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25 April 2014

Naprotechnology Or IVF?

 - Wednesday, 25 April 2012, 00:00 , by Pierre Mallia

The recent resurfacing of the IVF debate has brought in the controversy of whether one should be looking into a ‘technology’, which is presented as naprotechnology, instead of IVF

Certainly, a claim was made that this technology brings in just as good results as IVF and that therefore this suggestion may be worth considering.

The dilemma in discussing naprotechnology is that it is nothing new, really, but simply an extension of what before we used to call ‘natural procreation’ – or natural family planning (NFP), which can be used both to have babies or to prevent pregnancies. It was ‘invented’ (not really true – other than the name) by an American physician who pioneered it and in fact offered it as a Catholic alternative to IVF; this gave him a direct club class passage to be a permanent member of the Pontifical Academy for Life.

We need however to be careful when assessing its merits. Certainly, it has worked for many people, but unfortunately, as is often the case when vested interests (including religious) come into play, one can only look at the facts which support or beef up one’s own point of view. Would we not all be in favour of a natural method than a laboratory assisted one? The fact is that although the claim is that it is bringing in good results, one is not comparing the same group of patients.

Certainly, there are centres where IVF can be abused and doctors there may bypass natural methods and simply jump to a technology which fertilised an ovum in a lab. This is wrong, period. But it is certainly not the case here and it is irresponsible to think that in Malta we have some form of a ‘jungle’, as some have claimed. I have no axe to grind against anyone and neither do I have a vested interest in IVF or in naprotechnology. My field is ethics as applied in the medical world, and therefore it is my duty to assess claims and see that justice is done to all sides of the argument.

Unfortunately, the way naprotechnology is being presented leaves a lot to be desired as far as presenting it in a scientific and objective way goes. Having said that, there are doctors, especially in Catholic countries, who have taken courses and interests in this area. It is, on the other hand, not part of mainstream medical care – it does not form part of our curriculum, for example. It is therefore probably best to classify it as complementary. Meanwhile, normal natural procreation has always been part of the medical curriculum. So what is the difference?

The difference lies in educating patients more about the woman’s cycle and directing them to have sexual union within the period when the woman is ovulating. But is this already what we are doing? Naprotechnology takes it a little further by selling (or giving free?) biological markers of ovulation so that the woman knows when and where. It also follows what is called the Creighton model – which is a bio-psycho-social approach. If these markers fails, then the technology offers medical treatment like clomiphene, and if necessary even surgical treatment, like an attempt to open the tubes if these are clogged, etc.

So when one speaks about the ‘success’ rate of naprotechnology, one is including also these medical and surgical procedures, as opposed to IVF alone. This is not only not fair, but also unscientific (and probably fraudulent), as one should compare like with like. If I am to include people who took clomiphene or surgery as a success in one group, then with the IVF group I must also include those patients who did not arrive to IVF because the same medical / surgical treatments were used in the clinics offering IVF. We rarely (or at least that is how it should be) arrive to IVF before we have exhausted other methods as these.

When one looks up the name of the inventor on medical journals , one does not find any papers listed on PubMed (the scholar database for medical articles) of the inventor of the technology, and neither does one find papers on naprotechnology itself – other than one. This latter is a study by three people who compared naprotechnology with IVF in Ireland. They look at only two GPs offering the service and admitted its results were promising but stopped short of saying it was as good as IVF. In fact, they say that cohorts (groups) of patients should be studied.

So the scientific evidence is still lacking. The literature one finds is limited to those who use the technology, who of course can be said to have competing interests to say the least. I immediately got the feeling that one is taking a ride on Catholic teaching in order to have a technology which competes with IVF, when in reality it is offering nothing new other than new markers for ovulation. Then why give it such a buzzword of a name? One gets the feeling that the Catholic population is being manipulated. For example, one pragmatic argument against IVF was that it produces multiple pregnancies – twins, triplets, quadruplets… Yet so does clomiphene (a medical treatment which does not forego intercourse). In fact, clomiphene is the real demon of multiple births. So why is the argument used only against IVF?

The real issue is that IVF foregoes intercourse and natural sex. This is what we should focus on. Certainly, Natural Family Planning, as I still prefer to call it, is still valid for larger numbers who need education or support. But there will remain those for whom this method can never be helpful.

Those claims that IVF did not work for some couples and then naprotechnology did, probably should have never arrived to IVF in the first place. In any case, the numbers are not enough to approach a statistic and are probably due to abuse of IVF by offering it too early. This is not an argument against IVF; it is an argument against those negligent enough to offer a technology when it could be avoided. Responsible medical practice does not lead to this.

Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors

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