Routine postcoital testing is unnecessary

C.M.A. Glazener1,3 and W.C.L. Ford2

1 Cochrane Incontinence Review Group, Health Services Research Unit, Foresterhill Lea, University of Aberdeen, Aberdeen AB25 2ZD, UK 2 University of Obstetrics and Gynaecology, St Michael's Hospital, Southwell Street, Bristol BS2 8EG, UK

Dear Sir,

We would like to thank Oei et al. for their interesting comments on our recent paper (Glazener et al.., 2000Go) and their generous tribute to Professor M.G.R.Hull. We would like to make the following points in reply.

We feel that much of the controversy that surrounds the postcoital test (PCT) is due to confusion regarding its purpose between testing male rather than female infertility. We advocate the PCT as an investigation of sperm dysfunction whereas the ASRM Practice Committee considered the evaluation of the infertile female to detect cervical factors. However it is worth noting that their recommendation continues `The test may be reserved for patients in whom results will clearly influence the treatment strategy'. We contend that this is true of couples with <3 years infertility. We accept that the PCT result does not affect outcome in couples with more prolonged infertility and it might be unnecessary to test these patients, although we feel that a reliable diagnosis of sperm dysfunction remains valuable.

Standard semen analysis according to the World Health Organization (WHO) protocol has little prognostic power for conception unless the results are very poor. A better index of male fertility is needed. Like the bodies cited in the letter from Oei et al., the Royal College of Obstetricians and Gynaecologists (1998) failed to recommend a test of sperm function in their latest guidelines for Secondary and Tertiary practice. However, this was on the grounds that these are poorly standardized and that there is insufficient evidence of their efficacy rather than the absence of a need for them. We regret that no widely accepted test of sperm function is available to provide a reasonably accurate prognosis for conception in couples with sperm dysfunction. We have demonstrated that the PCT can achieve this but it requires great commitment to ensure proper timing of intercourse in the pre-ovulatory phase of the cycle and that valid negative tests are repeated before they are accepted. As our recent paper demonstrates, the test can only demonstrate its full prognostic potential when female factors are fully controlled.

The lack of discriminant power of the PCT in the randomized controlled trial conducted by Oei et al. may be explained because patients proceeded to assisted reproductive treatments irrespective of the PCT result (Oei et al., 1998Go): this explains the high conception rates in couples with a negative PCT, as they received effective treatment. If the test is not used to alter the management of the patients, it is hardly surprising that it has no effect on outcome.

Methodological points

The Materials and methods section of our paper clearly states that the present analysis was restricted to women with at least a year's infertility and with complete data. To increase rigour, we excluded couples who had a PCT result but no semen analysis (or vice versa), who were used for one analysis but not the other in the original paper (Glazener et al., 1987aGo). Furthermore, the results for couples with a poor positive PCT were intermediate between the negative and positive groups (not worse as stated in Oei's letter), due in part to inclusion of women who conceived before full diagnostic tests had been completed. According to the criteria of Oei et al. these couples were reclassified as negative if the poor-positive result was confirmed in a second cycle in good mucus, and those with only one result were excluded (Oei et al., 1995Go). This explains the decrease in numbers available for analysis compared with the 1987 paper.

No motile spermatozoa in one high power field (HPF) is different from no motile sperm in 20 HPF. The endpoint of Oei et al. is dependent on how hard one looks and this is unspecified (Oei et al., 1995Go). We state that we examine at least 5 HPF and require the detection at least one forward-progressing motile spermatozoon in more than half of them. The PCT as commonly performed is at best a semi-quantitative procedure. There is no control over the depth of the mucus on the microscope slide and the area of the HPF varies between different microscopes. Classification of tests with borderline results is bound to be imprecise. This is one reason why valid negative tests should be repeated and why we now routinely follow up negative or borderline PCT results with in-vitro sperm mucus penetration tests. Nevertheless the presence of at least one motile sperm per HPF has consistently been selected as the most discriminant end point for the PCT. Furthermore, this result was consistently achieved by a variety of doctors working in clinics at different times (Hull et al., 1982Go; Glazener et al., 1987aGo).

Treatment

Our 1987 study (Glazener et al., 1987bGo) considered high intracervical insemination and not true intrauterine insemination. Intrauterine insemination (IUI) is not our treatment of choice [as IVF and intracytoplasmic sperm injection (ICSI) are far more effective] but a number of meta-analyses suggest that it can increase the likelihood that a couple with moderate sperm dysfunction will conceive above what can be achieved with timed intercourse (Ford et al., 1997Go; Cohlen et al., 2000Go). Recent papers also favour IUI (Cohlen et al., 1998Go; Rammer and Friedrich, 1998Go; Guzick et al., 2000). Using frozen spermatozoa as a model for spermatozoa with impaired function provides further support for the view that IUI is effective (Goldberg et al., 1999Go; O'Brien and Vandekerckhove, 2000Go).

