Natural conception rates in subfertile couples following fertility awareness training.

PURPOSE: To analyze cumulative pregnancy rates of subfertile couples after fertility awareness training. METHODS: A prospective observational cohort study followed 187 subfertile women, who had received training in self-observation of the fertile phase of the menstrual cycle with the Sensiplan method, for 8 months. The women, aged 21-47 years, had attempted to become pregnant for 3.5 years on average (range 1-8 years) before study entry. Amenorrhea, known tubal occlusion and severe male factor had been excluded. An additional seven women, who had initially been recruited, became pregnant during the cycle immediately prior to Sensiplan training: this is taken to be the spontaneous pregnancy rate per cycle in the cohort in the absence of fertility awareness training. RESULTS: The cumulative pregnancy rate of subfertile couples after fertility awareness training was 38% (95% CI 27-49%; 58 pregnancies) after eight observation months, which is significantly higher than the estimated basic pregnancy rate of 21.6% in untrained couples in the same cohort. For couples who had been seeking to become pregnant for 1-2 years, the pregnancy rate increased to 56% after 8 months. A female age above 35 (cumulative pregnancy rate 25%, p = 0.06), couples who had attempted to become pregnant for more than 2 years (cumulative pregnancy rate 17%, p < 0.01), all significantly reduce the chances of conceiving naturally at some point. CONCLUSIONS: Training women to identify their fertile window in the menstrual cycle seems to be a reasonable first-line therapy in the management of subfertility.

[Contraception in adolescents]. / Empfängnisverhütung bei Jugendlichen.

PIP: In a study carried out in Germany between 1985-89 unintended pregnancy was found in 7.9% of girls aged 15-21 in 1985 and in 5.2% in 1989. A study of 2905 young people aged 14-18 in Austria indicated that 75% of girls and 55% of boys had sexual intercourse by age 18 making contraception vital for adolescents. Among oral contraceptives (OCs) micropills with 20 mcg ethinyl estradiol barely affect the follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels, but the gestagen component can induce bleeding, spotting, and breast symptoms. Discontinuation quickly restores the normal connection of the hypophysis and ovary without affecting later pregnancy. 5.1 years after the end of high-dose combination OC use for 9-46 months only 3 out of 13 women did not become pregnant. OCs reduce bleeding disorders, anemia, and dysmenorrhea, ovarian cancer, and endometrial cancer. Their effect on breast cancer is not clear. Phenobarbital and rifampicin accelerate OC metabolism, and OCs reduce the effect of anticonvulsives and tolbutamide (for hypoglycemia). Neogynon and Stediril D are postcoital pills used within 48 hours of intercourse. IUDs are not recommended, as adnexal infection is 1.5-2 times higher in girls 14018 using IUDs. The effectiveness of the diaphragm and condom depend on motivation; creams and vaginal sponges are useful but they may cause irritation. The Billings method produced only a 2.9 Pearl-index reliability in 7000 cycles, thus natural methods often fail. Before age 14 girls must have parental consent for prescription of OCs, after 14 the physician is not liable for OC prescription, but induced abortion still requires parental consent until age 18.^ieng

The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple's sexual behaviour during the fertile time: a prospective longitudinal study.

BACKGROUND: The efficacy of fertility awareness based (FAB) methods of family planning is critically reviewed. The objective was to investigate the efficacy and the acceptability of the symptothermal method (STM), an FAB method that uses two indicators of fertility, temperature and cervical secretions observation. This paper will recommend a more suitable approach to measure the efficacy. METHODS: Since 1985, an ongoing prospective observational longitudinal cohort study has been conducted in Germany. Women are asked to submit their menstrual cycle charts that record daily basal body temperature, cervical secretion observations and sexual behaviour. A cohort of 900 women contributed 17,638 cycles that met the inclusion criteria for the effectiveness study. The overall rates of unintended pregnancies and dropout rates have been estimated with survival curves according to the Kaplan-Meier method. In order to estimate the true method effectiveness, the pregnancy rates have been calculated in relation to sexual behaviour using the 'perfect/imperfect-use' model of Trussell and Grummer-Strawn. RESULTS: After 13 cycles, 1.8 per 100 women of the cohort experienced an unintended pregnancy; 9.2 per 100 women dropped out because of dissatisfaction with the method; the pregnancy rate was 0.6 per 100 women and per 13 cycles when there was no unprotected intercourse in the fertile time. CONCLUSIONS: The STM is a highly effective family planning method, provided the appropriate guidelines are consistently adhered to.

Definition and prevalence of subfertility and infertility.

A common definition of sub- and infertility is very important for the appropriate management of infertility. Subfertility generally describes any form of reduced fertility with prolonged time of unwanted non-conception. Infertility may be used synonymously with sterility with only sporadically occurring spontaneous pregnancies. The major factor affecting the individual spontaneous pregnancy prospect is the time of unwanted non-conception which determines the grading of subfertility. Most of the pregnancies occur in the first six cycles with intercourse in the fertile phase (80%). After that, serious subfertility must be assumed in every second couple (10%) although--after 12 unsuccessful cycles--untreated live birth rates among them will reach nearly 55% in the next 36 months. Thereafter (48 months), approximately 5% of the couples are definitive infertile with a nearly zero chance of becoming spontaneously pregnant in the future. With age, cumulative probabilities of conception decline because heterogeneity in fecundity increases due to a higher proportion of infertile couples. In truly fertile couples cumulative probabilities of conception are probably age independent. Under appropriate circumstances a basic infertility work-up after six unsuccessful cycles with fertility-focused intercourse will identify couples with significant infertility problems to avoid both infertility under- and over-treatment, regardless of age: Couples with a reasonably good prognosis (e.g. unexplained infertility) may be encouraged to wait because even with treatment they do not have a better chance of conceiving. The others may benefit from an early resort to assisted reproduction treatment.

