Hormone Testing for Personal Fertility Monitoring: A Review of Research
By: Alexandra Davidson
Director’s Note: The evidence supporting fertility awareness-based methods (FABMs) has expanded to include methods that track biomarkers such as cervical mucus and urinary hormone monitoring. Alexandra Davidson, a former FACTS elective participant, summarized the 2021 study by Bouchard et al titled, “Quantitative versus qualitative estrogen and luteinizing hormone testing for personal fertility monitoring.” [1] The authors compared two urinary hormone monitors that can be utilized with the Marquette Model: the ClearBlue Fertility Monitor (CBFM) and the Mira Monitor. Dr. Bouchard, the lead author, has also served as a speaker at FACTS conferences, and we are delighted to make those presentations available via our online, self-paced CME course. Also, join us in Austin, TX on April 19th and 20th for our annual in-person conference. Register by THIS FRIDAY, March 15th and save up to $50!
Introduction
Fertility awareness-based methods can be more challenging to employ to avoid pregnancy in special circumstances such as breastfeeding, perimenopause, and polycystic ovary syndrome (PCOS). The Marquette Model utilizes an algorithm that incorporates data from daily urine hormone levels analyzed by the ClearBlue Fertility Monitor (CBFM). This is often the method of choice for women undergoing transitions in fertility, such as postpartum or perimenopause, given the higher objectivity and efficacy of the Marquette Model compared to other methods in these special circumstances. [1][2][3] With the Mira Monitor’s quantitative measurement of urinary hormone levels, greater insight into daily fertility with the Marquette Model is on the horizon. With more research and detailed data, users may gain more confidence in their ability to accurately detect their fertile window. This is especially promising in the context of using the Marquette Model for women with PCOS.
“With more research and detailed data, users may gain more confidence in their ability to accurately detect their fertile window.”
Methodology
A group of 21 women with normal fertility and experience with the Marquette Model tested the same sample of morning urine with both the CBFM and the Mira Monitor. The participants did this once daily for three cycles, and results of the two monitors were compared. [1]
Results
Both monitors provided estimates of ovulation and the fertile window and were found to be accurate and highly correlated. For both the CBFM and Mira monitors, there was a statistically significant shift in the proportion of high days and an increase in estradiol levels starting 5 days before ovulation. The average estradiol level on the last low day was 158.3 ng/mL, increasing significantly to 199.0 ng/mL on the first high day of fertility. Additionally, the LH peak days identified by the CBFM and Mira monitor were highly correlated. No significant difference in user satisfaction was found with one monitor versus the other.
“The average estradiol level on the last low day was 158.3 ng/mL, increasing significantly to 199.0 ng/mL on the first high day of fertility.”
Discussion
While the Marquette Model is highly effective, there is still room to increase its efficacy, [1] particularly for users who need to avoid pregnancy for serious reasons. This concern is common in the postpartum and perimenopause transitions due to increased health risks associated with pregnancy in these contexts. During these phases of a woman’s reproductive years, it can also be more challenging to employ other FABMs. Beyond efficacy, the quantitative data generated through this new technology could benefit users with PCOS who are attempting to avoid pregnancy. One potential benefit is patients’ ability to see their hormone fluctuations on top of their chronically elevated baseline estrogen levels. Nevertheless, research is needed in users with PCOS to demonstrate specific advantages in this setting.
Bouchard et al [1] found that the CBFM missed peaks in approximately 5% of cycles in which there was an obvious peak with the Mira Monitor. This newer monitor has the potential to streamline the testing process. Users of the Marquette Model can add Wondfo LH (luteinizing hormone) test strips to decrease the incidence of missed peaks that sometimes occur with the CBFM alone. Additionally, women attempting to avoid pregnancy for serious reasons may add Proov strips, which test for progesterone metabolites in urine, to help confirm ovulation and the close of the fertile window. The Mira Monitor has the capability to test estrogen, progesterone, LH, and follicle stimulating hormone (FSH). This could eliminate the need for multiple brands of test strips, which can increase the mental burden of the method.
Statistically speaking, a potential challenge of using a quantitative monitor in place of a qualitative device is that data interpretation will become more complicated, as it will not remain categorical over time. While more data and personalization would seemingly improve efficacy of a method, this has not been shown to be the case. FABM efficacy is bound by two competing factors: personalization and complexity. Methods that are more detailed and personalized can be used more readily in special circumstances that may result in unexpected days of fertility. However, higher complexity makes it more challenging to achieve perfect use, which significantly impacts efficacy relative to typical use for most FABMs. To combat this potential challenge, the authors suggest implementing a protocol similar to that utilized in the TwoDay Method, but adapting it to refer to an estrogen threshold rather than the presence or absence of secretions. This could help account for the fluctuating levels of estrogen that are common postpartum and in perimenopausal women. An additional challenge is that the Mira Monitor, test wands, and instruction are costly, and it may be difficult or impossible for many patients to obtain insurance compensation.
“Methods that are more detailed and personalized can be used more readily in special circumstances that may result in unexpected days of fertility. However, higher complexity makes it more challenging to achieve perfect use, which significantly impacts efficacy relative to typical use for most FABMs.”
The generalizability of this study is limited due to its small size, duration, and homogeneous study population (all white, married, college-educated women). Still, the preliminary data provide promising new opportunities for research. This new technology has the potential to increase the efficacy of the Marquette Model, especially for users in special circumstances such as postpartum, perimenopause or PCOS. However, data proving efficacy of the Mira Monitor in place of the CBFM have not been published, so users must bear this in mind when considering this option to avoid pregnancy.
Other exciting doors this technology may open is the potential to further qualify the parameters of the Lactational Amenorrhea Method (LAM) in an ethical manner. LAM is an ideal FABM because it is extremely simple: if users are exclusively breastfeeding, amenorrheic, and less than six months postpartum, they may consider themselves infertile with 98% efficacy. However, many women in the United States struggle to meet the criterion of exclusive breastfeeding (at the breast) due to the need to pump to return to work, or even if only rarely need to leave their infant for an afternoon or evening. The effect on the efficacy of LAM of these brief lapses in nursing from the breast is unknown. Yet, hormone data collected from women who are nearly-exclusively breastfeeding at the breast could provide more detailed conditions for these women to continue using LAM.
References
[1] Bouchard TP, Fehring RJ, Mu Q. Quantitative versus qualitative estrogen and luteinizing hormone testing for personal fertility monitoring. Expert Rev Mol Diagn. 2021;21(12):1349-1360. doi:10.1080/14737159.2021.2000393.
[2] Fehring RJ, Schneider M, Raviele K, Rodriguez D, Pruszynski J. Randomized comparison of two Internet-supported fertility-awareness-based methods of family planning. Contraception. 2013;88(1):24-30. doi:10.1016/j.contraception.2012.10.010.
[3] Schneider MM, Fehring RJ, Bouchard TP. Effectiveness of a Postpartum Breastfeeding Protocol for Avoiding Pregnancy. Linacre Q. 2023;90(2):182-193. doi:10.1177/00243639231167235.
ABOUT THE AUTHOR
Alexandra Davidson
Alexandra Davidson is a fourth-year medical student at the University of Kansas School of Medicine in Salina, KS. She completed her undergraduate education at Kansas State University in Manhattan, KS. She plans to do her residency in obstetrics and gynecology and is interested in breastfeeding medicine, sexual education, and all applications of FABMs. She enrolled in the FACTS elective to build upon the self-directed learning she pursued on the topic and gain new knowledge that will help her offer holistic reproductive healthcare to her patients.
