Uncertainty of measurement and clinical value of semen analysis: has standardisation through professional guidelines helped or hindered progress?

This article suggests that diagnostic semen analysis has no more clinical value today than it had 25-30 years ago, and both the confusion surrounding its evidence base (in terms of relationship with conception) and the low level of confidence in the clinical setting is attributable to an associated high level of 'uncertainty'. Consideration of the concept of measurement uncertainty is mandatory for medical laboratories applying for the ISO15189 standard. It is evident that the entire semen analysis process is prone to error every step from specimen collection to the reporting of results and serves to compound uncertainty associated with diagnosis or prognosis. Perceived adherence to published guidelines for the assessment of sperm concentration, motility and morphology does not guarantee a reliable and reproducible test result. Moreover, the high level of uncertainty associated with manual sperm motility and morphology can be attributed to subjectivity and lack a traceable standard. This article describes where and why uncertainty exists and suggests that semen analysis will continue to be of limited value until it is more adequately considered and addressed. Although professional guidelines for good practice have provided the foundations for testing procedures for many years, the risk in following rather prescriptive guidance to the letter is that unless they are based on an overwhelmingly firm evidence base, the quality of semen analysis will remain poor and the progress towards the development of more innovative methods for investigating male infertility will be slow.

Brief communication: assessment and validation of nonspermicidal condoms as specimen collection sheaths for semen analysis and assisted conception.

The choice of nonspermicidal sheaths for specimen collection for diagnosis and/or fertility treatment is limited. Those that are available tend to be relatively expensive and as a results, offered selectively to patients. This study describes the evaluation of three over-the-counter nonspermicidal condoms as alternatives to specialized specimen collection sheaths. Sheaths were incubated with motile sperm for up to 2 h and the percent Grade A motility, percent progressive motility and progressive velocity assessed using an 'in-house' computer-assisted semen analysis system every 30 min. Two of the sheaths tested, Pasante Naturelle (PN) and the Durex Avanti Ultima were shown to be highly toxic to sperm, leading to immobilization of most specimens within 1 h. However the loss of sperm motility when sperm were incubated with the Pasante Unique (PU) condom was no greater than with either the control (rigid 60 ml specimen container) or the Male Factor Pak (MFP), a commercially available specialized semen collection sheath. In conclusion, the PU brand of condom could be used as a cheaper alternative to the specimen collection sheaths currently available. Furthermore, some brands of condom sold as nonspermicidal are in fact toxic to sperm and will immobilize most specimens within 1 h.

Monitoring fertility (semen analysis) by cancer survivors who banked sperm prior to cancer treatment.

STUDY QUESTION: What medical and psychological variables predict why men with banked sperm do not return for semen analysis after their cancer treatment has ended? SUMMARY ANSWER: Men who decline the offer of semen analysis are less likely to have reported adverse side effects during cancer treatment, and have a more negative experience of banking sperm and a more negative attitude towards disposal of their stored semen than those who attend. WHAT IS KNOWN ALREADY: Previous authors have noted that male cancer survivors seem reluctant to have their fertility tested after their treatment has ended. Moreover, the utilization rates of banked sperm are very low (<10%) and the majority of samples are kept for many years without being used. STUDY DESIGN, SIZE AND DURATION: A cross-sectional study of 499 cancer survivors who were sent a questionnaire about their views on sperm banking, fertility and post-treatment semen analysis between April 2008 and December 2010. PARTICIPANTS AND SETTING: Men (aged 18-55 years) who had banked sperm in Sheffield and Nottingham (UK) prior to gonadotoxic treatment for cancer more than 5 years previously. MAIN RESULTS AND THE ROLE OF CHANCE: Completed questionnaires were received from 193 men (38.7% response rate) whose samples had been banked for 9.18 ± 3.70 years (range = 4.94-26.21) and whose current age was 35.08 ± 7.08 years (range = 21.58-54.34; mean ± SD). One-third (35.8%) had never attended for semen analysis. In multivariate analysis, the odds of not attending for semen analysis were significantly greater among men who did not experience adverse treatment side effects [odds ratio (OR) = 5.72, 95% confidence interval (CI) = 2.10-15.56], who reported a more negative experience of banking sperm (OR = 1.82, 95% CI = 1.17-2.82) and a more negative attitude to disposal of their stored semen (OR = 1.56, 95% CI = 1.01-2.42). LIMITATIONS AND REASONS FOR CAUTION: Only 38.7% of those eligible agreed to take part. We do not know the characteristics of men who declined to take part, if they agreed to attend semen analysis without completing the questionnaire or whether they had chosen to have semen analysis performed elsewhere (e.g. private sector). Some of the measures used (e.g. experience of banking sperm) relied on men's recall of events many years previously. WIDER IMPLICATIONS OF THE FINDINGS: New strategies are required to encourage these men to engage with fertility monitoring programmes if sperm banks are to be used cost-effectively and men are to be given appropriate fertility advice. STUDY FUNDING AND COMPETING INTERESTS: This paper was supported by funding from Cancer Research-UK to C.E., A.A.P. and R.R. (C481/A8141). The views expressed are those of the authors. No competing interests declared.

