Fertility Awareness Methods (FAM)
Jo Taylor, APRN-CNP Women’s Health and Wellness Center Objectives
• Review common Fertility Awareness Methods (FAM) available and how each is used • Identify the efficacy, advantages, and disadvantages of using FAM • Learn strategies for patient education and counseling o Special considerations o Practical tips and resources o Become familiar with RHWP FAM Toolkit o FAM case studies
City of Columbus • Columbus Public Health Fertility Awareness Methods
Definition: The practice of determining a woman’s fertile period by using different measurements or observations and avoiding vaginal intercourse during those days to prevent pregnancy.
Sometimes called “natural family planning” or “periodic abstinence”.
City of Columbus • Columbus Public Health Biology of FAM
According to Contraceptive Technology (2018), FAMs rely on 5 biological facts: 1. The cycle of fertility and infertility that occurs 2. A single ovulation every month 3. The limited lifespan of the ovum (12 – 24 hours) 4. The limited lifespan of sperm in the cervical mucus and upper genital tract 5. The ability of a person using FAM to monitor cycle days and cyclic signs and symptoms
Hatcher et al. (2018). Fertility Awareness-Based Methods, Contraceptive Technology (pp. 395 – 416). New York, NY: Ayer Company Publisher Inc.
City of Columbus • Columbus Public Health Biology of FAM
Source: www.fertilityuk.org
City of Columbus • Columbus Public Health Signs of Fertility
• Days of the menstrual cycle • Ovulation pain, Breast tenderness • Cervical mucus changes • Basal body temperature rise • LH surge detected through use of OPK or monitor
City of Columbus • Columbus Public Health Fertility Awareness Methods
Benefits Challenges
. No cost or low cost • Less effective than many . Hormone free other methods . No side effects • Many require regular . May be culturally most menstrual periods appropriate for some • Requires discipline and women consistency to practice . No delay in return to fertility • No protection against STIs when stopped • Fertility markers can be . May also be used by impacted by stress or women TTC illness
City of Columbus • Columbus Public Health Approaches to FAM
1. Calendar-based 2. Symptoms-based 3. A Combination of both 4. Support of a mobile app
City of Columbus • Columbus Public Health FAM Efficacy
Most effective Least effective
75% 75% 88% 86% 80% 75% Calendar Sympto- Standard Two-Day Temperature Ovulation Days Rhythm Thermal
= Calendar Based = Symptom Based Reproductive access.org
City of Columbus • Columbus Public Health Some Evidence
A 2018 analysis of FAMs by the Journal of Obstetrics and Gynecology found that pregnancy rates “varied widely”.
Another study (2017) showed that most women (95%) felt FAM helped them better understand their bodies and improved communication with their partners.
City of Columbus • Columbus Public Health Calendar-based Overview
• Tracking or counting days of the menstrual cycle to find the beginning and end of the fertile period o Calendar or Rhythm method o Standard Days method • Low Cost • 75 – 88% effective in preventing pregnancy
City of Columbus • Columbus Public Health Calendar-based Rhythm Method
• Must track a minimum of 6 cycles, More is better • More effective when combined with other indicators such as cervical mucus evaluation or temperature
City of Columbus • Columbus Public Health Calendar-based Rhythm Method
How to: o Track cycles for 6 months o Count Day 1 as the first day of bleeding o Subtract 18 from the shortest cycle to get the first day of the fertile time period o Subtract 11 from the longest cycle to get the last day of the fertile time period o Need to update the calculations monthly and use the most recent 6 cycles
City of Columbus • Columbus Public Health Calendar-based Rhythm Method
Source: Family Planning: A Global Handbook for Providers
City of Columbus • Columbus Public Health Standard Days Method
• A calendar-based method that is simpler • Requires cycles of 26 – 32 days in length • Day 1 is the first day of bleeding • Days 8 – 19 are considered to be the fertile period • CycleBeads, a calendar, or a tracking app may be used
City of Columbus • Columbus Public Health Standard Days Method
How to use CycleBeads:
• On Day 1 of the menstrual period, place the rubber band on the red bead • Each day move the band one bead forward in the direction of the arrow • The fertile period is considered days 8 through 19 and is marked by a white bead • The colored beads are considered days of the non fertile period
https://www.cyclebeads.com/
City of Columbus • Columbus Public Health Symptom-Based
• Ovulation Method • Two Day Method • Basal Body Temperature (BBT) Method • Sympto-thermal Method • 75% - 86% effective
City of Columbus • Columbus Public Health Ovulation Method
• Tracks changes and characteristics of cervical mucus to determine fertile days and ovulation o Requires tracking for at least one cycle prior to use; more cycles is better o User must evaluate mucus every day o Women have the most mucus prior to ovulation with egg white and “slippery” consistency
City of Columbus • Columbus Public Health Ovulation Method
o Fertile days are considered when mucus first appears to after the slippery mucus goes away, typically 4 days after the mucus “peaks” (egg white) o The menstrual period is also considered unsafe
City of Columbus • Columbus Public Health Two Day Method
• Simpler version of the ovulation method • Two questions determines fertility: o Do I have cervical mucus today? o Did I have cervical mucus yesterday? • “No” to both = not fertile time • “Yes” to one or both = fertile
City of Columbus • Columbus Public Health Basal Body Temperature Method
• Temperature is lowest in the beginning of a menstrual cycle and rises with ovulation • Following ovulation, temperatures typically increase up to 97 – 99° F • Users must track temperature for a minimum of 3 full cycles prior to using
City of Columbus • Columbus Public Health Basal Body Temperature Method
• How to: o Take temperature every day before doing anything, while still in bed o Record temperature on tracking chart o Non-fertile time begins after temperature peaks for 3 days (0.4° to 1.0º) and end when the next menstrual period starts o Avoid intercourse from Day 1 of the menstrual period through the 3rd day of temperature increase
City of Columbus • Columbus Public Health Basal Body Temperature Method
City of Columbus • Columbus Public Health Sympto-Thermal Method
Combines ovulation and BBT instructions Intercourse is avoided from the first day of bleeding to 4th day of peak cervical mucus or 3rd full day of temperature increase – whichever happens later.
