By Anne Humm, DO
Editor’s Note: Each year, National NFP Week highlights the value of fertility awareness-based methods (FABMs) as evidence-based options that help couples achieve or avoid pregnancy in accordance with their family’s goals. Beyond family planning, many FABMs provide valuable insights into reproductive health through cycle charting and fertility biomarkers. In this review, Anne Humm, DO, who enrolled in the FACTS elective during her final year of medical school, summarizes “Fertility Awareness-Based Methods: Another Option for Family Planning” by Pallone et al. The review examines the effectiveness of multiple FABMs for pregnancy prevention while emphasizing the importance of patient education, informed choice, and individualized family planning.
The article “Fertility Awareness-Based Methods: Another Option for Family Planning” [1] primarily discusses the use and effectiveness of different fertility awareness-based methods (FABMs) in the context of preventing pregnancy. FABMs have been used in various ways for many years, utilizing signs such as cervical mucus and basal body temperature to identify potential times of fertility. Several methods explored in this article include the Billings Ovulation Method, the Creighton Model, the Sympto-Thermal Method, and the Two Days Method. The article compares FABMs to other common methods used to prevent pregnancy such as, but not limited to, condoms, intrauterine devices, combined pill and minipill, and sterilization. FABMs compare well with other methods of birth control in terms of effectiveness for pregnancy prevention. At the time of this article’s publication, only 1-3% of women in the United States were using FABMs. Lower percentages of use may have been due to a lack of awareness about FABMs among patients and medical professionals or because of perceived difficulty in learning the methods. It is important to note that FABMs are actually true methods of family planning because they can also be used for achieving pregnancy, although that is beyond the scope of this article.
“FABMs compare well with other methods of birth control in terms of effectiveness for pregnancy prevention… (and) it is important to note that FABMs … can also be used for achieving pregnancy.”
The first natural method of family planning that was developed in the 1920s was the Rhythm Method. There was some variability in this method’s rules in terms of timing intercourse and determining the fertile window. One instruction was to count days starting with menses as day 1 and consider days 12 through 19 as fertile days. Women were also instructed to track the length of their longest and shortest cycles and use the difference in length between those to adjust the start of their fertile window. Initially this method was reported to be very effective, but a meta-analysis showed a total unplanned pregnancy rate of 15-18.3%. Limitations to effectiveness include cycle irregularities and life stressors such as illness.
Observation of cervical secretions can be very useful for family planning as they are highly predictive of ovulation. Studies by the World Health Organization show 93% of women are able to distinguish between fertile and infertile type secretions. Specifically, secretions that are clear, slippery, stretchy and changing are considered fertile while infertile secretions would be dry, cloudy and not stretchy. In these methods, women consider themselves fertile on days of menstruation because it can mask cervical fluid secretions. The Billings Ovulation Method is the first cervical mucus-based method and characteristically teaches women to describe their secretions in their own words. Based on the highest quality research study done in India with low literacy women, pregnancy rates were 1% with perfect use and 10.5% with typical use. The Creighton Model uses standardized pictures and words to describe the cervical secretions observed. This method involves instructors specifically trained, generous patient counseling, and partner involvement in tracking. It is difficult to compare the typical use rates of Creighton Model with other methods since it classifies pregnancies differently. The Two Days Method, in contrast, is simpler and can be taught in one visit. This FABM is more focused on whether the woman notices secretions of any kind within the last two days to indicate fertility.
“Observation of cervical secretions can be very useful for family planning as they are highly predictive of ovulation. Studies by the World Health Organization show 93% of women are able to distinguish between fertile and infertile type secretions.”
Basal body temperature (BBT) is another indicator of fertility that uses the rise in temperature to confirm whether ovulation has occurred. The body rises in temperature when progesterone is produced following ovulation. This measurement is performed when waking up in the morning, and ovulation is confirmed based on three consecutive higher temperature days. Some drawbacks are that the BBT method does not predict the start of the fertile days, and alcohol or sleep disturbances can make the readings inaccurate. The Sympto-Thermal Method combines observations of cervical secretions, cycle data, and BBT to determine the opening and closing of the fertile window. Unplanned pregnancy rates vary with this method but are as low as 1-3% based on multiple high quality studies. Exclusive breastfeeding can also be used to prevent pregnancy. Pregnancy rates are as low as 2% if the patient meets the criteria for lactational amenorrhea, including if the woman is supplying 90% or more of the infant’s calories with breastfeeding at least every four hours during the day and six hours at night, has not resumed menses, and the infant is younger than six months old.
The evidence highlighted in this article suggests that FABMs, particularly those utilizing cervical mucus observations, are a valid method for preventing pregnancy. These methods could be a great option for patients who prefer not to take medications, are not interested in intrauterine devices or other implants, or are simply interested in more natural options for family planning. The strength of this article lies in the thorough analysis of the different types of FABMs available, how they work, and their relative pros and cons compared to each other. I would say a limitation of the article is that newer research is now available on these specific methods.
“The evidence … suggests that FABMs, particularly those utilizing cervical mucus observations, are a valid method for preventing pregnancy. These methods could be a great option for patients who prefer not to take medications or are not interested in intrauterine devices or other implants.”
This research and the FACTS elective provided a deeper understanding of how FABMs compare with commonly used pregnancy prevention methods, particularly regarding rates of unintended pregnancy. The experience also highlighted the significant influence that the female cycle has on overall health and the meaningful role cycle charting can play in improving health outcomes and supporting informed reproductive decision making. In the future, a research topic of this nature could benefit from the consideration of each of the method’s cost effectiveness, how that compares to traditional birth control, and how awareness of FABMs could be spread to more practicing physicians and patients.
References
[1] Pallone SR, Bergus GR. Fertility awareness-based methods: another option for family planning. J Am Board Fam Med. 2009 Mar-Apr;22(2):147-57. doi: 10.3122/jabfm.2009.02.080038. Erratum in: J Am Board Fam Med. 2009 Sep-Oct;22(5):596. Erratum in: J Am Board Fam Med. 2013 Jul-Aug;26(4):480. PMID: 19264938.
ABOUT THE AUTHOR
Anne Humm, DO, is a first-year Internal Medicine resident at University of Florida Health Jacksonville. She earned her Doctor of Osteopathic Medicine from Touro University Nevada in Las Vegas. During medical school, she completed the FACTS elective to deepen her understanding of fertility awareness-based methods and their role in evidence-based reproductive healthcare.
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