Natural & Safe The Handbook Sensiplan

Table of contents :
Natural & Safe:
......Page 5
What is Natural Family Planning?
......Page 12
Understanding your fertility
......Page 13
In the know...
......Page 14
A better understanding of your body signs
......Page 15
The history of natural methods
......Page 16
Sensiplan
......Page 17
Our Bodies
......Page 19
Fertility in men and women
......Page 20
The phase before ovulation - the follicular phase
......Page 24
Infertile days
......Page 27
Fertilization, implantation, and pregnancy
......Page 29
The cycle throughout a woman's life
......Page 30
In the know...
......Page 31
The variable follicular phase
......Page 32
Monophasic cycles
......Page 34
Observing and understanding the body's signs
......Page 37
The cycle chart
......Page 38
Bleeding
......Page 40
Observing cervical mucus
......Page 41
Learn your personal cervical mucus pattern
......Page 44
Entries on the cycle chart
......Page 46
The peak in the cervical mucus symptom
......Page 47
Special case
......Page 49
Basal body temperature
......Page 50
Special features of digital thermometers
......Page 52
In the know...
......Page 54
Daily routine
......Page 57
Changes in the cervix
......Page 59
Self examination
......Page 60
Position -
......Page 62
Other signs in the cycle
......Page 63
The method - Sensiplan®
......Page 67
Rule:
......Page 68
How do you evaluate the temperature?
......Page 69
How do you evaluate the temperature? (cont)
......Page 70
How is the peak cervical mucus day determined?
......Page 72
Start of the infertile time after ovulation
......Page 74
Entries on the cycle chart
......Page 75
The Minus-8 Rule
......Page 76
Entries on the cycle chart
......Page 77
For beginners: The 5-Day Rule
......Page 80
Special rule for those with a menstruation calendar: the Minus-20 Rule
......Page 84
Evaluating the cervix
......Page 85
How effective is Sensiplan if used correctly?
......Page 87
Evaluation errors
......Page 88
Becoming pregnant
......Page 89
Irregular cycles
......Page 90
Body signs and the fertile window
......Page 91
Identifying a pregnancy
......Page 92
Special life circumstances
......Page 95
Sensiplan after hormonal contraception
......Page 96
In the know...
......Page 97
Sensiplan rules after discontinuing hormonal contraceptive methods
......Page 98
Sensiplan after giving birth and during breastfeeding
......Page 100
Cervical Mucus
......Page 102
Entries on the cycle chart
......Page 103
Evaluating the cervical mucus
......Page 104
Evaluating the cervix
......Page 106
LAM - Absence of menstrual bleeding as a result of breastfeeding
......Page 108
Subjective experience
......Page 109
Observing cervical mucus
......Page 111
Method rules during perimenopause
......Page 113
Evaluating the cervix
......Page 114
Entries on the cycle chart
......Page 115
Cervix
......Page 119
Ovaries
......Page 120
Uterus
......Page 121
Refer to the table on page 51 and the examples below to determine how to round (up or down) individual temperatures taken.
......Page 123

Citation preview

Natural & Safe: The Handbook Fam ily Planning with Sensiplan™

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Malteser Arbeitsgruppe NFP

Natural & Safe: The Handbook Family Planning with Sensiplan

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Natural & Safe: The Handbook Family Planning with Sensiplan Authored by Malteser Arbeitsgruppe NFP Copyright © 2019 CydeForth LLC All rights reserved. No part of this book may be reproduced in any manner without permission except for brief quotations in articles or reviews. ISBN 978-1-7336878-0-5 (soft cover) ISBN 978-1-7336878-1-2 (e-book) CycleForth publishes the English language editions of Natural & Safe: The Handbook, Family Planning with Sensiplan and Natural & Safe: The Workbook, Family Planning with Sensiplan, and coordinates provision of education in the Sensiplan method with Reply Ob/Gyn & Fertility. Please visit www.replyobgyn.com/services/sensiplan. Malteser Arbeitsgruppe NFP is an interdisciplinary team that operates as part of Malteser Health Promotion and Prevention. Arbeitsgruppe NFP is focused on development of natural family planning ("NFP") and quality assurance in NFP consulting and training. Original German title: Arbeitsgruppe NFP der Malteser Deutschland gGmbH, Koln Naturlich und Sicher: Das Praxisbuch, 19th edition © 2000, 2015 TRIAS Verlag in MVS Medizinverlage Stuttgart GmbH & Co. KG, OswaldHesse-StraBe 50, 70469 Stuttgart, Germany © 1.-16. Auflage, Verlagsgruppe Lubbe GmbH & Co. KG, Germany DISCLAIMER: Information in this book is for educational purposes only without representations or warranties of any kind, express or implied. None of this information constitutes, or is a substitute for, professional medical advice, diagnosis, or treatment. A physician should be consulted for medical advice.

Malteser Arbeitsgruppe NFP

Natural & Safe: The Handbook Family Planning with Sensiplan Safe and effective family planning with Sensiplan™

Table of Contents 7 8 9 10 11 12 13 13 14 14 17 18 19 21 22 25 27 28

4

29 30 32 32

Our Bodies

Biomarkers

Did you know your body gives you signs that allow you to know when you are fertile? Learn to observe and interpret your unique signs and use them to help achieve your family planning goals.

