Fertility awareness-based methods of family planning are those that depend upon a woman
identifying those days during each menstrual cycle when intercourse is most likely to
result in a pregnancy. Accurate identification of those potentially fertile days is a
skill that requires a woman to apply knowledge about fertility to herself. This knowledge
is referred to as "fertility awareness."
If a woman can identify her potentially fertile days, a couple can use this information
to time intercourse either to avoid or achieve a pregnancy. Couples who have a basic
understanding about their fertility may be in a better position to understand how family
planning methods work and to choose the most appropriate method for their circumstances.
If they are using a barrier method or withdrawal, they will understand more clearly the
importance of using their chosen method consistently and correctly on potentially fertile
days. Also, they will probably understand that most family planning methods will not
affect their long-term fertility.
In addition, a woman who routinely observes her fertility signs, including bleeding and
cervical secretions, is more likely to detect a change from her usual patterns and may
seek healthcare at an early stage of a developing health problem.
Not widely available
Fertility awareness can be used effectively with three different practices during the
fertile time: withdrawal, barrier method use or abstinence. The term "natural family
planning" or NFP is often used to refer to abstinence during the fertile time.
Some couples prefer to use a barrier method or withdrawal, but only during the fertile
time. For couples at low risk for contacting STDs, this approach allows them to have
unprotected intercourse during part of the cycle, eliminating the need to use a barrier
method during each act of intercourse. This may be very important in areas where
contraceptives are expensive or the supply is inadequate or unreliable.
Unfortunately, the majority of family planning programs do not offer fertility
awareness education, which could help couples to use barrier methods or withdrawal more
effectively. For example, many couples do not use barrier methods or withdrawal
consistently. If couples only needed to use barriers or withdrawal during a few days of
each cycle, their consistent use during those days may improve and contraceptive
effectiveness would improve.
Little scientific information is available about how couples combine fertility
awareness with barrier method use or withdrawal to prevent pregnancy. Most major surveys
worldwide do not collect information about concurrent use of fertility awareness with
barrier methods or withdrawal. While a few published studies suggest that combining
fertility awareness with the use of barrier methods or withdrawal during the fertile time
is an acceptable alternative to using barriers or withdrawal all of the time, more
research is needed to test the effectiveness of these approaches.
Better accuracy
In recent decades, it has become possible to identify more accurately the fertile time,
as research using hormonal assays and ultrasound has demonstrated the relationship between
fertility sign patterns and the start and end of the fertile time.
The main indicators used today are observing cervical secretions, monitoring basal body
temperature, using calendar calculations based upon cycle length, or using a combination
of these indicators. Research has shown that using a combination of indicators is more
effective than using a single indicator.
As early as the 1800s, researchers recognized the association of cervical secretions
with conception in humans, but it was not until the 1960s and 1970s that clinical studies
were conducted to test the reliability of using cervical secretions to identify the
fertile time. In the 1920s, researchers observed that a woman's basal (resting) body
temperature rose during the latter part of the menstrual cycle, but it was not until the
1960s that clinical studies were conducted to test the accuracy of using basal body
temperature to identify the end of the fertile time.
In the 1930s, researchers discovered that the fertile time occurs for a few days during
the middle of the cycle, and calculations were developed to identify the fertile time.
Since the 1970s, other "minor" fertility sign indicators have been described as
changes in the position of the cervix, for example.
New developments
Ways to improve fertility awareness are being developed. For example, new techniques
that do not require daily observation of fertility signs are being tested to identify the
beginning and end of the fertile time. Newly developed formulas are better able to
identify the fertile time and are easier to use than older calendar rules, which have
existed since the 1930s.
If contraceptive failure rates associated with these new rules can be shown to be
comparable to other user-dependent methods, couples can be offered a simple and cheap
method that does not require interpreting fertility signs on a daily basis. Field testing
must be done to establish the failure rates of these new rules for identifying the fertile
time. Currently, one of the new rules is being pilot tested in Brazil.
Home test kits are also being developed to predict ovulation. Clinical trials are
currently under way to evaluate a new home test device, which determines potentially
fertile days by tracking cycle length and hormone metabolites found in urine. This device,
developed by Unipath, Ltd. in the United Kingdom, features a red and green light that
indicates whether or not a day is potentially fertile. Although this type of home test kit
will introduce new audiences to fertility awareness-based methods, the cost of the devices
may be prohibitive for many couples in developing countries.
Guidelines need to be developed for combining fertility awareness with the use of
barrier methods or withdrawal. As a first step in this process, a randomized clinical
study is being conducted at the University of Oxford in the United Kingdom by the authors
to determine the impact of fertility awareness education among condom users. Patterns of
condom use and risk-taking are being evaluated to determine if fertility awareness
education improves the consistent use of condoms during the highly fertile time in the
woman's cycle.
The more options that are available to couples, the more likely it is that they will
find a method that suits them. If fertility awareness approaches were more openly
discussed in family planning clinics, couples may be more comfortable about discussing how
they are actually using their methods. Providers would then be in a better position to
counsel couples in how to use their method more effectively.
-- Virginia Lamprecht and Cecilia Pyper
Virginia Lamprecht is a senior research associate in the Fertility Awareness and
Natural Family Planning Division of Georgetown University's Institute for Reproductive
Health in Washington.
Cecilia Pyper is a family physician and psychotherapist in the Department of Public
Health and Primary Care, University of Oxford, United Kingdom.
For more information, visit Family Health International's Website at www.fhi.org
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