A comparison of the fertile phase as determined by the Clearplan Easy Fertility Monitor™ and self-assessment of cervical mucus

Menstrual Cycle Parameters Are Not Significantly Different After COVID-19 Vaccination

Background: Some studies have suggested minor changes in the menstrual cycle after COVID-19 vaccination, but more detailed analyses of the menstrual cycle are needed to evaluate more specific changes in the menstrual cycle that are not affected by survey-based recall bias. Materials and Methods: Using a pretest-post-test quasi-experimental evaluation of menstrual cycle parameters before and after COVID-19 vaccination, we conducted an anonymous online survey of two groups of North American women who prospectively monitor their menstrual cycle parameters daily including bleeding patterns, urinary hormone levels using the ClearBlue Fertility Monitor, or cervical mucus observations. The primary outcome measures were cycle length, length of menses, menstrual volume, estimated day of ovulation (EDO), luteal phase length, and signs of ovulation. Perceived (subjective) menstrual cycle changes and stressors were also evaluated in this study as secondary outcome measures. Results: Of the 279 women who initiated the survey, 76 met the inclusion criteria and provided 588 cycles for analysis (227 pre-vaccine cycles, 145 vaccine cycles, 216 post-vaccine cycles). Although 22% of women subjectively identified changes in their menstrual cycle, there were no significant differences in menstrual cycle parameters (cycle length, length of menses, EOD, and luteal phase length) between the pre-vaccine, vaccine, and post-vaccine cycles. Conclusions: COVID-19 vaccines were not associated with significant changes in menstrual cycle parameters. Perceived changes by an individual woman must be compared with statistical changes to avoid confirmation bias.

Quantitative Versus Qualitative Estrogen and Luteinizing Hormone Testing for Personal Fertility Monitoring

BACKGROUND

A new fertility monitor is now available that provides quantitative measurement of urinary hormones, but clinical use requires validation against an established fertility monitor that provides only qualitative results.

RESEARCH DESIGN AND METHODS

Two fertility monitors were compared using daily first morning urine samples over 3 cycles of use in 21 women users with experience using a fertility monitor with the Marquette Method of Natural Family Planning.

RESULTS

Women were aged 33.4 ± 5.5 years and had menstrual cycles ranging between 23-41 days. The quantitative Mira Monitor estimates of ovulation were highly correlated with the qualitative ClearBlue Fertility Monitor (CBFM) estimates of ovulation. Both monitors provided an accurate estimate of the fertile window.

CONCLUSIONS

In this preliminary trial, the Mira monitor was shown to be effective at delineating the fertile window and ovulation. We demonstrated the feasibility of applying the Marquette Method algorithm with the use of the Mira monitor. Satisfaction differences between the two monitors did not reach statistical significance. We anticipate that quantitative fertility monitoring will give couples and health care providers new and unprecedented insights into the menstrual cycle and fertility.

Cervical mucus patterns and the fertile window in women without known subfertility: a pooled analysis of three cohorts

STUDY QUESTION

What is the normal range of cervical mucus patterns and number of days with high or moderate day-specific probability of pregnancy (if intercourse occurs on a specific day) based on cervical mucus secretion, in women without known subfertility, and how are these patterns related to parity and age?

SUMMARY ANSWER

The mean days of peak type (estrogenic) mucus per cycle was 6.4, the mean number of potentially fertile days was 12.1; parous versus nulliparous, and younger nulliparous (<30 years) versus older nulliparous women had more days of peak type mucus, and more potentially fertile days in each cycle.

WHAT IS KNOWN ALREADY

The rise in estrogen prior to ovulation supports the secretion of increasing quantity and estrogenic quality of cervical mucus, and the subsequent rise in progesterone after ovulation causes an abrupt decrease in mucus secretion. Cervical mucus secretion on each day correlates highly with the probability of pregnancy if intercourse occurs on that day, and overall cervical mucus quality for the cycle correlates with cycle fecundability. No prior studies have described parity and age jointly in relation to cervical mucus patterns.

