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15 May 2010, Volume 29 Issue 3
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Semen Analysis：A New Manual and Its Application to the Understanding of Semen and Its Pathology Jequier AM 2010, 29 (3):  136-138.  Abstract ( 2154 )   PDF (291KB) ( 7254 )   This article reviews the latest edition of the World Health Organization’s manual on semen analysis，a comprehensive instructional guide. The methodology used in the assessment of the usual variables in semen analysis is described，as are many of the less common，but very valuable，sperm function tests. Seminal fluid preparation techniques for procedures such as in vitro fertilization and intrauterine insemination are also outlined in the manual. In addition，it details many useful techniques for the assessment of seminal fluid. It will be a very useful manual for any laboratory that carries out analyses of seminal fluid. Related Articles | Metrics

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Practical Semen Analysis：From A to Z Brazil C 2010, 29 (3):  139-144.  Abstract ( 2656 )   PDF (299KB) ( 7318 )   Accurate semen analysis is critical for decisions about patient care，as well as for studies addressing overall changes in semen quality，contraceptive efficacy and effects of toxicant exposure. The standardization of semen analysis is very difficult for many reasons，including the use of subjective techniques with no standards for comparison，poor technician training，problems with proficiency testing and a reluctance to change techniques. The World Health Organization（WHO）Semen handbook（2010）offers a vastly improved set of standardized procedures，all at a level of detail that will preclude most isinterpretations. However，there is a limit to what can be learned from words and pictures alone. A WHO-produced DVD that offers complete demonstrations of each technique along with quality assurance standards for motility，morphology and concentration assessments would enhance the effectiveness of the manual. However，neither the manual nor a DVD will help unless there is general acknowledgement of the critical need to standardize techniques and rigorously pursue quality control to ensure that laboratories actually perform techniques ‘according to WHO’ instead of merely reporting that they have done so. Unless improvements are made，patient results will continue to be compromised and comparison between studies and laboratories will have limited merit. Related Articles | Metrics

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Quality Assurance and Quality Control in the Laboratory Andrology Pacey AA 2010, 29 (3):  145-148.  Abstract ( 3003 )   PDF (270KB) ( 7225 )   Quality assurance（QA）and quality control（QC）are fundamental aspects of any laboratory measurement. However，in comparison with other medical disciplines，the need for QA and QC in laboratory andrology has been recognized only recently. Furthermore，there is evidence that the effort required to undertake QA and QC has not been wholly welcomed by some clinicians. Nevertheless，accrediting bodies and regulatory authorities increasingly require evidence that laboratories have effective QA and QC measures in place because both are central to the quality management processes. Following the publication of the 5th edition of the World Health Organization Laboratory Manual，existing QA and QC systems will need to be updated to take into account some of the methodological changes recommended by the manual. Three of these are discussed in this commentary；they relate to:（i）the move to infer semen volume from its weight；（ii）the re-classification of sperm motility grades from four to three；and（iii）the publication of a lower reference limit for morphology of 4%（with a corresponding 95% confidence interval of 3%-4%）. The importance of QA and QC in all laboratory tests，including up and coming new tests to assess sperm DNA integrity，is discussed. The need for adequate initial training and continuing professional development programmes to support laboratory scientists performing andrology is also described. Related Articles | Metrics

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Semen Analysis with Regard to SpermNumber，SpermMorphology and Functional Aspects Eliasson R 2010, 29 (3):  149-154.  Abstract ( 2951 )   PDF (323KB) ( 7161 )   The new World Health Organization（WHO）Manual for Semen Analysis contains several improvements. One is that the 20 million spermatozoa per mL paradigm has been ousted in favour of proper calculations of lower reference limits for semen from men，whose partners had a time-to-pregnancy of 12 months or less. The recommendation to grade the progressive motility as described in the third and fourth editions of the WHO manual was not evidence-based，and WHO was therefore motivated to abandon it. However，the new recommendation is not evidence-based either，and it is difficult to understand the rational for the new assessment. It may have been a compromise to avoid returning to the rather robust system recommended in the first edition（1980）. The unconditional recommendation of the‘Tygerberg strict criteria’is not evidence-based，and seems to be the result of an unfortunate bias in the composition of the Committee in favour of individuals known to support the ‘strict criteria’method. This recommendation will have negative effects on the development of andrology as a scientific field. Given the importance of the WHO manual，it is unfortunate that the recommendations for such important variables，as motility and morphology，lack evidence-based support. Related Articles | Metrics

