Revised guidelines for human embryology and andrology laboratories

15 Pages·2015·0.17 MB·English

Revised guidelines for human embryology and
andrology laboratories
ThePracticeCommitteeoftheAmericanSocietyforReproductiveMedicineandthePractice
CommitteeoftheSocietyforAssistedReproductiveTechnology
Birmingham,Alabama
Theseguidelinesprovideclinicianswithspecificguidanceonlaboratoryprocedurestoensurethattheirprograms’
practicereflectscurrentrecommendations.(FertilSteril(cid:2)2008;90:S45–59.(cid:3)2008byAmericanSocietyforRe-
productiveMedicine.)
GUIDELINESFORHUMANEMBRYOLOGYLABORATORIES laboratories are not referral laboratories but main-
I. Organization of the Laboratory and Definition of tainspecificaffiliationwithaphysiciangroup(s).
Services Embryologylaboratoriesperformsomeorallofthe
A. GeneralLaboratory followingsteps:
1. The institutional affiliation, where appropriate, 1. Culture medium preparation and quality con-
plus the history and definition of services and troltesting
markets served, should be clearly defined for 2. Examinationoffollicularaspirateswithoocyte
eachembryologylaboratory. identification
2. The laboratory must undergo certification and 3. Oocytequalityandmaturitygrading
accreditation by an appropriate agency, e.g., 4. Spermpreparation:semencollectionandanal-
College of American Pathologists/American ysis,spermwashing
Society for Reproductive Medicine, Joint Com- 5. Inseminationofoocytes
missiononAccreditationofHealthcareOrganiza- 6. Evaluationoffertilizationandzygotequality
tions, or New York State TissueBank and must 7. Embryocultureandembryograding
beincompliancewithanylocal,state,orfederal 8. Embryotransfer(eitheruterineortubal)
licensing requirements and/or regulations. Any 9. Oocyte/embryo/sperm cryopreservation, stor-
current licenses, permits, and certification by ageandthawing
anyothergroupsoragenciesshouldbelisted. 10. Micromanipulation of human oocytes and/or
3. ThelaboratorymustsatisfyInstitutionalReview embryos (e.g. Intracytoplasmic Sperm Injec-
Board(orequivalentHumanInvestigationCom- tion [ICSI], Assisted Hatching [AH], polar
mittee)requirementsforanyinvestigativeproce- bodyorembryobiopsyforPreimplantationGe-
dures,ifapplicable. neticDiagnosis[PGD]).
4. Laboratory animals should be maintained C. The laboratory must have evidence of informed
humanely according to local, state, or federal consent for all procedures prior to performing
requirementsand/orregulations,ifapplicable. saidprocedures.
5. Embryology laboratories are considered manu-
II. LaboratoryPersonnel
facturers of transplantation products (gametes
A. PersonnelQualificationsandResponsibilities
and embryos) according to the FDA’s Cell/Tis-
Thereshouldbesufficientpersonneltoprovideem-
sue Transplantation regulations (1). All embry-
bryologyservicesasneededinatimelymannerwith
ology laboratories must be in compliance with
amechanisminplacetoprovidebackupforthelab-
theseFDAregulations.
oratory personnel. There are several categories of
B. SpecificLaboratoryProcedures
personnel. Staffing levels should be appropriate
Embryology laboratories are an integral part of In
forthesizeandvolumeoftheprogram;aminimum
Vitro Fertilization (IVF), Gamete Intrafallopian
oftwoqualifiedpersonsisrequiredwhoarecapable
Transfer (GIFT), Zygote Intrafallopian Transfer
ofperformingalltechnicalservices.
(ZIFT), Embryo Cryopreservation, Oocyte or Em-
1. EmbryologyLaboratoryDirector
bryo Donation, and Gestational Surrogacy Pro-
a. Qualifications: The individual must fulfill
grams. These are collectively known as Assisted
bothofthefollowingrequirements:
Reproductive Technologies (ART). Embryology
1) Anearneddoctoratedegree(Ph.D.)froman
accreditedinstitutioninachemical,physi-
Guideline cal,orbiologicalscienceasthemajorsub-
RevisedAugust2008.
ject or a medical degree (M.D. or D.O.)
ReceivedandacceptedJuly28,2006.
Reprintswillnotbeavailable. from an accredited institution or have
0015-0282/08/$34.00 FertilityandSterility(cid:4)Vol.90,Suppl3,November2008 S45
doi:10.1016/j.fertnstert.2008.08.099 Copyrightª2008AmericanSocietyforReproductiveMedicine,PublishedbyElsevierInc.
qualified as a laboratory director prior to 2) Ensuringthatthephysicalplant(space,fa-
July 20, 1999. Effective January 1, 2006, cilitiesandequipment)andenvironmental
all new laboratory directors should hold conditions of the laboratory are appropri-
High Complexity Laboratory Director ateandsafe.
(HCLD)orAmericanBoardofBioanalysis 3) Maintainingasepticconditionsinthelabo-
Embryology Laboratory Director (ABB- ratory.