City of Columbus • Columbus Public Health OPKs & Monitors
• Historically not recommended for the purpose of contraception although gaining in popularity and in the literature. • “Marquette” Model uses hormone monitoring along with calendar and cervical mucus. Requires 6 months of tracking prior to use. Monitor supplies are expensive and a potential barrier for patients. • “Persona” monitor available in Europe. Detects estrogen and LH in urine
City of Columbus • Columbus Public Health Apps
• Natural Cycles o First and only FDA-approved app o Enter menstrual cycle info and daily BBT o Typical use 93% effective o Backed by research o $39.99 for 4 months + BBT www.naturalcycles.com • Others – Clue, Kindara, Ovia, Glow
City of Columbus • Columbus Public Health Education & Counseling
• Consistency is KEY • Calendar-based methods require “Pre-work” • When in doubt, use a condom or abstain • Discuss emergency contraception, Consider advance provision • Medications, Illness, Stress, Travel can effect biomarkers
City of Columbus • Columbus Public Health Education & Counseling
City of Columbus • Columbus Public Health USMEC
Calendar-Based Symptom-Based
Peri-meno/Menopause
May use if greater than 6 Breastfeeding weeks postpartum, BF, and has had 3 postpartum cycles
May use if greater than 4 Post-Partum weeks postpartum, not BF, May use if greater than 4 and has had 3 pp cycles weeks postpartum and not BF
Irregular Bleeding delay delay
Vaginal Infection delay
City of Columbus • Columbus Public Health Practical Tips
• Determine willingness or preference to use different tracking methods o What appeals to you about FAM? o Do you want to count days, monitor your temperature, or evaluate your mucus? o Are you able to track your cycles for 6 months prior to starting to use? • Assess level of protection desired – using a tiered menu or chart of the FAM methods o How important is it to you to prevent pregnancy right now?
City of Columbus • Columbus Public Health Practical Tips
• Use FAM toolkit • Consider having one staff member designated to learning more about FAM to serve as a resource • Schedule follow up to review initial tracking and short term follow up after implementing • Think about billing by time o ICD-10 Z30.09, Z31.61 o more to come on this!
City of Columbus • Columbus Public Health FAM Toolkit
• Overview • Fact Sheets • Education Points • Chart • Apps
City of Columbus • Columbus Public Health Resources/References
Curtis, K. M. (2016). US medical eligibility criteria for contraceptive use, 2016. MMWR, 65, 1-104. DOI: http://dx.doi.org/10.15585/mmwr.rr6503a1
Family Planning National Training Center. Fertility Awareness. Retrieved from: https://www.fpntc.org/search?keys=fertility+awareness
Hatcher et al. (2018). Fertility Awareness-Based Methods, Contraceptive Technology (pp. 395 – 416). New York, NY: Ayer Company Publisher Inc.
HHS Office of Population Affairs. Natural Family Planning and Fertility Awareness. Retrieved from: https://www.hhs.gov/opa/pregnancy-prevention/birth-control-methods/natural-family-planning-and-fertility- awareness/index.html
Reproductive Health Access Project. Fertility Awareness. Retrieved from: https://www.reproductiveaccess.org/wp- content/uploads/2014/12/nfp.pdf
World Health Organization Department of Reproductive Health and Research and Johns Hopkins School of Public Health (2018). Fertility Awareness Methods, Family Planning: A Global Handbook for Providers (pp. 291 – 306). Baltimore and Geneva: CCP.
City of Columbus • Columbus Public Health FAM Case Study #1
You see a 30 year old woman that is 6 weeks post-partum for her check up. She is breastfeeding with some supplementing of formula and has another child at home that is two years old.
She wants to use natural family planning and because she’s tired of hormones. In speaking with her, she tells you that it would be overwhelming for her to get pregnant again.
What is your approach?
If she chose a FAM, when could she start?
City of Columbus • Columbus Public Health FAM Case Study #2
A 22 year old woman comes to see you. She tells you that she wants to use natural family planning as her method of contraception. Her sister gave her CycleBeads to try.
She has been keeping track of her periods in her phone. On average her cycles are every 27 days.
Is she a candidate for the Standard Days Method?
What if her period became irregular?
What if she recently used emergency contraception?
City of Columbus • Columbus Public Health FAM Case Study #3
A couple comes to your clinic that you saw 4 months ago. They have been using the Two Day Method. However, the woman reports difficulty in evaluating cervical mucus.
How do you respond?
What education do you provide?
City of Columbus • Columbus Public Health RHWP Clinical Training Program
Jo Taylor, APRN-CNP Women’s Health and Wellness Center Training Overview
• Learning Modules . Evidence-Based Contraception . LARCs . Fertility Awareness . Family Planning Coding and Billing o Consult 2 Code o 2 Sessions o Follow up Q & A
City of Columbus • Columbus Public Health Training Overview
• LARC Preceptorship . For providers . Hands-on experience at CPH . On-site assistance after training in your clinic
City of Columbus • Columbus Public Health Training Overview
Clinical Excellence Phone Calls . Quarterly . For any clinic staff . Planned topics: Care of the LGBTQ patient, Reaching adolescents . Submit suggested topics
City of Columbus • Columbus Public Health Thank You
Jo Taylor, MSN, APRN-CNP Program Manager IV RN Women’s Health & Wellness Center [email protected] 614-645-3569
City of Columbus • Columbus Public Health