Monthly Archives: August 2017

Listening to the Beat of a Different Drummer: On Becoming Aware of Fertility

Aaron Copland is one of the most famous American composers of the 20th century. In 1939, he published a perennially popular guide to music called What to Listen for in Music. In it, Copland says that he wants to raise two important questions. “1. Are you hearing everything that is going on? 2. Are you really being sensitive to it?” (Copland vii). To truly be musical, Copland insists, is not to know music history or to memorize the notes of a popular song. To be musical, there is “one minimum requirement for the potentially intelligent listener.” That one requirement is that “he must be able to recognize a melody when he hears it” (Copland 16).

Women’s health science is a very important body of knowledge, and at the center of it is the icon of her womanhood: ovulation. But for most Americans, ovulation — this singular melody of women’s reproductive health — is unrecognizable. Controlling fertility has been a component of women’s health since the advent of the Pill, and sex education has become ubiquitous even as it has remained controversial. But women still have very little fertility awareness. They are not “hearing everything that is going on” and are not “really being sensitive to it.” Learning to understand body literacy, in particular the signs surrounding ovulation, brings a wide range of benefits with it.

What most American people already know about the science of a woman’s reproductive system is not difficult to sketch out. There are the various body parts: the two ovaries, the uterus, the fallopian tubes, the egg, the cervix. Many people learn in primary school about the biology of reproduction. Every month, the lesson goes, a woman goes through a cycle. Her body sloughs off the lining of the uterus and disposes of the disintegrated egg. Then, a few days later, the follicles on the ovaries begin to engorge. A hormone coursing through the body, aptly named follicle stimulating hormone (FSH), is what causes this. After a few days of these ovarian follicles swelling, one of the follicles bursts and releases an egg. Ovulation occurs when the egg is released. This egg then spends 12-24 hours travelling down the Fallopian tube toward the uterus. This occurs usually about midway in a woman’s monthly cycle. If the egg is fertilized by sperm, the new embryo imbeds into the uterus. If the egg is not fertilized, it disintegrates and, a couple of weeks later, is discharged from the body along with the lining of the uterus with the onset of menses. And the cycle begins again: the follicles engorge; a follicle bursts; the egg travels; fertilization may or may not happen; if not, the lining of the uterus is discharged; and repeat.

That is what most people know. That pattern of the follicle bursting, ovulation happening, the egg traveling, the sperm (if present) fertilizing, and (if not present) the discharge of the disintegrated egg and the uterine lining is the faintest shape of a biological melody that is burdened with much deeper texture and profundity.

Toni Weschler, in her national bestseller Taking Charge of Your Fertility, details an outline of events in the reproductive system. What is more, these details are possible to chart. Further below, some of the life-changing benefits of knowing how to “hear” the music of the body will be explained. For now, it is enough to know that these changes are not just happening, but are observable – sometimes with the naked eye (44-70, 89-98).

After the first few days of a woman’s cycle, in a slowly rising and then sudden flood of estrogen, the follicles on the ovaries begin to swell. What also begins to happen is that a fluid is secreted from the cervix. Within the female body, this fluid acts like a hostel for sperm. It accommodates them and helps them on their journey. As the day approaches for the follicle to burst and release the egg, the cervical mucus becomes more and more viscous, slippery and clear. Actually, a woman can observe this change from day to day. Early in the cycle, the mucus is thick and tacky; but by the time the egg is finally released in ovulation, the mucus is stretchy and often clear, like raw egg whites. In the days after the egg has disintegrated, the mucus dries up. Mucus acts like a biological valve, in a way, because, without it, sperm are no longer viable. Mucus is healthy and normal. It is a note that the body is sounding that tells the observer that a fertile egg is being released for conception (52-60).

