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Home , Basal body temperature, Lactational amenorrhea, Natural family planning, Spermicide

Natural BRIAN A. SMOLEY, CDR, MC, USN, Camp Pendleton, California CHRISTA M. ROBINSON, LCDR, MC, USN, Naval Hospital Lemoore, Lemoore Station, California

Natural family planning methods provide a unique option for committed couples. Advantages include the lack of medical adverse effects and the opportunity for participants to learn about reproduction. Modern methods of involve observation of biologic markers to identify fertile days in a woman’s reproductive cycle. The timing of intercourse can be planned to achieve or avoid based on the identified fertile period. The current evidence for effectiveness of natural family planning methods is limited to lower-quality clini- cal trials without control groups. Nevertheless, perfect use of these methods is reported to be at least 95 percent effective in preventing pregnancy. The effectiveness of typical use is 76 percent, which demonstrates that motivation and commitment to the method are essential for success. Depending on the method, couples can learn about natural family planning methods in a - gle office visit, through online instruction, or from certified instructors. (Am Fam Physician. 2012;86(10):924-928. Copyright © 2012 American Academy of Family Physicians.) ▲ See related editorials amily planning allows individuals abstinence rather than an artificial contra- at http://www.aafp.org/ and couples to anticipate and attain ceptive method.2-4 afp/2012/1115/od1.html and http://www.aafp. the desired number, spacing, and Although less than 1 percent of respon- 1 org/afp/2012/1115/od2. timing of children. aware- dents to the 2006-2008 National Survey html. F ness methods of family planning use one or of Family Growth reported current use of ▲ Patient information: more biologic markers to identify fertile days NFP, 19 percent reported prior use of the A handout on natural fam- of a woman’s reproductive cycle. Intercourse rhythm method, and 5 percent reported ily planning, written by the is avoided or a contraceptive method is used prior use of some other NFP method.5 If authors of this article, is on these fertile days to avoid pregnancy. asked for family planning information, one- available at http://www. aafp.org/afp/2012/1115/ Conversely, couples desiring pregnancy are half of physicians report that they would p924-s1.html. Access to more likely to conceive if they have inter- provide information about NFP to prevent the handout is free and course during this fertile period. Fertility pregnancy, and three-fourths would pro- unrestricted. awareness methods qualify as natural family vide information about its use to achieve planning (NFP) if they are used with periodic pregnancy.6 This article discusses methods, mechanisms of action, and demonstrated effectiveness of NFP to enable physicians to provide appropriate information and coun- Table 1. Natural Family Planning Methods seling to their patients.

Method Description Methods and Mechanisms of Action Basal body Identifies the of the menstrual The five principal types of NFP are calen- temperature cycle by postovulatory increase in basal body dar calculation, charting temperature; all other days are considered fertile charting, cervical mucus monitoring, the Calendar calculation Predicts the fertile period by menstrual dating symptothermal method, and lactational Cervical mucus Identifies beginning and end of the fertile period amenorrhea4 (Table 1). The first four meth- monitoring from cervical secretions ods allow couples to plan intercourse around Lactational Maximizes suppression of during the days of increased fertility during the ; effectiveness limited to six months postpartum woman’s reproductive cycle. In lactational Symptothermal Based on cervical mucus monitoring; calendar amenorrhea, ovulation does not occur, and method calculations or basal body temperature charting there are no fertile days. Use of this method monitoring provides redundancy is limited to women who are exclusively breastfeeding during the first six months

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence Clinical recommendation rating References

