endobj Get notified of new articles with our ESHRE newsletter. Truncated telomeres and altered DNA integrity in sperm could negatively influence fertilization, pronuclei formation, embryo morphology and quality and thus could compromise blastocyst formation and implantation. >> /Im2 23 0 R When according to laboratory test a patient is diagnosed with azoospermia, further hormonal and genetic tests along with andrology, urology, genetic consultation and ultrasound scan are needed [35]. The 6th edition has presented the basic examination in a step-by-step and temporal manner, so that it can be reproduced precisely in any laboratory with the required equipment and expertise. It is therefore important that the report is fully reliable, which implies that semen analysis is performed in specialized laboratories strictly following the WHO guidelines and participating at external quality control programs. UNITED KINGDOM, Tanya Milachich and Desislava Dyulgerova-Nikolova, Innovations In Assisted Reproduction Technology. Epithelial cells are derived from the genitourinary tract, while round cells refer to either leukocytes or immature germ cells [1]. For the laboratory personnel, the manual has been streamlined to facilitate a step-by-step examination with several old tests being abandoned, while several new tests have been introduced. In fact, testing for ASA can be requested in case of unexplained couple infertility with normozoospermic male partner [9]. /A 28 0 R /H /I As stated above, semen volume mainly originates from the accessory sex glands, hence sperm concentration is influenced by their activity and does not represent a direct measure of testicular sperm output. Therefore, sperm centriole defects may cause failure of embryo development. Clinical Interpretation of Semen Analysis. To date, seven genes (SUN5, BRDT, PFMBP1, TSGA10, DNAH6, HOOK1, and CEP112) have been found mutated in infertile men with acephalic spermatozoa [20]. Prevalence of anti-sperm antibodies and relationship of degree of sperm auto-immunization to semen parameters and post-coital test outcome: a retrospective analysis of over 10 000 men. The need to increasingly define the seminal characteristics of both fertile and infertile males has led the World Health Organization (WHO) to publish successive editions of the "Manual for the examination and processing of human semen", the current edition being that of 2010 (5th edition). If they are present, a maturation arrest can be suspected (scenario D), while if they are absent, a proximal obstruction can be the cause (scenario E). HHS Vulnerability Disclosure, Help Since the publication of the first edition of the WHO (World Health Organization) Laboratory Manual for the examination of Human Semen in 1980, the reference values of sperm parameters have been . Semen parameters have a leading role both in natural conception and assisted reproduction technologies (ART) outcomes. Tournaye H, Krausz C, Oates RD. /BleedBox [0 0 595.276 779.528] The spectrum of semen phenotypes associated with centriole defects ranges from azoo/oligozoospermia to astheno/teratozoospermia. Three quantitative alterations can be distinguished as follows: Azoospermia: absence of spermatozoa in the ejaculate and in the pellet after centrifugation. Krausz, C., Farnetani, G. (2023). WHO laboratory manual for the Examination and processing of human semen Cancer healing by chemo- or radiation- therapy may disturb hormone production, ejaculation and spermatogenesis for long period of time or even permanently. In the large majority of patients affected by teratozoospermia (normal forms <4%), head, midpiece, tail, and cytoplasmic residue defects are combined, and different spermatozoa may present different types of abnormalities. Bjrndahl L. What is normal semen quality? The main microscopic semen alterations are summarized in Table 13.2. 6Department of Andrology, Cairo University, Cairo, Egypt. /Pages 2 0 R Failure in sperm production or low sperm count and motility, poor morphology, disturbance in sperm movement and progressive passage through the cervical mucus, uterus, ampulla of the oviducts, capacitation and acrosome reaction, binding zona peluccida, etc. 2013;1:4017. /Im1 22 0 R Knowles MR, Zariwala M, Leigh M. Primary ciliary dyskinesia. << /Creator Inclusion in an NLM database does not imply endorsement of, or agreement with, J Assist Reprod Genet. The 5th edition WHO manual utilized a population of 1,800 fertile men to obtain the reference distributions for semen parameters [1]. Distribution of semen examination results 2020 - A follow up of data There are still controversial study conclusions for the impact of IMSI procedure on in vitro cycle outcomes. Management of male factor infertility: position statement from the Italian Society of Andrology and Sexual Medicine (SIAMS): Endorsing Organization: Italian Society of Embryology, Reproduction, and Research (SIERR). Although the likelihood of spontaneous