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Detecting Ovulation
Detecting Ovulation Melvin R. Cohen, M.D., and Henry Hankin, M.D.
IN
precise timing of ovulation is important when well timed coitus is necessary for the sub fertile male to cause conception or when the in-vivo longevity of spermatozoa is minimal, as, for example, when the cervical mucorrhea of the woman is poor iri quality. Moreover, precise timing of ovulation is obviously necessary when irisemination is contemplated; its determination is perhaps most rewarding in patients with extremely irregular menstrual periods and infrequent ovulation. In a recent publication, Noyes 4 reaffirmed the theory that spermatozoa of certain species of mammals gradually attain the capability or capacity of penetrating ova during their passage through the female genital tract. If such "capacitation" is necessary in the human, it would constitute an additional reason for determining ovulation time exactly. In this paper, various technics for determining the time of ovulation are appraised. THE TREATMENT OF INFERTILITY,
METHODS OF DETECTING OVULATION
Ovulation in the human female is not a dramatic process, and but few women are aware of its occurrence. Subjective symptoms such as pelvic pain, midmonth spotting, and/or mucorrhea are too unreliable for the prediction of ovulation. 1 Direct Observation
Human ovulation has been observed by a few investigators. Decker,2 by ..,.
From the Division of Obstetrics and Gynecology and The Department for Research in Human Reproduction, Michael Reese Hospital, Chicago. This paper was presented at the Sixteenth Annual Meeting of the American Society for the Study of Sterility held in Cincinnati, Ohio, April 1-3, 1960. 497
498
COHEN & HANKIN
Fertility & Sterility
means of his culdoscope, described ovulation as follows: The fimbria of the tube becomes attached to the follicle, facilitating the extrusion of the ovum into the tube. Following this, the fimbria detaches itself from the ovary, and thus the graafian follicle is transformed into a fresh corpus hemorrhagicum. Doyle3 has described and photographed ovulation occurring without this fimbrial grasping action. During one isolated instance at culdoscopy, we were able to visualize ovulation and to confirm Decker's observations. Basal Body Temperature (BBT)
The BBT graph is probably the most universally employed method for timing ovulation. The temperature must be taken daily under strict basal conditions; we prefer the employment of rectal readings. Ovulation is thought to occur either at the low point before the sustained rise, a day or two before this point, or on the rise from low to high. There has been a great deal of difference of opinion regarding the exact interpretation of the BBT graph. When the curve is compared with other criteria, it is our impression that ovulation may occur at any time about the low pOint before the sustained rise. This may vary from patient to patient, or even during different cycles in the same patient. The day-to-day variation in the BBT curve is often difficult to interpret. When the entire graph has been completed, one can look back and designate the low point before the sustained rise, especially if this rise is sharp rather than the not uncommon "staircase thermal shift." When the temperature rise has been sustained for 2 consecutive days, we feel that ovulation has already occurred and that this patient need not be observed any longer during that cycle. Vaginal Smears
The interpretation of vaginal smears, prepared according to the technic of Papanicolaou 5 and stained by his method or that of Shorr,6 is a valuable technic for timing of ovulation. Daily smears beginning shortly after menstruation is over reveal gradually increasing estrogen effects until the smear becomes completely cornified. This occurs approximately at midcycle, after which the smear suddenly changes in that the cells become curled and clumped, or "exfoliated." We feel that ovulation probably occurs just short of complete cornification of the vaginal smear and use this test routinely in timing ovulation. However, the smear cannot be used in the presence of vaginitis and cervicitis and is very difficult to interpret following coitus.
