Is Contraception Right for You to Raise Fertility Awareness?

If you’ve ever written, texted, or uttered the words “birth control” to your friends in the past few years, you’ve probably seen an ad that said there was an app for that. Some companies promise that tracking your menstrual cycle with their app and algorithm will help you prevent pregnancy – no hormones, implants or IUD insertion are required.

All birth control apps rely on a method of contraception that has always existed called fertility awareness : essentially, you log certain physical characteristics every day to track your menstrual cycle until you can predict ovulation like clockwork. Avoid unprotected sex on or around ovulation days, and you are less likely to get pregnant. When done correctly, this method is effective, but how effective it is is a matter of some controversy.

This is the root of the recent controversy over birth control apps like Daysy and Natural Cycles . As with any birth control method, the effectiveness of fertility awareness depends on how well and consistently you use it. But unlike condoms or pills, we have no clear idea of ​​what the “average” use of fertility awareness looks like, and there is little scientific consensus on the quality of research behind this “ 93% effective! Claims. The FDA-approved Natural Cycles app has been researched and validated by Swedish medical authorities , but the UK found them misleading enough to ban some of its advertisements . Despite serious allegations of improper data collection and analysis , Daysy is still on the market All this makes it difficult for potential users to ignore the hype and make an informed decision about contraception.

On top of that, there is a lot of misinformation about contraception for fertility awareness in general. Hard believers often exaggerate its effectiveness, while skeptics reject it too quickly, making rather crude assumptions about the people who use them. To be clear, I spoke with research scientist Dr. Chelsea Police and obstetrician-gynecologist Dr. Rachel Peragallo Urrutia , who have conducted a systematic review of fertility awareness research over the past few years. If you are intrigued by the idea of ​​a birth control app or simply want to know more about fertility awareness, here is (almost) everything you need to know to decide if it’s right for you.

What is Fertility Awareness Contraception?

Fertility Awareness Methods, or FABM, aims to prevent pregnancy by dividing the menstrual cycle into “fertile” and “non-fertile” days. On fertile days, the chances of getting pregnant from unprotected sex are highest; on days without fertility, it is lowest. Figuring out which days there are is accomplished by carefully tracking biomarkers or physical indicators of how far you’ve come in your cycle.

There are several relevant biomarkers that you can track, which means there are several FABMs to choose from. These are the most common types:

Calendar methods, like the traditional “rhythm method,” track fertility by calendar days of the menstrual cycle. Once you are familiar with the length and frequency of your periods, you can use the standard menstrual timeline to determine the most and least fertile days. For example, in the standard days method, 8-19 days of the cycle are considered fertile.

Cervical mucus (or ovulation) techniques track ovulation by observing changes in cervical mucus, and this is exactly what it sounds like: mucus that comes out of the cervix. Its consistency and appearance change in response to hormonal fluctuations in the menstrual cycle, becoming characteristically elastic and slippery right before ovulation. The simplest method of excreting mucus is the two-day method : any day you observe, this mucus is considered fertile, just like the previous day.

Basal body temperature (BBT) methods also track ovulation, which causes a small but measurable increase in body temperature. Every morning, before you get out of bed, you take your temperature and write it down in the app or manually on graph paper. No matter how you write down the readings, the goal is the same: to determine the temperature jumps that accompany ovulation. The popular and somewhat controversial Natural Cycles app is an example of a BBT-only method.

Urine hormone- based methods use a device called a contraception monitor to check the level of estrogen and other hormones in the urine. These measurements are fed into an algorithm that calculates the fertile window.

Any of these single biomarker methods can prevent pregnancy when used correctly, but you can also combine them for more information. The use of the BBT method in combination with calendar and / or mucous methods is a symptothermic method ; BBT replacement hormone on the bladder makes it sympto-hormonal method.

This is very similar to Natural Family Planning (NFP). This is the same?

Yes and no. Scientifically, there is no real difference – NFP and FABM use the same methods – but there is often a significant difference in their social and moral backgrounds. As the Association for Fertility Awareness Professionals (AFAP) explains, NFP is traditionally taught in a Catholic context :

“Most NFP methods promote chaste abstinence (abstinence from any sexual activity) during the fertile phase of the cycle if a couple wishes to avoid pregnancy. The NFP does not condone sexual activity outside of marriage and often limits education to heterosexual, engaged, or married couples. ”

In contrast, fertility awareness is intentionally inclusive. AFAP welcomes all people, regardless of gender, sexual orientation, religion or marital status, and they openly support “the full spectrum of reproductive opportunities,” including condoms, fertility treatments and abortion.

What are the pros?

The most important thing to remember about FABMs is that they are nothing more and nothing less than just another birth control option. As with any method, you must weigh the pros and cons.

