How many attempts is it advisable to make in assisted reproduction?

By (gynecologist), (gynecologist), (embryologist), (gynecologist) and (embryologist).
Last Update: 10/06/2021

One of the most frequent doubts in assisted reproduction is how many treatments to perform, since success is not always achieved in the first attempt. The most advisable thing to do is to make a personalised assessment and, depending on each case and the type of treatment involved (artificial insemination, in vitro fertilisation [IVF], ovodonation...), make one number of attempts or another.

To determine when to stop or change your strategy, you must take into account the likelihood of pregnancy, stress, price, etc. In the case of Social Security, there are a limited number of treatments available per patient.

Why are attempts limited?

In assisted reproduction treatments, we understand as attempts the number of times a couple undergoes any of the techniques that are intended to help achieve a pregnancy.

Although there is no legal limitation on the number of attempts that can be made, there are a number of recommendations when deciding whether to continue treatment or change reproductive strategy.

These recommendations are based on the expected cumulative success rate of the treatments performed and the clinical particularities of each individual case. The decision should be made on the basis of the expected probability of pregnancy with a particular treatment.

Assisted procreation, as any other medical treatment, requires that you rely on the professionalism of the doctors and staff of the clinic you choose. Obviously, each clinic is different. Get now your Fertility Report, which will select several clinics for you out of the pool of clinics that meet our strict quality criteria. Moreover, it will offer you a comparison between the fees and conditions each clinic offers in order for you to make a well informed choice.

When deciding whether further attempts should be made, it is essential to evaluate the results obtained in the previous cycles.

The aim of limiting the number of attempts is to avoid useless treatments when there is no chance of achieving reproductive success, as each attempt is emotionally exhausting for patients and involves a series of risks, as well as a significant financial outlay in most cases.

Artificial insemination

Artificial insemination (AI) consists of depositing in the uterus a small amount of semen that has been previously capacitated in the laboratory. Sperm capacitation is a process that allows the selection of spermatozoa with better motility. These are the ones that will be introduced into the woman's body at the time of ovulation.

AI can be performed with partner or donor sperm. The latter is used in the case of:

  • In lesbian couples.
  • Single women
  • When the partner's semen is not suitable for use in treatment

The reproductive technique of insemination is usually the first option in cases of sterility of unknown origin, in patients with ovulatory problems and in women who do not have a male partner. The indication for AI will also influence the decision on how many cycles are performed with this technique, i.e. the reason for insemination will be taken into account.

In general, it is considered that if pregnancy has not been achieved after four artificial inseminations, the chances of achieving pregnancy will hardly improve with successive inseminations. Therefore, it is advisable to move on to a more invasive treatment such as in vitro fertilization (IVF).

In the case of artificial inseminations with donor sperm (AID), pregnancy rates are considered to improve until the sixth cycle. If pregnancy has not been achieved after 6 DAI, it will be the recommended time to change fertility treatment.

However, as we have already mentioned, this will depend on each case, because reaching 4-6 inseminations is not so common. Therefore, it is essential to study each patient individually before making a decision.

We recommend you visit the following article for more in-depth information on AI: Artificial insemination (AI): What Is Artificial Insemination (AI)? - Process, Cost & Types.

In vitro fertilization (IVF)

In vitro fertilization (IVF) is a reproductive technique in which, as its name suggests, fertilization takes place in the laboratory and not in the woman's body, as occurs naturally or in artificial insemination. There are two main types of IVF:

In both cases, the aim is to hormonally stimulate the woman to obtain a greater number of mature eggs. These are extracted from the ovaries by follicular puncture and fertilized to obtain embryos, which are then left in culture to evaluate their development and transfer the best ones to the mother's uterus.

In the case of IVF, the maximum number of cycles recommended is less clear, but some studies limit it to three. Others recommend up to four IVF attempts. In the words of Dr. Miguel Dolz:

In the end you have to set a limit because also, even if they are already controlled treatments and you have experience, obviously I think that with 3-4 cycles at the most that would be the normal number up to where we should go.

It should be noted that IVF attempts are counted according to the number of ovarian stimulations performed. Therefore, if in a hormonal treatment many eggs are obtained, several vitrified embryo transfers can be performed, which will increase the chances of pregnancy.