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Vol. 11, No.5, 1960
DETECTING OVULATION
499
\Vhen this technic can be used, it is a very useful and accurate method of timing ovulation, but unfortunately it requires cytologic training. Cervical Mucorrhea
We have reported extensively concerning the preovulatory outpouring of cervical mucus with characteristic spinnbarkeit. 7 We utilize a simple glass cannula to obtain cervical mucus daily. The mucus is blown out upon a glass slide and by means of a cover slip, the threadiness or spinnbarkeit is measured roughly in centimeters according to the method of Clift. 8 Cervical mucorrhea continues from 2 to 5 days. Following ovulation, the mucus becomes thick, and its "stretch" becomes minimal or disappears completely. We feel that this maximal spinnbarkeit is the best indication of optimal fertility. (Those patients who ovulate without demonstrating cervical mucorrhea are infertile.) The Fern Test
When thin glary cervical mucus is allowed to dry, crystallization or "ferning" occurs, visible under the low-power microscope. This phenom~non has been amply described by Papanicolaou,9 Campos da Paz,I° Roland,ll and others. In our hands, the fern phenomenon usually extends over too long a period of time for usefulness. However, an occasional patient who exhibits poor mucorrhea may show a positive fern test for only 1 or 2 days. In such patients, we have found the fern phenomenon of value in timing ovulation. The Farris-Behrman Rat-Ovary-Hyperemia Test
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Farris12 reported that the time of ovulation, within 6-12 hr. can be determined accurately by his rat-test method. His test depends on the hyperemic response of the ovaries of an immature rat after the subcutaneous injection of 2 mI. of morning urine. He reported that hyperemia occurs on 3-6 consecutive days during the time of follicle growth and that ovulation is thought to occur on the last day of hyperemia. Unfortunately, other investigators have been unable to duplicate his precise laboratory technic and so have not been able to corroborate his results. Our interest in the rat test was stimulated by the report of Behrman,13 who simplified the Farris test. The Farris-Behrman test was used by Dresner and Cohen14 in a group of 69 infertile patients during 130 cycles. The patients were instructed to restrict their fluid intake and to avoid the ingestion
500
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of alcoholic beverages. Daily morning urine specimens were collected, and 3 m!. were injected intraperitoneally into each of two 40- to 50-gm. immature female rats. The rats were of a local Wistar or Sprague-Dawley strain. They were chloroformed and sacrificed within 4 hr. of injection. An incandescent lamp was used for lighting. Hyperemia in one or more of the rats' ovaries indicated a positive reaction. The patients were seen daily until our own criteria for ovulation had been satisfied. Of the 130 cycles, 81 could be used for the correlation of the rat test with BBT and spinnbarkeit. Sixty-three of the 81 cycles showed a correlation of plus or minus 2 days in comparing the low point of the BBT with the day of a positive rat test. Sixty-nine of the 81 cycles showed the same correlation with the day of maximal spinnbarkeit. The vaginal smear correlated in 70 of 78 cycles within plus or minus 2 days. There was almost exact correlation between spinnbarkeit, vaginal smear cytology, BBT low-point, and the positive rat test in 10 patients successfully inseminated. This modified rat-ovary-hyperemia test, as performed in our laboratory, cannot be recommended for routine ovulation timing. It does indicate, however, that there is a substance excreted in the urine at midcycle that is probably L.H. Glucose Stick Test A simple test of ovulation, based upon the detection of glucose in cervical mucus, was reported recently by Birnberg et al. 15 He originally utilized Tes-Tape, '* but the technic was changed to include use of a cotton-tipped applicator into which was incorporated the same enzyme system and dye used in Tes-Tape. We recently reported our experiences with this test as compared to other criteria of ovulation in 63 infertility patients during 95 cycles. 16 There was fairly good correlation between the positive stick test, maximal spinnbarkeit, and vaginal-smear cornification. There was extremely poor correlation between the low point before the rise in the BBT graph and the stick test. This study in a sense indicated all of our standard methods of timing ovulation. In the series of 95 cycles, there were consistently negative stick tests in 20, and multiple positive stick tests during nine cycles. Nondiag"Product of Eli Lilly and Company, Indianapolis, Ind.
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Vol. II, No.5, 1960
DETECTING OVULATION
501
nostic vaginal smears were present in 26 cycles. Poor mucorrhea with absent spinnbarkeit occurred during 17 cycles. In our study, we demonstrated that ovulation can occur despite negative stick tests and absent or poor cervical mucorrhea. We feel, however, that the appearance of glucose in cervical secretions is physiologic and that perhaps the stick test is another indicator of fertility rather than a test of ovulation.
Fertility Testort Our technic of timing ovulation is time-consuming and tedious, as well as inconvenient for the patient. For these reasons, we are constantly on the alert for new ovulation tests, particularly those that may be utilized by the patient herself. We have recently evaluated the Fertility Testor of Doyle and EwersY The original glucose indicator was Tes-Tape, but this has been modified by Sapit. 18 It is claimed that the enzymes impregnated into this new test strip are purer and that the color-change indicator is more specific for glucose. The apparatus is designed for use at home by the patient. It consists of a barrel-type plastic applicator that permits the test strip to be exposed to the pool in the cul-de-sac without contamination from the labia or vagina. The color change is from pink to blue in the presence of glucose. Patients being treated with insemination were given the test kits and instructed to make a reading every morning beginning a day or two after the period. The result, either pink or blue, was recorded on their records and correlated with the temperature, mucus, and vaginal smear. Readings were taken until the BBT rise was sustained for several days. Twenty-two patients were followed by this method during 34 cycles. Seventeen patients were treated with heterologous insemination during 29 cycles, and five patients were treated with homologous insemination during five cycles. Seven pregnancies were achieved, all in the former group. There were only two conceptions in the group with positive Fertility Testor readings, and in both of these, correlation with the other criteria was excellent (Table 1). The other five patients had negative Testor readings, while the correlations between BBT low-point, cervical mucus, and spinnbarkeit were all within 2 days. Thus, one of our patients (#3604), seen at weekly intervals because of extremely irregular periods, had a posifProduct of Fertility Testor Company, Ottawa, Ill.
Fertility & Sterility
COHEN & HANKIN
502
TABLE 1.
