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The term fertility awareness is used to describe an individual's understanding of male and female reproductive anatomy and physiology as it relates to fertility.
FERTILITY AWARENESS METHODSFAMs include all family planning methods based on the identification of the fertile time.4 This knowledge can be used to plan or avoid pregnancy.
Being a Fertility Specialist with QFG we offer world class strategies for addressing infertility, access to the very latest assisted reproduction technology and techniques, and the highest standard of care. For a woman it includes being able to identify the fertile time during her menstrual cycle. For a couple it includes developing a shared understanding about their fertility potential at different stages of their lives and their ability to communicate about fertility issues with each other and with health professionals.
Knaus in Austria independently observed that ovulation occurred at a fixed interval of approximately 14 days before the next menstruation.
Information about fertility awareness is also useful in clarifying the difference between a normal physiological discharge caused by cervical secretions and an abnormal discharge caused by a sexually transmitted infection, as well as increasing awareness that if sexually transmitted infections are not treated then the fallopian tubes or vas deferens may be infected, potentially resulting in infertility.
This formed the basis of the rhythm or calendar method.6 In the 1950s, new methods of fertility control were developed based on the physiological signs of ovulation. During family planning consultations, fertility awareness improves people's understanding about how each method of family planning prevents fertilization taking place and how if the method is not used correctly, then the risk of pregnancy will increase. For example, how the combined oral contraceptive pill prevents ovulation and makes the cervical secretions thick and impenetrable to sperm as well as understanding how fertility can quickly return if pills are not taken as directed.3This chapter focuses on how fertility awareness can be used as a method of family planning, either to achieve or to avoid pregnancy. John and Evelyn Billings in Melbourne, Australia pioneered a method based on the changes in cervical mucus secretions.7 Dr. It offers an overview of the scientific understanding of fertility awareness methods (FAMs) and describes the practical application of the knowledge to manage and counsel couples wishing to use each method.
Combining indicators has been variously described as the sympto-thermal method,10 the muco-thermic method,11 or the double check method.12In 1972, the World Health Organization (WHO) established a task force on methods for the prediction and detection of ovulation. One of the major objectives was to develop an accurate, easy, and cheap test that could be used in the home to predict the start and end of the fertile time. WHO research13 on numerous markers of fertility found that the most accurate determinants of the start of the fertile time was the increase of oestrone-3-glucoronide (E-3-G) in urine, and the luteinizing hormone (LH) surge provides the most accurate marker of ovulation and predicting the end of the fertile time.
In 1996, the first personal hormone monitoring system an immuno-chemical self-test was launched.14 While researching highly sophisticated and technologically advanced natural methods, the challenge still remained to provide reliable, simple, low-cost methods. The Standard Days Method (fixed formula)15 and the TwoDay Method16 are more recent developments in this area. 1 summarizes the physiological changes that occur during the menstrual cycle and the observed indicators of fertility. Copyright © Dr Cecilia Pyper and Jane Knight 2003 in collaboration with Fertility UK, The Institute for Reproductive Health, Georgetown UniversityThe hypothalamus secretes pulses of gonadotrophin-releasing hormone (GnRH) to regulate the pituitary output of follicle stimulating hormone (FSH) and LH.
FSH and LH act on the ovaries to stimulate the production of the ovarian hormones, estrogen, and progesterone. In the first half of the cycle (the follicular phase), FSH controls follicular growth, the growing follicles secrete estrogen, and a surge of LH triggers ovulation. Estrogen and progesterone in turn affect the target organs—the endometrium (lining of the uterus), the cervix and cervical secretions and the breasts. If the egg is not fertilized, estrogen and progesterone levels decrease and the endometrium is shed at the next menstruation. In addition to its role in controlling the menstrual cycle, the hypothalamus also controls body temperature, sleep, thirst, appetite, and fluid balance.
However, women experience multiple waves of follicular development each cycle, but only one of these waves results in an actual ovulation.
In 100% of the women they studied, a wave of follicular development occurred in the first half of the menstrual cycle and culminated in ovulation around the middle of the cycle. To identify the fertile time during each menstrual cycle, it is essential to know the lifespan of the sperm in the female genital tract before ovulation, the timing of ovulation, and the length of time during which the ovum can be fertilized after ovulation.The lifespan of the sperm is up to 7 days.
