Is Fertility Awareness Too Difficult to Use? (Episode 600)

Full Transcript: Episode 600

Lisa Hendrickson-Jack:

This is the Fertility Friday Podcast, episode number 600.

Today I have what I think is an exciting episode, only because it’s one of the topics that I love getting into, which is: is fertility awareness too difficult for women? This is an important episode for you if you are using the method personally. We’ll talk about a few very important things to consider in order to ensure that you get the highest efficacy when using fertility awareness-based methods. But this episode is also important if you are a provider, if you are a woman’s health professional. It’s really important to face some of the challenges that result in unintended pregnancy head-on if you want to engage with fertility awareness-based methods.

This study I find to be so fascinating because it does show a lot of the trends that I’ve seen working with clients over the years. It does give some insight into the relationship between how well that user effectiveness number correlates with your client’s actions and intentions. And it really touches on the complexity of this topic of either avoiding or trying to conceive.

So before I get into it, let me share a little bit about the study. So the title of the study is really long. I’ll just read a portion of it: Pregnancies, Intentions, and Fertility Behaviors During Use of the Creighton Model Fertility Care System After Initial Intention to Avoid Pregnancy. So that’s a mouthful. But the Creighton Model is a mucus-only method with a very detailed charting system, similar to the detailed charting system that we teach our practitioners in the FAM program, but it is a mucus-only method.

And so as we’ll talk about in this study, they had several users. So they gathered nearly 300 users of this method. And in the study, they had them identify each cycle if their intention was to conceive or to avoid. They had them track their fertile signs as well as their intercourse. So they did the study based on a few different criteria. So we’ll get into all of that.

But because this study includes real life, this is what it looks like when I’m working with clients. You have some clients that are actively avoiding, some clients that are trying to conceive. But that doesn’t mean that their intentions or actions can’t change. And so, for example, you can be working with a client and initially at that intake, they say, “Okay, we’re avoiding and this is what we’re doing.” And quite literally in the middle of cycle two or three, you could see an act of intercourse on a fertile day and you check in and say, “Okay, well, so what’s going on? What’s happening?”

So the reason that I’m sharing that is because intentions are not always set in stone and they can change and shift. And of course that affects a lot of different things. So what I really like about this study is that it is looking at a population, a mixed population, which is always what I worked with. I didn’t ever work with only women who were trying to conceive or women who are trying to avoid. And even if you think about it, if a woman is trying to conceive, there might even be a couple of months where something happens and she has to back off for a bit. So it’s not always set in stone. It can change. So let’s go ahead and get into it.

So a little bit of detail about the participants of the study. There was just under 300 — 296 participants in the study. The average age of the women was 27 years, and 82% were Catholic, and 100% were married or in a long-term relationship, and 90% were newer users to the method. So that is an interesting segment of the population, just to kind of set the stage.

So this is interesting. The initial intention: all couples began intending to avoid pregnancy, but of course there was a shift over time. So many couples transitioned towards openness or intention to conceive during the study. So 84% of the cycles were reported as to be avoiding, meaning that at the beginning of the cycle they said, “Okay, this cycle we’re avoiding pregnancy.” 10% were identified as achieving, meaning they set that intention at the very beginning that we’re trying to conceive this cycle. And then 6% were uncertain or ambivalent.

And so those were questions kind of like “I’m not really trying or avoiding” kind of thing. And then interestingly, partner agreement: so they asked these questions to the male partners and the female partners separately, and the male and female intentions matched in 91% of the cycles. So I thought that was interesting as well that they tested that, and so most of the time they were on the same page, but obviously just under 10% of the time they did not match up. So again, very interesting.

So if we get into the study results, among the couples who specifically said our intention is to avoid pregnancy — 29% of cycles included intercourse on known fertile days. So these participants were trained in this method. They were told which days to consider fertile, which days to consider not fertile. But in 29% of cycles, there was at least one act of intercourse on a day that was known to be fertile, likely due to the presence of cervical fluid or being within the boundaries.

So in all methods there is either what would be called a count of three or a peak plus four. In all methods there is a period of time after we are trying to confirm ovulation that you consider fertile. And so we have the actual days where we would identify fertility with a mucus-only method that’s based on mucus observations, but we also have this buffer period. And so in 29% of the cycles, intercourse took place on a known fertile day. And then it says when including potentially fertile days, this increased to 44% of cycles. And another interesting point: even couples who reported that they were “trying as hard as possible to avoid” — nearly one-third still had intercourse on a day that was identified as fertile.

