WHO manual...Who should care?*

Christopher J. De Jonge1,3 and Christopher L.R. Barratt2

1 Reproductive Medicine Center, and Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, MN, USA, and 2 Reproductive Biology & Genetics Group, The University Medical School, Birmingham Women's Hospital, Edgbaston, Birmingham B15 2TG, UK

The long-awaited and much anticipated fourth edition of the World Health Organization (WHO) Laboratory Manual for the Examination of Human Semen and Sperm–Cervical Mucus Interaction has been published very recently (WHO, 1999). The primary objective(s) of the manual are to provide a framework for, and encourage the use of, standard policies and procedures for semen and sperm analysis, and to establish reference values for semen parameters. The goal is that global use of the manual and compliance with its policies and procedures will facilitate and enable the comparison and amalgamation of results between laboratories. One significant positive outcome is the seamless and (boundary-less) care of patients.

The above-mentioned goals and objectives are laudable, and they are consistent with the WHO's previous aims. However, numerous studies consistently demonstrate poor standardization of techniques in semen analysis (e.g. Ombelet et al., 1997). Consequently, there is little or no possibility of being able to compare test results between laboratories. Indeed, if current conditions persist, we simply will not have the ability to interpret test results that emanate from laboratories other than our own. Thus, the primary question is: will the fourth edition of the manual realize its primary objective?

The third edition of the manual (WHO, 1992) has been vociferously criticized (e.g. Barratt, 1995; Barratt et al., 1995; Ombelet et al., 1997). Criticism was primarily aimed at: (i) the paucity of detailed description for some procedures; (ii) the recommendation of several different methods to perform even the most basic of techniques; and (iii) the alteration of criteria for distinguishing and characterizing a normal spermatozoon and without, apparently, any basic biological or clinical supportive evidence. Not only have these three points of deficiency sparked considerable debate, but they have also made it virtually impossible to achieve consistent diagnostic testing of semen parameters and subsequent comparison of test results between laboratories.

The fourth edition of the manual has attempted to address the above-mentioned and other (criticized) points not mentioned herein. The specific details of all the revisions and amendments to the manual are beyond the scope of this text. However, three points will be discussed in order to provide a flavour of the changes that were made and to serve as an example of the strong effort by the Editorial Committee and contributors to accomplish the objectives and goals of the manual.

Firstly, detailed descriptions are provided for the main techniques, together with useful examples. For example, quantitative values are provided for grades of sperm motility (e.g. grade `a' is defined by sperm movement >20 µm/s at 20°C). In addition, a description is provided of the technique for examining the slide used for assessing sperm motility, i.e. a systematic selection of eight fields at least 5 mm from the edge of the coverslip. Moreover, a recommendation is given for the number of cells to count for sperm concentration, motility and morphology, and supported by examples of 95% confidence limits charts (assisting the technologist in carrying out the procedures and with the assurance of high quality).

Secondly, only one method for the examination and classification of sperm morphology, i.e. `strict' criteria, is provided. To aid in the preparation of good slides (critical for the assessment), descriptions of methods for preparing the slide and staining the specimen are given (recommendation of Papanicolaou, with Shorr and Diff-Quik staining methods included). Examination of the slides should be at x1000 total magnification.

Thirdly, internal/external quality control and proficiency testing are perhaps the most significantly revised sections in the new version of the manual. To emphasize the importance of this issue, a whole chapter (over one quarter of the main text) is provided, in which the basic principles and vital issues of quality control are detailed, including the use of control charts. The principle reason for the dramatic expansion in these areas is in an attempt to address the problems of accuracy and precision in, for example, sperm counting that have been reported in those countries where proficiency testing and quality control schemes have been implemented. It is anticipated that the new material will be well-received and implemented by all laboratories that perform semen analysis.

Without a doubt, the new manual will serve as a more useful text to assist technologists to perform high quality semen assessments using standardized techniques. In addition, the text will serve as an aid for understanding and appreciating the errors that can be made when performing a semen analysis and how to overcome/avoid these errors. However, will the manual be able to achieve its goal of improving the ability for the amalgamation and comparability of results between laboratories and of data from different sources? The answer to this question is quite difficult to ascertain. Quite frankly, the remarkably poor standards for performing semen analysis that are currently implemented throughout the world cannot be allowed to continue. Surely, something must happen.

