- Email: [email protected]
Site of semen collection and its effect on semen analysis parameters
Site of semen collection and its effect on semen analysis parameters Rashmi Shetty Licht, M.D., LiAnn Handel, M.D., and Mark Sigman, M.D. Department of Urology, Brown Medical School, Providence, Rhode Island
Objective: To determine whether the site of semen collection affects semen parameters by comparing semen samples collected at home with those collected in the office. Design: Prospective cohort study. Setting: An academic research environment. Patient(s): Men collecting semen samples both at home and in the office, either for a workup for infertility or for use in intrauterine insemination. Intervention(s): Semen analysis performed on all specimens, evaluating sperm count, sperm motility, total count, and total motile count. Main Outcome Measure(s): Semen analysis parameters. Result(s): There was no statistically significant difference in sperm count, sperm motility, total count, or total motile count between those samples collected at home vs. those collected in the office in either group of patients. Conclusion(s): The site of semen collection, whether at home vs. in the office, does not have a clinically significant effect on semen analysis parameters. (Fertil Steril 2008;89:395–7. 2008 by American Society for Reproductive Medicine.) Key Words: Semen collection, semen analysis, site semen collection
Many centers require patients to collect semen samples in an office setting, whereas others allow for semen collection, either at home or in the office. To our knowledge, there has never been a study to determine whether one site yields superior semen parameters than the other, and therefore there is currently no standard preference or protocol for the site of semen collection. This study determines whether the site of semen collection affects semen parameters. The World Health Organization recommends that ideally, the male patient should collect semen in a private room close to the laboratory (1). This recommendation is not based on comparative studies but may originate from a concern that semen quality may be compromised when collection occurs at home, whether the samples are for fertility evaluation or intrauterine insemination (IUI). This is because there is more of an opportunity for longer transit time and exposure to extreme temperatures. It has been proven that in raw semen, sperm motility declines over a number of hours, leading to recommendations that semen samples be processed or examined within 1 to 2 hours of collection (2). Exposure to extreme temperatures (>40 C and <20 C) also negatively affects motility (3). In addition, there is a concern that sperm function may decline over time, and thus samples for insemination should be collected in the office and processed promptly to separate spermatozoa from the seminal plasma. However, there is no clinical data to prove that this is actually necessary. Received July 10, 2006; revised and accepted February 21, 2007. Correspondence to: Rashmi Shetty Licht, M.D., Department of Urology, Brown Medical School, 2 Dudley Street, Rhode Island Hospital, Suite 174, Providence, Rhode Island 02906 (E-mail: rashmishetty17@yahoo. com).
0015-0282/08/$34.00 doi:10.1016/j.fertnstert.2007.02.033
In accordance with World Health Organization recommendations (1), patients are usually instructed to bring specimens collected at home to the laboratory within 1 hour of collection. They are also told to protect the semen sample from extremes of temperature. For example, we recommend having patients place the container in a pocket next to the body or in the waistband of their pants. It is hoped that adherence to these instructions will prevent the development of a significant difference between semen analysis parameters of samples collected at home vs. in the office. This study attempts to determine whether the site of collection has an effect on semen parameters. MATERIALS AND METHODS The study design was a prospective cohort study of two groups of patients: those who had collected semen during a workup for infertility and those who had collected semen for IUI. Patients were included in a group only if they had collected samples both at home and in the office. All patients were given instructions for the collection of semen and were given the option of collecting at home versus in the office. In each group, all patients had at least one semen sample collected at home and at least one semen sample from an office collection. If there was more than one collection at a certain site, the semen analysis parameters were pooled and averaged for each individual. All individuals were instructed to collect semen into a sterile container after 2 to 3 days of abstinence. The samples collected in the office were collected by masturbation alone. Although most of those men who collected at home did so through masturbation, patients who were unable to collect by masturbation were allowed to collect by interrupted coitus. If collecting at home, the semen
Fertility and Sterility Vol. 89, No. 2, February 2008 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.
