Fertility awareness education improves fertility cycle knowledge and may reduce time-to-pregnancy in subfertile women

Research suggests that low fertility awareness (FA) may be a contributing factor to infertility. The aim of this study was to determine whether education improves knowledge in FA and to explore the associations between FA knowledge and time to pregnancy (TTP). A 20-point self-administered FA questionnaire (FAQ) was completed by 180 subfertile women on their first visit to a hospital-based fertility assessment and research clinic, followed by an education session on FA. Women completed the same FAQ after receiving the education session. There was an increase in the FAQ score after the women received FA education (post-education FAQ score: mean, M = 15.68, SD = 1.8) compared with the score before the session [(pre-education FAQ score: M = 13.87, SD = 1.9), t(179)=-10.547, p < 0.001]. Pregnancy was achieved in 88 women (49%). Women with a higher post-education FAQ score (≥15 points) had a shorter TTP (M = 6.4 months, SD = 4.1) than women with post-education FAQ scores <15 [M = 8.8 months, SD = 6.0, t(86)=2.231, p = 0.028]. Greater time trying to conceive was negatively predictive of the hazard for achieving a pregnancy (b=-0.021, se = 0.008, p = 0.005), while age had no significant effect. FA knowledge in women attending a fertility clinic significantly improved after education. Higher FA may reduce TTP in subfertile women who are actively trying to conceive naturally.

Evaluating Evidence-Based Content, Features of Exercise Instruction, and Expert Involvement in Physical Activity Apps for Pregnant Women: Systematic Search and Content Analysis

Background

Guidelines for physical activity and exercise during pregnancy recommend that all women without contraindications engage in regular physical activity to improve both their own health and the health of their baby. Many women are uncertain how to safely engage in physical activity and exercise during this life stage and are increasingly using mobile apps to access health-related information. However, the extent to which apps that provide physical activity and exercise advice align with current evidence-based pregnancy recommendations is unclear.

Objective

This study aims to conduct a systematic search and content analysis of apps that promote physical activity and exercise in pregnancy to examine the alignment of the content with current evidence-based recommendations; delivery, format, and features of physical activity and exercise instruction; and credentials of the app developers.

Methods

Systematic searches were conducted in the Australian App Store and Google Play Store in October 2020. Apps were identified using combinations of search terms relevant to pregnancy and exercise or physical activity and screened for inclusion (with a primary focus on physical activity and exercise during pregnancy, free to download or did not require immediate paid subscription, and an average user rating of ≥4 out of 5). Apps were then independently reviewed using an author-designed extraction tool.

Results

Overall, 27 apps were included in this review (Google Play Store: 16/27, 59%, and App Store: 11/27, 41%). Two-thirds of the apps provided some information relating to the frequency, intensity, time, and type principles of exercise; only 11% (3/27) provided this information in line with current evidence-based guidelines. Approximately one-third of the apps provided information about contraindications to exercise during pregnancy and referenced the supporting evidence. None of the apps actively engaged in screening for potential contraindications. Only 15% (4/27) of the apps collected information about the user’s current exercise behaviors, 11% (3/27) allowed users to personalize features relating to their exercise preferences, and a little more than one-third provided information about developer credentials.

Conclusions

Few exercise apps designed for pregnancy aligned with current evidence-based physical activity guidelines. None of the apps screened users for contraindications to physical activity and exercise during pregnancy, and most lacked appropriate personalization features to account for an individual’s characteristics. Few involved qualified experts during the development of the app. There is a need to improve the quality of apps that promote exercise in pregnancy to ensure that women are appropriately supported to engage in exercise and the potential risk of injury, complications, and adverse pregnancy outcomes for both mother and child is minimized. This could be done by providing expert guidance that aligns with current recommendations, introducing screening measures and features that enable personalization and tailoring to individual users, or by developing a recognized system for regulating apps.

Prospective associations between physical activity and BMI with irregular periods and heavy menstrual bleeding in a large cohort of Australian women

STUDY QUESTION

Are physical activity (PA) and body mass index (BMI) associated with irregular periods and heavy menstrual bleeding (HMB) in Australian women?

SUMMARY ANSWER

Overweight and obese women have higher odds of both irregular periods and HMB than underweight/normal-weight women, but high levels of PA reduce the odds of HMB.

WHAT IS KNOWN ALREADY

Most studies on relationships between PA and menstrual problems have focused on female athletes, but there have been few population-based studies.

STUDY DESIGN, SIZE, DURATION

Prospective cohort study, 10618 participants in the Australian Longitudinal Study of Women's Health (ALSWH) who completed mailed surveys in 1996, with follow-ups in 2000, 2003, 2006, 2009, 2012, and 2015.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were aged 22 to 27 in 2000. They were asked to report their PA levels and the frequency of irregular periods and HMB in each survey. BMI was calculated at every survey from self-reported weight and height. Generalised estimating equation population-averaged model analyses were conducted to calculate odds ratios (OR) and 95% confidence intervals (95% CIs).

