Fertility and Sterility On Air - Roundtable: Data-driven analysis of fertility optimization

Welcome to Fertility & Sterility Roundtable, hosted by Dr. Emily Barnard and Dr. Ben Peipert! Each week, we will host a discussion with the authors of "Views and Reviews" and "Fertile Battle" articles published in a recent issue of Fertility & Sterility.

Today, we will be discussing the Views and Reviews from the June 2026 edition of Fertility and Sterility entitled “Data Driven Analysis of Fertility Optimization”

This Views and Reviews brought together experts, some of whom we will be interviewing today, who evaluated and summarized the evidence on optimization of fertility using diet and lifestyle interventions, surgical restoration of anatomy, menstrual cycle tracking, and comparative data between these methods and in vitro fertilization. The authors discuss what we know and where knowledge gaps exist. I do encourage our listeners to read the full breadth of articles as I know this topic is something almost all my patients ask me about.

Dr. Eve Feinberg is a Professor and REI fellowship program director in the division of Reproductive Endocrinology and Infertility at Northwestern University Feinberg School of Medicine. Dr. Feinberg is both an Editorial Editor at Fertility and Sterility and co-host of our big-sister podcast Fertility and Sterility On Air.

Dr. David Boedeker is a first-year Reproductive Endocrinology fellow at the National Institutes of Health and an active duty physician in the United States Air Force. He completed his obstetrics and gynecology residency at Walter Reed National Military Medical Center and earned a master's degree in health policy and administration from Columbia University.

Welcome to Fertility and Sterility Roundtable. This podcast will delve into sections of the journal previously unexplored in the Fertility and Sterility podcast family. Articles that we would consider some of the most timely, cutting edge, thought-provoking, and dare I say, controversial.

We will be joined by a couple of the authors each month to explore the themes, debate the pros and cons, and generally expand our knowledge in a conversational format. I'm your host and FNS interactive associate, Dr. Emily Barnard. And I'm your co-host and producer, Dr. Ben Peipert.

We will be covering articles in the fertile battle and views and reviews portions of Fertility and Sterility. This podcast is brought to you by the Fertility and Sterility family of journals in conjunction with the American Society for Reproductive Medicine. Welcome everyone to Fertility and Sterility Roundtable.

I'm your host, Dr. Emily Barnard, and I'm joined by my producer and co-host, Dr. Ben Peipert. Today, we will be discussing the views and reviews from the June 2026 edition of Fertility and Sterility, which is entitled Data-Driven Analysis of Fertility Optimization. This views and reviews brought together experts, some of whom we will be interviewing today, who evaluated and summarized the evidence on optimization of fertility using diet and lifestyle interventions, surgical restoration of anatomy, menstrual cycle tracking, and comparative data between these methods and in vitro fertilization.

The authors discuss what we know and where knowledge gaps exist. I do encourage our listeners to read the full breadth of articles as they know this topic is something almost all my patients ask me about at their visits. I would like to start by introducing our guests.

First, we're joined by Dr. Eve Feinberg. Dr. Feinberg is a professor and REI fellowship program director at the Division of Reproductive Endocrinology and Infertility at Northwestern University Feinberg School of Medicine. Dr. Feinberg is both an editorial editor at Fertility and Sterility, and you may have heard her.

She is the co-host of our Big Sister podcast, Fertility and Sterility on Air. Welcome, Dr. Feinberg. Hi, Emily.

Thanks for having me. Hi, everyone. We are also joined by Dr. David Boedeker.

He is a first-year reproductive endocrinology and infertility fellow at the National Institutes of Health and an active duty physician in the United States Air Force. He completed his obstetrics and gynecology residency at Walter Reed National Military Medical Center and earned a master's degree in health policy and administration from Columbia University. Welcome, Dr. Boedeker.

Yeah, thanks for having me. Just to get us started, I'd love to hear a little bit from both of the authors with us today about how the group came together to compile this comprehensive overview on how to optimize natural fertility. What was the inspiration for that? I'll speak to that.

So, as one of the editorial editors, we have the privilege of getting to choose topics, and part of this was driven by my interest in the rise of restorative reproductive medicine and taking the opportunity to really take a data-driven approach to each of the various components that are touted by RRM practitioners as the keys to fertility. So, when I broke down the views and reviews and my co-author and co-editorial editors, Marcel Cedars, when we broke this down, we looked at things like nutrition. We wanted to ask the question about inflammation.

We wanted to ask the question about things like anti-inflammatories like naltrexone. We wanted to think about being overweight and obesity and some of the contributions of nutrition. We wanted to think about endometriosis and endometriosis surgery.

