Bouchard, T., Fehring, R. J., & Schneider, M. (2013). Efficacy of a new postpartum transition protocol for avoiding pregnancy. Journal of the American Board of Family Medicine : JABFM, 26(1), 35-44. https://doi.org/10.3122/jabfm.2013.01.120126
Bouchard T, Fehring RJ, Schneider M. Efficacy of a new postpartum transition protocol for avoiding pregnancy. J Am Board Fam Med. 2013;26(1):35-44. doi:10.3122/jabfm.2013.01.120126
Bouchard, Thomas, et al. "Efficacy of a new postpartum transition protocol for avoiding pregnancy." Journal of the American Board of Family Medicine : JABFM, vol. 26, no. 1, 2013, pp. 35-44.
Marquette postpartum users had 8 unintended pregnancies per 100 women
Women on the Marquette postpartum protocol had 8 unintended pregnancies per 100 over 12 months. This cohort study followed 198 postpartum women who joined online, mostly breastfeeding. Among them, the rate with correct use was 2 per 100. The cohort had no control group.
Key Findings
Among 198 postpartum women charting online, 0 per 100 had an unintended pregnancy by 6 months of use. The total reached 8 per 100 women by 12 months.
With correct use, the rate in the first 12 months postpartum was 2 unintended pregnancies per 100 women. The two method-related pregnancies came in the ninth and 12th months.
Of 337 postpartum women who registered on the website, 198 (59%) used the online charting system: 183 breastfeeding and 15 not breastfeeding. Another 139 (41%) chose not to chart online.
Mean acceptability scores were 55.4 at 1 month, 57.7 at 3 months and 58.3 at 6 months on a 10 to 70 scale. The change across time points was not significant.
Interpretation
The study is a prospective cohort with no control group. The authors compare the rate with 11 to 24 per 100 woman-years for other natural family planning methods during the breastfeeding transition. They cannot say whether the lower rate reflects improvement or different participants. Volunteers were recruited online and were mostly white (73%), married (99%) and Catholic (79%). Only 74 women were still exposed at 12 months. Many registrants did not chart or had incomplete charts, and unreported pregnancies among women who stopped could make the rates an underestimate. The authors suggest the protocol may be more helpful for breastfeeding women after the first 6 months.
RRM Context
The Marquette method is a fertility awareness-based method. This protocol adapts its electronic hormonal fertility monitor to the postpartum transition. The authors cite earlier work. In it, two thirds of breastfeeding women ovulate before their first period after birth. Half of those have a luteal phase (the days after ovulation) long enough, in theory, to sustain a pregnancy.
Our editorial summary of this paper, not the article's abstract.
Abstract
Introduction
The postpartum period is a challenging time for family planning, especially for women who breastfeed. Breastfeeding delays the return of menses (lactational amenorrhea), but ovulation often occurs before first menses. For this reason, a protocol was developed to assist women in identifying their return of fertility postpartum to avoid pregnancy.
Methods
In this prospective, 12-month, longitudinal cohort study, 198 postpartum women aged 20 to 45 years (mean age, 30.2 years) were taught a protocol for avoiding pregnancy with either online or in-person instruction. A hand-held fertility monitor was used to identify the fertile period by testing for urinary changes in estrogen and luteinizing hormone, and the results were tracked on a web site. During lactational amenorrhea, urine testing was done in 20-day intervals. When menses returned, the monitor was reset at the onset of each new menstrual cycle. Participants were instructed to avoid intercourse during the identified fertile period. Kaplan-Meier survival analysis was used to calculate unintentional pregnancy rates through the first 12 months postpartum.
Results
There were 8 unintended pregnancies per 100 women at 12 months postpartum. With correct use, there were 2 unintended pregnancies per 100 women at 12 months.
Conclusion
The online postpartum protocol may effectively assist a select group of women in avoiding pregnancy during the transition to regular menstrual cycles.
Bouchard TP et al., 2026·Reproductive biomedicine online·Free to read
Do quantitative urinary hormone measurements on the Mira monitor predict and confirm ovulation accurately compared with ultrasound in women with regular menstrual cycles? Do Mira urine hormones correlate with serum hormones?
This was a prospective, single-centre, blinded diagnostic accuracy study with 52 women aged 19-44 years with regular cycles (24-38 days) who tracked 153 cycles over 18 months. Daily first-morning urine was tested with the Mira monitor for follicle stimulating hormone (FSH), oestrone-3-glucuronide (E13G), luteinizing hormone (LH) and pregnanediol glucuronide (PDG). Serial transvaginal ultrasounds (890 scans) confirmed the day of ovulation. Serum hormones were measured twice per cycle. The 121 ovulatory cycles from 49 participants with sufficient index test and reference standard data were included in the final analysis.
