• Methods of ABC (Artificial Birth Control)

• Methods of Natural Birth Control

• Advantages of NFP and Charting

• Moral Significance of Birth Control Methods

• Comparative Analysis of Birth Control Methods (chart)

• Checking and Charting Fertility Sign 1: Thermal Shift Patterns (BBT)

• Checking and Charting Fertility Sign 2: Cervical Fluid

• Checking and Charting Fertility Sign 3: Cervical Position

• Achieving pregnancy of a pre-selected gender

• Rules of natural birth control for ovulatory periods

• Basic NFP Guide (Sample Cycle Chart)

• Anovulatory "Cycles"

• Rules of natural birth control for anovulatory periods

• Lactational Amenorrhea Method (LAM)
• BBT Method (Temperature-Only)
• Billings Ovulation Method (Cervical Fluid Only)
• Infertility and Treatment

• Menopause

• Miscellaneous

• Sources and Further Reading

• Vasectomy: Both of a man�s vas deferens are cut to prevent passage of sperm
• Tubal Ligation: woman�s fallopian tubes are tied or cauterized to prevent union of sperm and egg
• Abortion
• Post-coital (�Morning-after�) Contraception: high dosage pill or IUD used within 72 hours of unprotected intercourse, to prevent fertilization or implantation
• Barrier methods:
  • Male Condom: Rubber sheath between the man and woman prevents union of sperm and egg. About 12 pregnancies occur over 1 year out of 100 couples using this method; effectiveness increases with spermicides used in concert.
  • Female Condom: Completely covers clitoris, greatly minimizing pleasure of intercourse for woman
  • Diaphragm: latex domes of various types and sizes which are filled with gooey spermicide and positioned over the cervix prior to intercourse; it slowly oozes the spermicide for 6 to 8 hours after intercourse before it may be removed; it must be removed within 24 hours. Diaphragms must be prescribed by a physician. About 18 pregnancies occur over one year in 100 women using this method.
  • Cervical Cap: Like diaphragm, it covers the cervix and is always used with a contraceptive cream or jelly and must be left in place for at least 8 hours after intercourse.  It differs in that it is smaller and more rigid than the diaphragm, and can remain in the vagina for up to 48 hours.  It can be uncomfortable and cause cervical abnormalities
  • Vaginal Sponges: Very frequently cause vaginal infections. Soft synthetic sponge, saturated with spermicide, and inserted into the vagina, over the cervix, prior to intercourse and left in place, like the diaphragm, for at least 6 to 8 hours. This method is available without a prescription in most drug and grocery stores. About 18 to 28 pregnancies occur over one year out of 100 women using this method.

• Oral Contraceptive Pills:
  • Old (pre-1975) High Dosage Pill: (Estrogen)
  • Low Dosage Pill: (Estrogen)
  • Mini-combination Pill:
  • Oral Combination Pill (estrogen and progestine): Regularizes cycle and prevents ovulation, using hormones to make body think the woman is perpetually pregnant. Must be taken consistently at the same time each day. Variety of available pills allows �matching� to individual woman. About 2 to 3 pregnancies occur over 1 year out of 100 women using this method. Effectiveness decreased by antibiotics. Causes weight gain, bad mood, and decreases sexual desire in woman; increases risk of vaginal thrush (candidiasis) and cervical erosion. Women going off the pill may experience months or even years of infertility before ovulation returns.
  • "Mini pill" (progestin only): Often prescribed to women who are sensitive to estrogen or breastfeeding. Its effectiveness is lower than the combination pill: about 3-7 pregnancies over a year out of 100 women using this method.
• Progestin Implants (�Norplant�): 6 matchlike-tubes are surgically inserted under the skin in the upper arm and left there for 5 years; they continually release progestin, inhibiting ovulation, changing the uterus lining, and thickening cervical mucus (to prevent sperm from entering the uterus). They cost several hundred dollars. Less than 1 pregnancy occurs over 1 year out of 100 women using Norplant.
• Intrauterine Device (IUD): Plastic and copper device, placed inside the woman's uterus and left there for as long as several years. About 2 to 3 pregnancies occur per year out of 100 women using this method. Presently off the market in the US due to proven cause of severe pelvic inflammatory disease and hence permanent infertility. Maintains uterus in a constant state of inflammation, causing painful periods. Especially unsafe for women with a history of pelvic infection or ectopic pregnancy.
• Depo-Provera Injections: 
• Suppositories: placed in vagina prior to intercourse to kill sperm
• Spermicidal creams and foams: Increased risk of cervical erosion. About 21 pregnancies occur over 1 year out of 100 women using this method.
• Post-coital douche--Douching shortly after intercourse. Because sperm can make their way beyond the cervix within 90 seconds after ejaculation, this method is ineffective and unreliable.
• Withdrawal

• Calendar (Rhythm) Method: Unreliable method based on the false assumptions (consistent 30-day cycles for all women with ovulation always on day 14) and requiring longer periods of abstinence than modern methods.  The rules were: last day of Phase I = shortest of last 10 cycles -19; and first day of phase III = longest of last 10 cycles - 10.
• Sympto-Thermal Method: BBT, cervical fluid, and cervical position used to determine fertility. Most effective method of natural birth control and is able to allow the maximum period of intercourse since it relies on not one but two key fertility signs. Also, cervical fluid may be dried up by decongestants, cough syrup, and antihistamines (which tend to dry up not only the sinuses, but cervical fluid as well), and cause a mistaken belief that post-ovulation dry-up has occured; in such cases, the BBT sign provides a back-up.  However, certain temporary or permanent conditions may make it impossible to use the BBT sign and therefore necessary to use the Billing's Ovulation Method. Detailed rules for using the STM are below.
• FAM (Fertility Awareness Method): Sympto-Thermal Method used to determine fertility, supplemented with barrier contraception during fertile periods
• NFP (Natural Family Planning): Sympto-Thermal Method used to determine fertility, with abstinence during fertile period
• Periodic Abstinence: natural birth control involving abstinence during periods of fertility and determination of fertility using Sympto-Thermal Method, Billing�s Method, Creighton Method, BBT Method, or Calendar Method
• Billing's Ovulation Method & Creighton Model- both use cervical fluid at vaginal opening as the only fertility indicator.  This method requires more abstinence than NFP and is slightly less effective than NFP (due to shortness of 2nd patch in double peaks). This method is the best choice for those women whose bodies do not respond to progesterone and therefore do not observe a thermal shift around ovulation as well as for women who for various reasons (including stress) may be experiencing a long cycle with "false starts," patches of wet cervical fluid indicating a preparation for ovulation, followed by a dry period with no temperature rise. It may also be useful for women who have certain BBT conditions which add on unnecessary days of abstinence, e.g. women with a fall-back temperature pattern or women with 10 or fewer days of elevated temperatures over the coverline. Detailed rules for using the Billing's Method are below.
• BBT Method- uses waking temps only as only indicator. It is very effective and simple, but may require more abstinence (especially the Phase III only version). The BBT Method is the best option for rare women who observe constant cervical fluid or encounter difficulty in interpreting the cervical fluid sign. Detailed rules for using the BBT method are below. 
• Fertility Computers: Measure, store, and interpret BBT data, displaying green or red light to signal safety from pregnancy risk or need to beware of risk. Some computers analyze cervical fluid as well for several days of the cycle when fertility is unclear from BBT alone.
• Lactational Amenorrhea Method (LAM): (Amenorrhea = long absence of menstruation). Suckling at breast indirectly inhibits hormones responsible for ovulation, so breastfeeding women may go for up to a year with the same sticky or dry or combination cervical fluid and no BBT rise (called a BIP, or  Basic Infertility Pattern. For this method, it is necessary to breastfeed frequently; otherwise ovulation can return as early as the first cycle after delivery (in about 6% of women, ovulation returns with the first cycle after delivery). Detailed rules for using the LAM are below. 
• Los Angeles Study (1976) was undertaken to compare the effectiveness of Sympto-thermal  and Billing's methods; it found 100% perfect use effectiveness for Sympto-thermal and 94% perfect use effectiveness for Billing's. Billing's also has the disadvantage that cervical fluid must be checked diligently throughout Phase III just as in Phase I, whereas STM users have the assurance of ovulation by elevated BBT pattern and needn't check cervical fluid again during Phase III, i.e. until menstruation begins the next cycle.

