Andrology services at Cambridge IVF and Ipswich IVF - a user guide

Introduction

The regional semen analysis services is provided from two specialist andrology laboratories located in Cambridge and Ipswich; patients can choose which laboratory they would like to be referred to. An accurate and meaningful semen analysis (SA) is an important element of the diagnosis and treatment of the subfertile / infertile couple and the clearance of a patient post vasectomy (PVSA). The laboratory’s main function is to provide a consistent and high quality level of diagnostic and post vasectomy semen analyses serving both the needs of healthcare professionals and patients in Cambridge, Ipswich and the wider surrounding region.

Cambridge IVF has an established gamete cryostorage facility (sperm and egg bank) which provides a further vital service to our patients and to oncology practitioners as well as to people wishing to store their gametes for social reasons. The bank can also provide donor sperm and eggs for use in assisted conception procedures such as IUI, IVF and ICSI at Cambridge IVF or via our satellite service from Ipswich IVF.

This information serves to provide service users with the information they need to advise and refer patients into the andrology system in a way that will allow us to offer the most efficient service and highest possible standards of care.

If after reading this you still have further questions (no matter how trivial you might imagine them to be), please feel free to contact us using the telephone number on the back page of this information leaflet or email Cambridge IVF.

Services provided

Diagnostic semen analysis

Almost one in every six couples will have difficulty conceiving naturally and be referred for fertility investigations. The single most common diagnosis is ‘sperm dysfunction’ or ‘male factor’ infertility which is apparent in one form or another in approximately 30% of men referred. A comprehensive and high quality semen analysis is essential to the diagnosis and treatment of male factor infertility and of treatment of the subfertile / infertile couple as a whole.

The laboratory team at Cambridge IVF have a wealth of experience in performing the range of tests which in combination provide a complete and accurate appraisal of semen samples and sperm function. The laboratory tests utilised are performed in accordance with the guidance set out by the World Health Organization (WHO) and the Association of Reproductive and Clinical Scientists (ARCS). The laboratory subscribes to the National External Quality Assurance Scheme (UKNEQAS) for Reproductive Science and our service is accredited by the British Standards Institute (BSI) to ISO9001.

Requesting a semen analysis

The patient should be provided with the following:

• A completed sample request form (C.IVF/LabForm/Andro/13)

Please ensure that the patient's name, NHS number, address and date of birth are completed along with details of his partner if possible. Remember to complete the practice information or use the practice stamp in the relevant section and indicate the type of test or tests which you are requesting. Include any other relevant details including previous semen analyses, history of testicular trauma or injury, genetic disease, previous radio or chemotherapy, chronic illness, recent febrile illness and any ongoing medication.

Although we adopt a universal precautions approach to our work, please clearly indicate any patient who you know to be an infection risk and ask the patient to declare this when booking their appointment.

• Patient information leaflet

You are welcome to print this document and provide copies to your colleagues. Copies of all andrology information and forms will also be available via our website (opens in a new tab). If you have any comments on the information, please email us.

Please do not use standard pathology request forms for semen analysis requests as this may result in delay and the patient being referred to the wrong laboratory or the sample being discarded if the test type requested is not clear.

Booking a semen analysis appointment

Once they have been provided with a completed referral form from their referring doctor, patients can telephone 01223 349010 (option 2) to make a semen analysis appointment for either laboratory. This service is available between the hours of 10:00 (10am) and 16:00 (4pm) Monday to Friday.

Patients can also request an appointment via email. We will reply within 48 hours.

Producing the semen sample

We recommend that all samples should be produced on site in our private sample production rooms in Ipswich and Cambridge. Where this is not practicable, samples can be produced at home for patients living within 30 minutes of either of the laboratories. We will provide each patient with a sterile, non-toxic, batch tested sample container to produce the sample into. These can be collected from Cambridge IVF prior to the appointment date for patients producing at home or will be provided for patients producing samples on site when they arrive. No other containers should be used and samples which are not produced into an appropriate container will be rejected, as such containers can be toxic to sperm immediately on contact and render the results inaccurate. We also discourage patients from taking a partner with them into the room as, in our experience, the resultant sample is more likely to be contaminated or incomplete.

