The European Journal of Contraception and Reproductive Health Care, 2015; Early Online: 1–6

Identification and prediction of the

fertile window using NaturalCycles
Elina Berglund Scherwitzl*, Angelica Lindén Hirschberg † and Raoul Scherwitzl*
*NaturalCycles Nordic AB, Stockholm, Sweden, and †Department of Women’s and Children’s Health, Division of
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Obstetrics and Gynecology, Karolinska Institutet and University Hospital, Stockholm, Sweden

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ABSTRACT Objectives The aim of the study was to evaluate the ability of a novel web and mobile
application to identify a woman’s ovulation day and fertile window, in order to use it as a
method of natural birth control.
Methods A retrospective study was performed on 1501 cycles of 317 women aged 18 to
39 years. Women entered their basal body temperatures, ovulation test results and date of
menstruation into the application.
Results The mean delay from the first positive ovulation test to the temperature-based
For personal use only.

estimation of the ovulation day was 1.9 days; the length of the luteal phase varied on aver-
age by 1.25 days per user. Only 0.05% of non-fertile days were falsely attributed and found
within the fertile window.
Conclusions The method is effective at identifying a user’s ovulation day and fertile
window and can therefore be used as a natural method of birth control.

K E Y WO R D S Natural birth control; Fertile window; Natural family planning; Fertility awareness; Basal body temperature;
Fertility monitor

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I N T RO D U C T I O N
and health risks that can result from other contraceptive
Using fertility monitors as a way to prevent pregnan- methods.
cies has become increasingly popular in recent years, Fertility monitors inform women about their fertil-
due to a rising interest among women to abstain from ity, enabling them to make conscious decisions about
hormonal contraception1–3. It has been shown in some family planning. For instance, a woman who better
studies that perfect-use effectiveness can be very high understands her cycle and knows when she ovulates
with such devices3–5. can plan her career and current situation around her
Women therefore have the opportunity to safely fertility. Current fertility monitors offer this informa-
prevent pregnancies without the recognised side effects tion, but they are often expensive, difficult to use and

Correspondence: Raoul Scherwitzl, Regeringsgatan 29, 111 53 Stockholm, Sweden. Tel: ⫹ 46 707 17 48 66. E-mail: raoul.scherwitzl@
naturalcycles.com

