abnormal semen parameters: what doctors should know

Sandro Esteves, MD., PhD. Director, ANDROFERT

Andrology & Human Reproduction Clinic Campinas, BRAZIL

Abnormal Semen Parameters

What doctors should know

Reproductive Andrology Surgery Workshop 2014 Al Jahra Hospital, KUWAIT

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ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2014 APRIL

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Abnormal semen parameters: what doctors should know

Lecture Outline Learning objectives Epidemiological trends and sperm development

Routine semen analysis: where we are today

Importance of sperm chromatin integrity and its clinical implications



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Epidemiological Trends •  10-15% of couples are infertile and 1 in 8 men seeks

medical assistance for male infertility. •  Male factor infertility is responsible for up to 50% of cases

of infertility: 20% as the sole reason and 30% as contributory.

•  Increased incidence of male infertility may be attributed to environmental factors and modern life habits such as obesity, ageing, exposure to gonadotoxins and certain endocrine disruptors.

•  Noticeable epidemiological increase in the incidence of testicular cancer and urogenital anomalies

Irvin S, et al 1996, Auger J et al, 1995, Irvine DS 1994, Jørgensen N et al 2001, Jørgensen N et al 2002, Swan SH 2003, Feki NC et al, 2009



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Abnormal Semen Multiple causes, not exclusive

–  Hormonal problems –  Genetic causes –  Varicocele –  Genital infection –  Chemotherapy, radiotherapy –  Cryptorchidism –  Idiopathic –  Gonadotoxin exposure –  Life-style factors –  Endocrine disruptors –  Etc.



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Routine Semen Analysis

Functional Status of

Reproductive Tract

Seminal Fluid and Sperm

Central Laboratory

Investigation



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•  Standardization •  Quality control •  Quality assurance •  Certification

Semen Analysis: Andrology Lab



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Standards



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New WHO Reference Values WHO 20101

1.5 15 39

32 (a+b) 58 4

<1.0

Semen Parameter WHO 1999 Volume (mL) ≥ 2.0 Count (x106/mL) ≥ 20 Total sperm number/ejaculate ≥ 40 Motility (%) ≥ 50 (a + b) Vitality (%) ≥ 75 Morphology (%)2 (14) Leukocytes (x106/mL) < 1.0

1Lower Limit (5% percentile), Recent fathers; 2Strict criteria Grade a = rapid progressive motility; Grade b = slow/sluggish progressive motility



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New WHO Reference Values Caution to Interpret Results



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New WHO standardsReasons for Lower Cut-off Values

•  Method for semen analysis (QC standards) •  Adoption of strict criterion for morphology •  Single specimen of each individual

Different way of generating data

•  Recent fathers with known TTP (≤ 12months) •  Selection bias

Population studied

Esteves et al. Urology 2012



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Critical Appraisal of the WHO New Reference Values for Human Semen and Impact on Diagnosis and Treatment of Subfertile Men

Esteves, Zini, Aziz et al, Urology, in press

Columbia USA

Melbourne Australia

Turku Finland

Oslo Norway

Edinburgh UK

Paris France

Copenhagen Denmark

2010 WHO Reference: 1,953 men



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Volume (mL) 1.5 Sperm count (x106/mL) 15.0 Total count (x106) 39.0 % Motile (total) 40 % Motile (progressive) 32 % Normal (strict criteria) 4 %Alive 58

Cooper et al. Hum Reprod Update 2010

WHO 2010: Recent fathers TTP≤12 mo. Percentiles

5% 50%* 95% 3.7 6.8 73.0 213.0

255.0 802.0 61 78 55 72 15 44 79 91

New WHO StandardsReasons for Lower Cut-off Values



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New WHO Standards: Implications Do we need to recall previous semen analysis

reports?

Abnormal

results WHO 1999

Reclassified as “Normal” WHO 2010

(38.7%)

Couples (N=987) with infertility duration >12 months

Source: ANDROFERT, Brazil

Morphology by strict criterion accounted for 53% of reclassification



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Referral Deferment Semen Parameters Case

study

Volume (mL) 2.3

Count (106/mL) 16.5 Progressive motility (%) 40

Vitality (%) 65

Morphology (%) 9

Reference

1999 2010

≥ 2 ≥ 1.5

≥ 20 ≥ 15

≥ 50 ≥ 32

≥ 75 ≥ 58

(14) ≥ 4



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Laboratories adopting the new standards should determine the strategy to communicate clinical significance of the reported results

