How Many Times Should You Try IVF Before Giving Up?

18 Dec
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Button - Ask Dr Sher MedBecause of the emotional, physical, and financial toll exacted by IVF, it is preferable that a couple undertake the process with the mindset that they will be in it for more than one attempt. If a couple can only afford one treatment cycle, IVF may not be the right course of action. Recall that on average, with conventional IVF, there is only about one chance in three that it will result in a live birth, and there is a tremendous letdown if it fails. 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 a gamble even in the best of circumstances.

Statistically speaking, a woman under 40 years of age, using her own eggs, having selected a good IVF program is likely to have a better than 70% chance of having a baby within three completed attempts – provided that she has adequate ovarian reserve, (the ability to producing several follicles/eggs in response to gonadotropin stimulation), has a fertile male partner (or sperm donor sperm) with access to motile sperm, and has a normal and receptive uterus capable of developing an “adequate” uterine lining. Women of 39-43 years of age who meet the same criteria, will likely have about half that chance (35%- 40%).

When the most “competent” embryos are selected for transfer using a new genetic process (introduced into the clinical arena by SIRM in 2005), known as comparative genomic hybridization (CGH), the birth rate per single, completed IVF cycle is likely to exceed 60% (regardless of the age of the egg provider) and, more than 85% within three such attempts.

Unfortunately, there will inevitably always be some women/couples who in spite of best effort at conventional IVF will unfortunately remain childless. In my considered opinion, it rarely advisable to undergo more than three IVF attempts using the same approach each time. There is of course one important caveat: in women where the reason for repeated IVF failure is finally uncovered, it would indeed be justifiable (assuming there are sufficient emotional, physical and financial resources) to continue trying, using a defined and new approach that addresses the reason for prior failures. Simply stated, “the time to stop trying is when there is no remediable explanation for repeated failure to achieve a viable pregnancy”.

One very interesting case comes to mind. It happened a few years back when I consulted with a 42 year old Australian patient (she happened to also be a physician) who had undergone 22 prior failed attempts at IVF elsewhere. After determining that the reason for prior failures (at least in part) was due to a hitherto unrecognized immunologic implantation dysfunction (IID), I took her through yet another IVF attempt using selective immunotherapy. She conceived (using her own eggs) and went on to have a healthy baby boy. This case serves to point out that the time to stop doing IVF should not always be based on the number of prior failed attempts alone.

When conventional IVF (with or without egg donation and/or CGH embryo selection) fails to yield a successful outcome, other options such as ovum donation, IVF surrogacy, or adoption should be considered.

Although it is the right of any healthy women who has a uterus and is capable of producing even one follicle/egg to have the right to decide on doing IVF using her own eggs, given the very low success rate after 43 years of age (less than 10% per attempt and under 25% within 3 tries) it is my opinion that women over 43 years should be advised to rather do egg donor IVF. Here, regardless of the age of the embryo recipient, the IVF birth rate after a single attempt is about 60% – and better than 80% within three IVF attempts.

Couples who choose to undergo IVF should be encouraged to view the entire procedure with guarded optimism, but nevertheless must be emotionally prepared to deal with the ever‑present possibility of failure. It is important 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.

344 Comments

  • Frances Silva says:

    I am in desperate need of finding all options that will help me to carry a child I have done ivf three times to no avail. I am becoming so depressed. Any suggestions

    • Geoffrey Sher says:

      When confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
      The most common causes of implantation dysfunction are:
      a) A “thin uterine lining”
      b) A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
      c) Immunologic implantation dysfunction (IID)
      Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women.

      I strongly recommend that you visit my NEW personal website at http://www.DrGeoffreySherIVF.com and when you reach the home page, go to my new Blog find the “search bar” and type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.

      • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
      • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
      • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
      • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
      • The BCP: Does Launching a Cycle of Controlled Ovarian
      • Stimulation (COS). Coming off the BCP Compromise Response?
      • Frozen Embryo Transfer (FET): What Does it Involve?
      • Hereditary Clotting Defects (Thrombophilia)
      • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
      • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
      • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
      • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
      • PGS in IVF: Are Some Chromosomally abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
      • Dysfunction (IID) & Infertility (IID):PART 1-Background
      • Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
      • Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
      • Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
      • Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report)
      • Traveling for IVF from Out of State/Country–
      • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
      • The Role of Nutritional Supplements in Preparing for IVF
      I invite you to call 702-699-7437 or 800-780-7437 and set up a one hour Skype consultation with me to discuss your case in detail.

