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1. 🧬 Case Discussion: Sperm Agglutination in Male Infertility
✅ Patient Presentation and Clinical History:
A 34-year-old male presented to our infertility clinic with a history of primary infertility for
two years. His spouse’s evaluation, including hormonal profiles, ultrasonography, and tubal
patency, was entirely normal. The patient had no previous medical conditions, surgery, or
sexually transmitted infections. He reported no occupational or lifestyle factors known to affect
fertility, such as prolonged exposure to heat, chemicals, or radiation. Physical examination
revealed normal-sized testes with no palpable varicocele or other anatomical abnormalities.
✅ Detailed Semen Analysis & Investigations:
The patient underwent a comprehensive semen analysis according to the WHO 2021 guidelines,
yielding the following results:
 Volume: 2.5 mL (Normal: ≥1.5 mL)
 Sperm concentration: 45 million/mL (Normal: ≥16 million/mL)
 Total motility: 50% (Progressive motility 40%; Normal: Progressive ≥30%)
 Morphology (Kruger's strict criteria): 16% normal forms (Normal: ≥4%)
Significant finding:
 Sperm Agglutination: Prominent head-to-head and tail-to-tail agglutination was
observed on microscopic examination, indicating an abnormal immunological reaction.
To further investigate the immunologic cause, additional tests were conducted:
 Anti-sperm antibody (ASA) testing: Positive results in semen and blood samples,
confirming immunologic infertility.
✅ Diagnosis & Management Strategies:
Diagnosis:
 The patient was diagnosed with immunological infertility due to sperm agglutination
secondary to anti-sperm antibodies (ASAs).

2. Management Strategies:
 Lifestyle Modifications:
o Avoid prolonged sitting, hot baths, saunas, and tight-fitting clothing to prevent
thermal stress.
o Regular physical activity and adequate hydration were advised.
 Medical Management:
o Short-term corticosteroid therapy (e.g., Prednisolone) may help reduce ASA
formation and agglutination severity.
o Immunosuppressive therapy is usually considered cautiously due to potential side
effects.
 Assisted Reproductive Techniques (ART):
o Intrauterine Insemination (IUI): Useful if agglutination is mild and progressive
motility is adequate after sperm washing.
o Intracytoplasmic Sperm Injection (ICSI): Recommended as a definitive
solution, particularly if severe sperm agglutination persists or previous IUI
attempts fail.
✅ Discussion Points:
1. Agglutination vs. Aggregation:
 Agglutination: This occurs when motile sperm cells stick together due to
immunological factors (antibodies), commonly head-to-head or tail-to-tail, indicating
the presence of anti-sperm antibodies.
 Aggregation: This involves the clumping of immotile sperm or sperm with other cells
or debris, typically non-immunological (usually due to viscosity, mucus, infection, or
semen debris).
Clinical significance:
Sperm agglutination is highly indicative of immunological infertility, while aggregation typically
indicates infection or semen viscosity issues.
2. WHO Criteria for Sperm Agglutination (WHO 6th Edition, 2021):
 Grade 1: Isolated sperm sticking together (minimal, <10%).
 Grade 2: Moderate agglutination involving 10-50% of sperm.
 Grade 3: Agglutination involving more than 50% but some free motile sperm visible.
 Grade 4: Complete agglutination, majority of motile sperm are clumped, very few free
sperm.
In this patient’s case, the degree of agglutination was significant (Grade 2-3), warranting
aggressive management strategies.

3. 3. Common Causes of Sperm Agglutination:
 Immunological factors:
o Anti-sperm antibodies (ASAs) produced due to disruption of the blood-testis
barrier.
 Previous genital tract infections:
o Chlamydia trachomatis, Mycoplasma genitalium, and other chronic infections.
 Inflammatory conditions:
o Prostatitis, epididymo-orchitis, urethritis.
 Previous testicular trauma or surgery:
o Testicular biopsies, surgery, vasectomy reversals.
 Varicocele or heat exposure (though less common, can indirectly cause inflammation).
✅ Attached Microscopic Images (Sperm Agglutination):
The microscopic images presented showed clear evidence of sperm agglutination:
 Image 1: Clusters of motile sperm with distinct head-to-head and tail-to-tail adhesion.
 Image 2: Prominent head-to-head sperm agglutination, characteristic of ASA
involvement.
 Image 3: Mixed patterns showing both head-to-head and tail-to-tail agglutination,
illustrating varying degrees of immunological interaction.
 Image 4: Wide field microscopic view clearly illustrating extensive sperm agglutination,
impacting sperm motility and fertility potential.
📌 Clinical Implications and Recommendations:
 Early recognition: Semen analysis must carefully differentiate agglutination from
aggregation.
 Routine ASA testing: Recommended for men with unexplained infertility and observed
sperm agglutination.
 Counseling and education: Patients must understand the immunological basis of their
infertility to set realistic expectations regarding treatment outcomes.
 ART decisions: Aggressive ART (ICSI) is strongly considered if moderate-to-severe
sperm agglutination persists despite medical interventions.