That is one observable sign or note. There are three more. The second discernible change is in the position of the cervix, which a woman can feel with her hand. The cervix is the opening to the uterus, where the egg is destined to arrive after its Fallopian journey. Normally, the cervix is situated relatively low and has a firmness to it. When ovulation is happening, the cervix does three things. It pulls upward; it softens; and the opening of the cervix widens. This occurs so that sperm can pass through that opening, through the uterus, and into the Fallopian tube as they travel in the above-mentioned fluid (66-67).

The third sign is one that is felt. The word that describes this is ‘mittelschmerz’ and it means “pain in the middle.” A follicle burst and the egg is released, and many women literally feel an ache in their midsection when this happens. It is like a kettle drum sounding the entry of the main character of an opera, the egg. Everything has been building up to ovulation. Everything changes after ovulation (70).

The fourth sign comes after ovulation. The egg travels down to the uterus and new hormones enter the symphony. Estrogen and follicle stimulating hormone leave the stage and, from the very place of the follicle burst, a new hormone-secreting structure shows up, sending luteinizing hormone (LH) into the body. A woman can observe when this happens. Her resting body temperature will rise about 0.4 degrees Fahrenheit. This part of the cycle – after ovulation – is called the luteal phase of the cycle, and this is the time that the hormone progesterone is present (89-98).

Through visually observing mucus, physically touching the cervix, sensing pain in the lower abdominal region and recording daily temperatures, a symphony about fertility can unfold, for every fertile woman, every day. And every body, literally, is unique. Deviations from this general process happen, and each deviation reveals something about the state of fertility.

Image result for woman with ear horn

There are nearly two billion fertile women on earth today, aged 15-49 (UNFPA 8). There are seventy-six million fertile women in the U.S. (Monte and Ellis 9). Most of them do not recognize their bodies’ ovulation melodies. The statistics show that even the medical establishment — doctors and medical students — has not often encountered this kind of body literacy. Dr. Thomas Hilgers, an expert on fertility, a clinical professor at the Creighton University School of Medicine, the developer of natural procreative NaPro Technology, and author of The NaPro Technology Revolution, says, “These major physiologic events that affect greater than 50 percent of our population during the reproductive years, have been almost completely ignored by the medical profession” (xviii, italics are in the original). His assertion is not mere opinion.

His claim is backed up by his and others’ commanding research. Not only do women remain ignorant of the facts about fertility awareness (Lundsberg et al. 767-8) but when over 200 third-year medical students were asked a battery of seven questions – including “During a woman’s cycle, when is progesterone produced in the highest amount?” and “How does cervical mucus act as a biological valve?” – test scores averaged 38% (Danis et al. 3). In another study, less than half of practicing physicians had up-to-date information about fertility awareness (Stanford et al. 672-5). Most doctors are unequipped to confidently investigate health problems and prescribe treatments based on fertility awareness.

Sex educators have not focused on fertility awareness, either. SIECUS, a leading organization in the development and promotion of so-called “comprehensive” sex education in the United States, states plainly and boldly, “We advocate for the right of all people to accurate information, comprehensive education about sexuality, and the full spectrum of sexual and reproductive health services” (SIECUS). Yet, among the hundreds of lessons available for primary and secondary students, a search for “fertility awareness” yielded nothing. Their focus is on breaking down reservations about sexuality, encouraging sexual activity while preventing disease and pregnancy, and exploring homosexual and gender identities. The bedfellows of SIECUS are Planned Parenthood Federation of America (PPFA), the American Association of Sexuality Educators, Counselors and Therapists (AASECT), and the Kinsey Institute. Among all four of their websites, a search for “fertility awareness” netted two entries, even though they all use the same language to describe their interest in biology and sexuality and “comprehensive” sex education. (“Comprehensive” is a misnomer; it is used to describe sex education that focuses on contraceptive use as well as abstinence, and is contrasted with “abstinence-only” sex education.) The highly regarded Guttmacher Institute, a leading research organization in the area of sexuality, charted the focus of different sex education requirements in each of the 50 states, and fertility awareness is not mentioned at all (Guttmacher “Sex”). Laura Wershler, a rare pro-choice feminist who advocates for fertility awareness, and has sat on the board of Planned Parenthood Canada for 10 years, and edits a blog for the Society for Menstrual Cycle Research, makes the import of their neglect plain when she says, “I say this over and over again. If anyone who considers themselves to be a pro-choice sexual and reproductive health care provider, if they are not [competently educating women on fertility awareness methods], they are not who they say they are. It’s as simple as that” (Wershler 00:17:45-00:18:05). In the musical metaphor, the influential sexuality educators might promote the free choice to perform opera in coffee houses or nursing homes, or to always protect one’s cello with a reliable case, or even to try to use every instrument in the orchestra for maximum musical pleasure; but the one neglected topic would be what a melody is and how to recognize it.

