While it is true that it will often take more than one IVF attempt to achieve a successful outcome, it is not good enough to simply offer this argument as a reason to just “keep on trying.” Ninety percent of my personal IVF practice involves treating patients who have experienced two or more prior IVF failures. Some had experienced more than 10 failures and believe it or not, in one case the couple had failed more than twenty prior attempts. A common thread often underlying such heartbreaks is the failure to thoroughly plan the IVF journey before embarking on it.

Preparing for IVF requires a very individualized approach. It is important to understand that each patient/couple is different and that a “one size fits all” or “cookbook” approach is inappropriate. Here are the steps that I follow to assure that patients are prepared for the IVF journey:

1. Evaluation of medical suitability for IVF: The Hippocratic doctrine declares “do no harm”. This means that every patient /couple must be carefully assessed medically and psychologically in advance of undergoing IVF in order to identify potential health hazards that could be revealed in the course of a cycle of treatment or during an ensuing pregnancy. The following are examples:
   

   a. Very young women, and those that don’t menstruate or ovulate regularly on
   their own are at inordinate risk of developing life endangering complications
   associated with severe ovarian hyperstimulation syndrome (OHSS) following
   administration of fertility drugs and require modified treatment regimes
   b. Women with certain hereditary blood clotting disorders (thrombophilia) are at much greater risk of early and late pregnancy complications and require specific treatments as soon as pregnancy is diagnosed.
   c. Women with cardiovascular disease or hypertension are at greater risk of developing pregnancy related complications that can compromise their well being as well as that of their baby(ies).
   d. Some women have hidden bleeding disorders due to blood platelet
   disorders or abnormalities in certain blood clotting defects which if
   undiagnosed can lead to serious complications during egg retrieval.
   e. The presence of active viral and bacterial sexually transmittable diseases should be identified and if possible treated in advance. In some cases where the risk of transmission to partner of baby cannot be avoided, detailed advance disclosure and counseling is essential. These are but a few examples to illustrate the point; there are many potential others.

2. Defining the cause of the infertility: About one third of infertility is due to female causes, one third due to male sperm dysfunction and the remaining third is due to a combination of both male and female factors. In addition, there is very often more than a single female (or male) factor contributing to the problem. To ignore this important factor can be detrimental to the success of IVF treatment. Here are a few examples:
   

   a. One third of women who have endometriosis also have a concomitant immunologic implantation problem. In such cases, the performance of IVF without appropriate selective immunotherapy will usually lead to failure.
   b. Tubal damage necessitating IVF is sometimes associated with internal uterine scarring and a poor endometrial thickening. Bypassing the tubal issue through IVF will usually not achieve a viable pregnancy unless the uterine lining can be improved concurrently.

3. Timing of treatment: With a few exceptions (very poor responders to fertility drugs), women undergoing repeated cycles of IVF need at least one full resting cycle after an unsuccessful cycle before undergoing another attempt.
4. Selecting the ideal protocol for ovarian stimulation: Most IVF failure is attributable to “poor embryo quality.” True, in many cases, unavoidable factors such as advanced maternal age or severe intractable male infertility lie at the root of this problem. However, poor embryo quality mostly stems from poor egg quality, which in turn is due to poor egg development in advance of administering the hCG trigger. This boils down to the selection of suboptimal protocols for ovarian stimulation and inappropriate timing of the administration of the hCG “trigger” shot.
5. Moving to third party parenting: There comes a time when it is necessary to decide whether to solicit the assistance of an egg donor or a gestational surrogate or whether to stop trying. I generally advise menopausal and premenopausal women of any age, and women over 43 (for whom the chance of successful IVF using own eggs is very small) to move to egg donation. Women with serious health conditions that contraindicate pregnancy, those who do not have a functional uterus and those who have an intractable immunologic or anatomical implantation dysfunction should consider using a gestational carrier. Likewise, there should be a timely recommendation for sperm donation made to men who have incurable absence of sperm production and those with intractable severe sperm dysfunction.

The objective with In Vitro Fertilization is to transfer “competent” embryos into an optimal uterine environment. This requires a very individualized and meticulous approach to evaluating and addressing those factors that can influence IVF outcome. All patients/couples should learn what they can reasonably expect before committing to IVF and to “plan the trip before embarking on the IVF journey.”