So if we look at the outcomes then of this study, among those who specifically said we want to get pregnant, 89% within 12 months of those couples did achieve a pregnancy. So nearly 90% of those who said, “Okay, we want to conceive” — 89% within one year did conceive. Now, those who said we’re not trying to conceive — but as I just said, there was about a third of the cycles where sex did take place on a day that would be identified as fertile — about 35% of those couples conceived within 12 months.

So that’s obviously interesting because that’s a pretty high pregnancy rate. And again, the reason why the study is interesting is because it’s really looking at not only the outcome, but the intention stated and then the behavior, and looking at when those two things didn’t match up.

So when they actually looked at what would be a true method failure, meaning that if there was no sex that took place on any fertile days as outlined in the method, the true method failure rate was 0.3%. So it was very, very low. So the true method effectiveness rate based on this study was very, very high — over 99%.

And so what this study showed was that the vast majority of failures, when we’re looking at failures, are related to user behavior — what activities they are taking. And in this study, they’re really highlighting that the failures in general were typically related to what in the fertility awareness world we would call achieving behavior. So you can say you’re avoiding, but if you’re actively having unprotected sex on days of fertility, then we would consider that to be achieving behavior.

So there’s a couple of other pieces of data that the researchers pointed out that I want to touch on just so that you get some of the context. Over half of the couples that were enrolled were avoiding pregnancy at the beginning of the study as we talked about, but still stated that they had a desire to conceive within about two years. And if you remember when I went over the demographics of the study, many of these were younger couples, potentially had recently been married or were becoming married shortly thereafter. So that’s something to be aware of as well.

And this is one of the reasons why I state that especially if you are a woman’s health professional and you’re providing fertility awareness services to clients, it’s not just important to ascertain what they’re saying right now. You also want to get a picture of if they’re thinking about pregnancy in the future and what their plans are and those types of things, because from experience, what I can tell you is that intentions can change. It’s incredible. And this is something our practitioners experience where at the beginning of their work with the client it’s like, “Okay, she told me that they’re avoiding,” and literally a couple months in, things can completely shift. It doesn’t always happen like that, but it’s certainly a possibility, and that was reflected in this study.

So couples who at the time of enrollment said that they intended to have a child within a year or two were significantly more likely to conceive even when they continued to report that they were avoiding pregnancy. And this is something that the researchers touched on, which is that there was a certain level of openness to pregnancy among some of these participants. So that even in itself is an interesting stat — that the couples who said “we’re avoiding, but we do want to have a child within a year or two” were more likely to conceive overall.

So another stat that I want to point out, because I found this to be very interesting and it’s certainly one that makes me think a little bit more: about 38% of participants did not record all acts of intercourse. And that is a problem. And this is something, of course, that comes up a lot in our training when we’re talking with our practitioners. In order to be able to support your clients and to assess their understanding of the method and to support them to ensure that if they’re trying to conceive, sex is happening at the right time — if they’re avoiding, that sex is happening at the right time and not happening during the fertile window — we really do need to request that our clients are noting when they’re having sex.

And also, if they’re using an app or if they’re using paper charts, what is actually happening? If they’re using protection, that should be noted. We should be really clear on what’s going on. Not because we’re nosy, but because in order to support our clients, we really need to know the full story of what’s going on. And so to me, that was a bit surprising — such a high percentage. 38% of participants did not record all acts of intercourse.

It said first that 112 couples could not be included in the analysis because we could not be confident that all intercourse was recorded. You can’t really identify a correct-use number or a failure rate if we’re not even noting when sex occurred or how that sex took place. Was there a condom used? Was there withdrawal used? What was going on? And so if we don’t have that data, it makes it difficult to actually come to accurate scientific conclusions.

So what are the implications of this? And getting back to the initial question at the top of the episode — is fertility awareness too complicated? So there are a few things I want to share. And of course I just want to say I’m sharing from my perspective. Now, I do not teach a mucus-only method. After working with over a thousand clients and especially working in groups for many years — I did group coaching programs for clients, so I’m working with multiple clients at a time — I can share some of the observations that I’ve seen and some of the wisdom or knowledge that I’ve gained.

We really have to look at this not just as a black and white: “these are the rules, this is the method.” We have to take into consideration our clients and their motivations, their fears, their level of understanding in order to really set them up for success.

