Melvin R. Cohen

Spinnbarkeit: A Characteristic of Cervical Mucus: Significance at Ovulation Time

The significance of changes in human cervical mucus at midcycle has aroused the interest of those involved in infertility research. This study examined the relationship of Spinnbarkeit to basal body temperature vaginal smears quantity of cervical mucus and spermatozoa longevity in 16 successfully inseminated patients. The thermal shift in basal body temperature occurred 10-21 days after onset of the previous menses. The thin mucorrhes lasted 2-7 days. Maximal Spinnbarkeit occurred on Day 10-20 and reached a length of 10-20 cm at the time od maximal production of cervical mucus. There was a close correlation between maximal Spinnbarkeit and optimal cornification in the vaginal smear. Spermatozoa longevity paralleled the degree of Spinnbarkeit. Maximal Spinnbarkeit occurred before the thermal shift in 9 patients and on the day of the thermal shift in 4 patients. These findings suggest that the outpouring of cervical mucus is associated with impending ovulation. Thus artificial insemination will be most successful if performed when cervical secretions are profuse thin acellular and exhibiting maximal Spinnbarkeit. The amount amd thinness of cervical mucus can be improved by administration of small doses of stilbestrol without inhibiting or delaying ovulation.

Results of bilateral ovarian wedge resection in 47 cases of sterility

A T FNE-YEAR intervals in the past two decades, we have reported our observations on patients in whom we diagnosed bilateral polycystic ovaries.l* 2l 3 We have described a syndrome characteristic of this lesion and adapted a surgical technique which has proved satisfactory. Since our first successful operation in 1929, we have operated upon seventy-five patients for this condition with increasingly encouraging results. In this report, we summarize the results of wedge resection of bot,h ovaries in those patients in the group who complained primarily of sterility. In the past, the prognosis in sterile matings has rested chiefly upon the results of tubal patency tests and the examination of the semen. Fundamental though these tests may be, it is our opinion that insufficient emphasis has been placed upon the reproductive role of the ovaries. More recently, tests for ovulation, such as endometrial biopsy, basal body temperatures, pregnandiol determinations, and daily vaginal smears have been carried out by some physicians to determine the occurrence and time of ovulation? We believe too little attention has been given to changes in the ovaries themselves, particularly in women who do not conform to the ovulatory pattern. One of the conditions encountered in patients complaining of sterility and amenorrhea, and one too frequently unrecognized, is bilateral polycystic ovaries. In this condition, ovulation occurs very rarely, at long intervals, or not at all, as shown by repeated endometrial biopsies and vaginal smears, basal temperature charts, and suggested by the history of sterility. The prognosis for fertility in these women grows progressively worse unless suitable positive measures are taken. The symptoms which prompt the patient to seek advice are, in the order of their frequency : 1, amenorrhea ; 2, sterility ; 3, hirsutism ; 4, pain (rarely) ; and 5, menometrorrhagia (occasionally). Underdeveloped breasts, acne, and/ or obesity are more often discovered by the physician than observed by the patient. Many of these women are psychically depressed. Bilateral polycystic ovaries are associated with a definite syndrome which we have described previously.3 In this condition, amenorrhea is usually secondary in character. After puberty, and for a period of a few years, there

The pH of cervical mucus and the postcoital test.

In this study, 25 women with 28-day cycles were considered for a total of 44 menstrual cycles. The women were subjected to the Sims-Huhner postcoital test at 6.2 hours after intercourse during the periovulatory period. Each couple was instructed to abstain from sexual intercourse for 4 days prior to the test. Samples of cervical mucus were obtained and evaluated for quantity, viscosity, elasticity, ferning, cellularity, pH, and the postcoital status of the spermatozoa (percentage motility and grade). The pH measurements were made by the use of phenaphthazine paper. After the establishment of the pH measurements the patients were divided into two groups (low and high pH) and statistically compared on the basis of the spermatozoal postcoital test results. The results obtained revealed significant differences (P < 0.01) between the low pH (less than or equal to 6.0) and high pH (greater than or equal to 6.1) groups with respect to percentage motility and grade of recovered spermatozoa. Ejaculate characteristics of the males corresponding to the two different pH groups showed no significant differences (P > 0.05).

