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‘Fertility Awareness-Based Methods’ and subfertility: a systema­tic review


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Fertility awareness based methods (FABMs) can be used to ameliorate the likelihood to conceive. A literature search was performed to evaluate the relationship of cervical mucus monitoring (CMM) and the day-specific pregnancy rate, in case of subfertility. A MEDLINE search revealed a total of 3331 articles. After excluding articles based on their relevance, 10 studies and were selected. The observed studies demonstrated that the cervical mucus monitoring (CMM) can identify the days with the highest pregnancy rate. According to the literature, the quality of the vaginal discharge correlates well with the cycle-specific probability of pregnancy in normally fertile couples but less in subfertile couples. The results indicate an urgent need for more prospective randomised trials and prospective cohort studies on CMM in a subfertile population to evaluate the effectiveness of CMM in the subfertile couple.
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Only 2% of nally successful couples conceived
after 12 cycles with unprotected intercourse. After
six unsuccessful cycles, subfertility has to be
assumed in 50% of all couples (Gnoth et al., 2003;
Wang et al., 2003; Sozou and Hartshorne, 2012).
Besides surgical and medical treatment for those
couples, there is a tremendous uprising trend to use-
assisted reproductive technologies (ART). ART
comprises all treatments or procedures used to
establish a pregnancy in which there is in vitro
handling of human oocytes, sperm and/or embryo.
The development of these techniques surely has led
to overtreatment in fertility care. However, there are
other less-known measures to ameliorate the likeli-
hood to conceive, the so-called fertility awareness-
based methods (FABMs).
FABMs use physical signs and symptoms that
change along with hormone uctuations throughout
the different phases of a woman’s menstrual cycle
to predict and monitor the fertile and infertile days
(Pallone and Bergus, 2009). This knowledge, re-
ferred to as ‘fertility awareness’, can be used either
to plan or to avoid a pregnancy. The key variables
which FABMs rely on are the reliable identication
of the fertile window (FW) and modication of
sexual behaviour (Frank-Herrmann et al., 2007).
Different modications of FABMs are known, cer-
vical mucus based methods, temperature methods,
combinations of both variables and calculation
methods. The most extensively studied method is
Sensiplan®, the symptothermal method of Natural
Family Planning (NFP), mucus, temperature and
calculation rules (Frank-Herrmann et al., 2007).
There is a compelling need to educate women
about their fertility awareness. Primary care
providers need to integrate fertility health literacy
into health promotion of women of reproductive
age. The guideline currently recommended by many
physicians is that women who wish to become
pregnant should have frequent random intercourse,
‘Fertility Awareness-Based Methods’ and subfertility:
a systema tic review
A. Thijssen1,2, A. Meier2, K. PAnis2, W. OMbeleT1,2
1Genk Institute for Fertility Technology, Department of Obstetrics and Gynaecology, Ziekenhuis Oost-Limburg, Schiepse
Bos 6, 3600 Genk, Belgium.
2Faculty of Medicine and Life Sciences, Hasselt University, Martelarenlaan 42, 3500 Hasselt, Belgium.
Correspondence at:
FAcTs VieWs Vis Obgyn, 2014, 6 (3): 113-123 Structured review
Fertility awareness based methods (FABMs) can be used to ameliorate the likelihood to conceive. A literature
search was performed to evaluate the relationship of cervical mucus monitoring (CMM) and the day-specific
pregnancy rate, in case of subfertility. A MEDLINE search revealed a total of 3331 articles. After excluding articles
based on their relevance, 10 studies and were selected. The observed studies demonstrated that the cervical mucus
monitoring (CMM) can identify the days with the highest pregnancy rate. According to the literature, the quality
of the vaginal discharge correlates well with the cycle-specific probability of pregnancy in normally fertile couples
but less in subfertile couples. The results indicate an urgent need for more prospective randomised trials and
prospective cohort studies on CMM in a subfertile population to evaluate the effectiveness of CMM in the subfertile
Keywords: Billings method, cervical mucus, conception, Creighton model, fertility awareness, infertility, natural
family planning, subfertility, symptothermal method.
114 FAcTs VieWs Vis Obgyn
ovarian function in women has been exact ovulation
detection through the use of daily sonography and
specic hormone testing (estradiol, luteinizing
hormone, progesterone) (Albertson and Zinaman,
1987). These clinical methods for cycle monitoring
are expensive and time-consuming. FABMs show
the same reliable results for determining the FW
and predicting the time of ovulation. The methods
are based on a detection of the FW and use symp-
toms the women are able to observe themselves,
such as bleeding rhythm, cervical mucus, measure-
ment of the basal body temperature, auto-palpation
of the cervix, etc. (Gnoth et al., 1996; Frank-
Herrmann et al., 2005). The rhythm method or
calendar-based method requires to calculate the
fertile days according to the length of the menstrual
cycles. This is possible because the duration of the
luteal phase is relatively stable (Evans-Hoeker et
al., 2013). The basal body temperature (BBT)
method uses a temperature elevation to determine
the day of ovulation. This rise (0.3° to 0.6° C) is due
to the progesterone surge (Pallone and Bergus,
2009). After ovulation, the BBT remains elevated
due to increased progesterone levels after ovulation
until next menstruation. Therefore, the temperature
rise identies the end, rather than the onset of the
fertile period. This implies that this method can
only be used to retrospectively identify ovulation.
Furthermore, there are other factors that limit the
accuracy of a BBT method used solely. Temperature
measurements may be disturbed by a variety of
factors, some women ovulate without a clear rise in
BBT and the shift may vary up to one day before
and three days after actual ovulation (Pallone and
Bergus, 2009).
On the other hand, cervical mucus patterns, which
reect rising estradiol, are shown to be accurate
markers of the onset of the fertile and infertile
phases of a woman’s menstrual cycle (Hume, 1991).
Cervical mucus is an aqueous or gel mixture of
proteins and mucopolysaccharids, ions and
compounds, and cells, primarily produced by the
endocervical epithelium (Fordney-Settlage, 1981).
Estradiol and progesterone levels are responsible
for the changes in characteristics of cervical
secretions during the menstrual cycle. Mucus
characteristics have been tried to be typed. The
secretion of the oestrogenic mucus (E mucus) is
stimulated by the rise in oestrogen produced by the
dominant follicle ve to six days before ovulation.
E mucus is clear, wet, stretchy and slippery, which
makes it ideal to facilitate the transport and the
survival of the spermatozoa in the cervix. In
addition, it leads to functional maturation of sperm
(capacitation) so that the fertilisation potential of
the ovum is increased. This mucus is present in the
optimally every other day. With application of this
guideline, some acts of intercourse will occur in the
FW (ASRM, 2008).
The use of FABMs could increase the pregnancy
rate when used properly. Our systematic review will
focus on cervical mucus and its function to become
a useful FABM. Previous studies showed that more
oestrogen-type mucus is present in the fertile days
of the menstrual cycle, but also an increasing trend
in the amount of mucus secretions can be noticed.
This rise in volume is associated with a change in
vaginal discharge, which women can monitor based
on different characteristics (Hilgers and Prebil,
1979). In addition, this awareness can be used to
evaluate the ovarian function (Moghissi et al.,
1972). It also provides information about the fertility
status of the different days in the cycle, because
fertile type mucus ensures a facilitated transport of
sperm cells to the ovary through the fallopian tubes
(Billings et al., 1972; Katz et al., 1997).
The main objective of this review was to
determine the effectiveness of cervical mucus as a
predictor for the FW. Furthermore, the probability
of whether or not cervical mucus monitoring is
associated with increased cycle-specic pregnancy
rates will be specically examined for the subfertile
Different methods for fertility awareness assessment
All FABMs are based on the detection of ovulation
and the related fertile window. Retrospectively,
ovulation occurred approximately 14 days before
the onset of the next menstrual cycle (Wilcox et al.,
2000). Throughout the woman’s menstrual cycle,
there is a six day fertile interval during which
conception more likely occurs if intercourse takes
place (Bilian et al., 2010). This FW comprises the
ve days before ovulation and the day of ovulation
itself. There is only a limited period of time during
which fertilisation can take place due to the limited
duration of viability of the ovum and sperm which
accounts for the different probabilities of conception
for days of the menstrual cycle (Colombo and
Masarotto, 2000). After ovulation has occurred, the
ovum will lose its ability to become fertilised after
10 to 24 hours (Stanford et al., 2002). The life span
of sperm within the female reproductive tract is
more variable. Spermatozoa have a life span of 24-
48 hours if hostile mucus is absent. When there is
proper oestrogenic cervical mucus, the fertilising
capacity of sperm can last 3-7 days in the perio-
vulatory period (Pallone and Bergus, 2009).
