Treatment Options for Negative Postcoital Test in Cervical Factor Infertility

Hanan A.J AL- Taee,Faris N. A. AL-Hady
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Keywords : Treatment Options,Negative Postcoital, Cervical Factor Infertility
Medical Journal of Babylon  6:1 , 2014 doi:1812-156X-6-1
Published :12 June 2014

Abstract

Thirty two infertile couples who have cervical factor as a cause for their infertility were investigated in Al-Amal clinic for infertility management. Causes of negative postcoital test were listed and treatment was stated. Significant improvement (p<0.05) of postcoital score after treatment noticed and total pregnancy rate (PR) was 37.5%. Intrauterine insemination achieved only 10% PR, for the patients who didn t respond to medical treatment. Cervical factor infertility needs special care and patience from the clinician, because it s easily treatable and can achieve good results after treatment.

Introduction

To manage infertile couples effectively the clinicians need a realistic and practical prediction of their chance of conception without treatment. If this is poor, the couples should proceed to definitive treatment immediately, otherwise they can be advised to continue trying to achieve a natural conception [1]. The Post Coital Test (PCT) of cervical mucus (CM) for detection of the presence of progressively motile sperm has become an important part of infertility investigation. It is used routinely in nearly half of infertility clinic in Britain and 2\3 of such clinic across Europe [2]. A PCT can suggest problems regarding the quality of the sperm or CM or the presence of antis perm antibodies. A negative test is only meaningful if it s repeatedly negative under perfect condition [3] The PCT has been the subject of controversy since it was first advocated by Sim s in 1866 [4]. Opinions are still divided as the value of the test in infertility investigation. From our opinion the PCT is useful monitor of sexual function, an indicator of sperm function, a barometer of periouvlatory hormonal status and a possible basic screen for the detection of cervical factor. Antagonists feel it s prognostic significance almost valueless [5-7]. The PCT is one of the most important tests in predicting the probability of spontaneous conception that lead to postponing of sometime harmful investigation and treatment [8-10]. This study is undertaken to examine clinically the many therapeutic potentialities provided to the physician in case of negative PCT, in an effort to determine it s role in infertility treatment.

Materials and methods

Thirty two infertile couples were
studied in Al-Amal Clinic for
Infertility Investigation and
Management, from April 2007 to
May 2008; the selection criterions of
the couples were:
1. Couples with primary infertility for
more than twelve months at first
presentation
2. Semen quality compatible with
conception.
3. Regular ovulatory cycle by Ultra
Sound (U\S), and normal hormonal
profile .. 4.Normal tubes provided by
hysterosalpingiography or laparoscopy.
5. Repeated negative PCTt.
6.Normal coital performance and
frequency.
Preovulatory phase PCT was done 6-
8 hours after coitus. Non-lubricated
speculum introduced into the vagina
gently. Mucus was aspirated with a
standard narrow 1 ml, 10 cm long
disposable syringe without needle.
Ductility (spinnbarkeit) was assessed,
CM parameters were noted and
judged according to criteria suggested
by Insler,et,al; [12] A sample of
mucus is then transferred onto a glass
slide and examined under the
microscope.The sperm were counted
and their degree of activity was
assessed . The sperm must be normal
in appearance and moving across the
slide and not shaking on the spot.
Results are considered valid only, if
mucus was in a good condition or if
the test had been repeated and timed
by (U\S) measurement of the follicle.
The pct was classified as follows:
positive: if at least one forward
progressing spermatozoon per field in
most (at least 5) high power field
(HPF). Negative: less than one
forward progressing spermatozoon in
most (HPF). [13-15] Negative results
need conformation in a second cycle.
Treatment was given according to the
result of the test, and the PCT was
performed before and after treatment
and the CM score as well. If
leukocytes were present, this indicate
an infection in either partner,
treatment with antibiotic was given
according to culture and sensitivity of
the CM, and we may prescribe an
antibiotic even the culture came back
negative [16].Both partner have been
treated to ensure that they are not
passing the disease back and forth .
To avoid exposing an early pregnancy
to antibiotic, the female take the drug
during the fallowing mense [17]. If
immunological cause is suspected by
presence of immotile spermatozoa or
shaking sperm on the spot, while the
original semen sample is normal; we
started the intermittent graduated dose
of prednisolon, together with condom
therapy for at least 3-6 months
[18,19]. Poor cervical mucus quality
and volume abnormality have been supplemented with a low dose oral
estrogen of 0.1-0.2 mg of
diethystilbestrol from 5th through the
thirteenth day of the cycle [20].
Acidic pH of CM was treated with
bicarbonate vaginal douches [21].
Unexplained poor pct or failed trial of
treatment was shifted to a series of
intrauterine insemination (IUI) with
the aid of ovarian stimulation
program with 100 mg clomiphen
citrate [22] from CD3-CD7 fallowed
by injection of 10,000 IU of human
chorionic gonadotropin. This is
fallowed 36 h later by artificial
insemination by husband sperm after
semen collection and preparation with
simple layer technique. Pregnancy
was based on positive pregnancy test
in urine.


