The long read: Investors are pouring money into apps that allow women to track their fertility. Can tech companies use data to change the world of womens reproductive health?
Will Sacks did not plan to go into the menstruation business. When he travelled from Toronto to Reno to attend his first Burning Man festival in August 2009, he only knew that he needed a change. At the age of 29, he was having a personal crisis. I had forgotten that I wanted to be an entrepreneur, he told me earlier this year. I had forgotten that I wanted to create a company that could put a dent in the universe. He quit his job as an energy efficiency consultant, shut down the small online business he had been running on the side, and booked a plane ticket to the desert.
Before beginning the drive to Burning Man from Reno airport, Sacks posted a message on Craigslist offering a ride in his rental car to anyone who needed one. A young woman named Kati Bicknell answered. Petite and pale, with thick brown hair, Bicknell looks like she stepped out of a preRaphaelite painting. She exudes an intense, slightly mischievous, energy. Sacks comes across as calmer. He locks eyes when he talks to you, pausing every few sentences to check in: are you still with him? Does his optimism sound naive?
Bicknell had flown to Reno from New York, where she had a job at TED Talks. The drive to Burning Man became the beginning of a shared mythology. After the gathering ended, Sacks and Bicknell dated long distance, taking overnight buses between Toronto and New York. One weekend in November, they found themselves having the birth control conversation.
We had been dating for three months, Bicknell told me not long ago. He said, I dont love wearing condoms and I was wondering whether you would be willing to go on the pill. I said No!
I was relatively unenlightened at that point, Sacks conceded, and Kati got pissed. Bicknell thought it was bullshit that the burden of birth control always fell on women. She suggested that her boyfriend get a vasectomy. Sacks balked. Then she brought up an alternative he had never heard of: the fertility awareness method (FAM). Fertility awareness involves regularly tracking certain physiological signs in order to determine when a woman can conceive and when she cannot.
Bicknell had always taken a strong interest in fertility. Her mother was one of over two million American women fitted with the Dalkon Shield in the early 1970s, a defective intrauterine device that caused hundreds of thousands of patients to suffer infections, miscarriages, and other serious problems; Bicknell grew up hearing how hard she had been to conceive. Ever since she began menstruating at 11, Bicknell had experienced highly irregular periods. No doctor ever investigated why; they simply put her on the pill.
In her 20s, Bicknell became concerned that the fake period the pill gave her every 28 days was masking a health problem that she should know about. A roommate gave her a copy of a book titled Taking Charge of Your Fertility, by a nurse named Toni Weschler. It is the bible of the fertility awareness method. By the time she met Sacks, Bicknell had already been practising it for three years.
Fertility charting is this thing Im already doing that can be used to prevent pregnancy, Bicknell told Sacks that night in November 2009. Its just the kind of cool, nerdy thing you would be super into. As she explained how it worked, Sacks became more and more stunned by his own ignorance.
I had an engineering degree and thought I knew everything, he told me. I was blown away. On the one hand I was shocked and dismayed that I had been under this totally false understanding of how womens bodies work. On the other, I was like, Wow, theres a side-effect free, hormone-free, form of birth control.
This is a technology that can change the world, Sacks thought. Bicknell agreed. That winter, they decided to ditch their jobs and move to Panama together. They rented a house near the ocean, took freelance gigs to pay the bills and spent the rest of their time in a hammock, poring over scientific studies and beginning work on their business pitch. When they returned north, they filed preliminary patents for an app that would make it easier for couples to practise fertility awareness.
They did not know how hard it would be to translate their ideas into a company. We had no idea what we were doing, Bicknell recalled, and we didnt even know it.
