Background
Effectiveness studies in Natural Family Planning (NFP) published over the past 20 years have shown a wide range of contraceptive efficacy and acceptability. This in part seems to be due to different NFP methodologies. Consequently, we decided to carry out an effectiveness study in Europe to examine one group of the most widely spread NFP methods, the symptothermal methods.

Methods
Between 1989 and 1995, 15 NFP groups from 10 European countries participated in a prospective European multicentre study. This paper relates to l328 women aged between 19 and 45 years and willing to participate for at least 12 cycles. Two types of symptothermal methods are mainly used, the symptothermal double-check methods (1046 women, 16865 cycles of exposure, 34 unintended pregnancies) and the symptothermal single check methods (214 women, 1495 cycles of exposure, 13 unintended pregnancies). The study was an observational study with prospectively collected data. The pregnancy rates, drop-out rates and lost-to-follow-up rates are presented separately for both subgroups according to the Kaplan-Meier method. The data are additionally analysed to find possible correlations between the occurrence of unintended pregnancies and several demographic variables.

Results
For the double-check methods, there was an unintended pregnancy rate of 2.6% at the end of the first 12 cycles of use (standard error or SE 0.55%), a drop-out rate for difficulties or dissatisfaction of 3.9% (SE 0.69%) and a lost-to-follow-up rate of 3.l% (SE 0.62%). In the single-check group there was a total of 13 unintended pregnancies at the end of the first 12 cycles of study participation giving an unintended pregnancy rate of 8.5% (SE 2.52%), a drop-out rate for difficulties or dissatisfaction of 3.0% (SE 1.76%) and a lost-to-follow-up rate of 23.4% (SE 4.35%). No pregnancy was observed in women over 40 years of age. Most pregnancies occurred because of deliberate unprotected intercourse in the fertile phase ("user failure").

Conclusions
The symptothermal double-check methods have proved to be effective family planning methods in Europe. The low drop-out-rate for difficulties or dissatisfaction with NFP shows the good acceptability.

I want to present to you my diagrams which can help users and teachers of the double check method (“English method”). My idea is based on the fact that about 80% of information reaches to a human brain through the eyes. Because of that the best effects of teaching is given by presenting words and images at the same time. My diagrams were consulted with the president of the Polish Association of NFP Teachers doctor Hanna Ceranska-Goszczynska. They were presented in four numbers of Bulletin of the Polish Association of NFP Teachers (27, 28, 29-30, 31/98).

There are five diagrams – one for an ordinary cycle and four for particular situations (breast feeding and return of fertility – 2, post-pill period –1 and premenopause –1). The diagrams show rules of recognition the beginning and the end of the fertile phase. As an example, the diagram for an ordinary menstrual cycle is shown below.

Fig. Recognition of the fertile phase in an ordinary menstrual cycle (by the double check method).

The bead system was developed as a mucus-only modification of existing ovulation and sympto-thermal methods. Instead of a chart, the system uses colored beads to monitor cycle days and fertility phases. Standard mucus observations are taught so that women may identify and categorize mucus as “dry, sticky or egg-white.”

For women with regular cycles, the first day of vaginal bleeding is marked with a large red bead with a white stripe (the “day one bead”.) Subsequent days of bleeding are marked with red beads. Using the guidelines of the “six day rule,” a large red bead with a green stripe (the “caution-day bead”) is placed at day six. After “caution-day,” green beads are placed day to denote “sticky” or “egg-white” mucus. Peak day is marked by a large green bead with a yellow stripe (the “peak-day bead”.) Four days of drying up past peak day are identified by half-green and half-yellow beads (“drying up beads.”) Post-ovulatory infertility is presumed on the evening of the fourth drying up day. Yellow beads are then placed for subsequent ‘dry” or “sticky”days. Gold beads are used to denote coitus and are placed after the specific bead of that day. During the instruction phase, the gold beads serve as a marker to insure method comprehension.

The bead system can be taught to women and couples with differing educational backgrounds. Instruction in the bead system also includes teaching in regard to individual cycle variation, lactational amenorrhea and “transitional” bead use (the return of fertility after LAM, pre-menopause, irregular cycles and after discontinuation of hormonal contraception.) The method is taught through an interactive format in which canvas drawings or slides are shown and the teacher first “listens and asks questions.”

The method has been favorably introduced in sites in Cameroon, Ghana, Mexico and Montana, USA.

In April of 2000, Kay Ek will have attended an international conference and teacher training in Melbourne, Australia. She will bring to Milan, the latest news from Drs. John and Lyn Billings. Her presentation will also update conference participants on the Billings Ovulation Method in the United States.

The presentation will include the simplicity of teaching and learning the Billings Ovulation Method based on years of scientific discoveries and updates received at the Billings Conference in Australia in April 2000.

The presenter will discuss developments in the promotion of the Billings Ovulation Method in the United States. This will include a brief discussion of materials that are available including WOOMB-approved slides, video and audio tapes, books as well as the use of local media to publicize upcoming classes.

There will be time left for questions and answers.

Objectives
The Billings Ovulation Method (BOM) can be very useful for diagnosis not only of ovarian disorders but also of cervical-vaginal pathologies (CVP), since it is based on cervical mucus, a physiological parameter which is very reliable and indicative of both ovulation and cervical function. This study is carried out in order to verify the diagnostic - preventive value of BOM for CVP, especially for subclinical and asymptomatic forms, which can be revealed through an abnormal pattern of mucus symptom

Study Methods
A protocol for study on CVP was elaborated to include those cases where an abnormal pattern of cervical mucus symptom recorded according to BOM had been found. A normal ovarian function was proved by hormonal assays or basal body temperature assessment. The protocol scheduled an accurate check of the low genital tract through cytologic-colposcopic examination and vaginal-cervical coltures. The sample analyzed consisted of BOM users wishing to avoid pregnancy, infertile patients using BOM to achieve pregnancy and women using BOM to study their menstrual cycles. The recording of cervical mucus symptom was examinated both in diagnostic and in therapeutic phase to point out how the symptom pattern was related to the kind of pathology and how it changed as a result of pharmacological or physical therapy.

