You’ve probably seen this chart or something like it before. It’s usually hanging in your doctor’s office while you’re laying straddled on a table with your feet in stirrups. Desperately trying to distract yourself from the moment, your eyes wander to wall art. Jackpot. That poster. That’s the one.
See how Fertility Awareness based methods are at the bottom? Not looking so great. Why is that? It’s a complex question with an even more complex answer. But here’s a few to start:
- Currently, most common source cited for the typical use numbers is the CDC 1995 National Survey for Family Growth. The survey is done retrospectively and requires individuals to recall which method they were using when they got pregnant over the last X months. This isn’t an awful way to collect numbers, but makes it hard to capture the nauce. (How important was avoiding pregnancy? What biomarkers were they charting? Were the biomarkers clear? Was the partner aware of fertility signs that day? Was there consent between the two partners?)
- -Furthermore, the number of contraceptives who use FABM’s is small, so to get statistically relevant numbers all FABM’s are lumped together for typical use. That means that someone using a self prescribed version of the rhythm method and someone charting 5 biomarkers meticulously everyday are treated the same, even though it’s clear that these to users would have vastly different efficacy rates. The good news is the 21st edition of Contraceptive Technology (the reference book used by most clinicians) due in Sept 2018 will have a new chapter dedicated to FAMB’s which we are really looking forward to delving into.
- In Chelsea Polis’s recent article, she identified a shortcoming in how numbers of FABM users is calculated. If a researcher calls up a participant in a study and they ask what method they are using and they say, “Fertility Awareness combined with a barrier method”, the researcher only puts down the barrier method as their sole use of contraception. In a way, this makes sense. If you are using a barrier method or withdrawal during your fertile window, then your contraception is as effective as that other method. On the other hand, it underestimates the number of FABM users and doesn’t account for how cycle literacy might improve the efficacy of other contraceptive use. For example if a couple using withdrawal also knows their fertile days, they might make different choices on those days than if they think they are fertile every day of the month. Likewise if a couple is using abstinence during their fertile window, they may be more likely to take risks on the “fringe” days of fertility. Again, there is nuance in our contraceptive decision making that is hard to translate to numbers.
- Another issue is that a common FABM, the Fertility Awareness Method that is described in Toni Weschler’s “Taking Charge of your Fertility,” doesn’t have any studies that specifically test the rules as they are outlined there. As an educator I take the time to explain the rules that are used in the studies we do have, and how the rules I’m teaching line up (ie where they are more conservative and where they are more generous). It’s a level of detail that can feel tedious to wade through, but fertility awareness is all about informed consent, and in the absence of perfect data, discussions are key.
- Lastly, a huge indicator of success rates in using a fertility awareness based method as contraception lies in the instruction they received and what type of support they had following instruction. Someone who downloads an app and wings it on their own is more likely to experience an unexpected pregnancy. During the learning period, are they abstaining? Using a barrier method? What about postpartum? Perimenopause? Post pill? If a person is learning during a transitional season, unintended pregnancy is more likely. This is when educator support is crucial.
FABM’s are really about living with your fertility. Say a person has used a FABM successfully for years and then one day, one time decides to not follow the rules. It doesn’t work. They have to actually follow the rules of the method according to their family planning wishes, every single act of intercourse. Coming from someone who has been charting for nearly a decade, it does become second nature - but you still have to do it. No IUD, Implant, Pill, or shot can contend with that level of complexity. It’s anything but set it and forget it.
I used to rave that using a FABM could be just as effective as the pill, and that can be true and it can also not be true. A pill suppresses ovulation from happening (most of the time), an IUD makes an inhospitable environment in the uterus for sperm, a condom prevents sperm from entering the vaginal canal all together. Intercourse still occurs. When someone is using a Fertility Awareness based method, it is intercourse itself, and its timing that determines the outcome, not a device or drug. (If someone is using a barrier method during their fertile period, the efficacy rate of the barrier method determines the outcome, not the FABM.)
In short, it’s complicated.
As an educator, I encourage people to ask the hard questions of whether or not they are willing to take that on. If they wake up to a positive pregnancy test, what will that mean for them? (Frankly, I think that if someone is sexually active period, that is a question worth exploring regardless of their family planning measures.) IUDs expel, condoms break, the pill fails to prevent ovulation - these things happen but when a FABM fails to prevent pregnancy (whether it was a method error or user error), there is no one to hold accountable but themselves - and that can feel very heavy.
Educators do what we can to teach with integrity, cover our bases in teaching the material, and provide appropriate follow up and support, but it’s important to manage expectations. Learning to chart your cycles could be uncomplicated and straightforward. It can also be the exact opposite. For women getting return of fertility post birth, coming off of months or years of hormonal contraceptive use, dealing with hormonal imbalance, and entering peri-menopause, charts may not be so clear cut. When a chart is difficult to read, there is a greater chance of error. If avoiding pregnancy is super top priority, you have to consider an “I don’t know what’s going on” day, a fertile day. When my clients leave our sessions, even if I have taught the material well, it’s up to them how they want to handle their days of fertility.
My relationship to FAMB efficacy rates has become a lot more nuanced. Of course I think it’s the greatest thing in the world and I’m so grateful to have these years of body literacy and knowledge - but I want people to know that they are signing on to listening and following their body. They are going to have to think about their choices on a cycle to cycle basis. It’s a lifestyle choice, not a prescription you can get from the corner drug store.
So will charting your cycles be effective in preventing pregnancy? Well that all depends. It can be. But if you’re looking for something that you don’t have to think about and requires little to no effort, a Fertility Awareness Based Method will never be able to contend with that. Even if we had saliva monitors on our toothbrush that told us when we were fertile, we would still have to make the decision of what do with our fertile window. We’re in the driver’s seat - and that’s kind of the point.
P. Frank-Herrmann et al, 2007. “The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couples sexual behavior during the fertile time: a prospective longitudinal study.” Human Reproduction.
Polis CB, Jones RK. Multiple contraceptive method use and prevalence of fertility awareness based method use in the United States, 2013-2015. Contraception. 2018 Apr 25
Grimes DA, Gallo MF, Halpern V, Nanda K, Schulz KF, Lopez LM, 2004. “Fertility awareness-based methods for contraception”. Cochrane Database of Systematic Reviews.