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Evaluation of the Postcoital Test
Evaluation of the Postcoital Test JOHN DANEZIS, M.D.,f> SABITA SUJAN, M.D.,t and AQUILES J. SOBRERO, M.D.
(PCT) or Sims-Huhner test is one of the important steps in the investigation of the infertile couple. The variety in terminology, technics, and classification, as well as the tremendous variation seen in its interpretation, point to the need for some standardization. Correlation between cyclic variations in the quality of the cervical mucus and PCT results has been studied from many approaches. Swyer5 • 26 pointed out that while the quality of mucus is significantly correlated with the day of the cycle, the extent of the sperm invasion and sperm activity within the mucus are not correlated. Williams,29.30 Bishop, and Donald are in general agreement with Swyer's conclusions. Lamar et al., and Harvey and Jackson showed that the penetrability of the mucus was greatest during midcycle, when the amount of mucus increased and viscosity diminished-as was first pointed out by Seguy and Simonnet. Shettles and Guttmacher in their study of cervical mucus suggested the proper day for artificial insemination. Moench observed that the degree of penetrability of cervical mucus by spermatozoa depended solely on its viscosity, and Abarbanel in his experiments showed that under the influence of progesterone the mucus became more viscous and sperm penetration was poor. In the present study, PCT results have been grouped according to whether or not the desired pregnancy was achieved, and the various factors-interval since coitus, cervical mucus quality, semen quality, and phase of the menstrual cycle-have been analyzed separately and in combination for each group. Semen analyses in the 2 groups have also been compared according to several criteria.
THE POSTCOITAL TEST
From the Margaret Sanger Research Bureau, New York, N. Y. *Visiting Research Fellow-appointment supported by the International Cooperation Administration under the Visiting Research Scientists Program administered by the National Academy of Sciences of the U. S. A. tMedical Fellow-appointment supported by the Abraham Stone Fellowship Fund.
559
560
DANEZIS ET AL.
FERTILITY
& STERILITY
MATERIAL AND METHOD
A total of 1257 peT were performed consecutively in 546 couples who were undergoing fertility studies at the Margaret Sanger Research Bureau. Of these, 316 involved 140 women who became pregnant, with 941 peT in 406 women who had not conceived at the time of our analysis. Timing of Postcoital Test
Postcoital tests are routinely scheduled during the so-called fertile period: the time of ovulation as determined by the basal body-temperature record. The determination of ovulatory cycles was made by a study of the BBT records, since endometrial biopsies were not performed in every case in the cycle studied. Ovulation was considered to have occurred on the last day of low BBT, just before the beginning of the sustained rise. The 3 phases of the menstrual cycle in each biphasic graph were designated as follows. Pre-ovulatory: from menses up to the commencement of the ovulatory phase Ovulatory: from 48 hours prior to the thermal shift up to 24 hours thereafter Post-ovulatory: from the end of the ovulatory phase to the subsequent menses Technic and Classification
The patients were instructed to report to the clinic as soon as possible after coitus. By means of long thumb forceps, a sample was first taken from the vaginal po~l. The excess of cervical mucus was then thoroughly wiped away from the external os and surrounding area, after which a specimen was obtained from inside the cervical canal by suction with a tuberculin syringe (without a cannula or needle). Gross physical characteristics of the mucus were recorded-amount, viscosity, color, and spinnbarkeit. In this study, the mucus was classified as positive or negative: positive when it was abundant, clear, watery, clean (without cells), and of good spinnbarkeit (over 10 cm.); negative when scanty, opaque, viscous, cellular, and of poor spinnbarkeit. The specimens were immediately examined microscopically for spermatozoa and cellular contents. Observations were recorded according to the following peT classification established by one of us (AJS) : Negative: no spermatozoa found in any specimen of endocervical mucus or of vaginal fluid Poor: spermatozoa present, but none motile in the endocervical-mucus specimen
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561
POSTCOITAL TEST
Fair: Up to 5 spermatozoa with motility of Grade 3 or better per dry highpower field (HPF, X 400)-or any number of spermatozoa with motility less than Grade 3 in the endocervical-mucus specimen Good: Six or more spermatozoa per dry HPF with motility of Grade 3 or better in endocervical-mucus specimen Excellent: Over 15 spermatozoa per dry HPF with motility of Grade 3 or better in endocervical-mucus specimen Semen Evaluation
The classifications used in semen evaluation in both clinical and laboratory work at the Bureau are those established by MacLeod13 for specimens of seminal fluid obtained after 3 days of continence. Semen is considered normal when: the volume measures from 2 to 5 ml.; its pH is between 7.0 and 7.6; liquefaction occurs within 20 min. after ejaculation, and the liquefied semen shows no thread formation. Quality is rated according to count, motility, and morphology as follows: Count
Good (G)
Passable (P)
Subnormal (S)
60 million or more per milliliter
20 to 60 million per milliliter
Fewer than 20 million per milliliter
60% or more 3+ or better
40-60% 2+ to 3+
Less than 40% Below 2+
80% or more oval cells
60-80% oval cells
Less than 60% oval cells
Motility
Percentage Grade Morphology
Motility of the spermatozoa is graded as follows: 0, no motion; >0, slow waving of tail, without forward motion; 1, slow progressive movementsnot necessarily forward motion; 2, more active, with forward motion; 3, good forward motion; and 4, very active-fastest speed observed in vitro. These gradations are subdivided by the addition of plus or minus signs to indicate greater or less motility than the designated digits. Thus 3+ would indicate progressive movements greater than 3 but less than 4; 3- would suggest a motility better than 2+ but not quite 3. This system of grading, admittedly arbitrary and subjective, nevertheless gives excellent results when applied by an experienced observer. From 1 to 9 semen analyses were recorded for each of the 546 couples studied. In most of the few cases with only 1 semen analysis, the semen was reported as excellent-and conception occurred shortly after infertility studies were begun. In the remainder of those having only 1 semen analysis, the husbands had moral scruples or psychologic difficulty in furnishing specimens. Those whose semen was evaluated more than 4 or 5 times were usually men
562
DANEZIS ET AL.
FERTILITY
& STERILITY
with subnormal or passable semen quality. These patients were closely followed during treatment; the average value of each separate criterion of semen quality was used as representative of the subject. For the purposes of this study, our standards of "passable" and "subnormal" semen quality were further subdivided as follows: Passable with good rrwtility (PI): Count within passable limits, but percentage of motile spermatozoa and grade of motility of good standards (60%, 3+ or better) . Passable with good count (P2): Percentage and grade of motility within passable limits, but count good (60 million or more per milliliter) . Passable (P): Quality as described above. Subnormal with good rrwtility (SI): Subnormal count, but grade and percentage of motile spermatozoa of passable or good standards. Subnormal (S): Quality as described above. RESULTS
As previously stated, the patients were divided into two major groupsthose who achieved pregnancy and those who did not. In each group, the main factors associated with the outcome of the PCT-cervical mucus, phase of the cycle, and semen-were studied separately and in combination. Evaluation of the PCT was made using the standard classification of negative, poor, fair, good, or excellent, with a gross classification of negative or positive. Negative tests included those designated in the standard classification as negative or poor (absence of sperm or sperm without motion), while the term positive was applied to the tests designated fair, good, or excellent (motile spermatozoa in the endocervical mucus). For this analysis, our results are presented in sections wherein the factors studied will be dealt with separately. Time Interval After Coitus
Although 82 per cent of all the PCT were performed from 1 to 4 hr. after coitus, the range of variation was from less than 1 hour to 8 hours or more. Therefore, all 1257 PCT were analyzed in order to study the relationship of the time interval to the results of the postcoital examination. In Fig. 1, the time interval after coitus is shown in four groups: up to 1 hour, from 1 to 4 hours, from 4 to 8 hours, and over 8 hours. The proportion of positive tests is unaffected by the time interval, unless the interval is longer than 8 hours. Of the PCT performed over 8 hours after coitus, 63 per cent were negative; however, since this group constituted only 4.5 per cent of the 1257 PC r performed, any statistical inference may be doubtful.
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13, No.6, 1962
563
POSTCOITAL TEST
Postcoital Test Quality and Cervical Mucus Quality
In evaluating the factors influencing peT results, attention should be paid to the quality of cervical mucus. Figure 2 presents the relationship between positive or negative peT and positive or negative cervical mucus as defined above. Among the 140 women who conceived, positive cervical mucus was recorded in 73 per cent of the positive peT and in 49 per cent of the negative peT. Among the 406 who failed to conceive, the percentage of positive cervical mucus was 67 per cent in positive peT and 39 per cent in negative peT. The difference between the two groups cannot be considered significant. Further data on the quality of the cervical mucus at each phase of the menstrual cycle and its relation to the peT results are presented in the left section of Fig. 3. As expected, the percentages of positive peT were highest 10 90
+ P.C.T. 0 - P.C.T. ~
80 70 Fig. 1. Results of 1257 postcoital tests according to interval since coitus. 'Yo 50
POSITIVE NEGATIVE
6'3%
57%
40 30 20 10 0
I TO 4 hr.
