New who standards for semen analysis - highlights and implications

Training Program in Assisted Reproductive Technology 2011
Cleveland Clinic Reproductive Research Center
New WHO Standards
for Semen Analysis:
Highlights and Implications
SandroEsteves, MD, PhD
Director
ANDROFERT
Center for Male Reproduction and Infertility
Campinas, BRAZIL

Learning Objectives
Esteves, 2

Semen Analysis
Esteves, 3

Cut-off reference values for semen characteristics as published in consecutive WHO manuals
*Strict (Tygerberg) criterion

New WHO StandardsHow they were obtained
1,953 semen samples of recent fathers
Time to pregnancy (TTP) ≤ 12 mo
5 studies in 7 countries on 3 continents
Laboratories with QC only
Morphology by strict criterion (Kruger)
Progressive and non-progressive motility
Lower reference limits (5th centile)
Esteves, 5

Percentile distribution of semen characteristics values of recent fathers whose partners had a TTP ≤ 12 months, used to establish the reference limits in the 2010 WHO manual
Cooper et al: World Health Organization reference values for human semen characteristics. Hum Reprod Update 16: 231-245, 2010
Esteves, 6

New WHO StandardsHow they were obtained
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.
“Studies were conducted in different regions of the world with some areas over-represented, such as Northern Europe, and others, such as Africa, parts of Europe and Central and South America, under-represented”
“The values presented are considered to represent global semen characteristics of fertile men”
Esteves, 7

New WHO Standards

New WHO references valuesCritical Appraisal
FINLAND
(Turku)
NORWAY
(Oslo)
DENMARK (Copenhagen)
UK
(Edinburgh)
USA
(Columbia, NYC, Minneapolis, LA)
?
FRANCE
(Paris)
?
?
?
?
?
AUSTRALIA
(Melbourne)
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Studies used to establish the new standards for human semen characteristics in the 5th ed. WHO Manual
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New WHO StandardsCritical Appraisal - Summary
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Female Partner Influence on the Potential Fertility of a Man
Esteves, 12

Referrals for
male partner evaluation
New WHO Standards
Implications for Clinical Practice
Varicocele treatment
Indications for assisted reproductive techniques
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Implications for Practice
Referrals for male partner evaluation
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Reclassification of semen analysis reports
Couples (N=987) with infertility duration > 12 months
Morphology results
accounted for 53%
of reclassification
Source: ANDROFERT, Brazil
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Male Infertility Evaluation
– much more than a simple semen analysis -
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Kamal KM, Jarvi K, Zini A: Microsurgical varicocelectomy in the era of assisted reproductive technology: influence of initial semen quality on pregnancy rates. FertilSteril 75: 1013-1016, 2001.
Richardson I, Grotas AB, Nagler HM: Outcomes of varicocelectomy treatment: an updated critical analysis. UrolClin North Am 35:191-209, 2008.

P=0.003
P<0.001
Mori et al. Does varicocele grade determine extent of alteration to spermatogenesis in adolescents? FertilSteril 90: 1769-1773, 2008.
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ICSI
Severe male factor infertility
Semen analysis results fall below new reference limits
Indications for ART
< 5% strict morphology thresholds currently used
Indications unlike to change due to new WHO reference values
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IUI
Mild male factor infertility
Unexplained male infertility
Indications for ART
Impact of new WHO reference values likely to be minimal
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Indications for ART- Summary
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Expanding the interpretation of the new WHO reference values: focus on the 50th percentile
Laboratories seeking to adopt the new standard should determine the strategy that would aid the clear communication of the clinical significance of the results
Debate is open
Should the new WHO reference values be adopted ?
Esteves, 23

Practical Points (1)
Esteves, 24

Practical Points (2)
Esteves, 25

New who standards for semen analysis - highlights and implications

by Sandro Esteves on Sep 22, 2011

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