Vol. 18 • Issue 4
• Page 35
Natural family planning (NFP) has come a long way over the years, but healthcare professionals have little knowledge of proven methods and do not readily prescribe NFP for patients.1,2
Types of NFP
Four methods of natural family planning are taught and implemented in the United States: the calendar rhythm method, the basal body temperature (BBT) method, the ovulation or cervical mucus method, and the symptom-thermal method (STM).1The calendar rhythm and BBT methods are considered outdated approaches.1The ovulation method (OM or cervical mucus only) and the STM method are considered more up-to-date with medical knowledge.1The Creighton Model FertilityCare System (CrMS) is a fertility awareness-based method that is a variant of the ovulation method.3,4A fertility awareness-based method is an approach that relies on identification of fertile days.5
b>History of CrMS
CrMS has religious underpinnings. In 1968, Pope Paul VI issued a document calling for the support of "responsible parenthood." He condemned contraception, sterilization and abortion.3Thomas Hilgers was a medical student at Creighton University at the time, and he developed a professional interest in natural reproductive health. In time he would become certified in obstetrics and gynecology and cocreate the CrMS.3
The CrMS tracks fertility through daily charting of external vulvar cervical mucus and the absence or presence of various types of bleeding.4These data are used to monitor the phases of fertility, infertility and overall gynecologic health.4The method is considered a "true" system of family planning because the charted information can be used in two ways: to avoid or to achieve pregnancy.4On any given day, couples have the freedom to use the information as they choose.4
The survival of sperm is directly related to the presence or absence of an ovulatory or periovulatory type of mucus.4The consistency of cervical mucus is directly related to levels of estrogen and progesterone. During ovulation, estrogen is high and progesterone is low, resulting in the clear, stretchy and lubricative mucus known as spinnbarkeit.6This type of mucus is essential for the transmission of sperm through the cervix. Leukocytes in the mucus also decrease at this time, enabling sperm to survive longer.4After ovulation, progesterone levels rise, resulting in sticky or cloudy mucus or a dry external vulva. This mucus forms a plug and inhibits transmission of sperm through the cervix.6
Menstrual Cycle and Cervical Mucus
In women with regular menstrual cycles, menstruation begins and tapers, then progresses to a few dry days. Mucus production starts, and dry days again ensue until the start of another cycle.7The CrMS describes the menstrual cycle in two phases: the pre-peak (or preovulatory) phase and the post-peak (postovulatory) phase.4Ovulation separates the two phases and is referred to as the "peak day."4The preovulatory phase is different for every woman and may change from cycle to cycle.4But the postovulatory phase is quite stable in most women, usually lasting 13 days from ovulation.7 Menstruation signals the beginning of a cycle and usually lasts 3 to 7 days.7Because the preovulatory phase is variable, CrMS generally considers menstruation a fertile time.7Some women may have a short menstrual period and early ovulation, and thus experience no dry days before the start of mucus symptoms.7Menstrual flow does not inhibit the migration of sperm, so if a couple engages in intercourse at this time, pregnancy may occur.7
As menstrual bleeding diminishes, vaginal discharge ceases.4The absence of menstrual blood and mucus signals an infertile time.7As ovulation approaches and estrogen increases, cervical mucus discharge becomes apparent.7 Mucus often begins as a sticky, cloudy or tacky to cloudy discharge and becomes clear, stretchy or lubricative in 1 or 2 days.7The consistency of mucus correlates with rising estrogen and follicular development.4 lear, stretchy or lubricative mucus is usually present for 3 to 4 days.7The last day of this type of mucus is the peak day.7After the peak day, progesterone levels rise.7The postovulatory phase begins, progressing to dry days and the start of a new cycle.7b>
Learning the System
In CrMS, practitioners teach couples how to identify the characteristics of cervical mucus and use it to manage reproduction.4FertilityCare practitioners receive specialized training. (See www.creightonmodel.com for information.) Couples leave the introductory CrMS session with enough information to make the system work, but the real teaching begins at follow-up sessions.7Avoidance of genital contact is recommended for the first cycle or month, whichever is shorter.4This gives the woman a chance to learn her mucus pattern without interference by seminal fluid.
