Effects of Timed Intercourse and Abstinence
Timed Intercourse Found Not Stressful for Women Seeking Pregnancy
European (i.e., National Institute for Health and Clinical Excellence or NICE) evidence based guidelines for sub-fertile couples seeking pregnancy is to have intercourse every 2-3 days. The guidelines also counsel against focusing intercourse during the fertile window based on indicators of fertility because it is thought to be too stressful. At the same time, the guidelines provide no evidence for this recommendation. Researchers, therefore sought to determine if timing intercourse based on self-observed indicators of fertility was stressful for couples seeking pregnancy.
The study was a prospective randomized controlled trial in which volunteer couples from the United Kingdom (UK) were randomized into either a group who were provided a digital urinary ovulation predictor kit based on detecting a rise from baseline in urine luteinizing hormone (LH) or a group of women who were advised to have frequent intercourse (every 2-3 days) and not use any self-observation fertility indicators. Of the 210 UK volunteer women/couples 115 were randomized into the digital LH kit group and 95 into the frequent intercourse group. Both groups of women were administered (at baseline and at the end of the study) two paper and pencil psychological subjective measures of stress, i.e., the Perceived Stress Scale (PSS) and the positive and negative affect schedule (PANAS). They were also provided with a measure of health status with a short form health survey (SF-12). All participants collected their first morning urine samples to measure cortisol levels as a biological measure of stress. The digital LH kits were designed to measure the rise from baseline urinary LH. The women receiving these kits were asked to have intercourse on the positive test days. The control women received the digital LH test kits after completion of the study as compensation. The study data was collected over two complete menstrual cycles.
The researchers found that there were no differences in subjective perceived stress with the PSS and the PANAS and the biological measure of cortisol at all measurement time points. Although pregnancy rates were not the main question of the study, they did find 43% of the women in the digital LH group achieved pregnancy and 30% in the control group. The odds of achieving pregnancy with the digital LH test kit and timed intercourse was 59% greater compared to the control group. The researchers concluded that there were no differences in stress with women using timed intercourse compared with women using frequent intercourse to achieve pregnancy, nor was the pregnancy rate negatively affected by use of focused intercourse during the estimate fertile window.
This is good news for couples who use fertility awareness based methods or Natural Family Planning (NFP) to achieve pregnancy, in that couples using these methods are asked to focus intercourse on the estimated fertile window to achieve pregnancy. However, this study was based on use of an objective test for urinary LH that provided a very clear indicator of pending ovulation. Randomized comparisons of different natural indicators of fertility (i.e., cervical mucus versus urinary LH testing) would need to be conducted to further understand the dynamics of achieving pregnancy with traditional indicators of fertility used with NFP methods
Tiplady, S., G. Jones, and M. Campbell, et al. 2012. Home ovulation tests and stress in women trying to conceive: a randomized controlled trial. Human Reproduction (Advance Access, published October 18, 2012).
Variability of the LH Surge among Women with Regular Menstrual Cycles
Recent studies have shown that there is considerable variability among the phases of the menstrual cycle (e.g., day of ovulation and the follicular and luteal phases) and with hormonal measures (i.e., luteal phase progesterone levels and the luteinizing hormone surge) (Alliende, 2002; Park, Goldsmith, Skutnick, Wojtczuk, and Weiss, 2007; Cole, Ladner, and Byrn, 2009). These recent studies did not investigate the variability of the luteinizing hormone (LH) surge configuration, amplitude, and duration in relation to the phases of the menstrual cycle and the estimated day of ovulation. Due to this gap, researchers sought to determine the relationship between the variants of the LH surge with the profiles of other reproductive hormones and the estimated day of ovulation (Direito, Bailly, Mariani and Ecochard, 2013).
This was a secondary analysis of prospectively collected data collected from healthy menstruating women between the ages of 18-45 from Natural Family Planning centers in five European countries in the mid-1990s. The researchers studied 107 women who had regular menstrual cycles from 24-34 days in length. These women were asked to record and chart on a daily basis their basal body temperature and changes in cervical mucus characteristics and to collect a first morning void urine sample. The urine samples were measured for LH, follicle stimulating hormone (FSH), esgrone-3-glucuronide (E3G), and pregnanedil-3a-glucuronide (PDG) with immunoassay techniques. The participants also underwent serial transvaginal ultrasounds every other day until a follicle was detected at least 16 mm in size, and then every day until evidence of the day of ovulation (US_DO). The researchers obtained 283 menstrual cycles of usable data.
The researchers discovered a variation in LH amplitudes, duration and configuration; i.e., short, medium, double and prolonged LH surges. They also described LH urges with single peaks, plateaus, double peaks, and multiple peaks. Prolonged LH surges were associated with longer cycle lengths, longer follicular and luteal phases, with lower E3G, PDG and LH levels on the third day of the cycles and higher LH and FSH levels during the luteal phase of the cycle. The women with LH surges with multiple peaks had smaller follicle sizes and significantly lower LH levels before rupture. The researchers concluded that multiple LH peaks might be a symptom of follicular insufficiency and a prolonged LH surge of luteal insufficiency. Both conditions might affect the probability of conception but further studies are needed to provide evidence with regard to pregnancies and birth outcomes.
Limitations, as discussed by the authors, were that the participants were rather homogeneous with a mean basal metabolism index (BMI) quite low compared to the European norm. They also eliminated any participants who were runners, breastfeeding, and those less than 3 months postpartum i.e., women who would have greater menstrual cycle variations due to those conditions. From a clinical and Natural Family Planning perspective, a diversity of LH surges should be expected even among regularly cycling women. This is of particular importance for women who use urinary LH test kits to time intercourse or to estimate fertility for avoiding pregnancy.
1. Alliende, M. E. 2002. Mean versus individual hormonal profiles in the menstrual cycle. Fertility and Sterility 78: 90-96.
2. Cole, L. A., D. G. Ladner, and F. W. Byrn. 2009. The normal variability of the menstrual cycle. Fertility and Sterility 91: 522-527.
3. Direito, A., S. Bailly, A. Mariane, and R. Ecochard. 2013. Relationship between the luteinizing hormone surge and other characteristics of the menstrual cycle in normally ovulating women. Fertility and Sterility 99: 279-285.
4. Park, S. J., L. Goldsmith, J. Skurmick, A. Wojtczuk, and G. Weiss. 2007. Characteristics of the urinary luteinizing hormone surge in young ovulatory women. Fertility and Sterility 88: 684-690.