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12 Objective Markers of Fertility (hormonal dosages, ultrasonography, etc) and Fertility Symptoms"
René Ecochard
CLER France

At least two components have to be taken into account when considering the possibility to use urinary hormonal measurements for identifying the fertile and infertile phase of the cycle : "true variations reflecting blood variations, and measurement errors due to both, the difference between blood variations and urinary variations in the morning voids, and the difficulties due to the measurement itself.

Limiting our description to pregnandiol (PDG), estrone - 1 - glucuronide, FSH and LH the following conclusions can be drawn from our experience and will be discussed during the presentation:

the levels are varying dramatically between women and between cycles, one day results are not sufficient to identify fertility or infertility: algorithms are needed to interpret the results on at least three days in a row, PDG results is much more stable and easy to interpret than other hormonal results, Ratios between hormones are correcting for day to day variations of urinary concentrations, the identification of the post ovulatory phase may be obtained with a high level of precision, the identification of the beginning of the fertile phase remain subject of a high degree of uncertainty.

13 Study of Different Mucus Types
M. Menarguez1, E. Odeblad2
1Pharmacists, M.D., Sección Departamental de Bioética, Universidad Católica San Antonio, Guadalupe, Murcia, Spain.
2M. D. , Ph.D. , Department of Medical Biophysics, University of Umea, Sweden.

Cervical mucus is an hydrogel with many important functions. It is involved in the sperm migration in the cervix, women´s fertile periods etc...This mucus, changes with the menstrual cycle, that means that it has different biophysical and biochemical characteristics along the cycle. That´s why it is an important element to identify ovulation, not only for the gynecologist, but also for women in Natural Family Planning.

Material and Methods
Samples are taken by aspiration of mucus from single crypts, and from the bulk. Part of the sample is spread it out on a slide and dried on air; another part is spread out on a cover slip, and immediately fixed in glutaraldehide 2,5%. The fixed samples are dehydrated, critical point is made and they are observed with Scanning Electron Microscope (SEM). The dried samples are observed with ligt microscopy and scanning electron microscopy.

We obtain different characteristics for each type of mucus. The images show very well how mucus L, S, P and G can be different in fixed and dried mucus samples.

The four different mucus types have been characterized, for the fist time with SEM in dried and fixed samples.

14 Ultrastructure of Estrogenic Subtypes of Cervical Mucus
Vigil P, Riquelme R., Pinto E., Ceric F.
Unidad de Reproducción y Desarrollo, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Chile.

Two main types of cervical mucus have been described during the menstrual cycle: oestrogenic and progestative. Oestrogenic type can be subdivided, according to Odeblad´s model in: L, S1, S2, S3, P6, Pa, P2, P4 and Pt.

The objective of the present work was to correlate the different types of mucus with the day of the follicular rupture (considered as day 0) determined by ultrasound. Cervical mucus samples were obtained from the cervical canal, with the use of an ASPIRETTETM from days -4 to day +1 of the menstrual cycle. Samples were air dried or fixed for SEM and dried by critical point.

The crystallization patterns were studied using light microscopy and the ultrastucture was studied with SEM. The presence of six subtypes of cervical mucus was determined during the periovulatory period: L, S1, S2, S3, P6b and P2. With SEM different types of networks were identified. These types were correlated with the patterns of crystallization found in the air-dried samples of cervical mucus. The L subtype was the most abundant type of mucus during this period and an inverse relationship was found between L and P2 subtypes. P2 and P6 mucus appeared on days -3 and -2 before ovulation.

This work shows a change in the subtypes of oestrogenic mucus in relation to ovulation. The L subtype may have a basic structural function, because of its presence through all the periovulatory period. The differents subtypes of cervical mucus found during the menstrual cycle are probably related to mucus function regarding sperm selection and transport throughout the female genital tract.

15 Viability of Human Spermatozoa
F. M. Fusi

Dept of OB/GYN Istituto Scientifico Ospedale San Raffaele- Milano

Fresh ejaculated spermatozoa are not able to fertilize an oocyte. Before they can determine fertilization, they must undergo a complex series of phenomena, which occur in the female genital tract. At ejaculation, spermatozoa, from their reservoir in the epididimus are mixed with vescicular and prosthatic secretions, the seminal plasma, in order to be placed in the vagina. Seminal plasma is just a transport medium, and spermatozoa can not survive in this medium for more than few hours. More than the 95% of spermatozoa ejaculated in vagina do not survive, due to the acid environment of vagina. When cervical mucus is present, the remaining 5% of spematozoa is captured and can begin the series of modifications called capacitation. Capacitation biochemically consists in the loss of proteins of the sperm coat, and in the modification of the plasma membrane, mainly regarding the content of cholesterol, which increases. Capacitation renders spermatozoa able to move in a hyperactivated way and to undergo a regular acrosome reaction.

In the cervical mucus spermatozoa are stored in the chryptae where they can survive for several days. Due to the utero-tubal contractions, part of spermatozoa are immediately transported to the tubae and peritonaeum. Other spermatozoa are stored and sent in the following days. The mean lifetime of a spermatozoon in the mucus is three days, but reports exist of exceptional conceptions occurred up to nine days after the sexual intercourse. The elements which determine the survival of spermatozoa into the mucus are a) the quality of the mucus, which depends on the characteristics of the cervical glands and on the estradiol produced by granulosa cells b) the quality of the semen, and c) the absence of bacteria in the ejaculated.

Capacitated spermatozoa are then able to fertilize an oocyte, if they can undergo the following modifications. A cohort of spermatozoa recognizes small amounts of progesteron produced by the cells of the cumulus surrounding the oocyte. Progesteron induces in this cohort an acrosome reaction, that is the exocytosis of the enzymes present in the acrosomal cap of the sperm head, a Golgi-derived structure. These enzymes, such as hyaluronidase and acrosin, solve the connections between cells, and allow the passage of other cohorts of spermatozoa toward the oocyte. Several cohorts of spermatozoa are sacrificed to allow few of them to arrive to the zona pellucida, a glycoprotein matrix which surrounds the oocyte. Few spermatozoa are able to bind the zona, have their own acrosome reaction and penetrate the zona. After zona penetration, which in humans is performed by 1 to 10 spermatozoa, spermatozoa become immotile, and are no longer the active element of fertilization. The oolemma extrudes microvilli, which recognize adhesion molecules of the equatorial segment of the sperm head, and in fact phagocytizes the spermatozoon. Once the first spermatozoon is incorporated, due to the exocytosis of the cortical granules of the ooplasma, the egg becomes “hardened” and no more penetrations are possible. This whole process, from the first acrosome reaction to the sperm incorporation takes no more than two hours.

16 Daily Fecundability Estimates and Their Application to fertility Regulation
Bernardo Colombo, Guido Masarotto
Department of Statistical Sciences, University of Padua, Italy

The purpose of the exercise, started in 1992 with the collaboration of seven European Centres, has been to prospectively collect data useful for the determination of daily fecundability estimates. For the purpose of obtaining a reasonable level of precision and allowing differential analyses according to various subgroups of subjects, a target of some 500 pregnancies was planned. Later on it was found possible, at least for some specific purposes, to make a retrospective use of similar data arising from a prospective study done about ten years before in New Zealand. Altogether information was obtained on 7017 cycles, from 881 women, with 575 pregnancies.

Only cycles with at least one day of complete intercourse were considered, with the exclusion of couples with mixed habits and of all cycles with even a single episode of protected intercourse or genital contact. Only healthy women, married or in a stable relationship, of 18-39 completed years of age, with a partner not suffering from infertility, were included in the study. For each cycle it was asked to record daily basal body temperature and mucus symptom, so as to allow the determination of reference days as surrogate markers of the time of ovulation: the day of last low temperature according to the three over six rule and the peak mucus day, respectively. The identification of this last marker was left to the local sites, while the previous one was determined in Padua.

