A Web-Based Global Educational Model for Training in Semen Analysis during the COVID-19 Pandemic

Infertility affects between 2.5% and 12% of couples worldwide, with male factor infertility solely accounting for 20% to 30% and contributing to 50% of the overall infertility cases [1]. In the United States alone, infertility affects 9.5% of men [2]. The clinical evaluation of male infertility is based on the semen analysis where the results can significantly influence the diagnostic interpretation and management. While many clinicians rely on semen parameters as a surrogate marker of a man's ability to father a child, the results of semen analysis should, however, be interpreted with caution considering its inherent limitations [3, 4].

A properly performed semen analysis and an adequate clinical examination of the male along with questions regarding current medical conditions and lifestyle circumstances that could affect sample quality, can provide valuable information related to a man's fertility potential. This information facilitates a better understanding of the physiology of the reproductive organs and the underlying causes of dysfunction [5, 6, 7]. However, manual semen analysis has its inherent challenges associated with high subjectivity, lack of standardization, inadequate quality control and quality assurance, as well as inadequate assessment of competency, and training of laboratory personnel performing the test [7, 8]. Unlike sperm concentration and motility, sperm morphology has even more subjectivity in reporting the results, with increased intra- and intervariability [8, 9, 10]. Therefore, quality control is imminent in preventing such variations and retaining uniformity in all assessments by all operators. This includes preanalytical (test requisition, correct sample collection, delivery of sample), analytical (mixing and loading of sample, correct preparation of smears or calculation of results), and post-analytical (correct reporting of results to the clinician) indicators. To minimize errors, daily, weekly, or monthly quality control of reagents and equipment is imperative. It is also important to identify and document the sources of error in sperm concentration, motility, and morphology. Several factors are responsible for variation in the results of sperm morphology, including differences in the methods used to prepare and stain specimens, differences in proficiency among technicians, and inherent differences in classification criteria and methods [11]. Thus, it is essential to have step-by-step protocols (Standard Operating Procedures), conduct training, and assess the performance of laboratory personnel using proficiency testing material and test competency assessments at regular intervals [6, 12].

Hands-on laboratory training sessions are critical to grasp an understanding of safe laboratory practices, correct use and setup of the microscopes, learn step-by-step methodology to conduct a proper semen analysis, and to troubleshoot possible errors. Furthermore, it should also encourage the trainee to participate in interactive discussion and teaching sessions. The performance of the trainee in semen analysis can be successfully evaluated by both the assessment of competency in adequately performing semen analysis and the assimilation of information delivered by multiple choice question (MCQ). In the past eighteen years that the hands-on assisted reproductive technology (ART) training program has been running at the American Center for Reproductive Medicine (ACRM), over 200 candidates from more than 45 countries have been successfully trained. ACRM's ART training program focuses on teaching candidates the newest practical techniques in both routine and advanced andrology. The Case Western Reserve University has recognized this ART training program with a Scholarship in Teaching Award. Most trainees found the program to be invaluable in terms of theoretical background and hands-on guidance, received by expert instructors at a pace that was best suited for their individual abilities.

However, during the COVID-19 pandemic with all its accompanying restrictions, the hands-on laboratory training had to be converted to a virtual training model (format) that utilizes PowerPoint presentations along with video demonstrations of the laboratory techniques presented by course speakers. The target participants for these virtual ART training courses included laboratory technologists, embryologists, undergraduate students, andrologists, and medical graduates among others.

The objective of this study is to evaluate the quality of the first three modules 1A, 1B, and 1 of the virtual training course on semen analysis based on the participants' responses to an online survey.

The online surveys were completed by a total of 2,444 participants from 60 to 64 countries. The demographics of the participants who answered the surveys for Modules 1A, 1B, and 1 are depicted in Table 1.

Table 1
Demographics of participants who answered the surveys for Modules 1A, 1B, and 1

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The primary reason for the participants having attended the ART lectures was the same across all three modules, namely ‘to improve knowledge, skills, and expertise in the field of andrology, male reproduction, ART, and infertility’ (Modules 1A: 48.8%, 1B: 72.2%, 1: 68.0%). Other reasons for wanting to attend the courses included: learning contemporary techniques (Modules 1A: 8.1%, 1B: 10.5%, 1: 7.6%), the opportunity of obtaining a certificate (Modules 1A: 2.4%, 1B: 6.4%, 1: 8.1%) as well as for the chance to build a global network and career (Modules 1A: 0.4%, 1B: 1.7%, 1: 2.1%). Also, the main expectation from the online ART courses resonated well across all the three modules as ‘to gain a better understanding of basics as well as recent advances in the field of andrology and human reproduction’ (Module 1A: 59.0%, 1B: 52.7%, 1: 69.3%).

