There are basically two approaches to fertility control.
The standard clinical approach has been to encourage couples to believe they are permanently fertile and insist that a method of contraception is in use every time they make love. This "continuous contraceptive approach" is certainly effective but there is a price to be paid, in health risks with some methods, and reduction of satisfaction levels with others. Since in fact there are only a few days in each monthly cycle when a women is fertile, many couples regret this "blunderbuss" approach of continuous contraception, where each day is treated as highly fertile, and are seeking alternatives.

The alternative approach which is therefore enjoying increasing publicity and demand is to offer couples a programme of education in fertility awareness, teaching them to identify accurately these few fertile days in each cycle. The couple can then build a natural loving sexual relationship around the fertility cycle, including the fertile days if they wish to plan a pregnancy, and avoiding them if pregnancy is not desired at that moment. It provides an efficient means of fertility control which is non-invasive and therefore free of side-effects and health hazards. This can be termed the "ecological approach", otherwise known as the Fertility Awareness Method, or Natural Family Planning.

Past Myths.
The main objection to this second approach has been its reputed unreliability.
The reasons for the high failure rates associated with the old "Calendar Rhythm Method" need to be understood, but must not be confused with modern techniques of Natural Family Planning, which on W.H.O. statistics has a biological failure rate of virtually zero. Back in the 1940's when the Rhythm Method was developed, the accepted fertility "facts" were that a woman always ovulated 14 days before onset of her next period, that her egg lived for 3 days, and that sperm also lived for up to 3 days. (None of these "facts" is actually correct!) A woman was required to calculate the date of her next period, then count back 14 days to her estimated day of ovulation. To avoid pregnancy, couples were told to avoid intercourse for 4 days before and after that date.

The reasons for the high failure rate (declared in all studies to be 33%) are obvious - irregular cycles, and misinformation.

The egg, in fact, is fertilisable for only 8-24 hours, but sperm can live up to 6 days given certain circumstances. The luteal phase (the time between ovulation and menstruation) is not a fixed gap of 14 days, but can be as short as 10 days for some women, and as long as 16 days for others. How does a woman know which one she has? No calculation method could embrace so many variables. Yet despite all that, it is amazing how many couples have used this method with success. I am meeting them all the time in NFP clinics! This calendar calculation method, with all its inaccuracies, is of course still used in most subfertility clinics, where couples are told to have intercourse 14 days before the period is due, which is too late for some, and too early for others.

New Knowledge.
A step forward in the identification of ovulation came in the 1950's with the introduction of the Temperature Method, perfected by Prof. John Marshall, a consultant neurologist in London. If a woman was prepared to take her temperature for a few mornings each month, before getting up, and at approximately the same time, with a special fertility thermometer, she would find that her body temperature was at a lower level until she ovulated.

After ovulation her temperature would rise and stay at a higher level for the next 2 weeks. If she had conceived, her temperature would continue to stay up, providing her with a free proof of pregnancy. If she had not conceived, her temperature would fall with the onset of her period and a new fertility cycle would start, repeating each time this biphasic temperature pattern.

Prof. Marshall's studies showed that if a couple waited till 3 high temperatures had been recorded after ovulation, the failure rate for the rest of the luteal phase was very low.

In the 1970's Prof. Tietze in his international review of all methods of contraception ranked the Temperature Method (Post Ovulation only) as a "highly efficient" method of contraception, comparable to sterilisation or a high dose pill.

The limitations of the method were, though it accurately confirmed the event of ovulation, and released nearly half the average cycle for infertile intercourse, it gave no warning of an approaching ovulation. When couples had intercourse based on Calendar Rhythm calculations before ovulation, the failure rate jumped from virtually zero to 19%.

The Temperature Method is also used in subfertility clinics, but its benefits are often lost when couples are told to have intercourse when the temperature dips and again when it rises. The Temperature could "dip" on any day if she took it earlier than usual. If she waits till the rise, hormone assays have shown that the rise can be delayed up to 48 hours after ovulation. Since the egg is fertilisable for as little as 8-24 hours it could well be a case of closing the door after the horse has bolted.

What was needed, both to plan or avoid pregnancy successfully, was a sign obvious to a woman, that her egg was ripening in her ovary. Here we are indebted to a team of doctors and researchers in Western Australia, headed by Drs. John and Evelyn Billings, who began to study the pattern of vaginal discharge in women. After years of double-checking their work with hormone assays, this is what they learnt:

As the egg-sac (follicle) starts ripening in the ovary, a hormone called estrogen is produced, which stimulates glands in the neck of the womb (cervix) to produce a wet, slippery, relatively clear mucus discharge.

This mucus is alkaline and neutralises the acidity in the vagina, enabling sperms to survive in it. It is also rich in nutrients which attract and feed the sperms prolonging their life for several days. Its thin watery nature has a molecular structure that produces a swimming lane structure through which sperm can migrate out of the vagina and into the cervix at incredible speed, and thereafter upwards towards the ripening egg.

The mucus increases in flow for approximately the 6 days that the follicle takes to fully ripen. It produces a sensation of wetness and lubrication at the external opening of the vagina which most women cannot fail to notice. When ovulation is imminent, the wet slippery mucus can become so clear that it looks like raw egg-white. This mucus is vital for sperm, who can live minutes or hours at most without it. But once in this mucus, the sperm can live for 3-6 days inside the neck of the womb.

As the egg is released, the mucus, having done its work, dries up and forms a plug in the neck of the womb to prevent the passage of any more sperms upwards. In that way the womb cavity is kept clear ready to receive the baby down the fallopian tube should it be conceived. The womb lining becomes very thick and spongy, ready for the baby to implant into it. However, some 10 to 16 days after ovulation, if there is no baby implanted in that lining, then the lining is washed away in menstruation, and a new fertility cycle starts. For this reason many older midwives used to speak of the menstruation as "the weeping of the disappointed womb".

The accuracy of the mucus symptom as a indicator of ovulation is beyond doubt. The hormone assays of James Brown in Melbourne, now supported by ultrasound studies in many centres, my own included, have all shown that the subjective observations of simple women, (even those with minimal education levels in developing countries), are as accurate in identifying ovulation as tests for L.H. peak. When these observations of mucus patterns are combined with minimal use of the Temperature Method, the biological failure rate of Natural Family Planning is virtually zero. The user failure rate as with all methods can be higher.

So whenever I am asked the question "How successful is NFP in preventing pregnancy?", my answer is always the same - "It's as successful as you make it. If you stick with the rules, it works. If you take risks, the failure rate is high because you are using the potentially fertile days". It goes without saying that mucus observation is vital to couples experiencing sub fertility. It frees them from inaccurate calculations and temperature charts that are only useful in retrospect. Instead it allows them to identify their potentially fertile phase, no matter how short or inadequate it may be, and enables them to maximise their chances of conception.

Couples who in all other aspects of their lives are trying to live in harmony with nature rather that in destructive conflict, often come up against a brick wall when seeking a natural solution to the most intimate area of their lives, their sexual relationship and the control of their fertility. There are at last several good books on the subject and simplified charting systems to help couples use the method successfully. Having used natural methods over 25 years of marriage, I am convinced of the benefits of NFP for modern society. I hope I have given you food for thought and dispelled some of the prejudice against natural methods.

If you would like further information about charting the fertility cycle, please contact me enclosing cheque or P.O for £4 and I will send you literature and the address of your nearest NFP teacher.

Mrs Colleen Norman
218 Heathwood Road,
Heath, Cardiff. CF4 4BS
Tel. 01222-754628

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