Fertility and Sterility Roundtable: Restorative Reproductive Medicine

Welcome to Fertility & Sterility Roundtable! Each week, we will host a discussion with the authors of "Views and Reviews" and "Fertile Battle" articles published in a recent issue of Fertility & Sterility. 

This week, we welcome Dr. Richard Paulson and Dr. Jamie Kuhlman to discuss Restorative Reproductive Medicine (RRM) — a field that describes itself as focusing on identifying and treating the root causes of infertility rather than bypassing or suppressing natural reproductive processes. In this episode, we explore whether RRM represents a truly novel approach to fertility care, examine its religious and political influences, and consider the potential risks the movement poses to access to evidence-based fertility treatments, including IVF.

Dr. Richard Paulson holds the Alia Tutor Chair in Reproductive Medicine and is Professor and vice-chair in the Department of Obstetrics and Gynecology at the University of Southern California, where he is also Director of the Fellowship in Reproductive Endocrinology and Infertility. He is past president of the American Society for Reproductive Medicine, and of the Pacific Coast Reproductive Society. Dr. Paulson has authored over 300 scientific articles and has received more than 35 awards for research and scientific presentations. He is the current Editor-in-Chief of “Fertility & Sterility Reports.” 

Dr. Kuhlman is a Licensed Psychologist and the Owner of Courageous Path Counseling, PLLC, in Nashville, TN. She specializes in infertility, postpartum, and maternal mental health through individual counseling and psychological evaluations for third-party reproduction. She is also a PRIMED Scholar with the American Society of Reproductive Medicine, focusing on advocacy within reproductive healthcare. 

The unscientific nature of the arguments of “Restorative Reproductive Medicine” and why we need to understand them
https://www.fertstertreports.org/article/S2666-3341(25)00111-4/fulltext

The illusion of reproductive choice: how restorative reproductive medicine violates reproductive autonomy and informed consent
https://www.fertstert.org/article/S0015-0282(25)00596-5/fulltext

View Fertility and Sterility at https://www.fertstert.org/

Welcome to Fertility and Sterility Roundtable. This podcast will delve into sections of the journal previously unexplored in the Fertility and Sterility podcast family. Articles that we would consider some of the most timely, cutting edge, thought-provoking, and dare I say controversial.

We will be joined by a couple of the authors each month to explore the themes, debate the pros and cons, and generally expand our knowledge in a conversational format. I'm your host and FNS Interactive Associate, Dr. Emily Barnard. And I'm your co-host and producer, Dr. Ben Peipert.

We will be covering articles in the fertile battle and views and reviews portions of Fertility and Sterility. This podcast is brought to you by the Fertility and Sterility family of journals in conjunction with the American Society for Reproductive Medicine. Welcome everyone to Fertility and Sterility Roundtable.

I'm your host, Dr. Emily Barnard, and I'm joined by my producer and co-host, Dr. Ben Peipert. Today, we will be discussing a timely topic, a term that you may have heard recently in the popular press or seen on social media, and that's restorative reproductive medicine, which is also called RRM. I would encourage you to go to the journal and look at FNS reports to read the editorial from Dr. Richard Paulson, who's one of our guests today.

The editorial is entitled The Unscientific Nature of the Arguments of Restorative Reproductive Medicine and Why We Need to Understand Them, which is in the September 2025 edition of that journal. We're joined not only by Dr. Paulson today, but also by Dr. Jamie Kuhlman, who was a participant at the briefing that the American Society for Reproductive Medicine held in September, addressing RRM. Thank you to both of our guests for joining.

I'll introduce Dr. Paulson first. Many of you know him, I'm sure. Dr. Paulson holds the Aaliyah Tudor Chair in Reproductive Medicine and is Professor and Vice Chair in the Department of Obstetrics and Gynecology at the University of Southern California.

He also is Director of the Fellowship in Reproductive Endocrinology and Infertility. Dr. Paulson is a past president of the American Society for Reproductive Medicine and also of the Pacific Coast Reproductive Society. Dr. Paulson has authored over 300 scientific articles and has received more than 35 awards for research and scientific presentations.

He's also the Editor-in-Chief of Fertility and Sterility Reports. Welcome, Dr. Paulson. Dr. Jamie Kuhlman, Ph.D. Thank you.

Thanks for having me. Pleasure to be here. We also are privileged to have Dr. Jamie Kuhlman joining us today.