We also wanted to look at cycle tracking. What did the data show in a fertile population? And then, what did the data show in an infertile population? And then, also wanted to look at things like thyroid prolactin and other endocrine components that may impact the likelihood of somebody getting pregnant without medical assistance. And so, we really broke down all those different components that are touted by RRM specialists to dive into the data to see what really is data-driven, what lacks data behind it, and I think to ask the question in a very honest and truthful way on what can we and should we be counseling patients on prior to moving towards medical therapies for infertility.

So, Dr. Boedeker, who's joining us today, was one of the authors on the optimization of conception with intercourse for women with infertility, and we'd love to get a summary on some of the recommendations that you had in your article in terms of supplements that patients should take. I know that this is something I get asked every day in all my clinic appointments. So, when kind of distilling down the data, what were some of the supplements that you would recommend as a fertility specialist? Yeah, I think that working on this article was really nice because it allowed me to really take a deep dive into supplements and vitamins that, as you mentioned, we get asked about pretty regularly.

And the thing that's kind of nice but also frustrating about this article, I think, is that right now the data really support things that we're already doing and that our patients are already doing. So, I think really the data suggests that if you have an overt hyper-hypothyroidism or abnormality with your prolactin levels or something like that, then you should definitely be treating it. But there's no really great data to suggest that you should be getting any medications without any overt endocrinopathy.

And in terms of vitamins and supplements, really taking a prenatal vitamin with folic acid is kind of the best thing that you can be doing from a data-driven standpoint. And some of these other supplements that our patients are probably asking us about, unfortunately, don't have data to really support them. From reading your article, it seems like adequate vitamin D and folic acid intake are two of the important nutrients to prioritize.

Do we think that patients can get an adequate amount of both of these from just any routine prenatal vitamin? So, you need 400 micrograms of folic acid in order to meet ACOG's recommendation of how much folic acid you need during pregnancy. And most prenatal vitamins are going to include that much. And that's definitely something when I'm working with patients to say, make sure that the prenatal vitamin that you're going to take crosses that threshold for folic acid.

But I think anecdotally, most prenatal vitamins do meet that metric. From a vitamin D standpoint, I've seen most prenatal vitamins have somewhere in the 400 international units of vitamin D. And ACOG recommends that you have 600 international units during pregnancy. So, we're not quite meeting that threshold, but presumably you'll make up for that deficiency with just diet and sunlight.

So, I don't think that you necessarily need an additional vitamin D supplement to meet your minimum. Yeah, I thought it was interesting that the Endocrine Society clinical practice guideline on vitamin D suggests against any vitamin D screening in healthy adults. And it was interesting that this guideline does not carve out any specific recommendations for infertility patients.

I think that there were some recommendations for other at-risk populations. And so, is there any indication to be screening for vitamin D levels in patients with infertility? Yeah, I don't think that there is any real indication to be screening for these deficiencies. I think one of the things that is notable when you're reading the paper is that a lot of the data that we describe in our vitamin D section is really observational.

So, I think that that speaks to some of the quality of the data. And I don't think that there is sufficient data to warrant screening and subsequent treatment. One of the other studies that we talk about during the paper that I think is interesting to highlight is the PPCoS1 study that talks about a relationship between vitamin D or one of the analyses that the authors looked at was a relationship between vitamin D and live birth and ovulation.

And they report that women who were vitamin D deficient were less likely to ovulate and achieve a live birth with clomid treatment with or without metformin. But I think that one of the things that I would encourage readers of that study and our views and reviews article to take with a grain of salt is that the individuals who were participating in the study, you know, most likely those people are going to be using letrozole now, not necessarily clomid with metformin. And so, I think that there's insufficient data to really recommend, you know, extrapolating this data with respect to vitamin D deficiency and suggesting that there's going to be an impact with ovulation rates or live birth rates.

For Dr. Barnard and Dr. Feinberg specifically, do you ever recommend any specific prenatal vitamins to your patients based on some of the differences seen across these supplements with respect to the specific levels of vitamin D, folic acid, or other contents? No, I generally tell patients to go to Target and find the least expensive prenatal vitamin that they can find. And if you look at the content of those vitamins, I mean, you will see that most prenatal vitamins actually contain 800 micrograms of folic acid. Many of them contain adequate amounts of nutrients.

I'm not at all convinced that the fancier or more expensive prenatal vitamins are better. And as we all know, you know, too much of a good thing is not good. And so, you really want to be careful with your fat-soluble vitamins.

You don't want to overdose on vitamin A, D, E, and K. And I just have yet to see any data showing that these pricier custom prenatal vitamins that are being sold for hundreds of dollars per month are any better or any more efficacious in the fertility realm or in the healthy baby realm than just a run-of-the-mill vitamin that you can buy at Target. Yeah, I feel similar to Dr. Feinberg. I think it is stuff for patients.

