Fertility-awareness practice and education in general practice

Recent research has demonstrated that more than 9 out of 10 women experiencing infertility believe they should receive fertility-awareness education (Hampton and Mazza 2015). This study also found that general practitioners (GPs) were consulted by women only 30% of the time, whereas trained teachers in fertility-awareness were found to be significantly better sources of information for fertility education. Considering the Rhythm method is the most frequently taught fertility awareness-based method (FABM) in general practice (Hampton and Newton 2016) and is also one of the least accurate, this should not come as a surprise.

Essentially, intercourse timed for a fertile time in the woman’s menstrual cycle has a higher chance of resulting in pregnancy than intercourse at non-fertile times (Thijssen et al. 2014). However, primary care physicians are known to have significant knowledge deficits regarding physiological interpretation of fertility (Pallone and Bergus 2009).

The menstrual cycle is core knowledge for medical students through to vocational primary care physicians, and is the basis for fertility awareness-based methods of family planning. By extension, initial management of sub- or infertility by fertility-awareness education should easily be able to be performed in a general practice setting. Nevertheless, recent qualitative data demonstrated that GPs believe they receive little training, have low confidence and have inadequate knowledge to advise on fertility-awareness issues (Hampton et al. 2016).

The most studied and implemented FABM, the Billings Ovulation Method, has utility in both aiding and preventing conception – the full breadth of family planning (Corkill and Marshell 2008). From a contraceptive perspective, this method has comparable efficacy (typical use 89.5%, perfect use 99%) (Pallone and Bergus 2009) to the combined oral contraceptive pill (typical use 91%, perfect use 99%) (Trussell 2011).

Australian family planning organisations provide much useful reference material on contraception but do not demonstrate adequate expertise in FABMs. Their contraception resources (FPAA 2013) misleadingly group all fertility-awareness contraceptive effectiveness as 76%, corresponding to effectiveness for the Rhythm method. This would be akin to assigning ‘hormonal contraception’ (including the Mirena, Implanon and oral contraceptive pills) a single effectiveness rate of 91% when in fact Mirena is >99%. It would be unacceptable if the latter statement was presented to patients, so the former should also be considered inadequate for informed consent.

Similar erroneous information is also apparent in current leading GP education, for example in the Royal Australian College of General Practitioners’ check unit on women’s health (RACGP 2016a). Both the misleading recommendations and lack of appropriate information regarding FABMs in such current educational materials compounds the lack of fertility-awareness expertise in general practice.

Seeing as GPs-in-training rely on the family planning educational material thus noted, as well as their GP supervisors who are likely similarly informed, it becomes apparent that fertility-awareness information desired by couples who are actively engaging in family planning may not be currently readily available or reliable in the general practice setting.

Professional development opportunities do exist to redress this lack of reliable education in university medical and general practice training curricula. For example, courses for the Billings Ovulation Method are accredited by the RACGP and the Australian College of Rural and Remote Medicine (ACRRM), and range from single-day to week-long training courses.

The recent community awareness campaign for general practice touts the good GP as one ‘who never stops learning’ and who is a specialist in life (RACGP 2016b). These statements are undeniably relevant to pre-conception and conception care. It is time that the community became confident in seeking such fundamental fertility management in the primary health care setting, and for GPs to be able to serve them adequately in this regard.

The author has attended Billings Ovulation Method courses as part of medical CPD and was a reviewer of the RACGP check program.