Doyle, Joseph B.

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The Linacre QuarterlyVolume 16 | Number 1 Article 5January 1949The Cervical Spoon ... an Aid to Spermigration andSemen SamplingJoseph B. DoyleFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationDoyle, Joseph B. (1949) "The Cervical Spoon ... an Aid to Spermigration and Semen Sampling," The Linacre Quarterly: Vol. 16: No. 1,Article 5.Available at: http://epublications.marquette.edu/lnq/vol16/iss1/5THE I,INACRE QUARTERLY The Cervical Spoon ... an Aid to Spermigration and Semen Sampling 41 Joseph 8. Doyle, M.D. Directo'r, Sterility Clinic, St. Elizabeth', Hospital ; A8IIiatant in Obst,etrica, Tutts Col/ege Medical School; Junior V 'iaiting Gyl/ecologist, St. Elizabeth's Hospital.: Junior Vi8iting Gynecologist and Obstetrician, Boston and Cambridge City Ho'pital Preliminary Report It is generally agreed that the Direct insemination of the eer-male contribution to the achieve- vix is unlikely, for actual inter-ment of pregnancy consists of the locking of the penis and cervix is successful deposition of a quanti- rarely possible.2 More usually, the tnti\"ely and qualitatively adequate ejaculate (average pH 7.39) :~ is seminal ejaculate deep enough in deposited in the vagina (pH 4.0 the vagina to permit sperm migra- to 5.0) and gravitates to the lion from the seminal pool through posterior fornix where the mixture the cervical mucus to the uterus of the ejaculate, vaginal secretion, ftnd tubes. The presence of the and cervical mucus forms the Inrgest number of viable motile "seminal pool" (pH 5.6 to 6.2 sperm in the distal end of the depending on the relative volume tubes at the time of ovulation is and pH of these constituents).-l the best assurance of fertilization. We have found the pH of the The "spreading" enzyme 'hyalur- usual pool to vary from 4.5 to 6.5 . onidase is believed to be released Since seventy-five per cent of the by the dying unsuccessful sperm sperm are in the first forty per csndidates in an amount adequate cent of the ejaculate,5 and the to dissolve the hyaluronic acid, a first few drops are the most jellylike complex, that holds the heavily populated, the best of the residual granulosa cells of the fol- sperm population is thus exposed . \ide to the ovum recently released to neutralization and immobiliza-b~' the ovary. The denuded ovum tion by the acid vaginal secretion is thus available for fertilization often before the complete lique-by the remaining sperm in the fa ct ion 0 f the s e min a I fluid tubal fluid whose pH is 7.2 to 7.5 (average thirty minutes)6 permits at ovulation time.1 maximum sperm motility to be From the Department of Obstetrics, Tufts College Medical School, and the Sterility Clinic, St. Elizabeth's Hospital, Boston. (Bulletin or the New E1lgla."d 1lledkal Center X: 225-281, Oct., 194-8) i I, ( I ! : I ! ) I L I' i' . i' II I I I , • t ./ J I I ............. ------------~. THE LIN ACRE QUARTERLY achieved. The , surviving residual active sperm ascend through the overlying fluid, mostly prostatic and seminal vesicular secretion, to the cervical mucus {which increases in amount, fluidity, and penetra- ' bility at the ovulation phase) ,1, ;,8 and drips down to make contact with the pool. Some sperm pene-trate the endocervix (they have been recovered from the uterus in three minutes) ;8 others die or lin-ger sluggishly in the mucus of the os, where the pH varies from 7.0 to 7.5 at ovulation time (pH 6.0 to 7.5 according to Reich et aI.9 ). If the ejaculate could be depos-ited in contact with cervical mucus under circumstances w her e the acid vaginal secretions could be minimized or eliminated, the pres-ence of increasingly large numbers of active sperm in the cervix and . the prolonged survival and activity of more sperm in the pool would demonstrate maximal migration and greater possibilities for ferti-_ lization of the ovum. There would then be an unbuffer:ed isoionic alkaline internal fluid matrix for spermigration in large numbers over a period of hours that would more nearly approximate physio-logic homeostasis than the usual , buffered pool where few sperm survive after one hour6 or, at the most, ten per cent after two hours. -l Physiologic homeostasis can be so achieved by providing a continuous isoionic fluid mat r i x for sperm migration through the .. use of a cervical spoon. Such a method is now presented. A concave lucite spoon has been devised to provide an innocuous inner lining of the posterior fornit and vaginal wall. It is inserted in j the vaginal canal, its shaft gently I depressed by flexion of the index finger against the relaxed per- I ineum and posterior vaginal wall , as the patient gently bears down. ! The cervix can be digitally felt as it dips into the spoon. The pro- · cedure is demonstrated to both : husband and wife in the physi-cian's office, where at probable ovulation time as determined by calendar calculation, thermal Shift, \ and/ or vaginal smear or cervical mucus study, the vagina is wiped , dry and free from accumulated ; debris. A clean vaginal tampon is ! left in place to absorb the