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Peritoneal recovery of sperm in patients with infertility associated with inadequate cervical mucus*
FERTILITY AND STERILITY Copyright • 1983 The American Fertility Society
Vol. 40, No.6, December 1983
Printed in U.8A.
Peritoneal recovery of sperm in patients with infertility associated with inadequate cervical mucus*
Sergio C. Stone, M.D. University of California, Irvine Medical Center, Orange, California
In an effort to complete an infertility evaluation in a group of 25 patients with unexplained infertility, except for persistent inadequate cervical mucus and poor-tonegative postcoital tests, laparoscopy was scheduled as close as possible to the ovulatory day of the cycle. Patients were artificially inseminated with their husbands' sperm 2 or 3 hours before laparoscopy. Sperm was recovered at the time of laparoscopy through a second probe from the pouch of Douglas before and after hydrotubation with a dilute solution of methylene blue. The results were compared with those obtained in a group of 15 women with unexplained infertility and normal cervical mucus and postcoital tests. Sperm were recovered from 8 of 15 control subjects (53.3%) and from 14 of25 patients (56.1%). In most cases with positive results, sperm were found in the peritoneal cavity before hydrotubation. It is apparent that sperm can reach the peritoneal cavity regardless of the quality or quantity of cervical mucus. It also appears that a normal postcoital test may not indicate adequate sperm transport into the upper genital tract. These results confirm previous observations and question the usefulness of many in vitro tests presently in use for evaluation of sperm penetration in the female genital tract. Fertil Steril40:802, 1983
The study of sperm penetration in the female genital tract is difficult. Numerous in vivo and in vitro tests have been designed to assess sperm penetration and survival in the cervical mucus. 1 -3 Adequate sperm penetration in the cervical mucus and/or several artificial media in vitro has been accepted as a method of evaluating sperm capacity to penetrate the upper female genital tract. The postcoital test (peT) is widely accepted as the most reliable of these tests, giving the best
Received November 1, 1982; rt
Stone Recovery of sperm and cervical mucus
possible idea of the sperm capacity to reach the fallopian tubes. 4 ,5 Nevertheless, Asch 6 ,7 and Templeton and Mortimer8 have reported that the peT may not accurately reflect sperm capacity to ascend the female genital tract. Also, pregnancy occurs rather frequently in our artificial insemination donor program, with poor preovulatory cervical mucus. Prompted by these observations, we studied, with a sperm recovery test (SRT) similar to that described by Asch, 6 a group of 25 couples whose infertility was thought to be related to, or caused by, inadequate cervical mucus production only. MATERIALS AND METHODS
A group of 25 couples with infertility lasting over 3 years, who had in common poor-to-absent cervical mucus and poor-to-negative peTs was selected from a larger group referred to our mediFertility and Sterility
Table 1. Peritoneal Recovery of Sperm Before and After Hydrotubation Sperm present Peritoneal cavity Vagina
Control subjects (n Patients (n = 25)
=
15)
Cervical mucus
After hydrotubation
%
n
%
n
%
n
%
15
100
21
84
15 4
100 16
6 10
40 40
8 14
53.3 56.0
cal center for all types of infertility. The cervical mucus was obtained on the immediate preovulatory days of the cycle as calculated by cycle day and basal body temperature record. The cervical mucus was considered to be poor ifit was scanty, opaque, no spinnbarkeit or ferning was present, and the pH was 6.0 or lower. The PCTwas considered poor if no motile sperm were present and negative if no sperm were found. A comprehensive evaluation revealed no other factor to explain their infertility other than the inadequate cervical mucus and PCT. Fifteen couples whose infertility workup was negative and who had good cervical mucus and PCTs were selected as control subjects. The diagnostic laparoscopy was performed in the immediate preovulatory phase of the cycle in both groups. No patients with endometriosis, pelvic adhesions, or tubal disease were included in this report. SPERM RECOVERY TEST
