A recent document prepared by the NFP Secretariat of the Australian Catholic Social Welfare Commission (ACSWC) contains several recommendations related to the service and delivery of service of natural family planning methods. A team of co-ordinators has been elected who will work closely with both Ovulation Method and Sympto-Thermal Method groups of NFP teachers. These co-ordinators are mostly teachers of one or other method, and therefore it is desirable that as far as possible, they all should understand the methods of natural family planning other than their own. One of the suggestions made by the Secretariat of the ACSWC was that all teachers should teach all methods and then invite the couples to choose the one they wish to use. This point needs analysis in the light of the history of the methodologies and in the development of the Ovulation Method (Billings). The World Health Organization (WHO) attached the name of Billings to the Ovulation Method so that its authenticity could be preserved.

These notes have been prepared to explain and emphasize why the Billings Ovulation Method must be kept separate from other natural methods. It is of importance and benefit to teachers of all methods that the reasons for this separation of methods be clearly understood. It is important to understand that the methods are different and why an indicator does not per se constitute a method. It is important to encourage all teachers to teach that methodology which they are best equipped to teach and with which they are most confident. Most of all it is desired that as teachers of natural family planning, we teach with love, not only the couples who in our society have shown a great need for our help, but also that all teachers should have a loving regard for each other and a respect for the work that we all do.

Couples coming to a centre to be taught the Billings Ovulation Method have usually already made a choice in the light of their past experiences. Some have abandoned contraceptive methods, some have found the IVF programme to be a failure, and some have discarded the Sympto-Thermal Method, finding Rhythm calculations and the Basal Body Temperature unsatisfactory, especially in cases of delayed ovulation, for example, breast-feeding, stress, in the years leading up to the menopause and also coming off contraceptive medication when various physiological disorders may be encountered. In some cases this dissatisfaction had resulted in abstinenece for many years as we heard from the couples, with consequent discontent and sometimes serious disturbances in the marriage with frustrations, alcoholism and intentions to resort to surgical solutions for fertility control. There were unhappy children.

Couples with no preformed ideas on methodology will logically expect to be advised as to which is the best method by those presumed to be experts. Logically they will be advised according to what the expert believes to be the best. They will not expect to be encouraged to use what is believed to be second best by the experts or to be taught what they, the experts, do not have faith in or are incapable of teaching professionally; as in medical practice, patients being unknowledgeable, accept the advice of professionals and are not expected to choose their own treatment. This would be considered unprofessional and unethical.

• (a) Rhythm calculations.
• (b) Cervical mucus response to ovarian hormones.
• (c) Basal body temperature (BBT)
• (d) Pain
• (e) Vulval swelling.
• (f) Bleeding.
• (g) Self-examination of the cervix.
• (h) Inguinal lymph gland sign.
• (i) Vaginal response to ovarian hormones.
• (j) Ovarian hormone monitoring, using Professor J.B. Brown's Ovarian Monitor. The Billings Ovulation Method uses:
  1. (i) The cervical mucus response.
  2. (ii) The vaginal response discharge.
  3. (iii) Bleeding.
  4. (iv) Vulval swelling.

Adjuncts are used as indicated, for example BBT, lymph gland sign, ovarian hormone monitoring using the Ovarian Monitor. The way that we finally arrived at the definitive Ovulation Method was by studying the various indicators individually between 1953 and 1969 and by being determined to get the best out of each one. We were greatly assisted by Professor J.B. Brown's laboratory work from 1962 onwards, and by Professor E. Odeblad from the mid-70's.

The study of natural family planning was begun in Melbourne with the Calendar Rhythm Method and as was widely acknowledged this method was only reliable when the woman had regular cycles. Our first 2 or 3 years were spent in correcting errors in the teaching of the Rhythm calculations and then the critical importance of the cervical mucus in the achievement of conception and as a marker of fertility was discovered by Dr. John Billings in a search of the scientific literature (Billings 1983); this was followed by his clinical studies which revealed that the occurrence of the cervical mucus secretion during the cycle is a familiar observation to every fertile woman. The woman's observations of the mucus immediately corrected the problems of the irregularities of ovulation and confirmed that the woman was able to recognize the mucus sign as an indicator of fertility 2 weeks before menstruation. There were some women who could not follow the instructions of the male teachers. For this reason the BBT was added as an adjunct to the cervical mucus sign. In teaching the BBT throughout the 1950's and 1960's Fr Maurice Catarinich, who was an expert counsellor to troubled couples, particularly in the problem of infertility, became an expert in BBT. He formulated excellent guidelines and conditions for its use and devised comprehensive charts and the marginal line. He insisted that the temperature should be taken under specified conditions and recorded daily, not just when ovulation was thought to be imminent. Ovulation in the cycles was sometimes missed unless daily recordings were taken from the beginning of the cycle. Mucus observations were made and recorded under specified conditions. The mucus and temperature records were separated from each other and from other indicators and recorded on special charts so as not to be influenced by one another.

The BBT is a hormone indicator which responds irregularly to the rise in progesterone which occurs only after ovulation has taken place. It is subject to influence by fever, alcohol, anti-depressants, and other circumstances. Because a rise in the BBT is indicative that ovulation has occurred even though it does not give the precise information as to when, it was found to be useful in some cases of infertility by establishing that ovulation was indeed occurring. However, as the rise usually occurs only after ovulation it was not very useful because it was already too late for fertilization to occur.

The temperature is useful in confirming that a bleeding episode is either menstrual or intermenstrual. It also confirms pregnancy.

The concept of studying patterns is important in the interpretation of all indicators in natural family planning, because they can be related with varying accuracy to the hormonal patterns. In using the BBT indicator, as has been mentioned, it is important that the whole pattern is recorded daily from the beginning to the end of the cycle under the specified conditions. In the presence of a poor mucus symptom, for example in the post-pill situation, the use of the BBT has been advantageous. Ordinarily, however, by recognition of the Peak symptom, a woman will identify true menstruation or will know that she is pregnant because menstruation has not occurred at the appropriate interval following an act of intercourse during the time of recognized fertility. Heavy intermenstrual bleeding sometimes obscures the Peak. All bleeding is covered by the rules of the Billings Ovulation Method (see Billings et al. 1989; Billings and Westmore 1992), so that conception does not occur unexpectedly. Intercourse is not recommended during heavy bleeding in contrast to directives in some Sympto-Thermal methods.

In the use of the multiple-indicator or Sympto-Thermal Method the mucus component is subjected to Rhythm calculations in the first part of the cycle even though irrefutable scientific evidence for the validity of the Early Day Rules of the Billings Ovulation Method exists as well as proof in the field for over 25 years. These rules exclude the use of days of heavy menstrual bleeding for intercourse. It is well known that some pregnancies occur from ignoring this rule. When the woman learns the Billings Ovulation Method she can identify the occurrence of an early ovulation. In some cases of apparent infertility it is necessary to overcome any taboo against the use of days on which any bleeding is present, because the women who consistently have short cycles will not achieve pregnancy unless intercourse occurs very early in the cycle.

The "alternate evening rule", an Early Day Rule, is necessary to ensure that the woman is not confused by the discharge of seminal fluid following intercourse on the previous evening. The Rhythm count eliminates this rule and prevents recognition of the Basic Infertile Pattern and point of change which is critical in determining the onset of possible fertility.

It is at this point that we see one of the important divergences between the Billings Ovulation Method and the multiple-indicator method. If it is taught that mucus observations must be checked by Rhythm counts, the woman will not gain confidence in her observations, indeed will not make accurate observations because acts of intercourse on consecutive days will prevent her from doing so. The valuable experience of learning to identify her Basic Infertile Pattern in average cycles thus will be denied to the woman. Later in the cycle her confidence in the mucus will be subject to the BBT rise. This marks the second important divergence. When the time comes for total reliance on the Basic Infertile Pattern, ovulation having been suspended, she will need to overcome her mistrust of the mucus which must now stand alone without these checks. The teacher must likewise gain confidence in the reliability of the Billings Ovulation Method because that is all that is left - just as good and reliable now as it was when the woman's cycles were regular and fertile, but there is much re-learning now to be done before the teacher's and the woman's confidence in the mucus patterns are established. The Early Day Rules and the Peak Rule remain the same in all the circumstances right through to the climacteric and beyond, when the woman has stopped ovulating permanently.

