Pope Francis will visit here next year, and 2018 will also mark the 50th anniversary of Humane Vitae, the missive by Pope Paul VI which enforced the Church's prohibition of all forms of artificial contraception. In this document, the Pope suggested that "medical science should, by the study of natural rhythms, succeed in determining a sufficiently secure basis for the chaste limitation of offspring".

Limitation of offspring, chaste or otherwise, is practised by the vast majority of sexually active people in Ireland today. Indeed, with the most recent data from 2010 showing that more than 94 per cent of sexually active people in Ireland use some form of contraception, it's difficult now to recall the days of a blanket ban on contraception. In those days, natural family planning, or condoms smuggled from England, were all that couples had to avoid an unwanted pregnancy.

The same 2010 study showed that roughly 3 per cent of people were using a natural method of contraception, such as Billings or the calendar method. Yet failure rates for such methods vary wildly, as there are multiple factors involved in using them perfectly. And nowadays they are being increasingly used for the opposite of what they were originally intended, as couples employ them to enhance their chances of conceiving.

Dr Deirdre Gleeson, a specialist in occupational health who is also a course director with the Natural Family Planning Teachers Association of Ireland (NFPTAI), is the first to admit these methods aren't for everybody.

“You have to be realistic: a natural method won’t work for everyone, but those it does work for are delighted and wish they had come to it sooner. But they need to be very motivated and disciplined. The main reason it will not work is lack of motivation, or if the woman’s husband or partner is not supportive.”

She estimates that roughly 5 per cent of couples are using these methods, and attributes this to a “resurgence” in interest in the natural approach. “Natural family planning fell off the proverbial cliff for about 20 years – people didn’t want to know about it. But we have seen a growing interest in recent years. There are very devout Catholic couples, but there are also people with no religious affiliation whatsoever who are looking for a green or eco approach to family planning.”

Green method

According to Gleeson, natural family planning is the traditional “Catholic method” which relies on abstinence during the fertile phase, while fertility awareness is the “green method” for couples who are against hormonal and other artificial contraceptives but will accept the use of barrier contraceptives such as condoms or the diaphragm during the fertile phase.

“I like to refer to the groups as the ‘holies’ and the ‘hippies’ . . . and they all get on very well,” she laughs. Gleeson admits to having “a foot in both camps”, as a member of the Irish Catholic Doctors’ Association.

The NFPTAI is secular, however, and has members of all faiths and none, she explains. “We teach it from the scientific aspect, and then you can take it or leave it. The point of it is to identify as accurately as you can the beginning and end of the fertile phase.”

The association uses a combination of the three classic natural family planning methods: calendar, body temperature, and Billings, in the symptom-thermal double-check method they teach.

It is an education-based method and requires three or four sessions of one hour’s duration in training for the woman or couple, although Gleeson explains there are now lots of smartphone apps available which make this slightly easier “and much more interesting”.

“If a woman wants the pill, or the coil, or the implant, they just go to their GP and submit to the doctor and have something inserted or a prescription written. This method is a lot more holistic and is a lot more woman-centred and couple-centred. The knowledge of your cycle is empowering whether you chose to use natural family planning or not.”

According to Gleeson, studies have shown that couples who use natural family planning have far more sex than couples who use artificial methods. “You do have abstinence for about a week each month, but we think they make up for lost time.”

As knowledge of the fertility cycle improves, modern methods have evolved greatly from original efforts at natural family planning, notes Gleeson.

“The older rhythm method was based on a regular 28-day cycle, which didn’t work for an awful lot of women. There were jokes like ‘what do you call a couple who use natural family planning? Mammy and Daddy’.”

Research carried out by Swedish biophysicist Erik Odeblad in the 1960s and 1970s changed this, however; he found that the cervix is as responsive as the pupil of the eye and his work on changes in the cervical mucus forms the basis of the Billings method.

Ita McDonnell of Naomi-Billings Ireland explains that the organisation has been running pre-marriage courses for more than 35 years, and says their services are as popular as ever.

“There is such choice out there in terms of contraception but we are finding a huge lack of knowledge, just of the very basics of what is happening. Most people don’t even know that the egg only lives for 24 hours. At the moment we find that the age profile has risen – the couples we speak to now are around 33 or 34.”

McDonnell asserts that the method is highly sensitive and says that not only is it effective in delaying pregnancy, hundreds of couples have been able to plan their families by using it.

