Having Realistic Expectations Regarding IVF Outcome: When is it Time to Stop or Change Course?

Dr. Geoffrey Sher - April 26, 2017
Having Realistic Expectations Regarding IVF Outcome: When is it Time to Stop or Change Course?

It is important for patients/couples contemplating IVF with their own eggs, to be aware that usually, in more than 50% of cases a single attempt will not result in a live birth and furthermore that the chance of success declines with advancing age of the egg provider.  Thus, given the emotional, physical, and financial toll exacted by IVF, it is preferable that no one undertake a one‑shot attempt. If a couple can only afford one treatment cycle, IVF is probably not the right course of action.  It is thus unreasonable to undergo IVF with the attitude that "if it doesn't work the first time, we're giving up." In vitro fertilization is somewhat a gamble even in the best of circumstances.

Statistically speaking, a woman under 40years of age who has normal ovarian reserve , a fertile male partner and a receptive uterus, is likely to have a > 75% chance of having a baby within three completed attempts (fresh and frozen transfers) where up to 2 (non PG tested)  blastocysts derived from her own eggs are transferred.  For women of 40-42 years of age, who meet the same criteria, the chance is about halved (i.e. 40%- 45%) and for women over 42 years the chance is probably <20%. Conversely, when the same subset of women have only the most “competent” embryos are PGT selected for transfer using a genetic process known as next generation gene sequencing (NGS), the baby rate per ET is likely to exceed 50% (regardless of the age of the egg provider) and reach close to 90% within three attempts. Unfortunately, there will inevitably be some women/couples who, in spite of best effort at conventional IVF, are destined to remain childless. In my considered opinion, the time to stop trying is when after there is no remediable explanation for repeated failure. As a general rule it is rarely advisable to try > 3 times using the same approach. A specific case that illustrates this point comes to mind. It happened a few years back when a 42 year old Australian (Physician patient) who had undergone 23 prior failed attempts at IVF came to me for treatment here in the United States. After discovering a hitherto unrecognized immunologic implantation dysfunction (IID) linked to autoimmune hypothyroidism with activation of uterine natural killer cells (Nka), I took her through an IVF attempt with her own eggs, but only this time I incorporated selective immunotherapy. She conceived and went on to have a healthy little boy. This case serves to illustrate that the time to stop doing IVF should not only be based on the number of prior failed attempts, when no definable “remediable” explanation for failure is present. Older women and those who have diminished ovarian reserve can often benefit from stockpiling their embryos over several successive egg retrievals and then testing these collectively (once) for chromosomal integrity (i.e., “competency”) using CGH. Thereupon one or two “competent” embryos can be transferred at a time with a high expectation of success. This process is called “Embryo Banking” with Staggered IVF”. When conventional IVF with or without “Embryo Banking” with PGT embryo selection fails to yield a successful outcome, other options such as ovum donation, IVF surrogacy, or adoption should be considered. Couples who choose to undergo IVF should be encouraged to view the entire procedure with guarded optimism but should be emotionally prepared to deal with the ever‑present possibility of failure. It is important however, for IVF patients to be made to realize from the outset that an inability to become pregnant should never be considered a reflection on them as individuals.


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