Extending the duration of the pill-free interval during combined oral contraception

The effect of increasing the duration of the pill-free interval from 7 to 9 and 11 days during the first 4 months of combined oral contraceptive therapy was studied by hormonal, ovarian follicle and mucus changes. Increasing the pill-free interval allowed more follicular development and more estradiol production. In some cases, pre-ovulatory values were achieved although ovulation did not occur. No differences could be detected between different types of combined oral contraceptive, including monophasic, triphasic, levonorgestrel-containing and gestodene-containing. The variation between individuals in the group of 28 was far greater than any variation in dose.

Efficacy and clinical profile of a new oral contraceptive containing norgestimate. U.S. clinical trials

The search for a highly selective progestin that exerts a potent and targeted progestational response with minimal or absent androgenic effect has paralleled investigation into the possible impact of these agents on cardiovascular disease in women. Such a progestin, norgestimate (NGM), in a dose of 250 micrograms, has been combined with ethinyl estradiol (EE) 35 micrograms in a new oral contraceptive (OC), Ortho-Cyclen or Cilest. Results of two long-term, multicentric clinical trials demonstrate that this formulation is comparable in efficacy to the norgestrel-containing OC Lo/Ovral. There were no statistically significant differences in pregnancy rate, and both OCs were well-tolerated in a large and diverse study population. In several areas, however, the inherently lower androgenicity of the norgestimate OC produced clinical changes compared with the norgestrel formulation. These changes were primarily evident in the more natural menstrual patterns with the norgestimate OC, its less severe impact on the endometrium, and, most important, its positive impact on lipoprotein metabolism. NGM/EE consistently produced statistically significant increases in high density lipoprotein (HDL) and concomitant improvement in the ratio of low density lipoprotein (LDL) to HDL. By cycle 24, this highly predictive parameter of atherosclerotic risk had decreased 7.7% in the NGM/EE group. Conversely, the norgestrel-containing formulation resulted in statistically significant decreases in HDL and increases in the LDL/HDL ratio; by cycle 24, these patients showed an 18.5% increase in the LDL/HDL ratio. All between regimen comparisons of mean changes in the LDL/HDL ratio were statistically significant, from baseline through cycles 3, 6, 12 and 24.

Addition of exogenous estrogens to improve cervical mucus following clomiphene citrate medication. Patient selection

Medication with Clomiphene Citrate and its effects on the quality of cervical mucus and the addition of exogenous estrogens in order to suppress abnormal mucus secretion are controversial issues. We have prospectively studied a group of 19 anovulatory women who were treated with clomiphene citrate in order to characterize those patients most likely to respond to the addition of exogenous estrogens. On day 14 of the cycle, 17 beta estradiol and cervical score were measured and 1 mg estradiol benzoate was injected intramuscularly. Cervical scores were below 7 in 12 out of the 19 patients before estradiol benzoate administration. In these patients, 17 beta estradiol rose from 751 +/- 541 to 1321 +/- 648 pg/ml (p less than 0.03), and cervical scores rose from 3.75 +/- 2.1 to 7.1 +/- 3.7 (p less than 0.01), after estradiol benzoate administration. Patients with cervical scores of 8-12 did not improve significantly. In the 12 patients with cervical scores below 7, those (n = 6) with 17 beta estradiol below 600 pg/ml experienced a significant improvement in cervical score, in contrast to those (n = 6) with 17 beta estradiol above 600 pg/ml who had no improvement. The reduction in cervical mucus accomplished with clomiphene citrate can be further improved by adding exogenous estrogens, mainly in patients who have low 17 beta estradiol levels concomitant with low cervical score.

A short course of menotropin after clomiphene failure in infertile women with luteal phase defects

Twenty-four women with luteal phase defects who were ovulatory on clomiphene therapy with or without human chorionic gonadotropin (hCG) at midcycle for three to eight cycles yet failed to produce a live birth were treated with a short course of menotropin (hMG-S), one to two ampules for five days in the early follicular phase followed or not followed by hCG at midcycle for three to eight cycles. The luteal phase defect was diagnosed with repeat endometrial biopsies with a lag time of three or more days prior to clomiphene therapy. A complete infertility workup revealed only eight patients (33%) with a purely endocrine factor (luteal phase defect). The rest (16 patients, or 67%) had one or two additional infertility factors. Two abortions occurred in this group during clomiphene therapy, while five pregnancies (four live births and one spontaneous abortion) occurred during hMG-S therapy. The ovulation rates were similar for hMG-S (89%) and clomiphene (91%) therapy, but the frequency of a normal ovulatory cycle was significantly greater (P = .026) for hMG-S therapy (71%) than for clomiphene therapy (57%). The midluteal mean serum progesterone level was lower and the mean luteal length shorter in the cycles with less than 130 ng/mL/d of total integrated luteal progesterone. The postcoital test results showed better cervical mucus, with increased mucus volume and better fluidity and spinnbarkeit, in hMG-S cycles than in clomiphene cycles. It appears that hMG-S treatment can improve ovarian function and achieve successful pregnancy in patients with luteal phase defects who fail to produce a live birth during clomiphene treatment.

