Immunology Department Basic Sperm Analysis Record

DEPARTMENT OF PATHOLOGY SOP name: Basic Semen Analysis Combined Laboratories Plymouth Hospitals N.H.S. Trust SOP No: AND/002

Appendix 3 – Immunology department – Basic Sperm Analysis Record

Name______D.O.B ____/____/______Partner’s Name:______D.O.B ____/____/______Date of sample ____/___/______Abstinence ______days Time collected_____:_____ Time analysed _____:_____ Analysed by ______Checked by ______

Sample Weight in g/ml ml >2.0 ml pH > 7.2 Sperm Count 106/ml 20x106/ml Dilution Used Motility A – Rapid %  25% class ‘A’ B – Slow % OR  50% class ‘A’ C – Non-Prog % and ‘B’ combined D - Immotile % Morphology >15% normal % (% normal forms) forms Round 106/ml cells Viscosity N or A Agglutinat N or A ion Debris N or A Liquefacti N or A on Count 1 = Rows counted / by ______Count 2 = Rows counted / by ______Count

SOP No: AND/002 Issue No: 2.4 Page 1 of 3 DEPARTMENT OF PATHOLOGY SOP name: Basic Semen Analysis Combined Laboratories Plymouth Hospitals N.H.S. Trust SOP No: AND/002

Comments:

______Morphology read by:______Morphology checked by: ______Dilution factors are: 1:2 = divide by 10 1:5 = divide by 4 (for 10 squares counted) 1:20 = divide by 1  Seminal Fluid Analysis – Appendix 5   These Tests are undertaken in the immunology section of Derriford Combined Laboratory, Level 06, Derriford Hospital. Please follow the instruction given below:   Instructions:  Please telephone the Immunology department for an appointment 01752-792293.  All appointments run at 9am.  No appointment = no testing will be done.  Abstain from intercourse or masturbation for 3 to 5 days before producing sample,  Smoking should be stopped for 3 months prior to test and kept alcohol intake to a minimum.  Clean the penile area before producing the sample by masturbation. Only use the container provided. Do not use a condom.  Once the sample is produced keep it at body temperature (inside pocket etc.) and bring it to the laboratory WITHIN AN HOUR OF PRODUCTION.  Complete all the details on the form.  Deliver to the Immunology Dept, combined laboratory, Level 06, Derriford Hospital, Plymouth.  If you are unable to attend your appointment for any reason please ring to cancel your appointment.   Please fill this in prior to your appointment:   Male partner’s full name:  Date of Birth: / /   Female partner’s full name:  Date of Birth: / /   GP and Practice (or referring Doctor:   Sample Information:  Date of Production: / / Time of production:   Abstinence (days):   Was there any spillage: Yes/No

SOP No: AND/002 Issue No: 2.4 Page 2 of 3 DEPARTMENT OF PATHOLOGY SOP name: Basic Semen Analysis Combined Laboratories Plymouth Hospitals N.H.S. Trust SOP No: AND/002

 If Yes, was the spillage the first part of the sample: Yes/No   Please indicate any of the following during the last 3 months:

 Illness:

 Medications taken:

 Alcohol consumption in units in last 48 hours:

 Your Signature: Date: / /

SOP No: AND/002 Issue No: 2.4 Page 3 of 3