STUDY DESIGN, SIZE, DURATION

This study is a secondary data analysis, combining data from three cohorts of women: 'Creighton Model MultiCenter Fecundability Study' (CMFS: retrospective cohort, 1990-1996), 'Time to Pregnancy in Normal Fertility' (TTP: randomized trial, 2003-2006), and 'Creighton Model Effectiveness, Intentions, and Behaviors Assessment' (CEIBA: prospective cohort, 2009-2013). We evaluated cervical mucus patterns and estimated fertile window in 2488 ovulatory cycles of 528 women, followed for up to 1 year.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were US or Canadian women age 18-40 years, not pregnant, and without any known subfertility. Women were trained to use a standardized protocol (the Creighton Model) for daily vulvar observation, description, and recording of cervical mucus. The mucus peak day (the last day of estrogenic quality mucus) was used as the estimated day of ovulation. We conducted dichotomous stratified analyses for cervical mucus patterns by age, parity, race, recent oral contraceptive use (within 60 days), partial breast feeding, alcohol, and smoking. Focusing on the clinical characteristics most correlated to cervical mucus patterns, linear mixed models were used to assess continuous cervical mucus parameters and generalized linear models using Poisson regression with robust variance were used to assess dichotomous outcomes, stratifying by women's parity and age, while adjusting for recent oral contraceptive use and breast feeding.

MAIN RESULTS AND THE ROLE OF CHANCE

The majority of women were <30 years of age (75.4%) (median 27; IQR 24-29), non-Hispanic white (88.1%), with high socioeconomic indicators, and nulliparous (70.8%). The mean (SD) days of estrogenic (peak type) mucus per cycle (a conservative indicator of the fertile window) was 6.4 (4.2) days (median 6; IQR 4-8). The mean (SD) number of any potentially fertile days (a broader clinical indicator of the fertile window) was 12.1 (5.4) days (median 11; IQR 9-14). Taking into account recent oral contraceptive use and breastfeeding, nulliparous women age ≥30 years compared to nulliparous women age <30 years had fewer mean days of peak type mucus per cycle (5.3 versus 6.4 days, P = 0.02), and fewer potentially fertile days (11.8 versus 13.9 days, P < 0.01). Compared to nulliparous women age <30 years, the likelihood of cycles with peak type mucus ≤2 days, potentially fertile days ≤9, and cervical mucus cycle score (for estrogenic quality of mucus) ≤5.0 were significantly higher among nulliparous women age ≥30 years, 1.90 (95% confidence interval (CI) 1.18, 3.06); 1.46 (95% CI 1.12, 1.91); and 1.45 (95% CI 1.03, 2.05), respectively. Between parous women, there was little difference in mucus parameters by age. Thresholds set a priori for within-woman variability of cervical mucus parameters by cycle were examined as follows: most minus fewest days of peak type mucus >3 days (exceeded by 72% of women), most minus fewest days of non-peak type mucus >4 days (exceeded by 54% of women), greatest minus least cervical mucus cycle score >4.0 (exceeded by 73% of women), and most minus fewest potentially fertile days >8 days (found in 50% of women). Race did not have any association with cervical mucus parameters. Recent oral contraceptive use was associated with reduced cervical mucus cycle score and partial breast feeding was associated with a higher number of days of mucus (both peak type and non-peak type), consistent with prior research. Among the women for whom data were available (CEIBA and TTP), alcohol and tobacco use had minimal impact on cervical mucus parameters.

LIMITATIONS, REASONS FOR CAUTION

We did not have data on some factors that may impact ovulation, hormone levels, and mucus secretion, such as physical activity and body mass index. We cannot exclude the possibility that some women had unknown subfertility or undiagnosed gynecologic disorders. Only 27 women were age 35 or older. Our study participants were geographically dispersed but relatively homogeneous with regard to race, ethnicity, income, and educational level, which may limit the generalizability of the findings.

WIDER IMPLICATIONS OF THE FINDINGS

Patterns of cervical mucus secretion observed by women are an indicator of fecundity and the fertile window that are consistent with the known associations of age and parity with fecundity. The number of potentially fertile days (12 days) is likely greater than commonly assumed, while the number of days of highly estrogenic mucus (and higher probability of pregnancy) correlates with prior identifications of the fertile window (6 days). There may be substantial variability in fecundability between cycles for the same woman. Future work can use cervical mucus secretion as an indicator of fecundity and should investigate the distribution of similar cycle parameters in women with various reproductive or gynecologic pathologies.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for the three cohorts analyzed was provided by the Robert Wood Johnson Foundation (CMFS), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (TTP), and the Office of Family Planning, Office of Population Affairs, Health and Human Services (CEIBA). The authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Compliance with daily, home-based collection of urinary biospecimens in a prospective, preconception cohort

Supplemental Digital Content is available in the text.

