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Natural contraception using the Billings

ovulation method

Article in The European Journal of Contraception and Reproductive Health Care July 2002
DOI: 10.1080/ejc.7.2.96.99 Source: PubMed

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The European Journal of Contraception and Reproductive Health Care 2002;7:9699

Natural contraception using the

Billings ovulation method
E. Attar, S. Gokdemirel*, H. Serdaroglu and A. Coskun
Division of Reproductive Endocrinology and Infertility, and *Women and Child Health Education and Research Unit,
Department of Obstetrics and Gynecology, Istanbul Medical School, Istanbul University; Florence Nightingale
Nursing School, Istanbul University, Istanbul, Turkey

ABSTR ACT Objective The Billings ovulation method (BOM) is a medical model of a natural
procreation education method based on scientific observation of the changes in the cervical
mucus. In this study we examined Turkish womens interest in accurate usage of
cervical mucus changes in determining the ovulation time.
Method Fifteen regularly cycling women monitored their fertility patterns in 30 cycles
using the BOM and urine luteinizing hormone (LH) kits. At the end of each cycle, the cervical
mucus monitoring chart and LH kits were collected from the subjects and analyzed.
Results The cervical mucus symptoms defined a potential fertile period of 10 days average
length, with the peak mucus characteristic occurring at a mean of day 13.65 2.62 of
the cycle. The duration of the LH surge, as observed in early morning urine samples, averaged
5 days, with the peak occurring at a mean of day 13.40 2.58 of the cycle. Data indicated
that there was a strong correlation between LH in the urine and the peak in self-observed,
cervicalvaginal mucus (p = 0.001).
Conclusion This study proved that women can distinguish patterns of ovulation and
anovulation by self-detection of variations in cervical mucus characteristics, and that urinary
LH levels strongly correlate with ovulation.

K E Y W O R D S Billings ovulation method, Cervical mucus, Urine luteinizing hormone

INTR ODU CTION

Despite the introduction of countrywide education
programs and easy accessibility of family planning
services that provide modern contraceptive methods,
traditional natural contraception is still the most
frequent method of contraception used in Turkey.
There exists a positive association between the educa-
tional level of both spouses and the use of
contemporary contraceptive methods. Therefore, it
would be a pragmatic approach to promote the use of
the most reliable method of natural family planning
(NFP) in this country. A womans educational level is a
stronger predictor of method choice than is that of her
husband1. The Billings ovulation method (BOM) is a
medical model of a natural procreation education
method, based on the scientific observation of changes
in the cervical mucus, which becomes clear, slippery
and copious in the periovulatory period2,3. Women
can detect their approximate times of ovulation
through the self-observation of mucus.
The method has many uses. It is possible to prevent
pregnancy by avoiding intercourse during this period.
The method can also help to combat various problems

Correspondence: Dr E. Attar, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Istanbul
Medical School, Istanbul University, P.O. 30 CAPA, 34272, Istanbul, Turkey
MS 2202
Received 111001
ORIGINAL AR TICLE 96 Accepted 23402
The Billings ovulation method
of childlessness. The woman becomes familiar with her
body and its functions. In this study, we examined
Turkish womens interest and accurate usage of
cervical mucus changes in determining the time
of ovulation. Urine luteinizing hormone (LH) kits
were used to check the accuracy of the womens ability
to judge ovulation by cervical mucus changes.
The present study may also play a role in promot-
ing the use of LH kits as an adjunctive device in
the education and use of NFP methods.
M ATER I ALS AN D M ETHO DS
We evaluated 30 natural cycles from 15 subjects
who were selected from women who applied to the
Women and Child Health Education and Research
Unit, Istanbul Medical School, Istanbul University, for
training in BOM. They were between the ages of
25 and 43 years (average 32 years), had no known
fertility problems and were not on any type of medica-
tion affecting the cervical mucus pattern of the ovula-
tion cycle. Their gynecological examination revealed
normal findings and no vaginal discharge was noted.
These subjects had learned to monitor their fertility
patterns using BOM. After participating in the educa-
tion program we introduced, all of the participants
became familiar with the cervical-mucus monitoring
charts and completed at least one cycle of cervical
mucus charting. Each subject was given a cervical
mucus-monitoring chart to record the characteristics
of cervical mucus, and a self-detection ovulation kit
(urine LH kit; Clearplan, Unipath, UK). This kit
included instructions for its use, and the women were
also given a full explanation by the research team.
For their subsequent cycles they monitored their
cervicalvaginal mucus and tested their urine for LH
with the urine LH kit. The urine LH kits were used
from the beginning of cervical mucus discharge until
the color change on the kit disappeared. At the end of
the womans menstrual cycle, the cervical mucus
monitoring chart and LH kits were collected and
analyzed.
Urine LH measurements
The LH surge in the urine was determined using an
ovulation self-test kit based on enzyme immunoassay
The European Journal of Contraception and Reproductive Health Care
Attar et al.
of the LH monoclonal antibodies in the urine. The
test used has a reported LH sensitivity of 30 mIU/ml4.
The LH surge can be detected as early as 36 h before
ovulation with 98100% accuracy. The reaction time
of enzymes with the antibodies in the urine is about
6 min with ten drops of urine.
R ESU LTS
The cervical mucus symptoms defined a potential
fertile period of 10 days average length, with the
peak mucus symptom occurring at a mean of day
13.65 2.62 of the cycle. The duration of the LH
surge, as determined in early-morning urine samples,
averaged 5 days, with the peak occurring at a mean
of day 13.40 2.58 of the cycle. These results are
summarized in Table 1. The data indicated that there
was a strong correlation between the LH in the urine
and the peak in self-observed cervicalvaginal mucus.
Analysis of data from the women who used BOM and
urinary LH kits revealed that Pearsons correlation
coefficient (0.956) was significant at the 0.01 level
(two-tailed) (p < 0.001). Urine LH levels were
elevated from 1 day before to 2 days after the cervical
mucus peak, when they were particularly high. Mucus
sensations and characteristics yielded a significant
correlation when simultaneously evaluated with
urinary LH levels. High fertility potential was also
indicated by pregnancies resulting from intercourse
during or immediately after the cervical mucus
peak. One of the women achieved pregnancy in
the first cycle of fertility-focused intercourse, and
two achieved pregnancy by the second cycle.
Using BOM, none of the 30 cycles failed to detect
ovulation.
Table 1 The day of ovulation as predicted by the
Billings ovulation method (BOM) and measurement of
urine luteinizing hormone (LH). Results are presented
as mean SD
Day of menstrual cycle when
Method ovulation occurred
BOM 13.65 2.62*
Urinary LH 13.40 2.58*
*p = 0.001, Pearsons correlation coefficient (0.956) is
significant at the 0.01 level (two-tailed)
97
The Billings ovulation method Attar et al.