Estimates of daily fecundability were then computed referencing days of intercourse to the conventional marker of ovulation. The width and location of a fertile phase in the cycle were first found. Then the said estimates were obtained, directly for cycles with only one day of intercourse in the fertile window, and through a model in cycles with multiple intercourse episodes.

The pattern of daily fecundability shows that in both cases the four days preceding the day of the conventional marker of ovulation are those with the highest level. The differences between European centres are not statistically significant and allow a reasonable aggregation of all those data. The New Zealand experience shows a different pattern for the level of fecundability, owing to various causes. On the aggregate European group some simple unvariate analysis with fixed effects has been done: only the previous reproductive history shows a significant link with fecundability. But several results need further exploration, still going on. The data base opens several lines for research on relation between physiology, behaviour and outcomes, with relevance to natural regulation of fertility. Some first results will be mentioned.

17 Variation in Fucundity in the Menstrual Cycle
Joseph B. Stanford, MD, MSPH, Ken R. Smith, PhD
University of Utah, Salt Lake City, Utah, USA

The objective of this study is to examine the probability of conception on different days of the menstrual cycle, as defined by the standardized observation of vaginal discharge from cervical mucus.

This is a retrospective cohort study using chart review from records of couples who used the Creighton-Model Fertility Care System at 6 different centers in the United States. Variables related to demographic and medical history were abstracted. All acts of coitus were abstracted, together with the type of vaginal discharge (if any) present on each day, and the type of bleeding (if any) present on each day. The primary analysis uses a statistical model adapted from one previously used for data based on basal body temperature (the Barrett-Marshall-Royston-Weinberg model).

Data are available from 401 eligible couples, of which 288 were of normal fertility at study entry. There are a total of 2407 completely recorded menstrual cycles of observation, and 108 conceptions.

  1. The maximum fecundity occurs from intercourse on the peak day, and the three days immediately preceding.
  2. The presence of high-fertility mucus in the three days prior to ovulation is associated with an crude probability ratio for conception of approximately 1.4, compared to low-fertility mucus.
  3. While women with a history of infertility had lower probabilities of conception than women without such a history, they still had an estimated probability of conception from intercourse on the peak day of about 14%.
  4. Results are pending for analyses of cycle-level probabilities for cycles with multiple acts of intercourse during the fecund interval and the influence of covariates such as age.

The clinical observation of vaginal discharge can be used to estimate the probabilities of conception during different days of the menstrual cycle. It is also a relevant parameter for couples with infertility.

18 Frequency of Intercourse Amoung Users of Natural Family Planning
R.T. Kambic, R.H. Gray, M. Barbato, J.L. Simpson, P. Mena, A. Perez, P. Tagliabue, F. Pardo, Stevenson, J. T.Queenan

This study reports the results of an analysis of intercourse frequency among a group of couples using NFP. The main aim of the study was to examine NFP resulted pregnancies, especially as regards coitus timing and gamete ageing. In this study we use the data registrations of intercourse frequency.

Owing to the geographical differences of the subjects, we have examined the total population, using age of mother, father, number of childrens, and ferttile phase duration.

Despite the differences among the various centres, in none of them we have noticed outstanding variations.

The results have showed a statistically relevant difference between those who want to avoid pregnancy (2.0 monthly intercourse frequency) versus 5.5 monthly intercourse frequency in those who wanted pregnancy.

General population data seem to show a superior monthly intercourse average, but the data are retrospectively collected and often overvalued.

19 Gametes Aging Studies and its Impact on NFP Future
Patricio Mena MD
Profesor Emerito Universidad de los Andes (Chile)

In the seventies two publications indicated that periodic abstinence was related to spontaneous abortion and malformations. These reports appeared later in Obstetrics and Gynaecology Textbooks. In USA some years ago only 14 gynaecologists out of 34000 were NFP providers.

In 1986, Prof. Joe L. Simpson begin a multicentric (Santiago de Chile, Milan, Washington, Bogota-Colombia and Lima -Peru) prospective study in order to examine the possibility that aging gametes in humans could be a cause of spontaneous abortions and malformations. The ideal material were NFP users. In them, 2% of pregnancies were consequence of coitus far of ovulation (Method related pregnancies). Early detection and follow up of all pregnancies until delivery facilitated diagnosis of abortions, pregnancy complications and newborns malformations. NFP charts have shown most probable fecundation coitus and ovulation.

Results: Abortions were 10.4% of cohort. Women with previous abortion having intercourse on Peak day or Peak - 1 had only 7% abortion risk, out of this window, risk tripled to 21%. This is a new knowledge to be used in recurrent abortion patients. Major anomalies were similar to general population (3.1%). Other byproducts of this research: Premature delivery risk was only 6.7%, less than 8-10% in developed countries and much less than 20% in countries with serious socioeconomic problems. Low weight babies (<2500 g) risk was 3.5%, similar to developed countries. Low frequencies was found for pregnancy hemorrhage, urinary infections, genital and other infections, high blood pressure and anemia.

This new information has already been published and obviously should become part of future gynaecology textbooks. WHO, AID and family planning agencies have recognized innocuousness of NFP methods. This should bring a change in world gynaecologists toward NFP. NFP acceptance by these agencies does not mean acceptance of true NFP but only safe use of infertile periods. There is not acceptance of abstinence and this includes the possibility of condoms during fertile periods. Obviously this is not a genuine NFP practice. It is denominated "Fertility awareness". On the other side we can not assure that pregnancies in couples who do not practice NFP with abstinence will get the excellent pregnancy and newborns results shown in this study.

20 The Twoday Method of Family Planning: A simple New Approach
Victoria Jennings, Marcos Arevalo, Irit Sinai, Rebecka Lundgren
Institute for Reproductive Health, Georgetown University Medical Center, Washington, D.C., USA

Established methods of Natural Family Planning, such as the Ovulation and the Symptothermal methods, can be very effective in helping couples avoid pregnancy. Furthermore, they have a number of other reproductive health benefits and can meet the family planning needs of a wide variety of people. However, as surveys in many countries reveal, a relatively small percentage of couples use these methods. One reason for low levels of use is the time involved in teaching and learning the method as well as the complexity of monitoring, recording, and interpreting fertility signs. A related issue is that the availabilaty of these methods is limited because many health and education programs that could potentially offer NFP do not have the resources to train staff and devote staff time to teaching NFP.

A new approach to identifying the fertile window of the menstrual cycle, which addresses these issues, has been developed. The TwoDay Algorithm is based on monitoring cervical secretions, according to a simple standard algorithm: if a woman has secretions either “today” or “yesterday”, she is fertile and should not have unprotected intercourse to avoid pregnancy. If she has no secretions on both days, she is not fertile and may not become pregnant even if she has unprotected intercourse. The TwoDay Algorithm appears to be simpler to teach, learn, and use than current natural methods. A large data set from a World Health Organization study of the Ovulation Method was used to determine the potential effectiveness of the TwoDay Algorithm in identifying the fertile window. Results suggest that it can be an effective alternative for potential users who lack the time to devote to learning more complex methods, do not have access to services that teach these methods, or prefer a method that does not require extensive interpretation of fertility signs. It also may be an appropriate approach for introducing natural methods.

Qualitative studies of the potential acceptability of the TwoDay Algorithm were conducted in Guatemala, Peru, and the Philippines, with positive results. Pilot studies are underway in these countries and will contribute to the final design of a multi-country effectiveness study. Results of the theoretical efficacy test and the qualitative acceptability study will be presented.

21 A New Simplified Calendar-Based method of Natural Family Planning
Marcos Arevalo MD MPH
Georgetown University, Washington DC, USA

Approximately 15% of contracepting couples worldwide report that they use some type of periodic abstinence to plan their families. But many of them lack correct information about their fertility, which hampers their efforts. And most family planning or other reproductive health programs do not offer methods based on periodic abstinence or information about fertility.

A new family planning method has been developed that can be easy to deliver by different types of health programs and easy to use effectively by low- or no-literacy populations. The Standard Days Method is based on counselling all users to abstain from unprotected intercourse on days 8 – 19 of every cycle to avoid pregnancy. Clients are taught to keep track of their cycle days and identify fertile days with the aid of a string of colored beads specifically designed for this purpose.

