What's your take on restorative reproductive medicine?

Highlights

• Experts warn that “restorative reproductive medicine” is an ideological term that can dangerously delay time-sensitive, evidence-based treatments like IVF for many patients.
• The diagnostic steps in RRM are already standard practice, but critics argue RRM wrongly excludes necessary advanced technologies like IVF, ICSI, and PGT-A.
• While some guidelines favor IVF over surgery for endometriosis-related infertility, other experts assert that timely surgical excision can improve outcomes and help avoid IVF.
• With supportive care addressing underlying health, approximately 50% of members at one clinic considering fertility treatment were able to conceive naturally.
• One specialist proposes a “diagnostic IVF cycle” to quickly identify which patients require IVF, while allowing others more time for restorative approaches.

Expert Insights

The Contested Definition of Restorative Reproductive Medicine

The term “restorative reproductive medicine” (RRM) has emerged as a significant point of contention among fertility specialists, with its definition and clinical utility subject to intense debate. Several experts view the term itself as problematic. Dr. Neel Shah, an OBGYN, describes it as an “ideological term that aims to devalue IVF.” This sentiment is strongly echoed by reproductive endocrinologist Dr. Thalia Segal, who asserts that RRM is “rooted in ideology and religion, not science.” She and others argue that RRM is not a new or comprehensive approach but a repackaging of standard preliminary diagnostics. As Dr. Segal notes, taking a history, performing an exam, and treating hormonal imbalances are “the same first steps that every reproductive endocrinologist already takes,” but for REIs, these steps are the beginning, not the endpoint. OBGYN Dr. David Sable cuts to the heart of the ambiguity, asking, “Is it: (1) good old-fashioned painstaking, step-by-step, thorough diagnostic...or is it: (2) fertility care, doing everything we can to avoid doing an IVF cycle?”

The Critical Factors of Time and Patient Exclusion

A primary concern voiced by clinicians is the potential for RRM to delay access to effective, time-sensitive treatments. Reproductive endocrinologist Dr. Brian Levine warns that the anti-IVF rhetoric often accompanying RRM advocacy “risks engendering a climate of hesitation and misinformation, wherein patients may delay seeking appropriate care.” Given that maternal age and conditions like diminished ovarian reserve are incontrovertible factors, he stresses that such delays are “clinically consequential, as the window for effective treatment narrows precipitously with advancing age.”

Beyond the issue of time, critics point to the exclusionary nature of an RRM-only framework. Dr. Segal highlights that it leaves patients with severe male factor infertility, genetic conditions, and other complex cases without viable solutions. She and reproductive endocrinologist Dr. Molly Moravek also note that RRM’s framework excludes LGBTQ+ families, single parents by choice, and cancer patients requiring fertility preservation. Dr. Moravek adds that the philosophy can be “thinly veiled anti-woman,” effectively blaming individuals whose bodies do not respond to its prescribed standards.

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"It's thinly veiled anti-woman: it effectively blames people whose bodies don't function according to restorative reproductive medicine's standards." Dr. Molly Moravek

The Debate on Surgery, Root Causes, and Evidence

The language of RRM, particularly its focus on treating “root causes,” is a major point of scientific dispute, especially regarding endometriosis. Dr. Eve Feinberg clarifies that “surgery for endometriosis doesn’t treat the ‘root cause’...[which is] likely aberrant gene expression.” Instead, she explains, surgery treats a symptom—the anatomical distortion and inflammation. She finds the verbiage of RRM both “enticing and misleading.” This is supported by evidence cited by reproductive endocrinologist Dr. Paula Amato, who points to ESHRE, ASRM, and Cochrane Review guidelines recommending IVF over repeat surgery for fertility in women with moderate to severe endometriosis. However, this view is not unanimous. Minimally invasive gynecologic surgeons Dr. Antonio Gargiulo and Dr. Andrea Vidali argue that professional bodies like ACOG are too quick to dismiss surgery. Dr. Gargiulo contends there is “strong evidence that excision of endometriosis...can more than double the live birth rate after subsequent embryo transfer,” helping some patients avoid IVF or repeated failures. Dr. Vidali frames the dismissal of surgical and lifestyle approaches as a defense of a “trillion dollar fertility industry model” that funnels patients into expensive IVF cycles with minimal diagnostic workup.

"Telling patients that the only compassionate option is the most expensive one is not science. It's ideology." Dr. Andrea Vidali

Synthesizing Approaches for Patient-Centered Care

While the foundational elements of RRM—optimizing health and addressing underlying conditions—are widely supported, the insistence on it as a replacement for assisted reproductive technology (ART) is rejected by most of the consulted experts. Dr. Shah notes that while greater support with cycle tracking and metabolic health helps many, every patient deserves choices for the “safest, shortest, and most supportive path” to a healthy baby. The core tension lies in integrating thorough diagnostics with timely, effective interventions. Dr. Sable proposes a pragmatic middle ground: performing a “diagnostic IVF cycle.” This approach would rapidly provide answers about ovulatory function, fertilization, and implantation, fast-tracking patients who definitively need IVF while allowing more time for a “restorative” approach for others. Ultimately, the consensus among these physicians is that infertility is a complex medical condition, not a moral issue. As Dr. Segal concludes, “patients deserve medicine, not ideology,” and a truly patient-centered approach requires access to the full spectrum of evidence-based care.

"Infertility is a medical condition, not a moral debate—and patients deserve medicine, not ideology." Dr. Thalia Segal