Patients are requested to:

• Abstain from intercourse for two to five days before producing the sample. Longer periods (more than seven days) of abstinence are not usually recommended as this can negatively affect the quality of the sample.
• Wash and dry hands and genitals prior to sample production.
• Produce the sample by masturbation and collect the sample directly into the sample container provided.
• Avoid the use of condoms as they may contain a spermicide which will kill the sperm and render the test invalid.
• Avoid the use of lubricants to assist in the process of sample production as these may negatively affect sperm function.
• Ensure that the container is correctly labelled with their full name and date of birth, and that the referral form is completed including the date and time of sample production. Samples which are not labelled correctly will be rejected.

The diagnostic semen analysis

We examine a number of important factors (detailed below) according to best practice guidelines published by the World Health Organization (WHO, 2021) and the Association of Reproductive and Clinical Scientist Guidelines for Good Practice (ARCS and BFS, 2020). You must consider that the ‘normal’ values we report against are to be considered as guidelines only and should not be viewed as clear cut threshold values against which any specialist fertility treatment is solely directed.

Sperm concentration (sperm count): Reported as millions per millilitre of semen. Normal samples are those reported with a concentration of 16M/ml or more and a total count in the ejaculate of greater than 39 million sperm.

Sperm motility: Sperm are graded on their ability to swim in a progressive manner. Those sperm which are progressively motile (grades ‘a’ and ‘b’ motility) can be considered together as ‘Progressively Motile’ and should account for more than 30% of the total sperm population. Non-progressive sperm (those which exhibit tail motion but are not moving forwards, grade ‘c’) and those which are immotile (grade ‘d’) are also reported. The WHO (2021) guidelines state the importance of the distinction between grades ‘a’ and ‘b’ as the extent of progressive sperm motility is related to pregnancy rates.

Sperm volume: The sample volume should be greater than 1.4 millilitres.

Sperm morphology: The shape and size of the sperm are assessed using a stained smear. A sample with less than 4% normal forms reported should be considered as subfertile.

Seminal pH: The pH of the sample should be greater than 7.2.

Antisperm antibodies (where requested). Antisperm antibodies cause agglutination of sperm (sperm sticking together). They are seen in approximately 5% of cases and may be indicated by trauma to the testes (such as sports injuries) or vasectomy reversal even where the other sperm parameters have returned to the normal range.

Round cell classification by peroxidase testing (where required): Round cells in semen are either leukocytes (and indicative of response to infection) or immature germ cells (and indicative of potential issues with sperm function). The presence of leukocytes, detected by peroxidase test in semen, is a reliable indicator of genital tract infections.

DNA fragmentation test (where requested): Sperm DNA integrity is of paramount importance for fertilization and development of healthy babies. Studies have shown a direct relationship between sperm DNA damage and male infertility. Several factors are known to negatively impact sperm DNA integrity (smoke, infections, varicocele, poor diet, cancer, etc). The result of this test will support clinicians and embryologists when choosing fertility treatments for that specific couple.

Reporting of results

A written report will be dispatched to the referring practitioner as soon as practicable and within 10 working days of the semen analysis being performed. Approved diagnostic terminology (as described below) is used to report the results along with an overall comment. All reports are checked and signed off by a HCPC State Registered Clinical Scientist specialising in reproductive science. Please note that results cannot be communicated directly to patients over the telephone. Patients are requested to allow two weeks for the results to be available, and should contact their referring surgery or clinic to receive them. Patients are advised to factor in the time for reporting of results when booking their appointment, particularly if they have a follow up appointment with the referrer scheduled. A repeat analysis may also be needed if the test results indicate subfertility, so patients are encouraged to book their appointments straight after referral to avoid delays or comprehensive information not being available following referral to secondary care.

