Nasal mucus ferning patterns.

Natural family planning methods utilized a number of signs and symptoms to determine ovulation. The calendar method of recording dates, basal body temperature, cervical mucus change, spinbarkeit, mittelscherz, spotting, breast tenderness position and consistency of the cervix, mood and libido changes are all used as indicators of fertility. On the cervical mucus changes evaluated, a characteristic called ferning has been studied extensively. Cervical mucus changes have been found to be under the control of the cyclic release of the hormones estrogen and progesterone. Estrogen indirectly stimulates ferning and progesterone prevents ferning by affecting the NaCL content of the mucus secreted by the columnar epithelial cells of the cervix. It has been found that estrogen and progesterone affect all columnar epithelial cells of the body. Therefore, mucus secreted by other columnar epithelial cells could also be evaluated for their cyclic ferning properties as well. The purpose of this study was to describe the cyclic ferning patters in the nasal mucus of women with regular menstrual cycles. The specific research questions addressed included: a) how does the stage of ferning in nasal mucus change with changes in basal body temperature; and b) how does the stage of ferning in nasal mucus change throughout the menstrual cycle? Data were collected through the use of a medical history questionnaire, basal body temperature chart, and nasal mucus samples collected daily. The data obtained were interval, but due to the small sample size of 25 women, frequency polygons were the only statistical measure used. Statistically, there were no significant relationships between nasal mucus ferning and basal body temperature. Clinically it was significant that as the temperature increased, the stage of ferning also increased. There was also no statistically significant relationship between nasal mucus ferning and the day of the menstrual cycle. In clinical observations, it was found that nasal mucus ferning patterns more closely resembled the effects of progesterone and estrogen.

NASAL MUCUS FERNING PATTERNS by Diana Lynn Peterson A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing The University of Utah December 1984 THE UNIVERSITY OF UTAH GRADUATE SCHOOL SUPERVISORY CO~1MITTEE APPROVAL of a thesis submitted by Diana Lynn Peterson 'rhis thesis has beell read by each member of the following supervisory committee ano. by majorilV vote has been found to be satisfactory. ---lZ",,--,'_ - 17 -13 Snz.~~~~~ Chairman: M. uzanne Tarmlna t3-11-8~ THE U~IVERSITY OF L1TAH GRAOL'ATE SCHOOL FINAL READING APPROVAL To the Graduate Council of The University of Utah: 1 have read (he thesis of Diana Lynn Peterson an Its final form and have found that (I) its format, citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures. tables. and charts are in place; and (3) the final manuscript is satisfactory to the Supervisory Committee and is ready for submission to the Graduate School. //- ;:3-y¥ Dale Approved for the Major Department ~~L Linda K. Amos Chairman Dean Approved for the Graduate Council James L. CIa on [)ean 01 The Graduare Sl.:hnol Copyright @ 1984 Diana Lynn Peterson All Rights Reserved ABSTRACT Natural fami planning methods utilize a number of signs and symptoms to determine ovulation. The cal­endar method of recording dates, basal body temperature, cervical mucus changes, spinbarkeit, mittelschmerz, spotting, breast tenderness, position and consistency of the cervix, mood and libido changes are all used as indicators of fertility. Of the cervical mucus changes evaluated, a characteristic called ferning has been studied extensively. Cervical mucus changes have been found to be under the control of the cyclic release of the hormones estrogen and progesterone. Estrogen indirectly stimulates ferning and progesterone prevents ferning by affecting the NaCI content of the mucus secreted by the columnar epithelial cells of the cervix. It has been found that estrogen and progesterone affect all columnar epithelial cells of the body_ Therefore, mucus secreted by other columnar epithelial cells could also be evaluated for their cyclic ferning properties as well. The purpose of this study was to describe the cyclic fern patterns in the nasal mucus of women with regular menstrual cycles. The specific research questions addressed included: a) how does the stage of ferning in nasal mucus change with changes in basal body tem­perature; and b) how does the stage of ferning in nasal mucus change throughout the menstrual cycle? Data were collected through the use of a medical history question­naire, basal body temperature chart, and nasal mucus samples collected daily. The data obtained were interval, but due to the small sample size of 25 women, frequency polygons were the only statistical measure used. Statistically, there were no significant relation ships between nasal mucus ferning and basal body tem­perature. Clinically it was significant that as the temperature increased, the stage of ferning also increased. There was also no statistically significant relationship between nasal mucus ferning and the day of the menstrual cycle. In clinical observations, it was found that nasal mucus ferning patterns more closely resembled the effects of progesterone than estrogen. v CONTENTS ABSTRACT. . LIST OF FIGURES . . ACKNOWLEDGMENTS Chapter I. INTRODUCTION .... Problem Statement ..... . Significance of the Study ... . II. REVIEW OF THE LITERATURE III. THEORETICAL FRAMEWORK .. Research Questions . . . . . . . Operational Definitions of Terms . IV. METHODS AND RESEARCH DESIGN .. V. VI. Des ign of the Study.. ... . Study Population .. . .... . Criteria for Inclusion . . . . . . . Human Subjects Considerations .. Data Collection Procedure ........ . Instrument . . . . . . . . . DATA ANALYSIS AND FINDINGS . Sample . . . . . . Data Analysis ... Discussion of Findings . . . . Limi ta t ions. . . . . . . . . . . . . SUMMARY AND IMPLICATIONS . iv viii ix 1 4 4 6 13 19 19 21 21 21 21 22 22 24 26 26 27 37 39 41 Summary. .. ........... 41 Implications for Further Research. . . 44 Implications for Nursing . . .. 45 APPENDIX: DATA COLLECTION TOOLS. . . . . . . . .. 46 SELECTED BIBLIOGRAPHY. . . . . . . . . . . . . . .. 49 vii LIST OF FIGURES 1. A general systems model describing the relationship between the reproductive subsystem, the focal system which is the reproductive female, and the suprasystem of health care providers. 16 2. A comparison of the frequency of stage 1 and 2 nasal mucus ferning and basal body temperature. 28 3. A comparison of the frequency of grade 3 and 4 nasal mucus ferning and basal body temperature . 30 4 • Percent reaching ferning stage 1 and 2 on anyone menstrual cycle day . 33 5 . Percent reaching ferning stage 3 and 4 on anyone menstrual cycle day . 