Comparison of Fertility Testor Results with Other Criteria of Ovulation in a Group of Women Who Conceived Following A.I.D. BBTZow point<'
P8tient
14f 12 13 65 11
3938 822 3384 3604 3083 3944 3868
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11
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14 13 13 58,59,60 11 11 11
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14 12 12,13 59,60 13 11 13
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14 11,13 13 59,61 11 11 11,13
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0 13,16 58,61,62 0 0 0
=
a BBT low point low point before the temperature rise. b spinnbarkeit maximal spinnbarkeit. c vaginal smear vaginal-smear cornification. d Fertility Testor positive Fertility donor insemination. fThe numbers day of the cycle when the Testor reaction. "A.I.D. tests were positive or when inseminations were performed. uZeros a negative or nondiagnostic report. hX test not performed.
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tive Testor reading on Day 58 that coincided with the presence of cervical mucorrhea. She became pregnant after two inseminations, the second performed on a day that the Testor reading was positive. Figures 1 and 2 show detailed correlations between the BBT curve, cervical mucorrhea, the vaginal smear, the postcoital test, the fern reaction, and the Fertility Testor. In patient 3384, the BBT low point occurred on Day 13. Good mucorrhea occurred on Days 13 and 14, with maximal spinnbarkeit on Day 13. The vaginal smear showed a precornified type on Day 12 and complete cornification on Day 13. The Fertility Testoc reaction showed pink on Days 10-12, blue on Day 13, pink on Days 14 and 15, and blue on Day 16. The successful insemination occurred on Day 13. In this patient, all the criteria of ovulation correlated well. Patient 3938 did not keep a very accurate BBT chart, but apparently the low point before the rise in the BBT curve was Day 14. The only day of good mucorrhea was Day 14. The vaginal smear showed cornification on Days 13 and 14. The fern test was positive on Days 13 and 14. The Fertility Testor from days 9 through 15 showed no change from the original pink color, although this patient obviously ovulated. Successful insemination was pedormed on Day 14, the day of the low point in the BBT curve and maximal spinnbarkeit. Correlation of the Fertility Testor results with the other criteria of ovulation was made in 18 patients during 26 diphasic cycles in which no conceptions occurred. In 10 cycles during which the Testor remained negative,
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Fig. 1. Ovulation chart of patient 3384. Triangle denotes insemination. Mucus is described as ti amount (1 + to 4 +), viscosity (K, thick; M, moderate; T, thin), spinnbarkeit (S) in centimeters, and number of white blood cells (1 plus = 25 per cent of high-power field; 4 plus high-power field covered). Vaginal smear is indicated as debris, degree of cornification, or exfoliation of cells. P.K. denotes the Sims-Huhner test. The fern reaction and the Fertility Testor results are indicated.
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ovulation was indicated by BBT dip, maximal spinnbarkeit, and vaginalsmear cornification. During 16 cycles, the Testor was positive. Eight of these cycles showed good correlation, while five cycles showed poor correlation with the BBT dip, cervical mucorrhea, and vaginal-smear cytology. In three cycles multiple positive readings occurred. Although our experience with the Fertility Testor has been very brief, it has not added to our armamentarium for the diagnosis of ovulation.
504
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Ovulation chart of patient 3938; see legend, Fig. 1.
Abdominovaginal Electropotential Differences
Parsons 19 • 20 has described a midcyclic alteration of the vaginal electropotential that appears with dependable regularity and is not found in the menopausal individual. His observations were made using extremely sensitive recording instruments and electrodes, which reduced the number of artifacts plaguing previous investigators. This midcyclic alteration in electropotential persists for 24-48 hr., and Parsons attributes this to ovulation. He has correlated these readings with pregnanediol excretion studies, and believes the secretory phase to be in the range of 20 days. He reported a series of 51 infertility patients, of whom 27 became pregnant when the ovulation time was determined by this method and coitus or artificial insemination was concentrated on that date.
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Vol. 11, No.5, 1960
DETECTING OVULATION
505
We have had no experience with this technic; it would not lend itself to employment as a general office procedure.
Sevag-Colton Test21 This is a chemical test for ovulation. Urine is collected daily for 5-7 days, beginning on the sixth or seventh day of the cycle. Ovulation time is evaluated according to the pattern of colorimetric readings. Using this method of ovulation timing, the authors reported 112 conceptions in 227 cases following an isolated coitus or single insemination . Behrman22 has used this test in a few cases and has found it to show excellent correlation with the day of maximal spinnbarkeit, vaginal smear cornification, and the rat-ovary-hyperemia test. We have had no experience with this test. Its accuracy and simplicity remain to be confirmed. DISCUSSION Our most valuable clinical test for ovulation timing still remains the change in the quantity, quality, and spinnbarkeit of cervical mucus. Despite the inconvenience to the patient and the tediousness of the daily observations, the results of the test are clinically rewarding. The test is easily performed and requires no complicated laboratory facilities. A patient who does not show mucorrhea may be anovulatory or may have a cervix whose glands are refractory to estrogenic stimulation. (Extensive endocervical cautery, for example, may completely destroy the mucus-producing glands.) The study of daily vaginal smears for evidence of cornification is also a useful tool and is almost as rewarding as cervical mucus studies in detecting ovulation. However, training and experience are necessary to interpret the changes incident to ovulation. Also, the smear becomes unreliable in the presence of vaginitis and after coitus. For these reasons, we have come to use it as a secondary criterion when mucus studies are atypical and then usually in correlation with the BBT and/or the fern phenomenon. Behrman reports that his greatest success is achieved through careful study of changes in the vaginal smear. The BBT curve alone, in our experience, has not been reliable in predicting ovulation. The Farris-Behrman rat-ovary-hyperemia reaction, the glucose stick test, and the Fertility Testor, which we have recently investigated, have not been sufficiently helpful to deserve inclusion in our routine of ovulation timing.
