WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* 00:20.530 --> 00:22.960 A United States Army Medical Department 00:22.960 --> 00:25.110 continuing education program. 00:26.750 --> 00:29.440 The 24th Annual Armed Forces Seminar on 00:29.440 --> 00:31.340 Obstetrics and Gynecology. 00:33.210 --> 00:36.190 Postcoital test cervical factor 00:38.350 --> 00:40.520 with Val David John M.D. 00:41.060 --> 00:43.830 Associate professor section of 00:43.830 --> 00:45.830 reproductive biology. 00:45.840 --> 00:48.470 Los Angeles County University of Southern 00:48.470 --> 00:50.110 California Medical Center. 00:53.220 --> 00:53.860 First of all, 00:53.860 --> 00:56.680 just a quick one minute physiological 00:56.680 --> 00:57.150 review. 00:57.150 --> 01:00.030 The cervical mucus admit cycle takes these 01:00.030 --> 01:02.730 big molecules of glycoprotein, 01:02.730 --> 01:04.330 links them up and there's a, 01:04.340 --> 01:06.390 what we need here is calcium. 01:06.570 --> 01:09.490 It's a dye sulfate bond and so on and 01:09.490 --> 01:11.950 forms my seller structures 01:11.960 --> 01:14.780 long strands of cervical mucus under 01:14.780 --> 01:17.420 the influence of estrogen at mid cycle 01:18.500 --> 01:21.280 C is the key and sperm transport next 01:23.030 --> 01:24.600 and this is a schematic. 01:24.600 --> 01:27.540 This is what it looks like you get to my cell and then the 01:27.540 --> 01:29.250 whole unit is called the rod. 01:29.260 --> 01:30.630 And each crept. 01:30.630 --> 01:31.530 It's not a true gland. 01:31.540 --> 01:34.490 Each crept secretes a long strand of 01:34.490 --> 01:35.800 this mucus, 01:35.810 --> 01:37.670 glycoprotein 01:37.680 --> 01:40.650 aggregate the distance between them 01:40.660 --> 01:42.430 3 to 10 microns. 01:42.430 --> 01:44.810 Perfect for the sperm head to fit through. 01:44.820 --> 01:46.030 It's a filter. 01:46.110 --> 01:48.230 There's probably nutritional 01:48.290 --> 01:49.630 necessities in here. 01:49.630 --> 01:51.450 It's like a service station. 01:51.460 --> 01:54.370 It's a depot for picking up storing 01:54.370 --> 01:57.270 spermatozoa and releasing sperm up into 01:57.270 --> 02:00.250 the upper general track and not your power steen 02:00.260 --> 02:02.290 talks about sperm transport and so on. 02:02.300 --> 02:05.200 But this is the gateway to 02:05.200 --> 02:05.810 happiness. 02:05.810 --> 02:06.020 You know, 02:06.020 --> 02:07.800 he just talks about that tunnel. 02:07.810 --> 02:09.140 But without the cervix, 02:09.140 --> 02:10.750 he's not gonna have any sperm up there. 02:10.750 --> 02:13.120 So we decided to spend a lot of time. 02:13.120 --> 02:16.040 We spent about four years now on the on the basic 02:16.050 --> 02:19.010 biochemistry and biophysics of cervical mucus. 02:19.210 --> 02:22.040 We're about ready to write up the whole 02:22.040 --> 02:22.640 series. 02:22.640 --> 02:25.590 And because I think we've done just about all we can 02:25.590 --> 02:28.330 do on the physiology of the cervix at mid 02:28.330 --> 02:31.150 cycle Next the alignment 02:31.160 --> 02:31.830 is real. 02:31.830 --> 02:32.450 If you look, 02:32.460 --> 02:35.260 if you do a lot of postcoital test and if you stretch the mucus 02:35.260 --> 02:36.860 out a little bit on a slide, 02:36.880 --> 02:39.480 you'll notice that sperm seem to follow each 02:39.480 --> 02:41.110 other in either direction. 02:41.310 --> 02:43.650 This is not just a one 02:43.910 --> 02:46.910 slide used for to show off or to 02:46.910 --> 02:47.970 talk make a point. 02:47.980 --> 02:50.980 But this is very very common thing to see on the field. 02:50.980 --> 02:53.790 If you stretch the mucus out oriented in a linear 02:53.790 --> 02:54.300 fashion, 02:54.310 --> 02:56.660 you'll see the sperm going in the same direction. 02:57.120 --> 02:59.250 This is a wet man. 02:59.260 --> 03:01.780 Next slide now the 03:01.780 --> 03:04.130 same type of mucus 03:04.140 --> 03:07.140 stretched out like this and 03:07.140 --> 03:09.750 allowed to dry under the cover slip will never 03:09.760 --> 03:10.460 firm. 03:10.570 --> 03:13.290 This is good cervical mucus under the cover slip. 03:13.290 --> 03:15.900 If you come back and look at your post coital test a 03:15.900 --> 03:16.340 week, 03:16.350 --> 03:19.270 two weeks later and allow that time for it to dry 03:19.270 --> 03:22.240 the crystallization process under a cover 03:22.240 --> 03:25.080 slip because it's a slow process does not 03:25.090 --> 03:27.210 allow for the classical firm. 03:27.340 --> 03:30.320 But we'll show you the crystallization in the same linear 03:30.320 --> 03:32.080 fashion that I'm talking about. 03:32.200 --> 03:34.600 These are the channels represented by the 03:34.600 --> 03:37.540 crystallization process at mid cycle. 03:38.220 --> 03:38.780 Next slide, 03:40.200 --> 03:42.730 here's the classical furniture is the same cervical mucus, 03:42.730 --> 03:44.090 one dried without cover slip, 03:44.090 --> 03:45.540 One dried under the cover slip. 03:45.550 --> 03:48.340 So it's a biophysical evaluation of 03:48.340 --> 03:49.550 whether you do have channels. 