395
had to be brought to the laboratory within 1 and one half hours of collection if for diagnostic evaluation and within 30 minutes if for IUI. For those samples transported from home, patients were instructed to place the container in a pocket or in the waistband of their pants. Office collection was conducted in a private room adjacent to the andrology laboratory. Once received, samples were immediately placed in a 37 C incubator until evaluation. Only samples with an abstinence period of 2 to 3 days were included. Samples were examined within 2 hours of collection. Standard semen parameters were recorded, including seminal volume, sperm density, motility, forward progression, and morphology. Sperm density was determined manually with the use of a Makler chamber (Sefi Medical Instruments Ltd, Haifa, Israel). Manual assessment of sperm motility was performed and morphology was scored by using strict criteria, both following the 1999 World Health Organization guidelines. Morphology was not scored on samples intended for IUI. The semen parameters of those samples collected at home were compared with those collected in the office to determine whether there was a statistically significant difference. Differences between means of normally distributed data were evaluated by using Student’s paired t-test. Sperm density, total sperm count, and total motile sperm count were log-transformed to normalize the data distribution. The means of the log-transformed data were evaluated by using Student’s ttest. A statistically significant difference was defined as P<.05. The study was approved by the hospital’s institutional review board. RESULTS The study populations consisted of 170 patients who were being evaluated for infertility (diagnostic group) and 97 who were collecting semen samples for use in IUI. There were
447 semen analyses in the diagnostic group, with 60% of patients having two semen analyses and 40% having three or more semen analyses. In the IUI group, there were 600 semen analyses, with 43% of patients having two semen analyses and 57% of patients having three or more semen analyses. The distribution of the numbers of semen analyses per patient at each site was not statistically significantly different in either the diagnostic group or the IUI group (P>.05). In the diagnostic group, 68% of samples collected at home were analyzed within 1 hour of collection, whereas 96% of those collected in the office were analyzed within 1 hour. In the IUI group, 97% of samples collected at home were analyzed within 1 hour, whereas all samples collected in the office were analyzed within that time frame. The data for the infertility workup group were analyzed separately from those of the IUI group of patients. The semen parameters of both groups are presented in Table 1. The infertility group comparison revealed no statistical difference between sperm count, sperm motility, total sperm count, total motile sperm count, or sperm morphology. Of note, there was a statistically significant difference in semen volume. This statistical significance, however, is likely to be of no clinical significance because the mean difference between the two volumes was only 0.27 mL (mean home semen volume, 2.82 mL vs. mean office semen volume, 3.09 mL). In the IUI group, there was no statistically significant difference between any of the parameters when comparing semen collection at home with that performed in the office. DISCUSSION Although some infertility centers require in-office collection because of concerns about inadequate collection technique and specimen transit time, to our knowledge, there has never been a study to compare semen analysis parameters when
TABLE 1 Comparison of semen analysis parameters at home vs. in the office for two patient groups.
Site of collection
Semen volume (mL)
Sperm concentration (millions per mL)
Patients collecting for infertility workup Home 2.82 (1.45) 37.5 (17.9–67.3) Office 3.09 (1.56) 38.5 (21.8–70.0) P value .0036 .9364 Patients collecting for IUI Home 2.76 (1.30) 66.0 (41.3–96.5) Office 2.66 (1.17) 61.9 (41.5–79.1) P value .2094 .1043
Total count (millions)
Sperm motility (%)
Total motile count (millions)
Sperm morphology (%)
98.1 (40.0–192.0) 50.8 (15.6) 43.3 (16.1–106.3) 4.69 (3.36) 113.6 (51.3–207.2) 51.1 (15.5) 53.1 (20.6–116.2) 4.43 (2.91) .0951 .7363 .0929 .0624 158.0 (83.6–255.1) 60.9 (9.71) 93.7 (52.3–164.6) 135.5 (92.6–199.5) 60.5 (10.2) 85.8 (50.8–122.6) .1354 .5681 .1266
Note: Means are presented with SDs, whereas medians of nonnormally distributed data are presented with 25%–75% quartile ranges. Shetty Licht. Site of semen collection and its effect on semen analysis parameters. Fertil Steril 2008.
396
Shetty Licht et al.
