Lactational Amenorrhea Method (LAM)
The lactational amenorrhea method of birth control takes advantage of the lack of ovulation caused by breastfeeding. Research demonstrates that, for up to six months postpartum, women who breastfeed exclusively or almost exclusively and who have not resumed menses have about a 2% chance of becoming pregnant. This method has been proven effective in multiple clinical trials worldwide, including in developed countries. In addition, both mother and infant receive the health benefits associated with breastfeeding.
Please note that all three conditions – exclusive breastfeeding, no menses, and infant less than six months – have to be met for the method to work. Exclusive breastfeeding assumes frequent nursing, with intervals of no longer than four hours during the day and no longer than six hours at night. The more one deviates from this pattern by feeding on schedule (rather than demand) and reducing suckling time by the use of pacifiers, the less likely it is to be effective. This type of breastfeeding delays the onset of menses and decreases the chances of ovulating prior to the first menses. By learning how to check cervical secretions with a certified health educator, a woman can increase the chances of this method working.
LAM has not been extensively tested with women who supplement direct breastfeeding with expressed breastmilk. Therefore, women who pump or express milk more than a few times per week should not rely on this method.
Unlike the Fertility Awareness Method (FAM, see below) or the Billings method (a form of FAM employed during breastfeeding), LAM is not based on the observation of a woman’s fertility signs. For that reason, women particularly concerned about conceiving may choose to integrate LAM with FAM.
LAM presents no halachic problems. In fact, the halacha encourages breastfeeding for at least two years, without concern for the potential reduction in fecundity during that time.
Since many physicians in the developed world are not completely familiar with the medical evidence behind this method, a number of references are included:
Berens P, Labbok M, The Academy of Breastfeeding Medicine. ABM Clinical Protocol #13:
Contraception During Breastfeeding, Revised 2015. Breastfeeding Medicine. 2015; Volume 10, Number 1, https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/13-contraception-and-breastfeeding-protocol-english.pdf
World Health Organization. Multinational study of breastfeeding and lactational amenorrhea (parts I and II). Fertility and Sterility. 1998; 70:450-471.
Labbok MH, Perez A, Valdes F, et al. The lactational amenorrhea method (LAM): a postpartum introductory family planning method with policy and program implications. Advances in Contraception. 1994; 10:93-109.
Perez A, Labbok MH, Aueenan J. Clinical study of the lactational amenorrhea method for family planning. 1992; 339:968-70.
Short RV, Lexis PR, RenfreeMB, Shaw G. Contraceptive effects of extended lactational amenorrheoea: beyond the Bellagio consensus. Lancet. 1991; 337:715-17.
Fertility Awareness Method (FAM)
By Michal Schonbrun, MPH, CHES
The Fertility Awareness Method (FAM) is an evidence-based tool for gaining body awareness (Body Literacy) and achieving or avoiding pregnancy. It is natural, safe and highly effective when learned and used correctly. Regardless of the goal, the overall purpose of FAM is to: accurately determine when the ‘window of fertility’ opens and closes; confirm that ovulation occurs; and verify that the menstrual cycle is in fact working as it should, in hormonal balance. When a woman knows how to identify her fertility days, pregnancy can be more easily achieved, or it can be avoided through abstinence or the use of other back-up methods.
FAM is often confused with the ineffective rhythm method, which uses calculations based on past cycle lengths to predict fertile days in the present cycle. In contrast, FAM relies on the daily observation of two or three fertility signs or biomarkers, in the present, so it is more accurate and reliable. FAM is also an effective alternative to using hormones or IUD’s during breastfeeding, as these methods can cause staining, prolonged bleeding and other unpleasant side effects.
FAM is based on five scientific facts:
1) The menstrual cycle is controlled by two primary ovarian hormones – estrogen and progesterone, and by two primary pituitary/brain hormones – FSH (Follicle-Stimulating Hormone) and LH (Luteinizing Hormone).
2) These four hormones cause discernable changes in the three fertility signs (described below), which signal the opening and closing of the fertile “window.” Ovulation occurs within this 3-5 day window, which means that identifying the exact day of ovulation is unnecessary because pregnancy is possible any time that the fertile window is “open.”
3) The woman’s egg lives 12-24 hours,
4) Sperm can live for 3-5 days, but only in supportive, fertile-quality secretions, and
5) The first part of the menstrual cycle can vary in terms of number of days ( 1-3 weeks long). This is the time it takes the body to prepare for ovulation. It differs for each person. The second part of the cycle is more “set,” lasting between 10-14 days on average. This is the time in which the body prepares for possible pregnancy.
Simply stated, a woman’s body is programmed to produce specific hormonal changes at certain times in the cycle in order to ensure optimal conditions for potential ovulation and pregnancy.
Fertility Awareness (FA) gives women the tools to easily monitor three fertility signs; the way in which each biomarker changes is relative for each and every woman:
1. Basal Body Temperature (BBT) is the temperature of the body at rest. It is taken upon waking with a special digital (oral) thermometer for one minute. BBT rises after ovulation, 0.2- 0.5 C (up to half of one degree Celsius) and temperatures stay relatively high for nearly two weeks (typically 10-14 days), until the next menses begins. Once this rise is verified, pregnancy is no longer possible.
