Women’s fertility awareness and decision making around perceived or estimated post-ovulation emergency contraceptive use: a narrative review

Background Emergency contraception (EC) is most effective when used within appropriate biological timing, yet many women make decisions based on perceived or estimated ovulation rather than objectively confirmed ovulation. Evidence directly examining women’s decision-making after ovulation remains limited. Objective To synthesize evidence on women’s fertility awareness, understanding of ovulation timing, mechanisms and timing of EC methods, and the social and healthcare factors influencing decisions about EC when intercourse is perceived or estimated to have occurred around or after ovulation. Methods A structured narrative review was conducted using PubMed, PubMed Central, Europe PMC, Scopus, and Embase, supplemented by major reproductive-health journals, World Health Organization guidance, professional society resources, and the International Consortium for Emergency Contraception literature database. Evidence published through February 2026 was identified using predefined eligibility criteria and synthesized thematically. Sources were interpreted according to whether ovulation was biologically confirmed, clinically estimated, or participant-perceived/app-predicted. Formal risk-of-bias assessment and statistical pooling were not performed. Results Clinical evidence indicates that levonorgestrel and ulipristal acetate primarily prevent pregnancy before ovulation, whereas the copper intrauterine device remains the best-established intrauterine EC option when ovulation may have occurred. The 52-mg levonorgestrel-releasing intrauterine device is supported by randomized evidence within the studied insertion window. Across diverse populations, fertility awareness was frequently limited, with many women inaccurately identifying the fertile window or relying on calendar calculations and mobile applications. Knowledge gaps, stigma, partner influence, healthcare access, and counseling quality further shaped EC-related decisions. Conclusions EC decisions around perceived or estimated ovulation reflect biological timing, fertility awareness, pregnancy-risk perception, and access-related factors. Direct evidence on decision-making after objectively confirmed ovulation remains limited, highlighting the need for improved counseling and research integrating objective ovulation assessment with women’s actual EC decisions.