Infertility
has been described as a major developmental crises. This study aimed
at detection of ovulation by less traumatic, rapid, OPD based techniques.
Infertile females in the reproductive age without any systemic or
local illness were evaluated by Cervical mucus (Spinabarkeit and arborisation
pattern), vaginal cytology and endometrial cytology, and compared
with endometrial biopsy. Specificity, sensitivity, positive predictive
and negative predictive values of each was calculated. We found majority
of cases in the age group of 20 to 25 years with 83% primary and 17%
secondary infertility. The endometrial biopsy was ovulatory in 68%
and proliferative in 32% cases. Cervical mucus studies, vaginal cytology
and endometrial cytology have 100% sensitivity each, however their
specificity was 95.6%, 97.05% and 72.36% respectively. We conclude
that vaginal cytology and cervical mucus studies are dependable methods
to detect ovulation. Endometrial cytology however should be coupled
with vaginal cytology and cervical mucus studies to conclude ovulation/anovulation.
Introduction
Infertility
is defined as involuntary childlessness after two years of attempting
to conceive (WHO). This is shortened to one year in developed countries,
1. It has been described as a major developmental crises affecting
15% of the child bearing population, 2. The significance of detection
of ovulation is therefore immense. All the cycles in a normal female
are not ovulatory. Inactive reproductive era, 1 in 10 to 1 in 50 regular
cycles are anovular. Hence the need arises of techniques that are
easily repeatable, rapid, painless, simple and cost-effective. Cervical
mucus studies, vaginal cytology and endometrial cytology offer these
advantages. The aims of these studies were to know the reliability
of these less traumatic, rapid, OPD based procedure of ovulation tests
in females and to aid public health centres at rural areas in the
investigation of infertile couple where well equipped pathological
laboratories are not available.
Material and Methods
One hundred cases of female infertility were evaluated, attending
Gynaecology and Obstetric OPD. We followed a well set protocol for
selecting our patients.
A detailed history was taken, and a per vaginum examination was performed
to rule out any local or systemic illness as a cause of infertility.
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Fig.
1 : Proliferative phase endometrial cytology showing
cells in monolayered flat sheet with prominent cell border, homogenous
cytoplasm, round nucleus and finely granular cytoplasm (HE X 150). |
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Fig.
2 : Histopathology (HE X 150) |
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Fig.
3 : Secretory phase A: Endometrial cytology showing cells
in loose monolayered sheet with round to oval nucleus separated
by large amounts of vacuolated cytoplasm and more granular chromatin
suggestive of secretory phase (HE X 150). |
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Fig.
4 : Histopathology (HE X 150). |
A menstrual calendar
was kept for a 3 consecutive cycles and patients with a menstrual
cycle of 28 ± 2 days were
selected. They
were given 3 dates on which they were required to report-Postmenstrual
(6-10 days), midmenstrual (15-16 days) and premenstrual (25-28 days).
Cervical mucus studies and vaginal cytology was done on each of these
occasions. Sample for endometrial cytology was collected only premenstrually.
With the help of a Sim’s speculum, cervix was exposed. The cervical
os was visualized and the endocervical mucus was aspirated with a
glass syringe. This was transferred to a clear dry glass slide. A
dry cover slip was placed over the block of mucus and then the cover
slip was gently withdrawn. The length of stretched mucus (spinnbarkeit)
was measured with the help of centimeter scale.3 A spinnbarkeit
of 0-5 cm postmenstrually, 6-20 cm midmenstrually and again 0-5 cm
premenstrually was suggestive of ovulation.
Vaginal cytology smears were collected from lateral vaginal wall and
stained by Papanicolaou method of staining. We spread cells without
clumping in the four corners and centre of the smear were counted
and maturation index was calculated. A mid indexal rise postmenstrually,
a right indexal rise midmenstrally and again a mid indexal rise premenstrually
was suggestive of ovulation.5
Following
evaluation of cervical mucus for spinnbarkeit, the remaining of the
mucus was allowed to air dry and then examined under low power of
light microscope for ferning.4 Negative or atypical ferning
pattern postmenstrually, positive ferning midmenstrually and again
negative or atypical ferning premenstrually was suggestive of ovulation.