Results
The study concerned 185 women BOM users clinically asymptomatic for CVP. Pathological results were found in 89% of colposcopies and in about 60% of cytologic examinations. In 40,66% of cases cervical HPV (Human Papilloma Virus) and/or ANTZ ( Abnormal Transformation Zone) type 2 were recognized. It is widely admitted the importance of these pathologies because they are potentially carcinogenic. The cervical-vaginal coltures were positive in 45,63% of cases: 78,7% diagnosed infections consisted of sexually transmitted diseases. The clinical check - up and the recording examination showed a more or less complete recovery of normal mucus symptom due to a resolved pathology and the return of normal cervical function.

Conclusions
This study confirms the already known importance of cervical mucus as reliable indicator of cervical function and the BOM’s usefulness for an early diagnosis of CVP, some of them frequently appear as subclinical and asymptomatic forms. Our results show the diagnostical-preventive importance of BOM for health and, particularly, for reproductive health. Moreover, it proves how possible difficulties in the application of BOM to avoid pregnancy can be overcome and how it is possible to diagnose and treat the infertility connected to a cervical factor.

Natural Family Planning was unknown in Viet Nam when we began to teach it in 1994.

First we worked with VINAFPA, Vietnamese Family Planning Association, in Hà Nôi and then in Nam Dinh and Ninh Binh Provinces, to train their staff and health workers. Gradually we were asked to train people from districts where Catholicism is dominant (46 to 55% of Catholics). These people mostly refuse contraceptive technics and abortion and are expecting for a better method than the classical Ogino one. This training takes place in rural areas as well as in Hà Nôi parishes. In Hà Nôi we also work with the ³Women Union². In 1999 we were asked to train nuns and couples in Da Nang, Hué, Ho Ci Minh City where NFP program begins.

We based our method on mucus observation and temperature chart. Self Observation Method (M.A.O. in French) became T.Q.S. in Vietnamese. We produced pedagogic items suitable to rural alphabetized people: booklet for user, booklet for monitor with pedagogic advice, leaflet for information, paintings preserved between plastic for teaching.

Sensibilisation period took a long time. It is still difficult to identify the actual number of users. However, TQS clubs begin to work. In Hà Nôi, information leaflet is distributed to all couples preparing their wedding and a monitor couple has just opened a consulting office in a church room. The women of ³Women Union² organise information in suburbian districts. Monitors are being trained in all mentioned towns.

Our program has technical and financial support from Fondation Leïla Fodil - Angoulême; financial help from Kirche In Not - Köln, Allemagne ; logistic help from C.G.F.E.D.- HàNôi. We aim at vietnamese autonomy in this program by the end of 2000.

Objective:
Offering for the women who desire an alternative to become pregnant with the collaboration between Cenplafam (Familiar Planning Center) and the Municipal Health Service Theory of studying : To become pregnant if for the majority is a natural and direct fact, for some women and couples the subject becomes difficult by several factors: since psychological problems until not harmony of the moment maximum fertility with the presence of the gametes for a fecundation until other factors more directly joined to the organic conditionals.

Method:
Individual attendance with the application of the Billings Ovulation Method

Results:
In Brazil, the Natural Planning Center has been showing positive in many cases when is identified blocking psychic factors of the conception, factors of compatibility of the sexual relationships with the fertile period, or till dependent factors of a posture more adapted for the free conception from pressures and tensions that end up modifying the own organic conditions.

Benefit for the population:
In all the Municipal Health Centers prevails the attendance for the contraception, for such it is guided in a priority way the attendance with the whole available human and technical arsenal.

The principal benefit is to become pregnant for who desires it a lot. Besides, offering a knowledge more natural about the ovulatory cycle and have a responsible paternity and maternity. For the population the absence of contraceptive medicine that generally cause problems for the woman and economic difficulties, more conjugal harmony mainly by the observation of the couple. We have an important experience in Curitiba-Paraná with a contract between CENPLAFAM AND MUNICIPAL HEALTH SERVICE. It is called CURITIBANA MOTHER . It works with a special attention for the mothers, in all ages, during the maternity. Although in initial phase it has been presenting important results.

Conclusions:
The life in first place. Positive experiences always make grow the hope, so we are interested in presenting our experience.

Objectives
Natural Family Planning (NFP) reliability depends on the correct identification of the fertility phase, in order to help motivated couples to achieve or postpone pregnancy. It is known that BOM users who have regular cycles usually do not need any hormone assays or other complicated and expensive techniques. To use the BOM correctly, couples have to be adequately trained in accredited Training Centers, where they learn to identify the phases of fertility and infertility with considerable precision and are helped to understand the real meaning of Responsible Procreation. However, for some particular circumstances of women’s reproductive life, as weaning, perimenopausal, postpill or long and irregular cycles, some diagnostical instruments can offer a scientific and valid aid to NFP. The aim of the present study is to confirm how women’s observations, following the BOM guidelines, are as reliable as modern laboratory tests. Besides, we demonstrated the BOM’s applicability in every situations of women’s life, even in anovulatory/irregular cycles.

Methods
We selected 10 breastfeeding women, 8 approaching menopause women and 5 women affected by endocrinological-gynaecological diseases (2 of them used the BOM to achieve pregnancy). All were BOM users and were monitored with hormone assay for an average of 29+/-2 days using the Brown’s Ovarian Monitor (OM) (St. Michael NFP Services, Pty. Ltd, Melbourne). This instrument utilizes a “homogeneous enzyme immunoassay” to measure estrone glucuronide (E1G) or pregnandiol glucuronide (PdG) in a timed specimen of urine. The hormone values are expressed in nmol/24 hrs and mmol/24 hrs +/- SEM respectively and the sensitivity of the system is 25-50 nmol/24 hrs for E1G and 3 mmol/24 hrs for PdG.