There has been a search for simple and reliable
methods for both predicting and conrming
ovulation. The golden standard of monitoring
FerTiliTy AWAreness-bAseD MeThODs – Thijssen eT Al. 115
mucus secretions of dry/humid feeling. In some
elaborated mucus methods women are asked to
describe the colour, texture and stretch of the
cervical discharge (Pallone and Bergus, 2009).
Table I shows four mucus categories ranging from
absence of discharge or dry mucus characteristics
(score 1) to transparent, stretchy and slippery mucus
(score 4) which is the commonly used typing. A
high mucus score is consistent with the presence of
fertile-type E mucus. Important conception studies
are based on this typology of mucus (Colombo and
Masarotto, 2000; Dunson et al., 2001; Bigelow et
al., 2004).
The rst method described is the Billings Ovula-
tion Method (BOM), in which women record the
mucus secretions ‘in their own words’ with a focus
on changes in cervical characteristics (Bhargava et
al., 1996; Stanford et al., 1999). Another more
standardised method, named the Creighton Model
(CrM), characterises cervical secretions by pictures
and precise words (Howard and Stanford, 1999;
Pallone and Bergus, 2009). In addition to the
methods above, the TwoDays Method (TDM) is the
simplest method, which focuses on the presence
or absence of cervical mucus and not on the
fertile phase of the menstruation cycle. Following
ovulation there is a second type of mucus, the
progesterone mucus (G mucus). This type is
produced by the progesterone release from the
corpus luteum. Progesterone stimulates the cervix
to produce G mucus, which inhibits sperm capacita-
tion and motility and blocks the passage of sperm.
This cervical secretion is considered infertile due to
the unchanging and generally dry, sticky, cloudy
and not stretching characteristics (Pallone and
Bergus, 2009; Stanford et al., 2002).
Cervical mucus monitoring (CMM) is performed
by observing these mucus secretions, whereby
internal checking of the vagina or cervix is not
necessary (Evans-Hoeker et al., 2013). The goal is
to identify the onset of the production of any type of
fertile mucus. Even a change of feeling (dry to
humid or wet) may be indicative of impending
fertility. The peak day can be identied as the last
day of any vaginal discharge that has type E charac-
teristics (Fig. 1) (Stanford et al., 2002). There are
different methods that use cervical mucus as a pre-
dictor of the FW. Each method uses a different way
to identify the fertile phase, but the main focus relies
on observing the absence or presence of cervical
Fig. 1. Physiologic parameters of the menstrual cycle that can be used to identify days during which intercourse may result in
pregnancy, i.e. the fertile window. LH: luteinizing hormone; P: peak day (Adapted from Stanford et al., 2002).
116 FAcTs VieWs Vis Obgyn
readers regarding the relevance of the title, resulting
in 315 remaining articles. After reading the abstracts
in the following stage, 39 articles were retained.
Having read the 39 papers carefully, the following
articles were excluded: studies mainly focusing on
avoiding pregnancy or natural family planning used
for contraceptive procedures and articles with
reference to cancer, breastfeeding or sex pre-
selection. Studies where cervical mucus was used
for the determination of the FW were included.
These also comprise methods like the Creighton
Model, the Billings Ovulation Method, the TwoDays
Method and the Symptothermal Method. Ultimately,
10 relevant studies were selected. Examining the
reference lists of the selected articles yielded no
new hits. A schematic overview of the search
strategy can be seen in Figure 2.
Multiple studies have been performed to obtain
information about the day-specic probability of
conception through observation of the vaginal
discharge, used as a marker of ovulation. This
systematic review compares the results of ten
different studies and examines the relevance and
outcome of each study. Nine out of the ten selected
articles were prospective cohort studies and one was
a retrospective cohort study (Table V).
Stanford et al. (2003) retrospectively evaluated-
data extracted from the Creighton Model Fertility
Care System in four different cities. Fertile and sub-
fertile couples were identied and, after selection,
1681 cycles from 309 fertile couples resulting in
80 pregnancies and 373 cycles from 117 subfertile
couples which resulted in 30 pregnancies, were
incorporated in the study. The highest probability of
conception could be seen on the mucus peak day
(identied as ovulation), both for fertile and
subfertile couples. For the fertile couples, the
probability to become pregnant on the mucus peak
day was 0,38 and for the subfertile couples 0,14.
The mucus peak day was appointed day 0. The
characteristics of the secretions (Dunson et al.,
2001). A woman is considered fertile on a given day
if she notices secretions on that specic day or the
previous day (Jennings et al., 2011).
The Symptothermal Method (Sensiplan®) uses a
combination of predictors, namely the BBT, record-
ing of cervical secretions and, important, calcula-
tion rules (Frank-Herrmann et al., 2007; Pallone
and Bergus, 2009). The opening of the FW is calcu-
lated from previous cycles (min. 12) but detection
of any fertile type of mucus marks the abrupt onset
of impending fertility (“what comes rst”). The
change of cervical mucus together with the rise in
BBT indicates the end of the fertile phase (“what
comes last”). Therefore, this method can be used
prospectively as well as retrospectively to identify
the periovulatory period (Gross, 1987). This meth-
od has been proven to be very effective in prospec-
tive studies (Frank-Herrmann et al., 2007) because
it is based on a double check mechanism: It can be
used by women with short, long or irregular cycles
(Frank-Herrmann et al., 2007) (Pallone and Bergus,
2009). Table II provides a short overview of the
different FABMs.
Materials and Methods
Search strategy
We made use of a computerised literature search
executed to search for studies examining the value
of CMM, specically applied to the subfertile
couple. The database used was MEDLINE, and the
following search terms were considered: fertility
awareness, self-assessment, cervical mucus,
infertility, subfertility, natural family planning,
conception, Symptothermal Method, Billings
Ovulation Method, Creighton Model, in combination
with ‘not contraception’. These keywords were
used in different combinations which led to 3331
hits. No time limitation or other lters such as
language restriction were entered in the search.
Subsequently, the reports were screened by two
Table I. — Classication of mucus symptoms from vaginal discharge.
Mucus score Feeling Appearance Secretions
1Dry, rough and itchy
or nothing felt
Nothing seen No secretions
2Damp Nothing seen Secretions
3Damp Mucus is thick, creamy, whitish, yellowish, or
4Wet, slippery, smooth Mucus is transparent, like raw egg white, stretchy/
elastic , liquid, watery, or reddish
(Adapted from Colombo and Masarotto (2000)).
FerTiliTy AWAreness-bAseD MeThODs – Thijssen eT Al. 117
showed that although ovulation detection can be
adequately determined with the peak mucus
symptom and the BBT, the combination gave a
signicant better correlation for a correct
identication of ovulation. Furthermore, the study
investigated the role of the changing quality of the
cervical mucus in relation to the probability of
conception. This technique was used by 346 women
and resulted in a cumulative probability of
probability of conception was greater than 0,5 for
day -3 to day +2 for the fertile couples and for day
-1 to day +1 for the subfertile couples.
Frank-Herrmann et al. (2005) reviewed the main
results of recent European cycle databases (WHO
database, German Long-term Cycle database, I
European Cycle Database and II European Cycle
Database) on ovulation detection and determination
of the FW performed by women themselves. Results
Fig. 2. — Schematic overview of the search strategy
Table II. — Overview of the different FABMs.
Methods Mechanism
Rhythm (calendar-based) method Calculation of the fertile days according to the length of a woman’s
previous menstrual cycles
The basal body temperature method Charting the BBT to detect ovulation day
Billings ovulation method Identication of the changes in vaginal discharge in a woman’s own
Creighton Model Identication of the changes in vaginal discharge with use of
pictures and suggested words
TwoDays Method Focus on the presence or absence of cervical mucus
Symptothermal Method Identication of the FW through use of the BBT and cervical
118 FAcTs VieWs Vis Obgyn
days before ovulation and ending on the estimated
ovulation day, with the peak day being two days
prior to the estimated ovulation. Additionally, the
pregnancy rate increased by 50% when women had
cervical mucus secretions for two days.
Also Bigelow et al. (2004) made use of the ESDF
database. From the database, 1473 cycles remained
after exclusion, resulting in 353 pregnancies. The
aim was to determine the day-specic probabilities
of pregnancy according to the timing of intercourse
relative to ovulation and/or the mucus characteristics.
The outcome proved that the day of lowest fertility
is ve days before ovulation and the day of highest
fertility is three days before ovulation, as detected
by BBT. However, the differences in daily-
fecundability are more attributable to a rise in
mucus score than the timing of intercourse relative
to ovulation.
