Natural Family Planning International

“In my 30 years in Brazil, I saw many promising apostolates rise and then fall as they abandoned the charisms of their founders.” —-Bishop Karl Jozef Romer, Pontifical Council for the Family, 2002 CCL Convention.

In the stated effort to simplify the teaching, the learning, and the use of the NFP method to be taught by the Couple to Couple League, its current management has dropped some of CCL’s traditional rules in favor of what they now call one rule. I challenge that description because it looks like three rules to me. In my last blog I told why I think it is a mistake to abandon the sympto-thermal Rule K as an excellent way to determine the start of Phase Three, postovulation infertility. In this commentary, I want to address the possible abandonment of Rule B and Rule C as well as the concept of one rule for several situations.

Rule C

The “C” in Rule C stood for Cautious and Conservative. For most couples it was excessively conservative. As we stated in the Fourth Edition of The Art of Natural Family Planning, Rule C “requires BOTH three consecutive days of full thermal shift AND four days of drying-up.” I don’t know if it added anything by way of effectiveness to the other sympto-thermal rules, but it was an option that probably gave added confidence to couples with a very serious need to avoid pregnancy. A 3-day full thermal shift crosschecking four days of drying up presents a visually strong indication of postovulation infertility to anyone who is adequately informed.

Rule B

The “B” in Rule B stood for “Billings” in honor of his work, but it was a sympto-thermal rule. That meant that we wanted a sufficient temperature cross-check on the four days of drying-up. At first glance it appears that one of the rules or options in CCL’s new system is identical to Rule B, but that’s not the case. According to what we have heard, the temperature requirement in Rule B is stronger than the option in CCL’s new system.

Dr. Josef Roetzer

The management and staff at CCL claim that their new system is based on that of Dr. Josef Roetzer. That seems to be true. They also claim that the new system has only one rule and that it is therefore easier to teach, understand and use. I have not seen Dr. Roetzer making such claims. I admire his work that started in the Fifties and has continued into the present time. In Austria and Germany he has faced difficulties that may well be worse than what we have faced in the States. We are indebted to him and are grateful for whatever progress he has made in Europe and in the States as well.

One rule or three rules?

As I understand it, the basic Roetzer postovulation rule is a 3 + 3 rule: Phase Three starts on the evening of Peak-plus-3 crosschecked by three days of thermal shift, all above the low temperature level (LTL) with the last one at the High Temperature Level (HTL). That’s the basis for the Rule R (for Roetzer) we wrote into The Art of Natural Family Planning many years ago. Call that Rule One.

The confusion or contention starts when the pattern doesn’t meet both of those criteria. As I understand it from listening to CCL recordings, the Roetzer system has two more options.

In one of them, if the temps are above the LTL but not at the HTL, three days of a closed (not just closing) and firm cervix confirm the three days of drying-up and slightly elevated temps. Call that Rule Two.

A third alternative is used when Rule Two does not apply. In this alternative, once again Peak Day plus 3 is not confirmed by an adequate temperature rise. In this third situation, you wait until Peak Day plus 4. If on P + 4 there are four days of temps above the LTL by any amount, you can consider the evening of P + 4 the start of Phase Three. Again, that means that if on Peak + 4 you have four temps that are only one-tenth of one degree F above the LTL, you could apply this rule. Call that Rule Three.

The need to make distinctions

My concerns are twofold. One has to do with merchandising, the other with methodology.

When Dr. Prem and Sheila and I were the dominant influences at CCL, we made distinctions. When two situations were clearly different from one another, we gave them two different names. It seems to me that in the options above, there are three different situations. I am not at all persuaded that clarity is well served by saying they are all examples of the same rule but just different adaptations. In short, the “one-rule” language looks to me like mere merchandising. In the old CCL we had four sympto-thermal Phase Three rules that were clearly distinguished on the basis of the strength of the temperature pattern and the days of drying-up. We now call this the Kippley-Prem system to distinguish it from whatever CCL is doing or will do. In the K-P method or system, When the temperature pattern is very strong, fewer days of drying-up are needed as a crosscheck. We give these four situations four different labels to distinguish between them. I can still recall one of my college philosophy teachers telling us repeatedly, “bene docuit qui bene distinguit” — “he teaches well who distinguishes well.”

Thus I find it confusing to recognize three different situations and then to group them together and call it just one rule. This has nothing to do with the merits of any of the three rules, just the terminology.

My concern about methodology is illustrated by Figure 14.6 in the Fourth Edition of The Art of Natural Family Planning. It is an unplanned pregnancy chart that is confused by the fact that the couple did not follow the rules at either end of the fertile time. That is, the couple apparently ignored four of the standard Phase One practices, but they still stopped marital relations once the wife began recording mucus. The last marriage act in Phase One was on Day 8, mucus recording started on Day 9, and Peak Day was Day 12. On Days 14,15, and 16, the temperatures were all two-tenths of one degree F. above the LTL. Day 16 was Peak + 4 cross-checked by three days of temps above the LTL, but no temp had reached the HTL. The couple engaged in the marriage act on Day 16. They became pregnant. Did the pregnancy result from the marriage act on Day 8 or on Day 16? We simply do not know. Researchers have told us that ovulation sometimes occurs as early as Peak Day minus 3 and as late as Peak Day plus 3. Pregnancy could have resulted from the marriage act on Day 8 or Day 16 without taking any sort of small miracle to explain it.