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The Usefulness and Significance of Assessing Rapidly Progressive Spermatozoa Bjorndahl L 2010, 29 (3):  155-157.  Abstract ( 2841 )   PDF (213KB) ( 7248 )   It is possible and clinically relevant to distinguish between slow and rapid progressive spermatozoa in basic semen analysis. This is discussed in light of the different purposes of semen analysis for the subfertile couple and the male patient. The two groups of progressive spermatozoa should be distinguished to help ensure that pertinent information available in the semen sample is not neglected. Related Articles | Metrics

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Assessing Human Sperm Morphology: Top Models，Underdogs or Biometrics? Auger J 2010, 29 (3):  158-167.  Abstract ( 3118 )   PDF (376KB) ( 7927 )   The assessment of the percentage of spermatozoa having an ‘ideal’morphology using so-called strict method is the method recommended in the latest edition of the World Health Organization（WHO） laboratory manual for semen analysis. This recommendation is a result of the statistical association between ‘ideal’sperm morphology and fertility，and of the current general belief that sperm morphology assessment should be used primarily as a fertility tool. The notion of an ‘ideal’sperm morphology has persisted despite the very low percentage of such spermatozoa in the semen of fertile men，a subject of intense controversy. The detailed categorization of each abnormal spermatozoon has thus，for a long time，been considered optional and partially redundant，an idea which is reflected in the earlier editions of the WHO manual. However，several recent studies have shown the importance of carefully assessing abnormal sperm morphology for use in the diagnosis of infertility，to determine fertility prognosis，and for basic or public health studies. One approach，which combines videomicroscopy and computer vision，and is the only approach able to assess the continuum of sperm biometrics，has been used successfully in several recent clinical，basic and toxicology studies. In summary，the visual assessment of detailed sperm morphology-including the categorization of anomalies allowing arithmetically derived indices of teratozoospermia-and the more modern computer-based approaches，although often considered to be redundant，are in fact complementary. The choice of the most appropriate method depends on the field of investigation（clinical，research，toxicology）and the problem being addressed. Each approach has advantages as well as certain limitations，which will be discussed briefly herein. Related Articles | Metrics

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Clinical Significance of the Low Normal SpermMorphology Value as Proposed in the Fifth Edition of the WHO Laboratory Manual for the Examination and Processing of Human Semen Menkveld R 2010, 29 (3):  168-177.  Abstract ( 3658 )   PDF (361KB) ( 7765 )   The very low cut-off value for sperm morphology of 4%morphologically normal spermatozoa，as proposed in the new edition of the World Health Organization （WHO）manual on semen analysis，is in agreement with recently published values and reflects the trend of a decline in reported mean values for normal sperm morphology. The reduced value for morphologically normal spermatozoa over the years may be due to several factors. The first is the introduction of strict criteria for the evaluation of sperm morphology. Other reasons may include the introduction of additional criteria for sperm morphology abnormalities and the suggested decrease in semen parameters because of increasing negative environmental influences. Although on its own the newly proposed very low normal value may not provide the strong predictive value for a males’ fertility potential，as originally reported for sperm morphology evaluated according to strict criteria，a good predictive value can still be obtained if the holistic，strict approach for sperm morphology evaluation is followed together with additional sperm morphology parameters now available，because certain morphology patterns and sperm abnormalities are now known to be of strong prognostic value. In addition，better international standardization of the technical methodology， consensus on the interpretation of sperm morphology evaluation criteria and standardized international external quality control（EQC）schemes，are of utmost importance to maintain the good predictive value of sperm morphology. Related Articles | Metrics

