By Jonathan Hebert, DO
Jonathan Hebert, MD wrote this article during his fourth year of medical school while participating in the FACTS elective. Through one woman’s experience, he explores how different fertility awareness-based methods (FABMs) can meet changing needs across different seasons of reproductive life. The postpartum period in particular highlights the value of finding the right method for the right season. Changing fertility patterns and the demands of new motherhood may make a previously successful method less practical. The ability to adapt and find a method that provides confidence and peace of mind is an important strength of fertility awareness-based care. To learn more about the various FABMs, register for one of our webinars here.
For this assignment, I interviewed Margo,* a young mother who learned and utilized two different natural family-planning (NFP) methods during important transitions in her life. Margo first encountered these methods shortly after she became engaged. Although she and her future husband had received dismissive comments about the effectiveness of using NFP, Margo was attracted by the idea of gaining a fuller understanding of her body’s natural fertility and avoiding hormonal birth control. She first learned to use the SymptoThermal Method, in which a woman is taught to track her basal body temperature (BBT) and cervical mucus to identify her fertile window.
Even with her history of hypothyroidism that resulted in a low baseline temperature, the SymptoThermal Method worked. She enjoyed the new ability to accurately predict her periods and recognized the method’s value as a tool for all women to use to foster confidence and self-respect. Margo and her husband were easily able to time intercourse around the identified peak day. Ovulation typically occurs within four days of peak day 97.8% of the time [1]. They conceived within the first month. She felt empowered by her ability to recognize her pregnancy days before a urine test confirmed it.
“Even with her history of hypothyroidism, the SymptoThermal method worked effectively for her.. fostering confidence and self-respect.”
Margo’s experience reflects a key benefit of FABMs: They can transform the ovulatory-menstrual cycle from something problematic and unpredictable into a powerful source of agency and confidence. In addition, her story demonstrates how the SymptoThermal Method can be used to both achieve and avoid pregnancy [3]. It was only after the birth of their first child that new problems related to her fertility arose.
Unfortunately, Margo had a negative experience with the birth of her child, which involved an unwanted C-section due to complications. She had hoped for a natural vaginal delivery and greatly prioritizes vaginal births for her future deliveries. Margo felt determined to space her next pregnancy to attempt a vaginal birth after C-section (VBAC) safely. She had planned to use the Lactational Amenorrhea Method (LAM) for up to six months postpartum. LAM relies on exclusive breastfeeding to suppress ovulation and is 99.5% effective in non-working women and 94.8% effective in working women [2]. Next, she planned to continue to use the SymptoThermal method to plan another pregnancy once her regular cycles returned. Things changed, however, when a close friend of Margo’s had a surprise pregnancy while using LAM. Margo felt she could not trust LAM, so she sought another option. A friend recommended the Marquette Method and Margo has since been using it with the assistance of an online teacher.
“The Lactational Amenorrhea Method (LAM) …relies on exclusive breastfeeding to suppress ovulation and is 99.5% effective in non-working women and is 94.8% effective in working women.”
Margo’s story also highlights how women who utilize FABMs may need to switch methods during the postpartum period. In school, medical students learn that more difficult regimens (as with medication, exercise routines, or diets) are a hindrance to patient compliance. FABMs themselves already require a certain amount of daily effort, which may be especially difficult to maintain for a woman dealing with the added stress of a newborn baby. As such, many have questioned which method would have the most advantages to utilize before, during, and after the postpartum period.
During the period of lactational amenorrhea and the first few new cycles postpartum, a woman will experience a time of hormonal instability as the Hypothalamic-Pituitary-Ovarian axis reestablishes a regular cycle. A woman’s cervical fluid changes and BBT shifts are less predictable due to fluctuations in the secretion of estrogen and progesterone. These natural changes create a circumstance in which the first few cycles postpartum can have a high unintended pregnancy rate [4]. Several studies identified the SymptoThermal method (cervical mucus and BBT alone) to be only 68% to 84% effective in preventing pregnancy in the postpartum period [5]. This is likely due to the combination of both biological and the aforementioned compliance-affecting factors related to the postpartum period.
