A survey on the status of semen analysis in 118 laboratories in China

Collecting baseline information on how laboratories perform testing is a reasonable first step towards establishing intra- and inter-laboratory standardization and quality control for semen analysis. We carried out a survey of the laboratories performing the testing in China's Mainland. A questionnaire, composed of 36 questions covering all aspects of semen analysis, was designed, and a copy was distributed to each of the 145 laboratories. Of these, 118 laboratories completed the questionnaires. The survey results showed that semen volume was measured visually in 53.6% （59/110） of the responding laboratories, and 70.9% （73/103） of laboratories analysed incompletely liquefied semen without any treatment. In addition, both manual-microscopic and computer-assisted semen-analysis systems were applied to analyse sperm concentration, motility and morphology. However, more than five methods were employed in routine sperm staining. An enzyme-linked immunosorbent assay was commonly used for determining whether antisperm antibodies were present. Several seminal biochemical markers were analysed in only 27.1% （32/118） of the responding laboratories. Generally, there was a lack of intra- and inter-laboratory quality control measures for semen analysis in all laboratories responding to this survey. In conclusion, the methods of semen analysis and the interpretation of test results in the surveyed laboratories differed markedly. In particular, many laboratories employed methods other than those recommended by the World Health Organization Laboratory Manual for the Examination of Human Semen and Sperm- cervical Mucus Interaction （1999）. These findings suggest an urgent need for the standardization of semen analysis with acceptable quality controls for each parameter to make the results repeatable and meaningful.

Practical semen analysis： from A to Z

Accurate semen analysis is critical for decisions about patient care, as well as for studies addressing overall changes in semen quality, contraceptive efficacy and effects of toxicant exposure. The standardization of semen analysis is very difficult for many reasons, including the use of subjective techniques with no standards for comparison, poor technician training, problems with proficiency testing and a reluctance to change techniques. The World Health Organization （WHO） Semen handbook （2010） offers a vastly improved set of standardized procedures, all at a level of detail that will preclude most misinterpretations. However, there is a limit to what can be learned from words and pictures alone. A WHO- produced DVD that offers complete demonstrations of each technique along with quality assurance standards for motility, morphology and concentration assessments would enhance the effectiveness of the manual. However, neither the manual nor a DVD will help unless there is general acknowledgement of the critical need to standardize techniques and rigorously pursue quality control to ensure that laboratories actually perform techniques ＇according to WHO＇ instead of merely reporting that they have done so. Unless improvements are made, patient results will continue to be compromised and comparison between studies and laboratories will have limited merit.

Semen analysis in 21st century medicine： the need for sperm function testing

Sperm function testing, once commonly performed for the infertile couple before employing assisted reproductive technology （ART）, has fallen out of favour in many reproductive medicine centers throughout the world. Indeed, the most recent addition of the ＇World Health Organisation （WHO） Laboratory Manual for the Examination and Processing of Hu- man Semen＇ now groups many of these procedures into a section termed Research Procedures. In large part, this reflects the current clinical practice of bypassing the in-depth evaluation of the male partner, while assuming that if a spermatozoon can be found for intracytoplasmic sperm injection （ICSI）, it must be a healthy cell capable of achieving fertilization. Never- theless, sperm function testing can provide valuable clinical insights into defects causing male infertility. Admittedly, in some cases, functional sperm deficiencies can be overcome using an ART. In other cases, couples will be empowered by the knowledge of the cause of their infertility, and for some couples, perhaps even the likelihood of ICSI success （relative to the spermatozoa）. The knowledge allows them to make truly informed reproductive decisions, including （perhaps） the de- cision to seek donor insemination, to adopt or to remain childless. Knowledge of the cause of their infertility may provide closure for couples and a sense of confidence regarding their choice of reproductive treatment.

Semen analysis standardization： is there any problem in Polish laboratories？

The aim of the study was to determine the degree of compliance of Polish laboratories with World Health Organization （WHO） recommendations, with regard to semen analysis methodology. A survey requesting information about methods of semen analysis was distributed to employees of 55 laboratories. Respondents who had participated in external seminological workshops （31%） were termed certified respondents （CR）, the remaining （69%）--non-certified respondents （NCR）. Only one laboratory （6%） in the CR group and none in the NCR were compliant with WHO guidelines for methods and equipment used to evaluate seminal volume, sperm motility, concentration, vitality and morphology. Most problems were of volume measurement （weighing method was reported by 17% of CR and 10% of NCR） and staining method for sperm morphology （Papanicolau or Diff-Quik were found in 33% of CR and 23% of NCR）. A three- or four-point grading of sperm motility was used by the majority of respondents; however, 17% of CR and 37% of NCR did not use a laboratory counter to tally spermatozoa. Although a haemocytometer method was used by 80% of laboratories in each group, the improved Neubauer chamber was used only by 42% of CR and 19% of NCR. In each group, 24% of laboratories did not perform a vitality test. Procedural errors and the interchangeable utilization of two or even three methods to analyse a given parameter was observed in both groups. The results indicate a need for standardisation of the methods and continuous, unified training in semen analysis in Polish laboratories.

