Terms and definitions
How does Natural Family Planning (NFP) differ from Fertility Awareness Based Methods (FABMs) and Natural Procreative Technology (NaPro Technology)?
Natural Family Planning and Fertility Awareness-Based Methods both refer to family planning methods that teach a woman how to identify her specific physical signs and symptoms that result from hormonal changes to determine when she may be fertile, and when she is not. Couples accept fertility as a normal state of health and share responsibility for family planning by modifying sexually intimate behaviors according to their family planning intentions. If a couple wishes to postpone pregnancy, they would choose not to have sex or genital contact during the potential fertile period; whereas, if they are trying to achieve pregnancy they would have sexual intercourse during their fertile window.
The term Natural Family Planning (NFP) highlights that these methods are based on observations of natural biological signs and excludes the use of artificial barriers or chemicals to prevent pregnancy. The term Fertility Awareness Based method (FABM) emphasizes the importance of understanding one’s fertility so that this information can be used not only for family planning, but also for maintaining a woman’s reproductive health.
Natural Procreative Technology (NaProTechnology), is an approach to women’s healthcare that utilizes the woman’s signs and symptoms of fertility to enable trained medical consultants to evaluate and treat various female biological conditions by both medical and surgical means. NaProTechnology does this by using biological information that a woman records in[N4] the Creighton Model charting system of NFP. This charting system provides prospective information regarding the woman’s cycle, bleeding patterns, and quality/amount of cervical mucus. With this information, doctors specifically trained in NaPro Technology can provide medical and surgical treatments that cooperate completely with the reproductive system.
Who can be trained to teach FABMs and how much does the training cost?
The pre-requisites and training costs vary by method.
The Billings Ovulation Method offers in-person and on-line teacher training at a cost of $575 for an individual or $675 for a couple which prepares them to teach women or couples how to chart their cycles. For more information, go to: http://www.boma-usa.org/resources.php?page=13
The Creighton Model programs for FertilityCare Practitioners or Instructors cost between $1,900 -$2,500. Creighton Medical Consultant training cost about $2,100. For more details about training requirements, go to: http://www.popepaulvi.com/education
SymptoPro costs $400 for an individual or $510 for a couple. This base price involves training done completely online with all digital materials that you can print out as needed. For more info: http://www.symptopro.org/learn/learn-to-teach-nfp.html
The Marquette University College of Nursing Natural Family Planning (NFP) teacher training program is a professional to provide professional NFP services. The cost is not available at this time, but for more info: http://nfp.marquette.edu/about.php
The Institute for Reproductive Health offers on-line training materials at no cost for health professionals: http://archive.irh.org/SDM_Training/index.php and others who wish to integrate the Standard Days Method in their services: http://irh.org/cycle-beads-toolkit/
What are some resources for teaching patients in Spanish?
The Billings Ovulation Method has educational materials available in Spanish, as well as numerous Spanish speaking teachers in the US, which can be located via their web-site.
Family of the America’s has developed a program to teach a version of Billings Ovulation Method to couples by comparing a woman’s fertility to the natural fertility of the earth. The program has been translated into a number of different languages including Spanish and has been used effectively to teach women and men with very low health literacy.
SymptoPro and Couple to Couple League offer their materials in Spanish for women or couples interested in learning the sympto-thermal method. There are a limited number of Spanish instructors, depending on your location.
The Marquette web-site also has materials available in Spanish.
Can FABMs be taught in the developing world? Can patients with low health literacy really learn these methods?
A large trial of the Billings Ovulation Method in India by the Indian Council of Medical Research Task Force on NFP (1996) followed 2059 women the majority of whom were illiterate. In this patient population, the perfect use rate was 1.1 pregnancies per 100 women years, with a typical use unintended pregnancy rate of 10.5 pregnancies per 100 women years.
The World Health Organization conducted a multi-continent study including many uneducated women and found that 94% of the women taught NFP were able to identify their fertile symptoms correctly on the first cycle.
Starting to use FABMs
How does a woman check her basal body temperature?
A basal body temperature (BBT) pattern is obtained by taking a woman’s waking temperature at the same time each day after several hours of uninterrupted sleep. A woman’s BBT is lower prior to ovulation and will rise .4 to .6 degrees Fahrenheit and stay elevated after ovulation. The higher elevated temperature signals the end of the fertile time.
