Recommendations for Human Sperm Morphology Assessment in 2025: An Expert Review From the French BLEFCO Group

Numerous publications have questioned the lack of analytical reliability and clinical relevance of sperm morphology assessment for infertility workup and before use of assisted reproductive techniques (ART). There is a huge variability in the performance and interpretation of this test. It has become necessary to evaluate its true medical service rendered to the patient.

To develop clinical guidelines for use of spermatozoa morphology assessment during male fertility check-up and before ART.

These guidelines were produced following a pre-defined standard methodology for narrative and Patient Intervention Comparison Outcomes (PICO) questions. The French Working Group (WG) on Sperm Morphology Assessment consisted of 15 members including an expert in statistics.

R1: WG does not recommend systematic detailed analysis of abnormalities (or groups of abnormalities) during sperm morphology assessment. R2: WG recommends that the laboratory should use a qualitative or quantitative method for detection of a monomorphic abnormality (globozoospermia, macrocephalic spermatozoa syndrome, pinhead spermatozoa syndrome, multiple flagellar abnormalities). The result may be given as an interpretative commentary or as a numerical report of the percentage of detailed abnormalities. R3: There is insufficient evidence to demonstrate the clinical value of indexes of multiple sperm defects (TZI, SDI, MAI) in investigation of infertility and before ART. Accordingly, the working group does not recommend the use of sperm abnormality indexes (TZI, SDI, MAI) in sperm morphology assessment. R4: WG gives a positive opinion on the use of automated systems based on cytological analysis after staining after qualification of the operators, and validation of the analytical performance within their own laboratory. R5: WG does not recommend using the percentage of spermatozoa with normal morphology as a prognostic criterion before IUI, IVF, or ICSI, or as a tool for selecting the ART procedure.

This article examines the clinical interest of sperm morphology assessment during fertility check-up and before ART. The overall level of evidence from studies is low, challenging current practices regarding sperm morphology assessment.

These guidelines suggest a significant simplification of sperm morphology assessment in the light of the examined publications while maintaining the detection of monomorphic sperm abnormalities.