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IVF is a fertility treatment that has helped millions of people have babies, from those struggling with infertility to LGBTQ+ couples and solo parents by choice. While there are still barriers to access — including the price and time commitment — IVF is, for many people, a miracle.
Recently, there has been increased discussion in the news and policy circles about a different approach to infertility called restorative reproductive medicine (RRM). Some social conservatives have billed this as an alternative to IVF, one which focuses on the “root causes” of infertility and enables family-building without using assisted reproductive technologies.
Depending on the source, you’ll either hear this is a revolutionary approach to infertility that works better (and for less money) than more medical approaches like IVF, or that it is right-wing pseudo-science that blames women for infertility and denies them needed treatment.
To understand these varying claims, we need context. What exactly is this? Who is it useful for? Is it effective? There is some nuance here, but it’s useful to start with one clear thing: despite its claims, RRM should not be seen as an alternative to IVF. It is, by definition, a more constrained set of options, which does not allow for all of the medical interventions that might lead to pregnancy.
What is restorative reproductive medicine (RRM)?
In both RRM and standard fertility care, patients undergo testing to find a diagnosis and can receive treatment for common underlying conditions such as PCOS.
RRM, however, does not include the creation of embryos and related treatments. RRM is a broad term, but it is largely practiced through a particular treatment protocol called natural procreative technology, or NaProTech. This approach to infertility was developed to be consistent with the teachings of Catholicism. The Catholic Church traditionally does not support the use of IVF, and some other components of infertility treatment (like the need for men to masturbate for sperm testing) may be unacceptable to very observant Catholics.
The starting point for RRM and for the NaProTech system in particular is cycle tracking. Cycle tracking, in general, is well established as helpful in achieving pregnancy (and is also used by some to time sex to avoid pregnancy). Randomized data shows that knowing when you ovulate — and having sex on those days — increases pregnancy rates. Many women will do a form of this cycle tracking even if they are not facing infertility; it is a standard recommendation from midwives or obstetricians for all patients trying to conceive. RRM adds additional observations to this, like cervical mucus and position tracking, both of which can be signs of ovulation.
This tracking is often combined with imaging, hormone testing, and sperm analysis. Once again, these interventions are generally a part of standard infertility treatment. A core underlying assumption is that there must be some reason for the infertility, and if it could be identified and treated, then pregnancy would be possible.
A paper from 2021 gives a good sense of the other most common treatments used in RRM. This is a report from two family physicians who treated couples using this system over a period of many years; the data covers 370 couples. Of these couples, nearly all (94%) engaged in cycle tracking. Eighty-two percent were treated with some kind of vitamins or supplements (most commonly Vitamin D), and most were given some lifestyle advice (diet, exercise). Eighty-one percent of couples were given medications to enhance cervical mucus. Twenty-two percent of couples received advice about male fertility, presumably reflecting some diagnosed issue with sperm health.
Turning to more medical treatments: 62% were prescribed an ovulation drug, and 73% were given progesterone in the second phase of the cycle. Almost half of the women were prescribed low-dose naltrexone, which is a treatment sometimes used in PCOS. Finally, 48% of women were prescribed surgery, largely laparoscopic surgery for endometriosis.
With the exception of endometrial surgery, which I get into more below, these are all treatments that you could find in standard fertility care, before potentially moving to IVF. RRM would typically spend more time optimizing with these options because IUI and IVF are not on the table.
How effective is RRM?
As with any technology someone is trying to sell you, there are many claims made by NaProTech about success. Case reports of couples who tried everything, and then were pregnant the first month after using this technology. Such reports provide (sometimes false) hope, but do not constitute evidence.
The best larger-scale evidence we have on success comes from the paper I cited above on interventions. In this sample of 370 couples, the live birth rate was 29% within two years of treatment. This was significantly higher for couples under 35 (34%) and for couples where the female partner had a BMI under 25 (40%).
As noted, at times, there have been efforts to compare this to IVF success rates. Conceptually, this doesn’t make very much sense given that this approach is limited to only certain types of treatment. In addition, it is very difficult to compare the data directly. There are no randomized controlled trials, and the patients seeking treatment are likely to be quite different from those doing IVF.
