While I was at LEMI Training last week, another conference happened that I wish I could have attended. It was the American Academy of Fertility Care Practitioners annual conference. Here is a link to the  meeting brochure. This meeting was for doctors and instructors who promote natural family planning, NFP, including the Creighton Method, which I use.

I know some of the presenters, I am thinking I might contact them and ask them to share a nugget or two for this blog. In fact, I got to visit with one extensively by chance two Saturdays ago at my husband’s 35 year Provo High School reunion. 

Dr. Joseph Stanford MD spoke at the conference. Hearing about this conference and Dr. Stanford reminded me that I have been meaning to finish a blog post I started about NFP a long time ago that involves an article he wrote. So here it is….

 Did you hear about the massive recall of birth control pills? http://thestir.cafemom.com/healthy_living/132363/massive_birth_control_recall_poses

It’s enough to make me grateful that I am a DIYer in the “birth control” department. I don’t really like that term because I think that we shouldn’t control birth as much as we should prepare ourselves mentally and physically to receive all the children that God wants us to have, regulated by the seasons of mothering that come through ecological breastfeeding. http://www.nfpandmore.org/The%20Seven%20Standards%20Summary.pdf

Of course we live in an imperfect world and unfortunately sometimes feel that we should “control” birth. But I feel that should be the exception, not the rule. When we as women treat our bodies like trees with seasons then we reap the blessings of: no harmful side-effects of hormones involved in hormonal birth control and learning to build our marriage in emotional ways when we abstain from intercourse.

(I do cheat a little on these seven standards with some gentle sleep training that I learned from Dr. Harvey Karp and Elizabeth Pantley, which don’t involve crying it out, but that is  a whole ‘nother blog post for another day!)

I would like to be at the point where I can just let the babies come as a Tree of Life Mom who goes through seasons. It takes complete emotional, physical, and financial health to be at that point, in the society we live in. The pioneers lived like this, but that was a different world. Allowing your body to go through seasons like a tree means becoming infertile due to LAM, or lactational amenorrhea (no fertility, and periods, due to ecological breastfeeding) like a tree is infertile during the winter time, and then fertile in the “spring” time of my mothering seasons, after my baby starts nursing less and eating solids. Click on the “seasons” tab above to read more about that.

Here’s a great article that Dr. Joseph Stanford, an LDS doctor who promotes NFP, wrote. He gave me permission to reprint it here. I have interspersed it with photos from our recent summertime activities at the swimming pool and our Independence Day celebration and other family times.

As a physician, I have encountered many Latter-day Saint married couples that struggle with issues that arise around their fertility and sexuality.  As they consider the choices offered by modern medicine, many find that they are just not satisfied.  Some couples have made a prayerfully considered choice to postpone the conception of their next child, but they do not like the side effects of a contraceptive method they are using, or the interference of a method with the experience of physical intimacy.  Some women find that they just don’t feel right about using chemicals in their body.  Other couples greatly desire pregnancy but are uncomfortable with procedures that a physician has recommended to try to help them get pregnant.  Some couples wonder whether it is necessary to suppress fertility in order to treat a health problem in the wife.  Other couples have prayerfully come to the understanding that their family size is complete, yet they are not quite comfortable with the permanent removal of a healthy function of the body through sterilization.  Unfortunately, sometimes couples find that differences about how to manage their fertility introduce unnecessary elements of tension into their sexual relationship.

It is to such couples that I wish primarily to address this article.  My purpose is to describe an approach that I call fertility respect [a], including its scientific basis, medical applications, advantages, and relative disadvantages.  I wish also to illustrate that fertility respect is fully concordant with LDS values regarding marriage, sexuality, and procreation, and that it strengthens marriages in physical, emotional, and spiritual dimensions.

What do I mean by fertility respect?  I use this term to mean an approach to fertility and sexuality that respects the divinely ordained nature of marital sexuality and that does not seek to suppress the normal functioning of the human reproductive system. Fertility respect includes ways for a woman to understand when she is ovulating and when she is fertile (i.e., the days of the menstrual cycle that intercourse can result in pregnancy). Fertility respect includes what is often called natural family planning (NFP), but it also includes a broader context of health, the marital relationship, and spirituality. Inherent to the concept of fertility respect is the mutual respect that ensues when a wife and husband use their understanding of their fertility to plan their family, respect the wife’s health, and enhance their sexual relationship. The two core underlying premises of fertility respect are,

1) Within marriage, sex is ordained and commanded by God for two inseparable and equally important purposes: procreation and the intimate union of husband and wife.  Marital sexuality is a divine gift and a sacred stewardship.  (Genesis 1:28; 2:24)

2) Marital sexuality is enhanced in all its dimensions when the normal functioning of the human reproductive system is respected, and where necessary, restored, rather than suppressed or bypassed.

