Cumulative pregnancy rates in patients with apparently normal fertility and fertility-focused intercourse

Fifty consecutive clients achieved pregnancy using a standardization modification of the Billings ovulation method (the Creighton Model Natural Family Planning System). Of 50 clients followed, 38 (76%) achieved pregnancy in the first cycle of fertility-focused intercourse, 45 of 50 (90%) achieved pregnancy by the third cycle and 49 of 50 achieved pregnancy by the sixth cycle (98%).

[Use-effectiveness of natural family planning by ovulation method]

Cervical mucus (CM) peak and plasma LH surge were examined in 19 women. The consistency of the CM peak and ovulation after the plasma LH surge demonstrated that as an indicator of natural family planning (NFP), the CM can scientifically predict the occurrence of ovulation. Based on these results, 300 healthy women were recruited into this study by self examination of CM. A total of 3,393 cycles was observed. There were 29 pregnancies reported, and the continuation rate was 90.3/100 women year. It showed that the NFP is an acceptable, safe and effective birth control method for Chinese women.

Routine hormone load tests are unnecessary in infertile men

A sample of 225 men examined at the Infertility Service Unit of this hospital had spermiograms, standardized in accordance with WHO guide lines, and a hormone stimulation test with injection of gonadotropin releasing hormone, thyrotropin releasing hormone, and ACTH. The serum concentrations of the following hormones were assessed: follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, oestradiol (E), thyroid stimulating hormone, cortisol, 21-desoxycortisol, 17-hydroxypregnenolone, 17-hydroxyprogesterone, dehydroepiandrosterone, dehydroepiandrosteronesulphate, androstenedione, testosterone (T), and dihydrotestosterone. The results of the spermiograms were found to be related to the concentrations of the following hormones: FSH, LH, T, and E. Thyroid and adrenal function in men without signs of endocrinological diseases failed to influence spermatic parameters.

Correlation of cervicovaginal fluid volume with serum estradiol levels and total follicular volume during human gonadotropin stimulation

During the normal menstrual cycle the volume of cervicovaginal fluid (CVF), as determined by the patient at home using a simple volumetric aspirating pipette, increases significantly over several days prior to the luteinizing hormone (LH) surge and decreases characteristically shortly after ovulation. The present study was undertaken to test the hypothesis that self-determined measurements of CVF volume would correlate positively with serum estradiol (E2) levels and with total follicular volume (TFV) in cycles stimulated with exogenous gonadotropins. Consequently, 20 infertility patients, undergoing human menopausal gonadotropin (hMG)-stimulated cycles, were asked to measure daily CVF. Routine serum E2 determinations and vaginal follicular ultrasound studies were performed up to and including the day of human chorionic gonadotropin (hCG) administration (designated day 0). The mean daily CVF volume (+/- SD) increased from 0.1 +/- 0.01 ml on day -6 to 0.7 +/- 0.40 ml on day -1 and then decreased to 0.6 +/- 0.40 ml on day 0. On day 0, 7 of 20 cycles (35%) demonstrated a decrease in CVF, which ranged from 0.1 to 1.0 ml (mean, 0.42 ml). The mean daily CVF correlated positively (correlation coefficient = r) with the mean daily serum E2 (r = 0.89) and with the mean daily TFV (r = 0.88). The mean daily correlation of TFV for E2 was r = 0.98. The correlation between CVF and E2 of individuals ranged from r = 0.38 to r = 0.99 and the correlation between CVF and TFV ranged from r = 0.12 to r = 1.0, while the individual correlations of E2 to TFV ranged from r = 0.60 to r = 0.99.(ABSTRACT TRUNCATED AT 250 WORDS)

Anisotropic crystalline microstructures in dendritic arborizations of dried mid-cycle cervical mucus: surface morphology and crystallographic study

Studies using scanning electron microscopic techniques permitted characterization of the nature and structure of the anisotropic elements present in dried preparations of mid-cycle cervical mucus. Sodium and potassium sulphates were located in the dehydrated matrix either isolated or bound to the dendrites. Depending on crystallization conditions, they appeared as well-formed individual crystals or as spherulites.

