IVF: How Many Times Should I Try?

Procreation, an inalienable right and one of the most insatiable of human needs, allows us as humans the opportunity to live on through our children. It is probably the subconscious drive to perpetuate our genetics and thereby leave definitive proof of our existence, that underlies the desire to reproduce. This urge morphs into desperation in many couples who are unable to conceive, becoming increasingly more acute when, with advancing age, they become more aware of their own mortality.

Although IVF offers hope to many infertile couples who might otherwise have no way of conceiving, it is not a panacea. In addition, every IVF procedure exacts an emotional, physical, and financial toll. No one gets through the process unscathed. Those considering IVF should learn what they can reasonably expect from it before committing to the procedure. Only once realistic expectations have been attained is the patient/couple ready to decide whether IVF is truly for them and when/whether/how and where to proceed with treatment

The ideal candidate/couple for IVF fits the following profile:

• The woman is under 40
• She has at least one ovary capable of responding normally to fertility drugs (normal ovarian reserve).
• The uterus and the endometrial lining are normal and capable of sustaining a healthy pregnancy
• She has been pregnant in the past, thereby proving that her eggs can fertilize. -She has access (through her partner or a designated donor) to healthy sperm.

These criteria are however, by no means absolute. In many cases, one or more of the following factors can be addressed to improve odds:

• Egg quality can be optimized (for the woman’s age) through revision of the protocol used for ovarian stimulation, and by better timing administration of the human chorionic gonadotropin (hCG) trigger shot
• Sperm function can be enhanced through selective medical or surgical interventions
• Surface lesions inside the uterus can be surgically corrected
• Immunologic implantation problems can be addressed through selective immunotherapy
• A deficient uterine lining can be improved with sildenafil (Viagra) and/or hormonal treatment.

There are, however, two detrimental factors that cannot be altered. The first is that with advancing age there will inevitably be a progressive increase in the incidence of chromosomal egg abnormalities, which in turn result in a reduction in overall embryo “competence.” The second is that diminishing ovarian reserve as evidenced by a low antral follicle count, low antimullerian hormone and inhibin levels, raised follicle stimulating hormone (FSH) - all on the 3rd day of the cycle and a history of poor ovarian response to stimulation with fertility drugs lead to fewer eggs being available.

Here is a practical example. Let's say a woman is 34 years old and her partner has normal sperm function. Following stimulation with fertility drugs, she develops a good number of mature follicles, she has a normal uterine cavity and upon optimal ovarian stimulation develops an excellent endometrial lining.Such a woman would, in an optimal IVF setting, have about a 45% chance of having a baby following a single cycle of IVF treatment. However, a woman of 41years who aside from her age fulfills the exact same criteria as her younger counterpart, would because of the adverse effect of the biological clock on egg and embryo quality have a less than half the chance of having an IVF baby.]

It follows that couples contemplating IVF should initially develop expectations based on an evaluation of those criteria that have the potential to impact outcome, and then temper their expectations with the realization that while some, adverse factors can be overcome through individualized management, not all can be.

There are some conditions that might not be reversible without resorting to other options such as egg donation and gestational surrogacy. These include:

• Advanced age over 43 years
• Severely diminished ovarian reserve
• Intractably damaged uterine lining due to prior intrauterine inflammation (endometritis), multiple surface lesions and post-surgical scarring
• Certain types of immunologic implantation dysfunction such as complete alloimmune (DQ alpha/HLA) matching of both partners

So what does this all boil down to? It means that each couple and their physician need to assess all the variables that can affect IVF outcome. Then, given their own unique set of circumstances and the capability of their chosen IVF program, the couple should develop realistic expectations. In most cases, through availing themselves to all medical fertility options, the vast majority of couples/individuals will over a few attempts, succeed.

But in the final analysis, there is a time to stop trying. Independent of the number of prior failed attempts, and aside from obvious limitations brought about by financial, emotional and physical constraints, the time to give up on IVF arrives when there is no potential remedy for the cause of failure.