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Natural Family Planning: An Update

Article  in  Canadian family physician Médecin de famille canadien · September 1986


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Christine Derzko
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Christine M. Derzko
Natural Family Planning: An Update
SUMMARY SOMMAIRE
Natural Family Planning (NFP) is defined by L'Organisation mondiale de la sante definit les
the World Health Organization (WHo) as methodes de planification familiale dites naturelles
"methods for planning or avoiding comme etant des methodes permettant << de
planifier ou d'eviter les grossesses par l'observation
pregnancies by observation of the natural des signes et sympt6mes naturels des periodes de
signs and symptoms of the fertile and infertile fertilit6 et d'infertilit6 du cycle menstruel. II est
phase of the menstrual cycle. It is implicit in implicite dans la definition de la planification
the definition of natural family planning, familiale naturelle, lorsque pratiquee dans un but de
when used to avoid conception that drugs, contraception, de ne pas faire usage de
medicaments, de moyen mecanique, de ne pas
devices and surgical procedures are not used, recourir a une intervention chirurgicale, de
there is abstinence from sexual intercourse s'abstenir de relations sexuelles pendant la periode
during the fertile phase of the menstrual de fertilite du cycle menstruel et que l'acte sexuel, au
cycle, and the act of intercourse, when it moment d'une relation, soit complet. >> 1 On peut
occurs, is complete."' The fertile period may determiner la periode de fertilite en utilisant la
be determined by using Rhythm, a calculation m'thode rythmique, un calcul base sur les cycles
precedents, la courbe de temperature basale, les
based on previous cycles, basal body secrtions de la muqueuse vaginale (methode
temperature (BBT) charting alone, mucus Billings cu d'ovulation), la courbe symptothermique
secretion alone (Billings or Ovulation (methode Serena), laquelle inclut l'observation des
method), or symptothermal charting (Serena seretions et la courbe de temperature basale.
method), which indudes observation of both L'article discute de l'efficacit6 de chacune de ces
methodes et analyse le profil social et psychologique
mucus and BBT. The effectiveness of each des couples qui utilisent les methodes naturelles de
method is discussed, and the social and planification familiale. On peut utiliser ces methodes
psychological profile of couples who use NFP non seulement pour eviter les grossesses, mais aussi
is reviewed. NFP methods can be used not pour en choisir le moment et, a ce titre, elles sont
only to avoid pregnancy, but also to achieve particulierement utiles pour investiguer et traiter
pregnancy and thus are particularly useful in l'infertilite. L'auteur d6crit le r6le de la clinique
Family Life au St. Michael's Hospital de Toronto.
investigating and treating infertility. The
function of the -Family Life Clinic at St.
Michael's Hospital in Toronto is described.
(Can Fam Physician 1986; 32:1913-1921.)
Key words: natural family planning, reproduction, contraception
El mm

Dr. Derzko is an assistant Division at St. Michael's Hospital, OVER THE LAST DECADE
professor in the Department of Toronto. Reprint requests to: St. there has been a resurgence of
Obstetrics and Gynecology at the Michael's Hospital, Dept of interest in a more "natural" approach
University of Toronto, and is the Obstetrics and Gynecology, 30 to living. Many young adults, in their
Director of the Reproductive Bond St., Toronto, Ont. M5B 1W8. attempt to seek harmony with nature,
Endocrinology and Infertility are exploring alternate methods of
CAN. FAM. PHYSICIAN Vol. 32: SEPTEMBER 1986 1913
conception control which are more cyclical as it is in women), and there- (LH) peak, and that this corresponds
natural than intrauterine contraceptive fore impregnation can occur at any to an increase in peripheral proges-
devices (IUCD), birth-control pills, time. Normally, in a non-hostile envi- terone levels to more than 4 ng/ml.8
and other chemical methods whose ronment, sperm survive 24-48 hours, The actual release of the ovum proba-
long-term and short-term side-effects but in hostile, acidic, vaginal secre- bly occurs on the day before the time
they consider problematic. It is esti- tions they die within 4-6 hours. In of the first temperature elevation.
mated that about four per cent of cur- estrogenic mucus, the fertilizing ca- Sometimes a mid-cycle dip in temper-
rently married North American cou- pacity of sperm is believed to be 3-5 ature to the lowest level of the cycle
ples rely on NFP.2 days. The process of fertilization it- may be recognizable, and this is be-
self requires about 5-8 hours to com- lieved to coincide with ovulation it-
plete.3 self.