The predictive value of zona-free hamster egg sperm penetration assay for failure of human in vitro fertilization and subsequent successful zona drilling

The value of various sperm parameters and the zona-free hamster egg sperm penetration assay (SPA) in predicting human in vitro fertilization (IVF) failure and subsequent successful fertilization with zona drilling was assessed. In 19 couples, throughout 31 IVF cycles, a total of 153 oocytes failed to be fertilized. In subsequent 12 cycles with zona drilling, 33 of 131 (25%) were fertilized. The incidence of teratospermia and asthenospermia was significantly higher in the study group than in the control, 74% versus 32% and 42% versus 5%, respectively. Although the mean values for the performance of sperm in SPA and fertilization of human eggs after zona drilling were remarkably similar (28 +/- 6 versus 28 +/- 4), there was no correlation between individual parameters (r = 0.15). Thus, whereas male factor infertility is more likely to be associated with teratoasthenospermia, neither the SPA nor other sperm parameters have any predictive value for failure in IVF. In addition, no criterion of sperm function has yet been identified that would eliminate oligoteratoasthenozoospermic males from consideration of IVF with zona drilling.

Circulating antisperm antibodies and fertility prognosis: a prospective study

In a prospective study performed on 235 couples with long-standing infertility (median 5 years), circulating antisperm antibodies (ASA) were determined with both a standard trayagglutination test (TAT) and a radioimmunoassay (RIA). Serum levels were correlated with results of sperm analysis (SA), postcoital testing (PCT) and in-vitro sperm--cervical mucus penetration testing (SCMPT), performed with cervical mucus and spermatozoa of patients and in parallel with material of fertile donors. A simultaneous microbial screening included Chlamydia trachomatis, mycoplasmas, Herpes simplex virus, gonococci, other potentially pathogenic aerobic and anaerobic bacteria and yeasts. The pregnancy rate 12 months after determination of ASA in the serum samples was 27% (64/235). Between ASA-positive and -negative male and/or female patients (TAT as well as RIA), no significant difference was found for any of the tested variables of SA, PCT, crossed SCMPT and colonization of genital secretions with microorganisms. Patients who later achieved pregnancy and those who did not did not differ with regard to serum antibody status (TAT as well as RIA). The findings suggest that the clinical significance of circulating ASA determined with the currently available methods is low. ASA in serum samples of infertile female and/or male patients do not influence the fertility prognosis.

The hypo-osmotic swelling test and the sperm mucus penetration test in determining fertilization of the human oocyte

The usefulness of the hypo-osmotic swelling (HOS) test and the sperm mucus penetration (SMP) test as sperm function tests for in-vitro fertilization was analysed in 56 couples. Using logistic regression analysis only the SMP test was independently related to fertilization (P = 0.004), no false negative results were obtained, i.e. no fertilization if sperm from the ejaculate failed to penetrate mucus. The HOS test was of no predictive value. The results justify a further examination of the SMP test in other IVF centres.

[Intrauterine insemination with "washed" sperm]

The authors have been performing intrauterine insemination with the washed sperm of the husband since 1986. Previous to the intervention husband and wife went through a very thorough infertility examination according to the principles of the WHO. The cycle of women given intrauterine insemination was monitored. The maximum value of estradiol was measured on the 12th and 13th day of the cycle and the maximum mean value of the follicles on the 13th-14th day. In cases of ovulation the mean value of serum progesterone was found to rise on the 14th-15th day of the cycle. The semen was washed and concentrated, different protein components and bacteria were eliminated and the fraction with good motility was used for insemination. Intrauterine insemination with washed human sperm was carried out with 2 groups of patients. In the series studied the authors induced with intrauterine insemination 24 pregnancies in 100 infertile marriages. Intrauterine insemination was found to be successful if the infertility was caused by the hostility or poor quality of the cervix mucus. The treatment may be successful also in cases with slighter alteration of the spermiogram, whereas no results can be expected from intrauterine insemination with spermiograms displaying more serious alteration.