This state of affairs is lamentable. Only a few organizations are giving serious priority to educating men and women about fertility awareness, such as the Fertility Awareness Collaborative to Teach the Science (FACTS) and Teen STAR (Klaus “Allowing” 5), which has programs in 30 countries, as well as recent app developers (Kindara). Various small natural family planning programs are in place to teach fertility awareness (ARCHSTL). The benefits that accrue to a woman when she becomes aware of the facts about fertility, of course, relate to being in control of her fertility. Below are some more benefits, but first, it is helpful to understand how the Pill works.

Many women use the Pill for birth control, as well as for a way to temper painful symptoms of irregular cycles. According to the Guttmacher Institute, about 14 million American women use some kind of hormonal birth control, whether it be the Pill, an IUD, a patch, or DepoProvera. That is 18% – nearly 1 in 5 – fertile women who use synthetic hormones (Guttmacher “Contraceptive”).

This is what is happening to them. The body naturally has an ebb and flow of hormones. Four are mentioned in this paper: estrogen and FSH prior to ovulation, and progesterone and LH after ovulation. The Pill and its cousins suppress this natural interplay of hormones. Regardless of what kind of synthetic hormone is used, the effect is nearly the same. The body is flooded with hormones that have a negative feedback loop. The natural process of ovulation, along with all the interplay of the hormones estrogen, FSH, progesterone, and LH, is shut down. The body ceases to ovulate. The cervical mucus thickens. The reproductive system is rendered infertile (Briden). A reliable sameness overtakes the body, and what once was a biological melody is shouted out by a chemical foghorn.

The effect that synthetic hormones can have on teenagers is worrisome. The results can be impaired bone development and delayed return of fertility after stopping using the Pill, among other known side effects. Says one researcher, “As an endocrinologist, I am deeply concerned about the consequences of the widespread use of powerful synthetic hormones by [teenagers] for both the reproductive and bone systems” (Prior 75). The negative potential of the Pill is not a necessary evil. Fertility awareness can help women skirt the physical risks of chemical contraceptives.

Fertility awareness cannot be practiced while synthetic hormones suppress fertility. But if one chooses to pass on the chemicals and practice fertility awareness instead, the benefits are wide-ranging. For teenagers, the benefit of having a knowledgeable woman teach fertility awareness has helped teens to have a deeper respect for their bodies, to have confidence in knowing when to expect their next period (after ovulation, during the luteal phase, the time from ovulation to the next cycle normally lasts the same number of days, every cycle). And, for those teens who learn fertility awareness after having been sexually active, many return to chastity (Klaus et al. “Undergirding”) . Dr. Hanna Klaus has developed an international sexuality education program for teenagers that incorporates fertility awareness and self-help coaching. Because of its success rate in encouraging abstinence, Teen STAR has been funded as an AIDS prevention program in Ethiopia and Uganda (Klaus “Allowing” 3-4). Even the young men who enter the program exhibit deeper self-respect for matters sexual.