A diagnostic laparoscopy was planned for the ovulatory day, as estimated by the cycle day and the basal body temperature pattern of at least the previous three cycles. An artificial insemination with the husband's sperm (AIH) was performed 2 to 3 hours before laparoscopy. In addition to a routine diagnostic laparoscopy, four samples were collected, one each from the vaginal pool, the cervical mucus, and the peritoneal fluid before and after hydrotubation with a dilute solution of methylene blue. The peritoneal fluid samples were observed fresh, immediately after recovery, and within 3 hours. In all cases in which no motile sperm could be found, the samples were centrifuged and resuspended in 2 ml of distilled water to lyse the the red cells and facilitate the finding of immotile sperm. No attempt was made to determine the total number of sperm present. In all samples containing motile sperm the morphologic characteristics were carefully evaluated in both the sample used for AIH and in the sperm recovered from the peritoneal cavity. Vol. 40, No.6, December 1983
Before hydrotubation
n
RESULTS
Sperm were recovered from 8 (53.5%) control subjects and from 14 (56%) patients (Table 1). In 6 of the 8 control subjects and in 10 of the 14 patients, sperm was present in the abdomen before hydrotubation. All cases with sperm recovered before hydrotubation also had sperm recovered after hydrotubation. The majority of sperm were motile, but in one control subject and four patients only immotile sperm were recovered. Sperm morphology was evaluated in the seminal fluid before AIH and in the sperm recovered from the peritoneal cavity. A small number of abnormal sperm were found in both samples. No statistical analysis was performed because < 100 sperm were recovered from nine cases. Seven pregnancies occurred in the 34 subjects followed for longer than 6 months: three from 13 control subjects (23%) and four from 24 patients (19%). One subject from each group conceived with a negative SRT. DISCUSSION
Our results confirm previous reports 6 - 8 showing that sperm can be recovered from the abdominal cavity in cases of abnormal PCTs. Our report expands previous observations, because our study group had not only inadequate PCTs, but also poor-to-absent cervical mucus. The finding of motile sperm at the time of laparoscopy in abdominal washings before and after hydrotubation in patients with repeated poor-to-negative PCTs and with poor-to-absent cervical mucus underscores the difficulty in evaluating and understanding sperm penetration ability.3-5 Grant9 in 1958 had already reported the finding of sperm in the uterus in 10% of patients with a negative PCT. If we consider the cervical mucus as the essential medium for sperm transport, it is difficult to explain the presence of numerous motile sperm in the peritoneal cavity of 14 of our 25 patients. It is possible to formulate that only a very small amount of cervical mucus is needed for adequate Stone Recovery of sperm and cervical mucus
803
sperm transport, or that some of the recognized characteristics of the cervical mucus are more important than others. The formulation of "cervical scores" may represent a very imperfect attempt to characterize the cervical mucus. Our understanding of what constitutes adequate cervical mucus may be very limited.lO It is of interest to stress that sperm were not recovered from all our control subjects in the presence of normal cervical mucus and peTs. Indeed, sperm was recovered in only 8 of our 15 normal control subjects. This finding raises again multiple questions regarding our understanding ofthe significance of the peT. Its value may be limited to the study or evaluation of the sperm's ability to penetrate and survive in the cervical mucus, with a more limited and restrictive relation to the capacity of the sperm to migrate to the upper genital tract. In fact, despite reports of good correlation between a normal peT and subsequent fertility,lO, 11 others have shown instead a poor correlation. 9 , 12 Our observations tend to agree with the latter position. A positiveSRT may have a prognostic value. Asch, 7 Templeton and Mortimer,13 and Koch et a1. 14 have shown that a significantly higher number of pregnancies occur in those patients with a positive SRT. Our group has not been followed long enough to allow:us to make any conclusions about future fertility. The recurring observation that motile sperm can be present in the tubes and abdominal cavity in patients with long~term infertility, regardless of their cervical mucus status, may help to redirect the research efforts toward the area of sperm.ovary interaction and away from the sperm-mucus ·relationship. The latter may have been overemphasized.