4. 🩸 Case Study: Partial D or Weak D Blood Group
Discrepancy
✅ Clinical History:
A 35-year-old patient previously identified as blood group O-negative by another laboratory
visited our center for routine blood grouping. The patient had no prior history of blood
transfusions, pregnancies, or significant medical conditions that could complicate blood typing
or induce alloimmunization.
✅ Detailed Laboratory Findings:
1. Initial Blood Grouping:
 Forward grouping using gel card methodology showed:
o ABO Group: Confirmed as Group O (anti-A: negative, anti-B: negative)
o Rh Typing: Unexpectedly showed a mild (+2 reaction) with anti-D reagent,
inconsistent with the previous O-negative classification.
o A mixed-field reaction was noted, suggestive of possible weak or partial D
antigen expression.
2. Confirmatory Testing (Weak D/Du Testing):
 To investigate this discrepancy, a Du (Weak D) test was conducted.
 Du test was Positive (+++).
 This result confirmed the presence of a weak or partial D antigen on the red cell
surface.
3. Verification through Repeat Testing:
 A fresh sample was collected and tested using a new gel card to exclude technical or
clerical errors.
 Repeat blood grouping consistently demonstrated a +2 reaction with anti-D reagent,
confirming the initial findings.
4. Additional Investigations:

5.  Saline washing, saline replacement technique, and pre-warming methods were
employed to rule out rouleaux formation, cold antibodies, or other technical interferences.
However, these measures did not alter the reaction strength, reinforcing the original
findings.
 Direct Antiglobulin Test (DAT) and Indirect Coombs Test (ICT) were negative,
excluding autoimmune hemolytic anemia or recent alloimmunization as contributing
factors.
✅ Interpretation & Conclusion (Weak D or Partial D Phenotype):
The observed results strongly suggest the presence of either:
 Weak D phenotype: A quantitative reduction in the D antigen expression on red cells.
 Partial D phenotype: Qualitative variation in D antigen expression, with certain antigen
epitopes missing or altered.
Clinical significance:
 Individuals with Weak D usually do not form anti-D antibodies and are generally safe to
receive Rh-positive blood, though this depends on subtype confirmation through genetic
testing.
 Individuals with Partial D phenotype can develop antibodies against the D antigen if
exposed to standard Rh-positive blood through transfusion or pregnancy.
Due to mixed-field reactions and persistent mild reactivity, a Partial D phenotype is more
likely, though a Weak D cannot be conclusively ruled out without further genetic analysis.
✅ Recommendations for Clinical Management:
1. Genetic Confirmation:
 RHD gene sequencing/genetic testing is strongly recommended for definitive
classification of the Rh variant. Genetic analysis will distinguish clearly between Weak D
and Partial D phenotypes, guiding future clinical decisions.
2. Blood Transfusion Protocol:
 Until definitive genetic confirmation, the patient should be cautiously considered Rh-
negative to prevent possible alloimmunization and subsequent hemolytic transfusion
reactions.
 Transfusions should utilize Rh-negative blood units whenever possible.

6. 3. Patient Education and Documentation:
 Clear documentation of this discrepancy is crucial.
 The patient should be informed about the clinical significance, particularly regarding
potential risks during transfusion or pregnancy.
4. Pregnancy Considerations (Female Patients):
 For females of reproductive age, Rh immunoprophylaxis (RhIg administration) might be
considered if Partial D phenotype is confirmed, to prevent sensitization during
pregnancy.
✅ Images of Gel Cards & Hematology Report:
 Gel card images demonstrated clearly defined mixed-field and weak reactions in anti-D
testing.
 Hematology report highlighted and confirmed the presence of a mixed-field reaction
and positive Du testing.
These findings reinforce the need for cautious clinical management until further characterization.
📌 Clinical Implication:
This case underscores the complexity in Rh blood group system typing. Laboratories must have
clear policies for interpreting and managing weak or partial D phenotypes to ensure patient
safety and optimal clinical outcomes.