The woman evaluates cervical secretions every day, before and after urination and before and after a bowel movement. Secretions are evaluated by wiping the opening of the vagina with white toilet paper. If mucus is present on the tissue, the woman feels it between the thumb and index finger and notes the consistency, color and change (the three C's). Consistency denotes the stretchability and quality. Color refers to cloudy or clear. Change refers to day-to-day changes. The woman also notes sensation of dryness or lubrication when wiping.7
Women who follow CrMS use stamps to chart daily characteristics of discharge.7Charts provide spaces to place a stamp and to handwrite characteristics. The woman also charts menstrual flow and describes it as heavy, moderate or light.7 hen a woman recognizes her peak day, she writes a P on that day's stamp.7
Each CrMS chart lasts for 6 months.7Follow-up appointments are important to learning the system and gaining confidence. They should be scheduled five times during the first 3 months of use and an additional three times over the remainder of a year.7After that, appointments should be made every 6 to 12 months.4
Natural Procreative Technology is a diagnostic and treatment philosophy used in conjunction with the CrMS to help medical consultants (NPs and physicians trained in CrMS and NaProTechnology) guide care.8CrMS lays the groundwork for a better understanding of ovarian and pituitary events.8For example, in one study, inflammation of the cervix was identified with 75% accuracy by CrMS charting.8Abnormalities can also be identified early using the CrMS8 hormones, laparoscopy and ultrasound. NaProTechnology focuses on treating these conditions with natural, less invasive methods.8
If a CrMS clinician finds abnormalities, he or she sends the chart to a medical consultant for evaluation.4Medical consultants practice in various settings throughout the United States and Canada. The complexity of the woman's problem will determine fees and treatments. If further follow-up is needed, the charts are sent to the Pope Paul VI Institute for evaluation and collaboration.4A key element of NaProTechnology is the concept of cooperative progesterone replacement therapy (CRPT), which stems from research showing that progesterone increases only after ovulation.8Thus, natural progesterone replacement must be started only during the postovulatory phase. When the peak day is known, medication can be administered in a timely manner.
Examples of problems that can be identified and treated with CRPT are infertility, ovarian cysts, irregular or abnormal bleeding, polycystic ovarian syndrome, repeated miscarriage, chronic discharges, and hormonal abnormalities.9Symptoms of premenstrual syndrome and depression have also been treated with CRPT.8
Effectiveness of CrMS
A meta-analysis of six studies encompassing 1,876 couples and 17,130 cycles found that CrMS had a use effectiveness ranging from 94.6% to 97.9%.6Under perfect, lab-like conditions, CrMS had contraceptive effectiveness that ranged from 99.5% to 99.8%.6CrMS is also used to achieve pregnancy. In a study to determine method effectiveness, 50 couples were evaluated. With the first cycle of use, 76% became pregnant. By the third cycle, the number increased to 90%. By the sixth cycle, 98% of the study participants became pregnant.6Another study evaluated the effectiveness of NaProTechnology in women with previous infertility.10Researchers followed 1,072 women who had been trying to conceive for at least a year (average age 35.8). After they initiated CrMS and used CRPT, crude pregnancy rates, withdrawal rates and adjusted pregnancy rates were comparable to cohort studies of assisted reproductive technology.10
Many studies have examined the psychological aspects of NFP. Newer studies show method satisfaction, but older research showed mixed results.11A 1966 study evaluating couples who used the rhythm method found that 74% felt natural family planning had harmed their marriages.11A 1970 study analyzed couples who used the BBT method and found that 48% of couples experienced some psychological stress from periodic abstinence.11
The methods in the above studies were older forms of NFP that have fallen out of favor. Since then, the ovulation method has been developed, and it is more effective and results in shorter periods of abstinence. A study published in 2003 repeated the 1966 questions to users of the ovulation method. Seventy-five percent of the comments were positive.
Advantages and Disadvantages
CrMS is a safe, natural and inexpensive way to monitor reproductive health. It has no medical contraindications, and it can be used throughout the world.12A disadvantage is that CrMS can be time consuming. It has a long learning curve with multiple education and follow-up days.
Sexual abstinence can place stress on couples. CrMS teaches a program titled SPICE. The acronym stands for "spiritual, physical, intellectual, creative and emotional."7SPICE presents the view that human sexuality is multidimensional, not limited to genital contact or intercourse.7 It encourages couples to embrace abstinence as a time to build their relationship.7
The American Academy of Fertility Care Professionals (AAFCP) offers training in CrMS and NaProTechnology. Nurse practitioners who want to learn the method can enroll in the medical consultant program. This 6-month program is offered through Pope Paul VI Institute for the Study of Human Reproduction. Requirements for participation are strict; CrMS providers may not use, prescribe or refer patients for contraception.4
Putting It Into Practice
By educating themselves about NFP, nurse practitioners can help women who want to use this method for family planning and reproductive health. Two ICD-9 codes are available for NFP counseling, but many insurance companies do not cover these services.
Brian Torske is a family nurse practitioner at St. Alexius Heart and Lung Clinic in Bismarck, N.D. He has a personal interest in natural family planning.
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