fertilization remains extremely unlikely even in case of cryptozoospermia, the importance in distinguishing between these two conditions refers to different in vitro fertilization options, i.e., in azoospermia testicular sperm extraction (TESE) must precede ICSI. Correa-Prez JR, Fernndez-Pelegrina R, Aslanis P, Zavos PM. The 6th edition is a step forward in our understanding of the complex subject of male infertility through evaluation of the human ejaculate. endobj Ten years after its last edition, WHO launches it sixth manual with detailed step-by-step procedures and methods for the laboratory examination and processing of semen, a reference document intended to maintain and sustain the quality of analysis and the comparability of results. Its based on principles of collaboration, unobstructed discovery, and, most importantly, scientific progression. Genetics of teratozoospermia: Back to the head. The WHO 6th edition manual highlights a new semen assay, the sperm DNA fragmentation index, for use after routine semen examination. Avidor-Reiss T, Carr A, Fishman EL. A return to the earlier classification of the 4th edition of WHO manual for sperm motility [10] is a welcome improvement as it allows a better characterization of motility and may provide additional prognostic information. /Subtype /Link Full size table. acrosomal arealack, partial or vesiculated; post-acrosomal laminalack or vesiculated; mitochondrialack, partial, disorganization; nucleussmall or large oval, narrow, wide or short, regional disorder, vacuoles occupying more than 4% of the nuclear area [87, 88]. 8600 Rockville Pike This condition is characterized by the production of spermatozoa with round head without acrosome, hence they are missing PLC, an acrosome phospholipase, essential for the activation of the oocyte. The extreme reduction in sperm vitality is known as necrozoospermia. The last (fifth) edition of the manual, published in 2010, defines serious decrease in cutoff values for sperm parameters related to chances of achieving pregnancy and thus its significance was widely discussed [3, 4]. 2016;37:449. /Subtype /Link Although routine sperm analysis is able to diagnose extreme conditions which are typically associated with functional and genetic defects, microscopic examination does not provide direct information on the functional integrity of the spermatozoa. Over the years, many reproductive specialists have been constantly debating, suggesting and remodeling the frame values in those guidelines. Liquefaction of the semen needs 1530min, and this process is regulated by the prostatic secretion, which is rich in citric acid acting in synergy with proteolytic enzymes (lysozyme, -amylase, and -glucuronidase) and prostatic specific antigen (PSA), a trypsin-like protease, that cleaves the semenogelin proteins. /C [0 1 1] /MediaBox [0.0 0.0 595.276 779.528] Different techniques for sperm retrieval: percutaneous epididymal sperm aspiration (PESA), microsurgical epididymal sperm aspiration (MESA), testicular sperm aspiration (TESA) or testicular sperm extraction (TESE) could be applied in order to obtain reproductive cells for further use in in vitro fertilization (IVF) or ICSI treatment [38]. There are limitations to semen analysis depending on the patient specificity and the use of good laboratory practice protocols. /MediaBox [0.0 0.0 595.276 779.528] Macrozoospermia is typically associated with a high rate of aneuploidy and polyploidy caused by the nondisjunction of chromosomes or defective cytokinesis during meiosis [16]. Mol Reprod Dev. /Filter /FlateDecode /Resources 17 0 R While the 5th percentile is commonly utilized as a statistical approach to determine cut-off norms in medical tests, this resulted in much controversy when applied to male fertility [2]. In 2021, the sixth edition of the WHO manual was published and included reference ranges from studies performed since 2010 combined with the data used in the previous 2010 manual (2. This condition is known as hematospermia and based on the age of the patient, it can have different etiology: in younger men (<40years), it could be due to inflammation or urogenital infections, while in older men (>40years), it could underlie more serious pathologies, such as prostate cancer [7]. This new discovery suggests the need of further exploration and observation of sperm structuresnot only in order to connect them to sperm function but also to clarify their significance. 