So when I first learned fertility awareness, as I’ve shared many times, I was very young. I was in my late teens when I first discovered the method. And as a young woman in my late teens, early 20s, I had a very black-and-white, I would say somewhat immature understanding of the complexity of this question of “am I trying to conceive or avoid?” So in my early 20s, I really thought that this was black and white, that everybody on Earth would be either a zero or a ten.

One of the things that we talk about a lot in our programs is the intention scale. Where are you on the intention scale? If someone says that they’re a zero, they may be motivated to terminate a pregnancy because they’re saying, “Zero, I’m not open to it at all.” If somebody is a ten on that intention scale, they are likely actively trying and may be pregnant right now. And so I often used to think that this was very black and white, but over the years and using this tool with clients and having these discussions, I would say that although there are some clients that are certainly on either end, the vast majority of people are somewhere in the middle. Even if that just means they’re a one or a two — maybe because they wouldn’t terminate — but a lot of clients find themselves in the middle.

Some of you listening might be thinking, “What? How is that possible? How could someone be in the middle?” But if you work with enough clients, you will realize that most people are not necessarily at the very ends of the spectrum, especially when you define what that would mean. And so that is something to take into consideration. And we have to be able to talk about it and unpack it. And we also have to recognize, as I’ve said already, that this is not something that you do once and then you move off from it. And you also have to take into consideration the partner — because you may think that you know where your partner is at, but until you have that conversation, many of our clients are surprised when they have that conversation with their partners because they thought their partner was in one place with regards to their openness to pregnancy, but they’re actually in a different place.

All of these things have to be taken into consideration. And one thing — if we look at the data and research on fertility awareness-based methods, if we look at the efficacy — typically fertility awareness-based methods that are mucus-only typically have lower effectiveness. There are a lot of different studies on the Creighton method in particular, some showing very high efficacy. And so what’s interesting about this study is that the actual pregnancy rates were a bit higher. The study gives us a lot of nuance on that, showing that, like I said, a third of couples who stated explicitly that they were avoiding were still having sex on days that were identified as fertile.

So we kind of see what was going on, but we do see this higher pregnancy rate. And so as practitioners, what do we do with that information? So for myself, one of the things I love to do is I love to go directly to the research and look at the methods that consistently show the highest efficacy. And this is something I’ve talked about many times. So the double-check sympto-thermal method — the method that includes mucus observations as well as a cross-check with mucus and temperature to confirm ovulation. So identifying that fertile window, identifying with two measures, not just mucus but temperature and mucus to confirm ovulation, but also using two methods to open the window. So yes, we look at mucus to open the window, but we also rely on a last-infertile-day calculation.

And when we look at these double-check sympto-thermal methods that employ that strategy and create a very well-defined fertile window that actually gives a bit more of a buffer so that the user is far less likely to be having sex a little too close to ovulation — which is really the issue with fertility awareness-based methods — the effectiveness is based on how well you are managing the pre-ovulatory phase.

If we divide the cycle into before ovulation and after ovulation, the only time pregnancy can really occur is in the pre-ovulatory phase. So the effectiveness of any fertility awareness-based method is really based on how well and how accurately you are managing that pre-ovulatory phase.

And so when we look at that factor, one of the reasons that the pre-ovulatory double-check sympto-thermal methods have higher efficacy rates — both absolute efficacy rates, but also typical-use efficacy rates — is because a lot of that confusion and gray area is totally removed by giving the users a little bit more structure for how they manage that pre-ovulatory phase.

And so as an instructor who’s now been in this field for over two decades, I would say that that is the key. We can talk about intention and we can talk about how we feel, how open we are to pregnancy. But ultimately your effectiveness isn’t based on your feelings. It’s based on your actions. And it is possible to be a little bit ambivalent and to be a little bit more open to pregnancy. But if you have a really strong system, if you have a good structure and you understand very clearly — no gray area — which days are fertile, which days are not, and there’s no room for discussion around it, then it is possible, even if your emotions are a little bit ambivalent, even if your ovaries are crying out, it is still possible to then take the appropriate action and to have these conversations with your partner so that you decide how you’re going to do this.

And this is one of the key important aspects of success when using fertility awareness-based methods in order to set your clients up for success. So again, the study is really interesting because it does show this nature of human behavior which I’ve seen over the years. And when you’re working with clients, I think you do have to recognize that sometimes you will see achieving behaviors in clients who are explicitly saying that they are avoiding pregnancy.