35 6. Percent reaching ferning stage 3 and 4 on any menstrual cycle day 36 ACKNOWLEDGMENTS The author is indebted to the thesis committee members, Ms. M. Suzanne Tarmina, Ms. Maureen Cleary, Dr. Dale Baker, and Dr. Dale Lund, for their time, dili­gence, guidance, dedication, and assistance throughout the preparation of this study. A special thanks is given to the women who partic ed in this study, and to Lynch for her he in recruiting them. CHAPTER I INTRODUCTION The desire to control conception is a universal social phenomenon. What is new is not the desire for prevention, but the need for an effective, harmless means of achieving such a goal. Some of man's earliest attempts to control population growth are difficult to know or understand. Disease, famine, war, human sacrifice, infanticide and natural catastrophies all served to limit population growth from birth on. In primitive societies the prime method of preventing large families was abortion. Other preventive measures used were delayed marriage, celibacy, sexual taboos, coitus interruptus, prolonged lactation and control of con­ception by herbs, magic and amulets. Magic potions have been used throughout history to prevent pregnancy. Women have ted concoctions of willow bark, the seeds and leaves of fruitless trees, roots of spotted cowbane, scrapings of the male deer horn, spider's eggs, skins of snakes and betel nut. Women have an equal number of odd concoctions into their vaginas to prevent pregnancy. Cut grass, alum, honey, ear wax, gold balls, stones, half a lemon, okra- like seed pods and cabbage have all been inserted into vaginas (Hines, 1936). In the days of ancient Egypt, women resorted to putting camel dung into their vaginas to prevent conception. are less traumatic. Today's methods, thankfully, Cassanova popularized the use of the condom as a barrier method of birth control in the 1700s. Sanger encouraged women to use a diaphragm in the early 1900s. The knowledge explosion in the area of female ility control in the last 20 to 25 years has emphasized the hormonal control of fertility instead of the barrier or natural methods. The "natural" methods of birth 2 control were relegated to a back seat by both researchers and women. But women's needs have been changing in the last 5 to 10 years. There has been an increased desire by women to take more control over their own bodies and their own fertility. Fertility awareness or natural planning methods have been attempting to meet this need. Fertility awareness or natural family planning methods utilize a number of signs and symptoms to deter­mine ovulation. The calendar method of recording men strual dates, basal body temperature, cervical mucus changes, spinbarkeit, mittelschmerz, spotting, breast tenderness, position and consistency of the cervix, mood, and libido are all used as indicators of fertility. 3 One sign of fertility that has not been studied in recent years is the phenomenon of mucus ferning. Papanicoloaou(1946) discovered that when cervical mucus was spread on a slide and allowed to air dry, it crystal­lized with arborization forming a fern leaf-like pattern. Other mucus secreting surfaces of the body were also found to display arborization of the mucus if left to air dry (Zondek, 1959). Nasal mucus secretions were then evaluated specifically for cyclic ferning patterns and biochemical properties (Abou-Shabanah & Plotz, 1957). The investigators found that both the biophysical and ferning properties of nasal mucus were also under the influence of estrogen and progesterone (Iacobelli, Garcea & Angelone, 1971; Moghissi, 1966). Evaluating cervical mucus changes has several distinct disadvantages. Spermicides, semen, vaginal infections and squemishness on the part of some women may all interfere with accurate testing. If nasal secretions do indeed mirror the ferning patterns of cervical secretions then the sexuality components of inaccurate testing would be eliminated. More research is needed in the area of natural family planning for those women who wish to use it. We need to find more and better indicators of ovulation. Nasal mucus ferning patterns need to be evaluated more extensively as a tool women might eventually use at home to increase fertility awareness and enhance the ability to predict ovulation. Problem Statement 4 The purpose of this study was to describe the cyclic ferning patterns in the nasal mucus of women with regular menstrual cycles. Si ificance of the St Unplanned and unwanted pregnancies are still occur­ring in our society at alarming rates despite the avail­ability of modern hormonal birth control pills and ot r devices. No birth control method available today is fail proof. Those methods with the highest theoretical effectiveness, also have high attrition rates due to the side effects of the methods. More research is needed in the areas of natural family planning for those women who cannot or will not use hormonal pills or other con-traceptive devices. Research in the area of fertility control in the sixties and seventies has focused on the endocrinology of the reproductive system. It is necessary to again focus on other parameters of fer­tility, specifically nasal mucus ferning patterns. Nasal mucus ferning patterns need to be evaluated more extensive to see if they might be used as an indicator of cyclic fertility and the ability to predict ovulation. Nasal mucus arborization was not studied thoroughly 5 enough to prove or disprove the process as an indicator of corpus luteum function. More research needs to be done at all levels. CHAPTER II REVIEW OF THE LITERATURE Positive evidence that ovulation has occurred in humans is through the recovery of an ovum or pregnancy. However, there are a number of other indicators which can be used as presumptive evidence of ovulation. Biphasic basal body temperature curve (BBT), an increase in blood progesterone levels in the luteal phase of ovulatory cycles and a change in the quality and quantity of cervical mucus can all be used as indicators of ovu­lation. Van de Velde in 1904 (Moghissi, 1980) observed that body temperature shows a biphasic pattern when measured at the basal level during the menstrual cycle. Basal body temperature has been found to be lowest in the follicular or preovulatory phase of a woman's cycle. Within the 24 to 72 hours after ovulation, the BBT rises and remains elevated during the luteal or postovulatory phase. The distinct rise in temperature, called the thermal shift, indicates that ovulation has occurred. The World Health Organization's definition of changes in BBT indicates that a shift in BBT to the hyperthermic phase of the cycle should occur within a period of 48 hours or less. Three consecutive daily BBTs should be at least 0.2°C higher than the previous six daily temperatures (Moghissi, 1980). The results of a study done in 1972 indicated that a single luteal phase progesterone assay could be used clinically to provide presumptive evidence of ovulation (Israel, Nishell, Stone, Thorneycroft & Moyer, 1972). Prior to 1972 ser progesterone assays throughout the cycle were used to prove an increase in progesterone levels. Israel found that between 11 and 4 days prior to the next menses a serum progesterone level in venous blood greater than 5 ng/ml was always followed by men­struation (Israel et al., 1972). Therefore, it was concluded that a progesterone level greater than 5 ng/ml provides presumptive evidence of ovulation. 