1 Andrology Centre, Department of Women and Child Health, Karolinska Hospital, Stockholm, Sweden, 2 Assisted Conception Unit, Birmingham Women's Hospital, University of Birmingham, Birmingham, 3 Endocrinology and Reproduction Research Group, School of Biomedical Sciences, Kings College London, London, UK and 4 Oozoa Biomedical Inc., West Vancouver, BC, Canada
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Abstract |
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Key words: effect of training/semen analysis/standardization/training courses/WHO
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Introduction |
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There have been several efforts made to improve the quality of semen analysis by recommending suitable methods and organizing training courses or programmes (Eliasson, 1971; Jequier and Ukombe; 1983, Jörgensen et al., 1997
; Franken et al., 2000
), but the effects of at least the earliest activities have, in the long run, apparently been limited mainly to the centres involved in the initial projects. The general lack of standardization of assessment criteria, laboratory procedures, patient information, sample collection and training is likely to be the main reason for results of semen analysis being unreliable and poorly comparable between laboratories.
Several studies have emphasized the importance of standardization of laboratory methods and training of staff to achieve reliable results in routine semen analysis (Mortimer et al., 1986; Dunphy et al., 1989
; Seaman et al., 1996
; Jörgensen et al., 1997
; Auger et al., 2000
). As a long-term project to improve standards in semen analysis the Special Interest Group in Andrology (SIGA) of the European Society of Human Reproduction and Embryology (ESHRE) decided to organize standardized training courses in semen analysis, aimed primarily at several regions in Europe. The basic concept was to teach robust and internationally accepted methods for semen analysis to improve quality and decrease variability in results among and within individuals.
The aim of this study was to investigate whether there were any immediate effects of the theoretical and practical training provided during the ESHRESIGA Basic Semen Analysis courses on the variability of assessments made by different observers.
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Materials and methods |
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A summary of course contents is given in Table II. Each course began with an introductory session where the scope and organization of the course were presented. An additional benefit of this introductory session was to allow the participants to meet and get to know each other before the first formal lecture. On the first day there was an initial practical session, referred to in the Results as the pre-test. Here the participants were expected to assess two samples using their current expertise using the standard equipment provided for the course, but without instruction. The paedagogical value of this pre-test was twofoldfirstly, all participants would have tried their best to use the equipment before we discussed the theoretical background and, secondly, a set of `real world' results was available as a basis for discussion on the variability of assessments. Subsequently, each component procedure (i.e. sperm concentration and motility on fresh semen, vitality and morphology assessments on ready made smears) was taught in a formal lecture followed by a practical session during which measurements were made on two fresh semen samples. The results of these assessments were analysed and discussed with the participants the following morning, before the first formal practical training session, referred to in the Results as training, took place. On the last day of the course, after the theory examination, there was a practical examination, referred to in the Results as examination, during which two assessments were made of sperm concentration, motility, vitality, and morphology. The examinations were not only marked, but the answers of the participants were also analysed and presented to the participants prior to announcing the outcome of the examinations. To pass the practical examination the participant needed to achieve at least half of maximum marks. For each variable assessed 50% of the marks depended on how close the result was to the expert value. With increasing difference between result and expert value there was a gradual decrease in marks. The other 50% of the marks were obtained based on data in the report handed in. Marks were given for correct handling of the original counting data and for calculations demonstrating that recommended methods were used and understood. The number of participants who passed the examinations in each course is given in Table III
.
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Course venues
There were 24 courses registered at the ESHRE Central Office between 1994 and 1999 (Table I). The eight courses included in the present analysis are listed in Table III
, and were selected for the present analysis because at least one of the authors was involved in running and/or teaching each course. The course language was English in these eight courses, even in the Nordic countries (organized jointly by ESHRE and NAFA) in order to eliminate the differences between the Nordic languages and to allow participation from the Baltic countries. Simultaneous translations were given by lecturers and tutors in the respective native tongue where necessary, except in Kharkiv where interpreters from the University of Kharkiv provided translation.
Data
The results from pre-test, training and examination were compared with results obtained by highly experienced technologists and/or course faculty (referred to as `expert' values). The difference in sperm concentration was expressed as a percentage of the expert value, to allow comparisons between samples with widely different sperm concentrations. All other variables were already expressed as percentages (motility fractions, proportion with normal or abnormal morphology, proportion of live sperm) or as a ratio (teratozoospermia index, TZI), and the differences between the participants' and the experts' values were used for comparisons. The expert value was always subtracted from the participant's value, so that when the participant underestimated a variable, the difference was negative.
In general, each participant assessed two samples during each practical session. During the course in Kharkiv there were some difficulties with translation and the availability of a limited number of phase contrast microscopes meant that not all participants were able to complete their analysis of two specimens in each practical session.