The next three prospective multicentre studies
(Colombo et al., 2006; Scarpa et al., 2006; Scarpa et
al., 2007) used another database which included
193 couples from four Italian centres using the
Billings Ovulation method. Inclusion criteria and
mucus scoring were similar to the ESDF study
(Table III and Table I respectively).
The rst study was performed by Colombo et al.
(2006) aiming to determine the effect of cervical
mucus symptoms on the daily fecundability. The
earlier study performed by Colombo and Masarotto
in 2000, had the objective to determine the relation-
ship between the intercourse patterns and the
fecundability (Table IV). In 2000, outcome
measures included 3255 cycles, 435 of which
resulted in a pregnancy; in 2006 respectively
963 cycles and 142 pregnancies (Colombo and
Masarotto, 2000; Colombo et al., 2006).
The mucus reference day, identied as day 0, is
dened as being the last day with the best quality or
peak mucus in a specic cycle, with uid mucus
and/or a wet-slippery sensation. Results showed
that the highest pregnancy rate can be found on day
0 with a probability of 0,429 in 2006, respectively
on day -2 with a probability of 0,203 in 2000.
conception of 81% after 6 months and 92% after
12 months.
Evans-Hoeker et al. (2013), investigated the use
and consistency of cervical mucus monitoring
(CMM) to determine the FW in women who wanted
to get pregnant. The second goal was to examine
whether monitoring mucus was associated with an
increased cycle-specic probability of conception
independent of intercourse frequency or use of
urinary luteinizing hormone monitoring kits. This
time-to-pregnancy study examined a cohort of 331
women between 30 and 44 years of age who had
been trying to conceive for three months or less and
had no known issues related to fertility. If women
checked their cervical mucus on a particular day,
they had to make a choice which type they observed
(Table I).The FW could be estimated through the
use of calendar based calculations. Cycles in which
women made consistent use of CMM were more
likely to result in conception. The results of this
study showed that fecundability increased with
increasing use of CMM.
A large multinational prospective cohort study,
the European Study of Daily Fecundability (ESDF,
database: Fertili), was conducted by Colombo and
Masarotto (2000) to determine the daily probability
of conception (Table IV) among healthy women
and to compare different statistical models on the
matter. Inclusion criteria for the ESDF are listed in
Table III. Women were instructed to keep daily
records of their BBT, cervical mucus symptoms
(Table I) and coitus. The results found by Colombo
and Masarotto (2000) are described in the next
section together with their results of a more recent
study (Colombo et al., 2006).
Dunson et al. (2001) used the data from the ESDF
to evaluate the theoretical effectiveness of the Two-
Day Algorithm. Out of the 2832 cycles studied, 434
resulted in a pregnancy. Data suggested that, for
most women, the TwoDay Algorithm was useful in
identifying the most fertile days of the menstrual
cycle. They showed that the pregnancy probability
was highest in the six day interval, beginning ve
Table III. — Overview of the inclusion criteria for the ESDF.
Women are experienced in use of a Natural Family Planning method
Married or in a stable relationship
Age: 18-40
Having at least one menses after cessation of breastfeeding or after delivery
No use of drugs or hormonal medications that could affect fertility
Couples have no history of fertility problems or disorders that might cause subfertility
Not mixing unprotected and protected intercourse
FerTiliTy AWAreness-bAseD MeThODs – Thijssen eT Al. 119
pregnancy rates when women were having
intercourse during the FW in which there was a
differentiation between self-estimated high, peak
and low fertile days. Figure 3 shows a cycle with
correct use of intercourse patterns on high and peak
fertility rated days, which resulted in a pregnancy.
A 12-month prospective, observational cohort
design was used to study 124 women seeking to
become pregnant with the use of this natural family
planning method. To determine their fertile days the
women utilised either cervical mucus monitoring or
electronic hormonal fertility monitoring (EHFM) or
both. The analysis showed a pregnancy rate of 0,87
at 12 months of trying when intercourse happened
on either high or peak days during the fertile window
and a pregnancy rate of 0,5 when intercourse
occurred only on days with a low mucus score.
Fertility awareness based methods (FABMs) are
another measure a couple can take to ameliorate
their likelihood to conceive. In order to evaluate the
effectiveness of cervical mucus monitoring (CMM)
in shortening the time to pregnancy, especially for
the subfertile couple, a literature search was
performed. After selection, a total of 10 articles
remained to be included in this systematic review.
The highest probability of conception is one or
two days before ovulation (Dunson et al., 1999;
Colombo and Masarotto, 2000; Dunson et al., 2001)
calculated from models solely using BBT signals.
The second study (Scarpa et al., 2006) investigated
the relationship between the self-observed
characteristics of cervical mucus on the day of
intercourse and the day-specic probability of
conception across the menstrual cycle. The most
fertile type mucus (mucus score 4) was registered
for six days on average. In general, mucus score 4
had a peak on day 13 of the cycle, in contradiction
to mucus score 1 which was unlikely to be seen
midcycle. Moreover, results showed that the
conception probabilities varied among the mucus
scores, increasing from mucus score 1 with a
probability of 0,003 to a mucus score 4 with a
probability of 0,29. In between, there was a
conception probability of 0,013 for days with mucus
score 2 and 0,025 for days with mucus score 3.
The third study (Scarpa et al., 2007) determined
adequate rules for timing of coitus to achieve
conception, based on calendar and cervical mucus.
Results showed that, in a midcycle interval begin-
ning on day 7 and ending on day 20, the probability
of conception increased with a rise in mucus score.
On days with the highest mucus score, there was a
40 times higher conception probability than on days
when no mucus score was noticed. Outside this
midcycle interval, conception probabilities were
negligible. Rules were established, based on the
increase in frequency of coitus on days within a
midcycle interval which had a mucus score at or
above a threshold value on a scale from 1 to 4.
The purpose of the nal examined study (Mu and
Fehring, 2014) was to determine and compare
Fig. 3. — Pregnancy cycle with correct use intercourse pattern on high and peakfertility rated days. (Adapted from Mu
and Fehring (2014)).
Table IV. — Daily probabilities of conception referenced to the day of temperature rise (3175 natural cycles with 434
pregnancies) according to (Colombo and Masarotto, 2000).
- 8 - 7 - 6 - 5 - 4 - 3 - 2 - 1 Temp.rise +1 +2
0,3% 1,4% 2,7% 6,8% 17,6% 23,7% 25,5% 21,2% 10,3% 0,8% 0,35%
120 FAcTs VieWs Vis Obgyn
Another important issue is the relevance of coital
patterns. The ASRM recommends sexual intercourse
at least every other day to optimize natural fertility
(ASRM, 2008). However, in case of subfertility,
there is no place to recommend just an increase of
coital frequency probably causing an increase of
psychological stress only. In contrary, couples
should be informed about the fact that a single
episode of intercourse on a day of highly fertile
mucus gives nearly the same chance of pregnancy
then multiple acts (Bilian et al., 2010).
Until now, most studies used a small sample size
and there is a need for prospective studies including
couples planning to become pregnant. Most studies
examined either excluded couples with fertility
problems or did not take them into account. We
urgently need a prospective study comparing fertile
and subfertile groups of couples with a duration of
infertility for at least 6 months and without an
obvious reason for infertility, such as tubal factor or
a very poor sperm quality.
Our ndings indicate that natural family planning
methods can be used as a diagnostic tool to identify
subfertility and its possible causes, but also provide
a better understanding of the menstrual cycle (Gnoth
et al., 2003). However, we still lack research on-
subfertile couples who use CMM and evaluate the
effect on conception probability and time to
Most studies that rely on mucus observations are
classied according to a rough 1 to 4 scale. This
scheme is non-invasive and easy to implement after
a minimal amount of training. It could be interesting
to better quantify these mucus characteristics and to
remove the potential subjectivity in this
classication. A few studies (Scarpa et al., 2006;
Evans-Hoeker et al., 2013) suggested to assess the
utility of urinary LH monitoring with CMM for
couples attempting pregnancy. A randomised trial
could provide information on the precise
relationships that exist between hormones and
mucus for women varying in their fecundability.
Until now, there are no evidence-based guide-
lines for couples to shorten their time to pregnancy
by timing intercourse. The only recommendation,
not evidence-based, is to have frequent intercourse
every other day. It is important for women to know
that CMM can decrease the time to pregnancy if
used properly. This method is easily taught with the
help of nurses/physicians and online education
(Sensiplan®). The combination of these two sources
of education and the use of an online fertility
charting system, can provide an efcient system to
shorten the time to pregnancy in a selected group of
patients with no obvious cause for infertility (Mu
and Fehring, 2014). However, evidence showed that
But for clinical usage the mucus symptom is
superior. Dunson et al. (2001) identied the
relationship between cervical secretions and day-
specic fecundability, providing evidence that
cervical mucus monitoring can be offered to couples
who are trying to conceive. By timing intercourse
on days with noticeable secretions, couples can
signicantly increase their chance of achieving
pregnancy (Bigelow et al., 2004) and Stanford et al.
