Most cases of recurrent IVF failure are related to the transfer of aneuploid embryos, meaning embryos with an abnormal chromosomal makeup. The rate of embryonic aneuploidy increases significantly with advancing maternal age. For example, at the age of 30, approximately two out of every three embryos may be aneuploid, whereas by the age of 40, six to seven out of every eight embryos are likely to be chromosomally abnormal. Such embryos often fail to implant or result in pregnancies that end in early miscarriage. Therefore, in cases of recurrent IVF failure, embryonic aneuploidy should always be carefully evaluated and excluded. Less commonly, other factors such as intrauterine space-occupying lesions, adhesions, congenital uterine abnormalities, or tubal blockage (hydrosalpinx) may contribute to repeated failure. Adenomyosis is another important and frequently overlooked condition that may adversely affect implantation and pregnancy outcomes.
Recurrent IVF Failures
IVF Treatment
In Vitro Fertilization (IVF)
In vitro fertilization (IVF) is an assisted reproductive treatment in which a woman’s eggs are retrieved from the body, fertilized with sperm in a laboratory setting, and the resulting embryos are then transferred into the uterus.
The treatment consists of three main stages:
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Ovarian Stimulation
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Egg Retrieval and Fertilization
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Embryo Transfer
Who Is Eligible for In Vitro Fertilization (IVF)?
A woman’s reproductive capacity—particularly her ovarian (egg) reserve—declines with age. For this reason, it is very important that women planning to conceive are evaluated based on their age, medical history, and current reproductive status.
Infertility is defined as the inability to achieve pregnancy after one year of regular, unprotected intercourse. In women aged 35 years and older, this period is considered six months. Women with a family history of early menopause, those who have undergone ovarian cyst surgery, have been diagnosed with endometriosis, or have had prior abdominal or pelvic surgery should be evaluated earlier.
Eligibility Criteria for IVF
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The uterus must be structurally suitable for pregnancy
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Ovarian reserve (egg capacity) should be considered adequate
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Sperm must be obtainable from the male partner, either through ejaculation or surgical methods
Basic Tests Before IVF
Semen Analysis (Sperm Test)
This is the initial evaluation for the male partner. If semen analysis results are normal, further testing is usually not required.
Ovulation Assessment
Ovulation can be assessed through:
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Progesterone testing performed on days 19–21 of the menstrual cycle, or
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Ultrasound monitoring to confirm ovulation
Assessment of Ovarian Reserve
Ovarian reserve is evaluated using transvaginal ultrasound performed during the early days of the menstrual cycle to count the number of follicles in the ovaries.
A count of fewer than six follicles suggests reduced ovarian reserve. Ovarian reserve tends to decline more rapidly after the age of 37.
Evaluation of the Fallopian Tubes (HSG)
Hysterosalpingography (HSG), also known as a uterine imaging test, is used to determine whether the fallopian tubes are open. It is preferably performed shortly after the end of menstruation.
HSG shows the structure of the tubes but does not assess their function.
Laparoscopy (When Indicated)
Diagnostic laparoscopy is rarely used for evaluation alone. It is more commonly recommended for therapeutic purposes, such as the treatment of endometriosis, when clinically indicated.
Intracytoplasmic Sperm Injection (ICSI)
ICSI is a fertilization technique that has been used since 1992 and is currently the most commonly applied method in IVF treatment. In this technique, a single sperm is injected directly into each egg using specialized equipment.
ICSI is particularly preferred in cases of male-factor infertility or unexplained infertility.
Preimplantation Genetic Diagnosis (PGD) and Embryo Selection
Preimplantation Genetic Testing (PGT)
Preimplantation Genetic Testing (PGT) is used to identify and select genetically healthy embryos in order to improve the chances of pregnancy, particularly in couples with a family history of genetic disorders or those who have experienced recurrent IVF failure. Genetic analysis is performed on samples taken from embryos, and only embryos without detected genetic abnormalities are transferred to the uterus.
This approach may help reduce the risk of genetic disease transmission in couples at increased risk.
PGT may offer important advantages especially in:
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Advanced maternal age (35 years and older)
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Recurrent pregnancy loss
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Inherited genetic disorders (e.g., thalassemia, sickle cell disease)
Some studies have reported that when embryos have undergone repeated genetic evaluation and are shown to have a normal chromosomal profile, pregnancy outcomes following transfer may be high, provided that the uterine environment is suitable. It is also well recognized that, in the absence of genetic testing, embryo implantation rates decline with advancing maternal age, becoming very low in the mid-40s.
Blastocyst Transfer (Day 5 or Day 6 Transfer)
Thanks to advances in laboratory culture systems, embryos can now be safely cultured to day 5 or 6 under laboratory conditions. Embryos that reach this stage are referred to as blastocysts.
Advantages
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Selection of embryos with the highest developmental potential
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Reduced risk of multiple pregnancy through the transfer of fewer embryos
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Closer monitoring of embryo development
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Compatibility with PGT (trophectoderm biopsy can be performed)
This method has become increasingly preferred in many centers and may be associated with improved pregnancy outcomes, depending on individual clinical factors.
Embryo Cryopreservation (Embryo Freezing)
In IVF treatments, freezing surplus embryos offers both economic and psychological advantages. Cryopreserved embryos can be thawed and transferred at a later time without the need for repeat ovarian stimulation.
Embryos are preserved using specialized protective solutions and stored in liquid nitrogen at −196°C.
According to current regulations in Türkiye, embryos may be stored for up to five years, with the written consent of the couple.