However, to the extent we can compare, IVF success rates are higher (as you would expect).
IVF success rates are generally cited per cycle of IVF, not per overall protocol. The per-cycle IVF rates are comparable or slightly lower than the two-year RRM success rates cited above, but that’s not a direct comparison because individuals generally have the option for multiple IVF cycles. CDC figures show a success rate for IVF of 51% for women under 35 (this is compared to the 34% for RRM above). The upshot: Based on the data, if you took the same population, you would expect those who had access to IVF to have a higher pregnancy rate.
Why do so many women get surgery?
One large difference between RRM and IVF is the approach to treating endometriosis. Endometriosis is a condition affecting an estimated 10% of women, causing a variety of symptoms, including pelvic pain and heavy periods. It can also be asymptomatic (known as “silent endometriosis”). It is caused by the excess growth of tissue resembling the uterine lining outside of the uterus. Women with endometriosis are at much higher risk of infertility; estimates suggest up to 50% of women with infertility have endometriosis.
In the NaProTech system, treatment — typically, surgical removal of tissues — is widely used. The view is that the endometrial tissue is a root cause of the infertility and, if removed, pregnancy would be more likely. This is not a consensus view and, indeed, the data is unclear. When IVF is an option, practitioners will sometimes treat endometriosis with surgery and sometimes proceed directly to IVF, depending on the details and severity.
The medical community — ACOG, for example — has expressed concern that this focus may lead women to believe that endometrial surgery would fix their infertility, when the data does not clearly support wide usage.
How might RRM impact fertility care?
An estimated one in five couples struggle with infertility, and all of these individuals deserve to have an opportunity to build their family. For some of this group — specifically, individuals who are not interested in pursuing technologies like IVF for religious reasons — RRM can be a very valuable option. Although the approaches used are extremely similar to those used in standard fertility care, some individuals may be more comfortable in these settings.
In addition, there may be lessons a larger population could take from the careful cycle tracking approach here — certainly, knowing how your cycle works before trying to conceive may be broadly helpful.
On the other hand, there are very significant concerns here. RRM is explicitly exclusionary to LGBTQ+ families and to single parents. In policy circles, this approach has often aligned with policies that restrict choice, up to linking with legislation that would eliminate the possibility of using IVF.
It would be an enormous mistake for policymakers to allow the existence of this constrained option to limit support for IVF. IVF provides a set of possibilities for infertile couples that go beyond those available in the RRM approach, and, for many people, it will be the only way that they can achieve pregnancy. As I have noted before, funding for fertility services like IVF is one of the ways we can increase the fertility rate, a commonly stated goal of many social conservatives. Making it more difficult for couples to conceive will move this backwards.
The bottom line
- Restorative reproductive medicine (RRM) is not a full alternative to IVF. RRM focuses on diagnosing and treating underlying fertility issues without using assisted reproductive technologies like IVF or IUI. It was developed to be consistent with the teachings of Catholicism, which opposes embryo creation.
- RRM often involves cycle tracking, hormone treatments, supplements, and even surgery (for endometriosis). While many treatments are similar to early-stage fertility care, RRM leans heavily on them due to its exclusion of IVF.
- IVF success rates for similar groups (e.g., women under 35) are notably higher (about 51% per cycle), though direct comparisons are complicated by different populations and treatment definitions.
- RRM is not inclusive of LGBTQ+ individuals or solo parents. Its alignment with anti-IVF policy positions makes it risky to frame as a broad solution to infertility — it should be viewed as one option among many, not a replacement for IVF.
Log in
I think one thing commonly missing from these discussions is what to do with embryos that will not be used. I underwent IVF prior to cancer therapy, as my doctors cared about me and wanted me to have options. I completed treatment, was able to conceive without embryos, but feel moral distress about what happens to them next. This distress is *not* universal, but does happen to those of us questioning when life begins, the value of creation, and what to do with potential children (destroy, use for research, give up for adoption, or have more than anticipated, etc etc). I think acknowledging that this distress is a not uncommon risk for IVF couples is important and germane to the NaPro discussion.
