From Wikipedia, the free encyclopedia

Fertility awareness as birth control
Background
B.C. type	Fertility tracking
First use	1950s (mucus) mid-1930s (BBT) 1930 (Knaus-Ogino) Ancient (ad hoc)
Failure rates (first year)
Perfect use	1-3%
Typical use	3-25%
Usage
Reversibility	Yes
User reminders	Dependent upon strict user adherence to methodology
Clinic review	None
Advantages and Disadvantages
STD protection	No
Periods	Increased prediction
Benefits	no side effects, can aid pregnancy achievement

Fertility awareness (FA) refers to a set of practices in which a woman observes one or more of her primary fertility signs to determine the fertile and infertile phases of her menstrual cycle. Fertility awareness methods may be used to avoid pregnancy, to achieve pregnancy, or as a way to monitor gynecological health. The term Fertility Awareness Method refers specifically to the method taught by Toni Weschler.

Contents 1 Terminology 2 Methods and characteristics 2.1 Potential benefits 2.2 Related practices 3 As birth control: to avoid pregnancy 3.1 With barrier and alternate methods 3.2 With abstinence 3.3 General birth control effectiveness 3.4 Fertility awareness effectiveness 4 Achieving pregnancy 4.1 Intercourse timing 4.2 Problem diagnosis 4.3 Pregnancy testing and gestational age 5 Scientific basis 6 Observational methods 7 History 8 See also 9 Further reading 10 Footnotes 11 External links

The term "Natural Family Planning" (NFP) is sometimes used to refer to any use of FA methods. However, NFP specifically refers to practices that are approved by the Roman Catholic Church — breastfeeding infertility, and periodic abstinence during fertile times. FA methods may be used by NFP users to identify these fertile times.

There are three primary fertility signs that may be used to practice FA:^[1]

• Basal body temperature (BBT)
• Cervical mucus (Systems relying exclusively on cervical mucus include the Billings Ovulation Method, the Creighton Model, and the Two-Day Method.)
• Cervical position (No studies have been conducted of women relying exclusively on cervical observations, though one such method has been suggested.)^[2]

Symptothermal methods combine observations of BBT, cervical mucus, and sometimes cervical position.

Fertility awareness has several aspects which may be seen as beneficial:

• There are no drug-related side effects to FA. There are no side effects at all, besides those that may occur from inserting fingers into the vagina for cervical observation (as some FA methods recommend).
• FA is free or very low-cost. Users may avail of a chart, calendar, basal thermometer, or software. The costs are extremely low when compared to other methods.
• FA can be used to monitor reproductive health. Changes in the cycle can alert the user to emerging gynecological problems. FA can also be used to aid in diagnosing known gynecological problems such as infertility.
• FA is versatile: it may be used to avoid pregnancy or to aid in conception.
• FA can be used by all women throughout their reproductive life, regardless of whether a woman is approaching menopause, is breastfeeding, or experiencing irregular cycles for other reasons.
• Use of FA can give insight to the workings of women's bodies, and may allow women to take greater control of their own fertility.
• When used as birth control, FA can be used with barrier contraception so that intercourse may continue through the fertile period. Unlike barrier use without FA, practicing FA can allow couples to use barrier contraception only when necessary.

Less accurate than symptoms-based methods are statistical or calendar-based methods such as the Rhythm Method. While the World Health Organization classifies both symptoms-based and calendar-based methods as "fertility awareness",^[3] some teachers of symptoms-based methods do not consider calendar-based methods to be fertility awareness.^[4] The Rhythm Method relies solely on counting days and applying a mathematical formula in order to estimate the onset of a woman's fertile period. Because of its lower accuracy, many FA teachers consider calendar rhythm to have been obsolete for at least 20 years.^[5]

Women who are breastfeeding a child and wish to avoid pregnancy may be able to practice the lactational amenorrhea method (LAM), or a stricter version known as Ecological Breastfeeding. These methods are not FA, but because they also do not involve devices or chemicals, they are often presented alongside FA as a method of natural birth control.

