The Ovulation Method Research and Reference Centre of Australia

Dr. John J. Billings
Reprint with permission

The Guidelines ot the Billings Ovulation Method and their Physiological Basis, with Particular Reference to Breast Feeding.

During breast feeding and in other circumstances when ovulation is delayed, the Billings Ovulation Method is the only natural method which can effectively provide for the postponement of pregnancy. One must beware of unreliable information which is likely to be provided by people who teach "the Mucus Method", because there are many mucus methods, and none of them will enable the woman to identify with confidence the presence of infertility before ovulation. This recognition of infertility in the pre-ovulatory phase depends upon understanding the scientific and practical concept of the Basic Infertile Pattern, which is an essential element of the authentic Billings Ovulation Method. The Basic Infertile Pattern is really very simple to understand, depending upon the fact that the mucus pattern of fertility is a pattern which recognizably alters from day to day, whereas the pattern of infertility, whether it is dryness or a discharge, is an unchanging pattern, remaining the same day after day. Those teachers of natural family planning who have not achieved excellent results during breast feeding, either partial or full breast feeding during the early months and for long afterwards, long after fertility has returned, have not been teaching the authentic Billings Ovulation Method, that is certain.

The efforts by the World Health Organization in exploring the natural child-spacing benefits of breast feeding together with a strong promotional campaign are greatly to be commended, particularly when supported by reliable breast-feeding education.

It is agreed by all breast-feeding authorities that breast feeding from birth to ensure ingestion of colostrum, demand feeding, and total breast feeding up to 6 months is sufficient without the addition of fluid or other food to ensure the optimum nutrition of the infant, protection from many infant diseases, as well as providing valuable psychological benefits to both mother and baby. Breast feeding is seen as a physiological extension after birth of the mother's nurturing role of her baby. Nature, in order for her to accomplish this, has provided an in-built hormonal suppression of ovulation so that fertility is suspended for a variable time during breast feeding whether this is total or partial. Return to fertility is related closely to the sucking patterns of the baby and the demand for milk -- the supply closely following the demand. Mothers and babies follow individual patterns and responses. The return of ovulation is also variable. When ovulation is suppressed oestrogens from the ovarian follicles remain low. Cervical mucus secretion occurs when a certain individual level of oestrogen is reached. The mucus pattern changes daily as the level of oestrogens increases. There is also the detectable sign of a lubricative sensation at the vulva close to ovulation attributable to the vital P-mucus, usually but not always accompanied by visible mucus of variable appearance.

The cervical mucus is stimulated and at first is due to the production of the fluid L-mucus, then the lubricative S-mucus which responds more slowly to the raised oestrogen level close to ovulation. The Peak symptom is identified by the intensely lubricative quality produced by the small amount (I—2%) of the total mucus recognized at the vulva -- the P-mucus, which is produced high up in the cervix in response to circulating noradrenaline. The rise in progesterone preceding ovulation is responsible for the definition of the Peak symptom, due in part to the production of G-mucus at the lower cervical crypts and in part to the drying action of the mucus by manganese from the pockets of Shawl The canal is closed gradually over the next 3 days following the Peak, by which time the egg, if unfertilized, will have disintegrated, leaving the remainder of the cycle infertile.

During weaning and the return to fertility, the mucus signs are often "damped down" so that there may be no visible signs. The lubricative sensation at the vulva is of great importance.

Not all discharges which leave the vagina are of cervical origin. The vaginal epithelium is also sensitive to oestrogen levels. When oestrogens are very low, the squamous epithelium of the vagina is composed of a basal layer only and there is at this time no vaginal discharge. The vulva is dry. When the oestrogens rise to a slightly higher level but too low to stimulate the cervix, the "intermediate" polyhedral cells surrounded by glycocalyx are stimulated to grow. These slough off into the lumen of the vagina and undergo Iysis, producing a milky, wet, watery discharge which varies in quality. The vulva is wet but the sensation lacks the characteristic lubricative quality of the cervical mucus close to ovulation.

