Revised guidelines for human embryology and andrology laboratories

15 Pages·2015·0.17 MB·English

Revised guidelines for human embryology and
andrology laboratories
The Practice Committee of the American Society for Reproductive Medicine and the Practice
Committee of the Society for Assisted Reproductive Technology
Birmingham, Alabama
These guidelines provide clinicians with specific guidance on laboratory procedures to ensure that their programs’
practice reflects current recommendations. (Fertil SterilÒ 2008;90:S45–59. Ó2008 by American Society for Re-
productive Medicine.)
GUIDELINES FOR HUMAN EMBRYOLOGY LABORATORIES laboratories are not referral laboratories but main-
I. Organization of the Laboratory and Definition of tain specific affiliation with a physician group(s).
Services Embryology laboratories perform some or all of the
A. General Laboratory following steps:
1. The institutional affiliation, where appropriate, 1. Culture medium preparation and quality con-
plus the history and definition of services and trol testing
markets served, should be clearly defined for 2. Examination of follicular aspirates with oocyte
each embryology laboratory. identification
2. The laboratory must undergo certification and 3. Oocyte quality and maturity grading
accreditation by an appropriate agency, e.g., 4. Sperm preparation: semen collection and anal-
College of American Pathologists/American ysis, sperm washing
Society for Reproductive Medicine, Joint Com- 5. Insemination of oocytes
missiononAccreditation ofHealthcareOrganiza- 6. Evaluation of fertilization and zygote quality
tions, or New York State Tissue Bank and must 7. Embryo culture and embryo grading
be in compliance with any local, state, or federal 8. Embryo transfer (either uterine or tubal)
licensing requirements and/or regulations. Any 9. Oocyte/embryo/sperm cryopreservation, stor-
current licenses, permits, and certification by age and thawing
any other groups or agencies should be listed. 10. Micromanipulation of human oocytes and/or
3. The laboratory must satisfy Institutional Review embryos (e.g. Intracytoplasmic Sperm Injec-
Board (or equivalent Human Investigation Com- tion [ICSI], Assisted Hatching [AH], polar
mittee) requirements for any investigative proce- body or embryo biopsy for Preimplantation Ge-
dures, if applicable. netic Diagnosis [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
requirements and/or regulations, if applicable. said procedures.
5. Embryology laboratories are considered manu-
II. Laboratory Personnel
facturers of transplantation products (gametes
A. Personnel Qualifications and Responsibilities
and embryos) according to the FDA’s Cell/Tis-
There should be sufficient personnel to provide em-
sue Transplantation regulations (1). All embry-
bryology services as needed in a timelymannerwith
ology laboratories must be in compliance with
amechanism in place to provide back up for the lab-
these FDA regulations.
oratory personnel. There are several categories of
B. Specific Laboratory Procedures
personnel. Staffing levels should be appropriate
Embryology laboratories are an integral part of In
for the size and volume of the program; a minimum
Vitro Fertilization (IVF), Gamete Intrafallopian
of two qualified persons is required who are capable
Transfer (GIFT), Zygote Intrafallopian Transfer
of performing all technical services.
(ZIFT), Embryo Cryopreservation, Oocyte or Em-
1. Embryology Laboratory Director
bryo Donation, and Gestational Surrogacy Pro-
a. Qualifications: The individual must fulfill
grams. These are collectively known as Assisted
both of the following requirements:
Reproductive Technologies (ART). Embryology
1) An earned doctorate degree (Ph.D.) from an
accredited institution in a chemical, physi-
Guideline
cal, or biological science as the major sub-
Revised August 2008.
Received and accepted July 28, 2006. ject or a medical degree (M.D. or D.O.)
Reprints will not be available. from an accredited institution or have
0015-0282/08/$34.00 Fertility and Sterilityâ Vol. 90, Suppl 3, November 2008 S45
doi:10.1016/j.fertnstert.2008.08.099 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.
qualified as a laboratory director prior to 2) Ensuring that the physical plant (space, fa-
July 20, 1999. Effective January 1, 2006, cilities and equipment) and environmental
all new laboratory directors should hold conditions of the laboratory are appropri-
High Complexity Laboratory Director ate and safe.
(HCLD) or American Board of Bioanalysis 3) Maintaining aseptic conditions in the labo-
Embryology Laboratory Director (ABB- ratory.
