1. 1 Fertility awareness (FA):  Fertility awareness provides basic information about fertility and reproduction, signs and symptoms of fertility during fertility cycle.  Importance: 1.Making decision about family planning, especially natural family planning. 2.Planning or avoiding pregnancy. 3.Enabling women to value their fertility. Dr. Okour- Fertility awareness

2. 2 Fertility awareness (FA):  Natural family planning (NFP): Identifying the fertile and infertile phases of a woman ’ s menstrual cycle by observing the signs and symptoms of fertility to: 1. Plan for pregnancy (maximizing chance for conception -timing of intercourse in fertile days of the cycle). 2. Avoid pregnancy (abstaining from intercourse in fertile days of menstrual cycle) without using any modern contraceptive methods.  Efficacy of NFP: if couples are taught by experienced teachers efficacy is up to 98%. Dr. Okour- Fertility awareness

3. 3 Fertility awareness (FA):  Advantages of NFP: No drugs or devices.No drugs or devices. Suits the woman ’ s normal physiology.Suits the woman ’ s normal physiology. No physical side effects.No physical side effects. Improve the communication about the sexuality and sharing responsibility about family planning.Improve the communication about the sexuality and sharing responsibility about family planning. Help conception.Help conception. Religiously, morally, and culturally acceptable.Religiously, morally, and culturally acceptable. Cost-effective- no need for medical supervision after adequate teaching.Cost-effective- no need for medical supervision after adequate teaching.  Disadvantages of NFP: Take time to learn fertility symptoms.Take time to learn fertility symptoms. Requires initial teaching.Requires initial teaching. High user-failure rate needs serious commitment of the couple.High user-failure rate needs serious commitment of the couple. Dr. Okour- Fertility awareness

4. 4 Fertility awareness (FA):  Scientific basis of fertility awareness Male physiology: facts on sperm: Sperm will survive for 3-7 days in a woman ’ s cervix in the presence of fertile mucus (alkaline mucus produced from the secreting cells lining the cervix).Sperm will survive for 3-7 days in a woman ’ s cervix in the presence of fertile mucus (alkaline mucus produced from the secreting cells lining the cervix). Sperm will be destroyed within hours if remaining in the vaginal acidic environment in the absence of alkaline cervical mucus.Sperm will be destroyed within hours if remaining in the vaginal acidic environment in the absence of alkaline cervical mucus. During the infertile phase, sperm cannot penetrate cervix due to a thick sticky mucus plug blocking the cervix.During the infertile phase, sperm cannot penetrate cervix due to a thick sticky mucus plug blocking the cervix. Sperm might be contained in the lubricating fluid man releases prior to ejaculation.Sperm might be contained in the lubricating fluid man releases prior to ejaculation. Dr. Okour- Fertility awareness

5. 5 Fertility awareness (FA):  Female fertility cycle physiology: Menstrual cycle vary in length from 23 or less days in short cycles to over 35 days in a long cycle. The average is 28 days.Menstrual cycle vary in length from 23 or less days in short cycles to over 35 days in a long cycle. The average is 28 days. Hormonal changes: divided into pre-ovulatory and post-ovulatory phases:Hormonal changes: divided into pre-ovulatory and post-ovulatory phases: 1.Pre-ovulatory phase: – Begins in the first day of blood, controlled by FSH and oestrogen. – As estrogen levels rise approaching ovulation, the endometrium becomes thicker, the cervix becomes higher, softer, and open. – Cervical changes to a very sperm-friendly (increasing salts, sugar, and amino acids to nourish sperm, with high fluid-98% water with transparent, slippery, and stretchy appearance), and basal body temperature remains low. – Cervical mucus changes to a very sperm-friendly (increasing salts, sugar, and amino acids to nourish sperm, with high fluid-98% water with transparent, slippery, and stretchy appearance), and basal body temperature remains low. – This phase ends with ovulation- within 36 hours after surge of LH, with variation in duration according to cycle length. Dr. Okour- Fertility awareness

6. 6 Fertility awareness (FA): 2.Post-ovulatory phase is the interval between ovulation and the next menstrual period which remains reasonably constant around 14 days. –This phase is controlled by progesterone released from corpus luteum. –Changes influenced by progesterone include softening the endometrium for plantation, cervix becomes lower, firm, and closed, and cervical mucus becomes hostile preventing sperm penetration. –Temperature rises by 0.2  C. Dr. Okour- Fertility awareness

7. 7

8. 8 Fertility awareness (FA):  Indicators of fertility: Waken up temperature. Waken up temperature. Cervical mucus changes. Cervical mucus changes. Changes in the cervix. Changes in the cervix. Calculation of cycle length. Calculation of cycle length. Minor indicators. Minor indicators.  The most effective method is combination between temperature and mucus symptoms (sympto-thermal method-Calendar method). Dr. Okour- Fertility awareness

