By: Sydney Flesher, DO
Editor’s Note: This week we feature the summary of a 12-month randomized controlled trial by Martins et al published in 2022 in Human Reproduction. [1] The research involved couples that were attempting to conceive either by monitoring the fertile window or using an every-other-day strategy, and assessed the impact of these strategies on the couple’s stress level. The authors found evidence that stress in these patients does not stem from “feeling pressured on the fertile period,” and that advice regarding timing of intercourse should be personalized for couples seeking to conceive. The authors stress the value of preconception care and fertility education to promote whole-person wellness in both women and men. To learn more about the impact of stress on fertility, join us for our FACTS virtual conference: Lifestyle for Healthy Cycles, on Friday, October 10th and Saturday October 11th.
Introduction
Recent research suggests time to conception can be shortened by targeting the fertile window. [2] Despite this data, some reproductive care guidelines recommend intercourse every other day, on the idea that this approach is less stressful for the couple trying to conceive. [2] Some studies suggest that rising fertility knowledge may increase anxiety levels in men and women wanting to conceive, [3] and that timed intercourse can be emotionally difficult and may have a negative impact on sexual functioning. [4]
“Some studies suggest that rising fertility knowledge may increase anxiety levels in men and women wanting to conceive, and that timed intercourse can be emotionally difficult and may have a negative impact on sexual functioning.”
Evidence is lacking to support guidelines on how to influence wellbeing and the psychosocial adjustment to optimize pregnancy. The study by Martins et al [1] summarized below adds new perspectives by asking, “Can knowledge of the fertile window and subsequent introduction of fertile window monitoring (FWM) versus every-other-day (EOD) strategies influence stress, anxiety, depression, and sexual functioning in individuals trying to conceive?”
Methodology
The researchers surveyed 450 individuals between October 2016 and November 2019, with 412 receiving the intervention and 288 being included in the final sample based on inclusion criteria. The following inclusion criteria were used: (1) being in a marital/cohabitation heterosexual relationship for 1 year, (2) not knowing of any condition that could prevent spontaneous pregnancy, (3) actively trying to conceive, (4) age 22 to 42, and (5) no previous children or pregnancies.
Participation was randomly allocated into FWM, EOD, or control group (CG) in a 1:1:1 randomized sequence. Intervention groups were shown one of two short animated videos with explanations of ovulation, fertile days, and sperm survival in the probability of conceiving, while the FWM group received information regarding cervical mucus and how it helps to detect ovulation.
The study assessed perceived stress, anxiety, depression, sexual functioning, and pregnancy with the primary endpoint being perceived stress. These assessments were made prior to intervention, and 6 weeks, 6 months, and 12 months after interventions.
Results
On average, study participants were 33 years old, married or cohabiting longer than 4 years, and trying to conceive for over 2 years. In this study, there were no significant interaction effects between groups of psychological and sexual wellbeing over time. While no significant differences were found between groups, there were significant time effects for stress, depression, and sexual functioning for participants in both intervention groups. Pregnancy rates were not statistically different between control and intervention groups.
Stress was found to be the lowest at 6 months post-intervention and highest at 6 weeks and 1 year, statistically significant changes from baseline. Depression also changed with time among all groups, with a significant increase post-intervention at 6 weeks and 1 year. Sexual function was also impacted in a time-wise fashion. For women, all aspects of sexual wellbeing declined over time, including satisfaction, desire, arousal, orgasm, and lubrication. Men also experienced significant effects in sexual function with intercourse satisfaction, erectile dysfunction, and orgasm being affected as time progressed.
“While no significant differences were found between groups, there were significant time effects for stress, depression, and sexual functioning for participants in both intervention groups … with a significant increase post-intervention at 6 weeks and 1 year.”
Discussion
This is the first study comparing recommendations in relation to psychological and sexual wellbeing with both FWM and EOD approaches on achieving pregnancy over one year. Although the sample size is relatively small, this research can guide professionals in addressing a couple’s stress and/or depression during fertility journeys.
