Fertility awareness
22085
224803257
2008-07-10T14:10:26Z
Sardanaphalus
427947
correcting previous
{{Infobox Birth control
|name = Fertility awareness
|image =
|width =
|caption =
|bc_type = Fertility tracking
|date_first_use = 1950s (mucus) <br />mid-1930s (BBT) <br />1930 (Knaus-Ogino) <br />Ancient (ad hoc)
|rate_type = Failure
|perfect_failure% = Symptoms-based: 1-3%<br /> Calendar-based: 5-9
|typical_failure% = 3-25
|duration_effect =
|reversibility = Yes
|user_reminders = Dependent upon strict user adherence to methodology
|clinic_interval = None
|STD_protection_YesNo = No
|periods = Increased prediction
|benefits = no side effects, can aid pregnancy achievement
|weight_gain_loss =
|risks =
|medical_notes =
}}
'''Fertility awareness''' (FA) refers to a set of practices used to determine the fertile and infertile phases of a woman's [[menstrual cycle]]. Fertility awareness methods may be used to [[birth control|avoid pregnancy]], to [[fertilization|achieve pregnancy]], or as a way to monitor [[female reproductive system|gynecological]] health.
Methods of identifying infertile days have been used for over a thousand years, but scientific knowledge gained during the past century has greatly increased the accuracy of these systems. From 1930 to 1980, all research and promotion of fertility awareness was done by those associated with the [[Roman Catholic Church]]. Fertility awareness organizations continue to be predominately Catholic, but some secular organizations now exist.
Systems of fertility awareness rely on observation of changes in one or more of the primary fertility signs ([[basal body temperature]], [[cervical mucus]], and cervical position), records of menstrual cycle length, or both. Other signs may also be observed: these include [[Mastodynia|breast tenderness]] and [[mittelschmerz]] (ovulation pains), urine analysis strips known as ovulation predictor kits (OPKs), and microscopic examination of saliva or cervical fluid. Also available are computerized [[fertility monitors]].
==Terminology==
Symptoms-based methods involve tracking one or more of the three primary fertility signs - [[basal body temperature]], [[cervical mucus]], and cervical position.<!--
--><ref name="tcoyf">{{cite book | first=Toni | last=Weschler | year=2002 | title=Taking Charge of Your Fertility | pages=p.52 | edition=Revised Edition | publisher=HarperCollins | location=New York | id=ISBN 0-06-093764-5 }}</ref> Systems relying exclusively on cervical mucus include the [[Billings Ovulation Method]], the [[Creighton Model]], and the Two-Day Method. Symptothermal methods combine observations of BBT, cervical mucus, and sometimes cervical position. [[Calendar-based methods]] rely only on a history of cycle lengths. While the [[World Health Organization]] classifies both symptoms-based and calendar-based methods as "fertility awareness",<!--
--><ref name="who">{{cite paper |title=Medical Eligibility Criteria for Contraceptive Use:Fertility awareness-based methods | version = Third edition |publisher=World Health Organization |year=2004 |url=http://www.who.int/reproductive-health/publications/mec/fab.html |accessdate=2007-06-12 }}</ref> some teachers of symptoms-based methods do ''not'' consider calendar-based methods to be fertility awareness.<!--
--><ref>{{cite web |last=Watson |first=Dana |title=Why Fertility Awareness Works and the Rhythm Method Doesn't |work=The Nurtured Birth |publisher=|year=2005 |url=http://www.nurturedbirth.com/fam.html#famworks |accessdate=2007-06-12 }}</ref>
Systems of fertility awareness may be referred to as fertility awareness-based methods (FAB methods);<ref name="who" /> the term Fertility Awareness Method (FAM) refers specifically to the system taught by [[Toni Weschler]]. The term [[natural family planning]]" (NFP) is sometimes used to refer to any use of FA methods. However, NFP specifically refers to practices that are approved by the [[Roman Catholic Church]]: [[Lactational amenorrhea method|breastfeeding infertility]], and periodic [[abstinence]] during fertile times. A method of FA may be used by NFP users to identify these fertile times.
Women who are breastfeeding a child and wish to avoid pregnancy may be able to practice the [[lactational amenorrhea method]] (LAM). LAM is distinct from fertility awareness, but because it also does not involve devices or chemicals, it is often presented alongside FA as a method of [[natural birth control]].
