Revised Guidelines for Human Embryology and Andrology Laboratories

Revised guidelines for human embryology and andrology laboratories

The Practice Committee of the American Society for Reproductive Medicine and the Practice Committee of the Society for Assisted Reproductive Technology Birmingham, Alabama

These guidelines provide clinicians with speciﬁc guidance on laboratory procedures to ensure that their programs’ practice reﬂects current recommendations. (Fertil Steril 2008;90:S45–59. 2008 by American Society for Re- productive Medicine.)

GUIDELINES FOR HUMAN EMBRYOLOGY LABORATORIES laboratories are not referral laboratories but main- I. Organization of the Laboratory and Definition of tain specific affiliation with a physician group(s). Services Embryology laboratories perform some or all of the A. General Laboratory following steps: 1. The institutional affiliation, where appropriate, 1. Culture medium preparation and quality con- plus the history and definition of services and trol testing markets served, should be clearly defined for 2. Examination of follicular aspirates with oocyte each embryology laboratory. identification 2. The laboratory must undergo certification and 3. Oocyte quality and maturity grading accreditation by an appropriate agency, e.g., 4. Sperm preparation: semen collection and anal- College of American Pathologists/American ysis, sperm washing Society for Reproductive Medicine, Joint Com- 5. Insemination of oocytes mission on Accreditation of Healthcare Organiza- 6. Evaluation of fertilization and zygote quality tions, or New York State Tissue Bank and must 7. Embryo culture and embryo grading be in compliance with any local, state, or federal 8. Embryo transfer (either uterine or tubal) licensing requirements and/or regulations. Any 9. Oocyte/embryo/sperm cryopreservation, stor- current licenses, permits, and certification by age and thawing any other groups or agencies should be listed. 10. Micromanipulation of human oocytes and/or 3. The laboratory must satisfy Institutional Review embryos (e.g. Intracytoplasmic Sperm Injec- Board (or equivalent Human Investigation Com- tion [ICSI], Assisted Hatching [AH], polar mittee) requirements for any investigative proce- body or embryo biopsy for Preimplantation Ge- dures, if applicable. netic Diagnosis [PGD]). 4. Laboratory animals should be maintained C. The laboratory must have evidence of informed humanely according to local, state, or federal consent for all procedures prior to performing requirements and/or regulations, if applicable. said procedures. 5. Embryology laboratories are considered manu- II. Laboratory Personnel facturers of transplantation products (gametes A. Personnel Qualifications and Responsibilities and embryos) according to the FDA’s Cell/Tis- There should be sufficient personnel to provide em- sue Transplantation regulations (1). All embry- bryology services as needed in a timely manner with ology laboratories must be in compliance with a mechanism in place to provide back up for the lab- these FDA regulations. oratory personnel. There are several categories of B. Specific Laboratory Procedures personnel. Staffing levels should be appropriate Embryology laboratories are an integral part of In for the size and volume of the program; a minimum Vitro Fertilization (IVF), Gamete Intrafallopian of two qualified persons is required who are capable Transfer (GIFT), Zygote Intrafallopian Transfer of performing all technical services. (ZIFT), Embryo Cryopreservation, Oocyte or Em- 1. Embryology Laboratory Director bryo Donation, and Gestational Surrogacy Pro- a. Qualifications: The individual must fulfill grams. These are collectively known as Assisted both of the following requirements: Reproductive Technologies (ART). Embryology 1) An earned doctorate degree (Ph.D.) from an accredited institution in a chemical, physi- Guideline cal, or biological science as the major sub- Revised August 2008. Received and accepted July 28, 2006. ject or a medical degree (M.D. or D.O.) Reprints will not be available. from an accredited institution or have

0015-0282/08/$34.00 Fertility and Sterility Vol. 90, Suppl 3, November 2008 S45 doi:10.1016/j.fertnstert.2008.08.099 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc. qualified as a laboratory director prior to 2) Ensuring that the physical plant (space, fa- July 20, 1999. Effective January 1, 2006, cilities and equipment) and environmental all new laboratory directors should hold conditions of the laboratory are appropri- High Complexity Laboratory Director ate and safe. (HCLD) or American Board of Bioanalysis 3) Maintaining aseptic conditions in the labo- Embryology Laboratory Director (ABB- ratory. ELD) certification or its equivalent. Labora- 4) Ensuring that patient confidentiality is tory directors grandfathered in are strongly maintained throughout the laboratory encouraged to seek HCLD or ELD certifica- ART process. tion. The laboratory director should have 5) Providing an approved procedural manual the expertise and/or specialized training in to all laboratory personnel, establishing biochemistry, cell biology, and physiology and maintaining a laboratory quality assur- of reproduction with experience in experi- ance program. mental design, statistics, and problem solv- 6) Providing consultation to physicians and ing. The laboratory director should be others, as appropriate, regarding labora- responsible for formulating laboratory pol- tory aspects of treatment. icies and protocols and communicating 7) Employing a sufficient number of qualified with the medical director regarding patient laboratory personnel to perform the work of progress and protocols as they affect the the laboratory. At a minimum, there should laboratory aspects of treatment. be two (2) qualified embryologists. Table 1 2) Two years documented experience in a pro- provides minimum staff sizes for the vol- gram performing IVF-related procedures. ume of cycles (retrievals and cryopreserva- This experience should include: tion cycles). Additional laboratory staff a) Familiarity with laboratory quality con- may be required if andrological and/or en- trol, inspection, and accreditation pro- docrinological duties are also assigned. cedures. c. The embryology laboratory director should b) Detailed knowledge of cell culture and ensure that all personnel receive appropriate ART and andrology procedures per- training for the ART laboratory procedures formed in mammalian systems. to be performed, obtain the required number 3) The embryology laboratory director of annual continuing education hours, and should have had a period of training of at demonstrate continued competency for the least six months (may be concurrent with ART laboratory procedures performed. documented experience) and completed d. An ‘‘off-site’’ laboratory director is one whose at least 60 ART procedures under supervi- primary directorship is at another physical fa- sion. A procedure is defined as a combina- cility, which has a separate identification tion of the examination of follicular number (SART number) and a separate med- aspirates, insemination, documentation of ical director. An off-site director has the same fertilization, and preparation for embryo responsibilities as an on-site director. While transfer. Satisfactory completion of this the laboratory is actively treating patients, period of training should be documented the off-site director is required to physically by a signed letter from the laboratory di- visit the laboratory at a frequency that will en- rector of the training practice. In addition sure the proper functioning of the laboratory to these qualification requirements, the and assure appropriate patient care. Minimum embryology laboratory director should: a) Obtain at least 12 hours of accredited TABLE 1 continuing education annually in assis- Recommended staff according to volume. ted reproductive technology or clinical Number of Minimum number of laboratory practice. laboratory cycles embryologists b) Demonstrate technical competency in the embryology laboratory by docu- 1–150 2 menting performance of specific proce- 151–300 3 dures and results that are within 301–600 4 acceptable standards for that program. >600 1 additional embryologist b. Responsibilities: These include: per additional 200 1) Providing accessibility for on-site, tele- cycles phone or electronic consultations as needed. ASRM Practice Committee. Revised guidelines. Fertil Steril 2008.

