1. Introduction

Infertility, defined as the inability to conceive after a year of regular intercourse without contraception, is a common and chronic problem affecting women and men and has an incidence of nearly 15% among couples worldwide ⁽¹⁾. Infertility in women ranks among the 5^th highest serious global disabilities leading to distress, depression, and, in some cases, discrimination ⁽²⁾. In most cases, the underlying cause, if properly investigated, can be identified and addressed ⁽³⁾. These are usually medical conditions (infectious, environmental, and genetic factors) and lifestyle practices (dietary, post-abortion complications, etc.) that have historically been under the realm of care of the family doctors ⁽⁴⁾.

Nonetheless, the treatment of infertility has increasingly shifted in the last three decades toward Assisted Reproductive Technology (ART), including in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) ⁽⁵⁾. ART is invasive, remarkably expensive, presents several risks for women, and concerns the short and longterm outcomes of the offspring produced. Furthermore, the technique has a moderate success rate that we can optimistically estimate at around 30-40% in women younger than 35 ⁽³⁾.

NaProTechnology (NPT) is a systematic and integrated approach to treat infertility based on a detailed knowledge of the woman’s ovarian and menstrual cycle events to identify the abnormalities and treat them as far as possible. This technique is more economical, has no contraindication and close to zero side effects, educates couples about their fertility, and monitors it, and family doctors can deliver it. The goal of NPT is to optimize the physiological conditions in each menstrual cycle to allow natural conception. Even if it remains difficult to compare the two approaches, NPT cannot be considered inferior to ART in terms of success rates ⁽³⁾.

This paper will argue that NaProTechnology is a better solution for infertility treatment than ART from several points of view: ethical, religious, medical, social, legal and environmental.

2. Religious and ethical concerns with ART

The longing for a child can be intense and overwhelming, and infertility can affect the stability of the couple and undermine the marriage itself. The Catholic Church recognizes the relevance of this issue and has deeply evaluated, beyond the spiritual support to these men and women, reproductive technologies that are morally acceptable, respectful of human dignity, and in line with the Magisterium. In judging the ethical soundness of any therapy for infertility the instruction of Dignitatis Personae specifies three criteria: a) the right to life and to physical integrity of every human being from conception to natural death; b) the unity of marriage, which means reciprocal respect for the right within marriage to become a father or mother only together with the other spouse; c) the specifically human values of sexuality which require «that the procreation of a human person be brought about as the fruit of the conjugal act specific to the love between spouses (Congregation for the Doctrine of the Faith, 2008 n. 12) ⁽⁶⁾. The central tenet of the Church teaching is the inseparability of the procreative and unitive aspects of married love, two essential aspects of creating the proper environment to nurture a new, defenseless human life ⁽⁷⁾. Gaudium et Spes (n. 50) -cited in Humanae Vitae (n. 10)- affirms that transmitting human life is the parents’ primary mission. In doing so, they are cooperators with the love of God the Creator and are the interpreters of that love⁽⁸⁾.

Modern secular society has severed this sacred union starting with the widespread use of contraception, which has gravely affected the stability of the marriage, increasing the infidelity and divorce rates and promoting a hedonistic idea of sexuality ⁽⁹⁾. This further advanced with the legalization of abortion as «routine medical practice», which ultimately becomes a human right with a progressive «de-escalation of consideration for the anthropological value of the human life» ⁽¹⁰⁾. In particular, the human embryo becomes a biological product freely disposed to fulfil our desires. The door further opens with the introduction of ART. It is a slippery slope that undermines human dignity as children become products of our technology, consumer goods which parents paid for and have a «right» to expect⁽¹¹⁾.

ART also poses other ethical dilemmas, mainly related to the practice to increase the success rate, such as the production of supernumerary embryos or selective abortion to eliminate extra embryos, and multiple pregnancies. There is a well-founded worry that we can abuse this technique for eugenic purposes, and, possibly, for human cloning ⁽¹²⁾. It is true that many states have put a moratorium on reproductive human cloning but permit at some degree therapeutic cloning, hence the only true ban, at the moment, remains to implant the clone embryo into a womb. In addition, human cloning has received in last decade a strong endorsement by several renown scientists such as Prof James Watson (Nobel prize in Physiology or Medicine in 1962), Prof. Udo Schuklenk, Prof. Hugh McLachlan and Prof. Edwards (who performed the first successful IVF baby in 1978), just to mention the most famous ones ⁽¹³-¹⁵⁾.