UP TOI 3.5%
4 TO 8 hr. 4.5%
10%
82%
100
m
90
80
Fig. 2. Cervical mucus and postcoital tests in 140 infertile women who conceived and 406 who did not.
o
7~/o
:~
11·1·
~50
~
49%
I
~O/o
POSITIVE MUCUS NEGATIVE MUCUS
6i
,~
:~ I~ a " I~
Mucu.
~:_
m:,
:i;+.L.:I.:I.l:. _
P.C.T.+ 232
P.C.T.84
~:~J;+.' ..
_ .
TOTAL 316
PREGNANT GROUP
P.C.T.+ 481
P.C.T.460
TOTAL 941
NON -PREGNANT GROUP
564
DANEZIS ET AL.
FERTILITY
& STERILITY
in the ovulatory phase-78 per cent for the pregnant and 61 per cent for the nonpregnant group, as compared with 59 per cent and 55 per cent respectively in the pre-ovulatory phase, and 74 per cent and 62 per cent in the postovulatory phase. It is also evident that a higher percentage of PCT in all 3 phases of the cycle was recorded for the pregnant group. POSITIVE POST-COITAL TESTS
POSITIVE CERVICAL MUCUS
o
100 90
•
60 "" SO
PREGNANT GROUP NON -PREGNANT GROUP
78°1.
80 70
0_ -0
-
74"
,,;,0--- ___ 074 %
:::::---n-,,'
61%
.62%
/
62%0""
----~.'" 68%"
"...
44%
40
54'"1.
\,
'039%
30
Fig. 3. Positive postcoital tests and positive cervical mucus in relation to phases of the menstrual cycle.
20 10
0L-____..L.~~~--~L---_+----__--~PRE -
OVULATORY
OVULATORY
POST
PRE -
OVULATORY
OVULATORY
OVULATORY
POST
OVULATORY
PHASES OF CYCLE
The percentages of positive cervical mucus (at the right in Fig. 3) show the same general pattern, with the peak in the ovulatory phase in both groups but higher for the pregnant group. Positive cervical mucus in the postovulatory phase for the pregnant group was found in 39 per cent of the PCT; this is in contradiction with the known adverse influence of progesterone on the cervical mucus; it is probably due to the elevation of estrogens, which are known to rise at that time. 12• 16 The columns at the bottom of Fig. 3 represent the over-all distribution of PCT recorded in the preovulatory, ovulatory and postovulatory phases of the cycle. As expected, owing to proper scheduling, the bulk of the PCT were done during the ovulatory phase. Comparisons of the distribution between pregnant and nonpregnant groups reveals no important difference. However, the slightly higher percentage of PCT done in the ovulatory phase for the pregnant group (57 per cent as compared with 49 per cent for the nonpregnant group), along with the better sperm penetrability in the ovulatory phase, might be considered slightly contributory toward the better results seen in the pregnant group. The above gross evaluation of our results, however, does not show in detail the differences existing between semen quality, cervical mucus quality, and the sperm invasion into and activity within the mucus for each type of PCT. By using the standard classification of PCT (negative, poor, fair, good, excellent), we were able to evaluate sperm invasion and sperm activity within the mucus. The different factors considered in this study in relation to the PCT are analyzed, in Fig. 4 and 5, for the pregnant and the nonpregnant groups
13,No.6,1962
VOL.
OVULATORY PHASE
PRE-OVULATORY PHASE P.C. MUCUS
565
POSTCOITAL TEST
SEMEN QUALITY
P.C. MUCUS
POST-OVULATORY PHASE
SEMEN QUALITY
P.C. MUCUS
SEMEN QUALITY
100-
8060%40-
. ~ Ib I
20-
0_
+-
10080-
P.CX EXCELLENT
GPPPSS I 2
I
%6040200_
100-
%~~~ 1~Ln. I~L- I~L.. 100-
+-
+-
GPPPSS 12
I
P.C.T. FAIR
GPPPSS I 2
I
80-
%:~= I~L .~LlL I ~liL
P.G. POOR
%'~!~ •~ ~~L .~ :~~s .lli c. GW1.
+-
+-
G~~PSIS
P.C. MUCUS
SEMEN QUALITY
G~~PSIS
P.C. MUCUS
I1i!I •
o
P.C. = Post - Coital Test
CERVICAL MUCUS QUALITY
+ -
Positive cervical mucus Negative cervical mucus
+-
SEMEN QUALITY
G PI P2 P 51 5
• T
NEGATIVE
G~~PSIS
P.C. MUCUS
SEMEN QUALITY
SEMEN QUALITY Good semen quality Passable with good motility Passable with good count Passable semen quality Subnormal with good motility Subnormal
Fig. 4. Results of 316 postcoital tests according to cycle phase, and quality of cervical mucus and semen in 140 infertile couples who conceived.
566
P.C. MUCUS
1008060%4020-
0_ 1008060-
4020-
•ill •
0_ 1008060%40-
~ +-
SEMEN QUALITY
P.C. MUCUS
& STERILITY
POST-OVULATORY PHASE
OVULATORY PHASE
PRE-OVULATORY PHASE
%
FERTILITY
DANEZIS ET AL.
P.C. MUCUS
SEMEN
SEMEN QUAL.ITY
~
L .~ L _~ ~
~ I:: ~ L~SA
ReT. EXCELLENT
A
[:5,5 A I
+-
GPPPSSA 12
I
I
GPPPSS A 12
I
+-
P.C.T.'OOO
GPPPSSA 12
I
20-
0_ 1008060 .... %4020-
0_ 1008060%4020-
0_
I~LL Irn~ I~~ +-
+-
G~~PSISA
G~f2PSISA
+-
G~~PSISA
P.C. MUCUS
SEMEN QUALITY
G~~PSISA
P.C. MUCUS
SEMEN QUALITY
!iii .P.C. = Post - Coitol Test CERVICAL MUCUS QUALITY
+ -
Positive cervicol mucus Negative cervical mucus
G PI P2 P SI S A
+-
P.C.T. POOR
G~P2PSISA
.illLJ.. .~J. .~I hi +-
D
+-
P.C.T. NEGATIVE
G~~PSISA
P.C. MUCUS
SEMEN QUALITY
SEMEN QUALITY Good semen quolity Passoble with good motility Passable with good count Possoble semen quolity Subnormal with good motility Subnormol Azoospermia
Fig. 5. Results of 941 postcoital tests according to cycle phase, and quality of cervical mucus and semen in 406 infertile couples who failed to conceive.
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POSTCOITAL TEST
567
respectively. Each figure presents 3 major groups corresponding to the preovulatory, ovulatory and postovulatory phases of the cycle. Each phase of cycle consists of 5 minor groups corresponding to the several qualities of peT. In each of these groups the black column represents the percentage of peT done in that particular phase and classified according to that particular quality; the 2 white columns represent the corresponding percentages of positive and negative cervical mucus; the stippled columns indicate semen quality. The conclusions that may justifiably be drawn from the data included in the two charts (Fig. 4 and 5) are the following: In both pregnant and nonpregnant groups there were fewer negative and poor peT than fair, good, and excellent peT in each of the 3 phases of the cycle. This is more evident in the ovulatory phase and more striking in the pregnant group. The positive correlation between the quality of peT and that of cervical mucus also emerges from the data in the charts. Semen Evaluation
Figure 6 shows the distribution of semen quality, using the standard classifications for the pregnant and nonpregnant groups. Semen was classified as good in 55 per cent of the pregnant couples, passable in 38 per cent, and subnormal in 7 per cent; for the nonpregnant group the corresponding figures were 38, 43, and 14 per cent, respectively, while 5 per cent were cases of azoospermia. That better semen quality exists in the pregnant group is clear, but the high incidence ( 43 per cent) of passable quality in the nonpregnant group is somewhat puzzling. In order to make a more precise evaluation of the factors involved in semen quality, the passable and subnormal groups were subdivided, as previously explained, into "passable with good motility," "passable with good count," and "subnormal with good motility." The subdivision is incorporated in Table 1 and Fig. 7. 100 PREGNANT GROUP . - . NON-PREGNANT GROUP
90 80 70 60
55% 0 __
%50
---
Fig. 6. Semen quality in 546 infertile couples, according to standard classification.
40 30 20 10 0
38%
GOOD
PASSABLE SEMEN
QUALITY
SUBNORMAL
AZOOSPERMIA
568
DANEZIS ET AL.
