Pilar Vigil, Md, PhD
Friday, 26 April 2013, Kuching, Malaysia

The John J. Billings Memorial Lecture

They have reached the end of their journey, and are now in eternal love.

They made their journey a pilgrimage, where every step was a unique goal, to reach their life’s ideal of love.

Let me share their steps on the way to love with you:

First Step: Life

Lyn and John were able to look at life as a miracle and as a gift.  They cared about life and every living creature, especially men and women.  They were able to see that fertility is a gift that enables us to be co-creators of life.  In this way they introduced a revolutionary concept: fertility as a gift and as a sign of health, not as a burden.  As Lyn said, “when you know this is true, you have to keep on going”…They restlessly fought to introduce the concept that being able to recognize fertility and infertility is an important knowledge that every woman ought to have.

 As a result of their work we now have a method that teaches women to read themselves, as it allows them to identify the changes that are naturally occurring in their bodies.

An important question arises: if this is so obvious and true why has it always been (since the very beginning) such a novelty? or such a sign of contradiction? 

Let us take a look at history: during the 60’s, the time of the baby boom, humanity had a problem of overpopulation. Researches tried to find a way to solve fertility issues by eliminating fertility.  In a different way, John looks at who we are and how we have been created, he looks at creation and finds a biological sign of fertility inscribed in human nature. He asks himself then if instead of simply eliminating this sign, women should understand and use it to be able to know more about themselves and to freely decide whether they wish to conceive a child. In this way, John tries to give an answer to all those who were in need of effective family planning.  His call to look after other people’s needs drives him away from his area of expertise, neurology, bringing him to gynaecology.  It is in this way that he makes a paramount discovery: women can recognize ovulation by the perception of sensory changes in the vulva. Women now have a tool to recognize their fertile and infertile periods. The Billings Ovulation Method is born.

This pilgrimage was not made alone.  John and Lyn had very good friends around them.  One of them was Dr. James Brown who looked at the mystery of the ovarian cycle and was able to describe the concept of the continuum.  But why is this such a difficulty?  As Dr. Brown wrote:

“The continuum is a process and is thus similar to other processes in the body. Therefore it cannot be described through measurements and standardized deviations. The continuum is reduced to bleeding patterns and the event of menstruation.”

Many gynaecologists, still concentrate on regularizing the bleeding patterns without understanding the underlying hormonal environment. After World War II, the concept of science is reduced only to measurable parameters. In this way, fertility and ovulation as being part of a continuum are too difficult to measure and objectivize so it is easier to eliminate them as an important concept. Women’s health issues are reduced to bleeding patterns.  Menstruation is the sign, ovulation the problem.

We find ourselves faced with different paradigms: ovulation vs menstruation as the important sign. These two ideas are not compatible; we are faced with a sign of contradiction.

The main aspect that a woman’s fertility awareness should consider is the accurate monitoring of ovulation, in the understanding that this constitutes the main event in the menstrual cycle. Dr. Brown showed that menstrual cycles can be classified into six main categories, which follow a certain order during the development of fertility at the onset of a woman’s reproductive life: i) cycles with no ovarian activity (i.e., amenorrhea), ii) anovulatory cycles with fluctuating estrogen levels, iii) cycles with anovulatory ovarian activity with constantly increased estrogen levels, iv) cycles with a luteinized unruptured follicle, v) cycles with ovulation followed by a deficient luteal phase, and vi) ovulatory cycles with adequate luteal phases, i.e., fertile. This constitutes a continuous progression encompassing almost all the types of cycles. This is the concept of the ovarian continuum, of which only the last stage, the fertile ovulatory cycle, can eventually lead to a viable pregnancy.

The key elements of a normal cycle that have been identified with the daily use of doctor’s Brown Ovarian Monitor are:

1.The day when estrone glucuronide starts rising towards the hormone peak. This is usually the time when women will start feeling the presence of mucus at the vulva. The mucus symptoms are generally a response to the initial estradiol rise marking the beginning of the fertile window in the woman. The two hormonal markers give an average fertile period of about 7 days.

Between the beginning of the estrone glucuronide increase and the ovulatory estrone glucuronide peak, there is normally a 4-5 day interval (sufficient to allow for spermatozoa survival in cervical mucus, an average of about 3-4 days).

