The new 5th WHO manual semen

parameter reference values – do they

help or hinder?

Roelof Menkveld, PhD

Andrology Laboratory, Department of Obstetrics and Gynaecology,

Tygerberg Academic Hospital and University of Stellenbosch.

ESHRE SIG-Andrology Campus Meeting

Thessaloniki, Greece
01 – 03 October 2009
Disclosure

I have no commercial or other activities that may reflect on the

contents of this lecture
Lecture objectives

• Give an overview of the evolution of the (normal) semen

parameter values of the different WHO manual editions
from 1980 to 1999
• Discuss the expected new proposed values of the
forthcoming 5th edition (2009/2010 ??)
• Discuss the usefulness of the expected new semen
parameter values with special reference to normal sperm
morphology
Evolution of the WHO manuals form the 1st edition
of 1980 to the 4th edition of 1999

1980 1999
Old manuals

Old wording in previous manuals

– 1st edition
• No specific wording or definitions for semen
parameter values ( Used normal and fertile range)
– 2nd and 3rd editions
• Used term “normal” values
– 4th edition uses term “reference” values
• Statement
– The (mean?) normal “reference” values quoted
are for “normal” men and NOT the MINIMUM
requirements for fertilisation
Old manuals

• Quoted “normal or reference” values

– Is a “hinder”
• Due to misinterpretations
– Many persons interpreted men with values
lower then quoted “normal” values as infertile
– Making wrong diagnosis and prognosis
– Leading to impropriate treatment
Expected changes in the new 5th edition

• New wording for definition of “normal” values

• Statements on aims and expectations
• Methods and materials
• New “normal” semen parameter values

Cooper, 2007 (ESHRE campus meeting)

New wording for definition of “normal” values in
5th WHO manual edition

• New wording for “normal of reference” values

– Will refer to
• Lower reference limits
• Reference ranges
Aim and expectations of the new WHO
manual (1)

• Aims
– Increasing the accuracy of the analytical results
– Providing more experimental details of common
methods
– Giving hints and details of what to do when QC
results are poor

Cooper, 2007 (ESHRE campus meeting)

 Aim and expectations of the new WHO
manual (2)

• Expectations
– To improve standardisation between laboratories
– Improve diagnostic values of semen analyses results
– Improve follow-up of therapeutic treatment

Cooper, 2007 (ESHRE campus meeting)

 Material and methods for 5th edition (1)

• Reference population
– Fathers (Couples with time to pregnancies of ≤ 12
months)
– 1600+ couples
– Five centres from 3 continents
• Samples
– Only 1 sample per father
– Complete sample after 3-7 days of abstinence

Cooper, 2007 (ESHRE campus meeting)

 Material and methods for 5th edition (2)

• Methods
– Only laboratories following WHO manual guidelines
(IQC + EQC laboratories only)
– Sperm concentration by haemocytometer only
– Sperm morphology evaluation according to STRICT
CRITERIA only
• Statistics
– Reference values based on the lower 5th percentile
limits

Cooper, 2007 (ESHRE campus meeting)

 Comparison of new expected 5th
WHO manual semen reference values

• To previous WHO manuals values

– 2nd to 4th editions (1987 to 1999)
• To recent published values in the literature
Normal values for WHO manuals, editions 2- 4 and
expected lower reference limits for WHO manual 5
WHO edition and year
Semen parameter
2nd - 1987 3rd - 1992 4th - 1999 5th - 2009/10

Volume (ml) 2.0 2.0 2.0 1.5

Sperm concentration (106/ml) 20 20 20 15

Total sperm count (106) 40 40 40 39

Motility (% progressive) 50 50 50 28

Vitality (% live) 50 75 75 59

Morphology (% normal) 50 30 (15) 3

Cooper, 2007 (ESHRE campus meeting)

 Recent studies proposing new “cut-off,
normal or reference” values

• Three types of literature studies

– Based on
• In vivo or in vitro pregnancies
• Fertile versus subfertile populations
• Lower interval values
In vivo or in vitro pregnancy
studies

