Background

HowtotreatHormonal basis ofthe method

Rules of themethod

Case studies

inside

www.aus t r a l i andoc to r. com.au

MARIAN CORKILL, director, WOOMB Internationaland Ovulation Method Researchand Reference Centre ofAustralia (OMR&RCA), EastBurwood, Victoria; training and education 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.

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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 oftheir cycles, Billings realised that itcould be recognised when a womenwas fertile, regardless of cyclelength.

The science of fertility has leapt

ahead in the intervening years, butmanagement of fertility remains aburning issue for many couples.

The Billings Ovulation MethodIn the mid-20th century, the idea ofconcentrating on ovulation as thesignificant event in the menstrualcycle was considered revolutionary.That ovulation occurred about twoweeks before menstruation had

already 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 the

validity 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.

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Natural fertility regulation —

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The Billings Ovulation Method

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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 MethodThe 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 ofthe 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 study

were 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 of22.3/hwy comprised:■ Conscious departure from the

rules 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 ofwhether 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 pageBillings 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 mature

Breakthrough bleeding Bleeding caused by a constantly raised oestrogen level — may be time of high fertility

Continuum Normal variants of ovarian activity experienced by every woman during her reproductivelife, from menarche to menopause (JB Brown)

Fertile (infertile) phase Time when intercourse can (cannot) result in pregnancy

Implantation bleeding Bleeding at embryo implantation

Luteal phase Interval of time between ovulation and menstruation — 11 to 16 days in a fertile cycle

Ovum survival Maximum of 24 hours

Peak Correlates closely to the time of ovulation. Last day on which slippery mucus is present

Pockets of Shaw Small pockets or folds in lower end of vagina which, under the influence of progesterone,dehydrate any discharge leaving the vagina

Rules Specific guidelines to achieve or avoid pregnancy

Sperm survival From a very limited time to 3-5 days, depending on type of cervical mucus present at timeof intercourse

Withdrawal bleeding Bleeding caused by withdrawal of oestrogen in the pre-ovulatory phase

G mucus Closes the cervix during the infertile times of the cycle, preventing entry of sperm andinfection

P mucus Liquefies 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 vulva

L mucus Present throughout the fertile phase. Supports P and S mucus and attracts low-qualitysperm, which are then eliminated

S mucus Provides nourishment for high-quality sperm and channels for sperm transport

S crypts Most 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

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www.australiandoctor.com.au18 | Australian Doctor | 19 December 2008

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tacand is a lso a versat i le instrument

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 ofcycle 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 couples

need 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 phaseOvarian/pituitary activityDuring 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 responseUntil 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 the post-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 that interrupt 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.

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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 recordThe 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 ofunchanging symptoms istermed the basic infertile pat-tern (BIP) and corresponds tolow oestrogen levels.

Billings Ovulation Method managementThe couple applies:■ Early Day Rule 1: avoid

intercourse on days of heavymenstrual bleeding:— fertility may begin during

menstruation, 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 allows

the woman to assess thestate of her fertility duringthe day.

— seminal fluid the day afterintercourse may mask anychange from her BIP.

Fertile phaseOvarian/pituitary activityAn 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 ofoestradiol, 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 responseThe 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 S

mucus 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 ofthe 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 ofoptimal 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 recordThe 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 MethodmanagementEarly 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 change

reflects the rise and peak ofoestrogen, 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.

OvulationOvarian/pituitary activityHigh oestradiol levels acti-vate a positive feedbackmechanism in the hypothala-mus, causing the pituitarygland to release a surge ofLH, 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 responseThe 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 recordThe 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 ofShaw and give inaccurateinformation.

Billings Ovulation Method managementPeak rule — from the begin-ning of the fourth day afterthe peak until the end of thecycle, intercourse is availableevery day at any time.

Luteal phaseOvarian and pituitary activityAfter 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 ofboth 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 responseBy 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 recordFor 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 Method managementBecause 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 inby L mucus forup to two days.

