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Libido and Sexual Behaviour in the Fertile Phase


									                                               Libido and                          OBJECTIVE
                                                 Sexual                            • To determine if a perceived rise
                                              Behaviour in                           of sexual desire during the
                                                                                     fertile phase might be an
                                               the Fertile                           influence on the breaking of the
                                                                                     abstinence rule, the basic rule
  Medical School of Granada, Spain
                                                 Phase                               of NFP
    Enriqueta Barranco Castillo, MD, PhD, Profesor of Obstetric and Gynaecology,
    Granada, Spain
    Françoise Soler, STM ‘s teacher, ACODIPLAN, Barcelona, Spain

         Material and Methods

         • 15 women users of STM                                                            Impulso sexual

         • Charting changes of sexual                                                       Aumenta
           desire during 2-3 cycles in a
           diary calendar of symptoms
         • Charting of sexual behaviour
           during this time
                                                                                   Chart 000467

         Results I                                                                 Results II

         • Analysed cycles : 37                                                    • Have declared the intention of
         • mean age: 32.72 years (TD 5.18)                                           avoiding pregnancy prior to
         • N children: 0.86 (TD 1.02)                                                participation to the study 93.8%
         • Education: 75% College                                                  • Previous experience with Billings
         • Work away from home: 87.5%                                                method: 6.2%
                        (mean hours 7.77/day)                                      • Previous experience with STM:
         • Married 43.8%, unmarried 43.8%                                            87.5% (mean 24.44 months)
         • Religion: Roman Catholic 62.5%

Barranco: Libido
                                                  Increase in libido during
     Results III                                  the menstrual cycle n = 19
                                                           Fertile phase                      Infertile phase
     •   Use of contraception method previously
     •   STM: 31.3%                                For one day        51.4% n = 19     For 1 day            13.5% n = 5
     •   BBTM: 18.8%
                                                   For 2 days         40.5% n = 15     For 2 days           13.5% n = 5
     •   Withdrawal: 37.5%
     •   Condom: 75%                               For 3 days         24.3% n = 9
     •   Pill: 18.6%
                                                   Decrease           18.8% n = 7
     •   IUD: 12.5%
                                                   For one day
     •   Diaphragm: 12.5%                          Decrease           21.6% n = 8
     •   Spermicides: 6.3%                         For 2 days
                                                   Not                48.6%
                                                   indicated                  n = 18
                                                   on return

           The fertility symptoms                            Statistic correlations                       (T Student)
           in the STM charting                                                 n = 19 cycles

     • The fertile phase was between 11-12        Number of fertile days   Rise of sexual desire               P = 0.5
       days in 37.9% of the cycles
                                                  First day of cervical    Rise of sexual desire               P = 0.001
     • The first day of the cervical mucus        mucus
       was between 9-12 days of the cycle         Mucus Peak day           Rise of sexual desire               P = 0.028
       in 59.9% of the charting
     • The mucus peak day was between             Rise of temperature      Rise of sexual desire               P = 0.003

       14-19 days of the cycle in 56.7% of        Rise of sexual desire    Unprotected intercourse during      P = 0.12
       the charting                                                        the fertile phase

     • The rise of temperature was                Rise of sexual desire    Protected intercourse during
                                                                           the fertile phase
                                                                                                               P = 0.25

       between 14-20 days of the cycle in         Rise of sexual desire    Charting of intercourse during      P = 0.86
       64.8% of the charting                                               the fertile phase


     • In our study group, during the fertile
       phase there was a significant rise in
       sexual desire in more than half of
       women, but the sexual activity
       during this phase had no correlation
       to this rise. The abstinence (no
       intercourse) rule was respected
       above other sexual behaviour

Barranco: Libido
Natural methods, gender and                                                    Background
                                                                   Gender equity included in Millennium
                                                                   Development Goals

                                                                   Widespread introduction of natural methods
                                                                   has the potential to address gender equity
                                                                   and sexuality

                                                                   National access to simple, newer natural
                                                                   methods may be achieved in 3-5 countries by
European Congress on Fertility
 Awareness-Based Methods                                           2010
      September 2008

 The Standard Days Method                                                     CycleBeads®
 Helps couples prevent                                            The SDM is used with CycleBeads, a color-
 pregnancy by knowing                                             coded string of beads to help a woman:
 which days they should
 avoid unprotected
 intercourse                                                        Track her cycle days
                                                                    Know when she is fertile
 Identifies days 8-19 of                                            Monitor her cycle length
 the cycle as fertile                                               Involve her partner

 Works best for women
 with menstrual cycles
 from 26 to 32 days

               TwoDay Method                                      SDM and TDM Introduction Studies

                                                                  16 service delivery settings in 7 countries
          Did I note any
                                      I can get pregnant today.   in Asia, Latin America and Africa
                     NO                                                                        health programs,
                                                                                               FP agencies and
           Did I note any
                               YES                                                             community
                                      I can get pregnant
                                      today.                                                   development
     Pregnancy is not likely today.

Lundgren: Natuural methods

                                         Gender-related Study
Quarterly interviews:                         Questions
                                   Can men use natural
  1600 male and female
  SDM users                        methods?
  822 female TDM users
                                   How does NFP use
Focus groups and in-               influence the couple
depth interviews:                  relationship?

   current and                     How does NFP use
  discontinued female              affect women’s
  and male users                   autonomy?