S46 ASRM Practice Committee Revised guidelines Vol. 90, Suppl 3, November 2008 standards would require a frequency of no less procedures under continuous supervision than 1 visit per month, while the lab is active. of the laboratory director or supervisor. The lab director should also be available at all b. In addition to meeting these requirements, the times by fax, phone, or email to address any embryology laboratory technologist should: issues that may arise. The off-site director 1) Obtain at least 12 hours of accredited con- must be present on site for any accreditation tinuing education annually in ART or clin- or certification procedures. A laboratory di- ical laboratory practice; rector shall direct no more than five separate 2) Perform at least 20 ART procedures per year. laboratories of any type. c. Experience and documented training in tis- 2. Embryology Laboratory Supervisor sue culture, sperm-egg interaction, or related The embryology laboratory may have one or more areas of animal reproduction is desirable. qualified laboratory supervisors who, under the di- The embryology laboratory technologist rection of the laboratory director, provide day-to- works under the supervision of a laboratory day supervision of laboratory personnel perform- director or supervisor. Programs for the ap- ing ART procedures. If the medical director is propriate training of embryology laboratory also the laboratory director, there should be a des- technologists should be in place with docu- ignated laboratory supervisor. If the embryology mentation of completion for each employee. laboratory director is primarily located off-site, d. Responsibilities: These include processing there should bea designated laboratory supervisor. specimens, being able to independently per- a. Qualifications: The embryology laboratory form all the routine technical procedures car- supervisor should either meet the qualification ried out in the embryology laboratory under requirements designated for laboratory direc- the supervision of a laboratory director or su- tor or fulfill both of the following require- pervisor, and reporting results. ments: B. Personnel Records 1) Have an earned bachelor’s or master’s de- There must be written documentation of compli- gree in chemical, physical, biological, ance with the section described above. This should medical technology, clinical or reproduc- include the following items: tive laboratory science from an accredited 1. An itemized list of all personnel, their capacity institution; (full-time versus part-time), and their shifts, if 2) Have documented training, which includes applicable. Include the total full-time equiva- performing, at a minimum, at least 60 ART lents filled by full-time and part-time personnel. procedures under supervision. 2. A list delineating the education, training, and job b. In addition to meeting these requirements, the qualifications of all laboratory personnel. embryology laboratory supervisor should: 3. An organizational chart documenting the chain 1) Obtain at least 12 hours of accredited con- of command so that a responsible individual tinuing education annually in assisted re- can always be identified. productive technology or clinical 4. An itemization of the training of personnel for laboratory practice each specific laboratory test offered; definitive 2) Perform at least 20ART procedures per year. training programs for all procedures should be c. Responsibilities: These include day-to-day established. supervision and oversight of the embryo labo- 5. An itemization of personnel participation in ratory and laboratory director responsibilities training courses, educational programs, and/or as authorized in writing by the embryology technical meetings and maintain a record of laboratory director. such participation. 3. Embryology Laboratory Technologist 6. Documentation delineating the continuing labo- a. Qualifications: Embryology laboratory tech- ratory experience necessary to maintain techni- nologists who perform ART laboratory proce- cal competency. dures should either meet the qualification 7. Documentation of the health status, physical ex- requirements for laboratory supervisor, or ful- aminations, or laboratory tests on personnel fill both of the following requirements: whenever required. 1) Have an earned bachelor’s or master’s de- 8. Annual performance reviews for personnel. gree in chemical, physical, biological, medical technology, clinical, or reproduc- III. Laboratory Space and Design tive laboratory science from an accredited The embryology laboratory should have adequate institution; space to ensure safe and comfortable working condi- 2) Have documented training, which includes tions and be of a design that is appropriate for the vol- performing, at a minimum, at least 30 ART ume of procedures performed.

Fertility and Sterility S47 A. The laboratory should be in a low-traffic, secure 5. General laboratory supplies, such as glassware, area; it should be physically isolated from other dish-washing equipment, etc., as appropriate to laboratory activities (e.g., designating a corner of the size of the laboratory. another lab is not adequate unless it is walled 6. A pH meter and osmometer for regular monitor- off). Use of toxic chemicals or radioisotopes, in- ing of media. cluding toxic cleaning materials, in the laboratory 7. It is the responsibility of laboratory personnel to is not permitted. Use of aerosols and pest control ensure that any material that comes into contact substances should not be permitted in the labora- with sperm, eggs or embryos is not toxic, using tory. an appropriate bioassay or animal model system. B. The laboratory should be in proximity to the proce- This includes, but is not limited to aspiration dure room. If not in proximity to each other, then needles, transfer catheters, plastic ware, glass- the laboratory must ensure that necessary condi- ware, culture media, and protein source. tions for embryo viability are not compromised. In- 8. All laboratory chemicals and reagents must be tercom communication is recommended where labeled to indicate date received, date opened, direct communication is not possible. and shelf life, where applicable. C. The incubators and their chamber space should be B. Procedure Manuals of sufficient volume and configuration to ensure 1. Procedure manuals detailing all aspects of the positive specimen identification and minimize the assisted reproductive technologies should be potential for errors. available in each laboratory. The purpose of D. Separate office space should be provided for record this manual should be to describe the laboratory keeping, data entry, and related administrative procedures in sufficient detail to assure repro- functions. Computer equipment should be available ducibility and competence in handling of human for data collection compliance. Appropriate refer- gametes, including specimen identification and ence books, journals, and other publications should labeling. The National Committee for Clinical be available for use by laboratory staff. Laboratory Standards (NCCLS) has a specific E. A general ‘‘wet area’’(i.e., media preparation, equip- format for procedure manuals described in ment, sterilization, etc.) should be separate from the NCCLS publication GP-2A. area in which oocytes and embryos are handled. 2. These manuals should be reviewed and revised F. Material for laboratory construction, ventilation of annually by the laboratory director and auxiliary the area, and cleanliness should be appropriate to personnel should be updated and trained on re- laboratory work. Walls and floors should be com- vised procedures. posed of materials easily washed and disinfected. 3. These procedure manuals should include, but Carpeting is not acceptable. not be limited to, all laboratory procedures. Lab- oratory procedures should include detailed pro- IV. Equipment and Procedure Manuals tocols, equipment and material lists, sources of These are minimum standards for each category. materials, and competency level required to per- A. All laboratories should maintain the following: form each procedure. 1. Incubator(s) with remote alarm system and 4. Maintenance manuals for all laboratory equip- emergency power back-up. The incubator ment should be maintained in the laboratory. should be monitored daily for appropriate tem- These should include daily, weekly, monthly, or perature and gas content before first opening annualmaintenance tobe performed on each piece when used for patient procedures. Incubators of equipment, documentation of maintenance should be monitored using calibrated thermom- completed, and corrective action taken, if any. eters and independent methods of gas analysis, 5. Policy manuals should be maintained in the not by digital display alone. laboratory. These policies might include, but 2. Microscopes suitable for oocyte recovery, deter- should not be limited to, procedures for record mination of fertilization, semen analysis, manip- keeping, result reporting, laboratory communi- ulation of oocytes or embryos, and/or cation, and disposition of business/billing pro- micromanipulation of oocytes or embryos cedures. should be used. C. Specific Aspects of Assisted Reproductive Tech- 3. Devices to maintain temperature and pH of me- nologies dia, eggs, and embryos during various phases of 1. Culture media preparation and quality control the procedure (slide warmers, incubators, water testing baths, heating block, isolettes, etc.). a. Culture media formulated de novo should uti- 4. Disposable materials (tissue culture grade plas- lize dedicated reagents, glassware, and tissue- tic) are recommended for steps that involve ex- culture-grade water (or its equivalent) in its posure to tissue and body fluids. preparation. Quality control testing utilizing

