Couple's Hypofertility: Scientific Value and Human Richness of the Billings Method

Many of these couples do not accept this recommendation and, along with others who fail to obtain a live baby by use of the technology, subsequently become pregnant. Most of these and many more who do not achieve pregnancy fortuitously could have been helped to do so by instruction in the Billings Method as will be described.

It is a sad commentary on current medical knowledge that when these women present to the Billings Ovulation Method teacher and the teacher asks the simple question "What about the cervical mucus?", the woman will almost invariably reply "What is that?" Although she has been under the care of the reproductive technology team for perhaps several months, she has never been given any information about the cervical mucus pattern nor the importance of the activity of the cervix in facilitating conception.

St. Thomas Aquinas used to say that he had two, and only two, sources of knowledge which he could trust as the truth, these being Nature and the Scriptures. More than eight centuries earlier, St. Augustine cried to God in his Confessions, "Our soul rises up to Thee, held up with the things which Thou has made...passing beyond them into Thee who has wonderfully made them". The Chinese people, most of whom are pagans, are very interested to know that the solutions to the problems regarding fertility can be found in Nature. It is especially in the knowledge of the wonderful way in which God has made women that success will be found. The Billings Method is to be accepted as the primary management of infertility, and no matter what other disorders may be contributory, it is obviously likely to be of considerable benefit for the woman to be able to recognize, at the time, a day, perhaps only a very occasional day, in which she is able to conceive.

Amongst the various methods of regulating fertility, it is only the natural methods which can help the couple to have a child. The Birth-Control Package, as it is called, of contraception, sterilization and abortion has nothing to offer at all.

In the IVF and GIFT programs hyperstimulation of the ovaries is used in order to produce multiple ovulations. About 6% of women treated are likely to develop a very dangerous disorder known as "hyperstimulation syndrome" as a result. Sometimes as many as 40 follicles are stimulated to mature and efforts must be made immediately to aspirate all of these follicles which do not ovulate, otherwise ovarian cysts remain. The level of circulating oestrogens may reach 20 to 30 times the normal levels of the natural cycle, one or both ovaries may enlarge up to 20 centimetres in diameter, abdominal pain and ascites may result, also increased blood viscosity, an imbalance of serum electrolytes with hypovolaemic shock, psychiatric disturbances with suicidal tendencies, and even death.

The hyperstimulation usually results in about 12 eggs being produced in younger women, with an average of 4 eggs in women over the age of 40 years. Of those which are fertilized a selection of embryos is made for 2 or 3 to be implanted, some being preserved for the future, others are used for experimentation and some are discarded immediately.. Very often the eggs are initially forzen, to be used in the next cycle when they are fertilized, because the hyperstimulation syndrome may also be provoked by the additional influence of hormones produced by the corpus luteum if pregnancy is induced in the treatment cycle. If all the implanted embryos survive, then procedure of "pregnancy reduction" may be advised, meaning abortion of one or more of the developing children. Many of you have read of the destruction of 3000 embryos in the United Kingdom recently, because they had reached their legal time limit of 5 years for their continued preservation.

These techniques are complicated by an increased incidence of ectopic pregnancies, spontaneous abortion, congenital abnormalities, premature labour and low birth weight. Efforts may be made following conception to detect abnormalities by ultrasound investigations, undertaken precisely because the affected child can then be eliminated by abortion.

Recently GnRH agonists, such as buserelin, have been administered intranasally in an effort to prevent hyperstimulation, and is still under trial.

The units undertaking these techniques often regard surrogacy as a treatment option, with little regard for the moral, legal, psychological and social problems which may result, and certainly without respect for the dignity and immeasurable value of the unborn child who shares our humanity as a human person from the time of conception. Many people who profess no specific religious affiliation can see that the dignity of every human person demands that conception should always be the result of a loving act of intercourse between the parents, without the intervention of any other individual.

It is appropriate to remember that all of Christ's humanity and divinity were at first present in a single cell in the womb of his Blessed Mother.