Clinical evaluation of a new combined oral contraceptive desogestrel--ethinylestradiol

A clinical study was performed with a new progestogen, desogestrel, in a 0.15 mg dose associated with 0.03 mg of ethinylestradiol and was administered cyclically during 21 days; 632 cycles were evaluated in 56 women. Side-effects were scarce and generally of a mild nature. Monthly bleeding was normal and present in all cycles. Patients with irregular cycles were normalized to 28/29 days. The intermenstrual bleeding (spotting) was an isolated event in 16 cycles. Mastalgia, the most frequent symptom, disappeared spontaneously in the majority of patients. In only 2 cases was it necessary to stop medication because of side-effects. The contraceptive effect was excellent; no pregnancies occurred. A progestative effect was evident in the cervical mucus and the endometrium. The patients who started treatment with acne improved noticeably. In the mild cases, acne disappeared completely. A discrete improvement in hirsutism was reported. The body-weight variation was not significant. Biochemical studies revealed an increase in HDL-C and a decrease in the ratio LDL-C/HDL-C. Cholesterol and triglycerides did not show variations, which could indicate a lesser cardiovascular risk.

Effects of clomiphene citrate on cervical mucus: analysis of some influencing factors

A multicenter study was performed to investigate the effects of a standard dose of clomiphene citrate (100 mg/day from day 5 of the cycle for five days) on the quality of cervical mucus. A total of 82 cervical mucus samples from 60 infertile patients (15 with secondary amenorrhea, 16 with delayed ovulation, 15 with anovulatory cycles, 14 with oligomenorrhea) was examined on the day of maximum follicular diameter. As a control we studied 54 cervical mucus samples from 47 patients with documented tubal sterility or infertile partners, who had spontaneous cycles with normal rhythm. Cervical mucus was unfavorable in 59% of the treatment cycles compared with 11% of the control cycles. Clomiphene citrate's antiestrogenic effect on cervical mucus was found to be related to the length of time between the last drug administration and the day of maximum follicular diameter (delta days), since cervical mucus was favorable in 64% of the cycles with a delta days more than 6 and in only 16% of the cycles with a delta days of 6 or less. Clomiphene citrate thus seems able to decrease cervical mucus quality. This could be one of the causes of the discrepancy between the rates of ovulation and pregnancy reported in patients treated with this drug.

Structural changes in human cervical mucus

The crystallization phenomenon of human cervical mucus was investigated with the help of scanning electron microscope. Changes in the conformation of crystals and ferning patterns were studied on different days of the menstrual cycle in both normally ovulating women and those using oral contraceptives. No crystalline structure was found on day 5 in both categories of women, whereas square crystals were observed on day 21 in normal woman. Nature and type of ferning pattern changes seen from days 11 to 14 in normal women were not seen during this period in women who were on oral contraception, instead a thick, viscous mucus was found during the entire period of the cycle.

Efficacy of human menopausal gonadotropins as therapy for abnormal cervical mucus

Traditional therapies for abnormal cervical mucus, other than timed intrauterine insemination, are noteworthy for being ineffectual. Patients (n = 27) with documented abnormal Insler scores in repetitive cycles and failure to conceive with traditional treatments were screened with conjugated equine estrogens (CEE) for estrogen responsiveness of the cervix. Only 5 patients were found unresponsive. Seventeen patients with CEE-responsive cervices then were treated with human gonadotropins (hMG), initially 1 ampule days 5 to 11. If the mucus failed to improve, the hMG was increased to standard doses. Eight patients responded to 1 ampule hMG with improved mucus and conception. The remainder required 2 ampules hMG. In patient cycles with corrected cervical mucus, the viable fecundibility (fv) was 0.35. This is significantly higher than predicted for this population (fv = 0.09; P less than 0.01). In all, 14 of 17 patients conceived viable pregnancies during hMG treatment. It is concluded that graduated hMG is efficacious in treating patients with abnormal cervical mucus responsive to CEE. It is preferable to either in vitro fertilization or gamete intrafallopian transfer, based on both cost and efficacy for most patients.