ELD)certificationoritsequivalent.Labora- 4) Ensuring that patient confidentiality is
torydirectorsgrandfatheredinarestrongly maintained throughout the laboratory
encouragedtoseekHCLDorELDcertifica- ARTprocess.
tion. The laboratory director should have 5) Providinganapprovedproceduralmanual
theexpertiseand/orspecializedtrainingin to all laboratory personnel, establishing
biochemistry,cellbiology,andphysiology andmaintainingalaboratoryqualityassur-
ofreproductionwithexperienceinexperi- anceprogram.
mentaldesign,statistics,andproblemsolv- 6) Providing consultation to physicians and
ing. The laboratory director should be others, as appropriate, regarding labora-
responsibleforformulatinglaboratorypol- toryaspectsoftreatment.
icies and protocols and communicating 7) Employingasufficientnumberofqualified
withthemedicaldirectorregardingpatient laboratorypersonneltoperformtheworkof
progress and protocols as they affect the thelaboratory.Ataminimum,thereshould
laboratoryaspectsoftreatment. betwo(2)qualifiedembryologists.Table1
2) Twoyearsdocumentedexperienceinapro- provides minimum staff sizes for the vol-
gram performing IVF-related procedures. umeofcycles(retrievalsandcryopreserva-
Thisexperienceshouldinclude: tion cycles). Additional laboratory staff
a) Familiaritywithlaboratoryqualitycon- mayberequiredifandrologicaland/oren-
trol, inspection, and accreditation pro- docrinologicaldutiesarealsoassigned.
cedures. c. The embryology laboratory director should
b) Detailedknowledge ofcellcultureand ensure that all personnel receive appropriate
ART and andrology procedures per- training for the ART laboratory procedures
formedinmammaliansystems. to be performed, obtain the required number
of annual continuing education hours, and
3) The embryology laboratory director
demonstrate continued competency for the
should have had a period of training of at
ARTlaboratoryproceduresperformed.
least six months (may be concurrent with
d. An‘‘off-site’’laboratorydirectorisonewhose
documented experience) and completed
primarydirectorshipisatanotherphysicalfa-
atleast60ARTproceduresundersupervi-
cility, which has a separate identification
sion.Aprocedureisdefinedasacombina-
number(SARTnumber)andaseparatemed-
tion of the examination of follicular
icaldirector.Anoff-sitedirectorhasthesame
aspirates, insemination, documentation of
responsibilities as an on-site director. While
fertilization, and preparation for embryo
the laboratory is actively treating patients,
transfer. Satisfactory completion of this
the off-site director is required to physically
period of training should be documented
visitthelaboratoryatafrequencythatwillen-
by a signed letter from the laboratory di-
sure the proper functioning of the laboratory
rector of the training practice. In addition
andassureappropriatepatientcare.Minimum
to these qualification requirements, the
embryologylaboratorydirectorshould:
TABLE 1
a) Obtain at least 12 hours of accredited
continuingeducationannuallyinassis- Recommendedstaffaccordingtovolume.
ted reproductive technology or clinical
Numberof Minimumnumberof
laboratorypractice.
laboratorycycles embryologists
b) Demonstrate technical competency in
the embryology laboratory by docu- 1–150 2
mentingperformanceofspecificproce- 151–300 3
dures and results that are within 301–600 4
acceptablestandardsforthatprogram. >600 1additionalembryologist
b. Responsibilities:Theseinclude: peradditional200
1) Providing accessibility for on-site, tele- cycles
phone or electronic consultations as
needed. ASRMPracticeCommittee.Revisedguidelines.FertilSteril2008.
S46 ASRMPracticeCommittee Revisedguidelines Vol.90,Suppl3,November2008
standardswouldrequireafrequencyofnoless procedures under continuous supervision
than1visitpermonth,whilethelabisactive. ofthelaboratorydirectororsupervisor.
Thelabdirectorshouldalsobeavailableatall b. Inadditiontomeetingtheserequirements,the
times by fax, phone, or email to address any embryologylaboratorytechnologistshould:
issues that may arise. The off-site director 1) Obtainatleast12hoursofaccreditedcon-
must be present on site for any accreditation tinuingeducationannuallyinARTorclin-
or certification procedures. A laboratory di- icallaboratorypractice;
rector shalldirect no more than fiveseparate 2) Performatleast20ARTproceduresperyear.
laboratoriesofanytype. c. Experience and documented training in tis-
2. EmbryologyLaboratorySupervisor sue culture, sperm-egg interaction, or related
Theembryologylaboratorymayhaveoneormore areas of animal reproduction is desirable.
qualifiedlaboratorysupervisorswho,underthedi- The embryology laboratory technologist
rectionofthelaboratorydirector,provideday-to- works under the supervision of a laboratory
daysupervisionoflaboratorypersonnelperform- director or supervisor. Programs for the ap-
ing ART procedures. If the medical director is propriate training of embryology laboratory
alsothelaboratorydirector,thereshouldbeades- technologists should be in place with docu-
ignatedlaboratory supervisor. If theembryology mentation of completion for each employee.
laboratory director is primarily located off-site, d. Responsibilities: These include processing
thereshouldbeadesignatedlaboratorysupervisor. specimens, being able to independently per-
a. Qualifications: The embryology laboratory formalltheroutinetechnicalprocedurescar-
supervisorshouldeithermeetthequalification ried out in the embryology laboratory under
requirementsdesignatedforlaboratorydirec- thesupervisionofalaboratorydirectororsu-
tor or fulfill both of the following require- pervisor,andreportingresults.
ments: B. PersonnelRecords
1) Haveanearnedbachelor’sormaster’sde- There must be written documentation of compli-
gree in chemical, physical, biological, ancewiththesectiondescribedabove.Thisshould
medical technology, clinical or reproduc- includethefollowingitems:
tivelaboratorysciencefromanaccredited 1. An itemized list of all personnel, their capacity
institution; (full-time versus part-time), and their shifts, if
2) Havedocumentedtraining,whichincludes applicable. Include the total full-time equiva-
performing,ataminimum,atleast60ART lentsfilledbyfull-timeandpart-timepersonnel.
proceduresundersupervision. 2. Alistdelineatingtheeducation,training,andjob
b. Inadditiontomeetingtheserequirements,the qualificationsofalllaboratorypersonnel.
embryologylaboratorysupervisorshould: 3. An organizational chart documenting the chain
1) Obtainatleast12hoursofaccreditedcon- of command so that a responsible individual
tinuing education annually in assisted re- canalwaysbeidentified.
productive technology or clinical 4. An itemization of the training of personnel for
laboratorypractice each specific laboratory test offered; definitive
2) Performatleast20ARTproceduresperyear. training programs for all procedures should be
c. Responsibilities: These include day-to-day established.
supervisionandoversightoftheembryolabo- 5. An itemization of personnel participation in
ratoryandlaboratorydirectorresponsibilities training courses, educational programs, and/or
as authorized in writing by the embryology technical meetings and maintain a record of
laboratorydirector. suchparticipation.
