However, my years of teaching this method have convinced me that the increased risk is small, if you can verify before intercourse that there is no cervical fluid at your cervix and your cervix remains in the lowest infertile position. The physiological possibility that sperm can survive in such a dry vaginal environ ment long enough for the cervical and hormonal changes that are necessary for their survival must be remote, and thus I personally would not consider this to be an unreasonable risk. But until studies verify my personal beliefs, unprotected intercourse at such times in the cycle must still be considered abandonment of the rules taught in this book.
Unprotected Intercourse on Preovulatory Sticky Days
The risk of unprotected intercourse during the preovulatory sticky cervical-fluid phase is a directly related issue. In reality, the only women who can have unprotected sex during this time with only a small rise in risk are those who have clearly established that they have a Basic Infertile Pattern of sticky days, as discussed here.
For all other women, you should not take the risk. The truth is that you are not extremely fertile at this time, because sperm need wet cervical fluid to survive beyond a few hours, and anyone with stickiness is probably still a few days from ovulation. However, it is also a fact that if you’re just a little unlucky, sticky fluid can turn to wet in the few hours before sperm will die, thus preparing the way for a conception in the days to follow.
Unprotected sex at this point is therefore the type of cheating that increases the “user failure” rates in all Fertility Awareness studies. I would argue that such acts are an incorrect use of the method. But if you still decide to take the increased risk, I strongly urge you to verify that there is no wet cervical fluid at the cervix before having sex. If there is, intercourse without a barrier would be truly risky.
A FINAL WORD ON CERVICAL POSITION AND CONTRACEPTIVE EFFICACY
By now, it should be obvious that your cervical position can play an important role in confirming your fertility status. So for those of you determined to take the absolute lowest risk of pregnancy while still using natural birth control, I suggest that you continue to use the standard rules but limit intercourse to when your cervix is in its lowest, most infertile position (with no wet cervical fluid at the cervix). Although no studies have been done, I believe that if women did this, NFP method failure would fall from 2% to well below 1% per year. Admittedly, you may find that such a guideline results in an extra day or so of abstinence, but this may be a trade-off that you’re happy to accept.
A NOTE ABOUT THE BILLINGS METHOD
Finally, I should mention here that many people around the world practice a simplified form of Fertility Awareness called the Billings Method. The primary way that it differs from the Fertility Awareness Method used in this book is that it relies exclusively on observing cervical fluid to determine the fertile phase, and requires abstinence during the fertile phase. Because it does not use basal body temperature to verify the occurrence of ovulation, failure rates are somewhat higher, though method failure is still listed at only 3% by Contraceptive Technology.
The problem is with user failure, which is generally quite a bit higher than the corresponding Sympto-Thermal rates. For this reason, I personally urge you to use a basal body thermometer in order to maximize both contraceptive efficacy as well as the number of days considered safe for unprotected intercourse.
CONTRACEPTIVE METHOD EFFECTIVENESS TABLE*
Typical User Method Method Failure
Chance 85% 85%
Spermicides (foams, creams, vaginal suppositories, etc.) 28% 18%
Cervical cap† (w/spermicidal cream or jelly) 6% 9%
Sponge‡ 12% 9%
Diaphragm (w/jelly/foam) 12% 6%
Withdrawal 22% 4%
Female Condom (Reality) 21% 5%
Male Condom (without spermicides) 18% 2%
The Pill§ 9% 0.3%
IUD** ≤0.8% ≤0.6%
Sterilization (male and female) ≤.5% ≤.5%
Depo-Provera 6% 0.2%
NFP‡‡
(FAM w/Sympto-Thermal rules as taught in this book, and abstinence during fertile phase) (see footnote ‡‡) 2
* All data in this table are adapted from Contraceptive Technology, Twentieth Revised Edition, 2011, unless otherwise noted.
† For women who have given birth, the failure rates are substantially worse, at 32% and 26%, respectively. These data taken from 2004, since not listed in 2011 edition.
‡ For women who have given birth, the failure rates are substantially worse, at 24% and 20%, respectively.
§ Method failure rate varies with type of Pill chosen.
** Method failure rate varies with type of IUD chosen.
‡‡ The 2007 edition of Contraceptive Technology puts NFP method failure of the Sympto-Thermal rules taught in this book at 2%, and that is the one we’ve chosen to print in this chart. The 2011 edition actually puts the method failure rate of the Sympto-Thermal method even lower at .4%, but that is because it’s based on a major German metastudy in which the pre-ovulatory rules are much more conservative than what is taught here. (They require that women take the earliest temp rise of their last 12 cycles and then subtract seven days to identify the first fertile day. While this will indeed bring down method failure rates, the trade-off is that many women will have almost no pre-ovulatory days that are considered safe.) To read the actual study, you can google The Effectiveness of a Fertility Awareness Based Method to Avoid Pregnancy in Relation to a Couple’s Sexual Behaviour During The Fertile Time: A Prospective Longitudinal Study (Human Reproduction, 2007, p. 1310).
