1. Two Day Method of Family Planning
My name is _____ _____ and I am responsible for ___________________ at the Institute for Reproductive Health Georgetown University.
The Institute is part of the GU School of Medicine and it’s mission is to improve access to fertility awareness-based method (FAB) also known as natural methods. Our strategy focuses on developing and testing simple, effective natural methods and then working with institutions that offer services (because it is these (your) institutions that have the resources and technical capacity to reach the users) to make these methods accessible to those interested in using them.
One of these methods is the Two Day Method, which we will be going over today.

2. Use of Family Planning (women in union, international surveys)
One of the reasons why we are working to develop simple natural methods and to make them accessible is because there is an unmet need for family planning. Here we see that among women in union worldwide:
Approximately half of women/couples are already using a method. This is the result of your work and the work of other organizations. You can be proud of this figure.
However, there are hundreds of millions of women (43%) who are not using any family planning method (even though they don’t want to get pregnant now). Many of them may be interested in a natural method, but they may not have access to one.
There are also current family planning users who are unsatisfied with their method. These individuals may eventually stop using it, which could result in an unwanted pregnancy. Some of them could also be interested in a natural method.
Eight percent (8%) report that they use a natural method. These women report using some type of periodic abstinence. In other words, they are avoiding sex on certain days of their menstrual cycle.
It is also important to note that it is necessary to be able to offer methods that don’t require supplies and that can be offered at both the clinic and the community level.
T: Now let’s look at other reasons for developing natural and simple methods.
Source: Levels and Trends of Contraceptive Use as Assessed in United Nations, Report ESA/P/WP.155 New York, 1999

3. Development of the Two Day Method
Goal: To find a highly reliable indicator that would easily identify a woman’s fertile days.
Detailed review of:
Literature on reproductive physiology
Counseling protocols for the ovulation and symptothermic methods
Charts from users of those methods
At the Institute, we realized that it was necessary to develop a method based on an indicator of fertility that would be easy to identify and would also reliably identify all potentially fertile days.
To do so, we reviewed protocols of pre-existing natural methods as well as training manuals and client charts and other sources of information. We found that the common factor for all potentially fertile days was the presence of cervical secretions. Hence, Institute researchers came up with the idea of the TwoDay algorithm, where the woman asks herself if she had secretion today and if she had them yesterday to identify the potentially fertile days. The TwoDay method is based only on the presence and absence of secretions.
Then, researchers from the Institute used several large data sets to determine the theoretical efficacy of the TwoDay Method , including data from a World Health Organization study and from a multi-center European study. The analysis was designed to answer two questions: 1) How effective would the TwoDay Method be in helping couples avoid pregnancy? And 2) How long is the fertile phase identified by the TwoDay Method? It was determined that efficacy of the method compares very well with reports on the efficacy of other widely used family planning methods and that the fertile phase of the cycle would average 12 days. The Insitute then conducted an efficacy study, which will discuss in greater detail later on in the presentation..
T: Let’s now go back to secretions. It is important to note that secretions are not only an indicator of fertility, but also in important factor in fertility, as we will see.

4. Function of Secretions
To protect the sperm against the acidic environment of the vagina
To transport the sperm (prevent or enhance motility)
Energy source for the sperm
Secretions have several functions:
They facilitate the fertilization process: The sperm can live for several (up to 5) days in the woman’s reproductive tract, but only when cervical secretions are present. If there are no cervical secretions, the acid environment of the vagina wears away the sperm almost immediately (despite the semen’s alkalinity).
They facilitate the sperm’s navigation towards the uterus: When secretions are more liquid (they have a greater water content, which occurs around the day of ovulation) they help the sperm to swim more efficiently towards the uterus. In contrast, when secretions are thicker (have a lower water content), they function like a thick plug that prevents the passage of the sperm, making the cervix more impenetrable.
They nourish the sperm: The carbohydrates in secretions serve to nourish the sperm.
T: Now, exactly why are secretions a good indicator of fertility?.

5. ¿Por qué las secreciones son un buen indicador?
Las secreciones se originan dentro del proceso hormonal que ocurre en el ciclo menstrual de la mujer, como respuesta a los estímulos del hipotálamo, la glándula pituitaria anterior y los ovarios que generan cambios en el vario mismo, útero, cerviz, etc. Específicamente sabemos que la HFC y HL estimulan la producción del estrógeno y la progesterona que a su vez estimulan el canal cervical produciendo cambios en el moco cervical.
Veamos como son estos cambios que son la base del Método de Dos Días, y que para efectos prácticos es el indicador que la mujer puede ver para determinar si esta o no fértil.

6. Thick cervical secretions
Secretions that are more liquid, transparent, stringy
Now we’ll see how and why secretions are a good indicator of fertility:
When secretions are very fluid (more water around the day of ovulation), they detach easily from the walls of the vagina and are more detectible around the vulva and entrance to the vagina.
In contrast, when secretions are thick and sticky (have a low water content), they don’t detach (aren’t expelled) and are not detectible around the vulva or exterior genitals.
If secretions are present, it is highly likely that the woman is fertile. If she is not having secretions, then a pregnancy is almost impossible.

