A United States Army Medical Department
continuing education program.
The 24th Annual Armed Forces Seminar on
Obstetrics and Gynecology.
Postcoital test cervical factor
with Val David John M.D.
Associate professor section of
reproductive biology.
Los Angeles County University of Southern
California Medical Center.
First of all,
just a quick one minute physiological
review.
The cervical mucus admit cycle takes these
big molecules of glycoprotein,
links them up and there's a,
what we need here is calcium.
It's a dye sulfate bond and so on and
forms my seller structures
long strands of cervical mucus under
the influence of estrogen at mid cycle
C is the key and sperm transport next
and this is a schematic.
This is what it looks like you get to my cell and then the
whole unit is called the rod.
And each crept.
It's not a true gland.
Each crept secretes a long strand of
this mucus,
glycoprotein
aggregate the distance between them
3 to 10 microns.
Perfect for the sperm head to fit through.
It's a filter.
There's probably nutritional
necessities in here.
It's like a service station.
It's a depot for picking up storing
spermatozoa and releasing sperm up into
the upper general track and not your power steen
talks about sperm transport and so on.
But this is the gateway to
happiness.
You know,
he just talks about that tunnel.
But without the cervix,
he's not gonna have any sperm up there.
So we decided to spend a lot of time.
We spent about four years now on the on the basic
biochemistry and biophysics of cervical mucus.
We're about ready to write up the whole
series.
And because I think we've done just about all we can
do on the physiology of the cervix at mid
cycle Next the alignment
is real.
If you look,
if you do a lot of postcoital test and if you stretch the mucus
out a little bit on a slide,
you'll notice that sperm seem to follow each
other in either direction.
This is not just a one
slide used for to show off or to
talk make a point.
But this is very very common thing to see on the field.
If you stretch the mucus out oriented in a linear
fashion,
you'll see the sperm going in the same direction.
This is a wet man.
Next slide now the
same type of mucus
stretched out like this and
allowed to dry under the cover slip will never
firm.
This is good cervical mucus under the cover slip.
If you come back and look at your post coital test a
week,
two weeks later and allow that time for it to dry
the crystallization process under a cover
slip because it's a slow process does not
allow for the classical firm.
But we'll show you the crystallization in the same linear
fashion that I'm talking about.
These are the channels represented by the
crystallization process at mid cycle.
Next slide,
here's the classical furniture is the same cervical mucus,
one dried without cover slip,
One dried under the cover slip.
So it's a biophysical evaluation of
whether you do have channels.
If you just drive the slide,
come back two weeks later a week later and take a look
and see if you have channel formation
and the under the alluvial influence,
under progesterone influence instead of a linear
alignment,
you get filament formation next slide and if you drive
that stretch it out,
you don't get the channel formation.
If you stretch,
that's the same patient,
middle initial phase,
stretch the mucus out and you get this kind of a
spongy appearance to the crystallization process.
Next slide and look so many patients are going to
have that at mid cycle abnormal cervical mucus
factor as far as alignment goes,
this is the semen.
I I use 20 this is dr Bernstein slide
and dr Power stein talked about that.
Anything over 20 we call that normal.
I just put this up because the question always comes up and you'll
see this figure here and 20 million.
Show up in my work up of the cervical factor.
These are are low normals.
We want something no less than this to
call it A and change that to 20
million.
No less than that to call it the normal semen
analysis Next now
I do the postcoital test prior to the
BBT elevation and you have to predict it
obviously.
And I like to put the patients on what I call a
mini B.
B.
T.
I don't like that.
Uh I don't like to put patients on temperatures throughout the
month for many cycles.
But when I'm working up working up the cervical factor I
like the Mid cycle
recorded.
For me.
It's very helpful to know where you are in the cycle.
So about a 56 day temperature
Right in the middle of the month is very helpful in evaluating
whether you're doing the test at the right time or not.
If this was day 14,
I'd wanted to do the test on day
1213 at the latest.
11.
And those 34 days are the key days
11 12 13.