Interpretation of results

There are strict and defined guidelines for the measurement and quality control of semen variables. It is important to realize that these values are not absolute in predicting an individual patient's fertility and no one parameter should ever be considered in isolation unless the result is absolute (for example the sperm count is reported as zero).

Laboratory testing is standardised to minimise procedural variation but this cannot be excluded completely as certain parts of the process of delivery are outside of our control. For example, a man may miss some of the sample and choose not to declare this.

An appraisal of the overall balance of the sample is much more indicative of fertility potential and should be considered alongside any concurrent investigations of the female when forming a diagnosis. The term ‘low sperm count’ should be considered ambiguous and is often anxiously misinterpreted by a patient despite a reduced sperm count being balanced to some extent by a higher than average motility score.

We are happy to provide assistance to service users in the interpretation of semen analysis results. Enquiries should be directed to the andrology team at Cambridge IVF (contact details below). Please note we are not able to offer an interpretation service directly to your patients.

Uncertainty of results

Uncertainty exists in any measurement of biological processes especially those calculated by subjective means with potential inter-operator variability. Such variability can be reduced by robustly enforcing best practice, standardising test methodology and equipment and by ensuring all staff participate in a program of regular quality assurance monitoring and evaluation. To minimise uncertainty in semen analyses and reduce the effect of sampling error, we perform multiple replicate counts comparing the results to ensure any difference falls into a non-significant tolerance limit of <5% as described by the WHO (2021) guidelines. Semen assessments will include no less than 200 sperm where practicable and tests are repeated to ensure a minimum of 400 sperm are routinely assessed. This practice serves to reduce the probability of random events or sampling errors confounding the reported results. If there are insufficient sperm in the sample to allow assessment of 200 sperm, this will be highlighted on the report to draw the attention to the requester that the uncertainty of this result may be elevated and certainly will deviate from our standard calculated uncertainty for the specific test.

All of our laboratory team are active participants in the National External Quality Assurance Scheme (NEQAS) for Reproductive Science.

Repeating of tests

If one or more of the factors listed above is found to be borderline or outside the normal range, we recommend the referral of the patient for a repeat analysis. It should be noted that if a patient has been unwell, stressed or is on certain medication this can affect the quality of the semen sample, and a second test is required to confirm or refute the findings. As semen quality can vary significantly with time, we do not recommend that a diagnosis be formed on the basis of a single semen analysis in any instance whether the result reported is normal or abnormal.

Referral for assisted conception treatment

If you wish to send a patient and his partner for further investigation and subsequent fertility treatment either for NHS funded or self-funded treatment, they can be referred to Cambridge or Ipswich IVF. We offer a full range of specialist treatment options from our facility in Cambridge or via our satellite arrangements with Ipswich Hospital and Guys and St Thomas Hospital in London. Our results as published by the HFEA are consistently higher than other providers in the region and although care may need to be self-funded by the patient, the money they invest in their care goes directly into the local NHS economy rather than to a private company for profit. Referrals for specialist fertility services should be directed to ‘The lead clinician’ at our address or via email using the contact details below.

Post vasectomy semen analysis (PVSA)

Semen testing to confirm azoospermia following vasectomy is absolutely essential. PVSA semen analysis adheres to the same stringent guidelines for sample production as diagnostic semen analysis.

Most recently published best practice guidelines suggest a change in best practice to clearance on the basis of a single large volume assessment of a semen sample rather than routine clearance after examination of two samples following density gradient centrifugation. Cambridge IVF have validated this practice and have changed our methodology to reflect this practice change.

There are strict acceptance criteria specified in the new guidelines as follows:

• Samples should be provided after a minimum of 12 weeks and 20 ejaculations post vasectomy.
• Samples should be complete and analysed within 60 minutes of production.
• Samples should be clearly labelled with three identifiers, these being the patient’s name, date of birth and postcode. Samples which are not labelled correctly will be rejected and a repeat sample requested.

Samples which do not meet the aforementioned criteria will still be analysed and a repeat sample requested to confirm or refute the findings as recommended in the most recent best practice guidelines.

