When is it time to stop IVF?

November 15, 2010Carole 16 Comments »

A new study by Professor Barbara Luke of Michigan State  looked at 300,000 IVF cycles in the US. Professor Luke’s study showed that 36% of women became pregnant after one cycle of IVF. Of women who went on to a second IVF cycle after the first cycle failed, only 12% more conceived (48%) in the second cycle. Continuing on for a third cycle produced a pregnancy in only 5% more of the women who had two failed cycles behind them (53%).

Percentages are confusing so let’s look at 100 women starting IVF using their own eggs. So if 100 women have a first IVF cycle, 36 become pregnant. If the 64 that did not get pregnant go on to a second cycle, 48% of the 64 will become pregnant, or another 30 will become pregnant on the second try. If the 34 that are still not pregnant go on to a third try, then another 19 will be pregnant. If the remaining 15 women go on to a fourth try, only about half again will get pregnant. More tries do not significantly increase the chances of pregnancy beyond the 50% rate. Dr. Luke concludes that there are diminishing returns after three IVF cycles and it may be time to look at other technical interventions  such as donor egg or surrogacy. Adoption of either an embryo or a already-born person are other options to consider.

What factors might change your chance of pregnancy? The jump in pregnancy rate between first and second cycles could be attributed to “tweaking” the stimulation cycle the second time or making other adjustments (like recognizing that ICSI is necessary). These data suggest that there is not much learning or improvement after the third cycle, meaning your clinic may have exhausted most of the bag of tricks they have after the third cycle.

Dr. Luke’s study did not look at the effect of maternal age or obesity on pregnancy rates which are two huge factors in outcome. None-the-less, the conclusions dovetail with my experiences in IVF clinics. We didn’t begin to lose our hope for a patient’s chance of conceiving until they had two failed cycles behind them. When we started seeing repeat cycles that had no adjustments in the stimulation and no adjustments in the technical approach, we began to expect that the odds of success would be slim.

So what do patient advocates recommend about when it is time to stop IVF? Resolve has a thoughtful article called “When is enough enough?” written by Eileen Ivey, LCSW-C, and Joan Rabinor, LCSW-C.  When patients reach the point of asking these questions will be different for every person struggling with infertility. Ivey and Rabinor’s  article focuses on four areas that patients should consider at some point, namely

  • “Evaluating and setting limits on our resources”

When they discuss resources, they mean not only financial resources, but also emotional and physical resources. IVF treatments are no cake walk. At what point are IVF treatments hurting instead of helping patients in their lives?

  • “Listening very carefully to our inner voices”

Here they recognize that IVF treatments may become all consuming and deafen patients to other options in their lives – paths untrod- that beckon to them and may be more possible if they get off the IVF merry-go-round.

  • “Teasing out the components of our wish for parenthood”

In teasing out the components of our wish for parenthood, they ask patients to consider what elements of parenthood are essential to them and which can be set aside. For instance, is it genetics or the experience of pregnancy or child rearing that are most important to you? Through intercourse, these desires were all wrapped up in one package. Assisted Reproductive Technology can let patients to chose among these competing needs. Egg donor or embryo adoption may be the answer if pregnancy and child rearing, and not genetics are most important. Everyone answers these questions differently, Hopefully a couple can get to the same page on this.

  • “Communicating in a plain and conscious way with our spouses”.

Which gets us to their final area of consideration, our partner or spouse. At some point, IVF is a clear and present danger to our deepest emotional relationships. Patients may find themselves in the position of  choosing between their partners and their relentless pursuit of parenthood. A failure to communicate about our deepest fears and hopes may doom a relationship. We have seen couples scream at one another in treatment rooms which underscores the emotional cost of infertility treatments. As outsiders observing this marital distress,  we wonder whether this couple really should raise a child together since the together part seems to have fallen by the wayside.

ASRM has published their ethical opinion on stopping treatment in this article “Fertility treatment when the prognosis is very poor or fertile” which is also worth reading.  You may be surprised to learn that ASRM thinks it is ethical to pursue treatment even in futile cases if the physician feels there may be a “psychological benefit” from pursuing treatment.  The idea here is that -assuming yet another try won’t bankrupt you- you can go on and accept that continuing treatment is futile after “one last try”- the psychological benefit is closure, apparently.

ASRM also recognizes that the issue of when to stop can “reveal conflicting interests among clinicians and their patients”. Doctors may be reluctant to stop treatment because they don’t want to accept “failure” on their part as a provider or they may feel that part of their job is to remain eternally hopeful and optimistic for you. On the other hand, doctors do have the right to refuse treatment if they think that it is unethical to pursue treatment when the odds of success are too low.

ASRM also comments on other non patient-centered motives for continuing or discontinuing treatment: “Decisions about treating or refusing to treat couples and/or individuals always should be patient-centered. Protecting fertility center success rates is not an ethical basis for refusing to treat couples and/or individuals with futile or very poor prognoses. Conversely, care should not be provided solely for the financial benefit of the provider or center.”

