Adherence to WHO 2010 Recommendations with regard to Semen Analysis Reports in the Laboratories if West Bengal

Adherence to WHO 2010
Recommendations with regard to
Semen Analysis Reports in the
Laboratories of West Bengal
Sujoy Dasgupta
MBBS MS DNB MRCOG
Consultant, Reproductive Medicine, Genome Fertility Centre, Kolkata

Semen Analysis
• An integral part of evaluation of a subfertile male.
• Reflects the genital tract health of a man three months prior to
collection

Variation of Semen Analysis Results
• Significant day to day variation
• Inter-Laboratory Variation

Standards of Semen Analysis
• Standard reference values are necessary, but how they are developed or
defined varies.
• The World Health Organization (WHO) has set specific recommendations
for reporting sperm parameters- 1980, 1987, 1992, 1999
• The data were derived from imprecisely defined reference populations
and obtained from laboratories with unknown comparability with
respect to analytical methodologies.

Esteves S C. Clinical relevance of routine semen analysis and controversies surrounding the 2010 World
Health Organization criteria for semen examination. Int Braz J Urol. 2014; 40: 443-53

WHO 2010 (5th Edition)
• Based on parameters in a large group of fertile men along with defined
confidence intervals from recent fathers with known time-to-pregnancy
(TTP).
• These reference values were based on limited data to define normal fertility,
along with consensus determination.
• The WHO does not consider the values set as true reference values but
recommends or suggests acceptable levels.
• The reason for this vagueness is partly that values may vary from region to
region.
• Laboratories rarely, if ever, perform these tests to determine regional levels,
owing to the time and cost.
• The WHO provides such foundation for parameters.

Cooper TG et al. World Health Organization reference values for human semen
characteristics. Hum Reprod Update. 2010; Vol.16: 3, 231–245

• Accuracy of the actual testing is of utmost importance and technician
dependent
• The parameters relative to the reference values are one of the first steps
that set the basis for referrals to specialists, investigation of
underlying causes, and determination of treatment options.
• Careful understanding of reference values determination should be
considered.
Reference Values

That’s Why
• Western Studies found the lack of uniformity among the laboratories in
assessing and reporting semen samples (Mainly WHO 1999, few studies WHO
2010)
• Our study looked into the adherence of reporting of semen analysis with the
WHO 2010 guidelines.

To determine adherence to WHO 2010
Standards while reporting Semen Analysis
Results
To compare the reference values quoted on
these reports with those set by the WHO 2010
Guideline
To compare the reporting of ART laboratories
and Non-ART laboratories with respect to
Semen Analysis
*ART- Assisted Reproductive Technology

Study Design
Observational Study
Study Subject
Semen Analysis reports obtained from January 2018 to June 2018
obtained from laboratories of West Bengal, India
1. Individual patients presented to our Fertility Clinic
2. Reports sent by the patients online to their treating doctors
3. Directly from the laboratory

Exclusion Criteria
• Reports done before 2012
• Reports showing Azoospermia/ Cryptozoospermia/ Severe
Oligozoopermia (where details of motility/ morphology analysis
not possible)
Approved by Institutional Ethics Committee

Study Methodology
Written Informed Consent from all the participants
Reports were anonymized
Details mentioned in the report were put in the Excel Sheet
Reports were compared against standards and references laid by WHO, 2010

If did not match with WHO 2010 standards or references
Search was made to determine
whether the reports matched with previous versions of WHO Semen Analysis Standards
(1999, 1992, 1987 and 1980)
Laboratories were divided in two Categories
1. ART Laboratories-
Laboratories attached with ART clinics
2. Non-ART Laboratories
Local/ regional pathology/ hospital laboratories

Results were expressed in numbers and proportions (%)
Results between ART and Non-ART laboratories were compared by
Z Score for 2 Population Proportions
p value <0.05 considered as significant

Number of Semen
Reports obtained
Individual patients presented to Fertility Clinics and/
or Gynaecologists
196
234Reports sent by the patients online to their treating
doctors
33
Directly from the laboratory 5
Excluded 23
Final Analysis N= 211
Number of Laboratory-Reports Obtained

N= 15
(7. 109%)
N= 196
(92.891%)
Total Number of Laboratories (N = 211)
ART Lab
Non-ART Lab

WHO Laboratory Manual
for the Examination and
Processing of Human
Semen FIFTH EDITION.
2010

Collection Details
• There is some evidence that the quality of semen specimens varies depending on how the
ejaculate is produced.
• Ejaculates produced by masturbation and collected into containers in a room near the
laboratory can be of lower quality than those recovered from non-spermicidal condoms used
during intercourse at home (Zavos & Goodpasture, 1989).
• The results of laboratory measurements of semen quality will depend on:
1. Whether a complete sample is collected. During ejaculation the first semen fractions
voided are mainly sperm-rich prostatic fluids, whereas later fractions are dominated by
seminal vesicular fluid (Björndahl & Kvist, 2003).
2. The time since the last sexual activity
3. The penultimate abstinence period.