                                             Percent of Cycles with
                                             Reported Intercourse
                                                       n=4025 cycles

                                                      n=3928 cycles


       Managing the Fertile Days   Men participate in SDM use by…
                                   Using a condom or
                                   abstaining during fertile

                                   Following wife’s

                                   Keeping track of fertile

                                   Purchasing CycleBeads
                                   and condoms

Lundgren: Natuural methods

    Women’s Opinion of the SDM

                                                                                               HOW DOES NFP USE
                                                                                               INFLUENCE THE COUPLE

                                                                                                    Mean Coital Frequency by Cycle
 Comparison of Mean Coital Frequency                                                                     (SDM and TDM use)
  All sexually active women           5.5 per cycle*
                                                            Days with intercourse per cycle

      Coitus-dependent                4.9 per cycle*                                          5.6
          methods                                                                             5.4
           SDM Users                   5.5 per cycle                                          5.2
             TDM users                 5.6 per cycle                                           0
                                                                                                    1   2   3   4   5     6   7   8    9 10 11 12 13
                                     *Stover et al, 2001
                                                                                                                        Cycle number

     Dimensions of Sexual
    Satisfaction Framework                                                                                      Key Themes
                   Physical               Emotional
                                     Love                                                       No change reported by many couples
Well-         Side effects           Respect/appreciation                                       Some report dissatisfaction with the fertile
              Menstrual changes      Harmony                                                    days
                                     Locus of control
                                                                                                Most report enhanced feelings of control,
                                     Moral congruence
                                                                                                love, mutual respect and physical well
 Sexual       Enhanced desire        Relaxation                                                 being
Pleasure      Sensation              Respite                                                    Heightened eroticism related to timing of
              Erotic touching                                                                   sex and non-coital practices

Lundgren: Natuural methods

    Effect of SDM on the couple                                                     Effect of TwoDay Method on
        relationship (India)                                                      the Couple Relationship (Peru)
  92% of rural users in India report that SDM use
  had a positive influence on their relationship
      increased partner communication
      Improved ability to negotiate sex
      increased affection/understanding
      improved sexual relations due to confidence in fertile

  8% cite a negative influence
      Husband angry/uncomfortable

   Source: Exit Interviews

In their words…                                                            In women’s words…
Influence on their                                                         Influence on their relationship
relationship                                                               “During the abstinence period, my
                                                                              husband spends more time with me
                                                                              going out and visiting family.”

“The SDM has helped us to come closer, understand each other’s
   needs. Unlike earlier, we now discuss intimate things with each         “During the 12 days when I am fertile,
   other and this has added pleasure to our otherwise monotonous              my husband and I share stories. I
   sex life.”                                                                 become a story teller on my fertile
                                                - male SDM user, India        days.”
“I feel good that my husband now understands how my body works.
    He pays attention to my suggestions and respects my wishes. For
    the first time he asks me if we can have intercourse. I am happy
    that he cares about me.”
                                                 -female SDM user, India

In men’s words…                                                            In women’s words…
Influence on sexual pleasure                                               Influence on sexual pleasure
   “I think that abstinence contributes to enjoying sex more,                 “We get to the moment in which we begin to caress each other,
   because we have greater desire.”                                           even the genitals, and we get to the point when the man as well as
                                                   -Honduras                  the woman feels good. How do you say it? When we finish. But
                                                                              there is not sex.”
   “How can I explain it..when one sleeps apart and you have to                                                             -Honduras
   make an appointment, things get good.”
                                                 -El Salvador                 “Unlike when I used pills, I always had a headache. You can have
                                                                              sex every day but you wouldn’t like it because you felt dry. My
                                                                              husband noticed that. When I used the SDM, it seemed natural, like
   “It seems like two months have gone by and we never move
                                                                              we were newlyweds again.”
   beyond these white beads.”

Lundgren: Natuural methods

                                        Comparison of Scores on
                                  Gender Equity Index pre/post SDM Use
                                          (Guatemalan Women)


      Comparison of Scores on    Women gained confidence and felt
     Right-to-Refuse Sex Index     empowered by knowledge of
          (Indian Women)                menstrual cycle

                                    “Knowledge of safe and unsafe period
                                      has been liberating.”
                                                             - El Salvador

                                    “Now we know about our bodies and how
                                      to protect ourselves during the unsafe
                                      days. Because of the necklace we know
                                      how our period comes.
                                                             - Benin

                                              Key Findings
                                 Men are interested in NFP

                                 Most men are able to use
                                 NFP correctly

                                 Many couples report
                                 enhanced sexual pleasure
                                 and strengthened partner
 DISCUSSION                      relationships

Lundgren: Natuural methods

               Key Findings
  Introducing NFP can strengthen efforts to improve
  gender equity by addressing couple issues and involving
  men in family planning.

  Continued expansion of NFP requires efforts to position
  natural options as methods that engage men
  constructively and enhance couple relationships.


Lundgren: Natuural methods

                                                          Background (1)
   Antwerp pupils' opinions about Family                     Biologically a new human being starts at the
   Planning methods with postfertilization                   fertilization of an ovum by a sperm
   effects                                                    2 opinions:
                                                                From this scientific fact, some give the embryo
       E Govaerts*, RT Mikolajczyk, P                           rights in agreement with all the human rights of the
                                                                Declaration of Human Rights.
       Hernalsteen, JB Stanford et al.                          Others have the opinion that there would be a
                                                                graduality and build in several for the juridical
                                                                status of the embryo unsure arguments.

       *AZ St.-Jozef in Turnhout

  Background (2)                                          Research question

    Informed consent and patient rights:                     Does belonging to one or the other
      The communication with the patient should be           opinion play a role in the attitude towards
      in a clear language. (Art. 7 §2)
                                                             a family planning method?
      The information given to the patient, to give his
      consent as meantin § 1, concerns the
      objective, […] the for the patient relevant
      contra indications, side effects and risks […],
      the possible alternatives and the financial
      consequences. (Art. 8 §2)

  Method                                                  Population

      705 girls 5th-6th year secundary school.             n = 705              %        n = 705           %
      19 public and private schools in the                 Belgian              88,0                       population)
      province of Antwerp (27,5% of 69                                                   General SS        22,7 (44)
      contacted schools).                                  Dutch                2,6
      Questionnaire with 41 questions in 8                 Italians             1,4      Technical SS 44,9 (27)
      areas related to fertility and attitudes             Moroccan             2,6      Professional      32,2 (26)
      towards family planning methods, use                 Turkish              1,8      SS
      and past use.                                                                      Artistic SS       0,1 (2)
                                                           Other                3,3

Govaerts: Antwerp pupils

  Philosophy of life – Practice                                            The ethical questions

    n = 705                      %           n = 705              %                  About 28 family planning methods was asked if they
                                                                                     would use them or not and if the knew them.
    Catholic                     79,8        > or 1/week          6,8                Thereafter follows the question why they choose a
                                                                                     specific method.
                                                                                             Question 12: “Below is a list of different features (12) methods
    Protestant                   1,6         1/month              4,2                        of birth control may have. Please let us know how important
                                                                                             the features are for you.”
    Muslim                       6,3         Some                 25,9                       1. Acceptable from my ethical / moral point of view.