The Mira LH peak day strongly predicted ultrasound-confirmed ovulation (R² = 0.96, P < 0.001; intraclass correlation coefficient = 0.971), with 96% of ovulations occurring within ±1 day. The Mira PDG increase was also strongly associated with ultrasound-confirmed day of ovulation (R² = 0.87, P < 0.001). First-morning urine hormones were significantly associated with serum hormones when collected within 90 min (LH: R² = 0.92; E13G: R² = 0.73; R² = 0.61; R² = 0.75). Anovulatory cycles were identified in 11% of regularly cycling participants.
Quantitative urinary hormone monitoring with the Mira monitor provides accurate prediction and confirmation of ovulation, with strong urine-serum associations supporting reduced reliance on serial serum draws in select patients. These findings support clinical adoption of quantitative urinary fertility monitoring.
Cycle Across the Lifespan · Cycle and General Health
Bouchard TP et al., 2026·Journal of ovarian research·Free to read
Reproductive hormones of the fertile window are often referenced to women in regular cycles, but this may not be representative of the hormonal profiles of women in different circumstances like polycystic ovarian syndrome, the postpartum period, and the perimenopause transition. This observational cohort study sought to identify the variability in the reproductive hormones in various clinical circumstances and to establish potential thresholds for each category based on hormone measurements with the Mira urinary hormone monitor. A total of 57 women (ages 22-51) in various circumstances (regular cycles, polycystic ovarian syndrome, postpartum and perimenopause) tracked Mira urine hormone measurements (estrone-3-glucuronide, luteinizing hormone, pregnanediol glucuronide), contributing 444 cycles of data. Using additive mixed models, hormone values were stratified by the four different reproductive categories. The perimenopause and polycystic ovarian syndrome groups demonstrated relative hypoestrogenic states, while the perimenopause group showed low luteal pregnanediol glucuronide and the polycystic ovarian syndrome/polyendocrine metabolic ovarian syndrome (PCOS/PMOS) group showed high luteal pregnanediol glucuronide. The perimenopause group had significantly higher luteinizing hormone values throughout the whole cycle. The fertile window hormone thresholds vary depending on a woman's specific reproductive category. Women in different circumstances should not necessarily use the same hormonal thresholds for the fertile window and ovulation. A larger dataset with ultrasound correlation to ovulation is required to delineate the fertile window with more precision. Hormone differences across the menstrual cycle could be used for targeted treatments in polycystic ovarian syndrome and perimenopause women.
Bouchard TP et al., 2026·Reproductive biomedicine online·Free to read
Does formation of the corpus luteum help to identify the day of ovulation on ultrasound when follicular collapse is missed, and how reliable are sonographers versus a review panel in identifying the day of ovulation on ultrasound? Sonographers in a clinic in Canada performed serial endovaginal ultrasound scans (six to eight per cycle) to identify the day of ovulation in regularly cycling women (n = 40) who were followed for one to five cycles (n = 85). The day of ovulation was identified by: (i) identification of the dominant follicle; (ii) disappearance of the dominant follicle; and (iii) identification and dating of the corpus luteum. The main outcome measures were inter-rater reliability between two sonographers, and Bland-Altman agreement between the supervising sonographer and a panel that reviewed each scan to identify the day of ovulation. Of the 85 menstrual cycles reviewed, two cycles did not have sufficient data to date ovulation, one cycle showed an incidental dermoid cyst, and 11 cycles showed anovulatory patterns. This left a total of 71 cycles (84%) for which intra-rater reliability between two sonographers for identifying the day of ovulation was high (intraclass correlation coefficient = 0.99, P < 0.0001), and Bland-Altman agreement showed no significant difference in the estimated day of ovulation between the supervising sonographer and the panel (t = -0.28, P = 0.78). Corpus luteum criteria were necessary to help identify the day of ovulation in 14 of 71 cycles (20%). The estimated day of ovulation can be determined reliably on ultrasound by trained sonographers using collapse of the dominant follicle and formation of the corpus luteum based on six to eight scans per cycle.
To summarize the evidence on typical and perfect-use effectiveness of fertility awareness-based methods for avoiding pregnancy during the postpartum period, whether breastfeeding or not. We conducted a systematic review of studies published in English, Spanish, French, or German by November 2021 in MEDLINE, EMBASE, CINAHL, Web of Science, and ClinicalTrials.gov. Abstract and full text reviews were completed by 2 independent reviewers. Study inclusion: at least 50 subjects who enrolled prior to experiencing 3 cycles after childbirth and were using a specific fertility awareness-based method to avoid pregnancy; unintended pregnancy rate or probability calculated; postpartum amenorrheic and postpartum cycling individuals analyzed separately; and prospectively measured pregnancy intentions and outcomes. Outcomes were abstracted and study quality was systematically assessed by 2 independent investigators. Four studies provided effectiveness data for 1 specific fertility awareness-based method among postpartum individuals. Of these, there were zero high quality, 1 moderate quality, and 3 low quality for our question of interest. Typical-use pregnancy probability for the first 6 cycles postpartum for Marquette Method users was 12.0 per 100 women years (standard error [SE] not reported) and for Billings Ovulation Method users ranged from 9.1 (SE 3.9) for non-lactating women <30 years old to 26.8 (SE 4.6) for lactating women <30 years old. Typical-use pregnancy probabilities for the first 6 months post-first menses for the Postpartum Bridge to Standard Days Method users was 11.8 (95% confidence interval 6.01-17.16) and for Billings Ovulation Method users was 8.5 per 100 women (SE 1.7). The current evidence on the effectiveness of each fertility awareness-based method for postpartum persons is very limited and of mostly low quality. More high quality studies on the effectiveness of fertility awareness-based method in postpartum persons are needed to inform clinical counseling and patient-centered decision-making.