For adults, the most obvious use that fertility awareness is put to is to regulate conception. For both the couple who is seeking to conceive and the couple who is seeking to come together without conceiving, knowing how to detect ovulation is powerful knowledge. One of the important facts about ovulation that informs natural family planning (NFP) is that the egg, once released from the ovary, lasts only 12-24 hours. The cervical fluid can keep sperm viable for up to 5 days. A woman could have sexual relations on Monday and conceive a child the following Friday, because the sperm can survive in the fertile mucus for up to 5 days. But, woman cannot conceive a child on any given day. Because the fertile window of each cycle is only 5-6 days, the rest of the cycle is naturally infertile (Weschler 161-79). The math is easy. If a woman has a cycle every month of the year, she is able to conceive only 70 or 80 days out of the whole year. The rest of the time, it is physically impossible for her to conceive.

Although the old joke, “What do you call a couple that uses NFP? Parents!” is funny, the truth is that fertility awareness methods of avoiding pregnancy have as high of a success rate as the most successful artificial contraception. And, while Planned Parenthood’s website claims that fertility awareness-based methods of avoiding conception have only a 76% effectiveness rate and that they are difficult to use, the Chinese women who demonstrated a 99% user-effectiveness rate would beg to differ (Xu 195-6). A state-side study of over 1,800 couples likewise yielded a high user-effectiveness rate of 95% (Creighton). And another peer-reviewed, prospective study shows that fertility awareness-based methods of avoiding conception had a user effectiveness rate of about 99%  (Frank-Hermann et al. 1310-1). Dr. Sally Dierschke-Kurz, the president of the Catholic Medical Association and a family practitioner in St. Louis, wistfully said in conversation, “I wish they [Planned Parenthood] would stop dragging out that awful study [with the 76%].” Among its weaknesses, the flawed study does not actually measure the use of scientific fertility awareness, but includes the “calendar method”, which is a method that is based on the average day of ovulation for many different women. It is not based on the individual biology of a woman, but rather on averages detached from the individual woman. The flawed study also does not take in to account whether the couple was seeking to conceive or seeking to avoid conception (Dierschke-Kurz).

Planned Parenthood’s bad science is only half of the problem, though. The other problem is what some women find to be patronizing counsel. What Planned Parenthood says is, “Fertility awareness methods don’t work as well as other types of birth control because they can be difficult to use” (Planned Parenthood). While fertility awareness advocates recommend learning fertility awareness from a competent instructor (Fertility Friday “22”), some women take offense that the science of fertility is too difficult for them. A not-uncommon response to being told that fertility awareness is too difficult is, “Excuse me? Since when are women too stupid to take their temperature, know if one of their body parts is currently releasing fluid, and write that down?” (Ransom). Feminists, Chinese women living under a one-child government policy and many others have taken the challenge of becoming aware of their own fertility and have discovered that they can overcome whatever difficulties Planned Parenthood meant to refer to.

That is all about avoiding conception. As for helping to achieve conception, the benefits of fertility awareness are dramatic. “Infertility is defined as the inability to conceive a child after one year of unprotected intercourse. For women who are older than 35, infertility is defined as six months without conception” (Johns Hopkins). That is the current working definition of infertility. Infertility not only bars a couple from becoming parents, but also injects confusion and discord into a couple’s home. They wrestle with the doubts, unmet desires, lack of understanding of the other spouse’s coping mechanisms, feelings of inadequacy and a sense that life has unfairly deprived one of a great blessing (Tao et al. 71). Additionally, since the advent of assisted reproductive technologies like in vitro fertilization, there has been a decreased interest in addressing the underlying causes of infertility (Hilgers 208).

What fertility awareness brings to the infertile woman, in the best of cases, is a child. By observing fertility, a couple will know that there is a fertile window within the woman’s cycle. Fertility-focused intercourse alone has had great effects. While the normal rate of infertility is estimated to be around 10% in the U.S., fertility-focused intercourse allowed 98% of random couples, whether fertile or infertile, to conceive a child by the third cycle (Hilgers 207, 235). This suggests that, by using fertility awareness, most cases of infertility can be solved.