WHO Laboratory Manual for the Examination and Processing of Human Semen FIFTH EDITION. 2010

Abstinence Period (AP)
Total (n= 211) 195 92.417%

Abstinence Period (AP)
Mentions AP Proportion of those who mention P value
ART Lab (n= 15) 15 100% 0.25014
(Not
significant)
Non ART Lab (n= 196) 180 91.836%
Total (n= 211) 195 92.417%

Collection Time (CT) and Examination Time (ET)
Total (n = 211)
Mentions CT 103
Proportions mentioning CT 48.815%
Mentions ET 52
Proportions mentioning ET 24.645%
Mentions both CT and ET 50
Proportions mentioning both CT and ET 23.697%
Mentions neither CT nor ET 106
Proportions of mentioning neither CT nor ET 50.237%

ART Lab (n= 15) Non-ART Lab (n= 196) Total (n = 211)
Mentions CT 11 92 103
Proportions mentioning CT 73.333% 46.939% 48.815%
P value 0.04884 (Significant)
Mentions ET 52
Proportions mentioning ET 24.645%

Mentions ET 5 47 52
Proportions mentioning ET 33.333% 23.979% 24.645%
P value 0.41794 (Not Significant)

Mentions ET 5 47 52
Mentions both CT and ET 5 45 50
Proportions mentioning both CT and ET 33.333% 22.959% 23.697%

Mentions ET 5 47 52
Mentions both CT and ET 5 45 50
Proportions mentioning both CT and ET 33.333% 22.959% 23.697%
Mentions neither CT nor ET 4 102 106
Proportions of mentioning neither CT nor ET 2.667% 52.041% 50.237%

Details of Collection
Total (n = 211)
Mentions Site of Collection 104
Proportions mentioning Site 49.289%
Mentions Completeness of Collection 102
Proportions mentioning Completeness 48.341%
Mentions Method of Collection 65
Proportions mentioning Method 30.806%

Mentions Site of Collection 12 92 104
Proportions mentioning Site 80.000% 46.939% 49.289%
Proportions mentioning Completeness 48.341%

Mentions Completeness of Collection 12 90 102
Proportions mentioning Completeness 80.000% 45.918% 48.341%

Mentions Completeness of Collection 12 90 102
Proportions mentioning Completeness 80.000% 45.918% 48.341%
Mentions Method of Collection 5 60 65
Proportions mentioning Method 33.333% 30.612% 30.806%

Liquefaction Time (LT)

Mentions LT No Mention Proportion of those who mention
ART Lab
(n= 15)
1- No mention
1- Satisfactory (?)
Non ART Lab
(n= 196)
38- No mention
3- Normal (1- WHO 2010
Ref)
1- Satisfactory (WHO 2010
Ref)
2- Liquefied (?)
1- Complete (WHO 2010
Ref)
1- Positive (?)
Total (n= 211) 163 48 77.251%

Mentions LT No Mention Proportion of those who mention P value
ART Lab
(n= 15)
13 1- No mention
1- Satisfactory (?)
86.667% 0.36812
(Not
Significant)
Non ART Lab
(n= 196)
150 38- No mention
3- Normal (1- WHO 2010
Ref)
1- Satisfactory (WHO 2010
Ref)
2- Liquefied (?)
1- Complete (WHO 2010
Ref)
1- Positive (?)
76.531%
Total (n= 211) 163 48 77.251%

Reference value of Liquefaction Time
WHO 2010/ 1999/ 1992 (<60
Min)
Wrong
Reference
No mention
of any
reference
Proportion of
those using WHO
2010Mentions
value
Only WHO
2010
Total (n= 211) 35 3 10 163 38/ 211= 18.009%