The cyclical changes in the physical properties of the cervical mucus and the results of the postcoital test.

The effect of the postcoital test on the cyclic changes in the physi cal properties of the cervical mucus during the preovulatory period was investigated, and the results obtained in women who conceived during the period of investigation (fertile group) were compared with the results obtained in those who did not conceive (infertile group). 3007 postcoital examinations were performed within 72 hours after intercourse on 505 couples complaining of infertility. No significant differences were found in the amount, viscosity, and spinnbarkheit of the cervical m ucus or in the motility and drive of spermatozoa between 94 couples who conceived and 411 couples who remainded infertile. The number of spermatozoa per high power field was significantly higher in the fertile group as compared with the infertile when the amount of mucus increased. When estrogenic changes in the mucus first became apparent, the concentration of spermatozoa rose and their motility and drive improved. No further improvement was seen with further changes in the mucus. When white blood cells in the mucus appeared, both the motility and the drive of spermatozoa decreased significantly, but their number per high power field did not change. No significant changes were found to occur in either motility or drive during 72 hours after intercourse and in the number of spermatozoa per high power field during the first 24 hours. However, concentration of spermatozoa decreased significantly during Days 2 and 3. In 26 tests following the coitus presumably responsible for pregnancy, the concentration, motility, and drive of spermatozoa in mucus were not found to be different from those for the whole group of fertile patients. The wide range of distribution of the results in both groups indicates that the results of the postcoital test cannot be used as a reliable index of fertility in an individual couple.

Sperm Survival at Estimated Ovulation Time: Comparative Morphology: Relative Male Infertility

Postcoital cervical mucus specimens were obtained from 45 couples and analyzed for sperm morphology. Sperm morphology was compared with analysis of semen previously obtained directly from male partners. Grade of motility was designated from grade 0 (no motility) to grade 4 (active forward progression). The sperms survived in the cervical mucus for as long as 58 hours around ovulation time. The surviving sperms exhibited comparable motility in the cervical mucus at ovulation time as was noted in the original sample. Morphologically the sperms surviving in cervical mucus were of superior quality compared to those obtained from the same male by friction or withdrawal. In 33 marriages given a guarded prognosis mainly based on the basis of substandard sperm conception eventually occurred giving an incidence rate of 17.1%. On the basis of these results the authors suggest that the Committee on Minimum Standards reconsider their established criteria for male sterility.

Effect of Continuous Administration of Small Doses of Chlormadinone Acetate on the Cervical Mucus and Postcoital Test

A study was undertaken to investigate the physical properties of the cervical mucus and spermatozoa survival in patients taking .5 mg of chlormadinone acetate daily without interruption. 10 women of reproductive age who complained of infertility were treated with .5 mg of chlormadinone acetate daily for 1 or 2 months. Cervical mucus and postcoital tests were performed over a period of 2-8 cycles prior to treatment and compared with similar tests performed during the administration of the drug. A marked decrease in the estrogenic pattern of the cervical mucus was seen during the treatment cycle. Similarly a decreased number of positive postcoital tests was observed. However active spermatozoa were present in 3 of the 10 patients studied. Moreover when spermatozoa were present their number motility and longevity did not differ significantly from the same parameters studied before the administration of the drug. These findings are interpreted to signify that while chlormadinone acetate administration might cause an increased hostility of the cervical mucus to sperm penetration and survival the contraceptive effect of this drug cannot be explained by cervical mucus changes alone.