    Witness                      0,9         times/year
    Jehova                                   < 1/year             33,3
    Other                        11,5        never                29,8

  The method of birth control is… acceptable
  from my moral / ethical point of view                                    Ethical reflections
                                                                                    No opinion

              No opinion                                                        Very important


          Very important                                                                      ..

                                                                                             …                        Do not know
                                                                            Not important at all

                                                                                                   0   10   20   30     40
                        ..                                                                                                   Yes
                                                                                Question 14: “In your opinion, are
                       …                                                        there any important ethical issues
                                                                                (anything that makes you feel that
                                                                                using the specific method would be
      Not important at all
                                                                                right or wrong) to consider in     Missing
                                                                                choosing a method of birth
                             0          10      20         30         40        control?”
                                                                                                                                    0               20                40                60

  Info working of the methods                                              Information
      Stage 2                                        Stage 3
      after fertilization                            after implantation                                                                       Pre implantation   Post implantation

      before implantation                                                              Should your                             60,0

                                                                                       GP/gynaecologist tell                   50,0
                                                                                       you details how the
                                                                                       method works?

                     Stage 1
                      before implantation
                                                                                                                                        Yes            No        Unsure       Missing

Govaerts: Antwerp pupils

  Opinion about the use of a method                                                                                           Stop the use of a method
        Would you consider using a                                                                                                  If you were using a birth control
        birth control method that                                                                                                   method, and you learned that
                                                                 Pre ovulatory          Pre implantation                                                                          Pre implantation   Post implantation
            stops the release of the                                                                                                     it sometimes works after
                                                                 Post implantation                                                       fertilization but before       60,0
            egg from the ovary                                                                                                           implantation (stage 2),
            (stage 1)                                     60,0
                                                                                                                                         it sometimes works after       50,0
            acts after fertilization, that                50,0                                                                           implantation in the uterus
            avoids a fertilized ovum to                                                                                                  (stage 3),                     40,0
            develop                                       40,0
                                                                                                                                    would you stop or continue using
            (stage 2)                                     30,0                                                                      the method?                         30,0

            acts after nidation in the                                                                                                                                  20,0
            (stage 3)                                     10,0                                                                                                          10,0

                                                           0,0                                                                                                           0,0
                                                                        Yes      No        Unsure     Missing                                                                  Stop     Continue     Unsure       Missing

  Loss of embryo Frequency during
  pre-/ postimplantation
                                                                                Pre implantation   Post implantation
                                                                                                                               1. In a deconfessionalized society ethical
         Pre implantation   Post implantation
                                                                                                                                  aspects don’t play a role for 23%.
                                                      Do not know
   60                                                                                                                          2. In a society, where contraception has

                                                    More than one
                                                                                                                                  been in use for 50 years, theoretical
                                                  time in 100 years
                                                                                                                                  ethical aspects for the choice of a
                                                    More than one

                                                  time in ten years                                                               method are still important to 55%.
                                                    More than one

                                                   time in one year

                                                  In more than half
                                                                                                                               3. Methods that act after fertilization seem
                                                     of the cycles
                                                                                                                                  to be a problem for about 30% of the
                                                                      0,0     10,0      20,0       30,0      40,0      50,0
    0                                                                                                                             study population.
        Yes       No        Unsure      Missing

  Conclusion                                                                                                                  Possible approach
        The GP/midwife stands in the non-judgment                                                                                   “Most of the time, the pill acts by preventing an
        counseling.                                                                                                                 egg from forming. This prevents pregnancy.
        The patient has right to information that takes                                                                             However, women on the pill can still
        care of his/her ethical sensibility.
                                                                                                                                    sometimes get pregnant. Some doctors think
        Which questions should be asked before
        starting contraception use?                                                                                                 that the pill may cause the loss of some of
              Does the patient have ethical problems with                                                                           these pregnancies very early in the pregnancy,
              possible postfertilization effects of a method?                                                                       before you would even know you were
              Which information is important to make a choice?                                                                      pregnant. Would knowing more about this
              Is a sympto thermal NFP method proposed as
              alternative?                                                                                                          possibility be important to you in your decision
                                                                                                                                    about whether to use the pill?”
                                                                                                                                        Larimore, Stanford: Postfertilization Effects of Oral Contraceptives
                                                                                                                                        and Their Relationship to Informed Consent (ARCH FAM MED/VOL 9, FEB 2000

Govaerts: Antwerp pupils


    SPANISH WOMEN’S OPINIONS ABOUT                                                            Index
       POSTFERTILIZATION EFFECTS                                                                1.   Introduction
     Authors:                                                                                   2.   Objectives
     Lopez del Burgo C., Lopez de Fez CM., Lopez Guzman J., De Irala J.
                                                                                                3.   Methods
     Preventive Medicine and Public Health, University of Navarra (Spain)                       4.   Results
     Biomedical Humanities, University of Navarra (Spain)
                                                                                                5.   Conclusions
     This research was supported by a grant from the Institute of Sciences
     for the Family of the University of Navarra (23017323).
     We thank to Dr. Joseph B Stanford (University of Utah) and Dr. Rafael
     T Mikolajczyk (University of Bielefeld) who first studied this issue in the
     USA and created the first version of the questionnaire