The rise in oestrogen responsible for the vaginal response is often due to a diminished sucking frequency or intensity following the introduction of some solids, or to ill-health of the baby, or to other interruptions to the breast-feeding patterns. A return to frequent feedings, if possible, will result in a return to vulval dryness. Greater substitution of breast feeding by food and fluid may result in greater follicle stimulation and higher oestrogen levels, enough to provoke cervical stimulation and mucus with fertile characteristics including lubricative qualities. This indicates that ovulation is impending. Increased breast feedings at this stage again may suppress ovarian activity and the vulva may again return to dryness. This reflection of hormonal patterns by the vulva is very sensitive. Oestrogens having once fallen to a low level will need several days for a sufficiently high level to be reached before cervical activity will be stimulated. This explains the rationale behind the "wait and see, 1, 2, 3" rule of the Billings Ovulation Method. Intercourse is postponed when a change occurs from the Basic Infertile Pattern whether the change is to mucus or bleeding. The 3 days allow for the drop in oestrogen to occur and the re-establishment of the Basic Infertile Pattern to take place, during which time there is continued postponement of genital contact. Intercourse may then be resumed on the evening of the 4th day and subsequent alternate evenings. In this way, any change from the Basic Infertile Pattern will be identifiable apart from seminal fluid which leaves the vagina for up to 24 hours following intercourse.

Bleeding

Not only the cervix and vaginal epithelium but also the endometrium responds by a follicular phase growth of glands and blood vessels when oestrogens rise. This may result in bleeding immediately before ovulation ("break-through bleeding" due to high oestrogen), or after some days when the oestrogen level has fallen, withdrawing its support from the endometrium ("withdrawal bleeding"). If ovulation does not precede a bleeding episode, the bleeding cannot be classified as true menstruation. If there has been a cervical mucus response following raised oestrogen but no rise in progesterone the vulva will lack the characteristic Peak symptom, as it is dependent on both the abrupt fall in oestrogen and the rise in progesterone. This ovulatory hormonal pattern is responsible for a quick response by the cervical and the vaginal epithelium particularly in the lower vagina where the pockets of Shaw now liberate manganese and contribute to the dehydration of any mucus traversing the vaginal canal. The vulva after the Peak is either dry or sticky but not wet or slippery. This explains why observations for the Billings Ovulation Method are made at the vulva. Any attempt to examine mucus higher up in the vagina or at the cervix will yield contradictory information.

In the absence of the Peak, pre-ovulatory hormonal levels still operate. The oestrogenic fluctuations can be recognized at the vulva. Eventually ovulation with a recognizable Peak symptom will occur but perhaps imperfectly so that the luteal phase is short (less than 11 days), signifying an infertile cycle. In the early days of total on-demand breast feeding it is likely but not inevitable that the oestrogen level will remain low due to suppression of follicular activity. The only guarantee that this is so is to make adequate vulval observations. The Billings Ovulation Method teaches the woman to recognize the unchanging vulval patterns which reflect low oestrogens. These patterns are:

  1. Dry.
  2. A vaginal cellular discharge which is unchanging except in amount.
  3. A combined dry pattern and discharge which remains unchanging except in amount.

Studied over 2 weeks without genital contact and beginning 3 weeks after the birth of the baby, this pattern of infertility is generally obvious. In Billings Ovulation Method terminology this is a Basic Infertile Pattern because it reflects a continuing low oestrogen level with consequent absence of cervical activity. This provides assurance that fertility is not imminent. A change in the Basic Infertile Pattern will alert the woman to a rise in oestrogens which may be observed either as a discharge of vaginal cellular origin or as cervical mucus. If bleeding occurs causing changes in the Basic Infertile Pattern it can be assessed as:

  1. Menstruation.
  2. Possible break-through bleeding with or without ovulation.
  3. Withdrawal bleeding.

Break-through bleeding may be slight or heavy. If slight, accompanying mucus will be detected at the vulva by sensation. Withdrawal bleeding may be heavy or light.