Reference value of Liquefaction Time
WHO 2010/ 1999/ 1992 (<60
Min)
Wrong
Reference
No mention
of any
reference
Proportion of
those using WHO
2010
P value
Mentions
value
Only WHO
2010
ART Lab
(n= 15)
4 1 10 4/ 15= 26.667% 0.36282
(Not
Significant)
Non ART Lab
(n= 196)
31 3 9 153 34/ 196= 17.347%
Total (n= 211) 35 3 10 163 38/ 211= 18.009%

Viscosity

Viscosity
Mentions Viscosity No Mention Proportions of those who
mention
ART Lab (n= 15) Normal- 11
Non ART Lab
(n= 196)
Normal 58
Good 2
Viscous/ Viscid 31
High/ Increased/ Thick- 13
Moderate/ medium-7
Less/ low/ Thin/ Slight/ Mild- 21
Liquid- 1
Mucoid- 4
Plus 2
Poor 1
Opaque 1
Positive 1
Semen- 1
Semiviscous 1
Total (n= 211) 156 55 156/ 211 = 73.934%

Viscosity
Mentions Viscosity No Mention Proportions of those who
mention
P value
ART Lab (n= 15) 11 Normal- 11 4 11/ 15= 73.333% 0.56192
(Not
Significant)
Non ART Lab
(n= 196)
145 Normal 58
Good 2
Viscous/ Viscid 31
High/ Increased/ Thick- 13
Moderate/ medium-7
Less/ low/ Thin/ Slight/ Mild- 21
Liquid- 1
Mucoid- 4
Plus 2
Poor 1
Opaque 1
Positive 1
Semen- 1
Semiviscous 1
51 145/ 196= 73.979%
Total (n= 211) 156 55 156/ 211 = 73.934%

Reference value of Viscosity
WHO 2010/ 1999/
1992 (Normal)
Other Reference No mention of
any reference
Proportion of those
using WHO 2010
Total (n= 211) 30 1 180 14.218%

Reference value of Viscosity
WHO 2010/ 1999/
1992 (Normal)
Other Reference No mention of
any reference
Proportion of those
using WHO 2010
P value
ART Lab
(n= 15)
3 12 20.000% 0.50286
(Not
Significant)
Non ART Lab
(n= 196)
27 1 (“Normally +”) 168 13.775%
Total (n= 211) 30 1 180 14.218%

Appearance

Appearance
Mentions No Mention Proportion of those who mention
Total (n= 211) 195 16 92.417%

Appearance
Mentions No Mention Proportion of those who mention P value
ART Lab
(n= 15)
14 1 93.333% 0.88866
(Not Significant)Non ART Lab
(n= 196)
181 15 92.347%
Total (n= 211) 195 16 92.417%

Reaction
Mentions
specific pH
“Alkaline” No
Mention
Proportion of those who
mention specifically
Total (n= 211) 184 12 15 87.204%

Reaction
Mentions
specific pH
“Alkaline” No
Mention
Proportion of those who
mention specifically
P value
ART Lab
(n= 15)
9 4 2 60.000% 0.00108
(Significant)Non ART Lab
(n= 196)
175 8 13 89.286%
Total (n= 211) 184 12 15 87.204%

There are currently few reference values for the pH of semen from
fertile men.
Pending more data, this manual retains the consensus value of 7.2 as a
lower threshold value.
Reaction

Reference value of pH
WHO Other
References
No mention of
any reference
Proportion of
those using WHO
2010
2010/ 1999/ 1992
(7.2-8.0)
Only mentions
WHO 2010
Total (n= 211) 43 4 3 “Alkaline” 161 20.379%

Reference value of pH
WHO Other
References
No mention of
any reference
Proportion of
those using WHO
2010
P value
2010/ 1999/ 1992
(7.2-8.0)
Only mentions
WHO 2010
ART Lab
(n= 15)
5 1 9 33.333% 0.19706
(Not
Significant)
Non ART Lab
(n= 196)
38 3 3- “Alkaline” 152 19.388%
Total (n= 211) 43 4 3 “Alkaline” 161 20.379%

Volume
Mentions Vol No Mention Proportion of those who
mention
Total (n= 211) 210 1 99.526%

Volume
Mentions Vol No Mention Proportion of those who
mention
P value
ART Lab (n= 15) 15 0 100% 0.77948
(Not
Significant)
Non ART Lab (n= 196) 195 1 (Adequate- ?)
Not calculable
99.489%
Total (n= 211) 210 1 99.526%

