Restorative Reproductive Medicine
Issue Brief
Overview
Infertility is unfortunately common among people seeking to start or grow their families, with one in six people of reproductive age affected by infertility globally, according to the World Health Organization. People seeking to start or grow their families may turn to their ob-gyn for support, as ob-gyns are uniquely qualified to provide prepregnancy counseling, which can include working with patients and their families to optimize health, address modifiable risk factors, provide education about healthy pregnancy, and understand and optimize their fertility through fertility awareness methods or tracking menstrual cycles in order to identify most likely times for conception. However, data suggests that 12% to 15% of people trying to conceive are unable to do so after one year of having unprotected sex, and that after two years, 10% still have not had a live birth. Many of those individuals will seek care from a reproductive endocrinologist, or an ob-gyn specializing in fertility care.
There are many causes of infertility. Some underlying medical causes can be identified and treated in order to start and grow a family. Sometimes, no specific cause is found, and the infertility is labeled “unexplained.” In many cases, when the goal is to have a baby, the most effective and compassionate approach to care is medical assistance.
Fertility treatments include a wide range of evidence-based interventions, including medications, which can increase egg production; procedures to address physiological reasons for infertility; and assisted reproductive technologies, which use evidence-based methods for fertilizing an egg and, in some cases, transferring an embryo to the uterus.
Physicians who provide fertility treatments work with patients to determine the path forward that best meets their medical needs, values, goals, and priorities. For example, some may prioritize the most expedient approach to start or grow a family, while others may prefer a more conservative approach. It is critical that people be able to work with their doctors to understand and to choose what is right for them.
Not every approach to fertility treatment will be effective for every patient, so having the full array of evidence-based medical interventions is essential. For some patients, for example those whose needs require using donor eggs or sperm, IVF is the only path to achieving pregnancy.
What is so-called “restorative reproductive medicine”?
Recently, a nonmedical approach called “restorative reproductive medicine” (RRM) has entered fertility discussions. When provided as the primary or only option, RRM can expose patients to needless, painful surgical interventions; limit their access to the full range of evidence-based fertility care interventions; and delay time to pregnancy, while potentially increasing overall costs. RRM is built on two major concepts: the incorrect suggestion that endometriosis is the dominant cause of infertility, and the idea that other causes of infertility can be addressed by fertility awareness and lifestyle changes.
The RRM movement is, at its roots, tied to the so-called personhood effort, which previously led to a temporary pause on IVF altogether in the state of Alabama, causing pain and confusion for people who were undergoing and planning to undergo IVF treatment in the state. The personhood effort seeks to elevate the legal status of fertilized eggs to that of people, leading to wide implications for access to medications, medical interventions, and management of high-risk pregnancy. Similarly, the RRM movement has been used to discourage patients from accessing evidence-based IVF in order to avoid the creation of fertilized eggs as part of the IVF process.
It is important to understand that RRM is not a medical term. Focusing on endometriosis excision as the chief barrier to pregnancy unnecessarily exposes some patients to the potential risk of complications associated with the procedure and may not be necessary to address in order to achieve a pregnancy. Concentrating on fertility awareness and lifestyle changes can add unnecessarily to the timeline; be ineffective and redundant, as most patients have already tried these methods before seeking infertility treatment; and make patients less likely to have a baby by delaying the identification and treatment process until patients are much deeper into—or even past—their fertility window. Although endometriosis excision, fertility awareness, and lifestyle changes may have value for some patients and should be a part of conversations people have with their doctors, they must not be the sole approaches available to people undergoing fertility treatment.
The values, goals, and needs of the patient should determine the appropriate course of treatment for infertility.
How does RRM leave many patients and families behind?
By focusing only on female patients, RRM approaches suggest that all infertility is caused by complications with the female reproductive system. But identifiable causes of infertility related to the male patient are just as common as those related to the female patient, according to the Eunice K. Shriver National Institute for Child Health and Human Development. The emphasis on limited female causes of infertility will leave those experiencing infertility due to male causes without treatment options.
Ob-gyns understand that families are diverse and come in many forms, and that fertility treatments can help empower individuals and couples of all kinds to start and grow the family of their dreams. However, RRM narrowly defines family by excluding LGBTQ+ people; people who intend to solo-parent; and people who may only be able to have a baby through fertility treatments, including IVF.
What are the policy implications of RRM?
Proponents of RRM advocate for policies that encourage a nonmedical and nonpatient-centered approach, discourage medical interventions, and establish barriers to evidence-based fertility care, thereby jeopardizing people’s ability to start and grow their families.
All people should have access to the full range of family-building health care grounded in medical science, compassion, and the freedom to make decisions with their physicians about which options will work best for them.ACOG firmly believes that science must be at the core of public health policies and medical decision making that affect the health and life of women and people seeking reproductive health care.
Recommendations
ACOG opposes policies that seek to divert patients away from the full range of evidence-based assisted reproductive technologies and toward the unproven concept of RRM through financial incentives or other mechanisms. Legislation that prioritizes RRM over evidence-based fertility treatment is an example of harmful interference in the practice of medicine.