The diagnostic and therapeutic potential of the postcoital test

The development of IVF practice in Ireland: a personal view

This paper traces the development of in vitro fertilization (IVF) in the Republic of Ireland from when the first attempts at using this technique were carried out in 1985 up to the present. Clinical changes are chronicled principally using the personal work of the author and his colleagues as representative of the day. The impact of the Catholic Church and the alterations in Medical Council governance guidelines over the years as these reflect societal changes are highlighted. The potential role of other regulators including Irish case law and the EU Tissue directive are discussed as well as the almost invariable private practice nature of the services provided and the various ways in which costs have been alleviated.

What is the seminal exposition among women requiring emergency contraception? A prospective, observational comparative study

OBJECTIVES

The aim of this study is to determine the number of sperm present in the vagina of women presenting for EC after unprotected intercourse or a condom accident.

STUDY DESIGN

A total of 69 women requesting EC were included in a prospective, observational and comparative study. The absence or presence and number of spermatozoa present were examined under light microscopy in endocervical and vaginal smears. An ethinylestradiol-levonorgestrel combination (100 mcg/500 mg for two doses, 12 h apart) was then prescribed. Twenty couples were taken as controls.

RESULTS

In 25 (36.2%) of the 69 women, spermatozoa were not observed. In the women in whom sperm could be identified, there were no significant differences in the mean (range) sperm count in relation to the reason for requesting EC, i.e., 11.0 (0.03-149.8) for condom slippage or breakage, and 8.1 (3.9-55) for unprotected intercourse. In the group of controls the median (range) number of spermatozoa (32.5 (2.5-304) was significantly higher (p=0.04) than the observed in the study group.

CONCLUSIONS

In one-third of the women presenting for EC, no sperm were identified in the vagina. When sperm were present, the number was much lower than that after intercourse among women wishing to conceive. The risk of an unwanted pregnancy is probably, therefore, lower for women who present for EC compared with that for women who truly have unprotected intercourse.

Evaluation of human spermatozoa in cervical mucus: comparison of different microscopic and extraction techniques

This study was designed to describe an accurate and consistent microscopic technique for the assessment of sperm number and motility in sperm-cervical mucus samples, such as those of postcoital tests (PCTs), and to identify a suitable method to extract functional spermatozoa from cervical mucus (CM). Sperm-CM preparations containing various sperm concentrations were counted using three different microscopic illuminations. The dark field-Makler technique was compared with the more classical bright field-slide technique currently used by our clinicians. Several sperm extraction techniques were applied first to bovine (BCM) and then to human (HCM) cervical mucus. Dark field microscopic illumination provided accurate, fast, and easy sperm identification. Counting variability was significantly greater with bright field-slide than with dard field-Makler, while sperm motility was always higher with this latter methodology. A high degree of agreement (intraclass correlation coefficient = 0.965) among three raters, i.e., low interobserver variability, was obtained only with dark field-Makler. Extraction procedures based on "swim-out," Percoll, trypsin, an enzyme cocktail, and mercaptoethanol resulted in small sperm yields in BCM. Mercaptoethanol and trypsin also showed poor sperm recovery in HCM. Among the protocols with the largest yields, the mechanical technique had the largest amount of residual CM, and bromelain reduced sperm motility. The extraction with dithiothreitol (DTT) showed the best results with a mean sperm recovery of 76% and enhanced sperm motility. Sperm viability as well as spontaneous and induced acrosome reaction were conserved in all techniques. In conclusion, use of the dark field-Makler counting technique in combination with DTT extraction of spermatozoa from CM samples, such as those of PCTs, would allow accurate and functional assessment of spermatozoa for preliminary contraceptive efficacy or infertility evaluation.

Therapeutic cup insemination with cryopreserved donor sperm: prognostic value of cervical mucus score at insemination and the number of motile sperm in mucus at 24 hours

OBJECTIVE

To examine the prognostic value of cervical mucus score at insemination and the number of motile sperm in mucus 24 hours after therapeutic cup insemination with cryopreserved donor sperm.

DESIGN

Retrospective analysis.

SETTING

Academic tertiary medical center.

PATIENTS

One hundred thirty-eight women with confirmed bilateral tubal patency who received therapeutic cup inseminations with cryopreserved donor sperm between 1986 and 1993.

INTERVENTIONS

All insemination cycles were monitored with serial daily urinary LH determinations with a single (n = 312) insemination or two inseminations (n = 212) performed on and/or 1 day after the day of LH surge detection. A single examiner assigned cervical mucus scores in all insemination cycles and recorded the number of motile sperm in mucus 24 hours after the first insemination in dual insemination cycles.

MAIN OUTCOME MEASURE

Pregnancy rate during various cervical mucus and motile sperm scores.