3. EmbryologyLaboratoryTechnologist 6. Documentationdelineatingthecontinuinglabo-
a. Qualifications: Embryology laboratory tech- ratory experience necessary tomaintain techni-
nologistswhoperformARTlaboratoryproce- calcompetency.
dures should either meet the qualification 7. Documentationofthehealthstatus,physicalex-
requirementsforlaboratorysupervisor,orful- aminations, or laboratory tests on personnel
fillbothofthefollowingrequirements: wheneverrequired.
1) Haveanearnedbachelor’sormaster’sde- 8. Annualperformancereviewsforpersonnel.
gree in chemical, physical, biological,
medical technology, clinical, or reproduc- III. LaboratorySpaceandDesign
tivelaboratorysciencefromanaccredited The embryology laboratory should have adequate
institution; space toensure safeand comfortableworking condi-
2) Havedocumentedtraining,whichincludes tionsandbeofadesignthatisappropriateforthevol-
performing,ataminimum,atleast30ART umeofproceduresperformed.
FertilityandSterility(cid:4) S47
A. The laboratory should be in a low-traffic, secure 5. General laboratory supplies, such as glassware,
area; it should be physically isolated from other dish-washing equipment, etc., as appropriate to
laboratory activities (e.g., designating a corner of thesizeofthelaboratory.
another lab is not adequate unless it is walled 6. ApHmeterandosmometerforregularmonitor-
off). Use of toxic chemicals or radioisotopes, in- ingofmedia.
cluding toxic cleaning materials, in the laboratory 7. Itistheresponsibilityoflaboratorypersonnelto
is not permitted. Use of aerosols and pest control ensurethatanymaterialthatcomesintocontact
substances should not be permitted in the labora- withsperm,eggsorembryosisnottoxic,using
tory. anappropriatebioassayoranimalmodelsystem.
B. Thelaboratoryshouldbeinproximitytotheproce- This includes, but is not limited to aspiration
dure room. If not in proximity to each other, then needles, transfer catheters, plastic ware, glass-
the laboratory must ensure that necessary condi- ware,culturemedia,andproteinsource.
tionsforembryoviabilityarenotcompromised.In- 8. All laboratory chemicals and reagents must be
tercom communication is recommended where labeled to indicate date received, date opened,
directcommunicationisnotpossible. andshelflife,whereapplicable.
C. Theincubators and their chamber space should be B. ProcedureManuals
of sufficient volume and configuration to ensure 1. Procedure manuals detailing all aspects of the
positive specimen identification and minimize the assisted reproductive technologies should be
potentialforerrors. available in each laboratory. The purpose of
D. Separateofficespaceshouldbeprovidedforrecord thismanualshouldbetodescribethelaboratory
keeping, data entry, and related administrative procedures in sufficient detail to assure repro-
functions.Computerequipmentshouldbeavailable ducibilityandcompetenceinhandlingofhuman
for data collection compliance. Appropriate refer- gametes, including specimen identification and
encebooks,journals,andotherpublicationsshould labeling. The National Committee for Clinical
beavailableforusebylaboratorystaff. Laboratory Standards (NCCLS) has a specific
E. Ageneral‘‘wetarea’’(i.e.,mediapreparation,equip- format for procedure manuals described in
ment,sterilization,etc.)shouldbeseparatefromthe NCCLSpublicationGP-2A.
areainwhichoocytesandembryosarehandled. 2. These manuals should be reviewed and revised
F. Material for laboratory construction, ventilation of annuallybythelaboratorydirectorandauxiliary
the area, and cleanliness should be appropriate to personnel should be updated and trained on re-
laboratory work. Walls and floors should be com- visedprocedures.
posed of materials easily washed and disinfected. 3. These procedure manuals should include, but
Carpetingisnotacceptable. notbelimitedto,alllaboratoryprocedures.Lab-
oratory proceduresshouldinclude detailedpro-
IV. EquipmentandProcedureManuals tocols, equipment and material lists, sources of
Theseareminimumstandardsforeachcategory. materials,andcompetencylevelrequiredtoper-
A. Alllaboratoriesshouldmaintainthefollowing: formeachprocedure.
1. Incubator(s) with remote alarm system and 4. Maintenance manuals for all laboratory equip-
emergency power back-up. The incubator ment should be maintained in the laboratory.
should be monitored daily for appropriate tem- These should include daily, weekly, monthly, or
perature and gas content before first opening annualmaintenancetobeperformedoneachpiece
when used for patient procedures. Incubators of equipment, documentation of maintenance
shouldbemonitoredusingcalibratedthermom- completed,andcorrectiveactiontaken,ifany.
eters and independent methods of gas analysis, 5. Policy manuals should be maintained in the
notbydigitaldisplayalone. laboratory. These policies might include, but
2. Microscopessuitableforoocyterecovery,deter- should not be limited to, procedures for record
minationoffertilization,semenanalysis,manip- keeping, result reporting, laboratory communi-
ulation of oocytes or embryos, and/or cation, and disposition of business/billing pro-
micromanipulation of oocytes or embryos cedures.
