Fertility Awareness Method of Birth Control - Sensiplan

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Fertility Awareness Method of Birth Control

Natural Family Planning by Sensiplan a short summary

Contents 1 Introduction 1.1 Changes in cervical mucus . . 1.2 Changes in body temperature 1.3 Changes in cervix position . . 1.4 Additional fertility signs . . .

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2 Documentation 2.1 Beginning of a cycle . . . . . . . 2.2 Charting cervical mucus . . . . . 2.3 Charting basal body temperature 2.4 Charting cervix position . . . . . 2.5 Charting additional fertility signs

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3 Determining fertile and infertile time 3.1 The infertile phase following ovulation . . . . 3.1.1 Evaluating temperature changes . . . 3.1.2 Evaluating cervical mucus . . . . . . . 3.1.3 Double check – putting it all together 3.2 The infertile phase at the beginning of a cycle 3.2.1 The Minus-8- or Doering Rule . . . . 3.2.2 The First-5-Days Rule . . . . . . . . . 3.2.3 The Minus-20 Rule . . . . . . . . . . . 3.3 Interpretation of cervix observations . . . . .

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1 Introduction The most important symptoms of fertility are the changes in the cervical mucus pattern and basal body temperature. Further body symptoms associated with the events of the cycle include changes of the cervix, breast symptoms, mid-cycle pain, mood swings, skin changes etc. The changes in the cervical mucus pattern and basal body temperature are signs which every woman can normally observe. But it is only possible to gain more specific information about fertile or infertile phases of the cycle if these observations are made regularly and recorded on a cycle chart (either on a paper chart or using a charting app).

1.1 Changes in cervical mucus After menstruation, a few days may follow where initially no cervical mucus is produced, and the vagina feels dry to the woman. That is, she feels and sees nothing. The cervical mucus that subsequently develops is often only perceived as a sensation of dampness, and there is nothing visible at the vaginal opening. As a rule, the cervical mucus is still cloudy at this stage, with a whitish or yellowish colour. It is thick, creamy, lumpy, sticky or tacky, and cannot be stretched. The closer it gets to ovulation and the more oestrogen is produced, the greater the increase in production of cervical mucus of a more fertile quality. It usually becomes clear, glassy and transparent, and sometimes has a slight yellowish tinge. At the same time, it becomes stretchy and feels smooth and slippery. Sometimes the cervical mucus becomes so fluid that it flows like water and is no longer visible. In this case, the woman perceives the vulva as being extremely wet. This is the peak of the typical changes of cervical mucus. Following this there is a reverse development. It becomes cloudy and lumpy again and loses its stretchability. The amount produced decreases or stops altogether, so that either nothing or just a sensation of dryness is perceived at the vulva. It is important to mention that every woman has her own individual pattern of cervical mucus development. However, after every increase in more fertile type cervical mucus, there is always a complete turnabout, and cervical mucus of a less fertile quality can be observed once again. Cervical mucus is observed during the day and recorded in the cycle chart in the evening. Here the most fertile type of cervical mucus for each day must always be recorded. The peak cervical mucus day is the last day of the individual’s most fertile cervical mucus. This peak day can only be determined in retrospect (i.e. on the evening of the following day), when there has been a turnabout to fertile cervical mucus of less quality.