Site of semen collection and its effect on semen analysis parameters
Vol. 89, No. 2, February 2008
collection was conducted at home vs. in the office. This study compared semen specimens collected at home and at the office for each patient, thereby making the comparison selfcontrolled. Although there can be variability in a patient’s semen over time, self-control is the best method for comparing sites of collection, because two separate and different patient groups would have even more variability among individuals, which would most likely not be attributable to just the site of collection. Patients were allowed to choose the site of collection. The patients in this study voluntarily collected specimens, both at home and in the office. Other patients who collected only at home or only in the office were excluded, to allow for a paired study design that used patients as their own controls. Thus, it is possible that for some patients, forcing them to collect at a certain site may have affected the semen parameters. This could not be evaluated in the current study. A potential source of bias stems from the possibility that some men in this study may have collected by interrupted sexual intercourse when collecting samples at home. Patients were instructed to collect by coitus interruptus only if they could not collect by masturbation. Because all patients collected in the office (by masturbation), this is unlikely to be a significant issue for this patient population. Patients who could not collect by masturbation would not have collected in the office and therefore would have been excluded from this study. This study also did not determine whether site of collection affected pregnancy rates. Delay in processing may affect sperm function, and thus pregnancy rate, without affecting semen parameters. Yavas and Selub (4) found that semen collection in the office rather than at home re-
Fertility and Sterility
sulted in higher pregnancy rates in IUI couples in those women who were treated with hMG. Although the study concluded that office collection resulted in higher pregnancy rates in women using hMG and that the office thus should be the preferred site of collection, there are many factors that prevent making this a reliable conclusion. It is important to note that this research did not have crossover patients and therefore was not self-controlled. Also of note, there was no statistically significant difference in pregnancy rates between semen collection in the office vs. at home in IUI couples when the women were receiving clomiphene citrate. Further studies are needed to determine definitively whether a delay in processing, such as home collection, affects pregnancy rates. In conclusion, the site of semen collection, whether at home or in the office, does not have a significant effect on semen analysis parameters. It is imperative to review semen collection instructions with each patient to ensure that proper collection and transportation guidelines are followed. Patients should be allowed to choose the site of collection without concern for an effect on semen parameters. REFERENCES 1. World Health Organization. WHO laboratory manual for the examination of human semen and sperm-cervical mucus interaction. 4th ed. New York: Cambridge University Press, 1999. 2. Appell RA, Evans PR, Blandy JP. The effect of temperature on the motility and viability of sperm. Br J Urol 1977;49:751–6. 3. Appell RA, Evans PR. The effect of temperature on sperm motility II. Is bacterial growth a factor? Fertil Steril 1978;30:436–8. 4. Yavas Y, Selub MR. Intrauterine insemination (IUI) pregnancy outcome is enhanced by shorter intervals from semen collection to sperm wash, from sperm wash to IUI time, and from semen collection to IUI time. Fertil Steril 2004;82:1638–47.
397
Objective: To determine whether the site of semen collection affects semen parameters by comparing semen samples collected at home with those collected in the office. Design: Prospective cohort study. Setting: An academic research environment. Patient(s): Men collecting semen samples both at home and in the office, either for a workup for infertility or for use in intrauterine insemination. Intervention(s): Semen analysis performed on all specimens, evaluating sperm count, sperm motility, total count, and total motile count. Main Outcome Measure(s): Semen analysis parameters. Result(s): There was no statistically significant difference in sperm count, sperm motility, total count, or total motile count between those samples collected at home vs. those collected in the office in either group of patients. Conclusion(s): The site of semen collection, whether at home vs. in the office, does not have a clinically significant effect on semen analysis parameters. (Fertil Steril 2008;89:395–7. 2008 by American Society for Reproductive Medicine.) Key Words: Semen collection, semen analysis, site semen collection
Many centers require patients to collect semen samples in an office setting, whereas others allow for semen collection, either at home or in the office. To our knowledge, there has never been a study to determine whether one site yields superior semen parameters than the other, and therefore there is currently no standard preference or protocol for the site of semen collection. This study determines whether the site of semen collection affects semen parameters. The World Health Organization recommends that ideally, the male patient should collect semen in a private room close to the laboratory (1). This recommendation is not based on comparative studies but may originate from a concern that semen quality may be compromised when collection occurs at home, whether the samples are for fertility evaluation or intrauterine insemination (IUI). This is because there is more of an opportunity for longer transit time and exposure to extreme temperatures. It has been proven that in raw semen, sperm motility declines over a number of hours, leading to recommendations that semen samples be processed or examined within 1 to 2 hours of collection (2). Exposure to extreme temperatures (>40 C and <20 C) also negatively affects motility (3). In addition, there is a concern that sperm function may decline over time, and thus samples for insemination should be collected in the office and processed promptly to separate spermatozoa from the seminal plasma. However, there is no clinical data to prove that this is actually necessary. Received July 10, 2006; revised and accepted February 21, 2007. Correspondence to: Rashmi Shetty Licht, M.D., Department of Urology, Brown Medical School, 2 Dudley Street, Rhode Island Hospital, Suite 174, Providence, Rhode Island 02906 (E-mail: rashmishetty17@yahoo. com).