• Van Zyl et al., 1975, 1976, 1990, 2006

• Eggert-Kruse et al., 1996
• Zinaman et al., 2000
Fertile versus sub- or infertile populations

• Ombelet et al., 1997

• Günalp et al., 2001
• Menkveld et al., 2001
• Guzick et al., 2001
Lower percentile intervals

• Ombelet et al., 1997 - Lower 10th percentile

• Menkveld et al., 2001 - Lower 10th percentile
• Haugen et al., 2006 - Lower 10th and 5th
percentile
Comparison of expected new WHO manual lower
reference values and recent published values

Publication
Semen parameter Haugen et al., 2006
Menkveld et 5th WHO
al., 2001* 5th 10th manual

Sperm concentration (106/ml) N/A 10.6 16.9 15

Motility (% progressive) 20 33 43 28
Morphology (% normal) 3 3 4 3

*Adjusted ROC curve values

Comments on expected new WHO manual
lower reference values

• New expected WHO lower reference values are more

or less in line with values of recent published literature

• New expected WHO lower reference values

Help or Hinder?

Not a great advantage/help for prediction of a

males possible fertility potential
 Comments on the expected lower
reference values of new 5th edition

• Need a more “precise or detailed” breakdown of

semen parameter values
• Need a new approach to interpretation of normal
sperm morphology values
 Need for a more “precise or detailed”
breakdown of semen parameter values
Classification of male fertility potential according to
semen parameters as used at Tygerberg Hospital
Fertility potential classification
Semen parameter
Infertile Subfertile Infertile

Concentration (106/ml) < 2.0 2.0 – 9.9 ≥ 10.0

Motility (% progressive) < 10 10 – 29 ≥ 30

Morphology (% normal) <5 5 - 14 ≥ 15

Semen volume (ml) < 1.0 > 6.0 1.0 – 6.0

Fertile = Optimal chance for pregnancy

Subfertile = Reduced chance for pregnancy
Infertile = Small change for pregnancy
 Need for a new approach for the
interpretation of normal sperm morphology
values
Sperm morphology

• Values as used at Tygerberg hospital and

according to the old editions of WHO manuals
are not applicable anymore due to decrease
in normal sperm morphology values over
years
• Possible reasons for decline in normal sperm
morphology parameters over years
• New approach for interpretation of sperm
morphology parameters is needed
Overview of declining sperm morphology values over years
70

60
Morphology (% normal)

50

40

30

20

10

0
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
Year of semen analyses
Menkveld etal., 1986; Menkveld, 2009
Examples of declining sperm morphology values form the
literature (1) Distribution of normal morphology – Van Zyl study - 1972

Morphology interval (%) Number of men Percentage

0 – 10 0 0.0
11 – 20 4 3.2
21 – 30 9 7.1
31 – 40 24 19.0
41 – 50 23 18.3
51 – 60 28 22.2
61 – 70 19 15.1
71 – 80 11 8.7
81 – 90 6 4.8
91 – 100 2 1.6

Total 190 100.0

Van Zyl, S Afr J Obstet Gynaec 10:17-23,1972

Examples of declining sperm morphology values
form the literature (2) Distribution of normal morphology –
Kruger et al., 1986
Morphology interval (%) Number of men Percentage

0 – 14 22 11.6
15 – 30 83 43.2
31 – 45 67 35.2
45 – 60 18 9.5

Total 190 100.0

Kruger et al., al., Fertil Steril 46:1118-23,1986

Examples of declining sperm morphology values
form the literature (3) – Frequency distribution of percentage
morphological normal spermatozoa in a population of men referred for IVF treatment (n
= 106)

Year = 1990
Mean = 16.7 ± 7.6%
normal
Range = 3 – 41% normal

Menkveld et al., Hum Reprod 5:586-92,1990

Declining sperm morphology values

• Decline due to three possible reasons

– Stricter application of evaluation criteria
– Negative environmental influences
– Additional parameters for sperm morphology
abnormalities
Stricter application of sperm morphology
evaluation criteria