Like the Pill and other non-barrier contraceptives, FA offers no protection against sexually transmitted diseases. FA methods require a woman to make regular, consistent effort to determine when her chance of fertility is low. Avoiding pregnancy by use of FA requires women to refrain from engaging in unprotected sexual intercourse for at least 8-10 days each cycle, whether through use of a barrier or alternate method, or through abstinence. Achieving the highest effectiveness rates can require an even longer period of alternate method use or abstinence, though it is rare for users to need to do so for more than two weeks. Perhaps for these reasons, other methods are more popular than FA among large sections of society.

FA can be used with any non-hormonal method of birth control so that intercourse may continue through the fertile period. Couples seeking maximum birth control effectiveness might use an alternate method during the infertile phase, and abstain from intercourse during the fertile phase.

A well-known usage of fertility awareness with abstinence is in accord with the teachings of the Roman Catholic Church, as natural family planning. For many women, the times of high fertility coincide with the time of highest libido, which can cause frustration if abstinence is used.^[6] For those using abstinence during the fertile time, the required "scheduling" of sex can be inconvenient or frustrating. Statistically, FA users who practice abstinence during the fertile period have intercourse about as often as users of other birth control methods.^[7]

The effectiveness of FA, as of artificial forms of contraception, can be assessed two ways: method effectiveness and actual effectiveness. The method effectiveness is the proportion of women correctly and consistently using the method who do not become pregnant. Actual effectiveness is the proportion of women who intended that method as their sole form of birth control where a woman does not become pregnant; it includes women who sometimes use the method incorrectly, or sometimes not at all. Effectiveness rates are generally presented per one year of use.

For all forms of contraception, actual effectiveness is lower than method effectiveness, due to several factors:

• mistakes on the part of those providing instructions on how to use the method
• mistakes on the part of the method's users
• conscious user non-compliance with method.

For instance, someone using oral forms of hormonal birth control might be given incorrect information by a health care provider as to the frequency of intake, or by mistake not take the pill one day, or simply not bother to go to the pharmacy on time to renew the prescription.

The highest birth control effectiveness rates for those using FA are found in couples who received instruction from an experienced teacher. When used correctly and consistently, studies have shown some forms of FA to be 99% effective,^{[8][9][10][11]} the same as oral contraceptives."Natural contraception 'effective'", BBC News, 2007-02-21. Retrieved on 2007-09-25. 

From Contraceptive Technology ^[12]:

• Post-ovulation methods (i.e. abstaining from intercourse from menstruation until after ovulation) have a method failure rate of 1% per year.
• The symptothermo method has a method failure rate of 2% per year.
• The cervical mucus-only methods have a method failure rate of 3% per year.
• Calendar rhythm has a method failure rate of 9% per year.
• The Standard Days Method has a method failure rate of 5% per year.

For all fertility awareness methods, actual effectiveness can be significantly lower than method effectiveness - some studies have found actual failure rates of 25% per year or higher.^[13][14][15] Actual failure rates vary widely depending on the population being studied and the teaching method - at least one study has found an actual failure rate of less than 1% per year,^[10] and several studies have found actual failure rates of 2-3% per year.^{[16][17][18][19]}

The most common reason for the lower actual effectiveness is not mistakes on the part of instructors or users, but conscious user non-compliance,^[11][18] i.e., the couple knowing that the woman is likely to be fertile at the time, but engaging in sexual intercourse nonetheless. This is similar to failures of barrier methods, which are primarily caused by non-use of the method.

A study by Barrett and Marshall has shown that random acts of intercourse achieve a 24% pregnancy rate per cycle. That study also found that timed intercourse based on information from a BBT-only method of FA increased pregnancy rates to 31%-68%.