Results
The simple observation of the cervical mucus symptom all along the cycle, according to the BOM, had already allowed the women to interprete the possible anovulatory pattern, to identify an inadequate length of the luteal phase or the “non-menstrual nature” of bleedings (when they were not preceeded by Peak identification that, as explained by BOM, indicates ovulation). The hormone assays had already confirmed the reliability of the women’s interpretations. In all the subjects the E1G baselines were detected, which corresponded to individual infertile pre-ovulatory pattern (identified as Basic Infertile Pattern by the BOM). This situation is characterized by an ovarian inactivity and can be used positively by the couples wishing to postpone pregnancy. Significant variations in the mean value of E1G baseline were not observed in the different groups, in spite of the different typology: Group A E1G baseline = 119.3+/-5.49 nmol/24 hrs; Group B = 123.8+/-4.82 nmol/24 hrs; Group C = 131.4+/-8.5 nmol/24 hrs. In 62.5% women ovulatory events were confirmed through the identification of the pre-ovulatory estrogenic peak followed by PdG rise. In the 4 ovulating breastfeeding women, that was the first ovulation after delivery and it was always associated with an inadequate luteal phase (mean length of luteal phase = 8.5+/-2.3 days; mean value of PdG = 6.78+/-0.66 mmol/24 hrs). In 3 cases the use of hormone assay allowed to exclude the hormonal origin of some bleedings due not to estrogenic endometrial stimulation, but to different problems: 1 case with uterine fibromas, confirmed by pelvic ultrasound scan; 2 cases with cervical phlogistic pathologies, confirmed by colposcopy. 2 subfertile women obtained pregnancy in the next cycle without therapy, following BOM instructions.

Conclusions
The Billings Method proved successful being applicable to every phase of the woman’s reproductive life, whether her cycles are regular, irregular or anovulatory. The Ovarian Monitor realized by Brown is one of the most accurate technique available to study ovarian activity. The combination of hormone assays with the mucus symptom observations can be very useful to detect potentially fertile days in special circumstances as well as to evaluate abnormal situations of medical interest. In fact it helps physicians to make differential diagnosis and find adequate therapies, as it offers objective data about the actual ovarian activity.

(*)Present address: Instituto de Medicina Reproductiva - Belgrano 854, (5500) Mendoza, Argentina.

CA-125 is an antigenic determinant on a high molecular weight glycoprotein expressed by tissues of Müllerian origin in the female genital tract. Evidences have been found demonstrating that CA-125 is synthesised and secreted by normal endocervical cells, with high concentrations in cervical mucus (CM). This prospective study was aimed to determine CA-125 levels in CM during the menstrual cycle of normally ovulating women and its relationship to gonadal steroids and ovulation.

Thirteen women with a normal fertility work-up participated during two consecutive cycles. CA-125 and proteins concentrations were measured in CM samples collected from the endocervical canal on alternate days in the early follicular and luteal phases and on daily basis around the periovulatory period. Results were correlated with hormonal determinations, serum CA-125 levels and ultrasound findings.

Twenty ovulatory nonconceptional cycles were analysed. The mean (±SD) concentration of CA-125 in CM (173,900 ± 128,900 U/mL) appeared relatively constant, with a large variation between the different samples, ranging from 9,000 U/mL to 830,000 U/mL. No clear trend could be detected as related to hormonal changes and ovulation. However, when mucus CA-125 concentration was multiplied by the total volume of the correspondent sample, a clear periovulatory increase of total CA-125 levels was found. This was further supported by the similar trend showed by the calculated CA-125: proteins concentration ratio.

Conclusions:
CA-125 is present in CM in high concentrations that vary widely along the cycle. Moreover, an increase of total CA-125 levels parallel to the augmented mucus production was observed during the periovulatory period. Associated variations in the concentration of this glycoprotein in cervicovaginal fluid (CVF) could serve to delineate the occurrence of the fertile period. By this way, a more objective parameter could be added to methods based in either subjective determination of CM physical changes or the measurement of CVF volume alone.

Are saliva cristallization tests useful for Natural Family Planning (NFP)?

Objectives

1. Count ferning pattern days on fertile-type mucus days
2. Count no-fern days on days during sympto-thermal post-ovulatory infertility.
3. Evaluate users’ satisfaction.

Methods
Three saliva cristallization home devices, OVU-TRAC, LADY-FREE and PC-2000, were tested by 16 experienced sympto-thermal method users during 97 cycles. Percentages were calculated for days when the expected ferning pattern, sign of estrogen action, was found on days of fertile-type mucus. Percentages were calculated for days without ferns, during the sympto-thermal post-ovulatory days, when progesterone is supposed to inhibit the ferning pattern

Results

1. %, 24 % and 9 % of the days of fertile-type mucus, for OVU-TRAC, LADY-FREE and PC-2000 respectively. Adding days when a transitional image (very few ferns or mere alignment of For the most fertile phase of the cycle, the expected clear ferning pattern was observed in only 38 cristals) was observed, we reach only 70%, 59 % and 32 %.
2. For the post-ovulatory phase, the expected absence of ferning was observed in only 55%, 57% and 87% of the sympto-thermal infertile post-ovulatory days, for OVU-TRAC, LADY-FREE and PC-2000 respectively.
3. Eleven participants found the test difficult to do, 15, difficult to interpret and 15, not reliable. They complained about contradictions with their NFP signs, about different results after a few more hours and from one cycle to the other, about the absence of clear fertility start and end, about time consumption and focus adjustments.

Conclusion
Compared to recognized signs of fertility and of infertility, results of saliva cristallization tests are not satisfactory. Not showing fertility when other signs herald it may cause unplanned pregnancy. Showing fertility signs during a phase demonstrated as infertile is confusing and stressful for the couple wanting to avoid conception. They are not recommended as alternatives nor as complements for NFP purposes.

Objectives
The purpose of this study was: A) To correlate the self-detection of LH surge in the urine with the self-observation of cervical mucus. B) To compare different methods for measuring the lenght of fertil phase: a) Detection of urinary LH peak (EVAPLAN) associated to the self-observation of the cervical mucus (Mucus-LH) b ) Sympto-thermal Method (STM) c ) Ovulation Method (OM) and d) Monitor Persona (MP)

Materials and Methods
A group of 18 regularly cycling women ( 20 to 45 years old) were trained in fertility recognition. A total of 78 regular cycles were recorded. In each cycle the following parameters were recorded: change in cervical mucus, mucus peak day, basal body temperature (BBT) , the dates each women had had sexual intercourse, and the urinary LH peak in the first morning urine sample (immunoreactives strips, EVAPLAN; ROCHE) which takes place 24 to 36 hours before ovulation. The termination of the fertile phase was set at the night of the 2nd day post LH surge as detected by Evaplan, because ovulation takes place 24 hs after the LH peak, and the ovum lives 24 hours after ovulation. Three women used MP daily during 17 out of 78 recorded cycles. The length of the fertil phase period was measured with strict compliance with each method's instructions. The means were compared overall with the nonparametric Kruskal-Wallis Test and pairwise with Dunn's Test. In 8 cycles, three women had sexual intercourse at the night of +2, +3 and +4 day post LH peak, which correspond to the fertile phase period (on the days +1,+2 or +3 post the mucus peak day) according to the Ovulation Method.