Definition Cervical mucus is the outward
Natural Family Planning is the tim- manifestation of the internal hormonal Basal Body Temperture
ing of coitus in accordance with the milieu.4 It is produced cyclically, in
response to estrogenic stimulation of The thermogenic effect of proges-
fertile phase of the menstrual cycle, to terone acting on the hypothalamus is
achieve or prevent a pregnancy. the mucus-producing glands of the
When pregnancy is to be avoided, pe- cervix, peaking in response to peak- well known to cause the rise in tem-
riodic abstinence is practiced; the cou- estrogen secretion and disappearing as perature of the luteal phase, which
ple recognizes pre-ovulatory symp- progesterone secretion appears and produces the biphasic graph charac-
toms and signs, and refrains from becomes dominant. Estrogenic cervi- teristic of ovulation. Temperatures
sexual intercourse and, indeed, any cal mucus is clear, acellular, copious, should be taken orally, vaginally or
genital contact until the infertile phase of low viscosity, has a spinnbarkeit rectally, always at the same time and
of the cycle is reached. On the other (thready stretchiness) which increases under the same circumstances every
hand, couples wishing to conceive as estrogen levels rise, and produces a day. Usually, a basal body tempera-
ferning pattern when allowed to dry ture is taken at a fixed time daily be-
learn to time intercourse so that it fore rising from bed. Although there
takes place during this fertile phase. on a slide. With the onset of proges-
terone secretion, the mucus becomes is consensus that the temperature rise
Successful use of NFP requires funda- in a biphasic graph is indicative of
mental knowledge and understanding white, cellular, scanty, thick and
of the physiology of reproduction, sticky, the spinnbarkeit decreases to ovulation, unfortunately, there is little
less than 1 cm and, when left to dry consensus about precisely when the
sometimes referred to as "fertility ovulation occurs in relation to the BBT
awareness". on a slide, the ferning is replaced by a
"beaded'" pattern. chart. Dates ranging from two days
before the temperature rise to three
The cervix acts as a reservoir as days after the elevation have been
Reproductive Physiology: well as a filter for sperm. Sperm can proposed as THE ovulation date. It is
Fertility Awareness be found in the oviduct within five agreed, however, that the thermal
Successful use of a natural family- minutes after ejaculation. During the shift demarcates the end of the fertile
planning method necessitates some estrogenic phase, sperm storage is phase.
basic knowledge about both male and known to occur, with the gradual re- Studies have shown that in 95% of
female reproductive functioning. This lease of sperm into the upper tract. women aged 20-40 years, menstrual
includes production and survival of cycles vary in length from 21-36
sperm in the male, ovum survival, days. The cycle consists of a follicu-
cervical mucus secretion, basal body Timing of Hormones and lar phase of 10-21 days and a luteal
temperature changes, and other less Menstrual Cycle Events phase of 1 1-16 days. Thus, a follicu-
obvious symptoms and signs accom- Studies have shown that mean time lar phase of <10 days is considered
panying ovulation in the female. The intervals exist during the menstrual short, of >21 days is called long.
following is a summary of the major cycle. (See Table 1.) More important, a luteal phase of
points which are included in teaching Speroff states that a significant <11 days is considered to be short
fertility awareness to patients. temperature rise is not noted until two and in infertile women may indicate a
The span of a woman's reproduc- days after the luteinizing hormone need for further investigation.
tive life lasts from menarche (average
age: 12.5 years), until menopause
(average age: 50.8 years). Fertility in Table 1
the woman is cyclical, with ovulation Timing of Hormones and Menstrual Cycle Events
occuring only once per cycle. The Events Mean time Median time
ovum is fertilizable for 10-24 hours
while it floats freely in the fallopian
tube, and if it is not fertilized during E 2 peak to LH peak 24 hours5 24 hours6
this time, pregnancy will not occur. LH peak to ovulation 9 ± 2 hours5 16.2 hours6
In the male, fertility begins with onset LH rise to ovulation 27.3 hours7 32 houre
the pubertal production of semen and E 2 peak to ovulation 34 + 3 hours5 24 hours6
then lasts for the remainder of life.
Sperm production is continuous (not Duration of E 2 rise 82.5 hours5
CAN. FAM. PHYSICIAN Vol. 32: SEPTEMBER 1986 1915
Types of If BBT charting is used strictly ac- cervical crypts where they are well
Natural Family Planning cording to this rule (i.e., avoiding in- protected from the hostile vaginal en-
tercourse and, indeed, any genital vironment, that sperm are able to sur-
1. Calendar Rhythm contact until after the third day of vive for days. The last day of fertile
The so-called "rhythm method" of high temperature has been recorded), mucus is called the peak day. Peak
natural family planning was devel- this method is totally effective in pre- mucus has been shown to correlate
oped on the basis of early work by venting conception. The effectiveness well with the LH surge and is followed
Fraenkel, Ogino and Knaus, which of the method when applied strictly, by ovulation, which usually occurs
defined the duration of the luteal ranges between 0.811-6. 612 pregnan- one day following peak mucus
phase. Given a predicted survival cies/100 woman years. (+ 2-3 days). Following ovulation,
time of 12-24 hours for the ovum Within the last few years, compu- rising progesterone levels inhibit
and 72 hours for sperm, the fertile terized thermometers have been intro- mucus secretion and result in sticki-
phase can be calculated as follows: duced which not only record day-to- ness or dryness felt at the vulva. Men-
1. The length of the menstrual cycle day BBTs but frequently are also struation occurs two weeks after peak
is recorded over the preceding 12 equipped to display graphically the mucus.