Day of cycle

Pregnanediol 3-glucuronideEstrone 3-glucuronide (nmol/24hrs)

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FOR most of her reproduc-tive life a woman will expe-rience fertile ovulatorycycles. However, all womenwill experience infertile vari-ants of the ovulatory cycle,particularly during breast-feeding, approach of menar-che and menopause, periodsof stress, and during andafter hormonal contracep-tion.

The hormone patterns andtherefore the symptoms inthese infertile cycles differfrom those of the fertile ovu-latory cycle. Recognisingthese variants is particularlyimportant for achievingpregnancy.

The ovulatory cycle hasbeen extensively studied, butthe other variants have beenlargely overlooked, as theyare not predictable. Largenumbers of cycles needed tobe studied so that the vari-ants could be documentedand their mechanism, fre-quency and impact on themucus symptoms and fertil-ity determined. Brown’sconcept of ‘the continuum’has done this, providinginformation on all phasesand variants of reproductivelife.7

Cycle variantsEarly ovulationFully ovulatory cycles asshort as 19 days occur, withoestrogen levels alreadyrising on day 1 and the fer-tile phase beginning duringmenstruation.

No ovarian activity — amenorrhoeaFSH production to the thresh-old level may be delayed,causing lengthening of thecycle. The FSH levels remainbelow threshold and no folli-cle begins the rapid growthphase. Little oestradiol is pro-

duced and the cervix remainsunstimulated. The womenexperiences a continuous BIP.

Anovulation — oestrogen peakIn this situation the develop-ing follicles produce oestradioland the follicle develops as inan ovulatory cycle. The dis-charge changes and FSH levelsrise to exceed the thresholdrequired for follicle stimula-tion but the ovulatory mecha-nism fails and no LH isreleased.

Follicle atresia results,oestradiol levels drop, BIPreturns, no progesterone isproduced and no peak dayidentified. Depending on theamount of oestradiol pro-duced and the sensitivity ofthe uterine endometrium ofthe individual, there may ormay not be sufficient stimula-tion of the endometrium toresult in oestrogen-with-drawal bleeding.

Anovulation — constantraised oestrogen levelsThe rise in FSH productionabove the threshold may arrestbefore the intermediate level isexceeded, resulting in chronicdevelopment of follicles butnone selected for ovulation.

The stimulated uterineendometrium may breakdown, resulting in oestrogenbreakthrough bleeding.

There are two possibleoutcomes:■ The feedback mechanism

corrects itself, FSH exceedsintermediate level and afollicle is boosted to ovula-tion. The final rapid rise inoestradiol output to pre-ovulatory oestradiol peakstops the bleeding. As thewoman is about to ovulate,she is in a phase of highfertility during this bleed.

■ Follicles remain in a stateof chronic stimulation,with oestradiol stabilisingat levels less than those ofthe pre-ovulatory peak.The discharge shows fertilecharacteristics but does notprogress. Stimulated uter-ine endometrium maybreak down, resulting inoestrogen breakthroughbleeding, sometimes at reg-ular 28-day intervals, orthe FSH may return tosub-threshold levels withreturn of the BIP.

Luteinised unruptured follicle(LUF)In this situation a follicle

develops and changingmucus pattern is experiencedbut no peak is identified.Some LH is released but notsufficient in amount to causeovulation.The LH that isproduced results in minorluteinisation of the follicleand a small amount of prog-esterone is produced for ashort time. LUF may or maynot be followed by bleeding.

Ovulation occurs but cycleinfertile: inadequate lutealphaseIn this situation ovulationoccurs and the peak symp-tom is usually identified.Progesterone levels riseabove those seen in a LUFbut are not sufficient to pro-duce a fully formed corpusluteum (deficient lutealphase). This situation mayalso occur if progesteronereaches normal post-ovula-tory values but falls prema-turely so that menstruationoccurs 10 days or less afterovulation (short lutealphase).

