Semen analysis WHO ys 5 th edition: 2010 Lower reference limits (5th centiles and their 95% confidence intervals) Pregnancy during 12m Other groups No guarantee

Motility 4A 3B 2C 1D

A>25% A+B>50% Systematic (manual method) : Grade a → rapid progressive motility ( ≥25 µm/s at 37 0C ) Grade b → slow progressive motility ( 5-25µm/s at 37 0 C) Grade c → non progressive motility (<5 µm/s ) Grade d → immotile

Motility Progressive motility (PR) Non-Progressive motility (NP) Immotile (IM)

Sperm morphology classification systems Normal reference range 1) Macleod >60% 2) WHO manual 2nd edition >50% 3) WHO manual 3rd edition >30% 4) ASCP (American society clinical pathology ) >80% 5) Strict (menkveld & kruger ) / WHO manual 4th edition >14% 6) WHO 2010 >4%

Lower reference limits (5th centiles and their 95% confidence intervals) for semen characteristics. Lower reference limitParameter 1.5 (1.4–1.7)Semen volume (mL) 39 (33–46) 40Total sperm number (106 per ej) 15 (12–16) 20Sperm concentration (106 per mL) 40 (38–42)Total motility (PR+NP, %) 32 (31–34)Progressive motility (PR, %) 58 (55–63) 75Vitality (live spermatozoa, %) 4 (3.0–4.0) 14Sperm morphology (normal forms, %) ≥ 7.2pH

DNA Damage/Fragmentation may result from intra- or extra-testicular factors can occur at any step of spermatogenesis may result from aberrant chromatin packaging during spermiogenesis, defective apoptosis before ejaculation or excessive production of reactive oxygen species (ROS) in the ejaculate

Extra testicular factors Drugs, Chemotherapy, RT Cigarette smoking (accumulation of toxic agents including the products of cigarette smoke such as cadmium) Genital tract inflammation,

Varicocele Testicular hyperthermia Androgen deprivation at the testicular level > 40y Testicular tumors Febrile Dis UTI Hormonal factors, (FSH, T)

Environmental Factors Occupational Exposure (chemical, thermal) Cell phone Lap Top, Wi Fi Agriculture, toxins Air Pollution (traffic workers) Heat Smoking

Indications Predicting ART outcome Idiopathic Infertility Men older than 40y Exposure to toxins and chemical agents High risk groups (Testicular tumor, Varicocele, Smoking, alcohol or opium abuse, ) Abortion

Aniline blue Toluidine blue SCSA Commet assay CMA3 Tunel

The effectiveness of IVF in unexplained infertility: a systematic Cochrane review Zabeena Pandian1,3, Siladitya Bhattacharya1, Dimitrios Nikolaou1, Luke Vale2 and Allan Templeton1 1Department of Obstetrics & Gynaecology, Aberdeen Maternity Hospital and 2Health Services Research Unit, University of Human Reproduction Vol.18, No.10 pp. 2001±2007, 2003

There was no signifcant difference in clinical pregnancy rates between IVF and expectant management. There was no evidence of a difference in live birth rates between IVF and IUI either without (OR 1.96, 95% CI 0.88 to 4.36) or with (OR 1.15, 95% CI 0.55 to 2.42) ovarian stimulation. Clinical pregnancy rates with IVF were signifcantly higher compared with GIFT (OR 2.14, 95% CI 1.08 to 4.22) as were the multiple pregnancy rates (OR 6.25, 95% CI 1.70 to 23.00).

CONCLUSIONS : The effectiveness of IVF in unexplained infertility remains unproven. Larger trials with adequate power are warranted.

Male infertility and environmental exposure to lead and cadmium Susan Benoff, Asha Jacob, Ian R.Hurley North Shore University Hospital. New York Human Reproduction Update vol.6, No.2pp

Role of sperm chromatin abnormalities and DNA damage in male infertility A.Agarwal1 and Tamer M.Said Center for Advanced Research in Human Reproduction, Infertility, and Sexual Function, Glickman Urological Institute, The Cleveland Clinic Foundation, Cleveland, Ohio, USA Human Reproduction Update, Vol.9, No.4 pp. 331±345, 2003

Sperm DNA integrity is essential for the accurate transmission of genetic information. Any form of sperm chromatin abnormalities or DNA damage may result in male infertility in-vivo fecundity decreases progressively when >30% of the spermatozoa are identified as having DNA damage.

The clinical signifcance of this assessment lies in its association not only with natural conception rates, but also with assisted reproduction success rates. Also, it has a serious impact on the offspring and is highly prognostic in the assessment of fertility in cancer patients.

Therefore, screening for sperm DNA damage may provide useful information in cases of male idiopathic infertility and in those men pursuing assisted reproduction. Treatment should include methods for prevention of sperm DNA damage.