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Christine
M.
Derzko
Natural
Family
Planning:
An
Update
SUMMARY
Natural
Family
Planning
(NFP)
is
defined
by
the
World
Health
Organization
(WHo)
as
"methods
for
planning
or
avoiding
pregnancies
by
observation
of
the
natural
signs
and
symptoms
of
the
fertile
and
infertile
phase
of
the
menstrual
cycle.
It
is
implicit
in
the
definition
of
natural
family
planning,
when
used
to
avoid
conception
that
drugs,
devices
and
surgical
procedures
are
not
used,
there
is
abstinence
from
sexual
intercourse
during
the
fertile
phase
of
the
menstrual
cycle,
and
the
act
of
intercourse,
when
it
occurs,
is
complete."'
The
fertile
period
may
be
determined
by
using
Rhythm,
a
calculation
based
on
previous
cycles,
basal
body
temperature
(BBT)
charting
alone,
mucus
secretion
alone
(Billings
or
Ovulation
method),
or
symptothermal
charting
(Serena
method),
which
indudes
observation
of
both
mucus
and
BBT.
The
effectiveness
of
each
method
is
discussed,
and
the
social
and
psychological
profile
of
couples
who
use
NFP
is
reviewed.
NFP
methods
can
be
used
not
only
to
avoid
pregnancy,
but
also
to
achieve
pregnancy
and
thus
are
particularly
useful
in
investigating
and
treating
infertility.
The
function
of
the
-Family
Life
Clinic
at
St.
Michael's
Hospital
in
Toronto
is
described.
(Can
Fam
Physician
1986;
32:1913-1921.)
SOMMAIRE
L'Organisation
mondiale
de
la
sante
definit
les
methodes
de
planification
familiale
dites
naturelles
comme
etant
des
methodes
permettant
<<
de
planifier
ou
d'eviter
les
grossesses
par
l'observation
des
signes
et
sympt6mes
naturels
des
periodes
de
fertilit6
et
d'infertilit6
du
cycle
menstruel.
II
est
implicite
dans
la
definition
de
la
planification
familiale
naturelle,
lorsque
pratiquee
dans
un
but
de
contraception,
de
ne
pas
faire
usage
de
medicaments,
de
moyen
mecanique,
de ne
pas
recourir
a
une
intervention
chirurgicale,
de
s'abstenir
de
relations
sexuelles
pendant
la
periode
de
fertilite
du
cycle
menstruel
et
que
l'acte
sexuel,
au
moment
d'une
relation,
soit
complet.
>>
1
On
peut
determiner
la
periode
de
fertilite
en
utilisant
la
m'thode
rythmique,
un
calcul
base
sur
les
cycles
precedents,
la
courbe
de
temperature
basale,
les
secrtions
de
la
muqueuse
vaginale
(methode
Billings
cu
d'ovulation),
la
courbe
symptothermique
(methode
Serena),
laquelle
inclut
l'observation
des
seretions
et
la
courbe
de
temperature
basale.
L'article
discute
de
l'efficacit6
de chacune
de
ces
methodes
et
analyse
le
profil
social
et
psychologique
des
couples
qui
utilisent
les
methodes
naturelles
de
planification
familiale.
On
peut
utiliser
ces
methodes
non
seulement
pour
eviter
les
grossesses,
mais
aussi
pour
en
choisir
le
moment
et,
a
ce
titre,
elles
sont
particulierement
utiles
pour
investiguer
et
traiter
l'infertilite.
L'auteur
d6crit
le
r6le
de
la
clinique
Family
Life
au
St.
Michael's
Hospital
de
Toronto.
Key
words:
natural
family
planning,
reproduction,
contraception
Dr.
Derzko
is
an
assistant
professor
in
the
Department
of
Obstetrics
and
Gynecology
at
the
University
of
Toronto,
and
is
the
Director
of
the
Reproductive
Endocrinology
and
Infertility
Division
at
St.
Michael's
Hospital,
Toronto.
Reprint
requests
to:
St.
Michael's
Hospital,
Dept
of
Obstetrics
and
Gynecology,
30
Bond
St.,
Toronto,
Ont.
M5B
1W8.
OVER
THE
LAST
DECADE
there
has
been
a
resurgence
of
interest
in
a
more
"natural"
approach
to
living.
Many
young
adults,
in
their
attempt
to
seek
harmony
with
nature,
are
exploring
alternate
methods
of
CAN.
FAM.
PHYSICIAN
Vol.
32:
SEPTEMBER
1986
- -
----
---
--- ---
im
illilli
ll-
--
El
mm
1913
conception
control
which
are
more
natural
than
intrauterine
contraceptive
devices
(IUCD),
birth-control
pills,
and
other
chemical
methods
whose
long-term
and
short-term
side-effects
they
consider
problematic.
It
is
esti-
mated
that
about
four
per
cent
of
cur-
rently
married
North
American
cou-
ples
rely
on
NFP.2
Definition
Natural
Family
Planning
is
the
tim-
ing
of
coitus
in
accordance
with
the
fertile
phase
of
the
menstrual
cycle,
to
achieve
or
prevent
a
pregnancy.
When
pregnancy
is
to
be
avoided,
pe-
riodic
abstinence
is
practiced;
the
cou-
ple
recognizes
pre-ovulatory
symp-
toms
and
signs,
and
refrains
from
sexual
intercourse
and,
indeed,
any
genital
contact
until
the
infertile
phase
of
the
cycle
is
reached.
On
the
other
hand,
couples
wishing
to
conceive
learn
to
time
intercourse
so
that
it
takes
place
during
this
fertile
phase.
Successful
use
of
NFP
requires
funda-
mental
knowledge
and
understanding
of
the
physiology
of
reproduction,
sometimes
referred
to
as
"fertility
awareness".
Reproductive
Physiology:
Fertility
Awareness
Successful
use
of
a
natural
family-
planning
method
necessitates
some
basic
knowledge
about
both
male
and
female
reproductive
functioning.
This
includes
production
and
survival
of
sperm
in
the
male,
ovum
survival,
cervical
mucus
secretion,
basal
body
temperature
changes,
and
other
less
obvious
symptoms
and
signs
accom-
panying
ovulation
in
the
female.
The
following
is
a
summary
of
the
major
points
which
are
included
in
teaching
fertility
awareness
to
patients.
The
span
of
a
woman's
reproduc-
tive
life
lasts
from
menarche
(average
age:
12.5
years),
until
menopause
(average
age:
50.8
years).
Fertility
in
the
woman
is
cyclical,
with
ovulation
occuring
only
once
per
cycle.
The
ovum
is
fertilizable
for
10-24
hours
while
it
floats
freely
in
the
fallopian
tube,
and
if
it
is
not
fertilized
during
this
time,
pregnancy
will
not
occur.
