Everything about Fertility Awareness totally explained
Fertility awareness (FA) refers to a set of practices used to determine the fertile and infertile phases of a woman's
menstrual cycle. Methods of identifying infertile days have been used for over a thousand years, but scientific knowledge gained during the past century has greatly increased the accuracy of these systems. From 1930 to 1980, all research and promotion of fertility awareness was done by those associated with the
Roman Catholic Church. Fertility awareness organizations continue to be predominately Catholic, but some secular organizations now exist.
Fertility awareness methods may be used to
avoid pregnancy, to
achieve pregnancy, or as a way to monitor
gynecological health.
Systems of fertility awareness may rely on observation of changes in one or more of the primary fertility signs (
basal body temperature,
cervical mucus, and cervical position), records of menstrual cycle length, or both. Some women also find useful observations of secondary fertility signs such as
breast tenderness and
mittelschmerz (ovulation pains), although no formal systems rely on secondary signs. Although not useful by themselves own for avoiding pregnancy, urine analysis strips known as ovulation predictor kits (OPKs) and microscopic examination of saliva or cervical fluid can identify fertile days. Also available are computerized
fertility monitors that analyze hormone levels in urine, basal body temperature, or electrical resistance of saliva and vaginal fluids.
Terminology
Symptoms-based methods involve tracking one or more of the three primary fertility signs -
basal body temperature,
cervical mucus, and cervical position. Systems relying exclusively on cervical mucus include the
Billings Ovulation Method, the
Creighton Model, and the Two-Day Method. Symptothermal methods combine observations of BBT, cervical mucus, and sometimes cervical position.
Calendar-based methods rely only on a history of cycle lengths. While the
World Health Organization classifies both symptoms-based and calendar-based methods as "fertility awareness", some teachers of symptoms-based methods do
not consider calendar-based methods to be fertility awareness.
Systems of fertility awareness may be referred to as fertility awareness-based methods (FAB methods); One book states that periodic abstinence was recommended
"by a few secular thinkers since the mid-nineteenth century," but the dominant force in the twentieth century popularization of fertility awareness-based 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. 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. 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. 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. Two speeches delivered by
Pope Pius XII in 1951 gave the highest form of recognition to the Catholic Church's approval—for couples who needed to avoid pregnancy—of these systems.
First symptoms-based teaching organizations
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. and the Pope Paul VI Institute (1985), teaching a new mucus-only system called the Creighton Model.
Up until the 1980s, information about fertility awareness was only available from Catholic sources. The first secular teaching organization was the Fertility Awareness Center in New York, founded in 1981.
Toni Weschler started teaching in 1982 and published the bestselling book
Taking Charge of Your Fertility in 1995. Justisse was founded in 1987 in Edmonton, Canada. 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.
Ongoing development
Development of fertility awareness methods is ongoing. In the late 1990s, the Institute for Reproductive Health at
Georgetown University introduced two new methods. 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.
Fertility signs
Most menstrual cycles have several days at the beginning that are infertile (pre-ovulatory infertility), a period of fertility, and then several days just before the next menstruation that are infertile (post-ovulatory infertility). The first day of red bleeding is considered day one of the menstrual cycle. Different systems of fertility awareness calculate the fertile period in slightly different ways, using primary fertility signs, cycle history, or both.
Primary signs
The three primary fertility signs are
basal body temperature (BBT),
cervical mucus, and
cervical position. A woman practicing symptoms-based 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. This temperature shift may be used to determine the onset of post-ovulatory infertility.
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. Fertile cervical mucus promotes sperm life by decreasing the acidity of the vagina, and also helps guide sperm through the cervix and into 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.
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'll 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'll 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.
Cycle history
Calendar-based systems determine both pre-ovulatory and post-ovulatory infertility based on cycle history. When used to avoid pregnancy, these systems have higher perfect-use failure rates than symptoms-based systems, but are still comparable to barrier methods such as
diaphragms and
cervical caps.
Mucus- and temperature-based methods used to determine post-ovulatory infertility, when used to avoid conception, result in very low perfect-use pregnancy rates. However, mucus and temperature systems have certain limitations in determining pre-ovulatory infertility. A temperature record alone provides no guide to fertility or infertility before ovulation occurs. Determination of pre-ovulatory infertility may be done by observing the absence of fertile cervical mucus; however, this results in a higher failure rate than that seen in the period of post-ovulatory infertility. Relying only on mucus observation also means that unprotected sexual intercourse isn't allowed during
menstruation, since any mucus would be obscured.