==History==
===Development of calendar-based methods===
{{Main|Calendar-based methods#History}}
It is not known exactly when it was first discovered that women have predictable periods of fertility and infertility. [[Augustine of Hippo|St. Augustine]] wrote about periodic abstinence to avoid pregnancy in the year 388 (the [[Manichaeans]] attempted to use this method to remain [[childfree]], and Augustine condemned their use of periodic abstinence).<!--
--><ref name="augustine">{{cite book |last=Saint |first=Bishop of Hippo Augustine | authorlink = | coauthors = Philip Schaff (Editor) |title=A Select Library of the Nicene and Post-Nicene Fathers of the Christian Church, Volume IV |publisher=WM. B. Eerdmans Publishing Co. |date=1887 |location=Grand Rapids, MI |pages=[http://www.ccel.org/ccel/schaff/npnf104.iv.v.xx.html ''On the Morals of the Manichæans'', Chapter 18] }}</ref> One book states that periodic abstinence was recommended ''"by a few secular thinkers since the mid-nineteenth century,"''<!--
--><ref name="wife">{{cite book | first=Marilyn | last=Yalom | year=2001 | title=A History of the Wife | edition=First edition | publisher=HarperCollins | location=New York | id=ISBN 0-06-019338-7 |pages=pp. 297-8, 307}}</ref> but the dominant force in the twentieth century popularization of fertility awareness-based methods was the [[Roman Catholic Church]].
In 1905 [[Theodoor Hendrik van de Velde]], a Dutch gynecologist, showed that women only ovulate once per menstrual cycle.<!--
--><ref>{{cite web | title=A Brief History of Fertility Charting | work=FertilityFriend.com | url=http://www.fertilityfriend.com/Faqs/A_brief_history_of_fertility_charting.html | accessdate=2006-06-18}}</ref> In the 1920s, [[Kyusaku Ogino]], a Japanese gynecologist, and Hermann Knaus, from Austria, independently discovered that ovulation occurs about fourteen days before the next menstrual period.<!--
--><ref name="singer">{{cite book | first=Katie | last=Singer | year=2004 | title=The Garden of Fertility | publisher=Avery, a member of Penguin Group (USA) | location=New York | id=ISBN 1-58333-182-4 |pages=pp. 226-7}}</ref> Ogino used his discovery to develop a formula for use in aiding infertile women time intercourse to achieve pregnancy.<!-- This if from the Japanese article on Ogino (as best I could tell from the internet translator I used), but that page does not cite its sources --> In 1930, John Smulders, Roman Catholic physician from the Netherlands, used this discovery to create a method for ''avoiding'' pregnancy. Smulders published his work with the Dutch Roman Catholic medical association, and this was the first formalized system for periodic abstinence - the [[Calendar-based methods|rhythm method]].<ref name="singer" />
===Introduction of temperature and cervical mucus signs===
In the 1930s, Rev. Wilhelm Hillebrand, a Catholic priest in Germany, developed a system for avoiding pregnancy based on basal body temperature.<!--
--><ref name="puzzle">{{cite journal |last=Hays |first=Charlotte |title=Solving the Puzzle of Natural Family Planning
|journal = Crisis Magazine |date=December 2001 |url=http://www.crisismagazine.com/december2001/cover.htm |accessdate=2007-03-18 }}</ref> This temperature method was found to be more effective at helping women avoid pregnancy than [[calendar-based methods]]. Over the next few decades, both systems became widely used among Catholic women. Two speeches delivered by [[Pope Pius XII]] in 1951 gave the highest form of recognition to the Catholic Church's approval—for couples who needed to avoid pregnancy—of these systems.<!--
--><ref>''Moral Questions Affecting Married Life'': Addresses given [http://www.ewtn.com/library/PAPALDOC/P511029.HTM [[October 29]], [[1951]] to the Italian Catholic Union of midwives] and [[November 26]], [[1951]] to the National Congress of the Family Front and the Association of Large Families, National Catholic Welfare Conference, Washington, DC.</ref><ref name="wife" /> In the early 1950s, [[John Billings|Dr. John Billings]] discovered the relationship between cervical mucus and fertility while working for the Melbourne Catholic Family Welfare Bureau. Dr. Billings and several other physicians studied this sign for a number of years, and by the late 1960s had performed clinical trials and begun to set up teaching centers around the world.<!--
--><ref>{{cite journal |last=Billings |first=John | authorlink = John Billings|title=THE QUEST - leading to the discovery of the Billings Ovulation Method | journal = Bulletin of Ovulation Method Research and Reference Centre of Australia | volume = 29 | issue = 1 |pages=pp. 18–28 |date=March 2002 |url=http://www.woomb.org/omrrca/bulletin/vol29/no1/thequest.shtml |accessdate=2007-03-18 }}</ref>
===First symptoms-based teaching organizations===
While the Billings initially taught both the temperature and mucus signs, they encountered problems in teaching the temperature sign to largely illiterate populations in developing countries. In the 1970s they modified the method to rely on only mucus.<ref name="puzzle" /> The international organization founded by Dr. Billings is now known as the World Organization Ovulation Method Billings (WOOMB).
