The Billings Ovulation Method (BOM) is a method which women use to monitor their fertility, by identifying when they are fertile and when they are infertile during each menstrual cycle. Users pay attention to the sensation at their vulva, and the appearance of any vaginal discharge. This information can be used to achieve or avoid pregnancy during regular or irregular cycles, breastfeeding, and peri-menopause. Described by the World Organisation of the Ovulation Method Billings (WOOMB) as "Natural Fertility Regulation", this method may be used as a form of fertility awareness or natural family planning, as well as a way to monitor gynecological health.

In trials method related pregnancy rates have ranged between 0% to 2.9%.^[1] In a recent trial in China 992 couples using the Billings Method were compared to 662 couples using the IUD. The method-related pregnancy rate amongst Billings users was zero and the total pregnancy rate was 0.5%.^[2] In studies up to the 1980s teaching related pregnancies ranged between 0% to 6%.^[1] Total pregnancy rates vary between 1 and 25%.^[3] Reasons for a higher total pregnancy rate include misunderstanding the method, risk taking, ambivalence toward pregnancy, and deciding to become pregnant.

John Billings developed the method as a form of natural family planning in accordance with his religious faith.^[4] He was recognized with a Papal knighthood in life, and condolences for his death were given by the Pope.^[5] Billings strove to raise awareness of the significance of cervical mucus to fertility to all people, regardless of their religion.

Thomas Hilgers later created the Creighton Model FertilityCare System as a variation of the Billings method. ^[6] While Hilgers describes his method as a "standardization" of the BOM, Billings and his wife disputed this claim in a position paper.^[7]

History[link]

The first recorded observations of the relationship between cervical mucus and survival of spermatozoa come from the mid-19th century.^[8] The topic was not systematically studied, however, for almost another century. In 1948, Erik Odeblad was studying mycoplasms in the female genital tract. During the course of his studies, he noticed that cervical mucus changed in a predictable pattern through the course of a woman's cycle. He continued his study of the cervix.^[9]

Independently in 1953, Dr. John Billings (1918–2007) discovered the relationship between cervical mucus and fertility while assisting the marriage consultant for the Melbourne Catholic Family Welfare Bureau. Some of the couples he worked with had serious reasons to postpone pregnancy, and followed the Catholic Church's teachings of only using natural methods of pregnancy avoidance. While Dr. Billings was familiar with the Calendar and Basal Body Temperature methods, he felt there was a need for something more flexible and more reliable. He embarked on a study of medical literature, and found the mid-19th- and early-20th-century references to cervical mucus and sperm survival. He instructed women using the Rhythm method to avoid intercourse also on all days, and for a few days after, they noticed vaginal discharge. This resulted in a dramatic decrease in unintended pregnancies among these couples.^[8]

In the early 1960s, Dr. James Brown took a position at the Royal Women's Hospital in Melbourne, Australia. Dr. Brown had earlier developed the first tests to measure oestrogen and progesterone, and he used these tests to assist Dr. Billings in further study of the relationship between cervical mucus and fertility. Dr. Evelyn Billings joined the research team in 1965. By the late 1960s, the rules for identifying fertile days had been established and teaching centers began to be set up around the world. The method was called the Ovulation Method, to emphasize that the central feature of a woman's fertility cycle was ovulation, rather than menstruation. In the 1970s, a committee of the World Health Organization renamed it the Billings Ovulation Method.^[8]

Scientific verification of the Billings Method is ongoing. Dr. James Brown continued to study ovarian activity until his retirement in 1985.^[10] Dr. Erik Odeblad was acquainted with the Billings Ovulation Method in 1977, and reported that his research into the activity of the cervix confirmed all the conclusions made by Dr. Billings.^[8] Dr. Odeblad's research into the cervix and cervical mucus also continued for many decades.^[11]

Fertility[link]