The Sympto-Thermal user failure rate is not listed. Based on the various studies throughout the medical literature, the traditionally calculated user failure rate appears to be about 10 to 12%. However, when intentional violation of the method rules is factored out, this number falls substantially.
Finally, method and user failure rates for other fertility-awareness based methods that use only one of the two primary signs (cervical mucus or basal body temps) are somewhat higher, with the most widely used of those, the Billings Ovulation Method (cervical fluid only), at a generally acknowledged method failure rate of approximately 3%.
APPENDIX E
THE DIFFERENCE BETWEEN NATURAL METHODS OF BIRTH CONTROL
Fertility Awareness-Based Methods (FABMs) are natural methods that involve observing at least one of the primary fertility signs: cervical fluid, waking temperature, and cervical position. Therefore, the first three below are not technically FABMs, but are sometimes grouped together because they are still natural.
The difference between the Fertility Awareness Method (FAM) and Natural Family Planning (NFP) is that those who practice NFP choose to abstain during the fertile phase, whereas those who practice FAM allow themselves the option of using a barrier during the fertile phase. The Couple to Couple League is the best known organization that teaches NFP.
APPENDIX F
Birth Control Rules When You Can Only Chart One Fertility Sign
The most effective method of natural birth control is one in which you chart at least two primary fertility signs to corroborate each other, as with the Sympto-Thermal Method taught in this book. However, there may be times in your life when it is not practical to chart more than one sign, so the rules below are more conservative to compensate. Still, you should be aware that charting only one sign, even with these modified rules, may result in lower contraceptive efficacy.
Before reading further, you should be sure that you have internalized the concepts in Chapters 6 and 11, including how to draw the coverline, how to establish your Basic Infertile Pattern (BIP), and how to identify your Point of Change.
In addition, during phases in your life when you don’t ovulate for weeks to months on end, you will want to follow the rules in Appendix J.
TEMPERATURE ONLY RULE
THERMAL SHIFT RULE
You are safe the evening of the 3rd consecutive day your temperature is
above the coverline, as long as the 3rd temp is at least 3/10ths above.
If you are only charting your waking temperature, you can’t consider yourself safe for unprotected intercourse until after ovulation, since temps don’t warn you of impending ovulation; they only confirm when it has already occurred.
In addition, you may prefer to not consider yourself safe until the 4th evening above the coverline, since you don’t have cervical fluid observations to corroborate your temps. Finally, you should never rely on this one rule if you’ve had a fever that could affect your temps, or your chart doesn’t clearly show an ovulatory thermal shift.
CERVICAL FLUID ONLY RULES
Note that if you are not charting temps, you must follow all the rules below.
Preovulatory
BLEEDING RULE
Avoid intercourse on any days of bleeding.
Since you can’t observe a thermal shift to confirm that the bleeding you are experiencing is true menstruation that occurs 12–16 days after ovulation, you must consider any bleeding as potentially fertile. This is because you can’t risk mistaking ovulatory spotting or some other cause of bleeding.
DRY DAY RULE
Before ovulation, you are safe the evening of every dry day. But the next day is considered potentially fertile if there is residual semen that could be masking your cervical fluid.
Waiting until evening assures that you haven’t missed the onset of developing cervical fluid during the day. But if there is residual seminal fluid the next day, it could mask cervical fluid, so you should abstain that day.
Postovulatory
MODIFIED PEAK DAY RULE
You are safe the evening of the 4th consecutive day after your Peak Day, the last day of eggwhite or lubricative vaginal sensation. If wet cervical fluid, bleeding, or lubricative vaginal sensations ever return, you must begin the Peak Day count again before considering yourself safe again.
The reason this rule is modified to be stricter than the normal Peak Day Rule (click here) is because there is no thermal shift to confirm that ovulation has actually occurred.
APPENDIX G
Checking Cervical Fluid Internally Before Ovulation
This type of observation is fairly tricky and not easily learned from a book. So if possible, I would encourage you to either take a class, meet with a FAM professional, or do a phone consultation to better understand the nuances of internal checking. You can find professionals through the links here.
The rules for the Sympto-Thermal Method of FAM are based on checking your cervical fluid externally, at your vaginal opening. The critical concept is to learn how to identify the Point of Change during those few days after your period ends, when your cervical fluid starts to evolve from dry to wet as you approach ovulation. Almost all women will have a pattern of transitional types of cervical fluid, whether it is sticky, rubbery, clumpy, or even just non-wet before it becomes wet. And you should be able to find all of these types at your vaginal opening when you wipe from front to back across your perineum with a flat folded piece of tissue.