In 1990, Carl Djerassi, one of the biochemists who created the oral contraceptive pill, predicted that the invention that had made him rich and famous could soon become obsolete. In an article in Science magazine, Djerassi explained that recent advances in his field had made it possible to track changes in blood hormone levels simply by taking samples of saliva or urine. This meant that, using simple cheek swabs, women could accurately predict the days when they could become pregnant. If they did so, taking the synthetic hormones that he had developed would become unnecessary. But Djerassi thought it was unlikely that fertility tracking would replace the pill. Why? Powerful pharmaceutical companies had a huge interest in pushing the pill. As for tracking, nobody had figured out how to make money from it.
For around 20 years, nobody did. But today, the market in smart wearables is booming. Biosensors connected to phones and other mobile devices make it easy to record, store, and analyse data about your body and behaviours. Apart from activity trackers which record information about how many steps you take each day, how many stairs you climb, calories you burn, and so on fertility trackers are the most frequently downloaded kind of health app in the Apple Store.
Fertility awareness apps have an enormous potential market: women from puberty to menopause. The industries that they could disrupt are huge, too. A 2013 study by Transparency Market Research estimated that in 2018, women worldwide will spend $23.3bn on contraceptives. Americans also spend $5bn a year on assisted reproductive technology treatments at least some of which fertility awareness advocates say they could avoid, if they and their doctors paid closer attention to their bodies.
All fertility apps rest on a fundamental insight: there are externally observable physiological signs that can help a woman track where she is in her menstrual cycle, and provide clues about her overall health. A woman can only become pregnant during ovulation, the 24 to 48-hour period after one of her ovaries releases a mature egg cell and it travels down the fallopian tube to her uterus. Sperm can survive in the body for as long as five days. Therefore, there are only six days per month when having sexual intercourse could lead to conception. The trick is to figure out when that window is. Then you can plan sex, or plan to use barrier contraception, in order to achieve or avoid pregnancy.
The crudest form of fertility tracking gave the field a bad name. The rhythm method involves simply counting the days starting when your period ends, and then abstaining from sex around Day 14, the midpoint when ovulation is supposed to take place in the average cycle of the average woman. As the historian of medicine and technology Deanna Day has documented, the rhythm method first became popular in the United States in the 1930s, when the first studies of average menstrual cycle lengths were translated into English from German and Japanese.
As a form of birth control, the rhythm method is notoriously ineffective. To predict individual fertility reliably, it is not enough to extrapolate from past cycles. You must attend to physiological signs that indicate when you will ovulate. Two are especially important: basal body temperature (BBT) and cervical fluid. BBT refers to a womans temperature upon waking. In the days or weeks before she ovulates, a womans BBT will usually hover between 36.1C and 36.5C. Progesterone, the hormone that induces the ovary to release an egg, causes it to spike up to 36.6C or higher, where it stays until the end of her period.
Ovulation also triggers the cervix to produce new kinds of secretions. The wetness that you might notice on the crotch of your underwear at different times of the month follows a predictable pattern: dry, sticky, creamy, egg white. Then you bleed; then start at dry again. If you are trying to get pregnant, it is egg white you want clear and resilient enough that you can stretch it an inch or more between your thumb and forefinger, before it snaps. On microscope slides taken at different points in the cycle it is possible to observe the ways in which cervical fluid dramatically morphs over the course of a given a month. Before and after ovulation, it honeycombs into a thicket, where sperm snag and stay, ensnared. On the days when fertilisation might occur, it stretches into tubes that look, and act, like tiny, high-speed rail tunnels.
If it is practised perfectly, fertility awareness can be almost as effective as the pill at preventing pregnancy. In 2007, a group of German scientists published a multi-year study of 900 women in the Oxford-based, peer-reviewed journal Human Reproduction. They found that, under conditions of perfect use, only 0.6% of the patients practising FAM became pregnant over the course of a year. But, given the chasm between perfect and average use, and the challenges involved in consistently observing and accurately interpreting physiological signals that vary from woman to woman, very few doctors endorse FAM as a form of contraception.
The tech entrepreneurs behind period tracking apps say that they can change this and that by gathering unprecedented amounts of data about understudied aspects of how female bodies work, they can revolutionise reproductive medicine.
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