Dr. Kuhlman is a licensed psychologist and the owner of Courageous Path Counseling, PLLC, in Nashville, Tennessee. She specializes in infertility, postpartum, and maternal mental health through individual counseling and psychological evaluations for third-party reproduction. She is also a primed scholar with the American Society for Reproductive Medicine, which focuses on advocacy within reproductive health care.

Thank you for joining us, Dr. Kuhlman. Of course. Happy to be here.

So I'm going to go ahead and start us off, but just so we're all on the same page, Dr. Paulson, could you tell us what restorative reproductive medicine is? So restorative reproductive medicine is the term that is applied to the latest iteration, I would say, to the practice of in vitro fertilization. There has been opposition to IVF really from the very beginning, actually before the beginning since Bob Edwards was really vilified in the lay press for many years as soon as people got wind of the fact that he was working on IVF, they made him out to really be a modern-day Dr. Frankenstein. And a lot of that sort of faded after Louise Brown was born and made the rounds and everybody saw that she was a normal, healthy baby.

But the underlying current of those who oppose any sort of reproductive manipulation or reproductive medicine, reproductive choice, whatever you want to call it, has been there all along. The reason that we're paying so much attention to restorative reproductive medicine today is not because there's anything novel about it, but because it has been put out by the Heritage Foundation. And we know that the Heritage Foundation has authored some very interesting things, right, including the latest pressure that they are putting on the current administration to basically change all of the politics.

And they have the ear of the current administration. When they say something, it often happens, and that is why we are paying attention to it. I would just point out that there is nothing novel about it.

It is simply a twisting of the scientific reality of what we have done in the field of infertility, and it's the latest iteration. Yeah, I think that's a great historical summary. I think that for some of our audience, I think it would be even helpful to go into, like, have you delved into what some of the specific interventions that restorative reproductive medicine is advocating for versus what they disagree with? Well, I think it's fair to say that they basically follow, you know, our practice committee recommendation on how to maximize natural conception.

The problem is, is that they think that that's all that is necessary, and they want everyone to spend a lot of time just worrying about that. The fundamental tenet is that they think that infertility is not a disease. In fact, that's the main line.

Infertility is not a disease. It is simply the consequence of all of the other bad things that are happening to you, and if you just fix all of those things, then infertility will go away. This is a naive point of view, and it is analogous to those who would rather go to the health food store and do that rather than taking antibiotics or do that instead of being vaccinated.

So, it is not fundamentally different. We react to it because we see the potential harm in patients following this path, wasting a lot of time, burning out on it, and eventually running out of the biological clock while they are waiting for all of these hypothetical things to happen to them. It is really a giant step backwards.

One of the analogies that I really like is the concept of willow bark. You know, willow bark was used for thousands of years to relieve pain and fever, and then in the 19th century, somebody identified the active compound as salicillin, and in 1897, Felix Hoffman at Bayer developed acetylsalicillic acid and patented it as aspirin, and in 1970, somebody figured out that it worked by actually blocking prostaglandin production, but these people would like for us to go back to willow bark. So, you say, well, we have aspirin.

We know how it works. They say, no, no, no, no, no. No, you need to go back to willow bark.

Willow bark is natural. It is not a pill out of a It is not a way of funding the pharmaceutical conglomerates that are using you, and it is a natural supplement. That's what you need to be doing, and that's what they're doing.

So, yes, they recommend that you follow the menstrual cycle. They recommend that you figure out you lose weight, try to do all of these things. Yes, everything that we recommend to enhance natural conception, but they stop short of IVF for a reason, because they don't want you to be messing with the gametes.

They don't want you to be messing with the whole reproductive thing. Just stop thinking about it and be healthy, and infertility is not a disease. This is a misstatement of fact.

It is not a scientific conclusion, and we need to speak up about it so that our patients hear the truth and not these sort of distortions. Yes, I could not agree more. I think there certainly are many patient populations that also cannot be helped with some of these interventions that restorative reproductive medicine talks about.

Do you care to comment on some of those, and do you feel like RRM just kind of ignores those people? They do. Yes, they absolutely ignore them, and it is obvious, I think, to anyone in our field that someone who is missing fallopian tubes is not going to get pregnant naturally, and whether those fallopian tubes are missing because of a surgical intervention or because they had bilateral hydrosalpinges or some other developmental anomaly, that person is not going to get pregnant without IVF. Analogously, men who have severe oligospermia that requires ICSI, they also need to have IVF to achieve pregnancy.

