There are already enough barriers out there that stand in the way of learning about our menstrual cycles – and I don’t think the cost of Fertility Awareness-Based Method (FABM) instruction should be one of them! Unfortunately though, because FABM instruction is not covered by Medicare or private health insurance here in Australia, it remains a cost that must be paid out of pocket (and FABM instructors definitely need to be reimbursed for their time and expertise!). Here’s hoping that one day we’ll see subsidised FABM instruction – over in the United Kingdom, FABM instruction is covered in some instances under the NHS! I for one distinctly remember first learning about the Symptothermal Method and being desperate to work with an instructor … but I couldn’t afford one. However I didn’t let that stop me, and this article is a compilation of tips for cost-effective cycle charting on a budget!

While I want to encourage you that self-teaching is possible and can be cheap (or even FREE) – I also need to emphasise that effectiveness is higher when learning with an instructor. For instance, the most well-known study of the Symptothermal Method was based on users who were under the close supervision of qualified instructors of the Sensiplan protocol. This study showed that with perfect use, a 99.6% effectiveness was possible. Typical use rates were 98.2%. Subsequent criticisms of the study argue that the typical use figure may not be generalisable to the broader population due to the study design (a prospective clinical trial). In addition, these rates are based on users who were following a Symptothermal Double-Check Method – many popular self-learning books (discussed below) are Symptothermal Single-Check Methods which means they are likely to have a perfect use effectiveness closer to 98%.

However, the point of this is to say that we don’t have any effectiveness studies on the outcomes of self-teaching the Symptothermal Method. The effectiveness of self-teaching remains unknown and is highly likely to be lower than working with an instructor. Because of this, it’s important that you commit plenty of time to studying the method in depth if you need to self-teach. Plus, it’s crucial to avoid any unprotected sex for at least the first three cycles of charting while you are learning. Basically – if you’re strongly “TTA” (trying to avoid a pregnancy), then you need to take the learning process very seriously.

All that said, let’s dig in to my top 4 tips for charting on a budget!

TIP NUMBER 1

You’re going to need some sort of manual to learn from. By far, the most popular self-teaching resource is the book Taking Charge of Your Fertility (TCOYF) by Toni Weschler. While TCOYF isn’t a Symptothermal Double-Check Method, it is a fantastic resource absolutely packed with information about the reproductive system. In my opinion though, it can be a little overwhelming for new users – my go-to recommendation for self-teachers is usually to opt for the Sensiplan Handbook and Workbook instead. Sensiplan is a Symptothermal Double-Check Method and has a solid evidence-base for use.

For more details on the difference between Double-Check and Single-Check Methods click here.

TCOYF and Sensiplan aren’t your only options though. There are a number of other resources (whether online or in book-form) that are available to you. All of them are designed to be used with an instructor if possible, but you can still access them even if you haven’t signed up to work with an instructor. Keep in mind that some of these manuals do include religious content. Here are just a few of many:

Symptothermal Double-Check Methods:

• [Book] (not free) Celsius and Fahrenheit. Natural Contraception and Conception Course Handbook, by Jessie Brebner
• [Book] (not free) Celsius. Sensiplan Natural & Safe: The Handbook (must also purchase the Workbook), by Sensiplan
• [Book] (not free) Fahrenheit and Celsius. A Couple’s Guide To Fertility, by SymptoPro
• [Book] (not free) Fahrenheit. The Art of Natural Family Planning Student Guide, by Couple to Couple League
• [Book] (not free) Fahrenheit and Celsius. Natural Family Planning The Complete Approach, by Natural Family Planning International, Inc
• [FREE Online Manual] Celsius. NFPTA-UK Online Fertility Guides
• [FREE Online Manual] Celsius and Fahrenheit. Sympto Method Manual
• [FREE Online Manual] Fahrenheit and Celsius. Natural Family Planning The Complete Approach, by Natural Family Planning International, Inc

Sympothermal Single-Check Methods:

• [Book] (not free) Fahrenheit. Taking Charge of Your Fertility, by Toni Weschler
• [Book] (not free) Fahrenheit. Garden of Fertility, by Katie Singer
• [Book] (not free) Celsius. Justisse User Guide, by Justisse Foundation

Check out your local second-hand bookstore for a cheap copy of TCOYF, or head to your library to borrow it for free. For example, here on the Gold Coast of Australia I can see with a simple library catalogue search that there are three physical copies of TCOYF at different libraries within a 15km radius. In addition to this, you can even read TCOYF for FREE online by visiting archive.org (keep in mind that this is the old edition and some rules have slightly changed – but it’s still perfectly valid and very useful).

Tip Number 2

You are going to need somewhere to record your daily observations of cervical fluid and basal body temperature (and optional cervix tracking). Here, you have two options – you can either chart on paper or on a smartphone app. You’ll need to decide which is the best fit for your personal life.

If you would like to chart on an app, there are a few popular options:

FREE: Kindara app*

FREE: Lutea app

PAID: Read Your Body app

You can download and use Lutea or Kindara for FREE – that’s right, without paying a single cent. No monthly or yearly subscription costs or hidden fees. The free version of Kindara doesn’t have the option to track vaginal sensation (which is a really important part of all Symptothermal Methods); however, with the free version you get four “custom fields”. You can use three of these custom fields to set up your own version of vaginal sensation tracking.

Read Your Body app is the gold standard with full customisation options that make it suitable for all Fertility Awareness-Based Methods (FABMs). It requires a small yearly subscription which is definitely worth it if within your budget.

*Since the time of writing this article, Kindara has been bought by a new parent company. They no longer have a support team, and it’s unclear if/when Kindara app might be retired forever. This means that if you choose to use Kindara, it’s important that you back up your data regularly via their desktop portal.

If you’re wanting to paper chart – even this can be done on a budget!!

My website provides a range of beautiful FREE downloadable paper charts which you can access here.