Use of certain calendar rules to determine the length of the pre-ovulatory infertile phase allows unprotected intercourse during the first few days of the menstrual cycle, while maintaining a very low risk of pregnancy. With mucus-only methods, there's a possibility of incorrectly identifying mid-cycle or anovulatory bleeding as menstruation. Keeping a BBT chart enables accurate identification of menstruation, when pre-ovulatory calendar rules may be reliably applied. In temperature-only systems, a calendar rule may be relied on alone to determine pre-ovulatory infertility. In symptothermal systems, the calendar rule is cross-checked by mucus records: observation of fertile cervical mucus overrides any calendar-determined infertility. Or, a calendar rule may require calculation, for example holding that the length of the pre-ovulatory infertile phase is equal to the length of a woman's shortest cycle minus twenty-one days. Rather than being tied to cycle length, a calendar rule may be determined from the cycle day on which a woman observes a thermal shift. One system has the length of the pre-ovulatory infertile phase equal to a woman's earliest historical day of temperature rise minus seven days.
Secondary signs
Many women experience secondary fertility signs that correlate with certain phases of the menstrual cycle. Examples include
breast tenderness and
mittelschmerz (ovulation pains).
Other techniques
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. During this window, ferning structures occur in cervical mucus as well as saliva.
Fertility monitors are available under various brand names. These monitors use a combination of the calendar method, OPKs, and sometimes computerized interpretation of BBTs.
Benefits and drawbacks
Fertility awareness has a number of unique characteristics:
- 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.
- Some symptoms-based forms of fertility awareness require observation or touching of cervical mucus, an activity with which some women are not comfortable. Some practitioners prefer to use the term "cervical fluid" to refer to cervical mucus, in an attempt to make the subject more palatable to these women.
- Some drugs, such as decongestants, can change cervical mucus. In women taking these drugs, the mucus sign may not accurately indicate fertility.
- Some symptoms-based methods require tracking of basal body temperatures. Because irregular sleep can interfere with the accuracy of basal body temperatures, shift workers and those with very young children, for example, might not be able to use those methods. For women with very irregular cycles - such as those common during breastfeeding, perimenopause, or with hormonal diseases such as PCOS - abstinence or the use of barriers may be required for months at a time. Many couples may not have the motivation or discipline to abstain or use barriers for long periods of time.
- Fertility awareness doesn't protect against sexually transmitted disease.
Effectiveness
The effectiveness of fertility awareness, as of most forms of
contraception, can be assessed two ways.
Perfect use or
method effectiveness rates only include people who follow all observational rules, correctly identify the fertile phase, and refrain from unprotected intercourse on days identified as fertile.
Actual use, or
typical use effectiveness rates are of all women relying on fertility awareness to avoid pregnancy, including those who fail to meet the "perfect use" criteria. Rates are generally presented for the first year of use. Most commonly the
Pearl Index is used to calculate effectiveness rates, but some studies use
decrement tables.
The failure rate of fertility awareness varies widely depending on the system used to identify fertile days, the instructional method, and the population being studied. Some studies have found actual failure rates of 25% per year or higher. At least one study has found a failure rate of less than 1% per year with continuous intensive coaching and monthly review,
When used correctly and consistently with ongoing coaching, some studies have shown some forms of FA to be 99% effective, the same as oral contraceptives.
From
Contraceptive Technology :
Post-ovulation methods (for example 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.
Reasons for lower typical-use effectiveness
Several factors account for typical use effectiveness being lower than perfect use effectiveness:
mistakes on the part of those providing instructions on how to use the method (instructor providing incorrect or incomplete information on the rule system)
mistakes on the part of the user (misunderstanding of rules, mistakes in charting)
conscious user non-compliance with instructions (having unprotected intercourse on a day identified as fertile)
The most common reason for the lower actual effectiveness isn't mistakes on the part of instructors or users, but conscious user non-compliance,
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.
Problem diagnosis
Regular menstrual cycles are sometimes taken as evidence that a woman is ovulating normally, and irregular cycles as evidence she's not. 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. Fertility charts can help diagnose hostile cervical mucus, a common cause of infertility. If this condition is diagnosed, some sources suggest taking guaifenesin in the few days before ovulation to thin out the mucus.
Pregnancy testing and gestational age
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.
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.
Further Information
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