© 2015 The European Society of Contraception and Reproductive Health

DOI: 10.3109/13625187.2014.988210
 Identification of the fertile window
based on basic mathematical tools which can produce
inaccuracies in detecting ovulation4,6–8.
In this pilot study, we investigated the accuracy of
detecting ovulation with this novel application for use
as a natural method of birth control. The hypothesis
was that this particular method would be comparable
to clinical methods of ovulation detection.
METHODS
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Materials
The application aims to be both safe and easy to use
– two essential attributes that make a birth control
method effective9. It requires the input of basal body
temperatures (BBT) and the date of menstruation.
Luteinising hormone (LH) test results are optional
entry points. The required basal thermometer and LH
tests are purchased separately. Users can enter their fer-
tility-related data into the application from devices that
are ubiquitous in everyday life, such as smart phones,
For personal use only.
tablets and laptops. BBT rises after ovulation, whereas
the LH surge appears 1 to 2 days prior to ovulation,
together providing strong indications of ovulation10–14.
Additional parameters include details such as whether
a user has had protected or unprotected intercourse or
the presence of cervical mucus.
The underlying technology is an algorithm that uses
predictive, mathematical models that are applied in
particle physics15. Based on data entered each day, the
algorithm delivers either a red or a green icon which
highlights, respectively, whether or not there is a risk
of pregnancy. The algorithm computes the following
parameters and their uncertainties: ovulation day, cycle
length, luteal/follicular phase length and average
temperature. At the beginning of each user’s cycle,
the ovulation day is initially predicted based on the
individual’s average ovulation day. Ovulation is then
confirmed, retrospectively, following the rise in tem-
perature. If entered, positive LH tests are included in
the analysis. In the luteal phase, green days (non-fertile
days) are only given once ovulation has been detected.
In the follicular phase, the algorithm gives green days
up until the predicted ovulation day minus the
estimated value of uncertainty. The value of uncer-
tainty depends on several factors such as the number
of measured cycles, the earliest ovulation detected, the
variation of ovulation day and the probability of sperm
survival. Subsequently, the number of red days (fertile
2 The European Journal of Contraception and Reproductive Health Care
E. B. Scherwitzl
days) per cycle given to the user is generally more than
the empirical value of 6 days, which is when a preg-
nancy can result from unprotected intercourse16,17.
In the first cycle, the average ovulation day is set to
occur 13 days before the onset of the next menstrua-
tion. This is determined by the user’s average cycle
length that is entered during registration. The total
error for ovulation day is computed based on the user’s
maximal cycle length variation, which is also indicated
upon registration. This therefore means a user can
start using the application at any point during her
menstrual cycle.
As more data are entered over time, the percentage
of green days typically increases. This is determined by
the quality and frequency of the BBT data given, as
well as the regularity of the user’s cycle. Regular
messages are sent to encourage the user to measure
her BBT as frequently as possible in order to improve
the overall results.
Using previously recorded cycles, the algorithm can
also predict a woman’s fertility status, forthcoming
ovulation day, menstruation and LH surge in up to five
future cycles. Both current and predicted fertility
statuses are illustrated with a status bar and calendar
view. A graph illustrates the recorded BBT plotted over
time alongside the analysis of recorded cycles. This may
be useful for users to share with their physicians when,
for instance, they are looking to conceive. An overview
of the user process and interface is shown in Figure 1.
Study design and participants
The study was performed as a retrospective investiga-
tion. All participants agreed to make their data avail-
able for clinical investigations before starting to use
the application. The participants remained anonymous
during the study.
Participants were recruited primarily in Switzerland
and Sweden through regular advertisements both
online and offline and through collaboration with
clinics that give advice on birth control.
Inclusion criteria were women aged between 18
and 40 years who were sexually active, not pregnant,
not planning to get pregnant, not using other methods
of birth control during green days and, finally, who
had entered temperature data points for at least 30
days. No other selection criteria were defined with
respect to cycle length, cycle regularity and any medi-
cal conditions that could affect fertility, such as the use
 Identification of the fertile window
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For personal use only.
Figure 1 (a) Schematic representation of the daily process of a user. Selected screenshots of the application: status
bar (b), graph (c) and calendar view (d).
of medication, low/high body mass index (BMI) or
smoking.
All users were required to fill out the online ques-
tionnaire before using the application, providing the
following information: age, cycle length, cycle varia-
tion, sexual activity, and whether they were planning
or not to get pregnant or whether they were already
pregnant. Further details included BMI, smoking fre-
quency, past use of hormonal contraception and, if so,
when they ceased to use it.The basal thermometer was
shipped to their home or purchased independently.
All data were stored in a database which could be
used for analysis and special event detection (e.g., preg-
nancies via pregnancy test and triphasic temperature,
delayed menstruation, anovulatory cycles).
Applying the above criteria, 1501 cycles of
