Important Notice

This booklet is not meant to provide instruction in the methods of Natural Family Planning (NFP) or take the place of participation in a NFP course. Couples wishing to learn NFP are encouraged to enroll in a full course of instruction with a certified NFP teacher.


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Graphics on pages 5, 8, and 12 are used with permission and reproduced from The Sympto-Thermal Method. Courtesy of the Diocese of Harrisburg, 1994.

Copyright 1999 by the Diocesan Development Program for Natural Family Planning, United States Conference of Catholic Bishops, Washington, D.C. All rights reserved. No part of this work may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.


Contents

• What is NFP?
  
  
• Human Reproduction and the Signs of Fertility
  
  
• The Ovulation Method
  
  
• The Sympto-Thermal Method
  
  
• A Word About Effectiveness
  
  
• NFP & the Couple's Relationship
  
  
• Further Information
  
  
• About the Authors

What is NFP?

Natural Family Planning (NFP) is an umbrella term for certain methods used to achieve and avoid pregnancies. These methods are based on observation of the naturally occurring signs and symptoms of the fertile and infertile phases of a woman's menstrual cycle.

NFP is not "Rhythm." The Rhythm (or Calendar) method was developed more than 50 years ago. It was based on the scientific theory that ovulation could be predicted by calculating from previous menstrual cycles. This method was inaccurate because it did not take account of the unique nature of a woman's menstrual cycle. Today's methods of NFP do take account of such variations. Based on observable signs and symptoms of the fertile and infertile phases of the menstrual cycle, NFP methods track the changes associated with ovulation and treat each cycle as unique. The accuracy of women's observations has been validated by scientific research.*

NFP is a holistic approach to family planning. Both husband and wife understand their fertility, emotions, and family planning intention (whether to have a baby or not). Its successful use to avoid pregnancy relies upon a couple's following what they know about the method and one another. Successful use of NFP requires a couple to communicate. In the daily charting of their fertility signs, couples quickly appreciate their shared responsibility for family planning. Husbands are encouraged to "tune into" their wives' cycles, and both spouses are encouraged to speak openly to each other about their sexual desires and their ideas on family size.

Couples using NFP to avoid pregnancy abstain from intercourse and genital contact when the woman is fertile and can conceive. The total days of abstinence will vary from woman to woman and even from cycle to cycle. For example, if a woman experiences a 28 day cycle, she may have up to eight days of abstinence (not counting menses). Or, if a woman has a 37 day cycle, she may have up to ten days of abstinence. Whatever the length of the fertile phase, no barriers or chemicals are used at any time to avoid pregnancy. To achieve pregnancy couples have intercourse during the fertile time of the cycle. NFP is not a contraceptive. It does nothing to suppress or block conception. Instead, couples adjust their behavior according to their family planning intention using the naturally occurring signs and symptoms of a woman's cycle.

NFP promotes openness to the transmission of human life and recognizes the value of children. Sexual relations are understood as love-giving as well as life-giving. It is true family planning. Because NFP respects the two-fold nature of sexual intercourse, it can enrich the bond between husband and wife. For these reasons it is an acceptable form of family planning for people of various religious and philosophical beliefs.


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*See Richard Fehring, DNSc., RN & Robert Kambic, MSH, Natural Family Planning Bibliography. (Washington, D.C.: Diocesan Development Program for NFP, 1995).



NFP is a holistic approach to family planning. Both husband and wife understand their fertility, emotions, and family planning intention (whether to have a baby or not).


Human Reproduction and the Signs of Fertility

Richard Fehring, DNSc, RN

To appreciate and understand NFP, some background in human reproductive anatomy and physiology is helpful. Let's start at the beginning. The male cell of reproduction is the sperm and the female cell of reproduction is the egg. The uniting of these two cells is called conception. It is the beginning of a human life.