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Comments on the Release of the Fifth Edition of the WHO Laboratory Manual for the Examination and Processing of Human Semen FordWCL 2010, 29 (3):  178-181.  Abstract ( 2584 )   PDF (277KB) ( 7090 )   The authors of the World Health Organization Semen Analysis Manual are to be congratulated on producing a new edition; it is an essential tool to disseminate good practice in andrology. However，the tests described have poor prognostic power to predict a man's fertility and show little about the underlying causes of sub-fertility. This commentary urges a revival of research into the diagnosis of male fertility. It suggests that fertility should be regarded as a continuum and that the artificial binary division between fertile and infertile should be abandoned. Models to predict a sub-fertile couple's chance of conception in a year should be developed on the basis of prospective data. These models would allow for sophisticated decision making about management. The future lies in the identification of tests to detect underlying pathologies open to specific treatment. Leads such as oxidative stress，defects in the intracellular regulation and the developing field of proteomics should be explored. Related Articles | Metrics

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Semen Analysis in 21st Century Medicine: the Need for Sperm Function Testing Lamb DJ 2010, 29 (3):  182-187.  Abstract ( 2773 )   PDF (306KB) ( 7469 )   Sperm function testing，once commonly performed for the infertile couple before employing assisted reproductive technology （ART），has fallen out of favour in many reproductive medicine centers throughout the world. Indeed，the most recent addition of the“World Health Organisation（WHO）Laboratory Manual for the Examination and Processing of Human Semen”now groups many of these procedures into a section termed Research Procedures. In large part，this reflects the current clinical practice of bypassing the in-depth evaluation of the male partner，while assuming that if a spermatozoon can be found for intracytoplasmic sperm injection （ICSI）， it must be a healthy cell capable of achieving fertilization. Nevertheless，sperm function testing can provide valuable clinical insights into defects causing male infertility. Admittedly，in some cases，functional sperm deficiencies can be overcome using an ART. In other cases，couples will be empowered by the knowledge of the cause of their infertility，and for some couples，perhaps even the likelihood of ICSI success（relative to the spermatozoa）. The knowledge allows them to make truly informed reproductive decisions，including（perhaps）the decision to seek donor insemination，to adopt or to remain childless. Knowledge of the cause of their infertility may provide closure for couples and a sense of confidence regarding their choice of reproductive treatment. Related Articles | Metrics

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Tests to Measure the Quality of Spermatozoa at Spermiation Amann RP 2010, 29 (3):  188-194.  Abstract ( 2645 )   PDF (301KB) ( 7427 )   This commentary is to critique the revised World Health Organization （WHO）semen analysis manual as it pertains to characteristics of a spermatozoon at spermiation. The aims of the revised WHO manual include improving the‘quality of semen analysis’without any restriction to clinical use. Furthermore，the manual states that semen analysis may be useful for （a）‘investigating male fertility status’and（b）‘monitoring spermatogenesis during and following male fertility regulation.’However，if the analysis of ejaculated spermatozoa is intended for the purposes described in （b），then cells that are abnormal at spermiation must be identified. This paper takes the position that the manual does not identify methods to estimate the quality of spermatozoa at spermiation. Instead，it uses a‘gold standard’of sperm passing through the cervical mucus or arriving near the site of fertilization. Although this standard is appropriate for drawing conclusions regarding the probability that an individual could impregnate his partner，it is not appropriate for studying illness of the testes per se. Herein，the measures of sperm quality presented in the WHO manual are critiqued with respect to the detection of spermatozoa that were abnormal at spermiation vs. those that became abnormal subsequently. Quality assessments based on the percentage of motile or ‘viable’spermatozoa are meaningless. Alternative quality attributes defining spermatozoa at spermiation are presented in this paper. In conclusion，assessment of spermatozoal quality at spermiation，on the basis of quality attributes of individual ejaculated spermatozoa，is best achieved through application of （a）a new paradigm for the morphological evaluation of sperm quality and（b）modern analytical techniques to evaluate，in an adequate sample，several appropriate independent attributes in each spermatozoon in order to more accurately identify the proportion of abnormal spermatozoa. Related Articles | Metrics

