THE CERVICAL FACTOR IN INFERTILITY: DIAGNOSIS AND TREATMENT

FERTILITY AND STERILITY Copyright ' 1977 The American Fertility Society Vol. 28, No. 12, December 1977 Printed in U.S.A. THE CERVICAL FACTOR IN INFERTILITY: DIAGNOSIS AND TREATMENT JOSEF Z. SCOT!" M.D.* ROBERT M. NAKAMURA, PH.D. JOSEPH MUTCH, M.D. VAL DAVAJAN,M.D.t Department of Obstetrics and Gynecology, University of Southern California School of Medicine, and Los Angeles County-University of Southern California Medical Center, Los Angeles, California 90033 One hundred and fourteen women with an abnormal fractional postcoital test (pet) and no other demonstrable cause of female infertility were included in this study. By utilizing the results of the postcoital test, it was possible to divide the patients into three major groups: (1) those with an anatomical cervical defect, (2) those with abnormal cervical mucus, and (3) those with an abnormal pet and normal cervical mucus. In the latter group the abnormality was due to either an abnormal male factor or an undetermined factor. The treatment used in all cases was either steroidal (diethylstibestrol) or mechanical (cervical cup insemination). In 53 of the patients there was an improvement in the pet as a direct result of therapy. Twenty-three of these patients became pregnant~ pregnancy rate of 43%. Of the entire group of 110 patients (excluding 4 patients whose husbands had azoospermia), only 21% became pregnant. Of the 57 patients who failed to respond to therapy, 41 have been followed for 1 year, and only 2 pregnancies have been noted without therapy. No correlation was found between an abnormal pet and the immunologic factor. The reported prevalence of infertility due to abnormal transport of spermatozoa in cervical mucus (cervical factor) ranges from 10% to 30%1,2 This diagnosis is made by microscopic examination of postcoital cervical mucus obtained just prior to ovulation in the midcycle. Numerous methods have been used in performing the postcoital test (PCT); however, no attempt was made to standardize this procedure until the development of the fractional in vivo postcoital test. 3 At this medical center for the past 8 years this method has been utilized routinely in the work~up of the infertile couple. The purpose of this paper is to present a differential diagnosis of the cervical factor in a select group of infertile patients and to discuss the therapeutic measures available for treating this clinical problem. Received July 7, 1977; accepted August 11, 1977. *Supported by the R. S. McLaughlin Foundation, Canada. treprint requests: Val Davajan, M.D., 1240 North Mission Road, Los Angeles, Calif. 90033. 1289 MATERIALS AND METHODS One hundred and fourteen women with no other demonstrable cause of female infertility were included in the study. All women had presumptive evidence of ovulation as determined by endometrial biopsy and/or a serum progesterone determination obtained during the luteal phase of the menstrual cycle. 4 All patients had bilateral tubal patency as demonstrated by hysterosalpingography and laparoscopy. Patients with multiple infertility factors were excluded from the study in order to outline a differential diagnosis based only on an abnormal cervical factor. The fractional PCT was performed 1 to 3 days prior to the rise in basal temperature. In the majority of patients this procedure was performed prior to obtaining a semen analysis. All couples were instructed to abstain from intercourse for at least 2 days prior to the initial test. The cervical mucus samples were collected within 2 hours following intercourse, using a clear plastic

1290 SCOTTET AL. catheter and a technique previously described. 3 5 Following collection of mucus, the catheter was cut into four segments. The segment at the distal 0.5 cm of the catheter contained mucus corresponding to the level of the internal os of the endocervical canal. In all cases, spinnbarkeit and sperm counts were first determined on mucus obtained from the internal os segment. For the postcoital test to be considered normal, there had to be at least five motile sperm per high-power field (x400) showing forward progression. A spinnbarkeit of 6 cm or greater was considered to be normal. If the test was abnormal at the level ofthe internal os, each ofthe other three segments was examined for presence of sperm and spinnbarkeit. Patients with an abnormal PCT as the only demonstrable factor in their infertility work-up were subdivided into three major groups: (1) those with an anatomical cervical defect, (2) those with abnormal cervical mucus, and (3) those with an abnormal PCT and normal cervical mucus (Table 1). Statistical analysis of results was performed by using life-table methods, the end-point being pregnancy. Cumulative pregnancy rates for each month of therapy were calculated. 