For pregnancy to occur, a number of conditions must be present to help the sperm and egg unite. The male sperm is produced in the testicles. During intercourse millions of sperm are released into the woman's vagina. To survive, sperm need to be in a good environment. The woman's vagina, which is mostly acidic, is actually a poor environment for sperm. However, at certain times in a woman's monthly cycle she produces a fluid called cervical mucus that will change the chemical nature of the vagina and is necessary for sperm survival. Sperm can live in cervical mucus from 3 to 5 days. If no cervical mucus is present, sperm die within hours.

Men produce sperm continuously throughout their lives. Women, on the other hand, are born with all the eggs they will ever have. During a woman's menstrual cycle, one or more of her eggs will develop and mature. Ovulation occurs when an egg (or eggs) fully matures and leaves the ovary. Usually only one egg is released during a woman's cycle. Sometimes a second egg is released within the same twenty-four hour timespan. The mature egg (or eggs) once released, will generally live for about twelve to twenty-four hours. Thus, for a woman to become pregnant, three factors are very important: healthy sperm; healthy egg; and cervical mucus for sperm survival.

There are three phases of a woman's menstrual cycle: pre-ovulation (the time before ovulation); ovulation (the time the egg is released by the ovary); and post-ovulation (the time after the egg is released).

Pre-Ovulation

The first phase of a woman's cycle begins on the first day of her bleeding ( ) and ends on the day of ovulation. A woman has thousands of eggs which are housed in two small organs called ovaries, one on each side of her body. The ovaries are near the fallopian tubes (see figure 1). It is in the fallopian tubes where, if present, sperm will meet egg, fertilization will occur, and new life will begin.

In the first part of the menstrual cycle, a chemical messenger (hormone) from the brain signals one or more of the thousands of eggs in a woman's body to develop. As the egg matures its follicle gives off another important hormone called estrogen. Estrogen is essential for fertility, because it helps to prepare both the inside of the vagina for sperm and the uterus for pregnancy. Most people know that the inside of the uterus must be built up with nutrient-rich endometrium cells to sustain a pregnancy; however, few people know the unique responsibility of the base of the uterus (cervix). The cervix is lined with mucus-producing cells that are stimulated by estrogen (see figure 1). When produced the cervical mucus will neutralize the acidic nature of the vagina, allowing the sperm to survive and move up through the uterus and into the fallopian tubes.

The length of the pre-ovulation phase of the cycle can change from cycle to cycle in the same woman. For example, a woman might ovulate (release an egg) on day 13 in one cycle and in the next cycle ovulate on day 10. Many reasons account for variations during this time, including: post-hormonal contraception, breast-feeding, and perimenopause. Research has also revealed that factors such as weight loss, emotional stress (good or bad), illness, and even diet can affect the time of ovulation. Despite this, the time of fertility can be known by a woman because her body produces signs that help her identify when her fertility begins and when her fertility ends.


Ovulation

Ovulation occurs when another hormone signals the ovary to release a mature egg. This is the optimal time of fertility. The cervix changes by rising in the pelvic cavity while the opening (os) widens and becomes soft.

Post-Ovulation

The third phase of the woman's menstrual cycle begins after ovulation and ends the day before her next period. This is called the luteal phase and is very stable in length (averaging about 10-16 days).

After ovulation has occurred the woman's body increases the release of another hormone called progesterone. Progesterone has a number of important functions. It elevates the woman's body temperature about 4 - 6 tenths of a degree Fahrenheit and can be detected by taking daily waking temperatures. This is called the Basal Body Temperature (BBT). Progesterone also prepares the lining of the uterus for possible implantation of a new life. When the woman's egg has been fertilized by the sperm, the embryo travels down the fallopian tube in a journey that takes six to nine days, and imbeds in the wall of the mother's uterus. The uterus will keep the new human being safe and nourished for the next 9 months. Progesterone will also stimulate cervical cells to produce a thick mucus that closes off the opening of the cervix and becomes a barrier to sperm and bacteria. If, on the other hand, fertilization does not occur, levels of progesterone will decrease, the mucus plug will dissolve, and the lining of the uterus will shed. This shedding of the lining of the uterus, experienced by the woman as bleeding, is called menstruation (menses).