Procedures Followed by Different NFP Groups

Much consideration has been given to procedures to be followed during breast feeding by different NFP groups.

The so-called Lactational Amenorrhoea Method (LAM) is said to be a "natural introductory method of natural family planning" but unless the woman is taught to recognize her positive signs of infertility and signs of impending fertility she may be directed towards using an artificial method when she suddenly fails to fit the LAM criteria. If the woman is taught the Billings Ovulation Method which means recognition of the Basic Infertile Pattern and knowledge of the Early Day Rules which apply, she will automatically pass from recognition of infertility to recognition of fertility. There is no reason for relying totally on guesswork for return of fertility when identification of fertile signs can be easily learned by the application of easy rules to accurate observations. This will entail some minimal restriction of intercourse which is not excessive when the teaching of the Billings Ovulation Method is in the hands of a competent teacher. The art is to encourage the woman to make simple but faithful vulval observations with due attention to sensations.

Unrestricted sexual intercourse will not allow correct recognition of early infertility because of the confusion caused by seminal fluid and other secretions and transudates due to the intercourse.

All around the world breast feeding and the Billings Ovulation Method are taught together with great success. Reports from several African countries stress that breast feeding is an ideal time to teach the couples. A ready recognition of infertility is followed by an appreciation of something different which is identified as fertility when followed by menstruation or as possible fertility which require the application of the Early Day Rules until the true Peak is defined and confirmed. The knowledge which has led to LAM is valuable in that it gives reassurance of probable infertility so long as the criteria are met. With very little extra effort the reassurance can be fortified by the recognition of physiological infertility as taught by the Billings Ovulation Method but only if this is done correctly. The transition from infertility to fertility is easily learned.

Problem Cases

There are some problem cases. Near the time of weaning due to a protracted follicular phase a prolonged high oestrogen level is sometimes sustained with almost continuous cervical stimulation producing mucus with fertile characteristics. The Ovarian Monitor will verify the high oestrogen level, but is unable to define days available for intercourse free from the possibility of conception.

In these circumstances there are choices of management available. If the baby is young it is in the best interests of the baby to continue breast feeding. The frequency of feeds could be increased. In many cases this will suppress follicular stimulation with a return of the Basic Infertile Pattern.

If the child is older and taking substantial amounts of solid food the couple might consider weaning the child. In this case ovulation would soon occur and a return to normal hormonal ovulatory patterns would become established with vulval patterns which are easy to follow.

The couple might simply decide to wait until nature determines the return of ovulation. Unless every effort is made at an early stage to teach the woman to understand her reproductive physiology she will remain at a disadvantage in managing her fertility naturally, especially if there should arise a sudden need to do so. The use of barriers at this stage would preclude adequate teaching of the Billings Ovulation Method.

A Sydney Meeting

In March this year a meeting sponsored by the International Federation for Family Life Promotion was held in Sydney to discuss the promotion of breast feeding and also the so-called Lactational Amenorrhea Method, and was attended by a number of international experts. Dr. Kevin Hume was invited to participate as a representative of WOOMB-lnternational. Dr Hume is the Vice-President of WOOMB-lnternational and made a statement on behalf of that organization in the following terms:

Background of the Ovulation Method

The World Organization of the Ovulation Method Billings (WOOMB-lnternational Inc.) has always encouraged full breast feeding with delay in the introduction of supplementary feeds for as long as possible, usually until 4 to 6 months after birth.

WOOMB applauds the efforts of the International Federation for Family Life Promotion (IFFLP) and other promoters of the Lactational Amenorrhoea Method (LAM) to encourage breast feeding.

Since 1972, when the studies of Doctors John and Lyn Billings and Professor lames Brown demonstrated with the help of hormonal studies that a woman could identify ovulation before the return of menstruation by her own observations, the Ovulation Method has been taught in conjunction with breast feeding.