• Introduction of STRICT CRITERIA

– Strict versus liberal approach
• Chanced from borderline spermatozoa previous
regarded as normal to TOO BE REGARDED AS
ABNORMAL
– Over critical approach for interpretation of normal
– Inadequate training
Negative environmental influences
• Exposure to pseudo-estrogens of mother, unborn baby and male
– Higher incidences of decrease in male reproductive health

• Higher exposure to toxic environment and occupation hasards

– Decrease in spermatogenesis and lower/poorer semen
parameters

• Higher incidences of sexual transmitted diseases

– Lower semen parameters
– Increase of leukocytospermia
– Increased sperm DNA damage
Decline due to introduction of additional parameters
for sperm morphology abnormalities

• For example
– Differential classification of acrosome morphology
• Normal
• Staining defects
• Too large
• Too small
• Other/Amorphous
New approach for interpretation of sperm
morphology parameters is needed

• Better use of existing sperm morphology parameters

• Better quality control
• Use of additional sperm morphology parameter,
especially in patients with teratozoospermia
according new lower reference value of ≤ 3% (Poor
prognosis group)
Better use of existing sperm morphology
parameters

• Acrosome morphology (Acrosome index)

– TZI
– Cytoplasmic residues
– Semen cytology
• Identification, reporting and treatment of WBC on
semen smears
Better quality control for sperm morphology
evaluation

Problem
• Lack of intra and interlaboratory quality control
• Lack off standardisation between different international
QC schemes
Solutions
• Betters adherence to WHO guidelines (aim of new WHO
manual)
• Better co-operation between and standardisation of the
different international QC schemes
Use of additional sperm morphology
parameters

In poor prognosis group (≤ 3%)

• Identification of abnormal sperm morphology patterns
– Abnormal acrosome staining
– Large sperm/acrosome patterns
– Small sperm/acrosome patterns
– Elongated sperm morphology patterns
Abnormal acrosome staining
Large spermatozoa/large acrosomes
Small spermatozoa/acrosomes
Conclusions (1)

• Expected new semen parameter values of soon to

released 5th edition of the WHO manual
– Not expected to be of increased help in diagnosis of
male fertility potential
– Expect very low normal sperm morphology normal
reference value of ≤ 3%
– Need to be aware of ongoing decrease in normal
sperm morphology values
Conclusions (2)

For solving problem of expected very low normal sperm

morphology value and ongoing decrease in normal
sperm morphology values
• Need more in-depth sperm morphology evaluation
parameters
• Need better intra- and inter-laboratory QC for sperm
morphology evaluation criteria
• Standardisation of international QC schemes
Tygerberg Academic Hospital and University of
Stellenbosch Medical School, Tygerberg (Cape
Town), South Africa

Thank you for your attention

References (1)

Cooper, TG. ESHRE Campus meeting. Reproductive

Andrology. Brussels, Belgium. 8-10 November 2007
Eggert-Kruse et al., Hum Reprod 11:139-46,1996
Günalp et al., Hum Reprod 16:110-4,2001
Guzick et al., N Eng J Med 345:1388-93,2001
Haugen et al., Int J Androl 27:66-71,2006
Kruger et al., Fertil Steril 46:1118-23,1986
Menkveld R. Asian J Androl 2009 (in press)
Menkveld et al., Arch Androl 17:143-4,1986
Menkveld et al., Hum Reprod 5:586-92,1990
Menkveld et al., Hum Reprod 16:1165-71,2001
References (2)

Ombelet et al., Hum Reprod 12:987-93,1997

Van Zyl, JA. S Afr J Obstet Gynaec 10:17-23,1972
Van Zyl JA and Menkveld R. Andrologia 38:87-91,2006
Van Zyl et al., Int J Fertil 20:129-32,1975
Van Zyl et al., Proceeding of the 17th congress of the
International Urology Society. Johannesburg, South
Africa. Diffudion Dion Editeurs, Paris. 2:263-71,1976
Van Zyl et al., In: Human spermatozoa in assisted
reproduction. Acosta et al., (eds). Williams and Wilkins,
Baltimore, USA. P319-24,1990
Zinaman et al., J Androl 21:145-53,2000