Background:

Exposures in the periconceptional environment may impact fertility and future health. Assessing time-varying exposures during the periconceptional window requires identifying approximate fertile windows around ovulation. In this prospective cohort study, we instructed women in daily cervical fluid observation and interpretation to identify incipient ovulation; they used this information to time daily urine collection for both partners. Timing and completeness of collection were compared to expert review.

Methods:

One hundred seventy couples planning pregnancy enrolled from community volunteers from 2011 to 2015; women were taught the Peak Day method to identify fertile windows. Both partners collected daily urine specimens from the first day of fertile-quality fluid (estimator of the beginning of fertile window). Men discontinued on the estimated day of ovulation/conception +2 days; women continued through the onset of next menses, or positive pregnancy test at estimated day of ovulation/conception +18 days. We compared dates from samples with participants’ fertility charts to determine proportion correctly collected. Also, expert reviewers judged on which days urine should have been collected, determining investigator-identified sampling days.

Results:

One hundred sixty-nine couples submitted 6,118 urine samples from 284 cycles. Reviewers and participants agreed in 87% of cycles for the date of the beginning of the fertile window ±3 days (65% exact-day agreement); agreement on ovulation date, ±3 days, was 93% (75% exact-day agreement). Five thousand three hundred twenty-nine female samples were expected based on investigator-identified sampling days, and 4,546 were collected, of which 82% were correctly collected on expected days. Fifty-nine percent of male samples were correctly collected relative to investigator-identified sampling days.

Conclusions:

Intensively-scheduled, biologically-triggered, at-home biospecimen collection can successfully be targeted to the periconceptional window and completed in a longitudinal cohort study.

Hormonal Contraception and the Informed Consent

Since the 1960s, hormonal contraceptives have become the most commonly used method of pregnancy prevention in the United States and the world. Oral contraceptives are used by a large percentage of women, including Christian women. There are known health risks to women demonstrated in research published since Pope Paul VI's prophetic encyclical Humanae vitae in 1968. These risks include venous thrombosis, cardiovascular risks, and an increased risk of cancer. These risks are medically recognized with continued scientific debate on the degree. The risks are significantly increased with preexisting conditions and in certain demographic groups. Discussing known and potential treatment risks is a standard that is both accepted by the medical community and is increasingly expected by patients. This discussion can be accomplished by the mechanism and principle of informed consent. Depending on the circumstances, abstinence or fertility awareness-based methods (FABMs) should be presented to patients. FABMs are licit, safe, and effective methods of pregnancy prevention. Informed consent is the most effective means of providing patients with pertinent information on the significant risks of contraception.

Summary

This article discusses the use of the informed consent to provide patients with information on the medical and ethical risks of oral contraceptives. FABMs and abstinence are presented as effective, safe, and licit preferences to oral contraceptives. Discussing known and potential treatment risks is accepted by the medical community and expected by patients (shared decision making). The authors discuss the historical context of Pope Paul VI's encyclical Humanae vitae in relationship to the development and rapid adoption of oral contraceptives.

Effectiveness of an Online Natural Family Planning Program for Breastfeeding Women

OBJECTIVE

To analyze the effectiveness of an online, nurse-managed natural family planning (NFP) program among breastfeeding women and subgroups of these women.

DESIGN

Longitudinal comparative cohort study.

SETTING

A university-based online NFP education program and menstrual cycle charting system.

PARTICIPANTS

Women (N = 816) with a mean age of 30.3 years (standard deviation = 4.5) who registered to use the online NFP system and indicated they were breastfeeding.

METHODS

Participants tracked their fertile times with an electronic hormone fertility monitor (EHFM), cervical mucus monitoring, or both. All unintended pregnancies were evaluated by professional nurses.

