Skip to main content

Natural conception rates in subfertile couples following fertility awareness training



To analyze cumulative pregnancy rates of subfertile couples after fertility awareness training.


A prospective observational cohort study followed 187 subfertile women, who had received training in self-observation of the fertile phase of the menstrual cycle with the Sensiplan method, for 8 months. The women, aged 21–47 years, had attempted to become pregnant for 3.5 years on average (range 1–8 years) before study entry. Amenorrhea, known tubal occlusion and severe male factor had been excluded. An additional seven women, who had initially been recruited, became pregnant during the cycle immediately prior to Sensiplan training: this is taken to be the spontaneous pregnancy rate per cycle in the cohort in the absence of fertility awareness training.


The cumulative pregnancy rate of subfertile couples after fertility awareness training was 38% (95% CI 27–49%; 58 pregnancies) after eight observation months, which is significantly higher than the estimated basic pregnancy rate of 21.6% in untrained couples in the same cohort. For couples who had been seeking to become pregnant for 1–2 years, the pregnancy rate increased to 56% after 8 months. A female age above 35 (cumulative pregnancy rate 25%, p = 0.06), couples who had attempted to become pregnant for more than 2 years (cumulative pregnancy rate 17%, p < 0.01), all significantly reduce the chances of conceiving naturally at some point.


Training women to identify their fertile window in the menstrual cycle seems to be a reasonable first-line therapy in the management of subfertility.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3


  1. 1.

    Raith-Paula E, Frank-Herrmann P, Freundl G, Strowitzki T (2013) Natürliche Familienplanung heute. Springer, Heidelberg ISBN 783642297830

    Book  Google Scholar 

  2. 2.

    Fehring RJ (2002) Accuracy of the peak day of cervical mucus as a biological marker of fertility. Contraception 66:231–235

    Article  PubMed  Google Scholar 

  3. 3.

    Fehring RJ, Schneider M, Raviele K (2006) Variability in the phases of the menstrual cycle. J Obstet Gynecol Neonatal Nurs 35:376–384

    Article  PubMed  Google Scholar 

  4. 4.

    Wilcox AJ, Dunson D (2000) The timing of the “fertile window” in the menstrual cycle: day specific estimates from a prospective study. BMJ 321:1259–1262

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Practice Committee of American Society for Reproductive Medicine in collaboration with Society for Reproductive Endocrinology and Infertility (2008) Optimizing natural fertility. Fertil Steril 90:S1–S5

    Google Scholar 

  6. 6.

    Gnoth C, Frank-Herrmann P, Freundl G, Kunert J, Godehardt E (1995) Sexual behavior of natural family planning users in Germany and its changes over time. Adv Contracept 11:173–185

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Klann N, Frank-Herrmann P, Sottong U (1993) Auswirkungen einer natürlichen Familienplanung: Wie verändern sich Sexualverhalten und Partnerschaft? Sexualmedizin 22:384–386

    Google Scholar 

  8. 8.

    Frank-Herrmann P, Gnoth C, Baur S, Strowitzki T, Freundl G (2005) Determination of the fertile window: reproductive competence of women—European cycle databases. Gynecol Endocrinol 20:305–312

    Article  PubMed  Google Scholar 

  9. 9.

    Ecochard R, Boehringer H, Rabilloud M, Marret H (2001) Chronological aspects of ultrasonic, hormonal, and other indirect indices of ovulation. BJOG 108:822–829

    CAS  PubMed  Google Scholar 

  10. 10.

    Gnoth C, Frank-Herrmann P, Bremme M. et al (1996) Wie korrelieren selbstbeobachtete Zyklussymptome mit der Ovulation? [How do self-observed cycle symptoms correlate with ovulation?]. Zentralbl Gynaekol 118:650–654

    CAS  Google Scholar 

  11. 11.

    Colombo B, Mion A, Passarin K, Scarpa B (2006) Cervical mucus symptom and daily fecundability: first results from a new database. Stat Methods Med Res 15:161–180

    Article  PubMed  Google Scholar 

  12. 12.

    Stanford JB, Mikolajczyk RT, Lynch CD, Simonsen SE (2010) Cumulative pregnancy probabilities among couples with subfertility: effects of varying treatments. Fertil Steril 93:2175–2181

    Article  PubMed  Google Scholar 

  13. 13.

    Frank-Herrmann P, Heil J, Gnoth C et al (2007) The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple’s sexual behaviour during the fertile time: a prospective longitudinal study. Hum Reprod 22:1310–1319

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    European Natural Family Planning Study Groups (1999) European multicenter study of natural family planning: efficacy and drop-out. Adv Contracept 15:69–83

    Article  Google Scholar 

  15. 15.

    Alliende ME, Cabezon C, Figueroa H, Kottmann C (2005) Cervicovaginal fluid changes to detect ovulation accurately. Am J Obstet Gynecol 193:71–75

    Article  PubMed  Google Scholar 

  16. 16.

