Symul, L., Wac, K., Hillard, P., & Salathé, M. (2019). Assessment of menstrual health status and evolution through mobile apps for fertility awareness. NPJ digital medicine, 2(1), 64. https://doi.org/10.1038/s41746-019-0139-4
Symul L, Wac K, Hillard P, Salathé M. Assessment of menstrual health status and evolution through mobile apps for fertility awareness. NPJ Digit Med. 2019;2(1):64. doi:10.1038/s41746-019-0139-4
Symul, Laura, et al. "Assessment of menstrual health status and evolution through mobile apps for fertility awareness." NPJ digital medicine, vol. 2, no. 1, 2019, pp. 64.
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Only 24% of estimated ovulations fell on cycle days 14 to 15
Only about 24 out of 100 estimated ovulations fell on cycle days 14 to 15 in a 2019 retrospective study of two fertility awareness apps. Researchers modeled ovulation in 109,161 cycles with a reliable estimate. In those cycles, the median follicular phase lasted 16 days.
Key Findings
Of 109,161 cycles with a reliable ovulation estimate (28,453 Sympto, 80,708 Kindara), only about 24% had ovulation on days 14 to 15 of the cycle.
In the same cycles, the median follicular phase (ovulation time) was 16 days, and 90% of ovulations occurred between day 10 and day 24.
The median luteal phase lasted 12 days in Kindara and 13 days in Sympto. About 35% of cycles had a luteal phase of 12 to 13 days.
Among those cycles, about 20% had a luteal phase of 10 days or less, a higher share than the 4.5% reported in a previous epidemiological study.
Temperature shifted by about 0.36 °C (0.7 °F) between the mid-follicular phase and the mid-luteal phase, consistent with a much smaller earlier cohort.
Interpretation
The study is a retrospective analysis of de-identified entries that app users logged themselves. The users were self-selected, about 30 years old on average, mostly in Europe or North America. A statistical model (a Hidden Markov Model) estimated ovulation from temperature and mucus entries. The study had no ultrasound or hormone testing. The reliability criteria removed about 40% of Sympto and about 89% of Kindara standard cycles. The authors list a possibly biased population and unverified mucus entries as limits. They did not test whether tracking helps users.
RRM Context
Fertility awareness methods locate ovulation from a woman's own body signs, such as temperature and cervical mucus. Cycle-charting-informed care starts from each woman's own timing. This dataset shows a wide spread in the estimated day of ovulation, which a calendar rule built on day 14 cannot reflect.
Our editorial summary of this paper, not the article's abstract.
Abstract
For most women of reproductive age, assessing menstrual health and fertility typically involves regular visits to a gynecologist or another clinician. While these evaluations provide critical information on an individual's reproductive health status, they typically rely on memory-based self-reports, and the results are rarely, if ever, assessed at the population level. In recent years, mobile apps for menstrual tracking have become very popular, allowing us to evaluate the reliability and tracking frequency of millions of self-observations, thereby providing an unparalleled view, both in detail and scale, on menstrual health and its evolution for large populations. In particular, the primary aim of this study was to describe the tracking behavior of the app users and their overall observation patterns in an effort to understand if they were consistent with previous small-scale medical studies. The secondary aim was to investigate whether their precision allowed the detection and estimation of ovulation timing, which is critical for reproductive and menstrual health. Retrospective self-observation data were acquired from two mobile apps dedicated to the application of the sympto-thermal fertility awareness method, resulting in a dataset of more than 30 million days of observations from over 2.7 million cycles for two hundred thousand users. The analysis of the data showed that up to 40% of the cycles in which users were seeking pregnancy had recordings every single day. With a modeling approach using Hidden Markov Models to describe the collected data and estimate ovulation timing, it was found that follicular phases average duration and range were larger than previously reported, with only 24% of ovulations occurring at cycle days 14 to 15, while the luteal phase duration and range were in line with previous reports, although short luteal phases (10 days or less) were more frequently observed (in up to 20% of cycles). The digital epidemiology approach presented here can help to lead to a better understanding of menstrual health and its connection to women's health overall, which has historically been severely understudied.
