Spinnbarkeit: A Characteristic of

Transcription

1 Spinnbarkeit: A Characteristic of Cervical Mucus Significance at Ovulation Time Melvin R. Cohen, M.D., Irving F. Stein, Sr., M.D., and Bernard M. Kaye, M.D. AccuRATE timing of ovulation is especially necessary ( 1) in artificial insemination in order to avoid wastage of donor semen; ( 2) in cases where the husband is relatively infertile and it is necessary to conserve his semen. While many physicians rely upon the basal body temperature curve for timing ovulation, the interpretation of such curves is varied. Some physicians believe ovulation occurs prior to the lowest point in the temperature cycle, while others believe that ovulation occurs either at the low point or following the thermal shift. We have been disappointed in our ability to interpret the basal body temperature curve for accurate timing of ovulation, and have placed greater reliance upon concurrent phenomena, such as changes in the quantity and viscosity of cervical mucus and the cyclic changes observed in the vaginal smear. Although the relationship between the occurrence of a profuse, thin cervical mucus discharge and the optimal time of fertility in the human has been recognized for the past century, in our opinion this relationship requires further evaluation. In his excellent review, "Cervical mucus: Cyclic variations and their clinical significance," Shettles quotes Robin who, in 1848, noted the viscous nature of human cervical secretions; and Smith who, in 1865, concluded that conception is most likely when the mucus contents of the cervix are in the most fluid condition. J. Marion Sims, who invented a vaginal speculum From Michael Reese Hospital, Chicago, Illinois. 201

2 202 COHEN ET AL. [Fertility & Sterility and first described the postcoital examination in 1868, observed that the test is positive for motile spermatozoa when the cervical mucus becomes clear and translucent, and about the consistency of the white of egg. Although these observations on human cervical mucus have been well documented, they have been almost disregarded by gynecologists. The significance of the cyclical outpouring of cervical mucus has been rediscovered in the past few years and has aroused great interest among students of sterility. The optimal time of fertility in domestic animals is the period of heat or 1. Thin, profuse, clear 2. Easy to aspirate 3. Spinnbarkeit _...JL (Thread formation) / :710 to 20 em. 4. Sperm &urvival optimal 6ood motility Numei'OIIS spermatozoa 5. ~ cell& normally absent Thick, scant, turhid Difficult to aspirate Spinnbarkeit (Thread formation)~ Oto lcm. ~ Sperm Sllrvival poor Poor motility 0 to few spermatozoa Pus cells usually present FIGURE l. Cervical mucus changes in the menstrual cycle. estrus. In 1925 Woodman and Hammond showed that during estrus, bovine cervical mucus is fluid and capable of being drawn out into threads, whereas in diestrus the mucus is thick. Seguy and Vimeux, and Seguy and Simonnet called attention to the optimal conditions of longevity of human spermatozoa in the fluid, glairy mucus of the cervix at midcycle. They postulated that these changes in cervical mucus were associated with ovulation and could be compared to the period of estrus in subprimate mammals. They correlated these changes with visual evidence of ovulation at laparotomy. Subjectively, many women observe an increased sticky, mucoid discharge which is typical at midcycle and which is present over a period of days. On occasion this discharge is blood-tinged and may be compared to the distinct bloody mucoid discharge present in the domestic animal "in heat." This mucus can be seen exuding from the cervix at midcycle and it may be aspirated from the endocervix and actually weighed, as reported by Viergiver and Pommerenke. Clift demonstrated certain rheologic properties

3 Vol. 3, No. 3, 1952] SPINNBARKEIT 203 of cervical mucus, especially flow elasticity and Spinnbarkeit. Flow elasticity, or elastic recoil of mucus, is measured by an instrument described by Blair. The use of the Blair capillary viscometer is a cumbersome method which we discontinued. We have had no experience with the new modification of the viscometer described by Clift, Glover, and Blair. Spinnbarkeit is easily tested and we have found it to be a very practical objective method for determining viscosity of cervical mucus. In performing this test (Fig. 1), a vaginal speculum is inserted, exposing the cervix. A glass cannula is inserted into the endocervix and by means of gentle suction, a quantity of endocervical mucus is obtained. This mucus is blown onto a glass slide and a cover slip is placed on it. The mucus adheres to both the slide and the cover slip, and by withdrawing the cover slip, a thread of mucus is formed which can be measured in centimeters (Fig. 2). Usually the cover FIGURE 2. Technic of aspirating cervical mucus using glass cannula and 10 cc. syringe. slip is withdrawn several times and the average length of the thread is ascertained. It is our purpose to show the relationship of Spinnbarkeit to other cyclic phenomena occurring during the menstrual cycle, such as basal body temperatures, vaginal smears, quantity of cervical mucus, and longevity of spermatozoa (Fig. 3). METHOD Observations on a group of 16 patients successfully inseminated, using donor semen, form the basis for this report. The indications for artificial insemination in this group were as follows: Azoospermia, 10 patients; oligospermia, associated with poor motility and a high percentage of abnormal forms, 4 patients; necrospermia, 2 patients. These women were instructed to take their basal body temperatures rectally, and to report at our office

