What is charting?

Charting enables a woman to know her body by tracking the physical signs of her cycle.  

This knowledge can be used in two main ways:

Health Monitoring

External signs or biomarkers provide an overview of reproductive functioning. Observing and recording this information routinely allows women to be active participants in monitoring their health. Irregularities such as change in cycle length, painful periods, abnormal bleeding, inability to conceive, or other gynecologic concerns may reflect underlying hormonal abnormalities.

Charting this information each day can provide key information to help trained clinicians diagnose health problems and treat various conditions.

Family
Planning

These daily observations of physical signs or biomarkers that change throughout a woman’s menstrual cycle indicate when a woman may be fertile.

Healthy men are almost always fertile.  Healthy women are almost always infertile.

Using this information, couples may time sexual intercourse according to their desire to achieve or avoid a pregnancy. Instructions have been developed to provide reliable effectiveness rates for avoiding pregnancy and are collectively often referred to as natural family planning (NFP), fertility awareness, or fertility awareness based methods (FABMs).

What signs can women observe and track?

Cervical Fluid

Cervical fluid secretions can be noted throughout the day, either through sensation and/or visual observations. Variations in cervical mucus reflect hormonal changes that affect the cervix.

Basal Body Temperature

An increase in the resting body temperature is an indicator of rising progesterone that can be detected after ovulation.

Urinary Metabolites

Byproducts of the hormones present can be measured in the urine stream, just as one would take a pregnancy test.

Cycle Days

Short, regular, or long cycles can be defined by knowing your total cycle length.

Different methods use different signs

*Methods taught in accordance with evidence based guidelines

Cervical Fluid Methods

Billings Ovulation Method

 

Records daily signs useful for health monitoring: Yes

Billings Ovulation Method® (BOM) is based on a woman’s daily observations of cervical fluid (also known as cervical mucus). A woman notes the sensation of cervical fluid at the vulva to determine if she may be fertile. Throughout a woman’s cycle, four simple rules are applied (three prior to ovulation and the fourth rule after the fertile phase ends). These rules are applied based on a couple’s desire to achieve or postpone pregnancy. Women should attend classes or receive instruction from a trained educator to ensure accuracy in using the method to achieve or postpone pregnancy.

Billings Ovulation Method  |  Método Billings 

www.boma-usa.org

 

Creighton Model FertilityCare System

 

Records daily signs useful for health monitoring: Yes

Creighton Model FertilityCare System (CrMS) is a comprehensive method for tracking a woman’s fertility by teaching her to objectively describe her cervical fluid or mucus observations throughout her cycle. Women learn to observe and record the quality and quantity of her cervical fluid in a standardized and systematic way and can time intercourse to either avoid or achieve pregnancy.

In addition, the CrMS chart serves as a tool for evaluating and monitoring a woman’s reproductive and gynecologic health through the new science of Natural Procreative (NaPro) Technology. Women or couples should attend classes or receive instruction from a trained educator to ensure accuracy in using the method to achieve or postpone pregnancy. Special attention is provided to help couples navigate the challenges that behavior change may present in their relationship.

Creighton Model |  Modelo Creighton

www.fertilitycare.org

www.CreightonModel.com

Two Day Method

Records daily signs useful for health monitoring: No

Two Day Method is based on daily observations of cervical secretions as an indicator of fertility. This simple, yet effective method may be taught in a brief office visit. A woman using the TwoDay Method checks for cervical secretions at least twice a day. She considers herself fertile if she notices secretions of any type, color or consistency either “today” or “yesterday.”

Two Day Method  |  Método Dos Días

www.irh.org/twoday-method

IRH: Two Day Method

Sympto-Thermal Methods

Sympto-Thermal Method

Signs used: Cervical fluid (external sign), basal body temperature (BBT).

Optional sign: Changes in the cervix.

Records daily signs useful for health monitoring: Yes

Sympto-thermal Method (STM) is based on a woman’s observations of her cervical fluid, basal body temperature (waking temperature), and other biological signs (e.g., changes in the cervix). A woman records the characteristics of her cervical fluid secretions and monitors the basal body temperature, which rises after ovulation. Couples cross-check these two primary signs and follow specific guidelines to determine the beginning and end of their fertile days. Women should attend classes or receive instruction from a trained educator to ensure accuracy in using the method to achieve or postpone pregnancy.