If after this number of attempts pregnancy is not achieved, the specialist will most likely recommend gamete donation (eggs or sperm).

If you want to learn more about the different types of IVF, you can visit this article: What Is the Difference between Conventional IVF & ICSI?

Hope in cases of infertility

Most couples who start a reproductive treatment do so full of illusion and hope, often with expectations that are too high. This makes it difficult to accept possible failure, which in many situations leads to frustration.

The rate of abandonment of assisted reproduction treatments by couples who wish to have children is very high. After one or more failures, patients often give up: almost 50% of couples who come to fertility centres give up after a first attempt.

Sometimes, the reason is exclusively economic, but most of the time other circumstances come into play, such as the stress and anxiety that these treatments cause to the couple. The emotional toll is also very high and some couples can't take the pressure. For this reason, it is important to consider before starting treatment how many attempts you are going to make and how far you intend to go.

Economic factor and Social Security

Apart from the emotional difficulties involved in trying fertility treatments, it is also important to take into account the financial factor. The cost of an artificial insemination ranges between 600 and 1,700 euros, while an in vitro technique involves an investment of at least 3,500 euros. If we move on to donated gametes, as we can see in the following table, the price increases considerably, and can reach up to 9,000€.

In addition, if complementary techniques are required, such as preimplantation genetic diagnosis (PGD), the price will increase even more.

Fortunately, it is possible to get some of these treatments on Social Security. The principles of action are decided by a group of experts in the field to ensure the rational use of the techniques. The aim is to reduce the potential risks that may arise from its use and to establish guidelines to determine in which situations there should or should not be public coverage. They depend on the age, the cause of infertility, the number of total cycles performed, etc.

In general, Social Security covers these techniques up to the age of 40. However, it is not regulated at the national level but at the autonomous community level, so there are variations between the different autonomous communities.

FAQs from users

What are the optimal conditions or requirements for a patient undergoing an IVF cycle?

By Juan Antonio García Velasco M.D., Ph.D. (gynecologist).

There are no optimal conditions, as each patient is different, but there are certain requirements for good physical and mental health to be able to carry a pregnancy to term. The younger the woman is, the better the results will be, as age is the main factor limiting the success of assisted reproduction.

As regards the number of IVF attempts before giving up, does it vary if it is conventional IVF or ICSI?

By Ana Mª Villaquirán Villalba M.D., M.Sc. (gynecologist).

Unless fertilization failure has occurred with IVF, we usually take into account all cycles done with both techniques before deciding to move on to another treatment such as egg donation. Even though each patient is different, the average number of IVF attempts recommended is 3 or 4 at our clinic.

Do all attempts at assisted reproduction treatments have the same price?

By Rebeca Reus BSc, MSc (embryologist).

In general, if it is the same treatment, all attempts have the same price. In the case of IVF, it should be remembered that these are counted on the basis of hormonal stimulation cycles, not transfers. Therefore, even if a transfer is cheaper, it is not an attempt as such.

How many artificial insemination attempts can be made?

By Rebeca Reus BSc, MSc (embryologist).

There is no legal limit to the number of attempts that can be made. However, many specialists consider that if pregnancy has not been achieved by the fourth insemination, the chances of achieving pregnancy through this technique are low. In some cases, up to six attempts are recommended.

Does the probability of pregnancy increase with the number of AI attempts?

By Marta Barranquero Gómez B.Sc., M.Sc. (embryologist).

The answer is yes. The success rate of AI is cumulative, i.e. it increases with the number of attempts. However, it has been shown that after the fourth AI, the pregnancy rate remains constant.

Therefore, if pregnancy has not been achieved after four AIs, it would be best to switch to in vitro fertilisation (IVF).

How many IVF cycles before success?

By Zaira Salvador B.Sc., M.Sc. (embryologist).

Depending on what lead to IVF failure on the first round, a second attempt could improve the success rate or not.

For instance, if the first IVF cycle failed because of poor uterine receptivity, the protocol will be changed so that it works better on the second attempt.

Usually, various aspects are modified the second time a couple undergoes IVF, something that helps achieve better outcomes in general. It depends, however, on the particularities of each case.

Suggested for you

As we have seen, one of the limitations when it comes to assisted reproduction treatments is their price. Do you want to know how much they cost? We tell you about it in the following link: Overview of the Main Costs of Fertility Treatments.

