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Cervix
Case: 30 year old G0 with a history of regular menstrual intervals every 27 x 4-5 days, a normal hormone evaluation (TSH and Prolactin concentration), basal body temperature (BBT) charting suggesting ovulation about 13-14 days prior to the onset of a subsequent menstrual flow, a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, an abnormal postcoital test (PCT) on cycle day 11 revealing no motile sperm per high power field 8 (eight) hours after intercourse, and a husband with proven fertility (one pregnancy in a previous relationship) and a normal semen analysis.
Question: What further testing or treatments should be considered in this situation?
Answer: If an abnormal postcoital test result is identified during the basic infertility evaluation then I consider intrauterine inseminations (IUIs) as a simple, relatively painless, low cost, and effective treatment option.
The reason for the abnormal postcoital test result is rarely identified since further diagnostic testing to identify whether the problem involves “hostile cervical mucus” or “cranky sperm” is generally not suggested because the results do not generally change the management plan (ie., IUIs).
Alternative treatments of abnormal cervical mucus (to make it more friendly to sperm) include alkaline douching, preovulation estrogen treatment, and robitussin (a mucolytic agent). I only suggest treating an abnormal postcoital test with these alternative treatments as a last resort, when IUIs are not (readily) available. For example, I had a patient who treated her hostile cervical mucus with baking soda douches just prior to intercourse since she lived a far distance from my office (a several hour drive) and her husband had a disability that made the possibility of IUIs very difficult. This patient did indeed become pregnant with alternative management.
One downside to the treatment(s) for an abnormal postcoital test is that ovulation normally only occurs monthly and the reproductive efficiency of a normal fertile couple is only about 20-25% per cycle (of trying). Therefore, the effectiveness of any cervical mucus treatment (to bypass a mucus barrier to sperm) in otherwise “unexplained infertility” is determined by the couple achieving a pregnancy and this normally takes several months (even for a normal fertile couple) to accomplish. Many couples are very disappointed if they try a “medical” treatment of abnormal cervical mucus and find that they are not pregnant within 3-6 months such that they need to re-consider (“starting over” with) IUIs.
Case: 26 year old G1 P1 with a history of regular menstrual intervals every 28-30 x 5 days, a normal hormone evaluation (TSH and Prolactin concentration), basal body temperature (BBT) charting suggesting ovulation about 12-13 days prior to the onset of a subsequent menstrual flow, a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, an abnormal postcoital test (PCT) on cycle day 10 revealing 0-1 motile sperm per high power field 5 (five) hours after intercourse, and a husband with proven fertility (one pregnancy with patient) and a normal semen analysis.
Question: What treatments should be considered in this situation? How could the couple have become pregnant in the past if the postcoital test is abnormal now?
Answer: A normal fertile couple is generally thought to have a 20-25% chance of pregnancy per attempted cycle. If the postcoital test is abnormal in a couple with otherwise “unexplained infertility” (following a full diagnostic infertility evaluation) then the couple still reportedly has a 4-5% chance of pregnancy per cycle of trying.
This means that the couple would occasionally be expected to get pregnant even with an abnormal postcoital test result, just at a markedly reduced rate of efficiency. Intrauterine inseminations bypass the sperm mucus interaction problem and therefore should restore the couple to a 20-25% chance of success per cycle. This 4-5 fold increase in reproductive efficiency for couples with an abnormal postcoital test is often well worth the relatively low expense and minimal involvement required for the IUI procedure.
Case: 32 year old G0 with a history of regular menstrual intervals every 24-25 x 3 days, a normal hormone evaluation (TSH and Prolactin concentration), basal body temperature (BBT) charting suggesting ovulation about 13 days prior to the onset of a subsequent menstrual flow, a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, an abnormal postcoital test (PCT) on cycle day 14 (of a 24 day cycle) revealing scanty thick cellular cervical mucus with no motile sperm per high power field 8 (eight) hours after intercourse, and a husband with proven fertility (two pregnancies in a previous relationship) and a normal semen analysis.
Question: What further testing or treatments should be considered in this situation?
Answer: The timing of the postcoital test with regard to the timing of ovulation is critical. The postcoital test should be performed within a few days prior to ovulation, but not following ovulation (since the elevated progesterone concentration makes cervical mucus less “friendly” to sperm).