ELD)certificationor its equivalent. Labora- 4) Ensuring that patient confidentiality is
tory directors grandfathered in are strongly maintained throughout the laboratory
encouraged to seekHCLDorELDcertifica- ART process.
tion. The laboratory director should have 5) Providing an approved procedural manual
the expertise and/or specialized training in to all laboratory personnel, establishing
biochemistry, cell biology, and physiology and maintaining a laboratory quality assur-
of reproduction with experience in experi- ance program.
mental design, statistics, and problem solv- 6) Providing consultation to physicians and
ing. The laboratory director should be others, as appropriate, regarding labora-
responsible for formulating laboratory pol- tory aspects of treatment.
icies and protocols and communicating 7) Employing a sufficient number of qualified
with the medical director regarding patient laboratory personnel to perform thework of
progress and protocols as they affect the the laboratory. At a minimum, there should
laboratory aspects of treatment. be two (2) qualified embryologists. Table 1
2) Two years documented experience in a pro- provides minimum staff sizes for the vol-
gram performing IVF-related procedures. ume of cycles (retrievals and cryopreserva-
This experience should include: tion cycles). Additional laboratory staff
a) Familiarity with laboratory quality con- may be required if andrological and/or en-
trol, inspection, and accreditation pro- docrinological duties are also assigned.
cedures. c. The embryology laboratory director should
b) Detailed knowledge of cell culture and ensure that all personnel receive appropriate
ART and andrology procedures per- training for the ART laboratory procedures
formed in mammalian systems. 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
ART laboratory procedures performed.
least six months (may be concurrent with
d. An ‘‘off-site’’ laboratory director is onewhose
documented experience) and completed
primary directorship is at another physical fa-
at least 60 ART procedures under supervi-
cility, which has a separate identification
sion. A procedure is defined as a combina-
number (SART number) and a separate med-
tion of the examination of follicular
ical director. An off-site director has the same
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
visit the laboratory at a frequency that will en-
by a signed letter from the laboratory di-
sure the proper functioning of the laboratory
rector of the training practice. In addition
and assure appropriate patient care. Minimum
to these qualification requirements, the
embryology laboratory director should:
TABLE 1
a) Obtain at least 12 hours of accredited
continuing education annually in assis- Recommended staff according to volume.
ted reproductive technology or clinical
Number of Minimum number of
laboratory practice.
laboratory cycles embryologists
b) Demonstrate technical competency in
the embryology laboratory by docu- 1–150 2
menting performance of specific proce- 151–300 3
dures and results that are within 301–600 4
acceptable standards for that program. >600 1 additional embryologist
b. Responsibilities: These include: per additional 200
1) Providing accessibility for on-site, tele- cycles
phone or electronic consultations as
ASRM Practice Committee. Revised guidelines. Fertil Steril 2008.
needed.
S46 ASRM Practice Committee Revised guidelines Vol. 90, Suppl 3, November 2008
standards would require a frequency of no less procedures under continuous supervision
than 1 visit per month, while the lab is active. of the laboratory director or supervisor.
The lab director should also be available at all b. In addition to meeting these requirements, the
times by fax, phone, or email to address any embryology laboratory technologist should:
issues that may arise. The off-site director 1) Obtain at least 12 hours of accredited con-
must be present on site for any accreditation tinuing education annually in ART or clin-
or certification procedures. A laboratory di- ical laboratory practice;
rector shall direct no more than five separate 2) Performat least 20ARTproceduresper year.
laboratories of any type. c. Experience and documented training in tis-
2. Embryology Laboratory Supervisor sue culture, sperm-egg interaction, or related
The embryology laboratorymay have one ormore areas of animal reproduction is desirable.
qualified laboratory supervisorswho, under thedi- The embryology laboratory technologist
rection of the laboratory director, provide day-to- works under the supervision of a laboratory
day supervision of laboratory personnel perform- director or supervisor. Programs for the ap-
ing ART procedures. If the medical director is propriate training of embryology laboratory
also the laboratory director, there should be a des- technologists should be in place with docu-
ignated laboratory supervisor. If the embryology mentation of completion for each employee.
laboratory director is primarily located off-site, d. Responsibilities: These include processing
there should bea designated laboratory supervisor. specimens, being able to independently per-
a. Qualifications: The embryology laboratory form all the routine technical procedures car-
supervisor should either meet the qualification ried out in the embryology laboratory under
requirements designated for laboratory direc- the supervision of a laboratory director or su-
tor or fulfill both of the following require- pervisor, and reporting results.