In the female genital tract, the survival of the sperm depends on the presence of alkaline cervical secretions (mucus), produced from the secreting cells lining the cervix. They identified the limits of the fertile window from 6 days before to 1 day after ovulation (Fig. Copyright © Dr Cecilia Pyper and Jane Knight 2003 in collaboration with Fertility UKDunson25 compared the North Carolina data with the Barrett and Marshall data26 that used the basal body temperature (BBT) increase as a marker of ovulation.
They used a new statistical model to correct for errors in estimating the day of ovulation. They suggested that BBT-based estimates of the day of ovulation are not perfect but have a high probability of being ± 1 day of the true ovulation day. The team concluded that women's fertility begins to decrease in the late 20s, with substantial decreases by the late 30s.
Fertility for men is less affected by age but shows significant decline by the late 30s27 (Fig. Probability of pregnancy relative to ovulation after intercourse on a given day of the cycle in women of different ages. Source: Dunson DB, Columbo B, Baird D, Changes with age in the level and duration of fertility in the menstrual cycle, Human Reproduction Vol 17, No 5 pp.
1399–1403, 2002Further research on the probability of conception on each day of the cycle is required to more clearly define the outer limits of the fertile time. This will require larger studies that use more precise markers of ovulation and more detailed data on intercourse frequency.Cycle Length Variability The length of a menstrual cycle is measured from the first day of menstruation, (the first day of fresh red bleeding) up to, but not including, the first day of the next menstruation.
The time from ovulation to the next menstruation is likely to be constant (approximately 10–16 days), whereas the time before ovulation is more variable (Fig.
Cycle length is most variable in the first few years after the menarche and in the years preceding the menopause. A woman's age minus her age at menarche (her gynecological age) is also an important factor when considering cycle length and regularity. Finally the fertile time can be identified by using fertility monitoring devices such as personal hormone monitoring systems, and saliva testing devices. Each of these indicators of fertility will change in response to the increasing and decreasing levels of estrogen and progesterone during the menstrual cycle. These indicators may be used alone to identify the fertile time but are more commonly combined to improve the effectiveness to avoid a pregnancy.MONITORING BASAL BODY TEMPERATUREThis section describes the monitoring of basal body temperature as a single indicator to identify the fertile time. Progesterone causes an increase in BBT (waking temperature), defined as the temperature before getting out of bed and after resting for at least 3 hours. If the reading is not taken within 1 hour of the target time then the actual time should be recorded and a note made that this reading is less reliable when interpreting the chart. Other factors or events that may disturb temperature readings include poor equipment or recording technique, alcohol, late night or disturbed night, oversleeping, illness causing low-grade pyrexia (fever), or medication such as antipyretics. Using temperature as a single indicator requires an average of 16 days of abstinence each cycle, because the couple have to abstain from intercourse until the temperature has remained at the higher level for 3 days.
For couples planning a pregnancy, temperature recording is of no value in predicting ovulation. In summary, using temperature as a single indicator, there is no indication of the start of the fertile time. All the conceptions occurred during the fertile window extending from 5 days before to 1 day after the temperature rise.

The chances of conception approximated to zero, 6 days before the day of the temperature rise, and 2 days after the temperature rise (Fig.
Slight variations in the guidelines are used by the Billings Ovulation Method and the Creighton Model.The hormones, estrogen, and progesterone influence the quantity and the quality of cervical secretions (Figs. The different types of secretions either impede or encourage sperm motility and this determines the state of fertility.7, 32 Fig. Copyright © Dr Cecilia Pyper and Jane Knight 2003 in collaboration with Fertility UK Fig. Copyright © Dr Cecilia Pyper and Jane Knight 2003 in collaboration with Fertility UKWhen the estrogen levels are low, there are minimal white, thick, and sticky secretions present at the cervix. The sperm are rapidly destroyed in the acidic environment of the vagina.The rising levels of estrogen alter the cervical secretions from being thick and sticky to becoming gradually more transparent, wetter, and stretchier.
The sperm move easily in these fertile secretions, which facilitate their movement upwards through the genital tract (Fig.