    Guida M, Tommaselli GA, Palomba S, Pellicano M, Moccia G, Di Carlo C (1999) Efficacy of methods for determining ovulation in a natural family planning program. Fertil Steril 72:900–904

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Bigelow JL, Dunson DB, Stanford JB, Ecochard R, Gnoth C, Colombo B (2004) Mucus observations in the fertile window: a better predictor of conception than timing of intercourse. Hum Reprod 19:889–892

    Article  PubMed  Google Scholar 

  18. 18.

    Stanford JB, White GL, Hatasaka H (2002) Timing intercourse to achieve pregnancy: current evidence. Obstet Gynecol 100:1333–1341

    PubMed  Google Scholar 

  19. 19.

    Dunson DB, Colombo B, Baird DD (2002) Changes with age in the level and duration of fertility in the menstrual cycle. Hum Reprod 17:1399–1403

    Article  PubMed  Google Scholar 

  20. 20.

    Wilcox AJ, Weinberg CR, Baird DD (1995) Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception, survival of the pregnancy, and sex of the baby. N Engl J Med 333:1517–1521

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Scarpa B, Dunson DB, Giacchi E (2007) Bayesian selection of optimal rules for timing intercourse to conceive by using calendar and mucus. Fertil Steril 88:915–924

    Article  PubMed  Google Scholar 

  22. 22.

    Gnoth C, Godehardt D, Godehardt E, Frank-Herrmann P, Freundl G (2003) Time to pregnancy: results of the German prospective study and impact on the management of infertility. Hum Reprod 18:1959–1966

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Practice Committee of American Society for Reproductive Medicine in collaboration with Society for Reproductive Endocrinology and Infertility (2013) Optimizing natural fertility: a committee opinion. Fertil Steril 100:631–637

    Article  Google Scholar 

  24. 24.

    Boivin J, Bunting L, Collins JA, Nygren KG (2009) Reply: International estimates on infertility prevalence and treatment-seeking: potential need and demand for medical care. Hum Reprod 24:2380–2383

    Article  Google Scholar 

  25. 25.

    Herbert DL, Lucke JC, Dobson AJ (2009) Infertility, medical advice and treatment with fertility hormones and/or in vitro fertilization: a population perspective from the Australian Longitudinal Study on Women’s Health. Aust N Z J Public Health 33:358–364

    Article  PubMed  Google Scholar 

  26. 26.

    Thijssen A, Meier A, Panis K, Ombelet W (2014) Fertility Awareness-Based Methods and subfertility: a systematic review. Facts Views Vis Obgyn 6:113–123

    CAS  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Gnoth C, Godehardt E, Frank-Herrmann P, Friol K, Tigges J, Freundl G (2005) Definition and prevalence of subfertility and infertility. Hum Reprod 20:1144–1147

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Ziller V, Heilmaier C, Kostev K (2015) Time to pregnancy in subfertile women in German gynecological practices: analysis of a representative cohort of more than 60,000 patients. Arch Gynecol Obstet 291:657–662

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Arbeitsgruppe NFP (2011) Natürlich und sicher—das Praxisbuch. Trias, Stuttgart, ISBN9783830423645

    Google Scholar 

  30. 30.

    Colombo B, Masarotto G (2000) Daily fecundability: First results from a new data base. Demogr Res 3:39

    Article  Google Scholar 

  31. 31.

    Evers JL (2002) Female subfertility. Lancet 360:151–159

    Article  PubMed  Google Scholar 

  32. 32.

    Snick HK, Snick TS, Evers JL, Collins JA (1997) The spontaneous pregnancy prognosis in untreated subfertile couples: the Walcheren primary care study. Hum Reprod 12:1582–1588

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Sozou PD, Hartshorne GM (2012) Time to Pregnancy: A Computational Method for Using the Duration of Non-Conception for Predicting Conception. PLoS One 7:e46544

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Robinson JE, Wakelin M, Ellis JE (2007) Increased pregnancy rate with use of the Clearblue Easy Fertility Monitor. Fertil Steril 87:329–334

    Article  PubMed  Google Scholar 

  35. 35.

    Pyper C, Bromhall L, Dummett S, Altman DG, Brownbill P, Murphy M (2006) The Oxford Conception Study design and recruitment experience. Paediatr Perinat Epidemiol 20(Suppl 1):51–59

    Article  PubMed  Google Scholar 

  36. 36.

    Stanford JB, Smith KR, Varner MW (2014) Impact of instruction in the Creighton model fertility care system on time to pregnancy in couples of proven fecundity: results of a randomised trial. Paediatr Perinat Epidemiol 28:391–399

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Manders M, McLindon L, Schulze B, Beckmann MM, Kremer JA, Farquhar C (2015) Timed intercourse for couples trying to conceive. Cochrane Database Syst Rev. doi:10.1002/14651858.CD011345.pub2

    PubMed  Google Scholar 

  38. 38.

    Scarpa B, Dunson DB, Colombo B (2006) Cervical mucus secretions on the day of intercourse: an accurate marker of highly fertile days. Eur J Obstet Gynecol Reprod Biol 125:72–78

    Article  PubMed  Google Scholar 

  39. 39.

