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Non-hormonal Contraceptive Methods

(Published July 2013)

Fertility Awareness

Description

A variety of contraceptive methods known variously as fertility awareness, natural family planning, rhythm, and other names may be suitable choices for couples who are highly motivated to abstain from vaginal intercourse or who use a barrier method during "fertile" days.

All fertility awareness methods are based on identifying the fertile days in a woman's menstrual cycle by counting the days in the menstrual cycle and/or noting changes in fertile signs such as cervical mucus and basal body temperature (BBT). On days identified as fertile, the couple either abstains from vaginal intercourse or uses a barrier method.

fertility awareness cycle beadsBecause these methods are based on the woman's ovulatory cycle, they are most effective for women who have reliably regular menstrual periods, between 26 and 32 days in length. Women who have two or more periods differing from this length within a single calendar year are not good candidates for these methods.

Use

  • With the symptom-based Billings Ovulation Method, women must determine the “Basic Infertile Pattern” when intercourse is safe to engage in by observing the character of cervical secretions for a few months and recording their observations on a special chart. Safe “dry” days are when there are no discernible cervical secretions and occur as menstruation tapers at the beginning of the cycle. Ovulation typically occurs one day before, during, or after the last day when cervical secretions are most abundant, clear, slippery, stretchy, and wet.37, 38

Couples may engage in intercourse every other night on preovulatory days (just after menses ends) if cervical secretions are not present. The alternate-night schedule is designed to prevent the woman from being confused about whether she is observing seminal fluid draining from her vagina as opposed to cervical secretions. Couples should abstain from intercourse and all intimate genital contact during days when the cervical mucus is abundant, clear, slippery, stretchy, and wet, as well as during heavy menstrual bleeding (when mucus may be present but undetectable).

  • With the Creighton Model FertilityCare System, which is based on the Billings Method, cervical mucus plus the absence or presence of various types of bleeding are charted to monitor fertility; the method is used both to prevent and to achieve pregnancy and evaluate a woman for reproductive disorders. Proponents say the model provides scientific data that can be used to predict fertile and infertile days in women with long and irregular menstrual cycles, those who are breastfeeding, and women who are in perimenopause and still ovulating.40
  • The TwoDay Method® requires women to monitor for cervical secretions every day. On any day when the woman observes secretions—or observed them the previous day—she considers herself to be fertile and avoids intercourse. When she notes 2 consecutive days without cervical secretions, she is unlikely to become pregnant from intercourse on that day.41
  • With the Standard Days Method®, the days of the menstrual cycle are tracked on a calendar. Day 1 is the first day of menstruation and days 8 through 19 are the fertile days, when unprotected intercourse is avoided. A product called Cycle Beads™ (www.cyclebeads.com) is a simple visual aid to help a woman keep track of her cycle days and fertile period.
  • With the calendar days method, a woman keeps track of her menstrual cycle for 6–12 months and then subtracts 18 from the number of days in the shortest cycle and 11 from the number of days in the longest cycle. The two resulting numbers indicate the beginning and end of the fertile period.
  • The ovulation method involves tracking changes in cervical mucus and/or BBT daily to determine fertile and non-fertile days. Cervical mucus changes in amount and texture around the time of ovulation, and BBT, which is measured every morning, rises by about 0.4° F around the time of ovulation.
  • Alternatively, women can monitor the timing of ovulation using ovulation kits, which are available without prescription at pharmacies.

For some women, libido is high during fertile days, making abstinence an undesirable practice. Other couples find that intimacy is enhanced by practicing non-penile-vaginal forms of sexual expression during the fertile period. For more detailed information on fertility awareness methods, see www.birth-control-comparison.info.

Effectiveness

  • This method is somewhat effective and hinges on correct and consistent use.
  • With typical use, the failure rate for these methods is 24 percent.7
  • To be effective, this method requires highly motivated couples where the woman has a reliably regular menstrual period.

Risks

  • The risk of unintended pregnancy for fertility awareness−based methods is 24 percent.7

Side Effects

None

Contraindications and Precautions

Medical Eligibility Criteria for Fertility Awareness Methods
The MEC have no contraindications or precautions to use of fertility awareness methods. The guidelines state that these methods can be used “without concern for health effects.”10 They also state, however, that certain conditions can make them more challenging to use, and they have developed an alphabetical criteria system for these methods (see box).

Medical Eligibility Criteria Categories

A = Accept. There is no reason this method cannot be used.