The first organization to teach a symptothermal method was founded in 1971. John and Sheila Kippley, lay Catholics, joined with Dr. Konald Prem in teaching an observational method that relied on all three signs: temperature, mucus, and also cervical position. Their organization is now called Couple to Couple League International.<ref name="puzzle" /> The next decade saw the founding of other now-large Catholic organizations - Family of the Americas (1977), teaching the Billings method,<!--
--><ref>{{cite web |title=About us |work=Family of the Americas |date=2006 |url=http://www.familyplanning.net/main.php?parent_id=1&id_area=1 |accessdate=2007-03-18 }}</ref> and the Pope Paul VI Institute (1985), teaching a new mucus-only system called the Creighton Model.<!--
--><ref>{{cite web |title=About the Institute |work=Pope Paul VI Institute |date=2006 |url=http://www.popepaulvi.com/about.htm |accessdate=2007-03-18 }}</ref>
Up until the 1980s, information about fertility awareness was only available from Catholic sources.<ref>Singer (2004), p.xxiii</ref> The first secular teaching organization was the Fertility Awareness Center in New York, founded in 1981.<!--
--><ref>{{cite web |title=About us |work=Fertility Awareness Center |date=2006 |url=http://www.fertaware.com/ |accessdate=2007-03-18 }}</ref> [[Toni Weschler]] started teaching in 1982 and published the bestselling book ''Taking Charge of Your Fertility'' in 1995.<ref>Weschler (2002)</ref> Justisse was founded in 1987 in Edmonton, Canada.<!--
--><ref>{{cite web |title=About Us |work=Justisse |date=2002 |url=http://www.justisse.ca/new/aboutUs.asp |accessdate=2007-03-18 }}</ref> These secular organizations all teach symptothermal methods. Although the Catholic organizations are significantly larger than the secular fertility awareness movement, independent secular teachers have become increasingly common throughout the 1990s and 2000s.
===Ongoing development===
Development of fertility awareness methods is ongoing. In the late 1990s, the Institute for Reproductive Health at [[Georgetown University]] introduced two new methods.<!--
--><ref>{{cite journal |author=Arévalo M, Jennings V, Sinai I |title=Efficacy of a new method of family planning: the Standard Days Method. | journal = Contraception | volume = 65 | issue = 5 |pages=333–8 |year=2002 | pmid = 12057784 | url=http://pdf.dec.org/pdf_docs/PNACQ416.pdf | doi = 10.1016/S0010-7824(02)00288-3 <!--Retrieved from CrossRef by DOI bot-->}}</ref><!--
--><ref>{{cite journal |author=Jennings V, Sinai I |title=Further analysis of the theoretical effectiveness of the TwoDay method of family planning |journal=Contraception |volume=64 |issue=3 |pages=149–53 |year=2001 |pmid=11704093 | doi = 10.1016/S0010-7824(01)00251-7 <!--Retrieved from CrossRef by DOI bot-->}}</ref> The Two-Day Method, a mucus-only system, and CycleBeads, a variant of the Rhythm Method, are designed to be both effective and very simple to teach, learn, and use.
== Fertility signs ==
Most menstrual cycles have several days at the beginning that are infertile (pre-ovulatory infertility), a period of fertility, and then several days just before the next menstruation that are infertile (post-ovulatory infertility). The first day of red bleeding is considered day one of the menstrual cycle. Different systems of fertility awareness calculate the fertile period in slightly different ways, using primary fertility signs, cycle history, or both.
===Primary signs===
The three primary fertility signs are ''basal body temperature'' (BBT), ''cervical mucus'', and ''cervical position''. A woman practicing symptoms-based fertility awareness may choose to observe one sign, two signs, or, all three.
[[Basal body temperature]] is a person’s temperature taken when they first wake up in the morning (or after their longest sleep period of the day). In women, [[ovulation]] will trigger a rise in BBT between 0.3 and 0.9 °C (0.5 and 1.6 °F) that lasts approximately until the next menstruation. This temperature shift may be used to determine the onset of post-ovulatory infertility.