(2003) showed that the highest pregnancy rate can
be seen on the mucus peak day (identied as
ovulation) both for fertile and subfertile couples.
Furthermore, the quality of the vaginal discharge
correlates well with the cycle-specic probability of
pregnancy in normally fertile couples but not in
subfertile couples (Stanford et al., 2003; Frank-
Herrmann et al., 2005; Scarpa et al., 2006). However,
several weaknesses of the study by Stanford et al.
(2003) should be taken into account: (i) there was
no independent marker of ovulation and (ii) the
retrospective design of the study.
Scarpa et al. (2006) compared their results with a
study performed by Wilcox et al. (2001). The
probability of conception on the peak day described
by Wilcox et al. (2001) is substantially lower than
the ndings reported by Scarpa et al. (2006). This
difference might be explained because, in the
Wilcox study, couples who wished to conceive were
less fertile than the couples selected for the Scarpa
study, who had more regular menstrual cycles. The
difference in fecundability on the peak mucus day
may be caused by including women who had already
given birth, which yielded a higher probability to
become pregnant. Despite this difference in the
probability of conception on the peak day by Scarpa
et al. (2006) and Wilcox et al. (2001), the number of
days with the most fertile-type mucus symptom was
six days in both studies.The pattern of the
occurrences of the different types of mucus
throughout the cycle and the peak day on day 13,
corresponds with previously described outcomes
(Wilcox et al., 2000).
To efciently shorten the time to pregnancy, a
couple could rely on timing coitus during self-
estimated high and peak fertile days in the FW,
based on days with the most fertile-type mucus
symptom (Scarpa et al., 2007; Evans-Hoeker et al.,
2013; Mu and Fehring, 2014). Scarpa et al. (2007)
suggested rules for timing intercourse to have a
higher probability of conception. However, among
women, there are differences in age, hormone
secretions, length of the menstrual cycles and
numbers of cycles attempting. This indicates that
some recommendationsmight work for some
couples, but not for everyone due to woman-specic
FerTiliTy AWAreness-bAseD MeThODs – Thijssen eT Al. 121
e V. — Summa
xamined s
Author Year Country Study design Population N° of
N° of
N° of
Colombo, et al.
2000 Europe Prospective Fertile NA 3265 434
Highest probability of conception is two days before the peak mucus day.
Dunson, et al.
2001 Europe Prospective Fertile 660 2832 434
The days estimated by the TwoDay Algorithm as fertile were the days with the
highest fecundability. There is twice as much chance to achieve a pregnancy
when intercourse nds place on a day covered by the TwoDay
Stanford, et al.
2003 USA Retrospective Fertile 309 1681 81 Observation of the vaginal mucus discharge can identify the days with the
highest pregnancy rate from intercourse in normal fertility and subfertility.
Subfertile 117 373 30
There is a signicant effect of the quality of mucus discharge on the cycle
- -
specic probability on conception by fertile couples, this relationship
couldn’t be found the subfertile couple.
Bigelow, et al.
2004 Europe Prospective Fertile NA 1473 353 Increasing trend in the day
- -
specic probabilities of pregnancy with increases
in the mucus score.
- -
et al.
2005 Germany Prospective Fertile NA 62 NA Cervical mucus symptoms in combination with BBT have a good
correlation with ovulation.
346 NA NA Women can monitor their cervical mucus changes to increase their
probability of pregnancy. FABMs seem to shorten the time to pregnancy,
and can be used in the management of subfertility.
Colombo, et al.
2006 Italy Prospective Fertile NA 963 142 Highest probability of conception: peak mucus day (day 0). A relationship
between the presence of the mucus symptom and the pregnancy rate could
be established.
Scarpa, et al.
2006 Italy Prospective Fertile 191 2536 161 Conception probability is negligible on days with no noticeable mucus
secretions and approximately 30% for days with most fertile
- -
type mucus
detected by woman.
Scarpa, et al.
2007 Italy Prospective Fertile 191 2536 161 TTP can be shortened when intercourse takes place on days with the
et al.
2013 USA Prospective Fertile 331 NA NA Fecundability increases with increasing consistency of CMM. The time to
pregnancy can be reduced through use of CMM.
Mu, et al.
2014 USA Prospective Fertile 124 469 NA
Intercourse on high or peak days increases the pregnancy probability.
basal body
al mucus moni
not a
o pr
122 FAcTs VieWs Vis Obgyn
Bigelow JL, Dunson DB, Stanford JB et al. Mucus observations
in the fertile window: a better predictor of conception than
timing of intercourse. Hum Reprod. 2004;19:889-92.
Bilian X, Heng Z, Shang-chun W et al. Conception probabilities
at different days of menstrual cycle in Chinese women.
Fertil Steril. 2010;94:1208-11.
Billings EL, Brown JB, Billings JJ et al. Symptoms and
hormonal changes accompanying ovulation. Lancet. 1972;1:
Colombo B, Masarotto G. Daily fecundability: rst results from
a new data base. Demogr Res. 2000;3:[39] p.
Colombo B, Mion A, Passarin K et al. Cervical mucus symp-
tom and daily fecundability: rst results from a new data-
base. Stat Methods Med Res. 2006;15:161-80.
Dunson DB, Baird DD, Wilcox AJ et al. Day-specic
probabilities of clinical pregnancy based on two studies with
imperfect measures of ovulation. Hum Reprod. 1999;14:
Dunson DB, Sinai I, Colombo B. The relationship between
cervical secretions and the daily probabilities of pregnancy:
effectiveness of the TwoDay Algorithm. Hum Reprod.
Evans-Hoeker E, Pritchard DA, Long DL et al. Cervical mucus
monitoring prevalence and associated fecundability in
women trying to conceive. Fertil Steril. 2013;100:1033-8
Fordney-Settlage D. A review of cervical mucus and sperm
interactions in humans. Int J Fertil. 1981;26:161-9.
Frank-Herrmann P, Gnoth C, Baur S et al. Determination of the
fertile window: reproductive competence of women
European cycle databases. Gynecol Endocrinol. 2005;20:
Frank-Herrmann P, Heil J, Gnoth C et al. The effectiveness of
a fertility awareness based method to avoid pregnancy in
relation to a couple’s sexual behaviour during the fertile
time: a prospective longitudinal study. Hum Reprod. 2007;
Gnoth C, Frank-Herrmann P, Bremme M et al. [How do self-
observed cycle symptoms correlate with ovulation?]. Zen-
tralbl Gynakol. 1996;118:650-4.
Gnoth C, Godehardt D, Godehardt E et al. Time to pregnancy:
results of the German prospective study and impact on the
management of infertility. Hum Reprod. 2003;18:1959-66.
Gnoth C, Maxrath B, Skonieczny T et al. Final ART success
rates: a 10 years survey. Hum Reprod. 2011;26:2239-46.
Gross BA. Natural family planning indicators of ovulation.
Clin Reprod Fertil. 1987;5:91-117.
Hilgers TW, Prebil AM. The ovulation method vulvar
observations as an index of fertility/infertility. Obstet
Gynecol. 1979;53:12-22.
Howard MP, Stanford JB. Pregnancy probabilities during use
of the Creighton Model Fertility Care System. Arch Fam
Med. 1999;8:391-402.
Hume K. Fertility awareness in the 1990s the Billings
Ovulation Method of natural family planning, its scientic
basis, practical application and effectiveness. Adv Contra-
cept. 1991;7:301-11.
Jennings V, Sinai I, Sacieta L et al. TwoDay Method: a quick-
start approach. Contraception. 2011;84:144-9.
Katz DF, Slade DA, Nakajima ST. Analysis of pre-ovulatory
changes in cervical mucus hydration and sperm penetrabili-
ty. Adv Contracept. 1997;13:143-51.
Moghissi KS, Syner FN, Evans TN. A composite picture of
the menstrual cycle. Am J Obstet Gynecol. 1972;114:405-
Mu Q, Fehring RJ. Efcacy of achieving pregnancy with fertil-
ity-focused intercourse. MCN Am J Matern Child Nurs.
Pallone SR, Bergus GR. Fertility awareness-based methods:
another option for family planning. J Am Board Fam Med.