My experience convinces me that many LDS couples, indeed couples of all faiths, are seeking for something better than on offer from mainstream society for managing their sexuality and fertility.  While I have made every effort to assure that what I present here as fertility respect is completely in harmony with the restored gospel of Jesus Christ, I do not claim to interpret Church doctrine.  It is my intent to provide insight, information, and resources to assist interested couples in their stewardship to manage their fertility and to strengthen their marriage and family. One woman described her own journey to fertility respect:

One morning, a month after being married, I stood at the bathroom sink, and just couldn’t bring myself to take another birth control pill. I had never read any negative literature about it, but after 3 days of staring at the wheel of pills, without taking one, I prayed about it, and felt calm as I tossed them into the trash.  My husband and I tried several barrier and spermicidal methods, and then decided to have a child, so I didn’t think about it for a year.  After the birth of our daughter, I was browsing at the library for breastfeeding information, and I came across a book entitled “No Risk, No Pill Birth Control.” The title certainly appealed to me, and so I read it carefully, and learned that a woman has certain biological indications of fertility.  This was very fascinating.  I began to chart my temperature.  As it happened, I was up so much at night breastfeeding and tending to our baby, that my temperature never rose enough to provide a reliable pattern.  After nine months of temperature taking, I gave up in frustration and returned to barrier methods.  I had a sense at this time that there must be a better way for couples to exercise a greater level of free agency in the planning of their families, and that the Lord must have another method of doing this besides contraception.  I prayed that I might find that method.  A woman I met during my third pregnancy happened to mention that she was an NFP instructor with the “Creighton Method.” I took these classes, and have been using the method for 2 1/2 years.  I have found that it is everything I want it to be, giving me a high level of confidence in its effectiveness, as well as avoiding the risks and bothersome nature of contraceptives. 

 

It is meeting many couples like this one that has motivated me to do systematic medical research in this area. In the rest of this article, I use a question and answer format to illustrate the many dimensions of fertility respect and related concepts.  In so doing, I draw on current medical research, current sociologic research, and my own medical experience, as well as scripture and statements from LDS Church leaders- the latter to be considered for perspective and not necessarily for doctrine.  I also give illustrative quotes from many couples that I have had the privilege of serving as a physician or knowing as a friend.  Because this article is directed to an LDS audience, all quotes that I have included throughout are from Latter-day Saints.  However, I could have given virtually identical quotes from couples of other faiths that I have likewise known. 

 

1. Understanding human fertility

Q. During which days in a menstrual cycle can we get pregnant?

A. A woman can get pregnant from intercourse during 5 or 6 days of each menstrual cycle, including the day of ovulation (ovulation=release of an egg) and 4 or 5 days preceding it. [1, 2]  The number of days in the menstrual cycle before ovulation can vary substantially, even in normal women with “regular” cycles. [3]  The number of days after ovulation and before the next menses is normally around 9-16 days in a group of women. However, for an individual woman, the length of the time after ovulation will usually only vary 1-3 days from cycle to cycle. [3,4]

Q. Why can’t I simply count days in my cycle to identify when I am going to ovulate?

A. Despite the common folk use of this approach, sometimes called “rhythm,” counting cycle days is not reliable for many women.  It is especially unreliable for women with irregular cycles, women who are breastfeeding, or women who are approaching menopause.

Q. How can I know which days are the fertile days?

A.  There are several ways used by modern methods of Natural Family Planning (NFP). Most NFP methods teach a woman to check her vaginal secretions to know the days when she could get pregnant.  She does this during routine use of the bathroom.  Characteristic changes in the vaginal secretions identify the approach and occurrence of ovulation, and also the end of fertility, regardless of the length of the menstrual cycle.   In some methods of NFP, urine hormone measurements or daily temperature recordings are also used to confirm that ovulation has occurred.  The basal body temperature rises after ovulation.

Q. Where do the changes in vaginal secretion come from?

A. From the cervix, an organ at the lower end of the uterus (womb).  About 6 days prior to ovulation, a increased flow of special fluid comes from the cervix.  As ovulation approaches, this cervical fluid (known in medical terms as Type E mucus) becomes more abundant, clear, stretchy, and slippery.  It sometimes, but not always, looks something like raw egg white.  After ovulation, the cervix rapidly ceases to produce this type of cervical fluid, instead producing Type G mucus. Type G mucus is dense and “gummy” in appearance if seen at all, but usually results in no observable vaginal secretions. [5,6]

Q. What is the function of the Type E cervical fluid?

A. The cervical fluid provides a biochemical and physiologic environment that promotes sperm survival and transport. [7] Scientists call the cervix a “biologic valve” that is open for sperm transport during the presence of Type E mucus, and closed to sperm in the presence of Type G mucus. [8] Therefore, the presence of Type E cervical fluid (recognized as vaginal secretions) is a reliable indicator of days when pregnancy is possible. [6]

Q. How can I check for cervical fluid?

Each time a woman uses the bathroom, she wipes externally with toilet tissue and characterizes what she sees on the tissue.  This simple procedure accurately reflects what is happening at the level of the cervix. [9] Some women do internal checks, but this is not necessary.

Q. I seem to have a vaginal discharge every day.  Can I still identify the fertile days?

A. Yes.  With proper instruction from a qualified instructor, you can learn to distinguish changes from the baseline discharge that you may have every day.  There may also be a medical condition causing the daily discharge that can be identified and treated by a physician.

Q. How do I know when I have ovulated?

A. The last day of vaginal discharge with certain “fertile” characteristics is identified as the “peak day.” The peak day has been shown in many studies to correlate closely with ovulation (plus or minus 2 days in about 95% of cycles). [9,10] The peak day is a highly reliable indicator that ovulation has occurred.  If a woman is taking her temperature, the rise in temperature will also confirm that ovulation has occurred.