Both cycles are ovulatorybut infertile. Both are fol-lowed by menstruation.Brown states that the inade-

www.australiandoctor.com.au 19 December 2008 | Australian Doctor | 21

The continuumThe four absolutes for fertility

■ Fertility is associated with rapid changes in hormone production. Anything static must be infertile. This is the basisfor the BIP.

■ Once ovulation has occurred, a very powerful mechanismoperates within a short time interval to prevent a further ovulation: multiple ovulations occur only within this one day ofovulation.

■ Pregnancy is proof of ovulation. The post-ovulatory rise inprogesterone output that produces the peak symptom is thenext best proof of ovulation.

■ In the absence of pregnancy, bleeding always follows ovulation, provided the uterine endometrium is responsive tohormone stimulation.Adapted from: Brown JB. The fertility absolutes, Melbourne: WOOMB,

2006: www.woomb.org/omrrca/BOMvCrMS.pdf (page 17)

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How to treat – natural fertility regulation — the Billings Ovulation Method

Case from a GPAbnormal cycles with possiblethyroid abnormalitiesA 28-YEAR-old woman pre-sented for medical reviewafter referral by her BillingsOvulation Method instructor.Her charting had shown sev-eral months of abnormalcycles, with excessive thickand sticky mucus during thetime of presumed BIP and noobvious changing developingpattern suggestive of ovula-tion.

In one cycle, bleeding wasnoted immediately followingfertile symptoms, thenresumption of fertile symp-toms noted straight after thebleeding. Progesterone mea-surements confirmed thatovulation had occurred, butthe charting was obviouslyconfusing.

The woman had a three-year-old daughter and a his-tory of two miscarriages in theprevious 12 months, whichhad caused considerable anxi-ety and some depressive

symptoms. Other historyrevealed longstanding fatigueand steady weight gain, butotherwise good general health.

Examination showed a

BMI of 25kg/m2, blood pres-sure 110/70mmHg, pulse 80beats/minute and regular, andpossible diffuse thyroidenlargement although clini-

cally she was euthyroid. Pelvicexamination and Pap smearwere normal.

General pathology testingrevealed normal results, apartfrom thyroid function tests,which initially showed a TSHlevel of 4.39mIU/L (normalrange 0.5-4mIU/L) withnormal T3 and T4 levels.Repeat measurementsrevealed a TSH level of6.14mIU/L, again withnormal T3 and T4 levels.Anti-thyroglobulin antibodieswere elevated, consistent withmild primary hypothyroidismof autoimmune origin orHashimoto’s disease.

In view of her symptoms,treatment was started withthyroxine 100μg daily. In thefollowing months her TSHlevel returned to the normalrange, associated with lessen-ing of her fatigue and anxietyand gradual return of hercycles to a normal pattern.Pregnancy and normal deliv-ery of her second childoccurred in the next year.

THE Billings Ovulation Method provides valuableinformation for the subfertile couple, as it allows thewoman to identify the time of maximum fertility ineach cycle.

A five-year Australia-wide study on use of theBillings Ovulation Method to achieve pregnancy hasexamined the efficacy of the Billings OvulationMethod in assisting couples to achieve pregnanciesand is currently being prepared for publication.

The study included 384 consecutive couples,regardless of cycle length, age or reproductive history,with 64 women lost to follow-up. In addition to edu-cation about the Billings Ovulation Method,clomiphene was used by 26 women to correct persis-tent infertile cycle variants. For some, time was nec-essary to allow adequate cervical response to ovula-tory hormones after stopping contraceptive use.

Results of the study were as follows:■ 82% of all couples had no prior knowledge of their

signs of fertility. In response to the survey ques-tionnaire after use, 95% stated that the BillingsOvulation Method had given them greater under-standing of fertility and infertility.

■ The confirmed pregnancy rate was 78.3%, withan average of 4.7 months from initial instruction toconception.

■ The average time trying to achieve pregnancy beforeentering the study was 15 months.