Most women need to observe the secretions for approximately three cycles before recognizing the changes with confidence.36 Changes in secretions can be masked by seminal fluid, spermicide, or vaginal infections. The Billings Ovulation Method37 and the Creighton Model, Napro Education Technology, described by Hilgers38 use cervical secretions only.A recent re-analysis of data from four small published studies (108 cycles) compared the observation of the peak day of cervical secretions with urinary LH. The analysis concluded that the peak day is very accurate in identifying maximum fertility and fairly accurate in identifying the day of ovulation and the end of the fertile time.39The Effectiveness of Using the Cervical Secretions as a Single Indicator A WHO multicenter study40 involving 725 participants showed that if couples are given good natural family planning (NFP) teaching and who follow the instructions correctly, then the cervical secretion indicator has a failure rate of approximately 3%. However, with typical use, which included cycles in which the method was used correctly and in cycles in which it was not, the study showed an overall failure rate of nearly 20%.
The TwoDay method16 involves women being taught to monitor whether vaginal secretions are present or absent. The women are taught to monitor their secretions each afternoon and evening, either by a feeling of dampness at the entrance to the vagina or by observing the secretions. Assuming that most couples have intercourse in the late evening or early morning, monitoring at these times avoids confusion between seminal fluid and cervical secretions. The estimated mean length of the fertile time (length of abstinence) for couples practicing the TwoDay Method is approximately 10 days.
As it is not uncommon for women to notice some secretions in the luteal phase as hormone levels fluctuate, the simple TwoDay Method may be found to require more lengthy times of abstinence.The TwoDay Method is based on a theoretical model. Secondary analysis42 of the data on cervical secretions from a large multinational European fecundability study assessed the relationship between the days predicted to be potentially fertile by the TwoDay Method and the day-specific probabilities of pregnancy based on 434 conception cycles. The authors concluded that if intercourse occurs on any given day relative to ovulation, the presence of cervical secretions was associated with a two-fold increase in the probability of conception. 11) in the muscle and connective tissue of the cervix.9 Women can learn to recognize these changes by gently palpating the cervix at approximately the same time each day. A woman may notice whether the cervix is low or high in the vagina, firm or soft to touch, and closed or slightly open. Palpating the cervix is rarely used alone as a single indicator, but the cervix changes are of particular value to women with long cycles, during breastfeeding when observing returning fertility, and during the perimenopausal years. Using the cervical changes—The fertile time starts at the first sign of the cervix becoming high, soft or open and the fertile time ends after the cervix has been low, firm and closed for three days.
A Canadian study44 confirmed that the cervix changes correlate with the cervical secretion and temperature indicators in identifying the fertile time.Less Precise Indicators of Fertility Estrogen and progesterone may cause other recognizable changes. These may include abdominal pain, abdominal heaviness, breast changes, intermenstrual bleeding, back pain, skin changes, and changes in libido and mood. The lengths of the shortest and longest cycles are used to identify the likely fertile time.
The calculation takes into account the life of the sperm and ovum to estimate the likely fertile time.
If a woman's longest or shortest menstrual cycle length changes, she recalculates her fertile time. The Standard Days method was derived from analyzing a large data set from a WHO study40 and estimating the theoretical probability of pregnancy on different days of the menstrual cycle. To use beads, a woman simply moves a black ring over a series of color-coded beads that represent her fertile and low-fertility days (Fig.
13) designed to avoid pregnancy consists of a small hand-held electronic monitor and simple disposable urine test sticks. The sticks collect information about the levels of hormones and the monitor reads and interprets this information.
The fertile time is indicated by red-light days and the infertile time is indicated by green-light days.
Many women find the device helpful while they are learning to identify their fertility signs. Well-informed women can use the method more intelligently and recognize which indicators may be affected by illness or stress. One third of women were randomized to receive information from the fertility monitor about the early fertile time (from the first rise in E3G until the LH surge is detected), one third received information about the late fertile time (the onset of the LH surge and the following 2 days), and a third did not receive any information (control group). A full description of the study methods has been reported.52Luteinizing Hormone Sticks Urinary LH dipsticks are widely marketed toward women wishing to achieve a pregnancy. The computer combines information about the temperature with a calculation based on cycle length. Over the past few years there has been an increasing number of saliva testing devices marketed directly to the public, mainly through the Internet.