Using the fourth edition of the WHO manual as the standard reference text for semen and sperm analysis, it is proposed that the following measures should be implemented in order to facilitate and ensure that the objectives and goals of the manual come to fruition.

Firstly, technologists and heads of laboratories should be made aware that a new, improved and updated WHO manual using some different and standardized techniques is available. They should be strongly encouraged to adopt the new manual in their laboratory (see below).

Secondly, professional societies should be encouraged to facilitate greater recognition of the importance and significance of the WHO manual to their membership/constituency. Societies can act as vehicles for dissemination of information, discussion, feedback and, possibly, training.

Thirdly, training courses already in operation in several countries should adopt the new version of the manual. A considerable network of course-trained technologists exists, at least in Europe, and they can be solicited to act as messengers to `spread the new gospel'. However, a brief refresher course (possibly a 1 day course) is likely to be necessary for previously trained technologists. The training courses can facilitate technologists getting the updated methods adopted into their respective laboratories.

Fourthly, external quality control schemes in operation in many countries provide an excellent vehicle for improving standards and maintaining proficiency. Laboratories with spurious results can often contact the organizer or other participants for advice on how to address variances. This system should be exploited to encourage users to adopt the updated WHO methods.

Fifthly, preliminary data suggest that structured training courses, e.g. those organized by the European Society of Human Reproduction and Embryology (ESHRE) (Bjorndahl and Kvist, 1998Go), provide significant improvements in technical competence. It is critical, however, that the methods of teaching (and assessment of the effects of training) should be constantly monitored and improved. Given the diverse environment(s) of many regions in the world, can such courses be the sole mechanism for training the vast majority of technologists performing semen analysis? Modern technologies (e.g. the internet) may be suitable for such purposes.

Last (but certainly not least), laboratory directors, technologists, clinical directors and administrators (the health care team) must be motivated to improve the standards under which semen and sperm analysis is performed in the clinical laboratory. In order to become motivated they will need to be educated so that they gain appreciation for the significance and importance of all the aforementioned. One very real and practical example that can provide motivation, is the one of how implementation of WHO standards by the laboratory can and will enhance the delivery of quality care to patients. By improving the quality of the semen analysis we will provide a better product, i.e. data, to the clinician who can then prescribe the most appropriate remedy. Furthermore, it can be reasoned that because semen analysis has been performed suboptimally, the ability to ascertain the relationship between semen parameters (data) and infertility has, as a consequence, been compromised.

In the fourth edition of the WHO manual, we have clearly defined standards of policy and procedure and with most (but probably not all) of the Achilles heel issues of previous editions reconciled. With today's technologies, e.g. the internet, we have a readily available means of disseminating the WHO manual worldwide. However, several key issues remain: (i) there should be a mechanism for assessing compliance; (ii) there should be a mechanism for monitoring the effectiveness of implementation; and (iii) there should be a mechanism for measuring quality improvement.

Legislation can be an effective tool for assessing and ensuring compliance. In the UK, the centres performing assisted conception need a licence from the Human Fertilisation and Embryology Authority (HFEA) and must abide by a strict Code of Practice. In the US, the government mandates (under the Clinical Laboratory Improvement Amendment, 1988) that clinical laboratories performing quantitative assessment of semen (deemed as high-complexity testing laboratories) operate under clearly defined standards, be staffed by personnel who have specific education, training and experience, and that the laboratories be inspected routinely to ensure compliance with the law. One problem with legislative oversight is that if there is no strict and efficient mechanism for ensuring that laboratories register and acknowledge that they perform semen analysis (high-complexity) testing to the authorities, then compliance becomes essentially an issue of honesty. However, it can be reasoned that at some point the law will catch up with the non-registered, non-compliant offenders.

