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
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

  1. 1. “Understanding Infertility” – New Delhi, India – August 2011<br />Will the new WHO Standards<br />for Semen Examination Change<br />the Clinical Management of<br />Male Infertility?<br />SandroEsteves, MD, PhD<br />Director<br />ANDROFERT<br />Center for Male Reproduction and Infertility<br />Campinas, BRAZIL<br />Esteves, 1<br />
  2. 2. Learning Objectives<br />Esteves, 2<br />
  3. 3. Semen Analysis<br />Esteves, 3<br />
  4. 4. Cut-off reference values for semen characteristics as published in consecutive WHO manuals<br />*Strict (Tygerberg) criterion<br />
  5. 5. New WHO references valuesHow they were obtained <br />1,953 semen samples of recent fathers<br />Time to pregnancy (TTP) ≤ 12 mo<br />5 studies in 7 countries on 3 continents<br />Laboratories with QC only<br />Morphology by strict criterion (Kruger)<br />Progressive and non-progressive motility<br />Lower reference limits (5th centile)<br />Esteves, 5<br />
  6. 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<br />Cooper et al: World Health Organization reference values for human semen characteristics. Hum Reprod Update 16: 231-245, 2010<br />Esteves, 6<br />
  7. 7. New WHO references valuesHow they were obtained <br />Cooper TG, Noonan E, von Eckardstein S, Auger J, Baker H, Behre H, Haugen T, Kruger T, Wang C, Mibzvo MT, Vogelsong K<br />World Health Organization reference values for human semen characteristics. <br />Hum Reprod Update 16: 231-245, 2010 <br />“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”<br />“The values presented are considered to represent global semen characteristics of fertile men”<br />Esteves, 7<br />
  8. 8. New WHO references valuesCritical Appraisal <br />FINLAND<br />(Turku)<br />NORWAY<br />(Oslo)<br />DENMARK (Copenhagen)<br />UK<br />(Edinburgh)<br />USA<br />(Columbia, NYC, Minneapolis, LA)<br />FRANCE<br />(Paris)<br />?<br />?<br />?<br />?<br />?<br />?<br />AUSTRALIA <br />(Melbourne)<br />Esteves, 8<br />
  9. 9. Studies used to establish the new limits for human semen characteristics in the <br />5thed WHO Manual<br />Esteves, 9<br />
  10. 10. New WHO references valuesCritical Appraisal - Summary<br />Esteves, 10<br />
  11. 11. Referrals for <br />male partner evaluation<br />New WHO reference values<br /><ul><li>Implications for Clinical Practice</li></ul>Varicocele treatment<br />Indications for assisted reproductive techniques<br />Esteves, 11<br />
  12. 12. Implications for Practice<br /><ul><li>Referrals for male partner evaluation</li></ul>Esteves, 12<br />
  13. 13. Implications for Practice<br /><ul><li>Reclassification of semen analysis reports</li></ul>Couples (N=987) with infertility duration > 12 months<br />Morphology results <br />accounted for 53% <br />of reclassification<br />Source: ANDROFERT, Brazil<br />Esteves, 13<br />
  14. 14. Male Infertility Evaluation <br />– much more than a simple semen analysis - <br />Esteves, 14<br />
  15. 15. Implications for Practice<br /><ul><li>Varicocele treatment</li></ul>Esteves, 15<br />
  16. 16. Implications for Practice<br /><ul><li>Varicocele treatment</li></ul>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.<br />Richardson I, Grotas AB, Nagler HM: Outcomes of varicocelectomy treatment: an updated critical analysis. UrolClin North Am 35:191-209, 2008.<br />
  17. 17. P=0.003<br />P<0.001<br />Mori et al. Does varicocele grade determine extent of alteration to spermatogenesis in adolescents? FertilSteril 90: 1769-1773, 2008.<br />Esteves, 17<br />
  18. 18. ICSI<br /><ul><li>Severe male factor infertility</li></ul>Semen analysis results fall below new reference limits <br />Implications for Practice<br /><ul><li>Indications for ART
  19. 19. < 5% strict morphology thresholds currently used
  20. 20. Indications unlike to change due to new WHO reference values</li></ul>Esteves, 18<br />
  21. 21. IUI<br /><ul><li>Mild male factor infertility
  22. 22. Unexplained male infertility</li></ul>Implications for Practice<br /><ul><li>Indications for ART
  23. 23. Impact of new WHO reference values likely to be minimal</li></ul>Esteves, 19<br />
  24. 24. Implications for Practice<br /><ul><li>Indications for ART- Summary</li></ul>Esteves, 20<br />
  25. 25. Expanding the interpretation of the new WHO reference values: focus on the 50th percentile<br />Laboratories seeking to adopt the new standard should determine the strategy that would aid the clear communication of the clinical significance of the results <br />Debate is open <br /><ul><li>Should the new WHO reference values be adopted ? </li></ul>Esteves, 21<br />
  26. 26. Practical Points<br />Esteves, 22<br />
  27. 27. Practical Points<br />Esteves, 23<br />