- Email: [email protected]
Postcoital testing in women during menotropin therapy
Vol. 37 PP 514-519, April 1982 Printed in U.SA.
Postcoital testing in women during menotropin therapy
Robert A. Skaf, M.D. Ekkehard Kemmann, M.D. * Department of Obstetrics and Gynecology, College of Medicine and Dentistry of New Jersey, Rutgers Medical School, Piscataway, New Jersey 08854
The authors were interested in determining the predictive value of postcoital testing in women who undergo human menopausal gonadotropin (hMG) therapy for the induction of ovulation. Fifty consecutive patients were studied whose husbands had acceptable semen analyses; 24 of the patients conceived. Postcoital testing was done after hMG stimulation on the day human chorionic gonadotropins (heG) were given or the day before. All but one patient had excellent cervical mucus quality. Sperm characteristics in cervical mucus were analyzed in regard to overall motility, number of active sperm per high-power field (HPF), and quality of movement. These data were correlated with outcome in terms of conception. A linear correlation could be shown between overall motility and pregnancy outcome once at least 40% motility was present; no pregnancy occurred in patients with 20% or less sperm motility. Once five or more active spermlHPF were noted, the chance of pregnancy was about 60%; this chance was not increasd with higher density rates. In all but one patient who conceived, sperm with maximum quality (+3 motility) were noted. Data were compiled in a postcoital score (range 0 to 12). Patients with a high score had a pregnancy rate of 70%, patients with an intermediate score, 23%, and none of the seven women with low scores conceived. Because menotropin therapy is costly, demanding, and potentially risky, it is suggested that one utilize results of postcoital testing as a guide in decisions about the continuation of such therapy. Fertil Steril 37:514, 1982
The postcoital test (peT) is generally accepted as part of a complete evaluation of the infertile couple; yet uncertainties exist about its value and interpretation. Generally it can be said that a "good" result ona peT indicates a favorable prognosis for resolution of the infertility situation. A "poor" result, however, may be difficult both to define and to interpret. l - 3 Numerous factors have to be considered; critical among these are cervical mucus, ovulation,4 and factors of male fertility, specifically quality of the semen
Received June 15,1981; revised and accepted November 5, 1981. *Reprint requests: Ekkehard Kemmann, M.D., College of Medicine and Dentistry of New Jersey, Rutgers Medical School, University Heights, Piscataway, New Jersey 08854.
36
specimen. 5 , 6 With numerous variables, then, it is not surprising to see pregnancies reported in patients even if peT results are considered "poor." Apparently, results of peTs in infertile versus fertile couples correlate better with cervical mucus characteristics than with motility or number of sperm seen at the time of testing. l In patients who undergo induction of ovulation with human menopausal gonadotropins (hMG) and human chorionic gonadotropins (heG), cervical factors that could adversely affect peT results can be exceptionally well controlled; patients are seen daily, serum estrogen levels are supranormal and monitored,7, 8 and cervical mucus can be accordingly well stimulated and supervised. 9 The peT is done under controlled conditions at the time of maximal cervical mucus stimulation, just prior to ovulation. Thus, major variables of postcoital
r Table 1. Number of Treatment Courses, Postcoital Tests (PCTs), and Pregnancy Outcome in 50 hMG-hCG-Treated Women
Number of patients Number of treatment courses Number ofPCTs
Treatment resuited in pregnancy
Treatment did not result in pregnancy
Total
24 64
26 89
50 153
53
71
124
testing that are not related to male factors are reduced or perhaps eliminated. For these reasons hMG-hCG-treated infertility patients represent an excellent model for study of postcoital testing; yet experience seems limited.lO We therefore present results of PCTs in hMG-hCG-treated patients and discuss the interpretation of the results. MATERIALS AND METHODS
During a 15-month period from July 1979 to November 1980, 50 infertile patients underwent 153 courses of induction of ovulation with hMGhCG treatment with resulting pregnancy in 24 of these patients (48%); during thEilse treatments 124 PCTs were performed (Table 1). Of the 50 patients, 45 were anovulatory due to either polycystic ovarian disease or normogonadotropic or hypogonadotropic anovulation, 4 patients had a short luteal phase, and 1 patient had hyperprolactinemia. Before treatment all patients had an infertility workup to document tubal patency by hysterosalpingography and/or laparoscopy. In the pregnant group, 14 patients (67%) had laparoscopies. In the group in which the treatment did not result in pregnancy (n = 26), 18 patients (69%) had laparoscopies. All male partners had been investigated. The semen volume ranged from 1.5 ml to 4.8 ml, with a mean of 3.1 ml. If a patient's husband had a semen count of less than 20 million/ml, markedly abnormal findings in sperm motility « 40% motile forms), or morphologic abnormalities « 40% normal forms), the patient was not included in this study. Frequently, such patients required artificial insemination donor (AID) therapy. Treatment was started on the third to fifth day after spontaneous or induced menses. Daily intramuscular injections ofhMG were given according to an individual schedule based on daily measurement of plasma estradiol (E 2) levels; frequent pelvic examinations were done to monitor cervical mucus development, namely, amount, consis-
