PCOS Awareness Month
FABMs Offer Key Insights into PCOS
By: Coco Thomas, DO
Director’s Note: During this last week of Polycystic Ovary Syndrome (PCOS) Awareness Month, we are featuring an interview with Anna,* a woman whose journey to fertility awareness began with a free period tracking app that eventually led her to modern methods of charting and a PCOS diagnosis. Dr. Coco Thomas, a former FACTS elective participant, interviewed Anna about how FABMs can guide a comprehensive diagnosis of common reproductive health concerns, such as irregular menstrual cycles. To learn more about how to address issues such as irregular cycles, as well as concerns related to free period tracking apps, join us for our upcoming virtual conference on October 18th and 19th to hear a diverse group of medical professionals tackle this problem with protocols from NeoFertility, FEMM, Creighton, and more.
Anna* held her 9-month-old baby in her arms, relaxed and joyful. Each day was another opportunity to be grateful for moments like these. There was once a time when Anna feared she would never experience this moment at all. Just a year prior, she was struggling with infertility and facing the possibility of assisted reproductive technology.
Anna’s fertility journey began five years ago. For some time, she tracked her menses using a free phone app. She noted very irregular periods just one to three times per year, which were heavy with cramping. However, these periods didn’t particularly bother her, and she never received any further workup for her irregular cycles. When she and her partner decided to start trying for pregnancy, her physician recommended weight loss and lifestyle changes to help, which Anna pursued.
Key insight: whole body wellness can help women on their fertility journey. [1]
To help her identify her fertile window, Anna also began using hormonal test strips, similar to those used with the Marquette Model. [2] Each morning, she would use urinary test strips to check for a steady rise in estradiol, followed by a luteinizing hormone surge which indicates ovulation. However, Anna had yet learned to chart with a formal fertility awareness-based method (FABM). Without guidance from an FABM-trained physician, Anna found the hormonal tracking challenging. She felt the test strips were sometimes inaccurate, and she had difficulty interpreting the results to determine her fertile window. Looking back, Anna understands that her irregular menses, paired with inconsistent urinary hormone measurements, may have indicated underlying health concerns.
Key insight: Urinary hormone tracking can be challenging, and additional support from a Marquette Model instructor or a knowledgeable physician can help improve understanding of fertility. [3]
As Anna continued her graduate degree studies, her fertility struggles continued. It was challenging to find a time to pursue pregnancy that aligned with her academic schedule and would still ensure she could graduate on time. Her first window of “opportunity” came and went as she diligently tracked various cycle biomarkers. Yet, her menses remained irregular, making it difficult to even predict her fertile window. The couple’s next opportunity would be the following year, and Anna planned to enter this interval as prepared as possible.
To explore her cycle irregularities, Anna underwent a hysterosalpingogram, a test designed to show the structure and patency of her uterus and fallopian tubes, which demonstrated cervical stenosis. She began seeing a fertility physician to pursue further investigation. This physician ultimately diagnosed Anna with polycystic ovarian syndrome (PCOS), explaining her years of irregular menses and difficulties conceiving. She was started on metformin with the intention of sensitizing her ovaries to insulin release.
Key insight: When struggling with tracking cycle biomarkers, consider the possibility of an underlying medical condition affecting the ability to track cycles, including hormonal imbalances. [5]
As she approached her second window when she hoped to conceive (and still graduate on time), Anna continued taking metformin. Importantly, she also started tracking her fertile window using cervical mucus observations, consistent with the Billings Ovulation Method. Unfortunately, her doctor was not able to provide information on these modern methods of charting, so she relied on online tutorials and pictures to learn about the different types of cervical mucus and implications for her cycle.
Key insight: Ready availability of reliable FABM educational materials and teachers is vital for couples to learn more about their fertility.
Next, her physician started Anna on Clomid to promote follicular development before using ultrasound to observe her ovaries to track follicle growth. After five days of taking Clomid, a follow-up ultrasound revealed one follicle was ready for release and another follicle was nearing this phase. Her physician ordered an HCG trigger to promote release of the first egg at this time. Anna and her partner were then able to time intercourse with this release.