Where motile or immotile sperm are observed in a sample a repeat analysis will always be requested.

We believe this change in practice will not compromise results but is more patient convenient, more cost-effective and will in most cases allow clearance of men post vasectomy sooner.

The rules for sample production are exactly the same as for fertility testing with regard to hygiene, abstinence, appropriateness of sample container and sample production by masturbation.

It is critical that the patient collects his entire sample for a PVSA sample. If this is not the case the test will not be performed and a repeat appointment will be required.

Due to the criticality of adhering to the sample acceptance criteria in maintaining the validity of the test, samples produced which do not meet the criteria will be rejected and a repeat test requested.

PVSA appointments

The process of booking an appointment for PVSA is exactly the same as that for diagnostic semen analysis. Once the patient has been provided with a completed referral form from their referring doctor they can telephone 01223 349010 (option 2) to make a semen analysis appointment for either laboratory. This appointment booking service is available between the hours of 10:00 (10am) and 16:00 (4pm) Monday to Friday. Patients can also request an appointment via email and we will reply within 48 hours.

The referring clinician should provide the patient with the following:

• A completed sample request form (C.IVF/LabForm/Andro/13)
• A patient information leaflet

The referring clinician should clearly state who is requesting the PVSA and when the vasectomy was performed on the sample request form.

Clearance post vasectomy

Published best practice defines clearance post vasectomy may be given following one sample 12 or more weeks and 20 ejaculations post vasectomy where no sperm are seen in one sample following evaluation of single large volume slide. In all other cases a second sample will be requested to confirm or refute the initial finding.

‘Special’ clearance

Persistent immotile sperm can exist in men due to either a failure to ejaculate regularly or anatomical anomalies which lead to retention in the genital tract. Special clearance can be granted in such cases where a concentration of less than 100,000 immotile sperm is observed in two separate semen samples produced in accordance with the sample acceptance criteria described above and analysed in the same laboratory in accordance with current best practice guidelines.

The assessment of PVSA samples via a postal service is now considered very poor practice and not recommended or supported as a mechanism to inform a clinical judgement.

Cambridge IVF cannot be held accountable where clearance has been granted in such circumstances and a patient then goes on to achieve an unplanned pregnancy.

Retrograde ejaculation (RE)

Retrograde ejaculation or ‘dry orgasm’ occurs when semen (opens in a new tab), which would, in most cases be ejaculated (opens in a new tab) via the urethra (opens in a new tab), is redirected to the urinary bladder (opens in a new tab). Normally, the sphincter of the bladder (opens in a new tab) contracts before ejaculation forcing the semen to exit via the urethra, the path of least resistance. When the bladder sphincter does not function properly, retrograde ejaculation may occur. Retrograde ejaculation may occur due to dysautonomia, following prostate surgery or as a complication of diabetes.

Men with suspected or confirmed retrograde ejaculation may wish to confirm the presence of sperm in their urine or arrange cryopreservation of sperm. Healthy sperm can reliably be harvested from post-ejaculatory urine in most cases of RE. The man is asked to drink a bicarbonate buffered solution prior to masturbation to ensure that his urine is better buffered to prevent sperm damage during their unavoidable time exposed to urine. The sample is processed in the lab and if sperm are present they are cryopreserved.

Please ensure that all patients for RE analysis inform staff when booking their appointment that they are retrograde patients as these appointments are longer to enable an effective analysis.

Surgical sperm retrieval (SSR)

In some cases, patients are unable to produce a semen sample by ejaculation. In such situations, it is possible to retrieve sperm surgically. This procedure can be arranged prior to the commencement of treatment where possible but is usually regarded as a last resort. Should SSR be required, the patient will need to attend Cambridge IVF to be consented and receive the relevant paperwork prior to the procedure being performed.

