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Urban Legends and the Postcoital Test

Posted Sep 25 2009 3:34pm

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 given yesterday's post on the endometrium and today's on the postcoital here is the "Question of the Day" from the book that "Pregnancy Magazine" was not interested in as "our readers are already pregnant."

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

Many couples ask their physicians about performing an endometrial biopsy or a postcoital test. Unfortunately, both of these tests have limited benefit in assessing the infertile couple. An endometrial biopsy is performed just before the onset of a woman’s menses and represents an attempt to identify an abnormality of the lining of her 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 to have their patients take extra progesterone, essentially obviating the need for the endometrial biopsy. At the present time, this test is most useful 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. 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 12–14 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. Couples for whom no motile sperm were observed during the postcoital test have conceived, for example. 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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