You can also find a range of other downloadable printable paper charts at the below links. Remember, it’s best to use the chart that corresponds to the method you will be using:

• TCOYF Downloadable Printable Charts
• Sensiplan Downloadable Printable Chart
• NFPTA-UK Downloadable Printable Chart
• Sympto Downloadable Printable Chart
• SymptoPro Downloadable Printable Chart
• Natural Family Planning International, Inc Downloadable Printable Chart

If you don’t have a printer at home, most libraries have communal printers that you can use. Here on the Gold Coast, my local library allows me to print an A4 sheet in black and white for only 15c. Assuming you have around 13 menstrual cycles in a year that’s only a cost of $1.95 to paper chart each year.

Tip Number 3

You’re going to need a basal body temperature thermometer to successfully use the Symptothermal Method. In most pharmacies here in Australia, the cheapest option I have found is the SurgiPack 6335 Digital Ovulation Thermometer for $20. You can purchase it online for cheaper, but then you’ll also need to factor in shipping costs. If you’re wanting to purchase a thermometer off of Amazon, the cheapest option I have found is the Mabis Digital Basal Thermometer (although remember to factor in shipping costs). Many people use and love this thermometer.

Tip Number 4

Peer support! I cannot stress this enough. It is SO important to have the support of other people who are on the same learning journey. Peer support can connect you with people who are just starting out like you are. Plus, there are others who have been charting for years and have a lot more experience and wisdom to share with you (not to mention support when interpreting difficult charts). This is where social media platforms come in. My two absolute favourites when it comes to online communities are found on Facebook:

• Fertility Awareness Method of Birth Control, and
• FAM Support Group

Fertility Awareness Method of Birth Control is a large private Facebook group with over 20,000 members. They have a wide range of useful files, and plenty of very experienced members. While the group is in no way a substitute for qualified instruction, it is a great way to get plenty of peer support. You can even practise your newfound charting skills with weekly group practise posts.

FAM Support Group is a smaller Facebook group with around 600 members. For those who are looking for a bit more of an intimate vibe this group is a great option with plenty of highly experienced members (many of whom are instructors themselves).

These groups are not a substitute for learning with an instructor; however, they definitely provide an extra safety-net with a strong sense of community and a drive to promote perfect-use charting.

Conclusion: Charting doesn’t have to break the bank

If you use a free learning manual or book, with free online peer support, and use the free app Kindara – your only cost is a thermometer which you can grab for $20 at the nearest pharmacy.

If you’re ready to invest in working with an instructor (it’s an absolute game-changer if you are able to make it happen) simply head to the Find An Instructor page.

Yesterday, Cosmopolitan published an article titled ‘Do You Know Enough About Your Body To Use Fertility Tracking Apps?’ Unfortunately, the article was packed full of misinformation and displayed an astounding lack of understanding about how Fertility Awareness-Based Methods (and our bodies) actually work. Luckily for me, I see these types of articles so frequently that I no longer have a heart attack when I read them; however, it is of huge (huge!) concern that readers may subsequently make choices about their reproductive healthcare based on inaccurate information.

These days, I really do have to wonder why the writers behind these articles never think to contact a qualified Fertility Awareness professional to speak to a credible source before they press ‘publish’.

Anyway, without further ado – let’s count all the ways that Cosmo got it wrong (like – really, really wrong).

[In regards to Fertility Awareness-Based Methods] ‘You may have heard this referred to as something like fertility tracking or the calendar method, but all describe the same thing: avoiding pregnancy by tracking the days on which you’re most fertile and planning your sex life around those days’.
Actually no, they don’t all describe the same thing. The Rhythm Method involves counting days of past cycles to make predictions about when you will be fertile in future cycles. This is problematic because there are many things that can cause our cycles to change each month. For this reason, the Rhythm Method has a very high failure rate and is not suitable for anyone who genuinely wants to avoid pregnancy. Thankfully, Symptothermal Methods involve zero predictions. Instead, they track cervical fluid and basal body temperature on a day-by-day basis so that you know whether or not you are fertile on any given day. Symptothermal Double-Check Methods are an exception to this – they actually incorporate a calculation (based on past cycles) as to when a user might first expect to see cervical fluid after menstruation. This calculation allows users to double check the opening of the fertile window (instead of just relying on cervical mucus). While calculation rules are indeed predictions, they act to make the method more conservative and are always overriden by actual physical observations. You can read more about the different types of FABMs by clicking here. 

‘”A healthy menstrual cycle is 28 days”, Dr Nate DeNicola, MD, an ob-gyn in Washington D.C. says’.
A healthy menstrual cycle can actually range from around 24 – 38 days. In fact, only around 1 in 10 women consistently experience a menstrual cycle of 28 days in length.

‘”If your cycle’s not at least somewhat regular, then this probably isn’t going to work well for you because the chance of predicting the fertile window to avoid is pretty low” Dr DeNicola says’.
Remember the bit above where we clarify that the Symptothermal Method doesn’t involve predicting fertile days? It doesn’t matter how irregular your cycle is, you can still track your cervical fluid and basal body temperature to know whether or not you are fertile on any given day. For those with extremely long cycles the same applies; however, it may mean you experience long periods of needing to use barrier protection such as condoms or a diaphragm (as opposed to the shorter fertile window in a normal length menstrual cycle).

“The chance of getting pregnant while solely using fertility awareness is 25 percent”
This statement is so problematic I don’t even know where to begin!

It seems that Cosmo is perhaps using older figures from the US National Survey of Family Growth which showed an overarching 24% failure rate for all different types of Fertility Awareness-Based Methods. The US NSFG report was careful to note however, that over 80% of respondents to their survey were using the Rhythm Method. This means that the results don’t really tell us anything useful about the Symptothermal Method. For more information on effectiveness rates, I highly recommend visiting this fantastic blog by Dr. Chelsea Polis who is a reproductive health epidemiologist with the Guttmacher Institute: http://chelseapolis.com/blog/understanding-effectiveness-estimates-for-fertility-awareness-based-methods-of-contraception

Currently, the CDC states that there is a 2 – 23% chance of pregnancy with typical use of fertility awareness – but this depends on which method you use. The 2% failure rate is based on a 2007 study of the Sensiplan method, which is a Symptothermal Double-Check Method (if you remember previously, Symptothermal Double-Check Methods are a little more conservative than Symptothermal Single-Check Methods due to the inclusion of calculation rules to double-check the opening of the fertile window). The 2007 study was based on the results of following 900 women over the course of 17,638 menstrual cycles. These women were working very closely with Sensiplan instructors and were found to have a 1.8% typical use failure rate, and a 0.4% perfect use failure rate.