The couple who submitted the chart in Fig. 14.6 knew that in their previous cycles the temperature shift was a clear four-tenths to six-tenths of one degree F above the LTL. They knew the temperature pattern by Day 16 was not like their previous experience, but they were not motivated to avoid pregnancy.

Rule B and Dr. Roetzer

In this case, the CCL Rule B would require them to wait two more days for a temperature reading at the HTL. We are told that Dr. Roetzer has had excellent experience with the rule calling for P + 4 crosschecked by a minimal rise in temps, but I have not seen any research published on it. I am also told that Dr. Roetzer tells couples to interpret the current cycle in terms of their previous cycle experience. If that were followed here, the couple would have waited two more days. So, the rule may not be so simple as it appears at first. Maybe the rule really is that you can use P + 4 with a mininimal rise in temps IF you have established from previous cycles that this is your common pattern. I would have no problem with that, and we addressed that situation in Figure 5.5 of the Fourth Edition of The Art of Natural Family Planning. So we will have to wait to see if CCL attaches the same qualifier that Dr. Roetzer apparently uses. (By the way, in the text for Figure 5.5 we note that we have never seen a shift of only two-tenths of one degree F above the LTL. That means a sustained thermal shift of the kind used for making decisions. Of course we have seen partial shifts on the way up to the high temperature level.)

Abandonment of Rule B and other CCL rules

And if that is the case, what sense is there in abandoning Rule B? If we understand what CCL is doing with its allegedly simplified, streamlined system (to use their marketing adjectives) it’s much ado about nothing or a lot of fuss over having less. It appears that CCL teachers are being asked to accept the loss of Rule C, the loss of Rule B, and the loss of Rule K with their clear distinctions. In return they are being asked to accept a basic rule that is essentially Rule R, another rule that is something like Rule B but lacks its high temperature requirement, another rule that accepts a low temp rise when there are three days of closed cervix to crosscheck the days of drying-up, and to call all of these a streamlined one-rule sytem.

The Kippley-Prem system

Our friends in the Czech Republic and Slovakia have been “competing” with the Roetzer system for some years. They have great respect for Dr. Roetzer and his teachers, but they have not been persuaded to adopt that system. They intend to keep what we now call the Kippley-Prem system. They are aware of a situation where some CCL-trained teachers were retrained in the Roetzer system and then wanted to return to the Kippley-Prem system. In our friends’ experience, couples who are acquainted with both systems are very happy with the clear distinctions and rules in the K-P system.

John F. Kippley
Author, Sex and the Marriage Covenant: A Basis for Morality (Ignatius, 2005)
Natural Family Planning: The Question-Answer Book, a short, free, downloadable e-book available at the home page of www.NFPandmore.org.

“In my 30 years in Brazil, I saw many promising apostolates rise—and then fall as they abandoned the charisms of their founders.” –Bishop Karl Jozef Romer, Pontifical Council for the Family.

One of the three principal charisms that Sheila and I brought to the Couple to Couple League was the charism of choice. By the time we met Dr. Konald A. Prem in 1971 we had used all three signs of fertility and infertility. From a book by the Kanabys, from an article by Dr. Prem, and through correspondence with two women who had lots of personal experience with the mucus and cervix signs of fertility during breastfeeding amenorrhea, we had learned all the signs well before we started CCL. All of that was helpful and oriented us toward freedom of choice among morally good alternatives. With regard to marital chastity, there was only one morally good choice–don’t engage in unnatural forms of birth control. With regard to breastfeeding, the evidence was clear that breastfeeding was best for both baby and mother and that ecological breastfeeding had the effect of naturally postponing the return of fertility. Thus, in our teaching program, we could not teach “choice” on those two matters. But with a system of fertility awareness, there was no moral imperative to teach one system to the exclusion of the others. So we opted to let individual couples choose which signs they wanted to use. We preferred using the signs in a crosschecking way, but we taught the signs in such a way that they could be used independently. Our pledge was to support the choice of the couple within the limits of the sign or signs they had chosen to use.

It is therefore disappointing to learn that the current management of CCL is abandoning two of the crosschecking Phase Three rules we developed. At first, we were heavily influenced by the mucus-only rule that said Phase Three starts on the evening of Peak Day plus four, so that was combined with the temperature requirement of three days of well elevated temperatures. As we became more aware of the temperature-only research, we realized that it had achieved excellent results. The well known biostatistician Christopher Tietze had said that the three-day temperature-only system for the start of Phase Three was as effective as surgical sterilization, and that was without any reference to mucus.

I am aware of two temperature-only studies that support the three-day rule used in Rule K. Thomas W. McGovern, M.D., wrote the effectiveness chapter in the Fourth Edition of The Art of Natural Family Planning, and this is what he said on pages 149-150 about these studies.