Results

1. The mucus peak coincided with the in LH surge 33% of the cycles. In the other cases, it appeared one day before (3%) or either the following day (36%) or two days after (19%) the surge in LH.
2. The means ± SD of the fertile phase length were: Mucus-LH surge, 8.28 ± 1.86 days ; Sympto-thermal method, 12.80 ± 2.20 days ; Ovulation Method, 11.25 ± 2.09 days and MP, 9.79 ± 2.22 days. These results showed that the STM requires a large period of abstinence than the OM, and this one a larger than the MP and Mucus-LH surge. The length of the fertile phase period determined by the Mucus-LH method was statistically similar (P>0.05) to Persona's value, but significantly different to MST or MO values (P<0.001).
3. There were no pregnancies in those cycles where sexual intercourse took place during the fertile phase detected by the OM method, when in fact the fertile phase was over according to EVAPLAN.

Conclusions
The high range of coincidence as detected by indicators of mucus peak day and LH surge showed that the immunoreactive strips are reliable for detecting ovulation and consequently for assesing the length of the period of abstinence in the fertile phase.

Objective
To determine the usefulness of the ovarian Brown monitor in the hormonal follow-up of urinary estradiol (E1G) and pregnanediol glucuronides (PdG) in women with primary infertility undergoing ovulation induction (OI) with recombinant FSH (Puregon). E1G and PdG levels were compared to normal cycle curves.

Materials and Methods
10 patients with an average of 3 years of infertility and 34 years of age, were included in this study. Their basal E1G and PdG levels were measured on day 3 of the cycle. In relation to this level, ovulation induction was initiated with doses of 50, 75 or 100 IU of recombinant FSH for four days. In day 4, according to the ovarian response measured by the urinary E1G level obtained, doses of FSH were increased in 30 % and given for another four days. A mean of 800 IU of FSH were used in each O.I. cycle. HCG (5000 IU) was given to initiate ovulation when E1G levels reached between 500-1000 nmol/24 h and PdG levels were <4.0 umol/24 h. The presence of 1, 2 or 3 follicles between 17-19 mm was required for the HCG shot. The mean value of E1G obtained before the HCG shot was 899 nmol/24 hrs and PdG was 3.9 umol/24 hrs. In normal non stimulated cycles an average of 140 nmol/24 h was reached in the day of follicular rupture.

Results
All patients presented follicular response and ovulation. Five of them got pregnant, with four normal term pregnancies and one first trimester abortion. One patient presented mild ovarian hyperstimulation during a conceptional cycle with a twin pregnancy.

Conclusions
The usefulness of the ovarian monitor for hormonal determination of E1G and PdG during ovulation induction was demonstrated. It allowed to make a personalized OI protocol which gave in the present study a 50% pregnancy rate.

About 45 years ago the German medical technology company Uebe,in Co-operation with G.K. Döring, developed the Cyclotest® women glass thermo- meter; about 15 years ago the development of the first computer Cyclotest was started together with G.K. Döring and the advice of G. Freundl and the NFP-group Germany.

This minicomputer Cyclotest® 2 Plus intergrate next to the high precision temperature measurement and hormone level determination a well sophisticated algorithm, basing on the analysis of thousands of user cycles, and is offering a worldwide unique dataline system to print out a coulered user-fertility-profile by a simple phone call. This easy handle 2-in-1 system offers, depending on the intention, monitoring the fertile phase through the basal body temperature and additionally monitoring the highly fertile phase for natural pregnancy planning by recommendation, when to look for LH peak. An efficacy-finding study by G. Freundl in 1998 confirmed the reliability of the device, published in „ Advances in Contraception“ 1998,14. Until today Cyclotest® 2 Plus is the only system worldwide offering this double check system for achieving a pregnancy.

During our long history of dialogue with Cyclotest® users, Uebe have learned the importance of communication, support and training of the users directly and the people counselling these women. As in the past we will only establish cooperations with partners understanding this philosophy how to realize natural conception or contraception.

We studied symptothermal modifications and signs of return of fertility in 87 mothers, in relation to the type and duration of breastfeeding. In 10 non lactating women out of 87 we observed the return of fertility between 37 and 88 days (mean 59.9 days) after delivery. One out of 87 mothers did not fully breastfeed.

76 women gave a complete breastfeeding for 110.5 ± 50.5 days after delivery. The mean suckling frequency at the last day of full breastfeeding was 5.2 ± 1.13 a day. Symptothermal signs of the return of fertility were observed after a mean of 162.5 days postpartum (a maximum of 440 and a minimum of 41 days) and after 58 days (117 to 288 days) from the end of full breastfeeding period. In 3 women (4.1%) fertility returned during full breastfeeding at 87.7 ± 30.9 days postpartum (52 to 106 days). In these cases the duration of the longest interval between breastfeeds was more than 6 hours.

Out of 73 mothers who had their fertility restored after the end of full breast feeding, 6 (8,2%), did not give a partial breastfeeding and observed the first symptothermal shifts of ovulation at a mean of 40,2 days after weaning . The mothers who after the full breastfeeding gave a partial breastfeeding, for 90,37 + 73 days, observed the return of ovulation at a mean of 65 days after the end of full breastfeeding. The difference between 40,2 and 65 resulted statistically significant (p< 0.005). 52.5% of the women who gave also a partial breastfeeding, had the return of fertility before weaning, with a mean suckling frequency of 3 ± 1.5 a day.

In conclusion we confirm, according to Consensus Conference of Bellagio, that complete breastfeeding, fulfilled certain conditions, provides a lactational infertility in more than 98% of the mothers in the first six months. If the duration of the longest interval between breastfeeds is more than 6 hours, ovulation can rarely occur at the second month post partum.