cycles. temperatures recorded for the entire In the ovulation method, women
2. The shortest and longest cycles are cycle. Furthermore, a red and a green learn to differentiate estrogenic cervi-
determined. light (green=infertile, red=fertile) on cal mucus from other vaginal secre-
3. The first day of the fertile period is the thermometer serves as a guide to tions: infected vaginal discharge, se-
calculated by subtracting 19 from the coital timing appropriate to the cou- minal ejaculate, secretions of sexual
length of the short-est cycle. ple's needs. Other innovations which arousal, lubricants and vaginal medi-
4. The last day of the fertile period is assist the woman in determining im- cations. Patients are instructed to re-
determined by subtracting 11 from the pending ovulation include a vaginal strict coitus to dry days from the ces-
longest cycle. probe to measure tissue conductance sation of menses until the onset of
changes which reflect rising pre- mucus secretion. They must then ab-
Coitus is to be avoided, therefore, ovulatory estrogen effects on the va- stain from intercourse until the fourth
between days (shortest cycle length gina, and a urine dip-stick LH rapid day following peak mucus each time a
- 19) and (longest cycle length - 11).
assay to determine the pre-ovulatory secretion build-up is noted. Even dur-
This method has proven to be LH surge. ing the dry days coitus is restricted to
rather unreliable, because most alternate days, in order that mucus
women's cycles are variable enough 3. Ovulation (Billings) Method build-up not be confused with seminal
to require long periods of abstinence Australian doctors John and Evelyn discharge. With the onset of proges-
to be sure of avoiding pregnancy. Ef- Billings pioneered the method of ob- terone secretion, the mucus becomes
fectiveness has been calculated as serving cervical mucus as a predictor sticky for a couple of days, then to-
ranging between 14.49 and 34.510 of ovulation. Women are taught to tally disappears, and the woman feels
pregnancies/100 woman years. observe mucus patterns at the vulva dry. During the period of secretion of
for a sensation of wetness and lubrica- fertile mucus all genital contact must
2. Basal Body Temperature Charting tion by using a combination of ordi- be avoided. The use of barrier
There is general agreement that a nary sensation, Kegel exercises, methods combined with the Billings
biphasic temperature graph is indica- finger palpation, a wipe through with Method during the fertile phase of the
tive of ovulation. The exact time, toilet paper or a combination of these. cycle, although it is practised by
however, when ovulation occurs, is The mucus on the toilet tissue is then many couples, is considered unac-
difficult to determine from the BBT inspected for colour and spinnbarkeit. ceptable by the proponents of the
chart alone. The onset of the infertile Cervical mucus, secreted by the Method.
phase is much easier to determine. cervix, undergoes changes in response Couples using the Billings Method
The commonest criterion used to de- to the secretion of estrogen and pro- record their findings on a monthly
termine the beginning of the infertile gesterone. Following menses, before graph using a series of colour-coded
phase is the "coverline". This is de- the estrogen levels reach a critical stamps: RED-bleeding, GREEN-dry-
fined as a line drawn on a BBT graph: point, several "dry" days occur. ness, WHITE with picture of BABY-
(0. 1°F (or 0.05°C)) which is above These are the infertile days. Grad- mucus, YELLOW-sticky mucus, x-
the highest normal temperature of the ually, as the woman's cycle pro- peak mucus, RED-STIPPLED-spotting.
low pre-ovulatory temperatures, ig- gresses, the 'dryness' is replaced by a Additional changes that occur in-
noring the temperature of the first sensation of moistness, which in- clude softening and ascent of the cer-
four days of the cycle and those af- creases under the influence of rising vix, and dilation of the cervical os,
fected by disturbances. At least six estrogen levels to a sensation of wet- both of which are maximal at mid-
low-temperature points must be re- ness and slipperiness when the mucus cycle. With the onset of progesterone
corded before drawing the coverline. is noted to develop spinnbarkeit. This secretion and ovulation, the cervix
The infertile period is that part of the is the fertile phase of the cycle. drops back and again lies low in the
cycle when intercourse cannot result Brown has reported that once a vagina, retums to its usual firmness
in conception. From the third (some threshold level for E 2 of and develops a closed cervical os with
say the second) day that a temperature 15 ug/100 ml/24 hours is exceeded, thickened secretions that solidify and
above the coverline has been recorded the mucus becomes sufficiently wa- form the protective mucus plug which
until day one of menses, intercourse tery to be felt at the vulva."3 It is in blocks further entry to the uterine cav-
will not cause conception. this fertile mucus, particularly in the ity. Instructor couples teaching the
CAN. FAM. PHYSICIAN Vol. 32: SEPTEMBER 1986 1917
Billings Method to other client cou- larities are common. The ovulatory throughout Quebec and parts of On-
ples strongly recommend observing response to hypothalamic-pituitary tario. These dedicated volunteers not
these cervical changes to confirm the stimulation is not predictable and, in- only teach the technical aspects of fer-
mucus findings. deed, may not occur at all. Thus, the tility control, but also provide couples
The ovulation method has a major possibilities may range from normal with the psychological and moral sup-
advantage over the rhythm method ovulation, through short luteal/long port necessary during the times of
and the BBT method in that it predicts follicular phase, to a total anovula- sexual abstinence, which may be par-
ovulation. With reasonable reliability, tion. Similarly, mucus secretion may ticularly difficult during the initial
it permits coitus during dry days, be- fluctuate from copious to erratic to learning period.