Scarpa B, Dunson DB, Colombo B. Cervical mucus secretions
most physicians do not give information about this
method and underestimate the value of this approach
(Stanford et al., 1999). All people involved in
infertility care should be informed about the
existence and effectiveness of the FABM, in order
to properly educate women about it and to decrease
the number of couples that will eventually need
assisted reproductive technologies.
Based on the results of the selected studies after
literature search, we can conclude that cervical
mucus secretions can be used as a good predictor of
impending fertility. All evaluated studies
demonstrated that observing the cervical mucus can
identify the days with the highest pregnancy
probability. When intercourse takes place on a day
in the fertile interval with the highest mucus score,
the time to pregnancy can be shortened signicantly.
According to the literature, the quality of the vaginal
discharge correlates well with the cycle-specic
probability of pregnancy in fertile couples but less
in subfertile couples. Most of the results are based
on studies with couples with unknown fertility
status. However, there is some evidence that cervical
mucus monitoring can become a very useful
approach for women with unexplained subfertility.
There is an urgent need for further research to
conrm the effectiveness of the CMM method to
increase the probability of pregnancy in subfertile
couples. If these methods prove to be effective for
the subfertile couple, more patients will become
pregnant without the need of assisted reproductive
technologies (ART). When comparing cumulative
pregnancy rates after ART with cumulative
pregnancy rates in natural cycles (Gnoth et al.,
2011) we nd congruent curves which is beautifully
in line with some simulation models (Stanford et al.,
2010). This suggests that ART may reach natural
fertility rates but cannot exceed them and patients
will not benet from a rush into ART.
These thoughts may help in offering a more
patient-friendly approach within infertility centres
and probably will also reduce ART-related costs for
subfertile couples and social systems.
Albertson BD, Zinaman MJ. The prediction of ovulation and
monitoring of the fertile period. Adv Contracept. 1987;3:263-
ASRM. Optimizing natural fertility. Fertil Steril. 2008;90:S1-6.
Bhargava H, Bhatia JC, Ramachandran L et al. Field trial of
billings ovulation method of natural family planning.
Contraception. 1996;53:69-74.
FerTiliTy AWAreness-bAseD MeThODs – Thijssen eT Al. 123
Stanford JB, Mikolajczyk RT, Lynch CD et al. Cumulative
pregnancy probabilities among couples with subfertility:
effects of varying treatments. Fertil Steril. 2010;93:2175-
Wang X, Chen C, Wang L et al. Conception, early pregnancy
loss, and time to clinical pregnancy: a population-based
prospective study. Fertil Steril. 2003;79:577-84.
Wilcox AJ, Dunson D, Baird DD. The timing of the “fertile
window” in the menstrual cycle: day specic estimates from
a prospective study. BMJ. 2000;321:1259-62.
Wilcox AJ, Dunson DB, Weinberg CR et al. Likelihood of
conception with a single act of intercourse: providing bench-
mark rates for assessment of post-coital contraceptives.
Contraception. 2001;63:211-5.
on the day of intercourse: an accurate marker of highly
fertile days. Eur J Obstet Gynecol Reprod Biol. 2006;125:72-
Scarpa B, Dunson DB, Giacchi E. Bayesian selection of optimal
rules for timing intercourse to conceive by using calendar
and mucus. Fertil Steril. 2007;88:915-24.
Sozou PD, Hartshorne GM. Time to pregnancy: a computational
method for using the duration of non-conception for predict-
ing conception. PLoS One. 2012;7:e46544.
Stanford JB, Thurman PB, Lemaire JC. Physicians’ knowledge
and practices regarding natural family planning. Obstet
Gynecol. 1999;94:672-8.
Stanford JB, White GL, Hatasaka H. Timing intercourse to
achieve pregnancy: current evidence. Obstet Gynecol.
Stanford JB, Smith KR, Dunson DB. Vulvar mucus observa-
tions and the probability of pregnancy. Obstet Gynecol.
... Among other relevant functions, the cyclical variability of CM provides information on the fertility status of women throughout the cycle [31,32]. There is evidence that CM is a crucial element for the identification of the time of ovulation [33][34][35]. ...
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There is an increasing number of couples interested in identifying the fertile window for the purpose of conceiving. From what has been published so far, it can be concluded that there are no reliable methods to predict ovulation, and, therefore, to predict the fertile window. Proteins of the cervical mucus (CM) could behave as biomarkers to allow the early and precise identification of ovulation. CM samples were collected from the lumen of the cervical canal from women of reproductive age, on three different days of the same menstrual cycle. Samples were first analyzed and classified by light microscopy. High-resolution mass spectrometry and bioinformatic analysis were performed afterwards to determine the in vivo changes of CM protein composition. CM underwent cyclical changes in its biophysical composition, which were evidenced by changes in the crystallographic patterns observed under the light microscope. The proteomic analysis revealed changes in the protein composition of CM along the cycle. Twenty-five out of the forty-eight total proteins identified could become potential biomarkers of ovulation. The coordinated changes in the composition of the CM around the time of ovulation could be happening to specifically grant access to a foreign body, such as the sperm might be.
... Despite the benefits of this strategy to prevent unintended pregnancy, most young women in SSA do not understand their menstrual cycle and fertility awareness knowledge has been reported to be low [19]. The lack of fertility awareness knowledge in the absence of or misuse of contraceptives could lead to negative health outcomes such as unintended pregnancy [15,20]. ...
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Objectives: The primary objective of this study was to examine the association between fertility awareness knowledge, and contraceptive use among sexually active female university students (FUS) in Cameroon. Methods: This study was designed as a secondary data analysis of a cross-sectional survey that was conducted between July and August 2018. We extracted and analyzed relevant data (i.e., socio-demographic characteristics, sexual behavior, fertility-related characteristics, and contraceptive use) using a modified Poisson regression with a robust variance estimator. Prevalence Ratios (PR) and 95% confidence intervals were estimated, and statistical significance was set at P≤0.05. Results: The median age of the sexually active FUS was 23 years (IQR = 21-25) and 99.3% indicated that they wanted to have children. Only 49.3% knew their fertile period and 62.5% of the sexually active FUS were current contraceptive users. We found a statistically significant association between fertility awareness knowledge and period abstinence (PR = 1.57;95%CI: 1.02-2.44, p = 0.049). In multivariate adjusted models, there was a statistically significant association between fertility awareness knowledge and male condom use (APR = 1.29; 95% CI:1.02-1.64, p-value = 0.032) and the withdrawal method (APR = 1.40;95% CI:1.02-1.93, p = 0.038). We found a statistically significant effect modification of "preferred timing to have children" on the association between fertility awareness knowledge and withdrawal method use. There was no association between fertility awareness knowledge and the use of oral contraceptive pills. Conclusion: Most of the female students intend to have children in the future, but their fertility awareness knowledge was suboptimal. There was a statistically significant relationship between fertility awareness knowledge, and the use of male condoms and the withdrawal method. The study underscores the need for FUS to be targeted with interventions to help them gain knowledge of their menstrual cycle to better plan or avoid unwanted pregnancy.
... Su et al. presented a review of currently available methods for the detection of ovulation. [2][3][4][5][6] Some ovulation detection devices have been developed and commercialized based on these methods. [2] Among these methods, one can distinguish the use of the ovulation test. ...
Background: Sometimes, women find it difficult to conceive a baby and others use contraceptives that often have side effects. Researchers have already established the importance of measuring basal body temperature (BBT) and the potential of hydrogen (pH). Method: We have designed and realized a device that allows the simultaneous measurement of the BBT and the pH. We used an Arduino Uno board, a pH sensor, and a temperature sensor. The device communicates with a smartphone, can be integrated into all e-health platforms, and can be used at home. We validated our ovulation detector by a measurement campaign on a group of twenty women. If the pH is >7 and at the same time, the BBT is minimum and <36.5°C, the women is in ovulation phase. If the pH is ≤7 and in the same time, the BBT is between 36.5°C and 37°C, the women are in preovulation or follicular phase. If the pH is ≤7 and in the same time, the BBT is >36.5°C, the women are in postovulation or luteal phase. Results: We tested the contraceptive aspect of our ovulometer on a set of seven women. We also tested the help of conceiving babies by having intercourse during the ovulation period fixed by our ovulation detector. The results are satisfactory. Conclusions: In the final version of our device, we displayed just in "fertility period" if the pH is ≥7 and the BBT is <36.5°C else we displayed in "nonfertility period."
... The effect of timed intercourse in fertile couples and subfertile couples is assumed to be different. The previous study showed that the quality of FABM like the vaginal discharge correlates well with the cycle-specific probability of pregnancy in normally fertile couples but less in subfertile couples (54). Approximately 85-90% of healthy young couples conceive within 1year, most within 6 months (1, 2). ...