The split denture: a new technique for artificial saliva reservoirs in mandibular dentures.

Xerostomia is a relatively common complaint that can make the wearing of dentures very uncomfortable for affected individuals. To help overcome this problem, a number of techniques have been proposed for incorporating reservoirs, containing salivary substitutes, into dentures. These have had varying degrees of success. This paper presents a case of a patient suffering from xerostomia who was successfully treated with a new form of reservoir denture. This new split-denture technique resulted in a reservoir denture that provided good lubrication of the oral tissues, was easily cleaned by the wearer and was produced from routine denture materials. Details of its design, construction and other potential applications are also presented.

Interrelationships between seminal parameters and sperm nuclear DNA damage before and after density gradient centrifugation: implications for assisted conception.

BACKGROUND: With an increase in the use of assisted reproduction technologies the requirements of the diagnostic semen analysis are constantly changing. METHODS: Spermatozoa from patients undergoing IVF were analysed by examining the conventional semen parameters and DNA/chromatin integrity, using in-situ nick translation (NT) and the Chromomycin A(3) fluorochrome, which indirectly demonstrates a decreased presence of protamine. Samples were examined before and after preparation using discontinuous density gradient centrifugation. RESULTS: Density gradient centrifugation enriched samples by improving the percentage of morphologically normal forms by 138% and sperm nuclear integrity by 450%. Sperm nuclear integrity as assessed by in-situ nick translation (NT) demonstrated a very clear relationship with sperm concentration, motility and morphology. Morphology correlated with fertilization rates of patients undergoing IVF, while NT values of the spermatozoa post-preparation were significantly lower in pregnant patients. CONCLUSIONS: We have demonstrated that along with the classical semen parameters, the assessment of nuclear integrity improves the characterization of the semen sample and may be used as a tool for allocating patients to specific assisted reproduction treatments.

Dissemination of wear particles to the liver, spleen, and abdominal lymph nodes of patients with hip or knee replacement.