0015-0282/08/$34.00 doi:10.1016/j.fertnstert.2007.02.033
In accordance with World Health Organization recommendations (1), patients are usually instructed to bring specimens collected at home to the laboratory within 1 hour of collection. They are also told to protect the semen sample from extremes of temperature. For example, we recommend having patients place the container in a pocket next to the body or in the waistband of their pants. It is hoped that adherence to these instructions will prevent the development of a significant difference between semen analysis parameters of samples collected at home vs. in the office. This study attempts to determine whether the site of collection has an effect on semen parameters. MATERIALS AND METHODS The study design was a prospective cohort study of two groups of patients: those who had collected semen during a workup for infertility and those who had collected semen for IUI. Patients were included in a group only if they had collected samples both at home and in the office. All patients were given instructions for the collection of semen and were given the option of collecting at home versus in the office. In each group, all patients had at least one semen sample collected at home and at least one semen sample from an office collection. If there was more than one collection at a certain site, the semen analysis parameters were pooled and averaged for each individual. All individuals were instructed to collect semen into a sterile container after 2 to 3 days of abstinence. The samples collected in the office were collected by masturbation alone. Although most of those men who collected at home did so through masturbation, patients who were unable to collect by masturbation were allowed to collect by interrupted coitus. If collecting at home, the semen
Fertility and Sterility Vol. 89, No. 2, February 2008 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.
395
had to be brought to the laboratory within 1 and one half hours of collection if for diagnostic evaluation and within 30 minutes if for IUI. For those samples transported from home, patients were instructed to place the container in a pocket or in the waistband of their pants. Office collection was conducted in a private room adjacent to the andrology laboratory. Once received, samples were immediately placed in a 37 C incubator until evaluation. Only samples with an abstinence period of 2 to 3 days were included. Samples were examined within 2 hours of collection. Standard semen parameters were recorded, including seminal volume, sperm density, motility, forward progression, and morphology. Sperm density was determined manually with the use of a Makler chamber (Sefi Medical Instruments Ltd, Haifa, Israel). Manual assessment of sperm motility was performed and morphology was scored by using strict criteria, both following the 1999 World Health Organization guidelines. Morphology was not scored on samples intended for IUI. The semen parameters of those samples collected at home were compared with those collected in the office to determine whether there was a statistically significant difference. Differences between means of normally distributed data were evaluated by using Student’s paired t-test. Sperm density, total sperm count, and total motile sperm count were log-transformed to normalize the data distribution. The means of the log-transformed data were evaluated by using Student’s ttest. A statistically significant difference was defined as P<.05. The study was approved by the hospital’s institutional review board. RESULTS The study populations consisted of 170 patients who were being evaluated for infertility (diagnostic group) and 97 who were collecting semen samples for use in IUI. There were
447 semen analyses in the diagnostic group, with 60% of patients having two semen analyses and 40% having three or more semen analyses. In the IUI group, there were 600 semen analyses, with 43% of patients having two semen analyses and 57% of patients having three or more semen analyses. The distribution of the numbers of semen analyses per patient at each site was not statistically significantly different in either the diagnostic group or the IUI group (P>.05). In the diagnostic group, 68% of samples collected at home were analyzed within 1 hour of collection, whereas 96% of those collected in the office were analyzed within 1 hour. In the IUI group, 97% of samples collected at home were analyzed within 1 hour, whereas all samples collected in the office were analyzed within that time frame. The data for the infertility workup group were analyzed separately from those of the IUI group of patients. The semen parameters of both groups are presented in Table 1. The infertility group comparison revealed no statistical difference between sperm count, sperm motility, total sperm count, total motile sperm count, or sperm morphology. Of note, there was a statistically significant difference in semen volume. This statistical significance, however, is likely to be of no clinical significance because the mean difference between the two volumes was only 0.27 mL (mean home semen volume, 2.82 mL vs. mean office semen volume, 3.09 mL). In the IUI group, there was no statistically significant difference between any of the parameters when comparing semen collection at home with that performed in the office. DISCUSSION Although some infertility centers require in-office collection because of concerns about inadequate collection technique and specimen transit time, to our knowledge, there has never been a study to compare semen analysis parameters when
TABLE 1 Comparison of semen analysis parameters at home vs. in the office for two patient groups.