Regarding the French study by B. Vincent et al., Dr. McGovern wrote: “In 17,496 cycles of using a temperature-only rule to determine the start of Phase III, there was only one clear perfect-use pregnancy. That yields a Pearl Index of .07 [that is, an effectiveness rate of 99.93 percent]. One statistical problem is that couples used either three or four days of thermal shift. Although this 1967 study does not meet today’s higher standards, it strongly supports the CCL four-day temperature-only rule and Rule K which calls for three days of full thermal shift cross-checked by at least two days of drying-up past Peak Day.”

Regarding the German 1967 study by Dr. G. K. Doering, Dr. McGovern wrote: “Phase III was determined by a three-day temperature-only rule. The 307 couples having relations only in Phase III contributed a total of 11,352 cycles and experienced 8 unplanned pregnancies, yielding a user-effectiveness Pearl Index of 0.8 [99.2 percent effectiveness rate]. Of those 8 pregnancies, ‘one was due to misinterpretation of a temperature rise caused by a cold, five were pure patient errors, i.e., intercourse during the fertile phase, and two had incomplete temperature records’.”

Dr. McGovern continued regarding the Doering study: “Phase I plus Phase III was used by 689 couples for 48,214 cycles. They experienced 125 unplanned pregnancies, yielding a user-effectiveness Pearl Index of 3.1 [a 96.9 percent user-effectiveness rate]. Among those 125 pregnancies, 6 were from relations on the second day of upward thermal shift. Of the rest, ’12 [couples] had misinterpreted temperature rises from colds, 13 conceived toward the end of the “safe” postmenstrual period, 56 were patient errors, and 38 had kept incomplete records…Conception never occurred on the third day of hyperthermia [well elevated temperatures]’.”

“Again, this study does not meet today’s higher standards. Rather obviously, the couples were in the study for more than the one-year limit currently required and it is not clear that all the couples using Phase I regularly used it to the limits of the Doering rule. Nevertheless, it continues to support all the temperature-based Phase III rules, and it is the basis of the Doering Phase I rule now being taught by CCL.”

You may wonder how and why we developed Rule K. We had questions about patterns in which the temperature rose before Peak Day. Sometimes we would see four or five days of well elevated temps by the time we saw P + 4. Since it had been well established that women were almost always infertile by the evening of the third day of well elevated temps, we wondered whether couples should have to wait another day or two for confirmation from the mucus sign. We discussed this with Dr. Prem, and he suggested that we should call for at least two days of drying-up past Peak Day to insure that the high temps were not caused by something other than postovulation hormones. That’s how Rule K came into existence. That is, according to Rule K, Phase Three starts on the evening of the third day of full thermal shift cross-checked by two (or 3) days of drying-up past Peak Day. (Full thermal shift means three consecutive days with waking temperatures at least four-tenths of one degree F. above the low temperature level.)

As we heard CCL’s new system explained, we learned that the basis for Phase Three is Peak-Day-plus-three as in Dr. Josef Roetzer’s system. Therefore, Rule K has been abandoned. We are told that the new rules were compared with the old rules on lots of charts in CCL’s files, and the new rules yield the same day or differ by only one day. Rather obviously, when the pattern is appropriate, Rule K with its Peak-Day-plus-2 crosscheck will always yield a start of Phase Three one day earlier than a Peak-Day-plus-3 rule.

We have heard the claims about how great it is going to be to have only one Phase Three rule, how simple it will be to teach and to use. Really? Is it really simpler to use a system that unnecessarily adds a day of abstinence? Sometimes one day can make a big difference. Consider asking your students this question: “Would you like to take ten minutes to learn a rule that sometimes shortens abstinence by one day (or even two days in some cases when compared with mucus-only rules)?” What do you think they will say? Is your purpose in teaching to make things as easy as possible for you or to make the practice of chaste NFP as easy as possible for your students?

This poses an ethical question for teachers whom I will now address. Many of you experienced teachers have used Rule K. You have taught it for years. You know the temp-only work behind it. You know it works as well as anything else. If you are presented with a chart by phone or in person that shows that the couple are in Phase Three that evening by Rule K, do you tell them that they need to wait one more day to comply with the new system? What if tonight is the last night they will be together for a week because of travel that starts tomorrow? What if the couple confides that they have been struggling with chaste abstinence and that a day makes a difference to them? What if the husband is shipping out tomorrow for six months in Iraq? Is your responsibility to be faithful to a system or to support the couple by giving them the information they need to arrive at the earliest possible interpretation of Phase Three that is consistent with the evidence? In my opinion, you are ethically and professionally obliged to tell them about Rule K. Of course, your situation is complicated because in the new system you will have hid this rule from them.

If the scenario of holding back valuable information does not appeal to you, you need to let the CCL Board of Directors hear from you—-and sooner than later.

More next week, God willing.

John F. Kippley
Author, Sex and the Marriage Covenant: A Basis for Morality (Ignatius, 2005)
Natural Family Planning: The Question-Answer Book, a short, free, downloadable e-book available at the home page of www.NFPandmore.org.