506
COHEN & HANKIN
Fertility & Sterility
CONCLUSIONS 1. Ovulation in the human female is not a dramatic process; the subjective symptoms accompanying it are too unreliable for timing of ovulation. 2. The daily variations in the BBT graph are difficult to evaluate for both patient and doctor, and are therefore of limited value for the accurate timing of ovulation. 3. When ideal conditions are present, the vaginal smear accurately reflects the ovarian state, and the trained cytologist may rely upon the smear for timing of ovulation. 4. Daily evaluation of the amount, thinness, and spinnbarkeit of cervical mucus requires no special training and in our experience has provided the best single index of the time of optimal fertility. 5. The fern test has proved valuable occasionally in patients who exhibit poor cervical mucorrhea. Usually, however, its value is limited because the positive reactions extend over too long a period of time. 6. The Farris-Behrman rat-ovary-hyperemia test as performed in our laboratory showed approximately a 75 per cent correlation with our criteria of ovulation. We cannot recommend it for routine ovulation timing. 7. The detection of glucose in cervical mucus by means of test sticks and -paper strips as a method of ovulation timing has been evaluated. It is our feeling that the appearance of glucose indicates fertility potential rather than the time of ovulation. 8. We have had no experience with the measurement of the vaginal electropotentials or the Sevag-Colton test as indicators of ovulation. Their accuracy, as well as their adaptability to general office procedures, remainto be confirmed. Division of Obstetrics and Gynecology Michael Reese Hospital Chicago, In.
REFERENCES 1. 2. 3. 4. 5.
STURGIS, S. H., and POMMERENKE, W. T. The clinical signs of ovulation-A survey of opinions. Fertil. & Steril. 1:113,1950. DECKER, A. Culdoscopi~ observations on tubo-ovarian mechanism of ovum reception. Fcrtil. & Steril. 2:253, 1951. DOYLE, J. B. Exploratory culdotomy for observation of tubo-ovarian physiology at ovulation time. Fertil. & Steril. 2:475, 1951. NOYES, R. W. The capacitation of spermatozoa. Obst. & Gynec. Surv. 14:758, 1959. PAPANICOLAOU, C. N. The sexual cycle in the human female as revealed by vaginal smears. Am. ]. Anat. 52:519, 1933.
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DETECTING OVULATION
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6. SHORR, E. New technique for staining vaginal smears: III. A single differential stain. Science 94:545, 1941. 7. COHEN, M. R., STEIN, I. F., and KAYE, B. M. Spinnbarkeit: A characteristic of cervical mucus; Significance at ovulation time. Pertil. & Steril. 3:201, 1952. 8. CLIFT, A. F. Rheologic properties of human cervical secretions. Proc. Roy. Soc. Med. 39:1, 1945. 9. PAPANICOLAOU, G. N. The Epithelia of Woman's Reproductive Organs. New York, Commonwealth Fund, 1948. 10. CAMPOS DA PAZ, A. Studies on the crystallization of cervical mucus and its relationship to cervical receptivity of spermatozoa. Am. /. Obst. & Gynec. 61 :790, 1951. II. ROLAND, M. A simple test for the determination of ovulation, estrogen activity and early pregnancy using the cervical mucus secretions. Am. /. Obst. & Gynec. 63:81, 1952. 12. FARRIS, E. J. Prediction of the day of human ovulation by the rat test. Am. /. Obst. & Gynec. 56:347, 1948. 13. BEHRMAN, S. J. Personal communication. 14. DRESNER, M. H., and COHEN, M. R. Ovulation time: A modified rat hyperemia test compared with other criteria. To be published. 15. BIRNBERG, C. H., KURZROK, R., and LAUFER, A. Simple test for determining ovulation time. /.A.M.A. 166:1174, 1958. 16. COHEN, M. R. Glucose reagent stick test compared with other criteria for detection of ovulation. Pertil. & Stenl. 10:340, 1959. 17. DOYLE, J. B., and EWERS, F. J. The Fertility Testor. /.A.M.A. 170:45, 1959. 18. SAPIT, D. Personal communication. 19. PARSONS, L., MACMILLAN, H. J., and WHITTAKER, J. O. Abdominovaginal electropotential differences with special reference to the ovulatory phase of the menstrual cycle. Am. J. Obst. & Gynec. 75:121, 1958. 20. PARSONS, L., LEMON, H. M., and WHITTAKER, J. O. Abdominovaginal electropotential differences in the menstrual cycle. Ann. New York Acad. Sc. 83:237, 1959. 21. SEVAG, M. G., and COLTON, S. W. Simple chemical method for the determination of ovulation time in women. /.A.M.A. 170:13, 1959. 22. BEHRMAN, S. J. Detection of ovulation. Postgrad. Med. 27:1, 1960.
