Original Article The impact of the new 2010 World Health Organization criteria for semen analyses on the diagnostics of male infertility O impacto dos novos critérios da OMS (2010) para avaliação seminal no diagnóstico da infertilidade Jaime Larach, M.D.ª, Dayalis González, D.O.ª, Saúl Barrera, M.D.ª, Roberto Epifanio, M.D.ª, Mayka Morgan, M.D.ª, Ana Palma D.O.ª ªInstituto Valenciano de Infertilidad, Panamá City, Panamá. Objective: To quantify the effect of the new 2010 World de referência, previamente abaixo dos valores em 1999. Health Organization (WHO) semen analysis reference Resultados: Um total de 255 amostras foram anali- values on reclassifying previous semen analysis parame- VDGDV D SDUWLU GDV TXDLV IRUDP UHFODVVL¿FDGDV WHUVDQGGH¿QLWLRQRISDWLHQWVZLWKPDOHIDFWRULQIHUWLOLW\ HP SHOR PHQRV XP SDUkPHWUR H IRUDP Method: A uni-institutional retrospective chart review. UHFODVVL¿FDGDV FRPR QRUPR]RRVSHUPLFRV 8VDQGR DV Men who consulted for infertility during 2012 at Panamá referências de 1999, houve uma maior prevalência de IVI Clinic. The news 2010 WHO criteria were aplied to achados anormais especialmente de teratozoospermia patients whose spermograms had been analyzed using TXH IRL GH HQTXDQWR D SUHYDOHQFLD GH QRUPR- WKHSUHYLRXVFULWHULDDIWHUZDUGVWKHUHFODVVL¿FDWLRQ ]RRVSHUPLD IRL GH &RP RV YDORUHV GH ZDV HYDOXDWHG &KDQJH RU 5HFODVVL¿FDWLRQ ZHUH GH¿QHG HVWHV HUDP H UHVSHFWLYDPHQWH $OpP GLVVR as the parameter being above the new reference values, com os critérios de 2010, houve uma maior varieda- previously being below that proposed by 1999 WHO. GH GH GLDJQyVWLFRV SDFLHQWHV IRUDP UHFODV- Result(s): A total of 255 samples were analyzed, from VL¿FDGRV SHOD PRUIRORJLD SHOD PRWLOLGD- ZKLFKZHUHUHFODVVL¿HGLQDWOHDVWRQHSDUDPHWHU GH HPYROXPHH QDFRQWDJHPGH DQG ZHUHUHFODVVL¿HGDVQRUPR]RRVSHUPLFV espermatozóides; asthenozoospermia foi o achado que Using the 1999 WHO values there was a higher preva- DSUHVHQWRX D PDLRU WD[D GH UHFODVVL¿FDomR OHQFHRIDEQRUPDO¿QGLQJVVSHFLDOO\RIWHUDWR]RRVSHUPLD Conclusão : Os novos valores de referência resultaram WKDW ZDV ZKLOH QRUPR]RRVSHUPLD SUHYDOHQFH ZDV em muitos de nossos pacientes, que tiveram um esper- :LWKWKHYDOXHVWKHVHZHUHDQG PRJUDPD DQRUPDO VHQGR UHFODVVL¿FDGR FRPR QRUPR- respectively. Also, with the criteria of 2010, a greater zoospermicos. Isto pode levar a uma nova perspectiva variety of diagnoses was evidenced. do seu diagnóstico e tratamento. SDWLHQWV ZHUHUHFODVVL¿HGE\PRUSKRORJ\ Palavras-chave: Andrologia, espermograma, critérios E\PRWLOLW\ E\YROXPHDQG E\ da OMS. VSHUPFRXQWDVWKHQR]RRVSHUPLDZDVWKH¿QGLQJZKLFK VKRZHGWKHKLJKHVWUHFODVVL¿FDWLRQUDWH INTRODUCTION Conclusion(s): The new reference values resulted in Clearly, the male and his semen quality is a key factor many of our patients, who had had an abnormal sper- in investigating and addressing infertility. As evidenced PRJUDP EHLQJ UHFODVVL¿HG DV QRUPR]RRVSHUPLFV 7KLV by Brugh, et al., 2004, male infertility accounts for the may lead to a different perspective on their diagnosis and LQIHUWLOLW\LQDOPRVWRIFRXSOHV treatment. Hence, the evaluation of the male partner is a crucial Key Words: Andrology, spermogram, WHO criteria, step in