Will the new who standards for semen examination change the clinical management of male infertility
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“Understanding Infertility”: A CME Course in Reproductive Medicine

“Understanding Infertility”: A CME Course in Reproductive Medicine
August 12-14th, 2011 New Delhi, India

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Will the new who standards for semen examination change the clinical management of male infertility Presentation Transcript

  • 1. “Understanding Infertility” – New Delhi, India – August 2011
    Will the new WHO Standards
    for Semen Examination Change
    the Clinical Management of
    Male Infertility?
    SandroEsteves, MD, PhD
    Director
    ANDROFERT
    Center for Male Reproduction and Infertility
    Campinas, BRAZIL
    Esteves, 1
  • 2. Learning Objectives
    Esteves, 2
  • 3. Semen Analysis
    Esteves, 3
  • 4. Cut-off reference values for semen characteristics as published in consecutive WHO manuals
    *Strict (Tygerberg) criterion
  • 5. New WHO references valuesHow 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
  • 6. 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
  • 7. New WHO references valuesHow 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
  • 8. New WHO references valuesCritical Appraisal
    FINLAND
    (Turku)
    NORWAY
    (Oslo)
    DENMARK (Copenhagen)
    UK
    (Edinburgh)
    USA
    (Columbia, NYC, Minneapolis, LA)
    FRANCE
    (Paris)
    ?
    ?
    ?
    ?
    ?
    ?
    AUSTRALIA
    (Melbourne)
    Esteves, 8
  • 9. Studies used to establish the new limits for human semen characteristics in the
    5thed WHO Manual
    Esteves, 9
  • 10. New WHO references valuesCritical Appraisal - Summary
    Esteves, 10
  • 11. Referrals for
    male partner evaluation
    New WHO reference values
    • Implications for Clinical Practice
    Varicocele treatment
    Indications for assisted reproductive techniques
    Esteves, 11
  • 12. Implications for Practice
    • Referrals for male partner evaluation
    Esteves, 12
  • 13. Implications for Practice
    • Reclassification of semen analysis reports
    Couples (N=987) with infertility duration > 12 months
    Morphology results
    accounted for 53%
    of reclassification
    Source: ANDROFERT, Brazil
    Esteves, 13
  • 14. Male Infertility Evaluation
    – much more than a simple semen analysis -
    Esteves, 14
  • 15. Implications for Practice
    • Varicocele treatment
    Esteves, 15
  • 16. Implications for Practice
    • Varicocele treatment
    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.
  • 17. 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.
    Esteves, 17
  • 18. ICSI
    • Severe male factor infertility
    Semen analysis results fall below new reference limits
    Implications for Practice
    • Indications for ART
    • 19. < 5% strict morphology thresholds currently used
    • 20. Indications unlike to change due to new WHO reference values
    Esteves, 18
  • 21. IUI
    • Mild male factor infertility
    • 22. Unexplained male infertility
    Implications for Practice
    • Indications for ART
    • 23. Impact of new WHO reference values likely to be minimal
    Esteves, 19
  • 24. Implications for Practice
    • Indications for ART- Summary
    Esteves, 20
  • 25. 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, 21
  • 26. Practical Points
    Esteves, 22
  • 27. Practical Points
    Esteves, 23