The cyclical changes in your signs of fertility, e.g., cervical mucus, basal body temperature, and other changes, provide you with extensive information about your body and fertility.

Foreword Preface to the New Edition Preface to the 1st Edition (1987) What is Natural Family Planning? Understanding your fertility Healthy, reliable, and rooted in partnership Conceiving with Sensiplan A better understanding of your body signs A new way The history of natural methods Our Bodies Fertility in men and women Female reproductive organs Male reproductive organs The female cycle The pathway for sperm in the female body Fertilization, implantation, and pregnancy The cycle throughout a woman’s life From girl to woman The variable follicular phase The stable luteal phase Monophasic cycles

35 Observing and understanding the body’s signs 36 The body's signs and symptoms 36 The cycle chart 38 Bleeding

39 40 44 45 47 48 50 52 55

Cervical mucus The appearance of cervical mucus Entries in the cycle chart The peak in the cervical mucus symptom Special case Temperature Special features of digital thermometers Disturbances and special circumstances Daily routine

57 C h a n g e s in the cervix

58 60 61 61 62 62 63

Self-examination Entries in the cycle sheet Other signs in the cycle Breast symptoms Mittelschmerz Intermenstrual bleeding Other signs

63 C h a n g e s in libido

The Sensiplan Method

Special Circumstances

The Sensiplan Method is a sympto-thermal method. The beginning and the end of the fertile time is identified using your unique biomarkers.

Sensiplan is designed to be used by cycling women throughout each stage of life. Even during breastfeeding, perimenopause, or after discontinuing hormonal contraceptives, Sensiplan can be just as effective.

65 The Method Sensiplan 66 How does the method work? 85 How effective is Sensiplan if used correctly? 86 Evaluation Errors

93 Special life circum stances 94 Sensiplan after hormonal contraception 96 Sensiplan after discontinuing hormonal contraception methods 98

87 Becoming pregnant 88 Irregular cycles

100

89 Body signs and the fertile window

104 106 106

90 Sex: How often? 90 Difficulty becoming pregnant 90 Identifying a pregnancy

107 107 108 109

Blank cycle charts may be found on pages 37 and 123.

109 111

They may also be downloaded at: www.replyobgyn.com/sensiplan, or www.nfp-online.de

115 117

Sensiplan after giving birth and during breastfeeding Observing body signs during breastfeeding Basic pattern of infertility LAM-Lactational Amenhorrea Method Is family planning actually necessary during breastfeeding? Sensiplan during perimenopause Subjective experience Decline in fertility during perimenopause Objective changes in your body's signs and symptoms Monophasic cycles Method rules during perimenopause How can I learn about Sensiplan? Glossary

120 Sensiplan at-a-glance

5

Foreword Sensiplan is a fertility awareness-based method of family planning, known also as natural family planning ("NFP"). It was developed in Germany over a period of decades by the Arbeitsgruppe NFP ("NFP Working Group") at the international aid agency Malteser International, and with help from the German Ministry of Health. Natural & Safe: The Handbook and Natural & Safe: The Workbook are two important Sensiplan resources, translated now for the first time in English. The Handbook describes the method, while The Workbook provides practice charts, case examples, and specific instruction for using the method throughout various phases of life. CycleForth LLC is the Des Moines, Iowa-based company that introduced Sensiplan in the United States in 2016, and now is making available the Natural & Safe companion texts. CycleForth specializes in development of cooperative and restorative health care products and services, and coordinates provision of Sensiplan and other fertility awareness-based methods through fertility educators at Reply Ob/Gyn & Fertility. For their decades of commitment to development of Sensiplan, we thank Malteser Arbeitsgruppe NFP. For their trainings in Sensiplan and many contributions to this project, we especially thank our German colleagues Dr. Ursula Sottong and Petra Klann-Heinen. For their work on this English translation and introducing Sensiplan in the U.S., we thank fertility educators Lori Hartley, Donna Zubrod, Emily Kennedy and Dr. Rachel Urrutia, and for her tireless efforts on graphics and layout of this text, we thank Barri Burch. To learn more about Sensiplan's established record of effectiveness, or to inquire about learning the method with a certified fertility educator either in clinic or via telehealth, please contact: Reply Ob/Gyn & Fertility Sensiplan Instruction, Suite 105 7535 Carpenter Fire Station Road I Cary, NC 27519 919-230-2100 I [email protected] I www.replyobgyn.com/services/sensiplan For information about Sensiplan instruction offered globally, please contact: Malteser Arbeitsgruppe SENSIPLAN Erna-Schefflerstr.2 I 51103 Cologne www.nfp-online.de I www.sensiplan.de

Preface to the New Edition Natural family planning (NFP) is en vogue. There have been countless new developments worldwide in this field in the past few years. This inevitably has produced confusion with regards to the quality, practicability, and, above all, reliability of these different methods, making it difficult for doctors and users alike to keep track of and choose the right method for them. For clarification, the method described in this book is the method specifically developed by Arbeitsgruppe NFP and trademarked as Sensiplan® in Europe, the USA, Canada, and other countries. Scientific studies that were established under the guidance of Professor Gunter Freundl {University of Dusseldorf), and which are being continued at the University of Heidelberg {Professor Thomas Strowitzki), confirm Sensiplan to be more than 99% effective with perfect use. When used consistently and correctly, Sensiplan is one of the most reliable methods there is whatever your situation in life. Sensiplan's effectiveness rate is, to a large extent, thanks to the NFP teachers working throughout Germany, and to the women and couples they work with. Over the last 25 years, they have provided the NFP Study Center with more than 40,000 cycle charts.