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1 Introduction

1.2 Changes in body temperature When a woman observes the course of her basal body temperature every morning during a cycle, she will discover that there are two temperature levels. In the first phase of the cycle before ovulation the temperature is slightly lower. Around the time of ovulation, it rises by at least 0.2 °C. This temperature shift is caused by progesterone, which is produced by the Corpus luteum during or after ovulation. The basal body temperature is taken first thing in the morning immediately after waking and before getting up. For this reason this temperature is known as the basal body temperature, or early-morning or waking temperature. The temperature is always taken in the same way within a cycle, either rectally, vaginally or orally. Rectal measurements are higher than vaginal or oral measurements. Taking the temperature under the axillary is, however, not suitable. For the measurements, a normal standardised digital thermometer with a calibration that allows for readings to two positions after the decimal point is the most suitable. The same thermometer must be used within any individual cycle. The temperature reading and the time of measurement are recorded in the appropriate column on the cycle chart. The lines on the cycle chart correspond to the graduated scale of the thermometer. Variations in measurement conditions and changes in the normal daily habits can falsify the course of the basal body temperature curve and can sometimes simulate a temperature shift. It cannot be predicted which circumstances will affect an individual woman’s temperature and which will not. She must determine this for herself by making a note of anything that may affect her waking temperature. This can be mistakes or variations in the measurement method, measurements at different times, day-to-day events (short or disturbed nights, going to bed late, alcohol, stress, emotional strain, excitement, change of surroundings through journeys, holidays, climate change, etc.), changes in daily routine, illness or indisposition.

1.3 Changes in cervix position The cervix itself also undergoes changes. Directly after menstruation, the cervix is closed. It is firm and is lowered towards the vaginal opening, so that a woman can palpate it relatively easily with her finger. When ovulation is approaching, the cervix becomes soft. It is opened slightly and raised up away from the vaginal opening. After ovulation it closes, and becomes firm and low again. The cervix should be examined once daily in the same position and always with the same finger. The results of self-observation are recorded on the cycle chart in the same way as the temperature and cervical mucus results (consistency, position and opening).

1.4 Additional fertility signs Approximately one third of all women are aware of a further symptom of fertility – the so-called mid-cycle pain. Furthermore, many women notice that their breasts undergo changes during the cycle. These so-called breast symptoms, however, are not so common. Moreover, neither mid-cycle pain nor breast symptoms are regular enough to allow for their use as an effective indicator of the infertile phase following ovulation.

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2 Documentation All observations related to fertility ought to be recorded in a cycle chart, including those factors which may affect or disturb fertility observations (see Chapter 1.2 for examples). Each observation is entered for each day of a cycle.

2.1 Beginning of a cycle The chart begins with the first day of menstruation which is the first day of dark red flow. This is also the first day of the cycle which is noted and referred to as Cycle Day (CD) 1. The date column is filled in on each successive day. Menstruation is marked below the date column. Menstruation and all types of bleeding during a cycle, such as brown or pink spotting, must be recorded.

2.2 Charting cervical mucus Cervical mucus is observed during the day, regarding both sensation and appearance. The observations are recorded on the chart in the evening. The sensation and appearance of the cervical mucus may change during the day. The most fertile quality of cervical mucus observed is recorded in the evening in the appropriate column. There are three categories for observing cervical mucus: • Sensation. Concentrate on your vaginal opening and try to feel your sensations. Does the opening feel moist or dry? Does it feel like something is running from your vagina into your underpants? Does it itch or did you experience any uncomfortable chafing feeling? • Feeling. Rub some cervical mucus between your fingers, then draw your fingers apart to see if it is stretchy. Rub your fingers together and feel whether the mucus is dry, oily, smooth or moist. • Appearance. Take a look at the mucus. Is it stringy? Is it lumpy? Is it transparent or whitish or yellowish? As cervical mucus can have a number of characteristics, the following table 2.1 should help to distinguish between each cervical mucus type. Depending on the charting technique chosen (paper chart, apps, etc.), mucus types might be named differently and adjustments ought to be applied. The described mucus appearances can also show pinkish, reddish or brownish tinges due to (mid-cycle) spotting. This should also be noted in the mucus observations on the chart.

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2 Documentation

Table 2.1: Cervical Mucus Types

Sensation dry, coarse, itching, un- and comfortable feeling

Appearance nothing visible, no cervical mucus at vaginal opening

Type DRY (d)

no feeling, no moisture, and no sensation at vaginal opening

nothing visible, no cervical mucus at vaginal opening

NONE (o)

moist

but

nothing visible, no cervical mucus at vaginal opening

MOIST (m)

moist or no feeling

and

cloudy, lumpy, yellowish, sticky, STICKY stringy-elastic, not stretchy (S)

moist or no feeling

and

thick, whitish, creamy, stringy- CREAMY elastic, not stretchy (S)

moist or no feeling

and

(crystal) clear, transparent, like raw EGGWHITE egg white, stretchy, thread-like, spin- (S+) nable, watery, runny

wet, slippery, slick, and / or greasy, oily, smooth, soft

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(crystal) clear, transparent, like raw WATERY egg white, stretchy, thread-like, spin- (S+) nable, watery, runny