The contraceptive effectiveness of the 8 – 19 standard window of fertility was theoretically tested by applying it to a WHO data set of over 7600 menstrual cycles. A pilot test of the method carried out at sites in the Philippines and in Bolivia produced good results in terms of effectiveness: of sixty-four couples who used the method, only one became pregnant while following the method’s rule. Three other couples reported that they had broken the rule and had intercourse during their fertile days anyway (and also became pregnant). Results were also good in terms of method acceptability.

The Standard Days Method showed that it can potentially be an effective method of family planning; it can be specially appropriate for underserved, low- or no- literacy populations.

A larger-scale effectiveness study is underway.

Results of the pilot study and preliminary information from the effectiveness study will be presented.

22 Fertility Awareness and Infertility Treatment. An Integrated Diagnostic-Therapeutic Protocol for a Natural Approach to a Couple's Infertility
A.L. Astorri, G. Pompa, E.Terranera, A. Cappella
Center for Study and Research for Natural Fertility Regulation, Catholic University of the Sacred Hearth, Rome, Italy

Objectives In the last fifty years, a constant decrease of average fertility has been reported. In fact already in 1982 a doubled number of infertile couples had been reported in the USA. According to recent WHO’s data, the number of infertile couples today would be 60-80 millions all over the world. The request of medical advice for infertility at our Centre has increased by over 50% in the last 5 years. To cope with this demand, a diagnostic-therapeutic protocol was elaborated aiming at achieving pregnancy in a natural way. The present study was carried out to evaluate the validity and the effectiveness of this protocol.

Methods The couples that addressed to our Centre were included in a protocol that considered the identification of various infertility factors, following an analytic and logical method. The protocol was divided into specific levels of research, applied both to man and woman in parallel, with integrated contribution of a team of specialists (gynaecologist, andrologist, endocrinologist). At the first level of the protocol the couple is expected to learn the Billings Ovulation Method (BOM) which, besides its proved diagnostic value, is very useful to identify the maximum fertility phase, i.e. when the couple have the highest chance to conceive. The mucus symptom recording following BOM instructions had a significant role for the identification of infertility due to a cervical factor as well as for the clinical monitoring of the cervical function.

Results The analysis of infertility factors in the 187 couples in our study showed in 50,27% of cases the coexistence of male and female factors of infertility. Infertility due to only female factors was found in 27,80% of cases. An isolated male factor was detected in 14,44% of cases. A “sine causa” infertility resulted in 7,49% of cases. From the analysis of female factors, a cervical-vaginal pathology was identified in 64,38% of cases. Conception was achieved in 78 couples (41,71%). In most cases (67,9%) the wait for conception was inferior to one year.

Conclusions The significant prevalence of infertility due to combined (male and female) factor proves the validity of the couple’s approach chosen for the protocol. Moreover, the achieved rate of success allows to consider the "natural" way as an effective alternative to the technological solutions that are considered today the most successful, valid and widely advertised, in spite of related ethical problems. Data of the present study suggest a wider spreading of an alternative management of infertility. These data also help to promote medicine as a guarantee to men and women of their reproductive health and to see the recovery of physiological mechanisms the most effective solution for the couple infertility and the true defence of conceived new life against every kind of manipulation.

23 Natural Family Planning (NFP) and Infertility: A Role in Selfcare and Adapted Treatment
Gnoth Chr., Freundl G., Frank-Herrmann P.
German NFP Study Group at the University of Düsseldorf and Department for Reproductive Medicine, Kliniken der Stadt Düsseldorf, Academic Teaching Hospital to the University of Düsseldorf, Düsseldorf, Germany

The reproductive behaviour in western countries has changed dramatically in the last two decades. Parenthood is now well planned often after long education and personal career. If these planned pregnancies do not occur as expected by the couples often early infertility care is demanded with the risk for infertility overtreatment. But late interventions may cause infertility undertreatment. The modern methods of Natural Family Planning (NFP) and the New Technologies offer tools for early diagnosis of infertility with several options on selfcare. A new concept of NFP as a main tool in adapted infertility treatment and selfcare was developed. Lifebirth rates in untreated subfertile populations reach 50% in 36 months. In this time the tools of selfobservation of NFP allow continous selfmonitoring by the couples after exclusion of major factors of infertility (tubal occulsion, anovulation, azzospermia, age > 35). The knowledge of NFP advisors and users should include symptoms of reproductive pathology and signs of cycle disturbances which need to switch to specialized treatment. Specialists for infertility should add NFP methods to their diagnostic tools for cost effective and adapted counselling of subfertile couples.

24 Cycle Characteristics of NFP Users Comming off the Pill and Consequences for NFP Teacing
Frank-Herrmann, P; Freundl, G; Gnoth, Ch; Godehardt, E; Schmoll, A
German NFP Study Group at the University of Düsseldorf, Germany 22% of the participants of the German prospective NFP study have discontinued oral contraceptives before study entry.

Objective It was the aim of the study to determine the cycle characteristics post pill with the help of parameters which can be observed by the women themselves during the cycle (cycle length, cervical mucus pattern, temperature rise, length of the follicular and luteal phases, etc.). The consequences on acceptability, efficacy and teaching of NFP will be discussed.

Methods In an ongoing prospective study 175 women have been observed for 3048 cycles immediately after having discontinued oral contraceptives. They have been compared to a controll group of women, who have never taken oral contraceptives (284 women, 6251 cycles).

Results 53% of the post pill women have normal cycle parameters already in the first cycle. This percentage increases up to 77% in the 3rd cycle and up to 89% in the 6th cycle. The cycle length is significantly prolonged up to the 8th cycle in comparison to the control group. The average length of the luteal phase is significantly shorter up to the 6th cycle. Th follicular phase is significantly prolonged up the 7th cycle. A significant delay of temperature rise and ovulation can be observed until the 8th cycle. It seems that some minor differences between the post pill group and the control group last for more than one year.

Conclusion The side effects of the contraceptive pill concerning the cycle parameters are reversible, however the phase of regeneration takes more time that usually is assumed. Special NFP rules for the post pill situation should consider these results.

25 First Results of a Retrospective Analysis on Natural Family Flanning (NFP) Discontinuation
Franca Crippa1, Vincenzo Bagnardi2
1Institute of Statistics, University of Pavia
2Department of Statistical Sciences, University of Milano Bicocca

The measurement of the performance of family planning methods requires the knowledge of the proportion of user-couples that continue to use the method successfully. Analyzing discontinuation with respect to different causes gives relevant information both on clinical and demographic value of the technique under study. As a matter of fact, the length of use expresses the acceptance of a planning technique. The extent to which it is likely to be used without interruption is therefore crucial.

Multiple decrement life tables (Potter, 1966, Tietze, Lewitt, 1968) allow one to compute such indicators per unit of time that take into account heterogeneity in its various forms. Discontinuation rates, in particular, vary considerably among different strata of users, for different termination causes.

In our paper, we consider scientific natural family planning (NFP): one or more biological symptoms (such as basal body temperature, cervical mucus and others) are self-observed by a woman so as to distinguish the fertile from the infertile phase of the menstrual cycle. We refer to approximately 700 NFP user-couples of C.A.Me.N. advisory center (C.A.Me.N. is the acronym of “Centro Ambrosiano Metodi Naturali”, Milan, a national center for NFP). Personal information was registered at entrance, while data on termination and its causes were collected retrospectively by the center itself.

We move from the impression (Kost, Trussel, 1987) of an alternative between user-couples whose NFP experience is a ‘family planning experiment’ in a long term contraceptive project and others that use it almost permanently. Given the self-selection of the users (quite similar to the National Fertility Survey data), our results support the impression forwarded above; in particular, the short-term attitude toward NFP couples with a phase of a family size in the making.