FERTILITY
&
STERILITY
TABLE 1. Semen Quality with Respect to Conception Semen quality
No. pregnant
Good (G) Passable with good motility (PI) Passable with good count (P2 ) Passable (P) Subnormal with good motility (SI) Subnormal (S) Azoospermia (A)
77 18 10 25 5 5
o
(55%) (13%) (7%) (18%) (3.5%) (3.5%)
140 (100%)
TOTAL
No. not pregnant
154 16 65 94 16 41 20 406
(38%) (4%) (16%) (23%) (4%) (1O%) (5%) (100%)
The category of "passable with good motility" covered 13 per cent of the pregnant cases but only 4 per cent of the nonpregnant cases, while 7 per cent of the pregnant and 16 per cent of the nonpregnant cases had semen "passable with good count." In the category designated "passable" were 18 per cent of the pregnant cases and 23 per cent of the nonpregnant. These observations indicate that motility is more important than sperm number in relation to chances of conception. 14 This finding is further clarified in Table 2, which shows that of the 34 cases whose semen quality was rated "passable with good motility,"18 patients (53 per cent) managed to achieve pregnancy, whereas only 10 (13 per cent) of the 75 cases with semen rated "passable with good count" and 25 (21 per cent) of the 119 rated "passable" were in the pregnant group. Five (24 per cent) of the 21 cases with semen "subnormal with good motility" became pregnant, while only 5 (11 per cent) of the 46 with subnormal semen did. 100 PREGNANT GROUP
90
e _ e NON - PREGNANT GROUP
80
70
60
55%
,, ,,
o
"10 50
,,
40 30
20
,,
,
,,
23% e
"13%
I:~o, "" IS%'__
..:..-__ ~
10%
~"'-.,~o.-.-"" ............ 4% ~.-. ~~%, 40/07% .... 8'3":'50/.-----03.5% o~--~------~------~------~----~~~--~~~--~
10
GOOD
PASSABLE WITH GOOD MOTILITY
PASSABLE WITH GOOD COUNT
PASSABLE
SUBNORMAL WITH GOOD MOTILITY
SUBNORMAL
___
AZOOSPERMIA
SEMEN QUALITY
Fig. 7. Semen quality in 546 infertile couples, according to special sub-classifications: 140 in the pregnant group; 406 in the nonpregnant group.
VOL. 13, No.6, 1962
569
POSTCOITAL TEST
TABLE 2. Incidence of Conception According to Semen Quality 8emen quality
Total case8
Good (G) Passable with good motility (PI) Passable with good count (P2 ) Passable (P) Subnormal with good motility (Sl) Subnormal (S) Azoospermia (A) TOTAL
231 34 75 119 21 46 20 546
No. pregnant
77 18 10 25 5 5 0 140
(33.33%) (53%) (13%) (21%) (24%) (11%)
No. not pregnant
154 16 65 94 16 41 20 406
(66.66%) (47%) (87%) (79%) (76%) (89%) (100%)
Figures 5 and 6 also include an evaluation of semen quality for each of the subdivisions made (by peT quality and by cycle phase-although cycle phase has no relation to semen evaluation) in the 2 groups of cases, pregnant and nonpregnant. It is evident that high quality of peT correlated with high quality of semen throughout both groups. It is interesting to note that the columns representing semen quality "passable with good motility" (PI) and "passable with good count" (P2) are generally higher in the better peT grade. This finding, more accentuated in the pregnant group, is further exemplified in Fig. 8, in which the percentage of positive peT has been plotted according to semen quality for both pregnant and nonpregnant groups. This Figure illustrates that the lower the quality ....en ....
::l100 ...J
90
ou
80
~
~ 70
'"~
... 60 ~ 50
~0.. 40 ~
30
~
20
~ ~ 10 u
~
0..
O~---L------~------~----~------~------~-GOOD
PASSABLE WITH GOOD MOT ILiTY
PASSABLE WITH GOOD COUNT
PASSABLE
SUBNORMAL WITH GOOD MOTI LlTY
SUBNORMAL
SEMEN QUALITY
Fig. 8. Postcoital tests in 1257 cases (316 in the pregnant group and 941 in the non-pregnant group), according to semen quality in 140 couples who achieved conception and 406 couples who did not.
570
DANEZIS ET AL.
FERTILITY
& STERILITY
of the semen, the fewer positive PCT were in either group, with no significant variations in the downward curves. Conversely, the better the motility, the better the PCT. Precoital Douche
When MacLeod and Hotchkiss introduced a special medicated douche as a treatment in certain cases of infertility, they restricted its use to the type of infertility in which neither partner showed striking abnormality. They attributed the success of this medication to temporary removal of some "incompatibility" that prevented the penetration of spermatozoa into the cervical canal but increased the sperm activity in the vaginal pool around the externalos. At the Bureau, in the course of studying any infertile couple whose first PCT is negative, poor, or fair, the patients are instructed to use a medicated precoital douche'" within an hour prior to intercourse. Subsequent postcoital tests are made and compared with the previous findings. Of the 396 PCT with precoital douche, 125 (31 per cent) remained unchanged in quality; in 22 instances (6 per cent) the quality was worse. Of the 249 cases whose peT showed improvement after precoital douche, 204 (82 per cent) showed improvement of one degree (from negative to poor, or from poor to fair, etc.); the remaining 45 cases (18 per cent) showed improvement of 2 degrees (e.g., from poor to good). In cases where improvement was noted, the patients were instructed to use precoital douches each time they had sexual intercourse during the fertile period. Postcoital Tests in Conception Cycle
In the course of the present study, 33 cases were encountered in which PCT were made during the cycle in which conception occurred; 30 of these PCT were performed during the ovulatory phase of the cycle. A summary of these 33 conception cycles is presented in Table 3, in which it is seen that positive cervical mucus was found in 27 PCT (82 per cent) although 29 of the peT (88 per cent) were rated fair, good, or excellent. During the conception cycle no peT was reported negative, but 4 (12 per cent) were rated poor (no motile spermatozoa were found in the endocervical specimen). Subnormal semen was recorded in 2 cases; 1 of these, however, was classified as subnormal with good motility. The importance of motility is further *Pro-ception sperm nutrient douche (dextrose, 71 per cent; potassium chloride, 0.70 per cent; sodium chloride, 25.75 per cent; calcium gluconate, 2.55 per cent), Milt!x Products, Chicago. TIl
VOL.
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POSTCOITAL TEST
571
TABLE 3. Cervical Mucus, Postcoital Tests, and Semen Quality in 33 Conception Cycles Cervical Mucus Positive Negative
27 (82%) 6 (18%)
Postcoital Test Excellent Good Fair Poor
6 (18%) 10 (30%) 13 (40%) 4 (12%)
Semen Quality Good 13 (40%) Passable with good motility 6 ( 18% ) Passable with good count 2 ( 6%) Passable 10 ( 30%) Subnormal with good motility 1 (3%) Subnormal 1 ( 3% )
shown in the 6 cases rated passable with good motility, which were three times as n)1merous as those passable with good count. Four of these 33 PCT were considered poor. In 2 of these, the cervical mucus was negative; in 3 the semen was rated passable, and in one the semen was subnormal. DISCUSSION
The time elapsing between coitus and the postcoital examination, according to our analysis of 1257 PCT, appears to make very little difference in the PCT results; at least this is so up to 8 hours after coition. According to Barton and Wiesner, spermatozoa remain motile 12-48 hours in the cervical mucus in vitro and ~ days in vivo. Sperm survival within the mucus after stilbestrol therapy was found by Stein and Cohen to be as long as 6 days. Tyler reported up to 134 hours in the absence of any therapy, and our own experience has shown survival up to 5 days during the fertile period. While we recognize that these instances are exceptional, we do regard the results of PCT performed within 8 hours of coitus as reliable. Our data are at variance with those of some investigators, who state that the time lapse should not exceed 2 hours. In reviewing our findings, we wish to make clear that survival within the endocervical mucus must not be equated with the capacity of spermatozoa for upward migration or fertilization. From the analysis of our results, we found that whenever better qualities of cervical mucus and of semen were reported, a better sperm penetration (in both density and motility) was noted. Analyzing the quality of cervical mucus in the positive and negative PCT, we found no important difference between those who achieved pregnancy and those who did not (Fig. 2). Better quality of mucus, however, resulted in better sperm penetration-as shown by the percentage of positive mucus whenever the PCT was positive, with higher values in the pregnant group. When the mucus was studied according to the 3 phases of the cycle, our observations were in agreement with the generally
572
DANEZIS ET AL.
