By Catherine A. Jimenez
April 3, 2019
Editor’s Note: Next week is National Infertility Awareness Week, so we are devoting the last two weeks of April to this common source of anguish and frustration for women and couples. This is a synopsis of a research article[i] reviewed by a 4th year medical student as part of an elective on fertility awareness with Dr. Marguerite Duane at Georgetown University College of Medicine. The 2018 article by Bouchard et al was published in Frontiers in Medicine and is titled “Achieving Pregnancy Using Primary Care Interventions to Identify the Fertile Window.”
Infertility is defined as a couple’s inability to achieve pregnancy after attempting random acts of intercourse for at least 12 months. This definition is based upon a study showing 85% of the general population will achieve pregnancy in this manner within one year. Many patients struggling with infertility often seek care and advice first from their family physicians. After one year of trying to achieve pregnancy with random intercourse and no other interventions, many family physicians refer patients to a reproductive endocrinologist for artificial or assistive reproductive technologies (ARTs). This approach can be expensive, time-consuming, and emotionally draining, all of which add stress to a couple’s relationship during an already difficult time. Furthermore, ARTs do not necessarily focus on diagnosing underlying causes of infertility.
The research article discussed here evaluated whether timing intercourse during a woman’s fertile window for up to 24 reproductive cycles, or approximately 2 years, could help couples achieve pregnancy by optimizing their natural fertility and/or identifying an underlying medical cause of infertility.
This study is a prospective cohort effectiveness study conducted over 24 menstrual cycles. The number of participants totaled 256 North American women aged 20-43 (mean 29.2 years) seeking to achieve pregnancy. Women were not asked about a prior history of infertility nor were they excluded if they had proven fertility. Since this was a cohort study, there was no control group of women attempting random and frequent intercourse for one year to compare results.
Participants used an online fertility tracking system to record one or more biological fertility indicators. Women recorded their fertility by (1) using electronic urinary hormonal monitoring (with the Marquette Model ClearBlue Easy Fertility Monitor), (2) noting cervical mucus changes and using the fertility monitor, or by (3) observing cervical mucus changes alone. The fertile window was calculated using a built-in algorithm through the online tracking system based on participants’ recordings. Results were analyzed with respect to nulliparous women versus women who had a previous live birth.
Of the 256 participants, 150 achieved pregnancy. The cumulative pregnancy rate was 78 per 100 women at 12 cycles of use, and by 24 cycles of use, the pregnancy rate was 86 per 100 women. For women using the fertility monitor, 83% conceived by 12 cycles and 100% achieved pregnancy by 24 cycles of use. For women using cervical mucus only, 72% achieved pregnancy within 12 cycles. For women using the fertility monitor and cervical mucus, 75% conceived by 12 cycles and 79% achieved pregnancy within 24 cycles of use.
Overall pregnancy rates across all three subgroups of women were 78% by 12 months and 86% within 24 months. Nulliparous and parous women had similar pregnancy rates overall. Interestingly, intercourse on “High” and “Peak” days of fertility as determined by the fertility monitor resulted in a pregnancy rate of 85% over 12 months of use, and intercourse on “Low” days of fertility resulted in only 1 pregnancy per 100 women over 12 months.
The likelihood of achieving pregnancy in the study population increased significantly with higher number of school years (higher formal education level) and already having living children (proven fertility). Time to achieve pregnancy was negatively correlated with the likelihood of achieving pregnancy. In other words, if a couple spent a greater amount of time trying to achieve, they were 10% less likely to get pregnant. This statistic may signal underlying medical causes of infertility that cannot be remedied by timing intercourse to the fertile window and may require medical or surgical intervention.
Applications in Patient Care
This study showed the benefit in attempting to conceive naturally using focused intercourse in the fertile window as determined by an electronic fertility monitor for up to 24 reproductive cycles. Family physicians can recommend the fertility monitor to help patients optimize their chances of conception using natural methods instead of relying on expectant management for 12 months prior to initiating an infertility workup. Use of the fertility monitor and online tracking of the woman’s reproductive cycle can facilitate diagnosis and treatment of medical causes of infertility. By correcting underlying causes of infertility, women may conceive naturally in a less stressful and much more cost-effective manner.
A future study would be helpful to compare couples of similar fertility at baseline using different interventions, such as random frequent intercourse, observing cervical mucus changes to focus intercourse during the fertile window, and using the fertility monitor to focus intercourse on days of high and peak fertility to determine if focused intercourse is better than random and frequent intercourse.
Editor’s Note: Although the rationale behind this study seems intuitive, the need for such research highlights the current state of medical education as it relates to fertility awareness. In the last five decades, the treatment of infertility has shifted to high-tech solutions that disregard the simplicity and usefulness of considering root causes of infertility first. An understanding of the female cycle and the three essential components necessary for conception (an egg, sperm, and healthy cervical mucus) can save couples not only thousands of dollars but also the emotional rollercoaster of pursuing artificial reproductive technologies without an adequate assessment of potential causes. The chart of the female cycle paints a picture of physical signs caused by hormones and tells a story about reproductive health. At FACTS, we are doing all we can to ensure all medical students as well as physicians in training and in practice learn about this practical and effective tool to educate women about their bodies and reproductive health and to assist couples as they plan their families.
Author Bio: Catherine A. Jimenez is a 4th year medical student at University of Illinois College of Medicine and plans to specialize in family medicine. While in medical school, she became a FACTS student ambassador. Reflecting on the FACTS online elective, she noted the course “has given me many useful tools for my future patients and a greater understanding of the complexities of fertility and pregnancy. I plan to practice women and children’s health within my scope as a family medicine physician. This course has greatly enhanced the care I can provide.”
[i] Bouchard TP, Fehring RJ, Schneider MM. Achieving Pregnancy Using Primary Care Interventions to Identify the Fertile Window. Frontiers in Medicine. 2018;4. doi:10.3389/fmed.2017.00250.
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Cycle Power Summit will host an online conference May 2-5, 2019 to empower women to manage their health and fertility. Enjoy more than 30 sessions with educators, researchers, leaders, thinkers, and medical professionals, including our very own FACTS experts, Marguerite Duane, MD and Alison Contreras, PhD. Earn CME and CNE credit hours.
On Thursday evenings in May, BOMA-USA will host a series of seminars, From Menarche to Menopause, for medical professionals and students to learn about the health advantages of monitoring fertility with Billings. The sessions are approved for CE credit hours for physicians and nurses. Register and find out more HERE!