Time to Pregnancy for Women Using a Fertility Awareness Based Mobile Application to Plan a Pregnancy

Young adult's views on using a poster to learn about fertility: redesigning the fertility education poster

Fertility awareness should be taught to everyone. The International Reproductive Health Education Collaboration (IRHEC) designed a fertility poster in 2019 but did not have a specific target group in mind. Studies have been conducted in Denmark and Sweden to determine how the poster can be redesigned. In this study, we carried out focus groups with young adults in the UK to ask their views of the poster, with the aim of redesigning it. Six focus groups were undertaken with twenty seven, 18-25 year olds. Five questions were asked: 1. What are your thoughts, feelings, and reactions to the poster? 2. Did you learn anything from the poster? 3. How has reading the poster impacted your opinions or thoughts about having children? 4. What are your opinions about using a poster format to inform and start reflections regarding family building? 5. Reading through each point are there any changes to be made? Content analysis was performed. Themes identified revealed the information on the poster gave the participants some anxiety and apprehension, especially regarding the effect of age on fertility, perceptions of IVF, and gaps in knowledge. The fertility education poster is a good resource for education, but other resources should be developed.

Factors influencing natural fecundity in fertile couples: a survey of puerperae and their partners

RESEARCH QUESTION

What is the fecundity rate among fertile couples, and which factors influence it?

DESIGN

Retrospective study of all puerperae attending Cruces University Hospital Human Reproduction Unit over 9 months. An anonymous questionnaire was circulated to all patients, and 2510 valid completed questionnaires were collected. The main inclusion criterion was natural conception resulting in delivery. Pregnancies resulting from ART and contraceptive method failure were excluded. Investigated parameters were time to pregnancy, age and smoking (in women and men), previous pregnancies and intercourse frequency. A mathematical formula was developed to predict the per-month fecundity rate (PMFR).

RESULTS

The cumulative fecundity rate was 29.08%, 54.26%, 68.61%, 89.88%, 96.95% and 98.63% (at 1, 3, 6, 12, 24 and 36 months); between 12 and 36 months, the average PMFR ranged from 8.53-7.48%. Only 1.68% of pregnancies occurred between 24 and 36 months, and only 1.37% thereafter. The best fecundity markers were obtained in the group who had sexual intercourse seven to eight times a week. Women and men younger than 25 years had lower fecundity markers than those aged between 25 and 40 years.

CONCLUSIONS

Fertile couples have a non-negligible per-month fecundity rate between 12 and 36 months, which should be considered when planning fertility studies. The lower fecundity rate observed in women and men aged younger than 25 years deserves more study. Coital frequencies of more than two or three times a week did not affect the fecundity rate and was better with frequencies of seven to eight times a week.

Experiences of users of period tracking apps: which app, frequency of use, data input and output and attitudes

RESEARCH QUESTION

What are the experiences of users of period tracking apps in relation to which apps they use, their frequency of use, the type of data and their attitudes to period tracking apps?

DESIGN

This was an observational mixed-methods study using an online survey designed using Qualtrics XM. The survey included 50 open-ended and multiple choice questions, but only specific questions were analysed in this study. The survey was promoted via social media for 22 days between 30 June and 21 July 2021.

RESULTS

Of the 375 total participants, 326 responses were complete and included in analysis. In the results section further down, this is explained as 330 complete responses, with 4 additional responses excluded due to data inconsistencies. The participants' age range was 14-54 years, with a mean of 26.0 (±7.81) years. Most participants (61.9%) had been using a period tracking app for 2 years or longer. Of these 85.6% entered more data when on their period, 31% at a frequency of once a day. There were approximately equivalent proportions of participants who felt that entering data into their app was either 'part of their normal routine' (43.3%) or 'not a priority' (38.0%). Thematic analysis of the participants' experiences of using period-tracking apps revealed five main themes: symptom tracking and understanding general health; concerns with period start date predictions; the problems with fertility tracking; concerns about cost; and concerns about data privacy.