Among other things, these scientific studies include new insights into how cycles react after stopping hormonal contraceptives, and how they change with breastfeeding and at the time of menopause. Over the past few years, NFP also has started to be used by couples trying to achieve a pregnancy. There are many doctors who now use fertility cycle monitoring to assist couples trying to conceive. This book is a compilation of our findings about natural family planning, made available to interested women and couples. We would like to extend a special thanks to the team of authors, Dr. Siegfried Baur, Dr. Petra FrankHerrmann, Dr. Elisabeth Raith-Paula, and Dr. Ursula Sottong, who have worked to present the medical background and underlying methodology, thus opening the opportunity for those interested to learn Sensiplan. Malteser Arbeitsgruppe NFP Cologne, Germany I Spring 2011

Preface to the 1st Edition (1987) This book has been written to describe natural family planning (NFP), For many couples, NFP is a method for avoiding pregnancy that is preferable to other methods that are made available. The Federal Ministry for Youth, Family, Women, and Health in Germany is supporting a model project with the aim to scientifically review natural methods and to distribute information about them. The authors of this book are the physicians Dr. Petra Frank-Herrmann, Dr. Elisabeth Raith-Paula, Dr. Jutta Sadlik and Dr. Ursula Sottong, and the educators Astrid Both, Brigitte Hrabe-Lorenz, Gunter Lorenz and the psychologist Notker Klann. The book was edited by Astrid Both. The following experts have reviewed the book to ensure it is scientifically accurate and evidence-based: Siegfried Baur, M.D., Consultant, First University Gynecology Hospital, Munich Gerhard Doring, M.D., Professor, University of Munich Xaver Fiederle, Professor, University of Education in Freiburg (specialty: principles of adult education) Gunter Freundl, M.D., Professor and Chief Physician, Gynecology Department at the City Hospital Dusseldorf-Benrath Kurt Hahlweg, Psychologist and Professor, Max-Planck Institute for Psychiatry Munich (specialty: partnership research}

The authors and editors were supported by Heidi Anzenhofer, Designer {University of Applied Sciences), Hans Heitmann, Designer (University of Applied Sciences), and Ludger Elfgen, who gave advice on the graphics. The following doctors also deserve a special thanks: Dr. Anna Flynn, Dr. Claude Lanctot, and Dr. Josef Rotzer. They gave the authors invaluable specialist advice from their many years of experience in the field of NFP. We also would like to thank: Ulrike Ballhausen, Augustinus Henckel-Donnersmarck, Manfred Herald, Franz Herzog, Vinzenz Platz, Ludwig Scholler, and Anton Schutz for their support in this endeavor. The NFP teachers deserve a special thanks, without whom the production and constant revision of the manuscripts would not have been possible, as well as Brigitte AGhauer, Silvia Hell, and Felicitas Weich, who exhibited amazing patience completing the manuscripts. We hope that this book will contribute to improving knowledge about natural methods of family planning and that it will give readers the motivation to delve deeper into this form of family planning. The Authors Bonn, Germany I February 1987

W hat is Natural Family Planning?

What is Natural Family Planning?

This is where natural family planning opens up the possibility for men and women alike to understand, and be jointly responsible for, their fertility.

Over the last 30 years, medicine has embraced a large number of natural and alternative remedies and has adjusted its own scope to accommodate the newly awakened health consciousness among the public. As well as placing trust in the healing powers of nature, the focus has been on a greater awareness of body signs and an emphasis on listening to your own body.

Using natural family planning allows for a profound knowledge of the biological structures and physiological processes of the human body. It creates a deeper understanding of the various factors that can influence and disrupt these processes. It also leads to an openness to give nature the space it needs by fostering a long-term commitment to a lifestyle that supports these natural processes. It may be this combination of being at one with nature and gaining knowledge, coupled with the opportunity to learn more about your own fertility, that has awakened your interest in natural family planning.

This alternative appeals to women in particular. This may be due to experiencing the natural cycles of menstrual bleeding, pregnancy, and childbirth, which may help women feel in touch with and live in harmony with their bodies. However, it appears men are also becoming increasingly open to this new level of understanding of the body’s own natural resources and are striving to find out more about the various options available. And so it is hardly surprising that more and more men and women are seeking out methods of family planning that are natural, safe, and healthy, allowing them to be in touch with their fertility. This encompasses both sides of the coin -- to avoid or to conceive a pregnancy. In addition, there is a growing awareness that equality is not just about sharing tasks of everyday living but also applies to sexuality and parenthood. 10

Sensiplan. Sensiplan is more than just a reliable method of family planning. It is a method that makes us very much aware of what is going on in our bodies gives us information about our own fertility, helps us gain a better understanding of our cycles, is free from harmful side effects, and supports the desire to have children. Sensiplan is a family planning method that encourages cooperation with your partner; it can be used in all stages of life and in every situation.

W hat is Natural Family Planning?

In the know... Natural Family Planning • Opens our senses and teaches women the subtle language of their own bodies • Allows for a better understanding of the female cycle and provides helpful information on cycle problems and common misconceptions about the cycle • Opens a new level of awareness for fertility ("fertility awareness") and allows one to experience fertility regardless of sexual activity.