In
the
male,
fertility
begins
with
the
pubertal
production of
semen
and
then
lasts
for
the
remainder
of
life.
Sperm
production
is
continuous
(not
cyclical
as
it
is
in
women),
and
there-
fore
impregnation
can
occur
at
any
time.
Normally,
in
a
non-hostile
envi-
ronment,
sperm
survive
24-48
hours,
but
in
hostile,
acidic,
vaginal
secre-
tions
they
die
within
4-6
hours.
In
estrogenic
mucus,
the
fertilizing
ca-
pacity
of
sperm
is
believed
to
be
3-5
days.
The
process
of
fertilization
it-
self
requires
about
5-8
hours
to
com-
plete.3
Cervical
mucus
is
the
outward
manifestation
of
the
internal
hormonal
milieu.4
It
is
produced
cyclically,
in
response
to
estrogenic
stimulation
of
the
mucus-producing
glands
of
the
cervix,
peaking
in
response
to
peak-
estrogen
secretion
and
disappearing
as
progesterone
secretion
appears
and
becomes
dominant.
Estrogenic
cervi-
cal
mucus
is
clear,
acellular,
copious,
of
low
viscosity,
has
a
spinnbarkeit
(thready
stretchiness)
which
increases
as
estrogen
levels
rise,
and
produces
a
ferning
pattern
when
allowed
to
dry
on
a
slide.
With
the
onset
of
proges-
terone
secretion,
the
mucus
becomes
white,
cellular,
scanty,
thick
and
sticky,
the
spinnbarkeit
decreases
to
less
than
1
cm
and,
when
left
to
dry
on
a
slide,
the
ferning
is
replaced
by
a
"beaded'"
pattern.
The
cervix
acts
as
a
reservoir
as
well
as
a
filter
for
sperm.
Sperm
can
be
found
in
the
oviduct
within
five
minutes
after
ejaculation.
During
the
estrogenic
phase,
sperm
storage
is
known
to
occur,
with
the
gradual
re-
lease
of
sperm
into
the
upper
tract.
Timing
of
Hormones
and
Menstrual
Cycle
Events
Studies
have
shown
that
mean
time
intervals
exist
during
the
menstrual
cycle.
(See
Table
1.)
Speroff
states
that
a
significant
temperature
rise
is
not
noted
until
two
days
after
the
luteinizing
hormone
(LH)
peak,
and
that
this
corresponds
to
an
increase
in
peripheral
proges-
terone
levels
to
more
than
4
ng/ml.8
The
actual
release
of
the
ovum
proba-
bly
occurs
on
the
day
before
the
time
of
the
first
temperature
elevation.
Sometimes
a
mid-cycle
dip
in
temper-
ature
to
the
lowest
level
of
the
cycle
may
be
recognizable,
and
this
is
be-
lieved
to
coincide
with
ovulation
it-
self.
Basal
Body
Temperture
The
thermogenic
effect
of
proges-
terone
acting
on
the
hypothalamus
is
well
known
to
cause
the
rise
in
tem-
perature
of
the
luteal
phase,
which
produces
the
biphasic
graph
charac-
teristic
of
ovulation.
Temperatures
should
be
taken
orally,
vaginally
or
rectally,
always
at
the
same
time
and
under
the
same
circumstances
every
day.
Usually,
a
basal
body
tempera-
ture
is
taken
at
a
fixed
time
daily
be-
fore
rising
from
bed.
Although
there
is
consensus
that
the
temperature
rise
in
a
biphasic
graph
is
indicative
of
ovulation,
unfortunately,
there
is
little
consensus
about
precisely
when
the
ovulation
occurs
in
relation
to
the
BBT
chart.
Dates
ranging
from
two
days
before
the
temperature
rise
to
three
days
after
the
elevation
have been
proposed
as
THE
ovulation
date.
It
is
agreed,
however,
that
the
thermal
shift
demarcates
the
end
of
the
fertile
phase.
Studies
have
shown
that
in
95%
of
women
aged
20-40
years,
menstrual
cycles
vary
in
length
from
21-36
days.
The
cycle
consists
of
a
follicu-
lar
phase
of
10-21
days
and
a
luteal
phase
of
1
1-16
days.
Thus,
a
follicu-
lar
phase
of
<10
days
is
considered
short,
of
>21
days
is
called
long.
More
important,
a
luteal
phase
of
<11
days
is
considered
to
be
short
and
in
infertile
women
may
indicate
a
need
for
further
investigation.
Table
1
Timing
of
Hormones
and
Menstrual
Cycle
Events
Events
Mean
time
Median
time
E
2
peak
to
LH
peak
24
hours5
24
hours6
LH
peak
to
ovulation
9
±
2
hours5
16.2
hours6
onset
LH
rise
to
ovulation
27.3
hours7
32
houre
E
2
peak
to
ovulation
34
+
3
hours5
24
hours6
Duration
of
E
2
rise
82.5
hours5
CAN.
FAM.
PHYSICIAN
Vol.
32:
SEPTEMBER
1986
1915
Types
of
Natural
Family
Planning
1.
Calendar
Rhythm
The
so-called
"rhythm
method"
of
natural
family
planning
was
devel-
oped
on
the
basis
of
early
work
by
Fraenkel,
Ogino
and
Knaus,
which
defined
the
duration
of
the
luteal
phase.
Given
a
predicted
survival
time
of
12-24
hours
for
the
ovum
and
72
hours
for
sperm,
the
fertile
phase
can
be
calculated
as
follows:
1.
The
length
of
the
menstrual
cycle
is
recorded
over
the
preceding
12
cycles.
2.
The
shortest
and
longest
cycles
are
determined.
3.
The
first
day
of
the
fertile
period
is
calculated
by
subtracting
19
from
the
length
of
the
short-est
cycle.
4.
The
last
day
of
the
fertile
period
is
determined
by
subtracting
11
from
the
longest
cycle.
Coitus
is
to
be
avoided,
therefore,
between
days
(shortest
cycle
length
-
19)
and
(longest
cycle
length
-
11).
This
method
has
proven
to
be
rather
unreliable,
because
most
women's
cycles
are
variable
enough
to
require
long
periods
of
abstinence
to
be
sure
of
avoiding
pregnancy.
Ef-
fectiveness
has
been
calculated
as
ranging
between
14.49
and
34.510
pregnancies/100
woman
years.
2.
Basal
Body
Temperature
Charting
There
is
general
agreement
that
a
biphasic
temperature
graph
is
indica-
tive
of
ovulation.
The
exact
time,
however,
when
ovulation
occurs,
is
difficult
to
determine
from
the
BBT
chart
alone.
The
onset
of
the
infertile
phase
is
much
easier
to
determine.