Cytological evaluation was done by obtaining material directly from
the uterus. With the patient in lithotomy position and cervix exposed
by Sim’s speculum, the cervix was held by Alley’s forceps.
The endometrial biopsy curette was passed into the uterine cavity
and a strip of endometrium was obtained. The specimen was transferred
to a previously marked dry glass slide. This was crushed by putting
another glass slide on it and then the two slides were pulled in opposite
directions. Cytological interpretation was done as follows:
The proliferative phase was characterized by monolayered flat sheets
with prominent cell borders and well defined homogenous cytoplasm.
Nuclear chromatin was finely granular (Figs. 1 and 2). The secretory
phase was characterized by loose flat monolayered sheets of cells
with nuclei separated by large amounts of vacuolated cytoplasm. Nuclear
chromatin was more granular (Figs. 2 and 3).
Results
The present study included the cases of age group 20-40 years. Majority
of cases (66) belonged to age group 20-25 years.
Out of 100 cases, 83 were of primary infertility and 17 of secondary
infertility. The duration of infertility ranged from 2-20 years. The
maximum duration of infertility in primary group was 12 years and
secondary group 20 years. Majority of cases belonged to 6-10 years
of duration.
The mean age of menarche was 13.2 years in our series. One patient
of primary infertility revealed a past history of tuberculosis, however,
investigations did not reveal tuberculosis. All the selected cases
had well developed secondary sexual characters.
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Endometrial biopsy
suggested ovulatory cycles in 68 cases and anovulatory cycles in 32
cases. Correlation of cervical mucus studies, vaginal cytology and
endometrial cytology was 95.6%, 97.06% and 80% for ovulatory and 100%,
100% and 70% for anovulatory cycles (Table 1).
We found difficulty in reporting 19 slides of endometrial cytology
and they remained inconclusive due to inability to obtain monolayer
sheets of glandular cells, overlapping of endometrial glandular cells
by endometrial stromal cells and poorly preserved morphology of endometrial
glandular cells.
The tests were evaluated for sensitivity, specificity, predicted value
for +ve test and predictive value for -ve test (Table 2).
Discussion
In the present series the cases selected were of primary and secondary
infertility in the age group of 20-40 years. Maximum patients were
of age group of 20-25 years.
The incidence of primary infertility in comparison to secondary infertility
was higher.
Cervical mucus studies revealed that it undergoes change in spinnbarkeit
and arborisation pattern to indicate occurrence of ovulation. The
correlation with biopsy was similar for anovulatory cycles with Engineer
et al7 and the correlation with biopsy for ovulatory
cycles was in between the percentage correlation found by Engineer
et al7 and Sarin8 (Table 3).
Exfoliative vaginal cytology showed a total percentage correlation
with biopsy of 98% which was higher than the findings of Engineer7
and Mehta9 (Table 4).
Correlation of endometrial cytology with biopsy was in 80.9% with
ovulatory cycles and 75% with anovulatory cycles. This was lower than
the findings of Johanission,10 and Morse et al.11
They had correlated between 90% and 100%. Probably this was as we
did not repeat the procedure once we were unable to conclude a smear.
Our findings were based on single sample obtained. However we hopefully
believe that a repeat sampling as done for other organs could improve
the results (Table 5).
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Conclusion
This study aimed at finding out the reliability of rapid/non-invasive,
painless, simple procedures which can be repeated easily.
On the basis of our study, we therefore conclude that the maximum
correlation was with vaginal cytology followed by cervical mucus studies
and then by endometrial cytology.
We recommend vaginal cytology and cervical mucus studies as dependable
techniques to detect ovulation. Endometrial cytology however, should
be coupled with vaginal cytology and cervical mucus studies to conclude
ovulation/anovulation.
Acknowledgement
Authors are thankful to then dean, Dr. AV Srikahande, IGMC, Nagpur.
We also extend grateful thanks to Dr. Ila Vora, TMC Navi Mumbai for
her able guidance.
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