S48 ASRM Practice Committee Revised guidelines Vol. 90, Suppl 3, November 2008 an appropriate bioassay system to evaluate the plement (e.g., human fetal cord serum, ma- media is required. ternal or donor serum) prepared in-house is b. Quality control testing is recommended when not recommended, if such media or supple- commercial media is purchased and used ments are prepared, the laboratory must within its labeled expiration period if pretest- test blood from the donor(s) with an ing by the manufacturer does not reflect media FDA-licensed, approved or cleared test suitability when in actual use in the labora- and show that the donor(s) is negative or tory. Documentation of quality control testing non-reactive for the following: HIV-1 and using an appropriate bioassay system must al- HIV-2, hepatitis B, hepatitis C, syphilis, ways be supplied by the manufacturer. Labo- HTLV-I and HTLV-II. Each batch of ratories should also establish tolerance limits blood-based media supplement should for acceptable receiving conditions for trans- also be tested using an appropriate method ported commercial media. before its use to ensure that it is not embry- c. Procedures and documentation for prepara- otoxic. tion of media. 7) Each batch of culture media should be 1) The sources of ultrapure (tissue culture tested before use for osmolarity. Media grade) water should comply with College pH testing should be performed follow- of American Pathologists (CAP) standards ing equilibration with C02 at concentra- for reagent grade water. If water is pro- tions used for ART procedures. All lots duced on site, a comprehensive program of media and media components should of quality control for the water system be recorded and traceable to each patient must be in place. This must include, but procedure (e.g. lot numbers recorded on should not be limited to, system sanitiza- oocyte/embryo data sheets in case of re- tion, cartridge exchange, part replacement, calls, adverse events, etc.). endotoxin tests and bacterial contamina- 2. Examination of follicular aspirates with egg tion (colony) testing, and chlorine and/or identification formaldehyde testing (if applicable). If ul- a. All procedures should be performed using trapure water is purchased, the source, sterile technique in an area that has appropri- shelf life, and storage conditions must be ate communication with and proximity to the strictly defined. While there are no set stan- egg retrieval area. If the egg retrieval room is dards for levels of endotoxins in embryo separated from the embryology laboratory, culture media, endotoxin testing of pur- then a mobile laboratory unit, modified infant chased water is recommended if it is not isolette, or other appropriate method must be certified endotoxin-free. in place for maintaining follicular fluid tem- 2) All lots of chemicals, prepackaged media, perature and pH. and other media components should be re- b. Written procedures for the egg search and corded and specific sources and product identification including media used for aspira- numbers identified as part of the procedure tion, temperature, pH requirements of fluid, manual and quality control sheets. Sepa- and rapidity with which each sample must rate, designated chemicals should be main- be evaluated should be available. tained specifically for ART. 3. Egg quality and maturity grading 3) Glassware washing protocols, including a. Written protocols should include description detergent type and source, type of water of stages of oocyte quality and maturity, mag- used, number of rinses, and exact proce- nification used, maximum time of observa- dure to be followed, should be strictly de- tion, media for observation, and remedial fined. Heat sterilization should be used steps to be used for immature oocytes. whenever possible. b. The morphological condition of all eggs 4) All media preparation should be performed should be documented. using sterile technique including location 4. Sperm preparation (including sample collection, and appropriate environment. analysis and sperm washing) 5) Appropriate refrigerated facilities should a. The protocol for sample collection should in- be available for media. It is suggested clude abstinence period, type of container that periodic checks of media be made us- used, facilities for collection, and/or time pe- ing an acceptable bioassay system. riod and conditions for sample collection out- 6) The protein source for medical use should side the laboratory, procedure and conditions be strictly defined. While the use of blood- for sample collection with seminal pouches based media or a blood-based media sup- and intercourse, and the acceptable time

Fertility and Sterility S49 period for sample collection and provision of 6. Determination of fertilization frozen back-up sample, if any, in relation to a. All oocytes that have been inseminated should egg retrieval. be examined for signs of fertilization by a sin- b. Written procedures for sperm washing should gle sperm (i.e., two pronuclei [2PN] should be include medium type and protein supplemen- documented). tation, if any; semen to medium ratio; relative b. The time interval from oocyte insemination to centrifugal force if centrifugation is used; examination for fertilization should be speci- sperm isolation technique and incubation, if fied. any; techniques for determination of sample c. If oocytes require removal of blood or cumu- parameters of concentration, motility, and lus cells prior to examination, this may be per- morphology. formed using a needle or narrow bore glass c. Laboratories should establish their own inter- pipette (pulled over a low flame), or another nal standards for minimal recovery of total suitable method. motile sperm cells for both male factor and d. If cleaning and examination of an individual non-male factor patients. This can be used as oocyte takes longer than 60 seconds, a tem- an internal quality assurance measure; while perature and pH controlled chamber or oil individual samples may occasionally deviate overlay should be provided to protect the from the expected range (this norm), compe- egg/embryo. tency in recovery of motile sperm should be e. Each fertilized oocyte with two PN may be maintained. transferred to fresh pre-equilibrated media. d. The prepared sample should be used in f. The status of each oocyte should be recorded. a timely fashion. g. Written procedures for the reinsemination of e. Sterile technique and universal precautions oocytes and/or micromanipulation should in- should be observed in all procedures. clude time frame for reinsemination, criteria f. When donor sperm is used for insemination, for use of initial sample (i.e., minimum motile complete documentation of its use should in- sperm and elapsed time since processing), clude source (either internal or external bank) time frame for re-examination of oocytes, and donor number. Programs should use only and hierarchy for embryo transfer of reinse- donor sperm banks that are accredited in the minated oocytes. state where the sperm will be used. Accredited h. Written policies should be developed for dis- sperm banks should provide documentation position of oocytes with evidence of abnormal that the bank selects and screens donors in ac- fertilization (i.e., disposal, culture, freezing, cordance with FDA, state, and ASRM Guide- micromanipulation, IRB-approved research lines (2). with consent). 5. Insemination of oocytes 7. Embryo transfer and embryo grading a. Written procedures for insemination should a. The procedure should be performed using include such details as types of pipettes sterile technique. used, maximum volume to be added to oo- b. The stage of zygote or embryo development at cytes, number of motile sperm to be used for transfer should be documented. insemination on a per oocyte, per dish, or c. The protocol for embryo transfer should in- per unit volume basis. Criteria for altering include type of medium; time from oocyte re- semination concentrations for varying degrees trieval and/or insemination to transfer; stage of male factor should be specified. The maxi- of embryo development at transfer; fate of ex- mum number of oocytes per dish or unit vol- cess embryos; type of catheter used; alternate ume should be stated. catheters available and circumstances for use b. Procedure sheets for each sample, time of in- of each; method of transfer; technique for semination, and relevant observation at time catheter flushing; and conditions and timing of insemination should be kept as part of the of transfer of remaining embryos. lab file. d. If the embryo transfer facility is separated c. Sperm sample volume added to oocytes from the embryo lab, appropriate equipment should be based on a determination of sample and techniques should be used to maintain concentration and motility performed before media temperature and pH during the proce- oocyte insemination. dure (e.g., infant isolette, oil overlay, or mo- d. During insemination of each dish, tempera- bile unit). ture, humidity, and pH of the media should e. It is recommended that patients be excluded be controlled using appropriate (e.g., infant from access to the laboratory to examine isolette, oil overlay) measures. ova, embryos, or for transfers.