  1. Introduction                                                                             1. Introduction
                                                                                                Knowing about postfertilization     effects        may              be
         Some methods of family planning (FP) occasionally                                      important to some women
         work after fertilization

                                                Postfertilization effects*:                                                                   Decision of using a method that
                                                                                                                                                 may act after fertilization

                                                   • Hormonal contraceptives                                                                                40%

                                                   • Emergency contraceptive pill                                                                         38%
                                                   • Intrauterine devices (IUD)


                                                                                                                                                Decision of using a method that
                                                                                                                                                   may act after fertilization
                                                                                                                                                           53% NO

  * Quality of evidence: Fair
  The U.S.Preventive Service Task Force grades the quality of
  the overall evidence on a 3-point scale (good, fair, poor)


                                                                                              2. Objectives
                                                                                                  To    explore  the   Spanish    women’s
      1.     Introduction
                                                                                                  attitudes towards the mechanisms of
      2.     Objectives                                                                           action of Family Planning methods
      3.     Methods
      4.     Results                                                                           • To identify beliefs and characteristics
      5.     Conclusions                                                                         possibly associated with those attitudes.


Lopez del Burgo: Spanish women’s opinion


                                                                                      3. Methods
                                                                                              Cross-sectional survey in a Spanish
     1.     Introduction
                                                                                              representative sample
     2.     Objectives                                                                                GFK-Emer Market Research Company
     3.     Methods                                                                                   Random stratified and multistage sampling
     4.     Results                                                                                   848 potentially fertile women, aged 18-49
                                                                                              Data collection:
     5.     Conclusions
                                                                                                      March-September 2005
                                                                                                      Computer-Assisted               Personal        Interviewing
                                                                                                      (CAPI) method



  3. Methods
       Data collection:
                                                                                          1.     Introduction
               30-item, anonymous questionnaire about FP*
                                                                                          2.     Objectives
       Univariate and multivariate logistic regression
                                                                                          3.     Methods
       analyses (SPSS, 13.0 version)                                                      4.     Results
                                                                                          5.     Conclusions
       Ethic Committee approval for the study

    *The questionnaire was originally developed in English by Dr. J. Stanford
    (University of Utah, USA) and Dr. R. Mikolajczyk (University of Bielefeld,
    Germany) and subsequently modified and adapted by the authors of the
    Spanish study.                                                                                                                                    


  4. Results                                                                          4. Results

       Characteristics of the sample:                                                     Women’s opinion about human life beginning:

   Age .……….……………………               25-34 years (39%)                                             OTHER* 28.7%
   Education ..…………….………           High school or compulsory school (<16y) (78.7%)                                                        40.5%
   Marital status …………………          Married (57.5%)

   Religion …….………………….. Catholics (78.9%), church attendance ocasionally

   Nº live births ………………….. 0 (48.4%)                                                                  16.5%
                                                                                            IMPLANTATION                      14.3%
   Desire for future pregancy ..   Yes (64,7%)

                                                                                      * Other: “there is no exact time”, “I am not sure”, “I do not have an opinion” and
                                                                                      “sometime before fertilization”.

Lopez del Burgo: Spanish women’s opinion

                                                                                                                                          Resultados                                                                                                     Resultados
     4. Results                                                                                                                                                                        4. Results
               Women’s attitudes about postfertilization effects:                                                                                                                             Women’s attitudes about postfertilization effects:

                   Would you consider using a birth control method that sometimes                                                                                                               Would you consider using a birth control method that sometimes
                         works after fertilization or after implantation?                                                                                                                             works after fertilization or after implantation?

                     After fertilization, the                                                              After fertilization, the
  100                egg develops into an                                                 100              egg develops into an
                                                                                                           embryo with many cells.
                                                                                                                                                                                      100                                         100
                     embryo with many cells.
                                                          After implantation in the                                                                 After implantation in the
                                                          uterus, the embryo develops                                                               uterus, the embryo develops
                                                          into a fetus.                                                                             into a fetus.
    75                                                                                      75                                                                                        75                                           75
                                                                                                                                    57%                                                                                                               57%

                                           45%                                                                                                                                                             45%
 FERTILIZATION                                                                          FERTILIZATION         OVARIO
 The egg unites                                                                             50
                                                                                        The egg unites
                                                                                                                                                                                      50                                           50
 with the sperm.
                    33%                                                                 with the sperm.
                              Before fertilization,                   22%                                 20%       Before fertilization,
                                                                                                                                                                  23%                                                 22%                20%                      23%
    25                        the egg is released                                           25                      the egg is released
                                                                                                                    from the ovary.VAGINA
                                                                                                                                                                                      25                                           25
                              from the ovary.VAGINA

      0                                                                                       0                                                                                        0                                            0
                    YES                      NO                   UNSURE                                  YES                         NO                       UNSURE                           YES        NO       UNSURE                YES          NO       UNSURE

          After Fertilization but before                                                                   After Implantation                                                               After Fertilization but before                After Implantation
                  Implantation                                                                                                                                                                      Implantation

                                                                                                                                          Resultados                                                                                                     Resultados
     4. Results                                                                                                                                                                        4. Results
               Women’s attitudes about postfertilization effects:                                                                                                                             Women’s attitudes about postfertilization effects:

                     Women’s decision about continuing the use of a method after                                                                                                                  Women’s decision about continuing the use of a method after
                   learning it may work after fertilization or after implantation                                                                                                               learning it may work after fertilization or after implantation