Q. Is the peak day the last fertile day in the cycle?

A. For up to 3 days after the cervix stops producing the Type E fluid, there may still be enough present in the cervix for sperm to penetrate the cervix, and ovulation in a few cases can be delayed up to the third day after the peak day.  Therefore, in some cases pregnancy can occur from intercourse as late as the third day after the peak day.

Q. I think I know when I ovulate. I get a pain around that time.

A. There are other symptoms of ovulation, but these are less reliable for most women.  Pain around the area of the ovaries (sometimes called mittelschmerz) can be a reliable indicator of the occurrence of ovulation in some women, but not of its timing, since it can occur before, during, or after ovulation. [11]

Q. Can technology be used to help a woman identify ovulation?

Devices based on the examination of saliva under the microscope and marketed on the internet have been found to be unreliable. [12]  Devices based on salivary or vaginal electrical resistance are in development and cannot yet be considered reliable for general use. [13] Methods to monitor ovulation have been developed based on measuring reproductive hormones in the urine (estrogen, LH, or progesterone), and one of these is currently available in the United States (the Clearblue Fertility Monitor®, formerly the ClearPlan Fertility Monitor). [14, 15]

Q. What are the modern methods of NFP?

A. There are three simple methods, and four more detailed methods. While the simple methods may be sufficiently accurate for many women, the detailed methods are more reliable.

Simple methods
Two simple methods have been developed by Georgetown University’s Institute for Reproductive Health for developing countries, but have also found a substantial following in developed countries. The Standard Days Method (sometimes used with CycleBeads™) is a fixed calendar formula that considers days 8-19 of the cycle as fertile days. [16] It is only suitable for use by women with cycles in the range of 23-32 days long (about half of women of reproductive age). [4,17] The TwoDay Method considers a day to be fertile if the woman had vaginal secretions either that day or the day before.18 Another simple method, Lactational Amenorrhea, is based on a set of criteria that must be met in order for pregnancy to be highly unlikely (<2%) while a woman is breastfeeding. The criteria, which must be strictly met, include exclusive breastfeeding with absolutely no supplements and the absence of menses. [19,20]

Detailed methods
The Sympto-Thermal Method is based on daily observation of vaginal discharge, combined with daily measurement of body temperature.  It was developed by a number of European physicians and scientists, and is available throughout most of the world. [21] The Marquette Method, developed at Marquette University, uses some or all of these parameters in combination with the Clearblue Fertility Monitor® to measure estrogen and LH in the urine. [22] The Billings Ovulation Method (developed by the Australian physicians Drs. John and Evelyn Billings) is based on daily observations of vaginal secretions. [23,24]  It is available throughout nearly all countries of the world. The Creighton Model FertilityCare System™ is a standardized adaptation of the Billings Ovulation Method, which was developed at Creighton University by Dr. Thomas W. Hilgers and colleagues. [9,25,26]  In addition to family planning, it has developed special applications for infertility and women’s gynecologic health, called NaProTechnology (natural procreative technology), discussed later. [27]  It is currently available primarily in North America and Ireland, but is rapidly becoming more available throughout the world. 

Q.  Isn’t this all the same as the rhythm method?

A.  No.  The calendar rhythm method was originally based on counting days from a woman’s past menstrual cycles [28], but most often is done by people simply guessing about which days are fertile. The only method similar to calendar rhythm that is listed above is the Standard Days Method.  The other modern methods of NFP discussed above are based on prospectively identifying the time of fertility based on biological signs.

Q. Isn’t NFP the Catholic method of birth control?

A. The reproductive processes and natural fertility signs were created by God for all of His children. Most of the scientific work to develop modern methods of NFP has been done by faithful Catholic physicians and scientists who have been interested in discovering a reliable method of family planning acceptable to the teachings of their Church. Most of the organizations and many of the instructors that teach NFP in the United States are Catholic, but many of the couples they teach are of other faiths, including Latter-day Saints. Surveys in the United States identify that about the same percentage of Latter-day Saints as Catholics are currently using a natural method of family planning (about 4% in each case). [29,30]   Unfortunately, most of these couples are using the outdated and less effective guesswork “rhythm” method, not the modern methods mentioned above.

Q. We wonder why we, as Latter-day Saints, would want to learn about family planning or women’s health from a Catholic organization or instructor.

A. I suggest that you consider the following statement from President Brigham Young:

It is our duty and calling…to gather every item of truth and reject every error.  Whether a truth be found with professed infidels, or with the Universalists, or the Church of Rome, or the Methodists, the Church of England, the Presbyterians, the Baptists, the Quakers, the Shakers, or any other of the various and numerous different sects and parties, all of whom have more or less truth, it is the business of…this Church…to gather up all the truths in the world pertaining to life and salvation, to the Gospel we preach, to mechanism of every kind, to the sciences and philosophy, wherever it may be found in every nation, kindred, tongue, and people and bring it to Zion. [31]

The Spirit of Christ is given to every man, and we are given prophetic instruction that we should search diligently in the light of Christ, and lay hold upon every good thing. [32] I believe that fertility respect should be considered in this context. 