Breastfeeding is associated with the suppression of ovarian and thus with a variable period of amenorrhea and infertility. The duration of infertility varies between individual women, between societies and appears to depend largely on infant feeding practices. Women who breastfeeding their infants frequently and who delay the introduction of supplementary feedings tend to remain amenorrheic for a longer period.

A study was conducted to determine the relation between infant feeding patterns and the duration of amenorrhea in Italian women. Most of them attended at the "La Leche League" meetings; it is an international organization that support and give information to breastfeeding mothers. Generally these are women who fully breastfeed their babies for five-six months and who continue to breastfeed for one year or more. In this study menses was chosen as a proxy for the recovery of ovulation and thus for the return of fertility because it is a discrete event that it easily recognized and recalled. Menses was defined as 2 consecutive days of vaginal bleeding with at least 1 day requiring sanitary protection. Bleeding episode that occurred before the 56th day postpartum was ignored, in agreement with LAM guidelines.

Our analysis show that the duration of amenorrhea is not only relate to the usual breastfeeding pattern (number, frequence and space between feedings). In detail we observe that some behavior show their significance in contributing to the overall effect: baby not having a pacifier; having above all night feedings; having frequent contact mother-baby; baby having a correct way of sucking at the breast, especially soon after the birth. Furthermore supplementation and scheduling of breastfeeding, as well as episodes of mother-baby separation, all increase the mother's change of ovulation after childbirth.

Most of the contributions to the topic "NFP and partnership" have been concentrating on the (slightly apologetic) question: Can practising NFP have a positive effect onto the quality of relationship?

Fortunately we can answer by now: Yes, it can! But beyond hypotheses we have spare real information about the way it really works. We have to study the process qualitatively, not only to be able to support the method, but to help the users to turn it into a way of life.

There is a scientifically articulated model of fertility integration (Fehring). This model sees fertility integration taking a couple through four stages or level of growth, such as 1. Contraceptive Attitude Level 2. Ecological Level, 3. Intimacy Level and 4. Transcendental Level. The model seems to be worth testing in the narratives of couples, and partly using it as a theoretical framework in understanding the process mentioned above.

This year the authors started a longitudinal study with support of NFP-Hungary to attain answers to these questions. This study is based mainly on interviews and on their processing by means of content analysis.

Methodology and first results are to be presented in the conference.

The aim is to present not the results of research but of reflection on the importance of Fertility Awareness Education in its own right and not merely as a the first stage in natural family planning, which will be referred to as FASU: family planning by Fertility Awareness and Selective Use. 1. Justify the neoacronym FASU: (1) it avoids the negative connotations and prejudices attached to NFP; (2) expresses the two stages of NFP; (3) indicates that the couple remain in control and have not handed it over to an artefact or pharmaceutical.

Fertility Awareness is a “New Form of Literacy”, enabling women to read messages about themselves in signs with which they know but have not understood.

Relevance of Fertility Awareness Education to some social problems in Africa.

1. POOR BASIC EDUCATION. See # 2 above.
2. POVERTY. Large families are often a result of poverty and aggravate it.. Fertility Awareness disposes people to plan their families and enables them to make an informed choice of a method. Women with properly spaced children have time for economic activities.
3. POOR NUTRITIONAL STATUS. Family Planning makes the food supply go further. For the relationship of Fertility Awareness to family planning, see above.
4. THE “PPE SPIRAL”. UNICEF has shown how POVERTY-POPULATION-ENVIRONMENT are aspects of one problem. Intervention in any one affects the others. Fertility Awareness affects poverty and environment through family planning and population.
5. FAMILY PLANNING. Fertility Awareness is a condition for an informed choice of a method. One does not have to believe in Humanae Vitae to think that Fertility Awareness should be integrated into development programmes.
6. POOR HEALTH OF WOMEN & CHILDREN + INADEQUATE MEDICAL SERVICES. Fertility Awareness disposes people to practise natural family planning, which contributes to maternal and child health. This relieves the pressure on medical services.
7. LOW STATUS OF WOMEN: Fertility Awareness increases a woman's self-understanding, helps her to appreciate her fertility and shows her how she can be in charge of it. She can dialogue as a partner with her husband about their sexual life.
8. HUSBAND-WIFE RELATIONSHIP. False ideas about fertility result in undesirable practices. Fertility Awareness produces understanding, dialogue, consideration for the other. Experience shows that couples who practice FASU enjoy more harmony.
9. PROMISCUITY. This is a social problem because of HIV. Fertility Awareness disposes people to practise self-control and to respect the place of sex in their total lives.
10. SPREAD OF HIV. People with Fertility Awareness understand how HIV is spread through sexual intercourse and are more likely to be careful about sexual partners.
11. UNWANTED PREGNANCIES. There is pragmatic evidence that teenagers who understand their fertility are more likely to avoid pre-marital intercourse. Fertility Awareness enables married couples to plan their pregnancies.
12. ABORTICIDE. Aborticide results from unwanted pregnancies, If Fertility Awareness reduces these, it also impacts the abortion rate. A pregnant woman who understands what is developing in her after fertilisation is more likely to allow it come to birth.

In the talk will be presented the work of a Natural Family Planning Methods Service in Cracow.

The Service is lead by the Pro Humana Vita Foundation since 1991.

The talk will present:

• methods of co-operation of specialists in our service;
• groups of clients who use our service;
• changes in the number of clients who come for the second and further visits in the years 1996-1999

It has been proved that the natural methods belong to the most reliable ways of family planning. Health harmlessness of NFP is generally accepted. Nevertheless, the use of NFP does not exceed 5 per cent of population mostly. We tried to know the opinions of NFP in different groups of our respondents and to find out the suitable ways of NFP spreading. Our study covered the following four groups of respondents: students of medicine, students of theology (both groups members were attending the last year of their studies), experienced NFP users and participants of NFP courses (asked in their very first lessons).There were 560 persons involved in the study (288 of them were men and 272 women).

Unreliability was considered as the most unfavourable feature of NFP by 88,7 per cent of students of medicine and 92,4 per cent of students of theology. The experienced NFP users and new NFP courses participants mentioned unreliability as the most important feature of NFP quite rarely (1,4 per cent and 5,4 per cent respectively). The experienced users complained of necessity to keep periodical abstinence (62,9 per cent) but three tenths of them (30,0 per cent) found out no negative features in NFP. The beginners (attendants of the first NFP lesson) considered NFP to be too complicated (60,2 per cent).

