By Chloe Maye
Editor’s Note: In this review, Chloe Maye, examines the article by Kiani et al. that evaluates the reported maternal and neonatal risks associated with assisted reproductive technology (ART) and explores the role of NaProTechnology as a potentially safer approach to addressing underlying causes of infertility. As a fourth-year medical student who participated in the FACTS elective, Maye illustrates how exposure to fertility awareness-based methods (FABMs) during medical training can broaden clinicians’ understanding of infertility evaluation and restorative approaches to address the underlying causes of infertility. Students and health professionals interested in learning more can explore the FACTS elective and CME course, and are invited to attend the upcoming FACTS annual conference on April 10th and 11th in Peoria, IL.
Introduction
In the 2020 article “Complications related to in vitro reproductive techniques support the implementation of natural procreative technologies,” Kiani et al. highlight that approximately 20% of couples worldwide face infertility issues [1]. More recent data from the World Health Organization (WHO) and the Centers for Disease Control (CDC) report similar data, with approximately 17.5% of couples experiencing infertility worldwide and approximately 19% of women in the United States reporting inability to achieve pregnancy after one year of trying to conceive [2] [3]. While this article defines infertility as “failure to become pregnant after 12 months of regular unprotected intercourse,” organizations like the American College of Obstetricians and Gynecologists (ACOG) have suggested the application of more nuance to the definition, recommending infertility evaluation for women greater than 35 years old after 6 months of regular unprotected intercourse [1] [4].
“Recent data from the WHO and CDC report … approximately 17.5% of couples experience infertility worldwide and approximately 19% of women in the United States report an inability to achieve pregnancy after one year of trying to conceive.”
Many couples struggling with infertility utilize assisted reproductive technology (ART) to achieve pregnancy. ART has become a globally accepted practice in over 100 countries, with estimates of 9,829,668 to 13,019,331 infants born via ART between its inception in 1978 and 2018 [5] [6]. At the time that the authors wrote this article in 2020, the most commonly practiced ART techniques included in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), controlled ovarian hyperstimulation, and embryo transfer [1]. While ART may be associated with high pregnancy and live birth rates, it is not without consequence. Potential complications for mother and baby exist both inside and outside the perinatal period. Furthermore, the authors of this article argue that the main goal of ART is to address infertility as a disease, aiming to achieve pregnancy without correcting underlying issues.
The authors of this article recommend that natural procreative technology, also known as NaProTechnology (NaPro), should be considered as a mainstream alternative method for people struggling with infertility, as it uses cycle tracking, medical interventions, and surgery to address the underlying gynecological causes. NaPro, first developed in the 1970s, uses the rules of the Creighton Model FertilityCare System (CrMS) to help patients and physicians identify dysfunction in a patient’s cycle and allow them to target treatment more specifically to the cycle abnormalities through medical intervention, such as clomiphene administration to induce ovulation, or surgery, such as laparoscopy or hysteroscopy [1].
“NaProTechnology should be considered as a mainstream alternative method for addressing infertility, as it uses cycle tracking, medical intervention, and surgery to address underlying gynecological issues to lead to pregnancy.”
The primary goal of this article and its supporting literature review was to identify and report the risks of ART to both mother and offspring, while finding current literature related to the NaPro approach.
Methodology
The authors utilized the following search string to identify articles relevant to their paper in PubMed: “infertility” AND “assisted reproductive technology” OR “NaProTechnology.” They evaluated all articles published in English through August of 2019 and selected articles that were either related to ART-associated complications or discussed the NaProTechnology approach [1].
Results
The authors of this study do not identify the number of articles that came up in their search, but focused on select articles’ findings related to ART complications for mothers, fetuses and newborns, and long-term potential complications of ART.
ART complications for mothers include increased risk of maternal mortality relative to the general pregnant population, ovarian hyperstimulation syndrome (OHSS), ectopic pregnancies, hypertension, and breast cancer, particularly among women undergoing stimulation with clomiphene. The article also underscored a higher risk of placental pathology (placenta previa and abruptio placentae), preeclampsia, and cesarean delivery amongst those who received ART [1]. Other complications associated with ART offspring include low/very low birth weight, miscarriage, perinatal mortality, small-for-gestational-age status, and stillbirth. Research varies on whether ART is associated with increased risks of preterm birth. In addition to these antenatal and perinatal complications, the authors found articles citing increased risks of anatomic anomalies, including neural tube defects, gastrointestinal atresia, omphalocele, and hypospadias.