03:49.550 --> 03:50.910 If you just drive the slide, 03:51.110 --> 03:54.090 come back two weeks later a week later and take a look 03:54.090 --> 03:55.680 and see if you have channel formation 03:58.510 --> 04:00.140 and the under the alluvial influence, 04:00.140 --> 04:02.850 under progesterone influence instead of a linear 04:02.860 --> 04:03.690 alignment, 04:03.700 --> 04:06.640 you get filament formation next slide and if you drive 04:06.640 --> 04:07.780 that stretch it out, 04:07.780 --> 04:09.230 you don't get the channel formation. 04:09.350 --> 04:10.110 If you stretch, 04:10.110 --> 04:11.240 that's the same patient, 04:11.400 --> 04:12.510 middle initial phase, 04:12.640 --> 04:15.280 stretch the mucus out and you get this kind of a 04:15.290 --> 04:17.950 spongy appearance to the crystallization process. 04:18.680 --> 04:21.660 Next slide and look so many patients are going to 04:21.670 --> 04:24.470 have that at mid cycle abnormal cervical mucus 04:24.470 --> 04:26.890 factor as far as alignment goes, 04:27.000 --> 04:28.150 this is the semen. 04:28.150 --> 04:30.810 I I use 20 this is dr Bernstein slide 04:31.090 --> 04:32.840 and dr Power stein talked about that. 04:32.840 --> 04:35.160 Anything over 20 we call that normal. 04:35.280 --> 04:37.990 I just put this up because the question always comes up and you'll 04:37.990 --> 04:40.920 see this figure here and 20 million. 04:40.920 --> 04:43.060 Show up in my work up of the cervical factor. 04:43.250 --> 04:44.850 These are are low normals. 04:44.860 --> 04:47.820 We want something no less than this to 04:47.820 --> 04:50.550 call it A and change that to 20 04:50.550 --> 04:50.930 million. 04:51.040 --> 04:53.800 No less than that to call it the normal semen 04:53.800 --> 04:56.770 analysis Next now 04:56.780 --> 04:59.320 I do the postcoital test prior to the 04:59.330 --> 05:01.550 BBT elevation and you have to predict it 05:01.560 --> 05:02.380 obviously. 05:02.390 --> 05:05.310 And I like to put the patients on what I call a 05:05.310 --> 05:05.810 mini B. 05:05.810 --> 05:05.980 B. 05:05.980 --> 05:06.590 T. 05:06.600 --> 05:07.960 I don't like that. 05:07.970 --> 05:10.830 Uh I don't like to put patients on temperatures throughout the 05:10.830 --> 05:12.890 month for many cycles. 05:12.900 --> 05:15.770 But when I'm working up working up the cervical factor I 05:15.770 --> 05:18.360 like the Mid cycle 05:18.920 --> 05:19.530 recorded. 05:19.530 --> 05:19.860 For me. 05:19.860 --> 05:22.350 It's very helpful to know where you are in the cycle. 05:22.480 --> 05:24.790 So about a 56 day temperature 05:25.650 --> 05:28.540 Right in the middle of the month is very helpful in evaluating 05:28.540 --> 05:31.230 whether you're doing the test at the right time or not. 05:31.240 --> 05:32.970 If this was day 14, 05:32.970 --> 05:34.460 I'd wanted to do the test on day 05:34.460 --> 05:37.040 1213 at the latest. 05:37.050 --> 05:37.880 11. 05:38.710 --> 05:41.170 And those 34 days are the key days 05:41.200 --> 05:43.360 11 12 13. 05:43.370 --> 05:45.880 If the if the temperature is going to rise on day 05:45.880 --> 05:46.540 14. 05:47.450 --> 05:49.580 So that's when we do the test. 05:49.590 --> 05:52.590 We decided to do the test at a two hour interval 05:52.590 --> 05:53.860 and dr treadway, 05:53.870 --> 05:56.750 commander treadway here got a PhD in sperm 05:56.750 --> 05:57.430 transport. 05:57.440 --> 06:00.240 He told us that he's the only guy in the 06:00.240 --> 06:00.930 world to do that. 06:00.940 --> 06:01.150 You know. 06:01.160 --> 06:04.150 Uh He found that 2.5 06:04.160 --> 06:05.370 hours is optimum. 06:05.380 --> 06:08.250 And fortunately he agreed with what we had already published 06:08.250 --> 06:10.520 since he got his PhD in our department, 06:10.740 --> 06:13.370 the two hour postcoital test. 06:13.370 --> 06:16.300 And we don't have time to get into the validity of that or 06:16.300 --> 06:17.270 the overnight test. 06:17.270 --> 06:20.170 I think that you ought to do the test at 06:20.170 --> 06:23.070 the optimum time when the sperm are getting into 06:23.130 --> 06:25.630 the maximum number of sperm in the cervical canal. 06:25.650 --> 06:27.280 How do I collect it? 06:27.450 --> 06:30.110 The reason I collected the way I collected it is 06:30.110 --> 06:32.790 because as a resident I was collecting it with 06:32.790 --> 06:35.790 syringes with glass tubing and half the time I was losing my 06:35.790 --> 06:38.780 specimen and lying to the patient and 06:38.780 --> 06:41.580 telling her to come back next month because the test 06:41.580 --> 06:42.330 wasn't any good. 06:42.340 --> 06:43.430 The reason wasn't any good. 06:43.430 --> 06:45.630 It was on my lab coat next 06:45.630 --> 06:48.580 line I 06:48.580 --> 06:50.940 decided to use a clear plastic catheter. 06:50.940 --> 06:51.460 These are N. 06:51.460 --> 06:51.620 G. 06:51.620 --> 06:53.940 Suction catheters you can steal in the hospital. 