In Our Control (36 page)

Perhaps because of the association of natural birth control with religious values and—to those on the outside of these institutions—prejudices, it has been difficult to build alliances between educators who are experienced in teaching natural family planning and women’s health organizations and clinics. As a result, many educated women are unaware that these options exist.

Toni Weschler began teaching fertility awareness in the early 1980s. Weschler embraced a symptothermal system that synthesized taking basal body temperatures and watching changes in cervical fluids and position. In 1995 she published
Taking Charge of Your Fertility,
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a truly radical book that instructed women in how to use fertility awareness methods to prevent or encourage pregnancy, and also simply to improve awareness of reproductive health, all from a secular, feminist perspective. Weschler’s point is that the FAM is the only method of family planning that is useful at all points in a woman’s reproductive life, from menarche to menopause, and if she chooses, for contraceptive and reproductive purposes. While
Taking Charge of Your Fertility
explains how to use FAM to prevent pregnancy and also to monitor gynecological well-being, Weschler tells me that the book attracts many more women who are looking to get pregnant. She theorizes that the book’s title may be part of this trend. It is telling that women pursue detailed, complex information about their bodies and menstrual cycles only in the context of trying to have a baby, when such knowledge would be useful in so many other contexts.

Another option for predicting fertility is to use devices such as fertility monitors and saliva tests to predict when ovulation is about to happen. Ovulation predictor kits test for the presence of luteinizing hormone (LH). Bursts of this hormone are usually followed by ovulation within twelve to thirty-six hours. Fertility monitors can be inconsistent, but they represent a technology that is still developing and changing, offering the promise of improved predictive powers in the future. A 2004 test of one such monitor, the Clearplan Easy, found that it has the potential to help
women narrow the window of time during which they can consider themselves fertile. However, fertility devices can still only predict ovulation around two days in advance. Since sperm can live for five days, this means a woman using a fertility test can easily become pregnant from sex that happened days before ovulation. Because of this, these technologies are best used in combination with other methods, such as the observation of cervical fluids.
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As Weschler notes, “These monitoring tests can be superb in adding yet another piece of evidence to corroborate the other fertility signs that women observe, and I personally believe that the more signs you chart, the more effective the method will be.”
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Rules of the Road: A Basic Outline of FAM

The method popularized by Weschler is exactly the more complicated set of practices that worried the researchers at Georgetown and women’s health educators all over the world. And yet, Weschler insists, it is simple and can be practiced in just minutes a day. What is outlined below is a basic description of the method—it is not intended to teach its use. Anyone interested in learning or practicing fertility awareness should talk to a doctor or health care professional, get a book specifically on the subject, or take a class on the method.

The first step is to get a chart where you can record various information throughout the month, including start date, cycle day, waking temperature, vaginal sensation, position of cervix, cervical fluid, whether you have sexual intercourse, and any other information that might be relevant in understanding the cycle—for example, recording food cravings or mood swings might help to diagnose and treat premenstrual syndrome. These charts can be found in books and photocopied or downloaded online. Fertility charting has, like everything else, gone digital in recent years. Jane, a thirty-something midwesterner tells me that she uses an online service that stores her charts and allows her to update from her phone.

On the first day of your cycle, begin taking your temperature with either a digital thermometer or a basal body glass thermometer upon first waking. This means leaving the thermometer by your bed and sticking it in your mouth before you get up, go to the bathroom, brush your teeth,
have breakfast, or move in any significant way. Some people believe that taking the temperature vaginally is more accurate, and if you are having trouble with taking it orally, you can try this, but make sure to be consistent—don’t switch between oral and vaginal readings in a certain month. To be accurate, you should have gotten at least three hours of sleep. It’s best to take the temperature at approximately the same time each day, as each hour of variation can cause slight inclines in temperature and can skew your results. Record your temperature on your chart, connecting the circles each day to form a line that goes up and down as the month progresses and shows how your body changes day to day.

The day your temperature rises noticeably—at least two-tenths of a degree higher than it has been for six days—use a ruler to draw a straight line across the entire chart at one-tenth of a degree above the highest temperature for the previous six days. Once your temperature has stayed above this “coverline” for three consecutive days, you can assume that ovulation has occurred and that you are no longer fertile for the month. If your temperature goes up but doesn’t stay above the coverline for three days, you must start counting again when it returns to a level above the line.

Remember this can be complicated by many things, from daylight savings to changing time zones to having a lot of alcohol the night before to having a fever. It is normal to have outlying temperatures that aren’t the result of ovulation, and you must be very careful when deciding that ovulation has indeed occurred.

After taking your temperature each morning, you should check your cervical fluid. This can begin as soon as you finish your period. Weschler advises, “Focus on vaginal sensations throughout the day (i.e., Does the outside of the vagina feel dry, sticky, or wet? Does it feel like you are sitting in a puddle of eggwhite?)”
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When using the bathroom throughout the day, check fluid by using clean fingers to separate the vaginal lips and use either tissue or fingers to gather a small bit of secretion between the thumb and pointer finger. Feel the fluid on your fingers before looking at it and notice if the texture is dry, creamy, pasty, or sticky. Observe the fluid and slowly draw your fingers apart. When women are preparing for ovulation, fluid will often stretch between fingers to distances of an inch or two and be clear in color like an egg white. Record observations about cervical secretions on your chart, being sure not to confuse other fluids—such
as semen, spermicide, or wetness resulting from sexual arousal—with cervical mucus. Because these substances can confuse charting, be sure not to chart if you have just had sex or used another form of contraception that involves spermicide (such as a diaphragm). Also be aware that many prescription drugs, including antihistamines and antibiotics, can affect cervical fluid. Try to check this fertility sign at least three times a day. With practice, women can identify their “peak” day: the last day of high-quality cervical fluid before ovulation happens, and, as the name suggests, the best day for having sex if pregnancy is desired.