Reference value of Volume
WHO 2010 Ref Other WHO Ref No mention of
any reference
Proportion of
those using WHO
2010
Mentions
value (1.5 ml)
Only
“WHO
2010”
1999/ 1992/ 1987
(≥ 2 ml)
Total (n= 211) 30 4 23 154 16.114%

Reference value of Volume
WHO 2010 Ref Other WHO Ref No mention of
any reference
Proportion of
those using WHO
2010
P value
Mentions
value (1.5 ml)
Only
“WHO
2010”
1999/ 1992/ 1987
(≥ 2 ml)
ART Lab
(n= 15)
5 1 1 8 40.00% 0.00906
(n= 196)
25 3 22 146 14.286%
Total (n= 211) 30 4 23 154 16.114%

Agglutination

Agglutination
Mentions Agglutination No Mention Proportion of those who
mention
Nil 5
Present 5
Nil 17
Grade II- 2
Grade I- 3
Clump+ 1
Present 14
Total (n= 211) 47 164 47/ 211 = 22.275%

Agglutination
Mentions Agglutination No Mention Proportion of those who
mention
P value
ART Lab
(n= 15)
10 Nil 5
Present 5
5 10/ 15= 66.667% 0
(Significant)
Non ART Lab
(n= 196)
37 Nil 17
Grade II- 2
Grade I- 3
Clump+ 1
Present 14
159 37/ 196= 18.878%
Total (n= 211) 47 164 47/ 211 = 22.275%

Reference value of Agglutination
WHO 2010 No mention of
any reference
Proportion of
those using WHO
2010
Mentions
(Nil)
Only mentions
WHO 2010
Total (n= 211) 6 4 201 10/ 211= 4.739%

Reference value of Agglutination
WHO 2010 No mention of
any reference
Proportion of
those using WHO
2010
P value
Mentions
(Nil)
Only mentions
WHO 2010
ART Lab
(n= 15)
1 1 13 2/ 15= 13.333% 0.1031
(Not Significant)Non ART Lab
(n= 196)
5 3 188 8/ 196= 4.082%
Total (n= 211) 6 4 201 10/ 211= 4.739%

• Total number of spermatozoa: this reflects sperm
production by the testes and the patency of the post-
testicular duct system
• Sperm concentration: related to fertilization and
pregnancy rates, is influenced by the volume of the
secretions from the seminal vesicles and prostate and is not
a specific measure of testicular function.
Sperm Concentration (million/ ml) & Total count (million/ ejaculate)

Total (n = 211)
Mentions concentration (conc) 206
Proportions mentioning Conc 96.630%
Mentions total count (TC) 34
Proportions mentioning TC 16.114%
Mentions both conc and TC 32
Proportions mentioning both conc and TC 15.166%
Mentions neither conc nor TC 3
Proportions mentioning neither conc nor TC 1.422%

Mentions concentration (conc) 15 191 206
Proportions mentioning Conc 100% 97.449% 96.630%
Mentions total count (TC) 34
Proportions mentioning TC 83.886%
Mentions both conc and TC 32
Proportions mentioning both conc and TC 15.166%

Mentions total count (TC) 11 23 34
Proportions mentioning TC 73.333% 11.735% 83.886%
P value 0 (Significant)
Mentions both conc and TC 21 32
Proportions mentioning both conc and TC 10.714% 15.166%

Mentions both conc and TC 11 21 32
Proportions mentioning both conc and TC 73.333% 10.714% 15.166%

Mentions both conc and TC 11 21 32
Proportions mentioning both conc and TC 73.333% 10.714% 15.166%
Mentions neither conc nor TC 0 3 3
Proportions mentioning neither conc nor TC 0.000% 1.531% 1.422%

Reference value of Sperm Concentration (Million/ ml)
WHO 2010 WHO
1999/ 1992/
1987
(≥20)
WHO
1980
(20-200)
Other
References
No mention
of any
reference
Proportions
using WHO
2010
Mentions
(≥15)
Only
mentions
WHO 2010
Total
(n= 211)
22 4 24 7 20 133 12.322%

Reference value of Sperm Concentration (Million/ ml)
WHO 2010 WHO
1999/ 1992/
1987
(≥20)
WHO
1980
(20-200)
Other
References
No mention
of any
reference
Proportions
using WHO
2010
P value
Mentions
(≥15)
Only
mentions
WHO 2010
ART Lab
(n= 15)
4 1 3 7 33.333% 0.01016
(Significant)
Non ART Lab
(n= 196)
18 3 21 7 20 126 10.714%
Total
(n= 211)
22 4 24 7 20 133 12.322%

