NaProTECHNOLOGY and Conscientious OB/GYN Medicine

In the last 50 years, a surge of reproductive technology has revolutionized the practice of obstetrics and gynecology. First, effective hormonal contraceptives were made available to the public in the 1960s and, since their debut, have been used to treat almost every gynecologic abnormality [1]. Second, in the past 30 years, infertility has largely been managed using assisted reproductive technologies (ART), primarily intrauterine insemination (IUI) with recourse to in vitro fertilization (IVF) when insemination fails [2]. As a result, the modus operandi in mainstream gynecology has been to suppress, or to bypass, the woman’s fertility cycle. Physicians and patients who (1) conscientiously object to the therapeutic use of hormonal contraceptives on the grounds that it subjects patients to ineffective treatment of symptoms rather than treating their underlying disease and (2) morally oppose the ART approach to infertility on the grounds that it jettisons a loving act of marital intercourse, the one context worthy of the conception of a new human being, are now able to pursue an alternative approach that accords with their consciences. NaProTECHNOLOGY (an acronym for natural procreative technology) is a woman’s health science that encompasses a unique medical and surgical application of gynecology. The foundation of NPT is the Creighton Model FertilityCare System (CrMS), see Figure 1, the only prospective and standardized means of monitoring the various patterns of a woman’s menstrual and fertility cycle for the natural regulation of fertility. For example, because it views infertility as a symptom rather than a disease, NPT seeks to diagnose and treat the underlying causes of infertility so that the couple can more successfully conceive within their own acts of intercourse, especially during peak-day-focused intercourse. NPT infertility protocols depend on patient-specific charting data. Some observations during the fertility cycle—dry, limited, or continuous mucus; short or variable post-peak phase; premenstrual spotting or tail-end brown bleeding—are external signs of possible underlying disease processes. A medical interpretation of these abnormal CrMS observations leads to a targeted biochemical and hormonal evaluation, which in turn identifies target organ dysfunctions: decreased production of estrogenic cervical mucus, intermenstrual bleeding or spotting, short or variable luteal phases, and suboptimal levels of the ovarian hormones (estrogen or progesterone). Common treatments for these pathologies include induction or stimulation of ovulation, medications to enhance cervical mucus, and hormonal support in the luteal phase. When these NPT medical approaches to infertility were used in a study of 1,239 infertile couples, they resulted in a live birth rate similar to that of cohort ART treatments [3]. In many cases, medical applications of NPT are sufficient to treat infertility successfully; in other cases, surgical intervention is also required. Surgical NPT is a specialized form of gynecologic surgery the primary aim of which is to reconstruct the uterus, fallopian tubes, and ovaries. The ovarian wedge resection (surgical removal of a portion of an enlarged ovary to restore its normal size), for example, is effective in healing polycystic ovaries (contributing to the long-term treatment of some of the endocrine and menstrual cycle abnormalities associated with polycystic ovaries). It also brings the patient a 70 percent chance of pregnancy i.e., it is twice as effective as clomiphene [4]. A significant benefit of surgical NaProTECHNOLOGY is “near adhesion-free” surgery. One of the biggest pitfalls of surgery, of course, is the formation of postoperative adhesions, which can decrease tubal motility (adversely affecting fertility) and cause small bowel obstructions (that frequently require emergency reoperation) [5]. To prevent these complications, NPT surgical techniques pay meticulous attention to detail, take a systematic approach, and use Gore-Tex adhesion barriers [6]. Published Gore-Tex protocols reveal a statistically significant decrease in subsequent adhesion scores on second-look laparoscopy [7]. For some reason, the use of Gore-Tex has been overlooked in even the most recent adhesion prevention reviews [8]. One even laments that adhesion prevention is a “surprisingly neglected aspect of the treatment of endometriosis,” but the reviewers make no mention of the use of Gore-Tex as an adhesion barrier. Other techniques of surgical NPT include laser vaporization and pelvic excision and repair surgery (PEARS) of peritoneal or ovarian endometriosis. PEARS is a form of plastic reconstructive surgery of the pelvis with the primary intent of removing diseased tissue within the pelvic organs and repairing organs in a way that does not form pelvic adhesions. PEARS can entail robot-assisted laparoscopy or laparotomy, minimizing postoperative adhesions and optimizing the patient’s chances for pregnancy. The effectiveness of treating infertility with medical and surgical NPT is comparable to that of ART interventions. The cumulative live birth rate in patients receiving IVF is between 45-55% [10]. In a study population of 1,045 patients treated with NPT infertility protocols, more than 60 percent became pregnant within 24 months and nearly 70 percent within 36 months [11]. The overall �per-woman� NPT pregnancy rate is higher than that of ART due, in part, to the high rate of dropout or discontinuation in patients who undergo IVF treatment [12]. In addition, a meta-analysis comparing conventional surgery and IVF for treatment of endometriosis-related infertility found that the per-woman pregnancy rates with surgery were 55.3 percent while those with IVF were 9.9 percent [13]. However, while it is true patients treated with NPT have significantly lower overall fecundability (a 3.13 percent chance of conceiving within a given period) than those treated with IVF (13.3 percent), it is also true that the number of women who ultimately achieve a pregnancy with NPT is higher than the number who get pregnant using ART [14]. Thus, although achieving a live birth with NPT may take longer, it has a greater chance of occurring than with IVF. For those interested in training in NPT, the Pope Paul VI Institute and Creighton University School of Medicine offer educational programs for those in primary care or ob/gyn (including fourth-year medical students) to train in the medical applications of NaProTECHNOLOGY [15]. They also offer a 1-year fellowship in the surgical applications of NPT for ob/gyns who have completed their residencies [16].