On the whole, total discontinuation rate is highest at twelve months, it keeps close to 20% at two years from entry and it drops below 10% after the third year. Excluding interruptions due to planned pregnancies, natural methods are dropped because they are found dissatisfactory, as either they are too difficult to adopt or considered less suitable then other contraceptives. Couples successfully overcoming this initial period tend to use NFP longer, as median residual lifetime increases with time. Other causes have little impact, as in particular accidental pregnancy involve a relatively modest number of couples. Observing discontinuation according to women characteristics implies some specifications, as log-rank tests and other statistical methods require checking the hypothesis of proportional risks. Such a discussion ends the paper as a topic of further study.

26 Factors Influencing the Number of NFP Clients of the NFP Teachers
CLER France

We have observed unexplained variations of numbers of clients per NFP teachers The present study tends to identify some of the predictors of these variations

The study design is a case control type : case are NFP teachers having a great activity and control the other NFP teachers whose activity is reduced.

The study factors are the following: place, phone call, organisation of the consulting, money, age of the last child ..

The study was conducted of a total of 180 teachers, in France, Belgium and Switzerland in 1999. We are in process of analysing the data. Final results will be presented at the Milan congress.

27 New Technologies to Detect the Fertile Period
G. Freundl

New technologies are called devices which help the woman to detect the fertile and infertile phase of her menstrual cycle. Such devices depend on events in the cycle which produce measurable symptoms. Such symptoms are BBT, cervical mucus, electrical resistance, hormons excreted in the urine, change of pCO2-content in the air we breathe and some skin symptoms. The lecture will report on devices already on the market and will show which devices are useful tools and are tested by correct statistical methods. Also some suggestions will be made concerning the way of judging them.

28 Evaluation of Fertile and Infertile Phases of the Menstrual Cycle According to the "CAMEN Sympto-thermal" and "PERSONA" Systems: Preliminary Data of an Italian Study
Bozzo G.1, Boerci M.1, Barbarto M. 1, Bertolotti G.2, Grimaudo E.3, Grandi S. 4, S. Cozzolino5
1 NFP teachers at CAMEN of Milano
2NFP teacher Hospital of Pavia
3NFP teacher of La Bottega dell’Orefice, Alcamo, TR. Sicilia
4NFP teacher of La Bottega dell’Orefice, Novara
5MD, gynaecologist trainee, Milan

Between May 1999 and December 1999, "Persona" monitors were distributed to 50 NFP users of the CAMeN sympto-thermal method. In order to verify the use or integration of "Persona" in NFP, the fertile and infertile phases of the female cycle, as defined through the two different modes of reading offered by this diagnostic method, were compared.

The complete charts covering a period of six menstrual cycles which collected all information together with those furnished by the "Persona" maintained daily, as requested, by each user - all experienced and expert in the use of the CAMeN sympto-thermal method - were analysed.

The data compared were: the duration of pre-ovulatory infertility; the duration of fertility; the indication of ovulation; the length of post-ovulatory infertile period. Each participant in the study was invited to define, cycle by cycle, whether there was an intention to achieve or avoid conception.

Firm decisions regarding the reliability of the "Persona" system or of NFP actually made by the couples, cycle by cycle, were also recorded. Data collected up to May 2000 are presented.

29 Applicatioin of Brown's Wvarian Monitor as an Aid in Natural Family Planning.
A.Saporosi1, M.C. Squintani1, E. Giacchi1, A. Cappella1, E. Menini2, J.B. Brown3
1Center for Study and Research for Natural Fertility Regulation,.
2Hormonal Biochemistry Laboratory, Catholic University of the Sacred Hearth, Rome, Italy.
3Department of Obstetrics and Gynaecology, University of Melbourne, Australia.

Today Natural Family Planning (NFP) can be supported by modern technologies which confirm the scientific basis of modern methods of NFP and will encourage the universal realization of the benefits of NFP.The Center for Study and Research for Natural Fertility Regulation (CSRNFR) has introduced the Brown’s Ovarian Monitor (OM) since 1992 after preliminary trials. The OM provides a quantitative measure of oestrone glucuronide (E1G) or pregnandiol glucuronide (PdG) in a timed specimen of urine. It is an accreditated laboratory assay which is simple enough for women to use at home or in an NFP centre. The present study reports a preliminary trial in which the hormonal information provided by the OM is compared to the information provided by the cervical mucus symptoms according to Billings Ovulation Method (BOM). The study also includes a limited comparison with the Unipath Persona system which also uses hormone evaluations.

The OM (St. Michael NFP Services Pty. Ltd., Melbourne) utilizes “homogeneous enzyme immunoassay”. It consists of assay tubes which contain all the reagents for the assay, and an electronic meter which provides a redout in light transmission to measure the rate of enzyme activity. The concentration of hormone is directly proportional to the change in light transmission and is expressed in absolute units by a reference to a standard curve. We recruited 71 volunteers who were studied for 137 menstrual cycles representing 2994 hormone assays or 11 women/years of experience. They collected and diluted urine daily at home and the hormone assays were performed at our Center. The couples were all users of the BOM and, unless specified, were spacing pregnancy. 16 women had irregular cycles requiring occasional periods of prolonged abstinence, 6 were approaching menopause with confusing symptoms, 10 were breastfeeding with returning fertility, 14 had medical-gynaecological pathologies, and 19 were having difficulty in conceiving. They were thus representative of the “difficult” cases presenting to an NFP clinic. Also included were 6 women with regular ovulatory cycles who were studied for at least 6 months so that the symptoms determined by the BOM could be compared with the information provided by the Ovarian Monitor and the Persona system (Unipath Ltd. Bedford, MK443UP, UK).

The couples who spaced pregnancy had intercourse according to the BOM rules but usually used the “PdG cut-off” rule (PdG values³ 7umol/24 hrs) of the OM for having intercourse in postovulatory phase. In some cases the PdG assays were continued throughout the luteal phase to study possible insufficiency. The hormone assays by the OM correlated well with the symptoms observed by the BOM. The first rise from base-line of the E1G values usually occurred on the same day as the first mucus change from the basic infertile pattern, indicating the beginning of the fertile phase. The day of maximum fertility (“Peak day”) by the BOM correlated within 24 hrs with the day of ovulation determined by the hormone assays. The beginning of the postovulatory infertile phase as determined by PdG values ³ 7 umol/24 hrs (the “PdG cut-off”) usually occurred one day earlier at least than the BOM indication. The Persona system showed a very good correlation with the BOM symptoms in regular ovulatory cycles. However, when the Persona did not provide sufficient data to time ovulation (19.1% cases), this could be timed by the BOM, confirmed by OM’s hormone assay. Thus, there is a strong case for users to incorporate the BOM instruction with Persona usage for more accurate results.

Among modern technologies the OM accurately identifies the first oestrogen rise, whether ovulation is occurring or has occurred and its timing, and the adequacy of the luteal phase, under all conditions of ovarian activity. Because of this accuracy in timing, fewer days of abstinence are required for spacing pregnancy than for the other two systems . Therefore, it is more complicated and time consuming. Yet, in its present form, it is not a substitute for the BOM and is best used in conjunction with the BOM for the elucidation of the more difficult cases. However, it offers significant advantages for infertile couples who are sufficiently motivated to use it.

30 Computer Education System for NFP - English Version
Professor, Institute of Computing Science, Pozna University of Technology, Poland

The developed software was prepared for teaching of Natural Family Planning (NFP) methods using programmed learning rules. In many professional papers there is underlined the important fact of learning process quality for efficient factors of NFP methods utilisation. The developed software can support learning process and control knowledge level of users. In learning process there are two different classes of users, taking into account the teachers (instructors) and clients. The system described here allows to collect the clients and theirs actual progresses in the NFP learning, supervising the data base containing all the users. The system is improved in the interactive human-computer interface for supporting the fertility awareness.