WHO Standards Interpretation

Esteves SC. Int Braz J Urol 2014



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Semen Analysis Results Not accurate to discriminate fertile from

infertile men

Male infertility workup goes far beyond a simple semen analysis. History, physical examination, laboratory and sperm function tests are minimum standards

Esteves, et al 2011; 2012; 2014



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Practical Points •  Routine semen analysis still central in

laboratory evaluation of male infertility •  WHO new reference limits are lowered

compared with previous references •  Caution to interpret new references

– Comparison with 90% percentile distribution is advisable

– Results not accurate to discriminate infertile from fertile males unless if at extreme levels

– Complete male infertility evaluation should be undertaken



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Lecture Outline Learning objectives Epidemiological trends and sperm development

Routine semen analysis: where we are today

Importance of sperm chromatin integrity and its clinical implications



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Why semen analysis is not enough



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Defects in Sperm DNA Structure

single-strand break

mis-match

damaged base double-strand

break

inter-strand crosslink

intra-strand crosslink

Single-strand DNA break (ss-DB) Double-strand DNA break (ds-DB) Base deletion or modification Inter or intra-strand cross linkage

Esteves et al 2013; Alvarez and Gosálbez 2011; Ward 2011



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Biological mechanisms of SDF Protamination Failure Replacement of histone to protamines during spermiogenesis

Oxidative Stress Epididymis transit Post-ejaculation: leukocytes, immature sperm, abnormal levels seminal plasma antioxidants

Apoptosis During sperm maturation (testis & epididymis)

Fernández et al. 2009; Alvarez and Sakkas 2010; Agarwal et al. 2013



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DNA Damage

Environmental factors Phtalate exposure, radiation, temperature Diseases Varicocele, GTI, fever Life-style Obesity, smoking Aging

External factors leading to SDF

Kort et al. 2006; Rubes et al 2007; Viloria et al 2007; Esteves & Agarwal 2011

SDF and Male Infertility Etiologies

Gosálbez et al. 2013



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SDF and Infertility: Why bother?



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19%

1.5%

Normal Elevated

Live Birth Rates with Intrauterine Insemination

OR = 0.07 [95% CI: 0.01-0.48]

Bungum et al. Hum Reprod 2007

IUI Outcome and SDF



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26%

42%

IVF ICSI

Pregnancy by Method in Cases of Elevated Sperm

DNA Fragmentation

IVF Outcome and SDF

Robinson et al. Hum Reprod 2012

Meta-analysis of 16 studies and 2,969 couples

Increased miscarriage in couples undergoing IVF/ICSI with high sperm DNA damage

Risk ratio (RR) = 2.16 95% CI: 1.54-3.03; p<0.00001

Bungum et al. Hum Reprod 2007



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Frequency of elevated SDF in men with normal semen analysis

Normal semen analysis results (WHO)



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Androfert; N=987

Practical Implications •  Successful pregnancies in IVF/ICSI cycles can be

obtained using semen samples with a high proportion of DNA damage

•  Sperm DNA damage is promutagenic and can give rise to mutations after fertilization, as the oocyte attempts to repair DNA damage before the initiation of the first cleavage.

•  Mutations occurring at this point will be fixed in the germline and may be responsible for the induction of infertility, childhood cancer in the offspring and for a higher risk of imprinting diseases

PANG M. G. et al Hum Reprod, 20: 1688–1694, 2005. Burrello et al Cytogenet Genome Res, 111:363–365, 2005.



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Fertility and Sterility 2014; 101(1):58-63



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Correlation between SCD and TUNEL

SCD more sensitive than TUNEL. Important to distinguish between the methods as they differently evaluate SDF.

20.6 11.5

% SDF SCD TUNEL Feijo & Esteves

Fertil Steril 2014; 101(1):58-63



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Management



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Take-home Messages (1)

•  Male infertility is a important health issue •  Despite being genetically-determined,

male fertility is modulated by external factors

•  Life-style modifications should be considered in males seeking fatherhood



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Take-home Messages (2) •  Normal semen analysis is not a

guarantee of fertility, and vice-versa •  Male infertility evaluation should go far

beyond routine semen analysis •  Minimal standards include history

taking, physical examination, semen analysis, sperm functional tests, and other tests as appropriate



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Take-home Messages (3) •  Sperm chromatin integrity critical for a

viable pregnancy •  Sperm DNA fragmentation common in men

with unexplained infertility •  SDF testing provides information that is

different and of better prognostic value than semen analysis

•  Grading SDF may help in designing a cost effective management



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Thank you Obrigado شكرا



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abnormal semen parameters: what doctors should know

Health & Medicine