Rural and Remote
Vol. 23 No 2 | Winter 2021
Letter to the Editor
Dr Joseph V Turner

This article is 3 years old and may no longer reflect current clinical practice.

Re: Fertility treatments other than IVF: fertility awareness methods, Autumn 2021 issue

It is pleasing to see dialogue on options other than IVF for people wishing to conceive. As Sutton and Allen point out, infertility is a common condition for which there are numerous treatments other than IVF that are both indicated and available.1 Non-IVF options are essential given that cost, sociocultural, and psychological factors limit IVF use, and that a minority of couples in Australia, including those who are infertile, access IVF.2

Initial management with lifestyle modification is introduced in the article, then ovulation tracking is discussed, noting that cycle awareness is an important aspect of achieving a pregnancy. They recommend ovulation tracking using blood test for luteinising hormone (LH) and then timing intercourse. There is, however, an evidence-based yet less-invasive technique that has been employed successfully for many years. Fertility awareness methods (FAMs) teach the woman to observe her mucus symptom which can then accurately predict the fertile window.3 Intercourse when there is peak fertile-type mucus present has been demonstrated to achieve higher pregnancy rates than intercourse when mucus is less fertile, or when there is no mucus present.4,5 A recent Australian study validated the utility of mucus monitoring and targeted intercourse for achieving pregnancy in fertile and infertile women.6 Given the considerable demonstrated benefit of teaching women how to monitor their mucus and cycle properly, it is unfortunate that this is not done routinely in primary care or fertility clinics.7

An area of increasing interest is that of restorative reproductive medicine. In a restorative approach, lifestyle, psychosocial, medical, and surgical deficits are individually addressed in order to restore optimum fertility for the couple. Several studies have demonstrated successful outcomes for management of infertility using this approach,8-10 however, we look forward to further research broadening the evidence base in this field. Sutton and Allen recommend testing for luteal phase progesterone deficiency,1 also known as luteal phase defect (LPD). Studies have identified that 67–86% of women diagnosed with unexplained fertility were found to have LPD, which has then been targeted with restorative reproductive medicinal and surgical treatment with good outcomes.9,10

The recommendation to test progesterone at seven days after the LH surge requires either serum or urine monitoring of LH. As mentioned above, women trained in FAMs are ideally placed to be able to determine the day of ovulation without the use of blood or urine testing. It is pleasing to note that Sutton and Allen recommend progesterone testing at a defined time after ovulation, rather than ‘day 21 in a 28 day cycle.’11 The latter cycle timing is commonly found in the literature11 and in clinical practice, and is not altogether helpful due to the variability in duration of women’s cycles and their timing of ovulation,12 particularly in those experiencing infertility.

In summary, the use of FAMs should be more widely encouraged since they are a cost effective, accurate, and non-invasive method of determining ovulation, which can assist timing of intercourse to achieve pregnancy and determine optimal timing of luteal phase investigations.



  1. Sutton C, Allen M. Fertility treatments other than IVF. O&G Magazine. Vol 23. No 1. Autumn 2021.
  2. Herbert DL, Lucke JC, Dobson AJ. Infertility, medical advice and treatment with fertility hormones and/or in vitro fertilisation: a population perspective from the Australian Longitudinal Study on Women’s Health. Aust N Z J Public Health. 2009;33:358-64.
  3. Evans-Hoeker E, Pritchard DA, Long DL, et al. Cervical mucus monitoring prevalence and associated fecundability in women trying to conceive. Fertil Steril. 2013;100:1033-8.e1.
  4. Scarpa B, Dunson DB, Colombo B. Cervical mucus secretions on the day of intercourse: an accurate marker of highly fertile days. Eur J Obstet Gynecol Reprod Biol. 2006;125:72-8.
  5. Ecochard R, Duterque O, Leiva, R, et al. Self-identification of the clinical fertile window and the ovulation period. Fertil Steril. 2015;103:1319-25 e3.
  6. Marshell M, Corkill M, Whitty M, et al. Stratification of fertility potential according to cervical mucus symptoms: achieving pregnancy in fertile and infertile couples. Human Fertility. 2019:1-7.
  7. Hampton K, Newton JM. Assisting women to conceive: a clinical update on fertility awareness. Australian Nursing and Midwifery Journal. 2016;24:24-6.
  8. Boyle PC, Stanford J. NaProTechnology (Natural Procreative Technology) – A Multifactorial Approach to the Chronic Problem of Infertilty. Sveikatos Mokslai. 2011;21:61-8.
  9. Stanford JB, Parnell TA, Boyle PC. Outcomes from treatment of infertility with natural procreative technology in an Irish general practice. J Am Board Fam Med. 2008;21:375-84.
  10. Tham E. Schliep,K, Stanford J. Natural procreative technology for infertility and recurrent miscarriage: outcomes in a Canadian family practice. Can Fam Physician. 2012;58:e267-74.
  11. Avagliano S, Deans R. Investigation of the couple with infertility. O&G Magazine. Vol 23. No 1. Autumn 2021.
  12. Wilcox AJ, Dunson D, Baird DD. The timing of the “fertile window” in the menstrual cycle: day specific estimates from a prospective study. BMJ (Clinical research ed). 2000;321:1259-62.

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