Pattern of Semen Analysis at Andrology Lab of Bangabandhu Sheikh Mujib Medical University : Findings and the Shortcomings to Overcome .

Background: The Infertility wing dept. of gyne & obst. at BSMMU provides services to the infertile couples who are referred from primary care levels and who cannot afford the expensive private facilities. The semen analysis is performed for the male partners of infertile couples at the Andrology Lab of BSMMU for detecting male factor abnormalities. Objectives: The objectives of the study is to find out the pattern of semen parameters in our population and to find out the frequency and type of abnormal semen parameters. Methods: This is a retrospective descriptive study of the semen analysis performed at the Andrology Lab of BSMMU during the year 2011. A total of 200 consecutive samples were analysed. The procedure and reference values were according to the WHO guidelines 1999. Results: Semen parameters were abnormal in 38.5%o of semen analysis. Severe male factor abnormality (azospermia and severe oligospermia combined) was in 28Vo. Sperm concentration had the highest variability followed by motility and morphology respectively in the normoozospermic males. Conclusion: Severe oligospermia and azospermia are the most common abnormalities among the infertile men presenting at the Infertility unit of BSMMU. It is recommended that the service at the Infertility wing of BSMMU should be more focused on these male factor abnormalities.


Introduction:
Male factor is a major cause of infertility in couples who fail to conceive.Male factor is solely responsible tn 207o of subfertile couples and contributory in another 17 7or .
Semen analysis is the basic and minimum investigation to do for diagnosing male factor.In fact it is the first step towards diagnosis of male factor in fertility work up.
During ejaculation, semen is produced from a concen- trated suspension of spermatozoa stored in paired epididymis mixed with fluid secretion from the accessory sex glands.The total number of spermatozoa reflect sperm production by the testis and the patency of post testicular duct system.The total fluid volume reflects the Address for Correspondence: Dr. Shakeela Ishrat Assistant Professor, Infertility wing, Department of Obstetrics & Gynaecology, BSMMU Cell phone: 017 12989722I, E-mail: shakeelaishrat@ yahoo.comsecretory activity of glands.The nature of spermatozoa (concentration, vitality, motility and morphology ) and the composition of seminal fluid are important for sperm function.
Semen analysis is the study of semen parameters namely volume, pH, sperm count, sperm motility and spenn morphology.Semen analysis is performed in almost all standard pathological laboratories of Bangladesh .Bang- abandhu Sheikh Mujib Medical University (BSMMU) is only public sector center in the country receiving refercal of infertility patients.The Infertility unit of BSMMU has been providing comprehensive diagnostic and therapeutic service (excluding assisted reproductive techniques) to the infertile couples since 2003.The Andrology Lab at the Infertility unit of the Department of Obstetrics and Gynaecology of BSMMU performs the semen analysis of Normal seminal fluid analysis ( World Health the male partners of infertile couples presenting for Organisation ,2002) 2 infertility workup.The methods and the reference values .Volume > 2ml at the Andrology Lab follows the WHO manual for .Sperm concentration > 20million/nrl examination of semen and sperm-cervical mucus .Sperm motility> 507o progressive or > 25Vo rapidly interaction2 (WHO guidelines 1999).The study was based progressive on the reports of semen analysis performed at the Androl-.Morphology ( strict criteri a)> I5Vo normal forms ogy Lab during the year 2011.The objective of the study .White blood cells < 1 million /rnl was to define the pattern of normal semen parameters in .Immunobead or mixed antiglobin reaction testx our infertile patient population and to find out the <ll%o coated frequency of abnormal semen parameters.
*tests for the presence of antibodies coating the sperm Methods t semen analysis terminology 2 The study was a descriptive analysis of the retrospective ' Normozoospermia-all semen parameters normal data collected and compiled at Andrology Lab of ' Oligozoospermia-reduced sperm numbers BSMMU.In the year 20L1, a total of 2288 infemle Mild to moderate : 5-20 million/ ml of semen couples attended the Infertility unit outdoor at BSMMU Severe : < Smillion/rnl of semen for the frst time.With a prevalence of infertility at l|Vo, ' Asthenoozospermia-reduced sperm motility the sample size was estimated to be 192.A total of 200 .Teratoozospermia -Increased abnormal forms of sequential semen analysis was taken for the study.