■ Of the 384 couples, 207 (54%) had known infer-tility factors; the confirmed pregnancy rate in thisgroup was 65%.

■ Fourteen of 37 couples who had previously unsuc-cessfully used IVF or other assisted reproductive

technologies (38%) achieved pregnancy.■ Of 48 women aged 38-46, 32 (66%) achieved

pregnancy.Advice is often given to have intercourse around

day 14, which may miss the fertile phase altogether.All couples wishing to achieve pregnancy shouldbe offered the opportunity to learn their optimalfertility.

Pre-session questionnaires completed by doctorsbefore attendance at our Menarche to MenopauseActive Learning Modules reveal a lack of currentknowledge on the science and signs of fertility. This,coupled with the fact that only 18% of couples wish-ing to conceive had a prior knowledge of their signsof fertility, indicates the importance of disseminatingaccurate information on the significance of mucusand cervical health for fertility.

What about urinary ovulation predictors?These devices can be useful in identifying the timeof ovulation, but their use can become expen-sive. There are also some limitations in their use.The LH surge is only a predictor of ovulation —the woman may or may not ovulate even thoughthe LH has surged (eg, in an LUF, despite theLH surge, ovulation does not occur). This is par-ticularly common for the woman with polycysticovary syndrome. When the woman is not awareof her signs of fertility, she has to guess theappropriate time to use the predictor, resulting innegative results because she is either ovulatingearlier or much later in the cycle than she expects.

Using the Billings Ovulation Method to achievepregnancy naturally

Case studies

References1. Billings EL, et al.Symptoms and hormonalchanges accompanying ovu-lation. Lancet 1972; 1:282-84.2. Odeblad E. Physicalproperties of cervical mucus.Advances in ExperimentalMedicine and Biology 1977;89:217-25.3. Weissmann MC, et al. Atrial of the OvulationMethod of family planningin Tonga. Lancet 1972;2:813-16.4. World HealthOrganization. A prospectivemulticentre trial of theOvulation Method of natur-al family planning. I: Theteaching phase. Fertility andSterility 1981; 36:152-58.5. World HealthOrganization. A prospectivemulticentre trial of theOvulation Method of natur-al family planning. II: theeffectiveness phase. Fertilityand Sterility 1981; 36:591-98.6. Qian SZ, et al. Evaluationof the effectiveness of a nat-ural fertility regulation pro-gramme in China. TheWoman of Today and HerIdentity: Femininity,Fecundity and Procreationcongress, Centre for Studyand Research in the NaturalRegulation of Fertility,Universita Cattolica delSacro Cuore. Rome, 8September 2000.7. Brown, JB. Ovarian activ-ity and fertility and theBillings Ovulation Method.Melbourne: WOOMBInternational, 2005:www.woomb.org.bom/sci-ence/variants.html

Online resource■ www.woomb.org

www.australiandoctor.com.au22 | Australian Doctor | 19 December 2008

quate luteal phase (deficientor short) is the mostcommon cause of temporaryinfertility and makes upabout 10% of all ovulatorycycles.

These cycle variants havebeen listed as if they wereseparate entities. Actually,one merges into the next, sothere is a continuous grada-tion — from no follicularactivity, through follicularactivity without an LHsurge, through increasing

maturation of the ovulatorymechanism, to the fully fertile ovulatory cycle. Thisis the pattern at menarche;the reverse occurs atmenopause.

These cycle variants do notnecessarily repeat themselvesfrom cycle to cycle. For exam-ple, with approach ofmenopause or during stress,the woman may experienceperiods of amenorrhoea,anovular ovarian activity orLUFs, interspersed with fertileovulatory cycles.

As none of these infertilevariants can be predicted atthe beginning of the cycle,the woman must be obser-vant of her symptoms at alltimes. Vigilant application ofthe rules of the Billings Ovu-lation Method enable her tohandle every type of cycleencountered.