Semen analysis with regard to and functional aspects sperm number, sperm morphology

The new World Health Organization （WHO） Manual for Semen Analysis contains several improvements. One is that the 20 million spermatozoa per mL paradigm has been ousted in favour of proper calculations of lower reference limits for semen from men, whose partners had a time-to-pregnancy of 12 months or less. The recommendation to grade the progressive motility as described in the third and fourth editions of the WHO manual was not evidence-based, and WHO was therefore motivated to abandon it. However, the new recommendation is not evidence-based either, and it is difficult to understand the rational for the new assessment. It may have been a compromise to avoid returning to the rather robust system recommended in the first edition （1980）. The unconditional recommendation of the ＇Tygerberg strict criteria＇ is not evidence-based, and seems to be the result of an unfortunate bias in the composition of the Committee in favour of individuals known to support the ＇strict criteria＇ method. This recommendation will have negative effects on the develop- ment ofandrology as a scientific field. Given the importance of the WHO manual, it is unfortunate that the recommenda- tions for such important variables, as motility and morphology, lack evidence-based support.

Semen analysis in chronic bacterial prostatitis： diagnostic and therapeutic implications

The significance and diagnostic value of semen analysis in chronic bacterial prostatitis has been extensively debated and remains controversial. To investigate the diagnostic relevance of semen culture in the bacteriological workup of prostatitis patients, we retrospectively analyzed a clinical database of 696 symptomatic patients. All patients were routinely subjected to a four-glass test, followed by semen culture and analysis. This allowed to dissect from the database three different diagnostic scenarios, and to compare the ＇two-glass＇ pre-/post- massage test and the standard ＇four-glass＇ test with a ＇five-glass＇ test （four-glass plus post-VB3 semen culture）. The ＇five-glass＇ test showed 3.6- or 6.5-fold increases in relative sensitivity and lesser reductions （-13.2% or -14.7%） in relative specificity for traditional uropathogens （TUs） compared with the four-glass or two-glass test, respectively. The area under the ROC curve and Jouden＇s index were increased, whereas positive and negative likelihood ratios were lower than comparators, indicating that the ＇five-glass＇ assay may be superior in confirming the negative outcome of both standard tests. The five-, four-, and two-glass tests detected TUs （Enterobacteriaceae, Enterococci, etc.） in 120, 33, and 20 patients and unusual pathogens （Streptococci, other Gram-positive species, Mycoplasmata, and others） in 130, 56, and 45 patients, respectively. When patients were subjected to pharmacological treatment, including a combination of a fluoroquinolone and a macrolide, no differences in eradication rates were observed between groups diagnosed with different tests, irrespective of pathogen category. Eradication was associated with long-term sign/symptom remission; no significant intergroup differences in sign/symptom scores were observed throughout a 24-month off-therapy follow-up period. In conclusion, our data support the usefulness of semen analysis in the diagnostic workup ofprostatitis patients when this test is used to complement the four-glass Meares and Stamey test. Improvement of microbiological assays conveys important diagnostic and therapeutic implications.

Semen Analysis and Fecundity Association Among Women with Polycystic Ovary Syndrome Experiencing Ovulatory Dysfunction Treated by Ovulation Induction