FERTILITY
& STERILITY
accepted view that a higher quality corresponds to the ovulatory phase and a lower to the pre- and postovulatory phases. Sperm penetration in relation to the quality of the cervical mucus and to the semen quality in both groups (Fig. 4 and 5) showed that the range of peT quality from negative to excellent was paralleled by quality of semen and of mucus, except for one striking discrepancy in the group in which pregnancy occurred. Of the positive peT performed in the postovulatory phase in this group, only 39 per cent showed mucus of positive quality (Fig. 3). This was not unexpected, in view of the generally accepted adverse influence of progesterone on cervica1 secretions. In spite of this, however, 74 per cent of the peT were positive in the postovulatory phase for the group becoming pregnant-a percentage nearly as high as the 78 per cent of the ovulatory phase, in which the correlation with positive mucus is quite close. This study confirms the influence of semen quality on the outcome of peT, indicating that semen quality is generally higher in men whose wives conceive. In addition, the results of the analyses (Fig. 8) of motility and density of the spermatozoa are in full agreement with MacLeod's statements: «the motile activity of the fertile group is consistently better than that of the infertile group" and «the chances of fertility increase with the rising quality of motility."14 However, as seen in Fig. 8, a higher sperm count had a favorable effect on peT outcome although not so important as the motility. Examination of the peT results for the 10 couples who achieved conception in spite of subnormal semen quality (Table 2) reveals that in the 5 cases where the spermatozoa of the subnormal semen were characterized by good motility, as many as 45 per cent of the peT results were positive (Fig. 8) whereas only 30 per cent were positive in the absence of good motility. This confirms Swyer's25 mention of the diagnostic importance of the peT in cases of subnormal semen, and indicates the influence of semen quality on peT outcome and hence on the chances of conception. Variations in the quality of cervical mucus throughout individual cycles18 as well as variations in the husband's semen quality lead us to the conclusion that repeated peT are preferable to a single peT in the evaluation of the infertile couple. This is in agreement with Southam and Buxton, though our figures show slightly higher values for quality of peT and of cervical mucus. SUMMARY
Analysis of 1257 postcoital test (peT) results performed in 546 patients under routine investigation for infertility are reported. Standardized classifications were used in the evaluation of these peT as well as of certain factors involved in the test-quality of semen, characteristics of cervical mucus, and
VOL. 13, No.6, 1962
POSTCOITAL TEST
573
phases of the menstrual cycle. Comparison is made between 316 peT made in a group of 140 women who became pregnant and the 941 peT made in a group of 406 who failed to conceive up to the time the present study was undertaken. The time interval between coitus and postcoital examination was studied in relation to peT results, but no Significant difference was found within 8 hours. Quality of cervical mucus found in each of the 3 phases of the menstrual cycle varied in accordance with known hormonal influence on cervical physiology-with no major difference between the women who conceived and those who did not, except that in the pregnant group mucus quality was better throughout the cycle. The women who achieved conception had better PCT results than those who did not. But in both groups sperm penetration was better during the ovulatory phase (including 30 of the 33 conception cycles reported) than in the pre- and postovulatory phases. The only discrepancy between sperm penetration and quality of mucus was found in the postovulatory phase of the group achieving pregnancy-where 74 per cent of the peT showed good sperm penetration, although the endocervical mucus was of poor quality in 61 per cent of these peT. Semen quality of husbands, as evaluated in 1 to 9 specimens obtained through masturbation, was better in the group that became pregnant. Motility (percentage and grade of motility) scored higher in the passable and subnormal semen groups tha.n sperm number, which again emphasizes the relatively greater significance of motile activity over sperm concentration in influencing conception. Higher motility and count of the spermatozoa in the semen gave better peT results in both groups. Of the 67 couples with subnormal semen, only 10 achieved pregnancy. Sperm penetration was found in 5 of these cases in 30 per cent of the peT; but in the other 5, which had superior motility, sperm penetration was found in 45 per cent of the peT. In 396 patients the effect of an alkaline-buffered precoital douche was found to be beneficial in 63 per cent of the cases. A.J. S. Margaret Sanger Research Bureau 17 West 16th St. New York 11, N. Y.
REFERENCES 1. ABARBANEL, A. R. Spennatozoa and Cervical Mucus. In The Problem of Fertility. Ed. by E. T. Engle. Princeton University Press, Princeton, N. J., 1946. 2. ASPLUND, J. The uterine cervix and isthmus under nonnal and pathological conditions. Acta. Radiol. Suppl. 91, 1952.
574
DANEZIS ET AL.
FERTILITY & STERILITY
3. BARTON, M., and WIESNER, B. P. The receptivity of cervical mucus to spermatozoa. Brit. Med. /. 2:606, 1946. 4. BISHOP, P. M. F. Post-coital Tests. In Mammalian Germ Cells. Ed. by C. E. W. Wolstenholme. Little, Boston, 1953. 5. BUXTON, C. L., and SOUTHAM, A. L. Human Infertility. Hoeber, New York, 1958. 6. CLIFT, A., and HART, J. Postcoital tests on a statistical basis. Fertil. Steril. 5:544,1954. 7. COHEN, M. R, and STEIN, 1. F. Sperm survival at estimated ovulation time. Comparative morphology: relative male infertility. Fertil. Steril. 2:20, 1951. 8. DANEZIS, J., SUJAN, S., and SOBRERO, A. J. Bacteriology of the cervix and postcoital tests. Int./. Fertil. In press. 9. DONALD, I. Results of Post-coital Tests Where Pregnancy Ensued. In Mammalian Germ Cells. Ed. by C. E. W. Wolstenholme. Little, Boston, 1953. 10. HARVEY, C., and JACKSON, M. H. Penetration of cervical mucus by spermatozoa. Lancet 11:723, 1948. 11. LAMAR, J. K., SHETTLES, L. B., and DELFS, E. Cyclic penetrability of human cervical mucus to spermatozoa in vitro. Amer./. Physiol.129:234, 1940. 12. LITTRELL, J. L., and TOM, J. Y. S. Fluctuations in the estrogen level throughout the menstrual cycle of one woman. Endocrinology 40:292, 1947. 13. MACLEOD, J. The male contribution to human infertility. Ann. Ostet. Ginec. 6 (June, 3 Fascicolo Speciale edito a cura del Centro Sterilita Coniugale di Milano): 120, 1953. 14. MACLEOD, J., and GoLD, R. J. The male factor in fertility and infertility. III. An analysis of motile activity in the spermatozoa of 1000 fertile men and 1000 men in infertile marriage. Fertil. Steril. 2: 187, 1951. 15. MACLEOD, J., and HOTCHKISS, R S. The use of a precoital douche in cases of infertility of long duration. Amer./. Obstet. Gynec. 46:424, 1943. 16. MARKEE, J. E., and BERG, B. Cyclic Huctuation in blood estrogen as a possible cause of menstruation. Stanford Med. Bull. 2:55, 1944. 17. MOENCH, C. L. /. Lab. Clin. Med.19:358, 1934. 18. SEGUY, J., and SIMMONET, H. Recherches des signes directs d'ovulation chez la femme. Gynec. Obstet. 28:657, 1933. 19. SHETTLES, L. B. Cervical factors in reproduction. Obstet. Gynec. 14:635, 1959. 20. SHETTLES, L. B., and CUTTMACHER, A. F. Amer. /. Physiol. 129:462, 1940. 21. SOUTHAM, A. L., and BUXTON, C. L. Seventy postcoital tests made during the conception cycle. Fertil. Steril. 7: 133, 1956. 22. STEIN,1. F., and COHEN, M. R Sperm survival at estimated ovulation time: Prognostic significance. Fertil. Steril. 1: 169, 1950. 23. STEINBERG, W. Cervical aspects in sterility and infertility. Fertil. Steril. 6: 169, 1955. 24. SUJAN, S., DANEZIS, J., and SOBRERO, A. J. Sperm migration and cervical mucus studies in individual cycles. Unpublished data. 25. SWYER, C. 1. M. Observations on the post-coital test. In Studies on Fertility. Ed. by R C. Harrison, VII: 79. Blackwell, Oxford, 1955. 26. SWYER, C. 1. M. The post-coital test. Ann. Ostet. Ginec. 78:43, 1956. 27. TYLER, E. T. The vagina and fertility. Ann. N. Y. Acad. Sci. 88:294, 1959. 28. WESTMAN, A. Acta Obstet. Gynec. Scand. 22:1,1942. 29. WILLIAMS, W. W. Interpretation of post-coital examinations of cervical mucus. In Proceedings of the Conference on Diagnosis in Sterility. Ed. by E. T. Engle, Thomas, Springfield, 1946. 30. WILLIAMS, W. W. The relation of post-coital sperm survival to fertility. In Proceedings of the Second World Congress on Fertility and Sterility. Ed. by C. Tesauro, 2:511, Topografia Poliglota Vaticana, Rome, 1957. 31. YOUSSEF, A. F. The uterine isthmus and its sphincter mechanism, a radiographic study. Amer./. Obstet. GfJnec. 75: 1305, 1958.