RESULTS

The correct use pregnancy rates were 3 per 100 users over 12 cycles of use, and typical rates were 14 per 100 at 12 cycles of use. At 12 cycles of use, total pregnancy rates were 16 per 100 for electronic hormone fertility monitor users (n = 380), 81 per 100 among mucus-only users (n = 45), and 14 per 100 for electronic hormone fertility monitor plus mucus users (n = 391).

CONCLUSION

Use of a nurse-managed online NFP program for women can be effective to help women avoid pregnancy while breastfeeding, especially with correct and consistent use.

Optimizing natural fertility: a committee opinion

This Committee Opinion provides practitioners with suggestions for optimizing the likelihood of achieving pregnancy in couples/individuals attempting conception who have no evidence of infertility. This document replaces the document of the same name previously published in 2013, Fertil Steril 2013;100(3):631-7.

The Home Observation of Periconceptional Exposures (HOPE) study, a prospective cohort: aims, design, recruitment and compliance

BACKGROUND

To examine transient environmental exposures and their relationship with human fecundity, exposure assessment should occur optimally at the time of conception in both members of the couple. We performed an observational, prospective cohort study with biomonitoring in both members of a heterosexual couple trying to conceive. Couples collected urine, saliva, and semen specimens for up to two menstrual cycles on days corresponding to the time windows of fertilization, implantation, and early pregnancy, identified based on the woman's observations of her cervical fluid.

RESULTS

Three hundred nine eligible couples were screened between 2011 and 2015, of which 183 enrolled. Eleven couples (6.0 %) withdrew or were lost to follow up. The most successful and cost effective recruiting strategies were word of mouth (40 % of participating couples), posters and flyers (37 %), and targeted Facebook advertising (13 %) with an overall investment of $37.35 spent on recruitment per couple. Both men and women collected ≥97.2 % of requested saliva samples, and men collected ≥89.9 % of requested semen samples. Within the periovulatory days (±3 days), there was at least one urine specimen collected by women in 97.1 % of cycles, and at least one by men in 91.7 % of cycles. Daily compliance with periovulatory urine specimens ranged from 66.5 to 92.4 % for women and from 55.7 to 75.0 % for men. Compliance was ≥88 % for questionnaire completion at specified time points.

CONCLUSIONS

Couples planning to conceive can be recruited successfully for periconceptional monitoring, and will comply with intensive study protocols involving home collection of biospecimens and questionnaire data.

Comparison of Abstinence and Coital Frequency Between 2 Natural Methods of Family Planning

INTRODUCTION

The length of periodic abstinence, due to overestimation of the fertile phase of the menstrual cycle, is often a cause for dissatisfaction, discontinuation, and user error with natural family planning (NFP) methods. The objective of this research was to compare the length of required abstinence (ie, estimated fertility) and coital frequency between 2 NFP methods.

METHODS

This was an analysis of data from a 12-month prospective comparison study in which participants were randomized into either an electronic hormonal fertility monitor (EHFM) group or a cervical mucus monitoring (CMM) group-both of which included a fertility algorithm as a double check for the beginning and end of the estimated fertile window. The number of days of estimated fertility and coitus was extracted from each menstrual cycle of data, and t tests were used to compare the means of these 2 variables between the 2 NFP methods.

RESULTS

The study involved 197 women (mean [SD] age 29.7 [5.4]) who used the EHFM to estimate the fertile window and 160 women (mean [SD] age 30.4 [5.3]) who used CMM to estimate the fertile window. They produced 1,669 menstrual cycles of data. After 12 months of use, the EHFM group had statistically fewer days of estimated fertility than the CMM group (mean [SD] days, 13.25 [2.79] vs 13.68 [2.99], respectively; t = 2.07; P = .039) and significantly more coitus (mean [SD] coital acts, 4.22 [3.16] vs 4.05 [2.88], respectively; t = 1.17; P = .026).

DISCUSSION

The use of the EHFM seems to provide more objectivity and confidence in self-estimating the fertile window and using nonfertile days for intercourse when avoiding pregnancy.

Physiological signs of ovulation and fertility readily observable by women

INTRODUCTION

Confirmation of ovulation can be difficult in clinical practice, as gold standard methods including serial transvaginal ultrasonography, serum luteinizing hormone (LH) measurements, or laparoscopic follicular observation are impractical. Numerous surrogate markers have been proposed and evaluated in relation to these gold standards that have more practical clinical applications.

