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Question 16. My friend keeps asking whether I had an endometrial biopsy or a postcoital test. Do I need these tests?

Posted Apr 07 2010 1:51pm
As we work our way through the 2nd Edition of 100 Q&A about Infertility, I suppose it is inevitable that some blog posts may end up getting recycled. When discussing the post coital test I always think of the story that I initially related in one of my first blog posts. It may not be the most politically correct story but here it goes....

Here is a true RE urban legend. Many years ago a very trustworthy and honest infertility specialist (not yours truly although I would hope to be described in this fashion) arrived at the office for his usual consultations. He was informed that Mrs. Jones (not her real name) was waiting for Dr. James (not his real name) in the exam room. She was scheduled for a postcoital test.

Dr. James went into the room, said hello and then sat down to perform the postcoital. As he was placing the speculum he asked Mrs. Jones the usual questions: “What cycle day are you?” “Day 14 ,”she replied. “Did you have an LH surge?” “Yes, last night,” she promptly informed the doctor. “OK, so how many hours ago did you have sex?” No answer. Dr. James asked again. The patient hesitated and then blurted out, “But Dr. James I am here for a postcoital test!” “Yes, I know, so when did you and your husband have relations?” She hesitated and then clarified her misunderstanding. “Oh my gawd, Dr. Jones, I thought I was supposed to have sex with you!” Dr. James removed the speculum. Stood up. Walked out of the room with his face blazing in embarrassment.This story was related to me by Dr. James, at a conference one year, so I have no reason to doubt its veracity. Of course, this became a huge inside joke at Dr. James’ practice as Dr. James was routinely asked after that exactly how much time he needed to perform any scheduled postcoital test!

We all want to help our patients and in the process we form some very close relationships, but clearly there are some limits that should never be crossed…even as part of the diagnostic evaluation. So here is today's Question of the Day.

16. My friend keeps asking whether I had an endometrial biopsy or a postcoital test. Do I need these tests?

In the past, the endometrial biopsy was a routine part of the fertility evaluation, but current practice has been to limit performance of this test to a minority of fertility patients. An endometrial biopsy is a simple office-based procedure that is performed just before the onset of a woman’s menses. It is usually performed without any anesthesia and is well-tolerated by most patients with the majority reporting uterine cramping that quickly resolves.

An endometrial biopsy can yield information about the hormonal status of the lining and can rule out chronic infection/inflammation in the uterus. The problem with the endometrial biopsy in terms of its usefulness as a fertility test is that abnormal biopsies are obtained in more than one-third of women with proven fertility. Therefore, the finding of an abnormal endometrial biopsy in fertility patients is of uncertain benefit. Most reproductive endocrinologists prefer simply to have their patients take extra progesterone, essentially obviating the need for the endometrial biopsy in most patients. At the present time, the endometrial biopsy is most reliable as a means to rule out endometrial cancer in those patients who are at increased risk of this disease. Patients at increased risk for endometrial cancer include those who have polycystic ovarian syndrome and infrequent, heavy periods but who do not receive the protective benefit of oral contraceptives or other progesterone-containing medications.

In patients who have experienced repeated IVF failures in spite of the transfer of good quality embryos, it is reasonable to perform an endometrial biopsy to ensure that the lining demonstrates the appropriate hormonal response, the absence of infection/inflammation or the correct expression of cell surface proteins. There is a class of cell surface proteins call integrins that play a putative role in implantation. Some physicians will perform an endometrial biopsy to ensure the proper expression of integrins on the surface of the endometrium. Abnormal integrin expression has been demonstrated in a range of clinical situations including the presence of a fluid filled fallopian tube or hydrosalpinx, but most experts consider testing for integrins to be investigational and limited to special circumstances.

The postcoital test was initially proposed as a means to evaluate the interaction of the male partner’s sperm and the female partner’s cervical mucus. This test is performed approximately 8 to 24 hours after intercourse at midcycle (around days 12 to 14 of the menstrual cycle). During a speculum exam, the physician collects a sample of cervical mucus. This sample is then placed on a slide and examined under a microscope for the presence of motile sperm. In addition to the presence or absence of sperm, the physician records the quality, quantity, and appearance of the mucus. Unfortunately, the postcoital test has very poor reproducibility and limited utility in the evaluation of infertile couples. For example, couples for whom no motile sperm were observed during the postcoital test have conceived. Although the spontaneous pregnancy rates are higher in those patients with a normal postcoital test, the information gathered in this way seldom provides any useful insight when developing a therapeutic plan.

Postcoital tests may prove more valuable in couples in whom, for social or religious reasons, the male partner is unable to provide a specimen for semen analysis. In these cases, a postcoital test reassures all parties that sperm are actually deposited in the vagina during the act of intercourse.
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