C = Caution. The method requires extra or special counseling to ensure correct use.

D = Delay. The method should be delayed until a condition is evaluated or corrected, and an alternative, temporary method of contraception should be offered.


Source: Reference 10

 

Symptom-based Methods (Billings Ovulation Method, Creighton Model FertilityCare System, TwoDay Method)

Category D (delay and offer temporary, alternative contraception)

  • Breastfeeding, <6 weeks postpartum. In general, women who are primarily breastfeeding, nursing only by breast (no pumping), and do not have periods are unlikely to have sufficient ovarian function to produce detectable fertility signs and hormonal changes for the first 6 months after giving birth.
  • Non-breastfeeding women, <4 weeks postpartum. Women who are not breastfeeding are unlikely to have sufficient ovarian function either to require a FAB method or to have detectable fertility signs or hormonal changes before 4 weeks after giving birth.
  • Irregular vaginal bleeding
  • Vaginal discharge
  • Use of drugs that affect cycle regularity, hormones, and/or fertility signs (e.g., lithium, tricyclic antidepressants, anti-anxiety drugs)
  • Acute diseases that elevate body temperature (relates to BBT methods)

Category C (provide extra or special counseling)

  • Postmenarche (due to possible menstrual irregularity)
  • Perimenopause (due to possible menstrual irregularity)
  • >6 weeks postpartum and breastfeeding. In general, women who are primarily breastfeeding, nursing only by breast (no pumping),  and do not have periods are unlikely to have sufficient ovarian function to produce detectable fertility signs and hormonal changes for the first 6 months after giving birth, but signs may increase beyond 6 weeks postpartum.
  • Postpartum and breastfeeding after menses begin (due to menstrual irregularity).
  • Postabortion. These women are likely to produce detectable fertility signs and/or hormonal changes, and the likelihood increases with the time postabortion.
  • Use of drugs that affect cycle regularity, hormones, and/or fertility signs (e.g., lithium, tricyclic antidepressants, anti-anxiety drugs)

Source: Reference 10


Calendar-based Methods (Standard Days Method, Calendar Days Method)

Category D (delay and offer temporary, alternative contraception)

  • Breastfeeding. In general, women who are primarily breastfeeding, nursing only by breast (no pumping), and do not have periods are unlikely to have sufficient ovarian function to produce detectable fertility signs and hormonal changes for the first 6 months after giving birth.
  • Non-breastfeeding women. Women who are not breastfeeding are unlikely to have sufficient ovarian function either to require a FAB method or to have detectable fertility signs or hormonal changes immediately after giving birth. They can start using a calendar-based method after they have had three postpartum menses.
  • Postabortion. These women are likely to produce detectable fertility signs and/or hormonal changes and can use a calendar-based method after they have had at least one postabortion menses.
  • Irregular vaginal bleeding
  • Use of drugs that affect cycle regularity, hormones, and/or fertility signs (e.g., lithium, tricyclic antidepressants, anti-anxiety drugs)
  • Acute diseases that elevate body temperature (relates to basal body temperature methods)

Category C (provide extra or special counseling)

  • Postmenarche (due to possible menstrual irregularity)
  • Perimenopause (due to possible menstrual irregularity)
  • Breastfeeding. In general, women who are primarily breastfeeding, nursing only by breast (no pumping), and do not have periods are unlikely to have sufficient ovarian function to produce detectable fertility signs and hormonal changes for the first 6 months after giving birth, but signs may increase beyond 6 weeks postpartum. They can use a calendar-based method after they have had at least three postpartum menses and their cycles are regular again.
  • Use of drugs that affect cycle regularity, hormones, and/or fertility signs (e.g., lithium, tricyclic antidepressants, anti-anxiety drugs)

Source: Reference 10

Advantages

  • Low or no cost
  • Readily available once trained in method
  • Also can be used to pinpoint fertile days in order to conceive

Disadvantages

  • Requires cooperation of male partner
  • Lower efficacy with typical use than other methods e
  • Lack of spontaneity on fertile days
  • Unsuitable for women with cycles of fewer than 26 or more than 32 days in length
  • No protection against STIs

Counseling Messages

  • Correct use of fertility awareness methods is important for these methods to be used successfully.
  • The calendar methods can be learned quickly and easily, whereas the ovulation methods require more practice and training for patients to accurately recognize changes in cervical mucus.
  • This method does not protect against STIs.