2.3 Charting basal body temperature

2.3 Charting basal body temperature The temperature readings to the nearest 0.05 of a degree Celsius (see table 2.2) are recorded by a dot in the appropriate column of the day. Rounding the temperature measurements to the nearest 0.05 degree helps to smooth the temperature readings without compromising the significance and efficiency. The temperature dots are joined up from day to day. If the temperature is not measured on a particular day, the neighbouring dots are not joined up. The time of measurement can be recorded in the ’measurement time slot’ above the temperature dot. Table 2.2: Examples for rounding temperature readings to the nearest 0.05°C

Measured 36.60°C 36.59°C 36.58°C

Rounded 36.60°C 36.60°C 36.60°C

36.57°C 36.56°C 36.55°C 36.54°C 36.53°C

36.55°C 36.55°C 36.55°C 36.55°C 36.55°C

36.52°C 36.51°C 36.50°C

36.50°C 36.50°C 36.50°C

Furthermore, it is recommended to measure the basal body temperature for at least three minutes. Some digital thermometers indicate their final measure with a beep or vibration but continue to measure after the signal. Thus, the longer a temperature is measured, the more accurate the measurement becomes. However, during an on-going cycle measurement lengths must not be changed!

2.4 Charting cervix position Observations of the cervix are recorded at the bottom of the chart in the ’cervix’ column. The amount of opening and the position, as well as firmness are noted by corresponding symbols. This, again, can depend on the charting technique chosen.

2.5 Charting additional fertility signs Additional fertility signs, such as breast symptoms, mid-cycle pain, skin changes, mood swings or libido, can be noted in a ’particular features’ or custom data column.

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3 Determining fertile and infertile time The fertile phase and the two infertile phases (pre- and post-ovulatory) are determined with the aid of the cervical mucus and the basal body temperature in double check. The following chapter will elaborate how it can be determined that ovulation occurred and how to tell that the fertile window is about to open at the beginning of the cycle.

3.1 The infertile phase following ovulation The menstrual cycle can roughly be divided into a low temperature level during the follicular phase (pre-ovulatory) and a high temperature level during the luteal phase (post-ovulatory). Ovulation occurs shortly before and during the shift from low to high but cannot be pinpointed exactly. The infertile time following ovulation begins either on the evening of the third day after the peak cervical mucus or on the evening of the day of the third higher temperature reading; whichever comes last.

3.1.1 Evaluating temperature changes To determine whether a temperature shift has taken place, three consecutive readings all higher than the preceding six are needed. The third higher temperature must be at least 0.2°C above the highest of the preceding six lower temperature readings (coverline, see figure 3.8). In order to identify the high temperature readings, each new temperature is compared day by day with the preceding six. ’Disturbed’ temperature readings are excluded and are not taken into account.

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3rd temperature must be at least 0.2°C above the highest of the pre-ceding six temperatures.

Figure 3.1: Chart depicting a normal temperature shift with the third temperature reading being at least 0.2°C above the coverline

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3 Determining fertile and infertile time

Exception rule #1 – Slow rise A slow rise is indicated by a temperature rise that slowly but gradually shifts over a longer period of time into the luteal phase range. To confirm ovulation, exception rule #1 is applied: If the third high temperature does not reach 0.2°C above the coverline, a fourth temperature is needed to confirm ovulation (see figure 3.2). This temperature, however, does not need to be 0.2°C higher than the coverline. It simply needs to be above the coverline, meaning 0.05°C higher than the highest of the previous six low temperatures is sufficient.

