Modern Natural Family Planning and the Family Physician. Christina A. Porucznik, PhD, MSPH Joseph B. Stanford, MD, MSPH

Transcription

1 Modern Natural Family Planning and the Family Physician Christina A. Porucznik, PhD, MSPH Joseph B. Stanford, MD, MSPH

2 Objectives Define fertility awareness and natural family planning Review biological basis for natural family planning Introduce several methods of modern natural family planning Review clinical utility of natural family planning Provide resources for physicians

3 Introduction During any given menstrual cycle, there are relatively few days during which sexual intercourse is likely to result in conception, the fecund window (or fertile window) The fecund window starts 5-6 days prior to ovulation and ends on the day of ovulation 1-5

4 Definitions Fertility awareness (FA): observation of biomarkers to determine likely day of ovulation and associated fecund window Natural family planning (NFP): practice of abstaining from genital contact during fecund window if couple desires to avoid pregnancy, or having intercourse during that time if the couple wishes to conceive

5 Physiology of the Fecund Window Ovum remains viable for <24 hours after ovulation 6 Prior to ovulation, estrogen stimulates cervix to produce Type E mucus which allows storage and survival of sperm for several days 7 After ovulation, progesterone stimulates production of Type G mucus which prevents sperm entry 8

6 Variability of Ovulation Even in women with regular menstrual cycles, there is a >10% probability of being in the fecund window as early as Day 7 and as late as Day 21 8 Accurate, prospective means are needed to identify the fecund window

7 Biomarkers of the Fecund Window Biomarker Type Can be used to identify Urinary luteinizing hormone (LH) Urinary estrogen metabolites Urinary progesterone metabolites Basal body temperature Vaginal discharge from cervical fluid The beginning of the fecund window The end of the fecund window Hormonal + + Hormonal ++ + Hormonal ++ Symptom ++ Symptom The most fecund days + can be used for this purpose; ++ most efficient for this purpose Adapted from 1

8 Natural Family Planning Methods Observation of one or more biomarkers to determine the beginning and end of the fecund window Three general categories Calendar-based Biomarker-based Sympto-thermal

9 Calendar-Based Methods

10 Individualized Calendar Algorithm From last six cycles Subtract 19 days from shortest cycle Subtract 10 days from the longest cycle To identify the fecund window Calculations should be revised if cycle duration changes 1 year probability of pregnancy <15% under typical use scenarios 9

11 Individualized Calendar Algorithm For example, if shortest cycle was 30 days and longest was 36 days 30-19= =26 Fecund window = cycle days 12 to 25

12 Individualized Calendar Algorithm Calendar calculations are almost never done correctly What patients call rhythm method and may approximate with use of a calendar is more likely guesswork than scientifically based calendar calculations

13 Standard Days Method (SDM) Simplified calendar algorithm Appropriate for women whose cycles range between 26 and 32 days long Approximately 2/3 of women in this range 10 Fecund window = cycle days 8-19 Field tested in many settings 1 year pregnancy probability 5% with perfect use and 12% with typical use 11-14

14 CycleBeads Visual reminder system that operationalizes the Standard Days Method (SDM) Each day of the cycle, one advances a black ring along a string of beads. White beads indicate potentially fecund days

15 Cervical Mucus Methods

16 Two-Day Method (TDM) User asks herself two questions each day 1. Did I notice any vaginal secretions today? 2. Did I notice any secretions yesterday? If answer to either question is YES then she considers that day fecund Pregnancy is unlikely after two dry days Field tests: 1 year pregnancy probability of 3.5% with correct use and 13.7% with typical use 15 Can be taught in a single office visit

17 Billings Ovulation Method (BOM) Characterizes and records quantity and quality of cervical mucus Identifies the mucus peak day marker of ovulation Field trials: one year probability of pregnancy 2-16% 16,17 Most couples require 3-4 sessions with a trained teacher to learn the method

18 Creighton Model FertilityCare TM System (CrM) Standardized vocabulary for describing cervical mucus Extensive training for instructors Couples complete 4-8 individual counseling sessions to learn the method 18 One year probability of pregnancy 19,20 Perfect use <1% Typical use 5-17%

19 Creighton Model FertilityCare TM System (CrM) Associated with Natural Procreative Technology (NaProTechnology) Protocols for medical evaluation and treatment of infertility and reproductive anomalies 21 Cohort of infertile couples treated by family physicians with NaProTechnology achieved live birth rates similar to more invasive technology with low incidence of preterm birth and multiple gestation 22,23