tween the cessation of menses and the imperceptible if there is lack of estro- Symptothermal charting relies on
onset of pre-ovulatory mucus secre- gen. Menses may also be absent, observation of cervical mucus and
tion. For some women, the need to spotty or excessive. During both of other physiological indicators of ovu-
observe only one sign, mucus secre- these periods, therefore, the mucus lation, in combination with the infor-
tion, is an advantage. For other method for coital timing is difficult mation offered by BBT changes. Symp-
women, who are perhaps less experi- and frequently unreliable. toms observed include:
enced and somewhat unsure of the 1. Mucus secretions at the vulva that
method, it may create considerable Childbirth resemble raw egg white. As described
anxiety. An international study by a Following parturition, the return of earlier, this mucus increases in re-
World Health Organization Task ovulation and pre-ovulatory mucus is sponse to rising levels of estrogen,
Force reported in 1981 that by the end highly unpredictable. Even after spon- peaks at ovulation, then disappears as
of the first observation cycle, 93% of taneous abortion, determining when progesterone dominates the endocrine
women were able to recognize their ovulation resumes is uncertain. It is scene.
mucus pattern, and 91% understood recommended that mucus observation 2. Vulvar fullness, also an estrogen ef-
the method well.14 Because of the begin at three weeks post partum in fect, is reported by many women at the
subjective nature of this approach to the non-lactating woman, and at about same time as peri-introital lubrication
family planning (i.e., the woman's six weeks in the nursing mother. is noted.
recognition of vulvar wetness), care Many factors determine the return of 3. Cervical palpation before ovulation
must be taken to include the husband ovulation including frequency, dura- reveals a progressively higher, more
or sexual partner in discussions and tion and intensity of feedings, in addi- open, softer and straighter cervix that
follow-up, lest he be made to feel that tion to maternal nutrition and general is flowing with mucus. With the onset
his only contribution is sexual abstin- physical health. There is no consistent of progesterone secretion, the cervix
ence. or predictable mucus pattern while a drops lower, closes, hardens, feels dry
Measurements of the effectiveness woman is breastfeeding. and comes to lie posteriorly against the
of using the mucus method vary, de- vaginal wall.
pending on whether total number of Oral contraceptives 4. Mittelschmerz, or mid-cycle pain,
pregnancies or method-failure-related is variable in duration, severity and lo-
pregnancies per 100 woman years are After discontinuation of the pill, cation. Sharp, short-lived, localized
discussed. Total failure rates range the return of normal ovulation is vari- pain may be due to actual follicle rup-
from a high of 39.7/100 woman years able and indeed may be considerably ture. More often, however, congestion
reported by Wade et al.,15 to a low of delayed, particularly in women with a and edema of peri-ovarian tissues is
9.7 pregnancies/100 woman years history of irregular menses or oligo- the likely cause of the discomfort,
found in Dolack's study.16 menorrhea. The ovulation method, especially if it is long lasting.
There is also a variation in method- which depends on mucus recognition, 5. Mid-cycle spotting or bleeding is
related pregnancy rates, ranging from is therefore unreliable as a predictor believed to result from the mid-cycle
12.2 pregnancies/ 100 woman years in of the safe period until ovulatory pre-ovulatory drop in estrogen secre-
Johnson's Australian study,"7 to 0 function normalizes. tion and the loss of support to the en-
pregnancies/100 woman years in 4. Sympto-Thermal Charting (Serena dQmetrium.
Klaus and Fagan's U.S. study. ' 8 Method) 6. Mastalgia or a feeling of breast
heaviness and sensitivity may also re-
Special Circumstances The fourth natural approach to con- sult from a drop in estrogen concentra-
ception control is symptothermal tion at mid-cycle, but more commonly
Under certain circumstances, ovu- charting (STC), also known as the
lation is abnormal or fails to occur at it is believed to be the result of proges-
Serena Method. Serena (taken from terone secretion.
all. This is particularly true peri-men- the French SErvice de REgulation des
archally, during lactation, pre- 7. Other cyclic symptoms reported in-
NAissances) was established in La- clude premenstrual acne, depression,
menopausally and after discontinuing chine, Quebec, by Gille and Rita
birth-control pills. Under these cir- edema, weight gain and increased ap-
Breault in the mid-1950s. After inten- petite and cravings, particularly for
cumstances, the secretion of estro- sively studying the natural approaches sugar. Migraine headaches, nausea,
genic mucus may be quite erratic. to family planning, the couple began visual disturbances and changes in
a program of instruction for other body odours have also been reported,
Peri1nenarche/preinenopause couples. They trained teacher couples but these symptoms are less reliable.