Because the decision to stop is a difficult one for physicians as well, perhaps patients shouldn’t rely on their physician to tell them when it is right for them to stop. When you go to on-line chat rooms that invite physician involvement, you will often find several physicians weighing in with different opinions about how to help a particular couple- which may or may not involve a transfer of care to their own clinic. This is human nature. Good physicians are driven to help their patients, perhaps more than is really beneficial for the patient. Not so good physicians may be driven by the business of IVF and their own success and this may inform their recommendation for you.  In either case, the bottom line is that this is your and your partner’s decision.

Frances W. Ginsburg, MD has written a very thoughtful piece about the physician’s role in  discussions about ending treatment, entitled “When Should Infertility Patients Consider Stopping Treatment?/Fact Sheet“. She comments on her own burden of having to recommend between a “sure thing and a long shot” without the benefit of a crystal ball.

This same fact sheet (keep scrolling down) also contains advice from Linda Hammer Burns, in “A Therapist’s View”, in which she considers the components of a “good” decision, namely that they are based on “sufficient and accurate” information and both partners (if applicable) participate and neither feels bullied by the other. Good decisions may mean a review of all options, even those that were previously rejected because priorities or perspectives may have changed since starting down the infertility treatment path.

She also suggests an interesting mental exercise. Project yourself into the future 20- 30 years from now and look back on this period of infertility treatment. If you stopped treatment today, do you think you will look back with regret or peace of mind? She notes that peace of mind may be due not to success of treatment but rather from being satisfied that good decisions were made based on the information/options available at the time.

Having to deal with infertility is unfair and difficult. Knowing when to stop is very difficult for most patients. External factors like running out of money to pursue treatments may eventually make the decision for patients- which is another emotional hardship. Infertility treatments often leave patients feeling that their lives are out of their control. When IVF treatments fail repeatedly, saying enough is enough may be the first step to feeling that your life is under your control again, allowing you to pursue other paths to parenthood or possibly considering other paths in your life that are now possible.

© 2010 – 2015, Carole. All rights reserved.

16 Responses to this entry

  • Sara Says:

    Very useful article. Does the 3-cycle recommendation apply to each doctor or overall? After a failed first cycle, would you recommended trying the 2nd and 3rd times also with the same doctor or go to a different doctor?

    If we go to a different doctor, can we expect the first cycle doctor to fully cooperate in transferring all the information (especially the really technical stuff that patients don’t understand) to the new doctor?

  • Anonymous Says:

    Carole, Are you aware of any ‘long-term’ (not OHS) bad effects of too much ovarian stimulation resulting from too many cycles?

  • Carole Says:

    The questions you have are good ones but I am not the one to ask. You need to discuss with your doctor what they recommend (for example, number of cycles, type of cycles) for your treatment. As far as changing doctors, that’s also a very personal decision. Patients may change doctors because they are frustrated with repeated failure or they don’t like the treatment options or any number of reasons. Usually when you change doctors, you would ask to have all your medical records (which include the technical lab data) copied and transferred to your new doctor. Doctors vary in how much informal info in addition to the medical record they will share with the next doctor. If it’s another doctor in the same practice it might be easier to discuss the record than if it’s their competition across town.

  • Carole Says:

    Over the years, there have been small studies, usually with scientific flaws that suggested increased risks of some cancers with repeated exposure to large hormone levels produced from ovarian stimulation. Large population studies have failed to show this effect. A recent blog post, http://fertilitylabinsider.com/2010/12/older-ivf-patients-cancer-and-parenting/, has links to two Swedish large scale population studies that are reassuring.

  • Pari Says:

    Carole, Could you write an article about the emotional, ethical, financial, and procedural aspects of adoption? Thanks!

  • Carole Says:

    I think the questions you raise about adoption are extremely important, but I am not the right person to discuss adoption issues since my expertise and experience don’t include adoption. However, you will find a ton of information on the adoption resource page on the Creating A Family website. Here’s the link: http://www.creatingafamily.org/adoption/resources.html Best Wishes!

  • Liz Says:

    This is a wonderful article. However, I think your interpretation of Barbara Luke’s study may be incorrect.

    By your interpretation, out of 100 patients starting out, a total of 84 patients would give live births by the third cycle, which means that 84% of all patients would have a baby by the third cycle.

    But the link you posted to the study says that “300,000 women had more than half a million IVF cycles that resulted in 171,327 first-time deliveries”, which means only 57% of all the 300,000 women got a baby after all the cycles. Another way to come to this conclusion is, they say that our chances of success are 53% after three cycles, which means that 53% of all patients who start out would get a baby after 3 cycles.

  • Carole Says:

    Thanks for your thought provoking comment. My example may have led you to conflate individual per event success rate and cumulative success rate for a group of patients over more than one try. The cumulative success rate is the total number of final successes from all first, second and multiple tries in the original group of women and should not be used as an estimate of how the individual will do in a particular try. The other thing is that the women who get pregnant on the first try are likely a different population type than the women who get pregnant on the second or third try. Everything being equal, the women in the 2nd try and 3rd try groups are likely to be more difficult to get pregnant than the pregnant on the first try patient. What Luke’s article found is that an individual’s per event chance of pregnancy does not markedly increase with each try and may decrease (diminishing returns) with each successive try for that individual patient. As an individual looking at a program’s rates, you can only use overall population statistics for women in your age group with similar fertility issues to estimate how you might do. In the future, if we can improve both our techniques and our ability to identify which patients are most likely to benefit from IVF, we hopefully can drive those rates much higher.