DISCU SSION health professional15. If couples have a better under-

standing of fertility awareness, they are in a stronger
All of the participants learned to recognize their
position to make informed decisions about how they
cervical mucus pattern as described in the BOM. In 30
wish to manage their reproductive and sexual health.
cycles, cervical mucus peak observed by the women
Effective use of NFP is strongly dependent upon
indicated ovulation. Therefore, our study confirms the
adequate instruction16. Therefore, self-observation of
conclusion reached in earlier studies that there is a
cervical mucus, when taught by a qualified family
direct correlation between cervical mucus changes
planning advisor, would be an effective and usable
and the potentially fertile phase of the cycle5,6. The
method, not only for family planning, but also repro-
accuracy with which the women were able to detect
ductive health. The method can also provide help in
changes in the cervical mucus pattern was demon-
various problems of childlessness17, as in our study
strated by the hormonal assays in urine. Our study
group, three of the women achieved pregnancy as they
revealed that peak mucus symptoms correlated well
had planned.
with the time of urinary LH surge. These results are
NFP can be placed among methods of great theo-
comparable to the studies reported in references 79.
retical effectiveness. However, the time during which
Although they found only a 47% correlation with the
implantation can occur varies widely in the menstrual
cervical mucus changes, Guida and associates have
cycle18 and the timing of this fertile window can be
shown that measurement of urinary LH level is an
highly unpredictable, even when menstrual cycles are
accurate method for the determination of ovulation
regular. Despite accurate identification of this fertile
and there was a 100% correlation of the latter with
phase, unwanted pregnancies are frequent. Therefore,
simultaneous ultrasonographic diagnosis of ovula-
NFP is not as effective as modern contraceptive
tion10. In our study, urinary LH levels were elevated
methods.
1 day before, and particularly 2 days following, the
In this study, changes in cervical mucus characteris-
cervical mucus peak. According to the World Health
tics defined a potential fertile period of 10 days
Organization, a surge in LH level in the urine takes
average length. This is a long period of time for
place about 6 h after ovulation11. Our results are in
couples who do not desire pregnancy. The Two-Day
agreement with this data because ovulation usually
Algorithm is also an observation-based method for
occurs 3 days after the cervical mucus peak. Cervical
identifying the fertile phase. It classifies a day as fertile
mucus symptoms could also be used as a guide for the
if cervical secretions are present on that day or the
timing of blood or urine samples for estimation of
day before 1921. This approach may be an effective
LH12.
alternative to the ovulation methods for some
Although they are considered outdated, the rhythm
regions where the current NFP methods are difficult
method and coitus interruptus are the most frequent
to implement.
techniques of contraception used. A significant
number of women worldwide use periodic abstinence
as their contraceptive method13. In Turkey, approxi- CONCLU SION
mately 63% of women of reproductive age use a con-
traceptive method. Of these women, 27% use natural The biological basis for the application of NFP
contraception to avoid pregnancy. In India, there is methods is the determination of the time of ovulation
an increasing usage of natural contraception among and thus of the fertile period. NFP is cheap, effective,
women over 35 years of age14. Many couples seeking without side-effects and may be particularly acceptable
family planning advice also request information about to those who are interested in learning about and using
natural and traditional methods of family planning. NFP. The method can also help to combat various
However, many more couples could also benefit problems of childlessness. This study proved that
from information about fertility awareness. Fertility women can distinguish patterns of ovulation and
awareness involves understanding basic information anovulation by self-detection of changes in cervical
about fertility and reproduction, being able to apply it mucus characteristics, and that urinary LH levels
to oneself and to discuss it with a partner or with a strongly correlated with ovulation.

98 The European Journal of Contraception and Reproductive Health Care

The Billings ovulation method
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