FERTILITY AWARENESS METHODS

(NATURAL FAMILY PLANNING - NFP)

Fertility awareness, or natural family planning, refers to methods of

planning and preventing pregnancy by observing naturally occurring
signs and symptoms of the fertile and infertile days of the menstrual
cycle.

To prevent pregnancy, the couple avoids intercourse on the days during

the menstrual cycle when the woman is most likely to become
pregnant (i.e. the fertile days) or periodic abstinence.
Essentials of NFP
 Man is always fertile
 Woman only fertile a section of life (6 – 9 days a month)
 Reliable sign – mucus
 Couple must co-operate
 Regular cycle

NFP can be used by different women e.g. – those who

 Have regular cycles

 Have irregular cycles
 Are breast feeding
 Are approaching menopause
 Are coming off the pill

Types
A. Calendar (Rhythm ) method
B. Basal Body Temperature (BBT) method
C. Mucus method
 D. Lactation Amenorrhoea method (LAM)

Advantages
 Signs always present in women
 No physical side effects
 Helps childless couples with short cycles achieve pregnancy
 Acceptable to religious groups opposed to AFP
 No need for prescription by medical personnel
 Improves knowledge of reproductive system and possible closer
relationship between couples
 Makes the couple responsible of their family planning
 Inexpensive
 Sex selection:- it has been claimed that those who use earlier days
of fertility get a girl, late days get a boy ( XY sperms last short - 10
hours: XX sperms last long – 76 hours)

Limitations
o Low effectiveness – some clients may have irregular cycles e.g. in
breast feeding, pre-menopausal, coming off the pill, egg-white
recurrences, illiteracy
o Require daily recording and availability of charts and calendars
o Long period of training required before use of the methods
o Require varying periods of sexual abstinence during fertile phase
o Require active co-operation of both husband and wife
o The temperature method does not tell which days are safe , so
the couple would have to abstain from intercourse from the
beginning of her menstrual bleeding until she has had 3 days of
elevated temperatures
Female Sexuality and Fertility Awareness

Bleeding Phase Oestrogen Phase Progesterone Phase

Dull High self esteem Premenstrual tension,
Low self esteem Cheerful, Irritable,
Physical discomfort Excitable , Impatient,
Active, Temper fits,
Loving with fertility Physical discomfort
symptoms of
ovulation

CALENDAR (RHYTHM) METHOD

The woman calculates the onset and duration of her fertility i.e. the
time during which a viable egg is available for fertilization by the sperm.

Instructions to the Client

 Keep a record of the menstrual cycle in a calendar chart for 8 – l2
months (i.e. the 1st day of menstrual bleeding to the day before
the next period)
 Mark the first day of bleeding on the calendar for the next 8 – 12
months
 Bring the marked calendar to the clinic

The FP Service provider finds the longest (e.g. 29) and the shortest
cycle (e.g. 26) of the client from the chart and uses the formula below
to calculate the safe days:

FORMULA

First fertile day

  To determine the first fertile day, subtract 18 days from the
number of days in the shortest cycle (26 – 18 = 8 days)

Last fertile day

 To determine the last fertile day, subtract 11 days from the

longest cycle (29 – 11 = 18)

The client is advised to abstain from sexual intercourse from Day 8 to

18th day if she does not want to have a baby (i.e. fertile period)

NB: To be much more reliable, the calendar method may need to be

combined with the mucus and BBT methods.

THE TEMPERATURE (BASAL BODY TEMPERATURE/BBT)

METHOD
The basal body temperature varies during the cycle or month. The
method enables a woman to determine the infertile days following
ovulation by recording a sustained rise in body temperature. From the
menstrual period to ovulation the temperature is at a lower level. After
ovulation the temperature rises. When the third consecutive high
temperature has been recorded, then it is safe to resume intercourse
for the rest of the cycle

Method

 The temperature is taken orally, vaginally or rectally before

getting out of bed.
 Special enlarged charts and a fertility thermometer are used to
make the reading and recording of the pattern easy.
NB: This method indicates only the safe days after ovulation i.e. late
safe days after the egg is dead. It does not tell which days before
ovulation are safe.

(Charting Practice)

CERVICAL MUCUS
Women are taught to recognize and interpret cyclic changes in cervical
mucus that occur in response to changing oestrogen levels.