There has been a phenomenal worldwide increase in the development and use of mobile health applications (mHealth apps) that monitor menstruation and fertility. Critics argue that many of the apps are inaccurate and lack evidence from either clinical trials or user experience. The aim of this scoping review is to provide an overview of the research literature on mHealth apps that track menstruation and fertility. This project followed the PRISMA Extension for Scoping Reviews. The ACM, CINAHL, Google Scholar, PubMed and Scopus databases were searched for material published between 1 January 2010 and 30 April 2019. Data summary and synthesis were used to chart and analyse the data. In total 654 records were reviewed. Subsequently, 135 duplicate records and 501 records that did not meet the inclusion criteria were removed. Eighteen records from 13 countries form the basis of this review. The papers reviewed cover a variety of disciplinary and methodological frameworks. Three main themes were identified: fertility and reproductive health tracking, pregnancy planning, and pregnancy prevention. Motivations for fertility app use are varied, overlap and change over time, although women want apps that are accurate and evidence-based regardless of whether they are tracking their fertility, planning a pregnancy or using the app as a form of contraception. There is a lack of critical debate and engagement in the development, evaluation, usage and regulation of fertility and menstruation apps. The paucity of evidence-based research and absence of fertility, health professionals and users in studies is raised.
Stanford JB et al., 2020·Hum Reprod·Free full text on PubMed Central
To what extent does the use of mobile computing apps to track the menstrual cycle and the fertile window influence fecundability among women trying to conceive? After adjusting for potential confounders, use of any of several different apps was associated with increased fecundability ranging from 12% to 20% per cycle of attempt. Many women are using mobile computing apps to track their menstrual cycle and the fertile window, including while trying to conceive. STUDY DESIGN, SIZE, The Pregnancy Study Online (PRESTO) is a North American prospective internet-based cohort of women who are aged 21-45 years, trying to conceive and not using contraception or fertility treatment at baseline. PARTICIPANTS/MATERIALS, SETTING, We restricted the analysis to 8363 women trying to conceive for no more than 6 months at baseline; the women were recruited from June 2013 through May 2019. Women completed questionnaires at baseline and every 2 months for up to 1 year. The main outcome was fecundability, i.e. the per-cycle probability of conception, which we assessed using self-reported data on time to pregnancy (confirmed by positive home pregnancy test) in menstrual cycles. On the baseline and follow-up questionnaires, women reported whether they used mobile computing apps to track their menstrual cycles ('cycle apps') and, if so, which one(s). We estimated fecundability ratios (FRs) for the use of cycle apps, adjusted for female age, race/ethnicity, prior pregnancy, BMI, income, current smoking, education, partner education, caffeine intake, use of hormonal contraceptives as the last method of contraception, hours of sleep per night, cycle regularity, use of prenatal supplements, marital status, intercourse frequency and history of subfertility. We also examined the impact of concurrent use of fertility indicators: basal body temperature, cervical fluid, cervix position and/or urine LH. MAIN Among 8363 women, 6077 (72.7%) were using one or more cycle apps at baseline. A total of 122 separate apps were reported by women. We designated five of these apps before analysis as more likely to be effective (Clue, Fertility Friend, Glow, Kindara, Ovia; hereafter referred to as 'selected apps'). The use of any app at baseline was associated with 20% increased fecundability, with little difference between selected apps versus other apps (selected apps FR (95% CI): 1.20 (1.13, 1.28); all other apps 1.21 (1.13, 1.30)). In time-varying analyses, cycle app use was associated with 12-15% increased fecundability (selected apps FR (95% CI): 1.12 (1.04, 1.21); all other apps 1.15 (1.07, 1.24)). When apps were used at baseline with one or more fertility indicators, there was higher fecundability than without fertility indicators (selected apps with indicators FR (95% CI): 1.23 (1.14, 1.34) versus without indicators 1.17 (1.05, 1.30); other apps with indicators 1.30 (1.19, 1.43) versus without indicators 1.16 (1.06, 1.27)). In time-varying analyses, results were similar when stratified by time trying at study entry (<3 vs. 3-6 cycles) or cycle regularity. For use of the selected apps, we observed higher fecundability among women with a history of subfertility: FR 1.33 (1.05-1.67). LIMITATIONS, Neither regularity nor intensity of app use was ascertained. The prospective time-varying assessment of app use was based on questionnaires completed every 2 months, which would not capture more frequent changes. Intercourse frequency was also reported retrospectively and we do not have data on timing of intercourse relative to the fertile window. Although we controlled for a wide range of covariates, we cannot exclude the possibility of residual confounding (e.g. choosing to use an app in this observational study may be a marker for unmeasured health habits promoting fecundability). Half of the women in the study received a free premium subscription for one of the apps (Fertility Friend), which may have increased the overall prevalence of app use in the time-varying analyses, but would not affect app use at baseline. Most women in the study were college educated, which may limit application of results to other populations. Use of a cycle app, especially in combination with observation of one or more fertility indicators (basal body temperature, cervical fluid, cervix position and/or urine LH), may increase fecundability (per-cycle pregnancy probability) by about 12-20% for couples trying to conceive. We did not find consistent evidence of improved fecundability resulting from use of one specific app over another. STUDY FUNDING/COMPETING INTEREST(S): This research was supported by grants, R21HD072326 and R01HD086742, from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, USA. In the last 3 years, Dr L.A.W. has served as a fibroid consultant for AbbVie.com. Dr L.A.W. has also received in-kind donations from Sandstone Diagnostics, Swiss Precision Diagnostics, FertilityFriend.com and Kindara.com for primary data collection and participant incentives in the PRESTO cohort. Dr J.B.S. reports personal fees from Swiss Precision Diagnostics, outside the submitted work. The remaining authors have nothing to declare. N/A.