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Semen Quality Analysis and the Idea of Normal Fertility Joffe M 2010, 29 (3):  195-198.  Abstract ( 3201 )   PDF (296KB) ( 7285 )   The World Health Organization （WHO）has extensively revised its manual for semen analysis，and seeks to provide reference limits for semen quality parameters. This raises the question of what is meant by ‘normal’（excluding the use of this term to denote a Gaussian distribution）. It could be taken in a purely statistical sense，using a biologically arbitrary cut-off point to denote an abnormal level，typically the extreme 5 percent of the population. Alternatively，‘normal’could be defined according to the biological concept of normality and abnormality，in terms of the point at which biological function becomes impaired. Either of these can be used in descriptive epidemiology，for example，to study trends，but in the case of fertility，both semen quality and functional fertility（time to pregnancy）are continuous variables with no clear threshold. The WHO manual uses the biological meaning of normal，in that it provides the semen parameter distributions for men who have recently fathered pregnancies that took 12 months or less to conceive. However，what is really needed is the same information the other way around: given a particular semen test result，what should be expected in terms of ability to conceive，and how long it is likely to take. In considering epidemiological research，the focus has been mainly on internal comparisons，rather than reference limits，but it would be beneficial if more attention were paid to the absolute levels and to what these mean in terms of function—in other words，if the data were better calibrated biologically. Related Articles | Metrics

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Defining Laboratory Reference Values and Decision Limits: Populations，Intervals，and Interpretations Boyd JC 2010, 29 (3):  199-204.  Abstract ( 3075 )   PDF (297KB) ( 7212 )   This article provides a brief overview of various approaches that may be utilized for the analysis of human semen test results. Reference intervals are the most widely used tool for the interpretation of clinical laboratory results. Reference interval development has classically relied on concepts elaborated by the International Federation of Clinical Chemistry Expert Panel on Reference Values during the 1980s. These guidelines involve obtaining and classifying samples from a healthy population of at least 120 individuals and then identifying the outermost 5% of observations to use in defining limits for two-sided or one-sided reference intervals. More recently，decision limits based on epidemiological outcome analysis have also been introduced to aid in test interpretation. The reference population must be carefully defined on the basis of the intended clinical use of the underlying test. To determine appropriate reference intervals for use in male fertility assessment，a reference population of men with documented time to pregnancy of<12 months would be most suitable. However，for epidemiological assessment of semen testing results，a reference population made up of unselected healthy men would be preferred. Although reference and decision limits derived for individual semen analysis test results will undoubtedly be the interpretational tools of choice in the near future，in the long term，multivariate methods for the interpretation of semen analysis alone or in combination with information from the female partner seem to represent better means for assessing the likelihood of achieving a successful pregnancy in a subfertile couple. Related Articles | Metrics

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Semen Analysis from an Epidemiologic Perspective Ellekilde Bonde JP 2010, 29 (3):  205-207.  Abstract ( 3140 )   PDF (653KB) ( 7265 )   The fifth edition of the World Health Organization （WHO）manual for semen analysis includes for the first time reference values for human semen characteristics. This paper considers whether such values will help to resolve the intensely debated data indicating temporal and geographical shifts in sperm counts and hypotheses that anthropogenic activities that result in the release of chemicals into the environment are detrimental to male reproductive health. The reasons that these reference values will not fulfil these purposes are also explained. Although established reference values for semen characteristics are of limited value in analytical epidemiologic research，the WHO guidelines are of utmost importance for supporting the development of appropriate research protocols. Moreover，in spite of its limitations，semen analysis is still a useful research tool in epidemiological research，and no superior alternatives are on the horizon. Related Articles | Metrics

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Normal Reference Ranges for Semen Quality and Their Relations to Fecundity Skakkebaek NE 2010, 29 (3):  208-210.  Abstract ( 2454 )   PDF (235KB) ( 7257 )   Several recent studies have shown that the fecundity of a man decreases progressively with sperm concentrations below 40 million spermatozoa per mL. Therefore，it is unfortunate that the new World Health Organization guidelines for semen analysis recommend lowering the lower cutoff value for normal sperm concentration from 20 to 15 million spermatozoa per mL. As a result large groups of subfertile men across the world may not receive appropriate andrological help in the future. Related Articles | Metrics