I think the other understated component of this, and I think it's not that subtle, is the fact that same-sex couples and people in the LGBTQ community also need IVF because of the inherent nature of their reproduction, and it is clear that the people that are in favor of RRM are also opposed to LGBTQ reproduction, and that is perhaps the thing that bothers them the most. I don't want to speak for them because I don't understand it, but it is transparent to all of us in the field that this is a component of their opposition to in vitro fertilization. And you touched on this briefly for a second, Dr. Paulson, but I think that there's clearly harm that is done when patients are pulled into restorative reproductive medicine in terms of the delay that occurs in their ability to follow up with the reproductive endocrinologist, and so I was wondering if, Dr. Kuhlman, could you comment a little bit on your own experience taking care of the mental health of these patients and what you've seen in terms of the impact of these delays in care? Absolutely.

There's so much distress during an infertility journey. Infertility can be just as psychologically stressful as going through cancer, so I think remembering that this is not an easy medical journey. This is very stressful with many ups and downs, and every unsuccessful cycle creates greater and greater stress that compounds over time, so the more we're doing something that isn't productive or isn't going to work, we are increasing depression, anxiety, isolation, relationship problems, and so I think there's a balance between trying to do something that's as least invasive as possible with recognizing there's a time element as well.

I think, too, this conversation about RRM really increases the stigma associated with IVF. When we have increased stigma around this, we are going to see more clients anxious about treatment, unsure about treatment decisions, possibly not choosing treatment decisions based on stigma. Social support is a great predictor of psychological success.

Having social support is wonderful for clients. What I worry about is having negative social support is actually a detriment, and it has a negative impact, and so if there are conversations about IVF being immoral or unethical or ineffective, one, it's a stigma. Two, people might lose their social support systems.

All of this continues to delay care and creates a lot of psychological harm. Yeah, those are great points, Jamie. I think one of the things that I'm wondering if any of our participants in this conversation would be able to kind of comment on is, you know, I've looked into some of the studies that the RRM practitioners are promoting.

We all agree in the field that there are people who meet the criteria for an infertility diagnosis. They've tried for six to 12 months, and they've been unsuccessful despite charting their cycles, making sure that their timing intercourse around their ovulation. There are people who will have an infertility diagnosis who will get pregnant on their own.

We know that that happens, but regardless of almost which study you look at from the RRM community, a majority of participants who have been trying for two or even three years are still not pregnant with these interventions. To us, we believe that IVF is the most effective intervention that we have in our toolkit for many of our patients, but we're facing a narrative where these RRM practitioners are saying it's actually not that effective, and they're using this data. So what do we make of that? And in this current political climate era of misinformation, how do we deal with that reality? Well, I think the problem is that they are using very poor scientific methods.

You have to remember that in the 70s or 80s, and some of the studies that you're actually that they are quoting are out of the 80s and 90s, when IVF was really quite inefficient. And it was true that it was quite possible that patients might have tried IVF and failed, and then later had surgery and so on. But a lot of it is bad science.

So over the years, we've gotten much better at understanding that you have to have a concurrent control group, that there is a baseline pregnancy rates, and that you cannot use anecdotal evidence. You can't say, well, willow bark worked for me, okay? So you want aspirin, and you say aspirin is better, but I'm going to tell you that my patient over here tried it, and it didn't work for him. And then I gave him willow bark, and everything got all better.

And that's not good science, right? We know that you need a population, that you need to have a clinical trial, that you need to have a control group, et cetera. And that is what's missing. And that is what makes it junk science, and really kind of an antiquated idea.

I assure you that if you look through the papers of fertility and sterility, this is the 75th anniversary of fertility and sterility. You can find the papers out of the 50s and the 60s, and they're very similar. They're saying, we took a group of 10 patients who had been infertile for a year or more, and we did something to them.

And lo and behold, a third of them became pregnant. And therefore, this is a good intervention. And of course, if you were to follow somebody for a year who has unexplained infertility for two years, you will find that about a third of them will get pregnant on their own at the rate of about 2% or 3% per month fecundability.

That's the background. And yes, you can do that. But the reality is, is that that is not an effective treatment, and what they are proposing is not an effective treatment.

That's the problem. The other thing that I think is bothersome about it is that they pretend that it's scientific. And this, to me, is the analogy to the people that were claiming that smoking is maybe or may not be related to lung cancer.

Experts disagree on both sides. Let's keep talking about it because experts disagree. You've got some experts here and some experts over there.