• A woman ovulates at only one time during her cycle, and an ovum can survive for only 12–24 hours.
• Cervical mucus enabling healthy sperm cells to navigate the genital tract is necessary for fertility
• Most commonly, spermatozoa live only one to three days in the presence of fertile mucus, with survival up to five days being rare. The possibility of pregnancy from sperm survival longer than five days has been compared to "the chances of winning a huge lottery."^[12]
• Menstruation will occur about 2 weeks after ovulation.
• A ten-year study of 45,280 subfertile couples in China found that 32.1% of women were able to achieve pregnancy and live birth through the use of Billings.^[13]

Function[link]

In the days leading up to ovulation the cervix responds to oestrogen by producing mucus capable of sustaining sperm survival. This mucus leaves the vagina as the woman is in an upright position. The mucus is observed through the sensation at the vulva and by looking at any discharge. Daily charting of these observations will reveal either an unchanging pattern indicating infertility or a changing pattern of sensation and discharge indicating fertility. Both of these patterns follow the hormonal patterns which control sperm survival and conception.^[14]

Billings Method teaches women how recognize and understand their signs of fertility. This can help in the early diagnosis and treatment of gynaecological disorders, and can contribute to a woman's reproductive health.^[15]

References[link]

External links[link]

• http://www.billingsmentor.org/ Web service offering guidance and learning of the Billings Method

Fertility awareness (FA) refers to a set of practices used to determine the fertile and infertile phases of a woman's menstrual cycle. Fertility awareness methods may be used to avoid pregnancy, to achieve pregnancy, or as a way to monitor gynecological health.

Methods of identifying infertile days have been known since antiquity, but scientific knowledge gained during the past century has greatly increased the accuracy of these systems. From 1930 to 1980, a lot of research and promotion of fertility awareness was done by those associated with the Roman Catholic Church.^{[chronology citation needed]} Fertility awareness organizations continue to be predominately Catholic, but some secular organizations now exist.^{[citation needed]}

Systems of fertility awareness rely on observation of changes in one or more of the primary fertility signs (basal body temperature, cervical mucus, and cervical position), tracking menstrual cycle length and identifying the fertile window based on this information, or both. Other signs may also be observed: these include breast tenderness and mittelschmerz (ovulation pains), urine analysis strips known as ovulation predictor kits (OPKs), and microscopic examination of saliva or cervical fluid. Also available are computerized fertility monitors.

Terminology[link]

This section may be confusing or unclear to readers. Please help clarify the section; suggestions may be found on the talk page. (September 2011)

^{[over-explained]}

Symptoms-based methods involve tracking one or more of the three primary fertility signs - basal body temperature, cervical mucus, and cervical position.^[1] Systems relying exclusively on cervical mucus include the Billings Ovulation Method, The Ovulation Method, the Creighton Model, and the Two-Day Method. Symptothermal methods combine observations of basal body temperature (BBT), cervical mucus, and sometimes cervical position. Calendar-based methods rely on tracking a woman's cycle and identifying her fertile window based on the lengths of her cycles. The best known of these methods is the Standard Days Method. The Calendar-Rhythm method is also considered a calendar-based method though it is not well defined and has many different meanings to different people.

Systems of fertility awareness may be referred to as fertility awareness-based methods (FAB methods);^[2] the term Fertility Awareness Method (FAM) refers specifically to the system taught by Toni Weschler. The term "natural family planning" (NFP) is sometimes used to refer to any use of FA methods. However, NFP specifically refers to practices that are approved by the Roman Catholic Church^{[citation needed]}, which are: the Lactational amenorrhea method, and periodic abstinence during fertile times. A method of FA may be used by NFP users to identify these fertile times.

Women who are breastfeeding a child and wish to avoid pregnancy may be able to practice the lactational amenorrhea method (LAM). LAM is distinct from fertility awareness, but because it also does not involve devices or chemicals, it is often presented alongside FA^{[by whom?]} as a method of "natural" birth control.

History[link]

Development of calendar-based methods[link]

It is not known exactly when it was first discovered that women have predictable periods of fertility and infertility. St. Augustine wrote about periodic abstinence to avoid pregnancy in the year 388 (the Manichaeans attempted to use this method to remain childfree, and Augustine condemned their use of periodic abstinence).^[3] One book states that periodic abstinence was recommended "by a few secular thinkers since the mid-nineteenth century,"^[4] but the dominant force in the twentieth century popularization of fertility awareness-based methods was the Roman Catholic Church.

In 1905 Theodoor Hendrik van de Velde, a Dutch gynecologist, showed that women only ovulate once per menstrual cycle.^[5] In the 1920s, Kyusaku Ogino, a Japanese gynecologist, and Hermann Knaus, from Austria, independently discovered that ovulation occurs about fourteen days before the next menstrual period.^[6] Ogino used his discovery to develop a formula for use in aiding infertile women to time intercourse to achieve pregnancy. In 1930, John Smulders, Roman Catholic physician from the Netherlands, used this discovery to create a method for avoiding pregnancy. Smulders published his work with the Dutch Roman Catholic medical association, and this was the first formalized system for periodic abstinence — the rhythm method.^[6]

Introduction of temperature and cervical mucus signs[link]

In the 1930s, Rev. Wilhelm Hillebrand, a Catholic priest in Germany, developed a system for avoiding pregnancy based on basal body temperature.^[7] This temperature method was found to be more effective at helping women avoid pregnancy than calendar-based methods. Over the next few decades, both systems became widely used among Catholic women. Two speeches delivered by Pope Pius XII in 1951 gave the highest form of recognition to the Catholic Church's approval—for couples who needed to avoid pregnancy—of these systems.^[4][8] In the early 1950s, Dr. John Billings discovered the relationship between cervical mucus and fertility while working for the Melbourne Catholic Family Welfare Bureau. Dr. Billings and several other physicians, including his wife, Dr. Evelyn Billings, studied this sign for a number of years, and by the late 1960s had performed clinical trials and begun to set up teaching centers around the world.^[9]

First symptoms-based teaching organizations[link]

While Dr. Billings initially taught both the temperature and mucus signs, they encountered problems in teaching the temperature sign to largely illiterate populations in developing countries. In the 1970s they modified the method to rely on only mucus.^[7] The international organization founded by Dr. Billings is now known as the World Organization Ovulation Method Billings (WOOMB).

The first organization to teach a symptothermal method was founded in 1971. John and Sheila Kippley, lay Catholics, joined with Dr. Konald Prem in teaching an observational method that relied on all three signs: temperature, mucus, and also cervical position. Their organization is now called Couple to Couple League International.^[7] The next decade saw the founding of other now-large Catholic organizations — Family of the Americas (1977), teaching the Billings method,^[10] and the Pope Paul VI Institute (1985), teaching a new mucus-only system called the Creighton Model.^[11]

Up until the 1980s, information about fertility awareness was only available from Catholic sources.^[12] The first secular teaching organization was the Fertility Awareness Center in New York, founded in 1981.^[13] Toni Weschler started teaching in 1982 and published the bestselling book Taking Charge of Your Fertility in 1995.^[14] Justisse was founded in 1987 in Edmonton, Canada.^[15] These secular organizations all teach symptothermal methods. Although the Catholic organizations are significantly larger than the secular fertility awareness movement, independent secular teachers have become increasingly common throughout the 1990s and 2000s.

Ongoing development[link]

Development of fertility awareness methods is ongoing. In the late 1990s, the Institute for Reproductive Health at Georgetown University introduced two new methods.^[16][17] The Two-Day Method, a mucus-only system, and CycleBeads and iCycleBeads (the digital version), based on the Standard Days Method, are designed to be both effective and very simple to teach, learn, and use.

Fertility signs[link]

Most menstrual cycles have several days at the beginning that are infertile (pre-ovulatory infertility), a period of fertility, and then several days just before the next menstruation that are infertile (post-ovulatory infertility). The first day of red bleeding is considered day one of the menstrual cycle. Different systems of fertility awareness calculate the fertile period in slightly different ways, using primary fertility signs, cycle history, or both.

Primary fertility signs[link]

The three primary signs of fertility signs are basal body temperature (BBT), cervical mucus, and cervical position. A woman practicing symptoms-based fertility awareness may choose to observe one sign, two signs, or, all three. Many women experience secondary fertility signs that correlate with certain phases of the menstrual cycle. Examples include abdominal pain and heaviness, back pain, breast tenderness and mittelschmerz (ovulation pains).