The
commonest
criterion
used
to
de-
termine
the
beginning
of
the
infertile
phase
is
the
"coverline".
This
is
de-
fined
as
a
line
drawn
on
a
BBT
graph:
(0.
1°F
(or
0.05°C))
which
is
above
the
highest
normal
temperature
of
the
low
pre-ovulatory
temperatures,
ig-
noring
the
temperature
of
the
first
four
days
of
the
cycle
and
those
af-
fected
by
disturbances.
At
least
six
low-temperature
points
must
be
re-
corded
before
drawing
the
coverline.
The
infertile
period
is
that
part
of
the
cycle
when
intercourse
cannot
result
in
conception.
From
the
third
(some
say
the
second)
day
that
a
temperature
above
the
coverline
has
been
recorded
until
day
one
of
menses,
intercourse
will
not
cause
conception.
If
BBT
charting
is
used
strictly
ac-
cording
to
this
rule
(i.e.,
avoiding
in-
tercourse
and,
indeed,
any
genital
contact
until
after
the
third
day
of
high
temperature
has
been
recorded),
this
method
is
totally
effective
in
pre-
venting
conception.
The
effectiveness
of
the
method
when
applied
strictly,
ranges
between
0.811-6.
612
pregnan-
cies/100
woman
years.
Within
the
last
few
years,
compu-
terized
thermometers
have
been
intro-
duced
which
not
only
record
day-to-
day
BBTs
but
frequently
are
also
equipped
to
display
graphically
the
temperatures
recorded
for
the
entire
cycle.
Furthermore,
a
red
and
a
green
light
(green=infertile,
red=fertile)
on
the
thermometer
serves
as
a
guide
to
coital
timing
appropriate
to
the
cou-
ple's
needs.
Other
innovations
which
assist
the
woman
in
determining
im-
pending
ovulation
include
a
vaginal
probe
to
measure
tissue
conductance
changes
which
reflect
rising
pre-
ovulatory
estrogen
effects
on
the
va-
gina,
and
a
urine
dip-stick
LH
rapid
assay
to
determine
the
pre-ovulatory
LH
surge.
3.
Ovulation
(Billings)
Method
Australian
doctors
John
and
Evelyn
Billings
pioneered
the
method
of
ob-
serving
cervical
mucus
as
a
predictor
of
ovulation.
Women
are
taught
to
observe
mucus
patterns
at
the
vulva
for
a
sensation
of
wetness
and
lubrica-
tion
by
using
a
combination
of
ordi-
nary
sensation,
Kegel
exercises,
finger
palpation,
a
wipe
through
with
toilet
paper
or
a
combination
of
these.
The
mucus
on
the
toilet
tissue
is
then
inspected
for
colour
and
spinnbarkeit.
Cervical
mucus,
secreted
by
the
cervix,
undergoes
changes
in
response
to
the
secretion
of
estrogen
and
pro-
gesterone.
Following
menses,
before
the
estrogen
levels
reach
a
critical
point,
several
"dry"
days
occur.
These
are
the
infertile
days.
Grad-
ually,
as
the
woman's
cycle
pro-
gresses,
the
'dryness'
is
replaced
by
a
sensation
of
moistness,
which
in-
creases
under
the
influence
of
rising
estrogen
levels
to
a
sensation
of
wet-
ness
and
slipperiness
when
the
mucus
is
noted
to
develop
spinnbarkeit.
This
is
the
fertile
phase
of
the
cycle.
Brown
has
reported
that
once
a
threshold
level
for
E
2
of
15
ug/100
ml/24
hours
is
exceeded,
the
mucus
becomes
sufficiently
wa-
tery
to
be
felt
at
the
vulva."3
It is
in
this
fertile
mucus,
particularly
in
the
cervical
crypts
where
they
are
well
protected
from
the
hostile
vaginal
en-
vironment,
that
sperm
are
able
to
sur-
vive
for
days.
The
last
day
of
fertile
mucus
is
called
the
peak
day.
Peak
mucus
has
been
shown
to
correlate
well
with
the
LH
surge
and
is
followed
by
ovulation,
which
usually
occurs
one
day
following
peak
mucus
(+
2-3
days).
Following
ovulation,
rising
progesterone
levels
inhibit
mucus
secretion
and
result
in
sticki-
ness or
dryness
felt
at
the
vulva.
Men-
struation
occurs
two
weeks
after
peak
mucus.
In
the
ovulation
method,
women
learn
to
differentiate
estrogenic
cervi-
cal
mucus
from
other
vaginal
secre-
tions:
infected
vaginal
discharge,
se-
minal
ejaculate,
secretions
of sexual
arousal,
lubricants
and
vaginal
medi-
cations.
Patients
are
instructed
to
re-
strict
coitus
to
dry
days
from
the
ces-
sation
of
menses
until
the
onset
of
mucus
secretion.
They
must
then
ab-
stain
from
intercourse
until
the
fourth
day
following
peak
mucus
each
time
a
secretion
build-up
is
noted.
Even
dur-
ing
the
dry
days
coitus
is
restricted
to
alternate
days,
in
order
that
mucus
build-up
not
be
confused
with
seminal
discharge.
With
the
onset
of
proges-
terone
secretion,
the
mucus
becomes
sticky
for
a
couple
of
days,
then
to-
tally
disappears,
and
the
woman
feels
dry.
During
the
period
of
secretion
of
fertile
mucus
all
genital
contact
must
be
avoided.
The
use
of
barrier
methods
combined
with
the
Billings
Method
during
the
fertile
phase
of
the
cycle,
although
it
is
practised
by
many
couples,
is
considered
unac-
ceptable
by
the
proponents
of
the
Method.
Couples
using
the
Billings
Method
record
their
findings
on
a
monthly
graph
using
a
series
of
colour-coded
stamps:
RED-bleeding,
GREEN-dry-
ness,
WHITE
with
picture
of
BABY-
mucus,
YELLOW-sticky
mucus,
x-
peak
mucus,
RED-STIPPLED-spotting.
Additional
changes
that
occur
in-
clude
softening
and
ascent
of
the
cer-
vix,
and
dilation
of
the
cervical
os,
both
of
which
are
maximal
at
mid-
cycle.
With
the
onset
of
progesterone
secretion
and
ovulation,
the
cervix
drops
back
and
again
lies
low
in
the
vagina,
retums
to
its
usual
firmness
and
develops
a
closed
cervical
os
with
thickened
secretions
that
solidify
and
form
the
protective
mucus
plug
which
blocks
further
entry
to
the
uterine
cav-
ity.
Instructor
couples
teaching
the
CAN.
FAM.
PHYSICIAN
Vol.
32:
SEPTEMBER
1986
1917
Billings
Method
to
other
client
cou-
ples
strongly
recommend
observing
these
cervical
changes
to
confirm
the
mucus
findings.