However, if you are using FAM for birth control, there may be situations before ovulation when you want to check your cervical fluid at your cervix, itself, including when:
•You just want more assurance that you are reading your cervical fluid correctly
•You aren’t sure whether you have accurately identified a dry day before ovulation
•You don’t see much cervical fluid at your vaginal opening and thus want to check what is coming out of your cervix
•You experience a discrepancy between what you feel and what you see (for example, if you feel completely dry but you see a round circle of wet on your underwear, or when you feel wet but observe nothing at your vaginal opening)
•You are physically active most of the day and thus sweat a lot
•You are breastfeeding or premenopausal, or any other time when you are not ovulating regularly, and are relying strictly on cervical fluid
Of course the only time it’s worth doing an internal check is on days that you have identified as dry externally, and thus you want to confirm that you are indeed safe for preovulatory intercourse. Once you find anything externally, you need to consider yourself fertile, so there is no need to check internally.*
For most women, the easiest way to reach the cervix is by squatting, though you may prefer to put one leg on the bathtub. Regardless, after you choose whatever position is most comfortable for you, insert your middle finger first, and then slightly pull it out and also insert your index finger, placing them on each side of your cervix.
If you find that it is hard to do so because you are really dry, then that in itself is a good indication of low estrogen levels and the fact that you are probably not fertile that day. In any case, the trick is to gently draw cervical fluid from the cervix with a finger on each side, then pull them out together as you draw out the cervical fluid. This is because one finger alone won’t allow you to remove whatever cervical fluid is actually at the cervix.
You will usually feel some type of moisture, since your vagina is similar to the inside of your mouth. And you will often find a white pasty or cloudy film on your fingers when you check internally. This is normal. What you are seeing is most likely just vaginal cell slough that is the result of the way your vagina cleans itself. After removing your fingers, pull them apart so you can determine what is between their tips. Is it wet? Creamy? Clear? Stretchy? Wave your fingers for a few seconds. If the secretion between your fingers dries, it’s likely not cervical fluid.
If you do plan on checking internally during such days, you will want to be sure that you really familiarize yourself with how your internal cervical fluid differs from your external (specifically, how your internal vaginal moisture affects what you observe externally), so that you will always have a point of reference for the future. You may prefer to use the special chart at the back designed specifically for internal/external checking.
The key point is that before ovulation, you should always note whatever is the wettest quality you notice that day, whether it’s internal or external. So, for example, if you feel dry externally, but internally, you noticed a wet creamy secretion from your cervix, to be conservative, you would want to use that observation in deciding whether or not to consider yourself safe that day.
Again, checking your cervical fluid internally is not required or expected for effectively practicing the Sympto-Thermal Method of birth control that is taught in this book. It is, however, one more step you can take to truly maximize its contraceptive efficacy, especially during those situations where you might want a little more assurance than just your external cervical fluid and waking temps. And of course, as always, you will have the cervical position itself to help corroborate the other signs.
You can see how internal checking is recorded on your chart below. Also, note that there is a special master chart at tcoyf.com with an additional row for internal cervical fluid.
Kendall’s chart. Checking cervical fluid internally. Kendall has decided that she wants to be even more conservative by checking her cervical fluid internally, in this case on Days 5–8. She notices that even though she is dry externally, there is a slight moist sticky film on her two fingers when she pulls them out. But since there isn’t any actual wet cervical fluid, she is reassured that she is indeed safe on those days.
Once she has determined that she is safe after ovulation by establishing Peak plus 3 (corroborated by three high temps above the coverline, not shown on this chart) she considers herself safe until the next cycle, and doesn’t bother checking her cervical fluid again. However, on Day 28, the day before her period, she has a wet vaginal sensation, which is common for her on the day prior to menses. It is just one more indication that her period is about to begin.
APPENDIX H
Tricky Coverlines
No thermal shift
Outlying temperatures
Erratic temperatures
Weak thermal shift w
hose 3rd temp does not reach 3/10ths above coverline
Temperatures that rise 1/10th degree at a time (slow-rise pattern)
Temperatures that rise in spurts (stair-step pattern)
Temperature that drops on day 2 of the thermal shift (fall-back pattern)
Fever
Before reviewing tricky coverlines, you may want to reread Chapter 9 on balancing your hormones, since these types of ambiguous thermal shifts could reflect a subtle imbalance or luteal phase deficiency.
NO THERMAL SHIFT
Now and then you may have an anovulatory cycle. If this occurs, you won’t see a shift in temperatures from lows to highs because no heat-producing progesterone will have been released from the corpus luteum.
In addition, you could be one of the small percentage of women whose bodies don’t respond to the effects of progesterone, and therefore don’t show a thermal shift even if you have ovulated. One of the only ways to definitively determine if ovulation has occurred is through ultrasound. Short of that, you could get a progesterone blood test if weeks have passed without a thermal shift, but it is not as accurate as an ultrasound timed right around ovulation. (Of course therein lies the Catch-22!)
You could be experiencing temporary anovulation due to any number of things, including illness, stress, or a follicular ovarian cyst, as described here. But if you notice many anovulatory cycles, you may have a medical condition such as Polycystic Ovarian Syndrome (PCOS), as discussed in Chapter 8. Finally, you could be starting to approach menopause, in which case you will stop ovulating as often as you used to.
Taking Charge of Your Fertility Page 42