Review question
We reviewed the evidence on the effect of timed intercourse (using ovulation prediction) versus intercourse without ovulation prediction in couples trying to conceive.
Background
Many couples find it difficult to achieve a pregnancy and have concerns about their fertility. In each cycle, a woman is fertile from approximately five days before ovulation (egg release) until several hours after ovulation due to the limited survival times of the sperm and egg. Identifying this fertile period of a woman's menstrual cycle to guide the timing of intercourse may therefore improve conception (pregnancy) rates. This may reduce unnecessary medical treatment and costs of advanced infertility treatment, but it may also cause adverse events such as stress. The fertile period can be identified using different methods, including urine ovulation tests (dipstick devices that can detect changes in hormones released into the urine, signifying when ovulation will occur), fertility awareness-based methods (FABM) (including calendar tracking, monitoring changes in cervix fluid and body temperature), or identifying when the egg is released on ultrasound. This review aimed to assess the benefits and risks of timed intercourse on pregnancy, live birth, negative effects, and quality of life in couples trying to conceive.
Study characteristics
We found seven randomised controlled trials (a type of study where participants are randomly assigned to one of two or more treatment groups) comparing timed intercourse versus intercourse without ovulation prediction in 2464 women or couples trying to conceive. The evidence is current to January 2023.
Key results
We added three new studies at this update. The newly included studies strengthened our confidence in the effect of ovulation tests on couples trying to conceive.
We concluded that timing intercourse around the fertile period identified using a urine ovulation test probably increased the chances of pregnancy and live birth in women under 40 trying to conceive for under 12 months compared to intercourse without ovulation prediction. The results suggest that if the chance of pregnancy following intercourse without using urine ovulation tests is 18%, the chance following timed intercourse with urinary ovulation detection would be 20% to 28%. Moreover, 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, as many of the studies were funded by the manufacturers of the urine ovulation test, the results should be interpreted with caution. There is insufficient evidence to conclude the effect of timed intercourse on clinical pregnancy (ultrasound-confirmed pregnancy), adverse events such as stress, and quality of life. Due to limited data, we are uncertain of the effect of FABM in timed intercourse on pregnancy outcomes, adverse effects, and quality of life compared to intercourse without ovulation prediction.
Quality of the evidence
The overall quality of the evidence ranged from moderate to very low. Additional studies in this field are needed. The main limitations of the evidence were the small number of included studies, small study sizes, and potential for bias, given that many of the studies were funded by the manufacturer of the ovulation prediction device. As a result, the findings should be interpreted cautiously, and future studies may modify our 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.
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.
To evaluate the benefits and risks of ovulation prediction methods for timing intercourse on conception in couples trying to conceive.
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.
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.
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.
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.