      I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

      Geoff Sher

  • Jaclyn says:

    Hi Dr. Sher, I guess a question I have is do people with frozen embryos give up and discard the embryos? From an ethical perspective I never thought I’d do this, but I’ve reached the end of my emotional rope. I’ve already been blessed with 3 children that were delivered when I was 26, 28 and 31. I always assumed I was still young enough to have a 4th and final baby at 33 years old. We’ve been TTC for 3.5 years now, with 2.5 of those years including fertility treatments and I’m exhausted. I went through IVF last January and was “a superstar IVF-er” according to my doctor. He even went so far as to promise me that I’m definitely having a baby with how “amazing” my genetically normal embryos looked. In addition to my “perfect” lining. I’ve transferred a total of four frozen embryos through 3 different FETs. Taken a small break between to recover, etc. I have two embryos left. I’ve been tested for Natural Killer Cells and that came back negative. Every single test comes back “normal.” I’m currently awaiting results for Endometrial Receptivity Test. If they come back “normal” I’m considering to be completely done and not transfer my two remaining embryos. Does that happen ever? Do people with genetically normal embryos just give up and walk away? I just turned 36 and my husband is 38 and for the first time I’m beginning to feel too old. Odds are it’s the 2.5 years of fertility treatments that have left me exhausted and tired, but at some point I should just move on and feel incredibly blessed with the 3 I had while I was young. Do you ever have patients with high quality, genetically normal embryos just give up after repeated FET failure?

    • Geoffrey Sher says:

      First off: It is quite possible that something secondary is being missed in your case.

      By the way, is the partner you now have the same as the one who sired your children because if not that might give me a clue as to whether you have an implantation dysfunction that is immunologic in origin. Remember, the concentration of NK cells in your blood has nothing to do with their toxicity, That can only be measured by the K-562 target cell test. Also, there are only a few labs in the world that can perform such testing reliably. Thus I would I need also to know where such testing was done.

      Another issue is that you mention that your embryos were “genetically normal”. Does that mean that you had them PGS-tested?