Inspection of laboratories by a body with deemed authority by the government, and perhaps even in collaboration with relevant professional societies, represents the next step towards compliance with the WHO manual. For example, a specific requirement should be that laboratories have on premises (and use) a copy of the WHO manual. Inspection also affords the opportunity to verify that laboratories have a programme in place for monitoring the effectiveness of WHO compliance. More specifically, laboratories should demonstrate that they have in place a quality control and quality assurance programme, together with a proficiency testing programme.

If the aforementioned approaches can be implemented, then it affords the clinician who orders the semen analysis the opportunity to act as a `consumer' gatekeeper. Clinicians requesting a semen analysis should be vigilant to ensure that the laboratory they have requested the testing from will perform the analyses in a manner that is in accordance with WHO standards and, if appropriate, that the laboratory is in compliance with national registry. An objective way to ensure that the clinician has the ability to discriminate between laboratories is to encourage the publication of laboratory performance results from external proficiency testing and quality control schemes. An example of this, albeit not in a strict sense, is the publication of assisted conception statistics, e.g. HFEA and SART/CDC (US-based Society for Assisted Reproductive Technologies/Center for Disease Control). Publishing results frequently compels programmes to continue striving towards excellence.

In conclusion, it could be argued that the third edition of the WHO Laboratory Manual for the Examination of Human Semen and Sperm–Cervical Mucus Interaction (WHO, 1992) allowed or even encouraged the use of non-standardized laboratory techniques and policies. Consequently, the burden of blame for the poor standards currently in existence in andrology laboratories could be placed on the WHO (however, this is not a strong argument and is likely to be illegitimate!). Standing in stark contrast, the revised and improved fourth edition of the manual addresses many concerns on the standardization of techniques and policy. Thus, and it cannot be stated strongly enough that, if operating standards between laboratories do not change dramatically, and for the better, then the WHO manual has not failed, we have.

Addendum

The following organizations act as a resource for information on proficiency testing:

Australasia
Fertility Society of Australia, External QC scheme, PO Box 1101, West Leederville, WA, Australia 6901

Europe
ESHRE
Lars Bjorndahl (Currently organizing the EHSRE external quality control scheme)

Andrology Laboratory, Reproductive Medicine Centre, Karolinska Hospital, Box, 140, 171–76 Stockholm, Sweden

UK
NEQAS Scheme
Ann Atkinson, Sub Fertility Laboratory, St Mary's Hospital, Manchester, M13 OJH, UK

USA
American Association of Bioanalysts, 917 Locust Street, Suite 1100, St Louis, MO 63101–1413, USA.

Proficiency Testing Service, 205 West Levee, Brownsville, TX 78520–5596, USA. E-mail: proficiency{at}ies.net

Notes

3 To whom correspondence should be addressed Back

This opinion was published on Webtrack 78, July 15, 1999

References

Barratt, C.L.R. (1995) On the accuracy and clinical value of semen laboratory tests. Hum. Reprod., 10, 250–252.[ISI][Medline]

Barratt, C.L.R., Naeeni, M., Clements, S. and Cooke, I.D. (1995) Clinical value of sperm morphology measurements for in-vivo fertility: comparison between World Health Organization (WHO) criteria of 1987 and 1992. Hum. Reprod., 10, 587–593.[Abstract]

Bjorndahl, L. and Kvist, U. (1998) Basic semen analysis courses: experience in Sweden. In Ombelet, W., Bosmans, E., Vandeput, H. et al. (eds), Modern ART in the 2000s. Parthenon Publishing, New York, USA, pp. 91–102.

Clinical Laboratory Improvement Amendment (1988) Title 57 Federal Register 7139, February 28, 1992.

Ombelet, W., Cox, A., Janssen, et al. (1998) Methodological differences in sperm morphology assessments. In Ombelet, W., Bosmans, E., Vandeput, H. et al. (eds), Modern ART in the 2000s. Parthenon Publishing, New York, USA, pp. 61–72.

World Health Organization (1992) WHO Laboratory Manual for the Examination of Human Semen and Semen–Cervical Mucus Interaction. 3rd edn. Cambridge University Press, Cambridge, UK, pp. 107.

World Health Organization (1999) WHO Laboratory Manual for the Examination of Human Semen and Semen–Cervical Mucus Interaction. 4th edn. Cambridge University Press, Cambridge, UK, pp. 128.