The strength of our paper is that it provides a clear rationale to proceed to IVF/ICSI without delay in couples with a negative PCT. However, it is sensible to confirm that the result is due to semen problems by an in-vitro test. The choice between IVF and ICSI then depends on semen quality and the number of oocytes available, and should be made in accordance with the current policy in the clinic.

Balasch appears to be arguing that the introduction of assisted reproductive technology alters the requirements for the diagnostic procedures required to decide on effective treatment (Balasch, 2000Go). Rational management should aim at minimizing the number of procedures that patients are subjected to. On the basis of our results, the PCT will both prevent couples with good sperm function but low sperm concentration from having ART unnecessarily and will also ensure that those with poor sperm function but an adequate conventional semen analysis proceed to necessary treatment without delay.

Notes

3 To whom correspondence should be addressed Back

References

Balasch, J. (2000) Investigation of the infertile couple: investigation of the infertile couple in the era of assisted reproductive technology: a time for reappraisal. Hum. Reprod., 15, 2251–2257.[Abstract/Free Full Text]

Cohlen, B.J., te Velde, E.R., van Kooij, R.J. et al. (1998) Controlled ovarian hyperstimulation and intrauterine insemination for treating male subfertility: a controlled study. Hum. Reprod., 13, 1553–1558.[Abstract]

Cohlen, B.J., Vandekerckhove, P., te Velde, E.R. et al. (2000) Timed intercourse versus intra-uterine insemination with or without ovarian hyperstimulation for subfertility in men (Cochrane Review). Cochrane Library, Issue, 4, Update Software, Oxford.

Ford, W.C.L., Mathur, R.S. and Hull, M.G.R. (1997) Intrauterine insemination: is it an effective treatment for male factor infertility? Ballieres Clin. Obstet. Gynaecol., 11, 691–710.[ISI][Medline]

Glazener, C.M.A., Ford, W.C.L and Hull, M.G.R. (2000) The prognostic power of the post-coital test for natural conception depends on duration of infertility. Hum. Reprod., 15, 1953–1957.[Abstract/Free Full Text]

Glazener, C.M.A., Kelly, N.J., Weir, M.J.et al. (1987a) The diagnosis of male infertility–prospective time-specific study of conception rates related to seminal analysis and post-coital sperm-mucus penetration and survival in otherwise unexplained infertility. Hum. Reprod., 2, 665–671.[Abstract]

Glazener, C.M.A, Coulson, C., Lambert, P.A. et al. (1987b) The value of artificial insemination with husband's semen in infertility due to failure of postcoital sperm-mucus penetration – controlled trial of treatment. Br. J. Obst. Gynaecol., 94, 774–778.[ISI][Medline]

Goldberg, J.M., Mascha, E., Falcone, T. and Attaran, M. (1999) Comparison of intrauterine and intracervical insemination with frozen donor sperm: a meta-analysis. Fertil. Steril., 72, 792–795.[ISI][Medline]

Goverde, A.J., McDonnell, J., Vermeiden,J.P. et al. (2000) Intrauterine insemination or in-vitro fertilisation in idiopathic subfertility and male subfertility: a randomised trial and cost-effectiveness analysis. Lancet, 355, 13–18.[ISI][Medline]

Guzick, D.S., Carson, S.A., Coutifaris, C. et al. (1999). Efficacy of superovulation and intrauterine insemination in the treatment of infertility. National Cooperative Reproductive Medicine Network. New Eng. J. Med., 340, 177–183.[Abstract/Free Full Text]

Hull, M.G.R., Savage, P.E. and Bromham, D.R. (1982). Prognostic value of the postcoital test: prospective study based on time-specific conception rates. Br. J. Obstet. Gynaecol., 89, 299–305.[ISI][Medline]

O'Brien, P. and Vandekerckhove, P. (2000). Intra-uterine versus cervical insemination of donor sperm for subfertility (Cochrane Review). Cochrane Library, Issue, 4, Update Software, Oxford.

Oei, S.G., Helmerhorst, F.M. and Keirse, M.J. (1995). When is the post-coital test normal? A critical appraisal. Hum. Reprod., 10, 1711–1714.[Abstract]

Oei, S.G., Helmerhorst, F.M., Bloemenkamp, K.W. et al. (1998). Effectiveness of the postcoital test: randomised controlled trial. Br. Med. J., 317, 502–505.[Abstract/Free Full Text]

Rammer, E. and Friedrich, F. (1998). The effectiveness of intrauterine insemination in couples with sterility due to male infertility with and without a woman's hormone factor. Fertil. Steril., 69, 31–36.[ISI][Medline]





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