There are three basic phases of a woman's menstrual cycle: pre-ovulation (the time before ovulation); ovulation (the time the egg is released by the ovary); and post-ovulation (the time after the egg is released by the ovary).


The Ovulation Method

Richard Fehring, DNSc, RN

The Ovulation Method (OM)* of Natural Family Planning makes use of the observation of cervical mucus to determine fertility and infertility. This method was first developed by Drs. John and Evelyn Billings of Australia. Although several variations of OM exist, OM continues to be popularly referred to as the "Billings Method."

The careful observation and charting of the presence of cervical mucus on a day to day basis will ensure a couple success in achieving their family planning goal. When practiced each day, this observation will soon become part of normal daily hygiene.

*For further information on the Ovulation Method see, Evelyn Billings & Ann Westmore, The Billings Method, Controlling Fertility Without Drugs or Devices (1995), available from BOMA, USA, see p. 18.

A primary sign of a woman's fertility is cervical mucus. When an egg in a woman's body starts to mature, the hormone estrogen increases and stimulates the cells lining the cervical canal to produce mucus. Once estrogen stimulates these cells, cervical mucus will be felt by the woman. The result of this hormonal activity is generally described by women as a feeling or sensation of wetness. Mucus can also be observed by wiping the vulvar area from front to back with toilet tissue each time the woman goes to the bathroom. When mucus is present on the tissue, it can be picked up and observed.

The woman must be consistent in daily sensing or observing the presence (or absence) of her mucus. During fertility, as the estrogen level rises, cervical mucus changes in consistency and quantity. The sensation also changes to one of slipperiness and greater lubrication, which the woman can notice as she goes about her normal daily routine. The last day of slippery mucus or a sensation of wetness is called Peak day. Ovulation occurs within 24 or 48 hours of the Peak.

After ovulation, estrogen levels start to drop off, progesterone levels increase and the cervical mucus becomes sticky and cloudy again and/or dry (see figure 2). The woman will experience a sensation of dryness. Once ovulation occurs the egg lives 12-24 hours. The fertile phase is from the beginning of the changing mucus pattern until the fourth day past Peak.

Achieving Pregnancy

If you wish to achieve pregnancy, obviously the best time to have intercourse is when the woman is fertile. The optimal time to achieve pregnancy (using cervical mucus as a sign) is the day(s) of the greatest quantity and quality of cervical mucus. Good quality mucus is stretchy, clear and gives the woman a sensation of lubrication.


Avoiding Pregnancy

Menstruation is a potentially fertile time since a woman can ovulate early in any cycle. If avoiding pregnancy is desirable, it is recommended that a couple abstain from intercourse during menses. In addition, because a woman will need to be alert for the on-set of mucus during the pre-ovulatory phase of the cycle, a couple must restrict intercourse to only the evening of every other dry day (that is, a day where no mucus was present and no sensation of wetness or slipperiness was felt by the woman).

Once cervical mucus has been observed, intercourse and all genital to genital contact must be avoided every day while mucus is present. During this time, the last day of mucus ( ) will have to be identified. Peak Day is identified as the last day of the most fertile sign, whether it is the last day of slippery, stretchy or blood tinged mucus or the last day of a lubricative, wet sensation. Peak Day cannot be reliably identified until the following day, when mucus undergoes a change under the influence of progesterone.

The Ovulation Method identifies the post-ovulatory phase of the cycle as beginning on the fourth day after the Peak of cervical mucus. This time of infertility will last up to the first day of menstruation. During this phase of the cycle, intercourse can occur any time of the day or night.


The Sympto-Thermal Method

Stella Kitchen

A multi-indexed method of Natural Family Planning. The Sympto-Thermal Method (STM)* charts the primary signs of fertility (cervical mucus & Basal BodyTemperature) as well as the secondary signs of fertility (cervical changes, breast tenderness, etc.). This method is based on the work of various scientists, including Billings, Doering, Keefe, Prem, Roetzer, and Vollman.