Lactational amenorrhea is 92 to 100 percent effective in preventing B 7 pregnancy during the first six months postpartum in women who exclusively breastfeed their infants, provided that does not resume. With perfect use, modern natural family planning methods can be as B 16, 20-23, effective in preventing pregnancy as hormonal contraceptives. 25, 28-30 The Creighton Model for cervical mucus monitoring and the B 16, 22-24 symptothermal method are the most effective natural family planning methods currently available.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml. postpartum, and applies only if menstrua- with a perfectly consistent 28-day cycle, the tion has not resumed. When these conditions rhythm method predicts an eight-day fertile are met, has been period from days 10 through 17. Variations shown to be 92 to 100 percent effective.4,7 in cycle length increase the length of the pre- Identification of the fertile period is the dicted fertile period.3,4,9 The Standard Days central focus of most NFP methods. In the Method is a simplified calendar method days leading up to ovulation, from that assumes a cycle length of 26 to 32 days the maturing follicles stimulates the section and sets a 12-day fertile period from days 8 of thin, stretchy, watery mucus in the cervi- through 19.10 cal canal that facilitates sperm entry into the upper reproductive tract. Sperm can remain BASAL BODY TEMPERATURE CHARTING viable there for up to five days. Sperm entry Basal body temperature charting takes is inhibited after ovulation by the secretion advantage of the increase in a woman’s tem- of thick, sticky cervical mucus stimulated by perature that occurs during the luteal phase increasing levels. The ovum is of the reproductive cycle. An increase of at capable of being fertilized for up to 24 hours least 0.4°F (0.2°C) above the baseline tem- after ovulation. The usual viability periods perature recorded early in the of sperm and ovum generate an average six- morning at the same time each Cervical mucus monitoring day fertile period that has been verified by day indicates that ovulation tracks cyclical changes in empiric studies.2,3,8 has occurred. This increase the amount or consistency is monitored over three con- CALENDAR CALCULATIONS secutive days, at which point of cervical secretions. Calendar methods of NFP are based on the fertile period is consid- the relative consistency in the length of the ered over. Because basal body temperature luteal phase of the reproductive cycle. The charting does not identify the beginning of rhythm method is the oldest NFP technique. the fertile period, it is of limited use. Cou- The length of past cycles is used to predict ples who desire pregnancy must use histori- the fertile period in the current cycle. The cal data to predict the next fertile period. beginning of the fertile period is calculated Couples trying to avoid pregnancy must by subtracting 18 days from the shortest of restrict intercourse to the luteal phase of the previous six to 12 cycles. The end of the the cycle.3,4,9 Basal body temperature chart- fertile period is calculated by subtracting 11 ing is typically used in combination with days from the longest cycle. For a woman other methods.

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CERVICAL MUCUS MONITORING questions: “Did I note secretions today?” Cervical mucus monitoring has become and “Did I note secretions yesterday?” If a the basis for most modern NFP methods. woman answers “yes” to either question, she These methods allow users to identify the is considered fertile.14 beginning and end of the fertile period by recognizing cyclical changes in the amount SYMPTOTHERMAL METHOD or consistency of cervical secretions. The The symptothermal method combines cal- Billings Ovulation Method, Creighton endar calculations, basal body temperature Model, and TwoDay Method are different charting, and cervical mucus monitoring. systems for observing cervical secretions Cervical secretions are the foundation for and using them as markers of fertility. The this method, and the other techniques pro- oldest of the three, the Billings Ovulation vide a “double-check.” Women may use Method, is taught worldwide, and instruc- other signs (e.g., consistency and position of tions are available online.11,12 The Creigh- the ) or symptoms (e.g., breast tender- ton Model is a standardized modification of ness, ovulatory pain) to aid in the identifica- the Billings Ovulation Method taught and tion of the fertile period.15,16 The Marquette personalized for couples over multiple ses- Model combines the use of an electronic sions.13 The TwoDay Method reduces the hormonal fertility monitor to detect metab- interpretation of cervical secretions to two olites of and luteinizing hormone in the urine with observation of cervical secre- tions or basal body temperature charting to Table 2. Effectiveness of Natural Family Planning identify the fertile period.2,17 Compared with Other Family Planning Methods Effectiveness of Modern NFP Methods Percentage of women with The effectiveness of family planning meth- an ods is measured for perfect and typical within the first year of use use. Perfect use failures represent failure of Contraceptive method Typical use Perfect use the method itself, whereas failures occur- ring during typical use include incorrect None19 85 — use.18 The reported failure rates for mod- (foams, creams, gels, vaginal 28 18 ern NFP methods range from less than 1 to suppositories, vaginal films)19 5 percent for perfect use, and 2 to 25 per- Withdrawal19 22 4 cent for typical use.16,19-30 The few random- (male, without )19 18 2 ized controlled trials of NFP methods have Diaphragm19 12 6 been limited by poor recruitment and high Contraceptive pill (combined), patch, or 9 < 1 dropout rates.31 Therefore, the evidence 19 for NFP methods is based on observa- Depo-medroxyprogesterone 6 < 1 tional trials that are prone to selection bias. (Depo-Provera)19 Although many of these studies were con- , implant, < 1 < 1 sterilization19 ducted in emerging and developing coun- Natural family planning tries, trials involving cervical mucus and Standard Days Method25-27 8 to 25 5 symptothermal methods have been done in 16,20-24 Billings Ovulation Method28,29 3 to 22 3 Europe and the United States. How- TwoDay Method30 14 4 ever, the procedures used to measure and Marquette Model20,21 11 to 14 1 to 2 calculate effectiveness rates may overes- 18 Symptothermal method16,22,24 2 to 8 < 1 timate the observed effectiveness. Some Creighton Model23 2 to 5 ≤ 1 trials have provided a more direct account- Lactational amenorrhea7 — 0 to 8 ing of method failures and used preferred statistical techniques to determine failure Information from references 7, 16, and 19 through 30. rates.16,19,25,28,30 A comparison of NFP meth- ods is provided in Table 2.7,16,19-30