4 204 COHEN ET AL. [Fertility & Sterility each day after the menstrual period for observations of vaginal smears and cervical mucus. Following artificial insemination, daily observations were made regarding longevity of spermatozoa in the cervical mucus. The vaginal speculum was inserted, without lubrication, and the routine procedure then followed was: ( 1) A small amount of vaginal secretion from l /-~ ~1l:d" SPINN8ARICEIT I CM. 6 C.hl. IS C:M. 12 Chi. 3CM. CERVICAL MUCUS ~~ ~ '41SCOSITY THICK MODERATE THIN THIW THICK QUANTITY + -+lti- lit + * LEUCOCVTES -Htt.ft 0 0 * SPERM SURVIVAL t -H+t + "" VAGINAL SMEAR El\FOLIATI\IE ~~ FrcuRE 3. Time of optimal fertility, showing correlation of various indications. the posterior fornix was plated on a glass slide and immediately immersed in equal parts of alcohol and ether, according to the method of Papanicolaou, and stained by means of the rapid Schorr stain. The degree of vaginal cornification was ascertained, using Rubenstein's criteria. ( 2) The tip of a glass cannula was inserted into the endocervix, and by means of gentle suction, a quantity of endocervical mucus was obtained for examination. This was blown out upon a glass slide and an estimation of the amount, from 0 to ++++ (profuse) was made. A glass cover slip was then placed upon this

5 TABLE 1. Comparison Between the Time of: (1 I Thermal Shift in the Basal Body Temperaturei (2) Thin Cervical Mucorrheai (3) Maximal Spinnbarkeit; (4) Optimal Vaginal Smear Cornifkationi (5) Longevity of Spermatozoai (6) Successful Artificial Insemination in 16 Patients Length of cycles in days Vaginal Optimal Pt. Day before Duration of Maximal smear longevity of Artificial No. Minimum Maximum Mode temp. rise profuse mucus Spinnbarkeit cornified spermatozoa insemination , , 16, , , , , , , 18, 19, , 10, , , 13, , , 16 Numbers (except in column 1) refer to day of cycle following onset of previous menses.

6 206 COHEN ET AL. [Fertility & Sterility blob of mucus and the Spinnbarkeit measured in centimeters. The cover slip was then replaced and the slide examined for the presence of white blood cells, red blood cells, and spermatozoa. RESULTS Table 1 shows a comparison between the time of: ( 1) thermal shift in the basal body temperature; ( 2) thin cervical mucorrhea; ( 3) maximal Spinnbarkeit; ( 4) optimal vaginal smear cornification; ( 5) artificial insemination; ( 6) longevity of spermatozoa. The basal body temperature was biphasic in all cases, but 4 patients demonstrated rather poor biphasic curves. Thermal shift occurred from Day 10 to Day 21 following onset of TABLE 2. Relationship of Maximal Spinnbarkeit to Basal Temperature Shift No. patients ToTAL: 16 Basal temperature shift 5 days before 4 days before 2 days before 1 day before Day of shift 1 day after Excellent Spinnbarkeit on Days 15 to 18 with shift on Day 16 previous menses, and the degree of shift varied between 0.2 and 1.0 F. The thin mucorrhea lasted from two to seven days, with a mode of three to four days. Maximal Spinnbarkeit occurred from Day 10 to Day 20. At the time of maximal production of cervical mucus, the Spinnbarkeit reached a length of em. There was close correlation between maximal Spinnbarkeit and optimal cornification in the vaginal smear. Longevity of spermatozoa paralleled the degree of Spinnbarkeit. Table 2 shows the relationship between the time of maximal Spinnbarkeit and the time of thermal shift. There were 9 patients in whom maximal Spinnbarkeit occurred before the thermal shift. Of these, 5 showed maximal Spinnbarkeit one day before the thermal shift; 2, two days; 1, four days; and 1 five days before the thermal shift. In 4 patients, maximal Spinnbarkeit occurred on the day of thermal shift. In 1 patient, there was excellent