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The aim of this study was to determine predictive factors for pregnancy and assess the cumulative pregnancy rate (CPR) and live birth rate (CLBR) in subfertile couples undergoing timed intercourse (TI) using ultrasound. This retrospective cohort study included 285 women (854 cycles) who started TI with ultrasound between January 2017 and October 2019. The overall clinical pregnancy rate was 28.1% (80/285) per couple and 9.4% (80/854) per cycle. Pregnant women had a higher body mass index (BMI), higher percentage of irregular menstrual cycles, a shorter duration of subfertility, lower serum follicle-stimulating hormone levels, and higher anti-Müllerian hormone levels than non-pregnant women. A longer duration of subfertility (≥24 months vs. <12 months; odds ratio: 0.193; 95% confidence interval: 0.043-0.859) and endometriosis ( vs. ovulatory factors; odds ratio: 0.282; 95% confidence interval: 0.106-0.746) as causes of subfertility were unfavorable factors that independently affected clinical pregnancy. In subgroup analysis, old age ≥ 35 years [ vs. < 35 years; odds ratio: 0.279; 95% confidence interval: 0.083-0.938), a longer duration of infertility ≥24 months ( vs. <24 months; odds ratio: 0.182; 95% confidence interval: 0.036-0.913) and a higher BMI ≥ 25 kg/m ² ( vs. >25 kg/m ² ; odds ratio: 3.202; 95% confidence interval: 1.020-10.046) in couples with ovulatory factor and a longer duration of infertility ≥24 months ( vs. <24 months; odds ratio: 0.185; 95% confidence interval: 0.042-0.819) in couples with non-ovulatory factors were significant independent predictive factors for pregnancy. No significant differences were found in the cycle characteristics between pregnant and non-pregnant women. The CPR substantially increased during the first three cycles and significantly increased until the sixth cycle. No significant increase was observed in the CPR after the sixth cycle. The CLBRs substantially increased during the first three cycles and significantly increased until the fourth cycle. No significant increase was observed in the CLBRs after the fifth cycle. When comparing CPRs and CLBRs according to subfertile causes, CRPs was significantly different and CLBRs was different with borderline significance. Our findings may indicate that women with a longer duration of subfertility or subfertility due to endometriosis have poor outcomes during TI with ultrasound. Women who failed to achieve conception by the fourth or fifth cycle of TI with ultrasound may be encouraged to consider advancing to the next treatment strategy.
... Sticky cervical mucus and positive OPK results allow women to self-estimate their peak fertility period and reporting these characteristics was associated with timing of condomless sex in our cohort. Other studies have found that cervical mucus status is the strongest indictor of upcoming fertility days and that self-tracking mucus characteristics reduces the time-to-pregnancy [12,24]. Our data are among the first from African women to demonstrate feasibility of tracking these indicators and alignment of fertility signs with condomless sex. ...
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Background For couples affected by HIV, and serodifferent couples in particular, pregnancy desire is often juxtaposed against the risk of HIV transmission between the couple and the potential neonate leading to thinking about measures to minimize risk of HIV transmission. We assess the use of fertility awareness methods [FAM] and evaluate the drivers of alignment between indicators of fertility and sexual behavior among HIV-serodifferent couples desiring pregnancy. Methods HIV-serodifferent couples from Thika, Kenya were enrolled into an open-label pilot evaluation of safer conception strategies. Women responded to daily 7-item short message service [SMS] surveys on FAM and sexual activity. Menstrual cycles were categorized as having condomless sex aligned, not aligned, or partially aligned to the predicted peak fertility. We used binomial logit models with generalized estimating equations to assess alignment between condomless sex during peak fertility days and FAM results. We used Cox proportional hazards to compare pregnancy incidence among months with sex and peak fertility aligned and mis-aligned. Results A total of 6929 SMS surveys across 252 menstrual cycles of 65 women were included. Reporting “sticky” cervical mucus (adjusted odds ratio [aOR]: 2.25, 95% confidence interval [95% CI]: 1.30, 3.90) and positive ovulation prediction kit [OPK] result (aOR: 2.07, 95% CI: 1.11, 3.86) were associated with increased likelihood of alignment of condomless sex during peak fertility. Pregnancy incidence was statistically similar among periods with sex aligned and not aligned with peak fertility. Conclusions Among women engaged in a comprehensive safer conception program, a moderate percentage of women aligned condomless sex and predicted peak fertility days at least once. While FAM, particularly cervical mucus and OPK, are an inexpensive option for couples to consider using as a component of their safer conception strategies, antiretroviral-based strategies remain important to minimize risk.
... Lack of knowledge of fertility leads to multiple undesirable health outcomes, such as unintentional or unplanned pregnancy in a marriage, and unsafe abortion among unmarried adolescences. 62,63 The finding of this study revealed that the prevalence ratio of teenage pregnancy was 1.3 times higher among teenagers who did not know the fertile time during the menstrual cycle compared to teenagers who knew the fertile time. This is consistent with other related studies in Ethiopia 64 and African countries. ...
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Background: Teenage pregnancy is a global issue raising concerns for all who are interested in the health and well-being of young women and their children. It carries major health and social issues with unique medical and psychosocial consequences for both adolescents and society in general. This study aimed at assessing the prevalence and factors associated with teenage pregnancy in eastern Ethiopia. Methods: A community-based cross-sectional study was conducted. Multi-stage simple random sampling procedure was used to select 2258 female teenagers. Interviewer-administered questionnaire was used for data collection. Data were entered into EpiData and analyzed using stata software. The Poisson regression model with robust variance estimation was used to examine the association of the independent variable with teenage pregnancy. An adjusted prevalence ratio (APR) with 95% confidence intervals (CI) was reported. Results: The prevalence of teenage pregnancy was 30.2% (95% CI: 28.3, 32.1). Age 16-17 years old (APR=7.05; 95% CI: 4.15,11.96), 17-18 years old (APR=9.85; 95% CI: 5.72,16.98), not being in school (APR=2.83; 95% CI: 1.93,4.16), lack of formal education (APR=1.11; 95% CI: 1.03,1.19), being married (APR=3.59; 95% CI: 2.83,4.56), parental divorce (APR=1.24; 95% CI: 1.08,1.42), having elder sister who had a history of teenage pregnancy (APR=1.11; 95% CI: 1.02,1.21), and not knowing fertile period in menstrual cycle (APR=1.31; 95% CI: 1.16,1.47) were independently associated with teenage pregnancy. Conclusion: One in three teenagers had been pregnant. Age, not being in school, lack of formal education, being married, parental divorce, having an elder sister who had a history of teenage pregnancy, and not knowing fertile period during the menstrual cycles were the factors associated with teenage pregnancy. In Ethiopia, further efforts are required in the prevention of teenage pregnancy, keeping girls in school and strengthening the policy of delaying child marriage, particularly in rural areas.