In this situation, the woman has regular but short intermenstrual intervals lasting about 24-25 days and the BBTs suggest that ovulation occurs about 13 days prior to ovulation. Therefore, this woman usually ovulates on about cycle day 10-12. The postcoital test that was performed on cycle day 14 of a 24 day cycle revealed scanty thick cellular cervical mucus (characteristic of postovulatory changes that occur in cervical mucus) since she most likely ovulated on day 10 or 11 of this cycle.
Whenever I believe that the postcoital test is timed after ovulation I repeat the study prior to ovulation on a subsequent cycle. I then base my treatment recommendations on the results of the properly timed postcoital test.
Case: 26 year old G0 with a history of regular menstrual intervals every 28-30 x 4-5 days, a normal hormone evaluation (TSH and Prolactin concentration), basal body temperature (BBT) charting suggesting ovulation about 12-14 days prior to the onset of a subsequent menstrual flow, status post cryosurgery (“freezing”) of the cervix 4 years ago for abnormal pap smears (with normal pap smears subsequently), a hysterosalpingogram (HSG) revealing a normal uterine cavity and bilateral tubal patency, an abnormal postcoital test (PCT) on cycle day 13 (of a 29 day cycle) revealing a small amount of clear (“egg white”) acellular elastic cervical mucus with no motile sperm per high power field 6 (six) hours after intercourse, and a husband with unproven fertility yet a normal semen analysis.
Question: What further testing or treatments should be considered in this situation?
Answer: The postcoital test appears to be well timed by the menstrual history and the physical characteristics of the cervical mucus. The result is abnormal since no motile sperm were seen per high power (microscopic) field of view.
The usual recommendation for treatment of an abnormal postcoital test is intrauterine inseminations so as to bring the sperm into the uterine cavity (beyond the cervix and its mucus).
Many women have had surgery on their cervix for abnormal pap smears. One potential problem with (complication of) these cervical surgeries is the destruction of cervical mucus producing cells so that the amount (or quality) of the cervical mucus that is subsequently formed may be reduced. This reduction in the cervical mucus quantity or quality may result in an inability of sperm to live normally within this mucus (resulting in an abnormal postcoital test result). The relative damage to the cervical mucus producing cells caused by various types of cervical surgery (including cryosurgery, the LEEP procedure, cervical “cold knife” conization, and laser ablation of the transformation zone) is not clear.
Case: 30 year old G1 S1 (spontaneous pregnancy loss at 19 weeks gestation following painless dilatation of the cervix, preterm premature rupture of the membranes, and passage of the fetus) with a history of regular menstrual intervals every 28 x 5 days, a normal hormone evaluation (TSH and Prolactin concentration), a hysterosalpingogram (HSG) revealing a normal uterine cavity (without evidence of an incompetent cervix) and bilateral tubal patency, a normal postcoital test (PCT) on cycle day 13 revealing 8-15 motile sperm per high power field 10 (ten) hours after intercourse, and a husband with proven fertility (one pregnancy with the patient) and a normal semen analysis.
Question: What further testing or treatments should be considered in this situation?
Answer: The history of a 19 week pregnancy loss following painless dilatation of the uterine cervix, rupture of membranes and expulsion of the fetus is classic for an incompetent cervix.
The obstetrician caring for this patient’s next pregnancy will most likely recommend a cerclage (band placed in the cervix to hold it closed) at 12-14 weeks gestation based solely on this obstetrical history. If this is so then further diagnostic testing is not required (since the test results will not change the management plan).
Identification of an incompetent uterine cervix can be accomplished by (a) a history of an asymptomatic second trimester pregnancy loss with painless cervical dilatation and rupture of the membranes, (b) ability to pass a sterile cervical dilator into the nonpregnant uterus (an 8mm dilator should not be able to easily pass through a normal nonpregnant cervix), and (3) a hysterosalpingogram that reveals a dilated lower uterine segment and dilated cervical internal os (abnormal findings on HSG are not always identifiable).
During a subsequent pregnancy, serial ultrasound examinations can often identify if the cervix is shortening or dilating prior to placement of the cerclage. The cerclage is usually placed in the early second trimester to allow for development of the major organ systems (embryogenesis) and also to avoid trapping a chromosomally abnormal gestation (that would normally be spontaneously lost during the first trimester) within the uterus. Cervical scarring after placement of an external cerclage may result in an increase in cesarean section rates by about 15%.
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