Fertility is Not a Disease

Managing a couple’s fertility to regulate their family size does not require removing said fertility from the woman’s or the man’s body. This is not primarily a religious issue. Some years ago a psychologist from the National Institutes of Health (NIH) who had no religious affiliation came to me for instruction in the Billings Ovulation Method of natural family planning. She had already used mechanical and hormonal contraceptives, but, responding to a comment I had made at an NIH meeting, she decided to seek a natural method. After using the method for three months she told me, “This method is so different—now I can be all there, now I am not holding anything back.” The contrast between contraception and fertility acceptance methods has never been explained more simply.

Today, hormonal contraceptives and sterilization are marketed aggressively and exclusively. While the physical side effects of contraceptive steroids on every organ system have been described in the medical literature, the personal, social, and spiritual effects of contraceptive steroid hormones, in fact of any blocking of the total mutual self-giving which is the essence of the marriage act—has consequences. Until the publication of “The Association of Hormonal Contraception with Depression” in JAMA Psychiatry in September 2016[1], too many family planning providers either denied the link to depression or prescribed anti-depressive medications rather than stopping the cause of the depression.

Contraceptives as the status quo

Removing fertility from the healthy body is a lifestyle choice and, when done with contraceptive steroids or surgery, is far from risk-free. The regulations which our Department of Health and Human Services (DHHS) have issued only consider the end—reproduction-free sexual relations—as significant. Despite today’s contraceptive inundation, 54% of unplanned conceptions[2] begin in a cycle in which the woman used contraception, usually hormonal. She may not have used the drug correctly or consistently, or it may have failed.

Public health providers tend to think in terms of reaching the lowest common denominator. In the last five years LARCs—Long Acting Reversible Contraceptives—have been heavily promoted by public and private health care providers, especially to single teen mothers right after giving birth, and to single women “at risk” for pregnancy, especially teens. LARCs are either etonorgestrel or similar subdermal implants, levonorgestrel or copper IUDs, which are expected to remain in place for at least three years, or depoprovera injections which must be repeated every three months. While women report physical side effects such as patternless vaginal bleeding with both IUDs and implants, removal requires medical intervention and women are often persuaded that the symptoms will subside, and asked to try the devices a little longer. Between 80-85% of women still use the devices one year after insertion. Reports of side effects are limited to physical symptoms.

Apparently, no one has asked these predominantly low-income young women how they feel about being sexually available at all times, nor has anyone published figures for the occurrence or incidence of sexually transmitted infections among LARC users. However, a recent U.S. Public Health Service study of 15–19-year-old low-income girls found that half were sexually active.[3] According to the study, the overall incidence of the most common infections—chlamydia, human papilloma virus, herpes, and gonorrhea—was 26% for the total group. As only half the group was sexually active, it is reasonable to conclude that their disease burden was 50%. Their number of partners was not reported, so one can only speculate about the girls’ relationships or self-esteem. By 2015, the Center for Disease Control reports skyrocketing rates of sexually transmitted diseases, particularly high among 15–19-year-old women.

A healthier approach to sex education and family planning

There is a better approach to helping youths manage their emerging sexuality and fertility. We began Teen STAR in 1980. STAR stands for Sexuality Teaching in the context of Adult Responsibility. With parental permission, Teen STAR students explore and discuss the physical, emotional, social, intellectual, and spiritual aspects of sexuality and fertility. Girls learn to observe their fertility cycle, boys learn to understand their changing body and how to master its reactions. In religious settings the Theology of the Body is taught explicitly, but even in secular settings the sexual relationship is taught as part of procreation. Behavioral outcomes of program participants from the Americas, France, Uganda, and Ethiopia show excellent support for both primary and secondary abstinence.[4]

Indeed, natural means of recognition of times of fertility and infertility are available, reliable, and offer well-documented options that are free, both of side-effects and cost. Yet only a small number of couples follow any of these natural methods of family planning as they are seldom taught integrally to medical students. If the woman has the temerity to ask about natural methods, her physician either:

  1. does not know much about them;

  2. says they don’t work; (Most patient information inserts in contraceptive pill packages still cite a 25% failure rate for typical use of natural methods. This figure is the sum for modern NFP methods [described below], calendar rhythm, and “home methods.” The 2016 FDA-approved package inserts of contraceptive medications still cite the 25% failure rate. [See any contraceptives described in PDR Physicians Desk Reference 2016]. The American Congress of Obstetricians and Gynecologists only began to cite more contemporary figures in their April 2015 ‘FAQ’.)

  3. belongs to a small select group who do know and advocate for fertility awareness based methods.

In 2013 the NIH offered $3,000,000 for proposals to produce non-hormonal contraceptives. (No active projects are on record—either no one applied, or none were funded.) But they need have looked no further, and saved taxpayer funds in the process.