“ART complications for mothers include increased risk of maternal mortality relative to the general pregnant population, ovarian hyperstimulation syndrome (OHSS), ectopic pregnancies, hypertension, and breast cancer.”
Furthermore, studies suggest that epigenetic defects, such as Beckwith-Wiedemann syndrome, Prader-Willi syndrome, and others, may be more common in babies conceived through ICSI and IVF than their naturally conceived counterparts. Lastly, due to exposure to exogenous hormones during fetal growth, it has been suggested in the literature that offspring conceived through ART may have an increased risk of certain endocrine-sensitive cancers, including neuroectodermal tumors, malignant lymphoma, and hepatoblastoma [1].
Discussion
The article’s discussion section focuses heavily on NaPro as a better option to minimize the negative consequences associate with ART. The authors argue that when presented with an infertile couple in practice, a multipronged approach of clinical evaluation, karyotyping, genetic screening, and counseling should be undertaken to determine the right path forward for the couple [1].
This article directly correlates women’s health with couples’ family-planning goals, emphasizing the benefits of NaProTechnology, which combines CrMS with medical and surgical interventions. For couples who want to avoid the risks of ART and better understand their fertility, NaPro is a valid, evidence-based alternative to the traditional ART methods. ART and NaPro methods report similar live birth rates [1] [7].
“For couples who want to avoid the risks of ART and better understand their fertility, NaPro is a valid, evidence-based alternative to the traditional ART methods.”
Although the authors thoroughly explained the possible negative consequences of ART, the article’s methodology led to a more one-sided view of fertility treatment options. The article clearly lists ART as a viable option for couples to pursue in lieu of NaPro, but the way the data is presented does little to assuage readers that ART should be considered as an option for achieving pregnancy. The article would have benefited from a more well-rounded methodology, incorporating complications and risks of NaPro into its literature search and results section. While a table is provided in the article for comparing the two approaches, there are no citations related to NaPro risks, nor is the lack of such information in scientific literature mentioned explicitly in the article.
In the future, I would like to see this research repeated with greater emphasis on truly comparing ART versus NaPro. Fertility awareness-based methods, such as Creighton, are an understudied field, so it is understandable that relevant literature may be sparse. However, a lack of articles would provide further proof of the need for additional research. Additionally, more studies need to be done looking critically at ART and its complications for women and men seeking fertility services.
References
[1] Kiani, A. K., Paolacci, S., Scanzano, P., et al. (2020). Complications related to in vitro reproductive techniques support the implementation of natural procreative technologies. Acta Biomedica, 91, 1–10. https://doi.org/10.23750/abm.v91i13-s.10525
[2] World Health Organization. (2023, April 4). 1 in 6 people globally affected by infertility. https://www.who.int/news/item/04-04-2023-1-in-6-people-globally-affected-by-infertility
[3] Centers for Disease Control and Prevention. (2024, May 15). Infertility: Frequently asked questions. https://www.cdc.gov/reproductive-health/infertility-faq/index.html
[4] American College of Obstetricians and Gynecologists. (2014). Female age-related fertility decline (Committee Opinion No. 589). Obstetrics & Gynecology, 123 (3), 719–721. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/03/female-age-related-fertility-decline
[5] Adamson, G. D., Zegers-Hochschild, F., & Dyer, S. (2023). Global fertility care with assisted reproductive technology. Fertility and Sterility, 120 (3). https://doi.org/10.1016/j.fertnstert.2023.01.013
[6] Adamson, G. D., Creighton, P., de Mouzon, J., Zegers-Hochschild, F., Dyer, S., & Chambers, G. M. (2025). How many babies have been born with the help of assisted reproductive technology? Fertility and Sterility, 124 (1). https://doi.org/10.1016/j.fertnstert.2025.02.009
[7] Stanford JB, Parnell TA, Boyle PC. Outcomes from treatment of infertility with natural procreative technology in an Irish general practice. J Am Board Fam Med 21(5):375-84, 2008;
ABOUT THE AUTHOR
Chloe Maye is a fourth-year medical student at Kansas City University – Joplin in Joplin, Missouri. She completed her undergraduate education at Missouri Southern State University in Joplin, MO. She plans to pursue a residency in obstetrics and gynecology and is interested in advocacy, health equity, and medical education. She enrolled in the FACTS elective to learn about different fertility awareness-based methods so she could have more informed conversations with her future patients.
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