During both extremes of reproduc- and organized them into teams, each
tive life (i.e., peri-menarchally and with a medical and a moral advisor. Advantages of STC: The STC method is
peri-menopausally), ovulatory irregu- The movement spread widely somewhat more complex to learn be-
1918 CAN. FAM. PHYSICIAN Vol. 32: SEPTEMBER 1986
cause it takes into consideration mucus fertility Clinic complaining of inability
symptoms, BBT changes and numerous to conceive, about 30% of the women
other signs and symptoms. On the become pregnant within six months of
other hand, it is a much more reliable being instructed in STC. For the re-
guide to the fertile period than any of mainder, the STC teaching becomes the
the component parts individually. Be- foundation for subsequent investiga-
cause of the complementary nature of tion and management of their inferti-
the observations, STC widens the limits lity. A single look at a symptother-
which each individual fertility indica- mally charted cycle readily indicates
tor would have. It is especially useful that ovulation has taken place (bipha-
in such conditions as vaginitis or sic graph), that appropriate mucus
fever, which blur one or other of the changes have occurred, and that coital
signs of ovulation. timing has been appropriate. Further-
more. there is a correct time during the
Effectiveness of STC: The successful cycle when each fertility test should be
use of STC in conception control ap- done. The test will repeatedly yield ab-
pears to depend upon two major fac- normal results if the timing has been
tors: inappropriate (e.g., a post-coital test
a) whether absence of mucus or calcu- done too early in the follicular phase or
lation or a combination of both in the luteal phase of the cycle). Fol-
were used at the beginning of the lowing treatment, the improved results -

cycle; and are also readily seen on the STC.


b) whether the method was being used I

to prevent pregnancy or only to Who Uses


space births. Natural Family Planning?
Total pregnancies varied from 4.920 The social and psychological
to 15.919/100 woman years. Methodo-
characteristics
logical failure ranged from 3.7/100 NFP as a methodof ofcouples who choose
woman years,21 when absence of
conception control
were recently reported by Daly and
mucus was the only parameter used in
Herold.24 The
the pre-ovulatory period, to 0.0/100 between 20 and majority 30
(61%) were
years of age; two-
woman years22 when a combination of
thirds of them had completed post-sec-
calculation and absence of mucus was
used. Furthermore, in a five-country been ondary school education; 62% had
married for less than five years;
study, the variation in pregnancy rates and 75% were childless or had one
was from 4.1/100 woman years for
pregnancy prevention, to 14.8/100
child.
woman years for child spacing. For
Abstinence during the fertile period
was liberally defined by 61% of cou-
Canada, these rates were 1.1 and 16.1
respectively.23 This 1: 16 ratio under- ples as precluding intercourse, but per-
scores how important motivation is in
mitting stimulation, including genital
stimulation
the successful use of this method and, sharp contrastto toorgasm, which is in
indeed, of any method which depends traditional NFP teach-
ing.
on periodic abstinence.
Of those who were not pregnant
Planining ta pregnancy: aii aipplication
of STC: Although the term "family
when
ing to
questioned, 42% were continu-
use NFP, and 25% were using a
combination of fertility-awareness and
THE NEW
planning"' tends to evoke the image of
preventing pregnancy, this article barrier methods. Combination
would be incomplete if the importance NFP/barrier users were more likely to
LOOK OF
of this method in establishing a preg- have been married for over five years,
nancy, in addition to investigating and
treating the infertile
and have more children than users of
NFP only. They were, therefore, more
couple, were not likely
RELIABILITY
emphasized. Certainly, couples wh1o to be limiting their family size, New identification -
have used and understood the signs rather than merely spacing their chil- same proven formula
and symptoms of STC to prevent preg- dren, as were the users of NFP
alone.24 Fiorinal contains ASA, caffeine
nancy have little difficulty in applying and butalbital. It has the potential
that same information to timing coitus The Family Life Clinic for being abused and should be
appropriately to enable a pregnancy to at St. Michael's avoided in chronic pain states
occur. How exciting it is for them to
Hospital, requiring continuous daily use for
know exactly when conception oc- University of Toronto a prolonged period.
curred! The Family Life Clinic (FLC) was SANDOZ CANADA INC., Dorval, Quebec H9S 1A9
Among couples who present to our set up in 1974, in the Department of SANDOZ'
Reproductive Endocrinology and In- Obstetrics and Gynecology at St. Mi-
CAN. FAM. PHYSICIAN Vol. 32: SEPTEMBER 1986 L III'I
I
CIMlPrescribing
Psign ailTM
intfomation available on request.
mi
'Aprsolifletablets Late Adverse Reactions: Long-term administration at
relatively high doses may produce an acute rheuma-
toid state. When fully developed a syndrome resembl-
chael's Hospital, a teaching hospital
affiliated with the University of
(hydralazine hydrochloride) ing disseminated lupus erythematosus occurs. The
Antihypertensive Agent frequency of these untoward effects increases with Toronto. Its mandate was to instruct
Actions dosage and duration of exposure to the drug and is individuals and couples in all methods
Hydralazine hydrochloride exerts its hypotensive higher in slowthan in fast acetylators. Antinuclear anti-
action by reducing vascular resistance through direct body and positive L.E.-cell tests occur. of family planning, including natural
relaxation of vascular smooth muscle.
Symptoms and Treatment of Overdosage
family planning. The Clinic's motto is:
Indications Symptoms: hypotension, tachycardia, headache, "Fertility by choice through under-
APRESOLINE Oral: Essential hypertension. generalized skin flushing, myocardial ischemia and standing". Through counselling and
APRESOLINE is used in conjunction with a diuretic cardiac arrhythmia can develop. Profound shock can
and/or other antihypertensive drugs but may be occur in severe overdosage. education, individuals or couples are
used as the initial agent in those patients in whom, in Treatment: No known specific antidote. Evacuate
the judgment of the physician, treatment should be gastric content, taking adequate precautions against best able to make a well-informed de-
started with a vasodilator. aspiration and for protection of the airway; if general
conditions permit, activated charcoal slurry is instilled.
cision about the optimal method of fer-
APRESOLINE Parenteral: Severe hypertension when tility control for them. Because birth
the drug cannot be given orally or when there is an These procedures may have to be omitted or carried
urgent need to lower blood pressure (e.g. toxemia of out after cardiovascular status has been stabilized, control generally -and STC, specifi-
pregnancy or acute glomerulonephritis). It should since they might precipitate cardiac arrhythmias or
be used with caution in patients with cerebral vascular increase the depth of shock.
