Since the first description of the postcoital test in 1866 by J. Marion Sims, and later in 1913 by M. Huhner, the test has been widely used in cases of subfertile couples.
Many experts believe the postcoital test is the cornerstone of the evaluation of fertility. The postcoital test is commonly used but, in recent years, its use as a diagnostic test of fertility has been debated due to some conflicting data.
Esther Leushuis, M.D., M.Sc.,a,c Jan Willem van der Steeg, M.D., Ph.D.b Pieternel Steures, M.D., Ph.D. c, Carolien Koks, M.D., Ph.D.d, Jur Oosterhuis, M.D., Ph.D. e, Petra Bourdrez, M.D. b, Patrick M.M. Bossuyt, Ph.D.f, Fulco van der Veen, M.D., Ph.D.c, Ben Willem J. Mol, M.D., Ph.D. c,f,Peter G.A. Hompes, M.D., Ph.D. a, CECERM study group
a Department of Obstetrics and Gynecology, Vrije Universiteit Medical Center, Amsterdam, the Netherlands,
b Department of Obstetrics and Gynecology, Vie Curie Medical Center, Venlo, the Netherlands
c Center for Reproductive Medicine, Academic Medical Center, Amsterdam, the Netherlands
d Department of Obstetrics and Gynecology, Maxima Medical Center, Valdhoven, the Netherlands
e Department of Obstetrics and Gynecology, Medish Spectrum Twente, Enschede, the Netherlands
f Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam, the Netherlands
Introduction
The postcoital test can identify couples with fertility problems due to a cervical factor, thus avoiding their mistaken classification as unexplained infertility. However, the data on the prognostic value of this test, when it comes to spontaneous pregnancies in subfertile couples, is inconclusive. The aim of this study was to evaluate the prognostic value of the postcoital test in a prospective multicenter cohort of subfertile couples, in relation to an existing model.
Material and methods
The study was designed as a prospective cohort study, conducted in 38 hospitals in the Netherlands. Couples who desired to have a child, had been having unprotected sex for over a year and the wife had a regular cycle were included in the study. A fertility diagnostic, which consisted of a history of fertility, a semen analysis, a postcoital test and an evaluation of the ovulation and of the fallopian tubes was performed.
The test was planned according to the basal body temperature, the cycle of the women and the results of the ultrasounds. The test would be considered normal if at least some spermatozoids with progressive motility were observed in one of the five fields at 400x.
Follow Up
The starting point was the spontaneous conception that leads to an ongoing pregnancy. We consider a ongoing pregnancy the presence of fetal cardiac activity in a transvaginal ultrasound, done at twelve weeks of gestation.
The Hunault model to predict spontaneous pregnancy was used as a reference model. This model includes five prediction variables: female age, duration of the subfertility, female primary or secondary subfertility and a good percentage of motile sperm in the semen analysis.
Evaluation
The results of the adjustment of the postcoital test were compared with the data of the reference model. This was achieved by testing and comparing the likelihood ratio of both tests. This test assessed whether the addition of the postcoital test in the reference model leads to a significant improvement in its efficiency.
Three concepts were used to compare the output of the postcoital test in relation to the reference model. First, the discriminative ability (ability to distinguish couples who are able conceive from those who aren't) of the models was evaluated. Secondly, the calibration of the models was assessed. Thirdly, the degree of classification between the reference model and model test was determined.
Results
7,860 subfertile couples started the diagnostic test. 948 of which had a severe male factor, 311 presented a bilateral tubal pathology, 1.311 presented a unilateral tubal pathology and 2.642 had fertility problems related to other factors. Thus, only 3.021 couples remained included in the study.
From this 3,021 couples, 537 (18%) had a spontaneous ongoing pregnancy within a year. The average probability of achieving that pregnancy, according to the model of Hunault without the postcoital test, was of 0.32 and of 0.29 when the postcoital test was included.
Discussion
This study showed that subfertile couples with a negative result of the postcoital test are less likely to have a spontaneous pregnancy, especially if sperm is found in the cervical mucus. Despite the forecast information and the test results as a prediction variable for spontaneous pregnancy, the adjustment of this model did not improve significantly, and even led to a nonsignificant reduction in the correct classification of couples who took the test and didn't get pregnant.
Although, the postcoital test does not help establish a prognosis for spontaneous conception, it's possible to identify couples who do not conceive as a result of a sexual dysfunction that may benefit from sex therapy or insemination during the natural cycle.
The postcoital test has forecasting value but not as a prognostic variable of a validated predictive model of spontaneous pregnancy, because it does not significantly enhanced the usefulness of the model. It slightly reduced the accuracy of the classification of couples who can or cannot get pregnant. The prediction information of the test is already incorporated in other semen analysis based variables.
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