The cervical mucus indicates the function of the cervix, which is responsive to ovarian hormones. The cervical mucus furnishes the most accurate indicator as has been scientifically proved. This comes as no surprise as we know that it is the mucus which is the essential ingredient of fertility, being responsible for the welfare of the sperm cells. Since the mucus also provides the sign of fertility which the woman readily recognizes, it is logical to regard it as the most accurate of the indicators, and logical to use it as a reliable method of defining infertility and fertility. The cervix may in some physiological states be unresponsive to hormones, for instance, as the cervix ages and also sometimes in younger women. By failing to produce mucus with fertile characteristics the cervix reliably indicates to the woman that she is infertile. The sperm cells under these conditions will not survive. The cervix, therefore, is a reliable indicator of fertility and of infertility in all physiological circumstances. A rise in the BBT following ovulation, in the presence of a non-responsive cervix and the absence of any mucus symptom, does not indicate fertility. The woman who knows the Billings Ovulation Method identifies her infertility in the cycle.

Besides the response of the cervix which produces a discharge, the vagina also responds to minimally raised oestrogen levels and produces a discharge, which results from the breakdown of the intermediate cells from the vaginal wall (Odeblad 1989). This occurs particularly in the reproductive stages of breast-feeding, premenopause and others where ovulation is delayed. The Billings Ovulation Method uses all this information to define the Basic Infertile Pattern. The recognition of the Basic Infertile Pattern, whether it is composed of dryness or an unchanging discharge of vaginal origin at the vulva, is a unique contribution of the Ovulation Method and was responsible for solving the "hard case" which other indicators could not do. It reflects a basic low level of oestrogen in the preovulatory phase of the cycle - too low to stimulate cervical mucus and therefore support sperm cells.

The Basic Infertile Pattern will be evident also in those circumstances when the cervix is unresponsive to raised oestrogen and produces no mucus and no support for sperm cells. This demonstrates the advisability of studying the patterns within the cycle. The Basic Infertile Pattern is an unchanging pattern reflecting a basic low level of oestrogen, or may result from the fact that the cervix is not responding to raised oestrogen level. The fertile pattern is a changing pattern, reflecting a steadily rising level of oestrogen as the woman comes closer and closer to ovulation. The maxium quantity of mucus and the most marked stringiness ("stretch") are usually evident a day or so before the Peak of the mucus symptom which is the last day of the slippery sensation, produced by the S-mucus and P-mucus secretions (Odeblad 1994). Closely related in time to the Peak symptom many women notice a soft swelling of the vulva, which they may describe as a "fat feeling". On the day after the Peak there is an abrupt change to dryness or, if any mucus is present, it will be sticky, and no longer slippery or wet.

In the days when we routinely taught the Temperature Method as well as the mucus sign we would often see on the charts that the woman had marked the Peak incorrectly. When asked, "Why did you mark the Peak here?" she would answer, "Because the temperature went up". It is not true to say that mucus and temperature will always correlate, because of the inaccuracies of the temperature shift. While some teachers of the Sympto-Thermal Method declare that the BBT is the sine qua non of methods, others, notably Professor Joseph Roetzer, never contradict the Peak symptom of the Ovulation Method in locating the beginning of post-ovulatory infertility.

When in the late 1960's the Rhythm calculations and BBT readings were dropped from our routine teaching, the Ovulation Method flourished. Simply by declaring the mucus adequate, women concentrated on this indicator and the rules were formulated and verified hormonally. In the mid-1970's they were again verified by Professor Odeblad's studies on the cervix. Towards the end of the 1960's women were asking repeatedly "Why is it necessary for me to take my temperature when I can identify the Peak so clearly?" and "Why must I keep taking my temperature when, for months on end, the temperature is not giving me any information?" Those who were breast-feeding were asking "Why must I keep taking my temperature when I am getting no help from doing so?" This was also a frequent complaint from the women who had reached the menopausal years. As a result of teaching the method without the BBT, it became easier and quicker to teach and to learn, especially as women now accepted the responsibility of teaching. It became simpler and it was, of course, very convenient because no devices were needed and couples quickly achieved autonomy. We realized then that this had a universal application for people anywhere in the world, in any circumstances and for all physiological conditions. Realizing this it was with great confidence that we first introduced the method overseas, first of all in Singapore, Malaysia and Hong Kong in 1969 and then in the next year in Latin America and so on. During the past 25 years the result has been that the Billings Ovulation Method is now taught in more than 100 countries. A survey in 1987 indicated that at least 50 million couples were using the method, and the number is increasing from year to year. It has also been estimated that 80% of natural family planning world-wide is now the Billings Ovulation Method. In 1978 an International Conference was conducted in Melbourne and attended by delegates from 48 countries. Knowledge of the authentic Ovulation Method was thus disseminated even more widely. ...........continued.PART 2..

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