PURPOSE

To review the evidence on physiological signs of ovulation timing and fertility in order to determine valid markers that can be easily identified by women.

METHODS

A literature review of primary resources in Ovid Medline was undertaken to identify studies examining physiological signs as they relate to gold standard assessment of ovulation. Studies examining the efficacy/effectiveness of different types of natural family planning were excluded.

RESULTS

The most commonly encountered physiological signs were urine LH, cervical mucus, and basal body temperature (BBT). Urine LH as assessed by home monitoring systems indicated ovulation 91 percent of the time during the 2 days of peak fertility on the monitor and 97 percent during the 2 peak days plus 1. Cervical mucus peak characteristics were identified 78 percent of the time ±1 day, and 91 percent of the time ±2 days of LH surge indicating ovulation. Further research supports the importance of cervical mucus in overall fertility, as conception rates were more closely related to mucus quality than to timing of intercourse related to ovulation. As a lone indicator of ovulation, BBT is at best a retrospective marker, and functions best in conjunction with other signs of ovulation. Additionally, salivary ferning, salivary and vaginal fluid electrical potential, finger-finger electrical potential, and differential skin temperature were postulated as possible indicators, but were not found to be temporally related to ovulation. The research on differential skin temperature is promising, but minimal thus far in number, and has not been evaluated as an adjunct to BBT as yet.

CONCLUSION

Home urinary LH monitors are becoming more widely available and less expensive giving women the potential to assess the ovulatory status of their cycle in real time. Cervical mucus observation is an effective and cost-efficient method, but requires some teaching to increase the confidence of users. In conjunction, LH monitors and cervical mucus can give the best indication of fertility and ovulation timing.

Cervical mucus monitoring prevalence and associated fecundability in women trying to conceive

OBJECTIVE

To assess the use of cervical mucus monitoring (CMM) in women trying to conceive and determine whether monitoring is associated with increased cycle-specific probability of conception (fecundability).

DESIGN

Time-to-pregnancy cohort study.

SETTING

Population-based cohort.

PATIENT(S)

Three hundred thirty-one women trying to conceive, ages 30 to 44 years, without known infertility.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

CMM prevalence and fecundability.

RESULT(S)

During the first cycle of the study, CMM was performed consistently (checked on >66% of pertinent cycle days) by 20 women (6%), inconsistently (34% to 66% of days) by 60 women (18%), infrequently (≤33% of days) by 73 women (22%), and not performed by 178 women (54%). Cycles in which CMM was consistently performed were statistically significantly more likely to result in conception after adjusting for age, race, previous pregnancy, body mass index, intercourse frequency, and urinary luteinizing hormone (LH) monitoring. Fecundability also increased with increasing consistency of CMM.

CONCLUSION(S)

Among women trying to conceive, CMM is uncommon, but our study suggests that CMM-a free, self-directed method to determine the fertile window-is associated with increased fecundability independent of intercourse frequency or use of urinary LH monitoring.

The Fertile Window and Biomarkers: A Review and Analysis of Normal Ovulation Cycles

El objetivo de este artículo es revisar los principales conceptos en la literatura acerca de la ventana de la fertilidad en pacientes con ciclos menstruales normales. El énfasis principal del artículo se ha dirigido al análisis de la teoría de Brown de la ovulación, revisar conceptos básicos de la ovulación, secreción y metabolismo de la hormona folículo estimulante, y al estudio clínico, ecográfico y bioquímicos del desarrollo folicular de la ventana de la fertilidad. Este artículo también repasa los biomarcadores clínicos y los diferentes metabolitos endocrinos que delimitan en la fase fértil del ciclo. Se revisan diferentes estudios en los cuales las valoraciones en suero y orina de los esteroides sexuales, han corroborado tener una correlación directa para enmarcar el período fértil. Actualmente tienen relevancia estos conocimientos en diferentes grupos de interés, sobre todo en mujeres con un alto nivel de motivación interesadas en el reconocimiento de su fertilidad, las cuales pueden beneficiarse mediante la aplicación de conocimientos técnicos actuales que detectan la ventana fértil. También estos conocimientos suelen cobrar importancia en aquellas personas que pertenecen a programas de regulación de la fertilidad (PRF), con intención de distanciar un embarazo, o de reconocer el periodo fértil del ciclo para conseguir un embarazo espontáneamente, o mediante programas de NaProTecnología. Otros grupos de interés, son aquellos en los cuales no se tiene experiencia en cursos de PRF, pero desean mejorar sus conocimientos en el reconocimiento de la fertilidad por medio de una breve entrevista, o por medio de cursos de orientación familiar.