Studies of cervical-mucus methods of fertility awareness have found pregnancy rates of 67%-81% in the first cycle if intercourse occurred on the Peak Day of the mucus sign.^[20][21]

Because of high rates of very early miscarriage (25% of pregnancies are lost within the first six weeks since the woman's last menstrual period, or LMP), the methods used to detect pregnancy may lead to bias in conception rates. Less-sensitive methods will detect lower conception rates, because they miss the conceptions that resulted in early pregnancy loss. A Chinese study of couples practicing random intercourse to achieve pregnancy used very sensitive pregnancy tests to detect pregnancy. It found a 40% conception rate per cycle over the 12-month study period.^[22]

Regular menstrual cycles are sometimes taken as evidence that a woman is ovulating normally, and irregular cycles as evidence she is not.^[23] However, many women with irregular cycles do ovulate normally, and some with regular cycles are actually annovulatory or have a luteal phase defect. Records of basal body temperatures, especially, but also of cervical mucus and position, can be used to accurately determine if a woman is ovulating, and if the length of the post-ovulatory (luteal) phase of her menstrual cycle is sufficient to sustain a pregnancy.

Fertile cervical mucus is important in creating an environment that allows sperm to pass through the cervix and into the fallopian tubes where they wait for ovulation.^[24] Fertility charts can help diagnose hostile cervical mucus, a common cause of infertility. Guaifenesin can help to produce fertile cervical mucus.

Pregnancy tests are not accurate until 1-2 weeks after ovulation. Knowing an estimated date of ovulation can prevent a woman from getting false negative results due to testing too early. Also, 18 consecutive days of elevated temperatures means a woman is almost certainly pregnant.^[25]

Estimated ovulation dates from fertility charts are a more accurate method of estimating gestational age than the traditional pregnancy wheel or last menstrual period (LMP) method of tracking menstrual periods.^[26]

Ova die if not fertilized within 24 hours of ovulation. Ovulation can be detected through changes in basal body temperatures, cervical mucus, and/or cervical position. Once ovulation has passed, conception is not possible for the remainder of the menstrual cycle. Sperm are able to fertilize an ovum for a period of up to five days after they have been ejaculated. If no fertile cervical mucus is present, the acidic environment of the vagina usually results in a dramatically shorter sperm life. Intercourse that occurs more than five days before ovulation is unlikely to result in pregnancy. Intercourse that occurs in the presence of cervical mucus, and/or right before the temperature shift is most likely to result in pregnancy. Most women experience fertile cervical mucus and cervical position changes five to seven days before ovulation occurs,^[27] giving them sufficient notice to avoid or plan intercourse (depending on their pregnancy intentions).

This description is an overview only. Women wishing to use Fertility Awareness to avoid or encourage pregnancy should seek appropriate instruction.

The three primary fertility signs are basal body temperature (BBT), cervical mucus, and cervical position. A woman practicing fertility awareness may choose to observe one sign, two signs, or, all three.

Basal body temperature is a person’s temperature taken when they first wake up in the morning (or after their longest sleep period of the day). In women, ovulation will trigger a rise in BBT between 0.3 and 0.9 °C (0.5 and 1.6 °F) that lasts approximately until the next menstruation. Sixty percent of the time, ovulation happens the day before the temperature rise. The other forty percent of the time, ovulation may happen a few days in either direction.

The appearance of cervical mucus and vulvar sensation are generally described together as two ways of observing the same sign. Cervical mucus is produced by the cervix, which separates the uterus from the vaginal canal. Cervical mucus is a heterogeneous mixture of different types of mucus, several of which have specialized functions. Some of its functions are similar to those of semen - cervical mucus promotes sperm life by decreasing the acidity of the vagina and providing nourishment to the sperm. One type of mucus has a structure that helps guide sperm into the cervix and then the uterus. The production of fertile cervical mucus is caused by the same hormone (estrogen) that prepares a woman’s body for ovulation. By observing her cervical mucus, and paying attention to the sensation as it passes the vulva, a woman can detect when her body is gearing up for ovulation, and also when ovulation has passed. When ovulation occurs, estrogen production drops slightly and progesterone starts to rise. The rise in progesterone causes a distinct change in the quantity and quality of mucus observed at the vulva.^[28] Each of the methods of fertility awareness observes and interprets this occurrence differently, and uses different rules to determine the onset of fertility and post-ovulatory infertility.

