Evaluation of the Standardization in Semen Analysis Performance According to the WHO Protocols Among Laboratories in Tehran, Iran

Development of a sperm morphology assessment standardization training tool

Training to improve the standardization of subjective assessments in biological science is crucial to improve and maintain accuracy. However, in reproductive science there is no standardized training tool available to assess sperm morphology. Sperm morphology is routinely assessed subjectively across several species and is often used as grounds to reject or retain samples for sale or insemination. As with all subjective tests, sperm morphology assessment is liable to human bias and without appropriate standardization these assessments are unreliable. This proof-of-concept study aimed to develop a standardized sperm morphology assessment training tool that can train and test students on a sperm-by-sperm basis. The following manuscript outlines the methods used to develop a training tool with the capability to account for different microscope optics, morphological classification systems, and species of spermatozoa assessed. The generation of images, their classification, organization, and integration into a web interface, along with its design and outputs, are described. Briefly, images of spermatozoa were generated by taking field of view (FOV) images at 40× magnification on DIC optics, amounting to a total of 3,600 FOV images from 72 rams (50 FOV/ram). These FOV images were cropped to only show one sperm per image using a novel machine-learning algorithm. The resulting 9,365 images were labelled by three experienced assessors, and those with 100% consensus on all labels (4821/9365) were integrated into a web interface able to provide both (i) instant feedback to users on correct/incorrect labels for training purposes, and (ii) an assessment of user proficiency. Future studies will test the effectiveness of the training tool to educate students on the application of a variety of morphology classification systems. If proven effective, it will be the first standardized method to train individuals in sperm morphology assessment and help to improve understanding of how training should be conducted.

Semen Analysis and Insight into Male Infertility

Objectives: Semen analysis is the cornerstone for the valuation of the male partner in the infertile couples. This test has been standardized throughout the world through the World Health Organization (WHO) since the1970s by producing, editing, updating, and disseminating a semen analysis manual and guidelines. A retrospective study to give an insight about  male infertility. Methods: This retrospective study assessed the semen findings of 1000 men evaluated at the  Department of Urology, Al-Kindy Teaching Hospital in Baghdad-Iraq  between January 2016 and May 2019. Semen analysis were done for them. Results: According to WHO standard for semen normality, 1000 samples that were analyzed, normospermia was shown in 835 (83.5%)males (95% CI=0.811-0.857) and 12% had oligospermia and the rest 4.5% was azospermia. The normospermic samples had significantly higher levels regarding the following parameters: count per ml (51.30±1.24) (P= 0.001), volume(3.34±2.31)(P=0.0001), pus cell (8.04±1.02)(P=0.0001), motility (22.81±5.8)(P=0.0001), abnormal motility (22.81±5.8)(P=0.0001) and  normal (V)(P=0.0001)or abnormal morphology (25.86 ±12.4)(P=0.0002) when compared with oligospermia. Conclusions: Semen analysis is the keystone of infertile couple. Semen parameters like sperm concentration, motility and morphology, are indicators for male reproductive function. Sperm concentration is declining and there is a significant association between sperm concentration and sperm parameters.

Simplified sperm testing devices: a possible tool to overcome lack of accessibility and inconsistency in male factor infertility diagnosis. An opportunity for low- and middle- income countries

Background

Manual semen assessment (MSA) is a key component in a male’s fertility assessment. Clinicians rely on it to make diagnostic and treatment decisions. When performed manually, this routine laboratory test is prone to variability due to human intervention which can lead to misdiagnosis and consequently over- or under- treatment. For standardisation, continuous training, quality control (QC) programs and pricy Computer-Assisted Sperm Analysis (CASA) systems have been proposed, yet, without resolving intra- and inter-laboratory variability. In response, promising simplified sperm testing devices, able to provide cost-effective point-of-care male infertility diagnosis are prospected as a plausible solution to resolve variability and increase access to sperm testing.

Materials and methods

A throughout literature research for semen testing, sperm analysis, smart-phone assisted semen analysis, ‘at-home’ semen testing, male infertility, infertility in developing countries, infertility in low- and middle-income countries (LMIC) and quantitative sperm analysis was performed. A total of 14 articles, specific to ‘at-home’ simplified sperm assessment, were included to treat the core subject.

Results

Continuous training and consistent QC, are sine qua none conditions to achieve accurate and comparable MSA. Compliance does not rule-out variability, nevertheless. Emerging simplified sperm assessment devices are an actual alternative to resolve the lack of standardisation and accessibility to sperm analysis. YO ® , SEEM ® , and ExSeed ® are commercially available, user-friendly smartphone-based devices which can accurately measure volume, sperm concentration (millions/ml) and total motile sperm count. More broadly, by cost-effectiveness, availability, accuracy and convenient application, these devices could effectively select patients for first-line artificial reproduction treatments such as intrauterine insemination.

Conclusions

Accuracy and cost-effectiveness make smart-phone based sperm testing devices a practical and realistic solution to overcome variability in MSA. Importantly, these tools represent an actual opportunity to standardise and improve male subfertility diagnosis and treatment, especially in LMIC. However, before clinical application is possible, guidelines, further testing with special attention on accuracy in washed sperm, availability, cost-benefit and reliability are required.

[Updates in protocol for human semen examination.]

Currently, the WHO laboratory manual for the examination and processing of human semen (5th edition, 2010) provides updated, standardized, evidence-based procedures and recommendations for laboratory managers, scientists and technicians to follow in examining human semen in a clinical or research setting. Despite the fact, there are several gaps and limitations in the interpretation of this compendium. Mostly, the WHO-protocol of estimation of peroxidase-positive cells and spermatozoa, as well as evaluation of their viability and morphology are not so affordable and applicable in Russia due to peculiarities of laboratory market. Furthermore, most of Russian manuscripts do not reflect a unified approach to the analytical stage of semen analyses. In order to standardize the protocol for human semen examination which adopted to Russian lab it was developed packing of reagents (GEMSTANDART-SEMEN ANALYSES, LLC 'GEMSTANDART', Saint Petersburg, Russia) allowing to obtain an accuracy and completeness of the examination. In summary, this approach is a necessary step in male fertility evaluation. Together with a clinical information, it is indispensable for planning the appropriate clinical management and tacking care in male health.