926 American Family Physician www.aafp.org/afp Volume 86, Number 10 ◆ November 15, 2012 Natural Family Planning

Table 3. Internet Resources for Natural Family Planning

Organization Web site Method

BOMA-USA http://boma-usa.org Billings Ovulation Method Couple to Couple League http://ccli.org/ Symptothermal method Family of the Americas Foundation http://www.familyplanning.net Billings Ovulation Method Center http://www.fertaware.com Symptothermal method Institute http://www.irh.org Standard Days and TwoDay for methods Justisse Healthworks for Women http://www.justisse.ca Symptothermal method Marquette University http://nfp.marquette.edu Marquette Model Northwest Family Services http://www.nwfs.org Symptothermal method Paul VI Institute for the Study http://www.popepaulvi.com Creighton Model of World Organisation of the http://www.woomb.org Billings Ovulation Method Ovulation Method Billings

Patient Counseling Despite challenges, NFP methods are a NFP methods have unique benefits and viable and effective family planning option important limitations. One benefit for for motivated patients, and may be the ideal patients is an enhanced understanding of option for some. Interested couples require the reproductive process. This knowledge instruction in their chosen method. The Stan- empowers couples to manage their repro- dard Days and TwoDay methods can be taught ductive lives without medical intervention. during an office visit.32 If this is not practical, By routinely observing biologic markers, or if couples are interested in other methods, women may detect medical problems and several organizations provide detailed infor- bring them to the attention of their physi- mation and instruction (Table 3). cian earlier than might otherwise occur. All The American Academy of Family Physi- NFP methods encourage couples to engage in cians’ policy statement on providing advice a shared discussion about sexual activity and about contraception is available at http:// reproduction. Finally, because these methods www.aafp.org/online/en/home/policy/ do not require pharmaceutical or procedural policies/c/contraceptiveadvice.html. intervention, they have no medical adverse Data Sources: We used search results from Essential 3,9 effects. Evidence Plus, the Cochrane Database of Systematic The limitations of NFP are related to the Reviews, the National Guideline Clearinghouse, and requirement of periodic abstinence. As evi- PubMed citations. Key terms included , contra- ception, contraceptives, oral, intrauterine devices, family denced by the relatively high failure rates planning, and natural family planning. Last search date: with typical use, some couples may not be September 17, 2011. able to do this. All NFP methods can, to The views expressed in this article are those of the varying degrees, overestimate the fertile authors and do not necessarily reflect the official policy or period and require longer periods of absti- position of the U.S. Navy Medical Corps, the U.S. Navy, or nence than might otherwise be needed.2 the U.S. Department of Defense. Additionally, illness, disrupted sleep, and the use of can alter or interfere The Authors with the observation and interpretation of BRIAN A. SMOLEY, CDR, MC, USN, is a family physician serv- 4 some biologic markers. The monitoring of ing with the 1st Marine Division at Camp Pendleton, Calif. fertility hormones in urine may provide NFP CHRISTA M. ROBINSON, LCDR, MC, USN, is a family physi- users with a more objective, specific, and cian and flight surgeon at Naval Hospital Lemoore, Lem- reliable marker of the fertile period.2 oore Station, Calif.