But there is more. By charting the signs of fertility, a woman has at her fingertips a tool for diagnosing the underlying cause of her truly persistent infertility. For example, the part of the cycle after ovulation is called the luteal phase; and an embryo uses this phase as a time to implant into the uterus. The high levels of progesterone during this time help him to settle in for the first nine months of his existence. But, “the single most common hormone abnormality in women of childbearing age is most likely the dysfunctional luteal phase” (Hilgers 106). If a woman observes that her luteal phase is rather brief, like fewer than 12 days, it could be that she will miscarry (and she can discover this risk before conceiving and before experiencing a miscarriage). In addition, we mentioned earlier that the luteal phase is marked by a slightly higher body temperature. But if the woman observes that her short luteal phase is also marked by a drop in temperature, it signals that she is a good candidate for miscarriage. This kind of information is very valuable in addressing this kind of infertility, and, sometimes, it might be corrected quite easily with a knowledgeable doctor. So, here again, infertility can be overcome with the help of fertility awareness knowledge. But without fertility awareness – without this information about the luteal phase recorded for a knowledgeable doctor – the next best approach to diagnosing a problem like this is to perform a hormone test on the 21st or 22nd day of the cycle (Hilgers 103). The accuracy of guessing at the luteal phase is obviously lower than not guessing. It would be like a karaoke singer closing his eyes and stopping his ears as a song begins, waiting for what feels like 30 seconds, and then beginning to sing, hoping to successfully harmonize with the melody. It might take a few songs before he makes a decent sound.

Other causes for infertility exist, and they, too, can be treated more effectively with the help of fertility awareness. Polycystic Ovary Syndrome (PCOS) is a fertility problem. The follicles that are supposed to engorge and then produce an egg are defective. Instead of having the normally-spaced follicles, the follicles are lumped together like grapes. The result is that the follicles do not engorge properly and rarely produce an egg. Although some women who have PCOS tend to be overweight, have more than normal amounts of facial hair, and perhaps even have diabetes, some do not. One of the surest signs, and surely the simplest to detect, is a longer-than-normal cycle or a non-existent cycle (Glenville 9-23). And, again, apart from charting the signs of fertility, diagnosing PCOS is more difficult. And, again, this cause of infertility can be treated. The aforementioned Dr. Dierschke-Kurz shared that a woman with PCOS can have her cycle essentially jump started with a month of hormone treatments (Dierschke-Kurz), and the ovaries, even with the unusual follicle formation, will afterward begin to ovulate normally. And, once that has happened, the woman could very soon become a mother.

The reality of the situation is that, every day, thousands and thousands of women shut down their reproductive systems with chemicals, conceive unplanned and sometimes dangerous pregnancies, become sexually active at the wrong time, or feel beaten by infertility. Every day, the vapid platitudes of women’s health advocates and a commitment to responsible sexuality are repeated to society. And every day, the United States remains in a Dark Age of reproductive health. The science is available and is being used by a small percentage of the population, and to great effect! They have discovered what the ancient psalmist knew, that humans are mysteriously wrapped in dignity, even down to their bodies; that they are “fearfully and wonderfully made” (Life Application Study Bible, Psalm 139:14). But a huge majority of otherwise well-informed and responsible adults are still tone-deaf to their own fertility oeuvre. No amount of wishing it were not so will change the fact that ignorance abounds about the benefits of knowing about ovulation. It remains true that the people who do understand fertility are rare and self-motivated, and that knowing fertility awareness is a tool for improved health, increased self-confidence, and effective family formation.

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Works Cited

AASECT https://www.aasect.org/about/about

ARCHSTL. ‘The Different Methods.’ Archdiocese of St. Louis. archstl.org/naturalfamilyplanning/page/different-methods

Briden, Lara. ‘Pill Bleeds Are Not Periods.’ Hormones Matter. 3 June 2015. http://www.hormonesmatter.com/pill-bleeds-periods/

Copland, Aaron. What to Listen for in Music. McGraw-Hill Book Company. 1967.