11 0 obj Sperm motility is classified based on the direction and velocity of sperm movement into the following categories: (i) progressive motility (rapid and slow); (ii) non-progressive sperm movement; and (iii) immotile spermatozoa [1]. In OA, spermatogenesis is unaffected, and the absence of spermatozoa in the ejaculate is due to bilateral distal or proximal obstruction of the urogenital tract. A revision will be needed to better guide the andrologist/clinician regarding the utility of these important assays [12]. There is a growing evidence that mutation in some of these genes (DNAH17, CFAP65, and CEP135) confers very poor prognosis even for IntraCytoplasmic Sperm Injection (ICSI) pregnancies [18]. Another, yet controversial, issue reflecting in low sperm count is obesity. Hum Reprod Update. It was therefore proposed that WHO reference ranges did not adequately reflect fertility dynamics of the male partner, with several investigators and clinicians believing that normal values were above the lower 5th percentile. The most important change proposed in the 6th edition is the adoption of decision limits to differentiate normal from abnormal ejaculates. The editors of the 6th edition acknowledge that the reference ranges described in the 5th edition should be abandoned as they are of limited value in differentiating fertile from infertile men. Mulhall JE, Albertsen PC. Jungwirth A, Giwercman A, Tournaye H, Diemer T, Kopa Z, Dohle G, et al. Still, in patients with terminal loss of spermatogenesis due to cancer treatment, frozen samples are the only chance of hope to father a biological child. WHO standards of Semen Analysis | ACIMC /CropBox [0.0 0.0 595.276 779.528] Abnormalities might affect sperm motility, sperm fertilize ability and conception. 13Department of Urology, Lilavati Hospital and Research Centre, Mumbai, India. The 5th edition has been criticized for neglecting the female factor as an important confounder [3] and for both over- and under-representation of various regions of the world [4]. Federal government websites often end in .gov or .mil. Google Scholar. When semen volume is reduced, different pH may indicate different etiology. The results obtained during the semen sample analysis could point out absence of spermatozoa, severe or mild deviation in sperm parameters or normal values for semen volume, sperm count and concentration, motility and morphology of the spermatozoa. The dataset used to help formulate the WHO 2010 values 1 was obtained from the editorial team of the sixth edition of the upcoming WHO laboratory manual. The presence of a high number of WBCs and a reduced ejaculated volume has been proposed as an indicator for infections and inflammations of the genitourinary tract [23]. Evolution of the WHO "Semen" processing manual from the first (1980) to London, SW7 2QJ, In: Bettocchi, C., Busetto, G.M., Carrieri, G., Cormio, L. (eds) Practical Clinical Andrology. Resurrecting the spermatogenesis process could be achieved depending on the factors inducing azoospermia. Modern day societyenvironment, lifestyle and diet are suspected to be harmful to different processes in the organism such as spermatogenesis and could negatively affect the quality and quantity of life through human lifespan including the ability to reproduce. In this paragraph, we are going to briefly describe informative semen analysiss outcomes. Publishing on IntechOpen allows authors to earn citations and find new collaborators, meaning more people see your work not only from your own field of study, but from other related fields too. >> /Annots [10 0 R 11 0 R 12 0 R 13 0 R 14 0 R] CAS In March 2021, the WHO released a preliminary draft of the 6th edition of its manual for public review and suggestions (https://www.who.int/publications/i/item/9789241547789). Especially extreme asthenozoospermia, with or without associated teratozoospermia (see below), is due to different genetic anomalies [11]. It has been argued that the 5th percentile is not applicable to assign normality in this case and proves unable to discriminate between fertile and infertile patients [3]. When diagnosed, and considering that Y chromosome infertility is inherited in a Y-linked manner, the patients should discuss and consult the specific genetic condition with genetics specialists as this could lead to infertility in the next generations [103]. The following table [69] represents changes for cut off values for semen parameters according consecutive WHO manuals: Sperm sample evaluation in a modern andrology lab might be measured by the means of CASA. In case the percentage of immotile sperm is higher than 40%, vitality test is indicated in order to distinguish vital and dead cells [1]. CrossRef Isolating an optimal fraction (higher count with progressive movement, morphologically normal rates) of spermatozoa gives the opportunity for selection and usage of the spermatozoa with a better fertilizability and higher chances to contribute for a viable fetus, for intrauterine insemination (IUI), IVF or ICSI. (PDF) The Effect of Ejaculatory Abstinence Interval on Sperm Parameters Lancet Diabetes Endocrinol. Fertility preservation via sperm freezing is an option. Class 3Low-quality spermatozoa (score 0) [81]. 