(PCT) or Sims-Huhner test is one of the important steps in the investigation of the infertile couple. The variety in terminology, technics, and classification, as well as the tremendous variation seen in its interpretation, point to the need for some standardization. Correlation between cyclic variations in the quality of the cervical mucus and PCT results has been studied from many approaches. Swyer5 • 26 pointed out that while the quality of mucus is significantly correlated with the day of the cycle, the extent of the sperm invasion and sperm activity within the mucus are not correlated. Williams,29.30 Bishop, and Donald are in general agreement with Swyer's conclusions. Lamar et al., and Harvey and Jackson showed that the penetrability of the mucus was greatest during midcycle, when the amount of mucus increased and viscosity diminished-as was first pointed out by Seguy and Simonnet. Shettles and Guttmacher in their study of cervical mucus suggested the proper day for artificial insemination. Moench observed that the degree of penetrability of cervical mucus by spermatozoa depended solely on its viscosity, and Abarbanel in his experiments showed that under the influence of progesterone the mucus became more viscous and sperm penetration was poor. In the present study, PCT results have been grouped according to whether or not the desired pregnancy was achieved, and the various factors-interval since coitus, cervical mucus quality, semen quality, and phase of the menstrual cycle-have been analyzed separately and in combination for each group. Semen analyses in the 2 groups have also been compared according to several criteria.
THE POSTCOITAL TEST
From the Margaret Sanger Research Bureau, New York, N. Y. *Visiting Research Fellow-appointment supported by the International Cooperation Administration under the Visiting Research Scientists Program administered by the National Academy of Sciences of the U. S. A. tMedical Fellow-appointment supported by the Abraham Stone Fellowship Fund.
559
560
DANEZIS ET AL.
FERTILITY
& STERILITY
MATERIAL AND METHOD
A total of 1257 peT were performed consecutively in 546 couples who were undergoing fertility studies at the Margaret Sanger Research Bureau. Of these, 316 involved 140 women who became pregnant, with 941 peT in 406 women who had not conceived at the time of our analysis. Timing of Postcoital Test
Postcoital tests are routinely scheduled during the so-called fertile period: the time of ovulation as determined by the basal body-temperature record. The determination of ovulatory cycles was made by a study of the BBT records, since endometrial biopsies were not performed in every case in the cycle studied. Ovulation was considered to have occurred on the last day of low BBT, just before the beginning of the sustained rise. The 3 phases of the menstrual cycle in each biphasic graph were designated as follows. Pre-ovulatory: from menses up to the commencement of the ovulatory phase Ovulatory: from 48 hours prior to the thermal shift up to 24 hours thereafter Post-ovulatory: from the end of the ovulatory phase to the subsequent menses Technic and Classification
The patients were instructed to report to the clinic as soon as possible after coitus. By means of long thumb forceps, a sample was first taken from the vaginal po~l. The excess of cervical mucus was then thoroughly wiped away from the external os and surrounding area, after which a specimen was obtained from inside the cervical canal by suction with a tuberculin syringe (without a cannula or needle). Gross physical characteristics of the mucus were recorded-amount, viscosity, color, and spinnbarkeit. In this study, the mucus was classified as positive or negative: positive when it was abundant, clear, watery, clean (without cells), and of good spinnbarkeit (over 10 cm.); negative when scanty, opaque, viscous, cellular, and of poor spinnbarkeit. The specimens were immediately examined microscopically for spermatozoa and cellular contents. Observations were recorded according to the following peT classification established by one of us (AJS) : Negative: no spermatozoa found in any specimen of endocervical mucus or of vaginal fluid Poor: spermatozoa present, but none motile in the endocervical-mucus specimen
VOL.
13, No.6, 1962
561
POSTCOITAL TEST
Fair: Up to 5 spermatozoa with motility of Grade 3 or better per dry highpower field (HPF, X 400)-or any number of spermatozoa with motility less than Grade 3 in the endocervical-mucus specimen Good: Six or more spermatozoa per dry HPF with motility of Grade 3 or better in endocervical-mucus specimen Excellent: Over 15 spermatozoa per dry HPF with motility of Grade 3 or better in endocervical-mucus specimen Semen Evaluation
The classifications used in semen evaluation in both clinical and laboratory work at the Bureau are those established by MacLeod13 for specimens of seminal fluid obtained after 3 days of continence. Semen is considered normal when: the volume measures from 2 to 5 ml.; its pH is between 7.0 and 7.6; liquefaction occurs within 20 min. after ejaculation, and the liquefied semen shows no thread formation. Quality is rated according to count, motility, and morphology as follows: Count
Good (G)
Passable (P)
Subnormal (S)
60 million or more per milliliter
20 to 60 million per milliliter
Fewer than 20 million per milliliter
60% or more 3+ or better
40-60% 2+ to 3+
Less than 40% Below 2+
80% or more oval cells
60-80% oval cells
Less than 60% oval cells
Motility
Percentage Grade Morphology
Motility of the spermatozoa is graded as follows: 0, no motion; >0, slow waving of tail, without forward motion; 1, slow progressive movementsnot necessarily forward motion; 2, more active, with forward motion; 3, good forward motion; and 4, very active-fastest speed observed in vitro. These gradations are subdivided by the addition of plus or minus signs to indicate greater or less motility than the designated digits. Thus 3+ would indicate progressive movements greater than 3 but less than 4; 3- would suggest a motility better than 2+ but not quite 3. This system of grading, admittedly arbitrary and subjective, nevertheless gives excellent results when applied by an experienced observer. From 1 to 9 semen analyses were recorded for each of the 546 couples studied. In most of the few cases with only 1 semen analysis, the semen was reported as excellent-and conception occurred shortly after infertility studies were begun. In the remainder of those having only 1 semen analysis, the husbands had moral scruples or psychologic difficulty in furnishing specimens. Those whose semen was evaluated more than 4 or 5 times were usually men
562
DANEZIS ET AL.
FERTILITY
& STERILITY
with subnormal or passable semen quality. These patients were closely followed during treatment; the average value of each separate criterion of semen quality was used as representative of the subject. For the purposes of this study, our standards of "passable" and "subnormal" semen quality were further subdivided as follows: Passable with good rrwtility (PI): Count within passable limits, but percentage of motile spermatozoa and grade of motility of good standards (60%, 3+ or better) . Passable with good count (P2): Percentage and grade of motility within passable limits, but count good (60 million or more per milliliter) . Passable (P): Quality as described above. Subnormal with good rrwtility (SI): Subnormal count, but grade and percentage of motile spermatozoa of passable or good standards. Subnormal (S): Quality as described above. RESULTS
As previously stated, the patients were divided into two major groupsthose who achieved pregnancy and those who did not. In each group, the main factors associated with the outcome of the PCT-cervical mucus, phase of the cycle, and semen-were studied separately and in combination. Evaluation of the PCT was made using the standard classification of negative, poor, fair, good, or excellent, with a gross classification of negative or positive. Negative tests included those designated in the standard classification as negative or poor (absence of sperm or sperm without motion), while the term positive was applied to the tests designated fair, good, or excellent (motile spermatozoa in the endocervical mucus). For this analysis, our results are presented in sections wherein the factors studied will be dealt with separately. Time Interval After Coitus
Although 82 per cent of all the PCT were performed from 1 to 4 hr. after coitus, the range of variation was from less than 1 hour to 8 hours or more. Therefore, all 1257 PCT were analyzed in order to study the relationship of the time interval to the results of the postcoital examination. In Fig. 1, the time interval after coitus is shown in four groups: up to 1 hour, from 1 to 4 hours, from 4 to 8 hours, and over 8 hours. The proportion of positive tests is unaffected by the time interval, unless the interval is longer than 8 hours. Of the PCT performed over 8 hours after coitus, 63 per cent were negative; however, since this group constituted only 4.5 per cent of the 1257 PC r performed, any statistical inference may be doubtful.
VOL.
13, No.6, 1962
563
POSTCOITAL TEST
Postcoital Test Quality and Cervical Mucus Quality
In evaluating the factors influencing peT results, attention should be paid to the quality of cervical mucus. Figure 2 presents the relationship between positive or negative peT and positive or negative cervical mucus as defined above. Among the 140 women who conceived, positive cervical mucus was recorded in 73 per cent of the positive peT and in 49 per cent of the negative peT. Among the 406 who failed to conceive, the percentage of positive cervical mucus was 67 per cent in positive peT and 39 per cent in negative peT. The difference between the two groups cannot be considered significant. Further data on the quality of the cervical mucus at each phase of the menstrual cycle and its relation to the peT results are presented in the left section of Fig. 3. As expected, the percentages of positive peT were highest 10 90
+ P.C.T. 0 - P.C.T. ~
80 70 Fig. 1. Results of 1257 postcoital tests according to interval since coitus. 'Yo 50
POSITIVE NEGATIVE
6'3%
57%
40 30 20 10 0
I TO 4 hr.