                     After fertilization, the                                                               After fertilization, the
  100                egg develops into an                                                 100               egg develops into an                                                      100                                         100
                     embryo with many cells.                                                                embryo with many cells.
                                                          After implantation in the                                                                     After implantation in the
                                                          uterus, the embryo develops                                                                   uterus, the embryo develops
    75                                                    into a fetus.
                                                                                            75            62.6%                                         into a fetus.
                                                                                                                                                                                      75                                           75    62.6%
                    48%                                                                                                                          UTERO
                                                                                            50                                                                                                                                     50
                                                                                        The egg unites
                                                                                                               OVARIO                                                                 50
 The egg unites
 with the sperm.                         27.5%                      24.5%
                                                                                        with the sperm.                                                             25%                                   27.5%      24.5%                                        25%
    25                        Before fertilization,
                                                                                            25                                     12.4%
                                                                                                                       Before fertilization,                                          25                                           25                 12.4%
                              the egg is released                                                                      the egg is released
                              from the ovary.VAGINA                                                                    from the ovary. VAGINA

      0                                                                                       0                                                                                        0                                            0
                   STOP              CONTINUE                     UNSURE                                  STOP                CONTINUE                          UNSURE                         STOP     CONTINUE    UNSURE               STOP       CONTINUE     UNSURE
                   USING               USING                                                              USING                 USING                                                          USING      USING                          USING        USING

          After Fertilization but before                                                                   After Implantation                                                               After Fertilization but before                After Implantation
                  Implantation                                                                                                                                                                      Implantation

     4. Results
               Women who:
                            Believe that human life begins at fertilization…
                            Consider it is important to distinguish between                                                                                                                   1.      Introduction
                            spontaneous and induced embryo loss…                                                                                                                              2.      Objectives
                            Refer having a religion…
                                                                                                                                                                                              3.      Methods
                       … were less likely to consider the use of a method                                                                                                                     4.      Results
                         with postfertilization effects*.
                                                                                                                                                                                              5.      Conclusions

          * Results from multivariate analyses. All logistic regression models were
          adjusted for age, education, country of origin, annual income, marital status, desire
          for future pregnancy, number of pregnancies, number of elective abortions,
          religion, opinion about human life begining and about embryonic loss’ cause.                                                                                                                                                           Contact:

Lopez del Burgo: Spanish women’s opinion


  5. Conclusions
                                                                                                                        SPANISH WOMEN’S OPINIONS ABOUT
                                                                                                                         FAMILY PLANNING METHODS WITH
       Potential postfertilization effects of family planning
       methods may influence women’s choice of a particular                                                                POSTFERTILIZATION EFFECTS
       FP method.                                                                                                       Authors:
                                                                                                                        Lopez del Burgo C., Lopez de Fez CM., Lopez Guzman J., De Irala J.
       Postfertilization effects of family planning methods                                                             Affiliation:
       should be disclosed to women in order to achieve                                                                 Preventive Medicine and Public Health, University of Navarra (Spain)
       informed choices.                                                                                                Biomedical Humanities, University of Navarra (Spain)



  Scientific evidence about the mechanisms of action                                                                •   Trussell J, Ellertson C, Stewart F, Raymond EG, Shochet T. The role of emergency
                                                                                                                        contraception. Am J Obstet Gynecol 2004; 190: S30-8.
  •   Larimore WL, Stanford JB. Postfertilization effects of oral contraceptives and
      their relationship to informed consent. Arch Fam Med 2000; 9: 126-33.                                         •   Mikolajczyk RT, Stanford JB. Levonorgestrel emergency contraception: a joint
                                                                                                                        analysis of effectiveness and mechanism of action. Fertility and Sterility 2007;
  •   The Practice Committee of the American Society for Reproductive Medicine.                                         88: 565-71.
      Hormonal contraception: recent advances and controversies. Fertil Steril
      2004; 82 Suppl 1: S26-32.                                                                                     •   Lahteenmaki P, Rauramo I, Backman T. The levonorgestrel intrauterine system
                                                                                                                        in contraception. Steroids 2000; 65: 693-7.
  •   Frye CA. An overview of oral contraceptives: mechanism of action and
      clinical use. Neurology 2006; 66: S29-36.
                                                                                                                    •   Stanford JB, Mikolajczyk RT. Mechanisms of action of intrauterine devices:
  •   Wertheimer RE. Emergency postcoital contraception. Am Fam Physician 2000;                                         update and estimation of postfertilization effects. Am J Obstet Gynecol 2002;
      62: 2287-92.                                                                                                      187: 1699-708.

  •   Wellbery C. Emergency contraception. Arch Fam Med 2000; 9: 642-6.                                             •   French R, Van Vliet H, Cowan F et al. Hormonally impregnated intrauterine
                                                                                                                        systems (IUSs) versus other forms of reversible contraceptives as effective
  •   Kahlenborn C, Stanford JB, Larimore WL. Postfertilization effect of hormonal                                      methods of preventing pregnancy. Cochrane Database Syst Rev 2004:
      emergency contraception. Ann Pharmacother 2002; 36: 465-70.
  •   American College of Obstetricians and Gynecologists (ACOG). Emergency oral
      contraception. Number 25, March 2001. (Replace Practice Pattern Number 3,
      December 1996). American College of Obstetricians and Gynecologists. Int J
      Gynaecol Obstet 2002; 78: 191-8.

                                                                                    * Quality of evidence: Fair


  Quality of Evidence
  The USPSTF (US Preventive Service Task Force) grades the quality of the
  overall evidence for a service on a 3-point scale:

  • Good:
      Evidence includes consistent results from well-designed, well-
      conducted studies in representative populations that directly assess
      effects on health outcomes.

  • Fair:
       Evidence is sufficient to determine effects on health outcomes, but
       the strength of the evidence is limited by the number, quality, or
       consistency of the individual studies, generalizability to routine practice,
       or indirect nature of the evidence on health outcomes.

      Evidence is insufficient to assess the effects on health outcomes because
      of limited number or power of studies, important flaws in their design or
      conduct, gaps in the chain of evidence, or lack of information on
      important health outcomes.

         U.S. Preventive Services Task Force Ratings: Strength of Recommendations and Quality of Evidence.
         Guide to Clinical Preventive Services, Third Edition: Periodic Updates, 2000-2003. Agency for Healthcare
         Research and Quality, Rockville, MD.

