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 a natural form of contraception that is safe and highly effective when used correctly and consistently. The overall purpose of FAM is to help a woman accurately determine when her ‘window of fertility’ opens and closes. On these days, pregnancy can be more easily achieved, or it can be avoided through abstinence.
FAM is often confused with the ineffective rhythm method, which uses mathematical calculations based on past cycle lengths to predict infertile days for the present cycle. FAM relies only on daily observation of fertility changes in the present, and is therefore more effective. It eliminates the problems of hormones affecting the milk in breastfeeding women and avoids the hassle of staining which can occur with pills and IUD‘s.
FAM is based on five scientific principles:
1) A woman’s cycle is controlled by the hormones estrogen and progesterone,
2) These hormones affect three fertility signs (described below), which signal ovulation and its aftermath,
3) The woman’s egg lives only 12-24 hrs,
4) Sperm can live for more than 3 days in fertile-quality secretions, and
5) From approximately 24 hours after ovulation for a period of two weeks, the cells surrounding the place (follicle) from which the egg was released (known as the corpus luteum) secrete hormones which inhibit further egg development. During this time, additional ovulation, and hence conception, cannot occur.
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 these changes by themselves:
Basal Body Temperature (BBT) is the temperature of the body at rest. It is taken upon waking with a special digital thermometer for one minute. A woman’s BBT rises approx. 0.5 C (half of one degree Celsius) after ovulation occurs, and the BBT stays relatively high for two weeks, until her menses begin. Once this rise is verified, a woman is no longer fertile for the rest of the cycle.
Cervical Secretions or fluids appear naturally and normally throughout the cycle. Secretion checks are important for diagnosing and treating infertility, but few are familiar with the opposite goal – using secretion changes for contraception. For most days of the cycle (regardless of length), secretions are dry, sticky, thick and acidic. In effect, these dry secretions act as natural spermicides. During the fertile days, at ovulation time, the secretions become milkier, wetter, and thinner, and resemble egg-white. These wet secretions are responsible for nourishing sperm and helping them reach the egg. Few women 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. Once she has learned, a woman can feel ‘fluent’ and confident within a few cycles. Furthermore, she can learn to differentiate between normal and abnormal secretions (e.g., those that indicate a yeast or bacterial infection).
Cervical Position changes occur only at the time of ovulation. When inserting a finger deep in the vagina, every woman can recognize the changes before, during and after ovulation. On infertile days, the cervix is lower, closed, and hard. At ovulation it moves upwards towards the uterus, opens, and softens. The purpose of these changes is to allow easy access for sperm on their journey towards the egg. This is the only fertility sign which requires internal checking.
A woman can decide whether to chart one, two, or three fertility signs. The more signs she checks, the more information and effectiveness she has, and the more confidence she will feel in interpreting her chart and applying the method rules. Charting requires 1-2 minutes a day initially. Within two learning sessions, most women are able to interpret their fertility signs independently. In order to be effective, FAM should be learned with a qualified teacher.
Charting can be a valuable aid for women trying to conceive. Charting can detect anovulation, late ovulation, luteal phase defects, unsuitable secretions, occurrence of miscarriage, and likely date of conception. 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 treatment can be reduced.
For more information, contact Michal Schonbrun through her website at www.poriutivit.com (click on “English” in the upper left corner of the home page).
Halachic Aspects of FAM
As with any method of contraception, a rabbinic opinion should be sought to determine whether delaying conception is permissible for the couple in their current life circumstances. If they are permitted to delay conception, this method does not interfere with the natural course of relations, nor does it lead to hotza’at zera lebatalah (wasting seed).
Avoiding relations during the fertile period (which, for the mikveh observing couple, means only the post ovulatory phase) can shorten the time available to the couple for marital relations (depending on the woman’s cycle length). In particular, mikveh night, when the mitzvah of onah normally applies, often falls during the fertile period. Some rabbinic authorities allow the woman to immerse for the purposes of physical closeness without intercourse. Others are afraid that this will lead to hotza’at zera lebatalah and recommend that the couple delay mikveh immersion.
The couple may also choose an alternative method of contraception for mikveh night. If they have been permitted to use spermicides, then they can do so during the fertile period to allow marital relations to take place. It should be remembered that spermicides are only 80-90% effective when used during the fertile period. If they have been permitted the use of a diaphragm, then this can also be used (in this case the advantage of FAM would be to know when it is really necessary to use the diaphragm and when it is not). In summary, a specific question should be asked of a halachic authority familiar with this method as to how to proceed.