The waking temperature is taken each day at about the same time (it can be taken up to 45 minutes before or after the usual time without considering the temperature disturbed, provided all temperatures are taken before 7:30 AM). This guideline can be relaxed once a woman is in the post-ovulatory infertile time and has charted for a few cycles.
How long would a couple have to abstain when learning an FABM for the first time or switching from a non-hormonal form of birth control?
The length of time that a couple needs to abstain from sexual intercourse and genital contact after stopping contraception is a complicated question. It depends on the type of birth control used and where in the woman’s menstrual cycle she was at the start of charting her signs of fertility. The following information applies to women stopping non-hormonal forms of birth control (please see the response to the next question for information about switching to an FABM from hormonal forms of birth control).
Family of the Americas and the Billings Ovulation Method encourage couples to abstain for at least the first menstrual cycle while learning to chart in order to be able to identify cervical mucus and learn to chart correctly. The Billings Ovulation Method proposes a modification of this rule if the woman has a good description of her cervical mucus build-up verified by a teacher. Once her mucus sign is confirmed, no more restrictions are placed on sexual activity after Peak + 4 . The peak day is defined as the last day of fertile type mucus.
In the Creighton model, the couple is instructed to abstain from sexual intercourse and any genital contact for one cycle in order to learn observations and charting without the presence of seminal fluid. This is true regardless of which form of birth control that was used before learning the model.
Some Sympto-Thermal methods recommend charting and abstaining for 2 weeks (in between the first and second classes of instruction). After this time the instructor can help a couple apply a guideline if there is one applicable at exactly 2 weeks. If a woman coming off of hormonal birth control has a delay in the return of her cycles, the instructor would advise to chart for 4 weeks. If at that point, there was no temperature rise to show that ovulation has occurred, they would then advise a mucus-only approach until the return of normal cycles.
Each method has its own guidelines for how long to abstain from sexual relations during the learning period or when switching from birth control. These are just a few examples of how this situation is addressed with different methods.
Can women use FABMs when they are coming off the pill? How do they do this?
Women can use some FABMs when discontinuing the pill, the patch, or other hormonal forms of birth control, but it is important for them to realize that the hormonal effects can persist for several months. The return to normal fertility and fertile signs will vary from woman to woman, and may vary depending on the type of pill or form of birth control she was using. For example, if a woman was on an injectable, such as Depo-provera, the average time to return to normal hormonal function is about 9 months after the last injection.
Since a woman’s return to fertility is more unpredictable during this period, as her body returns to her normal hormonal function, couples may need to abstain for more days at a time if they wish to avoid pregnancy. If a couple hopes to achieve pregnancy, it will be important to remember that they may have to be patient since they may experience a delay in their return to fertility after stopping hormonal birth control. Many FABMs have designed specific recommendations for women in this situation.
The Billings Ovulation Method and the Creighton model instruct couples to abstain from intercourse for one cycle in order to learn how to observe and chart cervical mucus without the presence of seminal fluid. This is true regardless of which birth control methods the couple had used. With the Billings Method, if no ovulatory build-up of cervical fluid is experienced the same rules apply as for any anovulatory situation.
A study of new Sympto-Thermal Method (STM) users (Gnoth, 2002) compared new STM users who were discontinuing OCPs with new users who had never used hormonal contraception and described the cycle characteristics. About half of the post cycles were normal, the remainder had some effect, the most common being a delay in peak mucus day (and ovulation), shorter luteal phases and higher rates of anovulatory cycles. These effects persisted for a few cycles after stopping OCP’s. The ability of new learners to observe fertility signs was unaffected and unintended pregnancy rates (a secondary outcome) were similar in both groups.
The Couple to Couple League (CCL, a STM provider) treats post pill learners exactly as any new user. CCL recommends abstaining until the post ovulatory infertile phase is positively identified in the first menstrual cycle and for uncertain/cautious learners adds one day to the rule to define this for the first cycle.
SymptoPro’s approach is to ask couples to chart and abstain for 2 weeks (in between the first and second classes). After this, the instructor can help couples apply an appropriate guideline if there is one applicable at exactly 2 weeks.
The Marquette Method (a Sympto-Hormonal method) has a backup protocol in place for first 6 months to ensure against user error or other factors, for example, when coming off the pill.