In many scientific centres the research for easier application of NFP methods are provided. There are two main approaches. The first one is a construction of special devices to measure hormone changes during the woman cycle. This research has been developed, for example, in University of Melbourne (Australia) and Massey University (New Zeeland) [1]. Second approach is based on the microprocessor technology for construction of the special programmable devices [5]. These systems were programmed according to chosen NFP method and were tested in many countries. PC utilisation for NFP learning started few years ago in Institute of Computing Science Pozna University of Technology (Poland) [2].

Programmed learning idea is very useful for computer implementation [5]. There exist many specialised software for teaching with control of learning on-line process. There is proposed the utilisation of two main features of personal computer system. First one is connected with the possibility of individual creation in learning process respect to the special features of personal perception system. Second one is connected with support for the user especially in many difficulties and duty actions, for example: drawing tables and curves, statistic analysis, solving equations, etc. The utilisation of computer system for fertility awareness was taken into account in previous years [2,5,6]. The NFP methods are named as the ecological methods and there are many peoples interested in these methods contrary to artificial contraception ones [3,4].

The impressive development of new directions of computer science (e.g. artificial intelligent methods, data base systems, rapid multimedia programming tools) suggest the realisation of learning processes using the tools mentioned above. There were also developed the learning software based on the experience with NFP methods and potential possibilities of new computer tools’ applications [5,6].


  • [4] Brown J.B., Blackwell L.F., Billings J.J., Determination of ovarian hormone levels in urine for identifying the fertile and infertile phases of the cycle, Family Health International Expert Meeting, North Carolina, 1984
  • [6] Urbaniak A., Expert system for diagnosis of womens' menstrual cycle using natural family planning method, in: IFIP - System Modelling and Optimization, J. Doleźal J., Fidler J., (ed.), Chapman&Hall, London 1996 (120-127)
  • [8] Flynn A., Brooks M.,. A manual of Natural Family Planning, Unwin Hyman Ltd, London 1996
  • [10] Raith E., Frank P., Freundl G., Naturliche Familienplanung heute, Springer Verlag Berlin Heidelberg, 1994
  • [12] Flejszman M., Urbaniak A., DSS for education of Natural Family Planning, Proc. of 3rd Conference Information Technology in Medicine – TIM’97, Ustroń (Poland), 1997 (in Polish)
  • [14] Urbaniak A., Flejszman M., Owczarzak J., Multimedia didactic software for natural family planning methods, European Institute of Family Life Education, IEEF European Conference, Birmingham, 1997

  • 31 Psychological, Pedagogical and Relational Aspects in the Use of new Technologies for Autodiagnosis of the Fertile Period of the Cycle
    Boerci M., Bozzo G.
    CAMEN Centro Ambrosiano Metodi Naturali Milan, Italy.

    The technological devices for auto-diagnosis of fertility are becoming available to a wider public and NFP teachers are receiving requests for comparison between NFP and the new methods. The new technologies are, in -fact, having impact on the lives of individuals and couples in a way that requires more knowledge, regarding the motivation of the choice, by those that use them. That which, initially, is considered just a technological support, successively raises numerous questions of acceptability and continued use which, often, lead to a course of integration between self-diagnostic capability by observation and the technical data. The following paper will try to explicate the reasons for choosing to use the new technologies and evaluate experiences of living and personal relationships through a possible integration with the scientific and cultural principles of NFP.

    Material and Methods
    The Ambrosian Centre for Natural Methods (CAMEN) of Milan contacted a large group of couples experienced in NFP and agreeable to using, simultaneously, the instrument for hormonal determination of fertility denominated "PERSONA". A questionnaire, regarding the acceptability of "PERSONA", composed of twenty-five points concerning open and closed questions was issued to each couple. The first objective was to sound out the personal acceptability of the instrument's capacity to simplify the interpretation of the diagnosis of fertility and increase the user's security and trust in the technical result. A further question investigated the response of the male partner and the effect it had on the relationship. Furthermore, we evaluated: the continued use, the possible association with contraceptives and the raising of moral implications.

    The results regarding acceptability of the new technology suggested that couples which are expert in self observation rely prevalently on their own capacity and knowledge of themselves, in preference to the technical information. A desire to integrate their own diagnostic capabilities is met with, mostly, in couples who are less experienced in the use of NFP, as a confirmation of their estimate, or in those who wish to share their personal responsibility with the technology to obtain greater assurance. With regards to living relationships, although the male partner appears to initially place much faith in the technological instrument, it does not really affect the serenity of intercourse.

    Diffusion of the new technologies raises many queries, in particular the methodological approach to it is different to that taken towards NFP. It introduces, however, the possibility that the initial approach to the new technologies may lead to NFP in all it's intended aspects, while safeguarding and favouring the capacity of the couple to get to know and understand themselves better month by month The new technological possibilities solicit NFP teachers and users to integrate the technical data into a vision of NFP that helps people to increase their self-awareness and the inseparable elements which constitute it.

    32 "Alec and Sara" - Sex Education Program for Students Between 15 and 17 Years - Results of a Prospective Study Based on 1500 Students of Both Sexes
    Sottong, U.1, Fiederle, X.2, Klann, N.3, Baur, S.4
    11Arbeitsgruppe NFP Köln
    2University of Freiburg
    3Deutsche Bischofskonferenz Bonn
    4University of Munich

    Sex education involves more than just the awareness of the fact that there are two different genders, it is concerned with the problems of girls and boys, men and women and the topic of contraception. Sex education is supposed to help adults to recognize their abilities and needs in their environment. Sex education helps to strengthen ones self-assurance, to improve ones communicational abilities and helps to take each other seriously.

    These assumptions were the basis for a project with the aim to develop materials for sex education in school.

    The book ‘Alec and Sara’ is supposed to give information on reproduction and family planning, to make young people more sensible to their own and their partners bodies and to enable them to communicate about different aspects of sexuality.

    Ten different units tell the story of Alec and Sara vicarious for most young people.

    The material offers didactic suggestions and comments for school lessons, it gives background information and uses photographs about the story of Alec and Sara. Possible topics for school lessons are „Being fertile“, „The ups and downs of hormones“, „Understanding and interpreting the language of the body“, „One needs to talk about thoughts and feelings“

    The project started in 1988 until 1991 with 800 students. Another 740 students were observed in 1996/97and was scientifically evaluated by the Psychological Institute of the University of Braunschweig.. The results show a significant increment of knowledge at the end of the project and even three month afterwards. At the same time they show a significant and increased attitude towards partnership.

    This means, that next to the fact that the students increased their knowledge in this field they started to talk and discuss about partnership and other topics.

    In sum, the results show that the main outcome of this project is the possibility for students to perceive themselves in a new way and to learn to talk with others about themselves and their needs. This combination of self-perception and exercises in communication offers the opportunity to talk about hot topics without touching the intimacy of the single student.

    33 "Happy Birthday" or How a Child Comes into Being
    G. Dahlberg1, U. Sottong2
    1Gesamtschule Hennef
    2 Arbeitsruppe NFP Cologne

    Children and adolescents live in a holistic way. They take on impulses and contextualise them, they integrate their own wishes and expectations but also their prejudices and experiences and thus ‘expand’ the original impulse. The transition between reality and fantasy is often not clearly cut.

    It is a difficult task to give young people an understanding of the wide range of ‘meaning’ of sexuality, to enable them to find their own standpoint and to gain knowledge and at the same time not to neglect the topic of reproduction. This task often fails because of unarticulated fears, problems and worries of educators, parents and teachers,

    In the theatre and through the process of acting, new structure and configurations are explored. It is played, spoken, seen, heard and lived on behalf of somebody else. Writing a play and its performance creates new room for thoughts and ideas but also for personal ‘formulations’ which are orientated on ones own life.