Although postpartum individuals may desire to use fertility awareness-based methods to avoid pregnancy, the evidence of the effectiveness of fertility awareness-based methods in this population is limited. More high-quality studies are needed to inform shared decision-making.
A protocol was developed and evaluated for nonovulating breastfeeding women to determine potential fertility with an electronic hormonal fertility monitor. The amount of required abstinence (i.e., days of potential fertility) through the first menstrual cycle indicated by the fertility monitor was significantly lower (17% of the total days) compared with the amount of abstinence (50% of the total days) indicated by the self-observation of cervical mucus.
Fehring RJ et al., 2017·J Obstet Gynecol Neonatal Nurs
To analyze the effectiveness of an online, nurse-managed natural family planning (NFP) program among breastfeeding women and subgroups of these women.
Longitudinal comparative cohort study.
A university-based online NFP education program and menstrual cycle charting system. Women (N = 816) with a mean age of 30.3 years (standard deviation = 4.5) who registered to use the online NFP system and indicated they were breastfeeding. Participants tracked their fertile times with an electronic hormone fertility monitor (EHFM), cervical mucus monitoring, or both. All unintended pregnancies were evaluated by professional nurses. The correct use pregnancy rates were 3 per 100 users over 12 cycles of use, and typical rates were 14 per 100 at 12 cycles of use. At 12 cycles of use, total pregnancy rates were 16 per 100 for electronic hormone fertility monitor users (n = 380), 81 per 100 among mucus-only users (n = 45), and 14 per 100 for electronic hormone fertility monitor plus mucus users (n = 391). Use of a nurse-managed online NFP program for women can be effective to help women avoid pregnancy while breastfeeding, especially with correct and consistent use.
A prospective six-year study (1975-1980) of 273 patients, monitored in the use of natural family planning (NFP), has shown that those with previously irregular menstrual cycles are disadvantaged in the subsequent use of the ovulation method after pregnancy in that they have fewer recognizable safe days and/or are more likely to have unplanned pregnancies than women who had regular cycles prior to pregnancy. Eight patients, seven nursing and one non-nursing mother, conceived during postpartum amenorrhoea. The reliability of memory in the recall of previous menstrual histories is discussed in relation to the results of an international study of menstrual cycles by the World Health Organization (WHO 1983). The relevance of prediction of menstrual events in natural family planning is also considered.
Fertility Awareness › Effectiveness › Typical and Perfect Use · Postpartum › Return of Fertility › Postpartum Charting · Menstrual Cycle › Cycle Biomarkers › Hormonal Markers
Thomas P Bouchard, Richard J Fehring, Mary Schneider
Tom Bouchard, T Bouchard, Rick Fehring, Dick Fehring, Rich Fehring, R Fehring, M Schneider
PMID 23288279 23288279 DOI 10.3122/jabfm.2013.01.120126 10.3122/jabfm.2013.01.120126 Bouchard et al. 2013, Bouchard 2013
Cite this article
Bouchard, T., Fehring, R. J., & Schneider, M. (2013). Efficacy of a new postpartum transition protocol for avoiding pregnancy. Journal of the American Board of Family Medicine : JABFM, 26(1), 35-44. https://doi.org/10.3122/jabfm.2013.01.120126
Bouchard T, Fehring RJ, Schneider M. Efficacy of a new postpartum transition protocol for avoiding pregnancy. J Am Board Fam Med. 2013;26(1):35-44. doi:10.3122/jabfm.2013.01.120126
Bouchard, Thomas, et al. "Efficacy of a new postpartum transition protocol for avoiding pregnancy." Journal of the American Board of Family Medicine : JABFM, vol. 26, no. 1, 2013, pp. 35-44.
Keywords
Adult, Amenorrhea/urine, Breast Feeding, Clinical Protocols, Estrogens/urine, Female, Fertile Period/urine, Humans, Internet, Kaplan-Meier Estimate, Longitudinal Studies, Luteinizing Hormone/urine, Middle Aged, Natural Family Planning Methods/instrumentation/methods, Outcome and Process Assessment, Health Care, Ovulation Detection/instrumentation/methods, Patient Acceptance of Health Care, Postpartum Period/urine, Pregnancy, Pregnancy, Unplanned, Prospective Studies, Estrogens, Luteinizing Hormone