Key insight: augmenting natural cycle tracking with fertility medications and ultrasound monitoring can help improve the success of timed intercourse. [6]
Anna knew this second window of opportunity would bring stressors, especially the feeling like “the clock was ticking.” She did her best to put that out of her mind, trying to enjoy this time in her fertility journey. She also navigated the well-intentioned advice from friends and family, including some unusual old wives’ tales. Her best friend proposed that Anna put her feet above her head after intercourse for 10 minutes; Anna politely said she would consider it.
After her perfectly timed HCG trigger and intercourse, Anna noticed changes in her cervical mucus: it was sticky and milky in color, with no dryness after her fertile window. After 2 weeks, she had a weakly positive pregnancy test. Her physician obtained blood progesterone levels at this time and found that Anna had a progesterone insufficiency. She was placed on supplemental progesterone pills until the end of her first trimester. Her physician suspects that Anna may have conceived previously but lost the pregnancy due to her progesterone insufficiency.
Key insight: Progesterone insufficiency can contribute to subfertility. Hormone testing after timed intercourse can be helpful in identifying this issue and starting treatment. [7]
Key insight: monitoring for changes in cervical mucus during and after the fertile window may indicate a change in fertility. [8]
During her first trimester, Anna experienced significant nausea, but her second and third trimesters were smooth sailing. Nine months later, she gave birth to a beautiful baby girl. In the next few years, Anna hopes to use FABMs again to get pregnant.
*Names have been changed to respect the privacy of the interviewee. All information is shared with permission.
References
[1] Kort, J. D., Winget, C., Kim, S. H., & Lathi, R. B. (2014). A retrospective cohort study to evaluate the impact of meaningful weight loss on fertility outcomes in an overweight population with infertility. Fertility and Sterility, 101(5), 1400–1403. https://doi.org/10.1016/j.fertnstert.2014.01.036
[2] Institute for Natural Family Planning Model. Institute for Natural Family Planning Model // College of Nursing // Marquette University. (n.d.). https://www.marquette.edu/nursing/institute-natural-family-planning/model.php
[3] Fehring, R. J., Schneider, M., Raviele, K., Rodriguez, D., & Pruszynski, J. (2013). Randomized comparison of two internet-supported fertility-awareness-based methods of family planning. Contraception, 88(1), 24–30. https://doi.org/10.1016/j.contraception.2012.10.010
[4] Arévalo, M., Jennings, V., & Sinai, I. (2002). Efficacy of a new method of family planning: The Standard Days Method. Contraception, 65(5), 333–338. https://doi.org/10.1016/s0010-7824(02)00288-3
[5] Cunha A, Póvoa AM. Infertility management in women with polycystic ovary syndrome: a review. Porto Biomed J. 2021 Jan 26;6(1):e116. doi: 10.1097/j.pbj.0000000000000116. PMID: 33532657; PMCID: PMC7846416.
[6] Kim, T., & Khan, Z. (2021). Clomiphene, metformin, or both for infertility with polycystic ovarian syndrome. 50 Studies Every Obstetrician-Gynecologist Should Know, 240–245. https://doi.org/10.1093/med/9780190947088.003.0044
[7] Young, S., & Lessey, B. (2010). Progesterone function in human endometrium: Clinical perspectives. Seminars in Reproductive Medicine, 28(01), 005–016. https://doi.org/10.1055/s-0029-1242988
[8] Fehring, R. J. (2002). Accuracy of the peak day of cervical mucus as a biological marker of fertility. Contraception, 66(4), 231–235. https://doi.org/10.1016/s0010-7824(02)00355-4
ABOUT THE AUTHOR
Coco Thomas, DO
Coco Thomas, DO is an emergency medicine resident at the University of Pittsburgh in Pittsburgh, PA. She completed her undergraduate education at the University of Scranton, Master of Business Administration degree at Saint Joseph’s University, and Doctor of Osteopathic Medicine at the Philadelphia College of Osteopathic Medicine. She is interested in leadership and healthcare administration. She enrolled in the FACTS elective during medical school to learn about the role of natural fertility awareness methods, and how she can better support women presenting with fertility-based problems.