2. Pregnancy Spacing

Q. How effective is NFP to space pregnancy?

A. For the detailed methods described above, pregnancy rates when taught by qualified instructors and used exactly according to instructions are about 1-2% in a year.  Accounting for user or teacher errors, the pregnancy rates are 3-5% in a year. [21,22,24-26,33-35] For the Standard Days and TwoDay methods, the pregnancy rates when used exactly according to instructions are 4-5% per year. [16,18] These pregnancy rates are comparable to other reversible family planning methods including oral contraceptives, condoms, and the diaphragm, and better than for spermicides. [36] 

Q. I don’t believe it can be that effective.  My doctor told me that NFP is not very effective and I have a friend who was using NFP and got pregnant.

A. National surveys give high “failure rates” for “rhythm,” because most of the people are actually using calendar guesses rather than modern NFP methods taught by a qualified instructor. [34-36]

It also makes a big difference as to which pregnancies are being included in the analysis. If a couple decides to have intercourse on a day that is identified as fertile, pregnancy is very likely. Most pregnancies during NFP fall into this category. The motivation to avoid pregnancy varies widely depending on the social situation of the couples, and so the total pregnancy rates in NFP studies varies from as low as 2% to as high 32%, depending on the population being studied. [34,35,37-39]

Q.  What is required to achieve high levels of effectiveness with NFP?

A.  Successful use of NFP to avoid pregnancy requires two things: 1) good instruction by a qualified instructor, and 2) cooperation of both husband and wife in communicating about the days that the woman can get pregnant and in deciding whether to have sex on those days when pregnancy can occur.

Q. How much time does it take to learn a method of NFP? 

A. Usually one month is enough to get started with competent use.  After that, additional follow-up sessions are necessary for the detailed methods to reinforce the habits needed for successful use,  and to address issues and questions that arise.  Most organizations that teach NFP suggest at least 4 follow-up visits over several months to one year. On the other hand, the simplified methods can generally be taught in one session.

Q. Can we learn this from a book or on the internet?

A. There are a variety of self-help books and websites available. [18,21,22,24,26] However, to date all of the studies of effective use of NFP effectiveness have been based on personal instruction. Working with a qualified instructor is the best way to tailor the use of NFP to individual circumstances. Most instructors do distance teaching via telephone or internet.

Q. Can we use NFP while breastfeeding?

A. Yes.  It is possible to identify the return of ovulation during breastfeeding.  However, this is a circumstance in which signs of fertility can be more complex, particularly when a mother begins weaning and fertility returns very quickly.  The guidance of an NFP instructor is very helpful during this transition. [26,40,41]

Q. I am currently approaching menopause and my cycles have become very unpredictable.  Can we use NFP to avoid pregnancy?

A. Yes. This is another circumstance in which the guidance of an NFP instructor is invaluable. As one woman described her experience: 

I liked that it is highly reliable during all phases of a woman’s reproductive life – a fact that was not lost on me as I went through years of very irregular periods during perimenopause. 

 

Q. I am currently taking birth control pills.  If I stop taking them, can we use NFP?

A. Yes.  With good instruction, women discontinuing birth control pills can use NFP effectively. [26]  Women should expect signs of disturbed and irregular function of their reproductive system for the first few cycles. [42,43]

Q. What are the advantages of using NFP to space pregnancies?

A.    1) It is safe, with no medical side effects.  2) It is effective. 3) There is no device to interfere with the physical intimacy of the marital embrace. 4) Women (and their husbands) become more in tune with the natural, divinely created cycles of the woman’s body. 5) There is no suppression of fertility, so a couple can use the same method to achieve pregnancy when they so choose, usually rapidly. 6) Successful use of NFP requires the cooperation and mutual respect of both husband and wife in the marriage.

Overall, the most common reasons that women become interested in using NFP relate to the lack of interference with the natural processes of the body. [40, 41] As one woman expressed it:

We started using it because I like the idea of not having to put foreign, chemical, or pharmaceutical things in my body.  There are no side effects and it is totally reversible. 

 

 

Q. What are the possible disadvantages of using NFP to space pregnancies?

A. The concerns that are generally expressed about NFP are the perceptions that 1) it is not reliable enough; 2) it is too complicated or too difficult; 3) it requires times of abstinence from genital contact; 4) the husband may not cooperate. 

These perceptions generally come from those who have never used modern methods NFP (though they might have used some version of “rhythm”). People who actually begin use of modern NFP methods have high rates of continued use of the method, especially relative to other methods of family planning. [25,34,38]

3. Seeking pregnancy

Q. How is NFP used to try to conceive?

A. By having intercourse on days that are identified as fertile, a couple maximize their chance of pregnancy in any given cycle.  Most couples will achieve pregnancy quickly, on average about 25-40% chance per cycle. This varies by age and other factors. [2,44-47]

Q. It is interesting that the same methods that can be used to avoid pregnancy can also be used to achieve pregnancy.

A.  Yes.  This is a fundamental difference between NFP and contraceptives, which can be used only to avoid pregnancy. One woman put it this way:

I liked knowing if my husband and I should decide at any time we wanted another child, we could change our minds about using NFP to avoid pregnancy.

Another woman described it this way:

Every child is a joint decision- my husband, me, and God.

A medical colleague once remarked to me that only “natural family planning” could be considered a true method of family planning, because it could be used to plan to conceive as well as to avoid pregnancy.  He further suggested that other so-called methods of “family planning” would be more accurately termed methods of “pregnancy avoidance.”