Support of the cardiovascular system is of primary
cally, are recognized to be a shared re-
accidents. sponsibility, the participation of cou-
importance. Shock should be treated with volume
Contraindications expanders without resortingto use of vasopressors, if ples in the instruction is encouraged.
Hypersensitivity to hydralazine, coronary artery dis- possible.
ease, mitral valvular rheumatic heart disease, and If a vasopressor is required, a type that is least likelyto Greater effectiveness in using this
acute dissecting aneurysm of the aorta. precipitate or aggravate cardiac arrhythmia should
be used, and the E.C.G. should be monitored while they
method can be anticipated if both
Warnings are being administered. partners attend the instruction sessions
Hydralazine may produce in a few patients a clinical Digitalization may be necessary. Renal function must and both participate in its implementa-
picture simulating systemic lupus erythematosus, be monitored and supported as required.
in such cases treatment should be discontinued im-
mediately. Long-term treatment with adrenocortico-
No experience has been reported with extracorporeal
or peritoneal dialysis.
tion, whatever method is ultimately
steroids may be necessary. Complete blood counts, chosen.
L.E. cell preparations, and antinuclear antibody Dosage and Administration Within the past five years, the Fam-
titer determinations are indicated before and periodi- Adjust dosage according to individual blood pressure
cally during prolonged therapy with hydralazine response. ily Life Clinic has become a vital and
and if patient develops arthralgia, fever, chest pain, Orally: Initial: 10 mg 4 times daily for the first 2 to 4 integral part of the Reproductive En-
continued malaise or other unexplained signs or days, 25 mg4 times dailyforthe remainder of thefirst
symptoms. If the results of these tests are abnormal,
treatment should be discontinued.
week, 50 mg 4 times daily for the second and subse-
quent weeks of treatment.
docrinology and Infertility Division. It
Usage in Pregnancy Maintenance: adjust dosage to lowest effective levels. is currently staffed by two nurse edu-
Animal studies indicate that high doses of hydrala- Following titration, some patients may be maintained cators who have been thoroughly
zine are teratogenic. Although there is no positive on a twice daily schedule.
evidence of adverse effects on the human fetus, Usual maximum daily dose is 200 mg, up to 300 mg trained in all birth-control techniques,
hydralazine should be used during pregnancy only if daily may be required in some patients. In such cases particularly in NFP. More recently,
the benefit clearly justifies the potential risk to the a lower dosage of APRESOLINE combined with a thia-
fetus. zide, reserpine or both, or with a beta-adrenergic- they have received extensive instruc-
blocking agent may be considered. When combining tion in infertility and abnormalities of
Precautions therapy, individual titration is essential to ensure that
Caution is advised in patients with suspected coron- the lowest possible therapeutic dose of each drug is the menstrual cycle. Under the direc-
ary-artery disease, at it may precipitate angina administered.
pectoris or congestive heart failure, and it has been Parenterally: patients should be hospitalized. Usual tion of reproductive endocrinologists,
implicated in the production of myocardial infarction. dose is 20-40 mg I.M. or by slow I.V. injection or I.V. they teach patients, help interpret
The "hyperdynamic" circulation caused by APRESO- driR repeated as necessary. Patients with marked
LINE may accentuate specific cardiovascular renal damage may require a lower dosage. symptothermal charts and test results,
inadequacies, e.g. may increase pulmonary artery For I.V. driR the ampoule(s) should be added to 5% arrange for appropriate testing to be
pressure in patients with mitral valvular disease. sorbitol solution, physiological saline or Ringer solution;
May reduce the pressor responses to epinephrine.
Postural hypotension may result.
glucose solution is not suitable for this purpose. Blood done at the correct time in the cycle,
pressure levels should be monitored. It may begin to
Use with caution in patients with cerebral vascular fall within a few minutes after injection, with an aver- and provide extensive emotional and
accidents and in patients with advanced renal age maximal decrease occurring in 10 to 80 minutes. psychological support to infertile cou-
damage. Peripheral neuritis has been observed and In cases with a previously existing increased intra-
published evidence suggests an antipyridoxine cranial pressure, lowering the blood pressure may ples.
effect and the addition of pyridoxine to the regimen if increase cerebral ischemia.
symptoms develop. Most patients can be transferred to oral APRESOLINE
Blood dyscrasias consisting of reduction in hemo- within 24 to 48 hours. 1985 Statistics from the Family Life
globin and red cell count, leukopenia, agranulocy-
tosis and purpura have been reported. In such cases Availability Clinic at St. Michael's Hospital,
the drug should be withdrawn. Periodic blood counts Tablets of 10 mg: yellow, uncoated, biconvex, scored, Toronto
are advised during therapy. MAO inhibitors should be and imprinted "FA" on one side and "CIBA" on the
used with caution in patients receiving hydralazine. other. The FLC nurses see an average of
Slow acetylators should probably receive no more Bottles of 100 and 500.
than 200 mg of APRESOLINE per day. When a higher Tablets of 25 mg: blue, coated, printed "GF" on one 130 clients each month and counsel an
dose is contemplated, and, whenever possible, it side and "CIBA" on the other.
may be advisable to determine the patient's acetyla- Bottles of 100 and 500. additional 75 clients by telephone. In
tion phenotype. Tablets of 50 mg: pink, coated, printed "HG" on one 1985, they saw 450 new clients/client
side and "CIBA" on the other.
