RRM: A proposed “morally superior” alternative to IVF

Restorative reproductive medicine (RRM) is gaining attention as an alternative to IVF, aiming to restore natural reproductive functions to enable pregnancy through unassisted intercourse. RRM, deeply intertwined with Catholic Church teachings, may not be suitable for everyone due to its religious underpinnings and restrictive practices.

Recently, I’ve been noticing articles describing an alternative to IVF — restorative reproductive medicine (RRM).

This is likely linked to the recent report “Treating Infertility: The New Frontier of Reproductive Medicine” by The Heritage Foundation, a conservative think tank known for its influence on US Republican policy.

In this report, The Heritage Foundation proposes RRM as an alternative to IVF. RRM is presented as a natural and holistic approach to resolving infertility, focusing on identifying and treating underlying causes.

One major form of RRM is NaProTechnology (Natural Procreative Technology).

What is restorative reproductive medicine, or NaProTechnology?

At its core, NaProTechnology’s philosophy is to treat infertility (and other gynecologic issues) as symptoms of underlying health problems, rather than as standalone diagnoses to be bypassed by IVF (Jemelka et al. 2013). The goal of NaProTechnology is to restore normal reproductive function so that a couple can achieve pregnancy through unassisted sexual intercourse.

In practice, this means identifying and addressing any medical problems (e.g. hormonal disorders, anatomical lesions, infections) that are hindering fertility.

RRM starts with a thorough review of a patient’s health, lifestyle, and reproductive history. Patients track their menstrual cycles using the Creighton Model FertilityCare System, noting signs like cervical mucus and period details. Regular visits allow the doctor to check this data, along with other tests like blood work and ultrasounds, to spot issues such as hormone imbalances or physical problems.

Treatment can include dietary advice, lifestyle changes, supplements, medications, or even surgery if necessary. The treatment plan is adjusted over time based on how the patient responds, with the goal of improving fertility and achieving pregnancy by unassisted intercourse.

This process can take months or years, depending on the patient’s specific needs and how well they respond to the treatments.

History of NaProTechnology and its ties to the Catholic Church

NaPro was developed in the 1970s and 1980s by OB/GYN Thomas W. Hilgers. He was inspired by Pope Paul VI’s 1968 document on contraception and reproductive ethics, which reaffirmed Catholic opposition to contraception and artificial reproductive methods. Hilgers founded the Saint Paul VI Institute, aiming to create a fertility treatment that aligns with Catholic moral teachings.

A major milestone in NaProTechnology’s development was the publication of The Medical & Surgical Practice of NaProTechnology in 2004, a 1200-page textbook by Hilgers compiling nearly 30 years of research. By 2025, over 800 healthcare providers had received training in NaProTechnology, though the number of fully trained NaPro surgeons remains small (only a few dozen). Many NaPro physicians are themselves devout Catholics or are practicing in Catholic healthcare systems.

The method’s foundation and development are deeply integrated with the Catholic Church, which opposes IVF and similar techniques on the grounds that they separate procreation from sexual intercourse and frequently involve the destruction of embryos (which the Church regards as human lives). By focusing on unassisted conception, NaProTechnology avoids these issues.

The influence of the Catholic Church on RRM places several restrictions on how RRM can be used:

Donor eggs or sperm are not permitted. Adoption is encouraged if RRM fails (see figure 40-8). No same sex couples or single individuals could use RRM since it focuses on unassisted conception.
No fertilization outside the body is allowed.
No intentional destruction of embryos.
Generally, IUI is not performed or any type of assisted reproductive technology.
No contraception.
No gestational carriers.

Because of these restrictions, RRM is limited in treating all forms of infertility, such as some forms of male factor infertility and tubal infertility, where IVF would still be necessary. It’s also not clear if it would be effective in older patients, who are more likely to have low AMH and produce aneuploid embryos. Additionally, IVF would likely be preferred for some cases of unexplained infertility or endometriosis, or PGT-M or PGT-SR in cases where the couple have a genetic mutation or chromosomal translocation.

How does restorative reproductive medicine compare to IVF?

From its inception, NaProTechnology has positioned itself as a morally and medically superior alternative to IVF and other assisted reproductive techniques. The Saint Paul VI Institute explicitly states that it “offers superior treatments to women and challenges mainstream medicine, which relies on contraception, in vitro fertilization, and abortion.”

The Heritage Foundation’s report frames IVF in a similar way, highlighting ethical concerns with embryo use and the separation of procreation from marital intimacy. They take it a step further and criticize the IVF industry, accusing it of being profit-driven, unregulated and suggesting that it offers only superficial “band-aid” solutions that fail to address underlying health conditions. RRM, they propose, is a superior method because it focuses on treating the underlying health issues causing infertility rather than just facilitating conception.

One way NaProTechnology positions itself as a replacement is by emphasizing its success rates. For example, the Heritage Foundation report notes that “success rates for RRM are similar to or better than IVF for many couples.” The report lists remarkable success figures for NaPro treatments in specific infertility diagnoses: reportedly achieving live birth in 81.9% of women with anovulation, 56.7% of those with endometriosis-related infertility, and 38.4% of those with blocked fallopian tubes. This data is also presented here, but it’s from the NaPro textbook so it’s difficult to independently verify or assess the data. The IVF success rates used for comparison in the report come from studies published in the 1980s or early 2000s, meaning they may not reflect current IVF outcomes, which have likely improved over time.