There is therefore a very important role for the natural family planning teacher in the face of the problem of apparent infertility. This teacher will bring to the couple the wisdom of the natural law, as well as compassion and love, especially love for the child; these attributes immediately communicate themselves to the couples, as the first interview begins with a simple medical history. As always the teacher learns to listen more than to talk, and this will help her to make observations regarding the conjugal relationship which may prove to be very important.

No detail should be ignored. The occupation of the husband may be important because it occasionally happens that working in a very hot environment can considerably reduce the husband's fertility; or it may be that his occupation involves frequent periods of absence from home. The smoking habits of both husband and wife are very important, as heavy smoking may reduce the fertility of both men and women. If the woman's cycle pattern is irregular the possibility of excessive exercise should not be overlooked. Regular strenuous exercise can diminish a woman's fertility, causing short luteal phases, delayed ovulation with irregular anovulatory bleeding and eventually amenorrhoea, which means that the woman has stopped ovulating. If she is not ovulating this means that her bones are being denied the normal stimulus of raised oestrogen levels in the cycle, which are very important for bone development in young women. The Billings Method charting is helpful in demonstrating a regular occurence of ovulation, when it reveals a normal fertile cervical mucus pattern.

Short luteal phases are a better indication of infertility than 'deficient luteal phases', the latter meaning diminished hormone production at this time. The corpus luteum formation is largely pre-determined by the quality of the follicular phase and the short or deficient luteal phase may be indicating a disturbance of the mechanism of ovulation, even that the follicle does not rupture to release the ovum, or perhaps the development of an empty follicle. A less than adequate follicular phase in the cycle can be confirmed by vaginal sonograms to study the endometrium, and the presence of a short or deficient luteal phase should not prompt a statement from the teacher that the woman is probably conceiving but the embryo is failing to implant successfully. The correct explanation is perhaps more likely to be that the disturbance of the mechanism of ovulation has resulted in a failure to conceive, for example, because the ovum has been released too early or too late, and it is gravely disturbing to the woman to be told that she may be having repeated natural miscarriages at an early stage of pregnancy.

Inquiries should alwys be made regarding previous illness and the use of contraception, especially contraceptive medication. Sometimes a woman or young girl has been worried by irregularity of her cycles; she should be informed that menstrual irregularity is not of itself an abnormality at all, and does not require treatment, nor does it interfere in any way with the successful application of the Billings Method to achieve or to postpone pregnancy. It is particulary undesirable that contraceptive medication be prescribed, following the mythology that the Pill can regulate the cycles, which it cannot. Especially in adolescent girls the Pill may seriously damage fertility, and this before it is known whether or not her fertility is normal.

Short luteal phases may also be the result of hyperprolactinaemia, and therefore should prompt the question of a nulliparous woman or one who has not been pregnant for many years, whether she has noticed secretion of milk by the breast. Such an observation would indicate the need for medical referral and investigation. Sometimes this disorder can be induced by psychotropic medication or be without a serious cause, and it can be successfully treated with bromocriptine.

It is wise to enquire gently regarding the frequency of intercourse, as especially in the presence of a short mucus symptom the fertile time may be consistently missed. On the other hand one has encountered cases where a very copious mucus symptom has caused embarrassment to the woman, so that she has avoided intercourse at the time during the cycle. These problems make themselves more evident when the woman commences charting after the initial instruction.

In a number of cases the woman is approaching the menopause. Sometimes she was recently married for the first time and realizes that it may be difficult for her to conceive. Or a woman who has some remorse about neglected opportunities to have more children when younger is anxious to have another child during the short time remaining when this may be possible. Our teachers have had many successes in these cases, helping the couples to have one or even two beautiful children immediately before menopause.

The Biology of the Cervix

It is now well known that women have cycles of fertility separated by longer times of infertility and that during the limited time of fertility in the cycle the cervix produces a special secretion which is essential for the nourishment and protection of the sperm, and the migration of those sperms selected for their high quality into the fallopian tube. This secretion is of low viscosity so it leaves the cervix and appears at the vulva as a vaginal discharge. This physiological event is familiar observation to every healthy fertile woman. There is consistency in the women's observations of the changing characteristics of this discharge from day to day but there is individual variation in the amount and in the number of days on which it is present.