IN
precise timing of ovulation is important when well timed coitus is necessary for the sub fertile male to cause conception or when the in-vivo longevity of spermatozoa is minimal, as, for example, when the cervical mucorrhea of the woman is poor iri quality. Moreover, precise timing of ovulation is obviously necessary when irisemination is contemplated; its determination is perhaps most rewarding in patients with extremely irregular menstrual periods and infrequent ovulation. In a recent publication, Noyes 4 reaffirmed the theory that spermatozoa of certain species of mammals gradually attain the capability or capacity of penetrating ova during their passage through the female genital tract. If such "capacitation" is necessary in the human, it would constitute an additional reason for determining ovulation time exactly. In this paper, various technics for determining the time of ovulation are appraised. THE TREATMENT OF INFERTILITY,
METHODS OF DETECTING OVULATION
Ovulation in the human female is not a dramatic process, and but few women are aware of its occurrence. Subjective symptoms such as pelvic pain, midmonth spotting, and/or mucorrhea are too unreliable for the prediction of ovulation. 1 Direct Observation
Human ovulation has been observed by a few investigators. Decker,2 by ..,.
From the Division of Obstetrics and Gynecology and The Department for Research in Human Reproduction, Michael Reese Hospital, Chicago. This paper was presented at the Sixteenth Annual Meeting of the American Society for the Study of Sterility held in Cincinnati, Ohio, April 1-3, 1960. 497
498
COHEN & HANKIN
Fertility & Sterility
means of his culdoscope, described ovulation as follows: The fimbria of the tube becomes attached to the follicle, facilitating the extrusion of the ovum into the tube. Following this, the fimbria detaches itself from the ovary, and thus the graafian follicle is transformed into a fresh corpus hemorrhagicum. Doyle3 has described and photographed ovulation occurring without this fimbrial grasping action. During one isolated instance at culdoscopy, we were able to visualize ovulation and to confirm Decker's observations. Basal Body Temperature (BBT)
The BBT graph is probably the most universally employed method for timing ovulation. The temperature must be taken daily under strict basal conditions; we prefer the employment of rectal readings. Ovulation is thought to occur either at the low point before the sustained rise, a day or two before this point, or on the rise from low to high. There has been a great deal of difference of opinion regarding the exact interpretation of the BBT graph. When the curve is compared with other criteria, it is our impression that ovulation may occur at any time about the low pOint before the sustained rise. This may vary from patient to patient, or even during different cycles in the same patient. The day-to-day variation in the BBT curve is often difficult to interpret. When the entire graph has been completed, one can look back and designate the low point before the sustained rise, especially if this rise is sharp rather than the not uncommon "staircase thermal shift." When the temperature rise has been sustained for 2 consecutive days, we feel that ovulation has already occurred and that this patient need not be observed any longer during that cycle. Vaginal Smears
The interpretation of vaginal smears, prepared according to the technic of Papanicolaou 5 and stained by his method or that of Shorr,6 is a valuable technic for timing of ovulation. Daily smears beginning shortly after menstruation is over reveal gradually increasing estrogen effects until the smear becomes completely cornified. This occurs approximately at midcycle, after which the smear suddenly changes in that the cells become curled and clumped, or "exfoliated." We feel that ovulation probably occurs just short of complete cornification of the vaginal smear and use this test routinely in timing ovulation. However, the smear cannot be used in the presence of vaginitis and cervicitis and is very difficult to interpret following coitus.
r
Vol. 11, No.5, 1960
DETECTING OVULATION
499
\Vhen this technic can be used, it is a very useful and accurate method of timing ovulation, but unfortunately it requires cytologic training. Cervical Mucorrhea
We have reported extensively concerning the preovulatory outpouring of cervical mucus with characteristic spinnbarkeit. 7 We utilize a simple glass cannula to obtain cervical mucus daily. The mucus is blown out upon a glass slide and by means of a cover slip, the threadiness or spinnbarkeit is measured roughly in centimeters according to the method of Clift. 8 Cervical mucorrhea continues from 2 to 5 days. Following ovulation, the mucus becomes thick, and its "stretch" becomes minimal or disappears completely. We feel that this maximal spinnbarkeit is the best indication of optimal fertility. (Those patients who ovulate without demonstrating cervical mucorrhea are infertile.) The Fern Test
When thin glary cervical mucus is allowed to dry, crystallization or "ferning" occurs, visible under the low-power microscope. This phenom~non has been amply described by Papanicolaou,9 Campos da Paz,I° Roland,ll and others. In our hands, the fern phenomenon usually extends over too long a period of time for usefulness. However, an occasional patient who exhibits poor mucorrhea may show a positive fern test for only 1 or 2 days. In such patients, we have found the fern phenomenon of value in timing ovulation. The Farris-Behrman Rat-Ovary-Hyperemia Test
~
...