Billings Ovulation Method management of cycle variationThe woman’s chart revealswhether the cycle is a fertileovulatory cycle or one of the

variants. Fertility and infer-tility is understood on a day-by-day basis regardless ofthe length of the cycle, andfertility is managed by fol-lowing the four rules.

Bleeding is recognised asthe four types listed in theglossary on page 18 — men-struation, breakthroughwith high oestrogen, oestro-gen withdrawal, or implan-tation. Any other bleedingcan be recognised as anaberration and should beinvestigated.

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Who should be referred to a Billings Ovulation Method teacher?REFERRAL to a Billings Ovulation Methodteacher can be suitable for couples tryingeither to achieve or avoid pregnancy.

The chart should reflect the life-stage of thewoman; for example, she may have a shortluteal phase and/or inadequate mucus symp-tom because she is weaning from breatfeedingor has stopped using hormonal contraception,when the chart would be reflecting one of thevariants of the continuum.

Alternatively if the chart does not reflect herlife stage but rather ovarian dysfunction, theBillings Ovulation Method teacher would rec-ommend further medical investigation.

The persistence of cycle abnormalities maybe due to metabolic or endocrine abnormali-ties or other diseases that require furtherassessment. Simple blood tests such as pro-lactin levels or thyroid function can oftendetect the cause of suppressed fertility; 50-60% of women with PCOS have an impairedinsulin response to an oral glucose test.

Professor Pilar Vigil, Faculty of BiologicalSciences, Catholic University of Chile, states:

“Women with ovulatory dysfunctions asso-ciated with irregular cycles and abnormalmucus patterns will not usually resume nor-mal cycling spontaneously without appropri-ate treatment. Follow-up studies have shownthat, in the absence of treatment, these con-ditions only worsen with time. Self-knowl-edge acquired by learning the BillingsOvulation Method is an invaluable tool forwomen willing to achieve a healthy repro-ductive system state.”

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www.australiandoctor.com.au 19 December 2008 | Australian Doctor | 23

Case from the authorsIrregular cycles prompt a timelyPap testA WOMAN in her early30s, an experienced BillingsOvulation Method user,reported that her cycles wereregular and normal inrespect to the changing fer-tile mucus pattern, the peakand the subsequent menstru-ation.

However, after the peakin two recent cycles, shenoticed a return of mucuswith fertile characteristicsthat she called copious,stretchy and slippery (seefigure 2). This clearly signi-fied a cervical abnormalityto the woman, whichprompted a visit to herdoctor for investigation.

A Pap test revealed adeno-carcinoma cells. Colposcopicexamination reported dys-

plasia. A cone biopsy con-firmed an adenocarcinomain the cervical canal and atotal hysterectomy was per-formed. The common iliac

and pelvic lymph nodes wereexamined microscopically,with no evidence of metasta-tic cancer present.

Eleven years later she is

still alive and attributes thisto her understanding,through the Billings Ovula-tion Method, of her normalphysiology.

Learning about theBillings OvulationMethod or referring toBillings OvulationMethodpractitionersIN Australia, Billings Ovulation Method training isconducted by the OvulationMethod Research and Reference Centre of Australia Ltd (OMR&RCA).

Although many womenhave taught themselves theBillings Ovulation Method,the service of an accreditedteacher is recommendedand available to all womenthroughout Australia, eitherthrough face-to-face counselling in their own areaor through telephone orInternet counselling services.

OMR&RCA is an accred-ited provider with theRACGP QA&CPD program and conducts category 1 educational activities fordoctors and other healthprofessionals.

Further information canbe obtained by telephoningBillings LIFE on 1800 335860 or visitingwww.woomb.org

There is an absence of compelling evidence that

alternating ibuprofen and paracetamol achieves

faster, safer, or more effi cient reduction of fever in

children compared to monotherapy.1

Keep it simple. Recommend monotherapy

with Children’s Panadol.