Lopez del Burgo: Spanish women’s opinion


                                                                                                                  •     database of 480 users

                         User Profile and satisfaction                                                            •     electronic enquiry send by email

                     with the sympto-thermal method
                                                                                                                  •     20 questions about personal information and situation,

                                                                                                                        fertility, day-to-day use and user satisfaction
                                        Study about NFP practise during the last 10 years
                                                                                                                        of the sympto-thermal method NFP
                                                                     in The Netherlands

                                                                                                                  •     response of 246 (= 51% of total enquiries)

                                                             drs. R. van Steinvoorn
                                                                      bestuurslid NFP-Nederland
       FA-NFP Conference Antwerp 2008                                                                    FA-NFP Conference Antwerp 2008

                           Age distribution                                                                                    Civil status
User profile

                                                                                                  User profile

                                                                                                                      NFP fits in a monogamous and stable relationship.
                note: average age of male = 31, average age of female = 29, with average                              note: most of the singles follow the NFP course just before marriage!
                of ~ 2 children/couple before starting NFP against ~ 3 children/couple at
                the moment.
       FA-NFP Conference Antwerp 2008                                                                    FA-NFP Conference Antwerp 2008

                           Educational level                                                                                   Motivation for use of NFP

                                                                                                                               (mentioned by proportion of respondents,
                                                                                                                               more options possible)
User profile

                                                                                                                               Religion / View of life                           65 %
                                                                                                                               Side effects of other methods                     49 %
                                                                                                                               Health reasons                                    22 %
                                                                                                                               Reliability                                       20 %
                                                                                                                               Ecological reasons                                 6%
                                                                                                                               Other (incl. child-wish)                          16 %

       FA-NFP Conference Antwerp 2008                                                                    FA-NFP Conference Antwerp 2008

Wong: User profile

                          Contraceptive history                                                                          General use of NFP

                                                                                                   NFP use
               note: 63% of the contraceptive pill users indicate that (hormonal) side-
               effects are the main reason to switch to NFP.
      FA-NFP Conference Antwerp 2008                                                                   FA-NFP Conference Antwerp 2008

                          Lifespan use of NFP                                                                            Reasons of drop-out

                                                                                                                                                                      note: about 65% of the
                                                                                                                                                                      drop-outs indicate to
                                                                                                                                                                      use or to think about
                                                                                   36 %                                                                               using NFP again in the
                                                                                                                                                                      near future!

                                                                                                                                                                      The real drop-outs
NFP use

                                                                                                   NFP use

                                                                                                                                                                      come from the
                                                                                                                                                                      • menopause (100%)
                                                                                                                                                                      • medical reasons
                                                                                                                                                                      • dissatisfaction (45%),
                                                                                                                                                                        with average use of
                   note: drop-out percentage after 1 year is 9%, and 36% in 10 years. 50% of                                                                            3.8 years (!)
                   drop-outs occur in the first 3 years of use.
      FA-NFP Conference Antwerp 2008                                                                   FA-NFP Conference Antwerp 2008

                          Efficacy of NFP                                                                                User failures of NFP

               Efficacy data taken from our database:

               •     user Pearl index: 3.0 (1.8-2.6)*
NFP use

                                                                                                   NFP use

               •     method Pearl index: 0.38 (0.4-0.6)*

               •     about 80% of the couples is still positive to very positive about NFP after
                     unintended pregnancy

                                                                                                                note: Use of extra contraceptives during fertile days is low, resulting in
               * Advances in Contraception, 15 (1999), 69-83.                                                      unintended pregnancies because of (fully aware) not keeping NFP rules!

      FA-NFP Conference Antwerp 2008                                                                   FA-NFP Conference Antwerp 2008

Wong: User profile

                          Trying to conceive…                                                                                      User satisfaction

                Child-wish (primary)
                                                                                                                         •   Study material and NFP consultant :          8.45      (scale 1 -10)

                12 cases
                • 5 x positive after using NFP

                          Parallel consultation of gynaecologist/doctor occurred                                         •   Additional value of NFP-course (instead of do-it-yourself):
                          Pregnancy occurred after 5, 12, 13 and 24 cycles without medical intervention                                      none                         2%
                                                                                                                                             little                       7%
                                                                                                                                             fairly much                 28 %
                •   3 x positive after medical treatment (IUI, IVF)
                                                                                                                                             much                        37 %
                                                                                                                                             very much                   24 %
                •   4 x negative (‘not yet’)

                Indication: NFP is a serious option, helpful for couples                                                 •   Overall-appreciation of NFP-method
                                                                                                                                            positive – very positive      94%

       FA-NFP Conference Antwerp 2008                                                                           FA-NFP Conference Antwerp 2008

                           Some comments…                                                                                          Some comments…

                ‘Het is juist fijn om als man en vrouw samen om te gaan met de                                           ‘Mede dankzij NFP heb ik mijn lichaam heel goed leren kennen, heeft de
                vruchtbaarheid en hier samen een weg in te vinden.’                                                      relatie met mijn partner zich verdiept en heb ik leren omgaan met mijn
                ‘We raden het vooral stellen aan die van plan zijn te trouwen, het is een

                hele goede voorbereiding op je huwelijk.’                                                                ‘NFP heeft een bijzondere invloed gehad op onze relatie. Het geeft veel
                                                                                                                         openingen tot gesprek onderling. NFP versterkt het zelfvertrouwen van
                ‘Therapeutisch voor het huwelijk. Je praat elke maand over seksualiteit.                                 een vrouw.’
                Geen sleur!’
                                                                                                                         ‘Wat een blijdschap dat we toch zonder medisch ingrijpen een kind hopen
                                                                                                                         te krijgen. Tijdens onze kinderwens-periode is er een aantal keren
                                                                                                                         contact geweest met de consulent van NFP. Deze gaf ons hele
                                                                                                                         waardevolle adviezen.’

