Most of the time there is a reason, and it falls into a small number of categories. How a failed cycle should be reviewed — and why some of the tests sold for repeated failure are not worth paying for.
The consultation after a failed cycle is one of the hardest in medicine. The reports were normal, the embryos looked good, the transfer went smoothly, and there is no pregnancy. The question that follows is always the same, and it deserves a better answer than “it happens”.
Most of the time there is a reason, and it falls into one of a small number of categories. Here is how we work through them.
First, the honest baseline
An IVF cycle is not expected to work every time, even when everything is done correctly. Cumulative live birth rates per egg retrieval reported by SART for 2023 are 53.2% under 35 and 26.2% at 38–40 — which means that for a woman of 39, roughly three cycles in four do not end in a birth.
That is not a reason to accept failure without investigation. But it does mean that a single unsuccessful cycle in a woman with otherwise reassuring findings is a statistically ordinary event, not necessarily evidence of a hidden problem. The picture changes after two or three.
The commonest reason, and the least discussed
The embryo was chromosomally abnormal
This accounts for the majority of failed implantations and early losses. An embryo can look excellent under the microscope — correct cell number, even division, good blastocyst expansion — and still carry the wrong number of chromosomes. Grading assesses appearance. It cannot see genetics.
The proportion of abnormal embryos rises with the age of the egg, which is why the same number of good-looking embryos yields fewer pregnancies at 40 than at 30. This is also the least satisfying answer, because for most couples it is not preventable — only, in some cases, detectable.
Where the problem is in the uterus
An abnormality in the cavity
Endometrial polyps, submucous fibroids, intrauterine adhesions and a uterine septum all reduce implantation, and all are correctable. If the cavity was assessed only by a routine ultrasound rather than a saline sonogram or hysteroscopy, it has not really been assessed.
Thin or unresponsive endometrium
Where the lining does not thicken adequately, implantation is less likely. Causes include previous instrumentation, infection, and reduced blood flow. Management varies and none of it is dramatic, but it needs identifying.
Untreated hydrosalpinx
A fluid-filled blocked tube measurably reduces IVF success because the fluid tracks into the cavity. This should be dealt with before a transfer, not after two failures.
Chronic endometritis
Low-grade inflammation of the endometrium is often silent and is found on endometrial biopsy with specific staining. Where present, it is treated with antibiotics and the cycle repeated.
Where the problem is in the sperm
A normal semen analysis does not exclude a sperm contribution. The routine test measures count, motility and morphology; it does not measure DNA fragmentation, which is associated with poor embryo development, implantation failure and early loss. Where embryos have repeatedly arrested at an early stage or failed to implant, fragmentation testing is worth doing rather than assuming.
Varicocele, infection, heat exposure, smoking and poorly controlled diabetes all contribute and several are modifiable.
Where the problem is in the cycle itself
- Poor ovarian response — too few eggs collected, leaving nothing to choose from. Often a protocol issue that can be changed next time.
- Premature progesterone rise before the trigger, which desynchronises the endometrium from the embryo. This is a recognised reason to freeze all embryos and transfer in a later, unstimulated cycle.
- Timing of transfer. In a small group with repeated failure despite good embryos, the window of implantation may be displaced.
- Laboratory conditions. Culture conditions, incubator stability and handling all affect embryo development. This is invisible to the patient, which is why cumulative laboratory performance matters when choosing a centre.
Other contributors worth checking
- Thyroid function. Subclinical hypothyroidism is common, easily corrected and associated with poorer outcomes.
- Antiphospholipid syndrome, where there is also a history of pregnancy loss.
- Poorly controlled diabetes or significant insulin resistance.
- Body weight at either extreme.
- Smoking, in either partner.
A caution about “recurrent implantation failure” testing. A large industry has grown up around immune testing, natural killer cell assays and intralipid or steroid therapy for failed implantation. Most of these tests are not validated for this purpose, and most of the treatments are not supported by good-quality trial evidence. They are expensive, and some are not harmless. Before agreeing to any of them, ask what trial evidence supports it and what the alternative is.
What a proper review after a failed cycle covers
| Question | What is reviewed |
|---|---|
| Did the ovaries respond as expected? | Dose, protocol, number and maturity of eggs collected |
| Did fertilisation happen normally? | Fertilisation rate, whether ICSI was used and whether it should have been |
| How did the embryos develop? | Day 3 and day 5 development, grading, whether any arrested and when |
| Was the endometrium right? | Thickness and pattern, progesterone at trigger, whether a freeze-all would have been better |
| Was the cavity normal? | Saline sonogram or hysteroscopy — and if not done, do it now |
| Is there a sperm factor? | Repeat analysis, DNA fragmentation where the pattern suggests it |
| Anything systemic? | Thyroid, glucose, weight, smoking |
The output of that review should be a written plan that differs from the last cycle in a specific, stated way. Repeating an identical cycle and hoping for a different result is not a plan.
At Cosmic. Every unsuccessful cycle gets a structured review with the embryology record in front of us, and you are told what we found and what we propose to change. Where we conclude the cycle was reasonable and the outcome was chance, we say that too — because inventing a diagnosis to explain a normal statistical event leads to expensive treatment for a problem you do not have.
Considering IVF, or unsure whether you need it?
Cosmic Women’s Hospital & IVF Center is a Level 2 ART clinic in Naroda, Ahmedabad, registered under the ART (Regulation) Act, 2021. Consultations are by appointment, and you will be given a written, itemised estimate before any treatment begins.
77-9383-9383
3rd Floor, The Capital Corporate, Nr. Naroda Muktidham, Naroda, Ahmedabad 382330 · Book an appointment
Sources
- Society for Assisted Reproductive Technology. National Summary Report, 2023 preliminary data. sartcorsonline.com
- European Society of Human Reproduction and Embryology. Guideline on recurrent implantation failure, and guideline on recurrent pregnancy loss.
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Cosmic Women's Hospital
Cosmic Women’s Hospital & IVF Center is a registered Level 2 ART clinic in Naroda, Ahmedabad — obstetrics, gynaecological surgery, IVF and ICSI, with ultrasound in-house and 24-hour emergency obstetric cover. Articles here are written by the clinical team and medically reviewed by Dr. Rahul Khatri or Dr. Bhargavi Khatri before publication.