Effects of 180 micrograms and 250 micrograms norgestimate on pituitary-ovarian function and cervical mucus

A double-blind cross-over study of 16 healthy women was carried out to evaluate the effects of norgestimate, a new progestogen, on pituitary ovarian function and cervical mucus. Treatment from cycle day 7 to 16 with 180 micrograms and 250 micrograms norgestimate led to suppression of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels, while progesterone (P) remained suppressed in 28 of 32 cycles studied, indicating inhibition of ovulation. Lack of ovulation in 30 cycles was associated in all but 3 with functional follicles, 2 of which luteinized. With 250 micrograms norgestimate, estradiol (E2) concentrations reached levels similar to those achieved during control follicular phase, but significantly higher concentrations of E2 were achieved with 180 micrograms norgestimate. Cervical mucus score was significantly depressed in all but 5 cycles (3 norgestimate 180 micrograms and 2 norgestimate 250 micrograms cycles). In conclusion, both dosages of norgestimate show good suppression of the hypothalamic-pituitary axis and cervical mucus.

Persistent infertility in ewes after prolonged exposure to oestradiol-17 beta

Merino ewes were treated with implants which released 300 micrograms oestradiol-17 beta per day or 5 mg progesterone per day, or both, for 9 months (Months 1-9), and after an 11-month intermission were treated again for 6 months (Months 20-26). Ewes were run with rams at Months 16, 28 and 40. Fertility was not affected by the first exposure period, but the second exposure to oestradiol reduced the fertility of ewes at both subsequent mating periods. Affected ewes returned to service more frequently (P less than 0.01) and were less likely to conceive (P less than 0.05). After mating, a normal population of spermatozoa was established in the caudal cervix, but transport through the cervix was impaired in affected ewes and there were fewer spermatozoa (P less than 0.01) in the cranial cervix. In affected ewes, the spinnbarkeit of cervical mucus was reduced (P less than 0.05), and the histological appearance of the cervix changed, looking like that of the uterus. Treatment with progesterone did not affect fertility, cervical mucus or sperm transport, but diminished the histological abnormalities produced by oestradiol (P less than 0.05). These results show that oestradiol-17 beta given after puberty can cause the same kind of permanent sexual transdifferentiation that is produced by the oestrogenic isoflavones in ewes with clover disease. The results suggest that this change may require more than a single exposure to oestrogen.

Influence of estrogens on vascular transudation and mucus production in the rabbit endocervix

The manner in which estrogens mediate cyclical changes in the viscoelastic properties and volume of cervical mucus is unclear. To identify the response to estrogens of each of the major mucus components (mucin[s], soluble proteins, and small electrolytes and water), the authors quantitated their accumulation rates before and during estrogen stimulation in the rabbit. Circulating radiolabeled markers (35S-sulfate and 131I-albumin) were used to monitor the incorporation of small and large molecular weight intravascular substances into the cervical mucus. The accumulation rate of mucins was unaffected by exogenous estrogen administration, despite significant increases in mucus volume. This increase in mucus volume was attributed to a significantly increased transudation of water and small electrolytes increasing mucus hydration as early as the first 2 hours of estrogen administration. Water, small electrolytes, and soluble proteins significantly increased during the third and fourth hours of estrogen administration, not only when compared with the unstimulated basal levels, but also when compared with the levels found during the first 2 hours of estrogen administration. No significant change occurred in mucin production, while significant changes occurred in the accumulation of proteins and small electrolytes, whether estrogen was given initially or terminally in the experiment protocol.

Sonographic evaluation of the cervix during ovulation induction

With the induction of ovulation, clomiphene citrate and human menopausal gonadotropin have the potential to stimulate the endocervical glands. We have found that the degree of mucus production can occasionally be quite large and hence is detectable by sonographic evaluation as an anechoic cervical mass. The incidence of this specific ultrasonic finding was found to be approximately 5%. This physiologic process should be differentiated from disease states affecting the cervix.

The influence of different copper wires on human sperm penetration into bovine cervical mucus, in vitro

The influence of four different copper-containing intrauterine devices (IUD) (Nova-T, Multiload, Fincoid 250 and copper-T 250) on the penetration of human sperm into bovine cervical mucus were assessed. Pooled samples of predetermined sperm concentration were suspended in Earl's medium in which a copper IUD was previously incubated for periods between one hour to fourteen days. The mean copper concentration was determined for each of the medium containing IUD and was found to be between 284 +/- 93 micrograms/100 ml to 392 +/- 138 micrograms/100ml. While there was no adverse effect on sperm motility by the copper-containing medium, there was a significant reduction in the number of sperm penetrated into the bovine cervical mucus as compared to the penetration of sperm suspended in pure Earl's medium. It therefore seems that the influence of copper on sperm penetration might be by an effect on the environment or spermatozoal migration rather than by direct effect of copper on sperm motility.

