Procreation – and with it the ability to achieve immortality by living on through one’s children – is one of the most insatiable human needs. This strong natural urge exerts tremendous pressure on couples unable to have a baby. And the pressure to reproduce becomes increasingly acute as couples grow older and become more aware of their own mortality. The introduction of In Vitro Fertilization (IVF) more than 30 years ago has made parenthood possible for millions who otherwise would never have been able to conceive.

The biggest decision an infertile couple will ever make in regard to IVF is whether or not they really want to become parents. An IVF procedure requires an enormous emotional commitment at each level of the program, whether or not IVF is successful. This has a permanent impact on the couple. Because the toll can be so great, both partners must be committed to supporting each other from the very beginning.

The IVF process is stressful and since in general per egg retrieval, there is at least as great a chance of not being successful, it is essential for IVF patients and their partners to be realistic about the prospects – to be guardedly optimistic but to prepare themselves emotionally so that they are not overwhelmed by failure in case IVF does not succeed. Both partners should be prepared to respond to a variety of emotionally stressful demands as they undergo IVF, including:

• Dealing with general stress “baggage” (shame, guilt, anxiety, depression, anger) they bring into the program because of their long‑standing battle with infertility
• Following new procedures; interacting with a strange and sometimes impersonal clinical staff, and perhaps with a constantly changing cast of characters
• Living in an unfamiliar environment: many couples will travel from another state or country to undergo IVF in a good program. This encompasses a different daily schedule, time‑zone changes, and separation from their normal support network
• Coping with the unpredictable emotions that the fertility drugs trigger in the woman
• Reacting to family and marital stress, which may be heightened by the constant need for mutual support
• Managing the financial aspects of the procedure

Couples react to the demands of IVF in strikingly different ways.

One expectant mother found that the stimulation phase of her second IVF treatment cycle (her first cycle had ended in an ectopic pregnancy) was the most stressful:

“One of the most difficult things I went through was the roller‑coaster ride waiting for the estradiol level. Would it be high enough? Would I have enough eggs? Would I have to be on another day of fertility injections? It was really the most exhausting part of the entire process.”

The mother of a one‑month‑old IVF son also found the waiting to be most trying:

“The expectation between each step was difficult for me. But waiting for the pregnancy test‑that was the hardest part!”

Fortunately, she produced numerous eggs, had two embryos transferred and several left for freezing/banking and she went on to conceive and give birth to a beautiful and healthy baby girl.

In contrast, the mother of IVF triplets said:

“I was at the point of giving up, and then found new hope through IVF. I was so excited and exhilarated through the whole process that the time just flew by.”

IVF‑related stress cannot be entirely avoided, but it can be mitigated by a staff that helps normalize or demystify the experience as much as possible. The creation of an environment where all the couples are “like me” can be encouraging to the anxious IVF couple. In addition, the opportunity to talk with other couples undergoing the procedure or with representatives of a support group may be helpful. Finally, the services of an in‑house counselor can be particularly beneficial.

IVF patients need to be prepared for the fact that about 15-20% of pregnancies miscarry, and the risk of miscarriage after in vitro fertilization is probably the same as for natural conception. The reason the IVF miscarriage rate sometimes appears to be higher is that an IVF pregnancy is diagnosed long before it normally would be in the case of a natural pregnancy. Most women who conceive on their own do not test themselves for pregnancy until they have missed their period, whereas with IVF the diagnosis of pregnancy is made before the woman misses a period. One should remember, however, that a pregnancy is not confirmed until the presence of a gestational sac has been diagnosed by ultrasound. If this criterion is used to verify pregnancy, then the miscarriage rate with IVF is no greater than that of the population at large.

But miscarriage can have a positive side, however. Painful as it is to the couple, the very fact that they conceived at all indicates they are likely to be able to do so again. It is reasonable to expect that although a successful pregnancy was not achieved on the first try, the fact that they could initiate a pregnancy means that their overall chances of having a baby will increase on subsequent IVF attempts.

Couples must realize that no matter how hard they try to become pregnant and no matter how hard the doctor tries through IVF (and other methods), no one can guarantee a successful outcome. Having a baby should represent the “icing on the cake;” the couple’s relationship should represent the “cake” itself. IVF often imposes significant stress on a relationship. It is thus very important that couples undergoing IVF be made aware of this fact and counseled that they should not lose sight of the other aspects of their relationship.

One nurse‑coordinator reminds her patients to…

” ‘Lighten up’ a bit by writing prescriptions for candlelight and wine.”

The father of triplets, meeting with a group of other IVF couples, commented:

“All of us have one thing in common‑we’ve been through the highs and lows of IVF. My wife and I represent the high! But it wasn’t always easy for us. I can’t emphasize enough how important it is for everyone to keep their chin up through the whole procedure.”