Reference value of Total Sperm Count (Million/ Ejaculate)
WHO 2010 WHO 1999/
1992/ 1987
(≥40)
No
mention of
any
reference
Proportion of those using
WHO 2010
Mentions
(≥39)
Only
mentions
WHO 2010
Total
(n= 211)
14 5 2 190 9.005%

Reference value of Total Sperm Count (Million/ Ejaculate)
WHO 2010 WHO 1999/
1992/ 1987
(≥40)
No
mention of
any
reference
Proportion of those using
WHO 2010
P value
Mentions
(≥39)
Only
mentions
WHO 2010
ART Lab
(n= 15)
4 1 10 33.333% 0.00062
(Significant)
Non ART Lab
(n= 196)
10 4 2 180 7.143%
Total
(n= 211)
14 5 2 190 9.005%

Sperm Motility (%)

Sperm Motility (%)
Total (n = 211)
Mentions Total Motility (TM) 50
No mention
of TM
Total 161
Calculable 65
Not calculable 96
Describes motility in hours
(0.5, 1, 2, 3, 4)
90
Proportions providing direct/ indirect
estimate of TM
54.502%

Sperm Motility (%)
Mentions Total Motility (TM) 6 44 50
No mention
of TM
Total 9 152 161
Calculable 6 59 65
Not calculable 3 93 96
Describes motility in hours
(0.5, 1, 2, 3, 4)
3 87 90
Proportions providing direct/ indirect
estimate of TM
80.000% 52.551% 54.502%

When to Assess Motility

Sperm Motility in Details (%)
Total
(n = 211)
Mentions Progressive Motility (PM) 109
Classifies PM (Grade A, Grade B) 17
No mention of PM 102
Proportion mentioning PM 51.659%
Mentions Non Progressive Motility (NPM) 103
Mentions Non motile Sperms 103
Only mentions “Non Motile Sperms”
Mentions all 3 categories- PM, NPM and Non-motile Sperms 96
Proportion mentioning all 3 categories 48.979%

ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
Mentions Progressive Motility (PM) 12 97 109
Classifies PM (Grade A, Grade B) 17
P value
P value

ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
Classifies PM (Grade A, Grade B) 3 14 17
P value
P value

ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
No mention of PM 3 99 102
Proportion mentioning PM 80.000% 49.489% 51.659%
P value

ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
Mentions Non Progressive Motility (NPM) 11 92 103
P value

ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
Mentions Non motile Sperms 11 92 103
P value

ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
Only mentions “Non Motile Sperms” 3
P value

ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
Only mentions “Non Motile Sperms” 3
Mentions all 3 categories- PM, NPM and Non-motile Sperms 10 86 96
Proportion mentioning all 3 categories 66.667% 43.876% 48.979%

Reference value of Total Motility (%)
WHO 2010 WHO 1999/
1992/ 1987
(≥50)
WHO 1980
(≥60)
No mention
of any
reference
Proportion
of those
using WHO
2010
Mentions
(≥40)
Only mentions
WHO 2010
Total
(n= 211)
20 4 18 4 165 11.374%

Reference value of Total Motility (%)
WHO 2010 WHO 1999/
1992/ 1987
(≥50)
WHO 1980
(≥60)
No mention
of any
reference
Proportion
of those
using WHO
2010
P value
Mentions
(≥40)
Only mentions
WHO 2010
ART Lab
(n= 15)
3 1 3 8 26.667% 0.05238
(Not
Significant)
Non ART Lab
(n= 196)
17 3 15 4 157 10.204%
Total
(n= 211)
20 4 18 4 165 11.374%

Reference value of Progressive Motility (%)
WHO 2010 WHO 1999/
1992/ 1987
(≥50
Grade A+B or
≥25% Grade A)
WHO 1980
(≥2 Forward
progression,
scale 0-3)
No mention
of any
reference
Proportion
s using
WHO 2010
Mentions
(≥32-
Grade A + B)
Only
mentions
WHO 2010
Total
(n= 211)
18 4 15 2 172 10.427%

Reference value of Progressive Motility (%)
WHO 2010 WHO 1999/
1992/ 1987
(≥50
Grade A+B or
≥25% Grade A)
WHO 1980
(≥2 Forward
progression,
scale 0-3)
No mention
of any
reference
Proportion
s using
WHO 2010
P value
Mentions
(≥32-
Grade A + B)
Only
mentions
WHO 2010
ART Lab
(n= 15)
3 1 3 8 26.667% 0.03236
(n= 196)
15 3 12 2 164 9.184%
Total
(n= 211)
18 4 15 2 172 10.427%