So what do other studies say about RRM? There hasn’t been very much, from what I’ve seen:

Stanford et al. (2007) used NaPro for 1072 couples. After 2 years, there were 273 live births (25.5%). However, 672 patients withdrew from the study, so 273/354 = 64.8% had a live birth for those that continued.
Tham et al. (2012) used NaPro in 108 couples. After 2 years of NaPro, there were 41 live births (41/108 = 38.0%). However, 52 participants withdrew from the study, so 41/56 = 66.0% had a live birth for those that continued.
Boyle et al. (2018) followed 403 patients who had previously undergone IVF without success. After 2 years, there were 74 live births (74/403 = 18.4%). When adjusting for the 275 patients who withdrew from the study, they reported an adjusted live birth rate of 32.1%.
Stanford et al. (2021) used RRM for 370 couples. After 2 years, there were 66 live births (66/370 = 17.8%). However, 209 patients withdrew from the study, so 66/161 = 41% had a live birth for those that continued.

I encourage you to go and check out these studies (they’re all open source), if you want to learn more about how RRM works and how patients are treated.

The issue here is how long couples need to be in the program. These three studies all had patients trying for 2 years, with most patients dropping out by this time. It’s hard to know how successful the treatment is if most people leave the study. For example, the women who stay might have less severe forms of infertility, which might increase their chance of success.

Other issues that I’m seeing with this research:

There are no IVF controls, or controls where patients receive no treatment, so it’s hard to know how effective RRM is. A recent meta-analysis (reviewed here) found that about 1 in 5 women achieve a natural (unassisted) pregnancy following a live birth by IVF, with most pregnancies occurring after 2-3 years. While RRM will use various methods to correct infertility, this research shows that there is a baseline level of success without any treatment, making it important to consider “untreated” patients when evaluating RRM. Furthermore, asserting that RRM has the same or similar success rates to IVF, per the Heritage report, requires that these two treatments are tested head-to-head.
Two years is a very long time for treatment! Many patients may prefer IVF to obtain embryos and transfer them, particularly if they’re older. The time-to-pregnancy is likely much shorter with IVF. However, this will depend on the patient (their age, diagnosis, history, etc.). Without studies evaluating this, it’s hard to compare the treatments.
These studies are mostly done by proponents of RRM. Independent studies need to be done to make sure there isn’t any influence by people who want RRM to succeed.
To my knowledge, there are no RCTs.

In terms of cost, RRM generally costs less than IVF. The Heritage Foundation report indicates that an 18-month plan can cost about $9,000 USD, covering initial assessments, ongoing tests, and early pregnancy monitoring. RRM tends to be more affordable because it does not require high-tech labs or specialized personnel, and it is often managed by family physicians or gynecologists, who are typically paid less than reproductive endocrinologists.

Conclusions

NaProTechnology and RRM presents a unique perspective on treating infertility, emphasizing natural and ethical approaches that are aligned with Catholic teachings. While it offers an alternative for those seeking treatments that align with specific moral frameworks, it isn’t for everyone.

It also isn’t clear how effective RRM is in treating infertility, due to a lack of research on the topic. While more affordable, the treatment times are long and a variety of patient groups may not be suitable candidates for RRM.

The Heritage Foundation’s report is positioning RRM as a replacement to IVF, and doesn’t shy away from trying to paint the IVF industry as ineffective. The report itself undermines the established success and need of IVF for many patients. Reproductive endocrinologist Jessica Ryniec recently posted a video on Instagram discussing the report, and highlighted her concerns:

The report is not written by reproductive endocrinologists, which raises questions about its expertise and validity.
It claims that infertility is neither a disease nor a condition (but is instead a symptom of an underlying reproductive problem, which must be treated to correct infertility).
The report repeatedly uses personhood language, asserting that early embryos are human lives with rights, referencing a recent Alabama Supreme Court ruling that recognizes frozen embryos as human beings.
Ryniec points out that the treatments proposed by RRM are already being implemented by IVF professionals.
The report challenges established scientific practices, labeling procedures like PGT as eugenics and voicing concerns over in vitro gametogenesis (IVG), which it claims could lead to “embryo farms” for commercial eugenics. IVG is a technique that’s being developed to make egg and sperm cells from stem cells, which could be sourced from a person’s skin cells.

Given The Heritage Foundation’s influence, there is a possibility that RRM may be considered as an alternative to IVF in the US. This development could shape future policies, potentially steering public and political support towards RRM and away from IVF.

It’s important to keep discussions balanced and based on solid evidence. Even if RRM is considered, it should be carefully compared with proven treatments like IVF to ensure that healthcare policies support the best possible options for everyone.

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About Embryoman

Embryoman (Sean Lauber) is a former embryologist and the founder of Remembryo, an IVF research and fertility education website. After working in an IVF lab in the US, he returned to Canada and now focuses on making fertility research more accessible. He holds a Master’s in Immunology and launched Remembryo in 2018 to help patients and professionals make sense of IVF research. Sean shares weekly study updates on Facebook, Instagram, and Reddit regularly. He also answers questions on Reddit or in his private Facebook group.