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Whither Must Spermatozoa Wander? The Future of Laboratory Seminology Aitken RJ 2010, 29 (3):  211-214.  Abstract ( 3233 )   PDF (305KB) ( 7288 )   This commentary celebrates the publication of the 5th edition of the World Health Organization Laboratory Manual for the Examination and Processing of Human Semen. This is the most complete text to date on the creation of a conventional semen profile and includes invaluable reference limits for specific aspects of semen quality based on the analysis of over 1 900 recent fathers. The new edition of the manual also includes detailed protocols for monitoring different aspects of sperm function and new chapters on the preparation of spermatozoa for assisted conception and cryopreservation. Given that this publication is the definitive statement on how to perform a descriptive semen analysis，we might speculate on the future of this field and the sorts of tests that might feature in future editions of the manual. Cell biologists are currently being empowered by the 'omics revolution，which is placing at their disposal technologies of unprecedented power to examine the biochemical composition of cells such as spermatozoa. Indeed，spermatozoa are perfect vehicles for this kind of analysis because they can be obtained as extremely pure suspensions，exist naturally in isolation and can be induced to express their capacity for fertilization and the initiation of embryonic development in vitro. The application of omics technologies to these cells，in concert with detailed assessments of their functional competence，should provide insights into the biochemical basis of defective semen quality. This information will then help us understand the causes of male infertility and to develop rational methods for its treatment and possible prevention. Related Articles | Metrics

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A Survey on the Status of Semen Analysis in 118 Laboratories in China LU JC;ZHANG HY;HU YA;HUANG YF;LV NQ 2010, 29 (3):  215-220.  Abstract ( 2980 )   PDF (259KB) ( 7166 )   Collecting baseline information on how laboratories perform testing is a reasonable first step towards establishing intra-and inter-laboratory standardization and quality control for semen analysis. We carried out a survey of the laboratories performing the testing in Mainland China. A questionnaire，composed of 36 questions covering all aspects of semen analysis，was designed，and a copy was distributed to each of the 145 laboratories. Of these，118 laboratories completed the questionnaires. The survey results showed that semen volume was measured visually in 53.6%（59/110）of the responding laboratories，and 70.9%（73/103）of laboratories analysed incompletely liquefied semen without any treatment. In addition， both manual-microscopic and computer-assisted semen-analysis systems were applied to analyse sperm concentration，motility and morphology. However，more than five methods were employed in routine sperm staining. An enzyme-linked immunosorbent assay was commonly used for determining whether antisperm antibodies were present. Several seminal biochemical markers were analysed in only 27.1%（32/118）of the responding laboratories. Generally，there was a lack of intra-and inter-laboratory quality control measures for semen analysis in all laboratories responding to this survey. In conclusion，the methods of semen analysis and the interpretation of test results in the surveyed laboratories differed markedly. In particular，many laboratories employed methods other than those recommended by the World Health Organization Laboratory Manual for the Examination of Human Semen and Spermcervical Mucus Interaction（1999）. These findings suggest an urgent need for the standardization of semen analysis with acceptable quality controls for each parameter to make the results repeatable and meaningful. Related Articles | Metrics

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Improving Precision in the Assessment of Round Cell Numbers in Human Semen Cooper TG;Hellenkemper B 2010, 29 (3):  221-224.  Abstract ( 2972 )   PDF (275KB) ( 7185 )   The aim of this study was to increase the precision of assessment of the number of round cells observed in the peroxidase test for detection of seminal leukocytes（granulocytes）. The dilution of semen was reduced and the volume of suspension examined was increased for semen samples containing between 0.6 and 6 million round cells per mL. A1+5（1∶6）dilution was compatible with measurable peroxidase activity and a sufficiently clear background for cell assessment. At this dilution，and with assessment of all 18 grids on both sides of the Neubauer-improved counting chamber，only three of the 10 samples （nominal cell concentrations of 1.9×10(6)-3.3×10(6) mL-1) presented 400 round cells or more. As lower seminal dilutions were incompatible with easy detection of round cells or their peroxidase reaction product，it was not possible to provide precise measurements（sampling error 5%）of the suggested lower reference limit of 1伊106 cells per mL. The results indicate that this poor precision of measuring 1×10(6) round cells per mL could explain the discrepant reports on the acceptability of the cut-off values for leukocytospermia. Such reference limits need to be established with statistically sound methods. Related Articles | Metrics