10Department of Medical Biosciences, University of the Western Cape, Bellville, South Africa. Subsequent studies provided further analysis and information for the importance of the new method evaluating sperm morphology for obtaining better results in patients with male factor infertility. The ability of a men to become biological father is not only a consequence of normal sperm count but is also linked to the normal function of the male reproductive tract and sperm activity. In consideration of the above, when interpreting a semen analysis report, it is important that the clinician ascertains whether a given laboratory participates in EQC programs with success. Schlegel PN, Sigman M, Collura B, De Jonge CJ, Eisenberg ML, Lamb DJ, et al. Currently, the 5th edition of the WHO manual, published in 2010, is implemented worldwide, and is considered one of the most used, yet contested documents in the field of male infertility [1]. Both conditions are associated with functional abnormalities leading to severe impairment of fertilizing ability. This feature could indicate the presence of an immunological cause of infertility, even though the presence of anti-sperm antibodies (ASA) should be confirmed by further testing, such as the commercially available mixed antiglobulin reaction test (MAR test). In fact, the large majority of spermatozoa does not fulfil the WHO criteria for being considered as normal even in the specimen of fertile men [1]. /Names [(Doc-Start) [3 0 R /XYZ 72 826.58 null] The clinical awareness of nutritional balance in disease occurrence, progression and outcome is still limited, but the need of balanced diet nutrients and antioxidants is urged and necessary [132, 133]. The approach in the sixth edition emphasizes that all major parts of spermatozoa should be assessed, with all staff who perform morphology assessments being trained to detect defects in all sperm regions. endobj Consequently, the 50th percentile of reference values would correspond to only 14% of typical forms. The rest of the tail consists of a principal piece (axoneme or ciliary structure surrounded by outer dense fibers), a fibrous sheath with longitudinal columns and an endpiece. Therefore, careful medical history taking is essential to rule out iatrogenic teratozoospermia. The five new studies have incorporated data from two regions in Europe, one from Africa and two from Asia, although notably 1,200 out of 1,789 participants originate from China alone, therefore skewing the reference values towards normality of specific geolocations that do not necessarily apply in different populations. The effects of sulfasalazine on human male fertility potential and seminal prostaglandins. These are classified as normal, borderline, and pathological. government site. The editors of the 6th edition should be commended for introducing tests of sperm DNA fragmentation (SDF) in the manual. (page.1) [3 0 R /XYZ 71 827.58 null] ASA have been found in several pathological conditions which may lead to the interruption of the blood-testis barrier, such as testicular torsion, testicular carcinoma, and orchitis [8]. /Type /Annot /Rotate 0 It is controversial whether high vacuolization in the sperm head is associated with higher DNA fragmentation and aneuploidy rate [81, 82] that may have adverse effect on embryo quality and postimplantation development and higher frequency of pregnancy loss at early gestational stages. As previous studies reported, abnormal tail structure is correlated to sperm motility disorders, as nonspecific flagellar anomalies (NSFAs) are found to be the most frequent flagellar pathology in severe asthenozoospermia, and thus reduces the chance for natural conception [61]. Books > Imbalance between the formation of ROS and the inability of the antioxidants to neutralize the excessive production of ROS is defined as oxidative stress (OS). This new Edition has made the analysis of basic semen parameters more robust, taking into account the criticisms and grey areas of the previous editions. This year the sixth edition of the WHO Manual is being published [ 2 ]. WHO laboratory manual for the examination and processing of human semen. Extended semen examinations in the sixth edition of the Concepts in diagnosis and therapy for male reproductive impairment. endobj Alshahrani S, Aldossari K, Al-Zahrani J, Gabr AH, Henkel R, Ahmad G. Interpretation of semen analysis using WHO 1999 and WHO 2010 reference values: abnormal becoming normal. Keywords: WHO laboratory manual 6th Edition; semen; sperm; sperm DNA fragmentation; << Performing at least two separate semen analysis is needed. Only 33% of spermatozoa from the examined samples appeared morphologically normal according to these criteria [86]. Improved semen quality after a short-interval second ejaculation. WHO laboratory manual for the examination and processing of human semen Link between sperm morphology and numerical or structural chromosome abnormalities are suggested and investigated [62, 63, 64]. /Subtype /Link Compared to the fth edition, the sixth edition features a returntorecommendingfewervariantsofdilution.Thereason isthatiftherearemanyalternatives,therearemore''limits'' to