Advantages of NFP and Charting

• Enables partners to enjoy intercourse with maximum pleasure and intimacy, and moreover:
  • Without risk of pregnancy if they determine that pregnancy is not desired at the time;
  • Without aesthetically unpleasant barriers like condoms;
  • Without cost (once they have learned the method);
  • Without the physical and emotional side-effects of hormone pills, Norplant surgery, IUDs, abortion, etc.
  • Without the moral dishonesty involved in use of ABCs;
  • Without compromising on related to abortion and the abortifacent mechanisms of hormone pills and the IUD
• Enables women:
  • To better understand themselves and their bodies, important at all times but especially for adolescent and premenopausal women, both of whom suffer from certain unnecessary confusion and anxiety which charting could eliminate.
  • To become aware of and diagnose fertility and gynecological problems in a timely manner, including the following:
    • UTI-Urinary tract infection- causes discharges which may be confused with healthy cervical fluid in absence of charting Multiple ovulation occurs in up to 10% of cycles, never occurs more than 24 hours after initial ovulation, and is responsible for fraternal twins, a tendency influenced by heredity
    • If midcycle spotting (which may be a sign of cervical cancer), occurs consistently, the cancer suspicion can be lifted (this is an outflow of endometrium during lull between fall in estrogen level and rise in progesterone level) and the spotting can be used as a secondary fertility sign (confirm ovulatory period).
    • Ectopic pregnancy (implantation outside uterus, usually in fallopian tubes) linked to PID (caused by STDs) and is always fatal to baby and presents grave risk to health and life of mother.
    • Corpus Luteum Cysts: 18 days of high temperatures with no period is in all probability due to pregnancy. If home pregnancy tests or ultrasound or blood tests indicate that there is no pregnancy, these cysts may be present.
    • Hypothyroidism: indicated by higher than average temperatures throughout cycle, light menses, long cycles, and/or infertility
    • Hyperthyroidism: indicated by higher than average temperatures throughout cycle, long cycles, anovulatory "cycles," long periods of wet cervical fluid, and/or infertility. 
  • To detect approach of PMS (Premenstrual Syndrome) several days in advance and take measures to minimize certain repeating pains
  • Enables women to distinguish between healthy cervical fluid and possible infections (symptoms of a true vaginal infection: itching, swelling, redness, unpleasant odor, unusual discharge), and gynecological problems.
  • Enables women to distinguish breakthrough and withdrawal bleeding during anovulatory "cycles" from menstruation beginning a new cycle, since the latter will follow a BBT rise and the former will not.
  • Enables women not seeking pregnancy to discern if ovulation was delayed in a given cycle, thus eliminating unnecessary worry about whether or not they have conceived. If ovulation was delayed, a long cycle is not cause for worry (as it would be without charting), for it does not indicate pregnancy until 18 days of heightened temperature are observed. Enables the woman to know one way or the other every cycle within 18 days of BBT rise without testing.
• Strengthens Marriage: Studies show that couples that use NFP have a divorce rate around 2%, compared to the divorce rate in the general population of about 50%. Similarly, the divorce rate among American Catholics remained low during the 1920s, at the time when Margaret Sanger organized the contraception movement and the divorce rate in the general American population first began to increase rapidly and did not itself begin to increase until after 1968, when Catholics began to use ABC widely in rebellion to Church teaching.  The increase in ABC since the 1920s parallels the increase in the U.S. divorce rate (1910: 1 divorce to 11 new marriages; 1925: 1 to 7, 1965: 1 to 4, 1970: 1 to 3, 1977: 1 to 2). While other causes are no doubt also responsible, this clearly discredits the view that ABC strengthens marriage and proves the counter claim. The reasons why NFP may be considered so effective in strengthening marriage include:
  • Requires both partners to share responsibility and burden of birth control;
  • Offers male partner opportunity to learn more about his partner and her body and needs, including when he can expect hormone-related emotional changes; 
  • As a result of the regular periodic abstinence involved in NFP, couples develop non-genital communication and expressions of affection, which can be equally meaningful and which tend to lose their meaning if they are always experienced only as a prelude to intercourse.
  • Couples using NFP are monthly reminded not to take their spouse for granted;
  • Couples using NFP do not experience sexual satiation or boredom on the one hand nor sexual addition and insatiable lust on the other;
  • Couples using NFP monthly relive the stimulating cycle of courtship, honeymoon, and marriage; 
  • The periodic abstinence eliminates woman�s feeling used or loved only for sex, because she too experiences a period of desire each month and sees that her husband controls his desire. THis abstinence increases her self-esteem and her respect for him. 
• For couples trying to achieve pregnancy:
  • Enables infertile couples seeking pregnancy to time their intercourse effectively. If a woman has long cycles, or has stress-related (including infertility-related stress) delayed ovulation, a couple that has intercourse from days 12-18 (based on the day 14 conventional wisdom), may nevertheless easily miss the fertility window. Also, a couple late in the cycle (e.g. day 23) not checking BBT and cervical fluid, may mistakenly conclude that the pregnancy window has passed, while in fact it is at its most fertile stage.
  • Enables infertile couples seeking pregnancy to find pleasure in sex as a carefree expression of love without the pressure of an effective erection and ejaculation every time throughout infertile phase, limiting the frustration of seeking pregnancy for a large part of the cycle in which the woman is nevertheless infertile, or to take a rest from the wearisome routine of constantly trying to get pregnant during this time.
  • Enables them to discern if ovulation was delayed in a given cycle, thus eliminating unnecessary worry about whether or not they have achieved pregnancy (if ovulation was delayed, they know not to get their hopes up early since a long cycle is to be expected and does not indicate pregnancy until 18 days of heightened temperature are observed). Enables the woman to know one way or the other every cycle within 18 days of BBT rise (without any tests).
  • Enables them to choose the gender of their child with 75-90% accuracy.
  • Enables them to know if pregnancy has occurred or not within 18 days (of consecutive high temperatures), before reliable results are possible with oral pregnancy tests (which can give false negative results since HCG levels are not yet elevated enough);
  • Enables them to know the precise date of conception and hence the EDC (estimated date of childbirth) with great accuracy. The most accurate prediction of the EDC is by the Prem Rule: EDC = first day of temperature rise - 7 days + 9 months.  Actual date has 99% likelihood of being within 14 days, 80% of +/- 10 days, 65% of +/- 7 days (Kippley 300). However, most doctors, because relatively few women chart, use the older by less accurate "pregnancy wheel" based on the Naegele Rule (EDC = first day of previous cycle + 7 days + 9 months), which assumes ovulation on Day 14. This is significant because doctors using an EDC obtained by the Naegele Rule may want to induce labor as much as 2 months early due to a late-cycle pregnancy which the Naegele Rule does not take into account. An accurate EDC is also helpful for eliminating erroneous timing of tests (e.g. amniosentesis) 
  • Enables them to identify if infertility is due to miscarriages they would be ignorant of if not charting (without charting, she ould think she merely had a long cycle with a late period). Thereafter steps can be taken to correct their infertility by treating the tendency to miscarry.
  • Enables them to identify if infertility is due to consistently short (less than 10 days) luteal phases (between ovulation and beginning of menstruation) and consequently inadequate time for implantation, knowledge which they could not know if they were not charting.  Thereafter steps can be taken to correct their infertility by lengthening the luteal phases.
  • Enables them to identify if infertility is due to a shortage of progesterone, indicated in charts by postovulatory, heightened temperatures dropping repeatedly back below coverline.  Thereafter steps can be taken to correct their infertility by increasing progesterone.
  • Enables them to identify if infertility is due to poor ovary activity and low estrogen levels, indicated in charts by long BIPs (Basic Infertile Patterns) (unchanging pattern of cervical fluid quality or dryness experienced instead of normal pattern of increasingly wet and fertile fluid). Thereafter steps can be taken to correct their infertility by treating these problems.
  • Change in BBT indicates that ovulation is occurring and no treatment is needed to stimulate ovulation (including the drug Clomis, almost always prescribed immediately to couples reporting infertility, regardless of whether the woman is actually ovulating)
  • Enables them to time endometrial biopsy (if necessary) properly, which is otherwise easily mistimed.