      By way of information added: It is one thing for a woman who has never been able to conceive (primary infertility) to come to grips with undergoing In Vitro Fertilization. It is quite another matter for someone who has successfully achieved a pregnancy in the past having to come to terms with a subsequent inability to conceive (secondary infertility). When this happens, it raises issues of guilt, a declining sense of self-worth and ultimately self-recrimination. The ramifications often impact family relationships involving partners and siblings. The truth is that secondary infertility can be just as difficult for individuals and family to deal with as primary infertility.
      There are many factors that contribute to the problem of secondary infertility. These include:
      Social and marital factors: In this modern day and age where at least one in two marriages ends in divorce, it is not surprising that there would be an inevitable hiatus in childbearing. This often results in a considerable delay in re-initiating family building. Since the biological clock keeps on ticking in the interim, advancing age can, and often does, have a profound affect on a woman’s ability to subsequently conceive and successfully complete a pregnancy. In my experience, this is one of the most common reasons for secondary infertility. In addition, by the time a decision is made to enter a new relationship, many men and women will have undergone a prior sterilization procedure which now needs to be addressed. To make matters worse, many such men and women first opt for surgical reversal of their occlusive surgery, only to learn in the end that the procedures were not successful, and they now need to consider in vitro fertilization (IVF) in one form or another.
      Financial factors: Here, the cost of raising a child often weighs heavily, especially in this present tough economic climate. This is becoming more of an issue as women playing an ever increasing role as a primary bread winner.
      Career demands: There can be little doubt that when it comes to climbing the career ladder, women are considerably disadvantaged by the fact that pregnancy and the immediate demands of child rearing take away from their ability to compete with men. As such, many women choose to delay having another child until such time as they have been able to make up for prior lost opportunity.
      Medical barriers to fertility: Certain common medical conditions, while not absolutely precluding pregnancy, make it much more difficult to conceive.
      Endometriosis: It is not uncommon for women with endometriosis to achieve a pregnancy, but find difficulty in doing so again at a later date. The reason for this is that while most women with endometriosis have patent fallopian tubes, the environment surrounding their tubes is compromised due to pelvic toxins that are produced by the endometriotic implants. These toxins compromise egg fertilization potential, making it more difficult for sperm in the fallopian tube to fertilize the egg upon its arrival there. As such, endometriosis is one of the commonest causes of secondary infertility.
      Tubal damage due to prior pelvic inflammatory disease: In first world countries, the early and often indiscriminate use of antibiotics for the slightest symptom has led to the point where an acute attack of pelvic inflammatory disease is often masked. As such, less than 30% of American women with tubal damage have knowledge that their tubes are compromised and that they might have subsequent difficulty in conceiving. Since, in many such cases the tubal damage will not have totally blocked both tubes, some of the women so affected might experience a pregnancy but have difficulty in conceiving again later down the line.
      Dysfunctional ovulation: Since ovulation as well as normal hormonal support of the early implanting embryo are both essential for a healthy pregnancy to occur, it follows that women with irregular or dysfunctional ovulation (e.g., polycystic ovarian syndrome – PCOS, persistent follicular luteal phase deficiencies or post birth control pill ovulatory problems) might sporadically conceive and thereupon find it difficult to do achieve another pregnancy later on.
      Immunologic Implantation Dysfunction (IID): has become ever more apparent that immunologic factors play an important role in achieving healthy implantation. Women with endometriosis (regardless of its severity), those with a personal or family history of autoimmune diseases such as lupus erythematosus, rheumatoid arthritis and thyroid autoimmunity (TAI), and some cases where the man and the woman share certain genetic similarities (alloimmune implantation dysfunction), will have activated CTL/NK cells that can inhibit or compromise healthy implantation. This is an often overlooked cause of secondary infertility. Most such autoimmune/alloimmune cases require selective immunotherapy and IVF.
      Antisperm Antibodies: Although infrequent, some cases of secondary infertility might also be caused by the woman harboring antisperm antibodies. In such cases IVF is mandated.
      Previous post-pregnancy uterine infection: Retention of products of conception after the birth of a child, miscarriage, or abortion can so damage the uterine lining as to result in subsequent implantation failure. Unless specifically looked for, this will usually be unknown to the patient, who will simply present with secondary infertility. Treatment is often difficult because such patients might not respond adequately to surgical removal of intrauterine scar tissue or to hormonal or Viagra therapy
      Male immunologic factors: Most men who have undergone a previous vasectomy more than 10 years earlier, will have antisperm antibodies that will interfere with fertilization. Such cases require IVF with intracytoplasmic sperm injection (ICSI). Here we offer a few words of caution to men who are considering undergoing surgical reversal of vasectomy. Always first have a test done to exclude the presence of circulating antisperm antibodies, because in such cases, even if the reversal is successfully performed, they will not be able to initiate a pregnancy without IVF/ICSI.
      Whatever the cause, secondary infertility often affects older couples disproportionately, creating a sense of urgency and even desperation in achieving a viable pregnancy before time runs out. It is for this reason that IVF becomes the treatment of choice in such cases. However, even IVF becomes progressively less successful with advancing age of the woman (whose eggs are being fertilized). In such cases it is important for the couple to be realistic with regard to their expectations. Here, options that include embryo banking and egg donation should be carefully considered.
      Another important point is that whenever a regularly ovulating younger woman (under 36 years of age) with patent fallopian tubes is diagnosed with secondary infertility, it is essential to consider underlying endometriosis or non-obstructive tubal disease as a possible cause. In such cases, IVF is again the treatment of choice.

      I urge you to access my new personal website at http://www.DrGeoffreySherIVF.com and from there, my new blog. When you get to the “home page” of the Blog, find the “search bar” and type in any of the articles below by title, “click” and you will immediately be taken to these. While on this blog, please take the opportunity to post any questions or comments with the full expectation that I will (as always) respond promptly.
      )
      • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
      • Unexplained IVF Failure
      • Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
      • Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
      • Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
      • Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
      • Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report)
      • Traveling for IVF from Out of State/Country–
      • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
      • The Role of Nutritional Supplements in Preparing for IVF
      • Frozen Embryo Transfer (FET): What Does it Involve?
      • Hereditary Clotting Defects (Thrombophilia)
      • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
      • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
      • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
      • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
      • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.

      I invite you to call 702-699-7437 or 800-780-7437 and set up a one hour Skype consultation with me to discuss your case in detail.

      I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

      Geoff Sher

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