Results

Antibiotic therapy was given according to culture and sensitivity results of CM; thirteen couples of our study group (40.6%) received such treatment and six couples show improvement of PCT and achieve pregnancy as well (PR: 46.5 %). The other seven couples, who didn t turn positive, underwent IUI courses. Short intermittent course prednisolone therapy was given to 12 couples (37.5%) who have been suspected to have immunological cause of their negative PCT. Four couples passed to negative PCT in the fallowing 3-6 months and PR was 33%. The remaining 8 couples have shifted to IUI program. Poor ferning, small volume CM was treated with estrogen therapy. Two pct scored proven to be better after treatment, (PR: 5%). Bicarbonate (NaHCO3) vaginal douches have been advised to acidic PH CM (n=3), pct score proved to be improved after NaHCO3 douching PR: 6%. So total PR was (37.5%) 12\32 with treating the cause. Twenty couples underwent IUI courses: only two become pregnant (PR 10%) the success rate of treatment show no significant difference (p>0.05) between treatment option offered according to Fischer exact test Table 1

Discussions

This study highlighted some treatment options for negative PCT in cervical factor infertility. Infection in either partner proved to be the cause in 40.6% of our study group, it was successfully treated and pregnancy rate after treatment was 46.5%. Inflammatory process and cell mediated immunological reaction in the cervix and vagina have been implicated as a causal factor in some causes of infertility, so routine cervical smear in causes of abnormal pct are useful in detecting couples with infertility , which maybe due to simple undetectable asymptomatic bacterial infection [16].Infectious organism in either partner may kill or maim sperm . Specific microorganism can be identified by performing culture of CM. Also we prescribe anti-biotic even if the culture came back negative [17] A poor PCT turned favorable after treatment with antibiotic (CM score were better after treatment than before treatment). The unexplained poor PCT is almost always due to presence of anti sperm antibodies in the CM or semen [23]. In immunological infertile patient, a PCT maybe negative even when no abnormality is observed in general semen test of the husband [23]. For unknown reasons 30% of all women produces anti bodies against sperm in CM. If a fairly recent semen analysis showed that unexposed sperm have normal forward motility, but the PCT shows them shaking or clumping, it ll suspect that the women is producing antibodies [18,24]. Steroid treatment is effective in treating sub fertile couples with antisperm antibodies, it suppress certain isotope in different lactation and improves sperm motility. Many steroid regimen have been advocated: long term low dose prednisolon; Intermitted high dose methyl prednisolon and intermittent graduated dose prednisolon [25,19], which was effective in treating our sub fertile couples. (PCT scores before treatment were <5, pct scores after were treatment >10). The 33% PR after short course intermitted prednisolon therapy was in accordance with that if Hendry and Sharma [25,19]. Mucus viscosity and volume abnormality maybe caused by surgical procedures performed on the cervix or by the use of clomiphene citrate used for ovulation induction. Twelve and half percent of our study group have this problem and have been treated satisfactorily with diethylstilbestrol of 0.1 - 0.2 mg from 5th-13th day of the cycle. One female have improved CM quality and have positive pregnancy test (PR :3%), the other failed to respond, and have been shifted to IUI program. Many researchers agreed that CM with good degree of ferning during the ovulatory period permits a better sperm penetration, and increase their possibility of conception [26]. Gibor, et,al; [27] and Everhardt, et,al; [21] , notice a great improvement of CM score after sodium bicarbonate vaginal douching (NaHCO3) . This was applied to 9.37 % who have negative pct. Acidic PH is unfavorable to sperm mucus penetration and is associated with infertility. PH measurement should be performed immediately after mucus collection to avoid misinterpretation of the result [28]. Glazener, et ,al ; [22], Friedman, et, al; [29] and Cohen, et, al; [30] , recommended IUI in case of negative PCT , while Oui, et, al; [31] advocate that IUI appeared of new benefit in case if infertility which was due to failure of sperm mucus penetration or defined by negative PCT . Twenty couples who attend our study underwent series of IUI for at least 3 cycles, only 2 (PR 10%) achieved pregnancy. These two couples were conclusively from the immunological case of negative PCT . This proves that washing the sperm from the antibodies by our preparation method, avoiding exposure to antibodies in semen and mucus. If IUI failed we can go IVF or ICSI [31]. On the basic of our study, pct will both prevent couples with good sperm function from having assisted reproductive technology unnecessarily and will also ensure that poor CM should proceed to necessary treatment without delay.

Conclusions

N/A

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