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How to treat Pull-out section w w w. a u s t r a l i a n d o c t o r. c o m . a u Complete How to Treat quizzes online (www.australiandoctor.com.au/cpd) to earn CPD or PDP points. inside Hormonal basis of the method Rules of the method Case studies The authors Natural fertility regulation — MARIAN CORKILL, director, WOOMB International and Ovulation Method Research and Reference Centre of Australia (OMR&RCA), East Burwood, Victoria; training and education administrator for OMR&RCA; co-ordina
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  Background Howtotreat Hormonal basis ofthe methodRules of themethodCase studies inside www.australiandoctor.com.au MARIAN CORKILL, director, WOOMB Internationaland Ovulation Method Researchand Reference Centre of Australia (OMR&RCA), EastBurwood, Victoria; training andeducation administrator forOMR&RCA; co-ordinator, healthprofessional activities/training,and senior trainer, BillingsOvulation Method.  The authors MARIE MARSHELL, director, WOOMB International;convenor, education committee,OMR&RCA; co-ordinator oftraining, WOOMB International;and senior trainer, BillingsOvulation Method. Pull-out section Complete How to Treat quizzes online (www.australiandoctor.com.au/cpd) to earn CPD or PDP points. MORE than 50 years ago, Dr JohnBillings recognised the associationbetween changes in cervical mucusand fertility. By asking women torecord the pattern of vulval dis-charge throughout the length of their cycles, Billings realised that itcould be recognised when a womenwas fertile, regardless of cyclelength.The science of fertility has leaptahead in the intervening years, butmanagement of fertility remains aburning issue for many couples.  The Billings Ovulation Method In the mid-20th century, the idea of concentrating on ovulation as thesignificant event in the menstrualcycle was considered revolutionary.That ovulation occurred about twoweeks before menstruation hadalready been established. However,irregular cycles and delayed ovula-tion meant this information was aninexact guide to fertility. The recog-nition in the early 1960s by DrEvelyn Billings of the pattern of pre-ovulatory infertility — an unchang-ing pattern of either dryness or dis-charge — helped eradicate theseuncertainties.Further research confirmed thevalidity of the Billings OvulationMethod and the rules of the methodhave remained unchanged since thattime. In the 1970s, on the recom-mendation of the WHO, the DrsBillings changed the name of theirmethod from the Ovulation Methodto the Billings Ovulation Method toidentify the method based on theirdiscovery. cont’d next page Natural fertility regulation — The Billings Ovulation Method  How to treat – natural fertility regulation — the Billings Ovulation Method Two Melbourne scientists, Pro-fessor James B Brown and Profes-sor Henry Burger have collabo-rated and validated the hormonalbasis of the Billings OvulationMethod. 1 Professor Erik Odebladfrom Sweden independently vali-dated the clinical findings of theDrs Billings in the 1970s. 2 The understanding of the scienceof infertility is ongoing, with thecollaboration of Brown and Ode-blad in measuring and documentingthe precise patterns of ovarian andpituitary hormones and studyingthe role the cervix plays in fertility. Efficacy of the BillingsOvulation Method The first published trial of theBillings Ovulation Method wasfrom Tonga in 1972. 3 This revealeda 0.5% method-related pregnancyrate (ie, pregnancies occurringdespite correct use of the method)with a 1% teaching-related preg-nancy rate (ie, pregnancies result-ing from incorrect teaching of themethod, or misunderstanding of themethod by the user).This trial confirmed the rules of the method as well as the impor-tance of accurate teaching andunderstanding of the signs andsymptoms of fertility. In 1976-78 an independent trial wasconducted by the WHO, in five coun-tries (India, the Philippines, NewZealand, Ireland and El Salvador). 4,5 This study had two phases: 869 cou-ples entered the three-month ‘teachingphase’, and 725 couples continued inthe 13-cycle ‘effectiveness phase’,with a total of 10,215 cycles in theentire study. The teaching phase showed thatin the first cycle of charting, 93.1%of women were able to record anidentifiable ovulatory mucus pat-tern denoting fertility, and that bythe third cycle of charting, 97.1%of women had an excellent or goodinterpretation of the method.The results for the entire studywere a method-related pregnancyrate of 2.2 pregnancies per 100woman years (hwy) and a totalpregnancy rate of 22.3 pregnan-cies/hwy. The total Pearl Index of 22.3/hwy comprised: ■ Conscious departure from therules of the method: 15.4/hwy. ■ Inaccurate application of instruc-tions: 3.9/hwy. ■ Method failure: 2.2/hwy. ■ Inadequate teaching: 0.3/hwy. ■ Uncertain: 0.5/hwy.Conscious departure from therules of the method will alwayspresent difficulties in assessing apregnancy rate for natural fertilityregulation, as couples may chooseto change their motivation fromavoiding pregnancy when theyknow the woman is fertile. A morerealistic way of assessing of whether a natural method is suc-cessful is to identify both themethod-related pregnancy rate andthe teaching-related pregnancy rate.A later study of the Billings Ovu-lation Method in 1996-97 con-ducted in China showed a method-related pregnancy rate of zero anda teaching-related pregnancy rateof 0.5%. 