Cervical position can be determined by squatting and inserting just-washed fingers into the vagina and feeling the entrance to the uterus. The cervix, a tiny pink nub, serves as the boundary between the womb and the vagina. At the beginning of the cycle, the cervix is low and hard. As days pass and hormones begin to flow, it slowly rises and begins to open and soften, preparing to welcome sperm as ovulation becomes imminent. (Women who have delivered children vaginally will always have a slightly open cervix). Once ovulation is over, it returns to its original low, closed position.

Keeping track of these three signs will help a woman determine when she is fertile. During fertile days, sex should either be avoided or a barrier method of contraception used. Remember, hormonal contraception like the Pill is incompatible with natural methods because women taking estrogen and progestin for birth control don’t have true menstrual cycles and don’t usually ovulate. Use of condoms, female condoms, diaphragms, and cervical caps is compatible with fertility awareness as long as you are able to correctly observe cervical fluids.

There are many things that can happen biologically that complicate or compromise FAM, including breastfeeding, perimenopause, chronic illness, thyroid problems, polycystic ovaries, and profoundly irregular cycles. Much like calendar-based methods, these contraceptive techniques work better for women with more regular menstrual cycles. Unlike calendar methods, FAM and symptothermal methods can account for more natural variation between cycles. If you fall into any category that makes using FAM more complicated, be sure to seek special counseling and assistance before attempting to use the method, and be aware that you may have risks that other women don’t have to deal with.

Clinical evaluations of symptothermal fertility control suggest that they
are highly effective. When used correctly, they approach hormonal contraceptives in their ability to prevent pregnancy. Of course this varies much more than other methods with imperfect use: when mistakes are made, it is an unforgiving method. A 2007 German study found that in a group of nine hundred women, fewer than two out of every hundred became accidentally pregnant, a failure rate of between .4 and .6 percent.
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Unlike many scientists studying FAM, who worry that subjects will find the method too complicated, lead researcher Petra Frank-Hermann isn’t concerned about the ability of women to follow FAM guidelines: “The women or couples who want to learn the method have to buy a book, or attend an NFP [natural family planning] course, or get some teaching by a qualified NFP teacher. Learning STM [symptothermal method] is usually no problem. There are precise rules that work. However, in contrast to the oral contraceptive pill or other family planning methods, STM needs more engagement and time to learn it.”
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I believe that this confidence in the abilities, motivation, and intelligence of adult women is warranted. If we want to take serious steps toward reproductive health, this sort of respect on the part of researchers and health educators is fundamental.

Making It Work: Questions and Controversies with Natural Birth Control

The major issue for most women when making a decision about birth control is efficacy: does it work, and how well does it work?

Sometimes it can be difficult to assess the efficacy of natural birth control because the multiplicity of methods and the complex process make it hard to study. Perfect use failure rates range from less than 1 to 9 percent,
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and actual use rates are often unavailable or inconsistent, but are much higher, undoubtedly in double digits. Many trials have serious methodological problems, including high dropout rates, which make conclusive data hard to come by.
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Determining if something works, however, means more than pulling apart ideal and actual use rates in a study. It means weighing risks and benefits in a real-world context. While fertility awareness has many upsides—lack of chemical intervention in the body, practically no financial
cost, and improved awareness of overall reproductive health, to name just a few—it also has significant considerations. First, it is a method best practiced by committed couples. While this aspect is in some ways a result of how the technique has been framed by the religious communities who have nurtured and developed it, it is important to note that FAM doesn’t provide protection from STDs and is a method that relies heavily on good partner communication. Second, it is a method best practiced by those for whom an unwanted pregnancy would not be devastating, either because they are able to have a child or have no moral objection to abortion.

When women opt to practice natural birth control, particularly FAM, they take responsibility for their reproductive choices in a way that is unique and radical. There is no pharmaceutical “big brother” sitting over your shoulder making sure that you don’t mess up. If you use this technique and get pregnant, you have no one to blame but yourself. But I see that as a good thing in many ways. Much of the conversation about birth control insists that if women have the means to control fertility, they will have more choices. Most of these means, however, fail to trust women with the basic abilities and motivations to act in a manner that reflects their desires and expresses autonomy.

Women want to be in control. For this reason, when they encounter natural birth control for the first time, they are often seized with the passion of a convert. This can be good and bad. It provides the energy to be diligent in learning and performing the method, but it can imbue women with a false sense of knowledge about their body. Some become convinced after a month or two of use that they “know” when they are ovulating. Others lose zeal with time and continue practicing some aspects of the method but not others. Toni Weschler addresses these tendencies, noting, “One word of warning about taking shortcuts: once you decide not to chart every day, it can be very tempting to slack off and either chart even less than recommended, or stop altogether, convincing yourself that you just
know
when you’re fertile.”
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Weschler says that this sort of overconfidence is one of the top reasons that women have unplanned pregnancies using the method. If you want to use this type of birth control, be warned that there are no shortcuts.

A young graduate student from a northeastern American college shared her story with me, illustrating the perils of this thinking: