Natural Family Planning International

Your Right to Know: The Internal Observations

As noted in the previous posting dealing with cervical mucus, Dr. Edward F. Keefe was the first doctor of record in the United States to promote and teach the observation of cervical mucus, starting in 1948 or 1949 with a reference in his Ovulindex thermometer booklet and more specifically with an illustration in the 1953 edition of that booklet. He wanted the mucus and temperature signs used in a cross-checking way, and he was thus opposed to the Billings emphasis on using it by itself. In 1975 he wrote the following review of the Billings’ book. This appeared in COVERLINE, the newsletter of the Natural Family Planning Association of Connecticut, Spring, 1975. Since he is the pioneer in this area, I thought it would be worthwhile to have his opinions available on the internet.

“Reflections on Mucus Alone as a Fertility Sign” by Edward F. Keefe, M.D.   A strong tone of advocacy marks Dr. Billings’ book, Natural Family Planning, the Ovulation Method, 2nd American edition. While its shortcomings are now well recognized in spite of the enthusiasm of its proponents, I welcome a chance to “place in the record” a review of this book.

Preparing the review brought to mind my early efforts to improve systematic abstinence as a means of family limitation. I recalled my excitement over a paper on the rheology of human cervical mucus (1. Clift, A.P., Proc. Roy. Soc. Med. 39:1945). Rheology is the study of flow. Women apply it every day when they judge such things as syrups, jellies, batters, ripeness of fruit, etc., in the kitchen. The paper made me wonder if a woman could not observe for herself the changes in the physical properties of her cervical mucus as well as its volume, changes which already could signify the fertile time in farm animals. I reported on preliminary studies of these aids in 1950 to a meeting of the medical staff of St. Vincent’s Hospital of New York. They listened politely but many questioned if there was a fertile time in women at all, not whether it could be recognized by temperatures or mucus.

The Ovulindex thermometer had just been developed by me. (I should disclose I still own the company that manufactures it.) In 1948 I wrote (anonymously) its first handbook, which said no more about mucus, I find now, than that its presence was to be recorded, along with the temperatures. But, by 1953, I was so confident that changes in the mucus were a valuable guide that I fully described them in the second edition. I illustrated the location of the cervix and how to test threading of the mucus between thumb and forefinger – a rheologic test.

In my office practice, at first I, too, taught the use of the mucus on the vulva, as does Dr. Billings. But it was insufficient, inconstant, and lagged beyond the true state of the ovaries according to my patients. Most of them had been “Rhythm-failures” many times over and they demanded perfect results. The best mucus sample was needed and the place to find it was in the cervical canal, unaffected by passage through the vagina. I encouraged them to remove the mucus directly from the cervix. After trying aspiration through a tube, we settled on removing the mucus with the fingers. In making such collections, my patients discovered there were changes in the cervix itself. They found at the approach of ovulation, as the mucus became abundant, thin and clear, the cervix itself softened and the canal opened. A search of the medical literature disclosed descriptions of this dilation of the canal, but to apply these changes to periodic abstinence was something new. I studied them for more than ten years. Many women were enthusiastic about the signs and asked why they did not receive more publicity. Meanwhile, my paper on this seemed to create little interest among doctors (2. Keefe, E.F., “Self-observation of the Cervix to Distinguish Days of Possible Fertility” Bull. Sloane Hosp for Women, 8:129, 1962). The spotlight was on Dr. Rock’s “100% effective pill.”

Somewhat later, my patients reported to me that the cervix is elevated as well into the pelvis before ovulation and descends after it. These were astonishing changes not mentioned in the literature. I felt certain enough of these signs to describe them in 1964 in the third edition of the Ovulindex thermometer handbook and in COVERLINE: Vol. 2, No. 4, 1970.

Meanwhile, Dr. Billings lectured to our obstetrical staff at St. Vincent’s and when he returned to Australia, his home, he kindly sent me The Ovulation Method, first edition (1964) which explained calculation of the cycle-pattern, temperature charting and the changes in mucus. In 1965, I learned from Dr. Lanctot that mucus was a “symptom” in the Sympto-Thermic Method. I was happy that others were working along the same lines as myself.

Just recently, Dr. Josef Roetzer of Voecklabruck, Austria, in explaining his sympto-thermal system at a “Round Table on Ovulation Prediction” in Rome, on April 4-6, 1974, described the changes in the cervix mentioned above, including its elevation at the fertile time. His patients, like mine, had discovered for themselves these signs. I still believe (2) “It could become common knowledge that, if a woman finds her cervix flaccid, gaping and streaming with mucus, there is a great chance of conception and, in the absence of these signs, there is less or no chance.” Dr. Billings’ book will help disseminate part of this knowledge and for that I welcome it. But I would rather that mucus signs supplement the charting of temperature, not replace them as the book demands. Moreover, just because mucus on the vulva is not a dependable sign, its shortcomings must not cause us to undervalue the changes in the cervical mucus and the cervix itself. I will go into this in a forthcoming book review.

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We do not have his book review. To see how all the signs are used in a cross-checking way, see our manual, Natural Family Planning: The Complete Approach at http://www.nfpandmore.org.