6 DIFFERENTIAL DIAGNOSIS AND TREATMENT Anatomical Defects of the Cervix (Table 2). Of the 114 patients, 9 had anatomical cervical defects (8%). Six of the nine had cervical stenosis. The diagnosis of cervical stenosis in these patients was made when the diameter of the cervical canal was found to be less than 2 mm. The patients had been infertile for 2 to 6 years. Four of the six patients with cervical stenosis had had a previous cone biopsy for mild to moderate cervical dysplasia. The other two patients had no history of infection, cautery, or surgical manipulation and were therefore considered to have congenital cervical stenosis. In three patients with poorly developed and very fragile columnar epithelium, this diagnosis was confirmed by colposcopic examination. Attempts to obtain cervical mucus from these patients uniformly resulted in acute bleeding even TABLE 1. Differential Diagnosis of Cervical Factor Diagnosis No. of patients % Anatomical defects 9 8 Abnormal mucus 63 55 Abnormal PCT with normal mucus 42 37 Total 114 100 Defect TABLE 2. Anatomical Defects Cervical stenosis Post-cone biopsy 4 Congenital 2 Abnormal endocervical epithelium with superficial veins December 1977 No. of patients with gentle manipulation. All cervical mucus cultures for bacteria were negative. None of these patients had a history of previous surgical procedure. This rare condition appears to be due to superficial varicosities lining the endocervical canal.7 All nine patients were initially given diethylstilbestrol (DES), 0.1 mg daily, on days 5 to 20 of each cycle. Since no response was noted in any of these patients the dose was increased to 0.2 mg daily. In the first two treatment cycles (using both 0.1 and 0.2 mg of DES) repeat PCTs were performed in all nine patients. Five of the six patients with cervical stenosis received intracervical insemination using 0.1 ml of husband's whole semen. This procedure was performed for four cycles. All six patients had gentle sounding at midcycle in an effort to dilate the canal. The three patients with abnormal endocervical epithelium were treated with cryosurgery in an effort to stimulate better epithelial growth. In these patients the repeat PCT was performed 2 months following therapy. Abnormal Cervical Mucus (Table 3). Ofthe 114 patients, 63 (55%) had abnormal cervical mucus. Two major types of abnormalities were noted. Twenty-eight of the sixty-three patients (44%) had poor quality of cervical mucus-very viscid mucus (poor spinnbarkeit) with a high cellular content. The volume of cervical mucus in these patients was comparable to that found in normally ovulating control subjects (0.2 to 0.6 mi). Thirtyfive of the sixty-three patients (56%) had very low quantity «0.1 ml) of cervical mucus. The mucus in all of these patients was clear, acellular, and had normal spinnbarkeit. All 63 patients in this group were treated with DES, 0.1 mg daily from days 5 to 20 of one cycle. The PCT was repeated during the first cycle of therapy, and if no improvement was noted the DES dose was increased to 0.2 mg daily and the PCT was performed for the third time. Abnormality Poor quality Poor quantity TABLE 3. Abnormal Cervical Mucus No. of patients 28 35 6 3 % 44 56

Vol. 28, No. 12 THE CERVICAL FACTOR IN INFERTILITY 1291 TABLE 4. Abnormal PCT with Normal Cervical Mucus Abnormality Lack of sperm penetration Low semen volume Oligospermia Azoospermia Immobilized sperm "Vaginal factor" Unexplained 6 «2 ml) 14 «20 million/ml) 4 7 11 No. of patients Abnormal PCT and Normal Cervical Mucus (Table 4). Forty-two patients had an abnormal PCT due to either a total lack of sperm penetration or the presence of only immobilized sperm in normal-appearing cervical mucus.s In the first group (24 patients) no spermatozoa were present in cervical mucus obtained from any level of the cervical canal. The husbands of all of these 24 patients were found to have an abnormality in their semen analyses. These factors included low semen volume (less than 2 ml) in six patients, oligospermia (less than 20 million sperm/ml) in fourteen patients, and azoospermia in four patients.9,10 The four men with azoospermia were excluded from the study and referred to the andrology clinic. In the second group (18 patients), sperm were present in the cervical mucus but all were nonmotile. The semen analyses in these 18 husbands were within the normal range. Cervical cup artificial inseminations were performed for each of the 38 women at midcycle, using her husband's semen. The Milex cup (Milex Products, Inc., Chicago, Ill.) was used for these inseminations. The cup was first fitted on the cervix and left there for 1 hour. The cup was then removed and a repeat PCT was performed. If an improvement was noted with the cup insemination technique, this method was used as therapy. When the cup was utilized as therapy, it