ments: B. Personnel Records
1) Have an earned bachelor’s or master’s de- There must be written documentation of compli-
gree in chemical, physical, biological, ance with the section described above. This should
medical technology, clinical or reproduc- include the following items:
tive laboratory science from an accredited 1. An itemized list of all personnel, their capacity
institution; (full-time versus part-time), and their shifts, if
2) Have documented training, which includes applicable. Include the total full-time equiva-
performing, at a minimum, at least 60 ART lents filled by full-time and part-time personnel.
procedures under supervision. 2. A list delineating the education, training, and job
b. In addition to meeting these requirements, the qualifications of all laboratory personnel.
embryology laboratory supervisor should: 3. An organizational chart documenting the chain
1) Obtain at least 12 hours of accredited con- of command so that a responsible individual
tinuing education annually in assisted re- can always be identified.
productive technology or clinical 4. An itemization of the training of personnel for
laboratory practice each specific laboratory test offered; definitive
2) Performat least 20ARTprocedures per year. training programs for all procedures should be
c. Responsibilities: These include day-to-day established.
supervision and oversight of the embryo labo- 5. An itemization of personnel participation in
ratory and laboratory director responsibilities training courses, educational programs, and/or
as authorized in writing by the embryology technical meetings and maintain a record of
laboratory director. such participation.
3. Embryology Laboratory Technologist 6. Documentation delineating the continuing labo-
a. Qualifications: Embryology laboratory tech- ratory experience necessary to maintain techni-
nologists who perform ART laboratory proce- cal competency.
dures should either meet the qualification 7. Documentation of the health status, physical ex-
requirements for laboratory supervisor, or ful- aminations, or laboratory tests on personnel
fill both of the following requirements: whenever required.
1) Have an earned bachelor’s or master’s de- 8. Annual performance reviews for personnel.
gree in chemical, physical, biological,
medical technology, clinical, or reproduc- III. Laboratory Space and Design
tive laboratory science from an accredited The embryology laboratory should have adequate
institution; space to ensure safe and comfortable working condi-
2) Have documented training, which includes tions and be of a design that is appropriate for the vol-
performing, at a minimum, at least 30 ART ume of procedures performed.
Fertility and Sterilityâ 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 the size of the laboratory.
another lab is not adequate unless it is walled 6. A pH meter and osmometer for regular monitor-
off). Use of toxic chemicals or radioisotopes, in- ing of media.
cluding toxic cleaning materials, in the laboratory 7. It is the responsibility of laboratory personnel to
is not permitted. Use of aerosols and pest control ensure that any material that comes into contact
substances should not be permitted in the labora- with sperm, eggs or embryos is not toxic, using
tory. an appropriate bioassay or animal model system.
B. The laboratory should be in proximity to the proce- 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, culture media, and protein source.
tions for embryo viability are not compromised. In- 8. All laboratory chemicals and reagents must be
tercom communication is recommended where labeled to indicate date received, date opened,
direct communication is not possible. and shelf life, where applicable.
C. The incubators and their chamber space should be B. Procedure Manuals
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
potential for errors. available in each laboratory. The purpose of
D. Separate office space should be provided for record this manual should be to describe the laboratory
keeping, data entry, and related administrative procedures in sufficient detail to assure repro-
functions. Computer equipment should be available ducibility and competence in handling of human
for data collection compliance. Appropriate refer- gametes, including specimen identification and
ence books, journals, and other publications should labeling. The National Committee for Clinical
be available for use by laboratory staff. Laboratory Standards (NCCLS) has a specific
E. A general ‘‘wet area’’ (i.e., media preparation, equip- format for procedure manuals described in
ment, sterilization, etc.) should be separate from the NCCLS publication GP-2A.
area in which oocytes and embryos are handled. 2. These manuals should be reviewed and revised
F. Material for laboratory construction, ventilation of annually by the laboratory director and auxiliary
the area, and cleanliness should be appropriate to personnel should be updated and trained on re-
laboratory work. Walls and floors should be com- vised procedures.
posed of materials easily washed and disinfected. 3. These procedure manuals should include, but
Carpeting is not acceptable. not be limited to, all laboratory procedures. Lab-
oratory procedures should include detailed pro-
IV. Equipment and Procedure Manuals
tocols, equipment and material lists, sources of
These are minimum standards for each category.
materials, and competency level required to per-
A. All laboratories should maintain the following:
form each procedure.