If the if the temperature is going to rise on day
14.
So that's when we do the test.
We decided to do the test at a two hour interval
and dr treadway,
commander treadway here got a PhD in sperm
transport.
He told us that he's the only guy in the
world to do that.
You know.
Uh He found that 2.5
hours is optimum.
And fortunately he agreed with what we had already published
since he got his PhD in our department,
the two hour postcoital test.
And we don't have time to get into the validity of that or
the overnight test.
I think that you ought to do the test at
the optimum time when the sperm are getting into
the maximum number of sperm in the cervical canal.
How do I collect it?
The reason I collected the way I collected it is
because as a resident I was collecting it with
syringes with glass tubing and half the time I was losing my
specimen and lying to the patient and
telling her to come back next month because the test
wasn't any good.
The reason wasn't any good.
It was on my lab coat next
line I
decided to use a clear plastic catheter.
These are N.
G.
Suction catheters you can steal in the hospital.
They come between eight and 14 or 16 in
size.
So customize the size to your patients external
cervical lost diameter just by eyeballing it.
You can pick out the right size catheter
and that's just a schematic uh
presentation of it.
Next slide,
here's the catheter.
I use a this is a a traumatic
cervical 10 Acura TLX makes
and by by
actually gripping a solid
table or something and clicking down to the
ratchet,
you loosen it so that when you click the first ratchet
here,
the actual grip doesn't close all the way and acts as a
trap and also as a holder for your
plastic catheter.
I leave a 2.5 centimeter
segments sticking out.
That's the usual length of the cervical canal and then I
bevel it a little bit to be able to slip it into the canal
very gently.
Now the way to collect it is just as you slip
the tip of this catheter into the external
loss.
You begin slow suction
back and you'll see a column of mucus move right back here a
solid column and usually with a she has any mucus with
very few bubbles in it and you have to
take my word for it.
This portion of the mucus collection will represent
most of the external cervical mucus because it's a
semi solid,
there's not that much mixing and the tip
of that catheter will represent the internal
cervical mucus.
Next line then you can take with the
scissors and cut right.
You can see the mucus in there,
it sticks into the catheter and you
can cut it right across.
I should make one other point for those who have not collected it back
up slide again.
The reason I have the scissors here is just as you
clear the cervix.
When you go all the way up to the 2.5 centimeters and click
down all the way on the ratchet.
Then you slowly withdraw your catheter and you have your column of
mucus in there,
you have to reach in and cut the trailing mucus.
There's some always leftover behind,
it's hooked to the crips and if you don't you'll pull
your sample out,
you'll lose it so you have to reach in and cut the mucus
off from the external
cervical oss.
Then you'll have a good uh segment of mucus.
Next slide this is an actual photograph where the
segments are cut and this is the
Internal losses where I start and for the first
time you can actually.
Next slide do a good spin bark height.
You can just use a little mosquito clamp,
drop a cover,
slip up there and pick it up and have a ruler in the back
and actually measure it anything over 6cm.
Using this volume is a
normal volume.
A normal spin bark.
I usually an excellent because you get 12 14
16 centimeter spin bar kite.
But it's accurate way of doing it instead of between your
fingers.
Some people do that.
Next slide.
So here's the fractional postcoital test as to
results we'd like to do it and and this is
all predicted.
We try to do it two hours before the two days
before the BBT shift.
Two days afternoons.
Just for standardization,
two hours after Coitus.
Within two hours at least five model
sperm per high powered field at the internal loss.
That's the low normal.
You can get pregnancies with less than that.
But the fertility rate drops off.
So I'd like to see five motile sperm at the
internalized to call that normal or greater.
Now if it's 20 sperm or just loaded with sperm.
Although you don't even have to get the same analysis then when they're
loaded with sperm,
the scene analysis has been excellent.
Even 10-20 sperm per high power field the
same analysis have always been normal.
So you could even skip the steam analysis.
However,
there are other other bits of information
you get from semen analysis.
We still have been getting them and I don't think that you
ought to totally disregard the same analysis.