UP TOI 3.5%
4 TO 8 hr. 4.5%
10%
82%
100
m
90
80
Fig. 2. Cervical mucus and postcoital tests in 140 infertile women who conceived and 406 who did not.
o
7~/o
:~
11·1·
~50
~
49%
I
~O/o
POSITIVE MUCUS NEGATIVE MUCUS
6i
,~
:~ I~ a " I~
Mucu.
~:_
m:,
:i;+.L.:I.:I.l:. _
P.C.T.+ 232
P.C.T.84
~:~J;+.' ..
_ .
TOTAL 316
PREGNANT GROUP
P.C.T.+ 481
P.C.T.460
TOTAL 941
NON -PREGNANT GROUP
564
DANEZIS ET AL.
FERTILITY
& STERILITY
in the ovulatory phase-78 per cent for the pregnant and 61 per cent for the nonpregnant group, as compared with 59 per cent and 55 per cent respectively in the pre-ovulatory phase, and 74 per cent and 62 per cent in the postovulatory phase. It is also evident that a higher percentage of PCT in all 3 phases of the cycle was recorded for the pregnant group. POSITIVE POST-COITAL TESTS
POSITIVE CERVICAL MUCUS
o
100 90
•
60 "" SO
PREGNANT GROUP NON -PREGNANT GROUP
78°1.
80 70
0_ -0
-
74"
,,;,0--- ___ 074 %
:::::---n-,,'
61%
.62%
/
62%0""
----~.'" 68%"
"...
44%
40
54'"1.
\,
'039%
30
Fig. 3. Positive postcoital tests and positive cervical mucus in relation to phases of the menstrual cycle.
20 10
0L-____..L.~~~--~L---_+----__--~PRE -
OVULATORY
OVULATORY
POST
PRE -
OVULATORY
OVULATORY
OVULATORY
POST
OVULATORY
PHASES OF CYCLE
The percentages of positive cervical mucus (at the right in Fig. 3) show the same general pattern, with the peak in the ovulatory phase in both groups but higher for the pregnant group. Positive cervical mucus in the postovulatory phase for the pregnant group was found in 39 per cent of the PCT; this is in contradiction with the known adverse influence of progesterone on the cervical mucus; it is probably due to the elevation of estrogens, which are known to rise at that time. 12• 16 The columns at the bottom of Fig. 3 represent the over-all distribution of PCT recorded in the preovulatory, ovulatory and postovulatory phases of the cycle. As expected, owing to proper scheduling, the bulk of the PCT were done during the ovulatory phase. Comparisons of the distribution between pregnant and nonpregnant groups reveals no important difference. However, the slightly higher percentage of PCT done in the ovulatory phase for the pregnant group (57 per cent as compared with 49 per cent for the nonpregnant group), along with the better sperm penetrability in the ovulatory phase, might be considered slightly contributory toward the better results seen in the pregnant group. The above gross evaluation of our results, however, does not show in detail the differences existing between semen quality, cervical mucus quality, and the sperm invasion into and activity within the mucus for each type of PCT. By using the standard classification of PCT (negative, poor, fair, good, excellent), we were able to evaluate sperm invasion and sperm activity within the mucus. The different factors considered in this study in relation to the PCT are analyzed, in Fig. 4 and 5, for the pregnant and the nonpregnant groups
13,No.6,1962
VOL.
OVULATORY PHASE
PRE-OVULATORY PHASE P.C. MUCUS
565
POSTCOITAL TEST
SEMEN QUALITY
P.C. MUCUS
POST-OVULATORY PHASE
SEMEN QUALITY
P.C. MUCUS
SEMEN QUALITY
100-
8060%40-
. ~ Ib I
20-
0_
+-
10080-
P.CX EXCELLENT
GPPPSS I 2
I
%6040200_
100-
%~~~ 1~Ln. I~L- I~L.. 100-
+-
+-
GPPPSS 12
I
P.C.T. FAIR
GPPPSS I 2
I
80-
%:~= I~L .~LlL I ~liL
P.G. POOR
%'~!~ •~ ~~L .~ :~~s .lli c. GW1.
+-
+-
G~~PSIS
P.C. MUCUS
SEMEN QUALITY
G~~PSIS
P.C. MUCUS
I1i!I •
o
P.C. = Post - Coital Test
CERVICAL MUCUS QUALITY
+ -
Positive cervical mucus Negative cervical mucus
+-
SEMEN QUALITY
G PI P2 P 51 5
• T
NEGATIVE
G~~PSIS
P.C. MUCUS
SEMEN QUALITY
SEMEN QUALITY Good semen quality Passable with good motility Passable with good count Passable semen quality Subnormal with good motility Subnormal
Fig. 4. Results of 316 postcoital tests according to cycle phase, and quality of cervical mucus and semen in 140 infertile couples who conceived.
566
P.C. MUCUS
1008060%4020-
0_ 1008060-
4020-
•ill •
0_ 1008060%40-
~ +-
SEMEN QUALITY
P.C. MUCUS
& STERILITY
POST-OVULATORY PHASE
OVULATORY PHASE
PRE-OVULATORY PHASE
%
FERTILITY
DANEZIS ET AL.
P.C. MUCUS
SEMEN
SEMEN QUAL.ITY
~
L .~ L _~ ~
~ I:: ~ L~SA
ReT. EXCELLENT
A
[:5,5 A I
+-
GPPPSSA 12
I
I
GPPPSS A 12
I
+-
P.C.T.'OOO
GPPPSSA 12
I
20-
0_ 1008060 .... %4020-
0_ 1008060%4020-
0_
I~LL Irn~ I~~ +-
+-
G~~PSISA
G~f2PSISA
+-
G~~PSISA
P.C. MUCUS
SEMEN QUALITY
G~~PSISA
P.C. MUCUS
SEMEN QUALITY
!iii .P.C. = Post - Coitol Test CERVICAL MUCUS QUALITY
+ -
Positive cervicol mucus Negative cervical mucus
G PI P2 P SI S A
+-
P.C.T. POOR
G~P2PSISA
.illLJ.. .~J. .~I hi +-
D
+-
P.C.T. NEGATIVE
G~~PSISA
P.C. MUCUS
SEMEN QUALITY
SEMEN QUALITY Good semen quolity Passoble with good motility Passable with good count Possoble semen quolity Subnormal with good motility Subnormol Azoospermia
Fig. 5. Results of 941 postcoital tests according to cycle phase, and quality of cervical mucus and semen in 406 infertile couples who failed to conceive.
VOL.
13, No.6, 1962
POSTCOITAL TEST
567
respectively. Each figure presents 3 major groups corresponding to the preovulatory, ovulatory and postovulatory phases of the cycle. Each phase of cycle consists of 5 minor groups corresponding to the several qualities of peT. In each of these groups the black column represents the percentage of peT done in that particular phase and classified according to that particular quality; the 2 white columns represent the corresponding percentages of positive and negative cervical mucus; the stippled columns indicate semen quality. The conclusions that may justifiably be drawn from the data included in the two charts (Fig. 4 and 5) are the following: In both pregnant and nonpregnant groups there were fewer negative and poor peT than fair, good, and excellent peT in each of the 3 phases of the cycle. This is more evident in the ovulatory phase and more striking in the pregnant group. The positive correlation between the quality of peT and that of cervical mucus also emerges from the data in the charts. Semen Evaluation
Figure 6 shows the distribution of semen quality, using the standard classifications for the pregnant and nonpregnant groups. Semen was classified as good in 55 per cent of the pregnant couples, passable in 38 per cent, and subnormal in 7 per cent; for the nonpregnant group the corresponding figures were 38, 43, and 14 per cent, respectively, while 5 per cent were cases of azoospermia. That better semen quality exists in the pregnant group is clear, but the high incidence ( 43 per cent) of passable quality in the nonpregnant group is somewhat puzzling. In order to make a more precise evaluation of the factors involved in semen quality, the passable and subnormal groups were subdivided, as previously explained, into "passable with good motility," "passable with good count," and "subnormal with good motility." The subdivision is incorporated in Table 1 and Fig. 7. 100 PREGNANT GROUP . - . NON-PREGNANT GROUP
90 80 70 60
55% 0 __
%50
---
Fig. 6. Semen quality in 546 infertile couples, according to standard classification.
40 30 20 10 0
38%
GOOD
PASSABLE SEMEN
QUALITY
SUBNORMAL
AZOOSPERMIA
568
DANEZIS ET AL.