GLAXOSMITHKLINE CONSUMER HEALTHCARE.82 HUGHES AVENUE, ERMINGTON, NSW 2115. 1800 028 533. PANADOL® is a registered trade mark of the GlaxoSmithKline group of companies. References: 1. Miller AA. Alternating acetaminophen with ibuprofen for fever: is this a problem? Pediatr Ann 2007 July;36(7):384-6, 388. GSKP00122AD

Figure 2: Monitoring reproductive health.

The cross on day 14 indicates recognition of the peak symptom. Areturn of mucus with fertile characteristics with a change to dryish onday 21 alerted the woman to the possibility that ovulation had beendelayed (hence the question mark). A further return to slippery mucuson day 26 indicated the need for medical investigation.

GP’s contributionCase studyJESSICA, now 30, has only 2-3 peri-ods a year, related to her diagnosis ofPCOS. In her teens she underwent aloop electrosurgical excision procedure(LEEP) for treatment of CIN3. She pre-sented to me for the first time in early2008, complaining of an increase in herabdominal girth. Her fat tummy was, infact, a 22-week pregnancy, which she

and her partner were very happy toproceed with.

Now, with six-month-old Patrickweaned, she is not keen to be pregnantagain for a while. She experiencesmigraine with aura, so oestrogen-con-taining contraception is contraindi-cated. Jessica is keen to avoid proges-terone because of the risk of irregularbleeding.

Jessica and her partner feel that con-doms are far too unromantic. Jessica’smother used “natural family planning”as Jessica was growing up and Jessica iskeen to give it a try. Jessica has nowreturned to full-time work.

Questions for the authorsHow accessible are accredited Billings

cont’d next page

DR MARTINE WALKERMosman, NSW

Adenocarcinoma of the cervixTotal hysterectomy performedNo evidence of metastatic cancer

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How to treat – natural fertility regulation — the Billings Ovulation Method

24 | Australian Doctor | 19 December 2008 www.australiandoctor.com.au

HOW TO TREAT Editor: Dr Martine WalkerCo-ordinator: Julian McAllan Quiz: Dr Wendy Morgan

Natural fertility regulation — theBillings Ovulation Method— 19 December 2008

INSTRUCTIONSComplete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzesby post or fax. The mark required to obtain points is 80%. Please note that some questions have more than one correctanswer.

ONLINE ONLY

1. Which TWO statements about the BillingsOvulation Method are correct?a) Women using the Billings Ovulation Method

are taught to be aware of the sensation of thevulva and any visible discharge

b) Internal examinations or touching of mucusdo not form part of the Billings OvulationMethod

c) Once a woman has learned her typical cyclepattern, she does not need to observe hersymptoms in every cycle

d) The Billings Ovulation Method is compatiblewith barrier methods of contraception

2. Lisa and Barry have a nine-month old boy.Lisa’s menstruation has resumed and she isinterested in using the Billings OvulationMethod to avoid another pregnancy atpresent, and asks how effective it is as acontraceptive. Which TWO statements aboutthe efficacy of the Billings Ovulation Methodas a contraceptive method are correct?a) The teaching phase of the WHO study

showed that by the third cycle of charting67% of women had at least a goodinterpretation of the method

b) In the WHO study the method-relatedpregnancy rate was 12.2 pregnancies per 100woman years (hwy)

c) In the WHO study the total pregnancy ratewas 22.3 pregnancies/hwy

d) Couples wishing to use the Billings OvulationMethod to prevent pregnancy should bemade aware of the importance of gainingaccurate information and assistance from anexperienced accredited teacher

3. Which TWO definitions of the terms usedby the Billings Ovulation Method are correct?

a) The basic infertile pattern (BIP) is theunchanging pattern of dryness or dischargebefore an ovarian follicle begins to mature

b) The peak indicates the optimal fertile time inthe cycle

c) G mucus acts as a filtering system bycapturing and eliminating low-quality sperm

d) P mucus provides channels for transport ofhigh-quality sperm

4. Which THREE statements about thehormonal basis of the Billings OvulationMethod are correct?a) Changes in cervical mucus are controlled by

the changing production of oestradiol andprogesterone during the cycle

b) The ovulatory cycle can be divided into twophases: the pre-ovulatory phase and theluteal phase

c) The length of the pre-ovulatory phase is fixedat about two weeks, however length of theluteal phase may vary, resulting in long cycles

d) During the time of fertility, the cervix producesmucus that is conducive to sperm selection,transport and survival