The woman must differentiate between sensations of “dryness”,

“moistness” and “wetness” at the vaginal opening during the menstrual
cycle to distinguish the different types of mucus.

TYPESY

 G – Type – Opaque and sticky; under the influence of

progesterone: Action –Protein fibres barrier
 L – Type – Transparent, a bit clumpy: Action – Neutralizes the acid
in the vagina; traps defective spermatozoa
 S – Type – Stretchy, slippery, transparent; under the influence of
oestrogen: Action: Forms channels, nourishes sperms in the
cervical crypts (ruggae) and gives energy, increases sperm motility
and protects the sperms. This lubricative mucus occurs close to
ovulation and is identified by a feeling of “wetness”.

To confirm:

 The vulva is wiped with a tissue or mucus removed with a finger

before urinating. According to Dr. Billings, a woman has to learn
to identify the Peak symptom by studying the mucus itself i.e. the
last day of wet, stretchy mucus or lubricative sensation.
Functions of Ovulation Mucus
1. Infertile mucus before it changes to fertile type acts as a barrier to
the ascent of sperms
2. Fertile mucus: - Promotes the sperm journey through the
branching canals of the mucus in the vagina (ruggae) and the
uterus to reach the egg; - Forms a protective envelope around the
sperm to save it from the destructive environment of the vagina; -
Nourishes the sperm by giving it energy

To Prevent Pregnancy

Under the rules of the cervical mucus method, abstinence should start
on the first day after menses that mucus is observed and continue until
the 4th day after the Peak symptom.

Ovulation (Fertile) Mucus

TYPES

Early Pap

 Is the first to appear and the first indication that ovulation is

approaching
 Occurs in early days before the Peak
 Called Pap because it feels and looks like baby food called pap. It
may be thick or thin
 It is not slippery; sometimes sticky
 If stretched, it breaks
 It is very cloudy (opaque)
 Chart sign- T wo red lines across (=)
Eggwhite

 Develops from early pap

 Feels, stretches and looks like the white of an uncooked egg, but
can also look cloudy. * No matter what it looks like and even if
nothing is actually seen, feeling is far more important than seeing.
 Chart sign – A red X (X)
 The presence of Eggwhite means ovulation is very near

The Mucus Sign

 Billings Method (BM) is concerned with mucus in the vagina i.e.
Mucus sign.
 The special ovulation mucus appears on only a few days in every
cycle
 The mucus can be both seen (stretching) and felt (slipperiness)
 Feeling the wet slipperiness is the most important thing
 It is mainly noticed while walking about or wiping at toilet

The Stretch Test

 The woman wipes after urination and notes whether it feels
slippery or non-slippery mucus or nothing at all
 She then applies the stretch test with her hand, to see whether it
stretches and remains stretched like the “white” of an uncooked
egg or it immediately breaks
 This test is done after every urination, every day, throughout the
cycle, including menses
 NB: Urine does not wash the mucus away

Sensation (Feeling)
 Dry – nothing is felt
 Sticky – feels like baby food ; not slippery
 Wet – feels like a little water or milk
  Slippery – like oil or the white of an uncooked egg
Infertile Sign (Dryness)
Most women feel nothing for most of the cycle i.e. Dryness, the
infertile sign

NB: Some women are never completely dry but have a persistent type
of mucus throughout the cycle.

Early Dry Days (EDDs) and Late Dry Days (LDDs)

o These are also known as Early and Late Infertile Days

o EDDs occur before the Peak
o LDDs occur after the Peak

Charting And Colours Used

The sign seen most during the day is charted at night before retiring

 Menses – Red
 Early Dry Days – Blue / Black
 Fertile Days – Red
 Late Dry Days – Blue / Black

Red means danger

Differences in Order of Importance

PAP EGGWHITE
1. Not slippery, sticky 1. Very slippery
2. Breaks 2 Stretches
3. Opaque / cloudy 3 Clear or a little cloudy

The Four Body Signs

 Menses
  Dryness
 Pap
 Eggwhite

NB. The number of days with these signs varies from woman to woman
and from cycle to cycle.