[Informations for the infertile couple]

The aim of the first consultation related to infertility is supposed to be the optimization of all factors that can increase the chances of pregnancy: more frequent sexual intercourse during the fertility windows; lifestyle modifications (better diet, decreased exposure to tobacco or other toxics); older couples can enjoy the same advice but should be proposed a quicker medical support. Maternal preconceptional advice must be transmitted. A testicular cancer must always be excluded in infertile men, while the risk of hormone-dependent cancers in infertile women remains undetermined. With the results of this first consultation, couples will generally be proposed the best solution to achieve their parental project: ovarian stimulation assisted reproductive technology (IUI, IVF or ICSI) or adoption.

Efficacy and Efficiency in Natural Family Planning Services

Relatively few Catholic couples in the United States use modern methods of natural family planning (NFP). So too, few Catholic physicians and health professionals prescribe the use of NFP methods for their patients. Reasons for low use of NFP methods include their perceived low efficacy; the complexity of learning, using, and teaching these methods; and the prolonged (and often unnecessary) required abstinence. Newer and simplified methods of NFP have been developed by physicians and scientists that are less complex and use modern technologies of detecting fertility and communicating instructions. Catholic physicians and scientists need to continue to answer the call by the Holy Fathers (from Pius XII to Benedict XVI) to develop secure and scientifically sound methods of NFP.

Optimizing natural fertility

This Committee Opinion provides practitioners with suggestions for optimizing the likelihood of achieving pregnancy in couples attempting conception who have no evidence of infertility.

Bayesian selection of optimal rules for timing intercourse to conceive by using calendar and mucus

OBJECTIVE

To find optimal clinical rules that maximize the probability of conception while limiting the number of intercourse days required.

DESIGN

Multicenter prospective study. Women were followed prospectively while they kept daily records of menstrual bleeding, intercourse, and mucus symptom characteristics. In some cycles, women sought to conceive, whereas in other cycles, they sought to avoid pregnancy.

SETTING

Four centers providing services on fertility awareness.

PATIENT(S)

One hundred ninety-one healthy women using the Billings Ovulation Method. Women were invited to enroll by their instructors if they satisfied the entry criteria. We excluded cycles in which mucus was not recorded on a day with intercourse.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Clinically identified pregnancies. There were 161 clinically identified pregnancies in 2,536 menstrual cycles from 191 women.

RESULT(S)

Our approach relies on a statistical model that relates daily predictors, such as type of mucus symptom, to the day-specific probabilities of conception. By using Bayesian methods to search over a large set of possible clinical rules, focusing on rules based on calendar and mucus, we found that simple rules that are based on days within the midcycle calendar interval that also have the most fertile-type mucus symptom present have high utility.

CONCLUSION(S)

Couples can shorten their time to pregnancy efficiently by timing intercourse on days that the most fertile-type mucus symptom is observed at the vulva.

Efficacy of cervical mucus observations plus electronic hormonal fertility monitoring as a method of natural family planning

OBJECTIVE

To determine the effectiveness of an electronic hormonal fertility monitor plus cervical mucus monitoring to avoid pregnancy.

DESIGN

A 12-month prospective clinical efficacy trial.

SETTING AND PARTICIPANTS

One hundred ninety five (195) women (mean age 29.8 years) seeking to avoid pregnancy with a natural method at 5 clinical sites in 4 cities.

INTERVENTION

Each participant was taught to track fertility by self-observation of cervical mucus and an electronic monitor that measures urinary levels of estrone-3-glucuronide and luteinizing hormone.

MAIN OUTCOME MEASURES

Correct- and typical-use unintended pregnancy rates.

RESULTS

There were a total of 26 unintended pregnancies, 3 with correct use. With 1,795 months of use, the correct-use pregnancy rate was 2.1% per 12 months of use (i.e., 97.9% effective in avoiding pregnancy when rules of the method were always followed) and the imperfect-use pregnancy rate was 14.2% per 12 months of use (i.e., 85.8% effective in avoiding pregnancy when rules of the method were not always followed and all unintended pregnancies and months of use were included in the calculations).