I mean, this is a common question that I get, what prenatal should I get? And they really look to us for advice. And yeah, I tend to focus a lot on making sure there is adequate folic acid content, like everyone here has been mentioning. But I agree, it is very expensive, kind of monthly endeavor for patients.

So I usually try to focus on these things that we know are data-driven. Yeah, I will say living in Chicago, I do often check vitamin D on patients, particularly in the winter months, just because we get so little sunlight. And that is the one thing that I will often tell patients is just supplement with an additional 2,000 IUs of vitamin D per day.

And again, it is not really data-driven. But I think in a climate like Chicago, where people are not going outside at all in the winter, it is a very reasonable general health recommendation that can translate to fertility and pregnancy. And I think in general, my advice to patients is really centered around healthier bodies will have healthier babies.

And when I counsel patients about what can you do to optimize your body preconception, I think so much of this is sensical, right? We want regular menstrual cycles. That is a vital sign. We want a diet that is filled with whole fresh foods, and that is good for prevention of colon cancer, and that is good for normalization of weight and prevention of insulin resistance and obesity.

We want to make sure that we are optimizing as much of our environmental toxins and exposures, minimizing exposures to things like alcohol, tobacco. We want to make sure that we are reducing stress because that can cause an inflammatory state, and we want to optimize our sleep. All of those are good, common-sense things that we can all counsel all of our patients on.

And I would argue that all REIs are already doing these things. That is very well said. I agree with that as well.

And thinking about some other supplements, one of the ones that I know a lot of my patients have read about and inquire is Coenzyme Q10 or CoQ10. And I was curious if you could speak to what was in this article. I thought it was very interesting how we sort of think about CoQ10 in unassisted conception versus maybe does that differ at all if someone is doing treatment like IVF? Yeah, I think what is interesting is the data that is presented in this article really talks about how CoQ10 has been shown in mice to improve conception rates, but there are no human studies.

And so can we extrapolate data from mice to humans? And I do not know the answer to that. And so I think it is a theoretical leap that theoretically it can improve mitochondrial function. And I think it is something that is ubiquitous.

Ubiquinol is ubiquitous. And people are recommending it left and right to patients everywhere that I look on the internet. People are talking about CoQ10, but there are no human data for it.

And so I think it is really hard to make recommendations to patients. I get asked about it every day as I am sure each and every one of you do too. And I think the best I can say is that they are in some mice studies.

It has potentially been shown to have some benefit, but we just do not have data to say how that is translated to humans. I am curious what you all think because I know some people will make the argument this is a pretty low-cost supplement and it is pretty benign. And so therefore, it is I think presumably pretty reasonable to offer it to patients and understand this probably is not going to be the silver bullet, but there is some biologic plausibility for why it might improve ART outcomes or pregnancy.

And so I can recognize that in order to really answer the question appropriately, you would have to do a huge RCT that is going to cost a lot of money. And for something that is so cheap, is it worth us putting all of this time and money and effort into answering this question when the intervention itself is so cheap? But on the flip side, I think that without that data, then you are almost introducing some misinformation to the field without adequate data to kind of back up what you are recommending. So I am curious when you are looking at some of the data that we talk about and using reviews with vitamins and supplements that are overall pretty benign and cheap interventions, how do you kind of grapple with this idea that they are not very costly, but they also maybe are pretty benign and how do you actually recommend that to patients? Yeah.

So I would say that I do not actually recommend it to patients, but I share the limitations of what we know and the limitations of what we do not know. And that is the exact discussion that I have is it is really inexpensive and there is potential biologic plausibility. And it is very reasonable to take a supplement.

And it may, again, it may improve your overall health and it might make you feel better and have more energy. If you do not like taking it or you think that the side effects are toxic for you, then do not take it. But it is out there.

People are using it. And I cannot recommend it, but I am not going to tell you not to take it is the approach that I take with patients. I think one of the challenges with any of those interventions is that these things can add up.

Like we talk about it being relatively affordable compared to an IVF cycle. But, you know, I did a quick perusal of some prices on Amazon. At some of the recommended regimens for CoQ10, you are still looking at about a dollar a day for an eight-week pretreatment period.

And that can, you know, that is about $120. And so, yeah, it is a drop in the bucket compared to an IVF cycle. But if you follow that same logic for several other supplements, you are still looking at hundreds of dollars that you are potentially spending on something that may not be proven in your particular scenario.

Yeah, I think another thing is that so many of our patients are coming to us after, you know, maybe trying on their own and taking these supplements for months or even years. And so it is, you know, your $120 estimate might be, it is like very conservative, I would argue, compared to the realities of how much money some patients are spending on some of these supplements. Yeah, I think it is just hard.

Like we probably will never have an RCT. We probably will never have a study to show these things. But I think as long as we are transparent with patients and we are counseling them on what we know and what we do not know is great.