Managing a couple’s fertility to regulate their family size can be achieved by understanding and heeding the physical sign(s) of a woman’s cyclic fertility. A man’s fertility begins at puberty and remains constant until age or disease reduce or remove it. A woman’s fertility begins at puberty and ends at menopause. As the egg cell matures in its follicle in each cycle, its rising estrogen causes the production of a changing mucus in her cervix which she can feel and see at the opening of her vagina. The discharge usually begins as a fairly dense material but becomes more fluid and slippery over the course of several days. The last day the mucus is slippery, clear and stringy is usually the day of ovulation. Couples who wish to conceive will ensure marital intercourse on the days of lubricative mucus; couples who wish to postpone conception will follow rules to avoid intercourse on the days of fertility, as it is known that sperm will survive for 3–5 days in the mucus which precedes ovulation.

Currently the Billings Ovulation Method, the Creighton Model, and Georgetown’s TwoDay Method rely on the mucus biomarker alone, while CCL (the Couple to Couple League) and Northwest Family Services add the postovulatory rise of the woman’s basal body temperature as well as a calendar calculation to determine the beginning and end of the couple’s fertile phase. The Marquette Model adds urinary testing for estrogen and luteinizing hormone (LH, the hormone which triggers ovulation) rise, as well as mucus and sometimes temperature observation, while LAM (Lactational Amenorrhea Method) and Georgetown’s SDM (Standard Days Method) rely on calendar calculations alone. All these methods have been professionally researched and need to be learned correctly from providers (or internet) and followed consistently to enable couples to manage their fertility reliably.

Fertility is not a disease.

The advent of non-coital methods of contraception gave rise to a highly lucrative industry which alters women’s bodies to remove their healthy fertility. Contraceptives are promoted aggressively and are now enshrined as a human “right” for which our government pays directly or by coercing third party payers.

The Affordable Care Act’s Contraceptive Mandate has limited the options for birth spacing to commodities approved by the FDA (Food and Drug Administration). Evidently the administration assumes that women want to include or exclude their fertility from any heterosexual encounter at will, and that they can do so without suffering any personal, physical, emotional, or spiritual sequelae.

By treating fertility as a disease, medicine today is close to coming full circle when it comes to ethics. Before Hippocrates, physicians might be either healers or killers. Hippocrates and his school taught that the function of the physician was to cure disease when possible, and relieve pain when cure was not possible. The physician-patient relationship was a fiduciary one, which obliged the practitioner to professional conduct irrespective of payment and to confidentiality. Altering or removing healthy organs was, and is, mutilation. Sadly, once this line was crossed with IVF (in vitro fertilization), manipulation and outright killing of embryos and fetuses became commonplace in Western medicine.

There is no need to remove fertility from the body of a woman or a man to allow them to have sexually fulfilling lives. What is needed is for men to understand the signs of the woman’s cyclic fertility and to behave in accordance with their family-building intentions.[5]

Featured Photo: Annabelle Shemer; CC-BY-NC-ND-2.0.

[1] Bradley, Sarah E.K., T.N. Croft and S.O. Rutstein. The impact of contraceptive failure on unintended births and induced abortions: Estimates and strategies for reduction. 2013. Demography and health division, ICF Macro, Calverton MD.

[2] Skovlund, C.W., Morch L.S, Kessing, L.V. Association of Hormonal Contraception with Depression. 2016 JAMA Psychiatry publ. online Sep. 28,2016. (doi:10.1001/jamapsychiatry.2016.2387)

[3] Forhan et. al. Prevalence of Sexually Transmitted Infections and Bacterial Vaginosis among Female Adolescents in the United States: Data from the National Health and Nutritional Examination Survey (NHANES) 2003–2004. MMWR Weekly. August 24, 2007/56(33); 852.

[4] See Cabezón CVigil PRojas ILeiva MERiquelme RAranda WGarcía C. Adolescent pregnancy prevention: An abstinence-centered randomized controlled intervention in a Chilean public high school. J Adolesc Health. 2005 Jan; 36(1): 64–9; and
Jorge Alvarado and Hanna Klaus. The PEPFAR Program in Ethiopia and Uganda: Two and three year post program behavioral outcomes. Presented at NFP preconference, Catholic Medical Association, October 12, 2016.

[5] Information about natural family planning providers is widely available online. The USCCB natural family planning office within the office of Laity, Marriage, Family Life, and Youth offers a diocese-wide directory.


Hanna Klaus, MD

Hanna Klaus, MD, is a Medical Mission Sister and OB/GYN who directs the Natural Family Planning Center of Washington, D.C., and is co-founder of the TeenSTAR program. She has served in Pakistan and Bangladesh and on the faculties of Washington and St. Louis Universities in St. Louis, MO, and at the George Washington University Medical Center in Washington D.C.

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