317 women were selected and analysed. Descriptive
The European Journal of Contraception and Reproductive Health Care
E. B. Scherwitzl
statistics, e.g., mean values and their standard deviations
(SDs), were used in this pilot study to illustrate
outcome.
R E S U LT S
Participants
The mean age of the participants was 30.1 (range
18 to 39) years. Prior to entering this study, 22% of
participants indicated that they had used hormonal
contraceptives and discontinued use within the last
2 months and 57% entered data for at least three con-
secutive cycles. The remaining participants completed
at least one cycle, entering data on 60% of the assigned
days. No pregnancies were reported or detected
following unprotected intercourse on green days.
3
 Identification of the fertile window
However, one pregnancy was detected due to unpro-
tected intercourse on a red day, which according to
the participant on follow-up took place the day before
her ovulation day.
Cycle and luteal phase length
The mean length of the cycle and duration of menstru-
ation among all cycles investigated was 28.8 ⫾ 5.0 days
(1 SD) and 4.2 ⫾ 1.0 days, respectively.The luteal phase
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length, defined as the time between ovulation and the
day before the onset of menstruation, was 13.1 ⫾ 2.7
days with an average variation of 1.25 days.
Temporal relationship between fertility
indicators
The temporal relationship between ovulation, BBT
shift and the surge of LH was investigated in a subset
of participants who entered positive LH tests. Posi-
tive LH tests which were not subsequently found
For personal use only.
to be false positive (ovulation was confirmed by
BBT) were produced in 161 cycles. For these cycles,
the time between the first positive LH entry and
the estimated ovulation day was evaluated. Figure 2
shows the distribution of the delay between the first
positive LH entry and the estimated ovulation day
in days, using BBT only as well as the combina-
tion of both BBT and LH. These distributions were
80
60
Frequency [%]
40
20
0
0 1
Estimated day of ovulation relative to 1st positive LH test
Figure 2 Temporal relationship between the first positive LH entry and the estimated ovulation day by the application
using only the temperature input (purple) and using both the temperature and LH inputs (black). In grey is shown the
expected distribution as reported in reference 18, where ovulation was detected via ultrasound. The lines represent
guides for the eye.
4 The European Journal of Contraception and Reproductive Health Care
E. B. Scherwitzl
then compared with the results of a study that used
similar commercially available LH tests but instead
employed ultrasonography to detect ovulation18. Our
temperature-based estimation of ovulation showed a
mean value of 1.9 days with an SD of 1.4 days. The
combination of both BBT and LH yielded a mean
value of 1.6 days with an SD of 0.8 days. The more
precise estimation by ultrasound found a mean value
of 1.5 days and an SD of 0.6 days18.
Percentage of green days
An overview of the percentage of green days is given
in Table 1. We distinguished between participants
who had used hormonal contraception two months
prior to the study and those who had not. In the first
cycle, users who had not previously been on hor-
monal contraception were given an average of 44%
green days, whereas users who had more recently
used hormonal contraception were given only 32%
green days. After three months, an average user who
enters both temperature and menstruation data
points can expect 55% green days per cycle (51%
for those who have previously used hormonal con-
traception). Users who entered data on more than
70% of the assigned days had, on average, 61% green
days after their first three completed cycles. When
ovulation test results were included, the number of
green days increased by 4%.
This study
Temperature with LH
Temperature only
Reference
HM Behre et al.,
Hum. Rep., (2000)
2 3 4
 Identification of the fertile window
Table 1 The percentage of green days as a function of
the number of ovulatory cycles recorded for the first
cycle and beyond three cycles, distinguishing between
users who had recently stopped hormonal contraception
(HC) and those who had not.
First More than
cycle three cycles
No After After
HC HC No HC HC
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Number of days 1260 363 2402 1276
Percentage of 44 32 55 51
green days
DISCUSSION
Identification of ovulation day
The length of the luteal phase and its variation of
∼1 day are in good agreement with an average
woman’s cycle8,19,20. The temporal relationship
For personal use only.
between ovulation, BBT shift and the surge in LH is
well documented and can be used to accurately test for
ovulation11–13,21. Figure 2 shows good agreement with
a previously published report by Behre et al.18.
The agreement between the published findings
and this pilot study strongly indicates that the correct
ovulation day is found within the resolution of the
method. Since the ovulation day is estimated correctly,
the fertile window can be identified and the frequency
of falsely attributed green days within the fertile
window can be assessed in retrospect. It was found that
only 0.05% of green days were falsely given within the
actual fertile window. This is further supported by the
fact that none of the users experienced an undesired
pregnancy as a result of intercourse on a green day. In
order to determine a valid Pearl Index for both perfect
and typical use, a prospective study with a larger popu-
lation, more cycles and more inclusion and exclusion
criteria is required. According to a sample-size calcula-
tion based on reference 2, 8060 cycles from 620
women would be needed to establish a valid Pearl
Index. Further studies should validate the safety of this
method.
Percentage of green and red days
The percentage of green and red days is comparable
to the yield of other fertility monitors on the market4.
The European Journal of Contraception and Reproductive Health Care
E. B. Scherwitzl
As expected from the literature, users who have recently