Sperm cryopreservation and storage

The Cryostore at Cambridge IVF offers a robust and HFEA licensed facility in which gametes and embryos can be stored for:

• Infertility patients
• People who are undergoing treatment for cancer which may result in premature infertility
• People undergoing gender reassignment therapy
• People wishing to freeze eggs or sperm for social reasons
• Gamete donors

Patients can self-refer into a self-funded care pathway by contacting Cambridge IVF directly. Referral for NHS funded sperm banking is currently limited to the cohort of patients undergoing treatment for cancer. Such referrals arrive from oncology, haematology and urology units all across the region and are processed as high priority; where possible, an out-of-hours referral service is offered to urgent patients whose treatment cannot be deferred to ensure everyone is offered the opportunity to bank their gametes prior to their treatment. NHS funded cryopreservation may also be available to patients undergoing treatment for gender dysphoria; however, funding is dependent on meeting criteria set out by their respective clinical commissioning group (CCG).

What is sperm cryopreservation?

The semen sample is analysed and then mixed with a solution designed to help it survive the freezing process called a ‘cryoprotectant’. This mixture is then loaded into special cryogenic freezing ‘straws’, 0.5ml of the mixture in each and is frozen and stored in liquid nitrogen (at temperatures less than -160C). Each straw is clearly labelled with the patient name, date of birth, hospital number and the date of freeze.

Requesting sperm storage

All patients who require sperm storage should receive the relevant patient information (C.IVF/LabFORM/Inform/7). A referral for freezing form (C.IVF/LabForm/Andro/9) should be completed before the referral is made and must include the following additional information:

• Reason for storage
• Chemotherapy plan (if appropriate)
• The date treatment is to commence or surgery is booked (if appropriate)
• Results of HIV 1+2, hepatitis B (core antibody and surface antigen) & hepatitis C screening (a copy of the blood results is required)
• Any assisted conception plan in place
• Whether the patient has had/planning on having a scan which involves a radioactive dye (dates and times are required)
• Contact name and contact details of the referring healthcare professional

Payment of freezing and storage fees

Referrals for patients for storage prior to an oncology-related procedure which is likely to affect their fertility will usually, but not in all cases, have their gamete storage funded by the NHS for up to three semen samples. The NHS will also pay for ongoing storage fees for such patients where their fertility remains impaired. Patients who require storage prior to assisted conception treatment, vasectomy or gender reassignment surgery normally fund the storage themselves. The fee for freezing sperm includes storage for the first year; an annual storage fee is then applied for every year that the samples remain in storage thereafter.

Family planning following treatment for cancer

The drugs which are used in chemotherapy can cause damage to sperm DNA which could affect any subsequent pregnancy resulting in the birth of a baby with an abnormality or birth defect. For this reason it is advisable for patients to use contraception during their treatment and for 12 months following on from its cessation. Some treatments will cause permanent and irreversible infertility or sterility, others will not. It is impossible for us to predict the effect a specific treatment will have on an individual or give an indication of when normal fertility will return.

Review and repeat sperm testing

Fertility can and will return in some patients, sometimes within months of the cessation of treatment; sometimes years later. We advise all patients who have banked sperm to return to the clinic for a review and semen analysis 12 months following surgical treatment or 24 months after cessation of chemotherapy treatment. This is the only way we can provide accurate information on an individual’s fertility to allow them to best plan contraception or trying for a baby. The 12 or 24 months review can be arranged by the patient direct with Cambridge IVF at no cost to those patients referred on an NHS funded care pathway.

Notes for referring clinicians

As there is no central funding for sperm storage outwith an oncology care pathway a referral letter will be deemed to be an official order unless the patient has agreed to fund his own storage. It remains the responsibility of the referring centre to obtain a signed undertaking to pay in such circumstances prior to referral.

The Andrology Service must be notified of any requests for storage by:

• Telephoning 01223 349010 (option 2) and by email (Monday to Friday) in the event that the referral is urgent and an appointment is needed immediately. For critical referrals out of hours, the laboratory on-call scientist can be contacted on 07702 959451.
• Arrangements can be made to have samples collected from or sent to the department for patients who are too ill to attend Cambridge IVF. In such circumstances consent will need to be taken at the referring centre by a member of the Cambridge IVF team by prior arrangement.

