Fertility awareness

Fertility awareness
Background
Birth control type	Behavioral
First use	1950s (mucus) mid-1930s (BBT) 1930 (Knaus-Ogino) Ancient (ad hoc)
Failure rates (first year)
Perfect use	Symptoms-based: 1-3% Calendar-based: 5-9%
Typical use	3-25%
Usage
Reversibility	Yes
User reminders	Dependent upon strict user adherence to methodology
Clinic review	None
Advantages and disadvantages
STD protection	No (* To be safe, one would have to switch methods and consistently and correctly use a barrier device, be almost completely celibate from many sexual behaviors, or else continuously be tested for STDs before, and intermittently, during sexual activity with one's partner, who would ideally also be monogamous, and such tests are not fail-safe)
Periods	Increased prediction
Benefits	no side effects, can aid pregnancy achievement

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, all 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

^{[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

Development of calendar-based methods

Main article: Calendar-based methods#History

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

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 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

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

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

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

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

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

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

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

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

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

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 every day and detailed record keeping. Some may find the time and detail requirements too complicated.

As birth control

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

• 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).
• 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

• 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.
• 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

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

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

Intercourse timing

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

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

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

• Lunaception

References

1. ^ Weschler, Toni (2002). Taking Charge of Your Fertility (Revised ed.). New York: HarperCollins. pp. 52. ISBN 0-06-093764-5. 
2. ^ Medical Eligibility Criteria for Contraceptive Use:Fertility awareness-based methods. Third edition. World Health Organization. 2004. http://www.who.int/reproductive-health/publications/mec/fab.html. Retrieved 2007-06-12. 
3. ^ Saint, Bishop of Hippo Augustine; Philip Schaff (Editor) (1887). A Select Library of the Nicene and Post-Nicene Fathers of the Christian Church, Volume IV. Grand Rapids, MI: WM. B. Eerdmans Publishing Co.. pp. On the Morals of the Manichæans, Chapter 18. 
4. ^ ^{a b} Yalom, Marilyn (2001). A History of the Wife (First ed.). New York: HarperCollins. pp. 297–8, 307. ISBN 0-06-019338-7. 
5. ^ "A Brief History of Fertility Charting". FertilityFriend.com. http://www.fertilityfriend.com/Faqs/A_brief_history_of_fertility_charting.html. Retrieved 2006-06-18. 
6. ^ ^{a b} Singer, Katie (2004). The Garden of Fertility. New York: Avery, a member of Penguin Group (USA). pp. 226–7. ISBN 1-58333-182-4. 
7. ^ ^{a b c} Hays, Charlotte (December 2001). "Solving the Puzzle of Natural Family Planning". Crisis Magazine. http://www.crisismagazine.com/december2001/cover.htm. Retrieved 2007-03-18. 
8. ^ Moral Questions Affecting Married Life: Addresses given October 29, 1951 to the Italian Catholic Union of midwives and November 26, 1951 to the National Congress of the Family Front and the Association of Large Families, National Catholic Welfare Conference, Washington, DC.
9. ^ Billings, John (March 2002). "THE QUEST — leading to the discovery of the Billings Ovulation Method". Bulletin of Ovulation Method Research and Reference Centre of Australia 29 (1): 18–28. http://www.woomb.org/omrrca/bulletin/vol29/no1/thequest.shtml. Retrieved 2007-03-18. 
10. ^ "About us". Family of the Americas. 2006. http://www.familyplanning.net/main.php?parent_id=1&id_area=1. Retrieved 2007-03-18. 
11. ^ "About the Institute". Pope Paul VI Institute. 2006. http://www.popepaulvi.com/about.htm. Retrieved 2007-03-18. ^{[dead link]}
12. ^ Singer (2004), p.xxiii
13. ^ "About us". Fertility Awareness Center. 2006. http://www.fertaware.com/. Retrieved 2007-03-18. 
14. ^ Weschler (2002)
15. ^ "About Us". Justisse. 2002. Archived from the original on 2006-11-16. http://web.archive.org/web/20061116202933/http://www.justisse.ca/new/aboutUs.asp. Retrieved 2007-03-18. 