The cervix changes position in response to the same hormones that cause cervical mucus to be produced and to dry up. When a woman is in an infertile phase of her cycle, the cervix will be low in the vaginal canal; it will feel firm to the touch (like the tip of a person’s nose); and, the os – the opening in the cervix – will be relatively small, or ‘closed’. As a woman becomes more fertile, the cervix will rise higher in the vaginal canal; it will become softer to the touch (more like a person’s lips); and the os will become more open. After ovulation has occurred, the cervix will revert to its infertile position.

There are other techniques for detecting ovulation. Unlike the three primary signs described above, these other methods are not considered sufficiently accurate to avoid pregnancy. They are often used by women seeking to conceive.

Ovulation Predictor Kits (OPKs) can detect imminent ovulation from the concentration of lutenizing hormone (LH) in a woman’s urine. A positive OPK is usually followed by ovulation within 12-36 hours.

Saliva microscopes, when correctly used, can detect ferning structures in the saliva that precede ovulation. Ferning is usually detected beginning three days before ovulation, and continuing until ovulation has occurred.

Fertility monitors are available under various brand names. These monitors use a combination of the calendar method, OPKs, and sometimes computerized interpretation of BBTs. Though the manufacturers claim high effectiveness rates for avoiding pregnancy, independent studies show failure rates comparable to the calendar method.

Many women experience secondary fertility signs that correlate loosely with ovulation. Examples include breast tenderness and mittelschmerz (ovulation pains).

It is not known exactly when it was first discovered that women have predictable periods of fertility and infertility. St. Augustine wrote about periodic abstinence to avoid pregnancy in the year 388 (the Manichaeans attempted to use this method to remain childfree, and Augustine condemned their use of periodic abstinence).^[29] One book states that periodic abstinence was recommended "by a few secular thinkers since the mid-nineteenth century,"^[30] but the dominant force in the twentieth century development of observational methods was the Roman Catholic Church.

In 1905 Theodoor Hendrik Van de Velde, a Dutch gynecologist, showed that women only ovulate once per menstrual cycle.^[31] In the 1920s, Kyusaku Ogino, a Japanese gynecologist, and Hermann Knaus, from Austria, independently discovered that ovulation occurs about fourteen days before the next menstrual period.^[32] Ogino used his discovery to develop a formula for use in aiding infertile women time intercourse to achieve pregnancy. In 1930, John Smulders, Roman Catholic physician from the Netherlands, used this discovery to create a method for avoiding pregnancy. Smulders published his work with the Dutch Roman Catholic medical association, and this was the first formalized system for periodic abstinence - the Rhythm Method.^[32]

Early Catholic doctrine considered complete sexual abstinence to be the most holy state for humans, with marriage allowed only for those without the fortitude required by an abstinent life. Into the early twentieth century, it was believed by some Catholics that the only licit reason for sexual intercourse was an attempt to create children. At the time, there was no official church position on any non-procreative purposes of intercourse.^[30] Internal rulings of the Catholic Church in 1853 and 1880 stated for the first time that periodic abstinence was a moral way to avoid pregnancy.^[33][34] The first public document addressing this issue, however, was the December 1930 encyclical Casti Connubii by Pope Pius XI, which declared that there was no moral stain associated with having marital intercourse at times when "new life cannot be brought forth." Although this referred primarily to conditions such as current pregnancy and menopause, another internal ruling in 1932,^[35] and the majority of Catholic theologians also interpreted it to allow moral use—for couples with "upright motives"—of the newly created Rhythm Method.^[34][36]

In the 1930s, Rev. Wilhelm Hillebrand, a Catholic priest in Germany, developed a system for avoiding pregnancy based on basal body temperature.^[37] This temperature method was found to be more effective at helping women avoid pregnancy than the Rhythm Method. Over the next few decades, both systems became widely used among Catholic women. The 1932 ruling approving periodic abstinence in some circumstances was made public in 1945,^[35] and two speeches delivered by Pope Pius XII in 1951 gave the highest form of recognition to the Catholic Church's approval of these systems for couples who needed to avoid pregnancy.^[38][30] In the early 1950s, Dr. John Billings discovered the relationship between cervical mucus and fertility while working for the Melbourne Catholic Family Welfare Bureau. Dr. Billings and several other physicians studied this sign for a number of years, and by the late 1960s had performed clinical trials and begun to set up teaching centers around the world.^[39] While the Billings initially taught both the temperature and mucus signs, they encountered problems in teaching the temperature sign to largely illiterate populations in developing countries. In the 1970s they modified the method to rely on only mucus.^[37] The international organization founded by Dr. Billings is now known as the World Organization Ovulation Method Billings (WOOMB).