When discussing effectiveness rates of FABMs, we currently don’t have a large and robust pool of evidence to draw from. Moderate quality studies tell us that the Sensiplan method has shown a 0.4% perfect use failure rate. This is very promising! When it comes to typical use however, we really need larger retrospective population-based surveys to give us a wider range of demographics and a more accurate estimate of real-world experiences. While we have a typical use estimate of 1.8% for the Sensiplan method, this estimate is based on a prospective clinical trial which isn’t as well suited to delivering typical use rates. It’s also based on users who were working very closely with an instructor – not those who were self-taught.

Unfortunately, the user-base of FABMs doesn’t really provide large enough populations to study for accurate typical use rates of individual methods. Additionally, there isn’t much incentive for these studies to be carried out considering there’s no pharmaceutical company behind the scenes waiting to profit from a new drug. I often wonder who’s going to be willing to fund further studies on FABMs!

The main takeaway here is that the discussion around FABM failure rates is highly nuanced and hasn’t been done justice by Cosmo.

“Ovulation, or the fertile window, is usually described as a five day window” [Dr DeNicola]’
Contrary to this, most studies actually show us that the biological fertile window is around six days. Five days leading up to ovulation, and the day of ovulation itself.

‘The basal body temperature can be measured orally, vaginally, or anally with an accurate thermometer that measures in tenths of degrees’.
This is a pretty big inaccuracy. Basal body temperature thermometers need to measure to two decimal places to be used with the Symptothermal Method – this is absolutely critical to ensure you’re picking up on the small shifts that occur after ovulation. If your thermometer only measures to the nearest tenth of a degree (that’s one decimal place) then it is not sensitive enough to be used for your charting practice. On top of this, while basal body temperature can be measured anally, I don’t know of a single person I’ve ever encountered who has done so. Most of us happily take our temperature orally each morning. You can find a list of recommended basal body temperature thermometers here.

‘Dr DeNicola says it doesn’t so much matter what time of day you take your temperature, but that you should always take it at the same time of day (like you would a birth control pill, for example).’
Basal body temperature (BBT) is your lowest core body temperature at rest, and it actually occurs around 4:30am each day. This is because your body temperature changes in a circadian rhythm – that is, it’s lowest in the early hours of the morning, and highest in the afternoon. The Symptothermal Method requires that you take your waking temperature (slightly different from true BBT) after at least 3 consecutive hours of sleep and at the same time each morning (give or take around 30 minutes). It’s very unlikely that you are going to get an accurate chart by taking your temperature at other times of the day (say lunchtime, or late afternoon), unless you’re having at least 3 consecutive hours of sleep prior. In addition to this, all effectiveness studies on the Symptothermal Method involved participants who were measuring their early morning waking temperature.

[In regards to cervical mucus] ‘Yes, I know, this is gross. Dr. DeNicola knows it, too. But such are the wonders of the human body’.
Ok.. wow, thanks for telling your readers that their bodies and how they work are ‘gross’. Nice to know that a trusted medical professional (who actually looks at vulvas, vagina’s and cervixes all day) also thinks the same! This is classic body-shaming and an extension of menstrual taboo – where anything to do with our reproductive systems has to remain ‘hush-hush’ for fear of offending anyone. Heaven forbid we accept and celebrate the wonderful biology that allows the continuation of the human race! If you’re interested in checking out photos of real-life cervical fluid, click through to the cervical fluid gallery.

‘If you haven’t caught on by now, even the most highly regular of cycles can go haywire, making it extremely difficult (if not impossible) to accurately guess when you’re ovulating, 100 percent of the time.’
Thankfully, none of us who use the Symptothermal Method are guessing as to when ovulation will occur! As mentioned above, the Rhythm Method (which is what most period tracker apps use) involves predicting and guessing when ovulation will occur. This makes it prone to a scarily high failure rate. The Symptothermal Method on the other hand, involves zero guesses or predictions – just checking in daily with your cervical fluid and basal body temperature to know whether or not you’re fertile – today.

‘If a fertility awareness-based method is something you’re truly interested in, Dr DeNicola urges you to please bring it up with your doctor. A good doc won’t ever shame your choices, even the ones that are statistically not great at preventing pregnancy.’
There are two parts I would like to break down here. First off, a doctor is actually not the best person to speak with if you’re interested in using a Fertility Awareness-Based Method. Why? Because most doctors receive little to no training on FABMs – at best they might hope for perhaps a pithy one-hour lecture. And as you can see from Dr DeNicola’s comments, it’s clear that this training was definitely not thorough enough. In fact, in a 2011 survey of United States Obstetrician-Gynaecologist physicians, 68% considered FABMs to be a poor option for most women. But when they were asked to estimate typical use effectiveness rates, the average answer given by these physicians was that 25% of couples practising a FABM would fall pregnant within a single year! This displays a clear lack of education about the different types of FABMs and their true effectiveness rates – and it is this lack of education which ultimately affects patients who have their earnest questions effectively ‘pooh-poohed’ and brushed aside.

Secondly, as we discussed prior, the discussion around effectiveness rates is complex. However, the Sensiplan Symptothermal Double-Check Method has been proven up to 99.6% effective with perfect use. To say that this method is ‘statistically not great at preventing pregnancy’ is factually inaccurate and exhibits a clear and disturbing bias against natural forms of contraception.

So while I’m not surprised to read this recent article from Cosmopolitan, I’m certainly disappointed.  Once again, the general public is left with inaccurate, incomplete and biased information to sift through when it comes to making decisions about Fertility Awareness-Based Methods.