And I just want to highlight in one of the other papers that was written on lifestyle factors, there is a table that says the knowns, the knowables, and the unknowables. And I really like the way that that group of authors looked at things like supplements, uniquely beneficial foods, dietary patterns, in terms of, you know, what do we know, what do not we know, and what are things that we will never know. And when it comes to supplements, what they said is the knowns are folic acid, as we talked about.

And then specifically, the use of combined antioxidants may improve outcomes of infertility treatment, but attribution to specific agents responsible is not currently possible. And so the unknowable part of it is specific effects of the nearly infinite number of bespoke dietary supplement formulations will never be known with certainty. And so I think as long as we are not pushing vitamins, I do have some issues when physicians have financial stakes or patents on vitamins or supplements.

I think that's problematic. But I think if you take it from the approach of just because we don't have data doesn't mean that we can't use it. I think it's okay to say that we don't know, and we probably will never know, and it's okay to try it, and you need to make that decision for yourself.

Are there any supplements, I don't know if it was mentioned in the paper, but any that you would actively discourage? Because I think most of us are very open to CoQ10 if a patient is interested in it, maybe some benefit. But anything that patients are coming to you where you're saying, like, actually, this could be harmful, or this is something we want to discontinue? Very rarely, and I think in part, it's just the limitations of my own knowledge on what some of those harmful effects are. I will say I once remember potentially seeing some data on DHEA and implantation, and that it may be more harmful for the endometrium.

And if you think about it in the situation of PCOS, like androgens can potentially cause desensualization of the endometrium. And so typically with DHEA, I will tell patients not to take it during a fresh cycle, but go ahead and take it if you're doing a freeze-all cycle. But apart from that, I think I just don't know enough about the nuances of supplements.

I oftentimes will work in close conjunction with a registered dietician and really look at it more holistically in terms of having a dietician work with the patient to map out the diet and what they might be missing in their diet and to get nutrients through food and through whole foods, rather than through an armamentarium of supplements. Building off that as the son of a dietician, I do want to give a shout out to that article, Diet, Lifestyle Factors, and Human Fertility. I think it's a great read, and I wish we had some of the authors here with us today, but please go and read that article.

I think it has some awesome data about nutrition and how we can counsel our patients. Yeah, Jorge Chavarro was the first author on that. And I have to say the table at the end was the one that I was referencing, and it's just fantastic.

I can't even sing the praises of it often enough in terms of what they touch upon. So alcohol, caffeine, weight loss, exercise, tobacco, cannabis, recreational drug use, supplements, dietary patterns, and again, breaking it down into those three columns of what we know, what we don't know, and what we will just never know. It's really one of the most impactful tables in a manuscript I've seen in a long time.

So I think each of these articles, each of these five articles in this series, was tremendous in terms of the effort that the authors put forth in writing these articles. And I think they're just really helpful for all of us in the field to look to see what the data show. I want to change course a little bit and just talk about inflammation.

I think for all of us who are on social media, we see this talked about all of the time. And so I'd be curious to hear from all of you, how do you talk to your patients about inflammation when they bring it up to you? And are there any patients you're actually screening for inflammatory disorders? I think about it, it's nebulous, right? Because I don't think that we have good markers to identify inflammation. I mean, there are some markers like CRP and others that will be elevated in inflammatory states.

But generally, they're not great markers. We know that obesity causes inflammation. And we know that patients who have obesity have higher rates of euploid pregnancy loss.

And so I think of it more as one of the undiagnosed in unexplained infertility. It's probably one of those things that we're not able to adequately capture in our diagnostic evaluation and workup, but something that probably is contributing more to infertility than we're able to calculate. And so I really spend a lot of time talking to patients about diet, and probably diet more than exercise, but diet minimization of alcohol.

Alcohol has been shown to be hugely pro-inflammatory and really minimizing how much people drink. I'm actually amazed, and I say this, my husband is not going to be happy with me because he works for Molson Coors, the beer company. And I really tell people who are trying to conceive to very much minimize their alcohol intake.

And alcohol is one of those things with a dose-response relationship where I would much rather see somebody have one drink every day for five days than have one day where they have five drinks. And that's been shown in the general medicine field. But I think that it's just one of those things that it is talked about.

It might be over-talked about, but I think that it's probably playing more of a role than we're able to fully articulate. But I think the things that patients can do to minimize inflammation on their body are things, again, like eating whole foods, minimizing toxic exposures like alcohol, definitely elimination of all nicotine, and just leading a healthy lifestyle, getting adequate sleep, and good nutrition through good sources has been shown in the general medicine world to reduce inflammation on the body. And I think that it probably has a role in fertility that, again, we can't quite quantify, but we know it's there.