And so my role is not to be punitive. I don’t judge. I don’t do any of those kinds of things. I always consider that my role is just to provide that education and to provide the structure and information and evidence so that I can really set my clients up for success. My role, the way I see it, is I want you to understand how the method works and I want you to be crystal clear. I want you to feel that there’s no gray area.

So some of you might be thinking, “But there is gray area.” Well, if there’s a gray area, then potentially the method that you’re using isn’t providing you with as clear data as you actually need to be successful. Because when we’re going through it, it is actually possible to be crystal clear and have no gray area. Does that ever mean that there’s a day that you’re unsure? No, of course. There may be days that you’re unsure. There may be days where you see mucus and you’re unsure of what you’re actually seeing and all of those kinds of things. But you also have to know what to do on a day that you’re unsure. You can be unsure, and that makes it a fertile day — or at least a potentially fertile day, a day that we would have to consider potentially fertile. So we actually have structure to handle some of those feelings that you may have or some of those uncertainties that you may see. The key is the structure. The key is the structure so that there’s still no gray area.

So again, with this paper, going back to that data — having one-third of participants having sex on days that are identified as fertile, having 35% of couples who said at the onset “okay, we are avoiding pregnancy” actually have a pregnancy — but only 0.3% of couples who actually used the method correctly and avoided intercourse on the days that were identified as fertile actually did conceive. So very interesting, and highlights an important distinction that we need to make between the method itself and how effective it is. So the method failure rates or the method efficacy, and the user failure rates or the user efficacy.

And so as practitioners, it is a really big responsibility. This is why I always say that it’s essential for practitioners to receive training in fertility awareness. Charting your own cycles is not sufficient to be teaching others. It’s just not — because you have to be able to not only understand your own cycle. You have to understand what to do in a wide variety of situations that you have never seen before. And that is why training is really important. And you also have to understand the user psychology and to have a structure and a system to be able to equip your clients to be effective in their method. And this is something that comes with training. It comes with experience. And it comes with having a structure around how to support clients.

And for many women who are using the method personally, they have come to their own kind of conclusion of how they’re going to use the method personally. And if you have used the method and you’ve been successful, you probably have some unsaid rules, some things that you do that you didn’t necessarily define that have allowed you to be successful. You have some assumptions about how others may be using the method. And you likely — when you have a client and you’re seeing them do certain things that you wouldn’t do — we’ve had many practitioners that are kind of like, “This is crazy. I’m shocked.” They’re surprised because their clients are taking risks or just doing actions or having sex on certain days when they personally are thinking, “I would never do that. I don’t understand.”

And this is again why it’s important to have training so that you can set your clients up for success, because your clients are not you. Some of us are very, very conservative and take a whole bunch of extra steps beyond the method to ensure efficacy, and some of us are a lot more open and willing to take different actions. And so what I always say is I’m here for all of it. I don’t think I’ve seen everything possible, but I’ve seen a lot. And so I’m prepared for it, and I have ways to support clients regardless of how conservative they are naturally or how open they are naturally and how likely they are to take risks. There are ways to support clients regardless of where they are on that spectrum, and there are ways to encourage them and support them.

And the other thing too is that a big piece of it is to really understand where your client is at. And I think one of the most challenging things for some of our practitioners are clients who are literally not one or the other — who are literally in the “I’m open to it, whatever” zone. It’s kind of hard for some of our brains to comprehend how it’s possible for this person not to be on one side or the other of this issue.

One last thing that I’ll say about fertility awareness-based methods is that it really does give women and couples the ability to plan ahead. And I think that’s one of my favorite things about this method. This is one of the reasons why I’m so passionate to equip clients to use this method and feel very confident about it, because it really does give you options that hormonal methods don’t necessarily give you.

So with fertility awareness-based methods, they are possible to use very effectively. And like I said, the double-check sympto-thermal method — the research consistently shows the highest efficacy, both method efficacy and user efficacy. Typical-use numbers are quite high with the double-check sympto-thermal method when we’re not just relying on one marker but we’re relying on mucus and temperature and the last-infertile-day calculation in these double-check methods. So we can really support our clients to have a high typical-use efficacy so that user failure is less likely to happen.