sperm . Oligoasthenoteratoozospermia-spermvariabls all
Semen analysis in the Andrology Lab of BSMMU follows subnormal the WHO guidelines 1999.The men provided semen for .Azospermia-no sperm is semen analysis after a minimum of 3 days and a maximum of 5 .Aspermia( anejaculation)-no ejaculate (ejaculation days abstinence.The sample was collected in a private failure) room near Andrology Lab.The specimen container was .Leucocytosperrnia-increased white cells in semen kept in room temperature for liquefaction.Liquefaction .Necroozospermia-all sperm are non viable or and appearance of the semen was assessed between 30 nonmotile.and 60 minutes.Semen volume was measured by aspirating the semen into a graduated syringe .The pH of the Descriptive statistical analysis was done using SPSS semen was measured by pH paper.Microscopic examinasoftware version 18. tion of unstained preparation of fresh semen was done for sperm number , motility and morphology using a light Results: microscope in a Makler counting chamber.
A total of 200 reports of semen analysis ( calculated and estimated sample size L92) were taken for the study.The The reference values and terminology used are enumerage of the subjects ,-g'"a from 22-60 years.A total of ated as follows' patients with normospermia semen volume was less than 2 ml.
A11 azospermic patients and those having < 10 sperm per high power field had pH 8. A11 the other semen specimen had pH value 7 .5.
Table I shows the normospermia as well as other abnor- malities causing infertility of the male.Abnormalities were present in 38.57o of the semen analysis.The most common abnormality was azoospermia (17.57o).The Andrology Lab reports lower reference limit of normal morphology as I47o 3 and accordingly teratospermia was 6%o.WHO guidelines 1999 states lower reference value for normal morphology as 307o1 and according to that teratospermia was 287o in our study.
The difference may be attributed to the fact that less severe abnormalities of semen are mostly treated with success at primary level.Difficult cases like azoospermia and severe oligospermia are referred to facilities like BSMMU.
A similar study was carried out 3 years back tn 2OO7 - -2008 in the Infertility unit by Anwary et als .The sample size was only 50.There wa s 4Vo nofinoozospermia, 427o azospermia and LSVo oligospermia.Frequency of azospermia was again the highest as it is now.The only 47o frequency of nofinoozospermia was probably because of inadequate sample size.
The former study by Anwary et als had sperm concentration of 19.43+25.18million/ml, motility 24.04+ 26.457o, normal morphology 21.62+26.157o.Our study has spenn concentration of 69.84t38.26million/ml,, sperm motility 69.51+8 .867o,normal morphology at 27 .56+l.95Vo.The different means and wider standard deviations in the previous study is probably because the statistical analysis included both abnormal and nofinal specimens whereas we included only the normal specimens.
The coefficient of variation in our study was highest with sperm concentration (54.78) followed by motility (L2.75).
It is similar to the findings of a study6 where coefficient of variation between subjects was highest for sperm concentration (187.8)followed by spenn motility (98.7).
The male partner can give semen at any time.For optimum results it is advisable to collect semen after a minimum 3 days abstinence.The semen quality depends on tirne since the last sexual activity.In the absence of ejaculation spermatozoa accumulates in the epididymis , 106 then overflow into the urethra and flushed out in urineT.
The fluids of accessory sex organs dilute the concentrated epididymal spefinatozoa at ejaculations .Spenn concen- tration is not a direct measure of testicular sperm output.
The total number of spenn per ejaculation (sperm concen- tration multiplied by semen volume) is a more accurate assessment of capacrty of testis to produce spefinatozoa and the patency of the male tract.It is recommended to calculate and report the total number of spermatozoa per ejaculatee.For this purpose semen volume has to be meas- ured more accutately.
A11 the azospermic samples and those with <10 sperm/[IPF had pH 8. Semen pH increases with time, so high pH values may provide little clinical useful informa- tion 10.
A major fraction of semen abnormalities in the males attending the Infertility unit of BSMMU is azospermia and severe oligospermia, that are not potentially correct- able.These irreversible conditions are amenable to ART (assisted reproductive techniques) using spenn of male partners or not amenable to ART when adoption or donor insemination is an option.More focused attention should be given on the evaluation and counseling of this group of patients.Since most of the patients will not be able to afford ART, we can offer them urologtcal consultation or surgery when feasible, or we can help them with adoption procedures in collaboration with social welfare personals of the hospital.
The semen analysis at Andrology Lab of Infertility unit of BSMMU still follows the WHO 1999 guidelines.There has been recent guidelines in the WHO Laborutory Manual for the examination and processing of human semen 5th edition published by WHO in 2OIO.
According to the recent WHO manual the volume is best measured by collecting the sample in a wide mouth gradu- ated measuring cylinder or by weighing the sample and then calculating the volume13.
The recent WHO manual recommends the use of phase contrast microi.opyfor semen analysis.It says that count- ing should be done in a Neuber counting chamber.The semen dilution and the areas of the counting chamber has been changed to allow 200 spennatozoa to be counted per replication '6.
The Andrology Lab reports motility as rapid linear, slow linear, nonprogressive and immotile.The present edition of WHO laboratory manual for examination and process- ing of human semen recommends that spermatozoa should be categonzed as progressively motile, non progressively motile and immotile 17.
The reference ranges and the reference limits of WHO manual 2010 are derived from data from between  semen samples of recent fathers in eight coun- tries on three continentslS. Lower reerence limit for semen volume is 1.5 ml (5th centile,957o Cl I.4-1.7)".
The lower reference limit for total motility (PR+NP) is 407o (5'h centile 957o CI 3 8-42).The lower reference limit for progressive motility ( 5* centile 95Vo CI) is 32Vo20.According to these reference limits the frequencies of oligospermia and asthenospermia would have been lower.

Conclusion :
The study reveals that severe oligospermia and azospermia are the most cofilmon abnormalities among the infertile men presenting at the Infertility unit of BSMMU.Services at this centre should take this into account and should be more oriented towards helping this group of patients.The semen analysis procedure and the reporting system presently practiced at the Andrology Lab of BSMMU, should be updated according to the WHO manual2010.Earlier the changes are made, better will be the quality of service.

Table - I
N ormoozo spermia and other abnormalitie s

Table - II
Semen of normoozospermic males: dffirent parameters