MAIN RESULTS AND THE ROLE OF CHANCE

At age 22 to 27 years, the prevalence of irregular periods was 19.4%. This remained stable over 15 years. There were no associations between PA and irregular periods. Overweight and obese women had higher odds of irregular periods [overweight: OR 1.08, (95% CI 1.00-1.17); obese: OR 1.29, (95%CI 1.18-1.41)] than women who were underweight/normal weight.The prevalence of HMB at age 22-27 years was 15.9%; this doubled over 15 years. Women who were highly active had 10% lower odds of HMB than women who reported no PA [OR 0.90, (95%CI 0.82-0.98)]. Overweight and obese women had higher odds of HMB [overweight: OR 1.15, (95%CI 1.07-1.23); obese: OR 1.37, (95%CI 1.26-1.49)] than women who were underweight/normal weight. Among obese women, high levels of PA were associated with 19% [OR 0.81, (95%CI 0.68-0.97)] reduction in the odds of HMB.

LIMITATIONS, REASONS FOR CAUTION

Data collected in the ALSWH are self-reported, which may be subject to recall bias. Reverse causation, due to menstrual problems impacting PA, is possible although sensitivity analyses suggest this is unlikely to have affected the results. Other conditions, e.g., polycystic ovary syndrome, for which no or incomplete data were available, could have affected the results.

WIDER IMPLICATIONS OF THE FINDINGS

Intervention studies are needed to assess the effect of increasing PA in women with HMB, but these preliminary findings suggest that promoting PA could be an affordable and feasible strategy for reducing HMB in young adult women.

STUDY FUNDING/COMPETING INTEREST(S)

The ALSWH is funded by the Australian Government. Funding for these analyses was provided by a University of Queensland (UQ) International Postgraduate Research Scholarship and a UQ International Development Fellowship. The authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Quality, Features, and Presence of Behavior Change Techniques in Mobile Apps Designed to Improve Physical Activity in Pregnant Women: Systematic Search and Content Analysis

Background

Physical activity during pregnancy is associated with several health benefits for the mother and child. However, very few women participate in regular physical activity during pregnancy. eHealth platforms (internet and mobile apps) have become an important information source for pregnant women. Although the use of pregnancy-related apps has significantly increased among pregnant women, very little is known about their theoretical underpinnings, including their utilization of behavior change techniques (BCTs). This is despite research suggesting that inclusion of BCTs in eHealth interventions are important for promoting healthy behaviors, including physical activity.

Objective

The aim of this study was to conduct a systematic search and content analysis of app quality, features, and the presence of BCTs in apps designed to promote physical activity among pregnant women.

Methods

A systematic search in the Australian App Store and Google Play store using search terms relating to exercise and pregnancy was performed. App quality and features were assessed using the 19-item Mobile App Rating Scale (MARS), and a taxonomy of BCTs was used to determine the presence of BCTs (26 items). BCTs previously demonstrating efficacy in behavior changes during pregnancy were also identified from a literature review. Spearman correlations were used to investigate the relationships between app quality, app features, and number of BCTs identified.

Results

Nineteen exercise apps were deemed eligible for this review and they were accessed via Google Play (n=13) or App Store (n=6). The MARS overall quality scores indicated moderate app quality (mean 3.5 [SD 0.52]). Functionality was the highest scoring MARS domain (mean 4.2 [SD 0.5]), followed by aesthetics (mean 3.7 [SD 0.6]) and information quality (mean 3.16 [SD 0.42]). Subjective app quality (mean 2.54 [SD 0.64]) and likelihood for behavioral impact (mean 2.5 [SD 0.6]) were the lowest scoring MARS domains. All 19 apps were found to incorporate at least two BCTs (mean 4.74, SD 2.51; range 2-10). However, only 11 apps included BCTs that previously demonstrated efficacy for behavior change during pregnancy, the most common being provide opportunities for social comparison (n=8) and prompt self-monitoring of behavior (n=7). There was a significant positive correlation between the number of BCTs with engagement and aesthetics scores, but the number of BCTs was not significantly correlated with functionality, information quality, total MARS quality, or subjective quality.

Conclusions

Our findings showed that apps designed to promote physical activity among pregnant women were functional and aesthetically pleasing, with overall moderate quality. However, the incorporation of BCTs was low, with limited prevalence of BCTs previously demonstrating efficacy in behavior change during pregnancy. Future app development should identify and adopt factors that enhance and encourage user engagement, including the use of BCTs, especially those that have demonstrated efficacy for promoting physical activity behavior change among pregnant women.

The effect of physical activity on reproductive health outcomes in young women: a systematic review and meta-analysis

BACKGROUND

In the context of increasing rates of overweight and obesity in young adult women, and the increasing numbers of women seeking help for fertility problems, it is important to understand whether physical activity (PA) could help with management of reproductive health problems, with or without weight loss.

OBJECTIVE AND RATIONALE

The primary aim of this systematic review and meta-analysis was to assess the effects of PA on selected reproductive health outcomes in young adult women, in order to inform best practice advice for women in terms of promoting fertility and reproductive health in young adulthood.