Moral Significance of Birth Control Methods

• ABC involves a serious moral offense, a dishonest expression of total self-giving, i.e. saying with body language that one gives oneself unreservedly, totally to the partner, and receives the same in return, while both in fact hold back their fertility.
• The moral offense can also be seen in that marital contraception and contraceptive premarital sex, contraceptive adultery, sodomy, anal and oral sex, all have the same logical basis: the goal of making sex sterile, regardless of means. Permitting one and not permitting another are inconsistent once one grants that the nature of sex is an expression of love, without reference to childbirth.
• The misuse of the sexual act implicit in ABC is more easy for some to see in view of its social consequences: increased adultery, fornication, pornography, homosexuality, births out-of-wedlock, STD's, abortions, teenage pregnancy, and government regulation of childbearing, which all skyrocketed in the wake of the availability and widespread use of the Pill starting in 1960.  These effects were specifically predicted by numerous individuals, include Ghandi and Pope Paul VI:
  • Ghandi (1925): �I urge the advocates of artificial methods to consider the consequences. Any large use of the methods is likely to result in the dissolution of the marriage bond and in free love.�
  • Anglican Bishop Charles Gore (1930), dissenting to the Anglican decision at Lambeth to allow ABC, said it would open Pandora's Box of social ills.
  • Pope Paul VI (Humanitae Vitae 17): "Upright men can even better convince themselves of the solid grounds on which the teaching of the Church in this field is based, if they care to reflect upon the consequences of methods of artificial birth control. Let them consider, first of all, how wide and easy a road would thus be opened up towards conjugal infidelity and the general lowering of morality. Not much experience is needed in order to know human weakness, and to understand that men -- especially the young, who are so vulnerable on this point -- have need of encouragement to be faithful to the moral law, so that they must not be offered some easy means of eluding its observance. It is also to be feared that the man, growing used to the employment of anti-conceptive practices, may finally lose respect for the woman and, no longer caring for her physical and psychological equilibrium, may come to the point of considering her as a mere instrument of selfish enjoyment, and no longer his respected and beloved companion.  Let it be considered also that a dangerous weapon would thus be placed in the hands of those public authorities who take no heed of moral exigencies. Who could blame a government for applying to the solution of the problems of the community those means acknowledged to be licit for married couples in the solution of a family problem? Who will stop rulers from favoring, from even imposing upon their peoples, if they were to consider it necessary, the method of contraception which they judge to be more efficacious? In such a way men, wishing to avoid individual, family, or social difficulties encountered in the observance of the divine law, would reach the point of placing at the mercy of the intervention of public authorities the most personal and most reserved sector of conjugal intimacy."

• The counter-measures proposed to combat these social evils (e.g. pro-contraceptive sexual education, free distribution of contraceptive devices) have failed to stem the tide to any noticeable degree and apparently have actually increased it: more sexual activity, more contraceptive use, more contraceptive failure, more pregnancy, more abortions, more births out-of-wedlock.
• Christian teaching, including Protestant, was always against ABC until 1930. 
  • Charles Provan (contemporary Evangelical Protestant theologian): "We have found not one orthodox theologian to defend Birth Control before the 1900s. NOT ONE! On the other hand, we have found that many highly regarded Protestant theologians were enthusiastically opposed to it, all the way back to the very beginning of the Reformation" (Kippley 267).
  • Luther: "Ths is a most disgraceful sin. It is far more atrocious than incest or adultery. We can it unchastity, yes, a Sodomic sin" (Kippley 267).
  • Calvin: described Onanism as a kind of homicide (Kippley 267).
  • J. Wesley: such sins are very displeasing to God, he will destroy the souls of those who practice them (Kippley 267).
  • 1870's: American Congress (expressing Protestant ethos and reacting against Neo-Malthusian promotion of condoms in wake of discovery of rubber in 1839) enacted the Comstock Laws proposed by the Protestant Anthony Comstock, against the sale and distribution of contraceptives, especially condoms.
  • 1908: Anglican Church expressly condemned ABC
  • 1920: Anglican Church again expressly condemned ABC: "We utter an emphatic warning against the use of unnatural means for the avoidance of conception" (Kippley 272). 
  • 1930: Anglican Church, in an abrupt change of course, at the Lambeth Conference, allowed careful and restrained use of ABC, becoming the first organized Christian body to permit ABC in history.
  • 1931: American Federal Council of Churches followed the Anglican bishops' decision to authorize ABC, suggesting that contraceptive use among married couples would be "careful and restrained."
  • 1931: Walter Maier (Lutheran theologian) responding to these decisions: "Birth control . . . involving the use of contraceptives, is one of the most repugnant of modern aberrations, representing a 20th century renewal of pagan bankruptcy" (Kippley 273).
  • 1931: Warren Chandler (Methodist bishop) responded: "The whole disgusting movement rests on the assumption of man's sameness with the brutes" (Kippley 273). 
  • mid-1930s: U.S. Supreme Court began limiting application of Comstock Laws (Kippley 491).
  • 1961: American National Council of Churches accepted unreservedly all ABC that operated by preventing conception (Kippley 288).
  • 1965: US Supreme Court struck down the last of the Comstock Laws still in force (Kippley 491).

Comparative Analysis of Birth Control Methods (chart)

* Listed in descending order of effectiveness for perfect use
* Effectiveness rate = 100%-failure rate, which is not actually the rate of non-pregnancy, but rather the rate of non-pregnancy where pregnancy would have occurred without the method in use
* Sources

• A few women do not have biphasic BBT pattern; they must rely on cervical fluid indicators alone (Billing's method), which requires more abstinence to be as effective
• Thermal shift patterns differ from one woman to another, but tend to remain similar from one cycle to another for a given woman
• BBT will be high if fever, alcohol the night before, less than 3 consequent hours of sleep; for each half-hour before usual time, temp will be approximately 1oF lower (and likewise ~.1oF higher for each half-hour after usual time). If woman awakes and needs to urinate at 6am and plans to get up at 8am, she should take her temperature at 6am, since at 8am she will have had only 2 hours of consecutive sleep.
• Daylight savings switches, travel to different time zones, antihistamines call for special attention because of their effects on BBT.
• On weekends during early phase I and during phase III, when BBT observations are not so important, couples may feel free to sleep in and check the BBT when they wake.  During Phase II, however, if they wish to sleep in, they should wake, insert the thermometer for the required 1-5 minutes, then go back to sleep and check and record the temperature later when they get up.
• Standard pattern: consistently low preovulatory temperatures, then distinct rise by at least .2oF, then consistently high postovulatory temperatures to the end of the cycle
• Drawing the coverline on charts: add .1oF to the highest of the six temperatures before the rise, excluding any unusual temperatures which can be accounted to fever, alcohol, restless night�s sleep (�rule of thumb,� so called since you cover with your thumb these temperatures, not counting them).  A simpler alternative is to draw the coverline .1oF above the highest temperature during the first 10 days, though this does not work for women whose BBT pattern remains high during the first few days of menstruation.  
• The equivalent of the coverline used in the CCL courses is called the Low temperature level (LTL), or pre-shift base (PSB), or pre-ovulation base (POB); this temperature level is equal to the highest of the six temperatures before the rise (the HTL, i.e. High temperature level, is the LTL + .4oF). This procedure allows for "shaving" off 1 high temperature from the "pre-shift 6," and setting the LTL as the next-highest of the six (moreover, two high temperatures may be "shaved," with the LTL either the third highest  temp or the arithmetical average of the 6, if this is higher). The coverline/LTL will be relatively consistent for a given women from one cycle to the next. If the pre-shift 6 are hard to identify, take Peak Day as the sixth and count backwards. Based on the LTL and HTL, Kippley distinguishes 3 kinds of temperature rises on which his Phase III rules are based: full shift (3 temperatures at least .4oF above the LTL), strong shift (three temperatures are at least .2oF above the LTL and the last reaches at least the HTL), and overall shift (all are at least .1oF above the LTL and at least one reaches the HTL). While this system is doubtless more complex than the coverline system, it allows for the use of Rules R and K, which can provide assurance of a safe day 1-2 days earlier (i.e. require 1-2 days less abstinence) than by the simpler Rule B which requires the clarification of the coverline only.
• 3 most-common non-standard thermal shift patterns:
  • Stair-step rise: Temperature rises slightly for three days (around days 17-20), then rises further
  • Slow-rise: Temperature rises about .1oF per day, with (approx.) day 17 the first day with a higher rise than the 6 days before it (hence first day above coverline).
  • Fall-back rise: Temperature rises above coverline, then drops back below about 2 days later, then returns above coverline again till end of cycle