3. Medical, social and legal concerns

4. Environmental concerns

According to the Environmental Protection Agency (EPA) report, released in 2010, and listing the 24 causes of global warming, there is clear evidence that the composition of the atmosphere is being altered as a result of human activities and that the climate is changing⁽³¹⁾. Furthermore, the world’s richest half billion people, seven percent of the global population, are responsible for fifty percent of the world’s carbon dioxide emissions. Meanwhile, the poorest fifty percent are responsible for just seven percent of emissions ⁽³²⁾.

Policy and lawmakers are gradually starting to reduce vehicle pollution and other known sources of environmental degradation as the global awareness of the human activities contribution to climate change is rising. Nonetheless, the ecological impact of medical industry is still largely overlooked. ARTs industry, in particular, warrants a special consideration amongst all healthcare activities, because beyond producing a carbon footprint, which is an additional source of carbon emission contributing to anthropic environmental degradation, it has the unique peculiarity of creating also a carbon legacy ⁽³³⁾. A carbon footprint is a cumulative use of resources and carbon emission that each individual generates during his life on this planet, whilst a carbon legacy results when a human being decides to procreate.

Obviously, carbon legacy also applies to people procreating through natural means, but procreation through ARTs in fertility centres provide this service for a fee and they can and should be regulated. From a bioethical point of view, one must ask if it is wise to artificially create more human beings contributing to an already overburden ecosystem and if an overly unregulated ART business is ethically justified.

Since 1978, birth of the first human baby through in vitro fertilization, till 2018 over 8 million babies have been born as a result of ARTs ⁽³⁴⁾. This number is not very impressive in general terms and surely is not the responsible of local population growth especially if we consider that ARTs are mostly offered in low birth rates countries.

However, if we look at this number in terms of carbon footprint, the situation appears concerning because the vast majority of these births happens in USA, the number one carbon emitter in the world. A country where each child will consume 7 times the resources of a child born in China ⁽³⁵⁾. In light of the above evidence, some authors have suggested that a moratorium on all fertility clinics would be the soundest decision from an environmental point of view ⁽³³⁾. This seems unlikely in the short term. An initial solution could be, at least, applying carbon caps to ARTs business and cutting the founds to ARTs for not biologically infertile couples.

5. NaProTechnology: an alternative solution

Many couples experiencing infertility believe that ART is the only hope for their condition. In most cases, infertility is a symptom of underlying problems causing difficulty in conceiving or recurrent miscarriages. If properly investigated, we can identify and correct infertility. NPT works precisely to identify the underlying correctable causes of women’s reproductive issues and use therapies that work cooperatively with the women’s naturally occurring fertility cycle.

NPT starts with an initial consultation to explain reproductive physiology, investigative and treatment options to the patients. In this way, dietary, lifestyle, and underlying medical causes of infertility (e.g., thyroid dysfunction, hormonal problems, etc.) will be diagnosed and addressed. At the same time, providers can teach patients how to gain confidence with fertility tracking methods (Creighton Model Fertility Care system) to understand their cycles. The initial process takes at least 3 months to familiarize with it, plus several follow-ups ⁽³⁶⁾.

The tracking of the cervical mucus may identify suboptimal hormonal levels’ underlying abnormalities and short or variable luteal phases. When the quality and quantity of cervical mucus is inappropriate, patients may take medications and supplements to improve them (e.g., Vit. B6, guaifenesin, several antibiotics) ⁽³⁷⁾. They may receive hormonal supplementation with human chorionic gonadotropin or progesterone support the luteal phase. Patients may need to take Clomiphene, an estrogenic medication, to stimulate ovulation (38). Depending on the hormonal biomarkers in charting and serum levels measured during the mid-luteal phase, they may adjust the medication dosages.