5. Which TWO statements about the pre-ovulatory infertile phase of the menstrualcycle are correct?a) During this phase FSH stimulates a group of

ovarian follicles into active growthb) The woman recognises this time of infertility

by awareness of an unchanging pattern ofdryness or discharge

c) Early Day Rule 1 is that intercourse isavailable on the days of heavy menstrualbleeding

d) Early Day Rule 2 is that intercourse isavailable every evening on days which have

been recognised as infertile

6. Which TWO statements about the fertilephase of the menstrual cycle are correct?a) When the dominant follicle is selected, it

becomes the major producer of oestradiol,which in turns suppresses FSH productionand support for the lesser follicles

b) Close to ovulation the woman will alwaysnotice both increased visible mucus and aslippery sensation at the vulva

c) Early Day Rule 3 is to avoid intercourse onany days of discharge or bleeding thatinterrupt the BIP

d) If ovulation is not confirmed, the couple canresume intercourse on the second day afterthe BIP has returned

7. Which TWO statements about ovulationare correct?a) High oestradiol levels lead via positive

feedback to the LH surge initiating ovulationb) The peak is identified as the last day of the

slippery sensation at the vulvac) The peak can be predicted in advance based

on mucus changesd) Ovulation is most likely to occur on the day

after the peak

8. Which THREE statements about the lutealphase of the menstrual cycle are correct?a) After ovulation the ruptured follicle is

transformed into the corpus luteum andproduction of progesterone increases rapidly

b) For the three days after the peak, thewoman’s record will indicate an absence ofthe slippery sensation

c) Just before menstruation, one or two days ofa wetter sensation may be recorded

d) The peak rule is that from the beginning ofthe third day after the peak until the end ofthe cycle, intercourse is available every day

9. Which THREE statements about cyclevariants and the Billings Ovulation Methodare correct?a) All women will experience infertile variants

of the ovulatory cycle at some stage in theirreproductive life time

b) In infertile cycles the peak may or may notbe identified

c) Infertile variants of the menstrual cycle canbe predicted at the beginning of the cycle

d) Using the Billings Ovulation Method, fertilityand infertility is understood on a day-by-day basis regardless of the length of thecycle

10. Kathy, 37, and Tim, 38, are keen to starta family as soon as possible. They areinterested in learning how to use theBillings Ovulation Method to maximize thechance of a pregnancy. Kathy’s cycle lengthis 28-32 days. Which TWO statements arecorrect?a) Kathy does not need to follow the Early Day

Rulesb) Kathy should apply the Early Day Rules until

she recognises the beginning of her fertilephase, and then postpone intercourse untilthe slippery sensation occurs

c) Kathy and Tim should be advised to haveintercourse around day 14, as this willdefinitely be the most fertile time of Kathy’scycle

d) Kathy and Tim should have intercourse whenKathy is aware of the slippery sensation at thevulva and for 1-2 days past the peak

www.australiandoctor.com.au/cpd/ for immediate feedback

How to Treat Quiz

CPD QUIZ UPDATEThe RACGP now requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2008-10 triennium. Youcan complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by postor fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.

NEXT WEEK Anorectal problems are one of the most common, and most commonly misunderstood, reasons for presenting to a colorectal surgeon. The next How to Treat looks at two of the mostcommon anorectal conditions encounterd by GPs — anal fistula and anal fissure.The author is Dr Stephen H Pillinger, consultant colorectal surgeon, Royal North Shore Hospital, St Leonards, NSW.