The
ovulation
method
has
a
major
advantage
over
the
rhythm
method
and
the
BBT
method
in
that
it
predicts
ovulation.
With
reasonable
reliability,
it
permits
coitus
during
dry
days,
be-
tween
the
cessation
of
menses
and
the
onset
of
pre-ovulatory
mucus
secre-
tion.
For
some
women,
the
need
to
observe
only
one
sign,
mucus
secre-
tion,
is
an
advantage.
For
other
women,
who
are
perhaps
less
experi-
enced
and
somewhat
unsure
of
the
method,
it
may
create
considerable
anxiety.
An
international
study
by
a
World
Health
Organization
Task
Force
reported
in
1981
that
by
the
end
of
the
first
observation
cycle,
93%
of
women
were
able
to
recognize
their
mucus
pattern,
and
91%
understood
the
method
well.14
Because
of
the
subjective
nature
of
this
approach
to
family
planning
(i.e.,
the
woman's
recognition
of
vulvar
wetness),
care
must
be
taken
to
include
the
husband
or
sexual
partner
in
discussions
and
follow-up,
lest
he
be
made
to
feel
that
his
only
contribution
is
sexual
abstin-
ence.
Measurements
of
the
effectiveness
of
using
the
mucus
method
vary,
de-
pending
on
whether
total
number
of
pregnancies
or
method-failure-related
pregnancies
per
100
woman
years
are
discussed.
Total
failure
rates
range
from
a
high
of
39.7/100
woman
years
reported
by
Wade
et
al.,15
to
a
low
of
9.7
pregnancies/100
woman
years
found
in
Dolack's
study.16
There
is
also
a
variation
in
method-
related
pregnancy
rates,
ranging
from
12.2
pregnancies/
100
woman
years
in
Johnson's
Australian
study,"7
to
0
pregnancies/100
woman
years
in
Klaus
and
Fagan's
U.S.
study.
'
8
Special
Circumstances
Under
certain
circumstances,
ovu-
lation
is
abnormal
or
fails
to
occur
at
all.
This
is
particularly
true
peri-men-
archally,
during
lactation,
pre-
menopausally
and
after
discontinuing
birth-control
pills.
Under
these
cir-
cumstances,
the
secretion
of
estro-
genic
mucus
may
be
quite
erratic.
Peri1nenarche/preinenopause
During
both
extremes
of
reproduc-
tive
life
(i.e.,
peri-menarchally
and
peri-menopausally),
ovulatory
irregu-
larities
are
common.
The
ovulatory
response
to
hypothalamic-pituitary
stimulation
is
not
predictable
and,
in-
deed,
may
not
occur
at
all.
Thus,
the
possibilities
may
range
from
normal
ovulation,
through
short
luteal/long
follicular
phase,
to
a
total
anovula-
tion.
Similarly,
mucus
secretion
may
fluctuate
from
copious
to
erratic
to
imperceptible
if
there
is
lack
of
estro-
gen.
Menses
may
also
be
absent,
spotty
or
excessive.
During
both
of
these
periods,
therefore,
the
mucus
method
for
coital
timing
is
difficult
and
frequently
unreliable.
Childbirth
Following
parturition,
the
return
of
ovulation
and
pre-ovulatory
mucus
is
highly
unpredictable.
Even
after
spon-
taneous
abortion,
determining
when
ovulation
resumes
is
uncertain.
It
is
recommended
that
mucus
observation
begin
at
three
weeks
post
partum
in
the
non-lactating
woman,
and
at
about
six
weeks
in
the
nursing
mother.
Many
factors
determine
the
return
of
ovulation
including
frequency,
dura-
tion
and
intensity
of
feedings,
in
addi-
tion
to
maternal
nutrition
and
general
physical
health.
There
is
no
consistent
or
predictable
mucus
pattern
while
a
woman
is
breastfeeding.
Oral
contraceptives
After
discontinuation
of
the
pill,
the
return
of
normal
ovulation
is
vari-
able
and
indeed
may
be
considerably
delayed,
particularly
in
women
with
a
history
of
irregular
menses
or
oligo-
menorrhea.
The
ovulation
method,
which
depends
on
mucus
recognition,
is
therefore
unreliable
as
a
predictor
of
the
safe
period
until
ovulatory
function
normalizes.
4.
Sympto-Thermal
Charting
(Serena
Method)
The
fourth
natural
approach
to
con-
ception
control
is
symptothermal
charting
(STC),
also
known
as
the
Serena
Method.
Serena
(taken
from
the
French
SErvice
de
REgulation
des
NAissances)
was
established
in
La-
chine,
Quebec,
by
Gille
and
Rita
Breault
in
the
mid-1950s.
After
inten-
sively
studying
the
natural
approaches
to
family
planning,
the
couple
began
a
program
of
instruction
for
other
couples.
They
trained
teacher
couples
and
organized
them
into
teams,
each
with
a
medical
and
a
moral
advisor.
The
movement
spread
widely
throughout
Quebec
and
parts
of
On-
tario.
These
dedicated
volunteers
not
only
teach
the
technical
aspects
of
fer-
tility
control,
but
also
provide
couples
with
the
psychological
and
moral
sup-
port
necessary
during
the
times
of
sexual
abstinence,
which
may
be
par-
ticularly
difficult
during
the
initial
learning
period.
Symptothermal
charting
relies
on
observation
of
cervical
mucus
and
other
physiological
indicators
of
ovu-
lation,
in
combination
with
the
infor-
mation
offered
by
BBT
changes.
Symp-
toms
observed
include:
1.
Mucus
secretions
at
the
vulva
that
resemble
raw
egg
white.
As
described
earlier,
this
mucus
increases
in
re-
sponse
to
rising
levels
of
estrogen,
peaks
at
ovulation,
then
disappears
as
progesterone
dominates
the
endocrine
scene.
2.
Vulvar
fullness,
also
an
estrogen
ef-
fect,
is
reported
by
many
women
at
the
same
time
as
peri-introital
lubrication
is
noted.
3.
Cervical
palpation
before
ovulation
reveals
a
progressively
higher,
more
open,
softer
and
straighter
cervix
that
is
flowing
with
mucus.
With
the
onset
of
progesterone
secretion,
the
cervix
drops
lower,
closes,
hardens,
feels
dry
and
comes
to
lie
posteriorly
against
the
vaginal
wall.
4.
Mittelschmerz,
or
mid-cycle
pain,
is
variable
in
duration,
severity
and
lo-
cation.
Sharp,
short-lived,
localized
pain
may
be
due
to
actual
follicle
rup-
ture.
More
often,
however,
congestion
and
edema
of
peri-ovarian
tissues
is
the
likely
cause
of
the
discomfort,
especially
if
it
is
long
lasting.