In this study,normal values of semen analysis were set for a general infertile population of couples among which most women had normal ovulation.The predictive capacity values of sperm quality,including concentration,motile count,progressive motile count,and morphology,are unclear for women with polycystic ovary syndrome(PCOS).A secondary analysis was conducted based on a randomized controlled trial investigating infertility among women with PCOS experiencing ovulatory disorder between 2011 and 2016 in China.A total of 1000 women received ovulation induction(acupuncture and clomiphene).We randomized the women with PCOS in 27 hospitals in China who received one of four interventions(acupuncture plus clomiphene,sham acupuncture plus clomiphene,acupuncture plus placebo,or sham acupuncture plus placebo).Semen analysis was performed for every male partner according to the World Health Organization(WHO)criteria.The outcomes included conception,clinical pregnancy,and live birth.Logistic regression was used to evaluate the predictive value of semen analysis among ovulatory women for conception,clinical pregnancy,and live birth.Among the 1000 couples,the number of couples who attained ovulation,conception,clinical pregnancy,and live birth were 780,320,235,and 205,respectively.Semen volume and motility were applied and used as prediction parameters for conception(area under the curve(AUC)of 0.62(95%confidence interval(CI),0.55–0.69)),clinical pregnancy(AUC of 0.67(95%CI:0.61–0.73)),and live birth(AUC of 0.57(95%CI:0.50–0.64)).No poor calibration was shown for these models in Hosmer–Lemeshow tests.The predictive capacity of semen analysis for treatment outcome in PCOS women with PCOS experiencing with ovulatory dysfunction is limited.

Semen quality analysis and the idea of normal fertility

The World Health Organization （WHO） has extensively revised its manual for semen analysis, and seeks to provide reference limits for semen quality parameters. This raises the question of what is meant by ＇normal＇ （excluding the use of this term to denote a Gaussian distribution）. It could be taken in a purely statistical sense, using a biologically arbitrary cut-off point to denote an abnormal level, typically the extreme 5 percent of the population. Alternatively, ＇normal＇ could be defined according to the biological concept of normality and abnormality, in terms of the point at which biological function becomes impaired. Either of these can be used in descriptive epidemiology, for example, to study trends, but in the case of fertility, both semen quality and functional fertility （time to pregnancy） are continuous variables with no clear threshold. The WHO manual uses the biological meaning of normal, in that it provides the semen parameter distributions for men who have recently fathered pregnancies that took 12 months or less to conceive. However, what is really needed is the same information the other way around： given a particular semen test result, what should be expected in terms of ability to conceive, and how long it is likely to take. In considering epidemiological research, the focus has been mainly on internal comparisons, rather than reference limits, but it would be beneficial if more attention were paid to the absolute levels and to what these mean in terms of function--in other words, if the data were better calibrated biologically.

External quality control and training of semen analysis in the Netherlands:starting point for further reduction of outcome variability

Semen analysis is characterized by high levels of intra-and inter-laboratory variability,due to a low level of standardization,high subjectivity of the assessments,and problems with automated procedures.To improve consistency of laboratory results,quality control and training of technicians are important requisites.The goals of this study are to evaluate the results of an external quality control(EQC)program and standardized training by ESHRE Basic Semen Analysis Courses(BSAC)on the variability in manual assessments of semen parameters.We performed retrospective analyses of(1)the interlaboratory variability in the Dutch EQC program and(2)the interobserver variability in BSACs for concentration,motility,and morphology assessments.EQC data showed that the interlaboratory coefficient of variation(CV)for concentration assessment decreased(range from 24.0%–97.5%to 12.7%–20.9%)but not for morphology and motility assessments.Concentration variability was lower if improved Neubauer hemocytometers were used.Morphology assessment showed highest CVs(up to 375.0%),with many outliers in the period of 2007–2014.During BSAC,a significant reduction of interobserver variability could be established for all parameters(P<0.05).The absence of an effect in the EQC program for motility and morphology might be explained by respectively the facts that motility assessment was introduced relatively late in the EQC program(since 2013)and that criteria for morphology assessment changed in time.BSAC results might have been influenced by the pretraining level of participants and the influence of external factors.Both EQC and training show positive effects on reducing variability.Increased willingness by laboratories to change their methods toward standards may lead to further improvements.

Impact of chronological ageing on semen parameters in southern Indian men visiting infertility centre:A retrospective study

Objective:To investigate the association between age and semen parameters among male partners of subfertile couples.Methods:This retrospective study analyzed the semen of 1523 infertile men aged 26 to 50 years.Data were extracted from GarbhaGudi IVF Centre database from January 2019 to September 2020.The basic semen parameters were interpreted according to the WHO manual 2021,6th edition.Semen parameters in different age groups were compared.Results:Total and progressive motile sperms were significantly higher in the age group of 26-30 years compared to other age groups(P<0.05).Normal sperm count was significantly higher in the age group of 26-30 years compared to the age groups of 41-45 years and>46 years(P=0.001).However,sperm head defects,neck and midpiece defects,tail defects,and cytoplasmic droplets showed statistically insignificant difference in all the age groups(P>0.05).Semen viscosity showed no statistical difference in all the age groups compared to the reference age group of 26 to 30 years.Conclusions:Higher age can lead to a significant decrease in normal sperms and motility in subfertile men.Hence,male partner age should be considered as one of the major determining factors for reproductive outcomes.