Did you have to wade through misinformation when you were looking into using the Symptothermal Method? I’d love to hear your experiences in the comments section below!

 

UPDATE July 2022: Before deciding to rely on a Fertility Awareness-Based Method (FABM) during the postpartum, it’s important to note that a 2022 systematic review found that “the current evidence base [for the effectiveness of fertility awareness-based methods for preventing pregnancy during postpartum amenorrhea and the transition to normal menses] is very limited and of mostly low quality”.

What does this mean? There is little scientific evidence for the safety and effectiveness of any type of FABM for pregnancy prevention during the postpartum. In addition, the evidence we do have is considered to be of low quality.

You can read more about this latest 2022 systematic review here.

 

A special note:
I would like to preface this article with the caveat that postpartum charting can be very challenging as it is a time of hormonal change and uncertainty while fertility slowly returns after birth. This can result in long periods of abstinence or barrier use that can be frustrating for some users. In addition, once-reliable fertility signs such as cervical fluid and basal body temperature can become confusing to track and special postpartum rules must be applied. For this reason, I don’t recommend that you learn a Fertility Awareness-Based Method for the first time during the postpartum period unless you will be working very closely with an instructor. You can find an instructor by clicking here. 

Birth is a radically transformative event. If you’ve recently expanded your family by birthing a child you’re likely very aware of this! You may be navigating new challenges and demands as you grow into this new facet of your identity.  

These challenges can be both mental and physical. Even if you’ve been cleared to resume intercourse by your healthcare provider you may be reluctant to “get back on the horse” as the saying goes. Every woman’s experience will be different but common causes of low libido centre around:

• perineal healing,
• c-section scar healing,
• sleep deprivation,
• body image issues,
• mental health issues (such as PPD and/or PPA),
• emotional overexertion (or a feeling of being “touched out”), and
• vaginal dryness as a result of low oestrogen due to breastfeeding.

Or, perhaps you’re on the other side of the equation and have been back in the sheets since week three!

Either way, it’s best to tackle the issue of contraception early on so that when the time comes you and your partner have a game plan ready.

During pregnancy, ovulation is suppressed due to high levels of placental progesterone and oestrogen. High levels of these hormones have a suppressive effect on the release of luteinising hormone from the pituitary gland in your brain. Luteinising hormone is required for the maturation and release of an ovum (egg) from your ovaries; therefore, suppressed luteinising hormone = no ovulation.

How soon you begin ovulating after giving birth will depend on whether or not you choose to breastfeed, and for how long. Why is this? Because breastfeeding suppresses ovulation – in some situations. Read on for more information.

Please note that this page contains affiliate links, meaning, at no additional cost to you, I may make a commission if you click through and make a purchase. This commission helps to keep this website up and running so that I can continue to provide resources for women to learn about Fertility Awareness. You can read more about this in the Advertising and Affiliates policy here.

“I will not be breastfeeding”

As the saying goes – fed is best! Many mothers will end up using formula due to work schedules, health conditions, difficulties with breastfeeding and pumping, societal norms, lack of support or simply due to personal preference. If you choose not to breastfeed (or are unable to), you should be aware that your fertility will return much more rapidly than those who are breastfeeding. This also applies if you are unable to exclusively breastfeed (continue reading below for a definition of exclusive breastfeeding). If you are not breastfeeding, or only partially breastfeeding and you wish to use a Fertility Awareness-Based Method (FABM) you will need to start charting your fertility biomarkers within two-three weeks of giving birth. This is because it is possible to ovulate as early as the fourth week postpartum if you are not breastfeeding! On average though, (if bottlefeeding) your first menstrual bleed is likely to return around eight weeks postpartum, with ovulation first occurring for 94% of women in their second menstrual cycle following birth. [1]

 

“I will be breastfeeding”

Many mothers will choose to breastfeed, especially with the World Health Organisation (WHO) recommending that infants be exclusively breastfed up until the age of six months. The WHO also recommends continued breastfeeding (in addition to supplemental foods) up until the age of two years. In Australia, the Department of Health recommends exclusive breastfeeding up until six months, with supplemental feeding continuing up until 12 months (and beyond if the mother and infant wish to continue). If you’re choosing to breastfeed, it may help to understand exactly how and why breastfeeding will affect your fertilty.

Prolactin – The Breastfeeding Hormone
Prolactin is a hormone released by the pituitary gland in your brain. It causes your breasts to secrete milk. During pregnancy, prolactin levels steadily increase, but lactation is suppressed due to high levels of placental oestrogen. During the 48 hours after birth, oestrogen levels drop rapidly and lactation can finally begin in earnest. These high prolactin levels after birth will not be maintained or increased unless suckling occurs.

Suckling of a baby on the breast stimulates nerves within the areola. These nerves then send a message to the hypothalamus and pituitary glands to produce a surge of prolactin and oxytocin. The surge of prolactin creates more milk, while the surge of oxytocin stimulates the “let-down reflex” that brings milk to the nipple.

The surge of prolactin begins to dissipate within three hours unless the breasts are stimulated during this time with further suckling.

To establish a successful breastfeeding relationship with the baby, it is recommended that this suckling begins as soon as possible after birth – preferably within the first hour of life. The WHO have a number of other recommendations to promote successful breastfeeding such as immediate and uninterrupted skin-to-skin contact after birth. You can read these recommendations here and here.

How Does Prolactin Affect My Fertility?

Prolactin has a suppressant effect on fertility because it disrupts the ability of the pituitary gland to release Follicle Stimulating Hormone (FSH) and Luteinising Hormone (LH). FSH stimulates the growth of follicles within your ovaries (follicles are small fluid-filled sacs that each house an ovum). Around the middle of your menstrual cycle, a surge of LH matures one ovum (or occasionally two or more in the case of twins and triplets). [You can read more about multiple ovulation here]. The surge of LH simultaneously causes the matured ovum to rupture through the follicle and ovarian wall, to be collected by the waiting fallopian tube. In this way, both FSH and LH are crucial for the event of ovulation to occur. If these hormones are suppressed (as is the case when prolactin levels are sustained at high enough levels), ovulation cannot take place.