FABMs and Infertility
Is infertility a problem for underserved patients?
Infertility affects underserved patients as much as other women. In the general population, studies show that 1 out 10 couples suffer from subfertility, which is comparable to what was found in a small sample of underserved patients in the metropolitan area of Washington, DC (DC).
With underserved patients it is important for a healthcare provider to ask about infertility. If the question is not asked, the patient will probably not report it since the assumption would be that help would be unavailable or costly. Any potential study of the prevalence of infertility among the underserved would likely be difficult. This is because the underserved patients would probably vent these issues with their families, and pastors, but seldom with their healthcare provider .
In the underserved patients in DC, patients had previously dealt with providers who did not clarify to them the reason of their subfertility, indicated there was nothing to do about it or suggested options beyond the patient’s budget. The underserved population does not seem much different than other populations in their desire to have children, and their concern is as big as any other human being who feels a call to parent a child. Their means might be modest or even scarce, but they wish to share it with their children in most cases.
Effectiveness in family planning
Why do the reported efficacy rates for FABMs differ so widely? Which ones do I believe?
Efficacy rates for NFP/FABMs are frequently reported as a combined typical use unintended pregnancy rate of 24%. This widely quoted figure is derived from retrospective surveys based on patient recall of women with unintended pregnancies who were asked which family planning method they were using at the time of conception.2 From this number, all NFP/FABMs are pooled, then adjusted to account for underreporting of abortion, and an estimated unintended pregnancy rate is generated. Fully 86% of NFP/FABM users surveyed identified the Calendar Rhythm Method—a much older and less effective method—as their primary form of contraception.3 This lumping together of NFP/FABM methods masks important differences in their effectiveness, a fact acknowledged by the author of this estimate.4
On the other hand, the FACTS research team used the Strength of Recommendation Taxonomy to review NFP/FABM studies published in peer-reviewed journals since 1980.5 The researchers found that with typical use, the effectiveness of individual NFP methods ranged from 85.8% to 98.4%, based on good-quality prospective cohort studies. Clearly prospective cohort studies of individual methods will produce more reliable data than a retrospective recall survey in which data for different methods are pooled. Therefore, NFP/FABMs are much more effective then what is commonly reported.
What are the typical and perfect use of OCPs and other forms of birth control, compared to FABMs?
Studies show that FABMs have unintended pregnancy rates comparable to those of many artificial methods of birth control. For example, with an unintended pregnancy rate of about 2%, the Sympto-Thermal Method is almost as effective as the IUD and more effective than injectable and oral hormonal contraceptives. There has been one “head to head” study that compared the effectiveness of the IUD with the Billings Ovulation Method. This study by Quian et al., published in China and reprinted in the Bulletin of the OMRRC , compared 1000 Billings users to 1000 women with an IUD for 12 months. The results showed that the Billings users had fewer unintended pregnancies than those with IUDs. While the one child policy in China may provide strong external reinforcement to use the method correctly, the study proves that the rules are effective for avoiding pregnancy and couples are capable of avoiding intercourse during the fertile period.
Using FABMs requires couple to modify their behavior depending on their family planning goals. When effectiveness rates for birth control methods that require behavior modification are examined (e.g., taking a pill or using condoms), it can be seen that most natural methods are as effective as the pill and significantly more effective than the condom which has an overall failure rate of 18%. A major difference between user directed artificial methods and FABMs is that most FABMs address the importance of behavioral choices during the fertile days as part of counseling in method use.
Selective intercourse vs. barrier methods
Why don't Fertility Awareness Based Methods allow for the use of barrier methods during the fertile window?
If couples use their knowledge of their fertile window in combination with a barrier method (e.g., condoms), this is more accurately referred to as a “Fertility Awareness Combined” approach. Some fertility awareness educators teach couples that they may use barriers during the fertile window, but it is important to note that that almost all of the research done on the effectiveness of FABMs has been done with couples using periodic sexual abstinence when they are fertile. If couples rely on a contraceptive barrier (e.g., condoms, etc.) during the fertile time, effectiveness rates are not improved and may in fact be lower. Why? Barrier methods have their own rates of failure, and with typical use are only about 80-85% effective, based on use throughout a woman’s menstrual cycle, i.e. during both the fertile and infertile periods. In reality, barrier methods will only fail during the fertile window, so if a couple chooses to use a barrier method during their fertile window, the failure rates will likely be higher.