was left on the cervix for at least 4 hours and then removed at home by the patient. Immunologic tests were performed for 76 of the 114 couples in order to determine whether there was a correlation between the abnormal 24 18 PCT and the immunologic factors of infertility. The tests used were those of Kibrick et ai., 11 Dukes and Franklin,12 and Isojima et al. 13 RESULTS Anatomical Cervical Defects None of the six patients with cervical stenosis became pregnant following gentle sounding or with the intracervical insemination technique. One of the patients did become pregnant 2 months following a dilatation and curettage for abnormal uterine bleeding, performed 1 year after her last visit to our clinic. The three patients with abnormal epithelium and varicosities underwent cryosurgery in an effort to induce better epithelial growth and to obliterate the superficial veins. The endocervical epithelium did regenerate within 2 months following cryosurgery. In one patient there was a marked improvement in mucus production which resulted in a normal PCT. She became pregnant in the third cycle following cryosurgery. The other two patients did not have an improved PCT following cryosurgery and did not become pregnant. DES therapy in the nine patients with anatomical defects did not result in improvement of either quality or quantity of mucus. Abnormal Cervical Mucus Poor Quality. A total of28 patients were treated with DES and there was improvement in cervical mucus quality in 11 of these patients (40%). In these 11 patients, the PCT before treatment had revealed no sperm at the internal os. Following therapy there was an improvement in the PCT. All 11 improved PCTs revealed more than five sperm per high-power field at the level of the internal os. There were six pregnancies in these eleven patients. The pregnancies occurred within two to four cycles of DES treatment (Tables 5 and 6). TABLE 5. Treatment of Abnormal PCT Diagnosis Treatment No. of patients No. improved No. pregnant % Pregnant % Pregnant of those improved Cervical stenosis and DES and dilatation 9 1 1" II" 100" abnormal epithelium or cryosurgery Abnormal mucus quality DES 28 11 6 21 55 Abnormal mucus quantity DES 35 18 5 14 28 Low semen volume Cup 6 6 3 50 50 Oligospermia Cup 14 10 5 36 50 Immobilized sperm Cup 18 7 3 17 43 Total 110 53 23 21 43 anumbers of pregnancies are too small for significance evaluation.

1292 SCO'IT ET AL. TABLE 6. Patients with Abnormal Mucus Treated with DES (N = 63) Mo of therapy 1 2 3 4 5 12 Probability of pregnancy in each rno Cumulative probability of pregnancy 0.07 0.07 0.19 0.26 0.09 0.35 0.10 0.45 0.00 0.45 0.00 0.45 Poor Quantity. There were 35 patients in this group. These patients received the same regimen of DES. The pet improved in 18 of the 35 patients in the first cycle of treatment (51%). In these 18 patients, five pregnancies occurred within the first four cycles of DES therapy (Table 5). There was a single pregnancy in the nonimproved group which occurred 13 months after the initial workup and unsuccessful treatment with DES. The probability of pregnancy seemed highest in these two groups treated with DES in the 2nd month of treatment (0.19) (Table 6). Abnormal PCT and Normal Cervical Mucus Lack of Sperm Penetration (Low Semen Volume and Oligospermia). In 24 patients the pet revealed a total lack of sperm penetration, although the cervical mucus had normal physical properties. The husbands of all 24 patients had an abnormal semen analysis (Table 4). Each woman received inseminations with her husband's semen, using the cervical cup. The use of cervical cup insemination in the six patients whose husbands had a low semen volume resulted in three pregnancies. All of the pregnancies occurred within the first four cycles of treatment (Tables 5 and 7). In 14 patients with no sperm noted in the pet, oligospermia was the sole contributing factor. Use of the cup insemination technique improved the pet in 10 of the 14 patients. Five of these ten patients became pregnant (Table 5). Immobilized Sperm. The use of cervical cup insemination in the 18 patients who had lm- TABLE 7. Patients Treated with Cup Insemination Technique (Male Factor) (N = 38) Mo of therapy 1 2 3 4 5 6 12 Probability of pregnancy in each rno Cumulative probability of pregnancy 0.13 0.13 0.10 0.23 0.06 0.29 0.24 0.53 0.08 0.61 0.00 0.61 0.00 0.61 December 1977 mobilized sperm in the initial pet resulted in improvement of the pet in seven patients. Three of these patients became pregnant following two to four cycles of cup insemination therapy (Table 5). In all patients treated with the cup insemination technique, the probability of pregnancy was highest during the 4th month of therapy (0.24) (Table 7). Immunologic Tests The Isojima, Franklin-Dukes, and Kibrick immulogic tests were performed in 76 of the 114 