• Helps women and couples who are trying to conceive by teaching them to understand the meaning of the signs of fertility and recognizing when they are most fertile. • May provide helpful diagnostic information for those struggling to become pregnant. • Provides reliable information a couple can use to help avoid pregnancy.

Understanding your fertility Sensiplan is a method based on observing physical changes during the cycle, allowing you to understand when you are and are not fertile. Armed with this information, you can see when intercourse can or cannot lead to pregnancy, and you can respond accordingly. The method described in this book is based on the signs your body produces during your cycle. The most important signs are changes in the cervical mucus (sympto) and changes in basal body temperature (thermal). This is why it is dubbed the "symptothermal method."

For many women who begin to observe their bodies' signs, it seems unimaginable that they really can pinpoint when they are fertile—to learn the language their body is speaking. But why? We take it for granted that we understand body signs such as hunger, thirst, or tiredness. Other signs, however, are not as immediately evident unless we have learned to watch for them. The changes throughout the female cycle is a good example, as these signs speak quietly, and many women do not recognize them for what they are or realize what they mean for their fertility.

11

W hat is Natural Family Planning?

Healthy, reliable, and rooted in partnership When thinking through reasons to choose a specific family planning method, the following factors are especially important: efficacy, safety, side effects, and partnership. Although there are a wide range of options available, about one in three women is not satisfied with her current family planning method. There are several reasons for this, including fear of possible side effects or decreased sexual pleasure, convenience, and the sense that all the responsibility is placed on one partner. What this boils down to is that the decision to use one family planning

method over another is more than just the choice of a method. Every woman and every man have their own, personal considerations, based on what this means for them as individuals and as couples. Healthy. Good health is important. Often times, we are careful about our medical treatments, exposure to toxins, what we eat, and how much time we spend exercising. However, we tend not to think about how our family planning methods impact us. Because Sensiplan is free of side effects, it can be a good family planning option for those interested in natural and healthy methods.

In the know... Advice and Support To learn more about Sensiplan's established record of effectiveness, or to inquire about learning the method with a certified fertility educator either in clinic or via telehealth, please contact: Reply Ob/Gyn & Fertility Sensiplan Instruction, Suite 105

7535 Carpenter Fire Station Road I Cary, NC 27519 919-230-2100 I [email protected] I www.replyobgyn.com/services/sensiplan

For information about Sensiplan instruction offered globally, please contact: Malteser Arbeitsgruppe SENSIPLAN Ema-Schefflerstr.2 I 51103 Cologne I www.nfp-online.de I www.sensiplan.de

12

W hat is Natural Family Planning?

Partnership. Fertility is about partnership, not something that happens alone. Natural family planning provides the know-how to understand and manage fertility. And while family planning is still left mainly in the hands of women, many women expect a strong level of commitment from their partners and more shared responsibility. This makes natural family planning methods like Sensiplan attractive because the method encourages partnership in the couple. Even if a woman uses Sensiplan largely on her own, she will need to reach agreement on

intercourse with her partner in order to achieve her reproductive goals. Efficacy and reliability. Reliability is one of the key requirements for any family planning method. Sensiplan, which has been scientifically studied for 30 years, has been found to be one of the most reliable family planning methods when it is used correctly and applied consistently.

Conceiving with Sensiplan In addition to being a method that is reliable for helping to avoid pregnancy, Sensiplan also supports women who are trying to conceive. By design, natural family planning advocates for awareness of fertility and an understanding of how conception occurs. It also helps women better understand what a normal cycle looks like and how to best time intercourse.

A better understanding of your body signs Natural family planning requires not only knowledge about the natural conditions and the physical processes in the male and female bodies, but also a learning phase for users to become confident in self-observation and in interpreting the signs the body sends. In our modern environment, we tend not to listen to what our bodies tell us. Part of learning natural family planning is taking the time to really understand the many different ways your body expresses itself through physical signs. In time, and with practice, the user will learn to trust her instincts and feel comfortable making and interpreting her observations. Working with a certified Sensiplan instructor is recommended and has been shown to improve the use of the Sensiplan rules and increase personal satisfaction with the method. 13

W hat is Natural Family Planning?

A new way Being aware of your own fertility and taking the first steps with natural family planning open up new realms of understanding and experience for women and men. Women need to evaluate their bodies in ways that are new and sometimes unfamiliar. Couples need to have conversations that have a direct impact on their day-to-day lives and how they express intimacy. All of this can be challenging and rewarding at the same time. How the fertile period is dealt with varies greatly, and every couple will find out what works best for them. It is not uncommon for there to be a shift in how couples interact, including in how they interact sexually.

The history of natural methods Records about women's fertility date back thousands o f years and can be found among the famous philosophers in antiquity and early Jewish writings.

Calendar Method. The first scientific findings on the fertile time are attributed to the gynecologists Ogina (Japan) and Knaus (Austria) who each discovered in the 1930s that ovulation occurs 12 to 16 days before the next menstruation. The rules they set up determined which were the infertile days based on previous cycle lengths (calendar or rhythm method).