Lack of hormones means no side effects

Hormonal contraception has side effects; there is no way around this. While some of them may be positive – lighter periods, less acne, lighter PMS – finding the right hormone cocktail can literally take years of trial and error. For this and other reasons, non-hormonal methods such as FABM have their advantages: like copper IUDs and condoms, FABM does not cause unpleasant hormonal side effects. But unlike IUDs, FABMs do not require a painful insertion process or affect the menstrual cycle – and unlike most condoms, latex allergy is not a factor.

Many methods are free or inexpensive

Physical and financial accessibility is another plus for FABM. Once you know what you are doing, the only equipment you will need to check your cervical mucus is your cervix, a finger, and a calendar or table. You take measurements yourself, on your own schedule, in the privacy of your own home.

Of course, some companies are looking to monetize fertility awareness, especially in education. This in itself is not necessarily a bad thing: to use it correctly requires a certain level of knowledge. Classes or one-to-one consultations with licensed medical practitioners are not free, but many are inexpensive or charged on a sliding scale. While neither is strictly necessary, a fancy thermometer and app subscription may still cost less than an OB / GYN appointment and a monthly prescription, depending on your insurance.

All power is in your (and your) hands

Tracking and recording biomarkers on a daily basis over the years gives you a more complete picture of your reproductive health than taking a pill or periodically remembering your IUD’s existence. Depending on how much you enjoy tracking your health metrics – and your background in the healthcare system – this can make a huge difference.

Using FABM also requires strong communication with your partner (s) and healthcare practitioners. For people in healthy, supportive relationships, teamwork can be beneficial; From the clinician’s point of view, treating a patient with a conscious interest in their health is a pleasure. Dr. Urrutia told me that she enjoys fertility counseling because it represents a “true partnership” between her and the patient.

What are the cons?

Depending on your point of view, the biggest advantage of FABMs may be their biggest disadvantage. These methods are the opposite of the “set and forget” principle – they require at least two people daily active participation, which makes them especially vulnerable to human error. But beyond that, one of the most frustrating obstacles to learning about FABMs is how little we know for sure about their use and effectiveness.

It is not immediately effective

The transition to FABM is not easy and fast. This is a period of increasing activity during which you track your chosen biomarkers every day, ideally without having sex at all. Even if your period is like a clock, this introductory period can last from one to three cycles: you need to know what “normal” looks like, but you also need time to get used to the methods.

Irregular periods make it difficult to adapt. If you stop taking pills recently in the puerperium and / or during breastfeeding, perimenopause, or have a medical condition that causes irregular menstruation, it may take longer to reach this baseline – up to six months. What, according to Dr. Urrutia? “You can’t just jump right in.” In other words, until you truly learn to track biomarkers and do so long enough to accurately predict fertile days, you cannot rely on FABM alone to prevent pregnancy.

No protection against STIs or STDs

Like any non-barrier birth control, FABM does not protect you from sexually transmitted infections. If your sex life carries a risk of infection and you rely on FABM to prevent pregnancy, be sure to use a barrier method such as condoms as a backup.

Do FABMs Really Work?

Almost all other methods of contraception have been studied to death. We know with a very high degree of certainty how many people use the pill, how reliably they use it, and how often the pill does not work under typical or flawless use.

Almost all of this does not apply to FABMs, which rarely become the subject of clinical trials. Since they are not widely used, this makes sense; the potential pool of study participants starts small and continues to decline as the exclusion criteria are applied. The data behind fertility apps often comes from private labs, so it’s proprietary – you can’t just google the results. Even peer-reviewed articles on FABM are not always reliable: they may be statistically inadequate, rely on their own or carefully selected data, exhibit a seriously flawed experimental design, or all three . Some studies even combine all FABMs into one method, which embellishes the wide variation in their performance:

Unfortunately, all of this means that there is a serious dearth of peer-reviewed data for FABM, and when it comes to making informed decisions, this is the biggest hurdle for both healthcare providers and patients.

The performance of ideal and typical use is not clearly defined

Of the roughly billion criteria to consider when choosing a contraceptive, most people focus on two numbers: how effective it is when used ideally and how effective it is when used typically. Knowing what sets them apart and your tolerance for that difference is critical.

Ideal use is more or less similar to what it sounds like: using a contraceptive method exactly as instructed each time. Dr. Polis defines it as “[] the effectiveness that we expect from someone who uses the method correctly and consistently every time.” Obviously, this is when contraception is most effective; flawless use results in high efficiency or low failure rates, depending on your point of view.

She explains that the typical use is less straightforward. “In short, typical use is the performance you would expect from the average person. … It includes some leeway to not fully follow the method’s instructions every time you use it. ” This means that typical utilization rates are lower (and higher failure rates) than ideal use.