The careful observation and charting of the several signs of fertility on a day to day basis by couples will ensure success in achieving their family planning goal. When practiced each day, this observation will soon become part of a woman's normal daily hygiene.

*For further information see: John Kippley's The Art of Natural Family Planning. (Cincinnati, OH: Couple to Couple League, 1996).


The Basal Body Temperature (BBT) is the waking temperature of a woman's body after she has had at least six hours of sleep. The role of the BBT in this method is to support and confirm the mucus sign and identify that ovulation has taken place. The BBT is taken at approximately the same time each day under the same conditions. During the pre-ovulatory phase it remains at a low level. It is only after ovulation has taken place that a significant rise in the temperature can be seen (see figure 3).

The beginning of the cervical mucus symptom is the beginning of the potentially fertile phase. In the pre-ovulatory phase, the increase in estrogen levels affect cervical mucus. As estrogen increases the cervical crypts are stimulated to produce mucus that is thin, clear, and lubricative. A woman will feel wet when estrogen levels increase. As cervical mucus gradually changes it will become clear in appearance and sometimes even blood tinged; stretchy when picked up and held between two fingers; and will have the sensation of slipperiness, lubrication, and/or wetness. Peak day is the last day of this type of mucus. Ovulation will occur on or around Peak, after which the mucus changes back to a thicker and sticky texture (see figure 2).

Additional signs during ovulation include: cervical changes; breast sensitivity; lymph node swelling in the groin; abdominal pain; and/or swelling of the vulva. When the presence of fertility signs are recorded on a chart, these secondary signs should also be noted and used to determine the event of ovulation.

As a direct result of ovulation the hormone progesterone is produced by the body and changes the characteristics of the cervical mucus, making it thick and sticky. The woman's body temperature also rises as a result of progesterone, and this change can be seen in the daily taking of the BBT. As described above, the first days of the BBT will be low (pre-ovulatory phase). A shift of about .4 F will occur after ovulation. The couple should observe six low temperatures prior to the Peak day. After Peak day, three high temperatures are recorded. The post-ovulatory (infertile) phase of the cycle is counted from the third high temperature after Peak until the onset of the next menses (the beginning of a new cycle). The post-ovulatory phase will last 10-16 days.

Achieving Pregnancy

The optimum time to achieve a pregnancy is from the onset of mucus until Peak day. The fertile phase continues until the woman experiences the third high temperature. A high temperature level sustained for 18-20 days past Peak day, confirms that conception has taken place. Knowing the exact time of conception assists physicians in determining the due date of the baby rather than guessing based on ambiguous data.

Avoiding Pregnancy

During the pre-ovulatory phase of the cycle, a woman must watch for the presence of cervical mucus. Days of dryness may be considered infertile and intercourse could take place in the evening of alternate nights. Alternate nights are used to ensure that any seminal fluid from the previous night's intercourse has not masked the onset of cervical mucus.

If pregnancy is to be avoided, a couple should stop having intercourse or genital to genital contact as soon as mucus is observed or a sensation of moistness is felt. Peak day is identified as the last day of the most fertile sign, whether it is the last day of slippery, stretchy or blood tinged mucus or the last day of a lubricative, wet sensation. Peak day cannot be reliably identified until the following day, when mucus undergoes a change due to the influence of progesterone.

The Sympto-Thermal Method emphasizes the relationship between BBT and the presence of mucus (see figure 2). Therefore, it is very important to make accurate observations, record them carefully, identify Peak day correctly, and confirm the beginning of the infertile time by a rising temperature pattern. When these signs have been confirmed, the infertile phase of the cycle begins and intercourse is again available.


A Word About Effectiveness (1)

"Effectiveness," as understood by the general public and family planning researchers, only refers to how well a method can be used to avoid conception. NFP, on the other hand, can be used for both achieving and avoiding pregnancy. As discussed in the previous chapters, NFP is very effective in helping couples identify the optimum time for conception. With regard to spacing or limiting pregnancies, NFP is up to 99% successful (2) when couples understand the methods, are motivated, and follow the guidelines.