The most positive features of NFP were found in its health harmlessness by the students of medicine (84,1 per cent) and in moral acceptability by the students of theology (68,2 per cent). But 12,1 per cent of medicine students stated that there is no priority of NFP at all. The experienced users appreciated its reliability (57,2 per cent) and moral acceptability 35,7 per cent) above all. The beginners found moral acceptability and health harmlessness (34,4 per cent to be the most important positive feature of NFP.

It can be concluded that the more a person is engaged in NFP, the more he/she recognizes the real priorities of NFP, and reliability especially. It was proved that instructing basic principles of NNF both students of medicine and students of theology help them to understand better the NFP problem in its complexity.

Pedagogy of the Family” as a new postgraduate specialisation for practising teachers was established three years ago at Eötvös University in Budapest. The subject „Communication in Family Life Education” offered a possibility to integrate NFP into the curriculum as part of the communication of a couple, and as a topic of the pedagogical communication at school at different levels. Constructivism (von Glasersfeld, Siebert) was considered as a theoretical framework of education.

Methodology
A model experiment has been carried out and its efficacy has been tested with a German evaluating method (target feedback of Fiederle) in a group of 20 teachers.

Results
Most percentage of teachers have found the integration of NFP into their postgraduate education informative and applicable for their future practice as pedagogues in family life education.

Conclusion
These results can be considered as first steps in integration NFP into education at university level in Hungary promoting available NFP counselling services and courses.

International reproductive health-care development has emphasised the introduction of contraceptive technology, the language of reproductive rights and the necessity of fertility control as the dominant paradigm in which gains in maternal and reproductive health are to be made.

Such a paradigm inadequately addresses the needs of women and mothers in the developing world. While a decrease in fertility may lower maternal death rates, significant improvements in maternal mortality can only come about through the introduction, provision and utilisation of emergency obstetrical care. The introduction of contraceptive technology invariably decreases the prevalence and duration of breastfeeding, depriving women of the protection afforded by lactational amenorrhea and increasing infant exposure to morbidity and mortality from infectious disease. In Africa, female HIV acquisition will only decrease when the “male-driven” nature of the epidemic is addressed through risk modification that emphasises partner reduction and partner selection.

New models of maternal health advocacy are needed. There is a fundamental unity between the provision of natural family planning and the provision of obstetrical care services that, together, reflect a commitment to the life, health, and well being of women and families. Health-care providers in developing countries should be trained and supported to provide instruction in fertility awareness, basic and comprehensive emergency obstetrical care and tiered levels of AIDS prevention. Achieving such levels of training and support, will necessitate a paradigm shift away from population control models, grounded in the provision of contraceptive technology to relational models that emphasises the life and dignity of the person as the just foundation for authentic human development.

Today there are about 1.5 billion adolescents in the world, In Italy adolescents make up for 11 million of its population. Life conditions have improved in Italy and throughout the world, nevertheless attention dedicated to this phase of life has not yet been enough assiduous and rigorous. Biology and anthropology have often neglected adolescent people, concentrating instead on adulthood ( due to the productive and decisional roles made in this period) or infancy ( because of the special needs and care). However, the adolescent lives in a very complex period of rapid physical, psychological and social change, which is incomparable to any other life stage. Furthermore they live in a time of bio-psychosocial uniqueness ( modification of the somatic aspect, i.e., becoming sexually well defined and especially, modification of the somatic image, i. e. how adolescents see themselves and how they think others see them. In this way, adolescents experiment with their attractiveness and success , a very important aspect for the delicate development of personality. They are easily influenced by environment factors that are sometimes divergent. The barycentre of life relationships is no longer the family.

People outside of the family become significant. Adolescents are also vulnerable to cultural models that offer a biased and influential view of adulthood, especially in the field of the sexuality.

In recent years, specialized centres for adolescents have been established, each with different aims and organizations. Since 1984 the Discussion School of adolescents, Couples and Families have been operative in Corridonia (Macerata). The School has gradually expanded its services and now works with preadolescents, adolescents, couples, families, educators and teachers to realize a large action education. The school’s purpose is to provide adolescents with specific information and discussion of their growth. All the topics, concerning somatic, cognitive, emotional, ethical and social changes are proposed as a “ school of life.” The aim is to give adequate and correct information on psycho-physical health and a formation on sexual and affective growth. Adolescents need qualified people to ask questions in case of need, not only because they are frightened for the seriousness of a problem, but more for the absence of a person they can open up to. Thanks to volunteer specialists and group-co-ordinators, the school helps adolescents with their choices, overcoming crises of identity. This does not give them direct answers, but rather tools to find answers by themselves. The school offers advice and therapy in Psychology, Psychiatry, Sociology, Gynaecology, Obstetric and Paediatrics.

The School presently deals with problematic situations also, but it especially stimulates auto promotion and growth by holding over 3,000 meetings every year. Each year the Directive Committee of the School selects the topics for each course, considering the needs and the psycho-physical and social maturation of each class of adolescents. The school consists in weekly seminars for each age approaching the following topics:

• in preadolescent age- between 10 and 13 years- verbal and non- verbal communication by interactive instruments;
• between 13 and 14 years, adolescence and relationship, especially the influence of others on personality;
• between 15 and 17 years, becoming adults, knowledge and consciousness of the body and its language;
• over 18 years, precedent topics are developed paying attention to the formation and growth of the couple.

Thanks to this way of upbringing, it has been possible a primary prevention (especially, psychological disorders and dangerous behaviours) and a global psycho- affective improvement of the person.

To ensure a continuous development in the activities of NFP teachers of the Arbeitsgruppe NFP (workgroup NFP) an Evaluation of 17 training courses was made in the years between 1990 and 1997. The basis for this evaluation are 334 training-candidates. The results of the written and oral examination which were carried out after the intermediate examination and after the final examination were analysed. The data show that for the most of the training courses (12 courses) the results are relatively good.

The analyses of the 25 categories of errors show weighty mistakes in combination with the use of the rules of NFP and gross mistakes in the exploitation of the mucus interpretation.