+
""t
Farris12 reported that the time of ovulation, within 6-12 hr. can be determined accurately by his rat-test method. His test depends on the hyperemic response of the ovaries of an immature rat after the subcutaneous injection of 2 mI. of morning urine. He reported that hyperemia occurs on 3-6 consecutive days during the time of follicle growth and that ovulation is thought to occur on the last day of hyperemia. Unfortunately, other investigators have been unable to duplicate his precise laboratory technic and so have not been able to corroborate his results. Our interest in the rat test was stimulated by the report of Behrman,13 who simplified the Farris test. The Farris-Behrman test was used by Dresner and Cohen14 in a group of 69 infertile patients during 130 cycles. The patients were instructed to restrict their fluid intake and to avoid the ingestion
500
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Fertility & Sterility
of alcoholic beverages. Daily morning urine specimens were collected, and 3 m!. were injected intraperitoneally into each of two 40- to 50-gm. immature female rats. The rats were of a local Wistar or Sprague-Dawley strain. They were chloroformed and sacrificed within 4 hr. of injection. An incandescent lamp was used for lighting. Hyperemia in one or more of the rats' ovaries indicated a positive reaction. The patients were seen daily until our own criteria for ovulation had been satisfied. Of the 130 cycles, 81 could be used for the correlation of the rat test with BBT and spinnbarkeit. Sixty-three of the 81 cycles showed a correlation of plus or minus 2 days in comparing the low point of the BBT with the day of a positive rat test. Sixty-nine of the 81 cycles showed the same correlation with the day of maximal spinnbarkeit. The vaginal smear correlated in 70 of 78 cycles within plus or minus 2 days. There was almost exact correlation between spinnbarkeit, vaginal smear cytology, BBT low-point, and the positive rat test in 10 patients successfully inseminated. This modified rat-ovary-hyperemia test, as performed in our laboratory, cannot be recommended for routine ovulation timing. It does indicate, however, that there is a substance excreted in the urine at midcycle that is probably L.H. Glucose Stick Test A simple test of ovulation, based upon the detection of glucose in cervical mucus, was reported recently by Birnberg et al. 15 He originally utilized Tes-Tape, '* but the technic was changed to include use of a cotton-tipped applicator into which was incorporated the same enzyme system and dye used in Tes-Tape. We recently reported our experiences with this test as compared to other criteria of ovulation in 63 infertility patients during 95 cycles. 16 There was fairly good correlation between the positive stick test, maximal spinnbarkeit, and vaginal-smear cornification. There was extremely poor correlation between the low point before the rise in the BBT graph and the stick test. This study in a sense indicated all of our standard methods of timing ovulation. In the series of 95 cycles, there were consistently negative stick tests in 20, and multiple positive stick tests during nine cycles. Nondiag"Product of Eli Lilly and Company, Indianapolis, Ind.
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nostic vaginal smears were present in 26 cycles. Poor mucorrhea with absent spinnbarkeit occurred during 17 cycles. In our study, we demonstrated that ovulation can occur despite negative stick tests and absent or poor cervical mucorrhea. We feel, however, that the appearance of glucose in cervical secretions is physiologic and that perhaps the stick test is another indicator of fertility rather than a test of ovulation.
Fertility Testort Our technic of timing ovulation is time-consuming and tedious, as well as inconvenient for the patient. For these reasons, we are constantly on the alert for new ovulation tests, particularly those that may be utilized by the patient herself. We have recently evaluated the Fertility Testor of Doyle and EwersY The original glucose indicator was Tes-Tape, but this has been modified by Sapit. 18 It is claimed that the enzymes impregnated into this new test strip are purer and that the color-change indicator is more specific for glucose. The apparatus is designed for use at home by the patient. It consists of a barrel-type plastic applicator that permits the test strip to be exposed to the pool in the cul-de-sac without contamination from the labia or vagina. The color change is from pink to blue in the presence of glucose. Patients being treated with insemination were given the test kits and instructed to make a reading every morning beginning a day or two after the period. The result, either pink or blue, was recorded on their records and correlated with the temperature, mucus, and vaginal smear. Readings were taken until the BBT rise was sustained for several days. Twenty-two patients were followed by this method during 34 cycles. Seventeen patients were treated with heterologous insemination during 29 cycles, and five patients were treated with homologous insemination during five cycles. Seven pregnancies were achieved, all in the former group. There were only two conceptions in the group with positive Fertility Testor readings, and in both of these, correlation with the other criteria was excellent (Table 1). The other five patients had negative Testor readings, while the correlations between BBT low-point, cervical mucus, and spinnbarkeit were all within 2 days. Thus, one of our patients (#3604), seen at weekly intervals because of extremely irregular periods, had a posifProduct of Fertility Testor Company, Ottawa, Ill.
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TABLE 1.