2. The day of estrone glucuronide excretion peak; this and the following day are the most fertile in the cycle. Ovulation normally occurs in the 26-48 h interval after the estrone glucuronide peak day, this gives a 5-6 days warning of ovulation.
3. The first pregnanediol glucuronide increase on the day of the estrone glucuronide peak or close to it, constituting a good sign of ovulation. This pregnanediol rise is very important because it explains the mucus peak symptom.
4. The day when the pregnanediol glucuronide excretion rate reaches or exceeds 7 µmol/24 h —i.e., the pregnanediol glucuronide threshold—, signaling the end of the fertile window.
5. Glucuronide pregnanediol levels should reach a certain value (13.5 µmol/24 h) for the cycle to be fertile.
6. The length of the luteal phase should be between 11 and 16 days.

During their pilgrimage John and Lyn also met Dr. Erik Odeblad.  He started a pioneer research that allowed establishing the relevance of cervical mucus for female fertility. During the menstrual cycle, two categories of cervical secretion can be identified: estrogenic mucus (E), with a translucent appearance, which has higher elasticity and predominates in the periovulatory period; and progestational mucus (gestagenic or G), with an opaque and sticky appearance, predominant in the luteal phase. Estrogenic mucus is divided into three types, S, L and P, each with a different function, and distinctive features regarding receptivity to spermatozoa.

Even though the three types of mucus are secreted throughout the whole cycle, one predominates over the others in the periovulatory period.

Type S Mucus: Its function would be to transport the spermatozoa to the S-mucus secreting crypts located in the cervical canal towards the site of fertilization. This mucus is very fluid and spermatozoa can migrate quickly through it, reaching the crypts in a 3 to 10 min period. The pattern of crystallization of S mucus is arranged in fine parallel lines.

Type L Mucus: This mucus has medium viscosity and spermatozoa travel through it more slowly; the mucus would act as a filter, holding spermatozoa with morphological alterations. Its shape similar to fern fronds or palm leaves characterizes the pattern of crystallization of mucus L.

Type P Mucus: This type is similar to type L since it also has a pattern of crystallization resembling fern fronds. It is more abundant on peak day, when the woman’s feeling of lubrication reaches a high at the vulvar level. P Mucus has five subtypes: Pt, Pa, P2, P4 and P6_B. One subtype of P mucus, P6, is very interesting, its mucus crystallization is characterized by a distinctive stellate geometry: from the central crystallization nucleus, 6 well-defined axes protrude. This type of mucus would be frequent on the day of highest fertility.

According to Dr. Odeblad’s scheme, spermatozoa migrate to the cervical crypts specifically through S and P6_B mucus, either to be stored, or to migrate directly to the uterine cavity.

It is worth noting that one of the main differences in the composition of S, L and G mucus is based on their percentage of water content, being 98 % for S, 95 % for L and 90 % for G mucus. Differences in composition as well as the existence of different crystallization patterns for cervical mucus are mainly due to the heterogeneous nature of cervical mucus, which is composed by several types of cervical secretion produced in specific regions of the cervix. This heterogeneity is evidenced in the morphological differences observed in its crystallization.

The ultrastructure of estrogenic mucus can be determined through scanning electron microscopy. Elstein and Daunter reported the presence of canals 30 μm in diameter through which spermatozoa, whose heads are ~ 5 μm in diameter, could easily migrate. Other SEM studies have found areas with a linear arrangement of estrogenic mucus fibres which allow spermatozoa migration, and also other areas resembling a filament mesh with multiple pores. The changes undergone by the ultrastructure as well as the biophysical properties of mucus along the cycle are mainly due to variations in sex steroid hormones, which affect mucus hydration and the expression of the glycoproteins (mucins) that comprise this hydrogel, among other features.

Mucins are mainly responsible for the rheological properties that characterize this hydrogel. To date, more than 20 mucin-encoding genes have been identified, and at least 13 of them are expressed in the female genital tract. Of the many mucins, those found in mucus are gel-forming secreting mucins. It has been proposed that the characteristic structure of mucus, in which mucins exert an important role, appear when these glycoproteins form something like a mesh of interconnected molecules. Mucin 5B is the main gel-forming mucin expressed by the endocervical epithelium, and reaches its peak in mid-cycle. Similarly, there is evidence of other mucins, which are expressed in the cervix during the ovulatory phase, such as mucin 4.