7. Cervical Secretions during the Menstrual Cycle
Preovulatory Days
Less Water
Less Fluid
Less detectable
Periovulatory Days
More Water
More Fluid
More detectable
Postovulatory Days
Less Water
Less Fluid
Less detectable
In summary:
During the preovulatory days (days before ovulation) secretions have a lower water content and are less detectable around the vulva. The periovulatory days (days around ovulation, including the day of ovulation itself), secretions have a higher water content and are more fluid. Secretions flow down the vaginal walls to the vulva where they are noticeable. On the postovulatory days, once again, secretions return to having a lower water content, are less fluid and less detectable.
It is important to remember that detectable secretions are a sign of fertility.
Detectable secretions = Sign of Fertility

8. What does the Two Day Method consist of?
It uses cervical secretions as an indicator of fertility.
The woman checks daily for the presence or absence of secretions (of any type).
If she notes secretions TODAY or YESTERDAY, she is considered to be fertile TODAY. To prevent pregnancy, avoid unprotected sex TODAY.
We have seen that cervical secretions are a reliable indicator of fertility. This method is based on the presence of secretions to identify fertile days. The consistency, viscosity, lubricity, elasticity or any other characteristic of the secretions is NOT important.
If the woman has noted secretions TODAY or YESTERDAY, she considers herself fertile TODAY and avoids unprotected sex TODAY if she wants to avoid a pregnancy. Thus the name of the method: the user takes two days (TODAY and YESTERDAY) into account when deciding whether or not she is fertile today.

9. Two Day Method Here we illustrate the method.
The woman asks herself two questions every day:
Did I have secretions TODAY?
Did I have secretions YESTERDAY?
If she noted secretions of any type today or yesterday, she is potentially fertile TODAY, and should avoid sex TODAY.
If she did not have secretions today or yesterday, her probability of pregnancy today is minimal, so she can have sex today without becoming pregnant.
And the NEXT DAY she repeats the questions.
To avoid possible confusion with semen (if the woman had sex the night before or early in the morning) and to have the most recent information possible, it is recommended that the woman not check her secretions in the morning, but wait until the afternoon and evening.

10. How to use the Two Day Method1 2 3
Determine whether you are on a fertile day and decide whether you can have sex or not.
When you are going to bed, think whether you had any that day.
Identify secretions during the day.
To use the method, the woman must do three things:
Check her secretions
Determine whether today is a fertile day
Depending on her reproductive intentions, decide with her partner whether they will have sex or not.
T: Now you must be wondering how effective is this method. .

11. Efficacy study of the Two Day Method
Main research questions
Is it effective?
Is it acceptable?
Can programs feasibly incorporate it into their services?
A clinical trial was performed to answer several questions:
Whether the method works to prevent pregnancy
Whether couples liked it, whether they felt it suited them. If a method is effective, but not acceptable, programs will not offer it.
Programs should adapt a method to each particular situation, in terms of their need for specialized human resources, training time, counseling time, equipment, physical facilities, etc.
T: Now let’s see how the effectiveness study was done.

12. Efficacy Study Multi-site prospective study
Services provided through existing programs.
450 clients were monitored monthly, each for 13 cycles.
This was an international, prospective, multicentric study.
Small groups of health workers from some existing programs were trained.
Then the health workers taught the method to 450 users.
Monthly follow-ups were done for one year, to gather information on how they were using the method, their satisfaction with the method, their menstrual regularity and whether or not they had become pregnant.
The clients frequented these programs and the providers were nurses, obstetricians, technicians and community workers.

13. Efficacy Study Sites n=450
The study was performed in 5 locations in three countries. This provided a sufficiently large and varied sample that would ensure the validity of the results.
T: The participants were from different socioeconomic levels, different races and different cultures, to give universal validity to the results.
Source: Arévalo et al. Fertility & Sterility, October 2004

14. Characteristics of Participants
Peru, Guatemala, Philippines
Area Rural
45%
Urban, semi-urban
55%
Age
24%
25-29
29%
30-34
26%
35-39
21%
The following were the characteristics of the participants:
The participants in Guatemala were mainly from rural areas.
A little over half came from areas with a greater degree of urbanization.
All were different ages and obviously had to be of childbearing age.
Source: Arévalo et al. Fertility & Sterility, October 2004

15. Parity 0% 61% 1-2 28% 3-4 11% 5+ Average # of children: 2.50%
1-2
61%
3-4
28% 5+
11%
Average # of children: 2.5
To ensure parity, all participants had to be women of proven fertility, either by having been pregnant in the last 24 months or who were using some reliable method of family planning.
T: Now let’s see the results of the study.
Source: Arévalo et al. Fertility & Sterility, October 2004