They have not been subject to rigorous research and cannot be recommended for contraceptive purposes.
The devices use a small plastic microscope to detect a possible ferning pattern as an indicator of fertility.Braat57 studied the reliability of predicting the fertile days by salivary ferning in 30 women with regular menstrual cycles.
The first group of women (n = 17) used the mini-microscope, which showed a sensitivity of 53%. The second group of women (n = 13) used a normal light microscope, which had a sensitivity of 86%. Eight out of 10 postmenopausal women tested positive and all of the men tested positive for signs of ovulation.
The researchers concluded that the saliva ferning test is unreliable for predicting the fertile time and its use should be discouraged.Fertility monitoring devices differ enormously in price and in effectiveness. Freundl and associates58 have developed a quality index score to be used to evaluate fertility monitors prior to full prospective clinical trials.
The days predicted as fertile by the monitors were compared with the fertile time by ultrasound and urinary LH.
The researchers concluded that a quality index score of less than 0.5 identifies a monitor whose accuracy in identifying the fertile time is sufficient to warrant prospective clinical trials (this includes Persona and computerized thermometers).
Devices with a quality index score of more than 0.5 identifies a monitor whose accuracy in identifying the fertile time is not sufficient to warrant prospective clinical trials (this includes all saliva testing devices). The most common combination women use is monitoring the cervical secretions and temperature indicators. Cross-checking the indicators, with a calculation based on the shortest length of a woman's previous six cycles, increases the effectiveness of accurately identifying the start of the fertile time. If combining the indicators of fertility, the fertile time starts at the first sign of cervical secretions, the first change from a low firm closed (and tilted) cervix or the first fertile day by shortest cycle calculation, whichever comes earlier.

14 illustrates a completed chart from a woman combining the observed fertility indicators with Persona. In this example, day 8 is the start of the fertile time (the calculation is the earliest indicator). There is no need to wait for the cervix to remain closed for 3 days or to perform a longest cycle calculation provided temperature and secretions are correlated.
Copyright © Dr Cecilia Pyper and Jane Knight 2003 in collaboration with Fertility UKWomen are encouraged to record factors or events that may disturb the menstrual cycle or the fertility indicators. The most recent effectiveness study shows the methodology is very effective when used correctly.
Lamprecht and Trussell performed an evaluation of well-designed effectiveness studies.66 They discuss the many factors influencing the effectiveness of FAMs, propose a framework for evaluating published reports on effectiveness, and provide guidance for the design of future studies.
Some of the variable factors include the indicators of fertility used, the teaching methodology, the characteristics of the study population, new or experienced users, new or experienced teachers, the methods used to calculate the pregnancy rates, methods used to confirm pregnancies, intention to conceive, or avoid indicated at the beginning of the cycle. For example, some efficacy studies have allowed women a three-cycle learning phase before recruitment to the study, whereas other studies, including the more recent Standard Days Method and TwoDay Method, women entered the study as soon as they started using the method. These factors are likely to impact on the effectiveness, because generally more experienced users of a method will use the method more effectively. Lamprecht and Trussel66 suggest that many FAM studies were flawed in design and did not calculate pregnancy rates correctly. They report on the few well-designed studies and provide guidance for the design of future studies.
Although the cost in the first few months was higher (nurses' time), once a couple understood the method they no longer needed to attend the clinic on a regular basis, and the ongoing cost of charts and thermometers was minimal.
In other consultations, health professionals may be alerted to the fact that the woman seems excessively anxious or disinterested. In practice, the use of barrier methods (particularly if used with additional spermicide) can make the recognition of cervical secretions difficult.
The study shows that couples who use barrier methods during the fertile time still take risks and have unprotected intercourse during the fertile time. The researchers conclude that FAMs are most unforgiving of imperfect use, but are extremely effective when either abstinence or protected intercourse is used during the fertile time. It is therefore recommended that a man be advised to pass urine between each ejaculation to flush out any remaining sperm.
Couples need to be counseled that they are at risk for sexually transmitted diseases and that although the lubricating fluids that escape from the penis long before ejaculation do not contain sperm, they can transmit infections such as the HIV virus.