Adverse Reactions Bottles of 100 and 500. couples. (See Table 2.)
Within the first day or two: headache, palpitations, Ampoules: 1 ml, each containing 20 mg hydralazine
tachycardia, anorexia, nausea, vomiting, diarrhea, hydrochloride, 103.6 mg propylene glycol, 0.65 mg of
and angina pectoris. They are usually reversible when methyl-p-hydroxybenzoate and 0.35 mg of propyl-p- Table 2
dosage is reduced or can be prevented or mini- hydroxybenzoate in water for injection. Reason for Attending
mized by administering reserpine or a beta-blocker Boxes of 10.
together with hydralazine. Complete Prescribing Information available on request. a Family Life Clinic
Less Frequent: nasal congestion; flushing; lacrima-
tion; conjunctivitis; peripheral neuritis,evidenced by References:
1 The Pharmacological Basis of Therapeutics, Sixth
Total no. new clients
paresthesias, numbness, and tingling; edema; dizzi- (client couples) No.
ness; tremors; muscle cramps; psychotic reactions Edition, Pages 799-801-Goodman and Gilman
characterized by depression, disorientation, or 1980. 2. Gifford, R.W., Isolated systolic hypertension to conceive 177
anxiety; hypersensitivity (including rash, urticaria, in the elderly. Postgraduate Medicine, Vol. 71,
pruritus, fever, chills, arthralgia, eosinophilia, and, No. 3, March 1982.3. Finnerty, F.A., M.D., Hyperten- NFP 130
rarely hepatitis); constipation; difficulty in micturition; sion in the elderly: Special considerations in
dyspnea; paralytic ileus; lymphadenopathy; spleno- treatment. Postgraduate Medicine, Vol. 65, No. 5, STC with barrier 90
megaly; blood dyscrasias, consisting of reduction in May 1979.4. Scriabine, A. Pharmacology of
hemoglobin and red cell count, leukopenia, agranu- Antihypertensive Drugs, Methyldopa, page 48,1980. Endocrine lx 12
locytosis, thrombocytopenia with or without purpura; STC post pill 41
hypotension; paradoxical pressor response.
Total 450
Mississauga. Ontario IPA
1920 L5N 2W5 0 -4057 LCCPP CAN. FAM. PHYSICIAN Vol. 32: SEPTEMBER 1986
The initial interview and teaching they are often the first to learn from a Calderone MS, ed. Manual of contracep-
session is expected to last 60-90 min- couple of their success in conceiving. tive practice. Baltimore: Williams and
utes. Two follow-up visits of 15-30 Wilkins, 1964:129.
minutes are planned after the first and Conclusions 11. Doring GK. Ueber die zuverlaesigkeit
third cycles. Subsequent visits are ar- der temperaturmethode zur empfaengnis-
ranged according to patient need. Natural family planning has broad verhuetung. Deutsche Med Wsc hr 1967;
As has been observed in other NFP applicability. It is not only useful as a 92:1055. Summary: The reliability of tem-
clinics, we have noted that failures method of controlling conception, but perature
tion.
records as a method of contracep
also as a means of achieving preg- The Yeatrbook of Obs-Gyn 1968:354.
often occur within a year if no follow-
up visit has taken place. For this rea- nancy. It is particularly helpful in in- 12. Marshall JA. Field trial of the basal
vestigating and managing infertility. body-temperature method of regulating
son, clients are urged to attend the fol- births. Lanicet 1968; 2:8- 10.
low-up visits if they are serious about NFP is based on the observation of
13. Brown JS. In: Klaus H. Natural Family
signs and symptoms which reflect en- planning:
avoiding pregnancy and wish to use a review. Obstet Gvnec Sanl'
NFP successfully. About 65% of our docrine changes occurring in the men- 1982; 37:134.
clients return for at least one follow-up strual cycle. The scientific basis is 14.
