible test result. Moreover, the high level of uncertainty associated with manual sperm motility and morphology can be attributed to subjectivity and lack a traceable standard. This article describes where and why uncertainty exists and suggests that semen analysis will continue to be of limited value until it is more adequately considered and addressed. Although professional guidelines for good practice have provided the foundations for testing procedures for many years, the risk in following rather prescriptive guidance to the letter is that unless they are based on an overwhelmingly firm evidence base, the quality of semen analysis will remain poor and the progress towards the development of more innovative methods for investigating male infertility will be slow.
Article
Does the prewash total motile sperm count (TMSC) have a better predictive value for spontaneous ongoing pregnancy (SOP) than the World Health Organization (WHO) classification system? The prewash TMSC shows a better correlation with the spontaneous ongoing pregnancy rate (SOPR) than the WHO 2010 classification system. According to the WHO classification system, an abnormal semen analysis can be diagnosed as oligozoospermia, astenozoospermia, teratozoospermia or combinations of these and azoospermia. This classification is based on the fifth percentile cut-off values of a cohort of 1953 men with proven fertility. Although this classification suggests accuracy, the relevance for the prognosis of an infertile couple and the choice of treatment is questionable. The TMSC is obtained by multiplying the sample volume by the density and the percentage of A and B motility spermatozoa. We analyzed data from a longitudinal cohort study among unselected infertile couples who were referred to three Dutch hospitals between January 2002 and December 2006. Of the total cohort of 2476 infertile couples, only the couples with either male infertility as a single diagnosis or unexplained infertility were included (n = 1177) with a follow-up period of 3 years. In all couples a semen analysis was performed. Based on the best semen analysis if more tests were performed, couples were grouped according to the WHO classification system and the TMSC range, as described in the Dutch national guidelines for male infertility. The primary outcome measure was the SOPR, which occurred before, during or after treatments, including expectant management, intrauterine insemination, in vitro fertilization or intracytoplasmic sperm injection. After adjustment for the confounding factors (female and male age, duration and type of infertility and result of the postcoital test) the odd ratios (ORs) for risk of SOP for each WHO and TMSC group were calculated. The couples with unexplained infertility were used as reference. A total of 514 couples did and 663 couples did not achieve a SOP. All WHO groups have a lower SOPR compared with the unexplained group (ORs varying from 0.136 to 0.397). Comparing the couples within the abnormal WHO groups, there are no significant differences in SOPR, except when oligoasthenoteratozoospermia is compared with asthenozoospermia [OR 0.501 (95% CI 0.311-0.809)] and teratozoospermia [OR 0.499 (95% CI: 0.252-0.988)], and oligoasthenozoospermia is compared with asthenozoospermia [OR 0.572 (95% CI: 0.373-0.877)]. All TMSC groups have a significantly lower SOPR compared with the unexplained group (ORs varying from 0.171 to 0.461). Couples with a TMSC of <1 × 10(6) and 1-5 × 10(6) have significantly lower SOPR compared with couples with a TMSC of 5-10 × 10(6) [respectively, OR 0.371 (95% CI: 0.215-0.64) and OR 0.505 (95% CI: 0.307-0.832)]. To include all SOPs during the follow-up period of 3 years, couples were not censured at the start of treatment. Roughly, three prognostic groups can be discerned: couples with a TMSC <5, couples with a TMSC between 5 and 20 and couples with a TMSC of more than 20 × 10(6) spermatozoa. We suggest using TMSC as the method of choice to express severity of male infertility. None. © The Author 2015. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
Article
Study question: Can mixture survival models help distinguish infertility from subfertility in couples with an unexplained unfulfilled child wish? Summary answer: Mixture models estimated that 47% of the couples were infertile; female age and previous pregnancy were significantly related to infertility, whereas duration of child wish was associated with a longer time to pregnancy for subfertile couples. What is known already: To differentiate between couples who require assisted conception and couples who still have good chances of natural, i.e. unassisted, conception, several prediction models of natural conception have been developed. Prognostic factors in these models are usually assessed by Cox proportional hazard models that cannot differentiate between couples with an unfulfilled child wish who are subfertile, i.e. have reduced ability to conceive naturally, and couples who are really infertile, i.e. are completely unable to conceive naturally. We evaluated whether a mixture survival model can make such a distinction. Study design, size, duration: Consecutive couples presenting at the fertility clinics of 38 centres in the Netherlands between January 2002 and February 2004 joined a prospective cohort study. Of the 7860 couples in the cohort, 3917 couples met our inclusion criteria. The median follow-up was 219 days, with a maximum of 5 years. Participants, setting, methods: Couples had to present with an unexplained cause of an unfulfilled child wish. A mixture model was used to estimate the proportion of couples who were infertile and the time to pregnancy for the subfertile couples. Main results and the role of chance: During the follow-up, 794 couples conceived naturally. The mixture model estimated that 47% [95% confidence interval (CI): 33-56%] of couples were infertile, despite the absence of objective factors indicating a cause for infertility. Of the evaluated prognostic factors, female age, duration of child wish, previous pregnancy, semen quality, BMI and cycle length, female age [odds ratio (OR): 1.11, 95% CI: 1.03-1.19] and previous pregnancy (0.22, 95% CI: 0.07-0.67) were significant predictors of infertility. Among subfertile couples, a longer duration of a child wish (FFR: 0.72, 95% CI: 0.61-0.85) was a significant prognostic factor for time to pregnancy. In the Cox models, all variables except BMI were significant predictors of time to pregnancy. Limitations, reasons for caution: The mixture model had limited power due to a low number of couples at the end of the follow-up period. Mixture model analyses on external, long-term follow-up data are necessary to validate our results. Wider implications of the findings: Mixture models could be a useful tool in selecting couples who require assisted reproductive technology because the effects of prognostic factors can be subdivided into effects on the fraction of infertile couples and effects on the time to pregnancy for subfertile couples, which is not possible in conventional models. Study funding/competing interest(s): This study was supported by grant 945/12/002 from ZonMw, the Netherlands Organization for Health Research and Development, The Hague, the Netherlands.
Article
To gauge the performance of laboratories and impact of the German semen analysis external quality control program (QuaDeGA) over its first 10 years. Retrospective analysis of QuaDeGA's twice yearly distribution of fixed semen samples and electronic material documenting sperm motility. Ranking of each participant's responses was determined according to their relation to a "target window." Multicenter. PAITENT(S): Healthy donors. None. Laboratory performance, World Health Organization (WHO) adherence. Over 19 runs, there was a steady increase of participants (280 laboratories), the largest group being private urologic practices. Although use of WHO-recommended Neubauer chamber (from 33% to 55%) and diluent (from 11% to 32%) increased, the opposite occurred with morphology staining protocols (from 41% to 19%). Overall, <8% of laboratories truly followed WHO guidelines. Median-based comparisons, replacing reference laboratories, resulted in a merging of performance rankings regardless of the protocols used. Adherence to WHO recommendations is low, with the majority of laboratories using methods expressly opposed by the guidelines. Participation in QuaDeGA was found to improve the performance of the laboratories involved in the program. However, the use of median-based ranking, while decreasing the extent of variance between laboratories, brings into question the significance of the rankings.