LACTATIONAL AMENORRHEA METHOD

Harnessing the contraceptive power of prolactin in the first six months after birth is known as the Lactational Amenorrhea Method (LAM). This natural method of contraception is proven over 98% effective [2] but it requires diligent adherence to three specific rules:

1. Baby must be less than six months old, and
2. Mother must not experience any vaginal bleeding after the first 56 days postpartum, and
3. Mother must be exclusively or almost exclusively breastfeeding.

If any of the above three criteria are not met at any stage, prolactin levels can quickly drop and ovulation could occur. Due to our modern lifestyles it is very difficult to fully meet all of the LAM criteria, and because of this, I highly recommend working with an instructor to ensure that your breastfeeding relationship meets the criteria of LAM. You can find an instructor to work with by clicking here.

I also recommend that if you wish to rely on LAM as postpartum contraception but you absolutely do not want to fall pregnant, that you chart your fertility in tandem to practising LAM from as early as possible after birth. It’s also a good idea to incorporate a concept known as ecological breastfeeding. Both postpartum fertility charting and ecological breastfeeding are covered in more detail below.

Menstrual Bleeding After Day 56:

• This is defined as any bleeding after day 56 that lasts for two or more days and requires sanitary protection for at least one of those days. If this occurs, it means that fertility is returning and LAM no longer applies.

Exclusive Breastfeeding: 

• Breast milk is the only sustenance the baby receives – he or she does not receive any other liquids or solids that are not breast milk. (If it is medically necessary to provide baby with other liquids or solids, the parents must understand that the contraceptive effect will lapse).
• The gap between breastfeeds should not exceed 4 hours during the day or 6 hours during the night. Reducing the frequency or duration of breastfeeds will reduce the effectiveness of LAM.
• No pacifiers or dummies are used. Babies suckle for comfort, not just food – comfort suckling plays an important role in the secretion of prolactin.
• Pumping breast milk (whether by hand or pump) has not been fully studied and will reduce the effectiveness of LAM.

The longer the duration of the breastfeed, the higher the level of prolactin that is released. Prolactin reaches higher levels during the nighttime hours – so once baby begins to sleep for longer periods at night, prolactin levels may drop low enough for fertility to return.

Unfortunately, the nature of LAM is such that it is not accessible to all women who would be interested in using it. In today’s society, many women have responsibilities and schedules that make it impossible to exclusively breastfeed for the first six months of infant life. In Australia, 11% of mothers have already returned to work at three months postpartum [3], and only 15% of babies are still being exclusively breastfed at the age of five months [4]. In the United States where there is no universal paid parental leave system, a whopping 58.6% of women have returned to work within three months of giving birth [5].

If you choose to partial breastfeed but cannot commit to exclusive breastfeeding, you will need to start charting your fertility biomarkers within two-three weeks of giving birth. Return of fertility may be quick or it may be delayed many months – during this time special postpartum charting rules will apply. It is highly advisable to work with an instructor during this time and you can find an instructor by clicking here.

Even for those women who could theoretically meet the requirements of LAM, the below meme might explain why not all choose to pursue this option!

What Happens When LAM No Longer Applies To Me?

At some point, you will no longer meet all three criteria to continue using the Lactational Amenorrhea Method. Perhaps your period returns before you reach the six month mark, or work commitments mean you can no longer exclusively breastfeed, or your baby begins to sleep through the night. Or perhaps your baby simply reaches six months of age and LAM no longer applies.

When LAM no longer provides natural infertility, most women are still in need of some form of contraception. The WHO recommends that couples wait a minimum of two years before trying for another baby [6]. This can be important to reduce the risk of adverse maternal, perinatal, neonatal and infant health outcomes.

How you choose to manage your fertility during this time will depend on how seriously you are wanting to avoid a pregnancy. Many women will already be planning their next pregnancy and will not be overly concerned on the spacing between births. Others will be at a life-stage where they are finished planning their family and don’t wish to fall pregnant ever again (and are perhaps looking into vasectomy or tubal ligation options).

Depending on your reproductive intentions, there are two natural methods available to you – FABM charting and ecological breastfeeding.

 

FABM CHARTING FOR THE POSTPARTUM

If you’re covered by the Lactational Amenorrhea Method and are seriously wanting to avoid a pregnancy, it’s important that you begin charting your fertility signs at the fifth month postpartum (at least two weeks before you reach six months postpartum).

This is because ovulation can occur either before or after your first menstruation/bleed; in fact, approximately 60% of breastfeeding parents who are past six months postpartum will ovulate before they have their first period. If you are part of this 60% you will want to be tracking your fertility signs to avoid falling pregnant on your first postpartum ovulation! In some cases though, it can take around three cycles for fertility to fully return – the first cycle is sometimes anovulatory, followed by a cycle or two with a short luteal phase not supportive of implantation.

How soon your fertility returns will depend on how your breastfeeding relationship plays out. Remember, frequent suckling stimulates the release of prolactin which has a suppressant effect on ovulation. For those who abruptly wean with the introduction of solids after the six month mark, fertility can quickly return. For those who wean very gradually this process can sometimes take longer.

This can be a confusing time for those who are using a FABM to chart – I liken the postpartum time to a kind of fertility “no-mans land“. This is because you no longer have the protection of the Lactational Amenorrhea Method, but you also don’t have regular, ovulatory cycles. It can mean long periods of abstinence or barrier-use (such as condoms) as you wait to try and catch your first ovulation.

In addition to this, postpartum charting presents two other unique challenges:

1. Cervical mucus can present differently due to breastfeeding
2. Waking frequently through the night with your baby can make it difficult to obtain an accurate basal body temperature reading

While you’re in this “no-mans land” or “cycle zero” as most refer to it, it is very important that you work closely with an instructor who is experienced in postpartum charting. You’ll need to be very confident at tracking a fertility sign that is influenced by oestrogen so that you can catch your first ovulation. This is because your temperature is only going to rise after ovulation has already occurred, which doesn’t offer you any protection against pregnancy considering sperm can survive up to 5-7 days in the reproductive tract. Once your temperature has risen it is too late to take back that unprotected sex from four nights ago!