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Handelsman DJ;Cooper TG 2010, 29 (3):  227-231.  Abstract ( 1730 )   PDF (317KB) ( 7309 )   Related Articles | Metrics

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Progress in Non-genomic Action of Progesterone PIAO Shu-hua;Yang Qing 2010, 29 (3):  232-234.  Abstract ( 2411 )   PDF (228KB) ( 7137 )   Progesterone can modulate the transcription of genes through the binding to nuclear-localized receptor. However, progesterone can also exert fast, nontranscriptional effects through the binding either to the classical nuclear receptor or the progesterone membrane receptor. The research in non-genomic action of progesterone makes it easier to understand many physical changes in animal and human body，and it also open a new way to explain and treat the hormone-depanded malignant tumor. Related Articles | Metrics

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Multiple Displacement Amplification and It’s Application in Preimplantation Genetic Diagnosis PENG Zhao-feng;SUN Ying-pu. 2010, 29 (3):  235-238.  Abstract ( 2514 )   PDF (242KB) ( 7071 )   The multiple replacement amplification technical（MDA）is a kind of the whole genome amplification（WGA）which based on strand displacement amplification. It has higher amplification efficiency rate and fidelity characteristics and so on. Although it is ued in the single cell amplification except a little defects, it has acquired great progress in the practice research and clinical application of preimplantation genetic diagnosis（PGD）. MDA has succeed in PGD when combined with standard PCR method. It makes master synchronism diagnosis of single test embryo biopsy, the single embryo cell gender and monogenic disorder come ture. MDA has impelled rapid development of PGD technology. Related Articles | Metrics

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The Effect of Oxidative Stress on Assisted Reproductive Techniques Setting OU Lei;GUO Yi-hong;SUN Ying-pu 2010, 29 (3):  239-242.  Abstract ( 2530 )   PDF (261KB) ( 7110 )   The manipulation of gametes and embryos in an in vitro environment when performing assisted reproductive techniques（ART）carries the risk of exposure of these cells to supraphysiological levels of reactive oxygen species（ROS）. The main objective of this review articles is to provide ART personnel with all the necessary information regarding the development of oxidative stress in an ART setting，as well as the sources of ROS and the mechanisms of oxidative stress-induced damage during ART procedures. The impact of oxidative stress on ART outcomes and the different strategies designed to prevent it are also discussed. Related Articles | Metrics

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Consensus on Infertility Treatment Related to Polycystic Ovary Syndrome LIU Yi-chao;YANG Ying;LI Wei;KUANG Hong-ying;HOU Li-hui;WU Xiao-ke 2010, 29 (3):  243-246.  Abstract ( 2515 )   PDF (250KB) ( 7086 )   The treatment of infertile women with polycystic ovary syndrome（PCOS）is surrounded by many controversies. Before any intervention is initiated, preconceptional counseling should be provided emphasizing the importance of lifestyle, especially weight reduction and exercise in overweight women, smoking, and alcohol consumption. The recommended first-line treatment for ovulation induction remains the anti-estrogen clomiphene citrate （CC）. Recommended second-line intervention, should CC fail to result in pregnancy, is either exogenous gonadotropins or laparoscopic ovarian surgery（LOS）. The use of recommended second-line interventions are associated with adverse reactions. Recommended third-line treatment is in vitro fertilization（IVF）. Insulin-sensitizing agents in PCOS should be restricted to women with glucose intolerance. Based on recent data available in the literature, the routine use of this drug in ovulation induction is not recommended. Aromatase inhibitors are the anti-estrogen, which are good for PCOS women, and the malformation rate is low. Insufficient evidence is currently available to recommend the clinical use of aromatase inhibitors for routine ovulation induction. Related Articles | Metrics