 

4. Infertility

Q. Many couples we know struggle with infertility.  What is happening?

A. Infertility or subfertility affects 10-15 percent of couples in the United States. [48]  While some infertility is the result of sexually transmitted diseases or other lifestyle factors such as smoking, more often infertility is due to health conditions that are not under control of the couple.  Infertility seems to be increasing in the world, and some scientists think that environmental factors are involved. [49]

Q. We are not comfortable with some of the things our physician has recommended for infertility evaluation and treatment.  Are there any options for a second opinion or a different approach that has the backing of medical science?

A. Yes.  Natural Procreative Technology (NaProTechnology) offers an approach to infertility that is medically sound and effective. Charting from the Creighton Model FertilityCare System is used as an integral part of the evaluation, and to adjust treatments. Medical tests are timed and informed by the woman’s fertility charting and directed towards diagnosing what the problems are that are preventing conception. Interventions are monitored based on the fertility charting to correct these problems to the extent possible and to optimize the fertile potential of the menstrual cycle. The goal is to restore normal human reproductive function so that pregnancy can be achieved from normal intercourse. [27,50] One woman described the experience of herself and her husband with this approach:

(this part  in the wife’s words are deleted, but you can read it here http://squaretwo.org/Sq2ArticleStanfordNFP.html

 

Since writing this, this couple has achieved a healthy pregnancy with NaProTechnology treatment, and two additional healthy pregnancies with the Creighton Model charting alone.

Q. Who developed NaProTechnology?

A. Thomas W. Hilgers, MD, and colleagues at the Pope Paul VI Institute for the Study of Human Reproduction, affiliated with Creighton University in Omaha, Nebraska. [27]

Q. How does NaProTechnology compare to in vitro fertilization (IVF) treatment for infertility?

A. There are no direct randomized trials. A comparison of two large studies is given in Table 1 below (deleted for easier formatting, see link above), and suggests that with sufficient time for treatment (up to 2 years), the live birth rate for NaProTechnology is similar to that for IVF, with fewer twins, which means fewer complications of premature birth and low birth weight. [50-53] NaProTechnology maintains a fundamental respect for the marital relationship as the source of children, and involves the couple as equal partners in their own treatment. Additionally, NaProTechnology is much less expensive.

Women’s health

Q. My doctor says that the pill is necessary to treat my medical condition.  Are there any viable alternatives?

A. Yes.  There are treatments available in NaProTechnology to manage menstrual disorders and women’s health conditions.  Rather than suppressing ovulation and the normal functioning of the reproductive system as the pill does, the goal of NaProTechnology is to restore the normal functioning and correct the underlying problem.  The woman charts the functioning of her reproductive system with the Creighton Model, and this information is used for further medical diagnosis and treatment of her condition. [27]

Q. What kind of health conditions can be treated with NaProTechnology?

A. Anything that is usually treated with the pill.  For example: irregular bleeding, heavy or painful menstrual periods, premenstrual syndrome (PMS), ovarian cysts, endometriosis, and so on.

Q. What are the advantages of using NaProTechnology to treat women’s health problems?

A.  1) It avoids side effects of synthetic hormones.  2) It puts a woman (and her husband) more in tune with the natural cycles of her body.  As one woman put it:

I like being in control of knowing what my cycles are doing.  Education is important, and knowledge of what is happening in your body on any given day is wonderful.

A husband from a different couple described their experience:

My wife and I have been married for six and a half years, and have three children (so far). Until the birth of our third child we used the contraceptive pill to help space our children, commensurate with our physical and mental health. We began to correlate my wife’s periods of depression with the contraceptive pill. We searched for an alternative and found the Creighton Model. We have found that this method has meant the cessation of my wife’s depression, probably for two reasons: firstly, not having the artificial hormones in her system; secondly, our entire relationship has become more loving and in keeping with the Lord’s plan for husband and wife as we cooperate with NFP. 

Q. Why didn’t my doctor tell me that there was another way to treat my medical condition besides the pill or other hormonal contraceptives?

A. Most likely he or she was not fully aware of the alternatives.  The pill is the standard approach taught in medicine, even though to date it has received approval from the United States Food and Drug Administration (FDA) for only two conditions (contraception and acne). Like many other things in medicine, seeking a complete view of the options often requires a second medical opinion.

Q. Why is the pill so prevalent in modern medicine?

A. At least some of the reasons are 1) It is an easy thing for physicians to prescribe in relatively little time, 2) There is heavy marketing by the pharmaceutical industry of the pill, and 3) Extensive funding for continuing medical education in obstetrics and gynecology comes from the pharmaceutical industry. Beyond medical influences, the “pill” has become nearly universal and a defining feature of modern culture. [59]

Q. My doctor told me that birth control pills have many health benefits.  Shouldn’t I take them for that reason?

A.  In today’s medical environment, many physicians have come to believe that birth control pills are good for a women’s health.  Some physicians go so far as to recommend that young women to go on the birth control pill as soon as they start menstruating, and to continue on it all the way through menopause, except for the times she wants to have children.

In my judgment, this line of thinking overstates the known benefits from birth control pills, minimizes the known risks, and simply dismisses the remaining uncertainties about these hormonal medications. Studies do point to some positive health outcomes from birth control pills, most notably a lower risk of ovarian cancer. [60]  However, there are rare but serious health risks to birth control pills, such as heart disease and blood clots [61], and there is good evidence of a higher risk of breast cancer for women who use the pill prior to their first pregnancy. [62,63] (Incidentally, a lower risk of both ovarian cancer and breast cancer can also be achieved by having several pregnancies and breastfeeding one’s children.) [64-67]

Q.  We really believe in nutritional approaches to health problems, and tend to distrust all medications (including the pill). Herbs seem more natural and healthy to us. 