14

Temperature Method. This method is based on changes in basal body temperature during a woman's cycle. The Dutch gynecologist van de Velde was the first to suspect a link between temperature and ovulation. The first person to recommend using temperature change for family planning was the German priest, Wilhelm Hillebrand, around 1935. In 1954, the German gynecologist Gerhard Doring published an easyto-follow guide on the temperature method, making it more widely known. Ovulation Method. The ovulation method, or cervical mucus method, was developed by the Australian neurologist John Billings starting in 1960 and is based on self­ observations of cervical mucus. This method also is considered by some not to be sufficiently reliable in the modern setting.

W hat Is Natural Family Planning?

Sympto-thermal Method. The sympto-thermal method combines the charting of basal body temperature and cervical mucus observations. This was first published by the Austrian doctor Josef Rotzer in 1965. In 1981, Arbeitsgruppe NFP was established in Germany and, in a model project supported by the German Ministry of Health from 1984 to 1991, paved the way for the sympto-thermal method Sensiplan, which is taught in Germany today and outlined in this book. Sensiplan incorporates components of other pioneering natural methods such as those associated with Doring, Rotzer, Billings, Thyma, and Flynn. The model project was overseen by an interdisciplinary scientific working group affiliated with various universities including primarily the University of Dusseldorf.

How has the Sympto-thermal method evolved? Arbeitsgruppe NFP now has a national network of teachers In Germany that is headquartered at Malteser Deutschland in Cologne. Related scientific research is conducted at the University of Heidelberg under the direction of Professor Thomas Strowitzki in cooperation with the Natural Fertility Section of the German Society for Gynecological Endocrinology and Fertility Medicine. Numerous recent publications in medical journals have helped to raise awareness in the field of gynecology of the method developed by the Arbeitsgruppe NFP.

Sensiplan With so many developments worldwide in the field of natural methods, Arbeitsgruppe NFP has, since 2010, assumed and trademarked the name Sensiplan for the method it developed. The aim of this is to be able to trace and attribute clearly the results and information related to this method, especially when it comes to scientific publications about the work developed by Arbeitsgruppe NFP.

Our Bodies The use of natural methods for family planning is based on developing a feel for our bodies and the signs they send us, and on building confidence in understanding what those signs communicate to us. For this to work, we need a basic understanding of our reproductive organs and the fertility processes in our bodies.

Our Bodies

Fertility in men and women With every cycle in the female body, a fertile egg (ovum) develops and is released by an ovary. Meanwhile, a healthy young man produces up to 100 million sperm a day in his testes. The window of time during each female cycle when the egg can be fertilized by a sperm is only 12-18 hours, and if the egg is not fertilized within this time, it dies. However, in the presence of cervical mucus in the woman's body, a man's sperm can survive and remain fertile for up to five days while waiting for ovulation. Thus, there are multiple days in a woman's cycle when an act of intercourse could lead to the fusing of an egg and sperm or fertilization. These days are called the"fertile days." Before using natural family planning, it is important that you first grasp this central fact about timing, as well as other aspects of the fertility processes in both the male and female bodies.

Shared fertility Since fertilization itself can occur only for 12-18 hours following ovulation, but the intercourse responsible could have taken place several days beforehand, it is important to understand the conditions that allow sperm to survive while waiting for ovulation. In the days leading up to ovulation, changes occur in a woman's body that enable sperm to survive for up to five days. To gain a better understanding of these changes, you must first understand how the female and male reproductive organs work. 18

Our Bodies

Female reproductive organs The internal female reproductive organs include the uterus, two fallopian tubes, and two ovaries. These organs are located deep within the pelvis and are connected to the outside of a woman's body through the vagina (Figure 1).

The Cervix The cervix, located in the lower part of the pear-shaped uterus, opens into the vagina. The opening of the cervix to the vagina is called the external cervical os, (Figure 2, #2 and #3) The Crypts The cervical canal has small folds in the surface known as cervical crypts. These crypts are lined with mucous glands, and they secrete various types of cervical mucus throughout a woman's cycle, depending on varying levels of hormones throughout the cycle. The changes in cervical mucus play an important role in sperm survival. (Figure 2, #4)

1 Uterus 2 Fallopian Tubes

3 Ovary 4 Vagina

Figure 1: Overview of the internal reproductive organs of a woman.

The Uterus and Uterine Lining The uterus is a pear-shaped organ made of strong layers of muscle. The internal walls are lined with a mucous membrane (endometrium) which thickens during the cycle and is shed with menstruation. When a woman becomes pregnant, the lining does not shed. The baby grows inside the uterus (uterine cavity) until he or she is born. (Figure 2, #5 and #6)

Our Bodies

The Fallopian Tubes The fallopian tubes branch off the uterus to the left and right sides. The ends of the fallopian tubes are funnel-shaped and freely mobile. Around the time of ovulation, they extend over the ovary to collect the released egg into the tube.

20

Figure 2: Section of the female reproductive organs

The Ovaries When a baby girl is born, her ovaries already contain all the eggs she will ever release in her life. At birth, each ovary contains about 400,000 eggs, of which only about 400-450 will fully mature during her lifetime. The ovaries are suspended from both sides of the pelvic wall by ligaments, and they produce the female reproductive hormones estrogen and progesterone.

1 2 3 4 5

6 Uterine lining 7 Fallopian tubes 8 Ovary 9 Follicle 10 Corpus Luteum

Vagina Cervix External os Cervical canal with crypts Uterus

Our Bodies

Male reproductive organs Sperm is produced in a man's testicles (Figure 3), It takes about three months for an immature sperm cell to reach maturity. Each sperm is about a six hundredth of a millimeter in length and consists of a head with a cap. a central section, and a fast, whipping tail. The cell nucleus with the genetic information is in the head, while the cap contains enzymes that help the sperm penetrate the membrane of the egg. Every time a man ejaculates up to 200-700 million sperm are propelled through the two sperm ducts and the urethra.