And I think that the strongest argument for that is those euploid pregnancy losses in our obese population. Yeah, I definitely agree. And I think that something that I've had patients that ask for inflammatory markers ordered on them before, and I just kind of to echo some of those sentiments that I just am not sure what the action item is afterwards besides doing everything that we're already trying to do in terms of optimizing diet and decreasing alcohol intake and stuff like that.

So I think the more helpful thing is just to counsel patients on lifestyle factors rather than screen a blood test. And then if it comes back positive or negative, I don't think that you can necessarily be reassured because I don't think that we really have a strong positive predictive value of that test in terms how it's going to impact reproductive outcomes if you do or do not do a treatment. I think it's kind of confusing like we're mentioning.

Yeah. And I've known a lot of patients who have symptoms and signs of stress and inflammation who have normal CRP. And so maybe that's not the best marker.

But I think, again, sort of from a common sense perspective, we should be counseling patients on whole foods and healthy diet. And I think that processed foods, packaged foods, artificial ingredients, artificial flavors, colors, toxins, etc. are not good for us, period.

And that probably extends far beyond general health to fertility. But I think that the healthier that we can be, and I feel like a broken record. I probably said that a thousand times so far.

But I think that the healthier we can be and the better diet we can have, the better off we will be, not just from a fertility standpoint, but from an overall health and risk reduction for cancer standpoint as well. I think those were all really good tips. I think a lot of times when patients are bringing up these concerns to us, it's important that we're hearing them and not minimizing them, but also sharing the limitations of the testing and what we have and all these kind of tangible things that they can do every day to try to improve their inflammatory state.

So I thought this was really great advice. While we have Dr. Boedeker here, I do want to talk a little bit about one of the interventions that's more popular with the restorative reproductive medicine community, which is luteal phase progesterone. Could you all talk about the validity of a luteal phase defect diagnosis and the efficacy of potential interventions? My understanding is that the diagnosis of a luteal phase deficiency has really been called into question.

I think that it really also calls into question the utility of using progesterone supplementation routinely. We talk a lot about in our article that there are some data that in very specific patient populations, which is kind of timely because our new RPL guidelines came out recently, that if you have somebody who's recurrent pregnancy loss who has first trimester of bleeding, there are potentially some data that that could potentially be helpful for that patient population. But for all comers, when we haven't necessarily... We don't have great data that luteal phase deficiency is a real diagnosis and that an intervention is actually going to be helpful.

I think that it really challenges whether we should be routinely prescribing this medication to everybody. Yeah, I think some of the strongest data about luteal phase defects and recurrent pregnancy loss really come in from a New England Journal article that showed no benefit of luteal phase progesterone in the prevention of recurrent pregnancy loss. I see a lot of patients who are on luteal phase progesterone.

And I, again, when we think about how do we get to the root cause, what we really want to do is we want to improve the ovulatory function. So how do we improve the ovulatory function? Well, you can improve the ovulatory function through interventions like weight loss, metformin, normalization of insulin resistance, but also clomid, letrozole. What those do is those improve the ovulatory function by getting to the hypothalamic pituitary-gonadal axis secreting FSH, tricking the brain into secreting extra FSH, either through occupying the estrogen receptor or through blocking the conversion of estrogen through aromatase inhibitors, and then having the brain normalize by producing extra FSH and triggering that cascade of hormones, follicular recruitment, and getting to a dominant follicle, which can then either trigger its own endogenous LH surge or by administering an LH surge.

So I think that giving progesterone is a band-aid. What you really want to do is you really want to improve that ovulatory function so that the ovary will produce its own progesterone in the luteal phase. And so you really want to optimize it.

So I would much rather put somebody on letrozole or on clomid as opposed to progesterone supplementation. Another article that is included talks a lot about menstrual tracking technologies and their impact on fertility. So if either of you would be able to, we'd love to hear a little bit of an overview of some of the various menstrual tracking strategies and how they could potentially be used to optimize unassisted fertility.

Yeah, so this article is called Menstrual Tracking Technologies and Fertility Evaluating Accuracy, Utility, and Impact on Time to Pregnancy. I thought this was a also a great paper in this series. First author is Hannah Milad, and senior author is Jessica Walter from Northwestern.

And Hannah, kudos to Hannah, who's a current rising third year resident who's going to be applying into REI, so watch out world. Hannah's coming and she's fabulous. But they put together a pretty comprehensive review, and I thought it was actually really interesting looking at the history of cycle tracking, looking at the biology of our menstrual cycle, and then really talking about the discovery of traditional methods of fertile window tracking, like how that all came into being with understanding the relationship of the ovaries to menstruation in 1793, and then really following the history of cycle tracking.