The effectiveness of NFP for pregnancy avoidance depends upon spouses following the guidelines of the method according to their family planning intention (i.e., spacing or limiting births). Those who are strongly motivated to avoid pregnancy and follow the method strictly are very effective in meeting their goal.

Effectiveness of Natural Family Planning in Avoiding Pregnancy

Number of pregnancies among 100 couples in one year.
Couples who carefully follow all     1-3
the guidelines for avoiding pregnancy all the time.

Couples who do not follow all the guidelines      2-15
for avoiding pregnancy all the time.

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(1) "Effectiveness" as used here is a technical term. It is employed by researchers to indicate how well a family planning method can be used to avoid pregnancy.
(2) See Section II, "Effectiveness of NFP Method," Fehring & Kambic, Natural Family Planning Bibliography (1995): pp 9-12.


NFP & the Couple's Relationship

Mary Shivanandan, STD

Couples who adopt NFP to space the births of children find that it brings about many positive changes in their relationship and even becomes a way of life. It begins with acceptance, and even wonder, at the way the human body is made. As one woman noted, "Knowing and learning about what goes on inside of my unique body amazed me."* Women especially find this information empowering. The woman gains a new respect for herself and often finds that her husband has a new supportive attitude: "My husband respects me as a person in my own right. He accepts my fertility as part of me." This new-found confidence contrasts with what one woman explained about how she felt using contraceptives: "I was required to sacrifice my health ... I felt as if I were an object and not an equal partner in our marriage."

Couples using NFP accept their fertility not as a nuisance or even a disease, but as a gift. When the physical pleasures of sexual intercourse are a couple's primary focus, the woman can feel used. NFP treats the woman not as a sexual object, but as the unique person she is. NFP does not downplay the importance of sexual union and sexual pleasure. Through the practice of periodic abstinence NFP helps couples to find other ways in which to be attentive to each other in each cycle. These other ways may be through cooking a favorite dish, or bringing home flowers. NFP can reignite the romance of dating for a married couple. As couples who use NFP often say: "Every cycle we have a wedding night." When spouses love one another enough to abstain and be more considerate of each other, both become more secure in their relationship.

Periodic abstinence is difficult at times. It also brings its own reward. Men find they can direct sexual urges in the service of love and not be controlled by it. Only if a man is in full possession of himself can he love his wife well. As one husband said, "NFP has challenged me to self-mastery so that I can freely give of myself." The nature of married love is total self-giving. If one is controlled by sex or withholds part of himself or herself (his or her fertility), that person cannot give totally to another. Self-mastery, on the other hand, can actually enhance sexual pleasure. Many couples explain: "Giving our whole selves to each other intensified the sensations of pleasure and the feeling of unity in this expression of our love."

When NFP is adopted as a lifestyle, fertility is regarded as a gift and children are valued and welcomed. A sense of awe at their power to procreate strikes many couples during the fertile time. One couple remarked that "NFP opened our hearts to children ... Children are a gift, a blessing, not a burden." Others have remarked that the time of fertility comes to be viewed with "a tremendous reverence" because fertility "is the time God created us to create." When a couple knows the most fertile time in the cycle and tries to achieve pregnancy, it becomes a shared joy.

NFP instruction puts the emphasis on a couple's shared responsibility not only for having children, but also for managing their combined fertility. Taking joint responsibility for fertility means that both spouses accept the challenge of abstinence during the fertile phase if they wish to avoid pregnancy. NFP requires couples to communicate. It helps them to talk about many things that may have been difficult to talk about before, including their sexuality. Through charting their fertility, they have a starting point for discussing the intimate aspects of their life, such as their sexual feelings and desires and their hopes or fears about pregnancy. Good, substantive interpersonal communication strengthens a marriage.