Clinical significance of the low normal sperm morphology value as proposed in the fifth edition of the WHO Laboratory Manual for the Examination and Processing of Human Semen

The very low cut-off value for sperm morphology of 4% morphologically normal spermatozoa, as proposed in the new edition of the World Health Organization （WHO） manual on semen analysis, is in agreement with recently published values and reflects the trend of a decline in reported mean values for normal sperm morphology. The reduced value for morphologically normal spermatozoa over the years may be due to several factors. The first is the introduction of strict criteria for the evaluation of sperm morphology. Other reasons may include the introduction of additional criteria for sperm morphology abnormalities and the suggested decrease in semen parameters because of increasing negative environmental influences. Although on its own the newly proposed very low normal value may not provide the strong predictive value for a males＇ fertility potential, as originally reported for sperm morphology evaluated according to strict criteria, a good predictive value can still be obtained if the holistic, strict approach for sperm morphology evaluation is followed together with additional sperm morphology parameters now available, because certain morphology patterns and sperm abnormalities are now known to be of strong prognostic value. In addition, better international standardization of the technical methodology, consensus on the interpretation of sperm morphology evaluation criteria and standardized international external quality control （EQC） schemes, are of utmost importance to maintain the good predictive value of sperm morphology.

Does exposure to computers affect the routine parameters of semen quality?

Aim： To assess whether exposure to computers harms the semen quality of healthy young men. Methods： A total of 178 subjects were recruited from two maternity and children healthcare centers in Shanghai, 91 with a history of exposure to computers （i.e., exposure for 20 h or more per week in the last 2 years） and 87 persons to act as control （no or little exposure to computers）. Data on the history of exposure to computers and other characteristics were obtained by means of a structured questionnaire interview. Semen samples were collected by masturbation in the place where the semen samples were analyzed. Results： No differences in the distribution of the semen parameters （semen volume, sperm density, percentage of progressive sperm, sperm viability and percentage of normal form sperm） were found between the exposed group and the control group. Exposure to computers was not found to be a risk factor for inferior semen quality after adjusting for potential confounders, including abstinence days, testicle size, occupation, history of exposure to toxic substances. Conclusion： The present study did not find that healthy： men exposed to computers had inferior semen quality. （Asian J Andro12005 Sep; 7： 263-266）

Effects of oncological treatments on semen quality in patients with testicular neoplasia or lymphoproliferative disorders

Pretherapy sperm cryopreservation in young men is currently included in good clinical practice guidelines for cancer patients. The aim of this paper is to outline the effects of different oncological treatments on semen quality in patients with testicular neoplasia or lymphoprol iferative disorders, based on an 8-year experience of the Cryopreservation Centre of a large public hospital. Two hundred and sixty-one patients with testicular neoplasia and 219 patients with lymphoproliferative disorders who underwent chemotherapy and/or radiotherapy and pretherapy semen cryopreservation were evaluated. Sperm and hormonal parameters （follicle-stimulating hormone （FSH）, luteinizing hormone （LH）, testosterone, inhibin B levels） were assessed prior to and 6, 12, 18, 24 and 36 months after the end of cancer treatment. At the time of sperm collection, baseline FSH level and sperm concentration were impaired to a greater extent in patients with malignant testicular neoplasias than in patients with lymphoproliferative disorders. Toxic effects on spermatogenesis were still evident at 6 and 12 months after the end of cancer therapies, while an improvement of seminal parameters was observed after 18 months. In conclusion, an overall increase in sperm concentration was recorded about 18 months after the end of cancer treatments in the majority of patients, even if it was not possible to predict the evolution of each single case ＇a priori＇. For this reason, pretherapy semen cryopreservation should be considered in all young cancer patients.