06:54.640 --> 06:57.320 They come between eight and 14 or 16 in 06:57.320 --> 06:57.770 size. 06:57.770 --> 07:00.730 So customize the size to your patients external 07:00.730 --> 07:03.410 cervical lost diameter just by eyeballing it. 07:03.540 --> 07:05.520 You can pick out the right size catheter 07:06.400 --> 07:08.680 and that's just a schematic uh 07:08.690 --> 07:09.800 presentation of it. 07:09.910 --> 07:11.340 Next slide, 07:12.440 --> 07:13.620 here's the catheter. 07:15.030 --> 07:17.610 I use a this is a a traumatic 07:17.610 --> 07:20.160 cervical 10 Acura TLX makes 07:20.500 --> 07:23.250 and by by 07:23.250 --> 07:25.860 actually gripping a solid 07:25.870 --> 07:28.750 table or something and clicking down to the 07:28.750 --> 07:29.170 ratchet, 07:29.180 --> 07:31.940 you loosen it so that when you click the first ratchet 07:31.940 --> 07:32.430 here, 07:32.490 --> 07:34.860 the actual grip doesn't close all the way and acts as a 07:34.860 --> 07:37.670 trap and also as a holder for your 07:37.670 --> 07:38.630 plastic catheter. 07:39.050 --> 07:41.590 I leave a 2.5 centimeter 07:41.600 --> 07:42.660 segments sticking out. 07:42.660 --> 07:45.270 That's the usual length of the cervical canal and then I 07:45.280 --> 07:48.170 bevel it a little bit to be able to slip it into the canal 07:48.180 --> 07:49.310 very gently. 07:49.840 --> 07:52.800 Now the way to collect it is just as you slip 07:52.800 --> 07:55.540 the tip of this catheter into the external 07:55.540 --> 07:56.030 loss. 07:56.040 --> 07:58.720 You begin slow suction 07:58.720 --> 08:01.610 back and you'll see a column of mucus move right back here a 08:01.610 --> 08:04.600 solid column and usually with a she has any mucus with 08:04.600 --> 08:07.520 very few bubbles in it and you have to 08:07.520 --> 08:08.560 take my word for it. 08:08.570 --> 08:11.390 This portion of the mucus collection will represent 08:11.390 --> 08:14.250 most of the external cervical mucus because it's a 08:14.250 --> 08:15.050 semi solid, 08:15.060 --> 08:18.000 there's not that much mixing and the tip 08:18.000 --> 08:20.360 of that catheter will represent the internal 08:20.790 --> 08:21.880 cervical mucus. 08:21.900 --> 08:24.550 Next line then you can take with the 08:24.550 --> 08:25.650 scissors and cut right. 08:25.650 --> 08:26.710 You can see the mucus in there, 08:26.720 --> 08:29.710 it sticks into the catheter and you 08:29.710 --> 08:30.670 can cut it right across. 08:30.670 --> 08:33.490 I should make one other point for those who have not collected it back 08:33.490 --> 08:34.590 up slide again. 08:34.820 --> 08:37.670 The reason I have the scissors here is just as you 08:37.670 --> 08:38.930 clear the cervix. 08:38.960 --> 08:41.790 When you go all the way up to the 2.5 centimeters and click 08:41.790 --> 08:43.300 down all the way on the ratchet. 08:43.590 --> 08:46.550 Then you slowly withdraw your catheter and you have your column of 08:46.550 --> 08:47.290 mucus in there, 08:47.300 --> 08:49.800 you have to reach in and cut the trailing mucus. 08:49.800 --> 08:51.750 There's some always leftover behind, 08:51.750 --> 08:54.750 it's hooked to the crips and if you don't you'll pull 08:54.750 --> 08:55.630 your sample out, 08:55.640 --> 08:58.350 you'll lose it so you have to reach in and cut the mucus 08:58.350 --> 09:00.360 off from the external 09:00.370 --> 09:01.920 cervical oss. 09:01.930 --> 09:04.790 Then you'll have a good uh segment of mucus. 09:04.800 --> 09:07.560 Next slide this is an actual photograph where the 09:07.560 --> 09:10.010 segments are cut and this is the 09:10.035 --> 09:12.995 Internal losses where I start and for the first 09:12.995 --> 09:14.265 time you can actually. 09:14.275 --> 09:16.525 Next slide do a good spin bark height. 09:16.815 --> 09:18.645 You can just use a little mosquito clamp, 09:18.645 --> 09:19.305 drop a cover, 09:19.305 --> 09:22.025 slip up there and pick it up and have a ruler in the back 09:22.055 --> 09:24.845 and actually measure it anything over 6cm. 09:24.855 --> 09:27.720 Using this volume is a 09:27.720 --> 09:28.540 normal volume. 09:28.550 --> 09:29.680 A normal spin bark. 09:29.680 --> 09:32.490 I usually an excellent because you get 12 14 09:32.490 --> 09:34.420 16 centimeter spin bar kite. 09:34.430 --> 09:37.020 But it's accurate way of doing it instead of between your 09:37.020 --> 09:37.530 fingers. 09:37.540 --> 09:38.680 Some people do that. 09:38.690 --> 09:40.510 Next slide. 09:41.600 --> 09:44.450 So here's the fractional postcoital test as to 09:44.450 --> 09:47.300 results we'd like to do it and and this is 09:47.300 --> 09:48.040 all predicted. 09:48.040 --> 09:50.920 We try to do it two hours before the two days 09:50.920 --> 09:52.670 before the BBT shift. 09:52.680 --> 09:53.790 Two days afternoons. 09:53.790 --> 09:55.240 Just for standardization, 09:55.770 --> 09:57.390 two hours after Coitus. 09:57.390 --> 10:00.170 Within two hours at least five model 10:00.170 --> 10:02.690 sperm per high powered field at the internal loss. 10:02.700 --> 10:03.940 That's the low normal. 