The evaluation of the technological tools/digital delivery methods used during the online ART course in all three modules is illustrated in Fig. 1. More than 85% of the participants responded positively that the digital delivery methods used had largely/completely met their expectations for all questions, except for the sound quality, where the percentage was equal to 71%. Similarly, the use of Dropbox for sharing written instructions, organization of practice sessions, sharing of the most frequently asked questions (FAQs), translation of the shared information into different languages, creation of short informative video clips, and voice messages were rated as either useful or very useful by more than 80% of the participants (Fig. 2). Although sharing of information using various electronic platforms was generally rated as very good or excellent by more than 80% of the participants, the preferred platforms appeared to be WhatsApp with a rating of 86%, Dropbox (85%), and WebEx (81%) (Fig. 3). Overall, analysis of the responses related to the technological tools used in the online ART course showed that 51.7% of participants found this program to be very useful and the digital delivery methods had completely met their purpose. Moreover, 33.0% had found these tools to be helpful and very good, although 11.9% found them neutral and good.

Fig. 1
Digital delivery methods rated by the participants according to their expectations. ART: assisted reproductive technology.

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Fig. 2
Utility of the measures to facilitate the use of WebEx.

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Fig. 3
Rating of the delivery mode of the course by the participants.

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More than 70% of the participants regarded the following aspects of program as either very good or excellent: 1) participants' level of interest in participating in the modules, 2) experience preparing for the courses, 3) course coordinators support, 4) ability to adjust to a completely online course, 5) timing and duration of the course, 6) choice of course faculty, 7) opportunity to ask questions, 8) level of interest to participate in future courses, 9) short videos about the lecture topics, 10) lectures given by the ACRM faculty/guest speakers, 11) discussion of updates in current clinical practice, and 12) MCQ assessments to improve learning (Fig. 4). The majority (>87%) of the participants gave ratings of either strongly agree or agree that the learning objectives were clear, the course content was well-structured and had appropriate depth and that, as an overall, their expectations of the course had been met (Fig. 5).

Fig. 4
Rating of aspects that were important for the participants. ART: assisted reproductive technology, ACRM: American Center for Reproductive Medicine, MCQ: multiple choice question.

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Fig. 5
Rating of the learning objectives and delivery of the course contents.

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Out of 2,444 participants, 28.0% found the application process for the online ART Course to be straightforward, while it was perceived as complicated by 29.7% of the participants. On evaluating the role of the Course Coordinators in organizing the current online ART course, 47.1% of candidates were in strong agreement that the Course Coordinators helped stimulate their interest in the course content. While 58.1% of the participants strongly agreed that the Coordinators effectively used WhatsApp to share detailed information about the course, 51.0% found the Coordinators helpful in clarifying their doubts, 49.0% strongly agreed that the Coordinators were prompt in their feedback, and 53.3% of candidates found them always approachable and courteous. Only about 3% of the candidates appeared not to have been satisfied with the Coordinators' performance.

The self-reported increase in the participants' knowledge following participation in these online lectures, as per the ratings provided by the participants before and after the lectures, was highly significant (p<0.0001) for all modules (Fig. 6, 7, 8). The self-reported benefits of participating in all three online ART modules and the ways how the information gathered was self-reported to help the participants in their line of work/area of study are listed in Table 2. The top 3 benefits were recognized as a deeper knowledge of 1) Andrology, male reproduction, ART, and infertility; 2) good clinical practices in an accredited clinical Andrology laboratory, and 3) contemporary techniques in Andrology/Embryology. The participants stated that the information gathered from the modules would help them implement strategies and protocols in their own workplace and update their knowledge, amongst the other selected options. Additionally, the participants became more familiar with clinical guidelines, laboratory protocols and correct interpretation of the results, implementing the quality control of instruments and procedures in their workplace, analyzing semen samples in a more standardized way, and increasing the biosafety level in their workplace.

Fig. 6
Knowledge rating before and after taking Module 1A. SD: standard deviation. ^***p<0.0001.

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Fig. 7
Knowledge rating before and after taking Module 1B. SD: standard deviation. ^***p<0.0001.

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Fig. 8
Knowledge rating before and after taking Module 1. SD: standard deviation. ^***p<0.0001.

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Table 2
Top self-perceived benefits of taking the course and the ways how the information gathered by the participants was self-perceived to help them in their line of work/field of study for all three online ART training modules

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The traditional ART training program organized by ACRM since 2004 has offered a unique opportunity for the participants to learn the latest techniques in routine and advanced Andrology along with the full spectrum of embryology-focused technology. In the last 18 years, the ACRM team has successfully trained over 200 candidates from more than 45 countries. The sudden disruption in face-to-face learning brought by the COVID-19 pandemic became an unexpected catalyst to convert the yearly ART training from the well-established traditional model to a fully online format for the first time.