6 In this study, whichreflects current stringent teacher-training requirements, the totalpregnancy rate was the same as theteaching-related pregnancy rate.What is clear from all these studiesis that couples wishing to use theBillings Ovulation Method to pre-vent pregnancy should be madeaware of the importance of gainingaccurate information and assistancefrom an experienced accreditedteacher of the method to achieve suc-cess.The efficacy of using the BillingsOvulation Method to achieve preg-nancy is currently being studied. from previous page Billings Ovulation Method – glossary of terms Basic infertile pattern (BIP)The unchanging pattern of dryness or discharge indicating relative inactivity of the ovariesbefore a follicle begins to matureBreakthrough bleedingBleeding caused by a constantly raised oestrogen level — may be time of high fertilityContinuumNormal variants of ovarian activity experienced by every woman during her reproductivelife, from menarche to menopause (JB Brown)Fertile (infertile) phaseTime when intercourse can (cannot) result in pregnancyImplantation bleedingBleeding at embryo implantationLuteal phaseInterval of time between ovulation and menstruation — 11 to 16 days in a fertile cycleOvum survivalMaximum of 24 hoursPeakCorrelates closely to the time of ovulation. Last day on which slippery mucus is presentPockets of ShawSmall pockets or folds in lower end of vagina which, under the influence of progesterone,dehydrate any discharge leaving the vaginaRulesSpecific guidelines to achieve or avoid pregnancySperm survivalFrom a very limited time to 3-5 days, depending on type of cervical mucus present at timeof intercourseWithdrawal bleedingBleeding caused by withdrawal of oestrogen in the pre-ovulatory phaseG mucusCloses the cervix during the infertile times of the cycle, preventing entry of sperm andinfectionP mucusLiquefies G mucus at beginning of fertile phase, allowing entry of sperm. Liquefying effectof P mucus close to the time of ovulation dissolves L and S mucus, causing lubricativesensation at the vulvaL mucusPresent throughout the fertile phase. Supports P and S mucus and attracts low-qualitysperm, which are then eliminatedS mucusProvides nourishment for high-quality sperm and channels for sperm transportS cryptsMost sperm are transported to S crypts where they are locked in by L mucus for up totwo days, at which time crypts are non-secretory and sperm immotile. P mucus unlocksS crypts enabling sperm to continue movement to fallopian tubes  CHANGES in cervical mucus arecontrolled by the changing pro-duction of oestradiol and proges-terone during the ovarian cycle.The woman’s observations of hercervical mucus are in effect self-bioassays for these hormones.The ovulatory cycle can bedivided into two phases: fromthe beginning of menstruationuntil the day of optimal fertilityin that cycle (‘the peak’), andfrom the peak until the begin-ning of the next menstruation(the luteal phase).The interval between ovula-tion and the next menstruationis 11-16 days in a fertile cycle,but the length of the pre-ovula-tory phase will vary and may beextended, resulting in longcycles, for example, in breast-feeding, perimenopausal womenor women suffering ovarian dys-function such as polycystic ovarysyndrome.During the time of fertility, thecervix produces mucus that is con-ducive to sperm selection, trans-port and survival, progressing overa variable number of days to aslippery sensation at the vulva. Thelast day on which this slipperymucus is present, whether in largeor minimal quantities, is the peak.Genital contact over the fertilephase has the potential to result inpregnancy.Women using the BillingsOvulation Method are taught tobe aware of the sensation of thevulva and any visible dischargeas they go about their dailyactivities and to record thisinformation each evening. Thewoman’s record gives her infor-mation about the current stateof her fertility, regardless of cycle length or reproductive lifestage and the likely day of ovu-lation.This information is valuable forall women, whether they arewishing to avoid pregnancy orconceive. It is also of particularbenefit in enabling women tomonitor their reproductive health,as they will quickly be alerted toany abnormal discharge and seekearly medical management.The Billings OvulationMethod is incompatible withany barrier methods of contra-ception, including withdrawal,as valid observations are com-promised. Internal examinationsor touching of mucus do notform part of the Billings Ovu-lation Method, as these can giveinaccurate information. Hormonal basis of the BillingsOvulation Method IN the Billings Ovulation Method couplesneed to use only four rules to achieve oravoid pregnancy throughout the woman’sreproductive life (see box below). Appli-cation of the four rules in the phases of themenstrual cycle is as follows. Pre-ovulatory infertile phase Ovarian/pituitary activity  During the