[[Image:cervical mucus1.jpg|thumb|125px|Cervical mucus]]
The appearance of [[cervical mucus]] and vulvar sensation are generally described together as two ways of observing the same sign. Cervical mucus is produced by the cervix, which separates the uterus from the vaginal canal. Fertile cervical mucus promotes sperm life by decreasing the acidity of the vagina, and also helps guide sperm through the cervix and into the uterus.
The production of fertile cervical mucus is caused by the same hormone (estrogen) that prepares a woman’s body for ovulation. By observing her cervical mucus, and paying attention to the sensation as it passes the vulva, a woman can detect when her body is gearing up for ovulation, and also when ovulation has passed. When ovulation occurs, estrogen production drops slightly and progesterone starts to rise. The rise in progesterone causes a distinct change in the quantity and quality of mucus observed at the vulva.<ref>{{cite web | author=James B. Brown |
title=Physiology of Ovulation | year=2005| work=Ovarian Activity and Fertility and the Billings Ovulation Method | url=http://www.woomb.org/bom/science/physiology.html | publisher=Ovulation Method Research and Reference Centre of Australia}}</ref>
The [[cervix]] changes position in response to the same hormones that cause cervical mucus to be produced and to dry up. When a woman is in an infertile phase of her cycle, the cervix will be low in the vaginal canal; it will feel firm to the touch (like the tip of a person’s nose); and, the os – the opening in the cervix – will be relatively small, or ‘closed’. As a woman becomes more fertile, the cervix will rise higher in the vaginal canal; it will become softer to the touch (more like a person’s lips); and the os will become more open. After ovulation has occurred, the cervix will revert to its infertile position.
===Cycle history===
Calendar-based systems determine both pre-ovulatory and post-ovulatory infertility based on cycle history. When used to avoid pregnancy, these systems have higher perfect-use failure rates than symptoms-based systems, but are still comparable to barrier methods such as [[diaphragm (contraceptive)|diaphragms]] and [[cervical cap]]s.
Mucus- and temperature-based methods used to determine post-ovulatory infertility, when used to avoid conception, result in very low perfect-use pregnancy rates.<ref>Kippley (2003), pp.121-134,376-381</ref> However, mucus and temperature systems have certain limitations in determining pre-ovulatory infertility. A temperature record alone provides no guide to fertility or infertility before ovulation occurs. Determination of pre-ovulatory infertility may be done by observing the absence of fertile cervical mucus; however, this results in a higher failure rate than that seen in the period of post-ovulatory infertility.<ref>Kippley (2003), p.114</ref> Relying only on mucus observation also means that unprotected sexual intercourse is not allowed during [[menstruation]], since any mucus would be obscured.<!--
--><ref>{{cite book |author=Evelyn, Dr. Billings, Ann Westinore, |title=The Billings Method: Controlling Fertility Without Drugs or Devices |publisher=Life Cycle Books |location=Toronto |year=1998 |pages=47 |isbn=0-919225-17-9 }}</ref>
Use of certain calendar rules to determine the length of the pre-ovulatory infertile phase allows unprotected intercourse during the first few days of the menstrual cycle, while maintaining a very low risk of pregnancy.<ref name="calendar">Kippley (2003), pp.108-113</ref> With mucus-only methods, there is a possibility of incorrectly identifying mid-cycle or anovulatory bleeding as menstruation. Keeping a BBT chart enables accurate identification of menstruation, when pre-ovulatory calendar rules may be reliably applied.<!--
--><ref>Kippley (2003), p.101 sidebar and Weschler (2002), p.125</ref> In temperature-only systems, a calendar rule may be relied on alone to determine pre-ovulatory infertility. In symptothermal systems, the calendar rule is cross-checked by mucus records: observation of fertile cervical mucus overrides any calendar-determined infertility.<ref name="calendar" />
Calendar rules may set a standard number of days, specifying that (depending on a woman's past cycle lengths) the first three to six days of each menstrual cycle are considered infertile.<ref>Kippley (2003), pp.108-109 and Weschler (2002), pp.125-126</ref> Or, a calendar rule may require calculation, for example holding that the length of the pre-ovulatory infertile phase is equal to the length of a woman's shortest cycle minus twenty-one days.<ref>Kippley (2003), pp.110-111</ref> Rather than being tied to cycle length, a calendar rule may be determined from the cycle day on which a woman observes a thermal shift. One system has the length of the pre-ovulatory infertile phase equal to a woman's earliest historical day of temperature rise minus seven days.<ref>Kippley (2003), pp.112-113</ref>
===Secondary signs===
Many women experience secondary fertility signs that correlate with certain phases of the menstrual cycle. Examples include [[Mastodynia|breast tenderness]] and [[mittelschmerz]] (ovulation pains).