WHO Task Force on Methods for the
sound. Of the several types of NFP, Determination
visit. of the Fertile Period.
each has its advantages and limita- prospective multicenter trial of the ovula-A
The Effectiveness of NFP tions. Each method can be success- tion method of natural family planning.
fully used when it is clearly under- The effectiven'ess phase. Fer^til Ster-il 198 1;
The effectiveness of NFP is difficult stood and appropriately applied. The 36:591.
to analyse because couples may not time has come for a wider dissemina- 15. Wade ME, McCarthy P, Braunstein
keep in touch with the clinic after the tion of information about these Harris GD, Abernathy JR, Suchindran CM,
second follow-up visit. Recognized GS, Danzer HC, Uricchio WA. A
methods, in order that more physicians randomized prospective study of the use-
factors include the couple's motiva- and patient/clients can take advantage effectiveness of two methods of natural
tion, the intensity of their desire to of them. * family planning. A/n J Obstet GYnecol
avoid pregnancy, and the experience, 1981; 141:368.
knowledge and motivation of the 16. Dolack L. Study confirms values of
teacher. References ovulation method. Hosp Propr 1978;
1. Flynn AM. Natural methods of family 59:64.
In 1985, ten unplanned pregnancies planning. Cl Obstet GYnec 1984; 1 1:66 1. 17. Johnson JA, Roberts DB, Spencer RB.
occured among the 250 new couples A surveY ev(alutationi of the efjficacv an
iel ejfi-
who presented for NFP instruction. 2. Klaus H. Natural family planning: a re-
view. Obs Gvn Surt, 1982; 37:128. ciencv ofjiiltral-il fniitilv planninig ser vices
(See Table 3.) aiud Inethocds in A ustrdlia. Repol-t of ( ie-
3. France JT, Graham FM, Gosling L, Hair search project. Sydney: St. Vincent's Hos-
The impact of the NFP program on PI. A prospective study of sex of offspring pital, 1978.
the successful investigation and treat- by timing intercourse relative to ovulation. 18. Klaus H, Fagan MU. Use-effectiveness
ment of our infertile patients is harder Fer-til Ster-il 1984; 4 1:894. and client satisfaction in six centers teach-
to quantify, but it is nevertheless re- 4. Colston Wentz A. Physiology of the ing the Billings Ovulation Method. Coni-
cognized as significant. All infertility menstrual cycle [Lecture notes]. Inzfertility traception 1979; 6:613.
Update. Boston: Harvard Medical Schooi, 19. Johnson JA, Roberts DB, Spencer RB.
patients are referred for instruction in 1984.
STC. Using the symptothermal charts, A surveY ev aluation of the efficacyan,tCSd effi-
5. Pauerstein CJ, Eddy CA, Croxatto HD, ciencv of naturaIl ftanily plaInnlinlg servi- ces
subsequent investigations are planned, Hess R, Siler-Khodr TM, Croxatto HB. (111(1 mnethodls in Austratliai. Report of a re-
appropriate treatment prescribed, and Temporal relationships of estrogen, pro- search pr-oject. Sydney: St. Vincent's Hos-
the success of treatment is gauged. gesterone, and luteinizing hormone levels pital, 1978.
The nurses at Family Life Clinic are an to ovulation in women and infrahuman pri-
mates. Aml J Obstet Gvnecol 1978; 20. Rice FJ, Lanctot CA, Garcia-Devesa
integral part of the team. In addition to 130:876. C. Effectiveness of the symptothermal
their other duties, they are frequently 6. WHO Task Force on Methods for the method of natural family planning: an in-
called upon to provide emotional sup- Determination of the Fertile Period. Tem- ternational study. hIit J Fert 1981; 26:222.
port for presenting couples. Because poral relationships between ovulation and 21. Johnson JA, Roberts DB, Spencer RB.
they work so closely with the couples, defined changes in the concentration of A surveY ea/lunation of the efficacy tandtl effi-
plasma estrdiol-17B, LH, FSH, and pro- ciency of naltuir(l ftllynilv planning serv ices
gesterone. Am J Obstet Gvnecol 1980; aimid metho(Ils in Australia. Report of (1 re-
Table 3 138:383. seair-ch project. Sydney: St. Vincent's Hos-
Unplanned Pregnancies pital, 1978.
7. Garcia JE, Jones GS, Wright GL. Pre-
of Attenders at a NFP Clinic diction of the time of ovulation. Fer-til 22. Wade ME, McCarthy P, Braunstein
Steril 198 1; 36:308. GD, Abernathy JR, Suchindran CM,
Reason for Harris GS, Danzer HC, Uricchio WA. A
NFP Method Failure No. 8. Speroff L, Glass RH, Kase NG. Clinical randomized prospective study of the use-
NFP alone Fertile phase gvyle/ologic(ll endcr inology (1,1d iniferti- effectiveness of two methods of natural
ignored 3 litv . 3rd ed. Baltimore: Williams and Wil- family planning. Am J Obstet Gynecol
NFP + kins, 1983. 1981; 141:368.
Condoms & foam In fertile phase 1 9. T ietze C. Use of effectiveness of contra- 23. Rice FJ, Lanctot CA, Garcia-Devesa
NFP + ceptive methods in the United States. In: C. Effectiveness of the symptothermal
condoms In fertile phase 2 Calderone MS, ed. Manuall of contracep- method of natural family planning: an in-
NFP + t ive prabc tic es. Baltimore: Williams and ternational study. hIt I Fert 1981; 26:222.
diaphragm & Jelly In fertile phase 4 Wilkins, 1964: 131.
24. Daly KJ, Herold ES. Who uses natural
Total 10 10. Tietze C. Use of effectiveness of con- family planning. Canl I Pub Heallth 1985;
traceptive mzethodis in the United,States. In: 76:20(7.
CAN. FAM. PHYSICIAN Vol. 32: SEPTEMBER 1986 1921

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