A. I am sympathetic to nutritional and herbal approaches, but I also believe that further research is needed to establish the effectiveness of most of those approaches. I suggest that self-help approaches are best addressed with an open-minded and competent physician who can help to identify all options and potential problems.  (I acknowledge that as a physician, I have a bias towards medical care.) Similar feelings to yours were expressed by one woman as she reflected on many years of use of NFP:

I liked being in control of my own body and not having to see a physician for a prescription or device.  I didn’t have to worry about “running out” of anything.  I found the method very consistent with my knowledge of my body being a temple.  I learned to be intimately in tune with my “temple”, and easily came to recognize when anything regarding my reproductive organs was amiss.  I took very seriously the admonition to use wisdom in all things and felt not using artificial hormones or devices would be beneficial to my general and reproductive health.  It just “felt right”.

6. Married life

Q. I am not sure that we would be able to abstain during the days that are fertile in order to avoid pregnancy.  Even if it is possible, it does not seem desirable.

A. This is a prominent concern of many couples who begin use of a method of NFP.  However, research shows that most people who begin use continue as satisfied users, and that their satisfaction and confidence with this approach increases with time. [68,69]

Q. We don’t understand all this talk about abstinence.  Aren’t there other ways of expressing sexual feelings during the fertile time?

A. Some people have advocated condoms, oral or anal intercourse, or mutual masturbation for “sexual satisfaction” during the fertile time.  Advocates of these practices sometimes use the term “fertility awareness” (instead of natural family planning). Such practices intend to thwart the natural procreative processes (instead of cooperate with them) and ultimately are not consistent with the philosophy of fertility respect.  Couples who combine these practices with fertility awareness are missing many of the benefits of fertility respect. Without being judgmental, instructors in the various methods of NFP will usually encourage couples to put aside such practices in order to reap the full benefits of fertility respect.

Q. Why is it against fertility respect to use barrier methods or withdrawal during the fertile time?  We know that Catholics believe this, but there isn’t anything LDS about that, is there?

A. First, it’s important to recognize that when used to avoid pregnancy, barrier methods or withdrawal during the fertile time are substantially less effective than abstinence. [16,18]  Second, and more importantly, the marital embrace is meant as a complete giving of each spouse to the other. Implicitly, the use of barrier methods sends the messages, “I give myself to you, except my potential fertility,” and “I accept all of you, except for your potential fertility.” As one wife said,
If my husband were to ask me to use a barrier method at the fertile times I would view it as a rejection of something in myself. I would see it as a way that he was doing something for his own gratification, rather than deal with the abstinence required to avoid pregnancy. I would feel objectified rather than as a full partner in our shared fertility. I like the fact that in this respect, I call the shots, or rather, my body calls the shots. I feel affirmed and supported for my own worth as a unique and valued human being.

Q. How many days of abstinence are required in order to avoid pregnancy?

A. On average, the time of fertility identified by most methods of NFP is 9-12 days around the time of ovulation each cycle.  This is more than the 5-6 days during which pregnancy is actually possible, because of variability in the biological signs of fertility.  I should also note here that most methods of NFP recommend that to avoid pregnancy, a couple abstain from intercourse during most or all of the first month that they are learning it.  This is because clinical experience has shown this helps a woman learn to distinguish normal vaginal secretions from seminal residue.

Q. That seems like a lot of days.  That won’t be easy.  I am concerned that so many days of abstinence could be harmful to our relationship.

You are not alone in feeling this way.  One woman described her experience in the transition to NFP:

We were very unsure about using NFP in the beginning because our relationship was not really that strong.  Inside the “bedroom” things were great as long as we had “intimacy” often.  For my husband, the thought of abstinence was almost unthinkable.  He agreed to using NFP only because he cares enough about my health that he didn’t want me on birth control pills.  When we began NFP that first month of abstinence was very difficult- it almost killed him.  But he was okay after that.  Our relationship has actually become better in all aspects because of NFP and a general determination from both of us to make it better.

Not every couple initially finds the periods of abstinence to be quite so difficult:

My husband has taken some time to accept this new method, because of its influence on our love life. It did seem odd for awhile to examine a chart before deciding if it was an appropriate time for romance.  The really great thing is that for all the self control and discipline involved in using the method, we have both gained a strong sense of freedom and control over our powers of procreation.

Even after using NFP for years, periods of abstinence can still be challenging.  One woman with five children described it this way:

Avoiding intercourse is more difficult now than it has ever been in the past.  I am moving out of the “mother with babies” mode into a “wife” mode and the NFP method is excruciatingly difficult some days!  So we do not take those “safe” days for granted.  Our time together goes to the top of the “to do” list on those days.  Nothing makes you more grateful for something than when you can’t have it.  This dynamic has undoubtedly strengthened our marriage. 

These quotes illustrate a seeming paradox.  Despite the challenges with abstinence, most couples using NFP report that their sexual relationship is enhanced.

Q. That doesn’t seem to make sense. How can the sexual relationship be enhanced if there are periods of abstinence?

A. There are at least four ways: 1) increased attention to all dimensions of the intimate relationship; 2) increased mutual responsibility and respect for decisions about sex and procreation; 3) the “courtship/honeymoon” phenomenon; 4) the value of self-mastery.