SEARCH METHODS

An electronic search of PubMed, EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science, SportDiscus, and Cochrane was performed for studies published between January 2000 and May 2018. Keywords and Medical Subject Headings terms related to PA, reproductive health, and weight gain were used. Studies were selected if they were intervention studies, if PA was delivered as part of an intervention to pre-menopausal women, and if any reproductive health outcome was reported. Quality analysis was performed using the Tool for the assEssment of Study qualiTy and reporting in EXercise.

OUTCOMES

Eighteen studies, with a mix of four types of study design (4 randomized controlled trials (RCTs), 11 randomized comparison trials, 2 non-randomized comparison trials, and 1 single-arm clinical trial), were identified. Comparisons included fertility treatment (four studies) and common treatments for women with polycystic ovary syndrome (PCOS) symptoms (nine studies). Pooled analysis of data from three of the four studies with a control group showed higher pregnancy [risk ratio (RR) 2.10, 95% CI (1.32, 3.35); three studies] and live birth [RR 2.11, 95% CI (1.02, 4.39); two studies] rates in the intervention groups compared with non-therapy controls. Aggregated data from the fertility treatment comparative studies (i.e. those that compared PA with standard fertility treatment such as clomiphene, gonadotrophins, and/or IVF) showed no significant intervention differences: RR 1.46, 95% CI (0.87, 2.45) for clinical pregnancy (four studies) and RR 1.09, 95% CI (0.56, 2.12) for live births (two studies). Pooled analysis from the comparison trials that used pharmaceutical or dietary treatment for PCOS as comparison showed higher pregnancy rates [RR 1.59, 95% CI (1.06, 2.38); five studies] and live birth rates [RR 2.45, 95% CI (1.24, 4.83); two observations] in the PA intervention groups than in the comparison groups. Analysis of other outcomes, such as ovulation rates, menstrual regularity, and conception rates, showed no differences between the PA intervention and comparison groups.

WIDER IMPLICATIONS

There is emerging evidence from RCT that PA may improve pregnancy rates in women with reproductive health problems. Comparative studies indicate that PA intervention may be as effective as other commonly used clinical intervention strategies for improving reproductive health outcomes. While the type, intensity, frequency, and duration of optimal PA intervention, and the role of PA independent of weight loss, remain unclear, these preliminary findings suggest that PA may be an affordable and feasible alternative or complementary therapy to fertility treatments.

Do physical activity, sitting time and body mass index affect fertility over a 15-year period in women? Data from a large population-based cohort study

STUDY QUESTION

Do physical activity (PA), sitting time (ST) and body mass index (BMI) affect fertility over a 15-year period in Australian women?

SUMMARY ANSWER

Moderate and high levels of PA confer advantages for fertility in women with normal BMI, but increased risk of infertility was observed in obese women.

WHAT IS KNOWN ALREADY

Higher BMI is positively associated with higher rates of problems with fertility, but the effects of physical activity and sitting time on fertility are less well understood.

STUDY DESIGN, SIZE, DURATION

Participants in The Australian Longitudinal Study of Women’s Health (ALSWH) completed mailed surveys in 2000, with follow-ups in 2003, 2006, 2009, 2012 and 2015 (N = 6130).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were aged 22 to 27 in 2000. They were asked to report their physical activity levels, sitting time and fertility problems in each survey from 2000 to 2015. BMI was calculated from self-reported weight and height. Cumulative incidence of fertility problems was calculated from 2000 to 2015 and hazard ratios (HR) and 95% CIs were calculated using survival analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

From 2000 to 2015, the cumulative incidence of fertility problems was 15.4% (95% CI: 14.5–16.4). High levels of PA were associated with reduced risk of problems with fertility [HR 0.82 (95% CI: 0.69–0.98)], and higher BMI was positively associated with fertility problems [overweight: HR 1.18, (95% CI 0.99–1.39); obese: HR 1.36, (95% CI 1.14–1.63)]. In survival analyses, incidence rates were highest in every survey interval in women who reported low PA levels and in women who were obese. Overall, ST was not associated with fertility problems. In stratified models, high levels of PA attenuated the risk of problems with fertility in women who were in the normal BMI category [HR 0.64, (95% CI 0.49–0.82)].

LIMITATIONS, REASONS FOR CAUTION

The ALSWH relies on self-reported data, which may be subject to recall bias.

WIDER IMPLICATIONS OF THE FINDINGS

The study provides estimates of problems with fertility in a cohort of young adult Australian women, and the results indicate that these are inversely associated with physical activity levels and positively associated with BMI. However, the high infertility risk in obese women was not attenuated by high levels of PA. The protective effects of PA were only observed in women with normal BMI. As rates of developing problems with fertility were highest in every survey interval among women who reported low levels of physical activity and in women who were obese, these findings suggest that improving physical activity levels could be an affordable strategy to reduce problems with fertility in women who are trying to conceive. These findings should be considered by clinical and public health practitioners.

STUDY FUNDING/COMPETING INTEREST(S)

The ALSWH is funded by the Australian Government. Funding for these analyses was provided by a University of Queensland (UQ) International Postgraduate Research Scholarship and a UQ International Development Fellowship. The authors declare no conflicts of interest.