Restorative Reproductive Medicine – what is it all about?
The Editorial Staff of the CHR
Today’s topic is dedicated to Restorative Reproductive Medicine (RRM), one more term introduced into the English language for political and ideological reasons that makes absolutely no sense. But this time it is not the extreme political left that plays word games to make a purely political point palatable to the public, - but the once widely admired Heritage Foundation, - very obviously on the political right – and recently no longer the voice of the conservative political right, - but increasingly the voice of the extreme, fringe right, as the defense of Tucker Carlson by Heritage Foundation president, Kevin Roberts, so well demonstrated.
By publishing a White Paper regarding fertility treatment recommendations in place of IVF, the Heritage Foundation not only demonstrated complete ignorance about modern infertility care but ended up promoting outdated treatments pursued decades ago. Medicine and politics just don’t match, whether on the political left or right!
This article originally appeared in the January issue of the CHRVOICE but was updated and reedited.
Everybody at the American Society for Reproductive Medicine (ASRM) appears very concerned, - and so seem also many medical journals, including some not even primarily in the infertility field.1 Who, therefore, can be surprised about all the press releases and articles suddenly talking about Restorative Reproductive Medicine (RRM). ACOG, for example, describes RRM as follows:2
Recently, a non-medical approach called “restorative reproductive medicine” (RRM) has entered fertility. 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.
The CHR, of course, fully agrees with ACOG on this matter but it appears to us that the emphasis of ACOG, ASRM, and many individuals who have been writing about RRM has overemphasized the socio-political aspects of the RRM movement and completely ignored the fact that physician -surgeons and, among them some very prominent names (see also later), have for many years been making the argument that endometriosis – if not guilty for all of female infertility - was at least guilt for a lot of female infertility. And they, therefore, have furthermore been arguing that practically every infertile woman should, therefore, have a diagnostic laparoscopy. And – if endometriosis is found – every woman should have excisional surgery. And that is, of course, bonkers!
In other words, it is not only the right of center Heritage Foundation – suddenly interested in female infertility – which publishes such surgery centered nonsense; the same arguments have been made for years (if not decades) by selected surgeons, for all practical purposes claiming special skills in rescuing infertile women (even with – and by some surgeons claimed, especially, in mild only stage I endometriosis cases.
It is, of course, true that the Heritage Foundation recently issued one of the organization’s so-called White Papers urging infertile couples to explore (especially surgical) non-IVF options.3 But then,- who can take anything coming from the Heritage Foundation these days too seriously. Even much of the foundation’s own staff no longer takes them seriously and has departed to a competing Conservative thinktank. Who, of course, can take seriously an organization that associates itself these days with Tucker Carlson – by some also lovingly called “Little Hitler,” who – not too surprisingly for those who have listened to his words carefully since he was booted by FOX (after he was booted by CNN) has now come out of the Nazi closet formally, - once the Qatari cash started streaming.
The 3 take aways of the Heritage Foundation’s White Paper by Ema Waters and Natalie Dodson were:
(i) The fertility industry is an under-regulated, multi-billion-dollar global enterprise that profits from the creation and selection of human life.
(ii) Traditional medical practices are typically owned and managed by physicians; the fertility sector is dominated by private equity firms and venture capital investors.
(iii) Modern reproductive healthcare is a narrowly conceived vision of women’s health. Restorative reproductive medicine (RRM) is a more comprehensive approach.
And Marguerite Duane, MD, a family practitioner by training, offers in the document an overview of RRM. Here are a few selected quotes from the document we found at times to be precinct and on other occasions to be quite “wacky:”
Restorative reproductive medicine (RRM) is an approach to health care designed to identify and treat root causes of reproductive or hormonal dysfunction to restore the reproductive system to the way it is designed to function. Although infertility is commonly labeled as a causal diagnosis of reproductive concerns, it is not the root cause but rather a symptom; RRM thus seeks to identify and treat the true underlying causes of infertility to restore health and fertility.
That “infertility” is considered “causal” for infertility is, of course, pure oxymoronish; but the rest of this paragraph could indeed have been written by a CHR staff member. The description of RRM protocols, however, speaks for itself: to characterize this description as anything but “wacky” would be a clear understatement. Looking up what the fancily-named protocols really denote, returns infertility practice over 50 years back to when the infertility “sub-specialty” (note the “ _ “) existed in a pre-science environment and, therefore, in the OB/GYN field was considered “the hocus-pocus subspecialty (among newly established subspecialties in obstetrics & gynecology).