Determination of the fertile window: reproductive competence of women--European cycle databases.

OBJECTIVES: The objective of the present paper is to review the main results of recent European cycle databases on ovulation detection and determination of the fertile window performed by the women themselves. METHODS: The ongoing German Long-term Cycle Database currently comprises 32788 prospectively collected cycle charts of 1551 women, the I European Cycle Database (10 countries) 1328 women/19048 cycles, the II European Cycle Database (six countries) 782 women/6724 cycles, and the World Health Organization Database (one European country) 234 women/2808 cycles. The women record cycle parameters (cervical mucus changes, temperature rise, etc.), family planning intention and sexual behavior. RESULTS: With the symptothermal method of natural family planning it has become possible to determine the fertile window in order to avoid pregnancy with a method effectiveness of 0.3%. According to a small sub-study, the ovulation time observed by the women themselves correlates closely with ovulation detected by ultrasound and measurement of luteinizing hormone (correlation within 1 day in 89% of the 62 cycles). Fertility awareness methods can be integrated into the management of sub-fertility. They seem to shorten the time to pregnancy. CONCLUSIONS: Self-observation of the fertile window puts women into a position to develop a high level of reproductive competence that could be used much more in different areas than is currently the case.

[The value of intrauterine insemination in fertility treatment]. / Die Bedeutung der intrauterinen Insemination in der Fertilitätstherapie.

Intrauterine insemination and the use of appropriately processed sperm is an mildly invasive, readily performed means of treating infertility. Particular indications are a poor cervical factor in the female, reduced fertility in the male, and immunological disorders or idiopathic sterility. Under optimal conditions (stimulated menses, case-oriented preparation of sperm) a treatment duration covering 4-5 cycles usually suffices; if success is not achieved within this time, other methods should be tried.

[Interaction of spermatozoa and the cervical mucus]. / Untersuchungen zur Interaktion von Spermatozoen und Zervikalschleim.

Interactions between spermatozoa and cervical mucus are important for the process of fertilization, especially in cases of sterility, whereby the whole system including both participants has to be evaluated. We have investigated couples, where the husband was suffering from a reduced fructose content or increased viscosity of the seminal plasma. We found that reduced fructose did not interfere with fertility; however increased viscosity of the seminal plasma did significantly reduce the chances of pregnancy. The various disturbances in spermatozoal morphology (Düsseldorf scheme) interfered with fertility in quite different ways. From the different forms of spermatozoa in cervical mucus one can define a specific disturbance in the man. Using cytophotometry for multiple spermatozoa, Feulgen-DNS-determination and aktin-determination of the single spermatozoon we found additional parameters to evaluate the infertile couple.

Present stage of knowledge of reproductive biology concerning natural family planning.

PIP: "The common cycle length variation of the woman's cycle in a healthy population is five days.... We believe that the temperature shift in the middle of the cycle is caused by the peripheral effect of estradiol and progesterone on the peripheral circulation. The time from the beginning of the development of an individual spermatozoa to the appearance of a ripe spermatozoon in the ejaculate is about three months. The lifespan of the ripe oocyte is 18-24 hours. The duration of fertilizing capacity of sperm can be five days with decreasing probability; in very rare cases it can be seven days. The probability of conception in our very simple model was 33.3% at ovulation day (day 0)." (EXCERPT)^ieng

[Clinical and endocrinologic aspects of treatment with pure FSH. A report of experiences]. / Klinische und endokrinologische Aspekte der Therapie mit reinem FSH. Ein Erfahrungsbericht.

Ovarian stimulation with pure urinary FSH (Fertinorm, Serono Freiburg, FRG) shows therapeutic efficacy in patients with chronic clomiphene-resistant anovulation and elevated androgen levels. In case of unsatisfactory ovarian response the rate of success can be improved by adding HMG. 20 patients were stimulated for a total of 36 cycles. Cycle monitoring was performed by transbdominal ultrasound and cervical mucus evaluation. Hormone determination (E2, LH, FSH, prolactin, testosterone, DHEAS) was carried out retrospectively. In 17 cycles HMG was added because of insufficient follicle maturation. Upon achieving a dominant follicle with a diameter of more than 1.6 cm (25 cycles, 14 of those with FSH stimulation only) HCG was applied for induction of ovulation. In 22 cycles ovulation occurred. 7 of those revealed sings of luteal phase deficiency. In anovulatory cycles (n = 3) there was a discrepancy between sonography and E2-levels. Premature increase in LH, partly with subsequent luteinization of follicles was observed in 7 of all 36 cycles (19.4%), 2 of those under sole FSH-stimulation. The number of dominant follicles on the day of HCG-application was 1.40 +/- 1.06 (n = 15) in cycles with FSH alone and 2.09 +/- 1.76 (n = 11) in cycles with additional HMG. Hyperstimulation (more than 4 leading follicles) was induced in 9 cycles (5 cycles with FSH only). In 7 (4) cases HCG had to be cancelled. Polyfollicular ovarian reaction and premature increase in LH preferentially occurred in cycles with high basel levels of LH and elevated LH/FSH-ratio.

Acrosome reaction of spermatozoa with different morphology.

The acrosome reaction of human spermatozoa with different morphological disturbances was evaluated after application of the triple staining method. After triple staining, spermatozoa which display only a small or an undetectable acrosomal region in Papanicolaou-stained semen smears, turn out to be unable to perform an acrosome reaction, whereas merely post-acrosomally hyper-elongated spermatozoa show a normal ability for acrosome reaction.