shouldbeused. C. Specific Aspects of Assisted Reproductive Tech-
3. DevicestomaintaintemperatureandpHofme- nologies
dia,eggs,andembryosduringvariousphasesof 1. Culture media preparation and quality control
theprocedure(slidewarmers,incubators,water testing
baths,heatingblock,isolettes,etc.). a. Culturemediaformulateddenovoshoulduti-
4. Disposable materials (tissue culturegrade plas- lizededicatedreagents,glassware,andtissue-
tic) arerecommended forstepsthatinvolveex- culture-grade water (or its equivalent) in its
posuretotissueandbodyfluids. preparation. Quality control testing utilizing
S48 ASRMPracticeCommittee Revisedguidelines Vol.90,Suppl3,November2008
anappropriatebioassaysystemtoevaluatethe plement(e.g.,humanfetalcordserum,ma-
mediaisrequired. ternalordonorserum)preparedin-houseis
b. Qualitycontroltestingisrecommendedwhen notrecommended,ifsuchmediaorsupple-
commercial media is purchased and used ments are prepared, the laboratory must
withinitslabeledexpirationperiodifpretest- test blood from the donor(s) with an
ingbythemanufacturerdoesnotreflectmedia FDA-licensed, approved or cleared test
suitability when in actual use in the labora- and show that the donor(s) is negative or
tory.Documentationofqualitycontroltesting non-reactivefor the following: HIV-1 and
usinganappropriatebioassaysystemmustal- HIV-2, hepatitis B, hepatitis C, syphilis,
waysbesuppliedbythemanufacturer.Labo- HTLV-I and HTLV-II. Each batch of
ratoriesshouldalsoestablishtolerancelimits blood-based media supplement should
for acceptablereceivingconditionsfor trans- alsobetestedusinganappropriatemethod
portedcommercialmedia. beforeitsusetoensurethatitisnotembry-
c. Procedures and documentation for prepara- otoxic.
tionofmedia. 7) Each batch of culture media should be
1) The sources of ultrapure (tissue culture tested before use for osmolarity. Media
grade) water should comply with College pH testing should be performed follow-
ofAmericanPathologists(CAP)standards ing equilibration with C0 at concentra-
2
for reagent grade water. If water is pro- tions used for ART procedures. All lots
duced on site, a comprehensive program of media and media components should
of quality control for the water system be recorded and traceable to each patient
must be in place. This must include, but procedure (e.g. lot numbers recorded on
should not be limited to, system sanitiza- oocyte/embryo data sheets in case of re-
tion,cartridgeexchange,partreplacement, calls, adverse events, etc.).
endotoxin tests and bacterial contamina- 2. Examination of follicular aspirates with egg
tion (colony) testing, and chlorine and/or identification
formaldehydetesting(ifapplicable).Iful- a. All procedures should be performed using
trapure water is purchased, the source, steriletechniqueinanareathathasappropri-
shelf life, and storage conditions must be atecommunicationwithandproximitytothe
strictlydefined.Whiletherearenosetstan- eggretrievalarea.Iftheeggretrievalroomis
dards for levels of endotoxins in embryo separated from the embryology laboratory,
culture media, endotoxin testing of pur- thenamobilelaboratoryunit,modifiedinfant
chased water is recommended if it is not isolette,orotherappropriatemethodmustbe
certifiedendotoxin-free. in place for maintaining follicular fluid tem-
2) Alllotsofchemicals,prepackagedmedia, peratureandpH.
andothermediacomponentsshouldbere- b. Written procedures for the egg search and
corded and specific sources and product identificationincludingmediausedforaspira-
numbersidentifiedaspartoftheprocedure tion, temperature, pH requirements of fluid,
manual and quality control sheets. Sepa- and rapidity with which each sample must
rate,designatedchemicalsshouldbemain- beevaluatedshouldbeavailable.
tainedspecificallyforART. 3. Eggqualityandmaturitygrading
3) Glassware washing protocols, including a. Written protocols should include description
detergent type and source, type of water ofstagesofoocytequalityandmaturity,mag-
used, number of rinses, and exact proce- nification used, maximum time of observa-
duretobefollowed,shouldbestrictlyde- tion, media for observation, and remedial
fined. Heat sterilization should be used stepstobeusedforimmatureoocytes.
wheneverpossible. b. The morphological condition of all eggs
4) Allmediapreparationshouldbeperformed shouldbedocumented.
using sterile technique including location 4. Spermpreparation(includingsamplecollection,
andappropriateenvironment. analysisandspermwashing)
5) Appropriate refrigerated facilities should a. Theprotocolforsamplecollectionshouldin-
be available for media. It is suggested clude abstinence period, type of container
thatperiodicchecksofmediabemadeus- used,facilitiesforcollection,and/ortimepe-
inganacceptablebioassaysystem. riodandconditionsforsamplecollectionout-
6) Theproteinsourceformedicaluseshould sidethe laboratory,procedure andconditions
bestrictlydefined.Whiletheuseofblood- for sample collection with seminal pouches
based media or a blood-based media sup- and intercourse, and the acceptable time
FertilityandSterility(cid:4) S49
periodforsamplecollectionandprovisionof 6. Determinationoffertilization
frozen back-up sample, if any, in relation to a. Alloocytesthathavebeeninseminatedshould
eggretrieval. beexaminedforsignsoffertilizationbyasin-
b. Writtenproceduresforspermwashingshould glesperm(i.e.,twopronuclei[2PN]shouldbe
includemediumtypeandproteinsupplemen- documented).
tation,ifany;sementomediumratio;relative b. Thetimeintervalfromoocyteinseminationto
centrifugal force if centrifugation is used; examinationforfertilizationshouldbespeci-
sperm isolation technique and incubation, if fied.
any; techniques for determination of sample c. Ifoocytesrequireremovalofbloodorcumu-
parameters of concentration, motility, and luscellspriortoexamination,thismaybeper-
morphology. formed using a needle or narrow bore glass
c. Laboratoriesshouldestablishtheirowninter- pipette (pulled over a low flame), or another
nal standards for minimal recovery of total suitablemethod.