Assess of the Value of Semen Examination Items in the Diagnosis of Male Infertility

Background: Although semen analysis is a basic method to evaluate male fertility, there was a certain deviation between the semen examination and the actual situation in clinical application. Objective: To evaluate the application value of semen examination items in the diagnosis of male infertility. Method: Males recruited from the Third Affiliated Hospital of Sun Yat-sen University from June 2017 to December 2018 were divided into three groups: normal fertility group, physical examination group (premarital physical examination), and male infertility group. Each group received the following examination such as semen analysis (including semen volume, sperm concentration, progressive motility, total motility, round cell concentration), acrosin activity, and sperm morphology. All the semen analysis items mentioned above were operated according to the WHO laboratory manual for the examination and procession of human semen (Fifth edition) and related documents. Results: The normal fertility group and physical examination group showed significantly higher levels in sperm concentration, progressive motility, total motility, and sperm morphology than those in the male infertility group (P < 0.05);both the normal fertility group and the physical examination group have a higher qualified rate in sperm concentration, progressive motility, total motility and sperm morphology than the male infertility group, all P < 0.001. The percentage of patients having all qualified items in each group was 28.13%, 6.67%, and 6.51% separately. Conclusion: The diagnosis efficiency was higher in sperm concentration, progressive motility, total motility, and sperm morphology than in other semen examination items. A more objective and efficient method of semen examination should be explored to facilitate the diagnoses of male infertility in the future.

The Effect of Age on Male Infertility in Gabon

Background: Male age significantly affects semen parameters. However, there is no evidence on the impact of aging on semen quality in men residing in Libreville, Gabon. Objective: To determine the effects of age on semen quality of patients visiting the Reproductive Laboratory at the Academic Hospital Mère Enfant located in Libreville, Gabon. Methods: This descriptive and prospective study was performed between the 1st of October 2021 and 30st of September 2022. This study involved patients who had semen analysis as part of fertility check-up. Semen analysis was performed following the World Health Organization, 2010 guidelines. Semen parameters such as volume, leucocytes count, sperm concentration, sperm motility, norml morphology and vitality were used in the current study. Descriptive statistics were performed. The Chi-square test and the Fisher test were used as statistical tools for the analysis of data. The ROC curve was used to illustrate the data. Results: A total of 148 patients were included in the study. Male infertility prevalence was 77.03%. The average age was 41 years with minimum and maximum of 24 and 61 years respectively. Secondary infertility was predominant (66.9%). Patients displaying asthenozoospermia (22.3%) followed by those displaying oligoasthenozoospermia (OAT) isolated (1.4%) or not (11.6%) were the most frequent semen parameter abnormalities. Men aged more than 45 years were 4.4 times likely to have abnormal semen parameters. Odd = 4.4 (IC 95% = [3.3 - 14.7]). Staphylococcus haemolyticus infection was more prevalent. Conclusion: Male age was found to significantly influence semen quality.

Quality assurance and quality control in the laboratory andrology

Quality assurance （QA） and quality control （QC） are fundamental aspects of any laboratory measurement. However, in comparison with other medical disciplines, the need for QA and QC in laboratory andrology has been recognized only recently. Furthermore, there is evidence that the effort required to undertake QA and QC has not been wholly welcomed by some clinicians. Nevertheless, accrediting bodies and regulatory authorities increasingly require evidence that laboratories have effective QA and QC measures in place because both are central to the quality management processes. Following the publication of the 5th edition of the World Health Organization Laboratory Manual, existing QA and QC systems will need to be updated to take into account some of the methodological changes recommended by the manual. Three of these are discussed in this commentary; they relate to： （i） the move to infer semen volume from its weight; （ii） the re-classification of sperm motility grades from four to three; and （iii） the publication of a lower reference limit for morphology of 4% （with a corresponding 95% confidence interval of 3%-4%）. The importance of QA and QC in all laboratory tests, including up and coming new tests to assess sperm DNA integrity, is discussed. The need for adequate initial training and continuing professional development programmes to support laboratory scientists performing andrology is also described.

Effect of varicocele on semen characteristics according to the new 2010 World Health Organization criteria： a systematic review and meta-analysis

This study investigated the effects of varicocele on semen parameters in infertile men based on the new 2010 World Health Organization laboratory manual for the examination of human semen. Semen analysis results （volume, sperm count, motility, and morphology） were the primary outcomes. An electronic search to collect the data was conducted using the Medline/PubMed, SJU discover, and Google Scholar databases. We searched articles published from 2010 to August 2015, i.e., after the publication of the 2010 WHO manual. We included only those studies that reported the actual semen parameters of adult infertile men diagnosed with clinical varicocele and contained a control group of either fertile men or normozoospermic men who were not diagnosed with varicocele. Ten studies were included in the meta-analysis, involving 1232 men. Varicocele was associated with reduced sperm count （mean difference： -44.48 x 106 ml-1; 95% Ch -61.45, -27.51 x 106 ml-1; P〈 0.001）, motility （mean difference： -26.67%; 95% Ch -34.27, -19.08; P 〈 0.001）, and morphology （mean difference： -19.68%; 95% Ch -29.28, -10.07; P 〈 0.001） but not semen volume （mean difference： -0.23 ml; 95% CI： -0.64, 0.17）. Subgroup analyses indicated that the magnitude of effect was influenced by control subtype but not WHO laboratory manual edition used for semen assessment. We conclude that varicocele is a significant risk factor that negatively affects semen quality, but the observed pooled effect size on semen parameters does not seem to be affected by the WHO laboratory manual edition. Given most of the studies published after 2010 still utilized the 1999 manual for semen analysis, further research is required to fully understand the clinical implication of the 2010 WHO laboratory manual on the association between varicocele and semen parameters.