Simultaneously, couples learn about the ovulation biomarkers to plan intercourse accordingly and maximize their chances of fertilization. In some cases, surgical intervention may be necessary (e.g., blocked or damaged fallopian tubes, endometriosis, etc.) to restore the woman’s normal reproductive cycle. NPT can also investigate and treat possible correctable causes of male infertility. NaProTechnology is, most importantly, a couple therapy.

The crucial distinction between NPT’s and standard ART’s approach to infertility is a commitment to exhaustively identify and treat the underlying correctable causes of infertility so that the couple may conceive through natural intercourse. NPT’s success rate is difficult to compare with ART for several reasons. The main ones are that there are too many differences in methods utilized and study populations at present and no properly structured randomized controlled trials.

A systematic Cochrane review concludes that there is insufficient data to demonstrate ART’s effectiveness over less intensive therapy for infertility ⁽³⁹⁾. There are some reports of data from NPT centres that effectiveness is similar or, in some cases, even better than ART ⁽⁴⁰⁾.

Stanford et al. reported the outcome of their experience with NaProTechnology in 1072 couples with an average female age of 35.8 years from 1998 till 2002. A third of these women had previously undergone ART and the mean length of time they had tried conceiving before starting NPT was 5.6 years. Approximately 40% of the couples conceived using NPT. Their mean age was 34.8 years and only 21% underwent ART before NPT. Amongst the live births, 4.6 % were twins, 88% were to term and only 1.4% of live births had low birth weight (less than 1.5 Kg) ⁽³⁾.

These results are to be considered at least in line with the best data available on ART, as it is also confirmed by the abovementioned Cochrane systematic review which found no data to consider that ART effectiveness is superior to other less invasive techniques, including NPT ⁽³⁹⁾.

Kiani et al. performed an extensive review of the literature of all articles published till July 2019 comparing ART and NaProTechnology and they found, beyond the high incidence of maternal and foetal complications (already discussed above) also a concerned increased frequency in genetic and epigenetic abnormalities in children born via ARTs ⁽⁴¹⁾.

According to Niemitz and Feinberg, epigenetic alterations could be related to some of the procedural steps used in ARTs, such as: in vitro culture, the media used, the induced ovarian hyperstimulation, or the maturational timing of the gametes that are harvested ⁽⁴²⁾.

NPT’s approach appears ethically and medically sound with its close to zero rate of complications, low costs, and the ability to disclose and treat several medical conditions affecting infertility and women’s general health, such as irregular cycles of abnormal bleeding, premenstrual syndrome, and polycystic ovarian syndrome ⁽⁴³⁾.

6. Conclusions

Human procreation is a personal act that should ideally involve the responsibility of a married couple and the structure of marital life. For believers, the procreation is a direct act of the Creator, and the spouses are cooperators and interpreters of God’s love in bringing to life a new person. The noble intention of treating infertility and having a child cannot justify any method or reproductive procedure to achieve the aim. Medical activities should be limited to assist the couple in their mission, treating or removing obstacles to the natural process without becoming a substitutive and manipulative act.

Assisted reproductive technology inherently endanger the essential and sacred values of human life and marriage. It undermines the harmony between human freedom and responsibility. It devaluates the Hippocratic nature of the medical profession by perpetrating a «divorce between science and morality» ⁽⁴⁴⁾, which compromises the primacy of person over things. Furthermore, ART poses potentially life-threatening risks for the woman and the foetus and carries long-term expensive medical, social, and legal drawbacks. In addition, the carbon footprint and legacy created by ART should be carefully considered by policy, and lawmakers in light of the growing evidence and concerns on anthropic contributions to climate change.

Providentially, there are ways to raise the next generation without the need to use ART. NaProTechnology is non-invasive, less risky, less expensive and protects «the physical and spiritual unity of the conjugal act» ⁽⁴⁵⁾, an approach that can treat infertility with success rates apparently similar to ART. NaProTechnology should be promoted and financed by governments and widely endorsed by the medical and the scientific communities.