tency, and spinnbarkeit. When E 2 levels reached 900 to 1500 pg/ml, hMG injections were withheld, and 48 hours later a single injection of 10,000 IU of hCG was given to trigger ovulation. s Patients were seen 2 days and 7 days later so that we could document ovulation and check for the possibility of the hyperstimulation syndrome. Pregnancy testing was done if the menses was missed. All patients had evidence of ovulation as a result of hMG-hCG therapy. All postcoital tests were done between 8:00 and 9:00 A.M. on the day hCG was given or the day before. The mean serum E2 level concentration at this time was (1174 ± 74 pg/ml) (mean ± standard deviation [8D]). Patients had been instructed to have intercourse the evening before, 8 to 12 hours before the test. The specimen was obtained from the endocervix, 1 to 2 cm above the external cervical os, with suction into a polyethylene tube (No. 18) attached to a 3-ml syringe. 2 Most patients presented with cascading, clear mucus, allowing direct entry into the cervix; if the cervix, however, did not show abundant clear mucus, the endocervical canal was entered after wiping the os with a dry swab. Volume, color, viscosity, and spinnbarkeit were recorded. Usually two or three slides were prepared and immediately examined microscopically by the' authors. A minimum of five high-power fields (HPF) were investigated from different sections of each slide. The overall motility (in %), the number of motile spermlHPF, and the quality of movement were recorded from the best section of the specimen. A 5-point score was generated for the estimation of each of these three characteristics (Table 2). Each PCT delivered an overall score from 0 to 12 points. For density, 0 points were given when no motile sperm were seen; a maximum of 4 points was given for 20 or more active spermlHPF. Motility of 60% or more received a maximum score of 4. Quality of movement was graded according to the method of Macleod, ranging from 0 when the sperm were immobile to 3 + when there was rapid movement across the HPFY Unless specified, the results of the best PCT of each patient are reported. Because of the prognostic potential of the PCT, results of the first PCT are also evaluated in this report. RESULTS
In 49 of 50 patients, cervical mucus was optimal at the time of examination and was clear thin, and contained few or no cellular debris. I~ 37
Table 2. Pregnancy Outcome in 50 hMG-Treated Patients with Regard to Findings at Postcoital Testing: A-Density, B-Motility, C-Quality of Movement A-Density Postcoital test score
0 1 2 3 4
Motile sperm/highpower field
No. of pregnant patients
0 1-4 5-9 10--19 > 20
No. of nonpregnant patients
% Pregnancy
2 9 2 7 6
0 10 60 56 65
No. of pregnant patients
No. of nonpregnant patients
% Pregnancy
1 7 16
2 1 5 12 6
0 0 17 37 72
No. of pregnant patients
No. of nonpregnant patients
% Pregnancy
1 4 19
7 6 3 10
1 3 9 11 B-Motility
PCT score
Overall motility %
0 1 2 3 4
0
< 20 < 40 < 60 60+
C-Quality PCTscore
Quality of movement
0--1 2 3 4
o or 1+ 2+ 2+/3+ 3+
these 49 patients, spinnbarkeit exceeded (often by 100% or more) 10 cm, and excellent ferning was noted. In one patient, despite a serum E2 level of 1814 pg/ml, cervical mucus remained thick, scant, and poorly stretchable. Over 80% of the slides were reviewed simultaneously by both authors. In most cases the scores given were identical, but when they differed, they differed by not more than ± 1. Table 2 shows results of PCT related to pregnancy outcome; motile sperm density (active spermlhigh-power field), overall motility (%), and quality of movement were separately assessed. SPERM DENSITY
In patients with less than five motile sperm/ HPF, only one pregnancy was recorded. Once five or more active spermfHPF were noted, the chance of pregnancy was about 60%. Our data did not indicate a correlation between sperm density and pregnancy outcome beyond this threshold. SPERM MOTILITY
No pregnancy was seen in patients who had less than 20% sperm motility, and only one pregnancy was seen in nine women with motility less than 40%. For higher motility rates a strong linear, positive correlation was noted between sperm 38
0
14 57 66
motility in cervical mucus and pregnancy outcome (,:;. = 0.96, a = 15.7, b = 1.8). Thus, the data suggested that once a threshold of around 25% to 30% was passed, the higher the number of active sperm, the better the chance of conception. SPERM QUALITY
No pregnancy was seen unless at least 2 + active sperm were noted. In 23 of 24 patients, 3 + active sperm were present on examination. In regard to outcome, the difference between 3 + versus 2 + quality was highly significant (x 2 = 9, P < 0.005). Figure 1 shows data that correlate results of the PCT score and treatment outcome. The maximum postcoital score of 12 indicated overall motility of 60% or better and 20 or more motile sperm/HPF with good forward motility. With scores exceeding 9 (high score), pregnancies were achieved in 70% of patients (n = 30), whereas none of seven patie,p.ts with a score of 5 or less (low score) conceived. In between, with an intermediate score of 6 to 9, was a group of patients (n = 13) with reduced fertility outlook; three patients conceived. Pregnancy outcome in patients with a high score was significantly better than that of patients with intermediate scores (P < 0.001).
