What's your take on restorative reproductive medicine?

Highlights

• Experts view "restorative reproductive medicine" as an ideological term for a standard fertility workup that purposely excludes proven treatments like IVF.
• Delaying advanced fertility treatment is a significant risk, as the window for successful intervention narrows with age and underlying medical conditions.
• There is disagreement on surgery, with some arguing it is overused while others contend that treating endometriosis surgically improves IVF outcomes.
• A diagnostic IVF cycle can serve as a middle ground, offering deep insights while accelerating treatment for patients who clearly need it.
• Supporting patients with cycle tracking and metabolic health can lead to natural conception, potentially avoiding the need for assisted reproductive technologies.

Expert Insights

Defining Restorative Reproductive Medicine

The term “restorative reproductive medicine” (RRM) has become a focal point of debate within reproductive healthcare, with clinicians offering sharply contrasting definitions and implications. Reproductive endocrinologist Dr. David Sable frames the core ambiguity, asking whether RRM is a “good old-fashioned painstaking, step-by-step, thorough diagnostic” approach or simply “fertility care, doing everything we can to avoid doing an IVF cycle.” Many specialists view its principles as integral to, but not a replacement for, conventional fertility care. Dr. Thalia Segal, a reproductive endocrinologist, asserts that the initial steps of RRM—a history, exam, and treatment of underlying conditions like PCOS or endometriosis—are already standard practice for any reproductive endocrinologist, representing the beginning, not the endpoint, of treatment. However, other experts see the term itself as problematic. Dr. Neel Shah, an OBGYN, calls it an “ideological term that aims to devalue IVF,” while Dr. Eve Feinberg, a specialist in pediatric and adolescent gynecology, finds the verbiage “enticing and misleading.”

"We are much better at giving results than we are at giving answers." Dr. David Sable

Ideological Concerns and Clinical Risks

A significant point of contention is the assertion that RRM is rooted in ideology rather than comprehensive medical science. Dr. Segal argues that its foundation is religious, which explains its exclusion of IVF, ICSI, and third-party reproduction—options medically necessary for many patients, including those with severe male factor infertility, genetic conditions, LGBTQ families, and single parents by choice. Dr. Molly Moravek, a reproductive endocrinologist, describes this framework as “thinly veiled anti-woman,” suggesting it blames patients whose bodies do not respond to its standards and can promote unnecessary surgeries. This ideological framing is seen as having tangible clinical consequences. Dr. Brian Levine, a reproductive endocrinologist, links the promotion of RRM to a burgeoning anti-IVF movement that creates a “false dichotomy” and engenders delays in care. He stresses that with age-sensitive conditions like diminished ovarian reserve, “such delays are not merely inconvenient; they are clinically consequential,” a sentiment echoed by Dr. Shah, who warns that delaying access to reproductive endocrinology can lower a patient's odds of success.

"The bottom line is infertility is a medical condition, not a moral debate—and patients deserve medicine, not ideology." Dr. Thalia Segal

The Contentious Role of Surgery in Infertility

The role of surgery, particularly for endometriosis, highlights a deep divide among specialists. Proponents of RRM are often criticized for an over-reliance on surgical intervention. Dr. Feinberg challenges the narrative that surgery treats the “root cause” of endometriosis, clarifying that it addresses symptoms like anatomical distortion, while the cause is likely genetic. Citing guidelines from ESHRE, ASRM, and a Cochrane Review, reproductive endocrinologist Dr. Paula Amato states that for women with severe endometriosis, evidence supports IVF over repeat surgery for achieving pregnancy. Conversely, minimally invasive gynecologic surgeons argue that surgery is being unfairly dismissed. Dr. Antonio Gargiulo criticizes ACOG guidance that he believes de-emphasizes endometriosis, stating there is “strong evidence that excision of endometriosis—particularly severe, deep infiltrating endometriosis—can more than double the live birth rate after subsequent embryo transfer.” Dr. Andrea Vidali, also a MIGS specialist, accuses the “trillion dollar fertility industry” of funneling patients into expensive IVF cycles without addressing underlying conditions, arguing that investigation and root cause treatment must remain central to patient-centered care.

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

Finding a Patient-Centered Middle Ground

Despite the sharp disagreements, some experts identify areas of overlap and propose pathways for integration. Dr. Shah notes that foundational, "restorative" support—such as tracking cycles and improving metabolic health—is undeniably effective, leading to natural conception for approximately 50% of members at Maven Clinic who are considering or undergoing treatment. This underscores that principles associated with RRM have clinical value when not positioned in opposition to assisted reproductive technologies (ART). Dr. Sable proposes a pragmatic approach to bridge the gap: incorporating a “diagnostic IVF cycle” into the workup. He suggests this can rapidly provide answers about ovulatory function, fertilization, and implantation, fast-tracking patients who definitively need IVF while allowing others more time for a less intensive approach. This model, he argues, would allow clinicians to “meet somewhere in the middle,” providing both answers and results more efficiently.

Clinical Takeaways for Physicians

For clinicians navigating this landscape, the central challenge is to separate evidence-based practices from ideological constraints. While the foundational diagnostic work and health optimization emphasized by RRM advocates are pillars of quality fertility care, the exclusion of proven ART presents significant risks to patient outcomes and equity. The debate over surgical intervention versus immediate IVF for conditions like endometriosis requires a nuanced, individualized assessment of a patient’s specific pathology, goals, and timeline. Ultimately, as Dr. Segal concludes, “infertility is a medical condition, not a moral debate—and patients deserve medicine, not ideology.” The physician’s role is to ensure patients are empowered with a full spectrum of scientifically validated options to find, in the words of Dr. Shah, “the safest, shortest, and most supportive path” to building their family.