10:04.980 --> 10:07.300 You can get pregnancies with less than that. 10:07.530 --> 10:09.570 But the fertility rate drops off. 10:10.530 --> 10:13.440 So I'd like to see five motile sperm at the 10:13.450 --> 10:15.730 internalized to call that normal or greater. 10:15.820 --> 10:18.760 Now if it's 20 sperm or just loaded with sperm. 10:18.770 --> 10:21.490 Although you don't even have to get the same analysis then when they're 10:21.490 --> 10:22.340 loaded with sperm, 10:22.340 --> 10:24.050 the scene analysis has been excellent. 10:24.940 --> 10:27.820 Even 10-20 sperm per high power field the 10:27.820 --> 10:29.680 same analysis have always been normal. 10:29.680 --> 10:31.510 So you could even skip the steam analysis. 10:31.690 --> 10:32.800 However, 10:33.680 --> 10:36.630 there are other other bits of information 10:36.630 --> 10:38.100 you get from semen analysis. 10:38.110 --> 10:41.030 We still have been getting them and I don't think that you 10:41.030 --> 10:42.950 ought to totally disregard the same analysis. 10:43.090 --> 10:45.980 If if you have some sperm on the post coital test 10:45.990 --> 10:48.940 between five and 10 as a borderline whether 10:48.940 --> 10:51.930 you'll have kind of a low normal seem analysis or not 10:51.950 --> 10:54.940 and a spin bark and less than five definitely have to have a 10:54.940 --> 10:57.820 semen analysis and a spin bar kite greater 10:57.820 --> 11:00.390 than six centimeters on that one segment. 11:00.400 --> 11:03.325 If you have no sperm at the inn lost 11:03.325 --> 11:06.275 and do the next segment and next segment and next segment, 11:06.285 --> 11:07.435 why don't we do this? 11:07.455 --> 11:10.315 Because 20% of patients with normal since 11:10.315 --> 11:13.075 unit tests will have an abnormal postcoital test, 11:13.195 --> 11:16.175 they'll have sperm at the external and mid segment of 11:16.175 --> 11:16.895 the catheter, 11:16.935 --> 11:18.865 but not no sperm at the internal loss. 11:18.955 --> 11:21.905 So about 20% of patients referred to me with 11:21.905 --> 11:24.555 a normal postcoital test done and just grabbing 11:24.555 --> 11:26.985 mucus with whatever method have had 11:26.995 --> 11:29.975 abnormal postcoital test when done with a 11:29.985 --> 11:32.700 with a factional or the catheter and 11:32.710 --> 11:35.450 that then took care of some of the unexplained 11:35.450 --> 11:38.440 infertility patients who definitely had an explanation. 11:38.450 --> 11:40.380 But the testing method wasn't any good. 11:40.980 --> 11:41.500 Next slide. 11:41.990 --> 11:42.100 Now, 11:42.100 --> 11:43.280 I wanted to show you results. 11:43.290 --> 11:46.090 You're going to end up in three types of 11:46.090 --> 11:48.910 patients at three kinds of circle factors anatomical. 11:48.910 --> 11:49.500 I hate them. 11:49.550 --> 11:52.420 They're the worst kind abnormal cervical 11:52.420 --> 11:54.110 mucus and the 11:54.110 --> 11:57.110 abnormal postcoital test with normal 11:57.110 --> 11:57.970 cervical mucus. 11:57.980 --> 12:00.890 Now these 114 excluding all 12:00.890 --> 12:02.410 patients with double factors. 12:02.410 --> 12:02.840 In other words, 12:02.840 --> 12:05.080 I had patients that had abnormal mucus and 12:05.080 --> 12:07.070 abnormal males. 12:07.080 --> 12:10.030 What I tried to do to come up with some kind of figure 12:10.040 --> 12:12.960 is to divide them up into groups with only one 12:12.960 --> 12:14.110 diagnosis. 12:14.980 --> 12:17.140 So anatomical defects, 12:17.140 --> 12:19.740 that's easy as the patient had abnormal 12:19.740 --> 12:20.230 mucus, 12:20.230 --> 12:22.940 there are two kinds of abnormalities I'll show you and if she 12:22.940 --> 12:25.490 had normal mucus with abnormal postcoital 12:25.490 --> 12:26.050 test, 12:26.060 --> 12:28.950 this was a either unexplained 12:28.960 --> 12:31.010 phenomena or a male factor. 12:31.020 --> 12:33.940 So they're 114 patients in in my 12:33.940 --> 12:36.750 own uh practice that I 12:36.750 --> 12:39.690 used to put these figures together and you 12:39.690 --> 12:41.420 have to do that because even at best, 12:41.420 --> 12:44.310 a postcoital test is a subjective test. 12:44.860 --> 12:45.730 Next. 12:46.860 --> 12:47.140 Now, 12:47.140 --> 12:48.350 the anatomical defects. 12:48.350 --> 12:49.950 I had six patients with stenosis. 12:49.950 --> 12:52.910 Here's the worst diagnosis when I get a phone call with a 12:52.910 --> 12:55.650 referral with a post cone cervical factor, 12:55.660 --> 12:56.810 I'm very unhappy. 12:56.820 --> 12:59.680 You're not going to correct that no matter what you do. 12:59.690 --> 13:02.470 I have tried to sound them and they it doesn't 13:02.480 --> 13:03.670 really help very much. 13:03.670 --> 13:05.060 They're not gonna make mucus. 13:05.070 --> 13:07.900 And with cryosurgery and co posCA p I hope we 13:07.900 --> 13:10.470 don't do as many cones as we did when I was a 13:10.470 --> 13:13.260 resident because when it comes to infertility, 13:13.280 --> 13:14.650 that's very, 13:14.650 --> 13:16.790 very bad diagnosis. 