Your Right to Know: The Internal Observations

As noted in the previous posting dealing with cervical mucus, Dr. Edward F. Keefe was the first doctor of record in the United States to promote and teach the observation of cervical mucus, starting in 1948 or 1949 with a reference in his Ovulindex thermometer booklet and more specifically with an illustration in the 1953 edition of that booklet.  He wanted the mucus and temperature signs used in a crosschecking way, and he was thus opposed to the Billings emphasis on using it by itself.  In 1975 he wrote the following review of the Billings’ book.  This appeared in COVERLINE, the newsletter of the Natural Family Planning Association of Connecticut, Spring, 1975.  Since he is the pioneer in this area, I thought it would be worthwhile to have his opinions available on the internet.

 “Reflections on Mucus Alone as a Fertility Sign”

by Edward F. Keefe, M.D.

A strong tone of advocacy marks Dr. Billings’ book, Natural Family Planning, the Ovulation Method, 2nd American edition.  While its shortcomings are now well recognized in spite of the enthusiasm of its proponents, I welcome a chance to “place in the record” a review of this book.

Preparing the review brought to mind my early efforts to improve systematic abstinence as a means of family limitation.  I recalled my excitement over a paper on the rheology of human cervical mucus (1. Clift, A.P., Proc. Roy. Soc. Med. 39:1945).  Rheology is the study of flow.  Women apply it every day when they judge such things as syrups, jellies, batters, ripeness of fruit, etc., in the kitchen.  The paper made me wonder if a woman could not observe for herself the changes in the physical properties of her cervical mucus as well as its volume, changes which already could signify the fertile time in farm animals.  I reported on preliminary studies of these aids in 1950 to a meeting of the medical staff of St. Vincent’s Hospital of New York.  They listened politely but many questioned if there was a fertile time in women at all, not whether it could be recognized by temperatures or mucus.

The Ovulindex thermometer had just been developed by me.  (I should disclose I still own the company  that manufactures it.)  In 1948 I wrote (anonymously) its first handbook, which said no more about mucus, I find now, than that its presence was to be recorded, along with  the temperatures.  But, by 1953, I was so confident that changes in the mucus were a valuable guide that I fully described them in the second edition.  I illustrated the location of the cervix and how to test threading of the mucus between thumb and forefinger – a rheologic test.

In my office practice, at first I, too, taught the use of the mucus on the vulva, as does Dr. Billings.  But it was insufficient, inconstant, and lagged beyond the true state of the ovaries according to my patients.  Most of them had been “Rhythm-failures” many times over and they demanded perfect results.  The best mucus sample was needed and the place to find it was in the cervical canal, unaffected by passage through the vagina.  I encouraged them to remove the mucus directly from the cervix.  After trying aspiration through a tube, we settled on removing the mucus with the fingers.  In making such collections, my patients discovered there were changes in the cervix itself.  They found at the approach of ovulation, as the mucus became abundant, thin and clear, the cervix itself softened and the canal opened.  A search of the medical literature disclosed descriptions of this dilation of the canal, but to apply these changes to periodic abstinence was something new.  I studied them for more than ten years.  Many women were enthusiastic about the signs and asked why they did not receive more publicity.  Meanwhile, my paper on this seemed to create little interest among doctors (2. Keefe, E.F., “Self-observation of the Cervix to Distinguish Days of Possible Fertility” Bull. Sloane Hosp for Women, 8:129, 1962).  The spotlight was on Dr. Rock’s “100% effective pill.”

Somewhat later, my patients reported to me that the cervix is elevated as well into the pelvis before ovulation and descends after it.  These were astonishing changes not mentioned in the literature.  I felt certain enough of these signs to describe them in 1964 in the third edition of the Ovulindex thermometer handbook and in COVERLINE: Vol. 2, No. 4, 1970.

Meanwhile, Dr. Billings lectured to our obstetrical staff at St. Vincent’s and when he returned to Australia, his home, he kindly sent me The Ovulation Method, first edition (1964) which explained calculation of the cycle-pattern, temperature charting and the changes in mucus.  In 1965, I learned from Dr. Lanctot that mucus was a “symptom” in the Sympto-Thermic Method.  I was happy that others were working along the same lines as myself.

Just recently, Dr. Josef Roetzer of Voecklabruck, Austria, in explaining his sympto-thermal system at a “Round Table on Ovulation Prediction” in Rome, on April 4-6, 1974, described the changes in the cervix mentioned above, including its elevation at the fertile time.  His patients, like mine, had discovered for themselves these signs.  I still believe (2) “It could become common knowledge that, if a woman finds her cervix flaccid, gaping and streaming with mucus, there is a great chance of conception and, in the absence of these signs, there is less or no chance.”  Dr. Billings’ book will help disseminate part of this knowledge and for that I welcome it.  But I would rather that mucus signs supplement the charting of temperature, not replace them as the book demands.  Moreover, just because mucus on the vulva is not a dependable sign, its shortcomings must not cause us to undervalue the changes in the cervical mucus and the cervix itself.  I will go into this in a forthcoming book review.

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 We do not have his book review.  Next week’s blog will look at the temperature sign.  To see how all the signs are used in a cross-checking way, see our manual, Natural Family Planning: The Complete Approach at