Comparison of Fertility Testor Results with Other Criteria of Ovulation in a Group of Women Who Conceived Following A.I.D. BBTZow point<'
P8tient
14f 12 13 65 11
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14 13 13 58,59,60 11 11 11
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14 11,13 13 59,61 11 11 11,13
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0 13,16 58,61,62 0 0 0
=
a BBT low point low point before the temperature rise. b spinnbarkeit maximal spinnbarkeit. c vaginal smear vaginal-smear cornification. d Fertility Testor positive Fertility donor insemination. fThe numbers day of the cycle when the Testor reaction. "A.I.D. tests were positive or when inseminations were performed. uZeros a negative or nondiagnostic report. hX test not performed.
=
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tive Testor reading on Day 58 that coincided with the presence of cervical mucorrhea. She became pregnant after two inseminations, the second performed on a day that the Testor reading was positive. Figures 1 and 2 show detailed correlations between the BBT curve, cervical mucorrhea, the vaginal smear, the postcoital test, the fern reaction, and the Fertility Testor. In patient 3384, the BBT low point occurred on Day 13. Good mucorrhea occurred on Days 13 and 14, with maximal spinnbarkeit on Day 13. The vaginal smear showed a precornified type on Day 12 and complete cornification on Day 13. The Fertility Testoc reaction showed pink on Days 10-12, blue on Day 13, pink on Days 14 and 15, and blue on Day 16. The successful insemination occurred on Day 13. In this patient, all the criteria of ovulation correlated well. Patient 3938 did not keep a very accurate BBT chart, but apparently the low point before the rise in the BBT curve was Day 14. The only day of good mucorrhea was Day 14. The vaginal smear showed cornification on Days 13 and 14. The fern test was positive on Days 13 and 14. The Fertility Testor from days 9 through 15 showed no change from the original pink color, although this patient obviously ovulated. Successful insemination was pedormed on Day 14, the day of the low point in the BBT curve and maximal spinnbarkeit. Correlation of the Fertility Testor results with the other criteria of ovulation was made in 18 patients during 26 diphasic cycles in which no conceptions occurred. In 10 cycles during which the Testor remained negative,
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Fig. 1. Ovulation chart of patient 3384. Triangle denotes insemination. Mucus is described as ti amount (1 + to 4 +), viscosity (K, thick; M, moderate; T, thin), spinnbarkeit (S) in centimeters, and number of white blood cells (1 plus = 25 per cent of high-power field; 4 plus high-power field covered). Vaginal smear is indicated as debris, degree of cornification, or exfoliation of cells. P.K. denotes the Sims-Huhner test. The fern reaction and the Fertility Testor results are indicated.
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ovulation was indicated by BBT dip, maximal spinnbarkeit, and vaginalsmear cornification. During 16 cycles, the Testor was positive. Eight of these cycles showed good correlation, while five cycles showed poor correlation with the BBT dip, cervical mucorrhea, and vaginal-smear cytology. In three cycles multiple positive readings occurred. Although our experience with the Fertility Testor has been very brief, it has not added to our armamentarium for the diagnosis of ovulation.
504
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Abdominovaginal Electropotential Differences
Parsons 19 • 20 has described a midcyclic alteration of the vaginal electropotential that appears with dependable regularity and is not found in the menopausal individual. His observations were made using extremely sensitive recording instruments and electrodes, which reduced the number of artifacts plaguing previous investigators. This midcyclic alteration in electropotential persists for 24-48 hr., and Parsons attributes this to ovulation. He has correlated these readings with pregnanediol excretion studies, and believes the secretory phase to be in the range of 20 days. He reported a series of 51 infertility patients, of whom 27 became pregnant when the ovulation time was determined by this method and coitus or artificial insemination was concentrated on that date.
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We have had no experience with this technic; it would not lend itself to employment as a general office procedure.
Sevag-Colton Test21 This is a chemical test for ovulation. Urine is collected daily for 5-7 days, beginning on the sixth or seventh day of the cycle. Ovulation time is evaluated according to the pattern of colorimetric readings. Using this method of ovulation timing, the authors reported 112 conceptions in 227 cases following an isolated coitus or single insemination . Behrman22 has used this test in a few cases and has found it to show excellent correlation with the day of maximal spinnbarkeit, vaginal smear cornification, and the rat-ovary-hyperemia test. We have had no experience with this test. Its accuracy and simplicity remain to be confirmed. DISCUSSION Our most valuable clinical test for ovulation timing still remains the change in the quantity, quality, and spinnbarkeit of cervical mucus. Despite the inconvenience to the patient and the tediousness of the daily observations, the results of the test are clinically rewarding. The test is easily performed and requires no complicated laboratory facilities. A patient who does not show mucorrhea may be anovulatory or may have a cervix whose glands are refractory to estrogenic stimulation. (Extensive endocervical cautery, for example, may completely destroy the mucus-producing glands.) The study of daily vaginal smears for evidence of cornification is also a useful tool and is almost as rewarding as cervical mucus studies in detecting ovulation. However, training and experience are necessary to interpret the changes incident to ovulation. Also, the smear becomes unreliable in the presence of vaginitis and after coitus. For these reasons, we have come to use it as a secondary criterion when mucus studies are atypical and then usually in correlation with the BBT and/or the fern phenomenon. Behrman reports that his greatest success is achieved through careful study of changes in the vaginal smear. The BBT curve alone, in our experience, has not been reliable in predicting ovulation. The Farris-Behrman rat-ovary-hyperemia reaction, the glucose stick test, and the Fertility Testor, which we have recently investigated, have not been sufficiently helpful to deserve inclusion in our routine of ovulation timing.