“It can be used to monitor your reproductive health, and that is a new area for us. Somebody who has been charting with us might note something slightly different and know that it isn’t what they should be seeing in that particular part of their cycle. Reproductive health is quite a big area with the use of the Billings method. For example, we can tell someone who is having difficulty in that perhaps their fertile phase is a bit short, and then they can go into their consultant with that information.”

Failure rates

Billings is based on changes in the cervical mucus, and McDonnell says the method becomes intuitive after some time. “Women get to know their developing, changing patterns, and that the cervix is now open. Couples can show love in other ways during this time. The cervix then closes after ovulation has occurred and the couple can have intercourse as much as they want during the next phase.”

Naomi-Billings have been collecting statistics since 1972 and the latest trial, carried out in China, showed a zero pregnancy rate. Ireland was part of a WHO trial during the 1970s, along with El Salvador, India and New Zealand, and the failure rate here was shown to be 2.8 per cent. Other studies have shown much higher failure rates, however.

“Billings are very honest about their figures but it may be that the couple have decided to instead go for a pregnancy,” says McDonnell.

On the reverse side, trials in couples with proven subfertility have shown significant success – 34 per cent of couples involved in one trial in Rome had become pregnant within 3-6 months, and in another trial 78.3 per cent became pregnant in between four and seven months.

“We can’t help everybody because some people might have another problem, but we will pick up polycystic ovaries and help with diagnosing endometriosis. Because we can monitor clients’ reproductive health, it may mean that they get the help they need a little bit sooner.”

Naomi-Billings sees a few hundred couples each year, on average, says McDonnell. “Couples may come back after three or four years to ‘brush up’ on the method. We work on the premise that we would upgrade our training every few years.”

The organisation receives no funding from the Catholic Church. "We have never asked the Church for anything because Billings taught that this method is for every woman. We would never ask anyone what religion they are. It is so popular but the thing is that there is no money in it. We are supported by the HSE so our services are completely free to people. There is that mentality out there that if something is free then it is not worth anything. But we don't want to charge anything because we feel this is knowledge that everyone should know and every couple should know."

Diaphragms and coils

Dr Shirley McQuade is medical director of the Well Woman clinics, which have about 30,000 consultations every year.

She explains that while it is several years since someone sought advice on natural family planning, there is a certain proportion of women who will only request non-hormonal methods of contraception, such as diaphragms and copper coils.

“We often get people coming in to say they have googled non-hormonal methods and copper coils are what came up so they want one.”

McQuade lectures medical students in University College Dublin on contraception. "That does include natural family planning methods but there is very much a Cinderella aspect to it – students need to know it is there, but in practical terms, the the vast majority of doctors are never going to need to use it."

She explains that the Persona system has been around for a few years now. This is a system that uses urine sticks, and gives a red, amber or green light for intercourse based on the “safety” of the timing.

“Quite a few women use that as a fertility monitor, which is the opposite of what it’s supposed to be used as,” she says.

A new fertility monitor called “Daysy” uses body temperature as a guide, harnessing new technology to provide an algorithm based on more than a million women’s menstrual cycles.

At almost €300, it isn’t cheap, and McQuade adds that she is not confident in the use of body temperature as an indicator.

“In the second half of the cycle after ovulation happens, progesterone goes up and body temperature goes up by 0.6 degrees. You can plot this out and note the rise but the problem is that the rise may not coincide exactly with ovulation. Also, your temperature needs to be taken before you get up in the morning, so before you even get out of bed. If you’ve had a late night the night before, that will upset the reading, or if you have a cold or anything, that too.”

Women can have quite regular cycles most of the time, but for several reasons their cycle can change. This is typically stress-related, such as the many college students that McQuade sees. She adds that women in their 40s will also encounter problems with natural family planning methods, as their cycles begin to change and vary.

McQuade keeps a chart in her consultation room based on recent research carried out in the US that looked at the failure rates of all contraceptive methods. To see in black and white that the failure rate of the pill with typical use is 9 per cent often startles women. With condoms, that jumps to 18 per cent.

“All contraceptive methods are really good in laboratory circumstances but once you take them out into the community, they aren’t as good. The best are those that have no user input, such as the coil, and the implant – those work. But everything else, where a person is involved who has to make a decision as to whether they do something or take something – the real-life use is very different.”

McQuade agrees that there are problems with natural family planning methods, much as there are with other contraceptive options. “Your choice of method depends on what stage you are at in your life and how big of a disaster a pregnancy would be.”