    34 Family Life Education in Polish Schools
    Teresa Krol
    General Inspector in the Ministry of Education, Poland

    Since the 1st of September 1999 a new educational set named “Family life education” has been implemented in all Polish schools by the regulation of the Minister of education. It begins in the 5th class of primary school (i.e. at the age of 12) and lasts till the end of the secondary school (age of approx. 19). It is foreseen for 19 hours per year in each class, delivered in the course of one semester. Educational targets:

    1. Integration of the family and school activities to prepare the youth to the responsible marriage and parenthood.
    2. Supporting the educational role of the family: acceptance and respect in the 661interpersonal relations.
    3. Promotion of the pro-life and health-seeking behaviours – especially in the field of of procreation.
    4. Help in building up the psychosexual maturity.

    Assumptions Systematic realization of the program regulated by the governmental law act enables us to supply children and youth, year by year, with the knowledge of family life – and sexual life education. We have been making an assumption that the introduction of the new subject “Family life education” to schools gives young people the possibility to get to know their sexuality in it’s broadest sense. It helps them to understand their fertility and gives the ecological view on their own health including knowledge of the fertility awareness methods.


    1. Increased awareness of the family influence on human life
    2. Promotion of the firm matrimonial unions based on love, fidelity, honesty and cooperation.
    3. Greater respect for the natural rhythm of fertility inherent to the woman’s cycle in the the future family planning


    1. Students will receive the knowledge regarding their puberty including the bio-psychological and social problems
    2. They will be prepared to cope with difficult situations they may encounter in adolescence (related to puberty, and other9
    3. They will be informed about the ecological, psychological and ethical aspects of NFP and it’s efficacy. The Ovulation and Sympto-thermal methods will be presented.

    Conclusions The Minister of education when introducing the program of “family life education” as a compulsory in Polish schools has been convinced that this program will protect families from crises and enable the young people to avoid any threats of the contemporary civilization.

    35 Significance of Components of the Teen STAR Program
    Hanna Klaus, M.D.
    Executive Director Teen STAR Program Betheseda MD, USA

    The efficacy of the Teen STAR Programme for undergirding virginity and/or facilitating a return to chastity has been reported previously. We now correlate behavioural outcome with programme components of the 1998-99 cohorts.48 French, 23 Swiss and 234 US females age 11-17 followed the 8-month programme which joins experiential learning of fertility signs to a developmental didactic curriculum which includes regular teacher-student interviews; 371 males aged 11-16 followed a parallel programme. A previously validated Likert-type 18 item questionnaire identified demographics, participants’ expectations for future abstinence, control of their emotions, empathy in dealing with others, overall helpfulness of the programme, frequency of topical discussions with parents and friends; age at first intercourse, time of last intercourse, contraceptive use, pregnancy and reasons for abstinence. Reasons for abstinence offered insigh into the locus of control.

    Greater control of emotions, greater empathy with others and overall helpfulness of the programme, were reported by 61-100% of virgin and non-virgin participants. Early adolescents age 11-13 spoke about the course to their parents more often than the older students. 80% of girls and 60% of the boys talked with their friends. Reasons for maintaining chastity showed external and internal loci in the US, but favored internal loci in France. Nearly half of the sexually active male and female participants discontinued intercourse 3 months prior to the end of the programme. Failure to discontinue intercourse was nearly always linked to contraceptive use in all three age groups. 2 miscarriages, one prior, one during the programme were reported.

    Conclusion: Tracking of fertility patterns joined to discussion correlates positively with maintaining virginity as well as a return to chastity. The overall 50% discontinuation rate exceeds that of the general population and can be an important tool for STD and premarital pregnancy prevention.

    36 Psychological Aspects of Coupe Relationships - Prospective Study on 533 Men and Women: Partnership in the Scope of Sexuality and Fertility
    Klann, N.1, Sottong, U.2, Hahlweg, K.3
    1Deutsche Bischofskonferenz Bonn
    2Arbeitsgruppe NFP Cologne
    3University of Braunschweig

    With the help of the following four samples which were chosen by chance, it is examined whether there exist differences between the various samples and gender related differences as such in the area of partnership and sexuality:

    1. clients of marriage-, family- and life counselling offices (N= 111)
    2. people who practise Natural Family Planning (NFP) (N= 158),
    3. people who practise other methods of family planning (N= 101) and
    4. women who consult a gynaecologist (N= 163).

    It becomes evident that women describe themselves as clearly more stressed in a disturbed relationship and that they experience the field of sexuality and ‘physical contact’ more intense and satisfactory in a good relationship than men. In the area of sexuality it is not exclusively the point of frequency of intercourse that is of importance but intense emotional experiences. This study is carried out by the work group ‘Natürliche Familienplanung’ (Natural Family Planning; AG-NFP) in corporation with the Institute of Psychology of the Technical University of Braunschweig, Prof. Dr. Kurt Hahlweg.

    37 NFP vs. Other Forms of Contraception. A Study with Women in the Reproductive Age
    Dr. Rose-Marie Van Hoof
    Catholic University of Louvain (KUL)

    Faculty of Medicine Institute for Familial and Sexuological Sciences

    This study describes the results of a request with 54 women using NFP and 78 women using contraception into their attitudes in their actual relationship.

    Some outstanding features emerge. The difference in attitude concerning contraception method. NFP-users communicate on a better way on this item. They have more esteem for natural and local contraceptive methods. NFP-users choose less for sterilisation of the woman. On a socio-demographic level they work rather part-time or at home, choose more for a classical family type and have a higher number of children.

    There is also a correlation between the relational satisfaction and the use of NFP, but further study is needed to allow definitive conclusions.

    38 Some considerations on the Acceptability of Natural Family Planning (NFP) and the Behavior of the Couple during the Fertile Phase
    F. Crippa1, E. Bagnardi2
    1Institute of Statistics, University of Pavia
    2Department of Statistical Sciences, University of Milano Bicocca

    Coherent use of Natural Family Planning implies the avoidance of sexual behavior at risk of conception during the fertile phase. Partners adhere to NFP rules by adopting personal solutions. The harmony and the communication of the couple are summarized by some data collected by C.A.Me.N. (Centro Ambrosiano Metodi Naturali (C.Am.E.N.) pertaining about 80 users, 45 women and 28 men. Our aim is to gain some information on strategies and responses that arise within the couples and at the individual level in practicing sexual abstinence. The qualitative analysis provides useful items of discussion.

    In the sample, 39,3% of subjects practice total abstinence, while 40% adopt sexual behaviors that exclude the risk of pregnancy. Sometimes such choices are experimented as a source of personal uneasiness and conflict. This is especially true when one or both the partners voluntarily increase mutual distance in everyday activities during the fertile phase, in order to maintain a strict adherence to their previous decisions. On the whole, communication and mutual support within the couple are relevant 89%. Even if 20% of subjects express dissatisfaction, PFN is largely considered an enrichment of the couple’s life, as it enlightens the marital relation under many different aspects, either ethical or sentimental and emotional.

    39 A Comparative Study on the Acceptance of Natural Family Planning (NFP)
    R-Mikolajczyk1, M-Rauchfuß2, S-Bisson3, D-Lamm4
    1St. Joseph Krankenhaus, Berlin, Germany
    2Institut für Sexualwissenschaft und -medizin, Charité, Berlin, Germany
    3Klinik für Geburtsmedizin, Charité, Campus Virchow-Klinikum, Berlin, Germany
    4Gesellschaft für Gynäkologie und Geburtshilfe in Berlin, Berlin, Germany

    Natural Family Planning (NFP) has spread until now only to a relatively low degree in the western European societies despite the favourable social orientation towards the "ecological way of life". However it dominates the family planning in Poland. Therefore the acceptance of NFP is to be investigated in a comparison between a subgroup of a Polish population and a comparable group of a western European society. At the same time the question is to be answered, if an increase in the use of NFP is possible and which factors are limiting to this development.

    A comparative survey by way of self-administered questionnaire was conducted between September 1997 and March 1998 on women in a maternity ward in a hospital both in Berlin (Germany) and Cracow (Poland). The studied groups were chosen primarily because of organisational aspects, but simultaneously they were well suited for the wished comparison. 860 questionnaires were distributed, the overall response rate was 57%.

