Infertility

The difference between RRM and standard reproductive medicine is very clear in patients who struggle with infertility.

For the couple, the investigation phase is often fairly straightforward or minimal, as per recommendations : semen analysis, a hystersalpingogram (HSG) to check tubes, and sometimes, tests to check thyroid function and ovulation (a day 21 or 23 progesterone test often done but recommendations acknowledge a week before menses is best). After completion of these preliminary investigations to rule out easily correctable issues, the patient younger than 35 is often offered ovulation induction medication for a limited number of cycles, followed by controlled ovarian stimulation with intrauterine insemination. Older patients or those not successful are encouraged to undergo in vitro fertilization, the standard approach which uses powerful hormones to suppress all ovulatory function in order to allow the ovary to respond to significant doses of hormonal stimulant medication to produce multiple eggs, which are harvested in an invasive procedure. These are then mixed with sperm collected most often through masturbation and fertilized in a lab, to be returned to the uterus in a future interventional procedure (or frozen for later use).   

All of these approaches generally aim to produce supraphysiologic levels of hormones and multiple eggs to circumvent the underlying issues, which may remain obscure for many. Occasionally a basal body temperature is used to confirm ovulation or help with intercourse timing, but charting is rarely used beyond these basic concepts and not generally recommended.

RRM  uses the fertility chart not to confirm ovulation is happening but as a window into the function of the reproductive system. Bleeding patterns and mucus production produce signs that are associated with various reproductive phases and abnormalities. These can be confirmed through blood tests, ultrasounds and other timed investigations. Screening for conditions such as thyroid dysfunction, PCOS and endometriosis are also common place. Correction with individualized doses of ovulation induction medication or luteal phase hormones and other supportive therapies aim to produce a normal looking chart and hormonal and ultrasound parameters that are optimal. Conception can occur through a natural act of intercourse.

Supplementing progesterone or other hormones in pregnancy used to be controversial, but is now standard care in many countries and for many situations.1 It has been suggested to reduce the risk of pregnancy loss in a meta-analysis2 for women with multiple miscarriages, although not all studies confirmed this. It is likely that there are common abnormalities that may contribute to why providing progesterone in pregnancy may be helpful. In the studies, there were not specific diagnoses or monitoring of the patients’ blood hormone levels except for their history of recurrent miscarriage. A recent randomized trial suggests that progesterone is most likely to be helpful when supplementation is started in the luteal (postovulatory) phase of the menstrual cycle, prior to a positive pregnancy test3.

The risks of ART (Assistive Reproductive Conception) like IVF and ICSI are well documented :

  • premature births and low birth weights in both multiple and singleton pregnancies
  • multiple pregnancies
  • congenital abnormalities

A more recent paper looked exclusively at patients with previous IVF (2.1 average attempts, range 1 -9). This was a group of patients very poor prognosis for every conceiving their own biological child…they were old, had nearly 6 years of infertility and had already tried IVF (almost always unsuccessfully). The overall success rate by lifetable analysis was 32.1% with no increased risk of twins or higher order births and low risk of premature or low birth weights (equal to the general population despite their high risk due to age and infertility). More studies are in the process of being analyzed and published including a large retrospective study (iNEST) which will include RRM and IVF patient outcomes in the analysis.

How successful is RRM for infertility?  A 2008 paper reviewed outcomes of over 1200 patients between 1999 and 2006, with an average age of 35.8 and 5.6 years of infertility, and found an overall success rate (live birth) of 52.8%; for women with secondary infertility the success rate was 73.9%, for women with only 1 -3 years of infertility 66.0% gave birth, most often healthy weight singleton baby. Women 41 years of age or older had a success rate of 50.9% and women 30 years of age and younger had a live birth rate of 59.1%.  The second paper looked at the outcome of treatment from 2000 – 2006, in women of similar age (35.4) with less years of infertility (3.2 years) and less IVF (8%). It found an overall live birth rate of 66%.

[1] C. Racowsky J. Geraedts M. Cedars A. Makrigiannakis R. Lobo. 2012. Best practices of ASRM and ESHRE: a journey through reproductive medicine Human Reproduction, Volume 27, Issue 12, 1 December

[2] Practice Committee of the American Society for Reproductive Medicine. 2015.Diagnostic evaluation of the infertile female: a committee opinion. Fertil Steril. Jun;103(6):e44-50. doi: 10.1016/j.fertnstert.2015.03.019. Epub 2015 Apr 30

[3] https://www.nice.org.uk/guidance/cg156/chapter/Recommendations

[4] Kaartinen N, Tinkanen H. 2017. Do in vitro fertilization treatments result in healthy babies? Duodecim.;133(8):728-34.

5] Okun N, Sierra S; Genetics Committee; Special Contributors. 2014 Pregnancy outcomes after assisted human reproduction.J Obstet Gynaecol Can. Jan;36(1):64-83. doi: 10.1016/S1701-2163(15)30685-X.