motile sperm cells for both male factor and d. If cleaning and examination of an individual
non-malefactorpatients.Thiscanbeusedas oocyte takes longer than 60 seconds, a tem-
an internal quality assurance measure; while perature and pH controlled chamber or oil
individual samples may occasionally deviate overlay should be provided to protect the
from the expectedrange (this norm),compe- egg/embryo.
tency in recovery of motile sperm should be e. Each fertilized oocyte with two PN may be
maintained. transferredtofreshpre-equilibratedmedia.
d. The prepared sample should be used in f. Thestatusofeachoocyteshouldberecorded.
atimelyfashion. g. Written procedures for the reinsemination of
e. Sterile technique and universal precautions oocytesand/ormicromanipulationshouldin-
shouldbeobservedinallprocedures. clude time frame for reinsemination, criteria
f. When donor sperm is used for insemination, foruseofinitialsample(i.e.,minimummotile
complete documentation of its use should in- sperm and elapsed time since processing),
clude source (either internal or external bank) time frame for re-examination of oocytes,
and donor number. Programs should use only and hierarchy for embryo transfer of reinse-
donor sperm banks that are accredited in the minatedoocytes.
statewherethespermwillbeused.Accredited h. Writtenpoliciesshouldbedevelopedfordis-
sperm banks should provide documentation positionofoocyteswithevidenceofabnormal
thatthebankselectsandscreensdonorsinac- fertilization (i.e., disposal, culture, freezing,
cordancewith FDA, state, and ASRM Guide- micromanipulation, IRB-approved research
lines(2). withconsent).
5. Inseminationofoocytes 7. Embryotransferandembryograding
a. Written procedures for insemination should a. The procedure should be performed using
include such details as types of pipettes steriletechnique.
used, maximum volume to be added to oo- b. Thestageofzygoteorembryodevelopmentat
cytes,numberofmotilespermtobeusedfor transfershouldbedocumented.
insemination on a per oocyte, per dish, or c. The protocol for embryo transfer should in-
perunitvolumebasis.Criteriaforalteringin- clude type of medium; time from oocyte re-
seminationconcentrationsforvaryingdegrees trieval and/or insemination to transfer; stage
ofmalefactorshouldbespecified.Themaxi- ofembryodevelopmentattransfer;fateofex-
mumnumberofoocytesperdishorunitvol- cessembryos;typeofcatheterused;alternate
umeshouldbestated. cathetersavailableandcircumstancesforuse
b. Proceduresheetsforeachsample,timeofin- of each; method of transfer; technique for
semination, and relevant observation at time catheter flushing; and conditions and timing
ofinsemination should be kept as part of the oftransferofremainingembryos.
labfile. d. If the embryo transfer facility is separated
c. Sperm sample volume added to oocytes from the embryo lab, appropriate equipment
shouldbebasedonadeterminationofsample and techniques should be used to maintain
concentration and motility performed before media temperature and pH during the proce-
oocyteinsemination. dure (e.g., infant isolette, oil overlay, or mo-
d. During insemination of each dish, tempera- bileunit).
ture, humidity, and pH of the media should e. It is recommended that patients be excluded
be controlled using appropriate (e.g., infant from access to the laboratory to examine
isolette,oiloverlay)measures. ova,embryos,orfortransfers.
S50 ASRMPracticeCommittee Revisedguidelines Vol.90,Suppl3,November2008
f. Adisposablesteriletransfercathetershouldbe external disaster preparedness (including provisions
used. for equipmentback-upintheeventofequipmentfail-
8. Oocyte/embryofreezing ure). In addition, the following guidelines are recom-
Embryo or oocyte freezing may be considered mended(3):
optional. A. Every body fluid sample (semen, blood, follicular
a. Awrittenprotocolshouldincludecryoprotec- fluid) should be handled using universal precau-
tantused(includingsourceandshelflife),me- tions(i.e.,asifitwerecontaminated).Alldonortis-
dia used, type of freezing container (e.g., sues and fluids should be subjected to appropriate
straw, vial, or ampule), stage of embryo for infectious disease screens and quarantine periods
freezing, freezing rate including procedure whereapplicable.
formanualorautomaticseeding,andstorage B. All accredited laboratories are required to have an
conditions. ExposureControlPlan.Arequirementofthisplan
b. All embryo freezing containers (e.g., each is to offer and document Hepatitis B vaccination
straw or vial) must be permanently labeled to all laboratory personnel. Anyemployee that re-
withatleasttwouniqueidentifiers.Amethod fuses is required to sign a waiver that is kept in
ofensuringprompt,accurateretrievalofcry- their employment record. Testing for additional
opreservedspecimensmustbeemployed.Du- STIs may be offered, but not required, with test
plicate records of all embryos in storage results to be directed as indicated by the em-
should be kept, in separate locations, exclu- ployee.
siveofthepatientchartinformation. C. Extraordinaryprecautionsshouldbetakentoavoid
c. Timelimitsforembryostorageshouldbees- accidentalwoundsfromsharpinstrumentscontam-
tablished by each individual laboratory and inatedwithbodyfluids.
determinedpriortofreezing. D. Disposable, nontoxic (non-powdered) gloves
d. If the laboratory performs cryopreservation, should be worn when handling fresh or frozen
there should be a system in place for the bodyfluidsoranymaterialthathascomeincontact
detection of low levels of liquid nitrogen. with body fluids. Gloves should be removed and
e. Procedures for thawing embryos should in- discardedwhenleavingthelaboratoryorhandling
clude cryoprotectant concentrations and me- thetelephone.Glovesshouldneverbereused.
dia used, temperature requirements for E. A laboratory coat or appropriate gown should be
thawing,criteriaforassessingembryoviabil- worn in the laboratory and removed upon leaving
ity, time period for embryo culture prior to thelaboratory.