Another man, holding his one‑month‑old son in his arms, added:

“I would encourage everyone definitely to maintain a positive attitude. The hardest part of the whole procedure is dealing with failures. It’s inevitable that when the first IVF attempt fails you just stop wanting to try because you don’t want to fail again. If you could just keep it in perspective and know IVF is a trial‑and‑error scientific procedure and sometimes you just have to expect problems that will help a great deal.”

It is important for couples to realize that there is little the woman can do to influence outcome following IVF in either a positive or negative way. Women often tend to blame themselves when they get a negative result. This is almost always unfounded and counterproductive, but it is also unfortunately relatively inevitable. Appropriate counseling and a good emotional support system can go a long way toward minimizing this misperception.

The physical demands of IVF ranging from the annoyance of hormone shots and blood tests to the discomfort of egg retrieval for the woman and the need for the man to produce a semen specimen on demand, all add to the emotional stress associated with the process. So does the financial burden and for couples that journey from afar to access IVF programs in another state or country, there is also the stress of travel, including jet lag and/or the general disorientation caused by temporarily living in unfamiliar surroundings.

Proper emotional preparation and mutual support throughout the treatment cycle will help both partners cope more effectively with the physical demands on the woman. And they should keep in mind that once the pregnancy is confirmed, the remainder of the gestational period will probably vary little from pregnancies experienced by all other expectant women.

Finally, there is little doubt that the overall expense of undergoing IVF often add to anxiety, stress and emotional lability. As one newly expectant IVF patient said:

“So far we’ve spent about $50,000 trying to get pregnant, so the IVF portion was really a minor part of the total cost. I first went through reconstructive surgery and several laparoscopies. I shudder to think of the money we spent on airfare to consult with doctors in other cities, plus hotel rooms and meals, to say nothing of all the income we lost by taking so much time away from work. Had we been advised from the that my tubes were permanently blocked and that I should go directly to IVF , we could have saved a lot of money Out of that $60,000 our insurance company has paid about $15,000, so we have been pretty lucky financially.”

Although this woman considered herself lucky to have paid “only” $45,000 out of her pocket, a similar outlay would be prohibitive for most other couples. That is why couples contemplating IVF should first determine whether their budget can accommodate all the direct and indirect expenses that IVF entails. IVF candidates should not automatically assume that their insurance will cover… In fact, while reimbursement practices do vary from company to company and from state to state the fact remains that in the United States less than 20% of IVF is covered.

As one new mother said vehemently:

“We’re still waiting for our insurance to pay. It’s been over a year since we went through the IVF program, and they just keep making excuses. So far we’ve
only received $900!”

The father of triplets expressed his concern about the unfairness of insurance companies that refuse to fund IVF but cover other surgical procedures without question:

“Through all of our infertility treatments, including artificial insemination and surgeries, the insurance companies argued and refused to pay. Then our
triplets were born seven weeks premature, and the hospital bill for them and my wife was more than $200,000. The insurance company said that was no problem and that they were going to pay the whole thing.”

The financial risk in IVF is great, but the return can be priceless. That is why it is so important for each couple to be absolutely sure of their willingness and financial ability to make such an investment before they attempt IVF. Yet more and more couples are willing to make the financial commitment. Why? When asked if he and his wife had difficulty deciding whether to undergo IVF given its cost and uncertain outcome, one new IVF father responded:

“Well, when you really want children you set your priorities. We think babies are more important than fancy vacations or a sailboat. We were able to budget for IVF. But we’re sorry that insurance doesn’t usually cover it because a lot of people just can’t spend $10,000 or so to go through these procedures.”

Because of 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 procedure for them. After all, there is only about one chance in three that IVF will be successful‑and a tremendous letdown if it fails.

I believe it is 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. But statistically speaking, the couple who have selected a good IVF program are likely to have a better than 70% chance if they undergo IVF three times, as long as their gametes can fertilize, and the woman is under 40 with a normal uterine cavity and a proper hormonal environment.

Unfortunately, some people will ultimately be unsuccessful. Repeated IVF failures and disappointments can exact such a financial and emotional toll as to become counterproductive and destructive on relationships. There is a time to stop trying. Couples trying to have a baby should always examine the option of adoption which can be very rewarding because it addresses both fertility as well as a social need. In my opinion, it is rarely advisable to undergo IVF repeatedly without there being a well defined and potentially remediable cause for failure.

One woman (who eventually adopted a newborn boy) described her disappointment over three failed IVF procedures:

“It’s very difficult to deal with. You go into any of these procedures with the expectation they will work. Somehow we are raised in our society to think that it’s not whether you are going to have children, but how many do you want? We plan for our car, and we plan for our house‑ and assume that the children are going to come. And when they don’t, it’s devastating. You are basically out of control of your own body. There is nothing that you can do to make the egg and sperm unite.”

Couples who choose to undergo IVF should realize from the outset that the inability to become pregnant should never be considered a reflection on them as individuals. They should view the entire procedure with guarded optimism but nevertheless must be emotionally prepared to deal with the ever‑present possibility of failure.