John F. Kippley

Your Right to Know: Cervical Mucus

It may seem strange in 2013 to write about your right to know about cervical mucus as a fertility marker, but outside the NFP movement proper education about cervical mucus as a sign of fertility seems to be hit-or-miss at best. For example, a study about the fertility awareness value of cervical mucus was published online just this past July 12, 2013 in Fertility and Sterility. This information is so basic that it’s amazing to see it reported in a scientific journal. You certainly have a right to know about the value of cervical mucus, and you also have a right to know about its limitations.
•Almost every fertile-age woman can identify it.
•It is a positive sign of the fertile time.
•It can work well for purposes of avoiding pregnancy, but it works better when used in a cross-checking way with waking temperatures.

Cervical mucus was known to the ancients. Aristotle described a white discharge as well as a red discharge. In the story of the two daughters of Lot who got their father drunk so that he would impregnate them (Gen 19:30ff), a question is raised, “How did they know the right days?” (I heard Dr. John Billings raise this question in a lecture years ago.) A number of researchers had something to say about cervical mucus starting in the 18th and 19th century. In 1855 Dr. W. Tyler Smith noted that cervical mucus “appears to afford a suitable medium for the passage of the spermatozoa through the cervix uteri into the uterine cavity.” (Jan Mucharski, History of the Biologic Control of Human Fertility)

Many others commented on it, but the first to introduce the observation of cervical mucus into natural family planning instruction was Dr. Edward F. Keefe, a New York City OB-GYN doctor who taught it to his patients. He first did this in 1949 by instructing users of his Ovulindex thermometer to note on their temperature charts “a clear vaginal discharge, seen for a few days before ovulation.” In his 1953 Ovulindex booklet, he included a drawing to show how “cervical mucus can be drawn out to a long, thin thread” a day or two before ovulation. Mucharski notes that “He also pointed out that a woman can determine ‘the approach of the fertile time in the falling temperatures and the changes of the cervical mucus; the end of the fertile time in the rising temperatures’.”

“In 1954, in an exhibit at the Chicago meeting of the American College of Obstetricians and Gynecologists, Keefe emphasized that ‘the probable date of the next ovulation cannot be predicted from calendar calculations or from basal body temperature studies alone without observation of cervical mucus’ ” (Mucharski). That was ten years before Dr. John Billings published his book on the sympto-thermal method of natural family planning.

Dr. John J. Billings taught the mucus sign in conjunction with the temperature sign in 1964, but by 1973 he had decided to use only the mucus sign by itself. What especially characterized the work of Dr. Billings and his wife Dr. Evelyn L. Billings, was their focus on the peak symptom that we describe as the last day of the more-fertile mucus before the drying-up process begins. Mucharski reports that hormonal research with 22 women found that the peak day “occurred in five women on the day of ovulation, in nine women one day before, and in four women two days before. The onset of the mucus occurred on the average of 6.2 days before the estimated day of ovulation.” That accounts for 18 of the 22, but what about the other four? In later research Hilgers would find that ovulation sometimes occurs one or two or even three days after the peak day.

The Doctors Billings and their supporters vigorously promoted what they called the Billings Ovulation Method that relied solely on the mucus signs to determine the limits of the fertile time. That raised questions about its effectiveness relative to the other available natural systems. A study in Australia (1978) found as follows: “(1) the symptoms-and-temperature method combined with preovulatory calculations [such as the 21-day rule] generated 1.5 percent failures per 100 woman-years of use; (2) the symptoms-and-temperature method combined with preovulatory cervical mucus appearance [instead of something like the 21-day rule] generated 3.39 percent failures (3) the ovulation method alone generated an associated failure rate of 11.2 pregnancies per 100 woman-years.” It is not clear from Mucharski if these rates were perfect-use or imperfect-use or a generic total rate.

An NIH study in Los Angeles found an OM imperfect-use rate of 39.7 and an STM imperfect-use rate of 13.7 pregnancies per 100 years of use. The OM group experienced six perfect-use pregnancies; the STM group experienced zero perfect-use pregnancies.

The advocates of the mucus-only systems continue to claim great effectiveness in avoiding pregnancy based on their own studies and methods of evaluating pregnancies. However, whenever a comparative study has been conducted, it has shown that those couples who use cross-checking signs have much higher effectiveness rates in terms of avoiding pregnancy.

One of the great advantages of cervical mucus is its advance indication of fertility. The woman who is well experienced in mucus observations and interpretations will be able to put this knowledge to good use during the irregularities of premenopause and during the delay of postpartum fertility especially when breastfeeding.

Summary. Cervical mucus is essential for mutual fertility since it provides a medium for sperm transport and an environment favorable to sperm life. Its presence can be noticed by almost all women at the most fertile time. Its use in fertility awareness was first promoted in the United States by Dr. Edward Keefe in the 1950s in conjunction with other signs of fertility and infertility. Comparative effectiveness studies about avoiding pregnancy favor using mucus in a cross-checking way with other fertility markers instead of just by itself.

And that is something you have a right to know.

John F. Kippley