5.
Mid-cycle
spotting
or
bleeding
is
believed
to
result
from
the
mid-cycle
pre-ovulatory
drop
in
estrogen
secre-
tion
and
the
loss
of
support
to
the
en-
dQmetrium.
6.
Mastalgia
or
a
feeling
of
breast
heaviness
and
sensitivity
may
also
re-
sult
from
a
drop
in
estrogen
concentra-
tion
at
mid-cycle,
but
more
commonly
it
is
believed
to
be
the
result
of
proges-
terone
secretion.
7.
Other
cyclic
symptoms
reported
in-
clude
premenstrual
acne,
depression,
edema,
weight
gain
and
increased
ap-
petite
and
cravings,
particularly
for
sugar.
Migraine
headaches,
nausea,
visual
disturbances
and
changes
in
body
odours
have
also
been
reported,
but
these
symptoms
are
less
reliable.
Advantages
of
STC:
The
STC
method
is
somewhat
more
complex
to
learn
be-
CAN.
FAM.
PHYSICIAN
Vol.
32:
SEPTEMBER
1986
1918
cause
it
takes
into
consideration
mucus
symptoms,
BBT
changes
and
numerous
other
signs
and
symptoms.
On
the
other
hand,
it
is
a
much
more
reliable
guide
to
the
fertile
period
than
any
of
the
component
parts
individually.
Be-
cause
of
the
complementary
nature
of
the
observations,
STC
widens
the
limits
which
each
individual
fertility
indica-
tor
would
have.
It
is
especially
useful
in
such
conditions
as
vaginitis
or
fever,
which
blur
one
or
other
of
the
signs
of
ovulation.
Effectiveness
of
STC:
The
successful
use
of
STC
in
conception
control
ap-
pears
to
depend
upon
two
major
fac-
tors:
a)
whether
absence
of
mucus
or
calcu-
lation
or
a
combination
of
both
were
used
at
the
beginning
of
the
cycle;
and
b)
whether
the
method
was
being
used
to
prevent
pregnancy
or
only
to
space
births.
Total
pregnancies
varied
from
4.920
to
15.919/100
woman
years.
Methodo-
logical
failure
ranged
from
3.7/100
woman
years,21
when
absence
of
mucus
was
the
only
parameter
used
in
the
pre-ovulatory
period,
to
0.0/100
woman
years22
when
a
combination
of
calculation
and
absence
of
mucus
was
used.
Furthermore,
in
a
five-country
study,
the
variation
in
pregnancy
rates
was
from
4.1/100
woman
years
for
pregnancy
prevention,
to
14.8/100
woman
years
for
child
spacing.
For
Canada,
these
rates
were
1.1
and
16.1
respectively.23
This
1:
16
ratio
under-
scores
how
important
motivation
is
in
the
successful
use
of
this
method
and,
indeed,
of
any
method
which
depends
on
periodic
abstinence.
Planining
ta
pregnancy:
aii
aipplication
of
STC:
Although
the
term
"family
planning"'
tends
to
evoke
the
image
of
preventing
pregnancy,
this
article
would
be
incomplete
if
the
importance
of
this
method
in
establishing
a
preg-
nancy,
in
addition
to
investigating
and
treating
the
infertile
couple,
were
not
emphasized.
Certainly,
couples
wh1o
have
used
and
understood
the
signs
and
symptoms
of
STC
to
prevent
preg-
nancy
have
little
difficulty
in
applying
that
same
information
to
timing
coitus
appropriately
to
enable
a
pregnancy
to
occur.
How
exciting
it
is
for
them
to
know
exactly
when
conception
oc-
curred!
Among
couples
who
present
to
our
Reproductive
Endocrinology
and
In-
fertility
Clinic
complaining
of
inability
to
conceive,
about
30%
of
the
women
become
pregnant
within
six
months
of
being
instructed
in
STC.
For
the
re-
mainder,
the
STC
teaching
becomes
the
foundation
for
subsequent
investiga-
tion
and
management
of
their
inferti-
lity.
A
single
look
at
a
symptother-
mally
charted
cycle
readily
indicates
that
ovulation
has
taken
place
(bipha-
sic
graph),
that
appropriate
mucus
changes
have
occurred,
and
that
coital
timing
has
been
appropriate.
Further-
more.
there
is
a
correct
time
during
the
cycle
when
each
fertility
test
should
be
done.
The
test
will
repeatedly
yield
ab-
normal
results
if
the
timing
has
been
inappropriate
(e.g.,
a
post-coital
test
done
too
early
in
the
follicular
phase
or
in
the
luteal
phase
of
the
cycle).
Fol-
lowing
treatment,
the
improved
results
are
also
readily
seen
on
the
STC.
Who
Uses
Natural
Family
Planning?
The
social
and
psychological
characteristics
of
couples
who
choose
NFP
as
a
method
of
conception
control
were
recently
reported
by
Daly
and
Herold.24
The
majority
(61%)
were
between
20
and
30
years
of
age;
two-
thirds
of
them
had
completed
post-sec-
ondary
school
education;
62%
had
been
married
for
less
than
five
years;
and
75%
were
childless
or
had
one
child.
Abstinence
during
the
fertile
period
was
liberally
defined
by
61%
of
cou-
ples
as
precluding
intercourse,
but
per-
mitting
stimulation,
including
genital
stimulation
to
orgasm,
which
is
in
sharp
contrast
to
traditional
NFP
teach-
ing.
Of
those
who
were
not
pregnant
when
questioned,
42%
were
continu-
ing
to
use
NFP,
and
25%
were
using
a
combination
of
fertility-awareness
and
barrier
methods.
Combination
NFP/barrier
users
were
more
likely
to
have
been
married
for
over
five
years,
and
have
more
children
than
users
of
NFP
only.
They
were,
therefore,
more
likely
to
be
limiting
their
family
size,
rather
than
merely
spacing
their
chil-
dren,
as
were
the
users
of
NFP
alone.24
The
Family
Life
Clinic
at
St.
Michael's
Hospital,
University
of
Toronto
The
Family
Life
Clinic
(FLC)
was
set
up
in
1974,
in
the
Department
of
Obstetrics
and
Gynecology
at
St.
Mi-
CAN.
FAM.
PHYSICIAN
Vol.
32:
SEPTEMBER
1986
THE
NEW
LOOK
OF
RELIABILITY
New
identification
-
same
proven
formula
Fiorinal
contains
ASA,
caffeine
and
butalbital.
It
has
the
potential
for
being
abused
and
should
be
avoided
in
chronic
pain
states
requiring
continuous
daily
use
for
a
prolonged
period.
SANDOZ
CANADA
INC.,
Dorval,
Quebec
H9S
1A9
SANDOZ'
L
I
I
Psign
mi
ailTM
I
I'I
CIMlPrescribing
intfomation
available
on
request.