13:16.820 --> 13:19.110 I've had two patients with no cones, 13:19.110 --> 13:21.600 but very static cervical, 13:22.260 --> 13:24.490 very small cervical canals. 13:24.830 --> 13:27.820 Then I have three patients in this group that we 13:27.820 --> 13:30.680 don't have a diagnosis for other than I 13:30.680 --> 13:32.490 can just describe these patients. 13:32.490 --> 13:35.150 Every time you test their epithelium you get a column of blood 13:35.150 --> 13:35.670 back. 13:35.780 --> 13:38.750 And if you culpa scope them and if you culture 13:38.750 --> 13:40.710 them they were culture they were negative. 13:40.920 --> 13:42.140 But on call posCA P. 13:42.140 --> 13:45.040 Dr Townsend said the epithelium 13:45.040 --> 13:46.340 is very low lying, 13:46.340 --> 13:48.810 very underdeveloped Columbia epithelium. 13:48.820 --> 13:51.570 Hypoplastic is that morphological 13:51.570 --> 13:52.110 disorder? 13:52.110 --> 13:53.260 I don't know that's what we call it. 13:53.260 --> 13:56.210 A hypoplastic and the cervical epithelium. 13:56.220 --> 13:59.190 These are patients that bleed very readily 13:59.200 --> 14:01.920 and a lot of them are not due to infection. 14:01.940 --> 14:04.360 We do get a culture on them when the when the 14:04.370 --> 14:06.770 services uh bleeds easily. 14:06.780 --> 14:09.330 We do get pap smears and look for cancer. 14:09.360 --> 14:11.730 But and and it's a small number three of those 14:11.730 --> 14:14.430 114 patients have this unexplained 14:14.440 --> 14:16.070 low lying columnar epithelium. 14:16.070 --> 14:18.800 Next slide here's what I 14:19.030 --> 14:20.770 have done in my practice with him. 14:20.770 --> 14:23.760 I dilated him with a sound and try to 14:23.760 --> 14:25.880 do interest cervical insemination. 14:25.880 --> 14:28.810 Just put a half a cc cervical mucus 14:28.810 --> 14:29.740 in the cervical canal. 14:29.740 --> 14:30.660 Not in the uterus, 14:30.700 --> 14:32.220 nothing ever happens. 14:32.260 --> 14:33.660 One patient had a D. 14:33.660 --> 14:33.790 N. 14:33.790 --> 14:34.030 C. 14:34.030 --> 14:35.990 Because she started bleeding from the nose 14:36.510 --> 14:38.770 cervix postponed. 14:38.960 --> 14:41.930 And one cycle after her referring physician 14:41.930 --> 14:44.470 deed deed in cedar to stop the bleeding. 14:44.470 --> 14:45.760 He didn't know where the bleeding was coming from. 14:45.760 --> 14:46.480 She got pregnant. 14:46.680 --> 14:49.360 So I I didn't do a thing for this patient. 14:49.370 --> 14:51.100 But there was one patient in here. 14:51.110 --> 14:52.200 She was the only one that had a. 14:52.200 --> 14:52.360 D. 14:52.360 --> 14:52.490 N. 14:52.490 --> 14:53.040 C. 14:53.100 --> 14:55.860 The rest of them had the decency did not get 14:55.860 --> 14:58.790 pregnant before I even saw but I just dilated them 14:58.790 --> 15:00.910 and did interest cervical insemination. 15:00.920 --> 15:02.650 Nothing happened now. 15:02.650 --> 15:05.560 We since the slide was made we have one 15:05.560 --> 15:07.850 patient in this group that's had washed 15:07.860 --> 15:09.040 sperm entry. 15:09.040 --> 15:11.700 Uterine insemination that's gotten pregnant. 15:11.710 --> 15:13.920 But the other five have not gotten pregnant. 15:13.930 --> 15:16.010 You can't put whole semen in the uterus. 15:16.010 --> 15:18.160 You might even immunize your patients. 15:18.170 --> 15:21.060 You're putting foreign protein in there and it doesn't 15:21.060 --> 15:21.490 work. 15:21.500 --> 15:24.040 Entry uterine insemination should not be done. 15:25.150 --> 15:27.770 What we do is wash the sperm and doing through 15:27.970 --> 15:30.700 insemination and you as anything and infertility. 15:30.700 --> 15:32.830 The first patient we did got pregnant. 15:32.980 --> 15:34.170 I thought great. 15:34.180 --> 15:36.040 The next five did not get pregnant. 15:36.050 --> 15:37.400 So that's where we stand. 15:37.400 --> 15:38.280 Cryosurgery. 15:38.280 --> 15:39.880 For the hypoplastic 15:39.890 --> 15:41.920 epithelium. 15:42.400 --> 15:45.360 Dr Townsend freezes the lower half of the canal 15:45.360 --> 15:46.360 for me. 15:46.630 --> 15:49.300 And I'm going by what he tells me as they 15:49.310 --> 15:51.460 regenerate regrow the epithelium. 15:52.020 --> 15:53.880 He thinks they've gotten better. 15:54.660 --> 15:57.150 Now I don't know the mucus has gotten 15:57.150 --> 15:58.320 slightly better. 15:58.330 --> 16:01.330 And one and one patient the patient got pregnant 16:01.330 --> 16:02.510 really did improve. 16:02.520 --> 16:03.990 She got pregnant. 16:04.000 --> 16:06.080 The third cycle after cryosurgery. 16:06.080 --> 16:07.620 It takes about two months for him to heal. 16:08.080 --> 16:10.910 So if you have a very bloody tap every time you 16:10.910 --> 16:13.660 try to get mucus I would help us cope them 16:13.740 --> 16:16.510 and if it looks like a very fragile epithelium and if the 16:16.510 --> 16:17.670 culture is negative. 16:17.680 --> 16:20.120 Go ahead use cryosurgery for those patients. 