804
Stone Recovery of sperm and cervical mucus
REFERENCES 1. Davajan V, Kunitake GM: Fractional in vivo and in vitro examination of postcoital cervical mucus in the human. Fertil Steril20:197, 1969 2. Moghissi KS, Dabich D, Levine J, Neuhaus OW: Mechanism of sperm migration. Fertil Steril 15:15, 1964 3. Davajan V, Nakamura RM, KIiarma K: Spermatozoan transport in the cervical mucus. Obstet Gynecol Surv 25:1,1970 4. Tredway DR: The interpret1ition and significance of the fractional postcoital test. Am J Obstet Gynecol 133:382, 1979 5. Scott JZ, Nakamura·RM, Mutch J, Davajan V: The cervical factor in infertility: diagnosis and treatment. Fertil Steril 28:1289, 1977 6. Asch RH: Laparoscopic recovery of sperm from peritoneal fluid in patients with negative or poor Sims-Huhner test. Fertil Steril 27:1111, 1976 7. Asch RH: Sperm recovery in peritoneal aspirate after negative Sims-Huhner test. Int J Fertil 23:57, 1978 8. Templeton.AA, Mortimer D: Laparoscopic sperm recovery in infertile women. Br J Obstet Gynaecol 87:1128,1980 9. Grant A: Cervical hostility: incidence, diagnosis, and prognosis. Fertil Steril 9:321, 1958 10. Giner J, Merino G, Luna J, Aznar R: Evaluation of the Sims-Huhner postcoital test in.fertile couples. Fertil Steril 25:145, 1974 11. Jette NT, Glass RH: Prognostic value of the postcoital test. Fertil SteriI23:29, 1972 12. Versteegh LR, Shade AR:The fractional postcoital test: a reappraisal. Fertil Steril 31:40, 1979 13. Templeton AA, Mortimer D: The development of a clinical test of sperm migration to the site of fertilization. Fertil Steril 37:410, 1982 14. Koch UJ,Hammerstein J, Zielske F: Clinical meaning of spermatozoa found in the peritoneal fluid after vaginal and intrauterine insemination. Fertil Steril (Abstr) 28:311, 1977
Fertility and Sterility
Vol. 40, No.6, December 1983
Printed in U.8A.
Peritoneal recovery of sperm in patients with infertility associated with inadequate cervical mucus*
Sergio C. Stone, M.D. University of California, Irvine Medical Center, Orange, California
In an effort to complete an infertility evaluation in a group of 25 patients with unexplained infertility, except for persistent inadequate cervical mucus and poor-tonegative postcoital tests, laparoscopy was scheduled as close as possible to the ovulatory day of the cycle. Patients were artificially inseminated with their husbands' sperm 2 or 3 hours before laparoscopy. Sperm was recovered at the time of laparoscopy through a second probe from the pouch of Douglas before and after hydrotubation with a dilute solution of methylene blue. The results were compared with those obtained in a group of 15 women with unexplained infertility and normal cervical mucus and postcoital tests. Sperm were recovered from 8 of 15 control subjects (53.3%) and from 14 of25 patients (56.1%). In most cases with positive results, sperm were found in the peritoneal cavity before hydrotubation. It is apparent that sperm can reach the peritoneal cavity regardless of the quality or quantity of cervical mucus. It also appears that a normal postcoital test may not indicate adequate sperm transport into the upper genital tract. These results confirm previous observations and question the usefulness of many in vitro tests presently in use for evaluation of sperm penetration in the female genital tract. Fertil Steril40:802, 1983
The study of sperm penetration in the female genital tract is difficult. Numerous in vivo and in vitro tests have been designed to assess sperm penetration and survival in the cervical mucus. 1 -3 Adequate sperm penetration in the cervical mucus and/or several artificial media in vitro has been accepted as a method of evaluating sperm capacity to penetrate the upper female genital tract. The postcoital test (peT) is widely accepted as the most reliable of these tests, giving the best
Received November 1, 1982; rt
Stone Recovery of sperm and cervical mucus