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Address correspondence to Brian A. Smoley, CDR, MC, of a fertility awareness based method to avoid pregnancy USN, at 1st Marine Division, Division Surgeon’s Office, in relation to a couple’s sexual behaviour during the fer- P.O. Box 555380, Camp Pendleton, CA 92055 (e-mail: tile time: a prospective longitudinal study. Hum Reprod. [email protected]). Reprints are not available 2007;22(5):1310-1319. from the authors. 17. Marquette University. Natural family planning. http:// nfp.marquette.edu. Accessed September 12, 2011. Author disclosure: No relevant financial affiliations to 18. Lamprecht V, Trussell J. Natural family planning effec- disclose. tiveness: evaluating published reports. Adv Contracept. 1997;13(2-3):155-165. REFERENCES 19. Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404. 1. World Health Organization. Health topics: family plan- ning. http://www.who.int/topics/family_planning/en/. 20. Fehring RJ, Schneider M, Barron ML. Efficacy of the Accessed September 12, 2011. Marquette Method of natural family planning. MCN Am J Matern Child Nurs. 2008;33(6):348-354. 2. Fehring RJ. Efficacy and efficiency in natural family plan- ning services. Linacre Q. 2009;76(1):9-24. 21. Fehring RJ, Schneider M, Raviele K, Barron ML. Effi- cacy of cervical mucus observations plus electronic 3. Jennings VH, Arevalo M. Fertility awareness-based hormonal fertility monitoring as a method of natu- methods. In: Hatcher RA, Trussell J, Nelson AL, Cates W ral family planning. J Obstet Gynecol Neonatal Nurs. Jr., Stewart FH, Kowal D, eds. Contraceptive Technology. 2007;36(2):152-160. 19th ed. New York, NY: Ardent Media; 2008:343-360. 22. European multicenter study of natural family planning 4. American College of Obstetricians and Gynecologists. (1989-1995): efficacy and drop-out. The European ACOG patient education: natural family planning. Natural Family Planning Study Groups. Adv Contracept. Washington, DC: ACOG; 2003. 1999;15(1):69-83. 5. Mosher WD, Jones J. Use of contraception in the United 23. Hilgers TW, Stanford JB. Creighton Model NaProEduca- States: 1982-2008. Vital Health Stat 23. 2010;(29):1-44. tion Technology for avoiding pregnancy. Use effective- 6. Choi J, Chan S, Wiebe E. Natural family planning: physi- ness. J Reprod Med. 1998;43(6):495-502. cians’ knowledge, attitudes, and practice. J Obstet Gyn- 24. Rice FJ, Lanctôt CA, Garcia-Devesa C. Effectiveness of aecol Can. 2010;32(7):673-678. the sympto-thermal method of natural family planning: 7. Van der Wijden C, Kleijnen J, Van den Berk T. Lacta- an international study. Int J Fertil. 1981;26(3):222-230. tional amenorrhea for family planning. Cochrane Data- 25. Arévalo M, Jennings V, Sinai I. Efficacy of a new method base Syst Rev. 2003;(4):CD001329. of family planning: the Standard Days Method. Contra- 8. Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual ception. 2002;65(5):333-338. intercourse in relation to ovulation. Effects on the prob- 26. Gribble JN, Lundgren RI, Velasquez C, Anastasi EE. ability of conception, survival of the pregnancy, and sex Being strategic about contraceptive introduction: the of the baby. N Engl J Med. 1995;333(23):1517-1521. experience of the Standard Days Method. Contracep- 9. Pallone SR, Bergus GR. Fertility awareness-based meth- tion. 2008;77(3):147-154. ods: another option for family planning [published correc- 27. U.S. Agency for International Development, George- tion appears in J Am Board Fam Med. 2009;22(5):596]. town University Institute for Reproductive Health. J Am Board Fam Med. 2009;22(2):147-157. Long-term use of standard days method: experience of 10. Georgetown University Institute for Reproductive Health. operations research study participants. http://pdf.usaid. About SDM. http://www.irh.org/?q=content/standard- gov/pdf_docs/PNADL887.pdf. 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