If if you have some sperm on the post coital test
between five and 10 as a borderline whether
you'll have kind of a low normal seem analysis or not
and a spin bark and less than five definitely have to have a
semen analysis and a spin bar kite greater
than six centimeters on that one segment.
If you have no sperm at the inn lost
and do the next segment and next segment and next segment,
why don't we do this?
Because 20% of patients with normal since
unit tests will have an abnormal postcoital test,
they'll have sperm at the external and mid segment of
the catheter,
but not no sperm at the internal loss.
So about 20% of patients referred to me with
a normal postcoital test done and just grabbing
mucus with whatever method have had
abnormal postcoital test when done with a
with a factional or the catheter and
that then took care of some of the unexplained
infertility patients who definitely had an explanation.
But the testing method wasn't any good.
Next slide.
Now,
I wanted to show you results.
You're going to end up in three types of
patients at three kinds of circle factors anatomical.
I hate them.
They're the worst kind abnormal cervical
mucus and the
abnormal postcoital test with normal
cervical mucus.
Now these 114 excluding all
patients with double factors.
In other words,
I had patients that had abnormal mucus and
abnormal males.
What I tried to do to come up with some kind of figure
is to divide them up into groups with only one
diagnosis.
So anatomical defects,
that's easy as the patient had abnormal
mucus,
there are two kinds of abnormalities I'll show you and if she
had normal mucus with abnormal postcoital
test,
this was a either unexplained
phenomena or a male factor.
So they're 114 patients in in my
own uh practice that I
used to put these figures together and you
have to do that because even at best,
a postcoital test is a subjective test.
Next.
Now,
the anatomical defects.
I had six patients with stenosis.
Here's the worst diagnosis when I get a phone call with a
referral with a post cone cervical factor,
I'm very unhappy.
You're not going to correct that no matter what you do.
I have tried to sound them and they it doesn't
really help very much.
They're not gonna make mucus.
And with cryosurgery and co posCA p I hope we
don't do as many cones as we did when I was a
resident because when it comes to infertility,
that's very,
very bad diagnosis.
I've had two patients with no cones,
but very static cervical,
very small cervical canals.
Then I have three patients in this group that we
don't have a diagnosis for other than I
can just describe these patients.
Every time you test their epithelium you get a column of blood
back.
And if you culpa scope them and if you culture
them they were culture they were negative.
But on call posCA P.
Dr Townsend said the epithelium
is very low lying,
very underdeveloped Columbia epithelium.
Hypoplastic is that morphological
disorder?
I don't know that's what we call it.
A hypoplastic and the cervical epithelium.
These are patients that bleed very readily
and a lot of them are not due to infection.
We do get a culture on them when the when the
services uh bleeds easily.
We do get pap smears and look for cancer.
But and and it's a small number three of those
114 patients have this unexplained
low lying columnar epithelium.
Next slide here's what I
have done in my practice with him.
I dilated him with a sound and try to
do interest cervical insemination.
Just put a half a cc cervical mucus
in the cervical canal.
Not in the uterus,
nothing ever happens.
One patient had a D.
N.
C.
Because she started bleeding from the nose
cervix postponed.
And one cycle after her referring physician
deed deed in cedar to stop the bleeding.
He didn't know where the bleeding was coming from.
She got pregnant.
So I I didn't do a thing for this patient.
But there was one patient in here.
She was the only one that had a.
D.
N.
C.
The rest of them had the decency did not get
pregnant before I even saw but I just dilated them
and did interest cervical insemination.
Nothing happened now.
We since the slide was made we have one
patient in this group that's had washed
sperm entry.
Uterine insemination that's gotten pregnant.
But the other five have not gotten pregnant.
You can't put whole semen in the uterus.
You might even immunize your patients.
You're putting foreign protein in there and it doesn't
work.
Entry uterine insemination should not be done.
What we do is wash the sperm and doing through
insemination and you as anything and infertility.
The first patient we did got pregnant.
I thought great.
The next five did not get pregnant.
So that's where we stand.