10-
•
Prellent
D
NonPrepent
8-
..•••
6
-
.•
;:
-. •
4
.:E
-
z•
2-
r
-
6.a-..&-I7-L..8~..L...L
L-.--I<-:l6-....
•• ---11......'-12 -
PCT Scor. Figure 1 Correlation of postcoital scores and treatment outcome.
Comparison of the PCT score with single factors ofthe postcoital test indicated that 90% of the patients who conceived could be predicted on the basis of a high (> 9) PCT score; therefore, the PCT score predicted the pregnancy group with greater accuracy than "good" density, motility, or quality results individually. The number of patients with either poor density or motility results with observed 0 pregnancy rates was less than half the number of subjects with low PCT scores (Table 2); on the basis of poor sperm quality, about an equal number of patients with a 0 pregnancy rate was identified as by the PCT score. Thus, the PCT score seems to have a higher accuracy in identification of both patients who are likely and those who are unlikely to conceive. As several patients had more than one PCT, analysis was made to compare the degree of consistency of PCT tests in cycles of hMG-treated patients. Fourteen of the 50 patients had two PCT tests with an average SD of 0.42 in the PCTscore, 12 patients had three PCT tests with an average SD of 1.04, and 11 patients had four or more tests with an average SD of 1.38. The results of the first
PCT in 50 patients was similar with regard to ultimate pregnancy outcome as the results of the best PCT score of124 determinations. None of the patients who on any PCT had a low score « 6) ever conceived. On the first PCT, 19 subjects who conceived had high scores; with repeat testing 2 subjects who conceived changed from an intermediate to a high score (Table 3). Results of PCT scores and of semen analysis showed no significant correlations. It should be said, however, that all semen analyses were judged to be acceptable and exceeded 20 million! ml in sperm counts. In 14 patients, morphologic semen analysis revealed less than 50% normal forms; in this subgroup, pregnancy was reduced (three pregnancies, 21%); however, 8 of these patients had high PCT scores, underlining the lack of correlation of PCT and semen analysis data. Four patients whose husbands had normal semen analyses had 0 PCT score and did not conceive. One of these patients had poor mucus development, as described above. The other three patients with PCT scores of 0 had good preovulatory cervical mucus but immobile sperm. All these patients could be shown to have antibodies in cervical mucus but not in the serum. None of their partners had antisperm antibodies in the serum. 12 DISCUSSION
Postcoital testing in hMG-hCG-treated women can be done in a well-controlled situation. Improper timing of the test is avoided as cervical mucus development is monitored. Poor mucus development is unlikely to occur, because the mucus is stimulated by large amounts of endogenous estrogen. During treatment estrogen levels and occurrence of ovulation are closely monitored. Thus, adverse factors that could influence cervical mucus characteristics are reasonably well controlled. Because cervical mucus development is a major factor in usual PC testing, the reduction of its contributing influence should lead to a PC testing system that may be easier to interpret and may Table 3. PCT Scores of24 Patients with Pregnancy: Comparison of Distribution of Low, Intetmediate, and High Scores During First and Best PCT First PeT
en
<6 6-9 >9
= 24)
o
5 19
BestPCT
en
= 53)
o 3
21
39
predominantly reflect factors of sperm quality. It is suggested that PC testing in hMG-treated patients represents a model situation for evaluation of in vivo sperm activity, particularly sperm penetration and survival at the cervical level. Evaluation of PCT parameters indicated that (1) once a threshold of five active sperm/HPF has been met, further increase in density is not correlated with increase in pregnancy rates, (2) that once a threshold of about 30% overall motility has been met, there is a positive correlation between pregnancy outcome and sperm motility in PC testing, and (3) almost all pregnancies occurred in patients who had 3 + sperm motility on PCT. Overall sperm motility may be the single most important parameter in postcoital testing. We attempted to condense the parameters of PCT into the PCT score. A "high" score (10 to 12 points) proved to be highly predictive in the attainment of pregnancy. In the prediction offertility, the score seemed to be a better discriminating factor than single-parameter observation and seemed to identify most clearly a subgroup of patients likely to conceive. In our study a high PCT score had a predictive value of about 70% pregnancy rate. Three of 13 patients with an intermediate score (6 to 9 points) conceived (23%), suggesting that the PCT score identified a group of patients with reduced fertility outlook during hMG-hCG therapy. None of seven patients with a low « 6 points) PCT score conceived. Clinical prudence suggests that the power of negative or poor PCT results is relative, and occasionally a pregnancy might occur. Three of our patients with low PCT « 6 points) scores were treated for only one or two cycles; thus, it cannot be excluded that pregnancy may have been obtained with further therapy. Indeed, Friberg and Gemzell reported a pregnancy in an hMG-treated woman who had no sperm on a 12- to 15-hour PCT.lO In general, the prospect of pregnancy in patients with a low PCT score can be expected to be rather unlikely. Our data indicate that already the first PCT during hMG therapy is highly predictive of the eventual outcome. Data from our investigation do apply only to hMG-treated patients. Their extrapolation to women without hMG therapy is speculative. We were not able to detect any clinical problems in males or females to explain intermediate PCT scores. Reviewing of the semen analysis data did not indicate recognizable problems in concentration, motility, or morphologic characteristics. However, it should be recognized that semen