Costa Figueiredo M et al., 2021·JAMIA Open·Free full text on PubMed Central
Fertility is becoming increasingly supported by consumer health technologies, especially mobile apps that support self-tracking activities. However, it is not clear whether the apps support the variety of goals and life events of those who menstruate, especially during transitions between them. Thirty-one of the most popular fertility apps were evaluated, analyzing data from three sources: the content of app store pages, app features, and user reviews. Findings: Results suggest that fertility apps are designed to support specific life goals of people who menstruate, offering several data collection features and limited feedback options. However, users often desire holistic tracking that encompasses a variety of goals, life events, and the transitions among them. These findings suggest fertility patients can benefit more from holistic self-tracking and provide insights for future design of consumer health technologies that better support holistic fertility tracking. Fertility apps have the potential to support varied experiences of people who menstruate. But to achieve that, apps need to expand their support by offering ways for more users to perform holistic, personalized, and personally meaningful tracking, so they can derive long-term benefit from the data they collect.
Ali R et al., 2020·Reprod Biomed Online·Free to read
To characterize mobile fertility tracking applications (apps) to determine the use of such apps for women trying to conceive by identifying the fertile window.
An exploratory cross-sectional audit study was conducted of fertility tracking applications. Ninety out of a possible total 200 apps were included for full review. The main outcome measures were the underlying app method for predicting ovulation, the fertile window, or both, price to download and use the app, disclaimers and cautions, information and features provided and tracked, and app marketing strategies.
All the apps except one monitored the women's menstrual cycle dates. Most apps only tracked menstrual cycle dates (n = 49 [54.4%]). The remainder tracked at least one fertility-based awareness method (basal body temperature, cervical mucus, LH) (n = 41 [45.6%]). Twenty-five apps measured dates, basal body temperature, LH and cervical mucus (27.8%). Seventy-six per cent of apps were free to download with free apps having more desirable features, tracking more measures and having more and better quality educational insights than paid apps. Seventy per cent of apps were classified as feminine apps, 41% of which were pink in colour. Mobile fertility tracking apps are heterogenous in their underlying methods of predicting fertile days, the price to obtain full app functionality, and in content and design. Unreliable calendar apps remain the most commonly available fertility apps on the market. The unregulated nature of fertility apps is a concern that could be addressed by app regulating bodies. The possible benefit of using fertility apps to reduce time to pregnancy needs to be evaluated.
Fertility Awareness › Technology › Cycle Tracking Apps · Menstrual Cycle › Cycle Biomarkers › Basal Body Temperature · Research Methods › Measurement and Statistics › Data Visualization and Cycle Analytics
Marcel Salathé, Laura Symul, Katarzyna Wac
M Salathé, L Symul, K Wac
PMID 31341953 31341953 DOI 10.1038/s41746-019-0139-4 10.1038/s41746-019-0139-4 Symul et al. 2019, Symul 2019
Cite this article
Symul, L., Wac, K., Hillard, P., & Salathé, M. (2019). Assessment of menstrual health status and evolution through mobile apps for fertility awareness. NPJ digital medicine, 2(1), 64. https://doi.org/10.1038/s41746-019-0139-4
Symul L, Wac K, Hillard P, Salathé M. Assessment of menstrual health status and evolution through mobile apps for fertility awareness. NPJ Digit Med. 2019;2(1):64. doi:10.1038/s41746-019-0139-4
Symul, Laura, et al. "Assessment of menstrual health status and evolution through mobile apps for fertility awareness." NPJ digital medicine, vol. 2, no. 1, 2019, pp. 64.