Sperm Morphology (%)

Abnormal Morphology

Total (n = 211)
Mentions Normal Morphology (%) 162
Not mentioning normal morphology 49
Proportion mentioning normal morphology 48.815%
Mentions Abnormal Morphology (%) in total 131
Mentions details of
abnormal
morphology
Structured and
systematic
65
Unorganized way
Only mentions “Abnormal Morphology”
No mention of abnormal Morphology 70

Mentions Normal Morphology (%) 15 147 162
Not mentioning normal morphology 0 49 49
Proportion mentioning normal morphology 100% 76.020% 48.815%
Mentions Abnormal Morphology (%) in total 131
Mentions details of
abnormal
morphology
Structured and
systematic
65
Unorganized way
Only mentions “Abnormal Morphology”
No mention of abnormal Morphology 70

Mentions Normal Morphology (%) 15 147 162
Not mentioning normal morphology 0 49 49
Proportion mentioning normal morphology 100% 76.020% 48.815%
Mentions Abnormal Morphology (%) in total 14 127 131
Mentions details of
abnormal
morphology
Structured and
systematic
11 38 65
Unorganized way 16
Only mentions “Abnormal Morphology” 20 20
No mention of abnormal Morphology 1 69 70

Reference value of Morphology (%)
WHO 2010 WHO
1999
(≥14)
WHO
1992
(≥30)
WHO
1987
(≥50)
WHO
1980
(≥80.5)
No
mention of
any
reference
Proportion of
those using
WHO 2010
Mentions
(≥4)
Only
mentions
WHO 2010
Total
(n= 211)
19 4 11 5 1 2 169 10.900%

Reference value of Morphology (%)
WHO 2010 WHO
1999
(≥14)
WHO
1992
(≥30)
WHO
1987
(≥50)
WHO
1980
(≥80.5)
No
mention of
any
reference
Proportion of
those using
WHO 2010
P value
Mentions
(≥4)
Only
mentions
WHO 2010
ART Lab
(n= 15)
4 1 3 7 33.333% 0.00386
(Significant)
Non ART
Lab
(n= 196)
15 3 8 5 1 2 162 9.184%
Total
(n= 211)
19 4 11 5 1 2 169 10.900%

• Sperm vitality, as estimated by assessing the membrane integrity of
the cells, may be determined routinely on all samples, but is especially
important for samples with less than about 40% progressively motile
spermatozoa.
• This test can provide a check on the motility evaluation, since the
percentage of dead cells should not exceed (within sampling error) the
percentage of immotile spermatozoa. The percentage of viable cells
normally exceeds that of motile cells.
Sperm Vitality (%)

Sperm Vitality (%)
Total
(n = 211)
Mentions Vitality 37
Does not mention vitality 174
Proportion mentioning Vitality 17.536%

Sperm Vitality (%)
ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
Mentions Vitality 7 30 37
Does not mention vitality 8 166 174
Proportion mentioning Vitality 46.667% 15.306% 17.536%

Reference value of Vitality (%)
WHO 2010 WHO
1999/
1992
(≥75)
WHO
1987
(≥50)
No mention of
any reference
Proportion of
those using
WHO 2010
Mentions
(≥58)
Only
mentions
WHO 2010
Total
(n= 211)
14 4 5 188 8.531%

Reference value of Vitality (%)
WHO 2010 WHO
1999/
1992
(≥75)
WHO
1987
(≥50)
No mention of
any reference
Proportion of
those using
WHO 2010
P value
Mentions
(≥58)
Only
mentions
WHO 2010
ART Lab
(n= 15)
3 1 11 26.667% 0.00906
(n= 196)
11 3 5 177 7.143%
Total
(n= 211)
14 4 5 188 8.531%

• 1. Epithelial cells from the genitourinary tract
• 2. Leukocytes (Pus Cells) and immature germ cells, collectively referred
to as “round cells” (Johanisson et al., 2000).
• Pus cells can be more precisely identified and quantified by detecting
peroxidase activity or the antigen CD45
• There is currently no reference range for peroxidase-positive cells in
semen from fertile men.
• Pending additional evidence, this manual retains the consensus value of
1.0 × 106 peroxidase-positive cells per ml as a threshold value.
Non-sperm cells (106/mL)