Fertility Awareness Based Methods teach couples to identify their window of fertility so that they can time their sexual relations according to their family planning goals (to attempt or avoid pregnancy). If a couple’s intention is to avoid pregnancy, they would refrain from sexual intercourse and any genital contact during the fertile time and show their affection for each other in non-genital ways. This practice safeguards the couple’s combined fertility from any side effects of hormonal birth control and provides couples with the opportunity to practice the cooperative behavior skills necessary for long term relationship success.
Remember, NFP or FABMs require participatory decision making, and actions consistent with a couple’s intentions.
Is it a challenge for a couple to avoid sexual relations on days they are fertile?
It can be a challenge for a couple to postpone sexual relations when a woman is fertile, especially since her sexual desire is typically highest then and her partner is usually most attracted to her at that time. That said, a challenge should not necessarily be perceived as negative. With some self-discipline and motivation, anyone can learn to meet challenges and become stronger for it! For instance, the challenge to eat more vegetables or add exercise to a sedentary lifestyle can be difficult but can drastically improve a person’s health and well-being. Likewise, choosing to have sex at certain times and abstaining from it at other times can be a challenge, but it is doable. Not only can this lead to greater self-control, but it may also increase mutual respect and improve intimacy in other areas of the relationship.
Most FABMs incorporate some teaching points on how to manage periodic sexual abstinence, so that it doesn’t become unnecessarily frustrating. Many FABMs users report an unexpected positive outcome from periods of abstinence followed by a long period of infertility. They say that it allows couples to have a “honeymoon” every month since their desire for each other naturally has time to increase.
Could avoiding intercourse during the fertile time negatively affect relationships?
This question is related to a couples’ level of emotional maturity and also to whether they mutually agree on common goals to achieve or avoid pregnancy. Each FABM addresses this concern.
Many FABMs provide relationship building techniques for couples to use during the fertile time if they are abstaining. Further, every successful relationship requires some self-control and sacrifice, and many couples find that this brief time of discipline helps to strengthen their relationship. Surveys of persons using these methods often find that despite the challenge of avoiding intercourse during fertile times, couples in fact have more satisfying sex lives, improved relationships, and feel more respected by their partners and in control of their fertility.
FABMs and breastfeeding, postpartum, or menopause
How do FABMs work if you are postpartum and breast feeding?
Women may use the Lactation Amenorrhea Method (LAM) if they are within 6 months of delivery, have not had a return of menses and are near exclusively breastfeeding will have an unintended pregnancy rate of less than 2%.
When a woman no longer meets the above criteria and has not had a return of regular cycles most FABMs will advise relying on the mucus pattern (including observations from tissue, sensation, and cervix). The presence of cervical fluid will give an indication of the return to fertility. “Patches” of mucus may appear before the actual buildup to ovulation. Any change from a dry mucus pattern should be presumed “possibly fertile.” Additionally, some women experience a constant mucus pattern during this time. A certified instructor can help the woman to determine what her “unchanging pattern” is and to treat that as if it were her own “dry” pattern. She would then be instructed to consider any change from that as possibly fertile.
If a woman were using LAM post-partum, when would she need to start charting with another method?
The answer to this question depends on a couple’s priority level to avoid a pregnancy when post-partum.
The Lactation Amenorrhea Method (LAM) guidelines are supposed to give 6 months of infertility, but SymptoPro also advises that any change in the baby’s sleeping or eating habits would indicate a good time to begin charting and using a cervical mucus-only approach. Additionally, while SymptoPro educates on the LAM method, they advise charting and applying a mucus-only approach as soon as the post-partum flow dwindles. SymptoPro provides breastfeeding criteria that allows for 12 weeks of infertility (starting with the day of birth) for women who are intensively breastfeeding by their definition. Beyond the first 12 weeks, SymptoPro recommends following a mucus only rule until fertility resumes rather than relying on breastfeeding alone.
Which method is best for perimenopausal or breastfeeding women?