9. 9 Fertility awareness (FA): 1. Temperature: Recording the daily basal T  (at the bed) with charting. Recording the daily basal T  (at the bed) with charting. A shift in T  confirm ovulation, and sustained rise in T  for 3 days indicates 48 hours past ovulation. A shift in T  confirm ovulation, and sustained rise in T  for 3 days indicates 48 hours past ovulation. Post-ovulatory phase begins in third day of high T . Post-ovulatory phase begins in third day of high T . In the pre-ovulatory phase the temperature keeps low until the ovulation occurs. In the pre-ovulatory phase the temperature keeps low until the ovulation occurs. If we apply the rule of 3 over 6 we get a typical T  chart. Six days (of low T  ) before T  shift, and 3 days after temperature rise. If we apply the rule of 3 over 6 we get a typical T  chart. Six days (of low T  ) before T  shift, and 3 days after temperature rise. Maintaining high T  after the third day of high T  indicates pregnancy. Maintaining high T  after the third day of high T  indicates pregnancy. Dr. Okour- Fertility awareness

10. 10 Dr. Okour- Fertility awareness

11. 11 Fertility awareness (FA): 2. Cervical mucus changes: Menstrual period (blood period) is followed by some dry days, which may be absent in short cycles, and more in long cycles. Menstrual period (blood period) is followed by some dry days, which may be absent in short cycles, and more in long cycles. Recording mucus changes (at the vaginal entrance) on the chart include sensation and appearance. Recording mucus changes (at the vaginal entrance) on the chart include sensation and appearance. Sensation include dryness (infertility), moistness (potential fertility), wetness (fertile). Sensation include dryness (infertility), moistness (potential fertility), wetness (fertile). Appearance of the fertile mucus is transperant, slippery, and stretchy (similar to raw egg white), which is the peak day of such mucus. Appearance of the fertile mucus is transperant, slippery, and stretchy (similar to raw egg white), which is the peak day of such mucus. After the peak day ends, dryness (infertile) will appear and will last until the next period. After the peak day ends, dryness (infertile) will appear and will last until the next period. Dr. Okour- Fertility awareness

12. 12 Dr. Okour- Fertility awareness AppearanceFinger Test Sensation at Vulva Early Mucus Scanty Thick White Sticky Holds its shape Moist or Sticky Transitional Mucus Increasing Amounts Thinner Cloudy Slightly Stretchy Wetter Highly Fertile Mucus Profuse Thin Transparent Stretchy (like raw egg white) Slippery

13. 13 Combining the temperature and mucus recordings This is a 28 day cycle with a five day period. The first mucus is recognized on Day 9 as a moist sensation. Peak day is Day 14 (the last F day). The temperature shift is observed on day 15. The mucus on days 27 and 28 is related to hormonal fluctuations prior to the next period. Any mucus observed during the post-ovulatory infertile phase can be disregarded. The couple are using Fertility Awareness to avoid pregnancy. They had intercourse on alternate dry evenings 6 and 8 and then abstained from the onset of the mucus symptom until the postovulatory infertile phase was confirmed by the third high temperature past peak day on day 17. The rest of the cycle was then available for unrestricted intercourse

14. 14 Fertility awareness (FA): 3. Changes in the cervix: Low, long, firm, closed, and dry cervix indicates infertility. Low, long, firm, closed, and dry cervix indicates infertility. High, short, soft, and open cervix indicates fertility. High, short, soft, and open cervix indicates fertility. 4. Calculation of cycle length: Based on the length of a woman ’ s previous 6-12 menstrual cycles. Based on the length of a woman ’ s previous 6-12 menstrual cycles. The length of the shortest and longest cycle are used to identify the likely fertile time. (Shortest cycle minus 20 = first fertile day, longest cycle minus 10 = last fertile day). In regular long cycles 26 – 32 days cycle, standard day rule may be applied (first fertile day is day 8, and last fertile day is day19). The length of the shortest and longest cycle are used to identify the likely fertile time. (Shortest cycle minus 20 = first fertile day, longest cycle minus 10 = last fertile day). In regular long cycles 26 – 32 days cycle, standard day rule may be applied (first fertile day is day 8, and last fertile day is day19). 5. Minor changes: include abdominal pain, abdominal heaviness, breast tenderness, back pain. Dr. Okour- Fertility awareness

15. 15

16. 16 Fertility awareness (FA):  Planning pregnancy: Conception is possible at any fertile day, but most probably with fertile mucus present, which is within two days prior to peak day. Conception is possible at any fertile day, but most probably with fertile mucus present, which is within two days prior to peak day.  Avoiding pregnancy: Couples should learn accurately identify the phases of fertility and infertility by observing and recording the indicators of fertility. Couples should learn accurately identify the phases of fertility and infertility by observing and recording the indicators of fertility. Some factors may disturb the cycle and affect the recordings. These include stress, travel, illness, medication, late night, and others. Some factors may disturb the cycle and affect the recordings. These include stress, travel, illness, medication, late night, and others. Dr. Okour- Fertility awareness

17. 17

18. 18

19. 19