16:20.530 --> 16:22.640 These five insemination here, 16:22.650 --> 16:23.820 none of them have gotten pregnant. 16:23.820 --> 16:26.130 Interest circle insemination doesn't seem to work. 16:26.160 --> 16:28.930 That's why we've gone to intra uterine washed 16:28.940 --> 16:31.880 sperm insemination and none of them responded to. 16:31.880 --> 16:34.670 Still best I still like still best 16:34.670 --> 16:36.480 draw because at 50.1, 16:37.190 --> 16:38.420 excuse me 16:39.330 --> 16:42.150 at 0.1 mg is still best for all. 16:42.160 --> 16:45.120 I get good response with a cervical mucus. 16:45.570 --> 16:48.400 At 0.2 I get slightly I 16:48.400 --> 16:50.270 improved my number of 16:50.280 --> 16:52.540 improved response 16:52.550 --> 16:54.850 group but I don't suppress 16:54.850 --> 16:55.640 ovulation. 16:55.680 --> 16:58.400 Now you get to 20 micrograms Anthony 16:58.400 --> 17:01.340 Lester dial or 200.65 of Premarin 17:01.340 --> 17:04.170 you're going to have a lot more ovulation suppression or at 17:04.170 --> 17:05.780 least delayed ovulation. 17:06.250 --> 17:08.370 So I'm still a still best straw man. 17:08.370 --> 17:11.350 I think it's just it's just as good if not better 17:11.350 --> 17:12.870 than the other estrogens to use. 17:12.880 --> 17:15.710 And you most certainly are not going to cause that uh 17:15.720 --> 17:18.430 diagnosis of the vagina using 1/10 of 17:18.430 --> 17:21.130 milligram and not during organogenesis. 17:21.170 --> 17:23.630 I give it to them not in these groups, 17:23.640 --> 17:24.780 these patients the other. 17:24.780 --> 17:27.120 So I'm gonna present between days 17:27.130 --> 17:29.640 five and 20 of each cycle 17:30.330 --> 17:31.520 when I use the best role. 17:31.520 --> 17:32.080 Next slide. 17:32.090 --> 17:35.060 Now there are patients that have cervical 17:35.060 --> 17:35.390 mucus, 17:35.390 --> 17:37.900 there's two kinds quality and quantity. 17:37.910 --> 17:40.880 This is the patient that has thick 17:40.890 --> 17:43.860 yellow cervical mucus and there's a patient that has 17:43.870 --> 17:46.280 clear but scanty cervical mucus, 17:46.290 --> 17:49.260 both these patients are treated with still best oral estrogen 17:49.260 --> 17:49.730 therapy. 17:49.740 --> 17:52.440 Next I give one 17:52.440 --> 17:55.280 mg days five through 20 and 17 17:55.280 --> 17:56.840 did not improve in this group. 17:56.850 --> 17:58.340 And 11 improved. 17:58.350 --> 18:00.300 Next slide by improved. 18:00.300 --> 18:03.070 I mean they had normal spin bar kind of the ones that 18:03.070 --> 18:03.540 improved. 18:03.540 --> 18:06.220 The 11 that improved this post coital test 18:06.220 --> 18:08.760 before was zero postcoital test 18:08.760 --> 18:11.500 after was right here listed. 18:11.510 --> 18:14.390 And out of the 11 that improved six of them 18:14.400 --> 18:16.600 got pregnant and I leave them on 18:16.600 --> 18:17.440 indefinitely. 18:17.450 --> 18:18.160 Next slide 18:19.490 --> 18:22.330 Now the 35 patients that had 18:22.340 --> 18:24.670 abnormal quantity scanty mucous. 18:24.670 --> 18:27.510 They're better than the ones that have enough mucus. 18:27.510 --> 18:30.510 But I think that's a bad group but half of 18:30.510 --> 18:33.460 them will improve on still best strong of the improved 18:33.460 --> 18:33.840 group. 18:33.840 --> 18:36.560 Next slide Of the 18:36.560 --> 18:39.210 18 that improved zero sperm at the 18:39.210 --> 18:41.810 postcoital test before treatment and then the 18:41.810 --> 18:44.100 sperm after treatment. 18:44.110 --> 18:45.950 five out of the 18 got pregnant. 18:47.590 --> 18:48.540 Next line. 18:49.310 --> 18:52.090 Now the abnormal postcoital test with 18:52.090 --> 18:53.550 normal cervical mucus. 18:53.550 --> 18:55.450 Good spin bar kite clear mucus. 18:55.480 --> 18:58.390 No sells everything looks fine 18:58.390 --> 19:00.890 when you examine it and if you did dry it out like I 19:00.890 --> 19:03.610 do do that biophysical test, 19:03.620 --> 19:05.120 Good channel formation. 19:05.370 --> 19:08.350 And there are two kinds of patients are gonna see no sperm 19:08.360 --> 19:09.980 or immobilize sperm. 19:09.990 --> 19:12.980 Now the ones that had double factors have excluded 19:13.010 --> 19:15.260 of the lack of sperm penetration. 19:15.710 --> 19:18.480 I had 24 of them low semen 19:18.480 --> 19:19.240 volume. 19:19.250 --> 19:22.190 Not talked about very much less than 19:22.190 --> 19:23.120 two ml. 19:23.120 --> 19:25.280 On more than one examination. 19:26.190 --> 19:27.260 Now with. 19:27.260 --> 19:28.250 Normal sperm camp. 19:29.250 --> 19:31.720 These patients ought to have the Mile X. 19:31.720 --> 19:33.000 Cup insemination. 19:33.800 --> 19:35.530 I'll show you the results of that. 19:35.540 --> 19:37.910 Allah go sperm you less than 20. 19:37.980 --> 19:40.950 Andrology haven't been able to increase the sperm count. 19:40.960 --> 19:43.890 And since most of the sperm are on the sheets in 20 minutes 19:43.890 --> 19:46.750 it seemed logical to us to keep them from getting on the 19:46.750 --> 19:48.570 sheets and keep them on the Cervix. 