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Study question: Can animation videos on how to optimize the chances of pregnancy influence stress, anxiety, depression and sexual functioning of individuals trying to conceive (TTC)? Summary answer: There were no differences between those educated to have intercourse every other day, on the fertile window and a control group (CG), and depression and sexual dysfunction significantly increased over time for all arms. What is known already: Recent findings indicate that time to pregnancy can be significantly shortened by targeting the fertile period, but some reproductive care guidelines recommend instead the practice of intercourse every other day on the basis that it is less stressful to the couple. Evidence to support guidelines on how to preserve well-being and psychosocial adjustment and optimize pregnancy chances is lacking. Study design, size, duration: We conducted a prospective, double-blinded, three-arm randomized controlled trial between July 2016 and November 2019. Participants were randomized to either not having any stimulus (CG) or visualizing a short animated video explaining how to improve chances of pregnancy by having intercourse every other day (EOD group), or by monitoring the fertile window (FWM group). Assessments were made before the intervention (T0), and 6 weeks (T1), 6 months (T2) and 12 months after (T3), with follow-ups censored in case of pregnancy. Participants/materials, setting, methods: Participants were childless individuals of reproductive age actively TTC and not diagnosed or unaware of a condition that could prevent spontaneous pregnancy. Individuals were excluded from recruitment if they had previous children or had a condition preventing spontaneous pregnancy. Our primary outcome was stress and secondary outcomes included anxiety, depression, sexual functioning and pregnancy. Primary analyses were performed according to intention-to-treat principle. Main results and the role of chance: Of the 450 randomized participants 127 were educated to use an every-other-day strategy, 135 to monitor the fertile window, and 134 received no intervention. Groups were similar regarding demographics and months TTC. Repeated measures analysis revealed that there were no significant interaction effects of psychological and sexual well-being between groups over time (P > 0.05). Significant time effects were revealed for stress (F(3,855) = 4.94, P < 0.01), depression (F(3,855) = 14.22, P < 0.01) and sexual functioning (time effects P values <0.001 for female sexual functioning dimensions and <0.002 for male dimensions), but not for anxiety (F(2,299) = 0.51, P > 0.05). Stress levels lowered after 6 months (P < 0.001) and returned to baseline levels at the 1-year follow-up. Depressive symptomatology significantly increased at 6 weeks (P = 0.023), and again 1 year after (P = 0.001). There were also significant decreases in all female sexual functioning dimensions (desire, satisfaction, arousal, pain, orgasm and lubrication). In men, there were significant variations in orgasm, intercourse satisfaction and erectile function, but not desire and sexual satisfaction. Revealed pregnancy rates were 16% for participants in the EOD group, 30% for the FWM group and 20% for the CG. Pregnancies were not significantly different between arms: EOD vs FWM (odds ratio (OR) 2.32; 95% CI 0.92-5.83); EOD vs CG (OR 0.74; 95% CI 0.30-1.87); and FWM vs CG (OR 1.71; 95% CI 0.70-4.18). Limitations, reasons for caution: Participants were recruited after transitioning to procreative sex. The study might be prone to bias as almost 30% of our sample fulfilled the chronological criterion for infertility, and other reproductive strategies could have been tried over time before recruitment. Wider implications of the findings: Our data suggest that stress does not arise from feeling pressured on the fertile period and that advice on timing of intercourse might have to be personalized. The increasing levels of depression and sexual dysfunction over a year emphasize the crucial role of preconception care and fertility counseling in promoting psychological and sexual well-being. Study funding/competing interest(s): This work was supported by European Union Funds (FEDER/COMPETE-Operational Competitiveness Programme) and by national funds (FCT-Portuguese Foundation for Science and Technology) under the projects PTDC/MHC-PSC/4195/2012 and SFRH/BPD/85789/2012. Trial registration number: NCT02814006. Trial registration date: 27 June 2016. Date of first patient’s enrollment: 19 July 2016.
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Background: Fertility awareness-based methods (FABMs) educate about reproductive health and enable tracking and interpretation of physical signs, such as cervical fluid secretions and basal body temperature, which reflect the hormonal changes women experience on a cyclical basis during the years of ovarian activity. Some methods measure relevant hormone levels directly. Most FABMs allow women to identify ovulation and track this "vital sign" of the menstrual or female reproductive cycle, through daily observations recorded on cycle charts (paper or electronic). Applications: Physicians can use the information from FABM charts to guide the diagnosis and management of medical conditions and to support or restore healthy function of the reproductive and endocrine systems, using a restorative reproductive medical (RRM) approach. FABMs can also be used by couples to achieve or avoid pregnancy and may be most effective when taught by a trained instructor. Challenges: Information about individual FABMs is rarely provided in medical education. Outdated information is widespread both in training programs and in the public sphere. Obtaining accurate information about FABMs is further complicated by the numerous period tracking or fertility apps available, because very few of these apps have evidence to support their effectiveness for identifying the fertile window, for achieving or preventing pregnancy. Conclusions: This article provides an overview of different types of FABMs with a published evidence base, apps and resources for learning and using FABMs, the role FABMs can play in medical evaluation and management, and the effectiveness of FABMs for family planning, both to achieve or to avoid pregnancy.
Fertility awareness methods as the first step in subfertility management An unfulfilled child wish is due to unexplained or mild male subfertility in more than half of the consulting subfertile couples. Since many of these couples can still conceive naturally within 1 year without treatment, expectant management (6-12 months) is proposed. However, in practice it often proves to be difficult to adhere to this approach, resulting in a quick shift to expensive assisted reproductive therapy (ART). Recent fertility awareness methods (FAMs) train couples to distinguish fertile from infertile days of the menstrual cycle, allowing them to target sexual intercourse on the most fertile days. By incorporating FAMs into expectant management, the latter is made more effective, increasing the chances of pregnancy. Furthermore, the health risks associated with ART are reduced. The symptothermal method is a combination of the temperature-based and cervical mucus secretion method. By applying this FAM and having fertility-focused intercourse, 92% of the women had become pregnant after 1 year, compared to 82% in studies without FAMs. For a subfertile subgroup, the cumulative spontaneous pregnancy rate after 8 months was less (38%), but still significantly above the spontaneous pregnancy rate without fertility awareness training (21.6%). Via educational materials and a network of trained teachers, FAMs are proposed. In order to fulfil this role properly, FAMs need to be recognised as the first step in fertility care in Belgium. Integrating FAMs can cause a judicious reduction in healthcare costs by reducing the number of multiple pregnancies and selecting only couples who genuinely need ART.
Oestrus is the period in the sexual cycle of female mammals where they become most receptive to mating and are most fertile. Efficient detection of oestrus is a key component in successful reproductive livestock management programmes. Oestrus detection in cattle is most often performed by visual observation, such as mounting behaviour and standing heat, to facilitate more successful prediction of optimal time points for artificial insemination. This time-consuming method requires a skilled, diligent observer. Biological measurements using easily accessible biomolecules in the cervico-vaginal mucus could provide an alternative strategy to physical methods of oestrus detection, providing an inexpensive means of rapidly and accurately assessing the onset of oestrus. In this study, glycosylation changes in cervico-vaginal mucus from three heifers following oestrus induction were investigated as a proof of concept to assess whether potential glycosylation-based trends could be useful for oestrus stage indication. Mucus collected at different time points following oestrus induction was immobilised in a microarray format and its glycosylation interrogated with a panel of fluorescently labelled lectins, carbohydrate-binding proteins with different specificities. Individual animal-specific glycosylation patterns were observed, however each pattern followed a similar trend around oestrus. This unique oestrus-associated glycosylation was identified by a combination of relative binding of the lectins SNA-I and WFA for each animal. This alteration in cervico-vaginal mucus glycosylation could potentially be exploited in future to more accurately identify optimal fertilisation intervention points compared to visual signs. More effective oestrus biomarkers will lead to more successful livestock reproductive programmes, decreasing costs and animal stress.
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An important problem in reproductive medicine is deciding when people who have failed to become pregnant without medical assistance should begin investigation and treatment. This study describes a computational approach to determining what can be deduced about a couple's future chances of pregnancy from the number of menstrual cycles over which they have been trying to conceive. The starting point is that a couple's fertility is inherently uncertain. This uncertainty is modelled as a probability distribution for the chance of conceiving in each menstrual cycle. We have developed a general numerical computational method, which uses Bayes' theorem to generate a posterior distribution for a couple's chance of conceiving in each cycle, conditional on the number of previous cycles of attempted conception. When various metrics of a couple's expected chances of pregnancy were computed as a function of the number of cycles over which they had been trying to conceive, we found good fits to observed data on time to pregnancy for different populations. The commonly-used standard of 12 cycles of non-conception as an indicator of subfertility was found to be reasonably robust, though a larger or smaller number of cycles may be more appropriate depending on the population from which a couple is drawn and the precise subfertility metric which is most relevant, for example the probability of conception in the next cycle or the next 12 cycles. We have also applied our computational method to model the impact of female reproductive ageing. Results indicate that, for women over the age of 35, it may be appropriate to start investigation and treatment more quickly than for younger women. Ignoring reproductive decline during the period of attempted conception added up to two cycles to the computed number of cycles before reaching a metric of subfertility.
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Cumulative pregnancy rates (CPRs) and live birth rates (CLBRs) are much better indicators of success in IVF programmes than cross-sectional figures per cycle or embryo transfer. They allow a better estimation of patient's chances of having a child and enable comparisons between centres and treatment strategies. A 10 year cohort study of patients undergoing their first assisted reproductive technique cycle was conducted. Patients were followed until live birth or discontinuation of treatment. All IVF and ICSI cycles and cryo-cycles with embryos derived from frozen pronuclear stage oocytes were included. The CPR and CLBR were estimated using the Kaplan-Meier method for both the number of treatment cycles and transferred embryos. The analysis assumed that couples who did not return for subsequent treatment cycles would have had the same chance of success as those who had continued treatment. A total of 3011 women treated between 1998 and 2007 were included, and 2068 children were born; women already with a live birth re-entered the analysis as a 'new patient'. For 3394 'patients under observation' with 8048 cycles, the CLBR was 52% after 3 cycles (the median number of cycles per patient), 72% after 6 cycles and 85% after 12 cycles. A CLBR of ∼ 50% was achieved for patients aged under 40 years, after the cumulative transfer of six embryos. The mean live birth rate from one fresh cycle and its subsequent cryo-cycle(s) was 33%. Our analysis also shows that ART can reach natural fertility rates but not exceed them. Most couples with infertility problems can be treated successfully if they continue treatment. Thereby ART can reach natural fertility rates. Even with the restrictions in place as a result of the German Embryo Protection Law, CLBR reach internationally comparable levels.