• Beginning first day after menses end, check at least 3x/day, including morning and night (before urinating is a convenient time) when you are not sexual aroused (arousal fluid can mask cervical fluid). Record wettest reading of the day.
• Check for cervical fluid quality (Menses *, Spottting (*), Nothing �, Sticky S, Creamy C, Eggwhite E, Sperm Residue R or ?) and vaginal sensation (dry cold, wet, lube)
  • Menses "*" = Actually dry days with respect to cervical fluid, but since the bleeding makes it impossible to verify, the symbol * is used to indicate that it is not analyzed.
  • Dry/Nothing "-" = absence of cervical fluid (to be distinguished from vaginal dampness, which is always present). To distinguish cervical fluid (always insoluble) from vaginal secretions and moisture (always soluble), test fluid in a glass of water for solubility. Or you can test the fluid by holding it in the air (vaginal moisture will evaporate within a few seconds; cervical fluid will not).
  • Sticky �S� (a.k.a. tacky) = opaque white or yellow, usually clear. May be thick. May be crumbly or like rubber cement. Stretches less than half a inch.
  • Creamy �C� = cloudy, lotiony, wet, watery, thin, smooth.
  • Eggwhite �E� = Usually clear, slippery, wet, stretchy (1-10 inches).  This fluid is the most fertile; the last day it is present is considered the "peak day" of a given cycle.  Women in early 20s may have 4-5 days eggwhite (clear, slippery, stretchy) fluid, older women, only 1-2 days.
  • Wet days are circled (i.e. C and E)
• The cervical fluid pattern is generally ***** ----- SSS CCC EE ----------------.  A "fluid patch," i.e. a dry day after the first appearance of fluid, can occur as well.  
• Sperm/Spermicide can mask cervical fluid and if not eliminated using Kegel exercises, should therefore be charted "R" or �?� and designate fertile days (pregnancy risk)
• Kegel exercises: flexing of vaginal (pubococcugeous or �PC�) muscles at various times in the day (A. tighten-1,2,3-release, and B. tighten-relax as fast as possible) to eliminate semen from vagina (during urination following intercourse), push cervical fluid down to the vaginal opening, maintain urinary continence, and increase sexual pleasure. Test effectiveness by tightening vagina around 1-2 fingers.
• Kegel exercises should be used to eliminate semen after intercourse so it is not confused with cervical fluid; Kegels should also be done before checking cervical fluid to push it down to the vaginal opening.
• Use fingers or tissue, from front to back, to avoid spreading bacteria. Feel it, check its strectchiness. Check underwear (fertile fluid forms circle, infertile rectangles). Eggwhite fluid drains quickly (especially after a bowel movement) and often forms a ball when it hits water in toilet.
• If fluid is not testable at vaginal opening, test it internally using index and middle fingers, but be consistent in checking either always internally or always at vaginal opening, or keep track of both in separate columns of your chart. Insert index and middle fingers to sides to cervical os, then bring them together at cervical tip, then remove fingers with fluid held tightly between them. If you observe inside and outside, check inside only once a day, at night, so as not to interfere with outside observations during the day.
• Peak day = usually either the day of ovulation or the day before ovulation (in rare cases may be as early/late as 3 days before/after peak day) and it occurs 1-2 days before the temperature shift.  In practice it is determined as follows: PK = the latest day when any of the following 3 symptoms is observed:
  • Last day of eggwhite cervical fluid (not necessarily the day of its greatest quantity) if present in the cycle (even if a day of creamy follows the last eggwhite day).  
    • If no eggwhite is observed in the given cycle, the last day of creamy cervical fluid is peak day.
    • Look for a BBT rise by the second morning after the last eggwhite day. If the BBT rise lingers and is not observed at this time, a creamy day following the last eggwhite day should be considered peak day, rather than the last eggwhite, which is usually considered peak day even when a creamy day follows the last eggwhite.
    • If more than one creamy day is observed after the last eggwhite day, then the last creamy day is peak day
  • Last day of mid-cycle spotting.
  • Last day of lubricative vaginal sensation (sensation may continue even a day after fluid ends).
• �Split Peaks� (a.k.a. double patch or double peak): The body prepares for ovulation, then experiences stress which delays it; a last eggwhite day is observed, but before 4 days can be counted (see natural birth control rules fo the postovulatory period below), eggwhite fluid reappears and then ends a second time. The final peak is the true peak. A false peak can be confirmed by the absence of a BBT rise during the 4-day-count.
• Write PK in peak day row on chart, then 1,2,3,4 in the squares following for the following days.

• Check once a day using middle finger (nail trimmed, hands washed with soap beforehand): cervix will progress from feeling firm (like nose tip) to soft (like lips). Squatting or standing with one foot on a stool are convenient positions, since they push the cervix closer to the vaginal opening. If necessary, pushing on the abdomen will also push the cervix still lower. 
• Check for SHOW: Softness (Firm, Medium, Soft), Height (low, midway, high), Opening (closed, partly open, open), Wetness (nothing, creamy, sticky, eggwhite). Note: cervix will always be partly open and oval-shaped for a woman who has already vaginally delivered a child, and the difference in opening will be subtler for her. (Wetness is technically a different symptom, but included here since it will be observed in any case.) You will notice in this order: Height, Softness, Opening, and Wetness.
• This sign is a good confirmatory sign, but not reliable alone.
• Experienced users needn�t checked this sign for most of the cycle. Begin checking when wet cervical fluid is first noticed at the vaginal opening (beginners should start the first day after menses end) and stop checking after BBT rise plus 2 days indicates ovulation.
• Nabothian cysts on the cervix are benign and treatable, and sometimes come and go as part of the cycle
• In height of fertility, a woman may not even be able to reach her cervix with her finger.
• The cervix of a woman who has already given birth vaginally will never close completely; likewise, the cervix of a woman who has never given birth vaginally will open very, very slightly.
• Cervix position is also related to pain in intercourse: when cervix is low, especially during post-ovulatory period, the penis may tap the cervix, causing pain; the same may occur in the straddling position, which pushes the cervix to its lowest point as well.
• The most conservative pregnancy avoiders may achieve 99% effectiveness by limiting intercourse to when the cervix is in the unfertile position (firm, low, closed) and there is no cervical fluid at the cervix tip. This single rule without cross-checking is much simpler than the Sympto-thermal rules below and more effective, and increases the required abstinence by only 1-2 days per cycle. The beginning of Phase III is the evening of Close+4.
• Usually cervix position and cervical fluid begin on the same day; sometimes the cervical position will change first, providing early warning of the onset of the fertile period and resulting in dry-open days when pregnancy is possible; cervical position may change after the appearance of cervical fluid.

• Secondary signs of approaching ovulation (not present in all women or all cycles): mid-cycle spotting, pain near ovaries, fuller vaginal lips, abdominal bloating, water retention, increased energy, accentuated vision, smell taste; increased sensitivity in skin and breasts.
• Most common secondary signs include increased sexual feelings during fertile period (due to the presence of the fertile eggwhite cervical fluid draining through the vagina, producing a sensation similar to sexual lubrication) and breast tenderness in early postovulatory stage (due to progesterone, and therefore ends at menopause.
• Mittelschmerz (pain near ovaries) is a good 2o sign for 20% of women: pain in middle for a few minutes to a few hours, occurs around ovulation.

• 21/20 Day Rule:  The end of the preovulatory infertile period (the last evening safe from risk of pregnancy) is the minimal cycle length (of the last 6-12 cycles) - 21 OR minimal cycle length (of the last 12-24 cycles) - 20, provided it is a dry day. Keeping track of cycle length for more than 24 cycles is unnecessary. Slightly more conservative than Last Dry Day Rule.

• For women with luteal phases longer than 16 days, Doering Rule is more appropriate.