possible idea of the sperm capacity to reach the fallopian tubes. 4 ,5 Nevertheless, Asch 6 ,7 and Templeton and Mortimer8 have reported that the peT may not accurately reflect sperm capacity to ascend the female genital tract. Also, pregnancy occurs rather frequently in our artificial insemination donor program, with poor preovulatory cervical mucus. Prompted by these observations, we studied, with a sperm recovery test (SRT) similar to that described by Asch, 6 a group of 25 couples whose infertility was thought to be related to, or caused by, inadequate cervical mucus production only. MATERIALS AND METHODS
A group of 25 couples with infertility lasting over 3 years, who had in common poor-to-absent cervical mucus and poor-to-negative peTs was selected from a larger group referred to our mediFertility and Sterility
Table 1. Peritoneal Recovery of Sperm Before and After Hydrotubation Sperm present Peritoneal cavity Vagina
Control subjects (n Patients (n = 25)
=
15)
Cervical mucus
After hydrotubation
%
n
%
n
%
n
%
15
100
21
84
15 4
100 16
6 10
40 40
8 14
53.3 56.0
cal center for all types of infertility. The cervical mucus was obtained on the immediate preovulatory days of the cycle as calculated by cycle day and basal body temperature record. The cervical mucus was considered to be poor ifit was scanty, opaque, no spinnbarkeit or ferning was present, and the pH was 6.0 or lower. The PCTwas considered poor if no motile sperm were present and negative if no sperm were found. A comprehensive evaluation revealed no other factor to explain their infertility other than the inadequate cervical mucus and PCT. Fifteen couples whose infertility workup was negative and who had good cervical mucus and PCTs were selected as control subjects. The diagnostic laparoscopy was performed in the immediate preovulatory phase of the cycle in both groups. No patients with endometriosis, pelvic adhesions, or tubal disease were included in this report. SPERM RECOVERY TEST
A diagnostic laparoscopy was planned for the ovulatory day, as estimated by the cycle day and the basal body temperature pattern of at least the previous three cycles. An artificial insemination with the husband's sperm (AIH) was performed 2 to 3 hours before laparoscopy. In addition to a routine diagnostic laparoscopy, four samples were collected, one each from the vaginal pool, the cervical mucus, and the peritoneal fluid before and after hydrotubation with a dilute solution of methylene blue. The peritoneal fluid samples were observed fresh, immediately after recovery, and within 3 hours. In all cases in which no motile sperm could be found, the samples were centrifuged and resuspended in 2 ml of distilled water to lyse the the red cells and facilitate the finding of immotile sperm. No attempt was made to determine the total number of sperm present. In all samples containing motile sperm the morphologic characteristics were carefully evaluated in both the sample used for AIH and in the sperm recovered from the peritoneal cavity. Vol. 40, No.6, December 1983
Before hydrotubation
n
RESULTS
Sperm were recovered from 8 (53.5%) control subjects and from 14 (56%) patients (Table 1). In 6 of the 8 control subjects and in 10 of the 14 patients, sperm was present in the abdomen before hydrotubation. All cases with sperm recovered before hydrotubation also had sperm recovered after hydrotubation. The majority of sperm were motile, but in one control subject and four patients only immotile sperm were recovered. Sperm morphology was evaluated in the seminal fluid before AIH and in the sperm recovered from the peritoneal cavity. A small number of abnormal sperm were found in both samples. No statistical analysis was performed because < 100 sperm were recovered from nine cases. Seven pregnancies occurred in the 34 subjects followed for longer than 6 months: three from 13 control subjects (23%) and four from 24 patients (19%). One subject from each group conceived with a negative SRT. DISCUSSION