secre-tion until the patient is ready for coitus at home. Before coitus, the husband places the spoon (which has first been washed in hot tap water and allowed to dry) beneath the ' cervix. Intromission from above is readily attained. Deep I gentle penetration with minimal ' coital movement will result in the deposition of the ejaculate into the spoon where it mingles freely with the cervical mucus. The leva-tor ani and vaginal muscles elevate the contents of the spoon to mix with the mucus of the cervix (see figure). Repeated voluntary con-tractions of these muscles are optional. The wife remains supine for at least one hour. Then the • , " I D THE LIN ACRE QUARTJ<:HLY 43 spoon is withdrawn by the hus-band as the wife gently bears down to relax the perineum. The contents of the "seminal spoon pool," liquefied ejaculate plus minimal cervical mucus and a trace . of vaginal secretion, are deposited in a clean boiled glass jar for !ltudy of viscosity, sperm count, morphology, and viability. The jar must be tightly capped to prevent escape of CO2 if pH is to be maintained. Our studies reveal that the cer-,. il'a I mucus at ovulation time has /I pH of from 7.0 to 7.5 by the nitrazine method. The pH of spoon semen samples varies from 6 .. 5 to 7.5, virtually isoionic with ('('rvical mucus. Motility and metabolism of the sperm are unaffected at pH 6.7 to 7.7.3 By contrast, the pH of the usual seminal pool ' (4.5 to 6.5) is not the optimum pH probably required by sperm from infertile husbands. When pH is lowered, sperm activity is reduced.3 Few sperm survive in the vagina after one hour;6 not more than ten per cent are viable after two hours. 4 Spoon semen samples col-lected after the spoon was left one to five hours in the vagina show fifty to eighty per cent of the sperm active. Fresh speci-mens withdrawn within thirty minute.s and left standing in the spocn within a large stoppered jar for five hours at room tem-44 THE LINACRE QUARTERLY . f>LA CIN,G 2 SPOON IN POSITION. perature show little change in motility, indicating that the lucite spoon is not deleterious to the sperm. Through the use of this pro-cedure, a virtually isoionic con-tinuous fluid medium at optimum body temperature is thus available for prolonged survival and con-' tinuing penetration of more numerous sperm through the cer-vical mucus. Fertility has been improved by better spermigratioD after alkaline douches of inexacti isoionicity. By keeping more sperm) alive in an almost isoionic mediuml of optimum viscosity and tem-perature that can be maintained for several hours at determinable pH, the spoon preserves the maxi-mum population potentiality for cervical penetration.l •S Hotchkiss3 says, "The motility' of the spermatozoa in the test tube is only presumptive evidence that, their activity in the cervix will be comparable. An inadequate; seminal pool, improper deposition, of the semen, viscid or hostile \·aginal and cervical secretions,! may discount the accuracy of THE LIN ACRE QCARTERLY 45 IIssuming that motility is satisfac-tory for uterine migration, even though the test tube sample of ~rmen exhibits satisfactory motil-ill- of the spermatozoa. The ideal s):stem of semen collection would permit a sample to be produced in contact with substances found in" \'h'o and preserved under the same l'onllitions of gas tension found in the human genital passages. The pH should be regulated to that in d,' o and the tem pera tu re at IIpproximately 87.5 C." At ovula-tion time the cervical mucus is increased from two to ten times in ,"olume, less viscid and more penetrable. I. 7 Hence, if the spoon is withdrawn within one hour, the slImple at ovulation time is a mix-tllre of Iiquified seminal fluid and ('('rdcal mucus, a more physiologic mcdium for viabili ty study. If obtllined in the premenstrual or ('lIrl)' postmenstrual ph a s e, the slIlIlple will contain minimal mucus which is then scant and viscid, lind will be a good mediu~ for a rount and morphology study of a pllre seminal fluid. l\IacLeod10•1l hilS shown that spermatozoa r('ljuire a utilizable carbohydrate ~Ul'h as glucose, fructose, maltose, or (tlycogen as a substrate in order to maintain sperm motility. Hug-/tins l :! has demonstrated that in the semen this carbohydrate is mainly fructo,\e from the seminal vesicles and is found mainly in the terminal half of the ejaculate_ Besides maintaining optimal pH, the cervical spoon pool preserves the vital fructose and enzymes, for example , fibrinolysin and hyaluronidase which are not infrequently diminished by partial or complete effluvium seminis . Twenty-four tests on twelve infertile couples were conducted at approximate ovulation time. No case was rejected because of other infertility factors, male or female. The sole criterion was deficient spermigration as indicated by the cervical mucus sperm count at eight hours postcoitus (the H uh-ner test). In predous eight-hour postcoital tests, four showed no sperm per high power field, due to effluviulll seminis, four showed one sperm per high power field, two showed five, and two showed ten. Table I shows the count of active sperm per high power field in the deep cervical mucus eight hours postcoitus and the percent-age of active sperm survivors, remaining in the spoon at the same eight hours postcoitus after vary-ing lengths of contact time of cen'ical mucus and ejaculate in the'spoon. TABLE I.