And the reality was, of course, that 99% of the experts all agreed that it was a cause of lung cancer. But the tobacco companies, for obvious reasons, were motivated to quote the 1% who said, well, maybe it goes this way, or maybe we had a study that went in the other direction. No, there is no question that IVF is the most effective form of fertility treatment that we have available.

It is the only kind of treatment for non-existent fallopian tubes, severe male factor, LGBTQ reproduction. And therefore, if you claim that this is not necessary or that you can circumvent it in other ways, you are distorting reality. And that's what's happening.

Honestly, I think the best way that we can fight back, Ben, is to say you are not using sound scientific methods. That is why you should listen to the experts of the American Society for Reproductive Medicine who are scientific experts who can evaluate the data and have come up with a particular conclusion. Going back to your question, Ben, I mean, I think we can all agree that IVF is the most effective method.

It is scientifically valid in that RM is using junk science. I think that why this is gaining traction is that's not translating well to patients. I can't tell you since I started learning and talking more about this, how much my social media feed is full of influencers, typically women.

They're saying that it's sound science, like you were saying, Dr. Paulson. And I think people don't understand the difference. They hear it has a scientific backing and they take that at face value instead of really understanding what the difference is.

I think that is hard for clients to discern what is good science and what's not good science. I also think RRM gives them something they're wanting. A lot of my patients feel very out of control, especially if you throw in an unexplained infertility diagnosis.

They want answers and they don't like hearing, even if it's the truth, you know, we don't have an answer. They don't like not being in control. I'm sure we've all had patients that would do whatever it took, eat whatever it took to become pregnant.

And so RRM kind of preys on this vulnerable population and says, Hey, we've got something for you to try. You can track your cycles, you can eat, you can do. And so there's something that they can go home and do rather than sitting and stewing in their feelings.

And there's an answer, right? There's some kind of hormonal balance, or this is dysregulated, all sorts of things that may or may not even be related. But there's a test, there's an answer, and there's a to do. And I think patients are wanting that.

The problem is, is that's not always reality. And what I fear is going to happen is it's going to create more self blame, because when these methods don't work, or it takes two, three, four years, and they're still not getting pregnant, then the message is, well, you didn't do enough to fix this, you didn't do enough, it is on you to do these things. And that's where this, we're going to see, I think, greater self blame.

And so I think that message, while the clients want that is actually, in the end can be really harmful for them, or at least for those that don't get pregnant. So I see this very analogous to the opposition to vaccination. This is, they're preying on the vulnerabilities of those who have children with autism, and they say, this is what caused it and you need to stop.

And it is still a relatively small minority of people that are opposed to vaccination, just like I think, I believe that it is a small minority of infertile patients who are going to subscribe to RRM. But the problem is, is that the administration and the government is now funding research that has to focus on RRM. It's the same way that Health and Human Services has suspended funding for the RNA vaccine.

That's a problem. That's a problem. It's not just a problem for those who are the non-believers, but it's a problem for the entire population.

And if instead of any sort of funding that we would get for fertility research, real fertility research, real scientific evidence-based research, we are instead going to be chasing the bogeyman of restorative reproductive medicine. It is a waste of time, effort, and most importantly, resources. One other thing we haven't said, and that is really the offensive nature of the fact that they call it restorative.

Restorative, as in you need to be restored. Something else is going all right, and we are going to fix it by restoring you. There is nothing restorative about restorative reproductive medicine.

It's a move backwards. It's a retro move for reproductive medicine. There's nothing restorative about it.

I completely agree. I think that language sounds really pretty on an Instagram ad, but there's nothing restoring happening. I'm thinking of a client I have who had cancer, young, I mean thirties, and had to have a hysterectomy.

And she froze her eggs beforehand. So she will have to use IVF and a surrogate to have a child when she's ready. And I was sharing with her a little bit about RM and what she's heard.

And I loved her line because she said, there's no restoring a new uterus. Like there's nothing that is going to restore my body and grow a new uterus. And I think you were getting at that, Dr. Paulson talking about fallopian tubes as well.

And I just, it really struck me that word is inaccurate. And also it is really ostracizing people that can't, yeah, we're never going to regrow a new uterus. Yeah, no, this is a great conversation.

I know Ben, Jamie, and I were all at the RM counter briefing. That was the same day the ASRM had their briefing. And I was really struck by the conversation.

They had some slides and they said on average patients who come to their clinics get six diagnoses. I think there is quite a litany of testing that is done. And I think people do really want to put their finger on something, even if it's not a science-based diagnosis.