    12% of the women in Berlin and 65% in Cracow use the concept of cyclical fertility for family planning. 7% in Berlin and 58% in Cracow know about the sympto-thermal method, 44% in Berlin and 87% about mucus observation. 92% of the NFP-use in Cracow is attributed to these two methods. 33% in Berlin and 47% in Cracow regard the sympto-thermal method as well practicable. To 54% in both groups the confidence in the efficacy of NFP would have a strong influence on the decision to its use. According to the problem areas in the NFP-use the doubts about its scientific character are higher rated in Cracow, whereas the observation, abstinence and the fear of the failure in the self-observation are equally rated in both groups.

    The difference in spread of NFP does not result from a different rating of use-related aspects. The NFP-use in Berlin is mainly limited by the low knowledge of newer methods, in Cracow by doubts about its scientific character. A potential for a higher spread of NFP exists in both groups.

    Parenteau, Suzanne, MD
    Seréna-Canada, Montréal, Canada

    The first step in services to parents who choose NFP while a child is breastfed is to help them choosing between the LACTATIONAL AMENORRHEA METHOD, LAM, and observation of fertility/infertility signs during breastfeeding while applying the usual NFP rules.

    With LAM, one counts on the delay in return of fertility that results from intensive breastfeeding. Clinical research has shown that the probability of pregnancy is below or around 1 % if the following 3 criteria are satisfied : 1. No return of menses 2. Full, or nearly full, breastfeeding 3. Baby less than 6 months old.

    If the criteria are still satisfied and if the parents choose LAM, the follow-up is focused on the intensity of breastfeeding and fullfillment of the criteria, until one of them is no longer satisfied. From that moment, observation of fertility/infertility signs must be regular, a chart kept and abstinence rules applied. The latter is also true for the parents who do not fulfill the eligibility criteria for LAM or who do not choose LAM as their first, temporary, post-partum NFP method. Those parents must be followed-up about their awareness of the NFP signs, and later on, about the abstinence rules.

    The first question parents in a breastfeeding situation ask NFP teachers is usually : « When will we be fertile again? » Unfortunately, we can never answer precisely. But we can tell them that the factors of successful breastfeeding : the frequency of feeds and the amount of sucking, the absence of other food or fluids than from the breast during the early months, and very gradual introduction of supplements after 6 months, are also factors of delay of return of fertility. We must add: time elapsed since delivery, and a personal factor that is unknown at the first experience.

    41 Cervical Mucus Pattern During and Post Breastfeeding
    Helvia Temprano
    Unit Human Reproduction. department of Obstetric and Gynaecology. Hospital Teresa Herrera. La Coruña. España

    Identify the most common basic infertile pattern (PBI) and relate the first menses with the type of breastfeeding

    Study Design
    122 weeks of maternal and mixed breastfeeding. We were studied 33 cycles: 30 post breastfeeding and 3 mixed, corresponding to 6 women. 53 samples of cervical mucus were studied: 23 during maternal breastfeeding, 15 with mixed and 15 postpartum period

    During maternal breastfeeding the corticosteroids can produce follicular growth. In the two cases with mixed, the number of sucking/day less than 6, induce the period with a difference of 9/19 weeks. The percentages of types of cervical mucus affirm the chart in the post breastfeeding cycle.


    1. The most common PBI is without mucus during maternal breastfeeding, and more 111easily with mucus, in the mixed.
    2. Relation between return to fertility and less 6 sucking/day.
    3. The percentage of types of cervical mucus are a usuful and objective measurement to 111decide the fertility of a sample.

    Key words: breastfeeding - cervical mucus - lactational amenorrhea method - Natural Family Planning - Postpartum period

    42 Monitoring Infertility and Outcome on Fertility in Breastfeeding Women, Billings Method Users
    E. Giacchi, A. Saporosi, P. Castellucci, G. Pompa, A. Cappella.
    Centre for Study and Research on Natural Fertility Regulation,
    Catholic University of the Sacred Heart – Rome

    It is known that breastfeeding delays the return of fertility after delivery, causing a more or less prolonged infertility. The pattern of prolactin secretion, closely related to frequency of suckling episodes, represents the physiological mechanism responsible for infertility. Scientific studies point out that, when a mother fully breastfeeds for at least six months, she generally remains amenorrhoeic and infertile for the whole period. As full breastfeeding prevents pregnancy in 98 % of cases in the first six month after delivery, breastfeeding is considered a natural method of fertility regulation (Lactation Amenorrhoea Method-LAM).

    The mucus symptom observation according to the Billings Method represents a valuable index for the identification of the infertility pattern and the fertile phase in the cycle. The pre-ovulatory infertility pattern identified by the Billings Method (Basic Infertile Pattern –BIP) corresponds to a situation of ovarian inactivity. Therefore the method can be used in every situation, when the pre-ovulatory phase is prolonged because of a delay of ovulation, or because of its failure. In particular we intended to study the mucus symptom pattern that characterises the physiologically prolonged pre-ovulatory phase and the outcome on fertility in a group of breastfeeding women, users of the Billings Method.

    A study on 60 breastfeeding women wishing to learn the Billings Method to postpone pregnancy was carried out at our Centre. Hormonal assays were performed on 25 women to check urinary oestrogen level underlying their BIP, and/or plasma progesterone or urinary pregnanediol values confirming the occurrence of ovulation. Hormonal plasma assays were performed by RIA methods and urinary hormones by "Homogeneous Enzyme Immunoassay” (EIA), using the Brown’s Ovarian Monitor (St. Michael NFP Services, Pty. Ltd, Melbourne).

    The BIP of dryness occurred in 38,3 % of women as well as the BIP of continuous vaginal discharge. The combined BIP of dryness and of continuous discharge was identified in 21,0 % of cases and only in one woman no BIP was identifiable during postpartum amenorrhoea, as menses occurred during the first two weeks of observation required by the Billings Method for the BIP identification. The oestrogen “baseline” corresponding to the pre-ovulatory ovarian inactivity was identifiable in all the women whose BIP had been monitored by hormone assays. During the time between the identification of the BIP and the first bleeding after delivery the percentage of infertile days available for intercourse ranged from 11,1 % to 91,4% (MEAN 52,8 + 22,4 DS). The first bleeding after delivery occurred during full breastfeeding in 33,3 % of women, in 23,3 % during weaning, in 43,4 % after weaning. The bleeding occurring during full breastfeeding was preceded: in 55,0 % of cases by a not prominent mucus symptom change; in 35,0 % of cases by a prominent change; in 10,0 % by the Peak symptom. The percentage of Peaks resulted to be progressively increased when the first bleeding occurred during and after weaning. Hormonal plasma or urinary assays confirmed ovulation when the peak had been recognised, but in 28,0 % of these cases a luteal deficiency was observed, as the progesterone/pregnanediol levels were found inadequate. However all the women had an adequate luteal phase within 1-7 cycles (MEAN 2.9 + 1.6 DS). Furthermore, we observed lower ovulatory oestrogen levels when a prominent mucus symptom occurred, but no Peak was identified because of its “hill pattern”, and because of the absence of vulvar slippery sensation.

    As a significant correlation between the hormonal milieu and the infertility/fertility pattern identified by the Billings Method was found, we were able to prove the accurancy of this method for monitoring infertility and the outcome of fertility in breastfeeding women. We were also able to confirm that the probability of conceiving is really low while a woman is fully breastfeeding. Despite full breastfeeding, an earlier outcome of the first bleeding was observed in our study with respect to other authors' observations. In fact, the first bleeding occurred in a range of 4-27 weeks from delivery (MEAN 15 + 5,8 DS). The observation of frequent luteal deficiency both before and after the occurrence of the first bleeding after delivery needs to be underlined. This may be the cause of the possible difficulty in carrying on a pregnancy for a few cycles after the outcome of ovulation in breastfeeding women. In conclusion, our experience suggests not to rely totally on a “presumed” infertility, when the outcome of a normal pattern of fertility can be well monitored by the mucus symptom in a simple and effective way.