The referring centre should arrange for HIV 1 and 2 and hepatitis B (core antibody and surface antigen) and C screening prior to the patients attendance for storage to ensure that the processing and storage of samples can proceed without unnecessary delay.

The patient should be provided with a copy of our sperm storage information and asked to consider the following key points prior to attending to store sperm:

• Distance to travel to produce the sample
• The likelihood of becoming infertile as a result of the treatment
• The fate of their stored sperm in the event of their death or mental incapacity
• The cost associated with storing sperm (if self-funding)
• That the quality of the stored sperm will have a bearing on the availability and chances of success of any subsequent assisted conception treatment

Storage of sperm must be encouraged in all men and boys of reproductive age, yet at the choice of the patient. This is particularly important in adolescent individuals who must make the decision free from coercion by either the referring centre or family members and friends. In such cases the referring centre will need to assess the maturity and competence of the individual (Gillick Competence) prior to making the referral.

In the event of the death of a patient who has banked sperm the referring centre should write to Cambridge IVF to inform us as soon as possible after the event that the patient has died to allow us to comply with the patient’s wishes and legislator requirements of the Human Fertilisation and Embryology Act (2008).

Any referral for sperm banking implies acceptance of the terms and conditions as stated above.

Queries and complaints

If you have any questions regarding any part of the andrology service provided by Cambridge IVF please do not hesitate to contact us using the contact details on the back of this information at any time between the hours of 08:00 and 16:00. If you are unhappy with any part of the service or wish to speak to someone about an issue relating to your care please contact our lead clinical scientist or, if you prefer, the patient advice and liaison service (PALS) at Addenbrooke’s hospital or telephone 01223 217756.

Key service personnel

• Cambridge IVF andrology administration team
  Telephone: 01223 349010 (option 2)
  Email Cambridge IVF andrology
• Consultant Embryologist and Person Responsible - Stephen Harbottle
  Telephone: 01223 349010
  Email Stephen Harbottle
• Andrology Service Lead - Elisa Ferraro
  Telephone: 01223 349010
  Email Elisa Ferraro

Finding Cambridge IVF in Trumpington

Please note that Cambridge IVF is not located on the main CUH campus.

We are very easy to access by car, public transport and bicycle. When approaching from Trumpington Road, look out for Bidwells Estate Agent (next to the Shell garage) on the corner of Maris Lane. Kefford House is immediately behind this complex of buildings and shares a car park with them.

Getting here by car

The clinic is just off Trumpington Road, easily accessible from the M11 and A11 if coming from outside Cambridge. There is plenty of free parking at the centre indicated by yellow parking bays marked with a ‘K’. It is important that you use these parking spaces and not the others which are allocated to other buildings. You can also park at the Trumpington Park and Ride and take a bus. There is a stop close to the centre on Trumpington Road (see below).

Cycling to Cambridge IVF

There is ample covered cycle racking provided directly outside of Cambridge IVF for those wishing to cycle.

Public transport – getting to Cambridge IVF by bus

Please visit the Stagecoach website (opens in a new tab) to plan your journey.

Finding Cambridge IVF at Ipswich hospital

The Cambridge IVF andrology service is located in the Central Zone, in the gynaecology clinic on the 1st floor. This is clearly signposted. A map of the hospital is available online, please see East Suffolk and North Essex NHS foundation trust - Get to Ipswich hospital. (opens in a new tab)

Getting here by car

The address for Ipswich hospital is:

Heath Road
Ipswich
Suffolk
IP4 5PD.

Please park in car park G. Please note that parking charges apply (pay and display).

Your appointment should not last longer than one hour.

Public transport

Please visit East Suffolk and North Essex NHS foundation trust - Get to Ipswich hospital (opens in a new tab) for more information on finding your way as well as information about how to get the hospital by public transport.

Further information

If you require any further information regarding the clinic and available treatments please call 01223 349010 or email Cambridge IVF enquiries.

Visit our website. (opens in a new tab)