CONCLUSIONS

The infrequency of data inputting and the wide range of symptoms tracked reflects the differing needs of participants from their period-tracking apps. This highlights the need for increased education and research into understanding the realities of variations in using apps.

Analyzing User Reviews of the First Digital Contraceptive: Mixed Methods Study

BACKGROUND

People in Western countries are increasingly rejecting hormone-based birth control and expressing a preference for hormone-free methods. Digital contraceptives have emerged as nonhormonal medical devices that make use of self-tracked data and algorithms to find a user's fertile window. However, there is little knowledge about how people experience this seemingly new form of contraception, whose failure may result in unwanted pregnancies, high health risks, and life-changing consequences. As digital contraception becomes more widely adopted, examining its user experience is crucial to inform the design of technologies that not only are medically effective but also meet users' preferences and needs.

OBJECTIVE

We examined the user experience offered by Natural Cycles-the first digital contraceptive-through an analysis of app reviews written by its users worldwide.

METHODS

We conducted a mixed methods analysis of 3265 publicly available reviews written in English by users of Natural Cycles on the Google Play Store. We combined computational and human techniques, namely, topic modeling and reflexive thematic analysis.

RESULTS

For some users of digital contraception, the hormone-free aspect of the experience can be more salient than its digital aspect. Cultivating self-knowledge through the use of the technology can, in turn, feel empowering. Users also pointed to an algorithmic component that allows for increased accuracy over time as long as user diligence is applied. The interactivity of the digital contraceptive supports mutual learning and is experienced as agential and rewarding. Finally, a digital contraceptive can facilitate sharing the burden of contraceptive practices or highlight single-sided responsibilities while creating points of friction in the required daily routines.

CONCLUSIONS

Digital contraception is experienced by users as a tamed natural approach-a natural method contained and regulated by science and technology. This means that users can experience a method based on a digital product as "natural," which positions digital contraceptives as a suitable option for people looking for evidence-based nonhormonal contraceptive methods. We point to interactivity as core to the user experience and highlight that a digital contraceptive might allow for collaboration between partners around contraceptive practices and responsibilities. We note that the user diligence required for the digital contraceptive to provide accurate and frequent data is sometimes not enough. Future research could look at designing (and redesigning) digital contraceptives with primary users and intimate partners, enhancing the experience of tamed naturalness; exploring how trust fluctuates among involved actors and in interactions with the technology; and, ultimately, designing more inclusive approaches to digital contraception.

Factors Used by Mobile Applications to Predict Female Fertility Status and Their Reported Effectiveness: A Scoping Review

Family planning, whether for pregnancy prevention or conception, is of pivotal importance to women of reproductive age. As hormonally driven methods, such as oral contraceptive pills, are widely used but have numerous side effects, women often seek alternative non-hormonal, non-invasive options, including fertility-tracking mobile applications (apps). However, the effectiveness of these apps as a method of contraception and conception planning has not been extensively vetted. The goal of this scoping review is to identify the various factors used by apps marketed as a method of contraception and/or family planning to predict a woman's fertility status, as well as their documented effectiveness. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines, a literature search was performed in CINAHL, MEDLINE, and Alt HealthWatch databases for articles published between October 1, 2017, and October 4, 2022. Quality assessment of eligible full-text articles was conducted using the Joanna Briggs Institute critical appraisal tools. A total of 629 articles were screened. Overall, 596 articles were excluded and the remaining 33 articles underwent full-text review. Seven articles were included in the final analysis, yielding data on the following five apps: Natural Cycles, Ava Fertility, Clearblue Connected, Ovia Fertility, and Dynamic Optimal Timing (DOT). Data supporting the effectiveness of these apps is limited. All apps provided predictions on fertility status throughout a woman's menstrual cycle using proprietary algorithms, biometric data, and self-reported menstrual cycle data. Further research, particularly independent research following a randomized controlled design, on the efficacy of these apps is needed to produce more robust results.