• First 4/5/6 days rule: The first five days of new cycle (regardless of length of menses) are safe from risk of pregnancy if there was obvious temperature rise 12-16 days earlier and the shortest cycle in the last year was 23-25 days (if the shortest cycle was 22 days, this becomes the First 4 days rule; if the shortest cycle was 26 days or longer, this becomes the First 6 days rule).

• Principle: The interval of 12-16 days after a thermal rise is strong evidence that the bleeding observed is not mid-cycle or abnormal bleeding, but true menses. Since it is very unlikely for both ovulation to occur on or before Day 10 (first 5-day rule + 5 day maximum sperm lifespan) and for sperm to survive 5 days in menses or dry environment, this rule is reliable.

• If any of a woman�s previous 12 cycles were 25 days or less, this rule becomes the �First 3 days rule.�
• If she has premenopausal symptoms, this rule is unreliable.
• If any of a woman�s previous 12 cycles were 25 days or less, this rule becomes the �First 3 days rule.�
• Women who claim pregnancy from sex during menses either had intercourse during a long period (day 6 or later) or during mid-cycle spotting, mistakenly assumed to be menses.

• Doering Rule: The end of the preovulatory infertile period (the last evening safe from risk of pregnancy) is the earliest day of sustained temperature rise (of the last 6-12 cycles) - 7, provided it is a dry day.  Slightly more conservative than Last Dry Day Rule.

• Women with long cycles including presence of less-fertile (i.e. sticky) cervical fluid from the end of menstruation up to the appearance of fertile cervical fluid (creamy, eggwhite) as well as 5+ days of fertile cervical fluid, this rule may be applied even in the presence of less-fertile (i.e. sticky) cervical fluid.
• An especially useful rule for couples with short luteal periods (less than 10 days of temperatures over the coverline).

• Dry day rule (a.k.a. Last Dry Day Rule): unprotected sex after 6pm every dry day following menses are safe from risk of pregnancy. The end of the preovulatory infertile period (the last evening safe from risk of pregnancy) is the last dry day.

• Principle: While sperm can survive a maximum of 5 days in fertile cervical fluid, in a dry environment or in sticky, infertile cervical fluid, they cannot and the risk is almost negligible (arousal fluid cannot sustain sperm until fertile cervical fluid appears).

• Dry day = no cervical fluid or menses + dry vaginal sensation throughout day.
• Effectiveness: 93-97%.  Most unplanned pregnancies come from late Phase I intercourse. To eliminate the added risk with this rule, for dry days after Day 5, check for cervical fluid externally several times during the day and internally in the evening before intercourse.
• Draw vertical line between last dry day and first sticky day to demarcate the preovulatory infertile period and the fertile period.
• Since sperm and spermicide can mask cervical fluid, they should be eliminated using Kegel exercises. Otherwise, they should be charted �?� and designate fertile days with pregnancy risk and NFP abstinence. If, by end of the day after intercourse, dry symptoms remain, that evening may be considered infertile.
• Ovulation predictor kits give only 1-day advance warning of ovulation, and since sperm can survive up to 5 days in fertile cervical fluid, they are not useful for birth control
• Rare women who experience no dry days before ovulation (instead sticky follow menses immediately) may consider sticky days �dry� for this rule.
• For "spacers," i.e. couples wanting to space pregnancies (as opposed to "avoiders," whose motivation for preventing pregnancy is higher), a riskier guideline allows intercourse on sticky days, provided there is not wet cervical fluid at the cervical tip.
• 6 cycles of experience checking fertility signs and charting recommended before using this riskier rule.

• Rule B: Day 19 (12 days of abstinence) Effectiveness 99+%
• Rule R: Day 17 (10 days of abstinence) Effectiveness 99%
• Rule K: Day 19 (12 days of abstinence) Effectiveness 99%

• Rule B (Temperature Rise +2 and Peak Day +4) (most conservative): the first evening safe from risk of pregnancy after 6pm is when both of the following conditions are met (if they both are met on the same day, this is called perfect coincidence):
  1. Temp Rise +2, i.e. the third consecutive day (i.e. Rise-2-3) with temperature over the coverline. By Kippley's system, there must be an "overall shift," in which all three temperatures are at least .1oF above the LTL and at least one (though not necessarily the last/third) reaches the High Temperature Level (HTL), i.e. .4oF above the LTL.
     
     Principle: BBT rise indicates ovulation has occurred and delay of 2 more days adds window in case of repeat ovulation of 2 eggs, each with a maximum 24-hour lifespan.
     
  2.  Peak Day +4 : the fourth day after the peak day (i.e. PK-1-2-3-4) without reappearance of wet cervical fluid is safe from risk of pregnancy after 6pm (and from thereon until end of cycle, i.e. until bleeding 12-16 days after temperature rise signals the beginning of the next cycle).
     
     Principle: Peak day indicates imminent ovulation and the delay of 4 days without a return of eggwhite fluid insures that the observed peak was not a false peak, that ovulation has indeed occurred, and that the vaginal environment has become dry and inhospitable to sperm.

• Draw vertical line between days 2 and 3 after temperature rise and another between days 4 and 5 after Peak Day to demarcate the fertile and postovulatory infertile periods (if they do not coincide, be conservative and consider the line further to the right to be the true threshold of the postovulatory infertile period).
• This rule may be too (i.e. needlessly) conservative for all but those who absolutely cannot afford a pregnancy.
• A more conservative version of this rule, which Kippley calls Rule C, allows intercourse only if there is a "full shift," with all 3 temperatures at least .4oF above the LTL). 
• If you have 10 or fewer days of elevated temperatures over the coverline, check if your temperature rise coincides with your peak day or occurs the day after. If so, you have a short luteal period, which makes implantation difficult and pregnancy unlikely. If not, you have a delayed response to progesterone, i.e. your body's BBT will not rise to reflect ovulation until several days later. If so, you should wait till the sustained temperature shift and count Rise-2-3 before resuming intercourse. A slightly more risky alternative to the added abstinence is to rely on the Billing's Method and determine end of fertile window by using the Peak Day + 4 Rule along with confirmation of no cervical fluid ("dry") and infertile cervical position.
• If sick, wait till third day without fever with sustained temperature over coverline.
• If you have a slow-rise pattern, wait till Temp Rise +4 day rather than +3 for extra safety.
• If you have a fall-back pattern, you should start the count to 3 again when the temperature returns above the coverline after then day 2 fall-back, necessitating an extra 2 days of abstinence (or, with slight risk, you can rely on the Billing's Method, i.e. determining end of fertile window by using the Peak Day + 4 Rule along with confirmation of infertile cervical position.
• Sticky fluid (instead of dry) is not a problem so long as wet cervical fluid has not reappeared during the four days after peak day (if it had, this would suggest that ovulation is still recent enough or soon forthcoming enough to make pregnancy possible). A reappearance of wet cervical fluid before a temperature rise is called a split peak or double patch or double peak and requires a restart of the PK-1-2-3-4 count. 
• Another variant is the split dry-up: a peak day followed by 2-3 days of drying up, then one day only of sticky cervical fluid, then dry days again with an obvious temperature rise. If this is observed, label the single sticky day as ? and continue count, e.g. PK-1-2-?-3-4.

• Rule R (R=Roetzer) (Temperature Rise+2 with "Strong Shift" and Peak Day+3): the first evening safe from risk of pregnancy after 6pm is when both of the following conditions are met:
  1. Temp Rise +2 with "Strong Shift", i.e. the third consecutive day (i.e. Rise-2-3) with temperatures at least .2oF over the LTL and the third at least .4oF over the LTL, and all after the peak day. 
  2. Peak Day + 3: the second/third day after the peak day (i.e. PK-1-2-3) without reappearance of wet cervical fluid.
  3. Cervix position is infertile

• Principle: If the temperature shift shows a medium-strong rise, a medium amount of time needs to be allowed for cervical fluid to dry up.

• If used with shaving, you should shave only one temperature, and that by no more than .1oF.

• Rule K (K= Kippley) (Temperature Rise + 2 with "Full Shift" and Peak Day +2): the first evening safe from risk of pregnancy after 6pm is when both of the following conditions are met:
  1. Temp Rise +2 with "Full Shift", i.e. the third consecutive day (i.e. Rise-2-3) with all three temperatures at least .4oF over the LTL. 
  2. Peak Day + 2: the second day after the peak day (i.e. PK-1-2) without reappearance of wet cervical fluid.

