The troubling state of the semen analysis

Field: Medicine (Health Sciences)

In an accompanying manuscript in this issue of Andrology, Tomlinson states that, '…diagnostic semen analysis has no more clinical value today than it had 25–30 years ago' (Tomlinson, 2016). In fact, some may argue that it has less clinical value than 25–30 years ago, and many andrologists would agree that there is an increasing skepticism about the clinical value of the semen analysis. This skepticism is likely the result of multiple factors, including changes in the practice of reproductive medicine stimulated by the advances of assisted reproduction therapies (ART) and associated financial decisions that have generally lead to less focus on underlying pathology and etiology of male infertility, leading to a spiral of associated financial decisions in the practice of reproductive medicine in many countries, including less governmental funding because of the false perception of diminished importance of research investigating human spermatogenesis and altered semen quality. Additionally, a greater awareness of the need for evidence-based data with a concomitant dearth of well-controlled outcome data regarding semen quality has lead to greater skepticism about the value of the semen analysis. Lastly, changes in the practice of the semen analysis itself have paradoxically resulted in more confusion, misunderstanding, and frustration instead of quality improvement. While these influences are generally well intentioned, it appears that unintended consequences may have in fact harmed the perceived or real utility of the semen analysis. In this issue of Andrology, two manuscripts address the current state of the semen analysis. In the first article, Tomlinson details the many components of semen analysis that introduce uncertainty to the reported results, and argues that 'adherence to guidelines…does not guarantee a reliable and reproducible test result' (Tomlinson, 2016). In the second article, Bjorndahl counters with the opinion that 'compliance with these recommendations has been in general mediocre', and calls for better involvement of accreditation agencies and journals in assuring that laboratories are in fact complying with the protocols of their reported methodology (Bjorndahl, 2016). These two papers differ in their assessment of the major underlying defects of current semen analysis, but both provide important insights into the problems and possible solutions needed to improve the semen analysis. We generally agree with many issues raised in these two opinion papers and would suggest the following ideas as a beginning to improving the perceived and actual utility of the semen analysis. Perhaps, the first step is to address if there is a role for the semen analysis beyond a qualitative (low complexity) analysis. The bar has been set very low by an increasing number of in vitro fertilization (IVF) clinics and their 'andrology laboratories' who simply grossly assess whether there are a suitable number of spermatozoa available for intracytoplasmic sperm injection (ICSI), as opposed to a quantitative (high-complexity) semen analysis that drives clinical decision-making to using ICSI (Palermo et al., 2015). This question reflects the poor perception of the semen analysis by many clinicians, largely because of the lack of many basic studies that should have been performed long ago and, in many cases, still have not been performed. The critical second question is if we (andrologists) can do better? Tomlinson highlights the myriad of pre-analytical, analytical, and post-analytical variables that can influence the accuracy of the semen analysis. While progress has been made in controlling for many of these variables at most accredited Andrology laboratories, it is painfully obvious to many educated observers that the purported compliance efforts and subsequent benefits may sometimes be less than advertised. It seems evident that because of the complexity in performing a semen analysis, there is a large potential for improvement. The third critical question is how to proceed in improving the quality and utility of the semen analysis. While some of the underlying factors are external to the analysis itself, it is clear that each of the factors contributing to the downward slide of the clinical utility of the semen analysis must be identified and rectified. The following suggestions are offered as possible first steps for improving semen analysis. We strongly advocate that the semen analysis is beneficial and necessary for addressing many clinical questions, including the assessment of the probability of obtaining a pregnancy naturally or with alternative therapies to ART, addressing underlying medical abnormalities causative of reduced fecundity, and potentially, as recent studies have indicated, in addressing potential long-term health issues of the subfertile male. Currently, andrologists are divided and fractionated in published opinion and practice as to what method and/or equipment to use for any given test, the best example being morphology. This leaves the field without structure and, in consequence, dysfunction. For our field to do better, we need a common starting place that is strictly adhered to that can facilitate evidence-based test changes to evaluate for clinical utility and quality improvement. If our field is to advance, those considered as 'expert' in the field must lead by example, in consensus and accord.