S50 ASRM Practice Committee Revised guidelines Vol. 90, Suppl 3, November 2008 f. A disposable sterile transfer catheter should be external disaster preparedness (including provisions used. for equipment back-up in the event of equipment fail- 8. Oocyte/embryo freezing ure). In addition, the following guidelines are recom- Embryo or oocyte freezing may be considered mended (3): optional. A. Every body fluid sample (semen, blood, follicular a. A written protocol should include cryoprotec- fluid) should be handled using universal precau- tant used (including source and shelf life), me- tions (i.e., as if it were contaminated). All donor tis- dia used, type of freezing container (e.g., sues and fluids should be subjected to appropriate straw, vial, or ampule), stage of embryo for infectious disease screens and quarantine periods freezing, freezing rate including procedure where applicable. for manual or automatic seeding, and storage B. All accredited laboratories are required to have an conditions. Exposure Control Plan. A requirement of this plan b. All embryo freezing containers (e.g., each is to offer and document Hepatitis B vaccination straw or vial) must be permanently labeled to all laboratory personnel. Any employee that re- with at least two unique identifiers. A method fuses is required to sign a waiver that is kept in of ensuring prompt, accurate retrieval of cry- their employment record. Testing for additional opreserved specimens must be employed. Du- STIs may be offered, but not required, with test plicate records of all embryos in storage results to be directed as indicated by the em- should be kept, in separate locations, exclu- ployee. sive of the patient chart information. C. Extraordinary precautions should be taken to avoid c. Time limits for embryo storage should be es- accidental wounds from sharp instruments contam- tablished by each individual laboratory and inated with body fluids. determined prior to freezing. D. Disposable, nontoxic (non-powdered) gloves d. If the laboratory performs cryopreservation, should be worn when handling fresh or frozen there should be a system in place for the body fluids or any material that has come in contact detection of low levels of liquid nitrogen. with body fluids. Gloves should be removed and e. Procedures for thawing embryos should in- discarded when leaving the laboratory or handling clude cryoprotectant concentrations and me- the telephone. Gloves should never be reused. dia used, temperature requirements for E. A laboratory coat or appropriate gown should be thawing, criteria for assessing embryo viabil- worn in the laboratory and removed upon leaving ity, time period for embryo culture prior to the laboratory. transfer, protocol for patient preparation for F. Safety glasses or goggles are suggested where ap- frozen embryo transfers and conditions under propriate. which embryo transfers will take place. G. Hands should be washed after removing gowns and 9. Micromanipulation gloves and immediately if they become contami- Micromanipulation is considered optional at nated with body fluids. All hand washing should each facility. be done with disinfectant soap and hot water or al- a. Protocols for micromanipulation should in- cohol-based solutions. clude circumstances and screening criteria for H. Disposable laboratory supplies must be used when- micromanipulation, procedures for processing ever possible. sperm samples, types of microtools to be I. Contaminated laboratory equipment and/or work made or purchased, media/protein source, and surfaces should be disinfected and sterilized after conditions for micromanipulation including a spill (e.g., 1:10 dilution of 5.25% sodium-hypo- temperature, pH and osmolarity, criteria for chlorite household bleach in water or other proce- judging oocyte maturity and oocyte and embry- dures approved by the Centers for Disease onic quality prior to micromanipulation, viabil- Control and Prevention [CDC]). ity following micromanipulation, and J. Mechanical pipetting devices should be used for the conditions under which embryo transfer will manipulation of liquids in the laboratory. Mouth pi- take place. petting is never permitted. b. Personnel should have demonstrated compe- K. All procedures and manipulation of body fluids tence in performing micromanipulation. should be performed to minimize the creation of droplets and aerosols. Complete facemasks or the V. Laboratory Safety and Infection Control use of appropriate hoods should be considered Procedures and policies on lab safety must be available when procedures are conducted which have a high to all laboratory personnel and should be reviewed an- potential for creating aerosols or droplets. Centrifu- nually by the laboratory director. Protocols should be gation or vigorous mixing of open containers repre- available for fire and electrical safety and internal and sents examples of this problem. Centrifuges may be

Fertility and Sterility S51 placed in exhaust hoods during use or non-aerosol syphilis and HTLV-I and -II screened serum centrifuges may be used. Capped tubes must be products. Use sterile techniques, appropriate dis- used for centrifugation. ease screens, and safe laboratory procedures. L. Eating, drinking, smoking, application of makeup, 7. All patient worksheets should have clear patient or manipulation of contact lenses are not permitted identifying information as well as laboratory ac- in the laboratory. cession numbers that uniquely identify the pa- M. All discarded body fluid samples and disposable tient during all related procedures. All Petri laboratory supplies should be disposed of properly dishes, test tubes and other materials that serve in a container marked BIOLOGICAL HAZARD for culture are labeled with proper identifiers. and disposed of accordingly. Labeling of straws or ampules for cryopreserva- N. Policies must be established to document all ad- tion must be indelible. verse laboratory incidents. All incident reports 8. Written and/or computer records of all labora- and corrective action plans should be included in tory aspects of the ART cycles for each patient the Quality Assurance review. should be maintained. All steps throughout the O. A copy of current Material Safety Data sheets and ART procedure must be traceable to the techni- other references that list the details of hazards and cal person performing the procedure, and the oo- the precautions for safe handling and storage of cytes must be accounted for from retrieval to chemicals and reagents should be available. embryo transfer/cryopreservation or disposal. 9. Documentation of emergency power generator VI. Quality Control/Assurance checks and automatic power transfer switch func- A. Quality Control (QC). tion should be made on a periodic basis. Also, 1. A written procedure manual must be readily system function checks should be made and docu- available and followed by laboratory personnel. mented (e.g., power off, high temp, low C02 alarms). After hours, alarms should be transmitted The laboratory director or designated supervi- to a person who can respond to these emergencies. sory personnel should review and update all procedures on at least an annual basis. Any changes B. Quality Assurance (QA) must be approved, signed and dated by the labo- 1. QA is a comprehensive program designed to ratory director or by designated proxy. Copies of look at the laboratory as a whole and to identify old or archival protocols and updated procedures problems or errors that exist in an attempt to im- should be retained for a period of at least two prove the entire process. Indicators used in a QA years. program should be objective, relevant to the lab- 2. Equipment should be maintained and calibrated oratory, and measure a broad range of specific on a daily, monthly, and annual basis as appro- events or aspects of treatment that reflect the priate to the type of equipment. This includes quality of care. For each indicator incorporated a record of instrument calibration, functional into the laboratory’s QA program, an appropri- checks of equipment when possible, and evi- ate threshold needs to be established. The thresh- dence of an active review of records. Documen- old sets the critical level of quality laboratory tation or corrective action when instruments and/ performance for each indicator. Since clinical or procedures malfunction should be kept. protocols are not uniform among ART laborato- 3. All new protocols should be validated and docu- ries, the threshold values must be specific for mented. each individual clinical laboratory (4). 4. The laboratory should define and maintain writ- 2. The quality assurance program should include ten criteria for preparation, storage, handling, a mechanism to review and analyze data in order and preparation of specimens. All reagents to identify problems related to the quality of care should be dated and used within the indicated provided by the laboratory. This should include, expiration date. but not be limited to, the following: 5. All media and protein supplementation should a. Mechanisms to detect clerical, transcriptional, be tested for quality utilizing bioassay systems or analytical mistakes. When problems and/or such as the one- or two-cell mouse embryo cul- adverse trends are identified, corrective mea- ture assay, or quantitative sperm motility or via- sures should be implemented to resolve the is- bility assay. Each batch of purchased media must sue to ensure quality patient care. There be tested by the vendor with an appropriate bio- should be later documentation whether cor- assay. It is up to the discretion of the laboratory rective measures instituted were able to effec- to perform additional quality control assays on tively resolve the problem. purchased media. b. Data from the laboratory should be gathered 6. Infection control (see safety procedures above). and analyzed on a regular basis and the infor- Use HIV-1 and -2, Hepatitis B, Hepatitis C, mation gathered should be used to identify