latter half of the precedingcycle, high output of oestradiol and prog-esterone by the corpus luteum suppressesproduction of FSH and LH by the pitu-itary. As the production of oestradiol andprogesterone wanes at the end of the cycle,this suppression is removed and the FSHlevels rise. FSH stimulates a group of ovar-ian follicles into active growth. After sev-eral days of growth the follicles start pro-ducing oestradiol. Cervical response Until the developing follicles start to pro-duce oestradiol, the cervix is occluded byG mucus, which is a natural barrier to Rules of the Billings Ovulation Method Rules of the Billings Ovulation Method There are four simple rules. Three relate to the pre-ovulatory phase, and one to thepost-ovulatory phase. Early Day Rule 1  Avoid intercourse on days of heavy menstrual bleeding. Early Day Rule 2  Alternate evenings are available for intercourse when these dayshave been recognised as infertile, ie, basic infertile pattern (BIP). Early Day Rule 3  Avoid intercourse on any days of discharge or bleeding thatinterrupt the BIP. If ovulation is not confirmed, allow three daysfrom return of the BIP before resuming intercourse. Peak rule From the beginning of the fourth day after the peak until the end ofthe cycle, intercourse is available every day at any time. To achieve pregnancy  Apply the Early Day Rules. This enables the change to the fertile pattern of mucus to berecognised. Intercourse is then postponed until slippery sensation occurs. This allowsoptimal fertility to be identified, so intercourse should occur while the slippery sensation isobvious at the vulva and for one or two days past the peak. To avoid pregnancy  Apply: ■ Early Day Rules ■ Peak rule Women usingthe BillingsOvulationMethod aretaught to beaware of thesensation of thevulva and anyvisible dischargeas they go abouttheir dailyactivities. cont’d next page  How to treat – natural fertility regulation — the Billings Ovulation Method 20 | Australian Doctor | 19 December 2008www.australiandoctor.com.au sperm. Its high viscositymakes it a mechanical plugthat closes the cervical canal,which is also narrowed at thistime by the fibromuscularsystem in the cervix. Preg-nancy cannot be achieved atthis time, as sperm survival isvery short and G mucus pre-vents transit of sperm, whichare quickly phagocytosed.  The woman’s record The woman recognises thistime of infertility by aware-ness of an unchanging patternof dryness or a sensation ordischarge that is the same dayafter day. This pattern of unchanging symptoms istermed the basic infertile pat-tern (BIP) and corresponds tolow oestrogen levels. Billings Ovulation Methodmanagement The couple applies: ■ Early Day Rule 1: avoidintercourse on days of heavymenstrual bleeding:— fertility may begin duringmenstruation, and bleed-ing could obscure mucus.— ovulation can occur asearly as day 5 of the cycle. ■ Early Day Rule 2: alternateevenings are available forintercourse when infertility(BIP) has been recognised:— evening intercourse allowsthe woman to assess thestate of her fertility duringthe day.— seminal fluid the day afterintercourse may mask anychange from her BIP. Fertile phase Ovarian/pituitary activity  An intermediate level of FSHproduction must beexceeded before a follicle isfinally boosted into its fullovulatory response, and amaximum level must not beexceeded, otherwise multipleovulations occur.The dominant follicle racingtowards ovulation producesrapidly increasing amounts of oestradiol, which stimulateproduction of cervical mucusand growth of theendometrium.As the oestradiol suppressesFSH production, support forthe lesser follicles is removedand the dominant follicle isselected. A maturation mech-anism is turned on to makethe dominant follicle receptiveto the second pituitarygonadotrophin, LH. Cervical response The cervix responds to risingoestradiol levels by producingmucus from different cryptsthroughout its length. Thevarious types of mucus havedifferent crystalline structures.Sperm survival may now beextended to 3-5 days.At the beginning of the fer-tile phase, P mucus dissolvesthe G mucus, allowing spermto enter the cervix.L mucus, present through-out the whole fertile period,forms a flexible mechanicalsupport for the more fluid Smucus that appears later. Itacts as a filtering system bycapturing and eliminatinglow-quality sperm, allowingonly the high-quality spermto reach and fill the S crypts.S mucus is secreted fromS crypts in the upper half of the cervix and is present instring-like formations in thecervical canal both beforeand up to three days afterovulation. S mucus provideschannels for sperm transportto the S crypts and nourish-ment for the high-qualitysperm.After intercourse, somesperm travel directly to theuterine cavity, but most areconveyed to the S crypts, wherethey are then locked in by Lmucus for up to two days, atwhich time these crypts arenon-secretory and the spermimmotile. Through this actionboth L and S mucus co-operateto bring about propagation of optimal sperm.Shortly before ovulation,the P crypts secrete P mucus,which dissolves the L and Smucus, releases sperm lockedin the crypts and conveysthem to the body of theuterus. It is also responsiblefor the very lubricative vulvalsensation, often without visi-ble mucus, which enables thepeak to be easily identified.  