The Complete Guide to Fertility Awareness

Jane Knight

• Publisher: Routledge
• Year: 2016
• eBook ISBN: 9781317654216
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

Fertility Awareness is key to understanding sexual and reproductive health at all life stages. It can be used to either plan or avoid pregnancy. Fertility Awareness Methods (FAMs) are highly effective when motivated couples are taught by trained practitioners. These methods are in demand for ecological, medical, cultural, religious and moral reasons. The ability to control fertility naturally is a lifestyle choice.

The Complete Guide to Fertility Awareness provides the science and methodology suitable for health professionals and a general audience. It covers reproductive physiology and the fertility indicators: temperature, cervical secretions and cycle length calculations. It explores ways to optimise conception and to manage conception delays. Case studies and self-assessment exercises are included throughout. The book addresses the scientific credibility of new technologies including fertility apps, home test kits, monitors and devices.

The Complete Guide to Fertility Awareness offers:

• evidence-based information for general practitioners, practice nurses, school nurses, midwives, sexual health doctors and nurses
• a unique perspective on subfertility for gynaecologists and fertility nurses
• an authoritative source of reference for medical, nursing and midwifery students
• a straightforward and practical reference for new and experienced FAM users
• the core text for the FertilityUK Advanced Skills Course in Fertility Awareness

Part I
Scientific background and methodology

1
Overview of Fertility Awareness

The term fertility awareness (FA) is used in different ways. It is essentially an educational process which provides individuals with a better understanding about fertility so that they are in a stronger position to make informed decisions about how they wish to both manage their reproductive health and take control of their fertility.

In the 1990s the Institute for International Studies in Natural Family Planning (Georgetown University) defined FA as:

Basic information and education on male and female reproductive physiology as it relates to fertility. For a woman this includes the ability to identify and interpret the signs, symptoms and patterns of fertility throughout her menstrual cycle. For a man it includes understanding his own reproductive potential. For both women and men, it contributes to their knowledge about their combined fertility at different stages throughout their lives and to their ability to communicate about fertility issues with health professionals and one another. [300]

The Institute for Reproductive Health (IRH), formerly the Institute for International Studies in NFP, now proposes a much broader definition of FA and one which more appropriately defines the ongoing educational process:

Fertility awareness is actionable information about fertility throughout the life-course and the ability to apply this knowledge to one’s own circumstances and needs. Specifically it includes basic information about the menstrual cycle, when and how pregnancy occurs, the likelihood of pregnancy from unprotected intercourse at different times during the cycle and at different life stages, and the role of male fertility. FA also can include information on how specific family planning methods work, how they affect fertility, and how to use them; and it can create the basis for understanding, communicating and correctly using family planning. [301]

Fertility Awareness: Education through Reproductive Life

Men and women have a right to understand their differences in reproductive physiology and their combined fertility potential. A man needs to understand that he is always potentially fertile, producing sperm continuously from puberty until well into old age; but the reproductive lifespan of a woman is much shorter by comparison: from menarche (first period) to menopause (final period), and her fertility is cyclical.

A woman’s reproductive lifetime can be roughly divided into four ages:

• ■ teenage years with the menarche and emerging fertility (12–18 years);
• ■ most fertile years (18–35);
• ■ mature years with declining fertility (35–45); and
• ■ peri-menopausal years with cessation of fertility at the menopause (45–55).

Family planning needs and intentions are likely to change throughout reproductive life, starting with a very strong need to avoid pregnancy, to a more relaxed approach when contemplating pregnancy, a time of actively trying to conceive, postnatal recovery and breastfeeding, family spacing, followed by a strong need to avoid pregnancy again when limiting the family.

A key insight from the 2013 National Survey of Sexual Attitudes and Lifestyles (Natsal3): a poll of 15,000 Britons (aged 16–44) revealed that people are having sex earlier and having children later, which means that, on average, women in Britain spend about 30 years of their life needing to avert an unplanned pregnancy, yet many are not being informed about or offered the full range of services. [401]

FA education provides fundamental knowledge at all stages of reproductive life:

• ■ FA helps young people to understand bodily changes associated with puberty and emerging fertility. It explains reproductive physiology and normal variations in the menstrual cycle, helping to distinguish between normal physiological vaginal secretions and pathological discharges including sexually transmissible infections (STIs). FA improves understanding about the vulnerability of the reproductive organs, the potentially damaging effects of STIs and the importance of protecting future fertility. This is sometimes referred to as reproductive health awareness (RHA).
• ■ FA information helps people to understand family planning choice, how different methods work, how a method interrupts fertility, how it fails if not used correctly and how fertility returns after the method is discontinued. Fertility awareness–based methods of family planning should be offered alongside other methods as part of a comprehensive sexual and reproductive health service.
• ■ FA-based methods of family planning are sometimes referred to as FAB methods, but referred to here as Fertility Awareness Methods (FAMs). They include all methods based on identifying the woman’s fertile time. It is essential to understand the length and variability of the menstrual cycle, the timing of ovulation during the cycle, changes in cervical secretions, changes in waking temperature and the effect of intercourse timing on the probability of conception. FAMs can be used to avoid pregnancy through natural family planning (NFP) requiring abstinence during the fertile time. They can also be used in combination with barrier methods or withdrawal. FAMs can provide effective family planning at all stages of reproductive life.
• ■ FA information helps couples to plan pregnancies and optimise preconception health; this can be particularly beneficial if they are having difficulty conceiving. Fertility-focussed intercourse may reduce time to pregnancy and avoid unnecessary fertility investigations and treatments. FA knowledge also helps to accurately time fertility tests and investigations. FA education should be a fundamental part of primary care preconception advice when couples first report difficulties conceiving.
• ■ FA information helps people to a better understanding of the woman’s reproductive lifespan, to consider the “right time” to have a baby and the risks of delaying childbearing, recognising that assisted fertility such as in-vitro fertilisation (IVF) cannot compensate for lost years.
• ■ In the first six months after childbirth, women who are fully breastfeeding and amenorrhoeic can make use of the natural time of infertility or Lactational Amenorrhoea Method (LAM) to space their families.
• ■ n FA information can help women to understand cyclic changes associated with declining fertility approaching the menopause, the onset of permanent infertility and post-menopausal changes which may be pathological.

FAMs fulfil the broader definition of family planning which encompasses reproductive health, planning a family as well as avoiding pregnancy. Family planning is about deciding if and when to start a family, and determining the number and spacing of children. Family planning needs change with age and social circumstances, and although practical instruction in FAMs may be requested only by a small percentage of women, there are many more who can benefit from general FA information. [475]

Health professionals need to improve women’s knowledge about fertility at all ages and stages: from young people’s contraception and sexual health services, through primary care to specialist preconception and fertility clinics, maternity services and menopause clinics. This life-course approach fits with the 2011 Royal College of Obstetricians and Gynaecologists (RCOG) report Women’s health care: A proposal for change, which states that

The women’s health network concept is about a woman-centred life-course approach based on the principle of the right care, at the right time, in the right place and provided by the right person…. The life-course approach sets out to maximise every opportunity that the health service has with a woman to improve her lifestyle and her general health, ultimately to improve her outcomes irrespective of her situation in society. Adopting such an approach to delivering health care will provide women with consistent information from a young age, enabling them to make better decisions about their health…. Reproductive and sexual health are relevant to almost all women and unfold across the life course; by default, health care needs are more predictable over a woman’s life compared with, for example, sporadic disease episodes. [494]

Women’s Knowledge of Fertility

Despite our sexually enlightened age, knowledge about fertility generally remains poor. A UK survey of fertility and reproductive health knowledge, conducted in 2007 by the Family Planning Association (FPA) and National Opinion Polls, reported that 29% of respondents thought short bursts of vigorous exercise, douching or urinating would stop a woman from getting pregnant after sex; 50% gave the wrong answer or did not know when the most fertile time is in a woman’s menstrual cycle; and 89% gave the wrong answer or did not know that sperm can live inside a woman’s body for up to seven days [182]

Most women lack a clear understanding about the fertile time. In the late 1990s, nearly 1,500 postnatal women were surveyed in South America, revealing that almost 60% of pregnancies were unintended. A substantial proportion of the women could not identify the time during the menstrual cycle when conception was most likely to occur: 40% thought conception was most likely mid-cycle, 25% thought conception was most likely immediately after a period and 7% thought conception was most likely just before a period. Almost 30% gave miscellaneous answers, including identifying menstruation as the most likely time of conception. The younger women were less knowledgeable about the fertile time. [219]

One might anticipate that women who are trying to conceive and actively seeking fertility knowledge may be better informed about their fertile time, but this is not necessarily the case. In 1997, a fertility clinic in New Zealand assessed the fertility knowledge of 80 new patients. Only a quarter of the women were considered to have an adequate understanding of FA to optimise conception, supporting the study hypothesis of a generally poor level of fertility knowledge among women presenting for treatment. [54] Similar results were found in a 2006 clinic audit. Of 281 women who had been trying to conceive for an average of one year, 50% were using ovulation predictor kits (OPKs), and 30% were using cervical secretions to optimise sex targeting, but less than half of the couples were estimated to be targeting the full width of the fertile time. [611]

In 2008, two fertility clinics in Australia conducted a questionnaire survey on the knowledge, attitudes and practices of 204 women, most of whom had been trying to conceive for more than a year:

• ■ 87% had used books and the Internet to try and improve their FA knowledge;
• ■ 68% believed they had timed intercourse to the fertile time, but
• ■ only 13% could accurately identify their a...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• CONTENTS
• Preface
• Acknowledgements
• Abbreviations
• List of figures
• List of tables
• Images and permissions
• PART I Scientific background and methodology
• PART II Avoiding pregnancy
• PART III Achieving pregnancy
• PART IV Teaching fertility awareness
• Appendices
• Bibliography
• Index