-EIGHT-HOUR SUR\'U'A), OF SPER~I Number of tests Spoon contact Average sperm/ HPF Cervix Spoonpooi 12 0-10 12 1 hour 18 70 % 8 2 hours 65 62 % 3 3 hours 100 66% 1 5 hours 125 50% I ! t, t } ............... -----------• 46 THE LINACRE QUARTERLY In two five-hour contact tests of fertile couples in the late phase of the cycle, the number of active surviving sperm in the spoon was respectively eighty and ninety per cent when viewed within one hour, and seventy-five per cent when viewed for uniformity eight hours postcoitus. It is therefore esti-mated that fifty to seventy-five per cent of active sperm survivors are available in the spoon pool for continuing the sperm invasion after five hours of cervical mucus contact. There is also definite increased motility in the sperm found in the cervix when the spoon is used, a quality MacLeod has shown to be paramount for semen evaluation. The spoon has been seen to completely prevent effluvium sem-inis. Two cases are presented as. examples. Case l.-One Hour Postcoital Tests Normal coitus 45-min. spoon contact pH sperm/HPF pH sperm/ HPF cervix 7.5 0 7.5 5-15 very active post. fornix 4.5 0-1 dead 5.5 20-30 dead spoon 7.0 70-80 very active pool 20-a0 dead introitus effluvium 5.0 5 dead 5.0 none prompt absent Case 2.-Five Hour Postcoital Tests On~ Tw~ Normal coitus hour spoon contact hour spoon contact pH sperm/ HPF pH sperm/HPF pH sperm/ HFP 50-70 very active cervix 7.5 0-1 dead . 7.5 5-10 active 7.5 post. fornix introitus effluvium 4.5 0-2 dead 4.5 2 dead prompt 7.5 (spoon pool) 4.5 Semen collection by the spoon has none of the disadvantages of the condom-coital method that is notoriously deleterious to the sperm motility a~d viabilitv.3 It has none of the 'personal, esthetic, or moral objections raised by not a few men to coitus interruptus and masturbation for the collection of a specimen of seminal fluid ejac-ulate, a medium that is not as complete a physiologic or func-tional vehicle for sperm viability as is the postcoital .cervical spoon •• u. 0-5 dead 70-80 75% active none absent 7.0 60-80 (spoon 75% active pool) 4.5 none absent specimen whose sperm are true survivors at the body temperature at the time of the sperm invasionl process. The spoon method as described meets the approval of, church moralists13 for it is pro-conceptive, permits marital inter-course, and does not prevent but rather' enhances spermigration by providing a continuous virtually isoiollic (pH6.5 to 7.5) physio-logic medium of optimum viscosity at body temperature. a • THE LlNACRE QUARTERLY 47 I t is no ' 'longer necessary to needlessly sacrifice in the vagina large numbers of the precious few anilable sperm from the unfor-tunate infertile husband. The '~poon should be useful to aid deep deposition of seminal fluid in such male deficiencies as hypospadia, '\ small penile size, premature ejac-ulation, small volume ejaculation, and oligospermia, by providing a protected trough for the ejaculate to reach the cervix. A relath'e increase in the effective migrating sperm population can be achieved. The spoon helps motility through preservation of maximum fructose and enzymes and by enabling the seminal fluid and cervical mucus to blend as the physiologic fluid matrix. analysis, specially for motility and viability assay. REFERENCES 1. ABARBANEL, A. R ., 1'r. Am. Soc. Study Of Sterility (19"6), p . 46. 2. DICKINSON, R . L., Human Sea: Anatomy, Baltimore: Williams and Wilkins Company, 1933. 3. HOTCHKISS, R. S., Fertility in )[en, Philadelphia: J . P. Lippincott, 194-4. 4. ZEIGLER, S. L., Fertility in Women, Philadelphia: J. B. Lippincott. 1944. 5. )fACLEOD, J., AND HOTCHKISS, R. S., J . Urol. 48:225, 1942. 6. MAZER, C., AND ISRAEL, S. L., D·ia.gnosia and 1'reatment of J1{en-str7lal DisorderB and Sterility, ed. 2, :-<ew York: Hoeber, 1946. 1. POAOIERENKE, W. T ., AND VIER-GIVER, E ., Am. J. ObBt. ot Gynec. 52:1023, 1946. 8. , ibid., 51 :192, 1946. 9. REICH, 'V. J., WILKEY, J. L., AND HEcHTOW, M. J., J. Indiana .11. A. 40:842, 1941. 10. )fAcLEOD, J., Am. J. PhY8iol. 132:198, 1941. SUMMARY.-This is a prelimin-ary report of a new method for maximum utilization of the migra-tion potentiality of the semen. The Cerdcal Spoon aids sperm deposi-tion, sperm survival, and sperm mi~ration. The method is simple and acceptable psychologically and morally. A physiologic postcoital sample is available for semen II. )fAcLEOD, J ., Endocrinology 29 :588, 1941. 12. HUGGINS, C. B., AND JOHNSON, A . A ., Am. J. Physiol. 103:514, 1933. 13. FORD, JOHN C., S.J., Professor of )foral Theology, Boston College, Personal Communication. .. . t f. u . I , I, ~ i I' 

The Cervical Spoon ... an Aid to Spermigration and Semen Sampling

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The Cervical Spoon ... an Aid to Spermigration and Semen Sampling

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