• Principle: If the temperature shift shows a very strong, decisive rise, less time needs to be allowed for cervical fluid to dry up.

• This rule often allows an extra safe day in those cycles where a sharp, strong temperature rise is observed.
• Developed by Drs. Doering and Vincent, who used the BBT condition alone and observed 99% effectiveness.
• If used with shaving, you should wait for Temp Rise +3 with the final three at least .4oF over the LTL and PK+2; or Temp Rise +2 with Full Shift and PK+3.

Basic NFP Guide for Ovulatory Period (Sample Cycle Chart)

Based on 32-day cycle with 20 days allowable intercourse (31% abstinence)

NBO = Needn't be observed
ENP = End of Next Period

• Anovulatory "cycles" are not really menstrual cycles at all but periods of various length before one menstrual period and an ovulation. They are sometimes called "cycles" nevertheless because they are charted as if they were: anovulatory bleeding at around day 30 is considered time to start a chart for a new cycle (however it is best to renumber the new chart, e.g. starting as 31, to keep track of the total cycle length).  
• Anovulatory "cycles" occur at different periods in a woman�s life, including adolescence, premenopause (~ age 50), breastfeeding, sickness, travel, weight gain or loss, underweight or overweight periods (18% body fat necessary to maintain normal ovulatory cycles), coming off the pill, norplant, or depo-provera (women may expect from zero to several months for cycles to return to former pattern after discontinuing ABC).
• �Patches of cervical fluid� pattern: Sometimes months or years necessary to build up estrogen level necessary for ovulation; this is seen as a pattern of alternating periods of dryness and cervical wetness.
• During anovulatory " cycles," non-menstrual bleeding may be mistaken for menstruation. Because of the absence of a temperature rise, charting women will be able to distinguish these forms of bleeding from menstruation: 1) breakthrough bleeding (with excess estrogen and inadequate progesterone, endometrium cannot maintain itself in uterus and leaks into vagina), and/or 2) estrogen withdrawal bleeding (estrogen build up to a point short of the threshold level, then drops)
• During an anovulatory "cycle," for purpose of birth control, it should be assumed that the woman is in a preovulatory phase and could ovulate at any time.

• These rules should be used when a BIP (Basic Infertility Pattern, a.k.a. "background fluid") is observed.  A BIP is a period of unchanging quality of cervical fluid and no BBT rise signaling that ovulation has occurred.  A BIP can be repeated dryness, or repeated stickyness, or repeated wetness. A BIP can be established after two weeks of observed repetition. A BIP may change for a given woman within a short time (e.g. 2 weeks of dry establishes a BIP of dry; if sticky appears and continues for 2 weeks, a new BIP of sticky has been established). 

• Patch Rule: as long as 2-week BIP remains constant, unprotected sex is safe from risk of pregnancy. When it changes (a "patch" of different quality cervical fluid, e.g. sticky patched on dry, or S,C,&E patched on dry, you are considered fertile each day until the fourth evening after peak day (effectively the same as the Peak Day + 4 Rule). If patch is sticky without creamy or eggwhite, you are safe on PK+2 day, with a very minimal increased risk. Treat bleeding as a fertile day.

• Unchanging Day Rule: If 2-week BIP is dry or cervical fluid remains constantly sticky, unprotected sex is safe from risk of pregnancy so long as that repeated stickiness or repeated dryness continues to repeat itself, until wet cervical fluid appears. Treat bleeding as a fertile day.
  • If 2-week BIP includes both sticky and dry, conservative users should have intercourse only on dry evenings, while a slight risk may be incurred by having intercourse on sticky evenings as well (best to check cervical fluid at cervical tip beforehand)
  • If 2-week BIP is repeated wet, abstinence is necessary until a BBT rise is observed.

• (Amenorrhea = long absence of menstruation). Suckling at breast indirectly inhibits hormones responsible for ovulation, so breastfeeding women may go for up to a year with the same sticky or dry or combination cervical fluid and no BBT rise (called a BIP, or  Basic Infertility Pattern. For this method, it is necessary to breastfeed frequently; otherwise ovulation can return as early as the first cycle after delivery (in about 6% of women, ovulation returns with the first cycle after delivery).  
• If you are "fully breastfeeding" (a.k.a. "ecological breastfeeding"), i.e. on request throughout day and night, without gaps of more than 4 hours during the day and 6 hours during the night, without pacifiers or bottles, formula or solid food, without feeding schedules, and in lying down position for naps and at night, or almost fully (not more than 15% of feedings supplemented), the average infertility period is 14 months from birth, but it is nevertheless recommended to resume checking for cervical fluid regularly after 6 months until the BIP changes (see Rules for anovulatory periods).  During the first 6 months, the effectiveness rate is 98%. 
• Ecological breastfeeding should continue after the child begins to take food (around 6-8 months postpartum), in which case another 6+ months of infertility results (Kippley 350). 
• CCL (Couple to Couple League) Study: of fully/ecologically breastfeeding women, amenorrhea (no periods) was observed for and average of 14.5 months and for at least 6 months in 93%, for at least 9 months in 84%, for at least 12 months in 56%, and for at least 18 months in 33%. This compares to observations of amenorrhea in culturally breastfeeding women for at least 6 months in only 8% (Kippley 339, 355).
• When to resume charting fertility signs:
  • Before 8 weeks postpartum, should any bleeding occur, a woman should resume charting and consider herself in Phase I for the following 6 weeks as a precaution; if cervical fluid, cervical position, and BBT do not show signs of fertility during this period, she may discontinue.  
  • After 8 weeks postpartum, any bleeding should be considered potentially menstrual and should likewise signal women to resume checking the cervical fluid and checking the BBT and to consider themselves in Phase I. If they notice a BIP, it will be necessary to use the rules for anovulatory periods from the Billing's Method.
  • After 3 months, any fertile cervical fluid (creamy and eggwhite) should considered potentially Phase II fluid and women should resume checking the cervical fluid and checking the BBT daily (sticky from 3-6 months of ecological breastfeeding needn't be considered indicatory of Phase II, though it should be after 6 months). Return of ovulation will probably be preceded by several "false starts," or patches of cervical fluid within a BIP. The return of cervical fluid after childbirth will probably be more abundant and for a longer time than in pre-pregnancy cycles; the luteal phases of the first few cycles will probably    be shorter (as short as 1 day). If sticky fluid appears consistently for more than 2 weeks, this may be considered a BIP and it will be necessary to use the rules for anovulatory periods and the Billing's Method.
  • Women should also resume checking the BBT if they notice a) a change in cervical position, b) a sudden decrease in suckling, c) the beginning of month 9 postpartum (this is when the rate of fertility return begins to increase rapidly) and/or d) the beginning of supplements to feeding if they observed an early return of periods in previous pregnancies (Kippley 357-58).
  • Mothers "partially breast feeding" (a.k.a. "cultural breastfeeding") should use the Rules for anovulatory periods from the end of Iochia (postbirth spotting). When using supplements, it is best to nurse first, then supplement, as this is better for the child and increasing the birth control effectiveness of LAM. 
• Most often, a period indicates the approach of the first post-pregnancy ovulation, but sometimes ovulation may proceed the first post-pregnancy period. From 1-6 months postpartum, pregnancy precedes the first postpartum pregnancy in only 1% of ecologically breastfeeding women; from 6-12 months in only 6%; after 12 months, the likelihood begins to increase rapidly (Kippley 357,361).
• Benefits of breastfeeding for child's health: reduces illnesses during first year of life, reduces ear infections, reduces susceptibility to diabetes, meningitis, child cancer, and giardia, reduces urinary tract infections during first 6 months, reduces SIDS (sudden infant death syndrome), reduces hospitalization during first year, reduces diarrhea, reduces lower respiratory infection, reduces thumb-sucking, reduces dental decay, reduces need for orthodontic worth, reduces speech problems, reduces tongue-thrusting, reduces incorrect swallowing; and increases neural development (a New Zealand study conducted over 18 years found a correspondence between academic success and length of time breastfed exclusively; another found an 8 point IQ advantage). Benefits for mother's health: quicker recuperation from childbirth, significantly reduces risk of breast cancer (most common cancer in Western world) (Kippley 335-338).
• Many doctors and theologians consider ecological breastfeeding a positive moral obligation (which admits of exceptions, e.g. when mother must work to provide for the family and breastfeeding failure, i.e. when breastfeeding doesn't occur due to various physiological reasons), basing their argument on moral law (children have rights to the best treatment their parents can reasonably provide for them) and the 4th commandment.