Site of collection
Semen volume (mL)
Sperm concentration (millions per mL)
Patients collecting for infertility workup Home 2.82 (1.45) 37.5 (17.9–67.3) Office 3.09 (1.56) 38.5 (21.8–70.0) P value .0036 .9364 Patients collecting for IUI Home 2.76 (1.30) 66.0 (41.3–96.5) Office 2.66 (1.17) 61.9 (41.5–79.1) P value .2094 .1043
Total count (millions)
Sperm motility (%)
Total motile count (millions)
Sperm morphology (%)
98.1 (40.0–192.0) 50.8 (15.6) 43.3 (16.1–106.3) 4.69 (3.36) 113.6 (51.3–207.2) 51.1 (15.5) 53.1 (20.6–116.2) 4.43 (2.91) .0951 .7363 .0929 .0624 158.0 (83.6–255.1) 60.9 (9.71) 93.7 (52.3–164.6) 135.5 (92.6–199.5) 60.5 (10.2) 85.8 (50.8–122.6) .1354 .5681 .1266
Note: Means are presented with SDs, whereas medians of nonnormally distributed data are presented with 25%–75% quartile ranges. Shetty Licht. Site of semen collection and its effect on semen analysis parameters. Fertil Steril 2008.
396
Shetty Licht et al.
Site of semen collection and its effect on semen analysis parameters
Vol. 89, No. 2, February 2008
collection was conducted at home vs. in the office. This study compared semen specimens collected at home and at the office for each patient, thereby making the comparison selfcontrolled. Although there can be variability in a patient’s semen over time, self-control is the best method for comparing sites of collection, because two separate and different patient groups would have even more variability among individuals, which would most likely not be attributable to just the site of collection. Patients were allowed to choose the site of collection. The patients in this study voluntarily collected specimens, both at home and in the office. Other patients who collected only at home or only in the office were excluded, to allow for a paired study design that used patients as their own controls. Thus, it is possible that for some patients, forcing them to collect at a certain site may have affected the semen parameters. This could not be evaluated in the current study. A potential source of bias stems from the possibility that some men in this study may have collected by interrupted sexual intercourse when collecting samples at home. Patients were instructed to collect by coitus interruptus only if they could not collect by masturbation. Because all patients collected in the office (by masturbation), this is unlikely to be a significant issue for this patient population. Patients who could not collect by masturbation would not have collected in the office and therefore would have been excluded from this study. This study also did not determine whether site of collection affected pregnancy rates. Delay in processing may affect sperm function, and thus pregnancy rate, without affecting semen parameters. Yavas and Selub (4) found that semen collection in the office rather than at home re-
Fertility and Sterility
sulted in higher pregnancy rates in IUI couples in those women who were treated with hMG. Although the study concluded that office collection resulted in higher pregnancy rates in women using hMG and that the office thus should be the preferred site of collection, there are many factors that prevent making this a reliable conclusion. It is important to note that this research did not have crossover patients and therefore was not self-controlled. Also of note, there was no statistically significant difference in pregnancy rates between semen collection in the office vs. at home in IUI couples when the women were receiving clomiphene citrate. Further studies are needed to determine definitively whether a delay in processing, such as home collection, affects pregnancy rates. In conclusion, the site of semen collection, whether at home or in the office, does not have a significant effect on semen analysis parameters. It is imperative to review semen collection instructions with each patient to ensure that proper collection and transportation guidelines are followed. Patients should be allowed to choose the site of collection without concern for an effect on semen parameters. REFERENCES 1. World Health Organization. WHO laboratory manual for the examination of human semen and sperm-cervical mucus interaction. 4th ed. New York: Cambridge University Press, 1999. 2. Appell RA, Evans PR, Blandy JP. The effect of temperature on the motility and viability of sperm. Br J Urol 1977;49:751–6. 3. Appell RA, Evans PR. The effect of temperature on sperm motility II. Is bacterial growth a factor? Fertil Steril 1978;30:436–8. 4. Yavas Y, Selub MR. Intrauterine insemination (IUI) pregnancy outcome is enhanced by shorter intervals from semen collection to sperm wash, from sperm wash to IUI time, and from semen collection to IUI time. Fertil Steril 2004;82:1638–47.
397