  • Anonymous Says:

    I am 45 and have had two failed IVF with my own eggs the last of which produced six eggs (two fair and four good). All were implanted. Should I try again with my eggs? With donor egg? In other words how do the above stats (84%) change with age?

  • Carole Says:

    All things being equal, the largest determining factor for pregnancy from IVF using your own eggs is maternal age. The CDC tracks this info annually. The latest statistics shows that all cycles in the US for women over 44 resulted in a pregnancy rate of 3.7%, Live birth rate of 1.5% (almost half lost to miscarriage), Singleton live birth rate of 1.2%. See whole report here http://www.cdc.gov/art/ART2009/sect2_fig6-15.htm#15 Even if you become pregnant, the miscarriage rate is high with your own eggs because even if they “look good” the chromosome number may be incorrect (too many or two few called aneuploidy). This is a normal consequence of aging. No, you should not use your own eggs. Yes, you should use donor if you are comfortable with this because it is your most likely path to parenthood. I am astonished that your healthcare providers did not disclose their pregnancy rate for your age group. The 84% rate could only be in the best clinics with the youngest aged patients (under 35 years old) or older using eggs from twenty-somethings. I wish you all the best going forward. Carole

  • Anonymous Says:

    I am 45 and have had two failed IVF with my own eggs the last of which produced six eggs (two fair and four good). All were implanted. Should I try again with my eggs?  With donor egg? In other words how do the above stats (84%) change with age?

  • Petunia Says:

    So, I started fertility treatment after having one child 5 years ago. He was conceived literally on our first month of trying to get PG. The second one has been far more difficult. We started fertility treatment at age 41. My RE was enthusiastic about my high number of follicles. We have graduated from Clomid, to IUI, to IU with stimulation. Reading more here, I am a little sad that we didn’t just start with IVF. All of that said, I am on day 3 before my first transfer. We retrieved 10 eggs and 7 fertilized. If this cycle doesn’t work, at my age of 42, is there much point in continuing to a second cycle? Reading here, it seems like my chances of getting PG with my own eggs are extremely unlikely. I imagine this may be a difficult question for you to answer without seeing my medical record. I may get lucky tomorrow, but just incase, I would like your read on going to a second cycle.

  • Carole Says:

    Hi Petunia,
    I don’t know if you will get pregnant. If you look at all the cycles performed in the US for women of 42 years of age in 2010 (the most recent year that is available to review) the chance of a live birth is between 5-12%. Women age 41-42 reported a 12.4% rate. By age 43-44, the rate was 5%. Another way of putting it, is that 88-95% of women in the US who were 42 did not become pregnant but went through the effort, expense and emotional ride of IVF only to be disappointed. The risk of Down’s syndrome as well as other chromosomal abnormalities increase with maternal age as well. The live birth statistic does not tell us whether these women had healthy children. Unfortunately, having a good number of eggs and a good fertilization rate does not necessarily mean that the embryos produced are chromosomally normal. I would speak with your doctor regarding your treatment but keep in mind that doctors, like patients, hate to give up and say we can’t do anything else for you. So most patients come to that conclusion on their own when they are exhausted with trying IVF without success and are ready to go down another road. It comes down to your resources (financial and emotional) and your appetite for risk. I wish you all the best for this cycle and hope a second cycle won’t even be an issue. Good Luck!! Carole

  • 39 and losing hope Says:

    After two natural pregnancies, which gave me my beautiful and healthy two kids, , I had three successive miscarriages at age 37 and 38 due to chromosonal abnormalities. Through two IVF cycles with PGD, we gathered a total of 3 chromosomally normal embryos. I’ve transferred two with no success, the first in a non-medicated cycle and the second in a medicated cycle. Is there any point to transferring the third? What are my chances? I am 39 now. Apparently I have a thin uterine lining, though it measured over 7mm at the last transfer, which my Dr was happy with. Not sure of this is due to the D&c’s or always had.

    Thank you–heartbroken.

  • Carole Says:

    Hi “39 and losing hope”,
    I am sorry you are having such a hard time. You might ask a second opinion from another doctor about the 8mm lining. This still seems a little thin. You might want to transfer the last one with a little thicker lining. I would seek a second opinion from another doctor on this point. Good Luck!! Carole

  • Matt Says:

    Looking at the study and the data, it appears that the example is incorrect. The claim “If the 64 that did not get pregnant go on to a second cycle, 48% of the 64 will become pregnant, or another 30 will become pregnant on the second try” is the statement that the conditional probability P(LB in cycle 2 | LB not in cycle 1) = 0.48. This contradicts the study. Based on the numbers used, the mistake may stem from a misunderstanding of the conditional probability with what the study calls “cumulative probability”, which is P(LB in cycle 2 OR LB in cycle 1).

Join the discussion