The amount of cervical mucus secreted during the cycle also varies on the basis of changes in ovarian sex hormones. During follicular development, when estradiol plasma levels reach average levels of 107 pg/mL, and the follicle is about 8-10 mm in diameter (about 6-7 days prior to ovulation), cervical mucus secretion starts to increase until it reaches 500 mg/day in the periovulatory period, being perceived by the woman. After ovulation, there is an increase in progesterone, and estradiol plasma levels fluctuate between 130 and 200 pg/mL. The amount of mucus secreted by the endocervix decreases to 50 mg/day, and the mucus becomes opaque and more prone to breaking when stretched despite the high levels of estradiol. This is due to the anti-estrogenic action of progesterone on mucus features.

In addition, at the cervix, progesterone induces release of cathepsins from leucocytes and increases the action of sialyltransferase, favoring the appearance of a dense mesh formed by the mucin molecules that make up the cervical secretion. The mucus secreted during the luteal phase (G mucus) has a much lower capacity to crystallize, and its ultrastructure presents pores with a diameter of 3 to 5 μm, rendering it impenetrable for spermatozoa.

Given the aforementioned features, mucus is expected to exert a series of very important biological functions. The main one is spermatozoa transport. Mucus constitutes the first barrier spermatozoa must go through in their journey towards the site of fertilization, and serves as a selective barrier allowing preferential passage of morphologically normal spermatozoa only, and only for 6 to 7 days of the menstrual cycle. Morphologically normal spermatozoa, which survive in cervical mucus, are known to keep their acrosome intact, and probably their capacity to fertilize the oocyte.   This is explained partly due to the high content of estradiol in periovulatory cervical mucus, since this hormone can delay the premature onset of the acrosome reaction. In addition, in mid-cycle the number of mucins expressed in the cervical canal increases, and, being highly hydrophilic in character, these glycoproteins cause the mucus to acquire a high water retention capacity, hence facilitating the migration of spermatozoa and maintaining the cervix moist and lubricated. Finally, pathogenic agents and several noxious agents could be trapped by mucins, preventing their advance into the uterus and Fallopian tubes. Additionally, it has been shown that cervical mucus possesses antimicrobial activity.

Why is fertility awareness useful for a woman?

A woman who knows how to recognize her normal pattern of fertility will be able to identify a number of ovulatory and/or gynecological dysfunctions that might occur during her life. Being able to recognize when menstrual or mucus secretion pattern irregularities should be considered normal is relevant. The different steps of the ovarian continuum will occur during a woman’s lifetime.  Every woman should be able to identify in which step of the continuum she is and in which step she should be.  There is no rule to this, as for example, there is no rule to when a woman should or shouldn’t become pregnant. But, today we know that in the case of women in whom normal ovulatory ovarian activity should be present, for example a 26 years old woman not trying to conceive, three or more abnormal cycles in a year as identified by the mucus symptoms, is inadequate. Such irregularity can be evidenced by a shorter luteal phase, or its absence in case of anovulation. Long or short cycles compared to women’s average cycle length (24 to 36 days) are also to be considered abnormal. The causes of menstrual irregularities and/or variations in the features of cervical secretion may be due to obstetric problems, endocrine dysfunctions (hypothalamic-hypophyseal, thyroid, adrenal and ovarian disturbances), metabolic disorders, genitourinary tract infections, neoplasia and iatrogenic causes, among others. Regarding endocrine dysfunctions, it is worth noting that there is no specific pattern of ovarian activity associated to each one of these. For this reason, each one has to be considered and discarded when making a differential diagnosis of ovulatory irregularity in a woman. In order to do so definitively, a hormone assessment considering all the aforementioned conditions must be obtained. Women with persistent ovulatory dysfunctions associated with irregular cycles and abnormal cervical mucus patterns generally do not spontaneously regain normal cyclical activity without appropriate medical treatment. It has been shown that in the absence of an adequate diagnosis and treatment, menstrual disorders become more serious over time and, therefore, the underlying pathology worsens as well.