Timed intercourse for couples trying to conceive

BACKGROUND

Many factors influence fertility, one being the timing of intercourse. The 'fertile window' describes a stage in the cycle when conception can occur and is approximately five days before to several hours after ovulation. 'Timed intercourse' is the practice of prospectively identifying ovulation and, thus, the fertile window to increase the likelihood of conception. Methods of predicting ovulation include urinary hormone measurement (luteinising hormone (LH) and oestrogen), fertility awareness-based methods (FABM) (including tracking basal body temperatures, cervical mucus monitoring, calendar charting/tracking apps), and ultrasonography. However, there are potentially negative aspects associated with ovulation prediction, including stress, time consumption, and cost implications of purchasing ovulation kits and app subscriptions. This review considered the evidence from randomised controlled trials (RCTs) evaluating the use of timed intercourse (using ovulation prediction) on pregnancy outcomes.

OBJECTIVES

To evaluate the benefits and risks of ovulation prediction methods for timing intercourse on conception in couples trying to conceive.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register, CENTRAL, MEDLINE, and Embase in January 2023. We also checked the reference lists of relevant studies and searched trial registries for any additional trials.

SELECTION CRITERIA

We included RCTs that compared methods of timed intercourse using ovulation prediction to other forms of ovulation prediction or intercourse without ovulation prediction in couples trying to conceive.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane to select and analyse studies in this review. The primary review outcomes were live birth and adverse events (such as depression and stress). Secondary outcomes were clinical pregnancy, pregnancy (clinical or positive urinary pregnancy test not yet confirmed by ultrasound), time to pregnancy, and quality of life. We assessed the overall quality of the evidence for the main comparisons using GRADE methods.

MAIN RESULTS

This review update included seven RCTs involving 2464 women or couples. Four of the five studies from the previous review were included in this update, and three new studies were added. We assessed the quality of the evidence as moderate to very low, the main limitations being imprecision, indirectness, and risk of bias. Urinary ovulation tests versus intercourse without ovulation prediction Compared to intercourse without ovulation prediction, urinary ovulation detection probably increases the chance of live birth in couples trying to conceive (risk ratio (RR) 1.36, 95% confidence interval (CI) 1.02 to 1.81, 1 RCT, n = 844, moderate-quality evidence). This suggests that if the chance of a live birth without urine ovulation prediction is 16%, the chance of a live birth with urine ovulation prediction is 16% to 28%. However, we are uncertain whether timed intercourse using urinary ovulation detection resulted in a difference in stress (mean difference (MD) 1.98, 95% CI -0.87 to 4.83, I² = 0%, P = 0.17, 1 RCT, n = 77, very low-quality evidence) or clinical pregnancy (RR 1.09, 95% CI 0.51 to 2.31, I² = 0%, 1 RCT, n = 148, low-quality evidence). Similar to the live birth result, timed intercourse using urinary ovulation detection probably increases the chances of clinical pregnancy or positive urine pregnancy test (RR 1.28, 95% CI 1.09 to 1.50, I² = 0, 4 RCTs, n = 2202, moderate-quality evidence). This suggests that if the chance of a clinical pregnancy or positive urine pregnancy test without ovulation prediction is assumed to be 18%, the chance following timed intercourse with urinary ovulation detection would be 20% to 28%. Evidence was insufficient to determine the effect of urine ovulation tests on time to pregnancy or quality of life. Fertility awareness-based methods (FABM) versus intercourse without ovulation prediction Due to insufficient evidence, we are uncertain whether timed intercourse using FABM resulted in a difference in live birth rate compared to intercourse without ovulation prediction (RR 0.95, 95% CI 0.76 to 1.20, I² = 0%, 2 RCTs, n = 157, low-quality evidence). We are also uncertain whether FABM affects stress (MD -1.10, 95% CI -3.88 to 1.68, 1 RCT, n = 183, very low-quality evidence). Similarly, we are uncertain of the effect of timed intercourse using FABM on anxiety (MD 0.5, 95% CI -0.52 to 1.52, P = 0.33, 1 RCT, n = 183, very low-quality evidence); depression (MD 0.4, 95% CI -0.28 to 1.08, P = 0.25, 1 RCT, n = 183, very low-quality evidence); or erectile dysfunction (MD 1.2, 95% CI -0.38 to 2.78, P = 0.14, 1 RCT, n = 183, very low-quality evidence). Evidence was insufficient to detect a benefit of timed intercourse using FABM on clinical pregnancy (RR 1.13, 95% CI 0.31 to 4.07, 1 RCT, n = 17, very low-quality evidence) or clinical or positive pregnancy test rates (RR 1.08, 95% CI 0.89 to 1.30, 3 RCTs, n = 262, very low-quality evidence). Finally, we are uncertain whether timed intercourse using FABM affects the time to pregnancy (hazard ratio 0.86, 95% CI 0.53 to 1.38, 1 RCT, n = 140, low-quality evidence) or quality of life. No studies assessed the use of timed intercourse with pelvic ultrasonography.