If you’re only tracking BBT, you’ll need to be investing in a time machine!

Fertility signs that are influenced by oestrogen are your cervical fluid and your cervical position. Because oestrogen levels rise in the lead-up to ovulation, it is important that you are very confident in charting these signs.

Symptothermal Method or Billings Ovulation Method charting for the postpartum

If you’re using a Symptothermal Method, there are special FABM rules that must be used for the postpartum. Special rules are required because cervical mucus is often affected by breastfeeding. These rules help each individual person to identify their personal “Basic Infertile Pattern”. It is for this reason that I don’t recommend you attempt to self-teach a FABM during the postpartum. Instead, I recommend working closely with an instructor who can carefully guide you to learn postpartum charting rules. You can find an instructor by clicking here.

The Symptothermal Method relies on both cervical mucus and basal body temperature (BBT). BBT only rises in a sustained fashion after ovulation has already occurred. Because ovulation can be significantly delayed in the postpartum, this means that BBT is not a very useful fertility biomarker for this specific life stage. Instead, you are relying on fertility biomarkers that are influenced by oestrogen, such as cervical mucus and changes in the cervix itself. It can be beneficial to pay closer attention than usual to cervix tracking – in many cases where cervical mucus remains confusing, the cervix provides the first clue that fertility is returning. Again, I recommend working with an instructor to learn about cervix tracking as the position of your uterus can sometimes affect how your cervix will be positioned during the fertile window.

One of the strengths of the Symptothermal Method is that we are always cross-checking two separate biomarkers (mucus and BBT) against one another. This means that Symptothermal mucus-checking protocols are often relatively “basic” because they always have the added security of a BBT cross-check. However, this can be a weakness of relying solely on Symptothermal Method postpartum protocols that are often of quite a basic nature in regards to cervical mucus.

In fact, if ovulation is delayed due to breastfeeding, I recommend that you seek out a cervical mucus only method such as the Billings Ovulation Method. Cervical mucus-only FABMs have highly detailed mucus-only protocols that are more well-suited to the postpartum than Symptothermal protocols. You can find Billings Ovulation Method instructors in the Instructor directory.

 

Marquette Method Charting

If you feel as though charting with the Symptothermal Method or the Billings Ovulation Method during the postpartum will simply be too difficult for you, it may pay to look into the Marquette Method. The Marquette Method is fantastic for postpartum charting because it simply involves testing your urinary hormone metabolites each morning using a special fertility monitor that measures oestrogen and luteinising hormone. You can find a Marquette Method instructor by clicking here. The Marquette Method also has a dedicated and active facebook group that you can join for more information – click here to take a look. If you’re interested in using the Marquette Method, keep in mind that it is a Catholic organisation and religious content will likely feature in the learning materials. The Marquette Method has a very high effectiveness rating (on par with the Symptothermal Method) and the fact that it involves very objective digital urine testing can be a reassurance for users who definitely want to avoid a pregnancy.

Barrier Methods

Finally, if you have a strong preference for a natural method of contraception, but are struggling to maintain a FABM charting practise while coping with the demands of caring for a new baby, don’t forget that barrier methods are also an option. Condoms are generally the most popular and easily accessible. If you used a diaphragm prior to birth, don’t forget that you will likely need a re-fitting to a larger size after birth.

 

ECOLOGICAL BREASTFEEDING

For those who are less concerned about falling pregnant and simply wish to naturally space their next child, a practise known as ecological breastfeeding may be a suitable option. Ecological breastfeeding is a term coined by John and Sheila Kippley of the Catholic organisation Natural Family Planning International. It involves exclusive breastfeeding (as outlined for LAM), but also includes six other standards that must be met. These standards can also be used to bolster the effectiveness of LAM.

The protocol encourages a very natural type of mothering and is said to extend amenorrhea (absence of periods) out until 14.5 months on average. Keep in mind that this is just an average – your period could return much earlier than this. For this reason, the method is not suitable for those who absolutely want to avoid an unplanned pregnancy.

The Seven Standards:

1. Breastfeed exclusively for the first six months of life
2. Pacify or comfort the baby at your breasts
3. No bottles or pacifiers
4. Sleep with your baby for night feedings
5. Sleep with your baby for a daily-nap feeding
6. Nurse frequently day and night and avoid schedules
7. Avoid any practice that restricts nursing or separates you from your baby

As you can see, it can be extremely difficult for a mother to meet these guidelines if she has responsibilities (such as a career or other small children) that will separate her from her baby. I don’t know very many mothers who have the option to nap with their baby every day!

In addition, almost all major health organisations (including Health Direct Australia and American Academy of Pediatrics) recommend against co-sleeping to reduce the risk of Sudden Infant Death Syndrome (SIDS). Interestingly, breastfeeding has been shown to reduce the risk of SIDS. The majority of SIDS cases also involve hazardous risk factors that are largely preventable. If you choose to co-sleep, the Australian Breastfeeding Association have a fact sheet of guidelines which you can access by clicking here. Unicef also have a guide for health professionals to discuss co-sleeping with their patients and you can read that guide here.

To read more about ecological breastfeeding you can click here for a pdf, or click here to purchase the book The Seven Standards of Ecological Breastfeeding: The Frequency Factor by Sheila Kippley.

 

However you choose to navigate the postpartum, rest assured you have a number of effective natural methods that you can turn to for contraception. A qualified Fertility Awareness Educator will be able to guide you toward the method that will be most suited to your individual situation. You can find a Fertility Awareness Educator by clicking here.

 

This online resource is not a substitute for qualified medical advice. Please ensure you discuss your postpartum contraceptive plan with a health professional and/or Fertility Awareness Educator to ensure you are receiving accurate guidance.