7 Vol. 3, No.3, 1952] SPINNBARKEIT 207 Spinnbarkeit on four consecutive days, Days 15 to 18, with the1;mal shift occurring on Day 16. In this selected group of 16 patients, leukocytes completely disappeared from the cervical secretion at the time of thin profuse mucorrhea and maximal Spinnbarkeit. In other patients whom we have treated, we have found that when the leukocytes do not disappear at this time, it is because of chronic endocervicitis which requires therapy. Patient 4 (Table 1) returned to us for artificial insemination when her first child was si,x months old. She was unable to take basal body temperatures because she was awakened many times during the night to care for her infant. Beginning on Day 9, she reported for daily vaginal smears and cervical mucus studies. This patient was inseminated only once, on Day 12, and promptly conceived. On this day, the vaginal smear was precornified, and the quantity of cervical mucus was++++; it was thin and showed a Spinnbarkeit of 10 em. Twenty-four hours later, on Day 13, the mucus was thicker, with a Spinnbarkeit of 3 em. and contained a few Grade II (sluggish) spermatozoa per high power field. At the time of writing, the patient is five months pregnant. DISCUSSION There are some conditions not associated with ovulation which may induce an outpouring of profuse, clear cervical mucus. For example, the administration of estrogens in the castrate will produce this type of mucus, although the duration of mucorrhea will depend upon the amount of estrogenic substance given and the time when this medication is stopped. On the other hand, progesterone will diminish the quantity and cause thickening of cervical mucus in the estrogen-primed castrate. In the normal pregnant state, estrogenic therapy will not affect the characteristic thick plastic type of mucus plug which some observers have felt was diagnostic of pregnancy. In the stilbestrol treatment of threatened and habitual abortion, a finding of profuse thin mucorrhea is evidence, in our experience, of a missed or pending abortion. Some patients exhibiting the bilateral polycystic ovary syndrome have shown persistent, thin cervical mucorrhea. This cervical discharge is not as profuse as that seen in fertile patients at ovulation time; its Spinnbarkeit is consistently low, varying from 3 to 5 em. Two patients with secondary amenorrhea not associated with polycystic ovaries were treated with mare's

8 208 COHEN ET AL. [Fertility & Sterility serum hormone. This stimulated a profuse mucorrhea of the characteristic thinness and thread formation which we see in normal women at ovulation time. In these two patients, although a menstrual period was induced, endometrial biopsy demonstrated only proliferative endometrium. In the average normal patient, the outpouring of cervical mucus of the type described is associated with impending ovulation (Fig. 3). Our results are in accord with Per Bergman's impression that the optimal time of fertility coincides with the "water phase of the cervical mucus; i.e., that phase of the cycle immediately preceding and coinciding with the thermal shift." The observations on cervical mucus are practical, simple, and clinically rewarding. This is significant for those patients requiring donor insemination and especially for patients with husbands of diminished fertility. An occasional patient will show no outpouring of cervical mucus throughout the cycle. Such women either have anovulatory cycles or have cervices which are refractory to estrogenic stimulation. An example of the latter is a patient who previous to our study had an extensive cauterization for chronic cervicitis with subsequent destruction of the cervical glands. The amount and thinness of the cervical mucus may be improved by the administration of small doses of stilbestrol ( mg. once daily) without inhibiting or delaying ovulation. In a previous communication, we demonstrated that the longevity of spermatozoa was increased by estrogenic administraton. The vaginal smear technic is valuable as a rough assay of estrogenprogesterone activity. Inasmuch as long training and experience are required to interpret changes in the smear incident to ovulation, the smear technic cannot be recommended as a simple routine aid in the detection of ovulation. CONCLUSIONS 1. The determination of Spinnbarkeit is a simple clinical test for the viscosity of cervical mucus. 2. Maximal Spinnbarkeit usually precedes or coincides with the thermal shift in basal body temperatures. 3. When artificial insemination is indicated, it is most successful if performed when the cervical secretion is profuse, thin, acellular, and exhibits maximal Spinnbarkeit.

9 Vol. 3, No. 3, 1952] SPINNBARKEIT 209 REFERENCES 1. Bergman, Per: Acta obst. & Gynec. Scandinav. (Suppl. 4), Vol. 29, Blair, G. W. S.: Kolloidzschr. 78:19, Clift, A. F.: Proc. Roy. Soc. Med. 39:1, Clift, A. F., Glover, F. A., and Blair, G. W. S.: Lancet 1:11.54, Cohen, M. R., and Stein, I. F.: Fertil. & Steril. 2:20, Rubenstein, B. B., and Guterman, H.: Am. J. Obst. & Gynec. 50:565, Seguy, J., and Simonnet, H.: Gynec. et obst. 28:657, Seguy, J., and Vimeux, J.: Gynec. et obst. 27:346, Shettles, L. B.: Obst. & Gynec. Surv. 4:614, Sims, J. M.: Brit. M. J. 2:465, Viergiver, E., and Pommerenke, W. T.: Am. J. Obst. & Gynec. 51:192, Woodman, H. E., and Hammond, J.: J. Agr. Sc. 15:107, Formation of International Fertility Association On October 18, 1951, in Rio de Janeiro, following the holding of the First Brazilian Congress on Sterility, delegates from twelve nations founded a new world medical society known as the International Fertility Association. Among the aims of this organization is that of working in conjunction with existing sterility societies in different parts of the world and holding international congresses at various important medical centers in the world. The first international meeting on fertility and sterility is scheduled to be held in conjunction with the ninth annual meeting of the American Society for the Study of Sterility in New York City, in May, For further information, write to Dr. Carlos D. Guerrero, Secretary-General, Miguel E. Schulz No. 19, Mexico, D. F., or to Dr. Abner I. Weisman, Associate Secretary-General, 1160 Fifth Avenue, New York 29, N.Y.