2. Cervical Secretions or fluids appear throughout the cycle, and signal when we are and are not fertile. For most days of the cycle (regardless of length), secretions are dry, sticky and acidic. In effect, these dry secretions act as natural spermicides which block and immobilize sperm. During the fertile days, which includes ovulation, our secretions become milkier, wetter, and more lubricative, often resembling the consistency of raw egg-white. These wet secretions are alkaline; they nourish the sperm and help them to swim upwards so they can reach and fertilize the egg. Few of us have been taught that these fluids are not only healthy and normal, but are essential for fertility and for conception! Learning one’s unique secretion pattern is like learning a new (body) language. Within a few cycles, anyone can learn to understand their own pattern and become sufficiently ‘fluent’ in identifying their fertile days. Furthermore, when a woman learns to differentiate between her normal secretion changes, she will easily be able to identify any abnormal secretions (e.g., those that indicate a yeast or bacterial infection).
3. Cervical Position and opening (os) also change during the “window” of fertility. When inserting the middle, longest finger deep in the vagina, every woman can feel one, two or three changes. On infertile days, the cervix is lower, closed, and firm when touched. During the fertile days, the cervix moves upwards towards the uterus, and it opens and softens. This allows easy access for sperm on their journey towards the egg. This is the only fertility sign which requires internal checking.
FAM requires checking two out of the three fertility signs, preferably BBT and secretions. The more signs a woman monitors, the more information and effectiveness she gains, plus increased confidence in being able to interpret her fertility chart and apply the method rules.
Charting requires two minutes a day initially. Within 2-3 cycles, most women are able to identify their individual patterns and interpret their fertility signs independently. To reach highest efficacy and confidence, it is recommended to learn FAM with a certified teacher. Theory can be learned from a book but implementing that theory on your own body can be a challenge.
Charting can be a valuable aid for women trying to conceive. Charting can detect anovulation, late ovulation, luteal phase defects, unsuitable secretions, the occurrence of miscarriage, and the likely date of conception. Charting can also alert a woman if her cycle is hormonally balanced. Many women with short or irregular cycles can know exactly if and when they are ovulating in relation to their mikveh date. In many cases, the need for medical tests and treatments can be avoided.
For more information, contact Michal Schonbrun through her website at https://poriutivit.com/en/home/ .
Halachic Aspects of FAM
For general information on medical aspects of the Fertility Awareness Method (FAM) as a contraceptive method or an aid to conception, please see above.
As with any method of contraception, a halachic authority should be consulted to determine whether delaying conception is permissible for the couple in their current life circumstances. If they are permitted to delay conception, this method is permitted. It does not interfere with the natural course of relations, nor does it lead to hotza’at zera levatalah (wasting seed).
FAM has several implications for the observance of taharat hamishpacha:
FAM and Onot Veset
When a woman tracking ovulation with the Fertility Awareness Method (FAM) determines that she is fertile based on both temperature and cervical secretions, and has three successive months with the same interval from her peak day of fertility to the onset of her bloodflow (i.e., the same luteal phase length), then she has established a veset kavua (a veset haguf based on fertility signs). In this case, she observes only the day or night of that interval as a veset and is released from observing the other onot perishah.
Tevilah and Marital Relations
FAM works by identifying the days on which a woman is most likely to conceive. A couple who wish to avoid pregnancy should avoid relations on those days, or use an alternate method of contraception.
Often, mikveh night falls during the time identified by FAM as conducive to conception. In this situation, a couple can rely on a barrier method of contraception, such as a diaphragm with gel or spermicide, to supplement FAM. (Learn more about barrier methods of contraception here.)
Alternatively, although Halacha encourages marital relations on mikveh night, husband and wife are permitted to make a joint decision to delay relations until later. A woman is still permitted to immerse on time even when she and her husband do not intend to have relations.
Another possible option in such cases is to delay counting the shivah neki’im. Since ovulation cannot be calculated precisely in advance, this requires caution to avoid postponing immersion any more than necessary.
FAM relies on a woman’s awareness of physiological changes that accompany her fertile days. This can involve external checks of cervical secretions, or internal checks of cervical secretions and the position of the cervix. It is preferable to practice FAM in a manner that does not cause one to become niddah unnecessarily.
A woman can check cervical secretions externally at the vaginal opening in one of four ways. Each can be performed in a way that does not make a woman niddah unnecessarily:
- Wiping the vulva externally (before urination) with toilet paper Stains found in this scenario may be disregarded.
- Examining secretions on undergarments (or on a reusable cloth pantyliner) The status of secretions here follows the usual rules of stains (e.g., stains on colored undergarments may be disregarded).
- Touching pubic hairs Stains found on the fingers after this may be disregarded so long as the secretions of a niddah color are cumulatively the size of a gris or less (roughly the area of a US dime or Israeli shekel). To avoid questions, a woman can perform this check by touch, washing her fingers off without looking at them.
- Wiping the vulva with one or two fingers Finding stains of any size on the fingers in this scenario could raise halachic questions, so a woman should perform this check by touch, washing her fingers off without looking at them.
From the perspectives of halacha and of FAM, a woman should check her secretions before urinating and not afterwards. This helps avoid both confusion caused by urine mixing with secretions and halachic issues related to seeing bloody discharge immediately after urination. (See more here.)
Performing internal checks is one of five possible FAM techniques, and is not mandatory. If a woman inserts her fingers internally to check secretions or cervical position, any discharge of a prohibited color that she sees on her fingers will make her niddah.
We follow the position of our site’s rabbinic supervisor, Rav Kenneth Auman, that a woman need not look at her fingers after inserting them to check internally, even during her shivah neki’im.
Cervical position is assessed only by touch, and a woman can assess cervical secretions just by touch and smell. (If necessary, she can turn to her FAM teacher for guidance in learning how to do this.)
Therefore, a woman can perform these internal checks effectively without looking at her fingers, and wash her hands after checking without looking at them. In this way, she can avoid unnecessarily becoming niddah or interrupting her shivah neki’im.
This article was updated on 7 March, 2021.