been on hormonal contraception have on average
longer cycles and therefore fewer green days for the
first three cycles, but no significant differences are
noticed beyond that22. This shows that this particular
method can be used immediately after discontinuing
a hormonal contraceptive and also if a woman has
irregular cycles. Besides being affordable, engaging and
easy to use, having a large percentage of green days
plays a crucial role in the appreciation of the method,
i.e., to accomplish low dropout rates and high usage
of protection during red days.
Strength and weaknesses of the study
This is the first study performed on a new type of
fertility monitor. The pilot study was performed in
a real-life environment without training or supervi-
sion. The inclusion of few selection criteria rendered
a random study population of women from Switzer-
land and Sweden. The downside of this approach is
that it gives diminished oversight into the quality of
the recorded data as well as the participants’ history
(e.g., type of hormonal contraceptive used, duration,
medical conditions, use of medication). The sample
size remains sufficiently large for the purpose of dem-
onstrating that the system identifies the ovulation day
correctly.
CONCLUSION
In summary, this initial study highlights the applica-
tion’s ability to accurately identify the ovulation day
and the fertile window. Furthermore, the application
provides an interesting platform for further studies,
where its database can be used to analyse participants’
data automatically, offering the ability to interact with
users in real time through messages, notifications or
surveys. Future prospective studies should compare the
effectiveness and user experience of this application to
other fertility monitors, as well as to hormonal contra-
ceptives.These studies could also be used to determine
an accurate Pearl Index.
AC K N OW L E D G E M E N T S
We thank Göran Berglund and Dolf van Loon
for fruitful and challenging discussions. We also
5
 Identification of the fertile window
thank Eliza Hazlerigg for carefully reading through
and editing the manuscript.
REFERENCES
1. Djerassi C. Fertility awareness: Jet-age rhythm method?
Science 1990;248:1061–2.
2. Bouchard TP, Genuis SJ. Personal fertility monitors for
contraception. Can Med Assoc 2011;183:73–6.
Eur J Contracept Reprod Health Care Downloaded from informahealthcare.com by Kainan University on 04/23/15
3. Freundl G, Frank-Herrmann P, Gnoth CH. Cycle
monitors and devices in natural family planning.
J Reprod Med Endocr 2010;7:90–6.
4. Freundl G, Frank-Herrmann P, Godehardt E, et al.
Retrospective clinical trial of contraceptive effectiveness
of the electronic fertility indicator Ladycomp/Baby-
comp. Adv Contracept 1998;14:97–9.
5. Frank-Herrmann P, Heil J, Gnoth C, et al.The effective-
ness of a fertility awareness based method to avoid preg-
nancy in relation to a couple’s sexual behaviour during
the fertile time: A prospective longitudinal study. Hum
Reprod 2007;22:1310–19.
For personal use only.
6. Royston JP, Abrams RM. An objective method for
detecting the shift in basal body temperature in women.
Biometrics 1980;36:217–24.
7. Prior JC, Vigna YM, Schulzer M, et al. Determination
of luteal phase length by quantitative basal temperature
methods: Validation against the midcycle LH peak. Clin
Invest Med 1990;13:123–9.
8. Fehring RJ, Schneider M, Raviele K. Variability in the
phases of the menstrual cycle. J Obst Gyn Neo 2006;
35:376–8.
9. Hatcher RA, Trussell J, Nelson AL. Contraceptive technol-
ogy. New York: Ardent Media, 2011.
10. Buxton CL, Atkinson WB. Hormonal factors involved
in the regulation of basal body temperature during the
menstrual cycles and pregnancy. J Clin Endocr Metab
1948;8:544–5.
11. WHO. Temporal relationships between ovulation and
defined changes in the concentration of plasma estradi-
ol-17β, luteinizing hormone, follicle-stimulating
hormone and progesterone. Am J Obstet Gynecol
1980;138:383–7.
12. WHO. Temporal relationships between indices of the
fertile period. Fertil and Steril 1983;40:773–5.
6 The European Journal of Contraception and Reproductive Health Care
E. B. Scherwitzl
Declaration of interest: ALH declares no conflict of
interest. EBS and RS are the scientists behind the
application and the company.
13. Hoff JD, Quigley ME,Yen SSC. Hormonal dynamics at
midcycle: A reevaluation. J Clin Endocr Metab
1983;57:792–4.
14. Ecochard R, Boehringer H, Rabilloud M, Marret H.
Chronological aspects of ultrasonic, hormonal, and
other indirect indices of ovulation. BJOG 2001;
108:822–7.
15. Berglund E, Cross section of W and Z inclusive produc-
tion and the W/Z cross section ratio in association with
one jet for the boson decaying into electron(s) with
ATLAS 7 TeV data. PhD thesis, 2012.
16. Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual
intercourse in relation to ovulation. Effects on the prob-
ability of conception, survival of the pregnancy, and sex
of the baby. New Engl J Med 1995;23:1517–21.
17. Wilcox AJ, Dunson D, Baird DD. The timing of the
“fertile window” in the menstrual cycle: Day specific
estimates from a prospective study. BMJ 2000;321:
1259–62.
18. Behre HM, Kuhlage J, Ganer C, et al. Prediction of ovu-
lation by urinary hormone measurements with the
home use ClearPlan Fertility Monitor: Comparison
with transvaginal ultrasound scans and serum hormone
measurements. Human Reproduction 2000;15:2478–82.
19. Lenton EA, Landgren B, Sexton L. Normal variation in
the length of the luteal phase of the menstrual cycle:
Identification of the short luteal phase. BJOG 1984;
91:685–9.
20. Lenton EA, Landgren B, Sexton L, Harper R. Normal
variation in the length of the follicular phase of the
menstrual cycle: Effect of chronological age. BJOG
1984;91:681–3.
21. Gerlinger C, Endrikat J, van der Meulen EA, Dieben
TOM, Düsterberg B. Recommendation for confidence
interval and sample size calculation for the Pearl Index.
Eur J Contracept Reprod Health Care 2003;8:87–92.
22. Vessey MP, Wright NH, McPherson K, Wiggins P.
Fertility after stopping different methods of contraception.
BMJ 1978;1:265–7.