Total
(n = 211)
Mentions other cells 201
Only “Pus Cells” 31
Only “Round Cells” 3
“Pus” + “Epithelial” Cells 80
“Round” + “Epithelial” Cells 1
“Pus” + “Round” Cells 10
“Pus” + “Epithelial” + “Round” Cells 76
Does not mention other cells 10
Proportion mentioning other cells 95.261%

ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
Mentions other cells 14 187 201
Only “Pus Cells” 3 28 31
Only “Round Cells” 1 2 3
“Pus” + “Epithelial” Cells 2 78 80
“Round” + “Epithelial” Cells 0 1 1
“Pus” + “Round” Cells 0 10 10
“Pus” + “Epithelial” + “Round” Cells 8 68 76
Does not mention other cells 1 9 10
Proportion mentioning other cells 93.333% 95.408% 95.261%

Reference value of Round/ Pus Cells (106/mL)
WHO 2010/ 1999/ 1992/ 1987 No mention of any
reference
Proportion of
those using
WHO 2010
Mentions
(<1)
Only mentions
WHO 2010
Total
(n= 211)
7 4 200 5.213%

Reference value of Round/ Pus Cells (106/mL)
WHO 2010/ 1999/ 1992/ 1987 No mention of any
reference
Proportion of
those using
WHO 2010
P value
Mentions
(<1)
Only mentions
WHO 2010
ART Lab
(n= 15)
4 1 10 33.333% 0
(n= 196)
3 3 190 3.061%
Total
(n= 211)
7 4 200 5.213%

Total
(n = 211)
Abstinence Period (AP) 195
Mentions CT 103
Mentions ET 52
Mentions Site of Collection 104
Volume 210
Liquefaction Time (LT) 163
Viscosity 156
pH 184
Appearance 195
Agglutination 47
Mentions concentration (conc) of sperms 206
Mentions total count (TC) of sperms 34
Mentions Total Motility (TM) 50
Mentions Progressive Motility (PM) 109
Mentions Normal Morphology (%) 162
Mentions Vitality 37
Mentions Non-Sperm cells 201

ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
P value
Abstinence Period (AP) 15 180 195 0.25014
Mentions CT 11 92 103 0.04884 (Significant)
Mentions ET 5 47 52 0.41794
Mentions Site of Collection 12 92 104 0.01352 (Significant)
Mentions Completeness of Collection 12 90 102 0.01078 (Significant)
Mentions Method of Collection 5 60 65 0.82588
Volume 15 195 210 0.77948
Liquefaction Time (LT) 13 150 163 0.36812
Viscosity 11 145 156 0.56192
pH 9 175 184 0.00108 (Significant)
Appearance 14 181 195 0.88866
Agglutination 10 37 47 0 (Significant)
Mentions concentration (conc) of sperms 15 191 206 0.5287
Mentions total count (TC) of sperms 11 23 34 0 (Significant)
Mentions Total Motility (TM) 6 44 50 0.0394 (Significant)
Mentions Progressive Motility (PM) 12 97 109 0.03236 (Significant)
Mentions Normal Morphology (%) 15 147 162 0.03156 (Significant)
Mentions Vitality 7 30 37 0.00208 (Significant)
Mentions Non-Sperm cells 14 187 201 0.71884

ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n =
211)
P value
Volume 6 28 34 0.00906 (Significant)
Liquefaction Time (LT) 4 34 38 0.36282
Viscosity 3 28 31 0.50286
pH 6 41 47 0.19706
Agglutination 2 8 10 0.1031
Concentration (conc) of sperms 5 21 26 0.01016 (Significant)
Total count (TC) of sperms 5 14 19 0.00062 (Significant)
Total Motility (TM) 4 20 24 0.05238
Progressive Motility (PM) 4 18 22 0.03236 (Significant)
Normal Morphology (%) 5 18 23 0.00386 (Significant)
Vitality 4 14 18 0.00906 (Significant)
Non-Sperm cells 5 6 11 0 (Significant)
Reference values as per WHO 2010

Mentions “WHO Reference”
ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
Mentions “WHO 2010” 3 13 16
1- All specific Reference Value
1- No specific Reference Value
1- Volume and total count 2010.
Sperm Concentration, TM, PM,
Morphology 1999 (“HYBRID Reference”)
No Ref for Viscosity and Vitality
3- No specific Reference
Value
9- Some Reference Value but
not all
1- Volume 2010,
Sperm concentration, TM,
PM, Morphology 1999
(“HYBRID Reference”)
Mentions “WHO 1999” 1 1
Mentions “WHO” but no
specific year
1 5 6
Does not mention
“WHO”
11 177 188
Proportion mentioning
“WHO 2010”
20.000% 6.633% 7.583%