Objective: To assess physicians' knowledge and practices of modern methods of natural family planning. Methods: A questionnaire was mailed to 840 physicians selected randomly from Missouri state licensing records for obstetrics-gynecology, family practice, general practice, and general internal medicine. Results: The response rate was 65%. A total of 375 physicians (69% of respondents) saw women for reproductive issues. About half (46%) of physicians reported that they mentioned natural family planning to at least some women when discussing family planning issues. Observing vaginal discharge of cervical mucus was discussed by 40% of physicians in the context of avoiding pregnancy and by 36% of physicians in the context of helping a couple achieve pregnancy. Twenty-two percent of physicians estimated the best possible effectiveness of natural family planning to avoid pregnancy to be greater than 90%, and 35% estimated the actual effectiveness to avoid pregnancy to be greater than 70%. (The threshold rates of 90% best possible effectiveness and 70% actual effectiveness were chosen to be somewhat less than those reported in medical literature.) Physicians who gave higher estimates of effectiveness of natural family planning and physicians who were aware of an instructor in their community were more likely to provide women with relevant information about natural family planning. Conclusion: Most physicians, especially those unaware of availability of instructors in their areas, underestimate the effectiveness of natural family planning and do not give information about modern methods to women.
To compare pregnancy rates when women have intercourse on self-estimated high and peak fertile days and when they only have intercourse on low fertile days during the fertile window (FW). We used a prospective observational cohort study design. Our convenience sample included 124 women who utilized our online charting Web sites to achieve pregnancy from January 2010 to November 2012. Participants used an electronic hormonal fertility monitor (EHFM) or self-observed cervical mucus or both to determine fertility during the estimated FW. Pregnancy rates were determined with Kaplan-Meier survival analysis. Chi square analysis was used to evaluate the efficacy of achieving pregnancy between two different intercourse patterns. The pregnancy rate was 87 per 100 women at 12 months when intercourse happened on high or peak days and 5 per 100 when intercourse occurred only on low days of the FW. Chi square analysis showed a greater proportion of pregnancies with intercourse on high and peak fertile days of the menstrual cycle (x = 40.2, p < .001, df = 1). Focusing intercourse on high or peak fertile days during the estimated FW enhances the probability of achieving a desired pregnancy. Fertility awareness-based online charting system is effective in helping women to determine their FW and target intercourse accordingly to achieve pregnancy.
To assess the use of cervical mucus monitoring (CMM) in women trying to conceive and determine whether monitoring is associated with increased cycle-specific probability of conception (fecundability). Time-to-pregnancy cohort study. Population-based cohort. Three hundred thirty-one women trying to conceive, ages 30 to 44 years, without known infertility. None. CMM prevalence and fecundability. During the first cycle of the study, CMM was performed consistently (checked on >66% of pertinent cycle days) by 20 women (6%), inconsistently (34% to 66% of days) by 60 women (18%), infrequently (≤33% of days) by 73 women (22%), and not performed by 178 women (54%). Cycles in which CMM was consistently performed were statistically significantly more likely to result in conception after adjusting for age, race, previous pregnancy, body mass index, intercourse frequency, and urinary luteinizing hormone (LH) monitoring. Fecundability also increased with increasing consistency of CMM. Among women trying to conceive, CMM is uncommon, but our study suggests that CMM-a free, self-directed method to determine the fertile window-is associated with increased fecundability independent of intercourse frequency or use of urinary LH monitoring.
To assess physicians' knowledge and practices of modern methods of natural family planning. A questionnaire was mailed to 840 physicians selected randomly from Missouri state licensing records for obstetrics-gynecology, family practice, general practice, and general internal medicine. The response rate was 65%. A total of 375 physicians (69% of respondents) saw women for reproductive issues. About half (46%) of physicians reported that they mentioned natural family planning to at least some women when discussing family planning issues. Observing vaginal discharge of cervical mucus was discussed by 40% of physicians in the context of avoiding pregnancy and by 36% of physicians in the context of helping a couple achieve pregnancy. Twenty-two percent of physicians estimated the best possible effectiveness of natural family planning to avoid pregnancy to be greater than 90%, and 35% estimated the actual effectiveness to avoid pregnancy to be greater than 70%. (The threshold rates of 90% best possible effectiveness and 70% actual effectiveness were chosen to be somewhat less than those reported in medical literature.) Physicians who gave higher estimates of effectiveness of natural family planning and physicians who were aware of an instructor in their community were more likely to provide women with relevant information about natural family planning. Most physicians, especially those unaware of availability of instructors in their areas, underestimate the effectiveness of natural family planning and do not give information about modern methods to women.
Requiring that women wait until the onset of menses to initiate a family planning method is a medical barrier that can result in unintended pregnancies. In the efficacy study of the TwoDay Method, a new fertility awareness-based method of family planning, women were taught the method in the first seven days of their cycles. This study tested a quick-start approach (providing the method at any time in the cycle) to TwoDay Method delivery. In Peru, 167 women were counseled in TwoDay Method use (regardless of cycle day) and followed for up to 7 months. They were interviewed periodically to assess their use of and satisfaction with the method. Simulated clients gauged providers' ability to correctly counsel in method use at different times of the cycle. No significant differences were observed in correct use, continuation rates, and acceptability of the method among women who were counseled at different points in the cycle; quality of counseling was not undermined by the quick-start approach. There is no need to limit delivery of the TwoDay Method to the first seven days of the menstrual cycle.
To determine whether normal women could predict and identify symptomatically the occurrence of ovulation, twenty-two volunteers were instructed in a pattern of vaginal "mucus symptoms " which had been established previously. Plasma luteinising hormone and urinary oestrogens and pregnanediol were measured to provide a "hormonal estimate" of the day of ovulation. A characteristic "lubricative" mucus identified by all the women occurred on the day of ovulation in five, 1 day before in nine, and 2 days before in four. The onset of mucus symptoms occurred 6·2 days (mean) before ovulation. It is concluded that the time of ovulation can be identified clinically, without recourse to temperature measurement or more specialised tests.
To investigate the conception probability among Chinese women. Prospective observational study. Clinics in hospitals and family planning institutes in 10 provinces and cities. A total of 851 healthy married women aged 18-35 years with normal menstrual cycles who wish to have babies and with no contraception. Urinary LH was measured around days of expected ovulation for 7 days. The Barrett and Marshall model was used for calculation of conception probabilities on each cycle day from day -5 to day +1 in women with multiple episodes of intercourse. Pregnancies in 1, 3, and >or=6 months. A total of 851 women with 2,055 cycles were analyzed. In 489 cycles there was only one episode of intercourse. A total of 601 pregnancies occurred. The conception probabilities from days in relation to ovulation -5 to +1 for a single episode of intercourse were 0.216, 0.102, 0.236, 0.233, 0.388, 0.293, and 0.386, respectively, and for multiple episodes they were 0.254, 0.271, 0.293, 0.365, 0.315, and 0.284, respectively, with the peak value at day -1. Recalculation of the efficacy of emergency contraception with low-dose mifepristone with the present conception probabilities showed higher efficacy. Conception probabilities among Chinese women are different from those in the literature. Further comparative studies are needed to confirm an ethnic difference.
To model the cumulative probability of pregnancy among couples with subfertility without a definitive diagnosis, according to different treatment strategies. A beta distribution of fecundity was fitted that reproduced the cumulative probability of pregnancy in prospective studies of natural fertility, and this distribution was applied to simulated cohorts starting with one million couples each. Probabilities of pregnancy were generated for each cycle of each couple. Simulation study. Hypothetic subfertile population. After 2 or 4 years of attempting pregnancy and diagnostic evaluation to exclude anovulation, tubal obstruction, and severe male factor, simulated treatments were applied to the remaining nonpregnant couples, with treatment effects based on published literature. Simulated cumulative probability of pregnancy. Initially, the cumulative probability of pregnancy was highest for early treatment with IVF, but over time, conservative treatment or frequent intercourse approached the same cumulative probability. In couples without clear indications for IVF, the main benefit of early IVF may be to shorten time to pregnancy, a benefit that must be weighed against costs and potential adverse outcomes. Couples should be encouraged to maintain regular intercourse to maximize chances of pregnancy, even after unsuccessful treatment attempts.