Figure 3: Overview of male reproductive organs. The arrows show how the sperm travel during ejaculation starting from where they are formed in the testicles through the sperm ducts and the urethra. 1 2 3 4 5 6 7 8 9

Testicle Epididymis Vas Deferens Bladder Seminal Vesicle Prostate Urethra Penis Anus

21

Our Bodies

The female ovulation cycle With every new cycle, a fertile egg matures in one of the two ovaries. It is released from an ovary during ovulation and drawn up into a fallopian tube. If an egg is not fertilized, menstruation will occur 12-16 days after ovulation, and a new cycle will begin. This recurring cycle in women is controlled by regulating centers in the brain. The hormones FSH (follicle stimulating hormone) and LH (luteinizing hormone), released by the pituitary gland, play an important role in this process. A cycle starts on the first day of menses and ends on the last day before the next menses begins. The cycle is divided into two phases: the phase before ovulation (follicular phase) and the phase after ovulation (luteal phase). During each cycle phase, hormone fluctuations cause changes in a woman's signs of fertility. With proper training and practice, a woman can learn to observe and interpret these changes and know when the fertile window begins and ends. The phase before ovulation the follicular phase At the start of the cycle, several follicles and the eggs within them will mature under the effects of the controlling hormone, folliclestimulating hormone (FSH). Only the 22

most mature follicle (dominant follicle) will burst and release its egg at ovulation, while the others will shrink and dissolve. The hormone estrogen is formed in the wall of the growing follicles. The larger the follicles grow, the more estrogen is created and released into the bloodstream. This means that the closer a woman is to ovulation, the higher the estrogen level in her blood. This prolonged sharp increase in estrogen levels triggers the pituitary gland to release luteinizing hormone (LH), which, in turn, causes ovulation. The effects of estrogen Estrogen has several effects on the female cycle, including: • The lining of the uterus begins to build again after it was shed during the last menses. * Cervical mucus becomes wetter, and the amount increases significantly. Cervical mucus that is high in estrogen will flow down the walls of the vagina to the vaginal opening, where a woman can observe its sensation and appearance. This type of cervical mucus is a sign that the ovary is preparing for ovulation.

Our Bodies

Follicle Maturation

Cervical Mucus Dry

Thickish Lumpy Moist

Ovulation

Glassy Stretchy Wet

Luteal Phase

Thickish Moist

Dry

Temperature ^

I

Bleeding

Duration of cycle

Figure 4: Overview of the hormonal changes in a woman's body and their effects within a cycle. 23

Our Bodies

The phase after ovulation the luteal phase After ovulation the follicle that ruptured and released the egg collapses and develops into a yellow colored mass known as the corpus luteum. The corpus luteum produces progesterone and to a lesser extent, estrogen.

The effects of progesterone Progesterone has the following impact on the female cycle: * The lining of the uterus thickens as it prepares for possible implantation of a fertilized egg. * The production of cervical mucus rapidly declines, and becomes thick, sealing the neck of the uterus with a mucus plug. The cervical mucus no longer trickles down to the vagina and therefore is no longer present at the vaginal opening in large quantities. * Basal body temperature rises by a few tenths of a degree Celsius (temperature shift) and remains elevated until the end of the cycle. The temperature shift confirms ovulation has occurred. If the egg is not fertilized, the corpus luteum breaks down within 12-16 days after ovulation; progesterone and estrogen levels drop, and a new cycle will begin. Because the progesterone drops, the temperature will also drop (Figure 5), and the lining of the uterus will shed. A new cycle begins.

Figure 5: Temperature curve over two cycles.

24

Our Bodies

The pathway for sperm in the female body Sperm released during ejaculation into the female body have a long way to travel to reach the egg that is ready for fertilization. They swim up to the vagina through the cervix and the uterine cavi­ ty to reach the egg in the upper third of the fallopian tube. (Figure 6)

Place of fertilization

Figure 6: Pathway of sperm in the female body

Infertile days On infertile days, the passage for sperm is blocked (Figure 7). The cervical mucus in the neck of the cervix is a thick and solid plug blocking the entrance to the uterus (a). The sperm cannot continue on their journey and remain in the vagina (b), where they soon die in its acidic environment.

25

Our Bodies

Fertile days On the fertile days, the cervical mucus plug breaks down (figure 8). The cervical mucus becomes thinner, wet, and more abundant (a). It is rich in proteins, salts, and sugars, and gives sperm the en­ ergy they need to continue their journey to the waiting egg. After ejaculation, the sperm is still 15-18 cm away from their target. The fastest among them take less than half an hour for the entire journey. Some remain in the crypts (b) in the cervix for a few days. From there, over the next three to five days, they will continue to travel through the uterus into the fallopian tubes. This variation in travel time increases the chance of a sperm at some point actually reaching the egg. (Figure 8)

26

Figure 8: Uterus on fertile days

Our Bodies

Fertilization, implantation, and pregnancy An entire army of sperm must leap into action to fertilize one egg. However, only one sperm will penetrate the egg's solid membrane and fuse with it. The egg then immediately closes so that no other sperm can enter, and a new life begins. The fertilized egg immediately starts cell division (Figure 9). Tiny hairs in the fallopian tube and muscle contractions transport the egg towards the uterus, which is ready for implantation and pregnancy by the time the egg arrives. The fertilized egg implants into the wall of the uterus about six days after fertilization. If all goes well over the next nine months, the fertilized egg will grow into a full term baby.