RESULTS

Ninety-one women conceived (66%) and seven of these achieved two pregnancies. The overall pregnancy rate per insemination cycle was 18.7%. Age and day of insemination were the only variables identified as having significant influence on cycle outcome. Pregnancy occurred with decreasing frequency as patient age increased and was nearly twice as likely after insemination on the day after the urinary LH surge as on the day of surge detection.

CONCLUSIONS

Insemination the day after the urinary LH surge is superior to the day of surge detection. Cervical mucus score and the number of motile sperm in mucus 24 hours after therapeutic cup insemination with cryopreserved donor sperm do not correlate with cycle outcome.

European postcoital tests: opinions and practice

OBJECTIVE

To assess differences in opinion and practice with regard to the postcoital test in Europe.

DESIGN

Multilingual questionnaire survey among heads of departments of obstetrics and gynaecology with large fertility clinics in 16 European countries.

SUBJECTS

Of 203 heads of departments, each responsible for 882 infertility cases per year (95% CI 657-1107) 145 (71%) responded. INFORMATION SOUGHT: Use of the postcoital test: its timing in relation to cycle and coitus, methodology used for the test, cut-off level of normality and treatments applied for abnormal test results.

RESULTS

The postcoital test is used in 92% (and routinely in 68%) of departments. There are large differences in timing of the test in relation to menstrual cycle and coitus, in microscopic magnification used, and in cut-off levels of normality. More than 10 different treatments are applied for abnormal test results.

CONCLUSION

Guidelines of the World Health Organisation are not followed and divergence in practice and opinion is wide enough to question whether infertile couples are better off with than without the test.

Evaluation of bovine cervical mucus penetration as a test of human spermatozoal function for an in vitro fertilization programme

Thirty-two couples participating in an in vitro fertilization (IVF) programme were evaluated as regards the prognostic value on fertilization of spermatozoal performance through flat capillary tubes filled with standardized midcycle bovine cervical mucus (Penetrak, Serono Diagnostics, Surrey, UK). A statistically significant correlation (P < 0.033) was observed between the distance travelled by the neat spermatozoa in the mucus and the % penetration of oocytes at IVF. There were also significant correlations between motility and progression (P < 0.004) and a borderline correlation between progression and the Penetrak results (P < 0.098). There was no significant difference between the Penetrak distances travelled between the 9 who conceived (33.4 mm) and the 23 who did not (29.9 mm). While the test does add to the knowledge of fertilization potential, the results extrapolated to a larger series would give false positive rates of 25% and false negative rates of 11%. The absence of a clear end point renders the Penetrak mucus penetration test insufficiently accurate to be used as a main measure of the male factor when advising for or against IVF therapy.

The effects of female sexual response in coitus on early reproductive processes

Research has shown that infertility and its medical investigation are stressful for couples and have adverse effects on sexual functioning. The purpose of this study was to examine how female sexual functioning could influence aspects of the reproductive process. This question was examined within the context of the postcoital test (PCT) routinely performed during the infertility investigation. The sample consisted of 85 women with a mean age of 30 years (SD = 3.8 years) and a mean infertile period of 2.5 years (SD = 1.1 years). Prior to the physiological examination, women completed a battery of questionnaires about their sexual functioning during the scheduled encounter engaged in for purposes of the PCT and during other nonscheduled encounters. The results indicated that the PCT contributed to deterioration in female sexual functioning, and in turn, a poor sexual response was associated with poorer physiological results. The implications of sexual behavior influencing physiohormonal reproductive factors are discussed.

Postcoital test: which form of spermatozoal motility is associated with a good fertility outcome?

The objectives of this study were to examine the predictive value of the PCT in relation to treatment-independent conception rates, to determine which cutoff point best predicted fertility outcome, and which form of spermatozoal motility on PCT is most significantly related to fertility outcome. A prospective study was undertaken of couples referred for the investigation of "unexplained" infertility. One hundred and twenty six couples were recruited between July 1984 and April 1986. On further investigation female infertility factors were identified in 32 (25%) of couples, who were therefore excluded from the study. All conceptions were treatment independent. The relationship between the result of the postcoital test and the chance of conception was studied using a modification of Cox's regression model of life table analysis. The mean length of involuntary infertility prior to referral was 75 months (range = 18-192, SD = 39.2). The mean length of follow-up was 18 months (range = 1-34, SD = 8.4). A 98% follow-up rate was achieved. Eighteen women conceived, giving a 32-month treatment-independent conception rate of 22%. A cutoff point of one spermatozoon exhibiting sluggish motility per HPF was the most effective method of classifying the results of the postcoital test (X2(1) = 4.28, P = 0.037, RR = 4.7. This would suggest that the most efficient form of spermatozoal motion in cervical mucus is slow or sluggish motility.