Defining laboratory reference values and decision limits＇ populations, intervals, and interpretations

This article provides a brief overview of various approaches that may be utilized for the analysis of human semen test results. Reference intervals are the most widely used tool for the interpretation of clinical laboratory results. Reference interval development has classically relied on concepts elaborated by the International Federation of Clinical Chemistry Expert Panel on Reference Values during the 1980s. These guidelines involve obtaining and classifying samples from a healthy population of at least 120 individuals and then identifying the outermost 5% of observations to use in defining limits for two-sided or one-sided reference intervals. More recently, decision limits based on epidemiological outcome analysis have also been introduced to aid in test interpretation. The reference population must be carefully defined on the basis of the intended clinical use of the underlying test. To determine appropriate reference intervals for use in male fertility assessment, a reference population of men with documented time to pregnancy of 〈 12 months would be most suitable. However, for epidemiological assessment of semen testing results, a reference population made up ofunselected healthy men would be preferred. Although reference and decision limits derived for individual semen analysis test results will undoubtedly be the interpretational tools of choice in the near future, in the long term, multivariate methods for the interpretation of semen analysis alone or in combination with information from the female partner seem to represent better means for assessing the likelihood of achieving a successful pregnancy in a subfertile couple.

Measurement and significance of sperm morphology

The measurement or evaluation and clinical significance of human sperm morphology has always been and still is a controversial aspect of the semen analysis for the determination of a male＇s fertility potential. In this review the background of the development of the evaluation criteria for sperm morphology will be discussed. Aspects of criticism on the strict criteria definition and use of the criteria for sperm morphology evaluation will be discussed as well as possible reasons for the decline in normal sperm morphology values and how we can compromise for this phenomenon resulting in the very low normal reference value as published in the 2010 WHO manual for the Examination and Processing of Human Semen. One of the possible solutions may be to give more attention to a limited number of abnormal sperm morphology categories and the inclusion of sperm morphology patterns. It is concluded in this review that if done correctly and with care and with strict application of existing guidelines as outlined in the 2010 WHO manual, sperm morphology measurement still has a very important role to play in the clinical evaluation of male fertility potential.

Tests to measure the quality of spermatozoa at spermiation

This commentary is to critique the revised World Health Organization （WHO） semen analysis manual as it pertains to characteristics of a spermatozoon at spermiation. The aims of the revised WHO manual include improving the ＇quality of semen analysis＇ without any restriction to clinical use. Furthermore, the manual states that semen analysis may be useful for （a） ＇investigating male fertility status＇ and （b） ＇monitoring spermatogenesis during and following male fertility regula- tion.＇ However, if the analysis of ejaculated spermatozoa is intended for the purposes described in （b）, then cells that are abnormal at spermiation must be identified. This paper takes the position that the manual does not identify methods to estimate the quality of spermatozoa at spermiation. Instead, it uses a ＇gold standard＇ of sperm passing through the cervical mucus or arriving near the site of fertilization. Although this standard is appropriate for drawing conclusions regarding the probability that an individual could impregnate his partner, it is not appropriate for studying illness of the testes per se. Herein, the measures of sperm quality presented in the WHO manual are critiqued with respect to the detection of spermatozoa that were abnormal at spermiation vs. those that became abnormal subsequently. Quality assessments based on the percentage of motile or ＇viable＇ spermatozoa are meaningless. Alternative quality attributes defining spermatozoa at spermiation are presented in this paper. In conclusion, assessment of spermatozoal quality at spermiation, on the basis of quality attributes of individual ejaculated spermatozoa, is best achieved through application of （a） a new paradigm for the morphological evaluation of sperm quality and （b） modern analytical techniques to evaluate, in an adequate sample, several appropriate independent attributes in each spermatozoon in order to more accurately identify the proportion of abnormal spermatozoa.