FERTILITY
&
STERILITY
TABLE 1. Semen Quality with Respect to Conception Semen quality
No. pregnant
Good (G) Passable with good motility (PI) Passable with good count (P2 ) Passable (P) Subnormal with good motility (SI) Subnormal (S) Azoospermia (A)
77 18 10 25 5 5
o
(55%) (13%) (7%) (18%) (3.5%) (3.5%)
140 (100%)
TOTAL
No. not pregnant
154 16 65 94 16 41 20 406
(38%) (4%) (16%) (23%) (4%) (1O%) (5%) (100%)
The category of "passable with good motility" covered 13 per cent of the pregnant cases but only 4 per cent of the nonpregnant cases, while 7 per cent of the pregnant and 16 per cent of the nonpregnant cases had semen "passable with good count." In the category designated "passable" were 18 per cent of the pregnant cases and 23 per cent of the nonpregnant. These observations indicate that motility is more important than sperm number in relation to chances of conception. 14 This finding is further clarified in Table 2, which shows that of the 34 cases whose semen quality was rated "passable with good motility,"18 patients (53 per cent) managed to achieve pregnancy, whereas only 10 (13 per cent) of the 75 cases with semen rated "passable with good count" and 25 (21 per cent) of the 119 rated "passable" were in the pregnant group. Five (24 per cent) of the 21 cases with semen "subnormal with good motility" became pregnant, while only 5 (11 per cent) of the 46 with subnormal semen did. 100 PREGNANT GROUP
90
e _ e NON - PREGNANT GROUP
80
70
60
55%
,, ,,
o
"10 50
,,
40 30
20
,,
,
,,
23% e
"13%
I:~o, "" IS%'__
..:..-__ ~
10%
~"'-.,~o.-.-"" ............ 4% ~.-. ~~%, 40/07% .... 8'3":'50/.-----03.5% o~--~------~------~------~----~~~--~~~--~
10
GOOD
PASSABLE WITH GOOD MOTILITY
PASSABLE WITH GOOD COUNT
PASSABLE
SUBNORMAL WITH GOOD MOTILITY
SUBNORMAL
___
AZOOSPERMIA
SEMEN QUALITY
Fig. 7. Semen quality in 546 infertile couples, according to special sub-classifications: 140 in the pregnant group; 406 in the nonpregnant group.
VOL. 13, No.6, 1962
569
POSTCOITAL TEST
TABLE 2. Incidence of Conception According to Semen Quality 8emen quality
Total case8
Good (G) Passable with good motility (PI) Passable with good count (P2 ) Passable (P) Subnormal with good motility (Sl) Subnormal (S) Azoospermia (A) TOTAL
231 34 75 119 21 46 20 546
No. pregnant
77 18 10 25 5 5 0 140
(33.33%) (53%) (13%) (21%) (24%) (11%)
No. not pregnant
154 16 65 94 16 41 20 406
(66.66%) (47%) (87%) (79%) (76%) (89%) (100%)
Figures 5 and 6 also include an evaluation of semen quality for each of the subdivisions made (by peT quality and by cycle phase-although cycle phase has no relation to semen evaluation) in the 2 groups of cases, pregnant and nonpregnant. It is evident that high quality of peT correlated with high quality of semen throughout both groups. It is interesting to note that the columns representing semen quality "passable with good motility" (PI) and "passable with good count" (P2) are generally higher in the better peT grade. This finding, more accentuated in the pregnant group, is further exemplified in Fig. 8, in which the percentage of positive peT has been plotted according to semen quality for both pregnant and nonpregnant groups. This Figure illustrates that the lower the quality ....en ....
::l100 ...J
90
ou
80
~
~ 70
'"~
... 60 ~ 50
~0.. 40 ~
30
~
20
~ ~ 10 u
~
0..
O~---L------~------~----~------~------~-GOOD
PASSABLE WITH GOOD MOT ILiTY
PASSABLE WITH GOOD COUNT
PASSABLE
SUBNORMAL WITH GOOD MOTI LlTY
SUBNORMAL
SEMEN QUALITY
Fig. 8. Postcoital tests in 1257 cases (316 in the pregnant group and 941 in the non-pregnant group), according to semen quality in 140 couples who achieved conception and 406 couples who did not.
570
DANEZIS ET AL.
FERTILITY
& STERILITY
of the semen, the fewer positive PCT were in either group, with no significant variations in the downward curves. Conversely, the better the motility, the better the PCT. Precoital Douche
When MacLeod and Hotchkiss introduced a special medicated douche as a treatment in certain cases of infertility, they restricted its use to the type of infertility in which neither partner showed striking abnormality. They attributed the success of this medication to temporary removal of some "incompatibility" that prevented the penetration of spermatozoa into the cervical canal but increased the sperm activity in the vaginal pool around the externalos. At the Bureau, in the course of studying any infertile couple whose first PCT is negative, poor, or fair, the patients are instructed to use a medicated precoital douche'" within an hour prior to intercourse. Subsequent postcoital tests are made and compared with the previous findings. Of the 396 PCT with precoital douche, 125 (31 per cent) remained unchanged in quality; in 22 instances (6 per cent) the quality was worse. Of the 249 cases whose peT showed improvement after precoital douche, 204 (82 per cent) showed improvement of one degree (from negative to poor, or from poor to fair, etc.); the remaining 45 cases (18 per cent) showed improvement of 2 degrees (e.g., from poor to good). In cases where improvement was noted, the patients were instructed to use precoital douches each time they had sexual intercourse during the fertile period. Postcoital Tests in Conception Cycle
In the course of the present study, 33 cases were encountered in which PCT were made during the cycle in which conception occurred; 30 of these PCT were performed during the ovulatory phase of the cycle. A summary of these 33 conception cycles is presented in Table 3, in which it is seen that positive cervical mucus was found in 27 PCT (82 per cent) although 29 of the peT (88 per cent) were rated fair, good, or excellent. During the conception cycle no peT was reported negative, but 4 (12 per cent) were rated poor (no motile spermatozoa were found in the endocervical specimen). Subnormal semen was recorded in 2 cases; 1 of these, however, was classified as subnormal with good motility. The importance of motility is further *Pro-ception sperm nutrient douche (dextrose, 71 per cent; potassium chloride, 0.70 per cent; sodium chloride, 25.75 per cent; calcium gluconate, 2.55 per cent), Milt!x Products, Chicago. TIl
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TABLE 3. Cervical Mucus, Postcoital Tests, and Semen Quality in 33 Conception Cycles Cervical Mucus Positive Negative
27 (82%) 6 (18%)
Postcoital Test Excellent Good Fair Poor
6 (18%) 10 (30%) 13 (40%) 4 (12%)
Semen Quality Good 13 (40%) Passable with good motility 6 ( 18% ) Passable with good count 2 ( 6%) Passable 10 ( 30%) Subnormal with good motility 1 (3%) Subnormal 1 ( 3% )
shown in the 6 cases rated passable with good motility, which were three times as n)1merous as those passable with good count. Four of these 33 PCT were considered poor. In 2 of these, the cervical mucus was negative; in 3 the semen was rated passable, and in one the semen was subnormal. DISCUSSION
The time elapsing between coitus and the postcoital examination, according to our analysis of 1257 PCT, appears to make very little difference in the PCT results; at least this is so up to 8 hours after coition. According to Barton and Wiesner, spermatozoa remain motile 12-48 hours in the cervical mucus in vitro and ~ days in vivo. Sperm survival within the mucus after stilbestrol therapy was found by Stein and Cohen to be as long as 6 days. Tyler reported up to 134 hours in the absence of any therapy, and our own experience has shown survival up to 5 days during the fertile period. While we recognize that these instances are exceptional, we do regard the results of PCT performed within 8 hours of coitus as reliable. Our data are at variance with those of some investigators, who state that the time lapse should not exceed 2 hours. In reviewing our findings, we wish to make clear that survival within the endocervical mucus must not be equated with the capacity of spermatozoa for upward migration or fertilization. From the analysis of our results, we found that whenever better qualities of cervical mucus and of semen were reported, a better sperm penetration (in both density and motility) was noted. Analyzing the quality of cervical mucus in the positive and negative PCT, we found no important difference between those who achieved pregnancy and those who did not (Fig. 2). Better quality of mucus, however, resulted in better sperm penetration-as shown by the percentage of positive mucus whenever the PCT was positive, with higher values in the pregnant group. When the mucus was studied according to the 3 phases of the cycle, our observations were in agreement with the generally