Alterations in protein, sialic acid and some enzymes in cervical mucus of female rats during NET-EN treatment

The effect of norethisterone enanthate (NET-EN) on cervical mucus protein, sialic acid and some enzymes (e.g. peroxidase, alkaline phosphatase and alpha-amylase) were studied in adult female rats. One mg NET-EN every 12 days was found to be an effective contraceptive dose of this drug in this species, acting primarily through the cervical mucus. NET-EN produced a highly significant increase in protein content and peroxidase and alkaline phosphatase activities. However, sialic acid content and amylase activity did not exhibit any definite pattern after NET-EN therapy. The increased protein content together with persistent elevated levels of peroxidase and alkaline phosphatase corroborates the hypothesis that NET-EN creates a progestogenic phase which prevents sperm penetration and thus conception.

Treatment with Norplant subdermal implants inhibits sperm penetration through cervical mucus in vitro

Attempts were made to collect several samples of cervical mucus in each of thirty-three cycles of women using NORPLANT subdermal implants, in seven cycles from NORPLANT-2 rod users, and in 33 control cycles. The attempts to collect a mucus sample were successful on 20 of 77 and 7 of 14 occasions in NORPLANT capsule and rod users, respectively, due to the scanty amount and stickiness found in the majority. All 59 attempts in control subjects were successful. The distance travelled by the fastest sperm and by the bulk of spermatozoa through the cervical mucus in vitro was assessed after 10 min of incubation with a normal semen sample. The best score for each cycle was considered for the comparison between treated and control cases. Sperm penetration was greatly impaired in mucus samples of implant users with penetration by the fastest sperm exceeding 10 mm in only two instances and exceeding 20 mm in none. In 30 of 33 control samples, the fastest sperm travelled 21 mm or more and in 28, the bulk of spermatozoa travelled further than 10 mm. Unsuccessful attempts to collect mucus and poor sperm migration were observed in NORPLANT implant users even when circulating estradiol levels were comparable to those seen in the late follicular phase of the normal menstrual cycle. These results suggest that the principal mechanism by which NORPLANT implants prevent pregnancy is by interference of sperm migration through cervical mucus.

The effect of benzalkonium chloride on ovulatory cervical mucus

Benzalkonium chloride is a potent spermicide belonging to the group of cationic detergents. Changes induced in cervical mucus have been evaluated by using scanning electron microscopy (S.E.M.).

[The intrauterine system with progesterone and synthetic progestational hormones]

Release of progesterone in the endouterine system modifies the cervical mucus and blocks proliferation of the endometrium. The mode of action is therefore hemostatic, antalgic and contraceptive. Results are excellent in these three, often combined indications.

Contraception and the cervix

In the human and subhuman primates the uterine cervix plays an important role in the reproductive process by its permissive and inhibitory action on sperm migration from the vaginal pool into the cervical canal, the uterine cavity and the fallopian tube, the site of gamete unification and fertilization. This is accomplished through physico-chemical (amount, clarity, viscosity, pH, electrolyte composition, etc.) alteration of the cervical mucus in response to the circulating sex steroids. In an ovulatory cycle, shortly prior to and at the time of ovulation the cervical mucus becomes most receptive to the spermatozoa whereas at other times, specifically following ovulation, it becomes hostile to the spermatozoa and virtually impenetrable. This unique property of the cervical mucus may, in addition to the presently available techniques (diaphragm, cervical cap and intracervical devices), allow identification of such potential contraceptive modalities as: pH modifier - changing the pH of the cervical mucus from alkaline to acid around the time of ovulation; Electrolyte modifier - changing electrolyte composition of the cervical mucus to produce a mesh impenetrable to spermatozoa. Finally, development of a temporary localized tissue-fixed immune antibody to spermatozoa in the cervical mucus is within the realm of reality and deserves the necessary attention.

Antiestrogenic effect of clomiphene citrate in a multiple follicular stimulation protocol

End-organ antiestrogenic effects of clomiphene citrate (CC) have been demonstrated in the female reproductive tract at the levels of the ovary, cervix, and endometrium. However, it has not been established whether this effect is manifested during concomitant human menopausal gonadotropin (hMG) administration, as occurs in hMG/CC stimulations of multiple follicular development. To assess this question a review was made of serum estradiol (E2) and cervical mucus in 47 hMG and 56 hMG/CC stimulations on days -2, -1, 0, and +1 relative to the day of hCG administration. E2 levels (pg/ml) were significantly lower in the hMG as compared to the hMG/CC group. However, comparing the hMG and hMG/CC groups, cervical mucus scores were significantly higher in the former. Furthermore, an analysis of covariance demonstrated that the cervical mucus scores on each day were significantly lower in the hMG/CC group (P less than 0.001). Thus, in hMG/CC stimulations for in vitro fertilization (IVF), despite the concomitant administration of pharmacologic doses of hMG, CC exerts an antiestrogenic effect on at least one end organ, cervical mucus production. Potentially, this antiestrogenic effect in IVF stimulations would be exerted at other female reproductive tract sites including the endometrium; however, its clinical significance, if any, is unclear.