The present study reports the quality of the first three ART training modules offered by the ACRM during the COVID-19 pandemic, which included modules on manual semen analysis, sperm morphology, and ancillary semen tests (evaluation of leukocytes concentration, sperm vitality and anti-sperm antibody). In recognition of the need for ART training to continue during the COVID-19 pandemic, the American College of Embryology (EMBCOL) supported ACRM's efforts of creating a unique opportunity and providing an accessible platform for both local and global candidates who needed ART training. Participants who achieved the pre-set passing score in the online MCQ test at the end of each ART training module were issued a certificate of participation endorsed by both the ACRM and the EMBCOL.

The majority (>87%) of the survey participants gave ratings of either strongly agree or agree that the learning objectives were clear, the course content was well-structured and had appropriate depth, and that as an overall, their expectations of the course had been met. When designing teaching and learning, good quality design is associated with the following: “clear learning objectives, carefully structured content, controlled workloads for faculty and students, integrated media, relevant student activities, and assessment strongly tied to desired learning outcomes” [14]. In the ART course herein presented, the first step in the creation of an outline for the components in each training module was to define clear objectives for the module as well as for each individual lecture within the respective modules. These specific objectives provided the broad structure for each module and the detailed topic covered. The learning objectives were designed to be clear cut and succinct. The course content and curriculum were created in a well-structured and comprehensive manner and helped define the objectives for each module.

Based on this, it appears that the ACRM was able to adequately modify the content of its annual ART course to suit the current needs of students amidst the COVID-19 pandemic, by switching to an e-learning approach. This has been previously shown to be useful in medical education [15, 16]. Overall, the structured online delivery model with clear cut objectives in the COVID-19 era seems to have helped the trainees acquire the knowledge and skills of the subject matter related to Andrology despite the physical distancing.

The contents of the training modules comprised a collaborative effort between andrologists, reproductive biologists, and clinical male infertility experts to cover all the objectives of the course. The faculty involved in this online course was all established international experts in the fields of Andrology and human ART, as well as experienced technical supervisors at the ACRM.

Prior to each module, relevant course resources were shared with all registered participants. These pre-module reading materials were carefully curated by the ACRM for each specific module based on the importance and applicability of the resource material. There were several reasons for sharing the resources ahead of the course session. First, it allowed registered participants from mixed levels of competence to familiarize themselves with the key concepts that were going to be discussed during a particular ART training module. This approach prescribes to the cognitive load theory which describes how new learners possess a working memory with a limited capacity to process new information, while those who already have some prior knowledge on a topic advance by linking new information to pre-existing knowledge [17]. Thus, learners who are novices in a subject matter are quickly overwhelmed when exposed to vast amounts of new terminology and concepts in lectures. These learners usually end up relying on mere surface learning [18]. Moreover, having early access to the pre-module learning resources presented the participants with a sufficient window whereby to read and better understand the subject matter at their own time and convenience. This could facilitate a deeper understanding, activate the appropriate knowledge connections that the participants may have initially lacked and steer their attention towards capturing information more comprehensively during the actual online session. As such, participants who engaged with the pre-module reading material could potentially have found it 1) beneficial in making the course topics easier to understand and follow, and 2) helpful in connecting with the new concepts in a more meaningful manner [17].

Although guidelines for the semen analysis are provided by the World Health Organization manual [6], the semen analysis process is reported to be prone to error and inconsistencies, including collection of semen samples, laboratory evaluation, and reporting of the results [9]. Here, the adherence to these guidelines does not necessarily provide good reliability of results due to lack of standardized records, technician subjectivity, and poor technician competence [9]. A large variation in the results is also reported between different laboratories [19]. Professional training is essential to improve the reliability of relevant semen analysis tests, where online training tools have been proposed to meet the needs of shrinking ART training courses globally [20].

Participants were required to complete and pass the MCQ component to qualify for conferment of the certificate in each online training module. However, a small percentage of trainees stated that they did not participate in the online assessment as they were either not well prepared or were not interested in taking the MCQ test. The goal of the MCQ test was to assess the understanding of the knowledge component of the candidates after the online training was provided.

The majority of the registered participants across all the three modules had taken the online MCQ test with very few opting not to do so. Based on participant feedback, one of the most common reasons given for not taking the optional MCQ test at the end of each module was the lack of stable internet access and/or intermittent connectivity. This is certainly a potential drawback of having an online assessment and this is discussed further below. Other reasons given by the participants for not having taken the MCQ tests were time constraints from concurrent work/study responsibilities, and having found out about the course and/or joining the training sessions very close to the actual training dates.