       FA-NFP Conference Antwerp 2008                                                                           FA-NFP Conference Antwerp 2008


                      User Profile and Satisfaction with a                                                                   80ies:
                                                                                                                              – Flanders: STM (Flynn) ObGyn Dr. Devos, Bruges
                      ST-NFP-method                                                                                           – Netherlands: STM (Rötzer) GP Dr. te Linteloo, The Hague
                      in Flanders and the Netherlands                                                                        1990: change to STM According to German
                                                                                                                             Arbeitsgruppe (NFP-DAG)
                      Roeline van Steinvoorn                                                                                 Spreading NFP-DAG by accredited voluntary NFP-
                      Margreet Boender                                                                                       teachers
                      Marie-Claire Van Wezenbeeck
                      Patrick Wong

Wong: User profile

     Aim of the study                               Materials and methods

       Outline User profile                          481 anamnesis charts of NFP-teachers 1990-2008
       Track User satisfaction                       309 phone requests April-July 2008
       Evaluate long term use                        men mean age: 33 (between 19 en 64)
                                                     women mean age : 31 (between 17 en 53)

     Results (1)                                    Geografic spread

       481 anamnesis data from clients
                                                                                                  Not in List
                                                                West Flanders

                                                           East Flanders

                                                                                Flemish Brabant           Limburg
                                                                                      8%                    8%

     Reason NFP-use                                 Number of children begin NFP use


                                 Unknown                                                              Mean : 1.2
                          0%       20%
         Effectiveness                               150

           4%                                        100

              Ecology                      Health     50

                2%                          72%

                                                            0          1        2          3              4         5      6      Onbekend
                                                                                          Number of children

Wong: User profile

     Marital status                                                                                Education woman
                                                                                                                               Unknown                    Secundary school
                        Unknown                    Not in List
                                                                                                                                 11%                           19%
                          5%                          1%

               Cohabitation                                                          58%
                  19%                                                                                                                                Higher no university

     Education man                                                                                 Results (2)

                                                                                                    309 data from phone requests
                                    Unknown                           Secundary school
                                      21%                                  20%

                                                                         Higher no university

     Reason to leave the method                                                                    Would recommend the method
                                                                                                                                                            Satisfied with
                                                                                                                                                           knowledge and
                                                                             No childwish,                                                                 experience but
                                                                                                          Not satisfied with       Unknown
                                                                             sterilisation as
                                                                                                         NFP and would not           8%                      would not
                                                                            definitive option
                                                   Menopause                       18%                   recommend it at all                              recommend it to
                                     Not in List
                                                                                                                2%                                             others
                 Unknown                                                                                                                                         2%

                                                                                  Too circuitous
      Medical reason
                       Child wish                  End relationship   pregnancy
                                                                                                                                        Satisfied with
                          4%                                             6%
                                                                                                                                       knowledge and
                                                                                                                                       experience and
                                                                                                                                     would recommend it
                                                                                                                                          to others

Wong: User profile

     Satisfaction with methodological
                                                                                                              Mean duration of use
      120                                                                                                                                                                                                                                                                          Onbekend; 37

                                                                                                     107      35

      100                                                                      96

                                                                                                                                                                       Mean number of years use who stopped (105): 3,5 years
       80                                                                                                     25
                                                                                                                                                                       Total mean (272): 4,9 years




       20                                                                                                      5







































             5 op 10   6 op 10   7 op 10   7.5 op 10   8 op 10   8.5 op 10   9 op 10   9.5 op 10   10 op 10




















     Conclusions                                                                                              General conclusion
            Majority very satisfied with methodologic approach :
            9/10                                                                                                        The method as taught by NFP-Vlaanderen and NFP-
            More than 88% would recommend the method                                                                    Nederland has a great satisfaction.
            70% uses NFP because of health reasons                                                                      There is need of a better follow up and support of NFP
            59% of men and 70% of women have higher                                                                     users
            77% couples are maried or cohabit
            21% stops because too circuitous or unplanned
            pregnancy (mostly in first 2 years)
            24% stops after several years because of menopauze
            or accomplished childwish

Wong: User profile

                                                                                                1. Know  what easily accessible information about 
                                                                                                   ‐ Natural Family Planning (NFP)
                                                                                                   ‐ Fertility Awareness Methods (FAM)
                                                                                                   ‐ and Lactational Amenorrhea Method (LAM)
                                                                                                   are available in WHO Family Planning Cornerstone,

                                                                                                1. Is such a way of presenting things trust worthy?  

                                                                           Soler F.
                                                                           Lafollie P.

                                                                                            1                               Soler F. Lafollie P.  ACODIPLAN  Anvers 6/9/08                  2

                                                     Family planning resources

WHO | Reproductive Health | HRP | What's new |
Publications | Contact | Search |
                 Evidence-based clinical and practical guidance
    Year                                Title                                 Languages
    2007      Family planning - a global handbook for providers              en - es
    2006      Reproductive choices and family planning for people            en
              living with HIV - Counselling tool
              Family planning home page

    2006      Essential medicines for reproductive health - guiding          en                                                                                                  p. 97
              principles for their inclusion on national medicines lists
    2006      The interagency list of essential medicines for                en - fr
                                                                                                                                                                               FAM  = 2 p
              reproductive health
    2005      Decision-making tool for family planning clients and           en - es - fr
              providers (Power Point files)                                                                                                                     Only  
    2004      Medical eligibility criteria for contraceptive use - 3rd       ar - en – es
              edition                                                        fr -pt - ru                                                              Standard Days Method 
    2004      Selected practice recommendations for contraceptive            ar - en – es fr    6  LANGUAGES           170 p.
              use- 2nd edition                                               - ro - ru                                                                  is offered as FAM !
                                          Evidence updates  ...
                                           ACODIPLAN  Anvers 6/9/08                         3                                        ACODIPLAN  Anvers 6/9/08                               4

                  186 p (FAM = 3) 
                        (LAM = 1)