Using an external device such as the ClearBlue fertility monitor to chart the urinary levels of estrogen and LH when determining the fertile window has been particularly effective. Sympto-hormonal methods, including the Marquette Method used by Margo, have proven to be highly effective in the postpartum period with correct use and typical use effectiveness of 97.9% and 85.8%, respectively. Established methodology includes checking urinary changes in estrogen and LH using a fertility monitor in 20-day intervals. About 15 test strips are used per month, during which the monitor attempts to identify an ovulatory peak. Marquette Method protocols detail when the monitor should be reset. For example, once the woman’s menses returns, the monitor is reset to indicate the beginning of each new menstrual cycle [6]. One study published found a decreased rate of pregnancies over 12 cycles using the method Margo used (ClearBlue urine hormone monitoring with added optional evening LH test for increased accuracy) compared to established methodology, with a trade-off of increased cost of use [7].
“Sympto-hormonal methods, such as the Marquette method used by Margo, have been shown to be highly effective in the postpartum period.”
In conclusion, the interview with Margo showed how different a woman’s experience with FABMs can be depending on where she is in her life. Different methods may be more comfortable or more effective in one season of life than in another, and women are always free to choose the method that suits their reproductive health needs. Although LAM is very effective at preventing pregnancy in the postpartum period, the sympto-hormonal branch of FABMs offered Margo another effective and evidence-based option that gave her peace of mind in the unpredictable postpartum period.
*All names have been changed to protect the interviewee’s privacy. All information is shared with permission.
REFERENCES
[1] Fehring, Richard, “Accuracy of the Peak Day of Cervical Mucus as a Biological Marker of Fertility” (2002) College of Nursing Faculty Research and Publications. 33. https://epublications.marquette.edu/nursing_fac/33
[2] Valdes, V., Labbok, MH., Pugin, E., Perez, A. 2000. “The efficacy of the lactational amenorrhea method (LAM) among working women”. Contraception: (62) no. 5: 217-9.
[3] Peragallo Urrutia R, Polis CB, Jensen ET, Greene ME, Kennedy E, Stanford JB. Effectiveness of Fertility Awareness-Based Methods for Pregnancy Prevention: A Systematic Review. Obstet Gynecol. 2018 Sep;132(3):591-604. doi: 10.1097/AOG.0000000000002784. Erratum in: Obstet Gynecol. 2019 Feb;133(2):382. doi: 10.1097/AOG.0000000000003142. PMID: 30095777.]
[4] [Bouchard T., Blackwell L., Brown S., Fehring R., Parenteau-Carreau S.. 2018. “Dissociation between cervical mucus and urinary hormones during the postpartum return of fertility in breastfeeding women.” The Linacre Quarterly 85 (4): 399–411.]
[5] [Schneider MM, Fehring RJ, Bouchard TP. Effectiveness of a Postpartum Breastfeeding Protocol for Avoiding Pregnancy. Linacre Q. 2023 May;90(2):182-193. doi: 10.1177/00243639231167235. Epub 2023 May 9. PMID: 37325426; PMCID: PMC10265386.]
[6] Bouchard T, Fehring RJ, Schneider M. Efficacy of a new postpartum transition protocol for avoiding pregnancy. J Am Board Fam Med. 2013 Jan-Feb;26(1):35-44. doi: 10.3122/jabfm.2013.01.120126. PMID: 23288279.]
[7] Schneider MM, Fehring RJ, Bouchard TP. Effectiveness of a Postpartum Breastfeeding Protocol for Avoiding Pregnancy. Linacre Q. 2023 May;90(2):182-193. doi: 10.1177/00243639231167235. Epub 2023 May 9. PMID: 37325426; PMCID: PMC10265386.]
ABOUT THE AUTHOR
Jonathan Hebert, MD, is a first-year OB/GYN resident training at Sisters of Charity Hospital in Buffalo, NY. He completed his medical degree at UTRGV School of Medicine in Edinburg, TX. Dr. Hebert enrolled in the FACTS elective to gain a better understanding of natural family planning methods and ways to share these methods with his patients so they are more empowered over their health and reproductive decisions.
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