19:48.580 --> 19:50.570 So we start cupping oligarchs, 19:50.570 --> 19:53.450 sperm were very practical in southern California 19:53.480 --> 19:54.570 just like San Antonio. 19:54.690 --> 19:57.480 And then four of my patients had 19:57.480 --> 19:58.140 as a sperm. 19:58.850 --> 20:01.670 And when we did the same analysis so those are 20:01.890 --> 20:03.650 the lack of sperm penetration 20:04.760 --> 20:05.980 immobilize sperm. 20:07.190 --> 20:09.090 You do you get good cervical mucus. 20:09.090 --> 20:09.660 You look in there, 20:09.660 --> 20:10.770 they're all mobilized. 20:10.780 --> 20:13.650 Everybody thought that is a immunological factor and it is 20:13.650 --> 20:16.640 not by our methods of immune checking 20:16.640 --> 20:17.460 the immunology. 20:17.470 --> 20:20.250 What we did was we thought well the vagina 20:20.260 --> 20:21.980 must be playing some role. 20:22.590 --> 20:25.280 So we bypass the vagina with a cup, 20:25.290 --> 20:28.080 we do a cup and then a one hour 20:28.080 --> 20:29.250 later postcoital test. 20:29.250 --> 20:32.030 In other words the first time the patient comes in with 20:32.040 --> 20:33.490 this kind of a diagnosis 20:34.260 --> 20:36.890 after the first post coital test. 20:36.900 --> 20:39.230 I then schedule them for a post coital test. 20:39.230 --> 20:42.200 But instead of having intercourse at home I have them come in with a 20:42.200 --> 20:43.340 fresh semen specimen, 20:43.740 --> 20:46.670 I clean off the vagina and the cervix put the cervical 20:46.670 --> 20:48.540 cup on and they come in different sizes. 20:48.570 --> 20:49.730 Put the semen in, 20:49.740 --> 20:51.970 have them do whatever they want to do for an hour, 20:51.980 --> 20:54.250 come back and I take off the cup, 20:54.260 --> 20:57.260 wipe off the cervix and do my post coital test. 20:57.260 --> 20:59.790 Following a cup insemination and if they 20:59.790 --> 21:01.650 improve then I use it for therapy. 21:02.000 --> 21:04.880 If I can't improve it then I don't have any 21:04.880 --> 21:06.880 way to treat the problem. 21:06.890 --> 21:09.420 So immobilized group instead of going right to the 21:09.420 --> 21:10.320 immunology, 21:10.330 --> 21:12.910 I would suggest that you schedule them for a cup. 21:12.920 --> 21:13.760 Postcoital test, 21:13.760 --> 21:16.510 one hour interval between the cup and the postcoital test. 21:16.520 --> 21:18.730 And we had seven 21:19.670 --> 21:22.500 that had improved tremendous number of sperm 21:22.510 --> 21:24.490 when we bypass the vagina. 21:24.600 --> 21:26.830 I put unexplained or vaginal factor. 21:26.830 --> 21:27.810 I don't know what that means. 21:28.480 --> 21:31.100 And 11 of them are just showed no 21:31.100 --> 21:31.510 improvement. 21:31.510 --> 21:32.920 They still had to mobilize sperm. 21:33.010 --> 21:35.890 Next line of the here's the 21:35.890 --> 21:37.220 cup for those that haven't seen it. 21:37.220 --> 21:38.170 It's a poor slide. 21:38.180 --> 21:38.850 It's a mile X. 21:38.850 --> 21:40.380 Comes in different diameters here. 21:40.380 --> 21:41.230 Here's the valve. 21:41.400 --> 21:43.170 You put the cup on first, 21:43.170 --> 21:44.800 you turn it upside down with the dome up, 21:44.800 --> 21:45.500 slip it in, 21:45.550 --> 21:46.530 flip it around, 21:46.540 --> 21:49.160 put it on the cervix and then you put the 21:49.160 --> 21:50.000 semen in, 21:50.150 --> 21:52.690 then push that ball valve down here, 21:52.700 --> 21:53.680 fold the stem up, 21:53.680 --> 21:54.530 leave it in the vagina. 21:54.540 --> 21:55.870 Leave it on for an hour, 21:55.950 --> 21:58.350 repeat the postcoital test following the cup. 21:58.350 --> 21:59.440 If you get improvement, 21:59.650 --> 22:02.470 then use it for treatment and do it admit cycle 22:02.670 --> 22:03.620 instead of one hour. 22:03.620 --> 22:06.460 Then I leave it on four hours and teach the patient how 22:06.460 --> 22:07.320 to pull it off, 22:07.330 --> 22:08.430 Take it off at home. 22:09.150 --> 22:09.900 That's just a cup. 22:09.910 --> 22:12.710 Next line of the 22:12.720 --> 22:13.820 low volume patients. 22:13.820 --> 22:16.600 I cupped them using the cup technique. 22:17.400 --> 22:20.320 And these are the number of cycles that they were cupped and I 22:20.320 --> 22:22.660 had three out of six patients got pregnant. 22:22.830 --> 22:25.180 And I want eight cycles on this patient. 22:25.180 --> 22:26.290 She didn't get pregnant. 22:26.310 --> 22:29.140 And in other words most of the pregnancies occur within four 22:29.140 --> 22:29.630 cycles. 22:29.630 --> 22:32.460 So I offered as therapy to a poor postcoital 22:32.460 --> 22:35.260 test with normal cervical mucus for ah little 22:35.260 --> 22:38.200 sperm or for a cup 22:38.260 --> 22:39.550 for low volume. 22:39.640 --> 22:41.950 I use it as therapy until the astrologists can 22:41.950 --> 22:44.070 improve these male factors. 