7 The rheologic and biophysical mucus have been studied by many invest ies of cervical ors. As early as 1855, Smith demonstrated that the cervix secreted mucus (Zondek & Rozin, 1957). Cervical mucus has an important function in human reproduction. Cervical mucus protects the uterine cavity by enhanc and in-hibiting sperm penetration into the uterus. The pro-duction of, and rheologic and biophysical ies of cervical mucus have been found to be under hormonal control. Estrogen causes the endocervical glands to produce increasing amounts of a mucoid secretion which 8 is abundant, elastic, watery, clear, isotonic and pene-trable by sperm. Progesterone conversely causes the mucus to become thick, opaque, scanty in amount and impen­etrable by sperm (Iacobelli et al., 1971). Papanicolaou (1946) was the first person to suggest that the rheologic phenomenon of arborization might also be due to estrogen stimulation (Papanicolaou, 1946). Papanicolaou spread mucus taken from the endocervical canal at midcycle on a slide, and let it air dry. After drying, he observed a crystallization of the mucus. Since this was found to be most abundant at the time of ovulation, estrogen was hypothesized to be the cause. Arborization or ferning of cervical mucus has also been studied as a test for corpus luteum function, determination of ovulation, estrogenic and progestational activity and early pregnancy. Rowland (1952) studied 20 women with regular cycles, 30 infertile women, and 40 women with menopausal symptoms for the presence of cyclic arborization terns. Women with regular cycles all showed ferning to be present from the fifth or seventh day to around the 22nd day of the cycle. The infertile women showed ferning patterns throughout the cycle and the menopausal women showed no fern-like pat terns. Through concurrent examination of basal body temperature, endometrial biopsy and vaginal cytology, fern patterns were confirmed to be due to estrogen. Zondek and Rozin (1954) also noted that ferning disap­peared prior to menstruation and confirmed that ovula­tion had occurred by endometrial biopsy. A third study in 1966 reconfirmed the findings done by endometrial biopsy. Arborization patterns appeared around day 9 or 10, reached a maximum during oculation and became atypical or absent after ovulation (Moghissi, 1966). 9 Zondek (1956) was the first to report that other mucus secreting surfaces, including the nasal epithelium, produced arborization when dried. The relationship between nasal and genital function has been known since Hypocrates. In healthy women, engorgement of the caver-nous tissues of the nose occurs in a cyclic pattern in conjunction with cervical mucus. The epithelium of both organs is chiefly columnar, ciliated, mucoid epithelium. Studies comparing the arborization of nasal and cervical smears were done in the late fifties. According to Ullery, Livingston and Abou-Shabanah (1959), Gonzalez studied 108 women, concluding that there was a high cor­relation between the crystallization that occurred in cervical mucus and that occurring in nasal mucus. The studies were again repeated in 1958 were comparable. Both nasal and cervical smears arborized in the ear and late proliferative phase and early secretory phase. When progesterone secretion was highest, both smears showed changes in the appearance of the fern pattern. Arborization remained longest however, in the nasal smears (Davis & Abou-Shabanah, 1958). Zondek (1~56) was the only researcher to conclude that arborization was important and reliable only in cervical mucus. The conclusion was reached after comparing the nasal and cervical smears of only two women. Cervical and nasal mucus is composed of 85 to 95% water, sodium chloride (NaC1) and other electrolytes, 10 proteins, mucins and saccharides. The biochemical basis for the phenomenon of arborization has been found to be dependent on the electrolyte concentration in the fluid, chiefly NaC1, and the ratio of NaC1 to proteins. Ferning results when crystals of sodium and potassium chloride form around a small and optimal amount (1- 15%) or organic matter (Moghissi, 1980). Zondek (1959) dialized mucus and was unable to produce arbor-ization until the mucus was mixed with electro lytes. Estrogen and progesterone affect both the NaC1 and protein concentration in mucus. Estrogen causes sodium excretion, and progesterone causes sodium reten-tion. This may be either a direct or indirect means through the excretion of water (Ullery et al., 1959). There has been no consensus about the measurement process of arborization. Rowland (1958) stated that true or typical cervical mucus ferning must cover the 11 entire field and have only minimal cellular elements present. If both atypical and true ferning are present, it must be labeled atypical. True arborization is dense-packed, the background is light and the leaves and stem are dark (Rowland, 1962). Moghissi (1966) graded crystallization from a one to a four plus. One plus was considered an atypical fern pattern and four plus a strongly preovulatory ferning pattern. Two and three plus were not delineated. Studying crystallization in 1972, Kessery found available measurement tools inade­quate and developed what was called the crystallometer. This device consisted of a glass slide with a central latticed area of 100 squares. Mucus was spread on the slide covering the latticed area and the number of squares covered by cyrstallization were counted. A percentage, or quantitative result was acquired (Kessery, 1972). In summary, all of the studies on cervical and nasal mucus ferning patterns were done in the late 1950s and early 1960s. Most of the findings of cervical fern­ing were confirmed to be due to estrogen by concurrent endometrial b ies. Specific levels of progesterone and estrogen in the system were not available at that time to compare to ferning patterns. There was also no consensus about the measurement process of arbori­zation. Atypical ferning was not evaluated as a measure- 12 ment tool of estrogen's effect. In all of the studies, the measurement process of arborization was different. CHAPTER III THEORETICAL FRAMEWORK General systems theory provided the theoretical framework for this research. General systems theory is based on the assumption that matter, in all of its forms, living and nonliving, can be regarded as a system and has certain discrete properties. Putt (1978) stated that all systems in the theory are organized units with a set of components that mutually react. A system is a whole comprised of parts or subsystems that mutually interact and are mutually interdependent. Each subsystem within a system is also part of a supra­system. The focal system is the component of primary attention composed of interacting and interdependent subsystems which are also part of a suprasystem. Any subsystem can also be a focal system with subsystems. Each subsystem, focal system and suprasystem has a semipermeable boundary that is able to regulate the amount of input or output processed. Boundaries consist of either physical or abstract lines of demarcation between the separate systems. Systems may be open or closed. Closed systems do not receive input or process output, but function 14 as independent