S52 ASRM Practice Committee Revised guidelines Vol. 90, Suppl 3, November 2008 and resolve problems. A copy of this report F. Satellite facilities may be set up to perform GIFT should be kept for review. Quality assurance procedures only if facilities are available to pro- also includes the turnaround time for reports vide IVF procedures as needed on site. and consistency of service as well as statisti- cal analysis of outcomes data. REFERENCES c. An adverse incident file should be maintained, including but not limited to significant clerical 1. U.S. Food and Drug Administration. Tissue guidances, rules and related documents. Available at: http://www.fda.gov/cber/tissue/docs. and analytical errors as well as unusual labo- htm. ratory results. 2. The American Society for Reproductive Medicine. 2008 Guidelines d. The practice must participate in data collec- for gamete and embryo donation. Fertil Steril 2008;90(Suppl tion for purposes of clinic submission in 3):S30–44. compliance with guidelines established by 3. Practice Committe of the American Society for Reproductive Medi- cine. Guidelines for development of an emergency plan for in vitro fer- SART. tilization programs. Fertil Steril 2008;89:793–5. 3. The laboratory must participate in proficiency 4. Mayer JF, Jones EL, Dowling-Lacey D, et al. Total quality improve- testing for those procedures for which it is avail- ment in the IVF laboratory: choosing indicators of quality. Reproduc- able. For those testing services in which a com- tive BioMedicine Online 2003;7(Comp. 1):192–6. mercial proficiency test is not available, the laboratory must establish an internal quality as- GUIDELINES FOR HUMAN ANDROLOGY LABORATORIES surance program. Consideration should also be I. Organization of the Laboratory and Definition of Ser- given to sharing samples with other laboratories vices or developing other means of external quality as- A. General Laboratory sessment. External quality assessment serves as 1. The institutional affiliation, history, definition of a companion to a laboratory’s internal quality as- services, and the purpose of the laboratory sessment program. should be clearly defined. VII. Satellite Facilities 2. The laboratory must be in compliance with any A satellite facility is a facility in which there is an state or federal licensing requirements. As ‘‘off-site’’ laboratory director whose primary direc- a high complexity laboratory, as defined by the torship is at another physical facility, which has a sep- federal Department of Health and Human Ser- arate identification number (SART number) and vices (HHS), an andrology laboratory falls under a separate medical director. ART laboratory services the purview of Clinical Laboratory Improvement may be provided in satellite facilities provided the Act of 1988 (CLIA’88) regulations. These regula- following criteria are met: tions undergo routine interval reviews with A. A laboratory director (see above) oversees all ac- amendments made as appropriate. Readers are tivities in the remote location. The director will advised to consult the most recent edition of the establish protocols, decide on medium prepara- regulations in order to ensure current applicability. tion and source, provide training to personnel, Any current licenses, permits, and certification by and determine methodologies to be used. any other groups or agencies should be listed. B. Qualified embryology technologists should be 3. The laboratory must satisfy any Institutional Re- employed at the satellite facility or provided by view Board (or equivalent Human Investigation the laboratory director as needed if the latter Committee) requirements for any investigative does not perform the procedures. Embryology procedures, if applicable. technologists should meet the educational and 4. Laboratory animals should be maintained ac- training criteria described herein. cording to local, state, or federal requirements C. The laboratory director should provide supervi- and/or regulations, if applicable. sion and document appropriate lines of daily com- 5. Andrology laboratories that cryopreserve semen munication with satellite facilities during all IVF for therapeutic use and/or prepare semen for use procedures. While the laboratory is actively treat- in reproductive therapies are considered manu- ing patients, the off-site director is required to facturers of transplantation products (sperm) physically visit the laboratory at a frequency according to the FDA’s Cell/Tissue Transplanta- that will ensure the optimal functioning of the lab- tion regulations (1). All andrology laboratories oratory and the delivery of quality patient care. involved in these activities must be in compli- D. A satellite laboratory must meet the same stan- ance with these FDA regulations. dards as any other embryology laboratory as de- B. Specific Laboratory Procedures scribed in these guidelines. It is recognized that a single standardized protocol E. Equipment and laboratory space should meet all of is inappropriate or unavailable for many andrology the standards listed above as appropriate for proce- laboratory procedures. In the absence of a widely dures that are performed at the satellite facility. accepted, standardized protocol, each laboratory