The first organization to teach a symptothermal method was founded in 1971. John and Sheila Kippley, lay Catholics, joined with Dr. Konald Prem in teaching an observational method that relied on all three signs: temperature, mucus, and also cervical position. Their organization is now called Couple to Couple League International.^[37] The next decade saw the founding of other now-large Catholic organizations - Family of the Americas (1977), teaching the Billings method,^[40] and the Pope Paul VI Institute (1985), teaching a new mucus-only system called the Creighton Model.^[41]

Up until the 1980s, information about fertility awareness was only available from Catholic sources.^[42] The first secular teaching organization was the Fertility Awareness Center in New York, founded in 1981.^[43] Toni Weschler started teaching in 1982 and published the bestselling book Taking Charge of Your Fertility in 1995.^[44] Justisse was founded in 1987 in Edmonton, Canada.^[45] These secular organizations all teach symptothermal methods. Although the Catholic organizations are significantly larger than the secular fertility awareness movement, independent secular teachers have become increasingly common throughout the 1990s and 2000s.

Development of fertility awareness methods is ongoing. In the late 1990s, the Institute for Reproductive Health at Georgetown University introduced two new methods.^[46][47] The Two-Day Method, a mucus-only system, and CycleBeads, a variant of the Rhythm Method, are designed to be both effective and very simple to teach, learn, and use.

• Basal body temperature
• Billings ovulation method
• Creighton Model FertilityCare System
• Natural family planning
• PERSONA (contraception)
• Toni Weschler

• Toni Weschler (2006). Taking Charge of Your Fertility, 10th Anniversary Edition, New York: Collins. ISBN 0-06-088190-9. 
• John F. Kippley and Sheila K. Kippley (1996). The Art of Natural Family Planning, Fourth edition, Cincinnati, OH: Couple to Couple League International. ISBN 0-926412-13-2. 

See also: Natural family planning#External links

• Couple to Couple League - A Catholic organization with information on the Sympto-Thermal Method of Natural family planning.
• Institute for Reproductive Health at Georgetown University - An organization developing and promoting fertility awareness methods
• Justisse - An online educational resource. Lists FA teachers trained by Geraldine Matus, director of the Justisse Center. Based in Edmonton, Alberta, Canada.
• Ovusoft - Information, software, message boards, and sample charts based on the book Taking Charge of Your Fertility by Toni Weschler
• Sister Zeus - A women's guide to synergistic fertility management.

v • d • e Birth control
Behavioral:	Avoiding vaginal intercourse: Anal sex, Oral sex, Non-penetrative sex, Masturbation, Abstinence Including vaginal intercourse: Fertility awareness, Rhythm Method, Withdrawal, Breastfeeding infertility
Barrier:	Condom, Female condom, Diaphragm, Lea's shield, Cervical cap
Spermicide	Contraceptive sponge
Hormonal:	Combined: Combined oral contraceptive pill ('the Pill'), Contraceptive patch, NuvaRing Progestogen only: Progestogen only pill ('minipill'), Depo-Provera, Norplant/Jadelle, Implanon
Anti-estrogen:	Ormeloxifene (a.k.a. Centchroman)
Intra-uterine:	IUD (copper or progestogen), IUS (progestogen)
Post-intercourse:	Contraception: Emergency contraception (pills or copper IUD) Abortion: Surgical abortion, Medical abortion (RU-486/abortion pill)
Sterilization:	Male: Vasectomy Female: Tubal ligation, Essure