entities. All living systems are open systems. For survival, a system must achieve internal and external balance. Equilibrium is maintained within a system through self-regulation of input and output, feedback and adaptation. Output is defined as the trans­ferance of a product, matter, energy or information, to the outside systems. Output represents the functions systems perform to provide external balance, and justify existence. Input is what a system accepts to provide internal balance. The outputs of one system become the inputs of another system. This creates a feedback mechanism of inputs and outputs between the subsystems, focal system and suprasystem. Systems can adapt to new or changing input by changing output. The principles of general systems theory can be applied to the concept of nasal mucus ferning. The physiological processes of the reproductive system involved in the end product of nasal mucus ferning are subsystems of the focal system which is the reproductive female. The reproductive female is in turn a subsystem of a suprasystem of health care providers. Each of the subsystems identified above accepts input, processes input to output via throughput, and expels output. The specific subsystems involved in the output of nasal mucus ferning are: the hypothalamus; the anterior pituitary; the ovaries; and columnar epithelium (Figure 1). All of the subsystems are open systems which receive input and exchange output with their environment. The balance, or equilibrium of the focal system is controlled by a feedback mechanism. The hypothalamus gland in the brain secretes or outputs substances known as releasing hormones. The 15 two specific hormones involved in reproductive physiology are follicle stimulating hormone-releasing hormone (FSH­RH) and luteinizing hormone-releasing hormone (LH-RH). In the focal system of the reproductive female, the cyclic nature of the menstrual cycle is due to the per­iodic secretion of releasing hormones by the hypothala­mus. To begin the cycle, FSH-RH is released by the hypo­thalamus. The semipermeable membrane of the anterior pituitary gland receives FSH-RH as input, and in turn releases or outputs follicle stimulating hormone (FSH). FSH is then absorbed by the ovary_ The ovary processes this information and produces a graffian follicle which then again outputs a hormone called estrogen. Estrogen is absorbed as input by the cervical columnar epithe­lial cells, and processing takes place which affects the protein and electrolyte concentration of the output, is mucus. The protein and electrolyte concentration of the mucus when stimulated by estrogen, causes the mucus to fern when air dried on a slide. Figure 1. ~ ____ ~~:~----~~~------------Health Care '" FSH-RH LH-RH \ I hypothalamus I " / I anterior pituitary \ FSH ""' LH ( columnar , epithelium ( ovaries \ / \ """"- /estrogen progesterone - \ J Providers Reproductive Female Reproductive System A general systems model describing the re­lationship between the reproductive subsys tem, the focal system which is the repro­ductive female l and the suprasystem of health care providers. 16 The hypothalamus continues to output FSH-RH, the anterior pituitary accepts FSH-RH as input, and outputs FSH. The ovary continues to input FSH and the graffian 17 follicle continues to grow and secrete or output increas-ing amounts of estrogen. Estrogen, via throughput, or processing, indirectly increases the amount of ferning occurring in cervical mucus. When es levels reach a certain degree, they are also absorbed as input by the hypothalamus. General systems t states that a system can adapt to new or changing input by changing output. Therefore, as the hypothalamus is now receiving high levels of estrogen as , it must change the output. Now instead of secret FSH-RH, the new product is LH-RH. The anterior pituitary is also able to absorb LH-RH, process it and in turn the product to luteinizing hormone (LH). The ovary inputs LH, which when processed by the ovary stops the growth of the graffian follicle and changes it to a corpus luteum. The corpus luteum then s progesterone. Proges-terone is absorbed by all cervical columnar epithelial cells and when processed by the cells, changes the elec trolyte and protein concentration of the mucus output. As the level of progesterone gradually increases, the amount of ferning present when the mucus is air dried on a slide, decreases. The hypothalamus continues to produce LH-RH, the 18 anterior pituitary continues to absorb LH-RH and produce LH, and the ovaries absorb LH and produce progesterone via the corpus luteum until the increasing levels of progesterone are picked up by the semipermeable membrane of the hypothalamus. The hypothalamus then changes the output because of the new input, and again produces FSH-RH. The cycle has been completed qnd will continue to do so via adaptation, feedback and the regulation of inputs and outputs. Nasal and cervical mucus are both produced by columnar epithelial cells. As estrogen levels rise, cervical mucus ferns when air dried on a slide, and as progesterone levels rise ferning decreases and even-tually disappears. Since nasal and cervical mucus are both produced by columnar epithel I cells, estrogen and progesterone should be accepted as input by both sites and processed with the same output. Therefore, what is known to occur in cervical mucus should also occur in nasal mucus. Nasal mucus ferning patterns should mirror cervical mucus ferning patterns. The focal system of the reproductive female is also a part of a larger suprasystem of health care pro­viders. Women, to be cognizant of their reproductive system, need to receive input from many different sour ces. Books, friends, schools, doctors and nurse clini­cians are all part of the suprasystem of health care providers that exchange input and output with women. Nurse clinicians are in a unique position to also be able to bring the other subsystems into focus. As teachers, nurse clinicians have access to books and information for referral and learning, and can also assess and diagnose signs and symptoms of the subsystem of reproductive physiology. Nurse clinicians through a shared feedback system with women can increase the knowledge level of both systems. Research tions 1. How does the stage of ferning in nasal mucus change with changes in basal body temperature? 