First, couples find that their intimate relationship is enhanced by increased attention to all its dimensions.  The dimensions of marital intimacy can be described as SPICE: Spiritual, Physical, Intellectual, Communicative/Creative, and Emotional. [70] As couples communicate more completely and respectfully about sexuality and intimate matters, they often communicate more about other areas of their lives as well.

One wife described it this way:

NFP has helped my marriage by helping me respect my husband more.  My love for him is greater because I know him better- we talk a lot about our relationship. 

Another wife described her list of advantages for fertility respect:

One of the biggest pluses is communication.  Sexuality, childbearing, parenting.  These are all such big issues.  With NFP, we make the decisions together, in fact we are forced to communicate.

This quote also illustrates the second point for enhanced sexuality: increased mutual responsibility for decisions about sex and procreation.  Another wife put it this way

I liked that family planning became a joint – almost spiritual – decision between my husband and I and not just my responsibility.  I felt my husband’s respect for my body and our combined fertility was enhanced as we communicated regarding our fertility status.  His cooperation and understanding of the method was essential.

 

Third, the experience of physical intimacy is often more enjoyable after a period of abstinence, a repeated “courtship-honeymoon” phenomenon:

I liked that our sexual life was enhanced in that we practiced greater variety in our love-making.  Days of no intercourse were replaced with other loving and very satisfying activities.  We then looked forward to our non-fertile days with anticipation.  (I’ll admit that I was surprised to discover we both felt the same way.  I was worried at the outset that any off-limits time would be a strong negative for him.)

The enhanced enjoyment of physical intimacy is not solely because of periods of waiting and anticipation.  It is also linked to an increased spiritual appreciation of the wonder and gift of sexuality and procreation:

After a few months [of using NFP] we realized, commenting to each other, how wonderful to have more understanding of these incredible bodies we have been given, and how much deeper were our expressions and feelings of love when we made love.  We were able to give God even more reverence for the gift of procreation. 

Another wife described her feelings in this way:

We have used different versions of natural family planning for the last 19 years and as a woman I find that being aware of my cycles helps me understand myself better.  We also fell it helps us appreciate the wonder of procreation.  Whether we have been striving to conceive or to avoid it at different times during our marriage, we are working with the natural order of things rather than separating ourselves from our sexuality by some artificial means.

Another couple expressed similarly the connection between directly experiencing the cycles of fertility and appreciating the wonderful gift of procreation:

We marvel at the love our Father in Heaven has for us- the miracle of conception, the signs He has given us (I compare them to the rising and setting of the sun), the sanctity of marriage, and the further growth possible in our relationship.

Fourth, the marital relationship is strengthened by the need for self-mastery.  As suggested in the comments above, couples gain “a strong sense of freedom and control over our powers of procreation.”   President David O. McKay taught the value of self-mastery:

Let each person be determined, in the name of the Lord Jesus Christ, to overcome every besetment–to be the master of himself, that the spirit God has put in your tabernacles shall rule…you cannot inherit eternal life, unless your appetites are brought in subjection to the spirit that lives within you, the spirit which our Father in heaven gave. I mean the Father of your spirits, of those spirits which he has put into these tabernacles. The tabernacle must be brought into subjection to the spirit perfectly, or your bodies cannot be raised to inherit eternal life; if they do come forth, they must dwell in a lower kingdom. Seek diligently, until you bring all in subjection to the law of Christ. [71]

In an April 1969 statement, the First Presidency commented on the issue of self-control and mutual respect in marriage:

…men must be considerate of their wives who bear the greater responsibility not only of bearing children, but of caring for them through adulthood.  To this end the mother’s health and strength should be conserved and the husband’s consideration for his wife is his first duty, and self-control a dominant factor in all their relationships. [72] 

President Spencer W. Kimball also commented on this issue:

Paul speaks of continence–a word almost forgotten by our world. Still in the dictionary, it means self-restraint, in sexual activities especially. Many good people, being influenced by the bold spirit of the times, are now seeking surgery for the wife or the husband so they may avoid pregnancies and comply with the strident voice demanding a reduction of children. It was never easy to bear and rear children, but easy things do not make for growth and development. But loud, blatant voices today shout “fewer children” and offer the Pill, drugs, surgery, and even ugly abortion to accomplish that. Strange, the proponents of depopulating the world seem never to have thought of continence!  Libraries are loaded with books with shocking pictures, showing people how to totally satisfy their animal natures, but few books are found on the self-control of continence. With a theory that “life is for sex,” every imagination of the minds of men devises ways to more completely get what they call “sexual fulfillment,” which they demand at the expense of all else–family, home, eternal life. [73]

Q. It seems to me that statements about abstinence in the scriptures and from church leaders refer primarily to unmarried people. The apostle Paul said “…to avoid fornication, let every man have his own wife, and let every woman have her own husband. Depart ye not one from the other, except it be with consent for a time, that ye may give yourselves to fasting and prayer; and come together again, that Satan tempt you not for your incontinency.” [74] Married people shouldn’t feel constrained or hesitant about sexual relations.   