40
analysis is a rather crude estimate of male fertility, and finer methods to measure sperm function are needed. Correlation with in vitro penetration systems will be of interest in the future. In addition, although all female partners of these males had excellent cervical mucus development, indistinguishable from patients who conceived, it is possible that there might also be a subgroup of women with yet unrecognizable cervical mucus problems. In all four patients with 0 PCT scores a possible underlying problem could be identified. In three patients cervical sperm antibodies could be detected. Interestingly, local antibodies seemed to interfere with sperm action despite the copious amount of mucus production at the time of maximum estrogen stimulation. The presence of cervical mucus antibodies in conjunction with a poor PCT test represents a good example of the relevance of antibody testing in infertility. It will be of interest to extend antibody evaluations to patients with a reduced PCT score. In one patient, what appeared to be a cervical mucus deficiency was apparent. These results emphasize the complexity of infertility factors in individual patients. hMG-hCG therapy is costly, demanding, and not without risk. Controversy exists in how long therapy should be continued if pregnancy is not achieved within several treatment cycles. Whereas some argue that generally two to five treatment cycles are enough,13 probably because the potential for pregnancy achievement may have been exhausted during that time, others maintain that the possibility of pregnancy remains unchanged with prolonged therapy and thus advocate long-term continuation of treatment. 14 It appears logical to utilize PCT results in this decision process. In the presence of good PCT scores, we feel it to be reasonable to continue with all efforts to induce ovulation in the patient with medical therapy. However, if, as in patients with low PCT scores, pregnancy appears unlikely, continuation ofhMG therapy seems wasteful without appropriate therapy directed at improvement of PCT results. REFERENCES 1. Blasco L: Clinical approach to the evaluation of sperm-
cervical mucus interactions. Fertil Steril 28:1133, 1977 2. Danezis J, Sujan S, Sobrero AJ: Evaluation of the postcoital test. Fertil Steril 13:559, 1962 3. Jette NT, Glass RH: Prognostic value of the postcoital test. Fertil Steril 23:29, 1972
4. Gibor Y, Garcia CJ Jr, Cohen MR, Scommegna A: The cyclical changes in the physical properties of the cervical mucus and the results of the postcoital test. Fertil Steril 21:197, 1970 5. Sobrero AJ, Macleod J: The immediate postcoital test. Fertil Steril 13:184, 1962 6. Glass RH, Mroueh A: The postcoital test and semen analysis. Fertil Steril 18:314, 1967 7. Notation AD, Tagatz GE, Steffer MW: Serum 17J3-estradiol: index of follicle maturation during gonadotropin therapy. Obstet GynecoI51:204, 1978 8. Kemmann E, Gemzell CA, Beinert WC, Beling CB, Jones JR: Plasma prolactin changes during administration of human menopausal gonadotropins in nonovulatory women. Am J Obstet GynecoI129:145, 1977 9. Insler V, Melmed H, Serr D, Lunenfeld B: The cervical score. Int J Gynecol Obstet 10:223, 1972
10. Friberg J, Gemzell C: Daily postcoital tests in the conception cycle during treatment of anovulatory women with human gonadotropin. Int J Fertil 17:178, 1972 11. Macleod J: Semen quality in one thousand men of known fertility and in eight hundred cases of infertile marriage. Fertil Steril 2:115, 1951 12. Shulman S, Gray BA, Stevens L: Studies on local immunity to sperm-diBBOlving of cervical mucus by use of Bromelin with retention of antibody activity. Am J Reprod Immunol 1:49, 1980 13. Speroff L, Glass RH, Kase NG: Induction of Ovulation. In Clinical Gynecologic Endocrinology and Infertility, Second Edition. Baltimore, Williams & Wilkins Co, 1978, p 375 14. Schwartz M, Jewelewicz R, Dyrenfurth I, Tropper P, Vandewiele RL: The use of human menopausal and chorionic gonadotropin for inducton of ovulation. Am J Obstet Gynecol 138:801, 1980
41
Postcoital testing in women during menotropin therapy
Robert A. Skaf, M.D. Ekkehard Kemmann, M.D. * Department of Obstetrics and Gynecology, College of Medicine and Dentistry of New Jersey, Rutgers Medical School, Piscataway, New Jersey 08854