2. How does the stage of ferning in nasal mucus change throughout the menstrual cycle? ional Definitions of Terms St of Fern Stage of ferning was defined as the degree of crystallization into a boston fern-like pattern, rated according to the following criteria: Stage 1 Stage 2 Stage 3 no ferning present atypical ferning present seen as small stars or snowflakes atypical ferning present seen as 19 XS or large snowflakes taking up approx­imately 1/2 of a high power field. The stems and side branches were thin and nondirectional 20 Stage 4 typical ferning present, seen as wide stems and thick side branches, directional branching, or longer, slightly thinner branching that ran the whole length of Nas Mucus the high power field, much like railroad ties. The viscus fluid secreted by the mucus glands in the columnar epithelium of the nasal cavity was con­sidered nasal mucus. Menstrual Ie Menstrual cycle was defined as the number of days counting from the first day of one menstruation to the last day before the next menstruation, and including both these first and last days. Basal Body Temperature The temperature of the body on first awakening and while still at complete rest was defined as basal body temperature. CHAPTER IV METHODS AND RESEARCH DESIGN Design of the Study A nonexperimental, longitudinal, descriptive design was used to describe the cyclic ferning patterns in the nasal mucus of reproductive women. Data were col-lected to answer the research questions. Study Population The population was composed of highly motivated women residing in Salt Lake City, Utah. Participation in the study was strictly voluntary. Subjects were recruited by word of mouth, signs posted in various areas employing women such as hospitals and clinics around the city, and by a cover letter inserted into all graduate student mailboxes at the College of Nursing. Participants were rewarded for study participation with a can of hair spray, a basal body thermometer, and a free progesterone assay test to prove ovulation. Criteria for Inclusion Participants had to meet the following criteria In order to be included in the study: 1. Between the ages of 18 and 40 years 2. Have menstrual cycles between 25 and 35 days in length for the last 6 months. 3. Currently not taking birth control pills or hormones, or have taken either in the last 6 months. 4. Have no overt signs of sinusitis. 5. Have an interest in finding out more about their fertility. 22 6. No history of infertility or endocrine disease. Human ects Considerations The study proposal was reviewed and approved by the Human Subjects Review Board at the University of Utah Medical Center. Anonymity of subjects was assured by the utilization of code numbers on the data collect tool. Subjects read and signed an Informed Consent Form prior to partic ation. Data Collection Procedure Participants were given an information sheet at the beginn of the study that explained the data collection procedure for them. The procedure was also verbally reviewed by the researcher to answer any ques­tions the participants may have had. Participants were required to obtain a nasal smear once a day for one complete menstrual cycle. The first smear was to be taken on the first day of menses, and 23 thereafter, until the next menses started. Nasal smears were obtained in the following manner. Approximately the same time each day, the participants inserted a sterile Q-tip one half inch into the nasal cavity. With a twisting, rolling motion the sides and floor of the nasal epithelium were wiped, first in one nostril, and then in the other. The thin film of mucus thus collected was rolled on a glass slide and allowed to air dry. Each individual participant's slides were coded with a research number. The participant wrote the date and the day of the menstrual cycle on the glass below the code number each day. When the mucus had dried complete , usually about 15 to 20 minutes, the slide was sprayed with hair spray by holding the hair spray approximately 6 to 8 inches away from the slide and then a fine film was sprayed over the mucus. The slide was then stored until transported. All slides, Q-tips, hair spray and slide boxes were provided for the icipants. Twice a week the participants deposited the slides in a collection box on the fourth floor in the University of Utah School of Nursing Building. The collection box was checked twice a week for slides. The slides were viewed under high power and graded as to the stage of ferning. Participants were also required to record basal body temperature once a day. A special basal body temperature (BBT) thermometer and BBT chart with a code number in the corner were supplied to each participant. An oral BBT was recorded each morning starting the day their menses began. The temperature was taken upon awakening, before any daily activity had begun. The BBT thermometer was placed under tongue for 5 minutes while the mouth was closed. The temperature was then read and recorded on the BBT chart provided. At the start of the second menses, the BBT chart and any final slides were returned to the investigator. All participants called the researcher on day 18 or 19 of the menstrual cycle, to make an appointment to have a venous blood sample drawn within the next 5 days. Less than 5 ccs of venous blood was drawn from the antecubital area for determination of a serum 24 progesterone level to confirm ovulation. A progesterone assay test was done on all serum samples collected. A serum progesterone level greater than 5 ng/ml was considered to provide presumptive evidence of ovulation. Only the women who had presumptive evidence of ovulation were included in the statistical analysis. Instrument The instrument for data collection was a medical history questionnaire and basal body temperature chart designed by the researcher (Appendix). The questionnaire consisted of 15 closed ended questions with 2 op tional open ended questions. The medical history form was evaluated by a panel of experts and found to be clear and readily understood. The medical history questions were not tested for validity and reI ility s the data obtained were used only for coding and screening purposes. An instruction sheet explaining 25 the collection procedures accompan the questionnaires. A basal body temperature thermometer was used to record daily morning temperatures. All of the women were given instructions on the use of the thermometer and recorded their temperature in tenths of a degree on the basal body temperature chart by circling the correct daily temperature. CHAPTER V DATA ANALYSIS AND FINDINGS Sample Thirty Caucasian women from Salt Lake City volun­teered to participate in the research study. To be included in the sample, the women had to meet the following criteria: a) be between 25 and 40 years of age; b) not currently on birth control pills or have taken them within the last 6 months; c) have no overt signs of sinusitis; d) had regular menstrual cycles for the last 6 months; and e) no history of infertility or endocrine disease. Five of the original 30 women were disqualified during the course of the study for the following reasons: a) one became pregnant; b) one developed a 2 week flu­like syndrome and dropped out of the study; and c) 3 women had anovulatory cycles confirmed by progesterone assay results less than 5 ng/ml in the luteal phase of the cycle. Of the 25 women remaining, all had pro gesterone assay levels greater than 5 ng/ml that gave presumptive evidence the study cycles were ovulatory cycles. The age range was from 24 to 34 years, with a mean age of 29 years. 27 Data is Data were analyzed under two categories: 1. The relationship of the stage of ferning in nasal mucus and basal body temperatures; 2. The relationship of the stage of ferning in nasal mucus and the day of the menstrual cycle. Stage of Ferning and Basal Body Temperature Twenty-five women took a basal body temperature each morning followed by a nasal mucus sample. The nasal mucus slides were then evaluated for ferning characteristics. The degree of crystallization into a boston fern-like pattern was graded from one to four. Two frequency polygons were set up to graphically illu-strate the frequency of each ferning stage for each .1°F temperature rise between 96.8°F and 98.8°F. A table was compiled to show the mode, median, mean and range at each ferning stage. 