Of fundamental importance to our discussion of infertility is the fact that, as a result of damage to the cervix by contraceptive medication or for reasons that we do not understand, the cervix may not respond to the hormonal pattern of fertility, or may do so perhaps in occasional cycles, but whenever it does occur the mucus is present for a very limited time, perhaps only for half a day which contrasts with the average of five or six days. The corollary of this fact is that some women are limited to rare opportunities of being able to conceive, perhaps one day or part of a day in only one of several cycles. Furthermore, the small amount of the discharge at this time may mean that she will not see it; however, she can be taught to recognize its presence by the more important observation of the slippery, lubricative sensation that even this small amount will produce on contact with the vulva.

The teacher will therefore help the woman to identify this important element of the instruction, remembering that the woman may have ceased to pay any attention to it, perhaps because she had come to understand that it was not an indication of any disease process, or perhaps had attributed it to sexual thoughts, or to physical weakness as the Chinese women have been inclined to do. The presence of this discharge, which is essentially a mucus substance, has been familiar since before her first menstruation and in all of those cycles in which she ovulated since that time.

For the majority of couples who have had difficulty in achieving conception no other course of action is necessary beyond competent instruction of the woman regarding the cervical mucus pattern and encouragement to keep a careful daily record, which occupies about a minute of her time each evening. A number of follow-up interviews may be necessary to ensure that a faithful record is being produced and also to encourage the woman to persevere, reminding her it may be a year or so before success is achieve. Experiences all over the world have included pregnancies in couples who have been anxious for a family for 10, 14, 18 and even 23 years in the case of one couple in India.

When the woman has what one might call a poor mucus symptom, Professor James Brown's Ovarian Monitor can be of great value in helping to identify the day of ovulation in the cycle,* and at the same time confirm that she is ovulating. If the necessary sequence of hormonal estimations is unable to be provided, help may be obtained by a Basal Body Temperature record when a typical biphasic pattern proves that ovulation has occurred; it has to be remembered that this does not identify the day of ovulation which has usually occurred a day or so before the temperature shift.

There are additional natural signs to help these women, particularly the soft swelling of the vulva, sometimes more noticeable on one side than the other, around the day of ovulation; some women describe this as a 'fat feeling'. The lymph node sign may be useful and also a heart rate sign, described by Professor Erik Odeblad as a result of his remarkable clinical perceptions.

There has been tardy recognition of the fact that many women suffer from prolonged and sometimes even permanent infertility following the use of contraceptive medication, as a result of damage to the S-mucus and P-mucus secreting cells. Fortunately natural recovery occurs after a few years in the majority of these women but less frequently in older women. The gradual return of fertility is often evident on the woman's daily record. However, the problem is compounded by the fact that the vagina may also have been damaged by the medication, particularly in the region of the Pockets of Shaw, so that a small amount of healthy mucus from the cervix may be dehydrated in the lower region of the vagina and therefore unable to be detected at the vulva. With the use of the Ovarian Monitor the woman can concentrate on observations of the days around the time of ovulation and so perhaps learn to detect minimal signs.

Normally there is a shedding of cells from the vagina, such as to produce a vaginal discharge if it were not for the activity of the Pockets of Shaw, where absorption takes place. Sometimes, following the use of contraceptive medication, the surface epithelium of the whole vagina is damaged and there is desquamation of the intermediate cell layer, with the production of a discharge composed of the glycocalyx which normally surrounds these cells, a compound of polysaccharide and protein. If this substance is not absorbed by the Pockets of Shaw the woman has a chronic discharge and may lose substantial amounts of protein over a long period of time, such as to cause her to lose weight and to be anaemic. Often various investigations of the discharge are undertaken with the suspicion that it is an infection, without recognition of its pathogenesis.

It is of critical importance in all of these complications of contraceptive medication, that the woman be warned that she should under no circumstances use this medication again.