Figure 9: Development and pathway of the fertilized egg. a. Fertilization of the egg; b. - d. Traveling and cell division; e. Implantation

Our Bodies

The cycle throughout a woman's life For almost forty years, from puberty to menopause and through different life circumstances, a woman's reproductive cycle will be her constant companion. The cycle is an expression o f her fertility. Contrary to popular belief, the 28-day cycle tends to b e the exception and not the norm. There is still a widespread notion that a normal cycle is 28 days, with little or no variation. But experts say that "the only regular thing about the cycle is its irregularity." Most women's cycles fluctuate by a few days, and more than 50% of women will see their cycle vary by up to seven days over the course of a year. Medical science considers cycle lengths of between 25 and 35 days as normal. A series of cycles of exactly the same length tends to be rare. You may be among the women who believe that their cycle is too irregular to be able to use natural family planning as a reliable method. Or you may firmly believe that your cycle is so regular you could set the clock by it. Neither of these is likely to be correct when you look at it closely. Our bodies do not work like clockwork as individuality and sensitivity affect our biological functions. So, every woman has her own cycle that changes continuously as she goes through puberty, phases of fertility, pregnancy, breastfeeding, and menopause. Also, life itself has its ups and downs that affect the cycle and give it its own individual course. 28

From the dawn of time, people have believed there to be a link between the phases of the moon and menstrual bleeding. The word "menstruation" actually comes from the 28-day cycle of the moon. It is possible that in the past when people lived much closer to nature, there was a certain connection. However, for most women, their cycle has its own individual pattern that varies over time. There even can be major fluctuations caused by different life circumstances or other facts science has yet explain. It is these outliers or relying on your "feel for your cycle" that are responsible for the high failure rate of natural family planning based just on calendars, because there is no way to tell in advance what variation a particular cycle might have. The major advantage of a symptothermal method such as Sensiplan is that the fertile and infertile days are not calculated based on past cycles but are determined on a dayto-day basis using real-time physical observations.

Our Bodies

In the know... Fluctuating cycle lengths New investigations have shown fluctuations in cycle length to be greater than previously expected. An NFP study closely examined over 35.000 cycles from some 1,600 women. Only about 13% of all these cycles were exactly 28 days long. While half of them ranged from 26-29 days, the other half significantly deviated. Charting the cycle lengths of one woman over a year shows just how great these fluctuations actually are. In this study, only 3% of 210 women had regular cycle lengths, where the fluctuation is just one to three days. In 16% of these women, the cycle length fluctuated by up to 5 days. Overall, in 58% of women, there was more than an 8-day difference between the minimum and maximum cycle length.

From girl to woman During puberty, it is normal for the cycle to have to "find its feet." After a woman's first menses, she likely will have irregular cycles that begin again in as few as 3 weeks, or as long as 6-8 weeks. In the first few years, this generally does not require treatment. The problem with these major cycle fluctuations is that some girls find it difficult to plan life without knowing when menstrual bleeding will occur.

A common treatment for these irregular cycles during puberty is hormone use. However, hormone use artificially regulates the entire rhythm of the cycle. Another option is to be understanding and patient with your body, allowing it to develop at its own pace. As the young woman ages, her cycle generally will become more regular, until it reaches its greatest stability between the ages of 25-40. It is only when a woman progresses toward menopause that cycle length again will have great fluctuations.

29

Our Bodies

The variable follicular phase Some people believe that ovulation and the resulting fertile time is exactly in the middle of the cycle. Many biology books incorrectly cite ovulation as happening on day 14 of the cycle. However, the ovulation day can fluctuate greatly, and it is the cycle phase before ovulation that is responsible for this fluctuation. This phase is generally known as the "follicular phase."

If the cycle is short, ovulation often happens very early, sometimes even on the 8th, 9th, or 10th day of the cycle. If the cycle is long, it may take several weeks until the follicle stimulating hormone (FSH) responsible for ovulation is carried from the pituitary gland in the brain to the ovaries, where it triggers the beginning of the ovulation process. If this occurs, ovulation may occur close to the time many other women would expect menstrual bleeding to begin. (Figure 10)

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Figure 24. Disturbances and special circumstances are entered in the same column as the temperature measurement they may have affected. Methods of measuring If you change your thermometer or the location that you measure your temperature mid- cycle, you must enter this as a possible disturbance on the cycle chart.

For many women, taking the temperature within thirty minutes before or after their usual measuring time will not affect the result. However, other women may observe a slight difference.

Measuring times While you are learning Sensiplan, it is especially important to record the time you take your temperature each day. This will allow you to learn if different times affect your temperature measurements.

A time change due to traveling or the clocks being set forward or backward should always be considered a possible disturbance.