Interobserver variation in estimation of day of conception intercourse using selected natural family planning charts

In order to study outcome of pregnancy related to timing of conception it is necessary to have both markers of ovulation and records of intercourse. Natural family planning (NFP) charts where the woman records basal body temperature (BBT) and mucus signs are ideal for this purpose. Much work has been done relating timing of BBT and mucus signs to ovulation, but very little work has been done to examine interobserver agreement on the interpretation of these signs. Four NFP experts examined 28 NFP pregnancy charts to determine the BBT rise, the mucus peak, and two most likely days of conception intercourse. The charts were selected because they provided difficulties in interpretation. The reviewers were able to agree on the most probable day of conception intercourse in 96.4% of cases, on the mucus peak in 74.1% of cases, and on the interval between the most probable conception intercourse and mucus peak in 70.4% of cases. There was poor agreement on the first day of the BBT rise (38.5%). The authors conclude that in selected difficult NFP charts, the mucus peak is a more valid indirect measure of ovulation both because it is subject to less interobserver variation and because it more closely approximates the timing of ovulation.

Improved penetration of spermatozoa into uterine fluids of women with abnormal postcoital tests

Cervical mucus-uterine fluid cross-penetration of husbands' and control sperm was assessed in 13 couples with poor or negative postcoital tests. Cervical mucus scoring and tray agglutination test identified six women with sperm-agglutinating antibodies and seven women with cervical dysmucorrhea. All males were normozoospermic, with penetration into control cervical mucus and control uterine fluids. Control sperm penetrated into cervical mucus and uterine fluids of three and five of the women with sperm-agglutinating antibodies and cervical dysmucorrhea, respectively. Penetration of husbands' spermatozoa into uterine fluids of patients with sperm-agglutinating antibodies was lower than that of control semen (P less than .05). Control and husbands' sperm penetration into uterine fluids of women with cervical dysmucorrhea were identical. In both groups, husbands' and control sperm penetrated uterine fluids more frequently than cervical mucus (75 versus 12%; P less than .001). On a six-month follow-up and midcycle intrauterine inseminations, six patients (46%) conceived. We conclude that uterine fluids of patients with sperm-agglutinating antibodies and cervical dysmucorrhea may provide a better milieu for spermatozoa than cervical mucus. This observation suggests a rationale for intrauterine inseminations to achieve pregnancy.

Physicians' views of periodic abstinence methods: a study in four countries

A study of the knowledge, perceptions, and behavioral intentions of physicians regarding periodic abstinence (PA) methods was undertaken in Mauritius, Peru, the Philippines, and Sri Lanka. Most respondents considered PA to be useful, although even the PA providers prescribed mainly non-PA methods. Detailed knowledge of PA methods was not evident, but most physicians were willing to initiate general discussion about PA with patients. Physicians favored methods perceived as "scientific" and "modern," which primarily prevent pregnancy and secondarily avoid other health risks. When carefully presented as "scientific" and "modern," methods presented to medical audiences may find acceptance and be more likely to result in referral.

Direct intraperitoneal insemination (DIPI) for the treatment of refractory infertility unrelated to female organic pelvic disease

344 couples with infertility unrelated to female organic pelvic disease underwent Direct Intraperitoneal Insemination (DIPI) for a total of a 429 DIPI cycles. Pregnancy per couple was 16.5% and per DIPI cycle 13.2%. DIPI was particularly effective in cases of infertility due to cervical mucus insufficiency and unexplained infertility with results respectively of 33.7% and 30.4% per couple and 30.7% and 28.7% per DIPI cycle. On the contrary, the results regarding male subfertility were 12.5% per couple and 10.5% per DIPI cycle. A significant difference was found (X2 A = 16.48, p less than 0.001) between these results and those of the group composed of cases of cervical mucus insufficiency and unexplained infertility. In cases of antisperm iso- and autoimmunization the results were on the whole poor, and were in any case influenced by corticosteroid pretreatment. The Pellet Swim-up Test (PST) proved to be a good prognostic sign for success of DIPI, since a significant difference was found between the PST group greater than or equal to 1.5 X 10(6)/ml (pregnancy per couple was 19.7% and per DIPI cycle 17.2%) and PST group less than 1.5 X 10(6)/ml (pregnancy per couple was 6.8% and per DIPI cycle was 4.5%) (X2 = 11.4. P less than 0.001).