The results of the evaluation confirm basically the overall plans of the training courses and also the idea to train special target groups (only doctors or nurses or medicine students..)

Another more training oriented evaluation which was rated by the candidates of 7 training courses (124 subjects) tries to get an idea of the overall plans of the materials that were used during the training’s and how the teaching team worked together, how they were able to transfer the content to the students. The results show that most of the candidates (staggering of the assessment between 60,9% and 93,8%) rated the course, the working method and the knowledge they have gained as overall positive and helpful.

A differentiated Evaluation of the course estimation shows that the combination of the leader team is important. The differences of the data are related to the abilities of the leader team. Leader teams who weren’t able to built a co-operative and trustful relationship to there students influenced the learning success and the experience of the training course itself.

The University of Navarre offers a wide variety of optional courses to the students from all fields as part of the general curriculum towards achieving different degrees. Since 1997, a new course is being offered to the students and is titled "Human sexuality and fertility" with 4,5 crédits (45 hours of theoretical and practical clases). The content of this course includes natural family planning (NFP). Concerning NFP, and at the end of the course, students are expected: to understand the basis underlying NFP (anatomy, physiology, etc.), to interpret both Billings and Symptothermal charts, to have adequate knowledge on different aspects concerning the delivery of NFP services (teaching methods, abstinence, psychological aspects of couple relationships, sexuality), and to have knowledge about current ongoing research projects or possible research questions for the future. The course is taught by a Midwife (Associate professor of "Community Medicine" and "Maternal and Infant Health" at the School of Nursing of the University of Navarre) and by two medical doctors (a general practitioner with a Masters Degree in Sexuality that is a visiting professor and a Public Health Epidemiologist that is an Associate Professor of "Epidemiology" in the Medical School of the University of Navarre). All three lecturers have experience in the use of NFP.

The results of this experience are promising: This course has systematically been the first course in the ranking of all optional courses selected by our students (more than 800 students requesting the course for only 50 available positions). Students are therefore selected on the basis of their academic performance.

In order to evaluate the perceived usefulness and quality of this course we have performed two types of evaluations: firstly, at the end of each course, students anonymously fill-up a quality questionnaire and secondly, questions concerning fertility were asked to 141 sixth-year medical students (just before the end of their studies, i.e. before obtaining their medical degree) to distinguish the knowledge and attitudes about NFP between those that participated in our course and those that did not take this course. Our aim was to use this information to request higher available positions or more courses on this topic to the University Officials.

The evaluations performed at the end of the courses yielded very positive results and the following are a sample of items and results from the questionnaire:

1. Question concerning ease of comprehension of the course, difficulty understanding contents: Too easy 1.6% Adequate 94.5% Difficult 3.5% Very difficult 0.4%
2. Question about teaching material used: Insufficient 5.5% Sufficient 25 Good 47.6% Very good 21.9%
3. Question about usefulness of the course: Not useful 1.1% Somewhat useful 10.3% Useful 52.5% Very useful 36.1%

Concerning the questionnaire of senior medical students, results are consistent with the beneficial effect of our NFP course:

Students who had taken the course presented higher knowledge scores concerning the menstrual cycle and fertility, a higher knowledge concerning the World Health Organization's participation in NFP activities and about local associations that work in the field; they also more frequently identified the correct fertile period in a hypothetical cycle presented to them, more frequently accepted the assertion that in some days of the cycle pregnancy "was impossible" and finally, more frequently stated that they would feel "confident" in giving family planning advice to a patient with a serious medical reason to avoid pregnancy, using NFP. Females presented better scores than males in general.

Conclusions: our two-year experience teaching NFP to university students from different backgrounds has been positive in terms of acceptance by students and perceived usefulness of courses. We are now planning to increase the available of positions by either teaching the course twice yearly or by slightly increasing the number of students in each course.

The main purpose of the study was to achieve own observations and results on lactation amenorrhoea in primipara group of women. The researches were carried on by Clinical Department of Obstetrics and Gynaecology of National Research Institute of Mother and Child in Warsaw, in 1996 – 1998.

Material and Methods
A group of mothers whose pregnancy was the first one, and who attended organised by the National Institute school for young parents (preparing to delivery), and whose antenatal care, delivery and postpartum care were delivered at the Clinical Department of Obstetrics and Gynaecology, were then recruited to serve as a study population. They expressed their agreement to participate in the experimental study.

The women were asked to carry on after child birth, an exact documentation in accordance with the instructions. They had to record their observations of lactating process, of the return of fertility signs, as well as they were obliged for the observance a schedule of gynaecological control examinations at puerperal and lactating periods.

Finally 138 women who kept all the records in proper way, were analysed.

Results
The average lactation infertility period depended on the duration of an exclusive breastfeeding, and it was as follows:

• 28,1 weeks in woman breastfed at 4 months postpartum
• 31,4 weeks in woman breastfed at 5 months postpartum
• 39,4 weeks in woman breastfed at 6 months postpartum
• 41,5 weeks in woman breastfed at 7 months postpartum and beyond Normalisation of the first three cycles lengths and luteal phase lengths were also noticed.

	C Y C L E S
	I	II	III
	mean SD	mean SD	mean SD
Beginning of the cycle (one week after delivery)	36,8 ± 16,0	41,5 ± 16,8	45,0±,63 ±,63
	(7 – 85)	(22 – 89)	(17 – 93)
Length of the cycle (days)	36,2 ± 19,0	31,6 ± 5,4	31,1 ±4,9
	(18 – 98)	(20 – 57)	(23 – 48)
Length of the luteal phase (days)	10,6 ± 5,2	10,8 ± 4,1	11,9 ±3,4
	(2 – 33)	(1 – 21)	(5 – 19)

Conclusions
The results received corroborate the other works in this area, informing that a great number of women have the lactation amenorrhea. This infertile period can be recognised by properly taught and motivated woman. It could have a significant meaning in this difficult period of marital life and could help to avoid a lot of stresses and strains. LAM is an alternative method to IUD or other contraceptives that may have negative impact on fertility physiology and may cause for woman a kind of physical and psychological discomfort. BIBLIOGRAPHY – by authors.