2 depicts the frequency of stage 1 and 2 ferning that occurred at each of the basal body temperature recordings. Seventy-one percent of stage 1 ferning occurred below 98.0°F and 69 occurred between 97.4°F and 98.2°F. As the ure increased over 98, the frequency of stage 1 ferning decreased. Sixty-three percent of stage 2 ferning occurred below 98.0°F and 65% occurred between 97.4°F and 98.2°F. 01 c: .r-l c: ~ 4Q-l; 30 N ro c: 25 eel ......, <J.; 20 01 eel .j.J U) 15 4-l 0 !>1 U 10 c <J.; ::; tr' (]) 5 ~ [::r..; - - I J / j I I / I 1\ I \ \ \ / \/ /'- / r ~ .,A' • /' ",. /' \ '\ \ \ \ \1 stage 1 stage 2 I, J \ I '\ / '- 96.8 97 .. 1 .2 .3 .4 .5.6.7.8.998 .. 1.2 .3.4 .5.6.7 .8 Basal Temperature 2. A comparison of the freuquency of stage 1 and 2 nasal mucus ferning and basal temperature. N 0::> There was a wide variation in the distribution pattern of stage 2 ferning which occurred throughout the 29 temperature range decreasing only slight and lowest recordings. at the highest Figure 3 depicts the frequency of stage 3 and 4 ferning that occurred at each of the basal body tem-perature recordings. Sixty percent of stage 3 occurred below 98.0°F and 69% occurred between 97.4°F and 98.2°F. Stage 3 occurred throughout the range except at 98.8°F. Stage 3 decreased in frequency after 98.2°F with wide variation in frequency between 97.4°F and 98.2°F. Fifty percent of stage 4 ferning occurred below 98.0°F and 70% occurred between 97.4°F and 98.2°F. Again there was variable frequency within the range of 97.4°F to 98.2°F. Table 1 compares the mode, median, mean and range of basal body temperatures to the stage of ferning. There was a wide variation between the number of obser­vations in each stage of ferning. The mode, median and mean all increased slightly as the stage of ferning went from stage 1 or no ferning, to stage 4 or typical ferning. Stage 4 ferning had a .1oF decrease in range over the other three. tn C 'r! C H ClJ 4-l -.::r 30 grade 3 grade 4 ~ 25 M ClJ rQ co H tn 4-l o ~ u c ClJ ::::! tJ1 ClJ H i:J:..; 20 - 15 - 10 - 5- ~ / I' V I -- ----- _/ /, ;, / "- I '- / , I "/ , ........ _- '/ '--' ..... / 96.Q 97 .. 1.2.3.4 .5.6.7.8.998 .. 1.2.3.4 .5.6.7.8.9 Temperature Figure 3. A comparison of the of 3 and 4 nasal mucus ferning and basal body temperature. w o 31 Table 1 Measures of Central Tendency of Basal Body Temperatures at Nasal Mucus Ferning Stage I, 2, 3, and 4 Number of Observations Mean Median Mode Range 1 N=214 97.7°F 97.7°F 97.4°F 96.9-98.9°F 2 N=95 97.8°F 97.8°F 97.7°F 96.9-98.9°F 3 N=247 97.8°F 97.8°F 97.8°F 96.9-98.9°F 4 B=56 97.9°F 98.0°F 98.1°F 97.0-98.9°F 32 Twenty-five menstrual cycles were evaluated to determine ovulation time. Ovulation time was computed by using the World Health Organization!s guidelines. The thermal shift was used as the ovulation point for all charts. The thermal shift was that point between which three consecutive daily BBTs were at least 0.2°F higher than the previous six daily temperatures (Vollman, 1978). Using the thermal shift as the zero point for all charts, each day occurring after ovulation was se-quentially numbered +1, +2, +3 ... up to +14. Each men strual day sequentially preceding ovulation was numbered -1, 2, -3 ... up to -14 days prior to ovulation. Plus and minus 14 was used to obtain the average 28 day cycle. All 25 women had a serum progesterone assay result at 5 ng/ml or greater that confirmed that the cycle was an ovulatory cycle. Figure 4 depicts the percentage of nasal mucus ferning at stage 1 and 2 on anyone menstrual cycle day. Stage 1, or no ferning occurred over 50% of the time only at the beginning and end of the cycle. Two days before the thermal shift, stage 1 occurred 43% of the time and fell to 18 of the time 2 days after ovulation, a drop of 25%. There was a steady decline in stage 1 from minus 14 days to minus 8 days before ovulation, and again an increase in no ferning present 100 OJ 01 90 rU -W U} 80 t:n c: 'r-! :::: 70 H OJ lJ-I 60 50 40 (!) 0('I1j 30 -W c: OJ C) 20 H OJ 0... 10 o Figure 4 . / '- //- I \..-- -I 14 12 10 8 6 13 11 9 7 ( - ) stage 1 stage 2 OVULATION "- , I I'" - ',I \ 4 2 5 3 \ \ , 1- 1 0 1 Menstrual cycle Percent reaching ing stage cycle day_ 2 4 6 8 10 3 5 7 9 ( + ) 11 12 I J 13 14 16 15 1 and 2 on anyone menstrual w w from 10 to 14 days after ovulation. Stage 2 ferning, or small atypical ferning is also represented on Figure 4. Stage 2 ferning manifested a gradual but slightly irregular increase in frequency between 14 and 3 days prior to ovulation. Stage 2 also declined from 28% 3 days before ovulation to 9% 1 day after ovulation. This was a drop of 19%. The post­ovulatory period fluctuated between 9 and 33%. Figure 5 depicts the percentage of nasal mucus ferning at stages 3 and 4. Stage 3 ferning, or large atypical ferning occurred at the highest percentage overall. Stage 3, ferning like stage 2, gradually increased overall from 14 days to 4 days prior to ovu­lation. But unlike stage 2, stage 3 had only a 1 day drop between minus 4 and minus 3 days of 22%, and then began a 34% rise in frequency up to 2 days after ovu-lation. It then remained consistently higher overall than preovulation levels. Stage 4 or typical ferning occurred less frequent than stage 3 and showed no marked frequency differences between pre and postovulation. There was one period 34 between 1 day before ovulation and 4 days after ovulation when the frequency varied only 10%. 6 depicts the combined percentages of stages 3 and 4. The curve resembles stage 3 with only slight variations. The frequency of stage 3 and 4 combined 100 90 (J) tn 80 to +-l (f) 01 70 C .r-l C 60 l-I (J) 4-l 01 50 C .r-l 'B 40 to (J) l-I 30 ClJ 01 to +-l 20 c (lj () l-I 10 OJ ~ 0 18 17 /~ 16 14 15 / I I \ / \ I \ I \ I 12 13 11 ( - ) 10 9 stage 3 stage 4 OVULATION /, /' I - I \ I -- \ I \ "- I ',I .... \ 1 -/ \1 I I 8 6 4 2 1 3 5 7 7 5 3 1 2 4 6 Menstrual cycle days I, I, / \ I \ / I \ I \ \ ' \ I / \ I i i I 9 11 13 15 17 8 10 12 14 16 ( + ) Figure 5. Percent reaching ferning stage 3 and 4 on anyone menstrual cycle day. w U1 100 tn OVUllATION c: .r-t c: 90 ~-l Q; 4-l 80 -:::r 'cd: 70 rei /\/\ M 60 'I Q; tn rei +J 50 U) 4-l 0 40 - 30 f\/'. 20 'd Q; c: 10 .r-t .D E 0 U 112 lIb I !3 I 6 t .