53

Observing and understanding the body's signs

Occurrences Unusual/special disturbances

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Figure 25. Sample cycle of Angela R.: The disturbance is caused by waking up later than usual. Figure 25 shows Angela R.'s temperature measurements. On weekdays she gets up at 7, however, on the weekends she sleeps late and does not take her temperature until later in the morning. The measurements taken on the weekend are much higher than her low temperature phase baseline, and therefore must be put in brackets as a disturbance. However, if there is a measurement that falls below baseline that generally is not considered a disturbance. For example, on cycle day 14, although Angela R. had to wake up early for a trip, her temperature measurement fell below her low temperature phase baseline but this does not need to be put in brackets.

54

O bserving and understanding the body's signs

f Occurrences Unusual/spedal disturbances Tim e 6® 7 7 3* Midcycle pain Breast symptoms

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Date: S e ct-2 Menstruation 1.

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Figure 26. Sample cyde of Petra J: Differences in measuring times do not result in a disturbance in her cycle.

Daily routine There are many factors in your dayto-day life that can impact your bodily functions and sleeping patterns. While activities such as drinking alcohol or going to bed unusually late may not individually affect your temperature measurements, several events together may cause a disturbance. Changes to your usual routine such as parties, holidays, chronic stress, or illness can affect your temperature.

The following variations to your normal routine may affect your basal body temperature. • not sleeping long enough or broken sleep • an unusually late bedtime • an unusually large amount of alcohol • eating late in the evening • partying late in the evening • stress, mental strain, excitement • changing environment (traveling, holidays, climate change)

55

Observing and understanding the body's signs

Illnesses and ailments Illness can, of course, cause your body temperature to rise, even if only slightly. If you notice an increased temperature measurement and signs of illness, this value must be put in brackets. Since signs of illness may have different underlying causes, it is difficult to compare it to past experiences; therefore in future cycle charts "illness11will always be counted as a disturbance and bracketed.

56

Special case - temperature readings that are too low Some situations can lead to a drop in basal body temperature. Reduction of temperature in a cold environment or very early measuring times are common causes and must be taken into account when interpreting your cycle charts. Occasionally, you may have temperature fluctuations that you will not be able to interpret clearly. In these cases, you may have to continue to make observations for several more days before the cycle chart can be understood. If you are unsure about your cycle pattern, consider yourself fertile.

O bserving and understanding the body's signs

Changes in the cervix Like cervical mucus and temperature, the cervix also changes throughout the cycle. Changes of the cervix can be monitored as an alternative to cervical mucus observations. Choosing to use the cervix sign instead of the cervical mucus sign can be especially helpful in women who have very little or no cervical mucus, or for whom the observation is impaired or cannot be evaluated for other reasons (Figures 27 and 28). After menstrual bleeding ends, the cervix is closed, feels hard, and protrudes deep into the vagina, making it relatively easy to touch with your finger. As you get closer to ovulation, the cervix softens, opens slightly, and rises a little, making it somewhat more difficult to reach. After ovulation, it again closes, becomes hard, and drops lower into the vagina.

Figure 27. The internal reproductive organs in a woman: the vagina is illustrated so you can see the cervix that protrudes into it. 57

Observing and understanding the body's signs

Figure 28. Changes in the cervix during the cycle

Self examination If you choose to use the cervix sign, you will start examining the cervix after the end of your menstrual bleeding. This will make it easier for you to understand and interpret the changes throughout your cycle. Examine the cervix once a day in the same position and with the same finger(s). It is easier if you bend over slightly or stand and put one foot on a chair or the edge of the bathtub. If you prefer, you can squat, sit, or lie down and raise your legs slightly.

58

After emptying your bladder, insert one or two clean fingers (index and middle finger) into the vagina, and move your fingers back and up (Figure 29). Circle your fingers around the cervical os and feel its texture. It protrudes into the vagina like a nub or cylinder and is smooth, in contrast to the rough vaginal walls. Then try to find the little dent of the cervical os opening into the cervix, and to assess how wide open it is. In a woman who has already given birth, this opening may be a slit and may never be fully closed.

O bserving and understanding the body's signs

Now move your finger back towards the edge of the cervix and determine if it is "hard" or "soft." The cervix can be hard - like the tip of your nose,or soft - like your lips or ear lobes. Some women may find it difficult to examine their cervix themselves because it may be scarred from operations or as a result of giving birth. If you find it difficult to reach the cervix, press against your lower abdomen with the other hand to push the uterus down so that the cervix moves closer to your finger. Finally, you can take cervical mucus directly from the cervix. To do this, lightly squeeze the cervix with two fingers and, keeping your fingers together, draw them out of the vagina. You can then judge the mucus between your fingers using the criteria explained on pages 40-41. Based on your experience and preference, it is best to opt for one of the two methods - either observing the cervical mucus or the cervix itself - and stick to it. Not every woman can observe all changes to the cervix. Some may only be able to tell how far open it is and how firm it is. This is perfectly adequate.

Figure 29. Cross-section through the female pelvis and hand position for the self-examination.

If you feel any cervix changes that concern you, call your gynecologist to have it checked.

59

Observing and understanding the body's signs

Entries on the cycle chart The observations for self-examination are entered on the cycle chart in the section "Cervix1' (Figure 30). O p enin g Use the following symbols to indicate how far open the cervical os is: Closed

*

Partially open

o

Completely open

O

Position Position the symbols of cervical os opening on the row marked "position and opening" to indicate how high or low the cervix is.

FirmnessEnter hard (h) or soft (s) on the row marked "Firmness," depending on the feel of the cervix.

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Appearance

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