And so I think that is probably why a lot of people are drawn to this. Do either of you have any thoughts on how we could better message things to patients? Some of our scientific articles and kind of what we're thinking about when we're saying unexplained infertility, because as we all know, we don't stop thinking at that. There are a litany of things that we're thinking about in our head, but these influencers and the Heritage Foundation, a lot of these people seem to be beating us a little bit in messaging to patients.

So I'd be curious if either of you had any thoughts on that, how we could do a little better job getting the science in front of patients in this era where science is kind of under attack. I think one thing I noticed with the counter briefing was stories. They had very little science.

It was not great science, but they had a lot of stories. And I applaud any woman who gets up and shares their story and has the courage. I mean, these were just to share their experience, but I think they pulled at heartstrings and I think that's what they were obviously intending to do.

And so I wonder if we had more stories, more examples of why IVF is important and we can throw science with that. The average person isn't going to care, frankly, about the litany and all the details of the scientific research. But if we can somehow combine that with the human element, I think it's really going to connect more with people.

We could also embrace restorative reproductive medicine by saying this is the first 10% of infertility care when you go to your fertility doctor. Yes, of course, we embrace it. We have a practice committee opinion about that.

It's called how to maximize natural conception. The key is don't spend too long in this particular arena. Move on when the time comes.

I do have a line that I use with my patients when they are diagnosed with unexplained infertility. And I tell them unexplained infertility is a term that we use. And what we mean by that is the testing that you have had done so far is all negative.

That means it all looks normal. That does not mean that we do not know what unexplained infertility is. Unexplained infertility is a block of being able to get together for the gametes.

The egg and sperm cannot get together. They're being blocked by a variety of things. It could be mild endometriosis that's in the fallopian tube.

There could be some problem in the cervical mucus or whatnot. The point is that we know that if we give that patient clomid and intrauterine insemination or letrozole and intrauterine insemination and they have unexplained infertility, we can increase their monthly fecundability threefold. So what are we doing? Well, we're helping the egg and sperm get together.

And more importantly, when those patients do IVF, they get pregnant at exactly the same rate like women who have blocked fallopian tubes. So if somebody has blocked fallopian tubes, you know it's a block to the egg and sperm getting together and that if you bypass it with IVF, they get pregnant at a particular rate. If you have unexplained infertility and you do IVF, you will have that same pregnancy rate.

In other words, there is nothing inherently wrong with your egg or with your sperm or with you or with anything else that you are doing. It is a mechanical block. I wish that we would embrace that as a potential explanation.

I'd like to share it with you because I think it helps patients understand they hate when we say unexplained. Yeah, unexplained just means that the tests that we can do that definitely show that there is a problem with the male or there's definitely a problem with ovulation, that instead we understand that that is a mechanical block of egg and sperm getting together. I think one thing that guides the field of REI and the way that we put labels and diagnoses on our patients with different types infertility is that whenever we identify a cause, you have tubal factor infertility, that sets you up for a series of evidence-based interventions that we can offer patients.

And I think to Jamie's point earlier, for these patients that have an unexplained diagnosis, they feel like there's a one-size-fits-all approach to their care. And I think that for some people that is frustrating. I think that the reality is we have interventions that we know work very well, but we're putting that up against a field that is creating more labels and creating more interventions for those labels.

But the science behind, you know, treating luteal phase deficiency with supplementary progesterone is really shoddy. Not only that, it's old and has been refuted. And so I think what's really challenging is we have to educate our patients on decades of science that have happened.

You know, if you put in a Google search today or you ask Dr. Google, what is luteal phase deficiency and could it be affecting my pregnancy rates? You may very well get some evidence from the 70s, 80s, and 90s that indicate that you could have a luteal phase deficiency. And in the past, doctors have used vaginal progesterone to help you. My mom was diagnosed with a luteal phase deficiency and was treated with vaginal progesterone.

Now she also had, I think, four subsequent miscarriages after me. But the reality is we know from the data that that does not necessarily help the vast majority of patients. So it's just there's this huge education gap that we're up against.

And I find that to be such a challenge in today's environment. You know, as you were talking, I was thinking too of helping with that education gap with kind of the people they will see first. So really making sure OBGYNs understand what this is, so that when their clients come and talk with them about that, that they are aware.

Making sure people like me in the mental health space, when they hear clients talk about this, are able to gently explain some of those things. Because I would imagine by the time they see an REI, they've been trying for a while. And I wonder if some of the REM people never even go to an REI.