BACKGROUND: The importance of particles generated by wear and corrosion of joint replacement prostheses has been understood primarily in the context of the local effects of particle-induced periprosthetic osteolysis and aseptic loosening. We studied dissemination of wear particles in patients with total hip and knee replacement to determine the prevalence of and the histopathological response to prosthetic wear debris in the liver, spleen, and abdominal para-aortic lymph nodes. METHODS: Postmortem specimens from twenty-nine patients and biopsy specimens from two living patients with a failed replacement were analyzed. Specimens of tissue obtained from the cadavera of fifteen patients who had not had a joint replacement served as controls. The concentration of particles and the associated tissue response were characterized with the use of light microscopy of stained histological sections. Metallic particles were identified by electron microprobe analysis. Polyethylene particles were studied with the use of oil-red-O stain and polarized light microscopy. The composition of polyethylene particles was confirmed in selected cases by Fourier transform infrared spectroscopy and hot-stage thermal analysis. Twenty-one of the patients studied post mortem had had a primary total joint replacement. Eleven of them had had a hip prosthesis for a mean of sixty-nine months (range, forty-three to 171 months), and ten had had a knee replacement for a mean of eighty-four months (range, thirty-one to 179 months). The other eight patients studied post mortem had had a hip replacement in which one or more components had loosened and had been revised. The mean time between the initial arthroplasty and the time of death was 174 months (range, forty-seven to 292 months), and the mean time between the last revision procedure and the time of death was seventy-one months (range, one to 130 months). RESULTS: Metallic wear particles in the liver or spleen were more prevalent in patients who had had a failed hip arthroplasty (seven of eight) than in patients who had had a primary hip (two of eleven) or knee replacement (two of ten). The principal source of wear particles in the majority of these patients involved secondary nonbearing surfaces rather than wear between the two primary bearing surfaces as intended. In one living patient, dissemination of titanium alloy particles from a hip prosthesis with mechanical failure was associated with a visceral granulomatous reaction and hepatosplenomegaly, which required operative and medical treatment. Metallic wear particles were detected in the paraaortic lymph nodes in 68 percent (nineteen) of the twenty-eight patients with an implant from whom lymph nodes were available for study. In 38 percent (eleven) of all twenty-nine patients with an implant who were studied post mortem, metallic particles had been further disseminated to the liver or spleen, where they were usually found within small aggregates of macrophages occurring as infiltrates without apparent pathological importance. Polyethylene particles elicited a similar response. They were identified in the paraaortic lymph nodes of 68 percent (nineteen) of the twenty-eight patients and the liver or spleen of 14 percent (four) of the twenty-nine patients. The majority of the disseminated wear particles were less than one micrometer in size. Currently available methods lack the sensitivity and specificity necessary to detect very low concentrations of submicrometer polyethylene particles and probably underestimated the prevalence of polyethylene wear debris in the liver and spleen. CONCLUSIONS: In this study, systemic distribution of metallic and polyethylene wear particles was a common finding, both in patients with a previously failed implant and in those with a primary total joint prosthesis. The prevalence of particles in the liver or spleen was greater after reconstructions with mechanical failure. (ABSTRACT TRUNCATED)

Fragmentation of an alkali metal-attached peptide probed by collision-induced dissociation fourier transform mass spectrometry and computational methodology.

Collision-induced dissociation of metal-cationized N-CBZ-Gly-Pro-Gly-Pro-Ala was studied by Fourier transform mass spectrometry. Lithium-, sodium-, potassium- and rubidium-cationized peptide species were generated by matrix-assisted laser desorption/ionization (MALDI) using 2,5-dihydroxybenzoic acid as matrix, together with appropriate metal salts. The experimental mass spectrometric results were interpreted with the aid of Monte Carlo conformational searches using the Amber(*) force field, together with ab initio molecular orbital calculations with Gaussian-94 for the singly lithium- and potassium-cationized peptides. It is concluded that metal coordination plays a key role in guiding the gas-phase fragmentation of the cationized peptide. In contrast to lithium and sodium, potassium and rubidium apparently do not coordinate to the C-terminal carbonyl. When the peptide is cationized with the two smaller alkali metals, losses corresponding to alanine and CBZ are observed, while the coordination of potassium and rubidium results in only CBZ loss upon dissociation.

Magnetic resonance imaging of the whole spine in suspected malignant spinal cord compression: impact on management.