Several comprehensive medical protocols have been developed, including Natural Procreative Technology (NaProTechnology), which is based on the Creighton Model. NaProTechnology aims to identify and treat underlying conditions through medical and surgical management to facilitate natural procreation. Dr. Phil Boyle, who was trained in NaProTechnology, has since developed NeoFertility, which can be used with the ChartNeo app or other FABMs to expand treatment options for infertility. NeoFertility is the newest RRM approach and seeks to address many more of the underlying issues that can contribute to infertility, including hormonal imbalances as well as autoimmune and inflammatory conditions. Fertility Education and Medical Management (FEMM) collaborates closely with the Reproductive Health Research Institute to address a wide range of women’s hormonal health issues using evidence-based medical protocols.
And then the White Paper presents a case report, - just like we used to practice medicine over 50 years ago!
The next section is authored by Patrick Yeung Jr., MD, one among a small number of talented – nowadays mostly laparoscopic and robotic surgeons who, as already noted in the introduction to this commentary, are making a very good living from doing a lot of endometriosis surgeries and, often, do not accept insurance coverage. Such a surgery not infrequently, therefore, exceeds the costs of a complete IVF cycle.
And just to reaffirm our earlier comment that colleagues specialized in endometriosis surgery have, indeed, significantly contributed to the rising popularization of the RRM concept, we here are quoting next from Dr. Yeung’s contribution to the White Paper, as he explains how detail-oriented and time consuming endometriosis surgery is:
But one-and-done surgery takes time. Excising endometriosis completely can take hours, and there’s only one billing code if you are in network. No medical professional can survive in network by excising endometriosis. We, like all centers of endometriosis, provide these services out of network or on a cash-pay basis in order to be able to do a good job. It takes time, expertise, and risk to go after all of the disease. And in some cases, there is a lot of it. For example, I have found endometriosis in the bowel, ovaries, fallopian tubes, and diaphragm, but it has also been found in the lungs, brain, and the back of the eye.
Nobody, of course, argues with the fact that some endometriosis patients will benefit from surgery, - but the patients who often do benefit from surgery are women with severe endometriosis symptoms during menses (dysmenorrhea) and/or pain during intercourse (dyspareunia). Beyond anecdotal data – often case reports - there are no data in the literature whatsoever to suggest that patients with advanced stages of endometriosis will benefit in time to pregnancy from surgery (in comparison to IVF). Very much to the contrary, recovery after such major surgery delays IVF treatment by at least 3-6 months. Moreover, resection of endometriosis often involves the ovaries and women after such surgery present with significantly decreased ovarian reserve, - not infrequently, indeed, in early menopause.
There is a reason why the infertility field has moved away from surgery and toward IVF: Going back 50 years ago, every “fertility specialist” (note “-“) had to be a good surgeon because surgery was the only treatment we had. In the early days of IVF – while pregnancy rates were still very low – surgery survived. But as pregnancy rates with IVF continued to improve, the choice became increasingly obvious. And IVF was the clear winner!
One, therefore, can summarize RRM in one very short sentence: It is an attempt by people who don’t know anything about treating infertility efficiently and cost effectively with treatments that were the routine 50 - or maybe even more - years ago. Would anybody do this in any other field of medicine?
And one more comment on the professional ignorance of the RRM proponents from the Heritage Foundation. Preceding above discussed recent White paper, Emma Waters a year earlier published another Heritage document, with title, “Why the IVF Industry Must Be Regulated.”4 This document even more than the recent one very clearly not only documented her substantial lack of knowledge but also demonstrates an astonishing lack of biological understanding. And we again quote:
There are profound issues with the way IVF is practiced in the U.S. (a statement we agree with) in many cases amounting to eugenics. Over 75% of fertility clinical offer preimplantation genetic testing for genetic issues: 73 percent offer testing for sex selection or hair, eye, and skin color.
Children born through IVF have a higher likelihood of cancer, autism, minor cleft palate, or congenital heart defects
She seems clueless about infertility as well as biology! Except for the first sentence, none of the subsequent facts is correct. She simply does not know what she is talking about. Just one more reason to feel sorry for the Heritage Foundation. It was an excellent intellectual source for logical Conservative thought for such a long time until the current leadership took over. What a waste!
REFERENCES
Liao et al., JAMA. 2025;.doi: 10.1001/jama.2025. https://jamanetwork.com/journals/jama/article-abstract/2842960
ACOG. Restorative Reproductive Medicine. June 2025. https://www.acog.org/advocacy/abortion-is-essential/trending-issues/issue-brief-restorative-reproductive-medicine
Waters E., Dodson N. Heritage Foundation. March 24, 2025. https://www.heritage.org/marriage-and-family/report/treating-infertility-the-new-frontier-reproductive-medicine
Waters E. Heritage Foundation, March 2024. https://www.heritage.org/life/report/why-the-ivf-industry-must-be-regulated