Cryosurgery.
For the hypoplastic
epithelium.
Dr Townsend freezes the lower half of the canal
for me.
And I'm going by what he tells me as they
regenerate regrow the epithelium.
He thinks they've gotten better.
Now I don't know the mucus has gotten
slightly better.
And one and one patient the patient got pregnant
really did improve.
She got pregnant.
The third cycle after cryosurgery.
It takes about two months for him to heal.
So if you have a very bloody tap every time you
try to get mucus I would help us cope them
and if it looks like a very fragile epithelium and if the
culture is negative.
Go ahead use cryosurgery for those patients.
These five insemination here,
none of them have gotten pregnant.
Interest circle insemination doesn't seem to work.
That's why we've gone to intra uterine washed
sperm insemination and none of them responded to.
Still best I still like still best
draw because at 50.1,
excuse me
at 0.1 mg is still best for all.
I get good response with a cervical mucus.
At 0.2 I get slightly I
improved my number of
improved response
group but I don't suppress
ovulation.
Now you get to 20 micrograms Anthony
Lester dial or 200.65 of Premarin
you're going to have a lot more ovulation suppression or at
least delayed ovulation.
So I'm still a still best straw man.
I think it's just it's just as good if not better
than the other estrogens to use.
And you most certainly are not going to cause that uh
diagnosis of the vagina using 1/10 of
milligram and not during organogenesis.
I give it to them not in these groups,
these patients the other.
So I'm gonna present between days
five and 20 of each cycle
when I use the best role.
Next slide.
Now there are patients that have cervical
mucus,
there's two kinds quality and quantity.
This is the patient that has thick
yellow cervical mucus and there's a patient that has
clear but scanty cervical mucus,
both these patients are treated with still best oral estrogen
therapy.
Next I give one
mg days five through 20 and 17
did not improve in this group.
And 11 improved.
Next slide by improved.
I mean they had normal spin bar kind of the ones that
improved.
The 11 that improved this post coital test
before was zero postcoital test
after was right here listed.
And out of the 11 that improved six of them
got pregnant and I leave them on
indefinitely.
Next slide
Now the 35 patients that had
abnormal quantity scanty mucous.
They're better than the ones that have enough mucus.
But I think that's a bad group but half of
them will improve on still best strong of the improved
group.
Next slide Of the
18 that improved zero sperm at the
postcoital test before treatment and then the
sperm after treatment.
five out of the 18 got pregnant.
Next line.
Now the abnormal postcoital test with
normal cervical mucus.
Good spin bar kite clear mucus.
No sells everything looks fine
when you examine it and if you did dry it out like I
do do that biophysical test,
Good channel formation.
And there are two kinds of patients are gonna see no sperm
or immobilize sperm.
Now the ones that had double factors have excluded
of the lack of sperm penetration.
I had 24 of them low semen
volume.
Not talked about very much less than
two ml.
On more than one examination.
Now with.
Normal sperm camp.
These patients ought to have the Mile X.
Cup insemination.
I'll show you the results of that.
Allah go sperm you less than 20.
Andrology haven't been able to increase the sperm count.
And since most of the sperm are on the sheets in 20 minutes
it seemed logical to us to keep them from getting on the
sheets and keep them on the Cervix.
So we start cupping oligarchs,
sperm were very practical in southern California
just like San Antonio.
And then four of my patients had
as a sperm.
And when we did the same analysis so those are
the lack of sperm penetration
immobilize sperm.
You do you get good cervical mucus.
You look in there,
they're all mobilized.
Everybody thought that is a immunological factor and it is
not by our methods of immune checking
the immunology.
What we did was we thought well the vagina
must be playing some role.
So we bypass the vagina with a cup,
we do a cup and then a one hour
later postcoital test.
In other words the first time the patient comes in with
this kind of a diagnosis
after the first post coital test.
I then schedule them for a post coital test.
But instead of having intercourse at home I have them come in with a
fresh semen specimen,
I clean off the vagina and the cervix put the cervical
cup on and they come in different sizes.