CONCLUSIONS

Correct use of an electronic hormonal fertility monitor with cervical mucus observations can be as effective as other fertility awareness-based methods of natural family planning. Comparative studies are needed to confirm this conclusion.

Validation of a reference ELISA for estrone glucuronide using urine samples normalized by dilution to a constant rate of urine production

A direct enzyme linked immunosorbent assay (ELISA) system has been optimized as a reference method for the measurement of first statistically significant rises in estrone glucuronide excretion rates in human urine by analysing samples pre-diluted at the time of the collection by the women subjects to a constant urine production rate of 150 mL/h. Validation was achieved by correlation of the individual menstrual cycle profiles with the corresponding estrone glucuronide excretion rates determined by radioimmunoassay (RIA) on the same urine samples for a total of 221 samples from nine cycles. The pre-dilution procedure removed random variations due to fluctuations in the daily rate of urine excretion and minimized between sample matrix effects. When the ELISA data were correlated with the RIA data, Deming regression gave a slope of 1.20+/-0.03 and an intercept of 4.6+/-1.8 nmol/24h (r=0.944) and a random experimental error of 14.2 nmol/24h. The major difference in the measurements was a proportional error of 20%, which was present in either the ELISA or RIA methods or in both. Comparison of the standard normal variate transformation of the ELISA and RIA data gave hormonal profiles of the individual menstrual cycles (N=9) that overlapped almost perfectly. Statistically significant rises or falls in the magnitude of the excretion rate in one profile were mirrored faithfully in the other.

Using cervical mucus and other easily observed biomarkers to identify ovulation in prospective pregnancy trials

To help fulfil the objectives of prospective studies of pregnancy and human development, such as the National Children's Study, there is a need to pinpoint ovulation and conception in a cohort of women. This paper discusses the suitability of using natural and easily observed markers of ovulation for detection of the most likely day of ovulation and conception. Of the biomarkers supported by clinical data, the use of cervical mucus is emphasised as it appears most promising. A considerable amount of data suggests that observation of changes in vaginal discharge from cervical mucus can closely approximate the day of ovulation, is easy to learn and suitable for a large group of women. While this approach could also be cost-effective, a significant drawback may be the learning phase which may take 2-3 instructional sessions for women to fully identify recurring changes across the menstrual cycle.

Reduced Fertilization Rates in Older Men When Cervical Mucus Is Suboptimal

OBJECTIVE

Cervical mucus is vital in the regulation of sperm survival and transport through the reproductive tract. The goal of this study is to assess whether the lowered fertility for men in their late 30s and early 40s is related to the nature of cervical mucus on the day of intercourse.

METHODS

In a prospective study of 7 European family planning centers, 782 couples not using birth control recorded daily observations of intercourse and the nature of cervical mucus. Using data from 1,459 menstrual cycles, 342 ending in pregnancy, we estimate day-specific conception probabilities in relation to mucus and male and female age.

RESULTS

On days where cervical mucus was not evident, intercourse for men in their late 30s and early 40s was 50% less likely to result in a clinical pregnancy, adjusting for intercourse timing and female age. As secretions become more conducive to sperm transport, the effect of male age diminishes steadily from 21% on days with damp secretions, to 11% on days with thick mucus, to only 4% on days with most fertile-type mucus.

CONCLUSION

The effect of male age on fecundability can be minimized by timing intercourse on days with optimal secretions.

LEVEL OF EVIDENCE

II-2.

New low- and high-tech calendar methods of family planning

Calendar-based methods are not usually considered effective or useful methods of family planning among health professionals. However, new "high-" and "low"-tech calendar methods have been developed, which are easy to teach, to use, and may be useful in helping couples avoid pregnancy. The low-tech models are based on a fixed-day calendar system. The high-tech models are based on monitoring urinary metabolites of female reproductive hormones. Both systems have high levels of satisfaction. This article describes these new models of family planning and the research on their effectiveness. The author proposes a new algorithm for determining the fertile phase of the menstrual cycle for either achieving or avoiding pregnancy.