Patients with suspected malignant spinal cord compression may present with a misleading sensory level or have multiple levels of compression that are not apparent clinically or on imaging of a limited area of the spine. To estimate how often this occurs and to evaluate a policy of magnetic resonance imaging (MRI) of the whole spine for any patient with suspected cord compression, data from 127 patients who had undergone MRI scans of the whole spine were reviewed. In 85 of 127 scans, there was evidence of compression of or impingement upon the spinal cord. A sensory level was present in 47 of these 85 patients, but in 12/47 (26%) the sensory level was four or more segments below or three or more segments above the actual lesion. Multiple levels of compression or impingement were found in 33 of 85 (39%) patients; in 24 of these, more than one region (cervical/thoracic/lumbar) of the cord was involved. For 32 patients who commenced radiotherapy to a treatment volume based on clinical criteria before the MRI scan was available, the radiotherapy fields needed modification in 16 (50%) as a result of the MRI findings. The results support a policy of MRI of the whole spine in any patient with suspected malignant spinal cord compression.

Eight-week toxicity study of 60 Hz magnetic fields in F344 rats and B6C3F1 mice.

Toxicity studies were performed by exposing F344/N rats and B6C3F1 mice (10 animals per sex per species per group) to transient-free, linearly polarized 60 Hz magnetic fields for 8 weeks. Targeted magnetic fields strengths used were 0 gauss (G; sham control fields did not exceed 0.001 G), 0.02 G, 2 G, and 10 G. Exposure was whole-body and continuous for 18.5 hr per day, 7 days per week. An additional group of rats and mice was exposed intermittently (1 hr on/1 hr off) to 10 G fields for the same period of time. Endpoints evaluated included morbidity, mortality, gross pathology, histopathology, body/organ weights, clinical chemistry (rats only), and hematology (rats only). All mice and all male rats survived until the end of the study. One female rat (2-G exposure group) died during Week 7 of the study; the death was not attributed to magnetic field exposure. In both studies, the mean body weight gains of exposed animals were similar to those of the respective controls. There were no gross, histological, hematological, or biochemical lesions attributed to magnetic field exposure. Statistically significant increases in liver weight and liver to body weight ratio occurred in female rats of all exposure groups but only at the termination. These data suggest that, for the variables evaluated in these studies, an 8-week exposure to linear-polarized, transient-free 60 Hz magnetic fields at field intensities of up to 10 G is not associated with significant toxicity in F344/N rats and B6C3F1 mice. Furthermore, there was no toxicity observed in animals receiving intermittent (1 hr on/1 hr off) exposures to 10-G fields. A 2-year study in F344/N rats and B6C3F1 mice is nearing completion of the in-life phase without overt toxicity in any exposed group. It is premature, however, to make any prediction concerning the possible influence of exposure to 60 Hz magnetic fields on cancer rates.

Prognostic indicators for intrauterine insemination (IUI): statistical model for IUI success.

A retrospective analysis of 260 completed intrauterine insemination (IUI) cycles was used in an attempt to identify significant variables predictive of treatment success. Couples received a maximum of three IUI cycles for the treatment of anovulation, cervical factors or unexplained infertility. Male factor problems were largely excluded by pretreatment screening. The overall pregnancy rate was 19.6% per completed cycle, the miscarriage rate 15.6%, the multiple pregnancy rate 23.5% and the cancellation rate 19%. Logistic regression identified four significant IUI variables [follicle number (P < 0.005), endometrial thickness (P < 0.005), duration of infertility (P < 0.01) and progressive motility (P < 0.05)] which were the most predictive of IUI success. The chance of conceiving when only one follicle was produced was only 7.6%, whereas with two follicles this chance increased to 26%. These variables were incorporated into a statistical model to allow the prediction of the chance of success in subsequent cycles. We conclude that careful patient selection criteria coupled with successful ovarian stimulation is the model for IUI success.

Applications of multidimensional-gas chromatography-mass spectrometry and gas chromatography-Fourier transform infrared-mass spectrometry.