Fertility and Sterility S53 must develop its own protocol for that particular sibilities for each type of laboratory personnel. The procedure with appropriate controls and methodol- following descriptions include a summary of cer- ogy to assure reliable, acceptable results. Androl- tain relevant items regarding qualifications and re- ogy laboratories perform some or all of the sponsibilities of laboratory directors, general following procedures: supervisors and testing personnel. Under CLIA 1. Semen analysis and procedures: the semen anal- ’88, personnel qualifications and responsibilities ysis is essential for the diagnosis of male fertility are also defined for technical supervisors and clin- potential. In addition to the standard semen anal- ical consultants (not included here). For andrology ysis, semen may be tested for fructose, adeno- laboratories, individuals may assume the role of sine triphosphate (ATP) and other biochemical more than one of these jobs provided they meet markers. Assays may include tests for sperm sur- all of the personnel qualifications and are able to vival, sperm viability, sperm membrane integ- meet all of the responsibilities cited. Laboratory rity, ability of sperm to penetrate human personnel should possess a current license issued cervical mucus in either a cross-match test or by the state in which the laboratory is located, if in capillary tubes (2, 3). Standards for semen such licensing is required. analysis are detailed in the World Health Organi- 1. Laboratory Director: zation (WHO) Laboratory Manual for the Exam- a. Qualifications. There are a number of different ination of Human Semen and Semen-Cervical paths for qualifying as the director of a high Mucus Interaction (4). complexity laboratory, such as an andrology 2. Sperm antibody testing: the sperm antibody as- laboratory, under CLIA ‘88. These include: says used must be able to measure the presence 1) An M.D. or D.O. with board-certification of sperm antibodies on the sperm as well as in in anatomic or clinical pathology, or both. the serum, cervical mucus, or seminal plasma. 2) An M.D. or D.O. with laboratory training These assays may work either directly or indi- (either one year of laboratory training dur- rectly on the sperm and fluids. Both positive ing medical residency or at least two years and negative controls must be used to validate of experience directing or supervising high the assay. The mixed antiglobulin reaction and complexity testing). the immunobead test are described in the 3) A board-certified Ph.D. scientist with a de- WHO Laboratory Manual (4). Other protocols gree in a chemical, physical, biological or are also available (5). clinical laboratory science from an ac- 3. Sperm penetration assay or the zona-free ham- credited institution and be certified by the ster oocyte test: human sperm fertility potential American Board of Medical Microbiology, is measured by the ability of sperm to penetrate American Board of Clinical Chemistry, the zona-free hamster eggs. Positive controls must American Board of Bioanalysis, the Amer- be utilized to validate test results. A discussion ican Board of Medical Laboratory Immu- of the zona-free hamster oocyte assay is found nology or other board deemed in the WHO Laboratory Manual (4). Other de- comparable by HHS. scriptions of the assay are available (6). 4) A person qualified under state law to direct 4. Sperm cryopreservation: sperm cryopreserva- laboratories within a state on or before tion involves the freezing and storage of human February 28, 1992. sperm for future use. Sperm for freezing may be 5) A person serving as a laboratory director obtained from either patients or donors. Guide- and qualified or could have qualified as di- lines for Sperm Donation have been established rector on or before February 28, 1992. by The American Society for Reproductive b. Responsibilities. The director must ensure: Medicine (7) and The American Association of 1) The quality of testing. Tissue Banks (8). 2) The safety of the working environment. 5. Preparation of sperm for intrauterine insemina- 3) That the test methodologies will provide tion with husband, partner or donor sperm: fresh quality results. and frozen sperm may be processed for intrauter- 4) That procedures are verified, accurate and ine or intracervical insemination. reliable. 6. Computer assisted semen analysis (CASA): lab- 5) That the laboratory is enrolled in an HHS- oratories must have a protocol that, on a periodic approved proficiency testing program. basis, validates that their assisted semen analysis 6) That QA and QC programs are estab- equipment is functioning correctly. lished and maintained. II. Laboratory Personnel 7) That acceptable levels of analytical per- A. Personnel Qualifications and Responsibilities: formance for each test system is estab- CLIA’88 has specific qualifications and job respon- lished and maintained.

S54 ASRM Practice Committee Revised guidelines Vol. 90, Suppl 3, November 2008 8) That all necessary remedial actions are perience, or both, in high complexity test- taken and documented whenever signifi- ing. cant deviations from the laboratory’s es- 4) Have previously qualified or could have tablished performance specifications are qualified as a general supervisor on or be- identified, and that patient test results fore February 28, 1992. are reported only when the system is 5) On or before September 1, 1992, have functioning properly. served as a general supervisor of high com- 9) That reports of test results include perti- plexity testing and as of April 24, 1995, nent information required for interpreta- have graduated from an approved medical tion. laboratory or clinical laboratory training 10) That consultation is available to the labo- program approved by the Accrediting Bu- ratory’s clients. reau of Health Education Schools 11) That the general supervisor provides on- (ABHES), the Commission on Allied site supervision of high complexity test Health Education Accreditation (CA- performance by qualified testing person- HEA), or other organization approved by nel with high school degrees. HHS; and have at least two years of clinical 12) That the laboratory has sufficient number laboratory training or experience, or both, of qualified personnel to perform testing. in high complexity testing. 13) That personnel have appropriate educa- 6) On or before September 1, 1992, have tion and experience before performing served as a general supervisor of high com- testing. plexity testing and as of April 24, 1995, be 14) That policies and procedures are estab- a high school graduate or equivalent and lished to monitor individual testing per- have successfully completed an official formance. U.S. military medical laboratory proce- 15) That an approved procedure manual is dures course of at least 50 weeks duration available to all personnel responsible for and have held the military enlisted occupa- testing. tional specialty of Medical Laboratory 16) That the responsibilities and duties of each Specialist; and have at least two years of consultant, each supervisor, and each test- clinical lab training or experience, or ing personnel are specified, in writing. both, in high complexity testing. c. The laboratory director must be accessible to 7) On or before September 1, 1992, have the laboratory to provide on-site, telephone served as a general supervisor of high com- or electronic consultation as needed. plexity testing; and be a high school grad- d. An individual may serve as a director of uate or equivalent and have had at least ten a maximum of five (5) certified laboratories. years of laboratory training and experi- 2. Laboratory General Supervisor. The laboratory ence, or both, in high complexity testing, should have at least one general supervisor including at least six years of supervisory who, under the direction of the laboratory di- experience between September 1, 1982 rector, provides day-to-day supervision of test- and September 1, 1992. ing personnel and reporting of testing results. b. Responsibilities. The laboratory general su- a. Qualifications. The general supervisor must pervisor must: have at least one of the following qualifica- 1) Be accessible, either on-site or via elec- tions: tronic means, to testing personnel at all 1) Possess a current license issued by the state times testing is being performed. in which the laboratory is located, if such 2) Provide day-to-day supervision of high licensing is required; and be qualified as complexity test performance by testing a high complexity laboratory director; or personnel. as technical supervisor. 3) Must be on-site to provide direct supervi- 2) Be a M.D. or D.O. or have earned doctoral, sion when high complexity testing is per- master’s or bachelor’s degree in a chemical, formed by qualified testing personnel physical, biological or clinical laboratory with high school degrees. science, or medical technology from an ac- 4) Monitor testing analyses and specimen ex- credited institution; and have at least one amination to ensure that acceptable levels year of laboratory training or experience, of analytic performance are maintained. or both, in high complexity testing. c. The laboratory director or technical supervi- 3) Qualify as testing personnel and have at sor may delegate to the laboratory general su- least two years of laboratory training or ex- pervisor the responsibility for:

Fertility and Sterility S55 1) Assuring that all remedial actions are taken approved by HHS; or have successfully whenever test systems deviate from the completed an official U.S. military med- laboratory’s established performance spec- ical laboratory training course of at least ifications. 50 weeks duration and have held the 2) Ensuring that patient test results are not re- military enlisted occupational specialty ported until all corrective actions have of Medical Laboratory Specialist. been taken and the test system is properly 4) Until September 1, 1997, have earned functioning. a high school diploma or equivalent; and 3) Providing orientation to all testing person- have documentation of training appropriate nel. for the testing performed prior to analyzing 4) Evaluating and documenting the perfor- patient specimens. Such must ensure that mance of all testing personnel on an annual the individual must have: a) the skills re- basis. quired for proper specimen collection, in- 3. Testing Personnel. The laboratory must have cluding patient preparation (if applicable), a sufficient number of people qualified as testing labeling, handling, preservation or fixation, personnel to perform high complexity testing. processing or preparation, transportation a. Qualifications. Testing personnel must meet at and storage of specimens; b) the skills re- least one of the following requirements: quired for implementation of all standard 1) Be a M.D. or D.O. in the state in which the laboratory procedures; c) the skills required laboratory is located or have earned a doc- for performing each test method and for toral, master’s or bachelor’s degree in proper instrument use; d) the skills required a chemical, physical, biological or clinical for performing preventive maintenance, laboratory science, or medical technology troubleshooting and calibration procedures from an accredited institution. related to each test performed; e) a working 2) Have earned an associate degree in a labo- knowledge of reagent stability and storage; ratory science or medical laboratory tech- f) the skills required to implement the qual- nology from an accredited institution. ity control policies and procedures of the 3) Have education and training equivalent to laboratory; g) an awareness of the factors that required for an associate degree that that influence test results; h) the skills re- includes at least 60 semester hours, or quired to assess and verify the validity of equivalent, from an accredited institution. patient test results through the evaluation This should include either a) 24 semester of quality control sample values prior to re- hours of medical laboratory technology porting patient test results. As of September courses, or b) 24 semester hours of science 1, 1997, have qualified under the terms of courses that include (1) six semester hours this section provided the individual per- of chemistry; (2) six semester hours of bi- formed high complexity testing prior to ology; (3) twelve semester hours of chem- April 24, 1995. istry, biology, or medical laboratory b. Responsibilities. Each individual performing technology in any combination, and train- high complexity testing must: ing that includes either of the following: 1) Follow the laboratory’s procedures for (a) Completion of a clinical laboratory specimen handling and processing, test training program approved or ac- analyses, reporting and maintaining re- credited by the ABHES, the CAHEA, cords of patient test results. or other organization approved by HHS. 2) Maintain records that demonstrate that pro- (b) At least 3 months documented labora- ficiency testing samples are tested in the tory training in each specialty in which same manner as patient specimens. the individual performs high complex- 3) Adhere to the laboratory’s quality control ity testing. policies, document all quality control ac- (c) Have previously qualified or could tivities, instrument and procedural calibra- have qualified as a technologist on or tions and maintenance performed. before February 28, 1992. 4) Follow the laboratory’s established correc- (d) On or before April 24, 1995, be a high tive action policies and procedures when- school graduate or equivalent and have ever test systems are not within the either graduated from a medical labora- laboratory’s established acceptable levels tory or clinical laboratory training pro- of performance. gram approved or accredited by the 5) Be capable of identifying problems that ABHES, CAHEA or other organization may adversely affect test performance or

S56 ASRM Practice Committee Revised guidelines Vol. 90, Suppl 3, November 2008 reporting of test results and either must should have a unique identification number. A correct the problems or immediately notify requisition slip or a form designating the patient’s the general supervisor, technical supervi- name, unique identification number, assay(s) to sor, clinical consultant or director. be performed, and the referring physician’s 6) Document all corrective actions taken name should accompany the specimen. when test systems deviate from the labora- 2. Procedure sheets for the tests performed by the tory’s established performance specifica- laboratory including the principles of the test, tions. preparation of any standards or controls, the B. Personnel Records methodology used, references, and criteria for There must be written documentation of compli- unacceptable results, if appropriate. If speci- ance with the section described above. This should mens are to be rejected, the criteria for rejection include the following items: and procedure for safe disposal of the specimen 1. A list of all personnel, their job descriptions, and must be established. shifts, if applicable. 3. Laboratory manuals should be reviewed and re- 2. A list of the education, training, and qualifica- vised annually by the director and signed. Aux- tions of all laboratory personnel. iliary personnel should be updated and trained in 3. An organizational chart documenting the chain any revised procedures. of command so that a responsible individual B. Laboratories should have a procedure for specimen can always be identified. A qualified individual log-in with the appropriate information on the spec- must be on duty or on call at all times. imen and patient. For example, given a patient 4. Document and maintain records of personnel name and date, the laboratory should be able to doc- training for each specific laboratory test offered. ument whether or not a specimen was tested, the re- Definitive training programs for all procedures sults of the test, the referring physician, and some should be established. unique code that identifies the patient. 5. Documentation of personnel participation in C. The location of all patient test records must be re- continuing education. corded in a manual. The test records should identify 6. Annual performance reviews for personnel. the person performing the test, the test results, as well as reference ranges. The results should be re- III. Laboratory Space and Design viewed by the laboratory director or supervisor The andrology laboratory should have adequate space and signed. These test results should be kept for and a design that is appropriate for the volume and a minimum of two years. type of procedures performed and that ensures safe D. Maintenance manuals for all laboratory equipment and comfortable working conditions. must be kept in the laboratory. This manual should A. The andrology laboratory may share space physi- include records of equipment performance and cally with other laboratory activity. However, any maintenance. activity requiring sterile technique (i.e., sperm E. All policy manuals should be maintained in the lab- preparation for intrauterine insemination) should oratory. These policies should include, but are not be physically separated from other activities. limited to, procedures for record keeping, result re- B. Adequate space should be provided for record porting, laboratory communication, and consent keeping, data entry, and related administrative procedures (if required by the institution). functions. C. Material for laboratory construction, ventilation of V. Laboratory Equipment and Supplies (9) the area, and cleanliness should be appropriate to A. Laboratory Equipment/Facilities the laboratory work. The use of carpet in tissue cul- Laboratories are required to maintain or have ac- ture or work areas is prohibited. cess to equipment necessary to perform andrology services. It is the responsibility of the laboratory di- IV. Laboratory Policy and Procedure Manuals rector to ensure that the proper equipment is in A. There should be a manual(s) in the laboratory place to perform the necessary assays. written in National Committee for Clinical Labo- 1. Certain laboratory equipment (i.e., laminar flow ratory Standards (NCCLS) publication GP-2A hoods, biohazard lab hoods, balances) must be format, that describes all procedures in sufficient certified by a qualified agency on an annual ba- detail to assure reproducibility and competence in sis. Certifications must be maintained on file handling of mammalian gametes. Procedure man- for review. uals should include, but are not limited to the fol- 2. The laboratory should have a program for check- lowing: ing and calibrating laboratory equipment such 1. Patient instructions for proper collection, label- as pipettors, thermometers, pH meters, centri- ing, and delivery of specimens. Each patient fuges, and refrigerators on a regular basis.

