By: Hannah Smith
Editor’s Note: Below is a summary of expert opinion recommendations from the American Society for Reproductive Medicine (ASRM). While on the FACTS elective in fertility awareness for medical students, Hannah Smith summarized recommendations and updates from 2017 and 2022. Of note, fertility awareness-based methods (FABMs) made an appearance in the 2022 update. Also, recommendations were made regarding diet and lifestyle as well as avoidance of environmental toxins and endocrine disruptors, as that body of research continues to grow. To learn more about the impact of lifestyle on fertility and the female cycle, be sure to join us at our virtual conference on October 10-11, 2025!
Introduction
In 2017, the American Society for Reproductive Medicine updated a committee opinion discussing ways to optimize fertility in people attempting conception without a known history of infertility. In this committee opinion, infertility is defined as “the failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse or exposure to sperm.”[1] The recommendations made were based on a consensus of expert opinion; they are not uniform counseling guidelines or explicitly evidence-based recommendations. An update to the recommendations in this committee opinion was made in 2022 [4] and will be discussed in comparison.
In the general population, approximately 80% of couples will conceive in the first six months of attempting; a higher rate of conception is seen in the first three months with unprotected intercourse and sperm exposure.[1] The likelihood of pregnancy in female patients 35 or older is significantly lower, while fertility in male patients does not appear to be affected until after the age of 50. [1]
Intercourse Frequency
A recommendation is made to explain the basics of the reproductive process to patients. Specific recommendations regarding intercourse frequency can induce stress, according to studies. [1] One study from 2005 evaluated approximately 10,000 semen samples of male patients with normal semen quality and found that, with daily ejaculation, samples still had normal sperm concentration and motility; in patients with oligozoospermia, sperm concentrations and motility were even increased. [2]
In contrast, a meta-analysis published in May 2024 showed that a short ejaculatory abstinence period was associated with better overall sperm quality, but a longer ejaculatory abstinence period was associated with higher sperm concentrations. [3]
The 2017 and 2022 committee opinions recommended advising patients that reproductive efficiency increases with intercourse frequency at a peak of every 1-2 days, but the frequency that works best for the couple is the optimal frequency during the fertile window. [1] [4]
“Specific recommendations regarding intercourse frequency can induce stress, … (so) the frequency that works best for the couple is the optimal frequency during the fertile window.”
Fertile Window
The fertile window is a six-day window ending on the day of ovulation. [1] This window of maximum fertility can be identified by patients via cervical mucus monitoring, tracking of intermenstrual intervals, and use of ovulation predictor kits. [1] The 2017 and 2022 committee opinions advised that pregnancy is most likely with intercourse occurring at any point on the 2 days before and the day of ovulation. [1] [4]
Monitoring Ovulation
A notable change from the 2017 committee opinion was a re-labeling of this section to the broader title of “Fertility Awareness Methods” in 2022. [4] In 2017, the committee advised that monitoring cervical mucus can be just as accurate for women with normal menstrual cycles as would be using basal body temperature or urinary hormones when having infrequent intercourse intentionally or unintentionally across the fertile interval. [1] One benefit of cervical mucus monitoring is that it is generally more cost effective than methods that require thermometers and urinary hormone kits.
In 2022, the committee advised that using fertility-tracking methods has been found to increase the probability of achieving pregnancy in an ovulatory cycle when used for the purposes of timing intercourse. [4] There is also a brief description of various methods, including cervical mucus monitoring, basal body temperature, urinary hormones, and the calendar method. [4] Overall, the recommendation was made to advise patients that fertility awareness-based methods (FABMs) should be used to inform timing of frequent intercourse rather than replace the approach to frequent intercourse across the fertile window. [4] Key findings relating to the biomarkers tracked by different FABMs are summarized below.
“The committee advised that using fertility-tracking methods has been found to increase the probability of achieving pregnancy in an ovulatory cycle when used for the purposes of timing intercourse.”
Cervical Mucus Monitoring
One study advised that intercourse on the day of peak cervical mucus (described as slippery and clear) had the highest probability of pregnancy, and chances were much lower on the day before and the day after this peak. [4]
Basal Body Temperature
When used with cervical mucus monitoring, changes in cervical mucus were closely correlated with the basal body temperature and were found to be more accurate than just use of a menstrual calendar. [4]
Urinary Hormone Detection
Many studies have validated the use of these urinary hormone monitors to detect the LH surge, and a randomized-controlled trial showed decreased time-to-pregnancy. However, there is still a 7% false positive rate, and patients should be advised that this LH surge detection suggests ovulation will occur in the 2 days following the LH surge. [4]
Calendar Method
No phone apps have been found to add significant clinical utility. [4] The major pitfall of this method is the assumption that each person’s cycle is consistent every time.