I thought it was really interesting. I guess I never knew that urinary ovulation test strips were first introduced after a World Health Organization task force was charged with correlating hormone markers to the timing of ovulation, and so the LH surge detection kits were kind of born, and it's relatively recent-ish. I guess I'm older than all of you, but it's in my lifetime in the 1980s.

And then it also talks about some of the historical tests that have been used looking from a birth control standpoint, and how do you use ovulation tracking as a way for prevention of pregnancy? And that's been used for a very, very long time in various different religions. Actually, cycle tracking in Catholicism has been used for a long time, for over 100 years, to prevent pregnancy. And the flip side of that, in Judaism, cycle tracking has been used to help couples to figure out when to time intercourse for pregnancy attempts.

So I feel like, religiously, these methods have been used for hundreds, if not thousands of years. So what I thought was really interesting was they talked about ovulation test kits. They talked about menstrual tracking and time to pregnancy, and it showed that menstrual tracking and time to pregnancy, depending on the method that you use, that you may be able to conceive on average one or two months quicker when you use menstrual tracking in an otherwise normal, what I would call a normally fertile or an untested population of patients.

Some of those studies were, in fact, funded, not surprisingly, by Clear Blue Easy, and they showed that Clear Blue Easy works, and you may get pregnant faster. But what I think is really interesting is when they looked at the data on using cycle trackers in an infertile population, using cycle tracking, and that's either through ovulation detection or using symptothermal methods, that really those have not been validated or studied in an infertile population. The primary use and the primary validation of those studies was for prevention of pregnancy.

And so in that setting, when the fertile window has closed, the progesterone rises. The temperature is therefore elevated by around 0.8 degrees. And pretty reliably, if you see that temperature elevation for three days straight, you are safe to have intercourse, and very few people will get pregnant once that fertile window is closed.

But what's interesting is in the realm of restorative reproductive medicine, they are flipping the script, and they are now touting cycle tracking as a way to treat infertility. And quite honestly, what I thought was so well done in this manuscript was they showed the lack of data or the paucity of data surrounding the use of these cycle tracking methods in an infertile patient population, showing that there really are not studies showing the benefit of these methods, specifically in patients who are struggling to conceive. So again, I think they're wonderful for patients who are opposed to hormone contraception or who don't tolerate hormone contraception.

We all know that aura paired with natural cycles, they have an FDA indication specifically for contraception, and that these methods work really well to establish that the fertile window is closed, but they just have not been validated for use in an infertile population. And they're certainly not considered to be treatment for infertility in the same way that the treatments that we use for infertility tried and true are efficacious in helping couples to overcome infertility. Yeah, I think it's really important to contextualize these results and these studies in the reality that these are all being conducted in a fertile population for the most part.

One of the studies I was most intrigued by was this 2023 Cochrane review of RCTs, which showed that there were higher live birth rates with urinary ovulation prediction kits compared to non-use of those kits. How should we frame these results when counseling our patients? Could it be that these OPKs are really just superior because of how hard it is for some couples to adhere to intercourse every two to three days? Yes. I mean, look, I always tell patients, I'm like, there's procreation and there's recreation, right? So, like, when you are not trying to conceive, sex is for recreation.

When you are trying to conceive, sex is for procreation. And you can try and make it fun, right? But I think most people will tell you that after a couple of months of trying, like every other day for 10 days from day 10 to day 20, like, it's not so fun. And so I think ovulation predictor kits are great in that sense in that they help you to target, like, when you actually should try to conceive.

And so I think many couples admittedly, like, miss that fertile window, or they think they know when they're ovulating, but their cycles are skewed, and they're missing their fertile window. And so I think that the LH predictor kits can, in fact, help patients to conceive a little bit sooner, help people to conceive a little bit sooner. But again, that's in an unproven population.

And when you look, it's really, if you look at some of these survival analyses, it's really just in the first couple months. So you get pregnant in three months instead of five months. And over time, like, if these studies were carried out long enough, I don't think they would really show a higher cumulative pregnancy rate.

I think you're just achieving your goal of pregnancy a few months sooner than you would have if you were not using ovulation predictor kits. So how do I translate that to clinical practice for a young couple, young being, like, less than 33? If they were just to come to me for procreative management consultation, I would tell them just, like, stop contraception and have fun. But for a 38-year-old couple who wants two kids, like, I would tell them the clock starts now, get an ovulation predictor kit, figure out your timing, have an intercourse on days outside of that just, you know, for fun, in case you miss your window.

But be ready that when you get that positive surge that day and the next day, you should try to conceive. And I think the other thing is, you know, kind of in a similar vein, you know, it's great for patients who have never used ovulation predictor kits before to be able to educate them on it. But I feel like so many of our patients also come in saying, I've been using OPKs for months, if not years.

And so then saying that this is going to be a treatment for your infertility just, you know, is completely misleading and inappropriate argument to make. Yeah. I mean, I would say most of my patients come in with lots of data.