• The most basic form allows intercourse during phase III only (postovulatory infertile period to menses, a.k.a. Luteal Phase), as determined by the Marshall Rule (5th day of elevated temperatures with an overall shift is safe from risk of pregnancy) or the CCL Rule (4th day of elevated temperatures with a full shift is safe from risk of pregnancy) or the cervical position cross- check (first safe day is when both Rise+2 and Close+3 have occurred).  
• The Phase III BBT method is the most effective and perhaps most simple of all NBC methods, but requires more abstinence than all the other methods. 
• A German doctor developed the Doering System which also allows intercourse during Phase I, where the last day of Phase I =  earliest day of sustained temperature rise (of the last 6-12 cycles) - 7, provided it is a dry day.  

• Phase I infertility starts the first dry day after menstruation and continues until first cervical fluid appears; Phase III infertility begins on PK+4 evening. 
• According to the Billing's Method, any bleeding should be considered potentially fertile, because without a BBT thermal rise 12-16 days earlier, it cannot be immediately established that the bleeding is menstrual bleeding (infertile) and not mid-cycle spotting (fertile).  Thus the First 5 Days Rule as well as the Temperature Change Rule cannot be used. Instead the Peak Day + 4 Rule and Dry Days Rule must be used.  The Peak Day + 4 Rule may need to be used several days in one cycle (once during menstruation and once more each time the body prepares to ovulate--which may be several times, as in repeated stress- or travel-related ovulation delays), and insures safety from pregnancy risk from the 4th evening to the next incidence of wet cervical fluid, but only if there is no fluid on the fourth and successive days.  If there is sticky and non-wet fluid, the rule is modified to Peak+2 if fluid. 
• Additionally Billing's method may use cervical position as a back-up check to confirm infertility: the beginning of Phase III is Close+3 with PK+4. 

• Some women have unusually high fertility due to characteristic short cycles (hence more fertile days per year) or long periods of fertile cervical fluid each cycle
• 85% of women using no protection will become pregnant after one year.
• Infertility is usually defined as a year of unsuccessful pregnancy attempts without protection; in fact a fertile, non-charting couple simply by missing the proper window could go a year without achieving pregnancy. Conversely, a charting couple can determine accurately if they have infertility within 4-6 cycles of unsuccessful pregnancy attempts despite timing intercourse properly.
• The infertility rate in the 1950s was about one couple in ten. In the 1990s, it was one couple in five. This is due to the chemical effects of contraceptives, delayed childbearing, poor health habits, environmental factors, and increased promiscuity which spreads sterilizing STDs like gonorrhea and clamydia (Kippley 305).
• Possible causes of infertility:
  • Possible causes of female infertility: Fallopian tubes closed or scarred, no ovulation, cervical fluid unsuitable for sperm penetration, Egg production low, Luteinized Unruptured Follicle Syndrome (LUFS) (Ovum remains inside luteinized follicle, unable to leave ovaries and break into the fallopian tubes), Endometriosis (growth of endometrial tissue outside the uterus), over-exercising, over-dieting, anorexia, obesity.
  • Possible causes of male infertility: sperm count (# of sperm per ejaculate) low, i.e. less than 50,000,000; sperm motility (% of sperm that swim well in a forward direction) low, i.e. less than 60%; sperm morphology (% of sperm with normal size and shape) low, i.e. less than 60%; and sperm concentration low (less than 20,000,000 sperm per milliliter of ejaculate). Since the 1930s, the average male sperm count has dropped by 50%. Varicocele veins may be a cause of low sperm count. Other causes include scarred sperm ducts, hormonal deficiency, testicular failure (due to sport injury, severe childhood sickness), antibodies to own sperm
  • Possible causes of fertility incompatibility: antibodies to man�s sperm in woman�s cervical fluid
• Infertility Testing
  • Problems in female fertility analyzed by charting, hormone blood tests, cervical fluid ferning tests (analyzes receptivity to sperm movement), postcoital test (analyzes compatibility of sperm and cervical fluid, within 2 hours of intercourse), ultrasound (identifies LUFS), endometrial biopsy (tests ability of endometrium to sustain implanted zygote), HSG (Hysterosalpinogram) (tests openness of fallopian tubes), laparoscopy (tests for endometriosis)
  • Problems in male fertility analyzed by sperm analysis (easily done, Results: Normal, Low, or Infertile). Also, the �hamster egg penetration test� is used to evaluate sperms� ability to fertilize an egg. A sperm culture may be taken to identify possible sperm clumping. Sperm can be obtained for analysis without the morally-objectionable practice of masturbating by using a perforated silicone condom (untreated with spermicides) or the Huhner test, which removes sperm from the vagina within several hours of intercourse and has the added advantage of simultaneously checking for compatibility of the man's sperm with the woman's cervical fluid.
• Simple Pregnancy Achievement Steps 
  • Do Kegels after each act of intercourse in order to eliminate old infertile semen, which may block new, fertile sperm.
  • Plan pregnancy attempts every day of fertile cervical fluid if man's sperm count is high, every other day if his count is marginal. For couples with marginal sperm count, it may also be useful to abstain for a week preceding the expected beginning of the fertile period.
  • Improve diet, curtail nicotine, reduce alcohol to at most a glass of wine a day, reduce caffeine, reduce over-exercising, reduce over-dieting, gain weight if necessary, try guaifensin (which increases the fluidity of bronchial as well as cervical mucus). Ideal weight is 100 pounds for 5 feet height, plus 5 pounds for every additional inch (45.7 kg for 152.4 cm height plus 2.3 kg for each additional 2.5 cm, i.e. 0.9 kg for each additional cm) (e.g. 158 cm height = 45.7 kg + (158 cm - 152.4 cm) * 0.9 kg/cm = 50.5 kg; 5'2" height:100 lbs + 2" * 5 lbs/" = 110 lbs; 110 lbs~50.5 kg).
  • Although a BBT rise signals that ovulation has occurred and a pregnancy attempt that night would in all likelihood be vain, an attempt that morning is nevertheless worthwhile.
  • Signs of achieved pregnancy available through charting: 1) 18 high BBTs is a an almost definite sign of pregnancy, as is a lesser number if it is at least 3 greater than your usual luteal phase length (i.e. for a women whose luteal phases are usually 13 days, 16 days of high BBTs is enough to conclude pregnancy is likely); 2) light bleeding 8 days into luteal phase ("implantation bleeding") 
• A Basic Survey of Infertility Treatment
  • Short fertility window due to low quantity of fertile cervical fluid: treated by timing intercourse effectively by charting
  • Short luteal phase, early miscarriages: treated with Progesterone, which delays menstruation and gives zygote adequate time to implant
  • Endomitriosis: treated with hormones or surgery
  • No ovulation: treated by woman�s weight normalization, if obese or anorexic; Clomid or Pergonal stimulate ovulation (Pergonal, the stronger drug, often stimulates release of multiple ova at once, increasing likelihood of fraternal twins if desired)
  • Low sperm count: treated by dietary changes, loose clothing, removal of varicocele vein in scrotum, which keeps testicular temperature higher than optimal
  • Low sperm motility and sperm antibodies: treated with sperm washing (motility increased by separating best swimmers by mixing ejaculate with culture and centrifuging) + IUI (or IVF or GIFT if IUI is unsuccessful)
  • Egg production low: treated with Clomid, which shortens luteal phase (Since Clomid also dries up cervical fluid, Clomid may actually not help but even prevent pregnancy if the problem is not related to egg production. For this reason, it is sometimes prescribed together with Estrogen, which compensates for the drying effect.)
  • Antibodies to man�s sperm in woman�s cervical fluid: hormonal treatment or condom therapy (intercourse for 6 months is regulated to prevent contact of sperm with cervical fluid, so that woman�s immune system will not attack them and her antibody level to the sperm falls; then strategically timed intercourse before antibodies have time to rise)
  • Non-fertilization due to low sperm count, incompatible or infertile cervical fluid, unexplained infertility: treated with Artificial Insemination (AI), a.k.a. Intra-Uterine Insemination (IUI): Insertion of sperm (either partner�s--"homologous"--or donor�s--"heterologous") through catheter either just outside the cervix or through the cervix and directly into the uterus. Least invasive of intercourse-bypass techniques. Usually performed in concert with sperm washing and Pergonal-stimulated ovulation. Morally objectionable due to masturbation and depersonalization of conception.
  • Non-fertilization: treated with In-vitro fertilization (IVF): several of a woman�s eggs are placed in petri dish and fertilized, then placed into uterus 2 days later.  Morally objectionable due to masturbation and depersonalization of conception.
  • Non-fertilization: treated with Gamete Intra-fallopian transfer (GIFT): woman�s eggs are removed from her ovaries and placed in her fallopian tubes together with partner�s (homologous GIFT) or a donor's (heterologous GIFT) sperm. Morally status is in question since it may be done by obtaining egg and sperm after an act of intercourse, without masturbation or as clear a depersonalization of conception.