===Other techniques===
Ovulation predictor kits (OPKs) can detect imminent ovulation from the concentration of lutenizing hormone (LH) in a woman’s urine. A positive OPK is usually followed by ovulation within 12-36 hours.
Saliva microscopes, when correctly used, can detect ferning structures in the saliva that precede ovulation. Ferning is usually detected beginning three days before ovulation, and continuing until ovulation has occurred. During this window, ferning structures occur in cervical mucus as well as saliva.
[[Fertility monitor]]s are available under various brand names. These monitors may use BBT-only systems, they may analyze urine test strips, or they may monitor the electrical resistance of saliva and vaginal fluids.
==Benefits and drawbacks==
Fertility awareness has a number of unique characteristics:
* FA can be used to monitor reproductive health. Changes in the cycle can alert the user to emerging gynecological problems. FA can also be used to aid in diagnosing known gynecological problems such as infertility.
* FA is versatile: it may be used to avoid pregnancy or to aid in conception.
* FA can be used by all women throughout their reproductive life, regardless of whether a woman is approaching menopause, is breastfeeding, or experiencing irregular cycles for other reasons.
* Use of FA can give insight to the workings of women's bodies, and may allow women to take greater control of their own fertility.
* Some symptoms-based forms of fertility awareness require observation or touching of cervical mucus, an activity with which some women are not comfortable. Some practitioners prefer to use the term "cervical fluid" to refer to cervical mucus, in an attempt to make the subject more palatable to these women.
* Some drugs, such as decongestants, can change cervical mucus. In women taking these drugs, the mucus sign may not accurately indicate fertility.<!--
--><ref name="ffh">{{cite web |year=2004 | url=http://www.fertilityfriend.com/HelpCenter/FFBook/ff_fertility_signs.html | title =How to Observe and Record Your Fertility Signs | work =Fertility Friend Handbook |publisher=Tamtris Web Services|accessdate=2005-06-15}}</ref>
* Some symptoms-based methods require tracking of basal body temperatures. Because irregular sleep can interfere with the accuracy of basal body temperatures, shift workers and those with very young children, for example, might not be able to use those methods.<ref name="ffh" />
==As birth control==
By restricting unprotected sexual intercourse to the infertile portion of the menstrual cycle, a woman and her partner can prevent pregnancy. During the fertile portion of the menstrual cycle, the couple may use [[barrier contraception]] or abstain from sexual intercourse.
===Advantages===
* There are no drug-related side effects to FA. There are no side effects at all, besides those that may occur from inserting fingers into the vagina for cervical observation (as some FA methods recommend).
* FA is free or very low-cost. Users may buy a chart, calendar, basal thermometer, or software, or employ a coach. The direct costs are low when compared to other methods.
* FA can be used with [[barrier contraception]] so that intercourse may continue through the fertile period. Unlike barrier use without FA, practicing FA can allow couples to use barrier contraception only when necessary.
===Disadvantages===
*Use of a barrier method is required on fertile days, otherwise the couple must abstain. To reduce pregnancy risk to below 1% per year, there are an average of 13 days where abstinence or barriers must be used during each cycle.<!--
--><ref name="german study">{{cite journal |author=Frank-Herrmann P, Heil J, Gnoth C, ''et al'' |title=The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple's sexual behaviour during the fertile time: a prospective longitudinal study |journal=Hum. Reprod. |volume=22 |issue=5 |pages=1310–9 |year=2007 |pmid=17314078 |doi=10.1093/humrep/dem003}}</ref> For women with ''very'' irregular cycles - such as those common during breastfeeding, perimenopause, or with hormonal diseases such as [[Polycystic ovary syndrome|PCOS]] - abstinence or the use of barriers may be required for months at a time. Many couples may not have the motivation or discipline to abstain or use barriers for long periods of time.