16. Prior Use of Family Planning
No method
21%
Rhythm
30%
Withdrawal
16%
Barrier
12%
Injectable
10%
Combined
6.2%
Pill
5.5%
IUD
1.5%
Source: Arévalo et al

17. Efficacy of the Two Day Method
Pregnancies for every 100 woman-years
Correct use (with abstinence)
3.5
Correct + incorrect
13.7
The results show that:
With correct use of the method, the pregnancy rate is a mere 3.5 pregnancies for every 100 woman-years. This means that if 100 woman use the method correctly for one year (i.e., do not have sex on the days the method identifies as fertile), at the end of the year, only 3 or 4 of them will have become pregnant.
On the other hand, if we add the pregnancies that occurred from incorrect use of the method, the failure rate is quite higher: (Incorrect use was defined as the situation were the woman was not able to identify her secretions (very few days with secretions) or identified days but had sex anyway.)
Why this large difference? Because the probability of pregnancy increases considerably if the couple has unprotected sex on their fertile days.
T: Let’s compare the effectiveness of the Two Day Method with the effectiveness of other user-directed methods .
Source: Arévalo et al. Fertility & Sterility, October 2004

18. Failure Rate for User-Directed Methods
Correct Use
Typical Use
Nothing 85
Spermicides 18 29
Periodic abstinence
1-9 25
Female condom 5 21
Diaphragm 6 16
Withdrawal 4 27
Standard Days Method 12
Two Day Method
3.5
13.7
Male condom 2 15
Pill
0.3 8
If we compare the effectiveness under “Correct Use” with “Typical Use,” the Two Day Method is more effective than almost all other method listed. Also, some of these less effective methods are being provided by health services.
If we also consider the method’s acceptability and the fact that it doesn’t require any supplies, the advantages of the Two Day Method are even more evident.
Remember, also, that many couples are not using any method at all (which leads to an annual pregnancy rate of 85%), because the existing methods are not acceptable to them or because the programs are not offering suitable options.
The Two Day Method can help to meet this need.
T: So if the method has all these advantages, why isn’t it available?
Source: Método de los Dos Días: Arévalo et al, 2004.
Otros métodos: Tecnología Anticonceptiva, 18th Edition 2004

19. How did women check their secretions?
Touching their genitals with their fingers and feeling or seeing
Observing or touching the toilet paper, underwear
By sensing only
The users found it quite acceptable to check themselves in order to determine whether they were having secretions or not, because all they need to do is touch their external genitalia to note the presence of secretions. (Many professionals erroneously believed that it was necessary for a woman to insert her fingers into her vagina.)
During the counseling, women were not taught specific techniques for “checking themselves.” They only received explanations of where to locates them. This was done on purpose, so that each one of them would decide on the most acceptable method of checking themselves. They demonstrated great creativity:
They touched themselves with their fingers and then looked at their fingers;
Others paid attention to the sensation of the secretions between their fingers;
Others observed the secretions on toilet paper, or on their underwear; and
Within a short time, they learned to “sense” the secretions on their genitals, without needing to touch themselves.
Later they discovered the physical characteristics of secretions and shared these discoveries with their health workers.
T: This concludes the presentation of the method. Are there any questions before we move on to the next activity in the training?

20. Two Day Method Lessons: Women want to know how their bodies work.
Women had no problem about observing their secretions.
They could identify their secretions in the first cycle of using the method.
Couples can avoid unprotected sex during their fertile days.
The women who participated in the study were typical clients of public programs (health ministries, NGOs working in rural communities). These women were not special clients nor were they selected based on any criteria of education or social class.
We learned the following:
Women want to know about their bodies and their fertility. We found that women who touched their secretions with their fingers were not uncomfortable doing so. They are definitely interested in knowing what is happening in their bodies.
They had no problem observing their secretions.
Partners were willing to cooperate.
Couples are able to respect the fertile days. They know in advance when the fertile days will be and they have sex on the previous or following days, or they use some type of protection.

21. Who can use the Two Day Method?
Women with cycles of any length.
Women with normal secretions.
Women willing to observe their secretions daily
Couples who can avoid sex for several days in a row every cycle.
One of the most important characteristics of the Two Day Method is that it is effective for women with highly irregular cycles. Secretions will be present during their fertile days, regardless of whether they occur early or late in the woman’s cycle. These variations do not affect the method.
The method is not a good choice for women with abnormal secretions (i.e., vaginal infections), because this could confuse the woman and make it hard to interpret her secretions.

22. Métodos basados en el conocimiento de la fertilidad
Lets compare now the Billings Method and the TwoDay Method
Both methods are based on identifying a woman’s fertile days by monitoring cervical secretions. With the TwoDay Method, a woman relies solely on the presense or absence of secretions to know if she could become pregnant today. With the Billings Methods, the woman not only monitors the presence of secretions but must also distinguish their characteristics.