AUTHORS' CONCLUSIONS

The new evidence presented in this review update shows that timed intercourse using urine ovulation tests probably improves live birth and pregnancy rates (clinical or positive urine pregnancy tests but not yet confirmed by ultrasound) in women under 40, trying to conceive for less than 12 months, compared to intercourse without ovulation prediction. However, there are insufficient data to determine the effects of urine ovulation tests on adverse events, clinical pregnancy, time to pregnancy, and quality of life. Similarly, due to limited data, we are uncertain of the effect of FABM on pregnancy outcomes, adverse effects, and quality of life. Further research is therefore required to fully understand the safety and effectiveness of timed intercourse for couples trying to conceive. This research should include studies reporting clinically relevant outcomes such as live birth and adverse effects in fertile and infertile couples and utilise various methods to determine ovulation. Only with a comprehensive understanding of the risks and benefits of timed intercourse can recommendations be made for all couples trying to conceive.

Survey Analysis of Quantitative and Qualitative Menstrual Cycle Tracking Technologies

Background and Objectives: Digital health and personalized medicine are advancing at an unprecedented pace. Users can document their menstrual cycle data in a variety of ways, including smartphone applications (apps), temperature tracking devices, and at-home urine hormone tests. Understanding the needs and goals of women using menstrual cycle tracking technologies is the first step to making these technologies more evidence based. The purpose of this study was to examine the current use of these technologies and explore how they are being used within the context of common hormonal and reproductive disorders, like polycystic ovary syndrome (PCOS), endometriosis, and infertility. Materials and Methods: This was a cross-sectional study evaluating menstrual cycle tracking technology use. Participants were recruited in January-March 2023 using social media groups and a Marquette Method instructor email listserv. Data were collected using an electronic survey with Qualtrics. Data collected included participant demographics, menstrual cycle characteristics, reproductive health history, and menstrual cycle tracking behavior. Results: Three-hundred and sixty-eight participants were included in the analysis. Women had various motivations for tracking their menstrual cycles. Most participants (72.8%) selected "to avoid getting pregnant" as the primary motivation. Three hundred and fifty-six participants (96.7%) reported using a fertility awareness-based method to track and interpret their menstrual cycle data. The Marquette Method, which utilizes urine hormone tracking, was the most frequently used method (n = 274, 68.2%). The most frequently used cycle technology was a urine hormone test or monitor (n = 299, 81.3%), followed by a smartphone app (n = 253, 68.8%), and a temperature tracking device (n = 116, 31.5%). Women with PCOS (63.6%), endometriosis (61.8%), and infertility (75%) in our study reported that the use of tracking technologies aided in the diagnosis. Most participants (87.2%) reported a high degree of satisfaction with their use and that they contributed to their reproductive health knowledge (73.9%). Conclusions: Women in our study reported avoiding pregnancy as their primary motivation for using menstrual cycle tracking technologies, with the most frequently used being a urine hormone test or monitor. Our study results emphasize the need to validate these technologies to support their use for family planning. Given that most women in this study reported using a fertility awareness-based method, the results cannot be generalized to all users of menstrual cycle tracking technologies.