Gas chromatography systems with coupled columns in a multidimensional (MD) mode have become more important for the analysis of complex mixtures, due to the increased selectivity that can be achieved by the use of multiple columns with differing stationary phases. Coupling two or more detectors can also help to increase the information content of the analysis. This review presents the various strategies used in multidimensional gas chromatography (MDGC), with Fourier transform infrared (FT-IR) and/or mass spectrometric (MS) detection, with an emphasis on applications of these techniques for analysis of components in complex matrices. © 1997 John Wiley & Sons, Inc.

Plasma mass spectrometry as a detector for chemical speciation studies.

Inductively coupled plasma mass spectrometry (ICP-MS), when coupled with the unique separating power of various chromatographic techniques, allows the detection of various elements at ultra-trace levels. The investigation of various toxic elements of environmental concern coupling relatively recent techniques, such as supercritical fluid chromatography (SFC) and capillary zone electrophoresis (CZE), to ICP-MS, is discussed. Comparisons have been made with detection limits obtained by using the flame ionization detector. The conventional technique of liquid chromatography for the speciation of vanadium, chromium and nickel is also discussed.

Prospective study of leukocytes and leukocyte subpopulations in semen suggests they are not a cause of male infertility.

OBJECTIVE: To determine the effects of leukocytes in semen on sperm quality and the ability to achieve conception. DESIGN: A prospective analysis of 512 couples attending a regional infertility clinic. Leukocyte subsets were quantified using a monoclonal antibody-based staining procedure. In addition to basic seminal parameters (density, motility, morphology, and antisperm antibodies), reactive oxygen species and immature germ cells were also quantified in the semen of each patient. The presence or absence of a treatment-independent conception was determined 22 months after the start of the study. Semen parameters were then related to the ability to conceive. SETTING: University-based center for reproductive medicine. PARTICIPANTS: Success or failure to conceive was recorded from 512 couples. Couples were then selected to minimize the influence of any pathology of the female on outcome. A final study group of 229 couples, in which the women had regular menstrual cycles, ovulatory midluteal serum P levels of > 18 nmol/L, and patent fallopian tubes was finally selected for analysis. MAIN OUTCOME MEASURE: Pregnancy. RESULTS: Leukocyte concentration (total or individual subsets) was not associated with either reduced semen quality or conception rates. Similarly, neither reactive oxygen species or antisperm antibody (immunobead) concentration had any bearing on the outcome. Of all semen parameters measured, only the level of immature germ cells was found to be negatively associated with the rate of conception. CONCLUSION: Measurement of seminal leukocytes in routine semen analysis appears to be of little prognostic value with regard to male fertilizing potential. As reactive oxygen species and antisperm measurement were of similar predictive value, the term "immunologic male infertility" should be redefined.

Prognostic significance of computerized motility analysis for in vivo fertility.

OBJECTIVE: To determine the predictive value of quantitative motility characteristics produced by the Hamilton Thorn Motility (HTM) Analyzer (Hamilton Thorn Research, Beverley, MA) for in vivo conception. DESIGN: A prospective analysis of 222 couples attending a regional infertility clinic. The measurements were made on a semen sample, and the presence or absence of a treatment-independent conception up to 22 months later was determined. The semen variables were then correlated to conception. SETTING: University based center for reproductive medicine. PATIENTS, PARTICIPANTS: The presence or absence of an in vivo conception was recorded in 222 couples in whom the influence on fertility of the female partner was minimized, i.e., normal in terms of history and examination, a regular menstrual cycle, ovulatory (midluteal serum P > 18 nmol/L [5.6 ng/mL]), and the outcome of the hysterosalpingogram was normal. The median follow-up time was 13 months (range, 5 to 22 months). INTERVENTIONS: None. MAIN OUTCOME MEASURE: Pregnancy. RESULTS: A number of variables were significantly related to time to conception. When a forward stepwise analysis was performed, the total number of spermatozoa was selected on the first step, and average path velocity was selected on the second step. No other variables were selected. The final variables consisted of the total number of spermatozoa and average path velocity. CONCLUSION: The measurement of quantitative motility and sperm number using a HTM Analyser is of clinical value.