 SYM & CAL                                                                                                21 Power Point files           total:  244 pages
   A Accept       C Caution                                                                                   nº 19 LAM                            6
                                                                                                              nº 20 Fertility awareness            8
   D  Delay
                                                                                                           English, français, español.
        ACODIPLAN  Anvers 6/9/08                                                            5                                            ACODIPLAN  Anvers 6/9/08                           6

Soler: WHO

                                                                            Positive aspects
                             Presentation                                   17 Fertility awareness method
                                                                            p. 239 ‐ 254  
      English, (Sept 2007)                                                    Large place given to FAM
                                                                                                                                                   Pregnancy rates 
      Spanish, (Feb 2008)                                                     Health benefits (protect against risks of pregnancy)
                                                                                                                                                   with consistent 
                                                                              Help women learn about their bodies and fertility
      Portuguese, (April                                                                                                                           use are 
                                                                              No side effects o health risks
      2008)                                                                   Advanced education not required                                      mentioned
      French, (May 2008)                                                      No harm to men who abstain from sex
          Arabic,                                                             In general, abstaining during fertile times is more 
                                                                              effective than using another method during fertile 
                                                                                                                                                   Methods are 
          Russian,        June 2008                                                                                                                divided into : 
                                                                              Allow some couples to adhere to their religious or                   Calendar based 
                                                                              cultural norms about contraception
          Urdu,                                                                                                                                    Methods
                                                                              Can be used to identify fertile days by both women 
    3 Previous cornerstones                                                   who want to become pregnant and women who want                       Symptoms‐                                          to avoid pregnancy                                                   based Methods
    health/publications/dmt/index.htm                                         (…)
                                                                              Withdrawal is not included
                               P. ACODIPLAN  Anvers 6/9/08             7                                        P. ACODIPLAN  Anvers 6/9/08                                   8

 Negative aspects 4)
                                                                           Negative aspects 6)
     COMPARING EFFECTIVENESS FP METHOD                                         Symptoms‐Based Methods (2007 p. 253)


                                                                           Family Fertility Education
                                                                           a resource package for teachers 
                                                                           of Natural Family Planning Methods 
                                                                                            WHO 1982
                                                                           Blat Centre for Health and Medical Education                                                p.93

                                ACODIPLAN  Anvers 6/9/08  
                                                               ?       9                                         ACODIPLAN  Anvers 6/9/08                                   10

 Negative aspects 11)
                                                                                                                                                                How many   

                                                                                                                                                                How many   
    The most effective FAM                                                                                                                                          in  
    (fertility awareness methods)                                                                                                                               Symptoms‐
    are omitted in pages 325‐334                                                                                                                                  based 
    ... and LAM                                                                                                                                                         ?

    ... and  vasectomy ...                                                                                                                                 ?
                                                                                                                                                Negative aspects 12)
                                ACODIPLAN  Anvers 6/9/08              11                                         ACODIPLAN  Anvers 6/9/08                                   12

Soler: WHO

                   DISCUSSION (a)                                                          DISCUSSION (b)
                                                                       • After reading 3 other last WHO cornerstones, 
 • The newest natural methods – some of them                                  • Decision‐making tool for family planning clients and providers
   efficient – are explained in ‘WHO Family Planning – a                      • Medical eligibility criteria for contraceptive us
                                                                              • Selceted practice recommendations for contraceptive use
   global handbook for providers’ but:
                                                                       • it seems: 
                                                                             very difficult to propose and use FAM,
   One much efficient (but not so new) sympto‐thermal                        competent people in NFP and FAM were not consulted to 
   (double check) is omitted and                                             write about those items, WHY?
   Information about others efficient FAM is                                 published studies on FAM or NFP in scientific reviews are 
   incomplete or/and tergiversated                                           ignored by authors, WHY?  
                                                                             Previous WHO publications were more correct.
   All FAM bundled together as ineffective methods. 

                        Soler F. Lafollie P. ACODIPLAN  Anvers                                  Soler F. Lafollie P. ACODIPLAN  Anvers 
                                                                  13                                                                                  14
                                          6/9/08                                                                  6/9/08  

                   Conclusions (a)                                                         Conclusions (b)
This congress could                                                    2. Propose an actualized presentation in Power 
                                                                          Propose an actualized presentation 
1. formulate recommendations for future and better 
   formulate recommendations                                              Point and pdf  of “Family Life Education, a 
   versions of the Family Planning a global handbook                      package for teachers of Natural Family 
   for providers, evidence based‐guidance … A WHO 
                                                                          Planning Methods” published by WHO in 
   family Planning Cornerstone
   In particular the following need attention:
                                                                          English (1982) and French and Spanish in 1989 
     ‐      chapter 17                                                 3. In “Decision making tool for family planning 
     ‐      chapter 18
                                                                          clients and providers” it is necessary to 
     ‐      appendix A
     ‐      appendix B                                                    propose more FAM than Standard Days 
                                                                          propose more FAM 
     ‐      and the back cover                                            Method 
                             ACODIPLAN  Anvers 6/9/08             15                            Soler F. Lafollie P. ACODIPLAN  Anvers 6/9/08         16

                   Conclusions (c)                                                         Conclusions (d)
 4. Users obtain high effectiveness with NFP/FAM,  
                                           if :                          Because people need to be given a very 
         Objective data about  all NFP/FAM are available,                wide range of options in family 
         Partners are motivated                                                                 no effective and 
                                                                         planning methods, and no effective and 
         and receive a correct training by experienced FAM               safe method should be black‐
                                                                         safe method should be black‐listed in 
         Male co‐responsability  is encouraged
                                                                         WHO documents.
 5. Other benefit of NFP/FAM is the safety and
                                                                                                     Thank you
     women empowerment
 the women empowerment
                             ACODIPLAN  Anvers 6/9/08             17                             Soler F. Lafollie P.    ACODIPLAN  Anvers 6/9/08     18

Soler: WHO


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