The authors were interested in determining the predictive value of postcoital testing in women who undergo human menopausal gonadotropin (hMG) therapy for the induction of ovulation. Fifty consecutive patients were studied whose husbands had acceptable semen analyses; 24 of the patients conceived. Postcoital testing was done after hMG stimulation on the day human chorionic gonadotropins (heG) were given or the day before. All but one patient had excellent cervical mucus quality. Sperm characteristics in cervical mucus were analyzed in regard to overall motility, number of active sperm per high-power field (HPF), and quality of movement. These data were correlated with outcome in terms of conception. A linear correlation could be shown between overall motility and pregnancy outcome once at least 40% motility was present; no pregnancy occurred in patients with 20% or less sperm motility. Once five or more active spermlHPF were noted, the chance of pregnancy was about 60%; this chance was not increasd with higher density rates. In all but one patient who conceived, sperm with maximum quality (+3 motility) were noted. Data were compiled in a postcoital score (range 0 to 12). Patients with a high score had a pregnancy rate of 70%, patients with an intermediate score, 23%, and none of the seven women with low scores conceived. Because menotropin therapy is costly, demanding, and potentially risky, it is suggested that one utilize results of postcoital testing as a guide in decisions about the continuation of such therapy. Fertil Steril 37:514, 1982
The postcoital test (peT) is generally accepted as part of a complete evaluation of the infertile couple; yet uncertainties exist about its value and interpretation. Generally it can be said that a "good" result ona peT indicates a favorable prognosis for resolution of the infertility situation. A "poor" result, however, may be difficult both to define and to interpret. l - 3 Numerous factors have to be considered; critical among these are cervical mucus, ovulation,4 and factors of male fertility, specifically quality of the semen
Received June 15,1981; revised and accepted November 5, 1981. *Reprint requests: Ekkehard Kemmann, M.D., College of Medicine and Dentistry of New Jersey, Rutgers Medical School, University Heights, Piscataway, New Jersey 08854.
36
specimen. 5 , 6 With numerous variables, then, it is not surprising to see pregnancies reported in patients even if peT results are considered "poor." Apparently, results of peTs in infertile versus fertile couples correlate better with cervical mucus characteristics than with motility or number of sperm seen at the time of testing. l In patients who undergo induction of ovulation with human menopausal gonadotropins (hMG) and human chorionic gonadotropins (heG), cervical factors that could adversely affect peT results can be exceptionally well controlled; patients are seen daily, serum estrogen levels are supranormal and monitored,7, 8 and cervical mucus can be accordingly well stimulated and supervised. 9 The peT is done under controlled conditions at the time of maximal cervical mucus stimulation, just prior to ovulation. Thus, major variables of postcoital
r Table 1. Number of Treatment Courses, Postcoital Tests (PCTs), and Pregnancy Outcome in 50 hMG-hCG-Treated Women
Number of patients Number of treatment courses Number ofPCTs
Treatment resuited in pregnancy
Treatment did not result in pregnancy
Total
24 64
26 89
50 153
53
71
124
testing that are not related to male factors are reduced or perhaps eliminated. For these reasons hMG-hCG-treated infertility patients represent an excellent model for study of postcoital testing; yet experience seems limited.lO We therefore present results of PCTs in hMG-hCG-treated patients and discuss the interpretation of the results. MATERIALS AND METHODS
During a 15-month period from July 1979 to November 1980, 50 infertile patients underwent 153 courses of induction of ovulation with hMGhCG treatment with resulting pregnancy in 24 of these patients (48%); during thEilse treatments 124 PCTs were performed (Table 1). Of the 50 patients, 45 were anovulatory due to either polycystic ovarian disease or normogonadotropic or hypogonadotropic anovulation, 4 patients had a short luteal phase, and 1 patient had hyperprolactinemia. Before treatment all patients had an infertility workup to document tubal patency by hysterosalpingography and/or laparoscopy. In the pregnant group, 14 patients (67%) had laparoscopies. In the group in which the treatment did not result in pregnancy (n = 26), 18 patients (69%) had laparoscopies. All male partners had been investigated. The semen volume ranged from 1.5 ml to 4.8 ml, with a mean of 3.1 ml. If a patient's husband had a semen count of less than 20 million/ml, markedly abnormal findings in sperm motility « 40% motile forms), or morphologic abnormalities « 40% normal forms), the patient was not included in this study. Frequently, such patients required artificial insemination donor (AID) therapy. Treatment was started on the third to fifth day after spontaneous or induced menses. Daily intramuscular injections ofhMG were given according to an individual schedule based on daily measurement of plasma estradiol (E 2) levels; frequent pelvic examinations were done to monitor cervical mucus development, namely, amount, consis-