transfer, protocol for patient preparation for F. Safety glasses or goggles are suggested where ap-
frozenembryotransfersandconditionsunder propriate.
whichembryotransferswilltakeplace. G. Handsshouldbewashedafterremovinggownsand
9. Micromanipulation gloves and immediately if they become contami-
Micromanipulation is considered optional at nated with body fluids. All hand washing should
eachfacility. bedonewithdisinfectantsoapandhotwateroral-
a. Protocols for micromanipulation should in- cohol-basedsolutions.
cludecircumstancesandscreeningcriteriafor H. Disposablelaboratorysuppliesmustbeusedwhen-
micromanipulation,proceduresforprocessing everpossible.
sperm samples, types of microtools to be I. Contaminated laboratory equipment and/or work
madeorpurchased,media/proteinsource,and surfaces should be disinfected and sterilized after
conditions for micromanipulation including a spill (e.g., 1:10 dilution of 5.25% sodium-hypo-
temperature, pH and osmolarity, criteria for chlorite household bleach in water or other proce-
judgingoocytematurityandoocyteandembry- dures approved by the Centers for Disease
onicqualitypriortomicromanipulation,viabil- ControlandPrevention[CDC]).
ity following micromanipulation, and J. Mechanicalpipettingdevicesshouldbeusedforthe
conditions under which embryo transfer will manipulationofliquidsinthelaboratory.Mouthpi-
takeplace. pettingisneverpermitted.
b. Personnel should have demonstrated compe- K. All procedures and manipulation of body fluids
tenceinperformingmicromanipulation. should be performed to minimize the creation of
droplets and aerosols. Complete facemasks or the
V. LaboratorySafetyandInfectionControl use of appropriate hoods should be considered
Proceduresandpoliciesonlabsafetymustbeavailable when procedures are conducted which have a high
toalllaboratorypersonnelandshouldbereviewedan- potentialforcreatingaerosolsordroplets.Centrifu-
nually by the laboratory director. Protocols should be gationorvigorousmixingofopencontainersrepre-
availableforfireandelectricalsafetyandinternaland sentsexamplesofthisproblem.Centrifugesmaybe
FertilityandSterility(cid:4) S51
placed in exhaust hoods during use or non-aerosol syphilis and HTLV-I and -II screened serum
centrifuges may be used. Capped tubes must be products.Usesteriletechniques,appropriatedis-
usedforcentrifugation. easescreens,andsafelaboratoryprocedures.
L. Eating,drinking,smoking,applicationofmakeup, 7. Allpatientworksheetsshouldhaveclearpatient
ormanipulationofcontactlensesarenotpermitted identifyinginformationaswellaslaboratoryac-
inthelaboratory. cession numbers that uniquely identify the pa-
M. All discarded body fluid samples and disposable tient during all related procedures. All Petri
laboratorysuppliesshouldbedisposedofproperly dishes, test tubes and other materials that serve
in a container marked BIOLOGICAL HAZARD for culture are labeled with proper identifiers.
anddisposedofaccordingly. Labelingofstrawsorampulesforcryopreserva-
N. Policies must be established to document all ad- tionmustbeindelible.
verse laboratory incidents. All incident reports 8. Written and/or computer records of all labora-
and corrective action plans should be included in tory aspects of the ART cycles for each patient
theQualityAssurancereview. should be maintained. All steps throughout the
O. AcopyofcurrentMaterialSafetyDatasheetsand ARTproceduremustbetraceabletothetechni-
otherreferencesthatlistthedetailsofhazardsand calpersonperformingtheprocedure,andtheoo-
the precautions for safe handling and storage of cytes must be accounted for from retrieval to
chemicalsandreagentsshouldbeavailable. embryotransfer/cryopreservationordisposal.
9. Documentation of emergency power generator
checksandautomaticpowertransferswitchfunc-
VI. QualityControl/Assurance
tion should be made on a periodic basis. Also,
A. QualityControl(QC).
systemfunctionchecksshouldbemadeanddocu-
1. A written procedure manual must be readily
mented (e.g., power off, high temp, low C0
availableandfollowedbylaboratorypersonnel. 2
alarms).Afterhours,alarmsshouldbetransmitted
The laboratory director or designated supervi-
toapersonwhocanrespondtotheseemergencies.
sorypersonnelshouldreviewandupdateallpro-
ceduresonatleastanannualbasis.Anychanges B. QualityAssurance(QA)
mustbeapproved,signedanddatedbythelabo- 1. QA is a comprehensive program designed to
ratorydirectororbydesignatedproxy.Copiesof lookatthelaboratoryasawholeandtoidentify
oldorarchivalprotocolsandupdatedprocedures problemsorerrorsthatexistinanattempttoim-
should be retained for a period of at least two provetheentireprocess.IndicatorsusedinaQA
years. programshouldbeobjective,relevanttothelab-
2. Equipmentshouldbemaintainedandcalibrated oratory, and measure a broad range of specific
on a daily, monthly, and annual basis as appro- events or aspects of treatment that reflect the
priate to the type of equipment. This includes quality of care. Foreach indicator incorporated
a record of instrument calibration, functional into the laboratory’s QA program, an appropri-
checks of equipment when possible, and evi- atethresholdneedstobeestablished.Thethresh-
denceofanactivereviewofrecords.Documen- old sets the critical level of quality laboratory
tationorcorrectiveactionwheninstrumentsand/ performance for each indicator. Since clinical
orproceduresmalfunctionshouldbekept. protocolsarenotuniformamongARTlaborato-
3. Allnewprotocolsshouldbevalidatedanddocu- ries, the threshold values must be specific for
mented. eachindividualclinicallaboratory(4).