 

This article has been referenced from a number of sources including NFPTA-UK teaching materials, The Complete Guide to Fertility Awareness by Jane Knight, Taking Charge of Your Fertility by Toni Weschler, and The Seven Standards of Ecological Breastfeeding: The Frequency Factor by Sheila Kippley.

For further information, click here for a reading list of useful material on women’s reproductive health.

The below specific references have also been cited:

[1] Howie, P. W ., McNeilly, A. S., Houston, M. J., Cook, A., and Boyle, H. Fertility after childbirth: Post-partum ovulation and menstruation in bottle and breast feeding mothers. Clinical Endocrinology (Oxford), 17(4):323–332, Oct 1982.

[2] https://www.contraceptionjournal.org/article/S0010-7824(97)00040-1/fulltext

[3] https://aifs.gov.au/publications/timing-mothers-return-work-after-childbearing/results

[4] Australian Institute of Health and Welfare 2011, 2010 Australian National Infant Feeding Survey: Indicator Results. Canberra: AIHW. URL: http://www.aihw.gov.au/publication-detail/?id=10737420927

[5] https://www.census.gov/prod/2011pubs/p70-128.pdf

[6]https://apps.who.int/iris/bitstream/handle/10665/69855/WHO_RHR_07.1_eng.pdf;jsessionid=C5713FDEE2A70056E45196212478BB20?sequence=1

 

Today, ABC Life published a journalism piece titled “Before You Try Fertility Awareness Methods For Contraception, Here’s What Doctors Want You To Know” which quoted statements from doctors Melissa Kang, Amanda Newman and Black along with editorial by Grace Jennings-Edquist. You can read it here.

The piece concerned me on multiple levels and I felt compelled to write this letter in the hopes that medical professionals are able to provide more accurate information in future. With growing rates of women interested in pursuing less-invasive forms of contraception, I think it is important that we can expect comprehensive, transparent and unbiased information about Fertility Awareness-Based Methods from our primary healthcare providers.

The editorial piece by the ABC focused disproportionately on negative aspects of FABMs, and did not provide accurate or comprehensive information about effectiveness rates. It also provided a misinformed picture of what everyday use of a FABM would look like for women, and displayed a lack of understanding about the importance of cervical fluid by seemingly focusing only on the importance of temperature.

Most disappointingly, it showed a distinct bias against FABMs and did readers a massive disservice by not allowing them access to all of the facts so that they might make their own fully-informed decisions.

My main concerns are outlined below as responses to specific quotes:

 

“The main drawback of these methods: They’re generally less effective than hormonal methods of birth control, because they’re just so damn hard to get right.”

The Symptothermal Method of Fertility Awareness is very simple and easy to use and learn – if you are a strong candidate for the method.

Success relies upon the accuracy of the method itself, the ability of the user to correctly apply the rules, and the willingness of the couple to adjust their sexual behaviour during the fertile window.

In addition, the largest study on the Symptothermal Method was based on those who were practising under the guidance of an instructor – learning with an instructor instead of self-teaching means that the Symptothermal Method need not be “damn hard to get right”.

Finally, we might do well to give women a little more credit for their intelligence. Surely it’s not just me that’s getting tired of this outdated rhetoric being dragged out every time it’s suggested that women might take charge of their own health and wellbeing? These sorts of attitudes seem very prevalent in the medical system where women are reporting gaslighting in disproportionate numbers, have been proven to have to wait longer than men in the ER and be less likely to receive pain killers, and where those with endometriosis are waiting up to seven years for a diagnosis.

With the right support, we are more than capable of learning how our fertility cycle functions.  Checking your cervical fluid for 5 seconds when you go to the toilet and taking your temperature for 30 seconds in the morning is not a hard task and is a great fit with many lifestyles. Interpreting your charts does take time to learn but that’s why we have so many great instructors to work with. You can find an instructor to work with by clicking here.

Of course, the Symptothermal Method is not a good fit for every woman, but a good instructor will identify very early on if this is the case and can then recommend that you choose a hormonal or LARC (long acting reversible contraceptive) option.

 

“The effectiveness of fertility awareness methods is quoted between 75 and 99 per cent, but the sympto-thermal method is thought to be more effective,” says Dr Kang. “The exact rates aren’t really known.”

The symptothermal method has been proven (via a prospective clinical trial) to be up to 99.6% effective with perfect use. This study followed 900 women over 17,638 menstrual cycles and was published in 2007 in the journal of Human Reproduction. Participants were using the Sensiplan Symptothermal Method and were using it under the guidance of an instructor. You can read about this study here: https://www.ncbi.nlm.nih.gov/pubmed/17314078

Typical use rates are less clear. The typical use rate published in the above study was 98.2%; however, typical use rates should ideally be calculated via population based surveys so that they are better reflective of a larger swathe of user demographics and therefore more generalisable to everyday life. The typical use rates we use for most contraceptives are obtained from the U.S. National Survey of Family Growth (NSFG). Rates of use for individual FABMs are too low for the NSFG to provide statistically-accurate typical use rates for each method. Instead, the NSFG provides an overarching typical use rate for all FABMs. Unfortunately, over 80% of survey respondents actually reported using the Calendar Rhythm Method, meaning this overarching typical use rate is skewed downward (and obviously obscures the individual use rates of different methods such as the Symptothermal Method).

In fact, Contraceptive Technology recently tweeted about this and you can read that tweet here: https://twitter.com/ContraceptTech/status/1102952910546259974

The overarching typical use effectiveness rate is estimated to be 85% for all FABMs as published in the most recent 2018 edition of Contraceptive Technology. You can read more about this in a blog post by Dr Chelsea Polis who is a leading epidemiologist with a special interest in the field of FABMs: http://chelseapolis.com/blog/understanding-effectiveness-estimates-for-fertility-awareness-based-methods-of-contraception

All this to say – exact rates for perfect use of the Symptothermal Method ARE known and they are shown to be up to 99.6% effective. Exact rates for typical use are estimated at 85% effective but this is an overarching figure that is skewed downward – as explained above.