20 Sympto-thermal Methods

21 Basal Body Temperature (BBT) BBT rises an average of 0.4 o C (0.7 o F) after ovulation BBT must be measured at approximately the same time each day, upon awakening BBT identifies only the end of the fecund window and must be used in conjunction with another method to identify the beginning of the fecund window

22 Sympto-thermal Methods Several methods and sets of rules Beginning of fecund window is identified using calendar and/or cervical mucus biomarker End of the fecund window is identified using peak cervical mucus biomarker and rise in BBT One large study with individual instruction with certified teachers reported one year pregnancy probability <1% with perfect use and 1.8% with typical use 24

23 Sympto-thermal Methods One common sympto-thermal method in use in the United States is that described in the book Taking Charge of Your Fertility by Toni Weschler, MPH This particular method has not been systematically researched for use effectiveness

24 Sympto-hormonal Methods

25 Marquette Model (MM) of NFP Includes 1. Measurement of urinary hormones using the Clearblue Easy Fertility Monitor 2. Observation of cervical mucus 3. Optional measurement of BBT One year probability of pregnancy: 1-3% with correct use and 11% with typical use 25,26

26 Clinical Utility of NFP

27 Factors Influencing NFP Effectiveness Effectiveness is dependent on accurate instruction Effectiveness studies have used trained teachers, not self-training via books or the internet Effectiveness to avoid pregnancy similar to behaviorally-related methods of contraception Condoms: must be used consistently and correctly Oral contraceptives must be taken consistently

28 Patient Characteristics and NFP Level of education does not influence effectiveness of NFP Symptom-based methods do not require that women have regular menstrual cycles to be effective Communication between and cooperation of both partners is required for effective use

29 There s an old joke What do you call people who use natural family planning?

30 There s an old joke What do you call people who use natural family planning? Parents

31 Like many misconceptions, there is a grain of truth in the joke Unlike any method of contraception, NFP methods can be used to avoid or achieve pregnancy Couples can change how they use the method at any time Allows for changing motivation Encourages communication within the partnership

32 NFP to Conceive NFP methods that teach women to identify ovulation can also be used to time intercourse for efficient conception Patient interest in NFP to conceive exceeds that to avoid pregnancy 27-29

33 NFP and Reproductive Health Systematic observation and recording of fertility signs helps women understand their fertility cycle NFP techniques can help diagnose reproductive problems such as polycystic ovarian syndrome, premenstrual syndrome, and infertility 30

34 Strengths of NFP No side effects Immediately adaptable to changing intention regarding avoiding or achieving pregnancy Minimal cost Empowering for woman Can provide valuable information for clinical diagnoses

35 Limitations of NFP No protection against sexually transmitted infections Abstinence from genital contact during the fecund window if intention is to avoid pregnancy

36 Implementation in Clinic If patient reports use of rhythm method or knowing when she is fertile Ask how she identifies her fertile time and counsel regarding unintended pregnancy if not based on a systematic method Refer to resources for learning an NFP method

37 Implementation in Clinic Patients should be offered the option of learning NFP as part of routine counseling regarding family planning and reproductive health Two simpler methods can be taught in a single clinic visit TwoDay Method Standard Days Method (CycleBeads ) As effective as barrier methods for pregnancy avoidance Do not teach a woman to identify ovulation

38 Referral to a Qualified Teacher Refer the patient to an NFP teacher If interested in learning to identify ovulation Or has a reproductive or gynecologic condition such as polycystic ovarian syndrome, endometriosis, infertility etc.

39 Resources: Calendar-based Methods Lactational Amenorrhea Method Standard Days Method (CycleBeads )

40 Resources: Biomarker-based Methods TwoDay Method Billings Ovulation Method Creighton Model FertilityCare TM System

41 Resources: Sympto-thermal Methods There are multiple sympto-thermal methods Two methods used in the USA are:

42 Resources: Sympto-hormonal Methods Marquette Model of NFP

43 Summary All modern NFP methods are least as effective as barrier methods for avoiding pregnancy In populations motivated to avoid pregnancy who receive detailed instruction, pregnancy rates can be as low as 1% NFP can also be used to achieve pregnancy

44 Summary NFP methods are low cost and free of medical side effects Knowledge gained using NFP Helps women understand their fertility Helps physicians diagnose reproductive anomalies

45 Summary Patients are interested in NFP To avoid pregnancy To conceive NFP should be offered as part of routine counseling for family planning and reproductive health with referral to trained teachers

