As a Midwife, I believe strongly in the wisdom of the body and our ability to harness its powers. This installment of Covering Contraception: Fertility Awareness Method or FAM (also known as Natural Family Planning or NFP) will give an overview of one such example of how we can use knowledge of our own body to empower our choices. One thing that I truly appreciate about this method of contraception is that it invites and requires the user to become familiar with their own body and its’ cycles. In addition to being used as a contraceptive method, the practice of FAM can allow the user to optimize timing for desired pregnancies.
***This post is intended as an overview of FAM only, if you desire to use this method, you will need more thorough education.***
Some old terms for this method are the ‘Calendar’ or ‘Rhythm’ methods. There is a very old joke about couples that use the ‘calendar method’ to prevent pregnancy. It goes something like this, “What do you call couples that use the calendar method?” Answer: Parents. In essence, these methods are the most basic version of the Fertility Awareness Method and only keep track of the timing of the menstrual cycle in order to avoid intercourse on certain days of the month. The problem with this is that there is much more involved in fertility than the timing of each monthly bleed.
Let’s start with a primer of the menstrual cycle. First, very few people actually have a 28 day cycle. The typical range for a “normal” cycle is 21-35 days. This is one item that I often end up discussing with clients as they often think they are abnormal, or that something is wrong, when they have any cycle length other than 28 days. In looking more closely at the menstrual cycle, it becomes clear why there can be such variation in normal. A brief overview of the phases of the menstrual cycle:
- Menstrual Phase: this phase starts on day 1 of bleeding which occurs in response to falling levels of both estrogen and progesterone. This phase last anywhere from 3-7 days and can range from light to heavy and may or may not involve cramping. There is a very wide range of experience for this portion of the cycle, for some it is negligible while for others it can be debilitating.
- Follicular Phase: this phase also starts on day one of bleeding, but extends beyond. The average length is 16 days but can range from 11-27 days and still be within normal range. During this phase the hypothalamus stimulates the pituitary gland to release Follicle Stimulating Hormone (FSH) which then encourages the ovaries to begin producing follicles which contain immature ovum. Typically anywhere from 5-20 will develop and one of these follicles will eventually produce a mature ovum or egg. This ovum will then produce estrogen to stimulate the lining of the uterus to build up in anticipation of a fertilized egg.
- Ovulatory Phase: the increased estrogen released by the mature follicle also causes the pituitary gland to release Lutenizing Hormone (LH) which in turn stimulates the mature egg to be released from the ovary into the fallopian tube. This is the phase in which pregnancy can occur. The released egg only lasts for 24 hours after which it is absorbed into the fallopian tube lining. (Even though the egg is only viable for 24 hours, it is important to remember that sperm may live for up to 5 days.)
- Luteal Phase: this phase starts with the release of the mature egg from the ovarian follicle and lasts through to the menstrual phase. The average length of this stage is 14 days but can range from 11-17 days. The empty follicle becomes the corpus luteum which begins to release increased amounts of progesterone and some estrogen. The progesterone prepares the increased uterine lining for implantation of a fertilized egg. If the egg is fertilized this will cause the release of Human Chorionic Growth (HcG) hormone which in turn will signal the corpus luteum to continue to release progesterone to sustain the pregnancy until the developing embryo can take over. If the egg is not fertilized the corpus luteum will dissolve leading to a decrease in progesterone and estrogen which then triggers the menstrual phase of the cycle.
While the Fertility Awareness Method does focus on the timing of the menstrual cycle, it also digs deeper into the workings of the body, to observe and assess other factors. In response to the complex mechanisms of the menstrual cycle, other areas of the reproductive system and body are affected and show signs that can be observed. These are the position and consistency of the cervix, the quality of cervical mucus and the basal body temperature. The FAM user must be able, willing and dedicated to preforming daily tasks to chart and record these factors. When these symptothermal methods are utilized, in combination, the effectiveness rate is around 88-95% at preventing pregnancy. Using the full symptothermal method also involves the use of a chart to record all of the gathered information. Over time, you can start to recognize patterns that can be used to prevent or plan pregnancy. Here is a basic explanation of this triad of factors that encompass the symptothermal information:
- Basal Body Temperature (BBT) Your BBT is the baseline temperature of your body at rest. As such, it should be taken every morning before getting out of bed and after at least 3 hours of uninterrupted sleep. The temperature is taken orally with a specially designed thermometer that is sensitive enough to detect changes as minor as a half a degree Fahrenheit. In response to the release of Lutenizing Hormone during the Ovulatory Phase and increased levels of progesterone, there will be a spike in your BBT within 12-24 hours post ovulation. Due to this, the increase in BBT occurs after ovulation, this information is best used over the course of several cycles to help predict a pattern or timing of ovulation. The temperatures results are recorded and graphed on a chart so one can begin predict their personal timing of ovulation.
- Cervical Mucus Cervical fluid or mucus is secreted in the cervix and changes throughout the menstrual cycle in response to the various hormones released. As ovulation grows closer the cervical fluid changes to increase the chances of fertilization. In general, the vagina is slightly acidic and sperm require an alkaline environment, as such fertile cervical mucus is alkaline. In addition, this fertile cervical mucus aids in sperm mobility, offers nourishment and acts as a filter for some unhealthy sperm cells. By monitoring your cervical mucus through out the menstrual cycle, it can be possible to detect the changes associated with the cycle and chart them to better understand when your fertile window is and is not. You can start to learn more about your cervical mucus and how to check it here.
- Cervical Position and Consistency As the cervical mucus responds to the hormonal changes of the menstrual cycle, so does the position and consistency of the cervix itself. When you are not fertile, the cervix is firm, the opening is small and the cervix itself is lower in the vaginal canal. As ovulation approaches, the cervix becomes softer, and rises in the vaginal canal as it opens slightly. These changes are also noted on a chart and can help to predict fertile windows.
***Again, as I stated above, this information is in no way intended to allow a person to start sing FAM. I am only offering an overview and if you are interested in this method, please look into the resources below.***
In conclusion, as a midwife, I am a huge fan of FAM. I believe that being in touch with and understanding the menstrual cycle and how our bodies function can only serve to empower us in our choices. I also appreciate how it can be used to either prevent pregnancy or to help achieve pregnancy. Lastly, for folks who do not want, or cannot use, synthetic hormones it is a good alternative. It does have some potential drawbacks as well. First, the user must have the ability to check the cervix and cervical mucus. It requires the use of a chart to record and monitor the cycle, and the use of a special thermometer to measure the BBT. This method also requires rigorous (although not technically difficult) daily activity that may not be feasible for all users. And lastly, it requires the ability to abstain from intercourse on specific days and/or the use of a barrier method.
What are your thoughts? Have you used this method, or would you consider it?
Image credit Aubre Tompkins, CNM
The seminal book on this topic is Taking Charge of Your Fertility by Toni Weschler, MPH. If you are interested in learning more about FAM, this is the book to invest in. The website is also a great place for resources and more information.
One of my favorite websites for contraceptive information of all types is Bedsider.org and they have a great page on Fertility Awareness
More information on the Menstrual Cycle from U.S. Department of Health and Human Services