Fertility and Sterility S57 Manufacturer supplied manuals or maintenance ter preparedness. Policies must be established to manuals for all laboratory equipment must be document all adverse laboratory incidents. All inci- maintained in the laboratory. dent reports and corrective action plans should be 3. There must be a mechanism for the safe handling included in the Quality Assurance review. Copies and disposal of biohazardous waste material in of current Material Safety Data Sheets and other the laboratory. references that list the details of hazards and the 4. All material that comes in contact with sperm precautions for safe handling and storage of chem- that is being prepared for cryopreservation or in- icals and reagents should be available. In addition, trauterine insemination must be tested for toxic- the following guidelines are recommended: ity. This testing requires the use of an appropriate A. The laboratory must undergo an annual safety in- bioassay. spection by personnel trained in this task. Results 5. All laboratory chemicals and reagents must be of inspections must be kept on file for reference. labeled with the date received and date opened This includes fire inspection, storage of hazardous and should be stored as recommended by the materials, infection control, and storage of volatile supplier/manufacturer. or hazardous materials. Adequate fire and safety B. Culture Medium Preparation and Quality Control precautions must be posted. The facility should be Testing well lighted and ventilated. 1. Culture medium formulated de novo should uti- B. All body fluids should be handled utilizing univer- lize dedicated reagents, glassware, and tissue- sal precautions (i.e., as if they were contaminated). culture-grade water (or its equivalent) in its prep- Safety precautions are to be taken when handling aration. Quality control testing is required utiliz- and disposing of any biological specimens. This in- ing an appropriate bioassay system, such as the cludes wearing gloves and laboratory coats and one- or two-cell mouse embryo culture assay, avoiding accidental wounds from sharp instru- or quantitative sperm motility or viability assay. ments. Hands must be washed immediately if they 2. Quality control testing is optional when com- become contaminated with biological materials. mercial media is purchased and used within its Disposable laboratory supplies should be used labeled expiration period. Documentation of whenever possible. quality control testing using an appropriate bio- C. All procedures involving body fluids should mini- assay system must be supplied by the manufac- mize the creation of aerosols or droplets. The use turer. of appropriate hoods should be considered when 3. When semen is processed for use in patient ther- procedures are conducted that have a high potential apy, the use of human serum or human albumin for creating aerosols such as centrifugation. Alter- or any other biologic product from any human natively, centrifuges designed to contain aerosols source with the exception of the patient’s own se- can be utilized. Tubes must be capped during centri- rum (autologous serum), will require documenta- fugation. tion oftransmissible disease testing, such as HIV-1 D. All accredited laboratories are required to have an and -2, hepatitis B, hepatitis C, syphilis and HTLV Exposure Control Plan. A requirement of this I/II. Similarly, when semen is processed for cryo- plan is to offer and document Hepatitis B vaccina- preservation with the potential for use in future pa- tion to all laboratory personnel. Any employee that tient therapy, the use of human serum or human refuses is required to sign a waiver that is kept in albumin or any other biological product from their employment record. Testing for additional any human source with the exception of the pa- STDs may be offered, but not required, with test re- tient’s own serum (autologous serum), will require sults to be directed as indicated by the employee. documentation of transmissible disease testing. E. Containers must be labeled as to their contents and 4. Cryopreservation medium for sperm freezing. dated. Similar to standards for other media, each lot F. Adequate facilities should be available for safe dis- of cryopreservation medium should have under- posal of hazardous or biological waste. All biohaz- gone quality control testing utilizing an appro- ardous waste should be placed in a container marked priate bioassay. BIOLOGICAL HAZARD and disposed of accordingly. VI. Laboratory Safety and Infection Control G. There should be no smoking, eating, drinking, or ap- A laboratory safety manual must be available to all plication of makeup in the laboratory. personnel and should be included in employee ori- H. Mechanical pipetting devices must be used for ma- entation. Laboratory procedures and policies on nipulation of liquids in the laboratory. Mouth pipet- lab safety should be reviewed annually by the labo- ting is not permitted. ratory director. Protocols should be available for fire I. Contaminated laboratory equipment and/or work and electrical safety and internal and external disas- surfaces should be disinfected and sterilized after

S58 ASRM Practice Committee Revised guidelines Vol. 90, Suppl 3, November 2008 a spill (e.g., 1:10 dilution of 5.25% sodium-hypo- a mechanism to review and analyze data in order chlorite household bleach in water or other proce- to identify problems related to the quality of care dures approved by the CDC). provided by the laboratory. This should include, J. There must be sufficient space available for work- but is not limited to, the following: ing. The room temperature, ventilation, noise level, 1. Mechanisms to detect clerical, transcriptional, and fume removal should be adequate. Utilities, or analytical mistakes. communication equipment, and housekeeping 2. Data from the laboratory should be gathered and should be adequate. analyzed on a regular basis in order to identify K. Radioisotopes or biohazardous chemicals cannot and resolve problems. A copy of this report be used in the same room where sperm are pre- should be kept for review. Quality assurance pared for intrauterine insemination or cryopreser- should also include the turnaround time for re- vation. ports and consistency of service as well as statis- L. Laboratory personnel should periodically review tical analysis of outcomes data. additional published safety guidelines as they be- 3. An adverse incident file should be maintained. come available (10). 4. The laboratory must participate in proficiency testing for those procedures for which it is available. For those testing services in which a com- VII. Quality Control/Assurance mercial proficiency test is not available, the A. Quality Control (QC) laboratory must establish an internal quality as- To assure reliable results, the following recommen- surance program. Consideration should be given dations must be followed: to sharing samples with other laboratories or de- 1. All new protocols should be validated by parallel veloping some other means of external quality testing (when possible prior to clinical imple- assessment. External quality assessment serves mentation. Protocol(s) documentation should in- as a companion to a laboratory’s internal quality clude a description of the assay, standards, assessment program. controls, calibration, and tolerance limits where applicable. Acknowledgment: This report was developed under the direction of the Prac- 2. The laboratory director and/or supervisor should tice Committee of the Society for Assisted Reproductive Technology and the review and update all procedures on at least Practice Committee of the American Society for Reproductive Medicine as a yearly basis. Copies of old protocols and up- a service to their members and other practicing clinicians. While this docu- dated procedures must be kept for at least two ment reflects appropriate management of a problem encountered in the prac- years. Effective dates of all changes to protocols tice of reproductive medicine, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other should be recorded. plans of management may be appropriate, taking into account the needs of 3. Equipment should be maintained and calibrated the individual patient, available resources, and institutional or clinical prac- against National Safety Board (NSB) Standard tice limitations. This report was approved by the Executive Council of the So- Reference Materials, when possible, on a regular ciety for Assisted Reproductive Technology and by the Board of Directors of basis. This includes a record of instrument cali- the American Society for Reproductive Medicine. bration, functional checks of equipment, when possible, evidence of an active review of records, REFERENCES and documentation of corrective action taken 1. U.S. Food and Drug Administration. Tissue guidances, rules and related when instruments malfunction. documents. Available at: http://www.fda.gov/cber/tissue/docs.htm. 4. All reagents, media and chemicals should have 2. Blasco L. Clinical tests of sperm fertilizing ability. Fertil Steril 1984;41: expiration dates recorded. All outdated materials 177–92. should be discarded in an appropriate manner. 3. Kremer J. A simple penetration test. Int J Fertil 1965;10:209–15. 5. Positive and negative controls should be used 4. World Health Organization. In: WHO laboratory manual for the examination of human semen and semen-cervical mucus interaction. 4th ed. when performing sperm antibody testing. Posi- Cambridge: Cambridge University Press, 1999:1–128. tive controls should be used when performing 5. Bronson R, Cooper G, Rosenfeld D. Sperm antibodies: their role in infer- the sperm penetration assay. tility. Fertil Steril 1984;42:171–83. 6. Infection control: HIV-1 and -2, hepatitis B, hep- 6. Wolf DP, Sokoloski JE. Characterization of the sperm penetration bioas- atitis C, syphilis and HTLV-I and -II screened se- say. J Androl 1982;3:445–51. 7. The American Society for Reproductive Medicine. 2008 Guidelines for rum products should be used. Sterile techniques gamete and embryo donation. Fertil Steril 2008;90(Suppl 3):S30–44. and universal precautions to limit microbial con- 8. American Association of Tissue Banks. Standards for Tissue Banking; tamination should be employed. 2002. 7. Daily monitoring of temperature, gases, and hu- 9. Gerrity M. Selection and use of equipment. In: Wolf DP, Bavister BD, midity (when appropriate) for all equipment Gerrity M, Kopf GS, eds. In vitro fertilization and embryo transfer: a manual of basic techniques. New York: Plenum Press, 1988:7–24. should be conducted on a daily basis. assoc. editors. B. Quality Assurance (QA) 10. Schrader SM. Safety guidelines for the andrology laboratory. Fertil Steril The quality assurance program should include 1989;51:387–9.

Fertility and Sterility S59