Basal body temperature[link]

This classifies a temperature reading collected when a person first wakes up in the morning (or after their longest sleep period of the day). In women, ovulation will trigger a rise in BBT between 0.3 and 0.9 °C (0.5 and 1.6 °F) that lasts approximately until the next menstruation. This temperature shift may be used to determine the onset of post-ovulatory infertility.

Cervical mucus

Cervical mucus[link]

The appearance of cervical mucus and vulvar sensation are generally described together as two ways of observing the same sign. Cervical mucus is produced by the cervix, which separates the uterus from the vaginal canal. Fertile cervical mucus promotes sperm life by decreasing the acidity of the vagina, and also helps guide sperm through the cervix and into the uterus. The production of fertile cervical mucus is caused by the same hormone (estrogen) that prepares a woman’s body for ovulation. By observing her cervical mucus, and paying attention to the sensation as it passes the vulva, a woman can detect when her body is gearing up for ovulation, and also when ovulation has passed. When ovulation occurs, estrogen production drops slightly and progesterone starts to rise. The rise in progesterone causes a distinct change in the quantity and quality of mucus observed at the vulva.^[18]

Cervical position[link]

The cervix changes position in response to the same hormones that cause cervical mucus to be produced and to dry up. When a woman is in an infertile phase of her cycle, the cervix will be low in the vaginal canal; it will feel firm to the touch (like the tip of a person’s nose); and, the os – the opening in the cervix – will be relatively small, or ‘closed’. As a woman becomes more fertile, the cervix will rise higher in the vaginal canal; it will become softer to the touch (more like a person’s lips); and the os will become more open. After ovulation has occurred, the cervix will revert to its infertile position.

Cycle history[link]

Calendar-based systems determine both pre-ovulatory and post-ovulatory infertility based on cycle history. When used to avoid pregnancy, these systems have higher perfect-use failure rates than symptoms-based systems, but are still comparable to barrier methods such as diaphragms and cervical caps.

Mucus- and temperature-based methods used to determine post-ovulatory infertility, when used to avoid conception, result in very low perfect-use pregnancy rates.^[19] However, mucus and temperature systems have certain limitations in determining pre-ovulatory infertility. A temperature record alone provides no guide to fertility or infertility before ovulation occurs. Determination of pre-ovulatory infertility may be done by observing the absence of fertile cervical mucus; however, this results in a higher failure rate than that seen in the period of post-ovulatory infertility.^[20] Relying only on mucus observation also means that unprotected sexual intercourse is not allowed during menstruation, since any mucus would be obscured.^[21]

Use of certain calendar rules to determine the length of the pre-ovulatory infertile phase allows unprotected intercourse during the first few days of the menstrual cycle, while maintaining a very low risk of pregnancy.^[22] With mucus-only methods, there is a possibility of incorrectly identifying mid-cycle or anovulatory bleeding as menstruation. Keeping a BBT chart enables accurate identification of menstruation, when pre-ovulatory calendar rules may be reliably applied.^[23] In temperature-only systems, a calendar rule may be relied on alone to determine pre-ovulatory infertility. In symptothermal systems, the calendar rule is cross-checked by mucus records: observation of fertile cervical mucus overrides any calendar-determined infertility.^[22]

Calendar rules may set a standard number of days, specifying that (depending on a woman's past cycle lengths) the first three to six days of each menstrual cycle are considered infertile.^[24] Or, a calendar rule may require calculation, for example holding that the length of the pre-ovulatory infertile phase is equal to the length of a woman's shortest cycle minus twenty-one days.^[25] Rather than being tied to cycle length, a calendar rule may be determined from the cycle day on which a woman observes a thermal shift. One system has the length of the pre-ovulatory infertile phase equal to a woman's earliest historical day of temperature rise minus seven days.^[26]

Other techniques[link]

Ovulation predictor kits (OPKs) can detect imminent ovulation from the concentration of lutenizing hormone (LH) in a woman’s urine. A positive OPK is usually followed by ovulation within 12–36 hours.