tency, and spinnbarkeit. When E 2 levels reached 900 to 1500 pg/ml, hMG injections were withheld, and 48 hours later a single injection of 10,000 IU of hCG was given to trigger ovulation. s Patients were seen 2 days and 7 days later so that we could document ovulation and check for the possibility of the hyperstimulation syndrome. Pregnancy testing was done if the menses was missed. All patients had evidence of ovulation as a result of hMG-hCG therapy. All postcoital tests were done between 8:00 and 9:00 A.M. on the day hCG was given or the day before. The mean serum E2 level concentration at this time was (1174 ± 74 pg/ml) (mean ± standard deviation [8D]). Patients had been instructed to have intercourse the evening before, 8 to 12 hours before the test. The specimen was obtained from the endocervix, 1 to 2 cm above the external cervical os, with suction into a polyethylene tube (No. 18) attached to a 3-ml syringe. 2 Most patients presented with cascading, clear mucus, allowing direct entry into the cervix; if the cervix, however, did not show abundant clear mucus, the endocervical canal was entered after wiping the os with a dry swab. Volume, color, viscosity, and spinnbarkeit were recorded. Usually two or three slides were prepared and immediately examined microscopically by the' authors. A minimum of five high-power fields (HPF) were investigated from different sections of each slide. The overall motility (in %), the number of motile spermlHPF, and the quality of movement were recorded from the best section of the specimen. A 5-point score was generated for the estimation of each of these three characteristics (Table 2). Each PCT delivered an overall score from 0 to 12 points. For density, 0 points were given when no motile sperm were seen; a maximum of 4 points was given for 20 or more active spermlHPF. Motility of 60% or more received a maximum score of 4. Quality of movement was graded according to the method of Macleod, ranging from 0 when the sperm were immobile to 3 + when there was rapid movement across the HPFY Unless specified, the results of the best PCT of each patient are reported. Because of the prognostic potential of the PCT, results of the first PCT are also evaluated in this report. RESULTS
In 49 of 50 patients, cervical mucus was optimal at the time of examination and was clear thin, and contained few or no cellular debris. I~ 37
Table 2. Pregnancy Outcome in 50 hMG-Treated Patients with Regard to Findings at Postcoital Testing: A-Density, B-Motility, C-Quality of Movement A-Density Postcoital test score
0 1 2 3 4
Motile sperm/highpower field
No. of pregnant patients
0 1-4 5-9 10--19 > 20
No. of nonpregnant patients
% Pregnancy
2 9 2 7 6
0 10 60 56 65
No. of pregnant patients
No. of nonpregnant patients
% Pregnancy
1 7 16
2 1 5 12 6
0 0 17 37 72
No. of pregnant patients
No. of nonpregnant patients
% Pregnancy
1 4 19
7 6 3 10
1 3 9 11 B-Motility
PCT score
Overall motility %
0 1 2 3 4
0
< 20 < 40 < 60 60+
C-Quality PCTscore
Quality of movement
0--1 2 3 4
o or 1+ 2+ 2+/3+ 3+
these 49 patients, spinnbarkeit exceeded (often by 100% or more) 10 cm, and excellent ferning was noted. In one patient, despite a serum E2 level of 1814 pg/ml, cervical mucus remained thick, scant, and poorly stretchable. Over 80% of the slides were reviewed simultaneously by both authors. In most cases the scores given were identical, but when they differed, they differed by not more than ± 1. Table 2 shows results of PCT related to pregnancy outcome; motile sperm density (active spermlhigh-power field), overall motility (%), and quality of movement were separately assessed. SPERM DENSITY
In patients with less than five motile sperm/ HPF, only one pregnancy was recorded. Once five or more active spermfHPF were noted, the chance of pregnancy was about 60%. Our data did not indicate a correlation between sperm density and pregnancy outcome beyond this threshold. SPERM MOTILITY
No pregnancy was seen in patients who had less than 20% sperm motility, and only one pregnancy was seen in nine women with motility less than 40%. For higher motility rates a strong linear, positive correlation was noted between sperm 38
0
14 57 66
motility in cervical mucus and pregnancy outcome (,:;. = 0.96, a = 15.7, b = 1.8). Thus, the data suggested that once a threshold of around 25% to 30% was passed, the higher the number of active sperm, the better the chance of conception. SPERM QUALITY
No pregnancy was seen unless at least 2 + active sperm were noted. In 23 of 24 patients, 3 + active sperm were present on examination. In regard to outcome, the difference between 3 + versus 2 + quality was highly significant (x 2 = 9, P < 0.005). Figure 1 shows data that correlate results of the PCT score and treatment outcome. The maximum postcoital score of 12 indicated overall motility of 60% or better and 20 or more motile sperm/HPF with good forward motility. With scores exceeding 9 (high score), pregnancies were achieved in 70% of patients (n = 30), whereas none of seven patie,p.ts with a score of 5 or less (low score) conceived. In between, with an intermediate score of 6 to 9, was a group of patients (n = 13) with reduced fertility outlook; three patients conceived. Pregnancy outcome in patients with a high score was significantly better than that of patients with intermediate scores (P < 0.001).
10-
•
Prellent
D
NonPrepent
8-
..•••
6
-
.•
;:
-. •
4
.:E
-
z•
2-
r
-
6.a-..&-I7-L..8~..L...L
L-.--I<-:l6-....
•• ---11......'-12 -
PCT Scor. Figure 1 Correlation of postcoital scores and treatment outcome.
Comparison of the PCT score with single factors ofthe postcoital test indicated that 90% of the patients who conceived could be predicted on the basis of a high (> 9) PCT score; therefore, the PCT score predicted the pregnancy group with greater accuracy than "good" density, motility, or quality results individually. The number of patients with either poor density or motility results with observed 0 pregnancy rates was less than half the number of subjects with low PCT scores (Table 2); on the basis of poor sperm quality, about an equal number of patients with a 0 pregnancy rate was identified as by the PCT score. Thus, the PCT score seems to have a higher accuracy in identification of both patients who are likely and those who are unlikely to conceive. As several patients had more than one PCT, analysis was made to compare the degree of consistency of PCT tests in cycles of hMG-treated patients. Fourteen of the 50 patients had two PCT tests with an average SD of 0.42 in the PCTscore, 12 patients had three PCT tests with an average SD of 1.04, and 11 patients had four or more tests with an average SD of 1.38. The results of the first
PCT in 50 patients was similar with regard to ultimate pregnancy outcome as the results of the best PCT score of124 determinations. None of the patients who on any PCT had a low score « 6) ever conceived. On the first PCT, 19 subjects who conceived had high scores; with repeat testing 2 subjects who conceived changed from an intermediate to a high score (Table 3). Results of PCT scores and of semen analysis showed no significant correlations. It should be said, however, that all semen analyses were judged to be acceptable and exceeded 20 million! ml in sperm counts. In 14 patients, morphologic semen analysis revealed less than 50% normal forms; in this subgroup, pregnancy was reduced (three pregnancies, 21%); however, 8 of these patients had high PCT scores, underlining the lack of correlation of PCT and semen analysis data. Four patients whose husbands had normal semen analyses had 0 PCT score and did not conceive. One of these patients had poor mucus development, as described above. The other three patients with PCT scores of 0 had good preovulatory cervical mucus but immobile sperm. All these patients could be shown to have antibodies in cervical mucus but not in the serum. None of their partners had antisperm antibodies in the serum. 12 DISCUSSION
Postcoital testing in hMG-hCG-treated women can be done in a well-controlled situation. Improper timing of the test is avoided as cervical mucus development is monitored. Poor mucus development is unlikely to occur, because the mucus is stimulated by large amounts of endogenous estrogen. During treatment estrogen levels and occurrence of ovulation are closely monitored. Thus, adverse factors that could influence cervical mucus characteristics are reasonably well controlled. Because cervical mucus development is a major factor in usual PC testing, the reduction of its contributing influence should lead to a PC testing system that may be easier to interpret and may Table 3. PCT Scores of24 Patients with Pregnancy: Comparison of Distribution of Low, Intetmediate, and High Scores During First and Best PCT First PeT
en
<6 6-9 >9
= 24)
o
5 19
BestPCT
en
= 53)
o 3
21
39
predominantly reflect factors of sperm quality. It is suggested that PC testing in hMG-treated patients represents a model situation for evaluation of in vivo sperm activity, particularly sperm penetration and survival at the cervical level. Evaluation of PCT parameters indicated that (1) once a threshold of five active sperm/HPF has been met, further increase in density is not correlated with increase in pregnancy rates, (2) that once a threshold of about 30% overall motility has been met, there is a positive correlation between pregnancy outcome and sperm motility in PC testing, and (3) almost all pregnancies occurred in patients who had 3 + sperm motility on PCT. Overall sperm motility may be the single most important parameter in postcoital testing. We attempted to condense the parameters of PCT into the PCT score. A "high" score (10 to 12 points) proved to be highly predictive in the attainment of pregnancy. In the prediction offertility, the score seemed to be a better discriminating factor than single-parameter observation and seemed to identify most clearly a subgroup of patients likely to conceive. In our study a high PCT score had a predictive value of about 70% pregnancy rate. Three of 13 patients with an intermediate score (6 to 9 points) conceived (23%), suggesting that the PCT score identified a group of patients with reduced fertility outlook during hMG-hCG therapy. None of seven patients with a low « 6 points) PCT score conceived. Clinical prudence suggests that the power of negative or poor PCT results is relative, and occasionally a pregnancy might occur. Three of our patients with low PCT « 6 points) scores were treated for only one or two cycles; thus, it cannot be excluded that pregnancy may have been obtained with further therapy. Indeed, Friberg and Gemzell reported a pregnancy in an hMG-treated woman who had no sperm on a 12- to 15-hour PCT.lO In general, the prospect of pregnancy in patients with a low PCT score can be expected to be rather unlikely. Our data indicate that already the first PCT during hMG therapy is highly predictive of the eventual outcome. Data from our investigation do apply only to hMG-treated patients. Their extrapolation to women without hMG therapy is speculative. We were not able to detect any clinical problems in males or females to explain intermediate PCT scores. Reviewing of the semen analysis data did not indicate recognizable problems in concentration, motility, or morphologic characteristics. However, it should be recognized that semen
40
analysis is a rather crude estimate of male fertility, and finer methods to measure sperm function are needed. Correlation with in vitro penetration systems will be of interest in the future. In addition, although all female partners of these males had excellent cervical mucus development, indistinguishable from patients who conceived, it is possible that there might also be a subgroup of women with yet unrecognizable cervical mucus problems. In all four patients with 0 PCT scores a possible underlying problem could be identified. In three patients cervical sperm antibodies could be detected. Interestingly, local antibodies seemed to interfere with sperm action despite the copious amount of mucus production at the time of maximum estrogen stimulation. The presence of cervical mucus antibodies in conjunction with a poor PCT test represents a good example of the relevance of antibody testing in infertility. It will be of interest to extend antibody evaluations to patients with a reduced PCT score. In one patient, what appeared to be a cervical mucus deficiency was apparent. These results emphasize the complexity of infertility factors in individual patients. hMG-hCG therapy is costly, demanding, and not without risk. Controversy exists in how long therapy should be continued if pregnancy is not achieved within several treatment cycles. Whereas some argue that generally two to five treatment cycles are enough,13 probably because the potential for pregnancy achievement may have been exhausted during that time, others maintain that the possibility of pregnancy remains unchanged with prolonged therapy and thus advocate long-term continuation of treatment. 14 It appears logical to utilize PCT results in this decision process. In the presence of good PCT scores, we feel it to be reasonable to continue with all efforts to induce ovulation in the patient with medical therapy. However, if, as in patients with low PCT scores, pregnancy appears unlikely, continuation ofhMG therapy seems wasteful without appropriate therapy directed at improvement of PCT results. REFERENCES 1. Blasco L: Clinical approach to the evaluation of sperm-
cervical mucus interactions. Fertil Steril 28:1133, 1977 2. Danezis J, Sujan S, Sobrero AJ: Evaluation of the postcoital test. Fertil Steril 13:559, 1962 3. Jette NT, Glass RH: Prognostic value of the postcoital test. Fertil Steril 23:29, 1972
4. Gibor Y, Garcia CJ Jr, Cohen MR, Scommegna A: The cyclical changes in the physical properties of the cervical mucus and the results of the postcoital test. Fertil Steril 21:197, 1970 5. Sobrero AJ, Macleod J: The immediate postcoital test. Fertil Steril 13:184, 1962 6. Glass RH, Mroueh A: The postcoital test and semen analysis. Fertil Steril 18:314, 1967 7. Notation AD, Tagatz GE, Steffer MW: Serum 17J3-estradiol: index of follicle maturation during gonadotropin therapy. Obstet GynecoI51:204, 1978 8. Kemmann E, Gemzell CA, Beinert WC, Beling CB, Jones JR: Plasma prolactin changes during administration of human menopausal gonadotropins in nonovulatory women. Am J Obstet GynecoI129:145, 1977 9. Insler V, Melmed H, Serr D, Lunenfeld B: The cervical score. Int J Gynecol Obstet 10:223, 1972
10. Friberg J, Gemzell C: Daily postcoital tests in the conception cycle during treatment of anovulatory women with human gonadotropin. Int J Fertil 17:178, 1972 11. Macleod J: Semen quality in one thousand men of known fertility and in eight hundred cases of infertile marriage. Fertil Steril 2:115, 1951 12. Shulman S, Gray BA, Stevens L: Studies on local immunity to sperm-diBBOlving of cervical mucus by use of Bromelin with retention of antibody activity. Am J Reprod Immunol 1:49, 1980 13. Speroff L, Glass RH, Kase NG: Induction of Ovulation. In Clinical Gynecologic Endocrinology and Infertility, Second Edition. Baltimore, Williams & Wilkins Co, 1978, p 375 14. Schwartz M, Jewelewicz R, Dyrenfurth I, Tropper P, Vandewiele RL: The use of human menopausal and chorionic gonadotropin for inducton of ovulation. Am J Obstet Gynecol 138:801, 1980
41