Many couples say that an NFP lifestyle deepens their faith in God. "(NFP) involved us with the Truth ....We experienced ... the conversion point in our lives." "NFP is putting ourselves in God's hands, totally allowing Him to work spiritually in our lives." With so many rewards for those who persevere with NFP it would be surprising if there were not also challenges. As one husband says: "The reality is that NFP is challenging .... (But) it is clear to me that working together through the tough times strengthens and enriches our marriage." And as another spouse says: "The value I experience in NFP is in the long run .... It forces you to place your immediate choices in the context of spouse, children, family and Creator."

Benefits of NFP

• Based on scientific fact;
  
  
• Cooperates with nature's design and treats each menstrual cycle as unique;
  
  
• Is effective for achieving or avoiding pregnancy;
  
  
• Can be used throughout a woman's reproductive life-time (e.g., post-partum, breast-feeding, perimenopause, etc.);
  
  
• Has no harmful side effects;
  
  
• Economical (fees typically charged only for first instruction);
  
  
• Values children;
  
  
• Requires mutual responsibility by husband and wife;
  
  
• Encourages couple communication;
  
  
• Fosters respect for and acceptance of the total person.
  
  
• Co-operates with God's design for spouses.

Information about NFP classes in your area can be obtained from your diocesan office of Marriage and Family Life (note: in some dioceses NFP programs can be found in a Catholic hospital, office of Respect Life Activities, Pastoral Programs, or Catholic Charities). If you are not sure who to call in your diocese please contact:

The Diocesan Development Program for Natural Family Planning
Secretariat for Pro-Life Activities
National Conference of Catholic Bishops
3211 4th St., N.E.
Washington, D.C. 20017
202-541-3240/3070
202-541-3054 FAX
e-mail: nfp@nccbuscc.org

The following are national NFP teacher training organizations. These organizations maintain lists of their certified teachers:

Billings Ovulation Method Association [OM]
P.O. Box 2135
St. Cloud, MN 56302
(651) 699-8139
(320) 654-6486 FAX
Website: boma-usa.org
E-mail: boma-usa@msn.com

Couple-to-Couple League [STM]
P.O. Box 111184
Cincinnati, Ohio 45211-1184
or:
4290 Delhi Pike
Cincinnati, OH 45238
(513) 471-2000
(513) 557-2449 FAX
Website: www.ccli.org
E-mail: ccli@ccli.org

Family of the Americas Foundation [OM]
P.O. Box 1170
Dunkirk, MD 20754
(301) 627-3346
(301) 627-0847 FAX
Website: www.familyplanning.net
E-mail: family@upbeat.com

Northwest Family Services, Inc. [STM]
4805 N.E. Glisan Street
Portland, OR 97213
(503) 215-6377
(503) 215-6940 FAX
Website: www.nwfs.org
E-mail: nfs@nwfs.org

Pope Paul VI Institute for the Study of Human Reproduction [OM]
(Creighton Model FertilityCare™)
6901 Mercy Road
Omaha, NE 68106
(402) 390-6600
(402) 390-9851 FAX
Website: www.popepaulvi.com


About the Authors

Richard Fehring, DNSc, RN, is Associate Professor and the Director of the Marquette University Institute for NFP, College of Nursing, Milwaukee, WI. Dr. Fehring is the Chairman of the Science and Research Committee for the American Academy of Natural Family Planning and has published on the science of NFP.

Stella Kitchen, Director of Natural Family Planning, Catholic Diocese of Harrisburg, PA. Stella has taught NFP for over fifteen years and is a trainer of teachers. Stella is a member of the NFP National Advisory Board to the Diocesan Development Program for NFP. She and her husband Roger have made NFP a vital part of their twenty-five year marriage.

Mary Shivanandan, MA, STD, teaches at the John Paul II Institute for Studies on Marriage & Family, Washington, D.C. Dr. Shivanandan is the author of Challenge to Love, which discusses the philosophy of NFP and couple experience. Dr. Shivanandan has spent 20 years in research and writing on marriage, family, and NFP.

Theresa Notare, MA, (Editor) is the Assistant Director of the Diocesan Development Program for Natural Family Planning, United States Conference of Catholic Bishops, Washington, D.C.

*This booklet has been generously funded by the Knights of Columbus.

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