*Fertility awareness does not protect against [[sexually transmitted disease]].<!--
--><ref name="uihc">{{cite web |year=2003 | url=http://www.uihealthcare.com/topics/familyplanning/fami4535.html | title =Natural family planning | work =University of Iowa Health Care Website | publisher =McKesson Health Solutions |accessdate=2006-06-15 }}</ref>
===Effectiveness===
The effectiveness of fertility awareness, as of most forms of [[birth control|contraception]], can be assessed two ways. ''Perfect use'' or ''method'' effectiveness rates only include people who follow all observational rules, correctly identify the fertile phase, and refrain from unprotected intercourse on days identified as fertile. ''Actual use'', or ''typical use'' effectiveness rates are of all women relying on fertility awareness to avoid pregnancy, including those who fail to meet the "perfect use" criteria. Rates are generally presented for the first year of use.<!--
--><ref name="hatcher">{{cite book | first=RA | last=Hatcher | coauthors=Trussel J, Stewart F, et al | year=2000 | title=Contraceptive Technology | edition=18th Edition | publisher=Ardent Media | location=New York | id=ISBN 0-9664902-6-6 | url=http://www.contraceptivetechnology.com/table.html }}</ref> Most commonly the [[Pearl Index]] is used to calculate effectiveness rates, but some studies use [[decrement table]]s.<!--
--><ref>{{cite book | first=John | last=Kippley | coauthors=Sheila Kippley | year=1996 | title=The Art of Natural Family Planning | edition=4th addition | publisher=The Couple to Couple League | location=Cincinnati, OH | id=ISBN 0-926412-13-2 | pages=p.141 }}</ref>
The failure rate of fertility awareness varies widely depending on the system used to identify fertile days, the instructional method, and the population being studied. Some studies have found actual failure rates of 25% per year or higher.<!--
--><ref>{{cite journal | author=Wade ME, McCarthy P, Braunstein GD, et al | title= A randomized prospective study of the use-effectiveness of two methods of natural family planning | journal=American journal of obstetrics and gynecology | year=October 1981 | volume=141 | issue=4 | pages=368–376 | pmid=7025639 }}</ref><!--
--><ref>{{cite journal | author=Medina JE, Cifuentes A, Abernathy JR, et al | title= Comparative evaluation of two methods of natural family planning in Colombia | journal=American journal of obstetrics and gynecology | year=December 1980 | volume=138 | issue=8 | pages=1142–1147 | pmid=7446621 }}</ref><!--
--><ref>{{cite journal | author=Marshall J | title= Cervical-mucus and basal body-temperature method of regulating births: field trial | journal=Lancet | year=August 1976 | volume=2 | issue=7980 | pages=282–283 | pmid=59854 }}</ref> At least one study has found a failure rate of less than 1% per year with continuous intensive coaching and monthly review,<!--
--><ref name="billings" /> and several studies have found actual failure rates of 2-3% per year.<!--
--><ref>{{cite journal | author=Frank-Herrmann P, Freundl G, Baur S, et al | title= Effectiveness and acceptability of the sympto-thermal method of natural family planning in Germany | journal=American journal of obstetrics and gynecology | year=December 1991 | volume=165 | issue=6 Pt 2 | pages=2052–2054 | pmid=1755469 }}</ref><!--
--><ref>{{cite conference | author=Clubb EM, Pyper CM, Knight J | title=A pilot study on teaching natural family planning (NFP) in general practice | booktitle=Proceedings of the Conference at Georgetown University, Washington, DC | year=1991 | url=http://www.fertilityuk.org/nfps822.html}}</ref><!--
--><ref name="german study" /><!--
--><ref>{{cite journal | author=Frank-Herrmann P, Freundl G, Gnoth C, et al | title= Natural family planning with and without barrier method use in the fertile phase: efficacy in relation to sexual behavior: a German prospective long-term study | journal=Advances in Contraception | year=June-September 1997 | volume=13 | issue=2-3 | pages=179–189 | pmid=9288336 | doi= 10.1023/A:1006551921219 }}</ref>
When used correctly and consistently with ongoing coaching, some studies have shown some forms of FA to be 99% effective,<!--
--><ref>Ecochard, R.; Pinguet, F.; Ecochard, I.; De Gouvello, R.; Guy, M.; and Huy, F. (1998) "Analysis of natural family planning failures. In 7007 cycles of use", ''Fertilite Contraception Sexualite'' 26(4):291-6</ref><!--
--><ref name="creighton2">Hilgers T.W. and Stanford J.B. (1998) "Creighton Model NaProEducation Technology for avoiding pregnancy. Use effectiveness", ''Journal of Reproductive Medicine'' 43(6):495-502</ref><!--
--><ref name="billings">[http://www.woomb.org/omrrca/bulletin/vol27/no4/chinaEvaluation.html Evaluation of the Effectiveness of a Natural Fertility Regulation Programme in China]: Shao-Zhen Qian, et al. Reproduction and Contraception (English edition), in press 2000.</ref><!--
--><ref name="creighton">Howard, M.P. and Stanford, J.B. (1999) "Pregnancy probabilities during use of the Creighton Model Fertility Care System", ''Archives of Family Medicine'' 8(5):391-402</ref> the same as oral contraceptives.<!--
--><ref>{{cite news |title=Natural contraception 'effective' |publisher=BBC News |date= 2007-02-21 |url=http://news.bbc.co.uk/2/hi/health/6375261.stm |accessdate=2007-09-25 }}</ref>
From ''Contraceptive Technology'':<ref name="conttech">James Trussell et al. (2000) "Contraceptive effectiveness rates", ''Contraceptive Technology'' — 18th Edition, New York: Ardent Media. On-press.</ref>
* Post-ovulation methods (i.e. abstaining from intercourse from menstruation until after ovulation) have a method failure rate of 1% per year.