22:44.420 --> 22:46.220 We have three out of six pregnancies here. 22:46.220 --> 22:48.250 Next slide mm 22:49.320 --> 22:52.160 To spur me a marked improvement with a 22:52.160 --> 22:52.590 cup. 22:53.250 --> 22:55.060 We have 14 of them. 22:55.070 --> 22:57.770 10 of them improved in a normal 22:57.770 --> 23:00.530 range of postcoital test from an abnormal range. 23:00.540 --> 23:03.340 Just using a simple technique of holding 23:03.350 --> 23:06.220 most of the semen against the service plain 23:06.230 --> 23:07.120 common sense. 23:07.120 --> 23:08.380 You can't increase number, 23:08.390 --> 23:10.070 you can increase time exposure. 23:10.080 --> 23:12.900 Five out of 10 patients got pregnant. 23:13.670 --> 23:16.490 Next slide Now if the postcoital 23:16.490 --> 23:17.710 test doesn't show improvement. 23:17.710 --> 23:19.850 Don't use the cup technique for therapy 23:20.620 --> 23:21.840 Immobilization. 23:21.850 --> 23:23.350 We had 18. 23:23.360 --> 23:25.830 We cut them and out of the Cup seven. 23:25.830 --> 23:28.380 Those are the seven that I talked about 23:28.380 --> 23:30.580 earlier and 11 did not improve. 23:30.590 --> 23:33.490 Out of these patients without any immunological testing. 23:33.490 --> 23:34.860 We had three pregnancies. 23:34.870 --> 23:36.310 Next slide 23:37.400 --> 23:38.480 All the patient, 23:38.480 --> 23:39.140 not all of them. 23:39.360 --> 23:39.910 Some 80. 23:39.910 --> 23:42.800 Some patients here were evaluated with 23:42.800 --> 23:44.610 Kendrick is Tajima Franklin Dix 23:45.310 --> 23:47.920 And including the mobilization uh 23:47.930 --> 23:48.850 group right here, 23:48.860 --> 23:51.070 18 of them none of them had a positive test. 23:51.080 --> 23:53.940 I had one positive kid brick test in lack of sperm 23:53.940 --> 23:54.690 penetration. 23:55.240 --> 23:57.970 So I don't know if it's a method the 23:57.970 --> 24:00.000 testing method for immunological testing 24:00.670 --> 24:03.650 or whether we ought to be looking at the cervical mucus as a 24:03.650 --> 24:06.160 better system for looking for immunological 24:06.160 --> 24:06.840 factors. 24:06.860 --> 24:07.580 I'm not sure. 24:07.580 --> 24:10.460 But it does not seem to be related immunological 24:10.460 --> 24:13.430 factors and bad postcoital tests don't seem 24:13.430 --> 24:16.050 to be related with our present methods of 24:16.050 --> 24:16.600 testing. 24:17.710 --> 24:20.630 Next line again, 24:20.640 --> 24:22.860 the percentage anatomical defects, 24:22.870 --> 24:23.850 abnormal mucus, 24:23.850 --> 24:25.880 abnormal postcoital test with normal mucus. 24:25.880 --> 24:28.060 Just what I gave you earlier. 24:28.070 --> 24:30.750 The overall results are not very good. 24:30.760 --> 24:31.330 Next. 24:31.340 --> 24:33.300 With all my pregnancies added up. 24:33.670 --> 24:36.410 Take everything I had that I gave you. 24:36.420 --> 24:37.570 If there's stenosis, 24:37.570 --> 24:38.230 dilatation, 24:38.230 --> 24:39.320 cryosurgery. 24:39.330 --> 24:41.700 Now we're going to enter you know and washed 24:41.700 --> 24:43.360 sperm insemination, 24:43.370 --> 24:44.460 abnormal mucus. 24:44.460 --> 24:44.720 D. 24:44.720 --> 24:44.860 E. 24:44.860 --> 24:45.200 S. 24:45.240 --> 24:46.860 Low semen volume cup. 24:46.870 --> 24:48.450 Olive go spur me a cup, 24:48.460 --> 24:50.180 immobilize sperm cup, 24:50.190 --> 24:51.640 putting all this together. 24:51.640 --> 24:53.620 The number of patients for them. 24:53.630 --> 24:56.460 I couldn't there was not enough of a follow up. 24:56.470 --> 24:58.780 We dropped them out of their number of pregnancies. 24:58.780 --> 25:00.000 That's only 22%. 25:00.670 --> 25:03.470 If you look at the improved group. 25:03.470 --> 25:06.210 In other words you give them the es remember 25:06.220 --> 25:08.950 some of improved some of them then if you 25:08.960 --> 25:11.890 do a postcoital test following a cup before you 25:11.900 --> 25:13.450 introduce it as therapy. 25:13.460 --> 25:15.500 And if you get improvement and use it. 25:15.510 --> 25:17.660 If I look at the improved group. 25:17.670 --> 25:20.230 The pregnancy rate is over 40%. 25:20.840 --> 25:23.330 So these are the figures I use in talking to my 25:23.330 --> 25:26.030 patients and trying to give them the prognosis of a 25:26.030 --> 25:28.870 cervical factor one to make a diagnosis 25:28.880 --> 25:30.790 to to predict what you can do for them. 25:30.940 --> 25:33.940 And we're using these techniques of estrogen 25:33.940 --> 25:36.650 and cut at the present time until we get more 25:36.680 --> 25:37.600 sophisticated. 25:37.610 --> 25:39.370 And I think that's my last slide, 25:39.380 --> 25:39.910 isn't it? 25:40.450 --> 25:40.870 Yes, 25:40.880 --> 25:41.870 thank you very much. 25:44.060 --> 25:46.470 This program was produced through the mobile 25:46.470 --> 25:48.910 facilities of the television Branch, 25:48.920 --> 25:49.940 Health Sciences, 25:49.940 --> 25:50.850 Media Division, 25:50.930 --> 25:52.580 Academy of Health Sciences, 25:52.580 --> 25:53.960 United States Army, 25:54.200 --> 25:55.970 Fort SAm Houston texas.