THE PEAK
 The Peak is the last day of Eggwhite slipperiness.
 That day is given a special name because ovulation occurs around
that time, and a special Chart sign – A double red X (x)
 Eggwhite may vary in amount, be irregular, disappear and then
return, may not appear in every urination, and is rare to find first
thing in the morning
 BUT any amount occurring once at any time of the day should be
charted as an Eggwhite day – a red X.
 The number of Eggwhite days varies, and it is therefore impossible
to recognize the Peak until there is no Eggwhite the next day. It is
noted by the client on looking back and saying, “Yesterday must
have been my Peak” and marks up a second red X (X) on top of
the first one of yesterday.

THE TIME OF OVULATION

It is not possible to know the moment of ovulation, but Eggwhite is the
sign that tells the woman it has already taken place.

 ALL ovulations take place within 24 hours around the Peak except
twins or triplets. The 2nd and 3rd eggs are released within 24 hours
of the first one.
 It is therefore necessary to leave 48 hours after the Peak to be
certain that all ovulations have taken place.
  The egg can survive up to 12 hours. It is necessary therefore to
wait a third day to be sure there is no egg alive ( i.e. 3 days)

The Three Red Zero Days

The three days following the Peak are known as the Three Red Zero
Days. The 4th day after the Peak is safe.

Interpretation

End of 1st Zero - Egg (ovum) released

End of 2nd Zero - One egg is dead

End of 3rd Zero – Any possible twin / triplet egg is also dead

THE GENITAL CONTACT RULE

To avoid pregnancy, there should be no genital contact on fertile days.
Breaking it accounts for many unexplained pregnancies.

Pregnancy may occur if there is any touching between the male and
female genital organs if the penis rests on the thigh outside the vagina,
even if there is no entry (penetration) or ejaculation. Before
ejaculation, a tiny amount of fluid is oozing from the penis.

Pregnancy needs only a drop of fluid and requires no pushing. When

the mucus meets the sperm, it leads it up to the egg like a ladder,
resulting in pregnancy.

NB: Many men have disowned their child thinking this is impossible.
CHARTING AND CHART SIGNS
Refer to charts.
SYMPTO-THERMAL OR COMBINED METHOD
 One chart can be used to record the mucus and the temperature
  Many women find that this is the ideal method as it provides
information from the mucus and the temperature methods.

Signs and Symptoms that occur around the time of Ovulation

 A dull aching lower abdominal pain

 A sharp pain on either side of the iliac fossa
 Tenderness in the breasts
 Inter-menstrual bleeding or spotting

Disturbances that may alter Temperature

3 Illness
4 Medication
5 Stress
6 Climatic changes
7 Disturbed sleep (insomnia)

LACTATIONAL AMENORRHOEA METHOD (LAM)

 Breastfeeding contributes significantly to both birth spacing and
child survival. It is a highly effective method of contraception.
 Populations with low contraceptive use in which infants are
intensively and extensively breastfed have lover fertility rates
than populations with infrequent, short durations of
breastfeeding.
 The breastfeeding woman will have a longer period of infertility
than the non-breastfeeding woman (4 – 6 weeks puerperium) BUT
neither can predict when ovulation will return.

How the Method works

  Suckling stimulates sensory (acini) cells in the nipple and areola;
they signal the hypothalamus to release various hormones. One of
these hormones, Prolactin, stimulates milk production.
 Suckling directly reduces the release of Gonadotrophin-Releasing
hormone (GnHR) by the hypothalamus, which in turn suppresses
the release of Luteinizing hormone (LH) required for follicle
stimulation in the ovary.
 Therefore, no ova, no fertilization.

How the Method works

 Suckling stimulates sensory (acini) cells in the nipple and areola;

they signal the hypothalamus to release various hormones. One of
these hormones, Prolactin, stimulates milk production.
 Suckling directly reduces the release of Gonadotrophin-Releasing
hormone (GnHR) by the hypothalamus, which in turn suppresses
the release of Luteinizing hormone (LH) required for follicle
stimulation in the ovary.
 Therefore, no ova, no fertilization.

Client Indications

 Women with babies less than 6 months, fully breastfeeding and

have amenorrhoea

Client Contraindications

 Women who are not fully breastfeeding and have resumed

menses

 Review information in the Procedure Manual.

 CYCLE BEADS

(Review from the Procedure Manual)