They come in with Oura rings, Whoop bracelets, Inedo, Mira. Like, they use everything. And so I just can't envision a world where I say, throw all of those away, and we're going to look at the cervical mucus that you're going to wipe from your vulva.

I can't even say it with a straight face. But we're going to look at the cervical mucus that you're going to wipe from your vulva. And we're going to tell you for up to 36 months that you have to have time to intercourse when that mucus becomes stretchy.

And we're going to toss out all of this more modern technology that we have for actual biomarker detection of the LH surge. And we're going to rely on whether our cervical mucus is stretchy or tacky. And that is superior to modern day treatments by a reproductive endocrinologist.

Like, I think it's almost insulting to our patients to market cervical mucus tracking as, quote, restorative reproductive medicine. Like, it's not restorative reproductive medicine. I think the name restorative reproductive medicine in and of itself is very misleading.

It's virtue signaling of a type of medicine that excludes populations of patients like our LGBTQ patients, our unmarried couples. It's a brand of medicine that is practiced by a group of people who have opposition to IVF, quite bluntly stated. But the idea that you're going to take somebody who's been trying to conceive for years, and you're going to tell them to track their cervical mucus, and that's treatment and therapy is dangerous, I think, in many ways.

We have so many patients also in the military who don't have access to care like throughout the country and end up kind of fighting to be stationed in the DC area because you can finally go to Walter Reed and you have much more access to IVF services at Walter Reed. Or you kind of have patients who will take leave and will use their own money to fly out to Walter Reed in order to finally seek care. Essentially, they're living in a hotel for a couple of weeks, or they're lucky maybe they have friends or family in the area.

But still, it's very expensive for them. I think that it's the thought of me telling patients that you have to wait a little bit more time and track your ovulation predictor kits or cervical mucus. This contributes to continued disparities in care.

Yeah. What I wanted to do with these articles is really show where are the data, and I think that there are data that these methods can be very reliably used for contraception and that these methods can be very reliably used for somebody who's beginning to try to conceive, and it may speed up the time to conception. But what these data also really show is that these methods are not studied, not well studied, and not with proven efficacy in a population of patients who has infertility.

And I think that that's a really important distinction that just because something works for one thing doesn't necessarily mean that it works for everything. While we're talking about ovulation prediction, I do think it's worth at least taking a little bit of time to talk about some of these more sophisticated testing modalities that have come out in recent years, these more quantitative assessments of urinary hormones. I think a lot of our patients feel like this additional information is better and helps them feel reassured regarding their ability to conceive.

Is that actually true, and do we think that these technologies are actually helping patients more so than the old school testing strips? Yeah, that's a great question, and we lack data to show that there's benefit. I will say that what we want are lead measures and not lag measures. So we want measures that tell us that ovulation is about to occur because once ovulation has occurred, then it's interesting to note retrospectively, oh yes, I ovulated on this day on this month, and that might help to predict when you're going to ovulate in a subsequent month.

But what you really want to know is you want to know when you're having that LH surge, so the rise in LH, the subtle drop in estrogen that may accompany that, and you want the sperm ready and waiting before that egg is ovulated or released from the ovary. So I have not seen data that shows that any of these other methodologies that look at urinary hormones, that look at progesterone metabolites, I have not seen data showing that any of those are superior to a good old-fashioned, and again I tell my patients, buy the cheapest LH strip that you can buy, but I have not seen data showing that any of those are more effective than a good old-fashioned LH kit. Now LH kits can have some limitations.

If you drink a lot of water, they can be difficult to interpret. Many patients have these bimodal LH surges where they have a peak, they have a trough, they have another peak, and it can be, in some patients, it can be difficult to interpret. And so perhaps in some of those patients where their cycles are not straightforward, some of those other data may be helpful.

But again, like, I'm not convinced that the more expensive and fancier methods like our prenatal vitamins, I'm not convinced that those are any more beneficial than the least expensive LH detector kit that you can buy. Yeah, and another limitation of these technologies is sometimes patients bring us these results and we now have to interpret them, and I think that sometimes we don't know the validity of the assays that are being used. We don't know what this or that particular metabolite is actually going to mean for their fertile window or the adequacy of a cycle, and I think that presents another problem for the field.

I agree. I mean, that is where cervical mucus can be kind of nice. That's easy.

It's easy. But again, it can be kind of nice for somebody who's tracking when they're about to conceive, and I actually think, like, great, do whatever method works, since cervical mucus for many patients can work to help you detect when you're about to ovulate in a couple who's just beginning to try to conceive. But once you have the diagnosis of infertility, you've been trying to conceive for a year, I think we're past the point of cervical mucus testing.

