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. 2023 Sep 15;9(9):CD011345.
doi: 10.1002/14651858.CD011345.pub3.

Timed intercourse for couples trying to conceive

Tatjana Gibbons  1 , Jane Reavey  2 , Ektoras X Georgiou  3 , Christian M Becker  1
Affiliations

Timed intercourse for couples trying to conceive

Tatjana Gibbons et al. Cochrane Database Syst Rev. .

Abstract

Background: 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.

Objectives: To evaluate the benefits and risks of ovulation prediction methods for timing intercourse on conception in couples trying to conceive.

Search methods: 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.

Selection criteria: 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.

Data collection and analysis: 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.

Main results: 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.

Authors' 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.

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Conflict of interest statement

TG has no conflicts of interest to declare.

JR has no conflicts of interest to declare.

EG has no conflicts of interest to declare.

CB has no conflicts of interest to declare.

Figures

1
1
Study flow diagram.
2
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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Forest plot displaying evidence for the use of urine ovulation prediction compared to spontaneous intercourse for the outcome live birth after use of the intervention for two cycles in fertile couples.
5
5
Forest plot displaying evidence for the use of urine ovulation prediction compared to spontaneous intercourse for the outcome perceived stress after three cycles in fertile couples.
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6
Forest plot displaying evidence for the use of urine ovulation prediction tests compared to spontaneous intercourse for the outcome clinical pregnancy after use of the intervention for three cycles in couples with unexplained infertility or male factor with a reduced motility index.
7
7
Forest plot displaying evidence for the use of urine ovulation prediction tests compared to spontaneous intercourse on pregnancy rate after use of the intervention for two or three cycles in mainly fertile couples (93%).
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8
Forest plot displaying evidence for the use of FABM compared to spontaneous intercourse for the outcome live birth after use of the intervention for seven to eight cycles in mainly fertile couples (90%).
9
9
Forest plot displaying evidence for the use of FABM compared to spontaneous intercourse on stress after 12 months in fertile couples.
10
10
Forest plot displaying evidence for the use of FABM compared to spontaneous intercourse for the outcome clinical pregnancy after use of the intervention for eight cycles in couples with unexplained infertility.
11
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Forest plot displaying evidence for the use of FABM compared to spontaneous intercourse on pregnancy rate after use of the intervention for two cycles to 12 months in mainly fertile couples (93%).
1.1
1.1. Analysis
Comparison 1: Urinary ovulation detection versus spontaneous intercourse, Outcome 1: Live birth
1.2
1.2. Analysis
Comparison 1: Urinary ovulation detection versus spontaneous intercourse, Outcome 2: Adverse event: stress
1.3
1.3. Analysis
Comparison 1: Urinary ovulation detection versus spontaneous intercourse, Outcome 3: Clinical pregnancy
1.4
1.4. Analysis
Comparison 1: Urinary ovulation detection versus spontaneous intercourse, Outcome 4: Pregnancy rate (clinical pregnancy or positive urine pregnancy test)
2.1
2.1. Analysis
Comparison 2: Fertility awareness‐based methods versus spontaneous intercourse, Outcome 1: Live birth
2.2
2.2. Analysis
Comparison 2: Fertility awareness‐based methods versus spontaneous intercourse, Outcome 2: Adverse events
2.3
2.3. Analysis
Comparison 2: Fertility awareness‐based methods versus spontaneous intercourse, Outcome 3: Clinical pregnancy
2.4
2.4. Analysis
Comparison 2: Fertility awareness‐based methods versus spontaneous intercourse, Outcome 4: Pregnancy rate (clinical pregnancy or positive urine pregnancy test)
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