But in that context, you have a woman who is cycling naturally. She has the opportunity to chart and see what’s happening in her cycle. And if we are seeing some cycle irregularities or abnormalities and she’s actively avoiding but she’s charting, we’re able to intervene and support her and see in real time how those interventions are taking effect. And so I’ve supported hundreds of clients to go through this stage if they’re coming off the pill. Those first cycles tend to be a little bit irregular as the body normalizes, but we can really support her and also have a strong focus on preconception nutrition. So while you’re still avoiding pregnancy, you’re able to really zone in and support hormonal balance, support menstrual cycle normalization, build up those nutrient stores preconception, all while you’re still using the method to avoid pregnancy.

And I’ve had a number of clients in the same kind of situation that’s outlined in this study where they are currently avoiding. Maybe they’re a younger couple, maybe they’ve been together for a long time, but now they’re thinking, “Okay, in a year or two, I want to start trying for a baby.” And I absolutely love working with clients in that phase because there’s just so much potential there. You’re still avoiding, but you have this wonderful runway to normalize your cycle and to build up your preconception nutrient stores, to learn and be educated about how your body works, to understand fertility awareness. And also to have your partner jump in on the preconception nutrition as well so that we can support his sperm health, your egg quality, your body, your nutrient stores — all these things.

So I absolutely love this window of time. It is just such a wonderful opportunity. And so for these couples, then, when they’re doing that, by the time they’re ready to try to conceive, oftentimes the cycle is in a much better place than it was before. And of course they may have been actively working on their preconception nutrition during that time.

Now contrast that to the birth control pill. Your intention can switch on a dime. You can go from — and one of the examples I often give is if you have — I’ve worked with many young couples, and let’s say they’re getting married in the fall or something like that. So it’s like “I’m avoiding, I’m avoiding, I’m avoiding,” but literally that month, that day that the wedding takes place, all of a sudden now we’re like 100%. Like, I’m ten out of ten on the intention scale. I’m ready to try and I want a baby right now. And it can go — it can shift like that in a day. It can shift very quickly.

And so if you’ve been using fertility awareness, you’ve been prepping your body — for example, as I shared in that example — so now your cycles are in line and all these things. So when you’re ready, your body’s already ready, right? Your mind can switch. You can go from “I’m avoiding” to conceiving overnight and your body’s there for it. It’s ready. But for someone who’s been on hormonal contraception, their heart can shift in a day, in a moment, just like that. But when they come off the pill, their body still goes through this transition for many months.

So this is a great opportunity for couples and women who are in that stage of thinking about future conception. Of course, there are a lot of benefits just for health and all of those reasons as well, but this is one of the reasons that I’m so passionate about fertility awareness because it is a method that can be used correctly — we can support our clients to have the high degree of efficacy that is reported in those studies when we’re using the correct system and when we are trained in the methods with the highest efficacy.

There is of course a time and place for all of the different methods. There are plenty of women who prefer mucus-only methods and there are a lot of reasons for that. So the best method really is the method that works best for the user. But over the years I’ve certainly found, especially having worked with a lot of women who are avoiding pregnancy and who are terrified of an unplanned pregnancy, that I’m far more comfortable teaching the highest efficacy methods so that they can have the structure they need to succeed.

But as you can see, there’s just such incredible potential here to support clients. The key is that when you’re working with clients in a professional way, you need to feel good about the method that you’re teaching and you need to feel like you’re equipping your clients to be successful. And so that’s why I always go back to the research and look at which methods are most effective.

So hopefully this episode has been interesting to you and has shed some light on some of the different aspects of fertility awareness charting. And if I go back to that original question — is fertility awareness too difficult? — it isn’t too difficult. We just need the right system, structure, and instruction. We just need that clarity and we need to get to that place where we can be really black and white. Is today a fertile day or not?

And to have those conversations about intention — if you’re not talking about it, sure, that means you could be taking risks and there could be that subconscious motivation. But if we put it out there and we have these discussions and acknowledge that we have — maybe although I’m not wanting to get pregnant right now, there’s a part of me that wishes I could be pregnant right now — if we can talk that out, then we can really divide out those emotions from your actions and you can still be effective at avoiding until you’re really ready to start trying.

So hopefully this episode has been helpful to you. It has been insightful, made you think a little bit, and also helped you get into the weeds a little bit — the nuances related to fertility awareness-based methods — but also with the knowledge that we can really support our clients to be successful as long as we tease out some of these issues and truly understand what are the reasons for user failure and how to support our clients to avoid that so that our clients can truly achieve their goals.

So with that said, I hope you have a wonderful weekend whenever you’re tuning into the show. And of course, as always, until next time, be well and happy charting.