16. ^ Arévalo M, Jennings V, Sinai I (2002). "Efficacy of a new method of family planning: the Standard Days Method." (PDF). Contraception 65 (5): 333–8. doi:10.1016/S0010-7824(02)00288-3. PMID 12057784. http://pdf.dec.org/pdf_docs/PNACQ416.pdf. 
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18. ^ James B. Brown (2005). "Physiology of Ovulation". Ovarian Activity and Fertility and the Billings Ovulation Method. Ovulation Method Research and Reference Centre of Australia. http://www.woomb.org/bom/science/physiology.html. 
19. ^ Kippley (2003), pp.121-134,376-381
20. ^ Kippley (2003), p.114
21. ^ Evelyn, Dr. Billings, Ann Westinore, (1998). The Billings Method: Controlling Fertility Without Drugs or Devices. Toronto: Life Cycle Books. pp. 47. ISBN 0-919225-17-9. 
22. ^ ^{a b} Kippley (2003), pp.108-113
23. ^ Kippley (2003), p.101 sidebar and Weschler (2002), p.125
24. ^ Kippley (2003), pp.108-109 and Weschler (2002), pp.125-126
25. ^ Kippley (2003), pp.110-111
26. ^ Kippley (2003), pp.112-113
27. ^ ^{a b} "How to Observe and Record Your Fertility Signs". Fertility Friend Handbook. Tamtris Web Services. 2004. http://www.fertilityfriend.com/HelpCenter/FFBook/ff_fertility_signs.html. Retrieved 2005-06-15. 
28. ^ ^{a b c} Frank-Herrmann P, Heil J, Gnoth C, et al. (2007). "The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple's sexual behaviour during the fertile time: a prospective longitudinal study". Hum. Reprod. 22 (5): 1310–9. doi:10.1093/humrep/dem003. PMID 17314078. 
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32. ^ Kippley, John; Sheila Kippley (1996). The Art of Natural Family Planning (4th addition ed.). Cincinnati, OH: The Couple to Couple League. pp. 141. ISBN 0-926412-13-2. 
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36. ^ ^{a b} Evaluation of the Effectiveness of a Natural Fertility Regulation Programme in China: Shao-Zhen Qian, et al. Reproduction and Contraception (English edition), in press 2000.
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38. ^ Clubb EM, Pyper CM, Knight J (1991). "A pilot study on teaching natural family planning (NFP) in general practice". Proceedings of the Conference at Georgetown University, Washington, DC. http://www.fertilityuk.org/nfps822.html. 
39. ^ Frank-Herrmann P, Freundl G, Gnoth C, et al. (June–September 1997). "Natural family planning with and without barrier method use in the fertile phase: efficacy in relation to sexual behavior: a German prospective long-term study". Advances in Contraception 13 (2-3): 179–189. doi:10.1023/A:1006551921219. PMID 9288336. 
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41. ^ Hilgers, T.W.; Stanford, J.B. (1998). "Creighton Model NaProEducation Technology for avoiding pregnancy. Use effectiveness". Journal of Reproductive Medicine 43 (6): 495–502. PMID 9653695. 
42. ^ ^{a b} Howard, M.P.; Stanford, J.B. (1999). "Pregnancy probabilities during use of the Creighton Model Fertility Care System". Archives of Family Medicine 8 (5): 391–402. doi:10.1001/archfami.8.5.391. PMID 10500511. 
43. ^ James Trussell et al. (2000) "Contraceptive effectiveness rates", Contraceptive Technology — 18th Edition, New York: Ardent Media. On-press.
44. ^ Ryder R (1993). ""Natural family planning": effective birth control supported by the Catholic Church". BMJ 307 (6906): 723–6. doi:10.1136/bmj.307.6906.723. PMC 1678728. PMID 8401097. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1678728. 
45. ^ Hilgers T, Daly K, Prebil A, Hilgers S (October 1992). "Cumulative pregnancy rates in patients with apparently normal fertility and fertility-focused intercourse". J Reprod Med 37 (10): 864–6. PMID 1479570. 
46. ^ Wang X, Chen C, Wang L, Chen D, Guang W, French J (2003). "Conception, early pregnancy loss, and time to clinical pregnancy: a population-based prospective study". Fertil Steril 79 (3): 577–84. doi:10.1016/S0015-0282(02)04694-0. PMID 12620443. 
47. ^ Nouriani, Mory (May 2006). Infertility. National Women's Health Information Center, U.S. Department of Health and Human Services, Office on Women’s Health. pp. 2. http://www.womenshealth.gov/faq/infertility.pdf. Retrieved 2007-06-08. . "Some signs that a woman is not ovulating normally include irregular or absent menstrual periods."
    Cooper, Phyllis G. (2006). "Female Infertility". Adult Health Advisor. http://www.fairview.org/healthlibrary/content/aha_finfert_wha.htm. . "A woman who is not ovulating normally may have irregular or missed menstrual periods."
    "Is Clomid Right For You?". JustMommies.com. 2007. http://www.justmommies.com/articles/clomid-and-ovulation.shtml. . "If you have an irregular cycle there is a good chance you are not ovulating normally."
48. ^ Weschler (2002), p. 173.
49. ^ Weschler (2002), p.316
50. ^ Weschler (2002), pp.3-4,155-156, insert p.7

Further reading

• 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.