Overall Impression and Compatibility with WHO 2010 Guideline
Total
(n = 211)
Mentions overall impression 54
No mention of overall impression 157
Impression correct
(As per WHO 2010)
41
Impression partially correct
(As per WHO 2010)
2
Impression totally incorrect
(As per WHO 2010)
11
Proportion providing correct impression 75.926%

Overall Impression and Compatibility with WHO 2010 Guideline
ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
Mentions overall impression 9 45 54
No mention of overall impression 6 151 157
Impression correct
(As per WHO 2010)
6 35 41
(As per WHO 2010)
1 1 2
(As per WHO 2010)
2 9 11
Proportion providing correct impression 66.667% 77.778% 75.926%

Laboratories TOTALLY complying with WHO 2010 Guidelines
All Values as per 2010 1 1 2
“Most” of these values 2 6 8
All References as per 2010 1 1 2
“Most” of the References 0 10 10
All Values and All References 1 1 2
Proportion providing All Values and
references
6.667% 0.510% 0.948%

Laboratories TOTALLY complying with WHO 2010 Guidelines
“Most” of these values 2 6 8
“Most” of the References 0 10 10
references
6.667% 0.510% 0.948%

Laboratories complying with WHO 2010 Guidelines w.r.t.
“Important” Parameters
(pH. Volume. Concentration, Count, Morphology, Motility)
ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total (n = 211)
references
6.667% 2.551% 2.844%

Keel BA, Stembridge TW, Pineda G, Serafy NT Sr. Lack of standardization in
performance of the semen analysis among laboratories in the United States. Fertil
Steril 2002;78:603–8.
• 77% and 59% reported sperm count and motility, respectively, according
to the WHO guidelines
• 35% of laboratories were either not familiar with the WHO manual or did
not have a copy of it in their laboratory
Baker DJ, Paterson MA, Klassen J, Wyrick-Glatzel J. Semen evaluations in the
clinical laboratory. How well are they performed? Lab Med 1994;25:509–14.
• sperm count, motility, and morphology were reported in 47%, 81%, and
78%, respectively.

Penn HA, et al. National semen analysis reference range reporting: adherence to the 1999 World Health
Organization guidelines 10 years later. Fertil Steril 2011;95:2320–3.
ART
Lab
(n= 15)
Non-
ART
Lab
(n=
196)
P value
Volume 6 28 0.00906 (Significant)
pH 6 41 0.19706
Concentration 5 21 0.01016 (Significant)
Total count 5 14 0.00062 (Significant)
Total Motility 4 20 0.05238
Progressive
Motility
4 18 0.03236 (Significant)
Normal
Morphology
5 18 0.00386 (Significant)

Murray KS, et al. The effect of the new 2010 World Health Organization criteria
for semen analyses on male infertility. Fertil Steril 2012;98:1428–31
• The 2010 reference values result in some infertile men being
reclassified as fertile if status is based on semen analysis alone.
• This may lead to fewer men being referred for proper infertility
evaluation or treatment.
ART Lab
(n= 15)
Non-ART Lab
(n= 196)
Total
(n = 211)
Impression correct
(As per WHO 2010)
6 35 41
(As per WHO 2010)
1 1 2
(As per WHO 2010)
2 9 11
Proportion providing correct impression 66.667% 77.778% 75.926%

Limitations
• Methods used to assess seminal parameters
• Small Number
• Regional Variation
• Quality Control (“Acceptable Difference”)
• Reference values do not attest to the quality of the actual semen
analysis or the accuracy of the measurement, both of which are
separate issues of quality assurance and were not the subject of this
study

Conclusion
• The adherence to the 2010 WHO semen analysis reference values is low
among all laboratories.
• Non-ART laboratories adhered to the recommendations less than ART
laboratories.
• Reference range parameters have changed over the years and are
controversial but remain the mainstay to define subfertility for men;
provide threshold for referral to specialists; and provide some guidance
to initiate potential investigations and treatment.
• More education and training of clinicians and laboratories is needed to
understand and report reference

Adherence to WHO 2010 Recommendations with regard to Semen Analysis Reports in the Laboratories if West Bengal

Adherence to WHO 2010 Recommendations with regard to Semen Analysis Reports in the Laboratories if West Bengal

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