So to be fair and to be clear, like, I'm not saying that it's a bad method. I think it's actually a fine method for people who are just learning their bodies and learning how to time ovulation. And whether you want to use cervical mucus or an LH predictor kit, I don't think that that really matters.

Like, they haven't actually tested head-to-head LH kit versus cervical mucus. I think it's a fine thing to think about either way. I think you can't go wrong.

My main point in this is not that these are bad methods. They're actually very good, very reliable methods. They've stood the test of time.

They're very good for helping couples contracept and they're very good for helping couples who are just starting to try to have a baby learn their bodies to know when to time intercourse. But these are not treatments for infertility. I will say that until I'm blue in the face.

It's the hill I will die on according to the recent Instagram trend. That is one of my hills I will die on is cycle tracking is not treatment for infertility. But I do appreciate that this conversation about cycle tracking just goes to show that this is not a one-size-fits-all approach.

And that's the same for all of our interventions as reproductive endocrinologists. We're going to work with our patients to find out what's going to work with them and come up with a treatment plan that's going to align with their values and their priorities. And I think that's one of the best things about our field.

Absolutely. And I think that there are things that you can learn about couples based on cycle tracking. Earlier today, I was seeing a new patient who was 42, and she told me her cycles were regular.

And I said, regular? Tell me what that means for you. And she said, oh, every 28 days. And I said, great, let's go through the last six months.

And she said she's been tracking her cycles. I was like, let's go through the last six months of your cycle. Tell me the first day of your January cycle and what's the first day of your February cycle.

And we went through January, February, March, April, May. And sure enough, her cycles were 22 to 26 days. They were not 28 days.

So you can't just take it at face value when a patient says that they have regular cycles. So I do think that cycle tracking can be diagnostic, and it can help me to better understand. I could tell you she has diminished ovarian reserve.

I could tell you she had DOR just based on her age alone. But it helped me to help her to understand what is happening. I said I can almost guarantee that your FSH in the beginning part of your menstrual cycle is going to be elevated, and your AMH is going to be low.

And you're prematurely recruiting a follicle, and you're probably ovulating around day eight and not ovulating around day 14. And while there may be an element of lack of timing of your cycles, you're 42. And so I don't think you have three years to optimize your cycles and cycle track and time intercourse.

We can try that for a couple of months. But this is a couple who wants to have two kids. And so that also needs to be taken into consideration.

What are their goals, and what are their hopes for their family size? And sometimes we have to act more aggressively based on age and overall goals for how people want to build their families. I think one of the most interesting papers in this series that I just want to highlight, and actually all these papers are super interesting in this series, but one that we haven't yet talked about is this systematic review that was done by Gansey and others with senior author Sarah Lentzen. And what they did was they looked for papers that compared restorative reproductive medicine to ART.

And so they identified 724 different papers via a systematic search using keywords. And then they had 16 full-text papers that they reviewed. And of those 16 full-text papers, none of the studies were actually considered to be eligible because there were no comparative RRM studies where they head-to-head compared restorative reproductive medicine to ART.

But what I thought was really beautifully done about this study is they looked at the actual text of the study. And of those zero eligible studies, 9 of 10 of the 16 full-text reviewed claimed that restorative reproductive medicine was superior to IVF. So just to give you a couple of quotes from these papers, one of the claims was that RRM live birth rates were comparable to ART.

And the authors elegantly showed that this claim is just not supported by the data presented in this paper. Another study said RRM should be first-line treatment before IVF. And this was a case report.

So again, no comparative RRM. And the claim is not supportive by the data shown. And then the last study that they talked about, they said NAPRO achieves high take-home baby rates.

And this was a retrospective cohort. And again, the claim is not supported by the data shown because they didn't have any comparative RRMs. So I think that the bottom line is that there's not a single study that's able to show that restorative reproductive medicine is comparable to or better than IVF.

There's not one single paper that's out there. And so I think when these RRM clinics tell vulnerable infertility patients that RRM is a superior alternative, they are making a claim that the entire published literature, including their own studies that are published in their own journal of restorative reproductive medicine cannot support. And I think that's both a disservice to patients and a disservice to society.

I would like to thank both Dr. Feinberg and Dr. Boedeker for joining us today. We had such a rich, robust discussion. We're so appreciative.

Again, we'd remind all of our readers to check out all of the full text articles. This was such a rich review and I think gave me a lot of good research-backed recommendations for when patients are asking me these questions, which they do every day on how to optimize their natural fertility. So thank you again to our guests.

Please tune in to our next podcast next month. And we'll see you then. Fertility and Sterility Roundtable was developed by Fertility and Sterility and ASRM as an educational resource in service to its members, other practicing clinicians, and members of the public.

The opinions expressed are those of the discussants and do not reflect the views of Fertility and Sterility or ASRM.