3rd temperature does not reach 0.2 degrees above the coverline. A fourth temperature is needed to confirm ovulation which needs to be at least 0.05°C above the coverline. 6

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3

2

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Figure 3.2: Chart depicting a slow rise shift with the third temperature reading not reaching 0.2°C above the coverline

Exception rule #2 – Fallback rise A fallback rise is indicated by a drop in temperature followed by a drastic rise in temperature (figure 3.3). To confirm ovulation has occurred, exception rule #2 needs to be applied: If the second or third temperature drops onto or even below the coverline, another fourth temperature is needed. This fourth temperature must be at least 0.2°C higher than the coverline to confirm ovulation.

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2

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2nd (or 3rd) temperature dips onto or below the coverline. A fourth temperature is needed to confirm ovulation which needs to be at least 0.2°C above the coverline.

Figure 3.3: Chart depicting a fallback rise with the third temperature falling below the coverline

These two exception rules must not be combined!

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3.1 The infertile phase following ovulation

3.1.2 Evaluating cervical mucus Peak of cervical mucus is the last day of the most fertile type of cervical mucus which can be either watery or eggwhite, depending on whichever comes last. Peak day can only be ascertained in retrospect. The cervical mucus assessment finishes on the evening of the third day after the peak cervical mucus (see figure 3.4). While monitoring the three days after the peak, if there is again cervical mucus of the same quality as at the peak, this day becomes the new peak cervical mucus day, and the three-day count must be re-initiated. A renewed appearance of cervical mucus of any quality that occurs after a completed double check of temperature shift and mucus dry-up has no significance and can be disregarded.

Peak day of cervical mucus is the last day of either eggwhite or watery fluid, whichever comes last, followed by at least three days of lesser quality mucus.

P1234 Figure 3.4: Chart showing the peak cervical mucus followed by a three day dry-up

3.1.3 Double check – putting it all together To determine the beginning of the infertile phase after ovulation occurred, all sympto-thermal methods use a double check of temperature shift and the dry-up of cervical mucus. Therefore, the described evaluations of temperature (see chapter 3.1.1) and cervical mucus (see chapter 3.1.2) are put together: The infertile time following ovulation begins either on the evening of the third day after the peak cervical mucus or on the evening of the day of the third higher temperature reading; whichever comes last. On the following pages, a compilation of example charts is shown to demonstrate how the double check works in order to determine the beginning of the infertile phase after ovulation. A short explanation is given with each chart.

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3 Determining fertile and infertile time

Figure 3.5: Chart depicting a normal temperature shift with the third temperature reading being at least 0.2°C above the coverline (CD31). Peak day of cervical mucus was observed on CD27 followed by a three day dry-up (CD30). The infertile phase (marked green) starts at the evening of CD31 because temperature evaluation was finished last

Figure 3.6: Chart depicting a normal temperature shift with the third temperature missing. A fourth temperature reading is needed, being at least 0.2°C above the coverline (CD22). Peak day of cervical mucus was observed on CD17 followed by a three day dry-up (CD20). The infertile phase (marked green) starts at the evening of CD22 because temperature evaluation was finished last due to the missing temperature on CD21

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3.1 The infertile phase following ovulation

Figure 3.7: Chart depicting a normal temperature shift with the third temperature reading being at least 0.2°C above the coverline (CD30). Peak day of cervical mucus was observed on CD26 followed by a three day dry-up (CD29). The infertile phase (marked green) starts at the evening of CD30 because temperature evaluation was finished last

Figure 3.8: Chart depicting a slow rise shift with the third temperature reading not reaching 0.2°C above the coverline (CD21). A fourth temperature is needed, being at least 0.05°C above the coverline (CD22). Peak day of cervical mucus was observed on CD21 followed by a three day dry-up (CD24). The infertile phase (marked green) starts at the evening of CD24 because cervical mucus evaluation was finished last

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3 Determining fertile and infertile time

3.2 The infertile phase at the beginning of a cycle Any appearance of cervical mucus marks the onset of fertility. Since cervical mucus does not appear in some women until a few days before ovulation, relying solely on cervical mucus observation to determine the beginning of the fertile time is not advisable. Therefore, the use of the dry day rule is not practicable by means of Sensiplan. For this reason, the infertile phase at the beginning of the cycle is determined by the doublecheck principle. This comprises the observation of the cervical mucus and the so-called Minus-8 (Doering) or the First-5-Days rule, which is explained in the following. An infertile phase at the beginning of a cycle can only be assumed if there has been a temperature shift and thus, ovulation occurred, in the preceding cycle.