Ovulation Method teachers have always been aware of the relative infertility that accompanies enthusiastic breast feeding. However, the Ovulation Method was offered to underpin the confidence of nursing mothers by alerting them to the appearance of mucus symptoms before the first ovulation. They have also taught the physiological variations that occur with returning fertility in the breast-feeding mother.

The understanding of the pre-ovulatory phase (greatly prolonged during breast feeding) was enhanced by the identification of a Basic Infertile Pattern of either vulval dryness or an unchanging discharge.

In breast feeding where the Ovulation Method is practised, changes from the Basic Infertile Pattern of a discharge are the result of fluctuations in oestrogen production. The "wait and see, 1,2,3" rule of the Ovulation Method enables women to cope with these changes as they occur, not with the benefit of hindsight.

We recognize that this rule does require some abstinence that in retrospect may not have been necessary. However, there was no knowing that at the time. The couple cope with this abstinence as a couple, in the interests of the mother and the rest of the family. The use of the Ovarian Monitor is very helpful in selected cases.

It is part of WOOMB policy to inform every woman, from the beginning of puberty if possible, of the facts of her fertility and of the natural signs of fertility and infertility. This is one of our primary aims.

If a woman presents for the first time during lactation and with no previous knowledge of her fertility, we believe that the opportunity to instruct her should not be lost. The period of lactational amenorrhoea with its inbuilt infertility is an excellent time for her to acquire and apply this knowledge where mistakes in interpretation carry for her less risk of an unexpected pregnancy. Trained teachers of the Ovulation Method agree that it is seldom difficult to teach the method at this time.

Women teachers who have successfully breast fed and followed the Ovulation Method make the best teachers of the nursing mother and her husband.

LAM and Ovulation Method Teaching

Ovulation Method teachers are well equipped to teach breast-feeding women who are following LAM because of their knowledge of female fertility and their enthusiastic endorsement of full breast feeding. However, it is contrary to the intensive training they have received before achieving accreditation to advise a woman to proceed with random intercourse irrespective of any changes in vaginal discharges other than significant bleeding after the 56th post partum day. Also they could not accept that training in the Ovulation Method should be postponed until bleeding occurs.

Comments on LAM in Practice

Women should be informed of the 2% pregnancy rate following LAM up to the first bleed.

The failure rate of the Ovulation Method, however poorly practiced, could not be any worse than this. In fact it should be better because of the precautions which the rules of the Ovulation Method for breast feeding require.

Women should also be made aware that at best only 60% of women will enjoy unrestricted intercourse up to the recommended 54/2 months in spite of full breast feeding.

If a woman comes to an Ovulation Method teacher with her mind made up to follow LAM the Ovulation Method teacher would respect that decision. She would emphasis:

WOOMB would support scientific surveys of the LAM to reinforce its claim of a 2% failure Rate. It has always promoted careful scientific studies, both clinical and laboratory based, for the elucidation of a sound basis of natural family planning. The most recent advance would be the Ovarian Monitor of Professor lames Brown which has proved beneficial in clarifying fertility/infertility during lactation as well as other situations.

The absence of any records in women following LAM weakens the identification of reasons for the occurrence of unexpected pregnancies and the establishment of an agreed method for classification of pregnancies. The frequency and pattern of intercourse should be identified by some record.

We understand that the World Health Organization/Family Health International are becoming more conservative in defining the limitations of LAM. We believe it would damage the image of lactation amenorrhoea as a natural method of fertility control if claims for effectiveness proved to be unsubstantiated or at least exaggerated in practice. The criteria for identifying significant first bleeding should be established.

The application of LAM in developing countries (but also in developed ones!) could be profoundly influenced by cultural practices which could distort its basic simplicity.

It is of paramount importance to establish criteria for what constitutes full breast feeding and a method for confirming that these criteria are adhered to. It would be a tragedy for the establishment of LAM and methods such as the Ovulation Method as valid methods of natural fertility control if LAM is brought into disrepute because of a poor protocol.

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