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
annualmaintenance tobeperformedoneachpiece
when used for patient procedures. Incubators
of equipment, documentation of maintenance
should be monitored using calibrated thermom-
completed, and corrective action taken, if any.
eters and independent methods of gas analysis,
5. Policy manuals should be maintained in the
not by digital display alone.
laboratory. These policies might include, but
2. Microscopes suitable for oocyte recovery, deter-
should not be limited to, procedures for record
mination of fertilization, semen analysis, 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.
should be used.
C. Specific Aspects of Assisted Reproductive Tech-
3. Devices to maintain temperature and pH of me-
nologies
dia, eggs, and embryos during various phases of
1. Culture media preparation and quality control
the procedure (slide warmers, incubators, water
testing
baths, heating block, isolettes, etc.).
a. Culture media formulated de novo should uti-
4. Disposable materials (tissue culture grade plas-
lize dedicated reagents, glassware, and tissue-
tic) are recommended for steps that involve ex-
culture-grade water (or its equivalent) in its
posure to tissue and body fluids.
preparation. Quality control testing utilizing
S48 ASRM Practice Committee Revised guidelines Vol. 90, Suppl 3, November 2008
an appropriate bioassay system to evaluate the plement (e.g., human fetal cord serum, ma-
media is required. ternal or donor serum) prepared in-house is
b. Quality control testing is recommended when not recommended, if such media or supple-
commercial media is purchased and used ments are prepared, the laboratory must
within its labeled expiration period if pretest- test blood from the donor(s) with an
ing by the manufacturer does not reflect media FDA-licensed, approved or cleared test
suitability when in actual use in the labora- and show that the donor(s) is negative or
tory. Documentation of quality control testing non-reactive for the following: HIV-1 and
using an appropriate bioassay system must al- HIV-2, hepatitis B, hepatitis C, syphilis,
ways be supplied by the manufacturer. Labo- HTLV-I and HTLV-II. Each batch of
ratories should also establish tolerance limits blood-based media supplement should
for acceptable receiving conditions for trans- also be tested using an appropriate method
ported commercial media. before its use to ensure that it is not embry-
c. Procedures and documentation for prepara- otoxic.
tion of media. 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-
of American Pathologists (CAP) standards ing equilibration with C02 at concentra-
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, cartridge exchange, part replacement, calls, adverse events, etc.).
endotoxin tests and bacterial contamina- 2. Examination of follicular aspirates with egg
tion (colony) testing, and chlorine and/or identification
formaldehyde testing (if applicable). If ul- a. All procedures should be performed using
trapure water is purchased, the source, sterile technique in an area that has appropri-
shelf life, and storage conditions must be ate communication with and proximity to the
strictly defined.While there are no set stan- egg retrieval area. If the egg retrieval room is
dards for levels of endotoxins in embryo separated from the embryology laboratory,
culture media, endotoxin testing of pur- then a mobile laboratory unit, modified infant
chased water is recommended if it is not isolette, or other appropriate method must be
certified endotoxin-free. in place for maintaining follicular fluid tem-
2) All lots of chemicals, prepackaged media, perature and pH.
and other media components should be re- b. Written procedures for the egg search and
corded and specific sources and product identification including media used for aspira-
numbers identified as part of the procedure tion, temperature, pH requirements of fluid,
manual and quality control sheets. Sepa- and rapidity with which each sample must
rate, designated chemicals should be main- be evaluated should be available.
tained specifically for ART. 3. Egg quality and maturity grading
3) Glassware washing protocols, including a. Written protocols should include description
detergent type and source, type of water of stages of oocyte quality and maturity, mag-
used, number of rinses, and exact proce- nification used, maximum time of observa-
dure to be followed, should be strictly de- tion, media for observation, and remedial
fined. Heat sterilization should be used steps to be used for immature oocytes.
whenever possible. b. The morphological condition of all eggs
4) All media preparation should be performed should be documented.
using sterile technique including location 4. Sperm preparation (including sample collection,
and appropriate environment. analysis and sperm washing)
5) Appropriate refrigerated facilities should a. The protocol for sample collection should in-
be available for media. It is suggested clude abstinence period, type of container
that periodic checks of media be made us- used, facilities for collection, and/or time pe-
ing an acceptable bioassay system. riod and conditions for sample collection out-
6) The protein source for medical use should side the laboratory, procedure and conditions
be strictly defined. While the use of blood- for sample collection with seminal pouches
based media or a blood-based media sup- and intercourse, and the acceptable time
Fertility and Sterilityâ S49
period for sample collection and provision of 6. Determination of fertilization
frozen back-up sample, if any, in relation to a. All oocytes that have been inseminated should
egg retrieval. be examined for signs of fertilization by a sin-
b. Written procedures for sperm washing should gle sperm (i.e., two pronuclei [2PN] should be
include medium type and protein supplemen- documented).