the diagnosis and treatment of couples atten- infertility. GLQJDQLQIHUWLOLW\¿UVWYLVLW2IFRXUVHZHQHHGDJHQHUDO medical history: anamnesis and physical examination, RESUMO DVLQDOO¿HOGVRIPHGLFLQHDUHSUHUHTXLVLWHV+RZHYHU Objetivo TXDQWL¿FDU R HIHLWR GRV QRYRV YDORUHV in andrology, performing at least one semen analysis, de referencia ( 2010) da Organização Mundial da ideally in a fertility center, is a mandatory step to esta- Saúde (OMS) para a análise do sêmen, em reclas- EOLVKWKHGH¿QLWLYHIHUWLOLW\PDQDJHPHQWIRURXUFRXSOH VL¿FDU SDUkPHWURV GH DQiOLVH GH VrPHQ DQWHULRUHV H D Like many other diagnostic tests, the minimum “normal” GH¿QLomR GH SDFLHQWHV FRP LQIHUWLOLGDGH PDVFXOLQD reference values have been changing over time. While Método: Estudo retrospectivo uni-institucional. Homens we can differentiate “normality” from “abnormality”, it que consultaram para infertilidade ao longo de 2012 na is important to note that having a parameter below a Clínica IVI Panamá. Os novos criterios de 2010 da OMS minimum normal reference value does not necessarily foram aplicados aos pacientes cujos spermograms foram mean being infertile, and males with values below these analisados usando os critérios anteriores (1999), e depois can still achieve pregnancies. At least two pathological DUHFODVVL¿FDomRIRLDYDOLDGD$OWHUDURX5HFODVVL¿FDUIRUDP spermograms, taken in a period of 15 days, is consi- GH¿QLGRVFRPRVHQGRSDUkPHWURDFLPDGRVQRYRVYDORUHV GHUHGDUHTXLUHPHQWWRGH¿QLWLYHO\HVWDEOLVK³DEQRUPD- Recebido em 02-03-13 Copyright - Todos os direitos reservados a Aceito em 13-03-13 SBRA - Sociedade Brasileira de Reprodução Assistida 93 94 Original Article lities” in male fertility. Other authors (Mortimer et al., RESULTS 1985, Castilla et al., 2006, Keel et al., 2006) recommend We reviewed the database for all spermogram samples 3 or 4 analyses in a period of 3 months, representing one analyzed during 2012 belonging to patients who consul- complete cycle of spermatogenesis. ted at the IVI Panama Clinic. In total 255 semen reports The semen analysis should be performed by using stan- were found for that period. dard techniques and criteria as described by the World The most frequently found diagnostic applying the 1999 Health Organization (WHO) and updated in 2002 by the SDUDPHWHUV ZDV LVRODWHG WHUDWR]RRVSHUPLD European Society of Human Reproduction and Embryo- followed by teratozoospermia associated with hyposper- logy (ESHRE). The reference values given by WHO are PLD 1RUPR]RRVSHUPLD IUHTXHQF\ ZDV approximate, and, in theory, each laboratory should esta- 7KHOHDVWIUHTXHQWZDVLVRODWHGK\SRVSHUPLD 6HH blish its own, but this task is almost impossible because Table 1. Teratozoospermia (isolated or associated) was RIWKHGLI¿FXOW\LQGH¿QLQJDQGREWDLQLQJDUHIHUHQFHIHUWL- WKH ¿QGLQJ ZKLFK SUHVHQWHG ZLWK WKH KLJKHVW IUHTXHQF\ le population. For this reason, most laboratories adopted IROORZHG E\ ROLJR]RRVSHUPLD K\SRVSHUPLD WHO criteria which come from a large fertile population, DVWKHQR]RRVSHUPLD DQG ¿QDOO\ FU\SWR]RRVSHUPLD 6HH EXWGRQRWLQWKHPVHOYHVFRQ¿UPIHUWLOLW\RULQIHUWLOLW\ Table 2. 6LQFH :+2 KDV SXEOLVKHG ¿YH HGLWLRQV RI ³:+2 Manual for the Examination of Human Semen and Table 1. 