• The Shettles Method, according to one study, is 75-80% effective for choosing girls and 80-90% effective for choosing boys (choosing a girl is slightly more difficult). Other, more recent, studies have claimed to refute it. It is controversial, but the best known method (selective spermicide methods are risky because a damaged sperm may fertilize the egg, causing birth defects).
• Theory: Experiments show that the XY sperm which will form a boy if they fertilize the egg are faster, lighter, shorter-lived, and less hearty than the XX sperm which will form a girl if they fertilize the egg. Various evidence supports the claim that the timing of intercourse relative to ovulation determines gender. This is apparently because the faster XY sperm will fertilize the egg if intercourse is timed just before or after ovulation (i.e. there is not sufficient time for the XY sperm to die off and allow the longer-lived by slower XX sperm to fertilize the egg), while XX sperm will fertilize the egg if intercourse is timed at the beginning of the fertile period (i.e. there is several days for the XY sperm to die off and allow the longer-lived but slower XX sperm to fertilize the egg).
• Practice:
  • For boy: After last dry day, do not have intercourse until peak day and PK+1, in order that XX hearty sperm, surviving from previous intercourse at the beginning of the fertile period, might not reach the egg before XY sperm from intercourse around ovulation.
  • For girl: Have intercourse throughout cycle up to 2 days before peak day. A woman should know from previous cycles her fertile window (days of creamy or eggwhite cervical fluid or vaginal lubricative sensation), and based on this, determine exactly the female-likely fertility window. As a general rule, intercourse should be timed 2-4 days before peak day (when fertile cervical fluid is present and it is too long before ovulation for XY sperm will to survive and fertilize the egg). (If a couple is infertile, it is not worth trying to have a girl, because these rules require you to abstain during the peak days of fertility.)

• Onset signaled by cycle irregularities (first shorter and more frequent, then longer and less frequent, with more anovulatory "cycles" interspersed; shorter luteal phases; fewer days of wet cervical fluid; more dry days or days of sticky cervical fluid; cervix position almost always low, hard, and closed; more midcycle spotting; cessation of postovulatory breast tenderness/ discomfort), hot flashes, and vaginal dryness.
• A woman is considered fertile for an entire year after her last period (to confirm that it was indeed her last).
• Premenopausal woman may have a BIP of dry every day with about 3 days a cycle of sticky, creamy, or eggwhite, making birth control very easy and the abstinence period very short.
• Premenopausal woman may have a BIP of sticky every day with about 3 days a cycle of creamy, or eggwhite, making birth control very difficult and the abstinence period very long.

• Ovum usually survive 12 hours (24 maximum); sperm usually survive 2-3 days (5 maximum); hence the 9-10 day �fertile period� of abstinence for NFP-users includes a significant safety margin on either side of the de facto period of fertility in any given cycle.
• Multiple ovulation: additional eggs are released from the ovaries into the fallopian tubes within 24 hours of the first ovulation, possibly resulting in multiple fertilization. This is why the 2 extra days of abstinence are required in NFP after ovulation has been determined by temperature rise, as in Temperature Rise + 2 (last multiple ovulation 24 hours after first + 24 hour maximum lifespan of the latest released egg = 48 hours). If both/3/etc. fertilized eggs imbed, then fraternal twins will be born (identical twins result from the division of a single fertilized egg). The rate of multiple fertilization is much higher than the rate of birth of fraternal twins (less than 1% in the US), due to natural miscarriages ("vanishing twin phenomenon"), and the rate of multiple ovulation still higher (probably around 5-10% of all cycles)
• In the idealized textbook 28-day cycle, ovulation occurs 14 days after beginning of menstruation, +/- 2 days, but this is very inaccurate as a guide to birth control
• Luteal (progestational) phase is a certain length, between 12-16 days, which varies +/- 1 day for any given woman and is unaffected by factors such as stress, travel, illness, exercise, sickness. Range of Luteal phase length for a given women can be identified by several months' charting (e.g.. 12-14 days, 14-16, 13-15)
• Mid-cycle bleeding can be mistaken for menstruation; BBT provides backup
• Stress may delay ovulation, lengthening making the abstinence period
• In a very short cycle, cervical mucus begins before menses end
• Length of cycle depends on ovulation--follicular (estrogenic) phase;
• Artificial lubrication and saliva kill sperm; better use egg-whites or lengthen foreplay to allow natural lubrication from Bartholin's gland ("arousal fluid") to flow
• STDs: chlamydia (most common today, destroys fertility if untreated), syphilis, gonorrhea, genital warts (may lead to cervical cancer), genital herpes (may be dangerous to developing embryo)
• Couples who postpone pregnancy indefinitely may experience problems in their relationship because, as the natural order dictates, the period of satisfaction in each other alone passes quickly and joint projects (preeminently child-raising) give new energy and direction for the marriage relationship. This may be why so many "trial marriages" and marriages of DINKs (double income, no kids) fail so quickly
• Abstinence for 6 weeks before EDC, as often prescribed, is unnecessary.  Likewise, the often-prescribed abstinence for six weeks after childbirth is not necessary; when the wife feels comfortable (about 3-4 weeks) is appropriate (Kippley 323).
• Suggestions for couples abstaining during Phase II
  • Develop non-genital expressions of affection
    • Husbands asking about their wives' day, bringing them small gifts, complimenting them, helping around the house, helping with the children and performing discipline, sharing about their problems and plans at work, not forgetting goodbye and hello kisses;
    • Wives sprucing up before their husbands come home, overcoming shyness to give unexpected physical expression of love, cooking meals their husbands especially like;
  • Don't feel sorry for yourselves
  • Embrace suffering as a possibility to grow
  • Take the difficulties one day at a time
  • Count your blessings frequently
  • Avoid stress, bad diet (e.g. iodine deficiency), overweight, underweight, and excessive exercise, which all delay ovulation, extending the period of abstinence. (Appropriate weight can be determined by this rule: 100 pounds + 5 pounds for each inch of height above 5 feet.)
  • Don't blame NFP for marriage problems
  • Pray for aid
  • Avoid the extremes of either being too cautious with hardly any physical expressions of love, and of being too reckless and engaging in arousing foreplay, both of which increase frustration.
  • Share your difficulties with your spouse and try to have a sense of humor and laugh and joke about them

Sources and Further Reading

• Weschler, Toni.  Taking Charge of Your Fertility: The Definitive Guide to Natural Birth Control and Pregnancy Achievement.
• Kippley, John and Shiela.  The Art of Natural Family Planning.
• Hatcher, Trussell, Stewart et al. Contraceptive Technology: 16th Edition. Irvington Publishers, New York, 1994.
• http://www.aldred.demon.co.uk/nfp/effect.htm Article with stats on Effectiveness (England CCL)
• http://www.aldred.demon.co.uk/nfp/bbc.htm Article on early Protestants and ABC (England CCL)
• http://www.transporter.com/fatherpeffley/Family/index.html
• http://www.ccli.org/ Couple to Couple League
• http://www.epigee.org/guide/natural.html Women�s Guide to Natural Birth Control
• http://www3.cems.umn.edu/~glaser/nfp.htm testimony, myths, etc.
• http://www.geocities.com/Heartland/Meadows/2879/info.html practical theology, etc
• http://www.omsoul.com/ One More Soul Org. On-line articles.