4. Thelaboratoryshoulddefineandmaintainwrit- 2. The quality assurance program should include
ten criteria for preparation, storage, handling, amechanismtoreviewandanalyzedatainorder
and preparation of specimens. All reagents toidentifyproblemsrelatedtothequalityofcare
should be dated and used within the indicated providedbythelaboratory.Thisshouldinclude,
expirationdate. butnotbelimitedto,thefollowing:
5. All media and protein supplementation should a. Mechanismstodetectclerical,transcriptional,
be tested for quality utilizing bioassay systems oranalyticalmistakes.Whenproblemsand/or
suchastheone-ortwo-cellmouseembryocul- adversetrends are identified, correctivemea-
tureassay,orquantitativespermmotilityorvia- suresshouldbeimplementedtoresolvetheis-
bilityassay.Eachbatchofpurchasedmediamust sue to ensure quality patient care. There
betestedbythevendorwithanappropriatebio- should be later documentation whether cor-
assay.Itisuptothediscretionofthelaboratory rectivemeasuresinstitutedwereabletoeffec-
to perform additional quality control assays on tivelyresolvetheproblem.
purchasedmedia. b. Data from the laboratory should be gathered
6. Infectioncontrol(seesafetyproceduresabove). andanalyzedonaregularbasisandtheinfor-
Use HIV-1 and -2, Hepatitis B, Hepatitis C, mation gathered should be used to identify
S52 ASRMPracticeCommittee Revisedguidelines Vol.90,Suppl3,November2008
and resolve problems. A copy of this report F. SatellitefacilitiesmaybesetuptoperformGIFT
should be kept for review. Quality assurance procedures only if facilities are available to pro-
also includes the turnaround time for reports videIVFproceduresasneededonsite.
and consistencyof service as well asstatisti-
calanalysisofoutcomesdata.
REFERENCES
c. Anadverseincidentfileshouldbemaintained,
includingbutnotlimitedtosignificantclerical 1. U.S.FoodandDrugAdministration.Tissueguidances,rulesandre-
lated documents. Available at: http://www.fda.gov/cber/tissue/docs.
andanalyticalerrorsaswellasunusuallabo-
htm.
ratoryresults.
2. TheAmericanSocietyforReproductiveMedicine.2008Guidelines
d. The practice must participate in data collec- for gamete and embryo donation. Fertil Steril 2008;90(Suppl
tion for purposes of clinic submission in 3):S30–44.
compliance with guidelines established by 3. PracticeCommitteoftheAmericanSocietyforReproductiveMedi-
cine.Guidelinesfordevelopmentofanemergencyplanforinvitrofer-
SART.
tilizationprograms.FertilSteril2008;89:793–5.
3. The laboratory must participate in proficiency
4. MayerJF,JonesEL,Dowling-LaceyD,etal.Totalqualityimprove-
testingforthoseproceduresforwhichitisavail- mentintheIVFlaboratory:choosingindicatorsofquality.Reproduc-
able.Forthosetestingservicesinwhichacom- tiveBioMedicineOnline2003;7(Comp.1):192–6.
mercial proficiency test is not available, the
laboratorymustestablishaninternalqualityas-
GUIDELINESFORHUMANANDROLOGYLABORATORIES
surance program. Consideration should also be
I. Organization of the Laboratory and Definition of Ser-
giventosharingsampleswithotherlaboratories
vices
ordevelopingothermeansofexternalqualityas-
A. GeneralLaboratory
sessment.Externalqualityassessmentservesas
1. Theinstitutionalaffiliation,history,definitionof
acompaniontoalaboratory’sinternalqualityas-
services, and the purpose of the laboratory
sessmentprogram.
shouldbeclearlydefined.
VII. SatelliteFacilities 2. The laboratory must be in compliance with any
A satellite facility is a facility in which there is an state or federal licensing requirements. As
‘‘off-site’’ laboratory director whose primary direc- a high complexity laboratory, as defined by the
torshipisatanotherphysicalfacility,whichhasasep- federal Department of Health and Human Ser-
arate identification number (SART number) and vices(HHS),anandrologylaboratoryfallsunder
aseparatemedicaldirector.ARTlaboratoryservices thepurviewofClinicalLaboratoryImprovement
may be provided in satellite facilities provided the Actof1988(CLIA’88)regulations.Theseregula-
followingcriteriaaremet: tions undergo routine interval reviews with
A. Alaboratorydirector(seeabove)overseesallac- amendments made as appropriate. Readers are
tivities in the remote location. The director will advisedtoconsultthemostrecenteditionofthe
establish protocols, decide on medium prepara- regulationsinordertoensurecurrentapplicability.
tion and source, provide training to personnel, Anycurrentlicenses,permits,andcertificationby
anddeterminemethodologiestobeused. anyothergroupsoragenciesshouldbelisted.
B. Qualified embryology technologists should be 3. ThelaboratorymustsatisfyanyInstitutionalRe-
employed at the satellite facility or provided by viewBoard(orequivalentHumanInvestigation
the laboratory director as needed if the latter Committee) requirements for any investigative
does not perform the procedures. Embryology procedures,ifapplicable.