-
I
chael's
Hospital,
a
teaching
hospital
affiliated
with
the
University
of
Toronto.
Its
mandate
was
to
instruct
individuals
and
couples
in
all
methods
of
family
planning,
including
natural
family
planning.
The
Clinic's
motto
is:
"Fertility
by
choice
through
under-
standing".
Through
counselling
and
education,
individuals
or
couples
are
best
able
to
make
a
well-informed
de-
cision
about
the
optimal
method
of
fer-
tility
control
for
them.
Because
birth
control
generally
-and
STC,
specifi-
cally,
are
recognized
to
be
a
shared
re-
sponsibility,
the
participation
of
cou-
ples
in
the
instruction
is
encouraged.
Greater
effectiveness
in
using
this
method
can
be
anticipated
if
both
partners
attend
the
instruction
sessions
and
both
participate
in
its
implementa-
tion,
whatever
method
is
ultimately
chosen.
Within
the
past
five
years,
the
Fam-
ily
Life
Clinic
has
become
a
vital
and
integral
part
of
the
Reproductive
En-
docrinology
and
Infertility
Division.
It
is
currently
staffed
by
two
nurse
edu-
cators
who
have
been
thoroughly
trained in
all
birth-control
techniques,
particularly
in
NFP.
More
recently,
they
have
received
extensive
instruc-
tion
in
infertility
and
abnormalities
of
the
menstrual
cycle.
Under
the
direc-
tion
of
reproductive
endocrinologists,
they
teach
patients,
help
interpret
symptothermal
charts
and
test
results,
arrange
for
appropriate
testing
to
be
done
at
the
correct
time
in
the
cycle,
and
provide
extensive
emotional
and
psychological
support
to
infertile
cou-
ples.
1985
Statistics
from
the
Family
Life
Clinic
at
St.
Michael's
Hospital,
Toronto
The
FLC
nurses
see
an
average
of
130
clients
each
month
and
counsel
an
additional
75
clients
by
telephone.
In
1985,
they
saw
450
new
clients/client
couples.
(See
Table
2.)
Table
2
Reason
for
Attending
a
Family
Life
Clinic
Total
no.
new
clients
(client
couples)
No.
to
conceive
177
NFP
130
STC
with
barrier
90
Endocrine
lx
12
STC
post
pill
41
Total
450
'Aprsolifletablets
(hydralazine
hydrochloride)
Antihypertensive
Agent
Actions
Hydralazine
hydrochloride
exerts
its
hypotensive
action
by
reducing
vascular
resistance
through
direct
relaxation
of
vascular
smooth
muscle.
Indications
APRESOLINE
Oral:
Essential
hypertension.
APRESOLINE
is
used
in
conjunction
with
a
diuretic
and/or
other
antihypertensive
drugs
but
may
be
used
as
the
initial
agent
in
those
patients
in
whom,
in
the
judgment
of
the
physician,
treatment
should
be
started
with
a
vasodilator.
APRESOLINE
Parenteral:
Severe
hypertension
when
the
drug
cannot
be
given
orally
or
when
there
is
an
urgent
need
to
lower
blood
pressure
(e.g.
toxemia
of
pregnancy
or
acute
glomerulonephritis).
It
should
be
used
with
caution
in
patients
with
cerebral
vascular
accidents.
Contraindications
Hypersensitivity
to
hydralazine,
coronary
artery
dis-
ease,
mitral
valvular
rheumatic
heart
disease,
and
acute
dissecting
aneurysm
of
the
aorta.
Warnings
Hydralazine
may
produce
in
a
few
patients
a
clinical
picture
simulating
systemic
lupus
erythematosus,
in
such
cases
treatment
should
be
discontinued
im-
mediately.
Long-term
treatment
with
adrenocortico-
steroids
may
be
necessary.
Complete
blood
counts,
L.E.
cell
preparations,
and
antinuclear
antibody
titer
determinations
are
indicated
before
and
periodi-
cally
during
prolonged
therapy
with
hydralazine
and
if
patient
develops
arthralgia,
fever,
chest
pain,
continued
malaise
or
other
unexplained
signs
or
symptoms.
If
the
results
of
these
tests
are
abnormal,
treatment
should
be
discontinued.
Usage
in
Pregnancy
Animal
studies
indicate
that
high
doses
of
hydrala-
zine
are
teratogenic.
Although
there
is
no
positive
evidence
of
adverse
effects
on
the
human
fetus,
hydralazine
should
be
used
during
pregnancy
only
if
the
benefit
clearly
justifies
the
potential
risk
to
the
fetus.
Precautions
Caution
is
advised
in
patients
with
suspected
coron-
ary-artery
disease,
at
it
may
precipitate
angina
pectoris
or
congestive
heart
failure,
and
it
has
been
implicated
in
the
production
of
myocardial
infarction.
The
"hyperdynamic"
circulation
caused
by
APRESO-
LINE
may
accentuate
specific
cardiovascular
inadequacies,
e.g.
may
increase
pulmonary
artery
pressure
in
patients
with
mitral
valvular
disease.
May
reduce
the
pressor
responses
to
epinephrine.
Postural
hypotension
may
result.
Use
with
caution
in
patients
with
cerebral
vascular
accidents
and
in
patients
with
advanced
renal
damage.
Peripheral
neuritis
has
been
observed
and
published
evidence
suggests
an
antipyridoxine
effect
and
the
addition
of
pyridoxine
to
the
regimen
if
symptoms
develop.
Blood
dyscrasias
consisting
of
reduction
in
hemo-
globin
and
red
cell
count,
leukopenia,
agranulocy-
tosis
and
purpura
have
been
reported.
In
such
cases
the
drug
should
be
withdrawn.
Periodic
blood
counts
are
advised
during
therapy.
MAO
inhibitors
should
be
used
with
caution
in
patients
receiving
hydralazine.
Slow
acetylators
should
probably
receive
no
more
than
200
mg
of
APRESOLINE
per
day.
When
a
higher
dose
is
contemplated,
and,
whenever
possible,
it
may
be
advisable
to
determine
the
patient's
acetyla-
tion
phenotype.
Adverse
Reactions
Within
the
first
day
or
two:
headache,
palpitations,
tachycardia,
anorexia,
nausea,
vomiting,
diarrhea,
and
angina
pectoris.
They
are
usually
reversible
when
dosage
is
reduced
or
can
be
prevented
or
mini-
mized
by
administering
reserpine
or
a
beta-blocker
together
with
hydralazine.