Special Situations During the IVF Process
IVF at Advanced Maternal Age
As a woman’s age increases, both egg quality and quantity decline, and the proportion of genetically healthy embryos decreases. For example, at the age of 40, the likelihood of obtaining a genetically normal embryo falls to below 15%. When advanced maternal age is combined with low ovarian reserve, the chance of success decreases significantly.
The impact of paternal age is more limited; however, a slight increase in certain genetic risks has been observed. There is currently no scientifically proven treatment that can increase ovarian reserve. In such cases, ICSI and short stimulation protocols are often preferred.
Intrauterine Adhesions / Tubal Blockage
Intrauterine adhesions may impair embryo implantation.
Diagnosis is made using hysterosalpingography (HSG), ultrasound, and hysteroscopy.
Office hysteroscopy is the preferred treatment approach, and repeat procedures may be required if necessary. To reduce the risk of recurrence, estrogen therapy, intrauterine balloon, or anti-adhesion gel applications may be used.
Endometrial Polyps
Depending on their size, endometrial polyps may reduce implantation rates or increase the risk of miscarriage.
In such cases—especially when there is a history of previous IVF failure—embryos may be frozen, the polyp removed, and embryo transfer planned afterward.
Fibroids (Myomas)
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Submucosal fibroids (located near the uterine cavity) and large intramural fibroids (within the uterine wall) may interfere with pregnancy.
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These fibroids may be surgically removed when indicated.
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Subserosal fibroids (on the outer surface of the uterus) usually do not require removal.
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Uterine artery embolization is not recommended for women who wish to conceive.
Thrombophilia
(Increased Tendency for Blood Clotting)
In patients with clotting disorders, the risks associated with IVF treatment may be increased.
Screening is recommended in individuals with a personal or family history of thrombosis.
When indicated, low–molecular-weight heparin and compression stockings may be used for prophylaxis. Anticoagulant therapy should generally be started 24 hours after egg retrieval and continued if pregnancy is achieved. Continuation of treatment during pregnancy is considered safe for maternal and fetal health when appropriately monitored.
Recurrent IVF Failure
In cases of repeated unsuccessful IVF attempts, expectation management is an essential first step. As maternal age increases, IVF success rates decline, and the likelihood of success with each attempt becomes lower. Therefore, recurrent failure may be defined earlier in younger women and later in older women.
In these couples, all variables that may negatively affect success should be carefully reassessed.
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Excess body weight and smoking in women are known to reduce IVF success rates.
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Careful evaluation of the uterus using 2D and 3D ultrasound, as well as confirmation of tubal patency, is required. Identified problems should be addressed when possible.
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Assessment of sperm DNA fragmentation in men remains controversial.
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Routine thrombophilia testing in women is not recommended.
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Endometrial sampling and timing embryo transfer based on the endometrium’s genetic signature have not shown clear benefit.
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In women with a normal uterus on 2D and 3D ultrasound, the benefit of routine hysteroscopy is debatable.
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The effectiveness of intrauterine PRP application remains controversial; however, it may be offered within the context of clinical studies.
After these evaluations, couples may be advised to continue IVF treatment with PGT-A (preimplantation genetic testing for aneuploidy).
Why Is Psychological Support Important?
IVF treatment is not only physically demanding but also emotionally intense. Infertility may feel like a missing link in the natural flow of life for many couples, often triggering feelings of stress, anxiety, guilt, and isolation.
Emotional Differences and Couple Relationships
Women often tend to express and share their emotions openly, while men may respond in a more reserved or inward-focused manner. Couples who are able to communicate effectively and empathetically tend to navigate the process more healthily. Unexpressed emotions, however, may accumulate over time and lead to relationship conflicts.
The Most Challenging Phase: Waiting
The waiting period following embryo transfer is often the most stressful stage of treatment, characterized by uncertainty and fluctuating feelings of hope and disappointment. Psychological support during this time can help strengthen the couple’s emotional resilience.
Does Stress Affect Success?
There is no clear scientific evidence that stress directly causes infertility; however, infertility itself is inherently stressful. Long treatment durations, unsuccessful attempts, and repeated cycles can significantly increase emotional burden. Additionally, the pressure of “not being stressed” can become a secondary source of stress.
Sexual Life and Infertility
During treatment, sexual activity may begin to feel task-oriented, which can negatively affect a couple’s natural intimacy. Psychological support can help couples regain balance and maintain emotional closeness during this period.
Doctor, Center, or Patient: What Determines Success?
Treatment success depends on the harmonious collaboration of a multidisciplinary team. In addition to factors such as a woman’s age, ovarian reserve, and the underlying cause of infertility, the physician’s expertise, laboratory quality, and the experience of the treatment center play a crucial role. In complex cases, treatment at advanced and specialized centers is particularly important.
What Are the Success Rates?
Treatment success depends on many factors. On average:
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Ovulation induction: approximately 10% pregnancy rate
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Intrauterine insemination (IUI): approximately 15–20%
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IVF: approximately 45–50% pregnancy rate, with an estimated 30% live birth rate
These rates may vary depending on the patient, treatment method, and center. It is also important to note that reported success rates in Türkiye are not routinely audited, and comparisons should therefore be made with caution.
What Is the Goal of Psychological Support?
The goal of psychological support is not to provide treatment, but to help couples recognize stress, develop effective coping strategies, and strengthen communication skills. Cultural, social, and individual differences should be taken into account, and a personalized support plan should be developed for each couple.