technologists should meet the educational and 4. Laboratory animals should be maintained ac-
trainingcriteriadescribedherein. cording to local, state, or federal requirements
C. The laboratory director should provide supervi- and/orregulations,ifapplicable.
sionanddocumentappropriatelinesofdailycom- 5. Andrologylaboratoriesthatcryopreservesemen
municationwithsatellitefacilitiesduringallIVF fortherapeuticuseand/orpreparesemenforuse
procedures.Whilethelaboratoryisactivelytreat- in reproductive therapies are considered manu-
ing patients, the off-site director is required to facturers of transplantation products (sperm)
physically visit the laboratory at a frequency accordingtotheFDA’sCell/TissueTransplanta-
thatwillensuretheoptimalfunctioningofthelab- tion regulations (1). All andrology laboratories
oratoryandthedeliveryofqualitypatientcare. involved in these activities must be in compli-
D. A satellite laboratory must meet the same stan- ancewiththeseFDAregulations.
dards asanyother embryologylaboratory as de- B. SpecificLaboratoryProcedures
scribedintheseguidelines. Itisrecognizedthatasinglestandardizedprotocol
E. Equipmentandlaboratoryspaceshouldmeetallof isinappropriateorunavailableformanyandrology
thestandardslistedaboveasappropriateforproce- laboratory procedures. In the absence of a widely
duresthatareperformedatthesatellitefacility. accepted, standardized protocol, each laboratory
FertilityandSterility(cid:4) S53
must develop its own protocol for that particular sibilitiesforeachtypeoflaboratorypersonnel.The
procedurewithappropriatecontrolsandmethodol- following descriptions include a summary of cer-
ogy to assure reliable, acceptable results. Androl- tainrelevantitemsregardingqualificationsandre-
ogy laboratories perform some or all of the sponsibilities of laboratory directors, general
followingprocedures: supervisors and testing personnel. Under CLIA
1. Semenanalysisandprocedures:thesemenanal- ’88, personnel qualifications and responsibilities
ysisisessentialforthediagnosisofmalefertility arealsodefinedfortechnicalsupervisorsandclin-
potential.Inadditiontothestandardsemenanal- icalconsultants(notincludedhere).Forandrology
ysis, semen may be tested for fructose, adeno- laboratories, individuals may assume the role of
sine triphosphate (ATP) and other biochemical more than one of these jobs provided they meet
markers.Assaysmayincludetestsforspermsur- all of the personnel qualifications and are able to
vival, sperm viability, sperm membrane integ- meet all of the responsibilities cited. Laboratory
rity, ability of sperm to penetrate human personnel should possess a current license issued
cervical mucus in either a cross-match test or by the state in which the laboratory is located, if
in capillary tubes (2, 3). Standards for semen suchlicensingisrequired.
analysisaredetailedintheWorldHealthOrgani-
1. LaboratoryDirector:
zation(WHO)LaboratoryManualfortheExam-
a. Qualifications.Thereareanumberofdifferent
ination of Human Semen and Semen-Cervical
paths for qualifying as the director of a high
MucusInteraction(4).
complexity laboratory, such as an andrology
2. Sperm antibody testing: the sperm antibody as-
laboratory,underCLIA‘88.Theseinclude:
saysusedmustbeabletomeasurethepresence
1) An M.D. or D.O. with board-certification
of sperm antibodies on the sperm as well as in
inanatomicorclinicalpathology,orboth.
the serum, cervical mucus, or seminal plasma.
2) An M.D. or D.O. with laboratory training
These assays may work either directly or indi-
(eitheroneyearoflaboratorytrainingdur-
rectly on the sperm and fluids. Both positive
ingmedicalresidencyoratleasttwoyears
and negative controls must be used to validate
ofexperiencedirectingorsupervisinghigh
the assay. The mixed antiglobulin reaction and
complexitytesting).
the immunobead test are described in the
3) Aboard-certifiedPh.D.scientistwithade-
WHO Laboratory Manual (4). Other protocols
greeinachemical,physical,biologicalor
arealsoavailable(5).
clinical laboratory science from an ac-
3. Sperm penetration assay or the zona-free ham-
credited institution andbe certified by the
steroocytetest:humanspermfertilitypotential
AmericanBoardofMedicalMicrobiology,
ismeasuredbytheabilityofspermtopenetrate
AmericanBoardofClinicalChemistry,the
zona-free hamster eggs. Positive controls must
AmericanBoardofBioanalysis,theAmer-
be utilized tovalidate test results. A discussion
ican Board of Medical Laboratory Immu-
of the zona-free hamster oocyte assay is found
nology or other board deemed
in the WHO Laboratory Manual (4). Other de-
comparablebyHHS.
scriptionsoftheassayareavailable(6).
4) Apersonqualifiedunderstatelawtodirect
4. Sperm cryopreservation: sperm cryopreserva-
laboratories within a state on or before
tioninvolvesthefreezingandstorageofhuman
February28,1992.
spermforfutureuse.Spermforfreezingmaybe
5) A person serving as a laboratory director
obtained from either patients or donors. Guide-
andqualifiedorcouldhavequalifiedasdi-
linesforSpermDonationhavebeenestablished
rectoronorbeforeFebruary28,1992.
by The American Society for Reproductive
b. Responsibilities.Thedirectormustensure:
Medicine(7)andTheAmericanAssociationof
1) Thequalityoftesting.
TissueBanks(8).
2) Thesafetyoftheworkingenvironment.
5. Preparation of sperm for intrauterine insemina-
3) That the test methodologies will provide
tionwithhusband,partnerordonorsperm:fresh
qualityresults.
andfrozenspermmaybeprocessedforintrauter-
4) Thatproceduresareverified,accurateand
ineorintracervicalinsemination.
reliable.
6. Computerassistedsemenanalysis(CASA):lab-
5) ThatthelaboratoryisenrolledinanHHS-
oratoriesmusthaveaprotocolthat,onaperiodic
approvedproficiencytestingprogram.
basis,validatesthattheirassistedsemenanalysis
6) That QA and QC programs are estab-
equipmentisfunctioningcorrectly.
lishedandmaintained.
II. LaboratoryPersonnel 7) That acceptable levels of analytical per-
A. Personnel Qualifications and Responsibilities: formance for each test system is estab-
CLIA’88hasspecificqualificationsandjobrespon- lishedandmaintained.
S54 ASRMPracticeCommittee Revisedguidelines Vol.90,Suppl3,November2008