April 18, 2022
FACTS Infertility Awareness Series
Acceptability of Fertility Awareness and Hormonal Support Among Subfertile Women
By Elizabeth Kane, MD
Editor’s Note: As a continuation of our infertility series, this is a summary of an in-depth survey of subfertile women attending a natural fertility service, determining their overall satisfaction with fertility awareness-based approaches to achieve pregnancies by natural conception. Elizabeth Kane, as a participant of a FACTS elective, summarized “Women’s views of a fertility awareness and hormonal support approach to subfertility,” which was published in 2013 by McLindon, et al., in the Human Fertility. To learn more from a personal perspective, read this interview with a couple that used the sympto-thermal method and required hormonal support to have their children.
Fertility awareness involves improving a woman’s understanding of her reproductive physiology with the aim of applying this knowledge to her own situation. Fertility awareness-based methods (FABMs) are often considered a family planning method for pregnancy avoidance, but FABMs have also been shown to decrease the time necessary to achieve pregnancy and may play a valuable role in fertility treatments. Many women report various barriers to accessing fertility treatments, including lack of control, financial costs, and treatment-associated pain. However, FABMs may be more acceptable and patients may experience greater satisfaction and better outcomes, as is shown in studies with similar low-intervention therapies. Few studies have evaluated the acceptability of FABMs in aiding conception, including the use of hormonal therapy for pregnancy support.
The purpose of this study  was to evaluate the use of a fertility awareness-based method for pregnancy achievement and hormonal support acceptability among a sub-fertile population. More specifically, this article reviewed a midwife-led model of fertility care that integrated pre-conception care, formal FABM instruction, preliminary diagnostic work-up, and medical review and management. They solely used the sympto-thermal method, which required patients to monitor and record symptoms of fertility — including cervical mucus changes and basal body temperature.
The study’s authors mailed a four-page survey tool to the last 250 consecutive women who wished to conceive after attending the Natural Fertility Service at Mater Mother’s Hospital in Brisbane, Australia. Overall, the FABM acceptance rate was higher in women who successfully conceived or who had a history of recurrent miscarriages.
Eighty-four women, or about one-third of those who received the questionnaire, responded. About two-thirds of respondents were open to charting and receiving clinical care using an FABM protocol. Approximately 85 percent of women accepted the use of temperature- recordings and the recording of cervical mucus. In addition, about 80 percent of women reported that, regardless of the outcome, it was worthwhile to utilize the natural fertility service. More women — about 75 percent — were comfortable with using hormonal therapy to support an early pregnancy, when compared to women relying on cycle support — about 67 percent. Finally, the majority of women surveyed expressed preference for hormonal therapy. Using luteal phase hormonal support was much more acceptable in women older than 35 years old (100 percent) versus women younger than 35 years (69.4 percent, respectively). A vaginal pessary was the most preferred method of administration.
Overall, FABMs were acceptable to the large majority of fertile and sub-fertile women intending to achieve a pregnancy. These women were also open to using hormonal therapy for cycle support and early-pregnancy support. The authors originally hypothesized that women desiring a more “natural” approach to fertility would have been less willing to accept hormonal interventions. However, the study’s results found their hypothesis was not supported. Participants were generally satisfied with hormonal therapy, a patient-centered and couple-centered approach, regardless of pregnancy conception outcome. Patients of this method may feel more in control, incur fewer financial costs, and suffer less treatment-associated pain and distress associated with many fertility treatments.
Some weaknesses of the study include the small sample size and the inclusion of a population drawn from a subset of women who had already reached out to a natural fertility service. Only about one-third of the women responded, and non-responders may have been part of the clinic’s population of refugees and non-English speaking patients, which further limits generalizability. Additionally, almost half of the participants were familiar with FABMs prior to entering the service, which likely influenced acceptability rates. Lastly, the survey responses were anonymous, limiting the authors’ ability to reach out to respondents for clarification.
Women may desire a different approach to fertility and subfertility treatment than what is commonly provided via reproductive endocrinology and infertility services. The high satisfaction rates and cost effectiveness of FABMs highlight the need for increased awareness about FABMs, as more women may benefit from the knowledge gained through charting their cycles. A potential direction for future research is to conduct a similar study among a more general population of women, including those who may have never heard of FABMs before. Researchers should consider cost-savings, overall effectiveness rates, and the emotional responses that women experience when using FABMs to achieve or avoid pregnancy.
The high satisfaction rates and cost effectiveness of FABMs highlight the need for increased awareness about FABMs, as more women may benefit from the knowledge gained through charting their cycles.
 Scarpa B, Dunson DB, Giacchi E. 2007. Bayesian selection of optimal rules for timing intercourse to conceive by using calendar and mucus. Fertility and Sterility 88, 915 – 924.
 Redshaw M, Hockley C, Davidson LL. 2007. A qualitative study of the experience of treatment for infertility among women who successfully became pregnant. Human Reproduction 22 , 295 – 304.
 Heijnen EM, Eijkemans MJ, De Klerk C, Polinder S, Beckers NG, Klinkert ER, et al. 2007 . A mild treatment strategy for in-vitro fertilisation: a randomised non-inferiority trial. Lancet 369, 743 – 749.
 McLindon LA, Beckmann M, Flenady V, McIntyre HD, Chapman M. 2013. Women’s views of a fertility awareness and hormonal support approach to subfertility. Hum Fertil (Camb) 16(4):252-7.
About the Author
Elizabeth Kane, MD
Elizabeth Kane is a family medicine resident at the University of Pennsylvania. She completed medical school at the University of Illinois at Chicago College of Medicine in Chicago, IL. She participated in a FABM elective during her fourth year. She is new to the world of FABMs but is hoping to educate colleagues and patients on the empowering nature of FABMs to help women take control of their fertility.