A randomized trial of web-based fertility-tracking software and fecundability

OBJECTIVE

To assess the effect of randomization to FertilityFriend.com, a mobile computing fertility-tracking app, on fecundability.

DESIGN

Parallel non-blinded randomized controlled trial nested within the Pregnancy Study Online (PRESTO), a North American preconception cohort.

PATIENT(S)

Female participants aged 21 to 45 years attempting conception for ≤6 menstrual cycles at enrolment (2013-2019).

INTERVENTION

Randomization (1:1) of 5532 participants to receive a premium Fertility Friend (FF) subscription.

MAIN OUTCOME MEASURE(S)

Fecundability (per-cycle probability of conception). Participants completed bimonthly follow-up questionnaires until pregnancy or a censoring event, whichever came first. We first performed an intent-to-treat analysis of the effect of FF randomization on fecundability. In secondary analyses, we used a per-protocol approach that accounted for adherence in each trial arm. In both analyses, we used proportional probabilities regression models to estimate fecundability ratios (FR) and 95% confidence intervals (CI) comparing those randomized vs. not randomized and applied inverse probability weights to account for loss-to-follow-up (intent-to-treat and per-protocol analyses) and adherence (per-protocol analyses only).

RESULTS

Using life-table methods, 64% of the 2775 participants randomized to FF and 63% of the 2767 participants not randomized to FF conceived during 12 cycles; these respective percentages were each 70% among those with 0-1 cycles of attempt time at enrolment. Of those randomized to FF, 72% were defined as adherent (68% of observed menstrual cycles). In intent-to-treat analyses, there was no appreciable association overall (FR = 0.97; 95% CI, 0.90-1.04) or within strata of pregnancy attempt time at enrolment, age, education, or other characteristics. In per-protocol analyses, we observed little association overall (FR = 1.06; 95% CI, 0.99-1.14), but weak-to-moderate positive associations among participants who had longer attempt times at enrolment (FR = 1.15; 95% CI, 0.98-1.35 for 3-4 cycles; FR = 1.14; 95% CI, 0.87-1.48 for 5-6 cycles), were aged <25 years (FR = 1.29; 95% CI, 1.01-1.66), had ≤12 years of education (FR = 1.32; 95% CI, 0.92-1.89), or were non-users of hormonal contraception within 3 months before enrolment (FR = 1.10; 95% CI, 1.02-1.19).

CONCLUSION

No appreciable associations were observed in intent-to-treat analyses. In secondary per-protocol analyses that accounted for adherence, randomization to FF was associated with slightly greater fecundability among selected subgroups of participants; however, these results are susceptible to unmeasured confounding.

Fertility Awareness-Based Methods for Women's Health and Family Planning

Background

Fertility awareness-based methods (FABMs) educate about reproductive health and enable tracking and interpretation of physical signs, such as cervical fluid secretions and basal body temperature, which reflect the hormonal changes women experience on a cyclical basis during the years of ovarian activity. Some methods measure relevant hormone levels directly. Most FABMs allow women to identify ovulation and track this "vital sign" of the menstrual or female reproductive cycle, through daily observations recorded on cycle charts (paper or electronic).

Applications

Physicians can use the information from FABM charts to guide the diagnosis and management of medical conditions and to support or restore healthy function of the reproductive and endocrine systems, using a restorative reproductive medical (RRM) approach. FABMs can also be used by couples to achieve or avoid pregnancy and may be most effective when taught by a trained instructor.

Challenges

Information about individual FABMs is rarely provided in medical education. Outdated information is widespread both in training programs and in the public sphere. Obtaining accurate information about FABMs is further complicated by the numerous period tracking or fertility apps available, because very few of these apps have evidence to support their effectiveness for identifying the fertile window, for achieving or preventing pregnancy.

Conclusions

This article provides an overview of different types of FABMs with a published evidence base, apps and resources for learning and using FABMs, the role FABMs can play in medical evaluation and management, and the effectiveness of FABMs for family planning, both to achieve or to avoid pregnancy.