Coital Practices
Similar evidence was provided in both the 2017 and 2022 committee opinions to demonstrate that coital position does not affect the fecundity of the female partner, that there is no relationship between orgasm and fertility, and there is no relationship between specific coital practices and infant sex. [1] [4]
However, there was a change in recommendations of lubricants during intercourse. In 2022, they referenced studies that demonstrated no effect of any type of lubricant on cycle fecundability for couples attempting conception. [4] This is a change from the 2017 committee opinion, which recommended that couples use only mineral, canola, or hydroxyethylcellulose-based lubricants when needed.
Diet and Lifestyle
Recommendations for diet and lifestyle modifications were based on efforts to improve overall health with no strong evidence to suggest significant effects on improving natural fertility. [1] [4] There is demonstrable evidence that smoking negatively affects fertility and should be avoided for those wishing to optimize natural fertility. [1]
Regarding alcohol use, there was no evidence to suggest moderate alcohol use had adverse effects on natural fertility, but heavy alcohol use should be avoided. [1] [4] Marijuana and other drug use is discouraged in couples attempting conception due to potential adverse effects on the developing fetus rather than any known effects on fertility. [1] [4] Moderate caffeine consumption (1-2 cups of coffee/day or equivalent) was not found to have any apparent adverse effects on fertility. [1] [4]
“There was no evidence to suggest moderate alcohol use had adverse effects on natural fertility, but heavy alcohol use should be avoided.”
In 2017, there was limited data to inform recommendations on environmental exposures, but this field of study has rapidly grown since then. In 2022, recommendations were made for reproductive-aged individuals to limit exposure to “endocrine-disrupting chemicals” found in daily items. [4] Lower fertility rates have also been found in individuals with greater exposure to ambient air pollution, especially those living close to major roadways. [4]
Conclusion
Overall, there did not appear to be significant changes in recommendations to patients wishing to optimize natural fertility. The updated opinion did present new information on the effect of environmental toxins and pollutants on fertility. It also discussed fertility awareness-based methods and their role in tracking fertility and the fertile window. This committee opinion serves to provide recommendations medical professionals can use to educate patients wishing to conceive.
Editor’s Note: To learn more about the potential impact of environmental exposures on fertility, follow the links to articles summarized by medical students on the FACTS elective:
- A Brief Review of Environmental Contaminant Effects on Female Fertility
- Environmental Factors and Male Fertility: A Review
References
[1] Pfeifer, S., Butts, S., Fossum, G., Gracia, C., La Barbera, A., Mersereau, J., Odem, R., Paulson, R., Penzias, A., Pisarska, M., Rebar, R., Reindollar, R., Rosen, M., Sandlow, J., & Vernon, M. (2017). Optimizing Natural Fertility: A committee opinion. Fertility and Sterility, 107(1), 52–58. https://doi.org/10.1016/j.fertnstert.2016.09.029
[2] Levitas, E., Lunenfeld, E., Weiss, N., Friger, M., Har-Vardi, I., Koifman, A., & Potashnik, G. (2005). Relationship between the duration of sexual abstinence and semen quality: Analysis of 9,489 semen samples. Fertility and Sterility, 83(6), 1680–1686. https://doi.org/10.1016/j.fertnstert.2004.12.045
[3] Lo Giudice A, Asmundo MG, Cimino S, Cocci A, Falcone M, Capece M, Abdelhameed AS, Capogrosso P, Morgado A, Tsampoukas G, Manfredi C, Russo GI. Effects of long and short ejaculatory abstinence on sperm parameters: a meta-analysis of randomized-controlled trials. Front Endocrinol (Lausanne). 2024 May 17;15:1373426. doi: 10.3389/fendo.2024.1373426. PMID: 38828413; PMCID: PMC11140051.
[4] Optimizing Natural Fertility: A Committee opinion. (2022). Fertility and Sterility, 117(1), 53–63. https://doi.org/10.1016/j.fertnstert.2021.10.007
ABOUT THE AUTHOR
Hannah Smith
Hannah Smith is a fourth-year medical student at Lincoln Memorial University DeBusk College of Osteopathic Medicine in Harrogate, TN. She completed her undergraduate education at the University of North Carolina at Chapel Hill in Chapel Hill, NC. She plans to complete a transitional year residency program before pursuing OB/GYN residency. She is passionate about reproductive justice and complex family planning education. She enrolled in the FACTS elective to gain a better understanding of natural family planning methods and ways to share them with patients so they feel more empowered over their health and reproductive decisions.
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