Depending on each case and the technique that is indicated for each patient, there can be a big difference in cost. Therefore, another key point when it comes to limiting treatments is the technique involved. In this article we explain what techniques exist: What is Assisted Reproductive Technology (ART)? - Techniques & Costs.

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References

Carpinello O, Casey Jacob M, Nulsen J, Benadiva C. Utilization of fertility treatment and reproductive choices by lesbian couples. Fertil Steril. 2016 Dec;106(7):1709-1713.e4. doi: 10.1016/j.fertnstert.2016.08.050. Epub 2016 Sep 22.

Robinson JN, Lockwood GM, Dokras A, Egan DM, Ross C, Barlow SH. A controlled study to assess the use of in vitro fertilization with donor semen after failed therapeutic donor insemination. Fertil Steril
. 1993 Feb;59(2):353-8. doi: 10.1016/s0015-0282(16)55673-8.

Szamatowicz M. Assisted reproductive technology in reproductive medicine - possibilities and limitations. Ginekol Pol. 2016;87(12):820-823. doi: 10.5603/GP.2016.0095.

Wainer R, Merlet F, Ducot B, Bailly M, Tribalat S, Lombroso R. Prospective randomized comparison of intrauterine and intracervical insemination with donor spermatozoa. Hum Reprod. 1995 Nov;10(11):2919-22.

FAQs from users: 'What are the optimal conditions or requirements for a patient undergoing an IVF cycle?', 'As regards the number of IVF attempts before giving up, does it vary if it is conventional IVF or ICSI?', 'Do all attempts at assisted reproduction treatments have the same price?', 'How many artificial insemination attempts can be made?', 'How many IVF attempts does it take to get pregnant?', 'Does the probability of pregnancy increase with the number of AI attempts?' and 'How many IVF cycles before success?'.

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Authors and contributors

 Ana Mª Villaquirán Villalba
Ana Mª Villaquirán Villalba
M.D., M.Sc.
Gynecologist
Bachelor's Degree in Medicine from the University of Valle, Colombia. Specialist in Obstetrics & Gynecology. Master's Degree in Human Reproduction from the University of Valencia and IVI. Currently, she is the medical director of Tahe Fertilidad. More information about Ana Mª Villaquirán Villalba
License: 303007571
 Juan Antonio García Velasco
Juan Antonio García Velasco
M.D., Ph.D.
Gynecologist
Graduate in Medicine from the Complutense University of Madrid. Intern specialist at Obstetrics & Gynecology at La Paz Hospital, 1992-1995. Graduate in Medicine and Surgery from the Autonomous University. Subspecialist in Assisted Reproduction from Yale University (USA). Main Lecturer of Gynecology at the Rey Juan Carlos University of Madrid. More information about Juan Antonio García Velasco
License: 282842556
 Marta Barranquero Gómez
Marta Barranquero Gómez
B.Sc., M.Sc.
Embryologist
Graduated in Biochemistry and Biomedical Sciences by the University of Valencia (UV) and specialized in Assisted Reproduction by the University of Alcalá de Henares (UAH) in collaboration with Ginefiv and in Clinical Genetics by the University of Alcalá de Henares (UAH). More information about Marta Barranquero Gómez
License: 3316-CV
 Miguel Dolz Arroyo
Miguel Dolz Arroyo
M.D., Ph.D.
Gynecologist
Bachelor's Degree in Medicine and Surgery from the Medicine Faculty of the University of Valencia (UV) and Doctor in Medicine, finished in 1988 and 1995, respectively. Physician specialized in Obstetrics & Gynecology. Expert in Reproductive Medicine, with more than 20 years' experience in the field. He is the Medical Director and founder of FIV Valencia. More information about Miguel Dolz Arroyo
License: 464614458
 Rebeca Reus
Rebeca Reus
BSc, MSc
Embryologist
Degree in Human Biology (Biochemistry) from the Pompeu Fabra University (UPF). Official Master's Degree in Clinical Analysis Laboratory from the UPF and Master’s Degree about the Theoretical Basis and Laboratory Procedures in Assisted Reproduction from the University of Valencia (UV). More information about Rebeca Reus

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