In the fertility awareness-based method (FABM) lessons during the FACTS elective, medical students learn about the psychosocial impact of infertility and how stress can play into the ability to conceive. In the Psychosocial Aspects of Infertility module, we learned infertility itself is a stressor that causes distress in daily life and can negatively impact fertility, creating a vicious cycle of failure to conceive. In some studies, psychological interventions have led to increases in pregnancy rates, but only among couples not treated with artificial reproductive technologies (ART). [5]
When compared to couples trying to conceive without prior knowledge about the female reproductive cycle and signs and symptoms of ovulation to increase the probability of pregnancy, being educated on specific strategies to try to conceive does not induce stress, anxiety, depression or sexual dysfunction. This study [1] suggests that regardless of fertility education and strategy, attempting to conceive is stressful. Stress levels after one year were not different from baseline but were significantly lower at 6 month follow up. Having received education, participants may develop a high expectation in the ability to solve fertility issues; not achieving pregnancy within a year could add stress in the face of uncertainty.
This study found that sexual function decreases as time and attempts to conceive pass. Sex on demand may create pressure on couples’ dynamics and possibly influence relationship quality, stress, and depression. Informing patients of this finding could improve continuity for those trying to conceive, which is particularly important given the stated feeling of wasting time by attempting natural conception after seeking fertility specialists. [6]
“This study found that sexual function decreases as time and attempts to conceive pass. Sex on demand may create pressure on couples’ dynamics and possibly influence relationship quality, stress, and depression.”
This study had a few limitations. The sample may constitute a subset of individuals who are trying to conceive and are actively searching for information to improve their likelihood of pregnancy. The study is prone to bias, as 30% of participants met criteria for infertility. The sample size was small, which limits the ability to draw conclusions regarding sexual functioning and pregnancy rates. Additionally, there was no monitoring of recommended practices to which the participants were allocated.
Despite these limitations, it can be concluded from this study that teaching individuals about the fertile window and ovulation does not cause additional stress, anxiety or depression. While fertile window monitoring does not lead to additional stress, it also does not accommodate for better psychological adjustment. Thus, individuals trying to conceive should receive earlier psychological support, and medical professionals should discuss stress and sexual functioning with these couples and monitor for symptoms of depression.
References
[1] Martins, et al. (2022) Effects of trying to conceive using an every-other-day strategy versus fertile window monitoring on stress: a 12-month randomized controlled trial, Human Reproduction, 37 (12), 2845–2855. https://doi.org/10.1093/humrep/deac228
[2] Manders, et al. (2015). Timed intercourse for couples trying to conceive. The Cochrane database of systematic reviews, (3), CD011345. https://doi.org/10.1002/14651858.CD011345.pub2
[3] Maeda, et al. (2016). Effects of fertility education on knowledge, desires and anxiety among the reproductive-aged population: findings from a randomized controlled trial. Human reproduction, 31(9), 2051–2060. https://doi.org/10.1093/humrep/dew133
[4] Kopitzke, et al. (1991). Physical and emotional stress associated with components of the infertility investigation: perspectives of professionals and patients. Fertility and sterility, 55(6), 1137–1143. https://doi.org/10.1016/s0015-0282(16)54365-9
[5] Hämmerli, et al. (2009). The efficacy of psychological interventions for infertile patients: a meta-analysis examining mental health and pregnancy rate.” Human reproduction update,15(3), 279-95. https://doi.org/10.1093/humupd/dmp002
[6] van den Boogaard, et al. (2011). Patients’ and professionals’ barriers and facilitators of tailored expectant management in subfertile couples with a good prognosis of a natural conception. Human reproduction, 26(8), 2122–2128. https://doi.org/10.1093/humrep/der175
ABOUT THE AUTHOR
Sydney Flesher, DO
Sydney Flesher, DO completed this review while on the FACTS elective as a fourth-year medical student at Ohio University Heritage College of Osteopathic Medicine in Athens, OH. She completed her undergraduate education at Ohio University in Athens, OH. She is an incoming family medicine resident at Penn Medicine Lancaster General Hospital in Lancaster, PA, where FACTS executive director, Dr Duane, trained and first learned about natural family planning methods from Dr. Pearl Huang-Ramirez. Dr. Flesher enrolled in the FACTS elective to learn more about fertility awareness-based methods and ways to share them with patients so they may take charge of their reproductive health.
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