The woman’s record The woman recognises thebeginning of her fertile phaseby a change in sensation at thevulva and in the visible mucus.Close to ovulation, the sensa-tion becomes slippery,although visible mucus maydiminish or disappear andthere may be a heightenedsensitivity and swelling of thevulva. The woman’s chartedrecord will reveal a changing,developing pattern, reflectingthe cervical response to risingoestrogen levels. Billings Ovulation Methodmanagement Early Day Rule 3 — avoidintercourse on any day of dis-charge or bleeding that inter-rupts the BIP. If the peak isnot recognised, allow threedays from return of the BIPbefore resuming intercourse.Any change from the BIPindicates ovarian activity;from this point, one of twothings can happen: ■ The most usual changereflects the rise and peak of oestrogen, and the peakbeing recognised. The peakrule for the post-ovulatoryphase is applied. ■ If the change is follicularactivity without ovulation,the peak will not be recog-nised and the BIP returns. Acount of three days from thisreturn of the BIP allows timefor the hormones to stabiliseat a low level and confirminfertility. Rule 2 is thenapplied while the BIP persists. Ovulation Ovarian/pituitary activity  High oestradiol levels acti-vate a positive feedbackmechanism in the hypothala-mus, causing the pituitarygland to release a surge of LH, initiating ovulation about37 hours after the beginningof the surge, or 17 hours afterits peak. The oestradiol levelreaches a peak about 36hours before ovulation thenfalls abruptly, with the prog-esterone level beginning torise as a result of the follicleluteinisation. The ovum is fer-tilisable for up to 24 hoursafter ovulation.Ovulation is most likely tooccur on the day of the peak,occasionally on the day afterthe peak, and rarely on thesecond day after the peak.Couples count to the third dayafter the peak to allow forovum survival from the possi-bility of ovulation occurringon the second day after thepeak. Cervical response The rising progesterone levelstrongly inhibits the oestro-gen effect and stimulates thecervix to once again produceG mucus. Over the threedays following the peak, thecervix is gradually occludedby the increasing G mucus.However L, S and P mucusare still present and channelsfor sperm transport stillexist.The rise in progesteronecauses the pockets of Shawto be activated to producemanganese, which extractsmoisture from any dischargepassing through the vagina. 6 This action causes theabrupt change from the slip-pery lubricative sensationthat defines the peak.  The woman’s record The peak indicates the opti-mal fertile time in the cycleand is identified as the last dayof the slippery sensation at thevulva, after a developingmucus pattern of variablelength. It is identified in ret-rospect on the day of changewhen the sensation at thevulva will be dry or sticky andno longer wet and slippery.Any visible mucus maynow appear thicker, reflectingthe dehydrating actions of thepockets of Shaw. It is impor-tant that no internal mucusobservation is performed, asthis will bypass the Pockets of Shaw and give inaccurateinformation. Billings Ovulation Methodmanagement Peak rule — from the begin-ning of the fourth day afterthe peak until the end of thecycle, intercourse is availableevery day at any time. Luteal phase Ovarian and pituitary activity  After ovulation the rupturedfollicle is transformed into thecorpus luteum and productionof progesterone increasesrapidly (approximately dou-bling each day), togetherwith a second rise in oestra-diol output, which in turnchanges the endometrium tosecretory.About seven days afterovulation, if pregnancy hasnot occurred, production of both oestradiol and proges-terone begins to decline,resulting in menstruation anda luteal phase of 11-16 days ina fertile cycle. Pregnancy issuggested when no menstrua-tion has occurred by day 17past the peak. Implantationbleeding may occur from day6 after ovulation. Cervical response By the beginning of the fourthday after the peak, the cervixis occluded by G mucus,which remains in place untiljust before menstruation,when it is dislodged to allowthe menstrual flow.  The woman’s record For the three days after thepeak, the record will indicatean absence of the slippery sen-sation. Just before menstrua-tion, one or two days of awetter sensation may berecorded (reflecting proges-terone level falling faster thanoestrogen level). From thefourth day past the peak untilthe beginning of menstruation,the couple experiencesabsolute infertility. Billings Ovulation Methodmanagement Because ovulation has alreadyoccurred, fertility is over forthis cycle. Intercourse is avail-able at any time until men-struation. from previous page Figure 1: Ovarian/cervical responses to women’s recorded symptoms. After intercourse,some spermtravel directly tothe uterine cavity, but most areconveyed to the Scrypts, wherethey are locked in by L mucus forup to two days. Day ofcyclePregnanediol 3-glucuronideEstrone 3-glucuronide(nmol/24hrs)
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