Ovulation Method teachersaround Australia — urbanand rural? What time andfinancial commitment willJessica and her partner needto make? Is it recommendedthat couples do revisioncourses over time?

Couples can access helpwith an accredited teacherthroughout Australia eitherby face-to-face, telephone orinternet teaching. There areteaching centres in all capitalcities and in some rural areas.The Australia-wide toll-freenumber (1800 335 860) givesaccess to an accreditedteacher in MelbourneMonday to Friday from10am to 4pm. Access tointernet teaching puts thecouple in contact with a tutorwho will guide them to inter-pret their chart. All teachingservices cost $100, whichincludes personal assistanceand necessary literature frominitial instruction untilautonomy. Follow-up ses-sions are usually recom-

mended every 2-4 weeks untilconfidence is attained. Onceautonomous, couples areencouraged to make furthercontact with their teacher if achange in reproductivelifestage causes confusion.

The theory of the BillingsOvulation Method is com-plex — is there any evidenceon teaching the method tocouples with intellectual dis-ability?

The theory is complexbut the practical applica-tion of the Billings Ovula-tion Method is simple.There has been no studyundertaken on the successof the Billings OvulationMethod for couples withintellectual disability butmany years of clinical prac-tice have shown that thesewomen can be taught toidentify their fertile andinfertile phases successfully.Teaching the husband isalso very important so thathe has an understandingand can help keep the

chart. Couples with anintellectual disability wouldrequire regular follow-upswith an accredited teacherto ensure they understandthe four simple rules andhow to apply them.

Does past treatment to thecervix such as a cone biopsyor LEEP interfere with theuse of the Billings OvulationMethod?

This depends on how muchdamage has been done to the

mucus-bearing crypts. Therecan be recovery but this isdependent on how radical thegland bed eradication hasbeen. The S and P crypts areresponsible for the propaga-tion of sperm and if they arenot functioning, fertile mucuswill not be present. If mucuscrypts are active, as must havebeen the case for Jessica’s pre-vious pregnancy, this will berevealed by the woman’schart.

Do vulval skin problems suchas eczema, chronic dischargesor use of vaginal lubricantsinterfere with use of theBillings Ovulation Method?

Women with chronic dis-charges have been able touse the Billings OvulationMethod successfully as theMethod is based on identi-fying patterns. The chronicdischarge will be presentcontinuously and if there isno mucus present infertilitywill be revealed by theunchanging nature of thechronic discharge. Fertility

will be identified by itschanging nature. A womanwith an intermittent dis-charge would learn to recog-nise her individual patternsat the time when this dis-charge was present.

This situation demandscareful teaching and thewoman would be encour-aged to have regular con-tact with her Billings Ovu-lation Method teacher.

Vaginal lubricants, usedto facilitate intercourse,would not interfere withthe use of the Billings Ovu-lation Method.

Patrick is now three yearsold and Jessica is keen to bepregnant again. She has beenusing the Billings OvulationMethod but does not seemever to detect signs of thefertile phase. She is dis-cussing with her doctor theuse of clomiphene. Doesclomiphene exaggerate oralter the mucus changesthroughout the menstrualcycle?

While some women usingclomiphene record fertilesymptoms, clomiphene candiminish the mucus over thefertile phase so Jessica wouldbe encouraged to be alert forany changes in vulval sensa-tion different from her BIP.She may only be aware ofthe slippery sensation for ashort time on one day. Preg-nancy can result from inter-course at this time if an ovu-lation with good hormonelevels occurs. She would alsobe encouraged to identifyany vulval swelling whichwould assist her to recogniseovulation. Jessica shouldalso be informed that ovula-tion can occur as late as Day21 in the clomiphene cycle.Jessica is probably experi-encing long, irregular cyclesassociated with her PCOS.She would be encouraged toreturn to her Billings Ovula-tion Method teacher to dis-cuss her chart to see if she isperhaps ignoring changeswhich may in fact indicatefertility.

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