The Billings method, Creighton Model, SymptoPro and CCL Sympto-Thermal methods and the Marquette model all provide specific guidelines for women with special situations, such as women who are breastfeeding or are pre-menopausal. It is important for women and couples to work with their trained instructors to ensure they are using their respective method correctly given their reproductive situations.
Specific post-partum instructions will vary by FABM and patients should work with their instructor for guidance with monitoring their return to fertility.
How do changes in a woman’s cycle during peri-menopause affect charting?
The peri-menopausal period is marked by significant changes in charting and can include: unexpected very short cycles, long cycles, unpredictable spotting/bleeding, a drier mucus pattern, and/or temperature patterns that are difficult to interpret. Again, the Billings and Creighton Model, SymptoPro, CCL Sympto-Thermal method and the Marquette model all provide specific guidelines for perimenopausal women. For example, Sympto-Pro instructors advise that one gives greater precedence to the cervical fluid pattern, and so they teach a mucus-only guideline for this time. Adding cervix checks, if not utilizing them yet, can help provide more information. Additionally, because of the unexpected short cycles in which the mucus buildup to ovulation can begin during menses, they advise treating menses as if fertile, then dry days afterwards to be infertile.
What are some examples of medical and surgical NaProTechnology interventions?
Medical consultants trained in NaProTechnology (or “NaPro”) can better evaluate and treat a variety of reproductive and gynecological problems because of what they learn from an individual woman’s Creighton Model charts. These include: premenstrual syndrome, polycystic ovarian disease, repetitive miscarriage, postpartum depression, and more. NaPro can also help detect many of the causes of infertility, including: luteal phase deficiencies, low progesterone levels, inadequate cervical mucus, PCOS, and endometriosis. These diseases can all be detected using the Creighton Model charts as well as targeted hormonal analysis. Once a cause is determined, targeted treatment strategies such as cycle specific hormonal supplementation or even surgery can be implemented. OB/Gyn doctors trained in NaPro Surgery utilize specific surgical techniques to treat underlying pathology that maximize a woman’s chance of conceiving naturally. (For more information, please visit www.naprotechnology.com)
Can FABMs be used if a woman has irregular cycles?
Some NFP methods or FABMs work no matter the cycling pattern of an individual woman. For example, the Billings method, Creighton Model, SymptoPro, CCL Sympto-Thermal method and the Marquette model can all be used by women with long or short cycles when discontinuing hormonal contraception, as well as during breastfeeding and during perimenopause. The Standard Days method and the original Calendar Rhythm method however, require regular menstrual cycles because they are based upon a woman’s cycle history.
It should be noted that most modern NFP methods provide information in “real time.” They are based upon a woman’s day-to-day observations where she can make decisions about her fertility based upon those observations.
Trained FABM instructors can provide couples with specific guidelines to learn how to best apply the method to their individual circumstances. It may not necessarily mean extended periods of sexual abstinence, but it may require additional instruction when help is needed.
Does stress affect the menstrual cycle? When a woman has a long cycle, is it usually the follicular or luteal phase that causes it?
If a woman experiences a stressful event or illness in the pre-ovulatory phase, ovulation will typically be delayed, leading to a longer cycle. If a stressful event or illness occurs in the post-ovulatory phase, this phase will beome shorter than normal, and menses will happen earlier than expected. Generally the luteal phase is a set number of days for each woman (between 12-16 days), and longer cycles reflect long follicular phases, which may be due to stress, illness or a number of other factors.
Are the subtypes of E-type mucus present simultaneously, or do they appear sequentially? What makes some mucus more fertile than other mucus (i.e. proteins, water content)? Is research being done on these factors?
In women, adrenal progesterone stimulates G mucus. Once estrogen rises, L mucus is produced. It opens the cervical canal which has been blocked by G type mucus, and it eliminates any imperfect spermatozoa. S mucus follows which nourishes sperm at least 72 hours in the crypt. P2 mucus opens the crypts, P6 cleans the sperm of certain enzymes, such as prostaglandins, and the zymogen granules make the mucus very slippery.
The foremost research pioneer on cervical mucus since the 1950s is Dr. Erik Odeblad (Sweden). Dr. Odeblad has identified cervical mucus types and conducted extensive research on cervical mucus or almost 50 years. Currently, Dr. Manuela Menarges (Spain) and Dr. Pilar Vigil (Chile) continue to research cervical mucus and have several recent publications.