46 References 1. Stanford JB, White GL, Hatasaka H. Timing intercourse to achieve pregnancy: current evidence. Obstet Gynecol 2002;100: Dunson DB, Baird DD, Wilcox AJ, Weinberg CR. Day-specific probabilities of clinical pregnancy based on two studies with imperfect measures of ovulation. Hum Reprod 1999;14: Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception, survival of the pregnancy, and sex of the baby. N Engl J Med 1995;333: Stanford JB, Smith KR, Dunson DB. Vulvar mucus observations and the probability of pregnancy. Obstet Gynecol 2003;101: Bilian X, Heng Z, Shang-Chun W, et al. Conception probabilities at different days of menstrual cycle in Chinese women. Fertil Steril Yuzpe AA, Liu Z, Fluker MR. Rescue intracytoplasmic sperm injection (ICSI)- salvaging in vitro fertilization (IVF) cycles after total or near-total fertilization failure. Fertil Steril 2000;73: Katz DF. Human cervical mucus: research update. Am J Obstet Gynecol 1991;165: Hilgers TW, Prebil AM. The ovulation method--vulvar observations as an index of fertility/infertility. Obstet Gynecol 1979;53: Kambic RT, Lamprecht V. Calendar rhythm efficacy: a review. Adv Contracept 1996;12: Germano E, Jennings V. New approaches to fertility awareness-based methods: incorporating the Standard Days and TwoDay Methods into practice. J Midwifery Womens Health 2006;51:471-7

47 11. Arevalo M, Jennings V, Sinai I. Efficacy of a new method of family planning: the Standard Days Method. Contraception 2002;65: Kalaca S, Cebeci D, Cali S, Sinai I, Karavus M, Jennings V. Expanding family planning options: offering the Standard Days Method to women in Istanbul. J Fam Plann Reprod Health Care 2005;31: Leon F, Lundgren R, Huapaya A, Jha P, Sinha R, Jennings V. Pressed for time: providing the Standard Days Method and oral contraceptives in India. J Fam Plann Reprod Health Care 2007;33: Leon FR, Blair C, Huapaya A, et al. Quality of delivery of the Standard Days Method as compared with contraceptive pills in Rwanda. J Fam Plann Reprod Health Care 2006;32: Arevalo M, Jennings V, Nikula M, Sinai I. Efficacy of the new TwoDay Method of family planning. Fertil Steril 2004;82: Klaus H. Natural family planning: a review. In. Bethesda, MD: Natural Family Planning Center of Washington, D.C.; 1995: Bhargava H, Bhatia JC, Ramachandran L, Rohatgi P, Sinha A. Field trial of billings ovulation method of natural family planning. Contraception 1996;53: Stanford JB, Smith KR. Characteristics of women associated with continuing instruction in the Creighton Model Fertility Care System. Contraception 2000;61: Hilgers TW, Stanford JB. Creighton Model NaProEducation Technology for avoiding pregnancy. Use effectiveness. J Reprod Med 1998;43:

48 20. Howard MP, Stanford JB. Pregnancy probabilities during use of the Creighton Model Fertility Care System. Arch Fam Med 1999;8: Hilgers TW. What is NaProTechnology? In: Hilgers TW, ed. The medical and surgical practice of NaProTechnology. Omaha: Pope Paul VI Institute Press; 2004: Stanford JB, Parnell TA, Boyle PC. Outcomes from treatment of infertility with natural procreative technology in an Irish general practice. J Am Board Fam Med 2008;21: Lintsen AM, Eijkemans MJ, Hunault CC, et al. Predicting ongoing pregnancy chances after IVF and ICSI: a national prospective study. Hum Reprod 2007;22: Frank-Herrmann P, Heil J, Gnoth C, et al. 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. Hum Reprod 2007;22: Fehring RJ, Schneider M, Raviele K, Barron ML. Efficacy of cervical mucus observations plus electronic hormonal fertility monitoring as a method of natural family planning. J Obstet Gynecol Neonatal Nurs 2007;36: Fehring RJ, Schneider M, Barron ML. Efficacy of the Marquette Method of natural family planning. MCN Am J Matern Child Nurs 2008;33: Stanford JB, Lemaire JC, Thurman PB. Women's interest in natural family planning. J Fam Pract 1998;46: Stanford JB, Hutchinson AG, Payne JG. Utah couples' potential use of natural family planning. Utah's Health: An Annual Review 2003;9: Stanford JB, Lemaire JC, Fox A. Interest in natural family planning among female family practice patients. Fam Pract Res J 1994;14: Danis P. A family physician's experience with NaPro technology. In: Hilgers TW, ed. The medical and surgical practice of NaProTechnology. Omaha: Pope Paul VI Institute Press; 2004:

49 Contact the Faculty Christina A. Porucznik, PhD MSPH Joseph B. Stanford, MD, MSPH