* The symptothermo method has a method failure rate of 2% per year.
* The cervical mucus-only methods have a method failure rate of 3% per year.
* Calendar rhythm has a method failure rate of 9% per year.
* The Standard Days Method has a method failure rate of 5% per year.
===Reasons for lower typical-use effectiveness===
Several factors account for typical use effectiveness being lower than perfect use effectiveness:
* mistakes on the part of those providing instructions on how to use the method (instructor providing incorrect or incomplete information on the rule system)
* mistakes on the part of the user (misunderstanding of rules, mistakes in charting)
* conscious user non-compliance with instructions (having unprotected intercourse on a day identified as fertile)
The most common reason for the lower actual effectiveness is not mistakes on the part of instructors or users, but conscious user non-compliance,<ref name="creighton" /><ref name="german study" /> i.e., the couple knowing that the woman is likely to be fertile at the time, but engaging in sexual intercourse nonetheless. This is similar to failures of barrier methods, which are primarily caused by non-use of the method.
==To achieve pregnancy==
===Intercourse timing===
A study by Barrett and Marshall has shown that random acts of intercourse achieve a 24% pregnancy rate per cycle. That study also found that timed intercourse based on information from a BBT-only method of FA increased pregnancy rates to 31%-68%.<!-- I couldn't find this study in a PubMed search, but it is mentioned in the Hilgers study -->
Studies of cervical-mucus methods of fertility awareness have found pregnancy rates of 67%-81% in the first cycle if intercourse occurred on the Peak Day of the mucus sign.<!--
--><ref>{{cite journal |author=Ryder R |title="Natural family planning": effective birth control supported by the Catholic Church | journal = BMJ | volume = 307 | issue = 6906 |pages=723–6 |year=1993 | pmid = 8401097}}</ref><!-- This isn't actually the study that found 67%, but it describes the "WHO study in Australia, India, Ireland, the Philippines, and El Salvador" that did. Hoping someone will find the correct ref and fix this.--><!--
--><ref>{{cite journal |author=Hilgers T, Daly K, Prebil A, Hilgers S |title=Cumulative pregnancy rates in patients with apparently normal fertility and fertility-focused intercourse | journal = J Reprod Med | volume = 37 | issue = 10 |pages=864–6 |year=1992 | month=Oct | pmid = 1479570}}</ref>
Because of high rates of very early [[miscarriage]] (25% of pregnancies are lost within the first six weeks since the woman's last menstrual period, or [[gestational age|LMP]]), the methods used to detect pregnancy may lead to bias in conception rates. Less-sensitive methods will detect lower conception rates, because they miss the conceptions that resulted in early pregnancy loss. A Chinese study of couples practicing random intercourse to achieve pregnancy used very sensitive pregnancy tests to detect pregnancy. It found a 40% conception rate per cycle over the 12-month study period.<!--
--><ref>{{cite journal |author=Wang X, Chen C, Wang L, Chen D, Guang W, French J |title=Conception, early pregnancy loss, and time to clinical pregnancy: a population-based prospective study | journal = Fertil Steril | volume = 79 | issue = 3 |pages=577–84 |year=2003 | pmid = 12620443 | doi = 10.1016/S0015-0282(02)04694-0 <!--Retrieved from CrossRef by DOI bot-->}}</ref>
===Problem diagnosis===
Regular menstrual cycles are sometimes taken as evidence that a woman is ovulating normally, and irregular cycles as evidence she is not.<!--
--><ref>{{Citation |first=Mory |last=Nouriani |title=Infertility |date=May 2006 |pages=p.2 |publisher=National Women's Health Information Center, U.S. Department of Health and Human Services, Office on Women’s Health |url=http://www.womenshealth.gov/faq/infertility.pdf |accessdate=2007-06-08 }}. ''"Some signs that a woman is not ovulating normally include irregular or absent menstrual periods."''<br>
{{Citation |last=Cooper |first=Phyllis G. | contribution = Female Infertility |title=Adult Health Advisor |year=2006 | contribution-url = http://www.fairview.org/healthlibrary/content/aha_finfert_wha.htm }}. ''"A woman who is not ovulating normally may have irregular or missed menstrual periods."''<br>
{{Citation | contribution = Is Clomid Right For You? |title=JustMommies.com |year=2007 | contribution-url = http://www.justmommies.com/articles/clomid-and-ovulation.shtml }}. ''"If you have an irregular cycle there is a good chance you are not ovulating normally."''</ref> However, many women with irregular cycles do ovulate normally, and some with regular cycles are actually annovulatory or have a luteal phase defect. Records of basal body temperatures, especially, but also of cervical mucus and position, can be used to accurately determine if a woman is ovulating, and if the length of the post-ovulatory (luteal) phase of her menstrual cycle is sufficient to sustain a pregnancy.