Creighton. ‘Effectiveness of the System.’ 2017. http://www.creightonmodel.com/effectiveness.htm

Danis, Peter G., et al. ‘Medical Students’ Knowledge of Fertility Awareness-Based Methods of Family Planning.’ Frontiers in Medicine, 1 June, 2017. dx.doi.org/10.3389%2Ffmed.2017.00065

Dierschke-Kurz, Dr. Sally. Telephone Interview. 5 Aug. 2017.

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Glenville, Marilyn. Natural Solutions to PCOS. MacMillan, 2012.

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Hilgers, Thomas W. The NaPro Technology Revolution: Unleashing the Power in a Woman’s Cycle. Beaufort Books, 2010.

Johns Hopkins Medicine. ‘Infertility Evaluation and Treatment.’ 2017. http://www.hopkinsmedicine.org/signature_obgyn/conditions_treatments/gyn_specialization/infertility_evaluation_treatment.html

Kindara. ‘Kindara Announces 75,000 Pregnancies Achieved With Fertility Tracking App.’ 10 June 2015. http://www.kindara.com/press-release/kindara-announces-75000-pregnancies

Kinsey Institute. ‘Our Research.’ 2017. http://www.kinseyinstitute.org/research/index.php

Klaus, Hanna. ‘Allowing the Body to Speak: The Power of Fertility Education.’ Humanum: Issues in Family, Culture and Science, No. 3, 2015, pp 1-5. humanumreview.com/uploads/pdfs/Klaus-2015IssueThree.pdf

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Monte, Lindsay M. and Renee R. Ellis. ‘Fertility of Women in the United States: 2012.’ United States Census Bureau. July 2014. http://www.census.gov/content/dam/Census/library/publications/2014/demo/p20-575.pdf

Planned Parenthood. ‘Fertility Awareness.’ 2017. http://www.plannedparenthood.org/learn/birth-control/fertility-awareness

Prior, Jerilynn C. ‘Adolescents’ Use of Combined Hormonal Contraceptives for Menstrual Cycle-Related Problem Treatment and Contraception: Evidence of Potential Lifelong Negative Reproductive and Bone Effects.’ Women’s Reproductive Health, Vol. 3, No. 2, 2016. Pp 73-92.

Ransom, Hannah. ‘7 Reasons Fertility Awareness is a Feminist Act.’ Holistic Hormonal Health. 4 August 2013. holistichormonalhealth.com/how-is-fertility-awareness-a-feminist-act/

SIECUS. ‘About us’. 2017. http://www.siecus.org/index.cfm?fuseaction=Page.ViewPage&pageId=472

Stanford, Joseph B., et al. ‘Physicians’ Knowledge and Practice Regarding Natural Family Planning.’ Obstetrics and Gynecology, Vol. 94, No. 5, 1999, pp. 672-8.

Tao, Peng et al. ‘Investigating Marital Relationship in Infertility: A Systematic Review of Qualitative Studies.’ Journal of Reproduction and Infertility, Vol. 13, No. 2, Apr-Jun 2012, pp. 71-80.

UNFPA. The State of the World Population 2011. United Nations Population Fund, 2011. ec.europa.eu/health//sites/health/files/eu_world/docs/ev_20111110_co01_en.pdf

Weschler, Toni. Taking Charge of Your Fertility: The Definitive Guide to Natural Birth Control, Pregnancy Achievement, and Reproductive Health. William Morrow, 2015

Wershler, Laura. ‘Increasing Body Literacy with Fertility Awareness.’ Fertility Friday, Episode 36, 31 July 2015. fertilityfriday.com/laurawershler/

Xu XJ et al. ‘Billings Natural Family Planning in Shanghai, China.’ Advances in Contraception, Vol. 10, No. 3, Sept. 1994. Pp. 195-204.

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