    Dunson DB, Baird DD, Wilcox AJ, Weinberg CR (1999) Day-specific probabilities of clinical pregnancy based on two studies with imperfect measures of ovulation. Hum Reprod 14:1835–1839

    CAS  Article  PubMed  Google Scholar 

  40. 40.

    Evans-Hoeker E, Pritchard DA, Long DL, Herring AH, Stanford JB, Steiner AZ (2013) Cervical mucus monitoring prevalence and associated fecundability in women trying to conceive. Fertil Steril 100:1033–1038

    Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Grimes DA, Gallo MF, Grigorieva V, Nanda K, Schulz KF (2004) Fertility awareness-based methods for contraception. Cochrane Database Syst Rev. doi:10.1002/14651858.CD004860.pub2

    Google Scholar 

  42. 42.

    NICE (2004) Fertility assessment and treatment for people with fertility problems. National Institute for Health and Clinical Excellence, London

    Google Scholar 

  43. 43.

    Hampton K, Mazza D (2009) Should spontaneous or timed intercourse guide couples trying to conceive? Hum Reprod 24:3236–3237

    Article  PubMed  Google Scholar 

  44. 44.

    Hampton KD, Mazza D, Newton JM (2013) Fertility-awareness knowledge, attitudes, and practices of women seeking fertility assistance. J Adv Nurs 69:1076–1084

    Article  PubMed  Google Scholar 

  45. 45.

    Blake D, Smith D, Bargiacchi A, France M, Gudex G (1997) Fertility awareness in women attending a fertility clinic. Aust N Z J Obstet Gynaecol 37:350–352

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Hammarberg K, Zosel R, Comoy C, Robertson S, Holden C, Deeks M, Johnson L (2016) Fertility-related knowledge and information-seeking behaviour among people of reproductive age: a qualitative study. Hum Fertil (Camb) 25:1–11

    Article  Google Scholar 

  47. 47.

    Brosens I, Gordts S, Valkenburg M, Puttemans P, Campo R, Gordts S (2004) Investigation of the infertile couple: when is the appropriate time to explore female infertility? Hum Reprod 19:1689–1692

    Article  PubMed  Google Scholar 

  48. 48.

    Sievert LL, Dubois CA (2005) Validating signals of ovulation: do women who think they know, really know? Am J Hum Biol 17:310–320

    Article  PubMed  Google Scholar 

  49. 49.

    Mu Q, Fehring RJ (2014) Efficacy of achieving pregnancy with fertility-focused intercourse. MCN. Am J Matern Child Nurs 39:35–40

    Article  Google Scholar 

  50. 50.

    Dunson DB, Sinai I, Colombo B (2001) The relationship between cervical secretions and the daily probabilities of pregnancy: effectiveness of the two day algorithm. Hum Reprod 16:2278–2282

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    Keulers MJ, Hamilton CJ, Franx A, Evers JL, Bots RS (2007) The length of the fertile window is associated with the chance of spontaneously conceiving an ongoing pregnancy in subfertile couples. Hum Reprod 22:1652–1656

    CAS  Article  PubMed  Google Scholar 

  52. 52.

    Stanford JB, Smith KR, Dunson DB (2003) Vulvar mucus observations and the probability of pregnancy. Obstet Gynecol 101:1285–1293

    PubMed  Google Scholar 

  53. 53.

    Gnoth C, Frank-Herrmann P, Freundl G (2002) Opinion: natural family planning and the management of infertility. Arch Gynecol Obstet 267:67–71

    Article  PubMed  Google Scholar 

  54. 54.

    Brosens I, Brosens J (2006) Managing infertility with fertility-awareness methods. Sex Reprod Menopause 4:13–16

    Article  Google Scholar 

  55. 55.

    De Cicco S, Tagliaferri V, Selvaggi L et al (2016) Expectant management may reduce overtreatment in women affected by unexplained infertility confirmed by diagnostic laparoscopy. Arch Gynecol Obstet. doi:10.1007/s00404-016-4246-z

    PubMed  Google Scholar 

Download references


The authors cordially thank Sylvia Heil-Schlehuber for her dedicated assistance and her valuable comments. The study was funded by the Jung-Stiftung für Wissenschaft und Forschung.

Author information



Corresponding author

Correspondence to P. Frank-Herrmann.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest. They do not have any financial relationship with the organization that sponsored the research. They have had full control of all primary data and they agree to allow the Journal to review the data if requested.

Ethical approval

Ethical approval was given by the Section of Natural Fertility of the German Society of Gynecological Endocrinology and Fertility Medicine at the University of Heidelberg. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki of 1964 and its later amendments.

Informed consent

Informed consent was obtained from all individual participants included in the study. They were free to withdraw at any time.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Frank-Herrmann, P., Jacobs, C., Jenetzky, E. et al. Natural conception rates in subfertile couples following fertility awareness training. Arch Gynecol Obstet 295, 1015–1024 (2017).

Download citation


  • Subfertility
  • Pregnancy rate
  • Natural family planning
  • Fertility awareness method
  • Sensiplan