Fertile cervical mucus is important in creating an environment that allows sperm to pass through the cervix and into the fallopian tubes where they wait for ovulation.<ref>{{cite web |last=Ellington |first=Joanna |title=Sperm Transport to the Fallopian Tubes |work= Frequently Asked Questions with Dr. E |publisher=INGfertility Inc |date=2004 |url=http://www.preseed.com/FAQs/FAQ3.php#Sperm_Leaking_Out_After_Intercourse-_Lessons_in_Sperm_Transport_Through_the_Cervix_ |accessdate=2008-04-27 }}</ref> Fertility charts can help diagnose hostile cervical mucus, a common cause of infertility. If this condition is diagnosed, some sources suggest taking [[guaifenesin]] in the few days before ovulation to thin out the mucus.<ref>Weschler (2002), p. 173.</ref>
===Pregnancy testing and gestational age===
[[Pregnancy test]]s are not accurate until 1-2 weeks after ovulation. Knowing an estimated date of ovulation can prevent a woman from getting false negative results due to testing too early. Also, 18 consecutive days of elevated temperatures means a woman is almost certainly pregnant.<!--
--><ref>Weschler (2002), p.316</ref>
Estimated ovulation dates from fertility charts are a more accurate method of estimating [[gestational age]] than the traditional pregnancy wheel or last menstrual period (LMP) method of tracking menstrual periods.<ref>Weschler (2002), pp.3-4,155-156, insert p.7</ref>
== Further reading ==
* {{cite book |author=Toni Weschler |authorlink=Toni Weschler |title=Taking Charge of Your Fertility |publisher=Collins |location=New York |year=2006 |isbn=0-06-088190-9 |edition=10th Anniversary Edition}}
* {{cite book |author=John F. Kippley and Sheila K. Kippley |title=The Art of Natural Family Planning |publisher=Couple to Couple League International |location=Cincinnati, OH |year=1996 |isbn=0-926412-13-2 |edition=Fourth edition}}
==Footnotes==
{{reflist|2}}
== External links ==
===Related information===
* [http://irh.org/ Institute for Reproductive Health] at Georgetown University - Developed and promotes the Standard Days Method (a calendar-based method) and the Two Day Method (a mucus-only method).
* [http://www.sisterzeus.com/directory.html Sister Zeus] - A women's guide to synergistic fertility management.
===Teaching organizations===
* [http://www.ccli.org/ Couple to Couple League] - An international Catholic organization that teaches a symptothermal method. Most teachers are married couples. Based in Cincinnati, Ohio, USA.
* [http://www.creightonmodel.com/ Creighton Model Fertility''Care''] - An international organization that teaches a mucus-only method. All teachers are physicians. Ongoing promotion and research of this method is done at the Pope Paul VI Institute. Based in Omaha, Nebraska, USA.
* [http://www.fertaware.com/fan_resources.html Fertility Awareness Network] - A network of secular teachers in North America; most teach a symptothermal method. Based in New York City.
* [http://www.justisse.ca/Practitioners.aspx Justisse] - Lists fertility awareness teachers trained by Geraldine Matus, director of the Justisse Center. Justisse is a secular organization that teaches a symptothermal method. Based in Edmonton, Alberta, Canada.
* [http://www.woomb.org/ World Organization Ovulation Method Billings] (WOOMB) - An international organization that teaches a mucus-only method. The founders of the organization were Catholic. Based in Melbourne, Australia.
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