considerandpreparewithanincreasedriskforconfusionand mistakes. Molecular and cellular endocrinology. . Despite the advances of modern science and reproductive medicine, for some men, the only chance to father a child is through donated sperm [120]. Despite many discussions about the clinical importance of semen parameters, semen analysis remains a fundamental step in clinical andrology. Viscosity is the characteristic of an ejaculate specimen to exhibit a homogeneous stickiness, which may be reduced or increased due to various conditions reported in Table 13.2. /Type /Annot Some external factors such as exposure to toxins (toluene, methoxyethanol, sulfur dioxide), metals (cadmium) chemotherapy and ionizing radiation (cancer treatment) may also influence ROS levels and form OS. /Border [0 0 0] In the chapter "Sperm preparation techniques", this 6th Edition briefly describes the MACS technique as a technique for selecting sperm with potentially undamaged DNA (i.e., with intact DNA). Semen examination is the cornerstone of the evaluation of male fertility potential. /Length 2054 >> For instance, in semen presenting all three parameters corresponding to the WHO lowest reference value, there are 11.7 million of progressively motile and 1.56 million morphologically normal spermatozoa. 2017;5:54453. >> Recently, DNA fragmentation tests have been widely incorporated in laboratory practice. In the large majority of OA cases and in primary testicular failure, TESE is the most viable treatment option. /CreationDate (D:20230630061751-00'00') 2019;40:669710. Since 1987, there are several updates in different editions of World Health Organization (WHO) manuals defining the optimal sperm parameters with reference to pregnancy outcomes. /Filter /FlateDecode The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. /Im0 21 0 R Routine semen analysis is a valuable diagnostic test although it has its own limitations. Prostate and seminal vesicles are target organs of androgens; therefore, severe androgen deficiency is associated with lower semen volume. >> In fertile men, who have different translocations the frequencies of sperm chromosomal abnormalities were high (3392%) in comparison to those with normal karyotype [65]. Another option is performing TESE and ICSI procedure when sperm cells are retrieved after the extraction. This controversy stems in part from the modest predictive value of SDF tests in reproduction and the multitude of available tests with variable thresholds and inter-lab variability. 8Andromed Health & Reproduction, Fertility Diagnostics Laboratory, Maroussi, Athens, Greece. The editors of the 6th edition have acknowledged these limitations (Appendix 8.1 of the manual) and stipulated that semen examination cannot strictly differentiate between pathological and normal samples. Sperm contains almost 3000 different kinds of mRNA coded for proteins that are active in the early embryo development period. /TrimBox [0 0 595.276 779.528] Hum Genet. Requirement for semen analysis and semen parameters have been set as recommended in successive editions of WHO in 1980, 1987, 1992, 1999 and 2010 [1]. endobj The https:// ensures that you are connecting to the << Google Scholar. Bonomo Teaching Hospital Andria, Andria, Italy. If we now apply the new criteria and deem men with parameters below the new normal threshold (borderline+pathological) as infertile, we will suddenly increase the number of infertile men in our practices. /C [0 1 1] As CBAVD has been associated with mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene [108, 109] investigating the condition and genetic testing and consultation prior the procedures should be provided as there is a risk for the couple to have a child with cystic fibrosis [110]. The reduction in sperm motility, called asthenozoospermia (total motility <42% and progressive motility <30%) can be due to congenital or acquired factors. Clinicians can still offer hope for natural pregnancy in these cases before opting to pursue ART. Slow progressive: 5 to <25 m/s, or at least one head length to less than half tail length/sec. Aggregation and agglutination are two different parameters. What seems to be the most important in the observation of motile spermatozoa under high magnification in real time is evaluating the presence of vacuoles in the head of the sperm cellnumber, size and location. Zinaman MJ, Brown CC, Selevan SG, Clegg ED. The majority of fertile men is expected to have their parameters within the range of the 50th percentile. PubMedGoogle Scholar. In fact, wide discrepancies in the assessments of sperm count, motility, and morphology can result when comparing semen analysis outcomes from different laboratories [4, 5]. Filimberti E, DeglInnocenti S, Borsotti M, Quercioli M, Piomboni P, Natali I, et al. Semen evaluation is divided into two parts: macroscopic and microscopic analysis (Fig. WHO laboratory manual for the examination and processing of human semen