The effectiveness of withdrawal method is estimated to be 96% effective with perfect use and 81% effective with typical use. This means that between four and 19 women out of 100 would conceive in 1 year using withdrawal method.71 This is estimated for couples using withdrawal method alone. Effective consultations skills are essential for working with clients requesting any user-dependent method.
If the woman is seen alone, every effort should be made to discuss the impact of abstinence on the relationship.FAMs alongside contraceptive pills and barrier methods are user-dependent methods. They all rely on the day-to-day vigilance and motivation of individuals to avoid pregnancy. For individuals who are ambivalent or forgetful, the potential exists to use the method incorrectly or stop using it altogether.
Although the fertile time is only approximately 8–9 days, the number of days of abstinence required varies from 8 to 17 days, depending on the method used.
Difficulties related to the length of abstinence may be directly related to the indicator used. Single-indicator methods generally involve the longest time of abstinence, typically around 16 days. Combined-indicator methods aim to accurately identify the fertile time and reduce the time of abstinence to an average of 10 days. Personal hormone monitoring has the potential for reducing the required time of abstinence still further.Fig. The study showed that 41% of the couples were worried about an unplanned pregnancy; this affected their attitude to intercourse in 28% of the men and 38% of the women. The majority of couples both men and women found abstinence difficult.Couples who choose to abstain from vaginal intercourse during the fertile time have different ways of coping with abstinence.
For some couples this involves being physically apart; for others, it involves being more imaginative with their lovemaking.
Bonnar and Lamprecht75 collected data on alternatives to vaginal intercourse during the fertile time as part of a pilot effectiveness study of Irish women who used a calculation based on the previous six cycles.
In addition, most women who choose to use FAMs for moral or ethical reasons have concerns related to the use of emergency contraception. Although emergency contraception usually works by preventing fertilization, it is undeniable that the mechanism may prevent implantation.76CONCERNS ABOUT BIRTH DEFECTSConcerns have been raised about the risk of birth defects or poor pregnancy outcomes caused by aged ovum or sperm at the time of conception. Unintended pregnancies among couples who use natural methods usually result from having intercourse at the beginning or end of the fertile time.
A prospective study showed no significant differences in rates of spontaneous abortion, low birth weight, or preterm birth among women using FAMs who had unintended pregnancies compared with women who had intended pregnancies.77,78,79The timing of implantation could be related to early pregnancy loss.
In a small study, women had a greater chance of having a miscarriage when conception occurred very late in the fertile time.80 It was suggested that pregnancies with late-implanting conceptuses might fail for several reasons. The receptivity of the endometrium decreases during the late luteal phase, and the corpus luteum is less responsive to HCG by 11 or 12 days after ovulation.
Unhealthy zygotes may develop more slowly or implantation may be abnormal, resulting in later and weaker production of chorionic gonadotrophin.
To the degree that imperfect embryos develop and are implanted more slowly, a limited window of receptivity may provide a gating mechanism to screen out impaired embryos. Larger studies are required to clarify these findings.SEX SELECTIONThere has long been an interest in predetermining the sex of the child at the time of conception. The ancient Greeks believed that male sperm were produced in the right testicle and boys were formed on the right or warmer side of the uterus and girls on the left. French noblemen were reported to have tied up or even cut off their left testicle in the quest for an heir. Over more recent years, endless theories have been expounded related to diet, intercourse position, and timing of intercourse in relation to ovulation. In view of the clinical nature and limiting factors of these treatments, many couples still maintain an active interest in any possible way to predetermine the sex of their offspring. Although some studies have shown an excess of male births closer to ovulation, others have shown an excess of female births. However, the current evidence clearly demonstrates that the manipulation of the timing of conception or characteristics of the menstrual cycle cannot be used to preselect the sex of the child.83USING FERTILITY AWARENESS METHODSUsing Fertility Awareness Methods After Stopping Hormonal Methods of ContraceptionWomen who are discontinuing hormonal methods of contraception before starting a FAM to achieve or avoid pregnancy require careful management and counseling.
Many family planning providers are not as confident to manage women at this time because the return of fertility is unpredictable.

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