A.  Certainly, a couple should not feel more abstinence means more righteousness. Marital relationships were ordained by God as much for the unity of husband and wife as for procreation. [75] 

On the other hand, I am sure that you will agree with me that there are a number of circumstances in which all married couples rightfully abstain from the marital embrace.  These include illness, some complications of pregnancy, absence of one of the spouses, and others.  Each couple has the opportunity and responsibility to consider with mutual respect when they should or should not have sex.  In scriptural words:

To every thing there is a season, and a time to every purpose under heaven…a time to embrace, and a time to refrain from embracing. [76] 

Q. Is there any scientific evidence that the use of Fertility Respect actually strengthens marriages?

A. One study of compared 504 Catholic couples using NFP with 694 Catholic couples not using NFP.  Those using NFP also had greater emotional and sexual satisfaction in their relationships, a much lower divorce rate, and stronger measures on a number of indicators of religious activity. [77]  This study does not prove whether the use of NFP is a cause or a result of religious activity and healthy marriage, but it does suggest that NFP use is associated with strong religiosity and with strong marriages.

Q. We have recently become engaged and have discussed these issues and decided we might like to use NFP.  When is the best time to learn it, to avoid the temptation for sexual intimacy before marriage?

A. I appreciate your caution in approaching this issue and strongly affirm your desire to remain chaste before marriage.  It is best for you both to attend the instruction together and to begin charting for at least 2 or 3 cycles before your marriage. Receiving this kind of instruction about your fertility can actually strengthen your desire to avoid temptation.  Also, most methods of NFP recommend abstinence during the first month of learning.  It would certainly be best to get that out of the way before the honeymoon!

Q. What effect does fertility respect have on teaching about sex and procreation to children?

A. One wife gave her experience:

As my children have grown into adulthood, I have been able to share with them basic reproductive facts I learned through NFP.   This has helped them gain a greater respect for the incredibly complex and awesome gift Heavenly Father has entrusted to all of us.  I learned much basic information through NFP classes that I had not before or since encountered through any other source.  This was invaluable to me as I helped my daughters understand their bodies. 

Another wife commented:

NFP treats the body as sacred.  The periodic abstinence that may be required makes our teaching to our children about the sacredness of sexuality a little more believable. 

 

7. Moral perspectives

Q. What have General Authorities said about birth control or family planning?

In the late 1800s and early 1900s, General Authorities universally condemned birth control along with abortion, both considered attacks on the fountains of life, in the context of decrying the tendency of the world to selfishly limit family size. In more recent years, there has been discussion that couples may need at times to space their pregnancies, while still emphasizing the commandment for married couples to procreate.  The Proclamation on the Family states:

The first commandment that God gave to Adam and Eve pertained to their potential for parenthood as husband and wife.  We declare that God’s commandment for His children to multiply and replenish the earth remains in force. We further declare that God has commanded that the sacred powers of procreation are to be employed only between man and woman, lawfully wedded as husband and wife. We declare the means by which mortal life is created to be divinely appointed. We affirm the sanctity of life and of its importance in God’s eternal plan. [78]

Elder Dallin H. Oaks stated

How many children should a couple have?  All they can care for!  Of course, to care for children means more than simply giving them life.  Children must be loved, nurtured, taught, fed, clothed, housed, and well started in their capacities to be good parents themselves.  Exercising faith in God’s promises to bless them when they are keeping his commandments, many LDS parents have large families.  Others seek but are not blessed with children or with the number of children they desire.  In a matter as intimate as this, we should not judge one another. [79]

President Gordon B. Hinckley emphasized the agency and accountability of each couple to the Lord in making these decisions:

Marriage is for companionship, and it is also for children. Much has been said…about birth control. I like to think of the positive side of the equation, of the meaning and sanctity of life, of the purposes of this estate in our eternal journey, of the need for the experiences of mortal life under the great plan of God our Father, of the joy that is to be found only where there are children in the home, of the blessings that come of a good posterity.  When I think of these values and see them taught and observed, then I am willing to leave the question of numbers to the man and the woman and the Lord. [80] 

In summary, the apostles and prophets have emphasized the responsibility of married couples to have children, have acknowledged that couples need to be prudent in having children and caring for them, and have left the specific decisions in this intimate stewardship of marriage between the couple and the Lord.

Q. Have any General Authorities said anything specifically about natural means of family planning?

Elder John A. Widstoe wrote

Birth control when necessary should be accomplished in nature’s way, which does not injure the man or the woman. A careful recognition of the fertile and sterile periods of woman would prove effective in the great majority of cases. Recent knowledge of woman’s physiology reveals “the natural method for controlling birth.” This method violates no principle of nature. [81]

Q. Once the decision has been made to space pregnancy, are there any moral issues that should be considered in making decisions about how to do so?

A. I believe that the following issues are relevant to these decisions: 1) respect for human life from its earliest stages; 2) respect for the divinely appointed process by which mortal human life is created; 3) respect for the body as a temple of the Holy Spirit.

Q. What do you mean by respect for human life from its earliest stages?

A. I believe that we should respect the sanctity of human life from the moment of conception (fertilization).  As Elder Lynn A Mickelsen stated it:

Teach our children to respect the sanctity of human life, to revere it and cherish it.  Human life is the precious stepping-stone to eternal life, and we must jealously guard it from the moment of conception. [82]

Q. Isn’t it an open question as to exactly when human life begins?

A. Biologically, it is indisputable that a new human entity with its own genetic identity and capacity for development is formed at the moment of conception (fertilization). 

To be continued…