Endocrine and metabolic disorders are the most frequent cause of ovulatory dysfunction, which constitutes the most commonly diagnosed problem and is predominantly linked to menstrual irregularity. Ovulatory dysfunction can be identified by means of fertility awareness by determining the presence or absence of fertility signs given by cervical mucus at the vulva, and be characterized by abnormal ovulatory activity, or by the lack of such activity. Abnormal ovulatory activity can be recognized by cycles with a short luteal phase or with pregnanediol glucuronide levels below the fertility threshold, if home monitoring is available. It is also important to consider that young nulliparous women with regular cycles (between 24 and 36 days) can have an occasional ovulatory dysfunction event identifiable by means of their fertility awareness record.

It has been shown that peri-menarcheal girls from a variety of ethnic and socio-economic groups are able to learn how to recognize their cervical mucus patterns and to distinguish ovulatory from non-ovulatory cycles. This suggests that if young women were taught to keep a record of their fertility and infertility signals, they would be able to detect ovarian dysfunctions in their early stages. In addition, it has been shown that when learned during adolescence paired to personal formation involving every aspect of the person, this knowledge constitutes an important tool to strengthen the sense of identity and prevent adolescent pregnancy.

During their pilgrimage, John and Lyn were unrelenting in their search of finding man as himself.  To find this man requires an estrangement from the exclusively quantifiable. This is where the scientist is called on to realize that true science is the one that is in constant search of truth.

Second Step: Love

In order to be able to look at creation, it is necessary to live in love, because love is a yes to belonging, and as Lyn said, “we were happy, we had one another”.

Lyn and John belonged to each other and together they belonged to life.

Lyn had a spouse who saw her and was able to care for and respect her feminine nature.

Unfortunately, this understanding and reverence to each other is not always present.  I will invite you now to hear an excerpt taken out from the extraordinary book written by C.S. Lewis That Hideous Strength:

“All this, which should have been uneasy joy, was torment to him, for it came too late. He was discovering the hedge after he had plucked the rose, and not only plucked it but torn it all to pieces and crumpled it with hot, thumb-like, greedy fingers. How had he dared?”

Love requires seeing the subject of love.

In order to be able to love we need to see ourselves. This is one of the reasons why the Billings Ovulation Method is about love. It helps us to look at ourselves and to recognize who we are.  Spouses can look at each other and discover the beauty in each one of them and in this way give themselves to one another.  In giving and receiving we say yes to belonging and in this way we say yes to love.

Third Step: Forgiveness

How do we say yes to belonging? By giving. The most difficult form of giving is for-giving. Forgiveness was a constant theme in the Billings’ life.

Breathing is fundamental for life.  During breathing we inhale and exhale. If during breathing we only receive the air that will get to our lungs, we die.  In the same way, if we only breathe out, we will drown. In life, in order to live in love we must give and receive. Always giving and never receiving will unable us for true love, as would happen if we were only willing to receive.

 In forgiving, we take the offenses and we give ourselves. This is why forgiveness is the most difficult form of love. John and Lyn taught us to give ourselves completely, and to receive from others what they were willing to give, many times wonderful gifts, but many times offenses.

Today we find ourselves before a science in crisis, where only the quantifiable is true and knowable. This is why concepts so difficult to quantify as fertility awareness and the ovarian continuum, which are fundamentals to the Billings Ovulation Method, find it so difficult to be recognized in the scientific community.

We need to shift out and gaze back to man, and, like John and Lyn, see in every person a creature to which an innate divine quality is bestowed.  We need to start our pilgrimage by looking at life. Life enlightens the womb of women.  This fact has recently been shown in the marvellous sculpture recently created by Dimitri Alithinos, in which he shows the womb of a woman iluminated by the miracle of life. Life enlightens the womb of woman, and so enlightens creation.

During their pilgrimage, John and Lyn continuously showed us that love is the fruit of simple steps taken in life.  Let us stop, look at life around ourselves and rejoice in it; love it and take from life what life and living creatures give us. Let us live, love and forgive, like John and Lyn did.

Let us go with them on our pilgrimage and let us rejoice looking forward to the day we finish our journey and we can all praise the Lord of eternal life together.

I would like to say goodbye thanking you for the gift of your lives in service of others, and encourage your own pilgrimage of life love and forgiveness, sharing an age-old gesture:

Wisdom, embodied by a science in search for truth,

Compassion, embodied in a mutual recognition and a reverence that recognizes the

Divine that resides in each and every one of you.