tation, if any; semen to medium ratio; relative b. The time interval from oocyte insemination to
centrifugal force if centrifugation is used; examination for fertilization should be speci-
sperm isolation technique and incubation, if fied.
any; techniques for determination of sample c. If oocytes require removal of blood or cumu-
parameters of concentration, motility, and lus cells prior to examination, this may be per-
morphology. formed using a needle or narrow bore glass
c. Laboratories should establish their own inter- pipette (pulled over a low flame), or another
nal standards for minimal recovery of total suitable method.
motile sperm cells for both male factor and d. If cleaning and examination of an individual
non-male factor patients. This can be used as 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 expected range (this norm), compe- egg/embryo.
tency in recovery of motile sperm should be e. Each fertilized oocyte with two PN may be
maintained. transferred to fresh pre-equilibrated media.
d. The prepared sample should be used in f. The status of each oocyte should be recorded.
a timely fashion. g. Written procedures for the reinsemination of
e. Sterile technique and universal precautions oocytes and/or micromanipulation should in-
should be observed in all procedures. clude time frame for reinsemination, criteria
f. When donor sperm is used for insemination, for use of initial sample (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 minated oocytes.
state where the sperm will be used. Accredited h. Written policies should be developed for dis-
sperm banks should provide documentation position of oocytes with evidence of abnormal
that the bank selects and screens donors in ac- fertilization (i.e., disposal, culture, freezing,
cordance with FDA, state, and ASRM Guide- micromanipulation, IRB-approved research
lines (2). with consent).
5. Insemination of oocytes 7. Embryo transfer and embryo grading
a. Written procedures for insemination should a. The procedure should be performed using
include such details as types of pipettes sterile technique.
used, maximum volume to be added to oo- b. The stage of zygote or embryo development at
cytes, number of motile sperm to be used for transfer should be documented.
insemination on a per oocyte, per dish, or c. The protocol for embryo transfer should in-
per unit volume basis. Criteria for altering in- clude type of medium; time from oocyte re-
semination concentrations for varying degrees trieval and/or insemination to transfer; stage
of male factor should be specified. The maxi- of embryo development at transfer; fate of ex-
mum number of oocytes per dish or unit vol- cess embryos; type of catheter used; alternate
ume should be stated. catheters available and circumstances for use
b. Procedure sheets for each sample, time of in- of each; method of transfer; technique for
semination, and relevant observation at time catheter flushing; and conditions and timing
of insemination should be kept as part of the of transfer of remaining embryos.
lab file. d. If the embryo transfer facility is separated
c. Sperm sample volume added to oocytes from the embryo lab, appropriate equipment
should be based on a determination of sample and techniques should be used to maintain
concentration and motility performed before media temperature and pH during the proce-
oocyte insemination. dure (e.g., infant isolette, oil overlay, or mo-
d. During insemination of each dish, tempera- bile unit).
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, oil overlay) measures. ova, embryos, or for transfers.
S50 ASRM Practice Committee Revised guidelines Vol. 90, Suppl 3, November 2008
f. A disposable sterile transfer catheter should be external disaster preparedness (including provisions
used. for equipment back-up in the event of equipment fail-
8. Oocyte/embryo freezing 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. Awritten protocol should include cryoprotec- fluid) should be handled using universal precau-
tant used (including source and shelf life), me- tions (i.e., as if it were contaminated). All donor tis-
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 where applicable.
for manual or automatic seeding, and storage B. All accredited laboratories are required to have an
conditions. Exposure Control Plan. A requirement of this plan
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. Any employee that re-
with at least two unique identifiers. A method fuses is required to sign a waiver that is kept in
of ensuring prompt, accurate retrieval of cry- their employment record. Testing for additional
opreserved specimens must be employed. 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.
sive of the patient chart information. C. Extraordinary precautions should be taken to avoid
c. Time limits for embryo storage should be es- accidental wounds from sharp instruments contam-
tablished by each individual laboratory and inated with body fluids.
determined prior to freezing. 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 body fluids or any material that has come in contact
detection of low levels of liquid nitrogen. with body fluids. Gloves should be removed and
e. Procedures for thawing embryos should in- discarded when leaving the laboratory or handling
clude cryoprotectant concentrations and me- the telephone. Gloves should never be reused.