    43 Categories of Cervical Secretions in Breastfeeding Women: How Much Specificity is Enough
    Irit Sinai, Marcos Arevalo, Victoria Jennings
    Georgetown University, Washington DC, USA

    Some methods of Natural Family Planning (NFP), such as the Ovulation Method and the Symptothermal Method, rely on the identification of changes in cervical secretions. To use these methods, women learn to differentiate between multiple characteristics of their cervical mucus and to correctly interpret and chart their findings. This allows them to identify their fertile window – the days each month in which they are most likely to conceive if they have intercourse. But is this detailed observation really necessary?

    We answer this question using data of 73 breastfeeding women in Australia, Britain, and Canada, collected by Family Health International from 1986 to 1990. The women were experienced users of the Symptothermal Method of NFP, and were followed starting 42 days postpartum for up to 13 cycles. Study participants were required to identify each day the appearance, amount, stretchiness, and sensation of their cervical secretions.

    Results suggest high correlation among some of these indicators, implying that for breastfeeding women, less detailed observation may be sufficient to accurately identify the fertile window.

    44 Lactational Amenorrhea Method (LAM) Simulation According to Sympto-Thermal Charts
    Suzanne Parenteau, Michelle Houde, Lise Cantin-Durivage and Denise Laflamme
    Seréna Canada, Montréal, Canada

    A review has been made of postpartum sympto-thermal charts with pertinent information about the LAM.

    Estimate the probability of pregnancy if LAM would have been used.

    The estimated probability of pregnancy with LAM will be less than 2 %.

    Data were gathered retrospectively from postpartum sympto-thermal charts of Natural Family Planning (NFP) users. Relationships have been analyzed among the resumption of menses, the shifts in temperature followed by a high level of 8 days or more, the peak mucus symptom, the breastfeeding status and time postpartum. Resumption of menses was defined as 3 contiguous days of bleeding and / or spotting. Full breastfeeding was considered ended when any supplements were given for 7 consecutive days.

    This analysis includes 273 breastfeeding experiences from 184 women aged of 17 to 40 with a mean age of 28,4 years who breastfed and fully breastfed for an average of 12,3 months and 4,6 months respectively. The mean parity was 2,3 children.

    For 262 breastfeeding experiences, data were available to estimate the probability of pregnancy according to LAM criteria. Lifetable calculations give a probability of 3,6 ± 2,5 % for having a temperature shift of 8 or more days during amenorrhea and full breastfeeding at 6 months postpartum. Since the probability of pregnancy in a normal ovulatory cycle is recognized to be 25 %, the probability of pregnancy, if the Canadian sample would have used LAM, is estimated to 0,9 ± 0,6 % at 6 months postpartum.

    LAM is a valid option as an introductory method of NFP. It is an easy method that combines the benefits of intensive lactation for the mother and for the baby. Alternative definitions of full breastfeeding have been explored.

    45 The 3 Years Project in Promoting NFP in Guangzhou (China)
    Ramon C. Ruiz
    The Hong Kong Catholic Marriage Advisory Council, Hong Kong, China

    A 3-year project, 1.4.96 – 31.3.99, was sponsored by MISEREOR and MISSIO in Guangshou (Canton), China, in the promotion of the Sympo-thermal method of NFP. It was approved by the Beijing (Peking) Family Planning Authorities.

    A total of 30,630 people have been reached through lectures and interviews. Many more through radio programmes, TV talks, newspapers articles, pamphlets and sale of NFP booklets.

    A total of 973 clients were studied. Some left the study. The remainder gave 14 unplanned pregnancies of which 12 were due to intercourse in the fertile time by mutual (both husband and wife) consent, 1 in the first phase and 1 in the second phase. Failure rate per 100 woman years was… User P 3,5 Method P 0,4.

    The method is acceptable to clients in Guangshou.

    46 Natural Family Planning in Latin America: An Informed Choice?
    Rebecka Lundgren, Javier Rodriguez, Saleg Eid, Jeanette Cachan, Jennings
    Institute for Reproductive Health, Georgetown University Medical Center, Washington, D.C., USA

    Many couples in Latin America use some type of natural family planning (NFP) method. However, few have any formal training in NFP, and often do not understand how to use it. Most Latin American organizations that provide NFP have limited capacity, and few multi-method family planning programs provide the information necessary for clients to select and effectively use a natural method. Clearly, strategies are needed to expand the availability of NFP services. Three studies were recently completed to provide information needed to develop strategies for NFP expansion.

    A regional policy study was conducted to explore the feasibility of expanding NFP through existing organizational structures. It consisted of interviews with key informants in seven Central American countries, including representatives of government health services, the Catholic Church, NFP organizations, non-governmental family planning organizations and donors. Significant infrastructural and programmatic weaknesses of NFP organizations limit their ability to expand services. Multi-method family planning providers were confident of their ability to provide natural methods, despite having no formal training or experience in NFP and having incorrect knowledge of basic concepts. Most respondents stated their willingness to form new partnerships to offer NFP, although specific reservations were raised.

    A diagnostic study in Honduras to determined how couples decide whether or not to use NFP, and whether multi-method family planning providers offer adequate information on NFP. Study methodology included 75 simulated client visits to services, 85 exit interviews with family planning users, 40 follow-up in-depth interviews, and 35 interviews with individuals who were identified as influential in family planning decisions. In addition, 30 interviews were conducted with providers. Study findings suggest that women receiving family planning services in Honduras do not receive adequate information to ensure informed choice regarding natural methods.

    A pilot effort was carried out in Bolivia with Catholic Relief Services, which coordinates with NGOs and the Ministry of Health in providing health services in rural communities. Community promoters were trained in NFP and provided NFP services in addition to their many other responsibilities. Interview with promoters revealed the importance of on-going technical support, supervision and encouragement to maintain quality of services. Data from these interview and from those with CRS technical staff and NFP clients suggest that NFP is an important mechanism for expanding the role of CRS and its partners into reproductive health.

    Based on the results of the policy and diagnostic studies, strategies to expand the availability of NFP services have been developed and studies are underway to test them.

    47 Family Planning - Individual, Global and Ethical Aspects
    Frank-Herrmann, P.
    German NFP Study Group at the University of Düsseldorf, Germany,

    Family planning has an individual, political, socioeconomic and ethical dimension and deals with gender aspects and sexuality. Some people think that the progress of mankind is linked to the population problems and to family planning.

    What are the actual facts and the future aspects and values in this area and what could be the role of natural family planning.

    I would like to illustrate some factors and values which according to my opinion seem to be necessary for a responsible parenthood on the individual and global level.

    48 Woman's Different roles in NFP, Within the context of the Culture of Life
    Montserrat Rutllant, Eyra Sanidas, Esperanza Coll
    Spanish Association of NFP Teachers

    Recently, post-feminism is developing with a more complete and broad point of view of the women's role in the different fields of society in the XXI century.

    The culture of love and life must include not only women's task as a wife, a mother, in family life, but also as a professional, in the university, investigation fields, sanitary and political areas, complementary to men's task in the humanization of culture.

    49 "Concealed Body Language" - Ways of Using the Fertility Awareness Program for Women's Health Projects
    U. Lennartz, P. Klann, U. Sottong
    Arbeitsgruppe NFP Cologne

    One of the main topics at the conference in Peking 1995 was the strengthening of girls and women as means of prevention of violence, abuse and any form of addiction. In addition there was and still is the aim to give girls and women the chance to become aware of themselves and to go their own self-chosen way. Only the woman who is able to live her life in a self-responsible way is prepared for the different phases of life. This enables women to cope with problems and demands which arise when it comes to the compatibility of occupational activities and family life.

    The life and health of women are strongly combined with reproduction. „ Concealed body language“ is a concept which aims to enable women to observe their bodies more consciously and to react in a self-responsible way to body-signs as a form of prevention and health advancement for themselves and their lifes.

    This material which has been developed and evaluated between 1991 and 1999 is designed for multipliers who work with women and who need concrete suggestions, copies, illustrations and so forth.

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