\ 1 ~ ! [ i I j ~ 13 11 9 7 5 3 1 2 4 6 8 10 12 14 ( - ) Menstrual Cycle Days ( + ) 6 • Percent reaching fern stage 3 and 4 on any menstrual day. w (j\ 37 is lower overall prior to ovulation and stays elevated after ovulation. The average percentage of ferning prior to ovulation was 40%, and the average percentage of ferning occurring after ovulation was 59% of the time. As in stage 3 ferning, there was a 22% drop in ferning between days minus 4 and minus 2 with a sustained 38 increase until 2 days after ovulation. Discussion of Findi The purpose of this study was to describe the cyclic ferning patterns in the nasal mucus of women with regular menstrual cycles. The specific research questions were: a) how does the stage of ferning in nasal mucus change with changes in basal body temperature; and b) how does the degree of ferning in nasal mucus change throughout the menstrual cycle? Papinicolaou (1946) was the first person to suggest that the theologic phenomenon of arborization or ferning was due to the stimulation of estrogen. Studies since then have confirmed that cervical mucus ferning occurs anywhere from the fifth to ninth day of the cycle to the 22nd day of the cycle. Zondek (1956) was the only investigator to note that ferning disappeared prior to menstruation. These studies confirmed that fern patterns were due to estrogen. The biochemical basis for the phenomenon of arbori­zation has been found to be dependent on the electrolyte 38 concentration in the fluid, chiefly sodium chloride, and the ratio of sodium chloride to proteins. Ferning results when crystals of sodium and potassium chloride form around a small and optimal amount (1-15%) of organic matter. Estrogen and progesterone affect both the sodium chloride and protein concentration in mucus. Estrogen causes sodium excretion and progesterone causes sodium retention (Moghissi, 1980). Van de Velde observed that body temperature shows a biphasic pattern when measured at the basal level during the menstrual cycle. Basal body temperature has been found to be lowest in the preovulatory phase, may dip lower right before ovulation and then rises 24 to 72 hours after ovulation and remains elevated during the postovulatory phase. The distinct rise in temperature, called the thermal shift, indicates that ovulation has occurred (Moghissi, 1980). This research found that the stages of ferning in nasal mucus did indeed ~imick the anticipated affects of estrogen and progesterone. But instead of ferning mim-icking the affects of estrogen, it ,mimi~ked the affects of progesterone. Both the percent reaching stage 3 ferning and the combined percentage of stages 3 and 4 ferning followed the normal anticipated basal body temperature curve which is influenced by progesterone. That is, the percentages were lowest in the preovulatory phase, fell slightly before ovulation, rose during and immediately following ovulation and remained elevated in the postovulatory phase. Stage 1, or no ferning, had just the opposite representation. It was hi st in the preovulatory phase, decreased immediately before ovulation and re­mained lowest in the postovulatory period. 39 There was no significant relations between stage of ferning and basal body temperature set apart from the day of the menstrual cycle. Stage 1 ferning did occur most frequently at lower temperatures. This research supports Zondek's findings that fern decreased prior to menstruation. If ferning patterns are due to estrogen, the expected outcome from an estrogen surge just prior to ovulation should be to cause increased ferning. Instead, the opposite result occurred. Previous researchers looked only at stage 4 ferning as true ferning and therefore obtained varying data. When ana ing both stage 3 and 4 ferning, the results are much different. Limitations 1. The operational definitions of the investigator were not the same as previous investigators~ therefore, interpretation of the data may be skewed. 2. A small sample size limited the amount of statistical analysis that could be used to increase the validity and reliability of the study. 3. The only available measure of ovulation was through computing the thermal shift from the basal body temperature chart. This could have skewed the data. 40 4. There was no way to assure that all nasal mucus slides had been prepared and fixed in the specified manner. Variations in methods by each participant could have altered the results obtained. CHAPTER VI SUMMARY AND IMPLICATIONS Summary Rationale and Objectives Natural family planning methods have been gaining in popularity as women have become disillusioned with the use of hormones and mechanical devices to control conception. There has been an increased desire by women to learn more about their own bodies and their own fer-tility. Fertility awareness or natural family planning methods have been attempting to meet this need. Fertility awareness methods utilize a number of signs and symptoms to determine ovulation. The calendar method of recording menstrual dates, basal body tem­perature, cervical mucus ferning, spinbarkeit, mittel­schmer~ spotting, breast tenderness, position and con­sistency of the cervix, mood and libido are all indi-cators of fertility. In the 1950s, nasal mucus ferning was also studied as an indicator of fertility; not thoroughly enoug~ however, to prove or disprove the method as an indicator of fertility. Thus, nasal mucus ferning needs to be evaluated further to prove or dis­prove its value as an indicator of fertility. The purpose of this investi ion was to describe the cyclic ferning patterns in the nasal mucus of women with regular menstrual cycles. Ie and Methods The sample was chosen from women volunteers within the Salt Lake City area. The age range was from 24 to 34 years with a mean of 29 years. Data were collected through the use of a medical history questionnaire, basal body temperature chart and nasal mucus samples collected daily upon ar ing. The data obtained were interval, but due to the small 42 sample size, frequency polygons were the only statistical measures used. The purpose of the study was only to describe ferning terns. Findings Conceptually, this study was guided by general systems theory. The reproductive subsystem of the reproductive female was analyzed to show cause for nasal mucus ferning. The reproductive system works on a series of inputs and outputs that are part of a feedback system of which nasal mucus ferning is an output. The hypo-thalamus outputs hormones which affect the anterior pituitary gland, which in turn processes them and outputs hormones which are taken in as input by the ovaries. Depending on the input hormone, FSH or LH, a follicle 43 or a corpus luteum develops. If the follicle deve increasing amounts of estrogen are secreted, and if the corpus luteum develops, increasing amounts of pro gesterone are the product. Estrogen is received as input by columnar epithelial cells which when processed, changes the ein and electro concentration of the output, mucus. This change makes the mucus fern when air dried on a slide. Progesterone conversely, in increasing amounts does just the opposite, and the mucus output does not fern. Since cervical mucus has been documented to have cyclic fern patterns in response to estrogen and progesterone, nasal mucus, also produced by columnar epithe cells, should also have cyclic ing patterns. Nasal mucus should mirror cervical mucus. Statistical , there was no significant relationship • between nasal mucus ferning grades 1, 2, 3, and 4 and basal body t ure. Clinically it was significant that as the ure increased the ferning grade also increased. The mode, median and mean temperatures all increased from 1 to grade 4. Statistically there was also no significant rela-tionship between nasal mucus ferning stage 1, 2, 3, and 4 and the day of the menstrual cycle. Clinically it was very significant that stage 3 and stage 3 and 4 combined mimicked the normal basal body t ure under the influence of progesterone. The fact that ferning was present in nasal mucus supports the theoretical framework that nasal columnar epithelial cells are permeable to estrogen and progesterone influ-ence. But because of the pattern of ferning throughout the cycle, the theoretical framework does not support estrogen as the cause of the ferning p~tterns. Pro-gesterone was clearly implicated as the cause of nasal mucus ferning. Implications for Further Research 1. Replication of the study using a much larger 44 sample size would allow for increased use of statistical measures to increase the validity and reliability of the study. 