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CONCLUSIONS 1. Ovulation in the human female is not a dramatic process; the subjective symptoms accompanying it are too unreliable for timing of ovulation. 2. The daily variations in the BBT graph are difficult to evaluate for both patient and doctor, and are therefore of limited value for the accurate timing of ovulation. 3. When ideal conditions are present, the vaginal smear accurately reflects the ovarian state, and the trained cytologist may rely upon the smear for timing of ovulation. 4. Daily evaluation of the amount, thinness, and spinnbarkeit of cervical mucus requires no special training and in our experience has provided the best single index of the time of optimal fertility. 5. The fern test has proved valuable occasionally in patients who exhibit poor cervical mucorrhea. Usually, however, its value is limited because the positive reactions extend over too long a period of time. 6. The Farris-Behrman rat-ovary-hyperemia test as performed in our laboratory showed approximately a 75 per cent correlation with our criteria of ovulation. We cannot recommend it for routine ovulation timing. 7. The detection of glucose in cervical mucus by means of test sticks and -paper strips as a method of ovulation timing has been evaluated. It is our feeling that the appearance of glucose indicates fertility potential rather than the time of ovulation. 8. We have had no experience with the measurement of the vaginal electropotentials or the Sevag-Colton test as indicators of ovulation. Their accuracy, as well as their adaptability to general office procedures, remainto be confirmed. Division of Obstetrics and Gynecology Michael Reese Hospital Chicago, In.
REFERENCES 1. 2. 3. 4. 5.
STURGIS, S. H., and POMMERENKE, W. T. The clinical signs of ovulation-A survey of opinions. Fertil. & Steril. 1:113,1950. DECKER, A. Culdoscopi~ observations on tubo-ovarian mechanism of ovum reception. Fcrtil. & Steril. 2:253, 1951. DOYLE, J. B. Exploratory culdotomy for observation of tubo-ovarian physiology at ovulation time. Fertil. & Steril. 2:475, 1951. NOYES, R. W. The capacitation of spermatozoa. Obst. & Gynec. Surv. 14:758, 1959. PAPANICOLAOU, C. N. The sexual cycle in the human female as revealed by vaginal smears. Am. ]. Anat. 52:519, 1933.
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6. SHORR, E. New technique for staining vaginal smears: III. A single differential stain. Science 94:545, 1941. 7. COHEN, M. R., STEIN, I. F., and KAYE, B. M. Spinnbarkeit: A characteristic of cervical mucus; Significance at ovulation time. Pertil. & Steril. 3:201, 1952. 8. CLIFT, A. F. Rheologic properties of human cervical secretions. Proc. Roy. Soc. Med. 39:1, 1945. 9. PAPANICOLAOU, G. N. The Epithelia of Woman's Reproductive Organs. New York, Commonwealth Fund, 1948. 10. CAMPOS DA PAZ, A. Studies on the crystallization of cervical mucus and its relationship to cervical receptivity of spermatozoa. Am. /. Obst. & Gynec. 61 :790, 1951. II. ROLAND, M. A simple test for the determination of ovulation, estrogen activity and early pregnancy using the cervical mucus secretions. Am. /. Obst. & Gynec. 63:81, 1952. 12. FARRIS, E. J. Prediction of the day of human ovulation by the rat test. Am. /. Obst. & Gynec. 56:347, 1948. 13. BEHRMAN, S. J. Personal communication. 14. DRESNER, M. H., and COHEN, M. R. Ovulation time: A modified rat hyperemia test compared with other criteria. To be published. 15. BIRNBERG, C. H., KURZROK, R., and LAUFER, A. Simple test for determining ovulation time. /.A.M.A. 166:1174, 1958. 16. COHEN, M. R. Glucose reagent stick test compared with other criteria for detection of ovulation. Pertil. & Stenl. 10:340, 1959. 17. DOYLE, J. B., and EWERS, F. J. The Fertility Testor. /.A.M.A. 170:45, 1959. 18. SAPIT, D. Personal communication. 19. PARSONS, L., MACMILLAN, H. J., and WHITTAKER, J. O. Abdominovaginal electropotential differences with special reference to the ovulatory phase of the menstrual cycle. Am. J. Obst. & Gynec. 75:121, 1958. 20. PARSONS, L., LEMON, H. M., and WHITTAKER, J. O. Abdominovaginal electropotential differences in the menstrual cycle. Ann. New York Acad. Sc. 83:237, 1959. 21. SEVAG, M. G., and COLTON, S. W. Simple chemical method for the determination of ovulation time in women. /.A.M.A. 170:13, 1959. 22. BEHRMAN, S. J. Detection of ovulation. Postgrad. Med. 27:1, 1960.