If after a year or so without pregnancy, the ability of the husband to produce healthy sperm cells should be investigated by the Sims-Huhner test, a valuable test which makes sperm counts unnecessary. The usefulness of this post-coital test, as it is also called, has been grossly underestimated because it is so often performed at the wrong time in the cycle. It can be predicted that if it is performed during the infertile phase of the cycle, no sperm cells may be able to be found at all, or those that are present may be immotile or otherwise damaged. So the test consists of taking a sample of mucus from the cervical canal during the fertile phase of the cycle, preferably on the day of maximum fertility as defined by the woman's observations. This will demonstrate not only that she has satisfactory mucus at the time but also the presence of healthy, vigorous sperm cells in the sample of mucus if the husband is able to produce such cells.

Physical and Emotional Stress

Physical and emotional stress can disturb the cycle, particularly by delaying ovulation. There can be no doubt that the fertility of the woman may be impaired as a result of stress, perhaps also by a disturbance of the intricate mechanisms which have to do with the passage of the egg cell into the fallopian tube and its initial movement towards the uterus, the assistance provided to the sperm cells not only by secretions of the cervix, but perhaps also by secretions within the body of the uterus and the fallopian tubes. It is certainly a recorded observation of many persons experienced in marital counselling that very often a pregnancy is delayed until a happy, peaceful conjugal relationship is established. Sometimes it is the failure to produce a child that is the source of discontent and irritability between the husband and the wife. It is here that the teacher can be helpful, employing at a commonsense level the gift of Counsel which she may fortunately have received with the Sacrament of Confirmation. In simple terms she can counsel the couple to concentrate on improving their love life, to develop between them an expressive recognition of the fact that it is their love for each other that has made the marriage and that this love will always exist to produce fulfilment in their lives. Moreover, if they pursue such a course, the resulting benefit to their relationship may make the difference between having or not having a child.

Importance of the Counselling Role of Natural Family Planning Teachers

This is a situation where the love, the compassion, and the generosity of the teacher become evident in the care and the wise counselling that she provides for the couple. Sometimes she may suggest that the couple seek to adopt a child or perhaps that they find some voluntary work which has to do with the care of abandoned, disadvantaged or handicapped children. It is unfortunate that there are now very limited opportunities in Western society to adopt a child, because of the widespread tolerance of abortion. There is a very strong link between contraception and abortion and the teacher of natural family planning soon becomes aware of this. Living the way of natural family planning in a marriage not only helps the husband and wife to love one another more, but it also teaches them to love their fertility and then to love the child. In that kind of happy marriage the child is conceived through an act of love, and loved even before conception has occurred, whereas contraception is what it says, "against conception" and therefore against the child. We should therefore, all of us, be as active as our circumstances perimit in helping to rid society of this evil of abortion, firstly by our compassionate care of the pregnant woman who for the moment sees no other solution for the problem that the pregnancy has caused but to proceed with abortion. She must be spared the suffering and long remorse that she will always experience if she is not helped to save the life of her child.

The natural family planning teachers also instinctively recognize that they can be of great help to parents struggling to fulfil their primary role of teaching their children their religious faith, the family virtues of love, justice, honesty, caring for those in need and an ennobling morality which includes the avoidance of genital relationships before marriage so avoiding risks of damage to their fertility.

Many will say that you cannot expect young people to be chaste and that human society has always been faced with the reality of abortion. What is certain is that there will be more chastitiy if the young people are given good information by their parents, with the recruitment of others if necessary to convey first of the message that we know that they are able to be chaste, if they have the will. And certainly there are babies which the childless couple might be able to adopt. We had an experience recently in China when, at an airport as we were moving from one city to another, we came across a group of young couples from Norway, about a dozen of them returning home, each with a tiny Chinese baby girl aged less than 6 months, abandoned babies who would otherwise have died but now permitted by the Chinese government to be adopted and taken home to Norway. The joy that radiated from that group was an unforgettable experience.

So that is what natural family planning is all about - love of God, thanksgiving for his gift of fertility, love between husbands and wives, love for the child and ultimately the gifts of the Holy Spirit moving from the security and stability of happy families into society, those gifts of Charity, Joy and Peace.