The definitions of typical and perfect use do not change from method to method, but their appearance does change. For ideal use of FABM, many boxes need to be checked, Dr. Polis explained: “[This requires] accurate tracking of all biomarkers involved in this method, their precise interpretation, and then complete avoidance of unprotected sex at every stage. a day that is considered fertile. “

If you can consistently check these boxes, FABMs are effective, but getting reliable data on ideal usage can be difficult. According to a systematic review published by Dr. Urrutia and Dr. Polis , one study found that Billings’ method of ovulation using only mucus could result in as little as 1 unplanned pregnancy in 100 person-years when used absolutely correctly. In other words, if 100 people flawlessly used the Billings ovulation method for a year, we would expect to see one unplanned pregnancy. For the calendar standard days method, this number is 5; for a two-day method for determining only mucus – 3.5.

Typical FABM usage data is a little easier to find — for some methods, that’s all we have — but the numbers are incompatible even within methods. When used routinely, the Billings method can result in 10 to 33 unintended pregnancies per 100 person-years, depending on the study. For standard days, this is 11-14 pregnancies; 14 for a two day. Even if you know that regular use is ineffective and you are realistic about your behavior, there is a big difference between 10 and 33 unplanned pregnancies.

In many ways, this is why the FABM discourse is so full of misinformation. Without reproducible, rigorously validated performance data from independent research, it’s hard to know exactly what you’re signing up for, especially when it comes to marketing jargon. Natural Cycles and DaysyView, which both use the BBT method, have recently faced backlash against their advertised typical performance metrics. But investigating the validity of these allegations and then taking action if they are legal can be painfully difficult. In June 2018, Dr. Polis published a critique of the study used in marketing DaysyView in reproductive health (which also published the original study), citing serious analytical and methodological flaws. Based on her comment, she believes the review was warranted, but the initial research is still alive and the creators of DaysyView faced no real repercussions other than a dismal App Store rating .

How to choose the method that’s right for you

If the pros and cons of FABM fit your lifestyle and want to get started, you need to do a little research first. But doing medical research on the Internet is difficult, confusing, and potentially dangerous. How to filter out chaff?

Look for quality sources

According to Dr. Polis, the best thing you can do is to avoid the hype. There are many people out there who would like to benefit from your decision to use FABM, be it an attractive app, an expensive training program, or even a book. Along these lines, she has a specific recommendation: “Try not to reach out to social media influencers to help you make your contraceptive decision.” With that said, it is possible to get quality information from commercial sources if you know what to look for, namely a detailed and clear explanation of all the risks and benefits.

If you’re just starting out and don’t know where to turn, try the FABM FAQs from Planned Parenthood , AFAP, and the American College of Obstetricians and Gynecologists (ACOG). For a more in-depth discussion that is still user-friendly, Dr. Polis has a great blog and an equally great Twitter feed where she talks about all the contraceptive stuff; The Reply OB / GYN site, where Dr. Urrutia practices, has an entire page dedicated to FABM . If you prefer to go straight to the literature, the Guttmacher Institute is a great resource.

If possible, find a qualified professional

Some FABMs (notably Billings Ovulation, Marquette and Sensiplan) actually require instruction from a certified professional to teach this particular method. There is no Federal Accreditation Commission; the certifications differ depending on the method. If you are interested in any FABM, especially one that requires coaching, use the AFAP Practitioner Guide to find a qualified instructor in your area, or online – most practitioners offer virtual consultations.

It’s worth noting that while a trusted doctor can be an excellent guide, your obstetrician / gynecologist may not be able to help; as Dr. Urrutia explained to me, FABMs are not part of formal obstetric and gynecological education. On a positive note, doctors who do offer FABM consultations (such as Dr. Urrutia) usually do so out of a genuine passion for the job, so if you can find one they will probably be happy to work with you.

Be honest with yourself and your doctor

When advising a patient interested in FABM, Dr. Urrutia’s main goal is to understand their reproductive plans. This involves many questions, each of which must be answered honestly and comprehensively so that she can recommend: “Do you want to have children? Do you want to have more children? When do you want to have [these] children? What’s your relationship like? … How much work do you want to do to make sure your method is effective? What [birth control methods] have you used in the past and how has it been for you? “She also emphasized that screening patients for intimate partner violence is an important part of this assessment: FABMs require mutual trust, respect and honesty that are not found in relationships with physical or emotional abuse.

If it sounds too complicated, it is. Choosing a contraceptive method is a life-changing decision that you deserve to know what you are getting into. Know yourself, know who is breaking the rules, and take your time to make the best decision.

Updated [4/23/2019 2:53 PM]: Edited to clarify that Natural Cycles ads were banned by the UK Advertising Standards FDA and not by the app itself. Also, the research used in Daysy’s marketing materials is a retrospective survey, not a clinical trial.