Sympto-Hormonal Methods

Sympto-Hormonal Methods

Signs used: Cervical fluid (external sign), urinary metabolite hormone 

Records daily signs useful for monitoring health: Yes

Sympto-hormonal Methods (SHM). Similar to the Sympto-thermal Method, SHMs use instructions that incorporate cervical fluid observations with a second sign, urinary metabolite hormone levels, to identify days of fertility. There are two SHMs: The Marquette Model (MM) and FEMM (Fertility Education and Medical Management).  The Marquette Model uses a hand-held electronic (ClearBlue Easy) fertility monitor to measure estradiol and luteinizing hormone (LH) urinary metabolites at home while FEMM uses urinary test strips to measure the presence or absence of luteinizing hormone in order to calculate the end of cycle fertility. Both methods also instruct a women to record cervical fluid observations. Women should attend classes or receive instruction from a trained educator either in person or online to ensure accuracy in using the method to achieve or postpone pregnancy.

Learn About SHM

FEMM (English)  |  FEMM (Spanish)

nfp.marquette.edu

www.femmhealth.org

Standard Days Method

Learn About SDM

Signs used: Fixed fertile window is identified 

Records daily signs useful for health monitoring: No

Standard Days Method identifies a fixed fertile window in the woman’s cycle when a couple could become pregnant if they have sexual intercourse during that time. All other days in a woman’s cycle are considered non-fertile. Any woman with regular cycles lasting 26 to 32 days who desires a natural, hormone-free method can use the Standard Days Method. If the couple does not want to get pregnant, they would avoid intercourse on days 8 through 19 of the woman’s cycle. A woman can use CycleBeads®, a color-coded string of beads, to track the days of her menstrual cycle and see which days she is most likely to get pregnant. This simple, but effective method can be taught in a brief office visit.

Standard Days Method  |  Método de Dias Fijos

www.irh.org/standard-days-method/

IRH: Standard Days Method

Lactational Amenorrhea Method

Learn About LAM

Records daily signs useful for health monitoring: No

Lactational Amenorrhea Method is a short-term family planning method based on the natural effect of breastfeeding on fertility. The act of breastfeeding, particularly exclusive breastfeeding, suppresses the release of hormones necessary for ovulation. If menses has not returned and the infant is exclusively or nearly exclusively breastfed, the method provides protection from pregnancy for a woman immediately following birth until the child is six months old. Please consider the further instructions to insure criteria for use are met.

Lactational Amenorrhea Method  |  Método de Lactancia y Amenorrea

www.irh.org/lam/

FAQs

What is an FABM?

A fertility awareness based method (FABM) is a method of family planning in which a woman observes external signs that reflect underlying hormonal changes and combines it with an effective set of instructions to help identify times of a woman’s cycle when pregnancy can and cannot occur. Using this information, couples may time sexual intercourse according to their desire to achieve or avoid a pregnancy. The term natural family planning or NFP may be more familiar, and highlights that these methods are based on observations of natural signs and exclude the use of artificial barriers or chemicals.

FACTS promotes FABMs that have a high quality of evidence according to the SORT Level 1 criteria, as outlined in our 2013 review paper. The information, or charts, gathered from FABMs can also be used to help diagnose and address reproductive health irregularities.

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 morning 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 30 minutes before or after the  usual time without considering the temperature disturbed).

Can FABMs be used if a woman has irregular cycles?

Some FABMs work no matter the cycling pattern of an individual woman.   For example, the Billings Ovulation Method® (BOM), Creighton Model, SymptoPro, CCL sympto-thermal and sympto-hormonal methods 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 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 women or 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.

Can FABMs be used even if the menstrual cycle is affected due to stress?

Yes. Charting can help a woman to see how stress is affecting her cycle and her fertility. For example, 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 may become 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. Daily observations through charting can help a woman to monitor these effects.

Can patients with low health literacy really learn these methods?

A large trial of the Billings Ovulation Method® (BOM)  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 woman-years, with a typical use unintended pregnancy rate of less than 2% pregnancies per 100 woman-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.

Could avoiding intercourse during the fertile time negatively affect relationships?

Despite the challenge of avoiding intercourse during fertile times, surveys of persons using these methods often show that couples have more satisfying sex lives, improved relationships, and feel more respected by their partners and in control of their fertility.

A key factor relates to a couples’ level of emotional maturity and also 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.  

What about using condoms or a barrier?

The overwhelming majority of FABM effectiveness studies involve couples avoiding genital contact during the fertile phase, with a few exceptions. Condoms or barriers are other forms of contraception that some couples choose to use in addition to using an FABM. However, condoms have an effectiveness rate of their own that is lower than evidence based FABMs. Couples who choose to combine methods should expect an effectiveness rate of the less effective method they use.

How do FABMs work if a woman is postpartum and breastfeeding?

Women may use the Lactational Amenorrhea Method (LAM) if they are within 6 months of delivery, have not had a return of menses and are near exclusively breastfeeding.  If they meet all 3 criteria, they 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 and sensation). The presence of cervical fluid will give an indication of the return to fertility. “Patches” of mucus may appear before the actual build up 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.

Which method is best for perimenopausal or breastfeeding women?

The Billings Ovulation Method® (BOM), 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.