3.2.1 The Minus-8- or Doering Rule To calculate the last infertile day at the beginning of a cycle, the Minus-8- or Doering Rule is used. Out of at least 12 ovulatory cycles, the earliest higher temperature is taken and 8 days are subtracted. Thus, the 8th day before the first high temperature reading is the last infertile day at the beginning of the cycle. E.g. if the earliest higher temperature reading of the last 12 charted, ovulatory cycles was found to be on CD 16, the last infertile day at the beginning of a cycle is CD 16 minus 8 days = CD 8. Likewise, a woman who’s found her earliest higher temperature to be CD 21 can assume infertility at the beginning of her cycle up until CD 13 (CD 21 minus 8 = CD 13). If cervical mucus has already been seen before this, or if a ’moist’ feeling or sensation is observed, then the fertile time begins immediately. ’Whichever comes first’ is valid here – in line with the double-check principle.

3.2.2 The First-5-Days Rule In the very first cycle in which observations are made, fertility must initially be assumed right from the beginning, since the woman cannot know whether there was a temperature shift in the preceding cycle. The Minus-8 Rule cannot be applied until 12 ovulatory cycles have been recorded, from which the earliest first higher reading can be determined. Until this time is reached, the First-5-Days Rule applies: The first 5 days of the cycle can be assumed to be infertile. When the First-5-Days Rule is in effect, if cervical mucus is observed any time within these first five days, the fertile time begins immediately. Here, too, ’whichever comes first’ is valid – in line with the double-check principle. Furthermore, an early Doering day trumps the First-5-Days Rule: If the earliest first higher reading occurs on the 12th day or even earlier during any of the first 12 cycles, then the First-5-Days Rule is no longer valid. From that point on, the rule is ’the earliest first higher reading minus 8’. E.g. the earliest first higher reading was found to be on CD 11 after only four charted cycles. CD 11 minus 8 days = CD 3, meaning the First-5-Day Rule is no longer valid. From this cycle on, the infertile phase at the beginning of the cycle ends on CD 3.

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3.3 Interpretation of cervix observations

3.2.3 The Minus-20 Rule Women who have never used hormonal contraception but kept record of their menstrual cycles with a menstruation calendar can extend the infertile period at the beginning of the cycle as well. Here, the shortest overall cycle length of the last 12 cycles is taken and 20 days are subtracted. E.g. if a woman kept a menstruation calendar during the last year and recorded 12 cycles, of which the shortest cycle was 26 days, she can presume an infertile period of 6 days at the beginning of her cycle. However, if cervical mucus or a ’moist’ sensation is observed any time within this ’infertile’ period, the fertile time begins immediately.

3.3 Interpretation of cervix observations Observations of the cyclical changes of the cervix increase the possibilities for interpretation. Especially if – for various reasons – cervical mucus is not available for double checking, the cervix is an adequate substitute. Immediately after menstruation the cervix is closed and firm and extends deep into the vagina, such that it can be palpated relatively easily with a finger. When ovulation approaches, the cervix becomes soft, opens slightly and is raised a little, such that it can sometimes hardly be reached any more. After ovulation it closes again, becomes firm, and its position lowers. Interpretation rules: • For as long as the cervix remains unchanged after menstruation, infertility can be assumed – provided that the first-5-days rule or the minus-8 rule are not already indicating fertility (double-check). • The fertile time begins as soon as there is any change in the cervix during the first phase of the cycle (opening, softening or raising). • A cervix that is raised high, soft and wide open indicates the most fertile time. • The infertile phase following ovulation begins on the evening of the third day when the cervix is closed and firm – with the temperature as a double check.

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