Less
Frequent:
nasal
congestion;
flushing;
lacrima-
tion;
conjunctivitis;
peripheral
neuritis,evidenced
by
paresthesias,
numbness,
and
tingling;
edema;
dizzi-
ness;
tremors;
muscle
cramps;
psychotic
reactions
characterized
by
depression,
disorientation,
or
anxiety;
hypersensitivity
(including
rash,
urticaria,
pruritus,
fever,
chills,
arthralgia,
eosinophilia,
and,
rarely
hepatitis);
constipation;
difficulty
in
micturition;
dyspnea;
paralytic
ileus;
lymphadenopathy;
spleno-
megaly;
blood
dyscrasias,
consisting
of
reduction
in
hemoglobin
and
red
cell
count,
leukopenia,
agranu-
locytosis,
thrombocytopenia
with
or
without
purpura;
hypotension;
paradoxical
pressor
response.
Late
Adverse
Reactions:
Long-term
administration
at
relatively
high
doses
may
produce
an
acute
rheuma-
toid state.
When
fully
developed
a
syndrome
resembl-
ing
disseminated
lupus
erythematosus
occurs.
The
frequency
of
these
untoward
effects
increases
with
dosage
and
duration
of
exposure
to
the
drug
and
is
higher
in
slowthan
in
fast
acetylators.
Antinuclear
anti-
body
and
positive
L.E.-cell
tests
occur.
Symptoms
and
Treatment
of
Overdosage
Symptoms:
hypotension,
tachycardia,
headache,
generalized
skin
flushing,
myocardial
ischemia
and
cardiac
arrhythmia
can
develop.
Profound
shock
can
occur
in
severe
overdosage.
Treatment:
No
known
specific
antidote.
Evacuate
gastric
content,
taking
adequate
precautions
against
aspiration
and
for
protection
of
the
airway;
if
general
conditions
permit,
activated
charcoal
slurry
is
instilled.
These
procedures
may
have
to
be
omitted
or
carried
out
after
cardiovascular
status
has
been
stabilized,
since
they
might
precipitate
cardiac
arrhythmias
or
increase
the
depth
of
shock.
Support
of
the
cardiovascular
system
is
of
primary
importance.
Shock
should
be
treated
with
volume
expanders
without
resortingto
use
of
vasopressors,
if
possible.
If
a
vasopressor
is
required,
a
type
that
is
least
likelyto
precipitate
or
aggravate
cardiac
arrhythmia
should
be
used,
and
the
E.C.G.
should
be
monitored
while
they
are
being
administered.
Digitalization
may
be
necessary.
Renal
function
must
be
monitored
and
supported
as
required.
No
experience
has
been
reported
with
extracorporeal
or
peritoneal
dialysis.
Dosage
and
Administration
Adjust
dosage
according
to
individual
blood
pressure
response.
Orally:
Initial:
10
mg
4
times
daily
for
the
first
2
to
4
days,
25
mg4
times
dailyforthe
remainder
of
thefirst
week,
50
mg
4
times
daily
for
the
second
and
subse-
quent
weeks
of
treatment.
Maintenance:
adjust
dosage
to
lowest
effective
levels.
Following
titration,
some
patients
may
be
maintained
on
a
twice
daily
schedule.
Usual
maximum
daily
dose
is
200
mg,
up
to
300
mg
daily
may
be
required
in
some
patients.
In
such
cases
a
lower
dosage
of
APRESOLINE
combined
with
a
thia-
zide,
reserpine
or
both,
or
with
a
beta-adrenergic-
blocking
agent
may
be
considered.
When
combining
therapy,
individual
titration
is
essential
to
ensure
that
the
lowest
possible
therapeutic
dose
of
each
drug
is
administered.
Parenterally:
patients
should
be
hospitalized.
Usual
dose
is
20-40
mg
I.M.
or
by
slow
I.V.
injection
or
I.V.
driR
repeated
as
necessary.
Patients
with
marked
renal
damage
may
require
a
lower
dosage.
For
I.V.
driR
the
ampoule(s)
should
be
added
to
5%
sorbitol
solution,
physiological
saline
or
Ringer
solution;
glucose
solution
is
not
suitable
for
this
purpose.
Blood
pressure
levels
should
be
monitored.
It
may
begin
to
fall
within
a
few
minutes
after
injection,
with
an
aver-
age
maximal
decrease
occurring
in
10
to
80
minutes.
In
cases
with
a
previously
existing
increased
intra-
cranial
pressure,
lowering
the
blood
pressure
may
increase
cerebral
ischemia.
Most
patients
can
be
transferred
to
oral
APRESOLINE
within
24
to
48
hours.
Availability
Tablets
of
10
mg:
yellow,
uncoated,
biconvex,
scored,
and
imprinted
"FA"
on
one
side
and
"CIBA"
on
the
other.
Bottles
of
100
and
500.
Tablets
of
25
mg:
blue,
coated,
printed
"GF"
on
one
side
and
"CIBA"
on
the
other.
Bottles
of
100
and
500.
Tablets
of
50
mg:
pink,
coated,
printed
"HG"
on
one
side
and
"CIBA"
on
the
other.
Bottles
of
100
and
500.
Ampoules:
1
ml,
each
containing
20
mg
hydralazine
hydrochloride,
103.6
mg
propylene
glycol,
0.65
mg
of
methyl-p-hydroxybenzoate
and
0.35
mg
of
propyl-p-
hydroxybenzoate
in
water
for
injection.
Boxes
of
10.
Complete
Prescribing
Information
available
on
request.
References:
1
The
Pharmacological
Basis
of
Therapeutics,
Sixth
Edition,
Pages
799-801-Goodman
and
Gilman
1980.
2.
Gifford,
R.W.,
Isolated
systolic
hypertension
in
the
elderly.
Postgraduate
Medicine,
Vol.
71,
No.
3,
March
1982.3.
Finnerty,
F.A.,
M.D.,
Hyperten-
sion
in
the
elderly:
Special
considerations
in
treatment.
Postgraduate
Medicine,
Vol.
65,
No.
5,
May
1979.4.
Scriabine,
A.
Pharmacology
of
Antihypertensive
Drugs,
Methyldopa,
page
48,1980.
Mississauga.
Ontario
IPA
L5N
2W5
0
-4057
L
CCPP
1920
CAN.
FAM.
PHYSICIAN
Vol.
32:
SEPTEMBER
1986
The
initial
interview
and
teaching
session
is
expected
to
last
60-90
min-
utes.
Two
follow-up
visits
of
15-30
minutes
are
planned
after
the
first
and
third
cycles.
Subsequent
visits
are
ar-
ranged
according
to
patient
need.
As
has
been
observed
in
other
NFP
clinics,
we
have
noted
that
failures
often
occur
within
a
year
if
no
follow-
up
visit
has
taken
place.
For
this
rea-
son,
clients
are
urged
to
attend
the
fol-
low-up
visits
if
they
are
serious
about
avoiding
pregnancy
and
wish
to
use
NFP
successfully.