The validity of the postcoital test

Opinion is divided on the clinical usefulness of the postcoital (Sims-Huhner) test in diagnosing infertility. To evaluate the validity of this test, we reviewed the world's literature in English and calculated four indexes of validity for each study with sufficient information. The sensitivity of the test ranged from 0.09 to 0.71, specificity from 0.62 to 1.00, predictive value of abnormal from 0.56 to 1.00, and predictive value of normal from 0.25 to 0.75. In addition to the problem of poor validity, the test suffers from a lack of standard methodology, lack of a uniform definition of normal, and unknown reproducibility. The postcoital test lacks validity as a test for infertility.

Human in vitro fertilization in couples with unexplained infertility and a poor postcoital test

The results of in vitro fertilization (IVF) with the husband's semen were compared in 3 groups of fully investigated infertile couples. In those with tubal infertility (n = 43) 194 out of 273 (71.1%) oocytes were fertilized, at least 1 oocyte being fertilized in 42 of the 43 couples (97%). In couples with unexplained infertility and a 'good' postcoital test (PCT) (n = 9), 39 out of 64 (61.5%) oocytes were fertilized in 8 of the 9 (88%) couples. In couples with unexplained infertility and a 'poor positive' PCT despite normal semen analysis, 16 out of 44 (36.3%) oocytes were fertilized in 5 of the 6 (83%) couples. These results show a good correlation between in vivo sperm penetration of cervical mucus and human IVF in couples with unexplained infertility.

Application of a bovine cervical mucus penetration test

One hundred seventy-eight ejaculates obtained from infertility patients were evaluated by routine semen analysis and by a bovine cervical mucus penetration test (BCMPT). A significant correlation (p less than 0.01) was observed between mucus penetration and both sperm count (r = 0.349) and sperm motility (r = 0.394). One hundred fifty-two of 178 patients (85%) had normal sperm counts (greater than 20 x 10(6)/ml). Of these patients, 68% had good (greater than 30 mm), 26% had questionable (21-30 mm), and 7% had abnormal (less than 20 mm) penetration values. One hundred sixty-one of 178 patients (90%) had normal sperm motilities (greater than 40%). Of these patients, 71% had good, 25% had questionable, and 4% had abnormal penetration values. Conversely, 46% and 18% of patients with abnormal sperm count and motility, respectively, had normal penetration values (greater than 30 mm). A significant relationship (p less than 0.05) was observed between the BCMPT and pregnancy problems not apparent by semen analysis data, and may prove to be a useful adjunct to the use of routine semen analysis in evaluating male fertility.

Human sperm velocity and postinsemination cervical mucus test in the evaluation of the infertile couple

Homologous artificial insemination (AIH) followed by postinsemination cervical mucus test (PIT) was performed in 100 couples in a prospective study to evaluate suspected cervical or male factor infertility. A portion of the ejaculate was submitted for standard semen analysis as well as turbidimetric analysis of sperm velocity. In a review of 333 cases evaluated for infertility, the average sperm velocity in a normal semen analysis was 96.5 mu/sec, for those with normal postcoital test (PCT) 96.6 mu/sec, and in those that established a pregnancy 91.6 mu/sec. These are significantly higher than the values obtained for abnormal semen analysis and abnormal PCT (64.6 and 63.6 mu/sec, respectively; p less than 0.001). Patients with normal PIT (WHO criteria for normal PCT consisting of greater than or equal to 7 motile sperm/hpf) had sperm velocity of 87 mu/sec compared to velocities of 46 mu/sec for abnormal PIT (p less than 0.001). Four of the five patients with abnormal PIT (in spite of normal semen analysis and normal cervical mucus) had sperm velocities less than 75 mu/sec. Likewise, all 8 patients who had normal PIT in spite of abnormal semen analysis had sperm velocities greater than 75 mu/sec, even though the sperm motility was below normal in 5 of them. Sperm velocity is a more sensitive indicator of sperm function when compared to standard semen analysis results.

Prognostic value of the postcoital test: prospective study based on time-specific conception rates

Time-specific conception rates were studied prospectively after a carefully validated post-coital test (PCT) in a consecutive series of 80 ovulatory women without any pelvic or seminal cause for their previous infertility. The PCT was performed on endocervical mucus collected 6-18 h after intercourse. The definition of a negative result, indicated by the absence of forward-moving sperm, depended on the finding being repeated in a second cycle and on the presence each time of fully developed mucus, indicated simply by its abundance, ductility and clarity. The time to conception was inversely related to the number of motile sperm seen. Simpler analysis showed a fivefold greater chance of conception associated with a positive compared with a negative PCT; after 2 years the cumulative conception rates were 84 and 16% respectively.