Saliva microscopes, when correctly used, can detect ferning structures in the saliva that precede ovulation. Ferning is usually detected beginning three days before ovulation, and continuing until ovulation has occurred. During this window, ferning structures occur in cervical mucus as well as saliva.

Computerized fertility monitors are available under various brand names. These monitors may use BBT-only systems, they may analyze urine test strips, they may use symptothermal observations, they may monitor the electrical resistance of saliva and vaginal fluids, or a combination of any of these factors.

Benefits and drawbacks[link]

Fertility awareness has a number of unique characteristics:

• FA can be used to monitor reproductive health. Changes in the cycle can alert the user to emerging gynecological problems. FA can also be used to aid in diagnosing known gynecological problems such as infertility.
• FA is versatile: it may be used to avoid pregnancy or to aid in conception.
• Use of FA can give insight to the workings of women's bodies, and may allow women to take greater control of their own fertility.
• Some symptoms-based forms of fertility awareness require observation or touching of cervical mucus, an activity with which some women are not comfortable. Some practitioners prefer to use the term "cervical fluid" to refer to cervical mucus, in an attempt to make the subject more acceptable to these women.
• Some drugs, such as decongestants, can change cervical mucus. In women taking these drugs, the mucus sign may not accurately indicate fertility.^[27]
• Some symptoms-based methods require tracking of basal body temperatures. Because irregular sleep can interfere with the accuracy of basal body temperatures, shift workers and those with very young children, for example, might not be able to use those methods.^[27]
• FA requires action daily, detailed record keeping. Some may find the time and detail requirements too complicated.

As birth control[link]

By restricting unprotected sexual intercourse to the infertile portion of the menstrual cycle, a woman and her partner can prevent pregnancy. During the fertile portion of the menstrual cycle, the couple may use barrier contraception or abstain from sexual intercourse.

Advantages[link]

• There are no drug-related side effects to FA. Side effects may occur from inserting fingers into the vagina for cervical observation (as some FA methods recommend) [citation needed].
• FA can be free or very low up front cost. Users may buy a chart, calendar, basal thermometer, or software, or employ a coach. The direct costs are low when compared to other methods.
• FA can be used with barrier contraception so that intercourse may continue through the fertile period. Unlike barrier use without FA, practicing FA can allow couples to use barrier contraception only when necessary.
• FA can be used to immediately switch from pregnancy avoidance to pregnancy planning when the woman decides it is time to plan for conception.

Disadvantages[link]

• Use of a barrier or other backup method is required on fertile days; otherwise the couple must abstain. To reduce pregnancy risk to below 1% per year, there are an average of 13 days where abstinence or backup must be used during each cycle.^[28] For women with very irregular cycles — such as those common during breastfeeding, perimenopause, or with hormonal diseases such as PCOS - abstinence or the use of barriers may be required for months at a time.
• FA has higher failure cost than many methods. Typical use effectiveness is lower than most other methods thus the cost for failures is higher than for most methods.^[29]
• Fertility awareness does not protect against sexually transmitted disease.^[30]

Effectiveness[link]

The effectiveness of fertility awareness, as of most forms of contraception, can be assessed two ways. Perfect use or method effectiveness rates only include people who follow all observational rules, correctly identify the fertile phase, and refrain from unprotected intercourse on days identified as fertile. Actual use, or typical use effectiveness rates are of all women relying on fertility awareness to avoid pregnancy, including those who fail to meet the "perfect use" criteria. Rates are generally presented for the first year of use.^[31] Most commonly the Pearl Index is used to calculate effectiveness rates, but some studies use decrement tables.^[32]

The failure rate of fertility awareness varies widely depending on the system used to identify fertile days, the instructional method, and the population being studied. Some studies have found actual failure rates of 25% per year or higher.^[33][34][35] At least one study has found a failure rate of less than 1% per year with continuous intensive coaching and monthly review,^[36] and several studies have found actual failure rates of 2-3% per year.^{[28][37][38][39]}

When used correctly and consistently (i.e., perfect use) with ongoing coaching, under study conditions some studies have found some forms of FA to be 99% effective.^{[36][40][41][42]}

From Contraceptive Technology:^[43]

• Post-ovulation methods (i.e. abstaining from intercourse from menstruation until after ovulation) have a method failure rate of 1% per year.
• The symptothermo method has a method failure rate of 2% per year.
• The cervical mucus-only methods have a method failure rate of 3% per year.
• Calendar rhythm has a method failure rate of 9% per year.
• The Standard Days Method has a method failure rate of 5% per year.