Intrauterine insemination

Fifty-six couples with infertility due either to subnormal sperm (n = 40), hostile cervical mucus (n = 5) or idiopathic infertility (n = 11), were treated with intrauterine insemination of washed sperm. A total of 78 treatment cycles were completed. Nine pregnancies resulted from these insemination cycles, giving an overall pregnancy rate of 8.3% per treatment cycle. Eight pregnancies occurred in the andrologic group after 56 treatment cycles. One pregnancy was established in the patient group with idiopathic infertility after 15 treatment cycles, while no pregnancy occurred in the patient group with infertility due to cervical mucus hostility. The mean number of years of infertility in the couples conceiving following treatment was 7 years (range 3-11). The spontaneous pregnancy rate in this patient group is low. The data obtained in this study suggest that in selected patients intrauterine insemination will result in an acceptable pregnancy rate. There is a need for a randomized prospective study designed to compare the efficacy of intrauterine insemination with that of alternative treatment modalities.

The immunobead technique: an indicator of disturbed sperm cervical mucus interaction

A group of 20 couples with repeatedly poor post coital tests (PCT's) where no coital disorders or cervical mucus abnormalities were present, were included in the study. The results of the Direct Immunobead (IB) and Tray-agglutination tests were compared with the results of the sperm-cervical-mucus-contact (SCMC) and post coital tests (PCT's) of each couple in order to determine the sensitivity, specificity and predictive value of the Direct IBT as a screening test for sperm antibodies. The positive predictive value of the IBT was 80%. It was also clear that a strong positive SCMC-T result correlated with agglutinating antibodies in the semen or seminal plasma. In conclusion, the IBT is a sensitive, specific and predictable test for sperm antibodies.

Identification and management of clomiphene citrate responses

Clomiphene citrate (CC) is widely used for induction of ovulation; however, adequate time is rarely used to monitor patients on this form of therapy. Two hundred thirty-one infertility patients qualified for this study in 1155 cycles, during which basal body temperature charts were kept and the quality of cervical mucus was evaluated. Nine types of responses were classified: three ovulatory (O1, O2, O3), three anovulatory (A1, A2, A3), and three miscellaneous (M1, M2, M3). The overall, uncorrected pregnancy rate was 54.9%, and 79.2% showed ovulatory responses. The most common response was O1 (normal responses, 38.5%) with the highest pregnancy rates (92.1%). Poor estrogenic response with poor cervical mucus (CM) (O2) was fairly common (13.4%) and had poor pregnancy rates, even with the addition of estrogens (12.9%). It is suggested that this new classification of CC responses will help to identify and more efficiently manage patients undergoing this form of therapy.

The sperm-mucus interface: patterns of disorder in the diagnosis of specific causes of penetration failure causing infertility

In 94 infertile couples with negative postcoital tests (PCTs) the results of an in-vitro sperm-mucus invasion test (SMIT) were compared with seminal analysis (excluding sperm density less than 1 x 10(6)/ml) and agglutination assays for antisperm antibodies in semen (MAR, TAT) and in mucus (TAT). Abnormalities at the sperm-mucus interface were classed into three types. (i) Failure to form semen clefts and of spermatozoa to colonize the clefts was closely correlated with oligo-asthenoteratozoospermia, and vice versa, the two tests agreeing in 90% of cases (P less than 0.001). Most of the discrepancies, in which sperm-dense clefts developed despite low sperm counts, were due to antisperm antibodies in semen. (ii) Failure of spermatozoa to invade mucus, despite normal sperm colonization of clefts, was closely correlated with the presence of antisperm antibodies in semen (positive MAR or TAT), and vice versa, the tests agreeing in 81% of cases (P less than 0.001). (iii) Failure of sperm survival after normal invasion of mucus could not be correlated significantly with the TAT results on mucus, but more extensive study of this question is needed. Finally a normal SMIT result was associated with a significantly improved chance of conception (39 versus 10% at 12 months), particularly with artificial insemination, suggesting undisclosed coital failure as the cause of the negative PCT. In conclusion, the invasion test, when assessed in the foregoing detail, offers a reliable and simple substitute for laboratory assessment of both seminal quality and the presence of antisperm antibodies in semen, and would be applicable in general infertility practice everywhere.