Put the semen in,
have them do whatever they want to do for an hour,
come back and I take off the cup,
wipe off the cervix and do my post coital test.
Following a cup insemination and if they
improve then I use it for therapy.
If I can't improve it then I don't have any
way to treat the problem.
So immobilized group instead of going right to the
immunology,
I would suggest that you schedule them for a cup.
Postcoital test,
one hour interval between the cup and the postcoital test.
And we had seven
that had improved tremendous number of sperm
when we bypass the vagina.
I put unexplained or vaginal factor.
I don't know what that means.
And 11 of them are just showed no
improvement.
They still had to mobilize sperm.
Next line of the here's the
cup for those that haven't seen it.
It's a poor slide.
It's a mile X.
Comes in different diameters here.
Here's the valve.
You put the cup on first,
you turn it upside down with the dome up,
slip it in,
flip it around,
put it on the cervix and then you put the
semen in,
then push that ball valve down here,
fold the stem up,
leave it in the vagina.
Leave it on for an hour,
repeat the postcoital test following the cup.
If you get improvement,
then use it for treatment and do it admit cycle
instead of one hour.
Then I leave it on four hours and teach the patient how
to pull it off,
Take it off at home.
That's just a cup.
Next line of the
low volume patients.
I cupped them using the cup technique.
And these are the number of cycles that they were cupped and I
had three out of six patients got pregnant.
And I want eight cycles on this patient.
She didn't get pregnant.
And in other words most of the pregnancies occur within four
cycles.
So I offered as therapy to a poor postcoital
test with normal cervical mucus for ah little
sperm or for a cup
for low volume.
I use it as therapy until the astrologists can
improve these male factors.
We have three out of six pregnancies here.
Next slide mm
To spur me a marked improvement with a
cup.
We have 14 of them.
10 of them improved in a normal
range of postcoital test from an abnormal range.
Just using a simple technique of holding
most of the semen against the service plain
common sense.
You can't increase number,
you can increase time exposure.
Five out of 10 patients got pregnant.
Next slide Now if the postcoital
test doesn't show improvement.
Don't use the cup technique for therapy
Immobilization.
We had 18.
We cut them and out of the Cup seven.
Those are the seven that I talked about
earlier and 11 did not improve.
Out of these patients without any immunological testing.
We had three pregnancies.
Next slide
All the patient,
not all of them.
Some 80.
Some patients here were evaluated with
Kendrick is Tajima Franklin Dix
And including the mobilization uh
group right here,
18 of them none of them had a positive test.
I had one positive kid brick test in lack of sperm
penetration.
So I don't know if it's a method the
testing method for immunological testing
or whether we ought to be looking at the cervical mucus as a
better system for looking for immunological
factors.
I'm not sure.
But it does not seem to be related immunological
factors and bad postcoital tests don't seem
to be related with our present methods of
testing.
Next line again,
the percentage anatomical defects,
abnormal mucus,
abnormal postcoital test with normal mucus.
Just what I gave you earlier.
The overall results are not very good.
Next.
With all my pregnancies added up.
Take everything I had that I gave you.
If there's stenosis,
dilatation,
cryosurgery.
Now we're going to enter you know and washed
sperm insemination,
abnormal mucus.
D.
E.
S.
Low semen volume cup.
Olive go spur me a cup,
immobilize sperm cup,
putting all this together.
The number of patients for them.
I couldn't there was not enough of a follow up.
We dropped them out of their number of pregnancies.
That's only 22%.
If you look at the improved group.
In other words you give them the es remember
some of improved some of them then if you
do a postcoital test following a cup before you
introduce it as therapy.
And if you get improvement and use it.
If I look at the improved group.
The pregnancy rate is over 40%.
So these are the figures I use in talking to my
patients and trying to give them the prognosis of a
cervical factor one to make a diagnosis
to to predict what you can do for them.
And we're using these techniques of estrogen
and cut at the present time until we get more
sophisticated.
And I think that's my last slide,
isn't it?
Yes,
thank you very much.
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