They just immediately off-ramp to REM. And so I think too, thinking about who are the kind of frontline, who sees these patients first, and making sure that they understand where they're referring to or what's going on in their community, so that they can help educate a patient of like, oh, I don't know if that's the right choice for you. Or let me tell you about the science with this.

Because they're going to see more people initially than you guys will. Yeah. You know, Ben, I was contacted by one of my colleagues who said that they had a relative who was being treated for infertility overseas, and that they wanted her to get KIR and HLAC typing.

So I must admit that I had to go to open evidence. And it turns out that KIR stands for killer cell immunoglobulin-like receptor. And HLAC, of course, is human leukocyte antigen C. And it talked about how this is helpful in transplantation and so on.

But then I put in the question, does KIR and HLAC have anything to do with infertility? And oh, my goodness, I got a bunch of references. So let's remember that there is junk science, not just out in the lay sector and in the Heritage Foundation, but it actually exists within what could arguably be called mainstream science. I mean, these are real publications and real journals that have been around for a long time.

The American Journal of Reproductive Immunology has been around for a very long time. So there's lots of problems. And I think the best way to fight that is simply to keep telling the truth and to keep harping on the fact that the scientific method is not easy.

Science is a slow slog. And the reason that we are where we are is because we have been studying this field for a long time. And that is why we have come up with these conclusions.

And going to lay groups and groups that feel that the willow bark is the way to go is not going to get you the best time. What can reproductive endocrinologists and our associated health care professionals like you, Dr. Kuhlman, do to help our patients navigate in a world where RRM is trying to make itself an equivalent and valid option for our patients? Listening to the counter briefing and hearing so many stories of not feeling heard, they said they sat with their doctor for two hours. Now, that's pretty unrealistic for most clinics.

But they talked about feeling pushed, not feeling heard was the theme that I got from a lot of those stories. I think what we can do is maybe take a pause. We might see these patients all day, every day.

But for this one patient, it is their whole life. And it's all consuming right now. So taking that breath, taking that pause, and maybe trying to find increased empathy, whether that's as simple as how you start an email, how you answer the phone, how you explain results.

It doesn't have to be we have to carve out two hours for our patients. But I think there are small tweaks in language that could convey that. I also think taking a multidisciplinary approach, partnering with other health care professionals, such as mental health professionals that maybe do have the space.

I see clients for an hour. So I have a little more time and space to kind of walk through. And I can work with clients a lot on what options feel best to them.

How are they feeling about it, navigating that. So kind of noticing when someone might be hesitant, giving them some referrals and places to process what they're going through it, so they don't feel rushed, or they feel like someone in their team is very empathetic, I think can be helpful. It's great to have your perspective on that, Jamie.

And that is so true. For my part, I have tried to specifically address each proposed treatment that the patient brings in. So they went on to the internet, and they wrote down 10 things that they hear they're supposed to be using.

They're supposed to be using PRP, and the ERA, and CoQ10, and DHEA, and all that other kind of stuff. So we take them one thing at a time. And we say, so it's not that so the wrong thing, I think, to do is to say is to just dismiss it out of hand.

Oh, that's ridiculous. That's not evidence-based. Yeah, that's not convincing.

What I think is more convincing is to say, that is an interesting point of view. And I want you to know that it is an interesting hypothesis. We have looked into that, and it turns out that it doesn't do anything.

So that, I think, is a little bit more helpful when you can address each of those things in turn. So if you say, well, DHEA, the way that it is being used, it elevates your androgen level in the circulation. We've looked into that.

We've studied it. It can actually elevate your testosterone into the low male range. So people get those kinds of side effects.

And if you look at the testosterone level in the follicular fluid, it's another order of magnitude higher. So it's very dubious that elevating your testosterone in the peripheral circulation is going to make a difference. CoQ10, one of my favorites, gets used all the time.

I said, yes, it works really well in mice. There are no human studies. And the way that it works is it's supposed to increase energy in the mitochondria.

So if that were true, that would greatly increase your energy output if you were a long-distance runner or a cyclist. And it would be abused by the athletes, and it would be banned. And it's not banned, and it's not being abused by the athletes, because it doesn't do that in humans.

So I think it's possible to go through each of these putative interventions and putative beneficial ways of treating infertility and to say, yes, we've thought about that, and we have found that that doesn't do anything. That is why I'm not advising you to do it. I love that approach of taking each concern or each suggestion thoughtfully, compassionately.

I think when people, they don't always have to be right. They don't always have to have someone take their suggestion. But if they feel like their suggestion was heard and was discussed, then they will leave feeling, even if it's a decision that they didn't know about or didn't sign on at the beginning, will feel much more positively about that decision because their concerns were heard.

We know the opposition to IVF, this is not new. And I'd love to hear if you have some historical context on kind of how this has evolved over time. Yes.

Well, I think it's important to remember that the Catholic Church in particular, but I would say in general, the Christian religions have been opposed to the idea of intervening in the reproductive process. And a lot of people take it back to about 1968. Remember that the birth control pill was approved in the early 1960s.

And Pope Paul VI came out with an encyclical called Humanae Vitae, which basically opposed contraception. So people said, oh, the Pope is against the pill and so on. And that was, those were kind of the two teams.

When fertility treatment came around, there was no specific prohibition because fertility treatment had not really been much of a reality. But when IVF started, there was the anticipation that sooner or later, the religious side was going to chime in. And this happened in the late 1980s.

And we already had our IVF program running. And I still remember that I had a patient who was about halfway through the IVF process when the encyclical came out. And I must tell you that we all anticipated that IVF was probably not going to fly.

The idea of letting egg and sperm meet in the laboratory just did not seem very consistent. But we were optimistic that intrauterine insemination would be all right, especially if you were doing it in the context, let's say, of a heterosexual marriage, that that would be all right. But of course, that's not what happened.

Pope Paul II, John Paul II, who was the Pope at that time, and his good friend Cardinal Ratzinger, who later became Pope Benedict, came out with an encyclical called Donum Vitae, The Gift of Life, which entirely and completely opposed fertility treatment. They actually quoted an encyclical from Pope Paul John XXIII from 1961. And I have to quote this exactly.

It said, The transmission of human life is entrusted by nature to a personal and conscious act, and as such is subject to the all holy laws of God, immutable and inviolable laws which must be recognized and observed. For this reason, one cannot use means and follow methods which could be illicit in the transmission of the life of plants and animals. So obviously, IVF is a way that you could transmit life in animals.

In fact, animal studies are critical to the things that we do in biology. And they basically said you can't do anything. I paraphrase it as saying, thou shalt not touch the gametes.

That is the fundamental opposition. Don't interfere with it. Don't intervene with it, right? Remember, they are opposed to sex education in school.

They're opposed to all of these kinds of things. Don't think about it. Pretend that it doesn't exist.

And I must tell you that this is not the only group that is opposed to IVF. I remember when I was junior faculty, I was called to a local TV show to talk about a new book that had been put out that was called The Mother Machine. And I have to tell you that there is a sect who calls themselves ultra feminists who are also very opposed to IVF.

They believe that fertility should not be forced upon women by the patriarchal society. And therefore, that book was called The Mother Machine, implying that women were made to be machines to help men reproduce. And this is a very interesting sort of twisted way of expressing people's desire to reproduce as a exploitation of women, commodification of children, the reinforcement of the nuclear family, interference with bodily autonomy, and health risks.

Now, we have not heard from this group in some time. And I'm sure that they haven't gone away. I'm totally convinced of it.

But remember, this is the kind of opposition. In my mind, the opposition to IVF is fundamentally philosophical and deeply held. And the reasoning that people give us, like they say, oh, life begins at conception or at fertilization, and that is why you shouldn't have IVF.

I'm just not sure that I believe them anymore. Yes, that is used as the excuse. But the real reason is, we don't want you to be doing that.

Just stop doing that. Stop thinking about it, stop interfering with it. And you want a reason? I'll give you a reason.

That is a human being. That's a human being. And you shouldn't be, therefore, doing anything with that human being in the laboratory.

And if that embryo dies, that's a human death and it's on you. That is such nonsense that you can't believe that. And yet they tell you they believe it.

I think that that is a justification for their deeply held emotional and religious beliefs. I just wish they would say it. This is my emotional, philosophical, and religious belief.

Don't say, oh, and by the way, I've got the science to prove it. You do not have the science to prove it. I respect your religious opinion.

I respect your philosophy. But that is not realistic. I think that's a really good point, Dr. Paulson.

I think one of the most frustrating things in interacting with, in particular, the International Institute of Restorative Reproductive Medicine is the fact that they are explicit, that they are not an ideologically driven organization. But if you do any degree of digging into who is leading this organization and who is supporting this organization, whether it's the Heritage Foundation or the St. Paul VI Institute out of Omaha, Nebraska, which is where Napro Technology or one of the schools of RRM is based out of, you see the clear ties to the Catholic Church, and to embryonic personhood, and to anti-choice sentiments. That lack of transparency is extremely worrying to me, and there's no disclosure from RRM practitioners about their personally held beliefs.

A lot of them are unwilling to refer to reproductive endocrinologists because they don't want to facilitate in vitro fertilization. Yeah, I wonder if it's a little bit akin to a crisis pregnancy center, really, where you could see an OBGYN and get full spectrum counseling, you could see an REI get full spectrum fertility counseling, or you could end up in a clinic where you're only going to get a limited number of options and may not know. If you're not savvy on that sort of thing, you may not know that the other options exist, and then you get in this pattern where you're wasting a lot of really precious time.

If you look into the Restore Act that was passed in Arkansas this past year, there's actually a provision that says that restorative reproductive medicine providers or other providers who have personal disagreements with in vitro fertilization do not need to refer if a patient is not going to be able to get pregnant via their services or would like to be referred to those services, and that is extremely worrisome to me. For me, I think about this as, like, kind of akin to, like, informed consent. By not sharing all options based on an ideological or religious belief, you're not giving your clients all the information they need to make a decision.

I know when I do counseling for intended parents or egg donors or gestational carriers, these consultations and screenings, a lot of it has to do with informed consent. Do you know what you're signing up for? Do you know all of your options? Do you feel like you can access all of your options? So, yeah, that's very concerning to me, one, that they are being presented as an equal option, and two, they're not being required to refer. I know in our field, if we have to discontinue services because we're not able to treat someone, we have to refer.

It's not just saying, oh, there's this IVF thing, but, you know, don't worry about it. They don't even have to bring it up at all. That is, to me, a direct violation of informed consent.

I think RM is pushing that they're giving women choice. I know I've seen that on social media. We're here to give women choices in their care, but real choice means you are given accurate information.

You are being explained the pros and the cons, and then you are given the choice. That's patient autonomy. It is not giving a limited set of choices or framing certain choices as negative because they don't fit with your ideological views.

This feels a lot like they're having an ideological view first and then creating science to back it up rather than what we do is we do their research and we understand something, and then we make conclusions based on this, and this feels like they're doing it the opposite way, and I think in the end that, well, one, you're never going to convince someone otherwise if they're there for ideological reasons, and if there are patients that don't want to do IVF because they are opposed to it, great. Let's find other options for you. The key is accuracy, giving patients all the information, and letting them make an informed choice.

My parting thought would be that I want my colleagues in reproductive endocrinology and infertility to be aware of the fact that there is significant opposition to what we do for philosophical, religious, emotional reasons, and that's okay, but we should label it as such, and in the same way when patients come in and they want to talk about unproven therapies that we should listen to them and then explain that it's an interesting hypothesis, we thought about it, we investigated it, and it turns out that it didn't work, and then that was not the correct approach, and that is why I'm advising that you follow the treatment outline that we have been talking about. I think that's the perhaps best way in my mind to approach this problem. We're not going to change anyone's mind, just like Jamie said.

That's exactly right, and all of these intermediate steps about personhood, all of those are just excuses to try to testify what is an underlying, deeply held, sincere belief that you should not be messing with things reproductive, but that is not, in my experience, the best way to serve our patients, and I think that we will come out in the final analysis that we are right because we are following the science and we are following the data. I really want to thank both of our guests today, Dr. Kuhlman, Dr. Paulson. This was such a great discussion.

I know many of our listeners may not have heard yet about restorative reproductive medicine or RRM, so I think this was really enlightening to get the historical perspective to learn about what this is, and I also really hope this was galvanizing. Ben mentioned the legislation in Arkansas that's passed. This is the first state where that's happened.

There will probably be more where this is proposed. I hope this can encourage all of us to be advocates, advocates not only on the state and federal level, but just with our patients, like Dr. Paulson was discussing, kind of answering their questions, having empathy, really sitting with them and discussing the science. So we really appreciate everyone listening and we welcome feedback.

We hope this podcast inspires both those experienced with advocacy efforts and newcomers alike that this is a critical time in our field, both with potential opportunities and new challenges. Thank you so much for listening. Until next time.

Fertility and Sterility Roundtable was developed by Fertility and Sterility and ASRM as an educational resource in service to its members, other practicing clinicians, and members of the public. The opinions expressed are those of the discussants and do not reflect the views of Fertility and Sterility or ASRM.