I am at the beginning of the NaPro process. This seems like a fair assessment of RRM vs. IVF based on the data we have. There are many reasons that couples decide to use IVF. A woman who had her fallopian tubes damaged by endometriosis and thus had them removed (not for “fun” but because they were riddled with scar tissue, causing pain, etc.) obviously would not benefit from RRM. IVF in that case is the only option. The way I understand some of the recent buzz about RRM is it might be coming from a feeling that women, in particular, who bear the brunt of the pressures of infertility treatment, are looking for something different. Just like with MAHA and everything else in the health sphere right now, there’s an undercurrent of feeling that the status quo is not the end all be all. So, like you say, we need to be presenting options to women, not a dichotomy.
This is not something that I had heard about in these terms and was a very useful write up. If I were to guess about what is elevating this debate, the common guidance given by obs is to “try for a year and then come back if it hasn’t worked.” This leaves a lot of women desperate for guidance and open to being influenced in that time period, which is how you end up with non-devout Catholics discovering and seeking our RRM.
I have personal experience here. It took me longer to conceive my second, so I ended up reaching out to a very Catholic friend who teaches natural family planning and she passed along some great non-religious resources and offered some coaching on cycle tracking that definitely helped us conceive. For many others in my circle who didn’t have a personal resource, they leaned heavily on their Oura rings or social media to get similar guidance.
I think we could refuse to engage in the politicized dichotomy presented in the broader debate and insist on the similarities – “both IVF and RRM offer fertility counseling – they differ in the prioritization of surgical endometriosis care and the availability of egg harvesting and artificial insemination.” Why? I think you can make women feel like they have to “pick sides” instead of shopping from the best of both options. Ultimately, I think this article does a great job of breaking down the evidence based perspective for the procedures involved but I would not be surprised if RRM is spiking because of a dearth of guidance from traditional OBs office in the conception phase.
What is so incredibly infuriating to me about this, as someone who struggled with infertility and ultimately had to go through six rounds of IUI before getting pregnant, all the techniques and tactics highlighted in RRM are things that (hetero couple) PEOPLE ARE ALREADY DOING! No one doesn’t get pregnant first try and then just goes, “oh well – I guess IVF!” No one! You do all the tracking and mucus and crazy hoodoo you find online (“take mucinex and put in a menstrual cup AFTER ejaculation to keep the sperm in… you got it!”) because moving into assistive technology is time consuming, costly, PAINFUL and usually your insurance doesn’t cover it until you’ve already been TRYING for an extended time (for hetero couples). This is just another excuse that insurance and the weird daddy-state is going to use to say “we can’t cover reproductive tech until you’ve proven to us you’ve done all this BS for X years…” For a govt that says they want more babies they sure are making it hard to get the babies in the first place, and then take care of them properly after they’re in the world!
I agree this aspect is really frustrating. As someone alluded to above, I think what funnels a lot of nonreligious people to NaPro is thinking it’s the only way for an in-depth education on advanced cycle tracking methods (like cervical mucus tracking, for example.) it obviously isn’t/shouldn’t be as the Church has no monopoly on “the biology of the female body.” If more OBs would just spend time teaching this stuff, it could be brought out from under the religious/conservative umbrella and just be part of the process. Some people may want to spend longer trying these methods than others before moving to IVF. Its a shame that these things are pitted against each other.
“RRM is explicitly exclusionary to LGBTQ+ families and to single parents.”
What exactly do you mean by this? That doctors providing RRM care turn away these patients? Is this universal?
Medically speaking, the approaches described in the article are compatible with these scenarios, unless you need IVF for a donor egg. But e.g. lesbian couples and single mothers by choice can absolutely conceive without IVF (and without a clinician doing the insemination, if that’s also ruled out here) and could benefit from the options that RRM does offer — unless they’re being proactively turned away. More clarity would be helpful here.
Hey! NaPro patient here that can answer this question. I loved my NaPro treatment experience and an very fortunate that it worked for me. What I did not love at all were the invasive questions into my personal life. NaPro was only available to me through a Catholic hospital (I am Catholic, which is how I even knew about it). They explicitly would only provide NaPro for the purpose of fertility treatment to heterosexual married couples. You did not have to be Catholic, but lgbtq and single people were excluded. I wish this were not the case and that secular hospitals would provide similar options.