Our results confirm previous reports 6 - 8 showing that sperm can be recovered from the abdominal cavity in cases of abnormal PCTs. Our report expands previous observations, because our study group had not only inadequate PCTs, but also poor-to-absent cervical mucus. The finding of motile sperm at the time of laparoscopy in abdominal washings before and after hydrotubation in patients with repeated poor-to-negative PCTs and with poor-to-absent cervical mucus underscores the difficulty in evaluating and understanding sperm penetration ability.3-5 Grant9 in 1958 had already reported the finding of sperm in the uterus in 10% of patients with a negative PCT. If we consider the cervical mucus as the essential medium for sperm transport, it is difficult to explain the presence of numerous motile sperm in the peritoneal cavity of 14 of our 25 patients. It is possible to formulate that only a very small amount of cervical mucus is needed for adequate Stone Recovery of sperm and cervical mucus
803
sperm transport, or that some of the recognized characteristics of the cervical mucus are more important than others. The formulation of "cervical scores" may represent a very imperfect attempt to characterize the cervical mucus. Our understanding of what constitutes adequate cervical mucus may be very limited.lO It is of interest to stress that sperm were not recovered from all our control subjects in the presence of normal cervical mucus and peTs. Indeed, sperm was recovered in only 8 of our 15 normal control subjects. This finding raises again multiple questions regarding our understanding ofthe significance of the peT. Its value may be limited to the study or evaluation of the sperm's ability to penetrate and survive in the cervical mucus, with a more limited and restrictive relation to the capacity of the sperm to migrate to the upper genital tract. In fact, despite reports of good correlation between a normal peT and subsequent fertility,lO, 11 others have shown instead a poor correlation. 9 , 12 Our observations tend to agree with the latter position. A positiveSRT may have a prognostic value. Asch, 7 Templeton and Mortimer,13 and Koch et a1. 14 have shown that a significantly higher number of pregnancies occur in those patients with a positive SRT. Our group has not been followed long enough to allow:us to make any conclusions about future fertility. The recurring observation that motile sperm can be present in the tubes and abdominal cavity in patients with long~term infertility, regardless of their cervical mucus status, may help to redirect the research efforts toward the area of sperm.ovary interaction and away from the sperm-mucus ·relationship. The latter may have been overemphasized.
804
Stone Recovery of sperm and cervical mucus
REFERENCES 1. Davajan V, Kunitake GM: Fractional in vivo and in vitro examination of postcoital cervical mucus in the human. Fertil Steril20:197, 1969 2. Moghissi KS, Dabich D, Levine J, Neuhaus OW: Mechanism of sperm migration. Fertil Steril 15:15, 1964 3. Davajan V, Nakamura RM, KIiarma K: Spermatozoan transport in the cervical mucus. Obstet Gynecol Surv 25:1,1970 4. Tredway DR: The interpret1ition and significance of the fractional postcoital test. Am J Obstet Gynecol 133:382, 1979 5. Scott JZ, Nakamura·RM, Mutch J, Davajan V: The cervical factor in infertility: diagnosis and treatment. Fertil Steril 28:1289, 1977 6. Asch RH: Laparoscopic recovery of sperm from peritoneal fluid in patients with negative or poor Sims-Huhner test. Fertil Steril 27:1111, 1976 7. Asch RH: Sperm recovery in peritoneal aspirate after negative Sims-Huhner test. Int J Fertil 23:57, 1978 8. Templeton.AA, Mortimer D: Laparoscopic sperm recovery in infertile women. Br J Obstet Gynaecol 87:1128,1980 9. Grant A: Cervical hostility: incidence, diagnosis, and prognosis. Fertil Steril 9:321, 1958 10. Giner J, Merino G, Luna J, Aznar R: Evaluation of the Sims-Huhner postcoital test in.fertile couples. Fertil Steril 25:145, 1974 11. Jette NT, Glass RH: Prognostic value of the postcoital test. Fertil SteriI23:29, 1972 12. Versteegh LR, Shade AR:The fractional postcoital test: a reappraisal. Fertil Steril 31:40, 1979 13. Templeton AA, Mortimer D: The development of a clinical test of sperm migration to the site of fertilization. Fertil Steril 37:410, 1982 14. Koch UJ,Hammerstein J, Zielske F: Clinical meaning of spermatozoa found in the peritoneal fluid after vaginal and intrauterine insemination. Fertil Steril (Abstr) 28:311, 1977
Fertility and Sterility