About
65%
of
our
clients
return
for
at
least
one
follow-up
visit.
The
Effectiveness
of
NFP
The
effectiveness
of
NFP
is
difficult
to
analyse
because
couples
may
not
keep
in
touch
with
the
clinic
after
the
second
follow-up
visit.
Recognized
factors
include
the
couple's
motiva-
tion,
the
intensity
of
their
desire
to
avoid
pregnancy,
and
the
experience,
knowledge
and
motivation
of
the
teacher.
In
1985,
ten
unplanned
pregnancies
occured
among
the
250
new
couples
who
presented
for
NFP
instruction.
(See
Table
3.)
The
impact
of
the
NFP
program
on
the
successful
investigation
and
treat-
ment
of
our
infertile
patients
is
harder
to
quantify,
but
it
is
nevertheless
re-
cognized
as
significant.
All
infertility
patients
are
referred
for
instruction
in
STC.
Using
the
symptothermal
charts,
subsequent
investigations
are
planned,
appropriate
treatment
prescribed,
and
the
success
of
treatment
is
gauged.
The
nurses
at
Family
Life
Clinic
are
an
integral
part
of
the
team.
In
addition
to
their
other
duties,
they
are
frequently
called
upon
to
provide
emotional
sup-
port
for
presenting
couples.
Because
they
work
so
closely
with
the
couples,
Table
3
Unplanned
Pregnancies
of
Attenders
at
a
NFP
Clinic
Reason
for
NFP
Method
Failure
No.
NFP
alone
Fertile
phase
ignored
3
NFP
+
Condoms
&
foam
In
fertile
phase
1
NFP
+
condoms
In
fertile
phase
2
NFP
+
diaphragm
&
Jelly
In
fertile
phase
4
Total
1
0
they
are
often
the
first
to
learn
from
a
couple
of
their
success
in
conceiving.
Conclusions
Natural
family
planning
has
broad
applicability.
It
is
not
only
useful
as
a
method
of
controlling
conception,
but
also
as
a
means
of
achieving
preg-
nancy.
It
is
particularly
helpful
in
in-
vestigating
and
managing
infertility.
NFP
is
based
on
the
observation
of
signs
and
symptoms
which
reflect
en-
docrine
changes
occurring
in
the
men-
strual
cycle.
The
scientific
basis
is
sound.
Of
the
several
types
of
NFP,
each
has
its
advantages
and
limita-
tions.
Each
method
can
be
success-
fully
used
when
it
is
clearly
under-
stood
and
appropriately
applied.
The
time
has
come
for
a
wider
dissemina-
tion
of
information
about
these
methods,
in
order
that
more
physicians
and
patient/clients
can
take
advantage
of
them.
*
References
1.
Flynn
AM.
Natural
methods
of
family
planning.
Cl
Obstet
GYnec
1984;
1
1:66
1.
2.
Klaus
H.
Natural
family
planning:
a
re-
view.
Obs
Gvn
Surt,
1982;
37:128.
3.
France
JT,
Graham
FM,
Gosling
L,
Hair
PI.
A
prospective
study
of
sex
of
offspring
by
timing
intercourse
relative
to
ovulation.
Fer-til
Ster-il
1984;
4
1:894.
4.
Colston
Wentz
A.
Physiology
of
the
menstrual
cycle
[Lecture
notes].
Inzfertility
Update.
Boston:
Harvard
Medical
Schooi,
1984.
5.
Pauerstein
CJ,
Eddy
CA,
Croxatto
HD,
Hess
R,
Siler-Khodr
TM,
Croxatto
HB.
Temporal
relationships
of
estrogen,
pro-
gesterone,
and
luteinizing
hormone
levels
to
ovulation
in
women
and
infrahuman
pri-
mates.
Aml
J
Obstet
Gvnecol
1978;
130:876.
6.
WHO
Task
Force
on
Methods
for
the
Determination
of
the
Fertile
Period.
Tem-
poral
relationships
between
ovulation
and
defined
changes
in
the
concentration
of
plasma
estrdiol-17B,
LH,
FSH,
and
pro-
gesterone.
Am
J
Obstet
Gvnecol
1980;
138:383.
7.
Garcia
JE,
Jones
GS,
Wright
GL.
Pre-
diction
of
the
time
of
ovulation.
Fer-til
Steril
198
1;
36:308.
8.
Speroff
L,
Glass
RH,
Kase
NG.
Clinical
gvyle/ologic(ll
endcr
inology
(1,1d
iniferti-
litv
.
3rd
ed.
Baltimore:
Williams
and
Wil-
kins,
1983.
9.
T
ietze
C.
Use
of
effectiveness
of
contra-
ceptive
methods
in
the
United
States.
In:
Calderone
MS,
ed.
Manuall
of
contracep-
t
ive
prabc
tic
es.
Baltimore:
Williams
and
Wilkins,
1964:
131.
10.
Tietze
C.
Use
of
effectiveness
of con-
traceptive
mzethodis
in
the
United,States.
In:
Calderone
MS,
ed.
Manual
of
contracep-
tive
practice.
Baltimore:
Williams
and
Wilkins,
1964:129.
11.
Doring
GK.
Ueber
die
zuverlaesigkeit
der
temperaturmethode
zur
empfaengnis-
verhuetung.
Deutsche
Med
Wsc
hr
1967;
92:1055.
Summary:
The
reliability
of
tem-
perature
records
as
a
method
of
contracep
tion.
The
Yeatrbook
of
Obs-Gyn
1968:354.
12.
Marshall
JA.
Field
trial
of
the
basal
body-temperature
method
of
regulating
births.
Lanicet
1968;
2:8-
10.
13.
Brown
JS.
In:
Klaus
H.
Natural
Family
planning:
a
review.
Obstet
Gvnec
Sanl'
1982;
37:134.
14.
WHO
Task
Force
on
Methods
for
the
Determination
of
the
Fertile
Period.
A
prospective
multicenter
trial
of
the
ovula-
tion
method
of
natural
family
planning.
The
effectiven'ess
phase.
Fer^til
Ster-il
198
1;
36:591.
15.
Wade
ME,
McCarthy
P,
Braunstein
GD,
Abernathy
JR,
Suchindran
CM,
Harris
GS,
Danzer
HC,
Uricchio
WA.
A
randomized
prospective
study
of
the
use-
effectiveness
of
two
methods
of
natural
family
planning.
A/n
J
Obstet
GYnecol
1981;
141:368.
16.
Dolack
L.
Study
confirms
values
of
ovulation
method.
Hosp
Propr
1978;
59:64.
17.
Johnson
JA,
Roberts
DB,
Spencer
RB.
A
surveY
ev(alutationi
of
the
efjficacv
an
iel
ejfi-
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