2. lication of the study including cervical mucus smears would allow for better comparisons of the two measures of cyclic estrogen and progesterone activity. 3. Further studies also need to be able to document ovulation with more precision, so that day of the men-strual cycle and ferning are exact measures. 4. Further studies need to compare other columnar epithelial cells output and day of the menstrual cycle. 5. Nasal and cervical mucus ferning needs to be an with serial progesterone assay results to see if the level of progesterone in venous blood has any affect on stage of ferning. lications for Nursin 45 The most important implication for nurse clinicians is to remember that to provide comprehensive health care to women, clinicians must always be open to new information from all sources. The interaction between reproductive women and nurse clinicians is one of shared teaching and learning for the best comprehensive growth of both. Nurse clinicians have to be willing to con­tinually learn and grow. Nurses must continue to read, attend conferences, take refresher courses and become better listeners to increase their own knowledge base and abilities. And last, nurse clinicians must continue to evaluate research with an open mind and to pursue research that is geared toward helping women to better understand the natural physiology of the body. APPENDIX DATA COLLECTION TOOLS MEDICAL HISTORY Code Number Age Age of first menses Last menstrual period Number of pregnancies Are your menstrual periods regular? Are your periods 25-35 apart? Are you now on birth control pills? Have you taken BCPs in the last 6 months? Are you now taking any kind of medication? If so, what Have you ever tried to get pregnant and could not? Have you ever been told you have something wrong with your ovaries or uterus? Have you ever taken fertility drugs? Do you have any allergies? If yes, to what Do you now have an upper respiratory infection/cold? Yes No Adapted from Kass-Annese, B., Hammond, K., Kahn, S. & Richwald, G. (1979). Fertility awareness method. San Francisco: Telesis Corporation. 47 48 Usual lime Cy DA DA ~ :T emperature (BBT) C y T + l E E 0 A Y 1 9~123456789:123456789~12 2: 9;123456789~123456789:12 3 '9; 1 23456789: 1 2345678 9 ~ 1 2 4 123456769~123456789~12 5 :9~ 123456789g 123456789: 12 6 9~123456769~123456789~12 7 9;1214S67e9;i23A5678~;12 8 9~123456789~123456769~12 9 9~123456789~123456789~12 10 ,9~ 123456789~ 123456769~ 12 11 ;9; 123456789~ 123456789~ 12 ,12 1 19; 123456789~ 123456789~ 12 113 [9;123456789~12345-6789~12 14 :9~ 123456789,~ 1234_56789tl_~_ :15 !9~'23456789:123456789~12 1 " 16 !9~ 123456789~ 123456789~_12 17 !9~123456769~123456789~12 18 19~ 1234 56 789~ 1 23456789~ 12 19 '9~123456789~123456789~12 20 9;123456789:123456789~12 21 9;123456789:123456789:12 22 9~123456789:123456789~12 '23 ;9;123456769~123456789~12 24 !9~123456769~123456789~12 25 9~123456789~123456789~12 26 9~123456789:123456789:12 27 9~123456769~123456769~12 28 9;123456789~123456789~12 29 9~123456789~123456789~12 30 :9~1234~678~:12J4~ti189~12 31 :9~123456769:123456789~12 32 :9~ 123456769~ 123456769~ 12 33 9~123456789:123456789~12 34 9~123456789:123456789~12 35 9~123456769~123456789~12 36 9i123456789~123456769~12 37 9;123456189~123456769~12 38 9~123456789:123456789:1~ 39 9;123456789~123456769:12 40 9~123456189~'23456789~12 SELECTED BIBLIOGRAPHY 50 Abou-Shabanah, E.H. & Plotz, E.J. (1957). A biochemical study of the cervical and nasal mucus fern non. American Journal of Obstetrics and 74:3. Davajan, V., Nakamura, R. & Michsell, D. (1971. A sim­plified technique for evaluation of the biophysical properties of cervical mucus. American Journal of Obstetrics and Gynecology. 109:1042. Davis, M.E. & Abou-Shabanah, E.H. (1958). Comparative study of cervical and nasal smears in women. Fertilit and Sterilit. (; 344. Hines, N.E., Ph. D. (1936). ception. Baltimore: Company. Medical history of contra­The Williams and Wilkins Iacobelli, S., Garcea, N. & Angelone, C. (1971). Bio­chemistry of cervical mucus: A comparative analysis of the secretion from preovulatory, postovulatory, and pregnancy periods. Fertility and Sterility. 22:727. Israel, R., Nishell, D., Stone, S., Thorneycroft, I. & Moyer, D. (1972). Single luteal phase serum progesterone assay as an indicator of ovulation. American Journal of Obstetrics and Gynecology. 12:1042. Kass-Annese, B., Hammond, K., Kahn, S. & Richwald, G. (1979). Fertili awareness method. San Francisco: Telesis Kessery, E. (1972). A simple method for measuring crystallization of the cervical mucus and its application in human sperm migration. International Journal of Fertilit. 17:201. Moghissi, K. (1966). Cyclic changes of cervical mucus in normal and progestin-treated women. Fertilit and sterilit. 17:663. Moghissi, K. (1980). Prediction and detection of ovulation. Fertility and Sterility. 34:89. Papanicolaou, G. (1946). A general survey of the vaginal smear and its use in research and diagnosis. American Journal of Obstetrics and Putt, A.M. (1978). General systems theory applied to nursing. Little, Brown and Company. 51 Rowland, M. (1952). A simple test for the determination of ovulation, estrogen activity, and early preg­nancy using the cervical mucus secretion. American Journal of Obstetrics and 10 Rowland, M. (1958). The fern test: A critical analysis. Obstetrics and 11:30. Rowland, M. test. (1962). The office application of the fern Clinical Obstetrics and Gynecology. 5:218. Sage, M., Okigahi, T., Davajan, F. & Nakamura, R. (1977). Mechanism of crystallization of purified human midcycle cervical mucus. American Journal of Obstetrics and Gynecology. 29:154. Ullery, J., Livingston, N. & Abou-Shabanah, E.H. (1959). The mucus fern phenomenon in the cervical and nasal smear. Obstetrics and Gynecology Survey. 1441. Vollman, R.F. (1978). The menstrual cycle. Philadel­phia: W. B. Saunders Company. Wolf, D., Blasco, L., Khan, M. & Litt, K. (1977). Human cervical mucus II. Changes in viscoelasticity during the ovulatory menstrual cycle. Fertilit and Sterilit. 28:47. Zondek, B. (1956). Functional significance of cervical mucus. Internat 1 Journal of Fertilit I 1(3). Zondek, B. (1959). Arborization of cervical and nasal mucus and saliva. Obstetrics and Gynecology, 13 ( 4 ) • Zondek, B. & Rozin, S. (1954). Cervical mucus arbori­zation: Its use in the determination of corpus luteum function. Obstetrics and 3:463.