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accepted view that a higher quality corresponds to the ovulatory phase and a lower to the pre- and postovulatory phases. Sperm penetration in relation to the quality of the cervical mucus and to the semen quality in both groups (Fig. 4 and 5) showed that the range of peT quality from negative to excellent was paralleled by quality of semen and of mucus, except for one striking discrepancy in the group in which pregnancy occurred. Of the positive peT performed in the postovulatory phase in this group, only 39 per cent showed mucus of positive quality (Fig. 3). This was not unexpected, in view of the generally accepted adverse influence of progesterone on cervica1 secretions. In spite of this, however, 74 per cent of the peT were positive in the postovulatory phase for the group becoming pregnant-a percentage nearly as high as the 78 per cent of the ovulatory phase, in which the correlation with positive mucus is quite close. This study confirms the influence of semen quality on the outcome of peT, indicating that semen quality is generally higher in men whose wives conceive. In addition, the results of the analyses (Fig. 8) of motility and density of the spermatozoa are in full agreement with MacLeod's statements: «the motile activity of the fertile group is consistently better than that of the infertile group" and «the chances of fertility increase with the rising quality of motility."14 However, as seen in Fig. 8, a higher sperm count had a favorable effect on peT outcome although not so important as the motility. Examination of the peT results for the 10 couples who achieved conception in spite of subnormal semen quality (Table 2) reveals that in the 5 cases where the spermatozoa of the subnormal semen were characterized by good motility, as many as 45 per cent of the peT results were positive (Fig. 8) whereas only 30 per cent were positive in the absence of good motility. This confirms Swyer's25 mention of the diagnostic importance of the peT in cases of subnormal semen, and indicates the influence of semen quality on peT outcome and hence on the chances of conception. Variations in the quality of cervical mucus throughout individual cycles18 as well as variations in the husband's semen quality lead us to the conclusion that repeated peT are preferable to a single peT in the evaluation of the infertile couple. This is in agreement with Southam and Buxton, though our figures show slightly higher values for quality of peT and of cervical mucus. SUMMARY
Analysis of 1257 postcoital test (peT) results performed in 546 patients under routine investigation for infertility are reported. Standardized classifications were used in the evaluation of these peT as well as of certain factors involved in the test-quality of semen, characteristics of cervical mucus, and
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phases of the menstrual cycle. Comparison is made between 316 peT made in a group of 140 women who became pregnant and the 941 peT made in a group of 406 who failed to conceive up to the time the present study was undertaken. The time interval between coitus and postcoital examination was studied in relation to peT results, but no Significant difference was found within 8 hours. Quality of cervical mucus found in each of the 3 phases of the menstrual cycle varied in accordance with known hormonal influence on cervical physiology-with no major difference between the women who conceived and those who did not, except that in the pregnant group mucus quality was better throughout the cycle. The women who achieved conception had better PCT results than those who did not. But in both groups sperm penetration was better during the ovulatory phase (including 30 of the 33 conception cycles reported) than in the pre- and postovulatory phases. The only discrepancy between sperm penetration and quality of mucus was found in the postovulatory phase of the group achieving pregnancy-where 74 per cent of the peT showed good sperm penetration, although the endocervical mucus was of poor quality in 61 per cent of these peT. Semen quality of husbands, as evaluated in 1 to 9 specimens obtained through masturbation, was better in the group that became pregnant. Motility (percentage and grade of motility) scored higher in the passable and subnormal semen groups tha.n sperm number, which again emphasizes the relatively greater significance of motile activity over sperm concentration in influencing conception. Higher motility and count of the spermatozoa in the semen gave better peT results in both groups. Of the 67 couples with subnormal semen, only 10 achieved pregnancy. Sperm penetration was found in 5 of these cases in 30 per cent of the peT; but in the other 5, which had superior motility, sperm penetration was found in 45 per cent of the peT. In 396 patients the effect of an alkaline-buffered precoital douche was found to be beneficial in 63 per cent of the cases. A.J. S. Margaret Sanger Research Bureau 17 West 16th St. New York 11, N. Y.
REFERENCES 1. ABARBANEL, A. R. Spennatozoa and Cervical Mucus. In The Problem of Fertility. Ed. by E. T. Engle. Princeton University Press, Princeton, N. J., 1946. 2. ASPLUND, J. The uterine cervix and isthmus under nonnal and pathological conditions. Acta. Radiol. Suppl. 91, 1952.
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3. BARTON, M., and WIESNER, B. P. The receptivity of cervical mucus to spermatozoa. Brit. Med. /. 2:606, 1946. 4. BISHOP, P. M. F. Post-coital Tests. In Mammalian Germ Cells. Ed. by C. E. W. Wolstenholme. Little, Boston, 1953. 5. BUXTON, C. L., and SOUTHAM, A. L. Human Infertility. Hoeber, New York, 1958. 6. CLIFT, A., and HART, J. Postcoital tests on a statistical basis. Fertil. Steril. 5:544,1954. 7. COHEN, M. R, and STEIN, 1. F. Sperm survival at estimated ovulation time. Comparative morphology: relative male infertility. Fertil. Steril. 2:20, 1951. 8. DANEZIS, J., SUJAN, S., and SOBRERO, A. J. Bacteriology of the cervix and postcoital tests. Int./. Fertil. In press. 9. DONALD, I. Results of Post-coital Tests Where Pregnancy Ensued. In Mammalian Germ Cells. Ed. by C. E. W. Wolstenholme. Little, Boston, 1953. 10. HARVEY, C., and JACKSON, M. H. Penetration of cervical mucus by spermatozoa. Lancet 11:723, 1948. 11. LAMAR, J. K., SHETTLES, L. B., and DELFS, E. Cyclic penetrability of human cervical mucus to spermatozoa in vitro. Amer./. Physiol.129:234, 1940. 12. LITTRELL, J. L., and TOM, J. Y. S. Fluctuations in the estrogen level throughout the menstrual cycle of one woman. Endocrinology 40:292, 1947. 13. MACLEOD, J. The male contribution to human infertility. Ann. Ostet. Ginec. 6 (June, 3 Fascicolo Speciale edito a cura del Centro Sterilita Coniugale di Milano): 120, 1953. 14. MACLEOD, J., and GoLD, R. J. The male factor in fertility and infertility. III. An analysis of motile activity in the spermatozoa of 1000 fertile men and 1000 men in infertile marriage. Fertil. Steril. 2: 187, 1951. 15. MACLEOD, J., and HOTCHKISS, R S. The use of a precoital douche in cases of infertility of long duration. Amer./. Obstet. Gynec. 46:424, 1943. 16. MARKEE, J. E., and BERG, B. Cyclic Huctuation in blood estrogen as a possible cause of menstruation. Stanford Med. Bull. 2:55, 1944. 17. MOENCH, C. L. /. Lab. Clin. Med.19:358, 1934. 18. SEGUY, J., and SIMMONET, H. Recherches des signes directs d'ovulation chez la femme. Gynec. Obstet. 28:657, 1933. 19. SHETTLES, L. B. Cervical factors in reproduction. Obstet. Gynec. 14:635, 1959. 20. SHETTLES, L. B., and CUTTMACHER, A. F. Amer. /. Physiol. 129:462, 1940. 21. SOUTHAM, A. L., and BUXTON, C. L. Seventy postcoital tests made during the conception cycle. Fertil. Steril. 7: 133, 1956. 22. STEIN,1. F., and COHEN, M. R Sperm survival at estimated ovulation time: Prognostic significance. Fertil. Steril. 1: 169, 1950. 23. STEINBERG, W. Cervical aspects in sterility and infertility. Fertil. Steril. 6: 169, 1955. 24. SUJAN, S., DANEZIS, J., and SOBRERO, A. J. Sperm migration and cervical mucus studies in individual cycles. Unpublished data. 25. SWYER, C. 1. M. Observations on the post-coital test. In Studies on Fertility. Ed. by R C. Harrison, VII: 79. Blackwell, Oxford, 1955. 26. SWYER, C. 1. M. The post-coital test. Ann. Ostet. Ginec. 78:43, 1956. 27. TYLER, E. T. The vagina and fertility. Ann. N. Y. Acad. Sci. 88:294, 1959. 28. WESTMAN, A. Acta Obstet. Gynec. Scand. 22:1,1942. 29. WILLIAMS, W. W. Interpretation of post-coital examinations of cervical mucus. In Proceedings of the Conference on Diagnosis in Sterility. Ed. by E. T. Engle, Thomas, Springfield, 1946. 30. WILLIAMS, W. W. The relation of post-coital sperm survival to fertility. In Proceedings of the Second World Congress on Fertility and Sterility. Ed. by C. Tesauro, 2:511, Topografia Poliglota Vaticana, Rome, 1957. 31. YOUSSEF, A. F. The uterine isthmus and its sphincter mechanism, a radiographic study. Amer./. Obstet. GfJnec. 75: 1305, 1958.