patients. Only one positive test (Kibrick) was noted and that was in a patient who had lack of sperm penetration on pet. None of the patients with immobilized sperm in the cervical mucus had a positive immunologic test. DISCUSSION In this study three major categories of abnormalities of the cervical factor were found: anatomical defect, cervical mucus abnormality, and abnormal pet secondary to either a male factor or an unexplained factor. The treatment used in all cases was either steroidal (DES) or mechanical (cervical cup insemination). In 53 patients (48%), there was improvement in the pet as a direct result of therapy. Twenty-three of these patients became pregnant, for a pregnancy rate of 43%. Of the entire group of 110 patients (4 with azoospermic husbands were excluded), there was an over-all pregnancy rate of 21% (Table 5). A I-year follow-up of 41 of the 57 patients (72%) who failed to respond to therapy revealed only two pregnancies. These pregnancies occurred 7 and 13 months after termination of treatment, and therefore cannot be attributed to successful treatment. These two pregnancies have been excluded from the final statistical analysis. The life-table analysis (Tables 6 and 7), which is in essence a cumulative probability analysis, was utilized to distinguish the fact that after 4 months of treatment there is a diminishing return which becomes of major importance for the infertility expert to recognize. Patients can then be advised that the probability of pregnancy is almost nonexistent after this period of treatment. Anatomical cervical defects are the easiest to diagnose but the most difficult to treat. To date, no really successful modality of treatment has been found. The use of lam inari a has been recommended but no results have been published. With the use of colposcopy and directed punch biopsies

Vol. 28, No. 12 THE CERVICAL FACTOR IN INFERTILITY 1293 for the diagnosis of cervical neoplasia, it is hoped that the incidence of cervical stenosis secondary to conization can be reduced. It should be noted, however, that the role of cone biopsy as a cause of cervical stenosis is still being debated in the literature. l4 15 In this study, four of six patients with stenosis had cone biopsies and in none of these patients was there any improvement with dilatation or DES therapy. Intracervical insemination using whole semen was also totally unsucessful. In an effort to overcome this cervical factor, intrauterine insemination using washed sperm is being attempted at this institution. In patients with abnormal pets secondary to both abnormal quality and quantity of cervical mucus, DES therapy improved the mucus secretion in approximately one-half of the patients (46%). The treatment was somewhat more successful in patients with poor mucus quantity (51%) as compared with patients with poor mucus quality (39%). The mechanism by which a daily dose of 0.1 mg or 0.2 mg of DES taken from day 5 to day 20 of each cycle effects mucus production by endocervical cells in patients who have normal levels of estradiol is not yet understood. DES either may have a direct effect at the cellular level in the endocervical canal or affect the hypothalamic-pituitary system by a positive feedback mechanism and thus increase the endogeneous estradiol secretion. 16 Since only one-half of these patients responded to DES therapy, a direct effect on the endocervical cells is probably more likely. It may be postulated that some patients either partially lack specific receptor sites for estrogen in the cells of the endocervical epithelium or have abnormal mucus production capabilities. Patients with abnormal mucus who fail to respond to 0.1 mg of DES rarely respond to higher doses of the drug. The reason for continuing the use of DES even with all of the adverse publicity the drug has received is 2-fold: (1) the drug is effective at a very low dose which does not interfere with ovulation and (2) it is commercially available at a low dose, unlike most other estrogen preparations. At this clinic the effect of 0.1 mg of DES has been much better than that obtained with 0.3 mg of conjugated estrogen. With a 0.625-mg or 1.25-mg dose of conjugated estrogen, ovulation suppression or delay has been noted. A male factor must always be suspected when the pet is abnormal and yet the cervical mucus is noted to be normal in appearance and physical characteristic (spinnbarkeit). The two abnormalities of semen which were most successfully treated with the cervical cup insemination technique were a low volume of seminal plasma and oligospermia. Medical therapy for low volume and oligospermia has not been successful in most instances. Since most of the spermatozoa are not maintained in the vagina for more than 20 to 30 minutes, it seemed reasonable to use the cup to allow the sperm to have a much longer exposure time at the cervical os. The cup insemination technique was also utilized in patients in whom only immobilized sperm were found in the cervical mucus. The reason for using the cup in these patients was to by-pass the vagina and allow for direct entry of sperm into the cervical mucus. In almost 40% of these couples the use of the cup technique changed an abnormal pet into a normal test. The reason for this "vaginal factor" is unknown. Whether there is a "hostile" vaginal secretion in some infertile women or a lack of some necessary "protective factor" in the seminal plasma of some of these husbands is as yet undetermined. There was no correlation between immobilized sperm found in the pet and the Isojima spermimmobilizing immunologic test. None of the 18 patients with immobilized sperm in the cervical mucus had positive Kibrick, Franklin-Dukes, or Isojima immunologic tests. There was only one positive test (Kibrick) in 1 of the 76 couples tested and that was found in a patient with an oligospermic husband. In none of the postcoital cervical mucus samples examined microscopically was any spermagglutination noted. In fact, spermagglutination in cervical mucus has not been observed in this clinic during the past 7 years. With the use of the cervical cup technique in selected patients (low volume semen, oligospermia, immobilized sperm) who had an initially abnormal pet which improved following cup insemination, a reasonable pregnancy rate of approximately 48% was obtained (11 of 23). Before instituting this therapy all patients must have a cup pet test performed. If the use of the cup does not change the results of the pet, the cup technique should not be used as therapy. Patients who do have improved pets after the administration of DES may be treated for at least 1 year, since DES therapy requires very little effort or expense. However, it should be noted that the probability of pregnancy after the first 4 months of therapy in this study was zero.

1294 SCOTIETAL. In summary, all infertile couples should have an accurately performed postcoital test. Three major abnormalities can be expected. If abnormal cervical mucus is found, DES therapy is helpful in some 45% of the patients. In approximately 38% of these patients a pregnancy can be expected. If the defect is secondary to a male factor or to immobilized sperm, the cup PCT should be performed. If the cup technique improves the PCT this method can be used as therapy. In approximately 50% of such couples pregnancies were achieved. The over-all pregnancy rate of 21% in all patients with the diagnosis of cervical factor does not appear to be encouraging; however, the rate is more than doubled (45%) in all patients who respond to either DES or cup therapy. Further research must be undertaken to improve the therapeutic results. REFERENCES 1. Steinberg W: The role of the cervical factor in sterility. Fertil Steril 6:169, 1955 2. Weil A: Antigen of the adnexal glands ofthe male genital tract. Fertil Steril 12:538, 1961 3. Davajan V, Kunitake GM: Fractional in-vivo and in-vitro examination of post-coital cervical mucus in the human. Fertil Steril 20:197, 1969 December 1977 4. Israel R, Mishell DR Jr, Stone S, Thorneycroft IH, Moyer D: Single luteal phase serum progesterone assay as an indicator of ovulation. Am J Obstet Gynecol 112:1043, 1972 5. Tredway DR, Settiage DS, Nakamura RM, Motoshima M, Umezaki CU, Mishell DR Jr: The significance of timing for the post-coital evaluation ofthe cervical mucus. Am J Obstet Gynecol 121:387, 1975 6. Hill BA: Principles of Medical Statistics Ninth Edition. New York, Oxford University Press, 1971, p 220 7. Townsend D: Personal communication 8. Kunitake GM, Davajan V: A new method of evaluating infertility due to cervical mucus-spermatozoa incompatibility. Fertil Steril 21:706, 1970 9. MacLeod J, Gold R: The male factor in fertility and infe~tility. Fertil Steril 4:10, 1953 10. Sabrera AJ, MacLeod J: The immediate post-coital test. Fertil SterilI3:184, 1962 11. Kibrick S, Belding DL, Merrill B: Methods for the detection of antibodies against mammalian spermatozoa. II. A gelatin test. Fertil Steril 3:430, 1952 12. Dukes CD, Franklin RR: Sperm agglutinins and human infertility: female. Fertil Steril 19:263, 1968 13. Isojima S, Li TS, Ashitaka Y: Immunologic analysis of sperm-immobilizing factor found in sera of women with unexplained sterility. Am J Obstet Gynecol 101:677, 1968 14. Boddington MM, Spriggs AI: Cervical cone biopsy and fertility. Br Med J 2:271, 1974 15. Kullander S, Sjoberg NO: Treatment of carcinoma in-situ of the cervix uteri by conization. Acta Obstet Gynecol Scand 50:153, 1971 16. Tsai CC, Yen SS: The effect of ethinyl estradiol administration during early follicular phase of the cycle on the other gonadotropin levels and ovarian function. J Clin Endocrinol Metab 33:917, 1971