dia used, temperature requirements for E. A laboratory coat or appropriate gown should be
thawing, criteria for assessing embryo viabil- worn in the laboratory and removed upon leaving
ity, time period for embryo culture prior to the laboratory.
transfer, protocol for patient preparation for F. Safety glasses or goggles are suggested where ap-
frozen embryo transfers and conditions under propriate.
which embryo transfers will take place. G. Hands should be washed after removing gowns and
9. Micromanipulation gloves and immediately if they become contami-
Micromanipulation is considered optional at nated with body fluids. All hand washing should
each facility. be done with disinfectant soap and hot water or al-
a. Protocols for micromanipulation should in- cohol-based solutions.
clude circumstances and screening criteria for H. Disposable laboratory supplies must be used when-
micromanipulation, procedures for processing ever possible.
sperm samples, types of microtools to be I. Contaminated laboratory equipment and/or work
made or purchased, media/protein source, 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-
judging oocytematurity and oocyte and embry- dures approved by the Centers for Disease
onic quality prior tomicromanipulation, viabil- Control and Prevention [CDC]).
ity following micromanipulation, and J. Mechanical pipetting devices should be used for the
conditions under which embryo transfer will manipulation of liquids in the laboratory. Mouth pi-
take place. petting is never permitted.
b. Personnel should have demonstrated compe- K. All procedures and manipulation of body fluids
tence in performing micromanipulation. should be performed to minimize the creation of
droplets and aerosols. Complete facemasks or the
V. Laboratory Safety and Infection Control
use of appropriate hoods should be considered
Procedures and policies on lab safety must be available
when procedures are conducted which have a high
to all laboratory personnel and should be reviewed an-
potential for creating aerosols or droplets. Centrifu-
nually by the laboratory director. Protocols should be
gation or vigorous mixing of open containers repre-
available for fire and electrical safety and internal and
sents examples of this problem. Centrifuges may be
Fertility and Sterilityâ 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. Use sterile techniques, appropriate dis-
used for centrifugation. ease screens, and safe laboratory procedures.
L. Eating, drinking, smoking, application of makeup, 7. All patient worksheets should have clear patient
or manipulation of contact lenses are not permitted identifying information as well as laboratory ac-
in the laboratory. cession numbers that uniquely identify the pa-
M. All discarded body fluid samples and disposable tient during all related procedures. All Petri
laboratory supplies should be disposed of properly dishes, test tubes and other materials that serve
in a container marked BIOLOGICAL HAZARD for culture are labeled with proper identifiers.
and disposed of accordingly. Labeling of straws or ampules for cryopreserva-
N. Policies must be established to document all ad- tion must be indelible.
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
the Quality Assurance review. should be maintained. All steps throughout the
O. A copy of current Material Safety Data sheets and ART procedure must be traceable to the techni-
other references that list the details of hazards and cal person performing the procedure, and the oo-
the precautions for safe handling and storage of cytes must be accounted for from retrieval to
chemicals and reagents should be available. embryo transfer/cryopreservation or disposal.
9. Documentation of emergency power generator
checks and automatic power transfer switch func-
VI. Quality Control/Assurance
tion should be made on a periodic basis. Also,
A. Quality Control (QC).
system function checks should bemade and docu-
1. A written procedure manual must be readily
mented (e.g., power off, high temp, low C02
available and followed by laboratory personnel.
alarms).After hours, alarms should be transmitted
The laboratory director or designated supervi-
to a personwho can respond to these emergencies.
sory personnel should review and update all pro-
cedures on at least an annual basis. Any changes B. Quality Assurance (QA)
must be approved, signed and dated by the labo- 1. QA is a comprehensive program designed to
ratory director or by designated proxy. Copies of look at the laboratory as a whole and to identify
old or archival protocols and updated procedures problems or errors that exist in an attempt to im-
should be retained for a period of at least two prove the entire process. Indicators used in a QA
years. program should be objective, relevant to the lab-
2. Equipment should be maintained and calibrated 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. For each indicator incorporated
a record of instrument calibration, functional into the laboratory’s QA program, an appropri-
checks of equipment when possible, and evi- ate threshold needs to be established. The thresh-
dence of an active review of records. Documen- old sets the critical level of quality laboratory
tation or corrective action when instruments and/ performance for each indicator. Since clinical
or procedures malfunction should be kept. protocols are not uniform among ART laborato-
3. All new protocols should be validated and docu- ries, the threshold values must be specific for
mented. each individual clinical laboratory (4).