The collaboration between EMBCOL and ACRM in developing this new teaching format has also made it possible for the ACRM to share extremely specialized expertise and technical know-how freely with a wider global audience, thereby promoting the inclusion of participants regardless of their competencies or prior experience. Besides making the information accessible to a large audience, the online format of free training organized by the ACRM also merits the importance of having a common ground in male fertility evaluation worldwide, despite the financial ability to participate in specialized programs, which are usually very expensive. This has been further confirmed by senior exponents of the Andrology and Embryology fields, who have provided their endorsement of this innovative program through private communications with the course management.

Despite having several clear advantages, online teaching also presents with certain limitations. While theoretical knowledge could easily be delivered online through concise lectures, certain skills still require a hands-on approach to be developed. This is particularly true for semen analysis and any laboratory protocols, which can be learnt well only through repeated practical training and experience. Moreover, although each lecture in itself was relatively short, the total length of time taken for the entire series of lectures within each module was adequate enough to require the participants to remain online for an extended amount of time. This presented a higher probability for the participants to become disengaged and get distracted than they would during a conventional in-person meeting [21].

The ability to attend the online sessions may have also been challenging for some participants due to either poor or unstable internet connectivity, or other reasons beyond the course management's control. For example, access to the platform used to host the online training platform (WebEx) is restricted in some countries (such as Iran, Algeria, and Nigeria amongst others) and therefore the participants from those regions had to rely on virtual private network (VPN) to ensure connectivity. During the first training session, this restriction resulted in a large number of candidates being unable to either complete the online MCQ test or they inadvertently obtained a lower score as they were in a rush to complete the test, fearing they would lose the internet access.

Taking these challenges into consideration, from the second session onwards, several measures were implemented to address the aforementioned issues when plausible. To navigate the connectivity issues due to restriction in certain regions, the team of coordinators was pro-active in providing VPN access to those participants who faced difficulties in joining the training sessions via WebEx. Additionally, the time allotted for completing the MCQ test was also lengthened. The minimum score needed to pass the module was set at 65%, although this score is considered akin to a grade D or grade point average (GPA) of 1.0 based on conventional American standards [22].

Each module was run as a 2 hours training session followed by an hour of the MCQ test. In Modules 1A and 1, there were six 15-minute lectures followed by one 15 minute Q&A session, while Module 1B had four lectures of 15 to 30 minutes, with one 10 minute Q&A session. The tight schedules in these half-day training sessions were just right for the delivery of lectures. As a result, not much time was available for interaction between speakers and attendees, which limited the opportunity for the speakers to immediately address any questions or doubts that the participants may have had [23, 24]. Hence, the management relied on the survey results to gather participant feedback and identify any weaknesses in the general organization of the training.

It must be kept in mind that the nature of surveys as a strategy for identifying areas of improvement may inherently be biased. Although the survey responses were anonymized before being analyzed, desirability bias cannot be excluded [25]. This is linked to the human tendency of providing feedback which may be considered favorable by others. Another potential source of bias is the tendency of some participants to provide only extreme or neutral answers, which cannot be realistically addressed [26]. Furthermore, only a moderate percentage of participants were from English-speaking countries. To limit this bias, the survey was extensively revised by a pool of international coordinators as well as collaborators with large experience in teaching, to make each question understandable and unambiguous to an international audience. In future, the survey questions may also be translated into the first language of the participants in order to avoid comprehension bias.

In conclusion, we report our experience in utilizing a web-based delivery model as an alternative to the conventional in-person training which had enabled the ACRM to provide continuous education on a global platform. We have shown that the online training for certain ART-related modules can be conducted by means of providing expert-led video demonstrations, power point presentations, clinical lectures, and online interactive e-learning activities. Moreover, complex issues in reproductive biology could be covered by interplay of both laboratory and clinical professionals. The application of several online-based communication tools such as WhatsApp, Dropbox and Cisco WebEx were instrumental in implementing the web-based delivery model.

Leading into the future, the success of this online training creates an emerging avenue for a blended form of learning with both in-person and online education platforms for the Andrology and embryology specialties involved in ART training. The impact of having a virtual modality in place of hands-on learning for ART laboratory professionals during the COVID-19 requires further investigation to determine its effectiveness by comparing to the traditional approach. This comparison will help improve the current strategies for teaching and learning in specialized fields like Andrology. In fact, the inclusion of the best features from both hands-on and e-learning approaches will enhance the design and the implementation of future teaching strategies.