1999 WHO diagnostics and percentage of reclassi- Sperm-Cervical Mucus Interaction.” The latest of 2010 ¿FDWLRQ used a fertile population in 14 countries and decreased the normal minimum cutoffs of 1999 criteria. The main Diagnostics N: 255 5HFODVVL¿FDWLRQ objective (Cooper et al., 2011) was to improve the inci- Normozoospermia 0 dence of misdiagnosis and thereby improve the clinical Teratozoospermia: management of patients. Of course, using these para- PHWHUVWRGH¿QLWLYHO\HVWDEOLVKQRUPDOLW\ZRXOGEHYHU\ Oligoasthenoterato- risky: while WHO evaluated a large and varied population zoospermia: (all of them fertile) some biases can be found regarding Oligoteratozoospermia: population which might lie outside (underdiagnosed or Teratozoospermia/ overdiagnosed) the range used in 2010 WHO. A man hypospermia: VKRXOGQRWEHFODVVL¿HGDVIHUWLOHRULQIHUWLOHEDVHGRQO\ Oligoasthenoterato- on the spermogram or semen analysis. zoospermia/ Recently, Murray et al., 2012, published a study to assess hypospermia: the impact of the new 2010 WHO criteria on spermo- Astenoteratozoospermia: JUDPVDQGLQWHUSUHWLQJDQGGH¿QLQJWKHFKDQJHIURPWKH FXWRIIVRI:+27KH\IRXQGUHFODVVL¿FDWLRQLQVHPL- Astenoteratozoospermia/ hypospermia: nal volume, sperm concentration, motility and morpho- ORJ\ RI DQG UHVSHFWLYHO\ IRU Oligoteratozoospermia/ SDWLHQWVZLWKPXOWLSOHVHPHQVDPSOHVDQG hypospermia: DQGUHVSHFWLYHO\IRUSDWLHQWVZLWKDVLQJOH Cryptozoospermia 4/255 VHPHQ VDPSOH 7KHLU VWXG\ DOVR VKRZHG WKDW RI SDWLHQWVZHUHUHFODVVL¿HGRQDWOHDVWRQHSDUDPHWHU /HW Hypospermia: ò XVUHPHPEHUWKDWUHFODVVL¿FDWLRQZDVGH¿QHGDVDVHPHQ parameter changing from being below the old reference TOTAL: value to being above the new reference value.) As shown, the application of the current 2010 WHO criteria to the samples increases the incidence of normozoosper- Table 2.7RWDOIUHTXHQF\RI¿QGLQJV LVRODWHGRUDVVRFLD- mia principally because of morphology and sperm motility. ted), 1999 WHO. The objective of this study is to quantify at IVI Panama FINDING N: 255 clinic the magnitude of change in the interpretation of Teratozoospermia spermograms when we apply the new criteria of 2010 WHO criteria, in comparison to the 1999 WHO criteria. Oligozoospermia Hypospermia MATERIALS AND METHODS Asthenozoospermia We conducted a review of all spermogram reports made Normozoospermia during 2012 for patients consulting for infertility at IVI Panamá Clinic. All reports have data concerning moti- Cryptozoospermia lity, concentration, morphology and volume. First, we applied both 1999 and 2010 WHO reference values, establishing the respective diagnosis for each sample. RIVDPSOHVKDGUHFODVVL¿FDWLRQLQDWOHDVWRQHSDUD- :H WKHQ DQDO\]HG WKH SHUFHQWDJH RI UHFODVVL¿FDWLRQ RU meter, with astenoteratozoospermia associated with hypos- change and also other issues such as the frequency of SHUPLD EHLQJ WKH GLDJQRVWLF ZLWK WKH KLJKHVW UHFODVVL¿FD- GLDJQRVHV DQG ¿QGLQJV LVRODWHG RU DVVRFLDWHG WR HDFK WLRQUDWH $VZHDQWLFLSDWHGQRUPR]RRVSHUPLDDQG WHO interpretation, as well as the characteristics of the cryptozoospermia were the only diagnoses which were not UHFODVVL¿FDWLRQDQGWKHQHZHYLGHQFHDOLNH UHFODVVL¿HG6HH7DEOH The minimum reference