 

“”The problem is that I don’t know anybody who’s perfect and you probably don’t know either,” says Dr Newman. For that reason, “if you don’t care if you get pregnant or not, it’s fine, it might delay it,” Dr Newman says — but she wouldn’t recommend it for women who certainly don’t want to fall pregnant.”

I find this statement problematic. I certainly don’t know a single person who is perfect! And yet all of us non-perfect humans are out here using contraception on a daily basis. While this is not such a huge issue for LARCs (long acting reversible contraceptives such as IUDs and implants) where typical and perfect use effectiveness rates are essentially the same, I wonder whether Dr Newman makes the same remarks about the Pill, the Vaginal Ring, the Patch, Condoms and Diaphragms? All of the above methods have typical use rates that are much lower than their perfect use rates and yet they are used by millions of non-perfect humans around the world every day. I find it problematic that medical professionals appear to hold FABMs to higher standards than they do other methods of contraception.

 

“And there is absolutely no doubt that if you really want to avoid an unplanned pregnancy, then natural methods are really not the way to go.” Dr Black agrees, adding: “They’re not cost-effective, those methods, because the cost of unintended pregnancy is very high and very frequent with those methods.”

This statement is reflective of a very strong bias against FABMs or “natural methods”. I would encourage Dr Black to educate him/herself about the actual rate of unintended pregnancy that users can expect when using the Symptothermal Method – as discussed in preceding paragraphs. When counselling patients on contraceptive options, it is important for medical professionals to remember that effectiveness rates are not the only points a patient will be considering. For many women who ‘really want to avoid an unplanned pregnancy’ – there will be other criteria that are just as important, such as avoiding side effects.

I can speak from personal experience here as a Symptothermal Method user who began using the method in 2016. It was absolutely out of the question for me to fall pregnant at that time, but I was also adamant that I did not want to have synthetic hormones circulating in my bloodstream, nor a foreign medical device inserted into my uterus. With all these factors taken into consideration, the Symptothermal Method was the best choice for me… just like it would be for so many other women who never get the chance to hear about it due to bias and lack of education from their primary healthcare provider.

 

“Fertility awareness methods are very hard to get right for women who have irregular periods — and irregularity can be caused if “you’re stressed, because you’re travelling, you’re unwell, you’ve got a cold or something,” says Dr Newman.”

FABMs work exactly the same way whether you have a textbook 28-day cycle or a 150-day cycle caused by PCOS. They still provide the same information – they alert you to the opening and closing of your fertile window and what you do with that information is up to you. However, long cycles will involve extended periods of either abstinence or barrier use (such as condoms), and this can be a very unattractive option for many couples. In this way, irregular cycles can be charted perfectly accurately with a FABM, but the couple should be comfortable with extended periods of condom use or abstinence. If using condoms for weeks or months on end (depending on the length of the cycle) is not an attractive option, then it would be advised that the couple should choose a different method of contraception.

 

“If you get icky about words like ‘mucus’ and ‘cervix’, these methods won’t be for you, as they require getting pretty up close and personal with your body.”

I don’t exactly have an issue with this statement as it is true that many women won’t be comfortable with the level of scrutiny required to accurately use the Symptothermal Method. What I do have an issue with is that the flipside of this statement was never offered – that cervical fluid is an absolutely fascinating hydrogel that provides a wealth of information about your fertility status. Understanding how this fluid changes throughout your cycle can provide women with a huge boost of confidence and body literacy. You can read about how cervical fluid works by clicking here.

Understanding how cervical fluid operates can also erase misguided concerns about “vaginal discharge” – many women spend years of their lives concerned that they have vaginal infections when they are really seeing perfectly healthy cervical fluid. Using a FABM can also mean reassurance for many women who might be curious or worried as to whether they are ovulating. Emphasising the incredible benefits of the level of body literacy that FABMs promote would have been a fair inclusion in this article. Instead, it seems the author chose to focus on the negatives – which really only apply to a small group of women who are uncomfortable with getting acquainted with their own cervical fluid.

 

“If a couple is highly motivated to use a fertility awareness method, “they need to learn to do this properly, and that means learning how to take your temperature accurately and every day,” says Dr Newman.”

This statement again shows a lack of understanding of the Symptothermal Method. The Symptothermal Method requires users to track both temperature and cervical fluid, and in fact it is cervical fluid tracking which can be most confusing for new users. In many cases, understanding how to track and chart cervical fluid is more important than temperature. This is because cervical fluid is influenced by rising oestrogen in the lead up to ovulation. It therefore acts as a warning to the user that ovulation is approaching. Temperature only rises after ovulation, meaning it is a great way to confirm that ovulation has already occurred, but doesn’t give the user any useful information prior to this. This is important because sperm can survive up to 5-7 days in the reproductive tract meaning you need to have at least this many days’ warning that ovulation is approaching.

 

“And keep in mind that fertility awareness methods involve abstaining from sex for the at-risk days.”

This statement only applies to those with a religious reason to avoid the use of barriers. The rest of us? We’re getting down and dirty with barrier methods of contraception during our fertile window – and enjoying stress-free unprotected sex during the rest of our cycle. Barrier methods of contraception can include condoms (male or female), diaphragms, cervical caps and more. For most of us, this is a very small price to pay to be able to enjoy unprotected sex during the rest of our cycle, free from any side effects of our chosen contraceptive. Those who practise a FABM are very aware that barrier use during the fertile window means that we are relying on the effectiveness of the barrier method as opposed to our chosen FABM during this time. In saying this, some studies appear to show that FABM users experience higher effectiveness rates than expected when using barrier methods. The largest study on the Symptothermal Method showed that barrier-users experienced a 99.4% perfect use effectiveness rate while abstinence-users experienced a 99.6% effectiveness rate.

 

Here’s hoping we will see a more informed and well-rounded piece on FABMs by the ABC in future. I would also hope that doctors Melissa Kang, Amanda Newman and Dr. Black will aim to provide less biased guidance to their patients when counselling on contraceptive options.