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.