4. The laboratory should define and maintain writ- 2. The quality assurance program should include
ten criteria for preparation, storage, handling, a mechanism to review and analyze data in order
and preparation of specimens. All reagents to identify problems related to the quality of care
should be dated and used within the indicated provided by the laboratory. This should include,
expiration date. but not be limited to, the following:
5. All media and protein supplementation should a. Mechanisms to detect clerical, transcriptional,
be tested for quality utilizing bioassay systems or analytical mistakes. When problems and/or
such as the one- or two-cell mouse embryo cul- adverse trends are identified, corrective mea-
ture assay, or quantitative sperm motility or via- sures should be implemented to resolve the is-
bility assay. Each batch of purchased media must sue to ensure quality patient care. There
be tested by the vendor with an appropriate bio- should be later documentation whether cor-
assay. It is up to the discretion of the laboratory rective measures instituted were able to effec-
to perform additional quality control assays on tively resolve the problem.
purchased media. b. Data from the laboratory should be gathered
6. Infection control (see safety procedures above). and analyzed on a regular basis and the infor-
Use HIV-1 and -2, Hepatitis B, Hepatitis C, mation gathered should be used to identify
S52 ASRM Practice Committee Revised guidelines Vol. 90, Suppl 3, November 2008
and resolve problems. A copy of this report F. Satellite facilities may be set up to perform GIFT
should be kept for review. Quality assurance procedures only if facilities are available to pro-
also includes the turnaround time for reports vide IVF procedures as needed on site.
and consistency of service as well as statisti-
cal analysis of outcomes data.
REFERENCES
c. An adverse incident file should be maintained,
1. U.S. Food and Drug Administration. Tissue guidances, rules and re-
including but not limited to significant clerical
lated documents. Available at: http://www.fda.gov/cber/tissue/docs.
and analytical errors as well as unusual labo-
htm.
ratory results. 2. The American Society for Reproductive Medicine. 2008 Guidelines
d. The practice must participate in data collec- for gamete and embryo donation. Fertil Steril 2008;90(Suppl
3):S30–44.
tion for purposes of clinic submission in
3. Practice Committe of the American Society for Reproductive Medi-
compliance with guidelines established by
cine. Guidelines for development of an emergency plan for in vitro fer-
SART.
tilization programs. Fertil Steril 2008;89:793–5.
3. The laboratory must participate in proficiency 4. Mayer JF, Jones EL, Dowling-Lacey D, et al. Total quality improve-
testing for those procedures for which it is avail- ment in the IVF laboratory: choosing indicators of quality. Reproduc-
tive BioMedicine Online 2003;7(Comp. 1):192–6.
able. For those testing services in which a com-
mercial proficiency test is not available, the
laboratory must establish an internal quality as-
GUIDELINES FOR HUMAN ANDROLOGY LABORATORIES
surance program. Consideration should also be
I. Organization of the Laboratory and Definition of Ser-
given to sharing samples with other laboratories
vices
or developing other means of external quality as-
A. General Laboratory
sessment. External quality assessment serves as
1. The institutional affiliation, history, definition of
a companion to a laboratory’s internal quality as-
services, and the purpose of the laboratory
sessment program.
should be clearly defined.
VII. Satellite Facilities 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
torship is at another physical facility, which has a sep- federal Department of Health and Human Ser-
arate identification number (SART number) and vices (HHS), an andrology laboratory falls under
a separate medical director. ART laboratory services the purview of Clinical Laboratory Improvement
may be provided in satellite facilities provided the Act of 1988 (CLIA’88) regulations. These regula-
following criteria are met: tions undergo routine interval reviews with
A. A laboratory director (see above) oversees all ac- amendments made as appropriate. Readers are
tivities in the remote location. The director will advised to consult the most recent edition of the
establish protocols, decide on medium prepara- regulations in order to ensurecurrent applicability.
tion and source, provide training to personnel, Any current licenses, permits, and certification by
and determine methodologies to be used. any other groups or agencies should be listed.