Reasons for lower typical-use effectiveness[link]

Several factors account for typical use effectiveness being lower than perfect use effectiveness:

• conscious user non-compliance with instructions (having unprotected intercourse on a day identified as fertile)
• mistakes on the part of those providing instructions on how to use the method (instructor providing incorrect or incomplete information on the rule system)
• mistakes on the part of the user (misunderstanding of rules, mistakes in charting)

The most common reason for the lower actual effectiveness is not mistakes on the part of instructors or users, but conscious user non-compliance,^[28][42] i.e., the couple knowing that the woman is likely to be fertile at the time, but engaging in sexual intercourse nonetheless. This is similar to failures of barrier methods, which are primarily caused by non-use of the method.

To achieve pregnancy[link]

Intercourse timing[link]

A study by Barrett and Marshall has shown that random acts of intercourse achieve a 24% pregnancy rate per cycle. That study also found that timed intercourse based on information from a BBT-only method of FA increased pregnancy rates to 31%-68%.

Studies of cervical-mucus methods of fertility awareness have found pregnancy rates of 67%-81% in the first cycle if intercourse occurred on the Peak Day of the mucus sign.^[44][45]

Because of high rates of very early miscarriage (25% of pregnancies are lost within the first six weeks since the woman's last menstrual period, or LMP), the methods used to detect pregnancy may lead to bias in conception rates. Less-sensitive methods will detect lower conception rates, because they miss the conceptions that resulted in early pregnancy loss. A Chinese study of couples practicing random intercourse to achieve pregnancy used very sensitive pregnancy tests to detect pregnancy. It found a 40% conception rate per cycle over the 12-month study period.^[46]

Problem diagnosis[link]

Regular menstrual cycles are sometimes taken as evidence that a woman is ovulating normally, and irregular cycles as evidence she is not.^[47] However, many women with irregular cycles do ovulate normally, and some with regular cycles are actually annovulatory or have a luteal phase defect. Records of basal body temperatures, especially, but also of cervical mucus and position, can be used to accurately determine if a woman is ovulating, and if the length of the post-ovulatory (luteal) phase of her menstrual cycle is sufficient to sustain a pregnancy.

Fertile cervical mucus is important in creating an environment that allows sperm to pass through the cervix and into the fallopian tubes where they wait for ovulation. Fertility charts can help diagnose hostile cervical mucus, a common cause of infertility. If this condition is diagnosed, some sources suggest taking guaifenesin in the few days before ovulation to thin out the mucus.^[48]

Pregnancy testing and gestational age[link]

Pregnancy tests are not accurate until 1–2 weeks after ovulation. Knowing an estimated date of ovulation can prevent a woman from getting false negative results due to testing too early. Also, 18 consecutive days of elevated temperatures means a woman is almost certainly pregnant.^[49]

Estimated ovulation dates from fertility charts are a more accurate method of estimating gestational age than the traditional pregnancy wheel or last menstrual period (LMP) method of tracking menstrual periods.^[50]

See also[link]

• Billings ovulation method
• Creighton Model FertilityCare System
• Fertility monitor
• Lactational amenorrhea method
• Lunaception

References[link]

Further reading[link]

• Toni Weschler (2006). Taking Charge of Your Fertility (10th Anniversary ed.). New York: Collins. ISBN 0-06-088190-9. 
• John F. Kippley and Sheila K. Kippley (1996). The Art of Natural Family Planning (Fourth ed.). Cincinnati, OH: Couple to Couple League International. ISBN 0-926412-13-2.