Evaluating Outcome Criteria Used in Methadone Maintenance Programs

This report reviews the results of several large methadone maintenance programs and analyzes the outcome measures used. Criteria measures were often vague and sometimes not defined. Many studies base their findings on unverified patient self-report because costs for more reliable and systematic data collection are prohibitive. Available data does not allow for resolution of the pro- or antimethadone maintenance views for treatment of heroin addiction.

The Effects of an Intracervical Steroid-Releasing Device on the Cervical Mucus *

The purpose of this investigation was to study the effect on the cervical mucus of sex steroids released from a silastic capsule placed within the cervical canal. Dow-Corning silastic tubing with a wall thickness of .42 mm and an outside diameter of 2.61 mm was used to prepare the capsule made it radiopaque. A V-shaped device similar to a common safety pin to produce a spring action was made. The capsule was attached to the device. A special instrument was needed to permit easy insertion or removal of the device without trauma to the endocervix. An attached nylon thread provided identification. Infertile patients with normal ovulatory cycles were chosed except for 1 patient who was a multipara. Pretreatment and treatment cycles were studied by basal body temperature cervical mucus and vaginal smear cytology. Ovulation was confirmed by endoscopy. Progesterone-containing silastic capsules were used for patients who had normal mucorrhea or hypermucorrhea. Estrogen-containing silastic capsules were used for those patients who had poor preovulatory mucuus. Estrogens selected were 17beta-estradiol estrone and the 3-methyle ether of ethinyl estradiol (mestranol). The device was inserted either immediately postemenstrually to study its effects during the current cycle or postovulatory to study the effect on the next cycle. The capsule remained in place during 1 or 2 cycles. The effects of intracervical progesterone-containing devices in 6 patients during 7 cycles were observed. In each patient pretreatment mucus had been excellent. During the treatment cycle cervical mucus was markedly decreased in colume and became thicker. Spinnbarkeit was decreased and ferming disoppeased. The treatment did not alter the longevity of spermatozoa in 4 of 6 patients with poor pretreatment postcoital tests. In 2 patients with excellent pretreatment postcoital tests the postcoital test during treatment cycles. Showed reduction of longevity of spermatozoa. With intracervical estrogen-releasing devices there was very little alteration of cervical mucus except in 1 patient. No side effects were noted. There were 2 expulsious 1 in a patient with a lacerated cervix and 1 due to only partial insertion. The failure of estradiol and estrone to affect cervical mucus was disappointing. However mestranol caused a marked increase in the quantity and spinnbarkeit together with diminished viscosity of the cervical mucus of the 1 patient tested. The postcoital test was also positive in this patient. The quanitity of estradiol and estrone released could be insufficient to produce a biologic effect. 0Concerning fertility control the effects shown in the postcoital test might be sufficient to interfere with sperme transport. VThe contraceptive effect could be augmented by a longer capsule to cause suppressive changes in the endometrium. @Although nulliprous patients retain the device satisfactorily in parous patients retention must be improved.

Interval tubal sterilization via laparoscopy

Abstract Laparoscopy is rapidly becoming an important diagnostic technique. As proficiency is attained, operative procedures may be performed. A simplified method of tubal sterilization in conjunction with laparoscopy, modified after the Steptoe technique, is given in detail. Our series of fifty interval sterilizations is presented.

Hormone therapy to control postpartum breast manifestations

Abstract Two hundred and forty-seven patients have been studied, 223 of whom have received varying hormone medications in order to test their efficacy in the suppression of the symptoms associated with lactation. Of these, 49 have received various short-acting preparations and 174 have received various long-acting preparations. More patients were placed in the latter series after an initial screening period, the number tried on the preferred preparations being thereby increased. At the present moment, the results of this study indicate that, of all the preparations tried, the two long-acting medications, estradiol valerate and the combination of estradiol valerate and testosterone enanthate, are the preferred agents for suppression of pain, engorgement, and lactation. Furthermore, the administration of at least one of them (estradiol valerate plus testosterone enanthate) within 4 minutes or less of delivery of the placenta appears to give a greater percentage of excellent results.