Unfortunately, in some of the courses, occasional participants failed to deliver a result at a session because of a lack of time due to minimal laboratory experience. A colour-blind participant did not participate in vitality assessments, but with this exception all but two participants managed to assess all samples at the practical examinations (Table III).
Purpose of the analysis
The focus of interest was to investigate any decrease in variability of results within the participant groups over time, i.e. from pre-test to training and then to examination. Therefore, group-averaged results were not considered for statistical analysis.
Statistical methods
Distributions of results for each sample were examined using box-and-whiskers plots. Analysis of variance (ANOVA) was used to compare standard deviations over the three phases (i.e. standard deviations of the pre-test, training, and examination samples). Where differences in distribution between the three phases did not allow direct analysis, log-transformation was performed. Tests for linear trend were used to determine whether a trend line was significantly different from zero.
Comparisons of concordant participant results (i.e. as compared with the expert results) were performed using the 2-test. The arbitrary limit of ±10% was employed according to established standards in routine clinical andrology (Mortimer, 1994b
).
Calculations were performed using GraphPad PrismTM 3.02 and GraphPad InStatTM 3.05 (GraphPad Software, San Diego, CA, USA, www.graphpad.com; Motulsky, 1996). Production of figures was also performed using GraphPad PrismTM 3.02.
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Results |
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Morphology
Normal forms
The variability of assessments of sperm morphology had already decreased at the training phase as compared with the pre-test as measured by average standard deviation (Figure 4: one-way ANOVA P < 0.001; linear trend slope = 5.221, r2 = 0.4296, P < 0.001, pre-test to examination). The proportion of results within ±10% of expert values (Table IV
) increased from 37% at pre-test to the very high level of 88% at training and 90% at examination (
2-test P < 0.001; linear trend P < 0.001).
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Discussion |
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The results of the pre-test evaluations confirm and extend the findings of Jequier and Ukombe showing large variations among results obtained by different individuals examining the same semen sample, while a training programme does reduce the inter-observer errors (Jequier and Ukombe, 1983). It is not suggested that a 4 day course constitutes a comprehensive training programme for andrology technologists, rather it represents the initial, baseline theoretical and practical education that must then be followed by a further iterative process comparing a trainee's performance against reliable, reference values. Regular analysis of such data will provide positive reinforcement as concordance increases (Mortimer, 1994a
,b
; Franken et al., 2000
). This practice provides a natural foundation that should be completed by robust internal quality control procedures (Clements et al., 1995
). Wider-scale concordance can then be achieved by participation in an external quality assurance program (EQAP), but only if the EQAP provides feedback of performance against reference values. Participation in a successful EQAP can also serve as the basis for ongoing proficiency testing programmes (Franken et al., 2000
).
All participants were expected to be at least familiar with the WHO manual, and most had indicated prior to the course that they complied with WHO recommendations. Because the technology as such is unsophisticated, adaptation to, or familiarization with, the equipment used on the course should not have been a major factor. Certainly, working within a group of peers can always be expected to be beneficial in any professional setting, but while this situation may have led to a greater comfort for the participants it is difficult to see how it could improve someone's ability to perform differential motility and morphology counts or to use the haemocytometer. The simple fact that a participant's result is different from that of the `experts' does not intrinsically create a change in how s/he performs a technique; only proper training can do this. We believe that the strong positive reinforcement during the course, where participants see the progressive decrease in discrepancies while training, illustrates the benefit of this structured training course.
In addition to the present study, there is also documentation of long term effects of the ESHRE Basic Semen Analysis courses. In Belgium (Punjabi and Spiessens, 1998) the participants showed a notably increased awareness of the need for standardization of semen analysis as well as a decrease in variability during the courses, as in the present study. In the Netherlands (Vreeburg and Weber, 1998
) a large group of participating laboratories had significantly changed their laboratory procedures to reduce errors by starting to use positive displacement pipettes, improved Neubauer haemocytometers, heated (37°C) microscope stages and by complying with WHO motility and morphology criteria within 6 months of the course.
There is a need for improved standards in semen analysis. Cost effective health care for the couple seeking help for infertility includes accurate semen analysis. Semen analysis performed with improper and therefore unreliable methods without internal and external quality control is a waste of resources and often provides the wrong diagnosis, which causes negative effects for both the couple and the health service provider. Robust and reliable methods for semen analysis are availablemethods that have been standardized and successfully used for training. These methods should therefore be used in all semen laboratories. This analysis provides strong support for the ESHRESIGA initiative on standardized, comprehensive training courses in basic semen analysis, as well as for further development of the ESHRESIGA Quality Assurance Program.
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Acknowledgements |
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Notes |
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References |
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Submitted on September 20, 2001; accepted on November 3, 2001.