In the 1996, The national research of Mother and Child in Poland realised the governmental project titled “Promotion of mother and child health, directed mainly at family planning. To identify the local needs in this respect, three regions of Poland were chosen: the middle of the country, the south west and the north east. In all these regions, 1400 women were questioned about issues connected with mother and child health and family planning.

As the results are more or less representative of the female population of Poland, I tried to analyse several questions regarding the opinion of a woman’s role, fertility awareness and maternity. I would like to find the following answers:

1. What are the women’s attitudes toward the traditional role of wife and mother,
2. What is their opinion about being a mother and being involved in a job,
3. What is their knowledge of fertility and NFP,
4. How do they trust contraception.

I received the following results:

1. More than 3/4 of Polish women accept their traditional role of being wife and mother (higher education changes the opinion a little)
2. 90% presume that children give a woman’s life the most meaning. The same percentage consider that taking a job gives an additional meaning to their lives.
3. The fertility awareness of Polish women (independent of age), in general is very low. Only 15% of women have enough NFP knowledge to trust it.
4. Almost ¾ of women are of the opinion that contraception is the most reliable way to avoid pregnancy (the difference between highly educated and minimally educated women is interesting).

Conclusions
This is the matter of great importance and urgency to provide women, especially young girls, with the information about:

• their fertility, and
• natural family planning methods (to balance the information of contraception found in every magazine).

In 1999-2000 a study has been carried out to investigate what women know about NFP in Hungary.

Methodology
In a group of 120 women (aged of 18-45) a questionnaire was applied to collect data. Participants were asked also about their interest in NFP, their attitude toward the self-observation, the co-operation with the partner and their priorities in selection of an appropiate family planning method.

Results
4% of the participants could define NFP correctly, others could do it partly or with mistakes or gave a misinterpretation. 25 of 100 women stated she knows about the ‘sympto-thermal method’ but only 11 of them could define it. 68% of the participants would like to have more information on NFP. Most women (76%) held self-observation important. 78% would like to be supported by her partner and even would lay claim to their partner’s co-operation. Most women would like to use a family planning method that is

• safe (63%)
• ‘least harmful to their health’ (58%)

In some cases however women have considered effectiveness of family planning method more important than their own health.

Conclusion
Collected data show that it is worth promoting NFP work to fill the lack and need of information on fertility awareness in Hungary.

This study was conducted to evaluate methods and results of the counselling activity of IRSeF Institute (Istituto Ricerca Sessualità e Fecondità), an Italian organization that provides services in the area of Natural Family Planning. Since 1962 our Institute gave information and support with regard to female fertility, but only from 1969 we started to collect cycle charts in an archive.

We analyse a total amount of 1366 women with 7627 cycles collected between 1969 and 1999. In this period we introduced interested women or couples to the observation of the usual signs and symptoms of fertility (mucus, basal temperature and cervix). The counselling was mainly carried out by mail. We consider advantages and disadvantages of this way to teach. We also evaluate the importance of the use of instruction manuals and magazine and the success of meetings and conferences.

By epistolary advice we was able to reach distant persons, which easily learned NFP techniques. We evaluate the success of the teaching of cervix observation in order to predict the fertile period and to cross-check the external signs of fertility. Among the prospects of research and teaching we point out the study of special situations, like postpartum and premenopause.

The scope of the proposal of natural methods to adolescents is an informative and formative one.

The school of Discussion for Adolescents, Couples and Families of Corridonia organizes formative courses for adolescents divided in age groups (13-14 years of age, 15-17 years of age, over 18 years of age) with the aim of offering points for in depth study and comparison on aspects which regard individual personal and relational growth. In the course of these encounters natural methods are presented. This in depth study is helpful not only as the grasping of biological knowledge but it contributes as well to psychological and affective growth in the context of global sexual education.

These is no specific age at which to furnish information; never-the-less diversified according to different age groups: more generic for the younger age groups, greater detail for the older ones. It is important not to limit the contents to anatomy and physiology extending and developing themes such as man/woman complementarity; man/woman diversity, which is complex and not reserved simply to physical, but structural of the person; the physical changes of puberty, the cyclicity of the female organism. By underlining the biological and psychological unity and inseparability of the human being the bases from which considerations of the formative type on the meaning of sexuality should emerge. The proposal of natural methods varies from that of sexual education based on the prevention of unwanted pregnancy and sexually transmitted disease. Natural methods can in fact be a stimulus for the young for a peculiar vision and culture of sexuality, intended not as something to be had, but something to be, in the freedom and responsibility of the couple. The contribute in fact to a global understanding of oneself, to the acceptance and integration of corporal changes, to being defined man or woman prepared for sexuality as reciprocal knowledge and communication.

Hence, natural methods not only in function of regulating fertility in adult couples, selected and motivated, but also as an informative and educative moment in the growth of the person and of forming couples.

Cana Movement is a Non-Governmental Organisation concerned with pre-marriage preparation and family life support and education. A thriving branch of Cana Movement is that committed to the teaching and promotion of Natural Family Planning (NFP). Trained teachers provide NFP counselling and courses throughout the Maltese Islands for couples who are planning to get married in the near future and for married couples. NFP courses are held in individual towns for the benefit of the clients. The interest in NFP in Malta seems to be on the increase, however, there are a limited number of voluntary teachers and the demand is exceeding the supply. Following a need analysis a new curriculum was planned on the ever-changing needs of society. The programme planning has involved reviewing the past teacher-training curriculum; identification of the strengths and constraints of the old programme; the setting of goals and the means of solving those needs; the teaching and learning strategies and evaluation.

Adult education philosophy was chosen as the theoretical framework of the programme. The educational approaches adopted were relevant to the teachers’ needs and to the aims and content of the programme which is firmly rooted in strategies for facilitating adult learning. The programme contains both a theoretical base and a practical base and was planned on a part-time weekly basis. Applicants needed to be either health professionals or teachers. Seven participants have initiated the programme. In addition all qualified NFP teachers were invited to attend any sessions that they consider as helpful for them. Evaluation is the last phase of the educational encounter. Although this project is still in its initial phase, evaluative feedback of the individual sessions presented so far was very positive. In conclusion evaluation follows the eventual implementation of the innovative NFP teacher-training curriculum and where appropriate will bring in new skills, knowledge, and experiences to NFP teachers for the benefit of society.