Effects of norgestimate (0.250 mg) in combination with ethinyl estradiol (0.035 mg) on cervical mucus

The antifertility effect of norgestimate (Ng), 0.250 mg, in combination with ethinyl estradiol (EE), 0.035 mg, on cervical mucus was investigated. The study was conducted over two consecutive cycles: a control cycle followed by a study cycle during which medication was given. Basal body temperature, cervical mucus and karyopyknotic index of vaginal cells were evaluated during both cycles. Disappearance of cyclicity of these parameters in the study cycle as well as monophasic basal body temperature were suggestive of inhibition of ovulation caused by the combination pill. Deterioration of sperm penetration may be reflective of anovulation and a direct antifertility effect of Ng on cervical mucus.

[Parameters of ovulation in clomiphene citrate treated cycles. The effect of pre-ovulatory administration of oestrogen and human chorionic gonadotropin]

This study was undertaken to evaluate the parameters used for monitoring ovulation in patients on clomiphene citrate treatment for the induction of ovulation. The mean serum oestradiol level for every follicle larger than 17 mm on the day before ovulation was 1 885 pmol/l. This value is significantly higher than the value found in spontaneous cycles. The maximum average pre-ovulatory follicle size was 22 mm, also significantly larger than in spontaneous cycles. The maximum pre-ovulatory cervical mucus score is significantly lower than that found in spontaneous cycles. The average midluteal serum progesterone and oestradiol values were significantly higher than in spontaneous cycles. These differences should be taken into consideration in interpreting the results of patients treated with clomiphene citrate for ovulation abnormalities and before in vitro fertilization. Seven patients with a healthy cervix had poor cervical mucus scores in spite of high pre-ovulatory serum oestradiol levels; scores did not improve with administration of exogenous oestrogen, but became optimal with subsequent human menopausal gonadotrophin treatment. Poor cervical mucus despite ovulation and adequate pre-ovulatory serum oestradiol levels in patients on clomiphene treatment should therefore be considered as an indication for gonadotrophin treatment. Pre-ovulatory administration of human chorionic gonadotrophin had no effect in increasing midluteal serum progesterone and oestradiol levels.

The effects of Cyclofenil on the Cervical Mucus Score (Insler)

Daily simultaneous cervical mucus evaluation and ultrasonography of the Graafian follicular growth and ovulation were studied (in the mid-cycle) in 8 infertile British women during 30 Cyclofenil-stimulated cycles, and compared with 18 non-stimulated normal ovulatory cycles in 12 subjects (controls). In the 16 Cyclofenil-induced ovulatory cycles, there was an early (5 days prior to the day of ultrasonic ovulation) Full Cervical Mucus Score (Insler) in 69% of the cycles, and the Full Cervical Mucus Score lasted for 7 days or more in 63% of the cycles. In 38%, there was persistence of the Full Cervical Mucus Score on the third day after ultrasonic ovulation. In the 14 Cyclofenil-treated anovulatory cycles, a Full Cervical Mucus Score was recorded on one or more occasions in the mid-cycle in 29% of the cycles. The classical teaching of prediction of the probable timing of ovulation by Cervical Mucus Scoring is not applicable to Cyclofenil-stimulated cycles.

Comparison of the action of nonoxynol-9 and chlorhexidine on sperm

The effect on sperm motility of nonoxynol-9 chlorhexidine diacetate was compared in semen and cervical mucus. Both compounds had similar spermicidal potency in semen, abolishing sperm motility within 3 minutes at 0.5 mg/ml. When these compounds were allowed to diffuse into mucus, the subsequent survival of sperm in the mucus was different. Restricted penetration and loss of motility occurred rapidly after treatment with 0.1 mg/ml chlorhexidine, whereas sperm survived normally in mucus after prolonged contact with 200 mg/ml chlorhexidine. When the compounds were mixed directly with the mucus before sperm penetration was attempted, chlorhexidine still immobilized sperm, but concentrations of nonoxynol-9 that would be spermicidal in semen had no effect in mucus.