B. Qualified embryology technologists should be 3. The laboratory must satisfy any Institutional Re-
employed at the satellite facility or provided by view Board (or equivalent Human Investigation
the laboratory director as needed if the latter Committee) requirements for any investigative
does not perform the procedures. Embryology procedures, if applicable.
technologists should meet the educational and 4. Laboratory animals should be maintained ac-
training criteria described herein. cording to local, state, or federal requirements
C. The laboratory director should provide supervi- and/or regulations, if applicable.
sion and document appropriate lines of daily com- 5. Andrology laboratories that cryopreserve semen
munication with satellite facilities during all IVF for therapeutic use and/or prepare semen for use
procedures. While the laboratory is actively treat- 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 according to the FDA’s Cell/Tissue Transplanta-
that will ensure the optimal functioning of the lab- tion regulations (1). All andrology laboratories
oratory and the delivery of quality patient care. involved in these activities must be in compli-
D. A satellite laboratory must meet the same stan- ance with these FDA regulations.
dards as any other embryology laboratory as de- B. Specific Laboratory Procedures
scribed in these guidelines. It is recognized that a single standardized protocol
E. Equipment and laboratory space shouldmeet all of is inappropriate or unavailable for many andrology
the standards listed above as appropriate for proce- laboratory procedures. In the absence of a widely
dures that are performed at the satellite facility. accepted, standardized protocol, each laboratory
Fertility and Sterilityâ S53
must develop its own protocol for that particular sibilities for each type of laboratory personnel. The
procedure with appropriate controls and methodol- following descriptions include a summary of cer-
ogy to assure reliable, acceptable results. Androl- tain relevant items regarding qualifications and re-
ogy laboratories perform some or all of the sponsibilities of laboratory directors, general
following procedures: supervisors and testing personnel. Under CLIA
1. Semen analysis and procedures: the semen anal- ’88, personnel qualifications and responsibilities
ysis is essential for the diagnosis of male fertility are also defined for technical supervisors and clin-
potential. In addition to the standard semen anal- ical consultants (not included here). For andrology
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. Assays may include tests for sperm sur- 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 such licensing is required.
analysis are detailed in theWorld Health Organi-
1. Laboratory Director:
zation (WHO) LaboratoryManual for the Exam-
a. Qualifications. There are a number of different
ination of Human Semen and Semen-Cervical
paths for qualifying as the director of a high
Mucus Interaction (4).
complexity laboratory, such as an andrology
2. Sperm antibody testing: the sperm antibody as-
laboratory, under CLIA ‘88. These include:
says used must be able to measure the presence
1) An M.D. or D.O. with board-certification
of sperm antibodies on the sperm as well as in
in anatomic or clinical pathology, or both.
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-
(either one year of laboratory training dur-
rectly on the sperm and fluids. Both positive
ing medical residency or at least two years
and negative controls must be used to validate
of experience directing or supervising high
the assay. The mixed antiglobulin reaction and
complexity testing).
the immunobead test are described in the
3) A board-certified Ph.D. scientist with a de-
WHO Laboratory Manual (4). Other protocols
gree in a chemical, physical, biological or
are also available (5).
clinical laboratory science from an ac-
3. Sperm penetration assay or the zona-free ham-
credited institution and be certified by the
ster oocyte test: human sperm fertility potential
American Board of Medical Microbiology,
is measured by the ability of sperm to penetrate
American Board of Clinical Chemistry, the
zona-free hamster eggs. Positive controls must
American Board of Bioanalysis, the Amer-
be utilized to validate 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-
comparable by HHS.
scriptions of the assay are available (6).
4) A person qualified under state law to direct
4. Sperm cryopreservation: sperm cryopreserva-
laboratories within a state on or before
tion involves the freezing and storage of human
February 28, 1992.
sperm for future use. Sperm for freezing may be
5) A person serving as a laboratory director
obtained from either patients or donors. Guide-
and qualified or could have qualified as di-
lines for Sperm Donation have been established
rector on or before February 28, 1992.
by The American Society for Reproductive
b. Responsibilities. The director must ensure:
Medicine (7) and The American Association of
1) The quality of testing.
Tissue Banks (8).
2) The safety of the working environment.
5. Preparation of sperm for intrauterine insemina-
3) That the test methodologies will provide
tion with husband, partner or donor sperm: fresh
quality results.
and frozen spermmay be processed for intrauter-
4) That procedures are verified, accurate and
ine or intracervical insemination.
reliable.
6. Computer assisted semen analysis (CASA): lab-
5) That the laboratory is enrolled in an HHS-
oratories must have a protocol that, on a periodic
approved proficiency testing program.
basis, validates that their assisted semen analysis
6) That QA and QC programs are estab-
equipment is functioning correctly.
lished and maintained.
II. Laboratory Personnel 7) That acceptable levels of analytical per-
A. Personnel Qualifications and Responsibilities: formance for each test system is estab-
CLIA’88 has specific qualifications and job respon- lished and maintained.
S54 ASRM Practice Committee Revised guidelines Vol. 90, Suppl 3, November 2008