The diagnosis of male infertility--prospective time-specific study of conception rates related to seminal analysis and post-coital sperm-mucus penetration and survival in otherwise unexplained infertility

Infertile women without any inherent female infertility factors and able to secrete normal cervical mucus were studied prospectively in relation to post-coital sperm-mucus penetration (PCT) and their partner's seminal analysis, excluding men with azoospermia. Time-specific cumulative conception rates calculated as for life-table analysis were related to each measured seminal variable on routine analysis of 2-3 samples (volume, density, proportion with progressive motility, and proportion with normal morphology); to various derivatives from combinations of these variables; to seminal findings after vital staining; and to the PCT results. The best seminal predictor of fertility was the motile normal sperm density (MNSD), the 18 month conception rates being 57.4% +/- 4.6 (SE) and 30.2% +/- 5.9 (ratio 1.9, P less than 0.001) above and below a derived threshold value of 4 x 10(6)/ml. The PCT led to rates of 55.6% +/- 4.3 and 14.9% +/- 5.1 (ratio 3.73, P less than 0.001) for positive and negative results, respectively. The PCT also gave rise to a significantly distinct intermediate poor-positive sub-group (conception rate 30.6% +/- 9.0). Seminal analysis (the MNSD) did not affect the conception rate associated with a positive PCT but helped to discriminate further with a negative PCT (conception rates 22.5% +/- 8.7 with an MNSD above 4 x 10(6)/ml versus 5.6% +/- 4.8 below, P less than 0.05). The PCT was the single best predictor of fertility but seminal analysis (the MNSD) was of additional value after a negative PCT.

Superovulation with intrauterine insemination in the treatment of infertility: a possible alternative to gamete intrafallopian transfer and in vitro fertilization

In vitro fertilization and embryo transfer (IVF-ET) and gamete intrafallopian transfer (GIFT) are used to treat intractable infertility in women with no distortion of the pelvic viscera, despite the lack of controlled trials demonstrating efficacy. The mechanism of any purportedly enhanced cycle fecundity in ovulatory women without significant distortion of the pelvic viscera is unclear, but both GIFT and IVF-ET increase the number of male and female gametes at the site of fertilization. Intrauterine insemination (IUI) during human menopausal gonadotropin (hMG)-stimulated superovulatory cycles has similar potential but does not require oocyte retrieval. To evaluate the possibility that simply increasing the number of gametes at the site of fertilization might account for pregnancies attributed to IVF-ET and GIFT, the authors retrospectively analyzed the outcome of couples undergoing IUI during hMG cycles between 1983 and 1986 in women with normal pelvic anatomy. IUI during hMG-stimulated cycles yielded a cycle fecundity (f) of 0.17 for endometriosis, 0.29 for cervical factor, and 0.19 for idiopathic infertility, which approaches the fecundity of normal women and equals or exceeds that reported for IVF-ET and GIFT. The authors conclude that treatment with IUI in hMG cycles, alleviating the need for invasive oocyte retrieval, should be considered for inclusion in a randomized, controlled trial in comparison with IVF-ET and GIFT.

The association between smoking and female infertility as influenced by cause of the infertility

Smoking histories were compared in 901 women with infertility of different types and 1264 women admitted for delivery at seven collaborating hospitals. The relative risk for infertility associated with cigarette smoking prior to the infertility diagnosis for nulliparous cases or first live birth for controls was calculated using a multivariate logistic-regression model to control for potential confounding factors, including center, age, religion, education, number of sexual partners, and contraceptive use. The adjusted risk for infertility attributed primarily to cervical factor (n = 96) was 1.7 (P = 0.04), to tubal disease unrelated to endometriosis (n = 225) was 1.6 (P = 0.009), to ovulatory factor (n = 389) was 1.0 (not significant [NS]), and to endometriosis (n = 191) was 0.9 (NS). The authors conclude that cigarette smoking is significantly associated only with certain types of primary female infertility.

The value of artificial insemination with husband's semen in infertility due to failure of postcoital sperm-mucus penetration--controlled trial of treatment

Artificial insemination with husband's semen into the cervical canal and uterine cavity (high AIH) was assessed by a randomized controlled prospective study in 46 couples whose infertility was due to failure of sperm mucus penetration, as defined by negative postcoital tests, after excluding all interfering female factors and men with sperm density less than 1 x 10(6)/ml. Seminal analysis was abnormal in 18 of the 46 men and sperm antibodies in semen were detected in 19 of the remaining 28 with normal seminal analysis. Overall, the cumulative conception rate after 6 months with AIH was 4.7 (SE 3.8)% and without treatment was 6.6 (SE 3.9)%. The results were unaffected by the findings on seminal analysis or by the presence or absence of sperm antibodies in semen. AIH appeared to be of no benefit.