Repeated IVF failure: possible causes and next steps

Key takeaways

Having several transfers that do not lead to pregnancy is painful, and it does not always mean something is wrong. Each transfer carries a chance of not working.
ESHRE suggests considering further investigation once your predicted chance of implantation over the transfers you have had was above 60%.
Embryo factors, especially chromosomal abnormalities that become more common with age, are a leading reason embryos do not implant.
Many tests and treatments marketed for implantation failure have limited evidence. Ask what each one is for and what the data show.

What "repeated implantation failure" means

There is no single agreed number of failed transfers that defines repeated implantation failure (RIF). In 2023, the European Society of Human Reproduction and Embryology (ESHRE) described RIF as a situation where transfers of embryos thought to be viable have failed often enough, for a specific patient, to justify further investigation (ESHRE).

ESHRE recommends using a threshold of 60%: if, based on your age and embryos, you had a predicted cumulative chance of implantation above 60% across your transfers and none implanted, it is reasonable to talk about further testing or treatment options. This personal approach recognizes that two failed transfers mean something different for a 32-year-old with tested embryos than for someone with fewer or untested embryos.

Embryo factors

An embryo's chromosomes play a large role. Aneuploidy, meaning an abnormal number of chromosomes, is strongly linked to miscarriage (SART). Egg quality and quantity decline with age, especially after 37 and more sharply after 40, and the risk of chromosomal abnormalities in eggs rises from the mid-thirties onward (SART).

Some people consider preimplantation genetic testing for aneuploidy (PGT-A). It can help rank embryos, but it cannot guarantee a pregnancy (SART). The UK regulator rates PGT-A red for improving the chance of having a baby for most fertility patients, partly because it often reduces the number of embryos available to transfer (HFEA).

Egg and sperm factors

A low response to stimulation may reflect diminished ovarian reserve. This is usually suggested by a high FSH level, a low AMH level, or a low antral follicle count (SART). A different medication protocol, or donor eggs, may be discussed.

Sperm also matter. ICSI, where a single sperm is injected into an egg, is typically used when sperm quality is very poor or when fertilization failed in an earlier IVF cycle (SART).

Uterine factors

Problems with the shape or lining of the uterus can affect implantation. ASRM notes that fibroids, polyps, a uterine septum, or fluid-filled fallopian tubes (hydrosalpinx) may need to be corrected before IVF to improve success rates. If these were not checked earlier, your clinician may suggest a uterine evaluation.

Lifestyle and general health

According to ASRM, smoking reduces IVF success rates by up to 50%, and obesity can lower pregnancy rates and raise the risk of miscarriage. Reviewing medications and supplements and managing long-term conditions with your doctor is part of a careful review after failed cycles.

Tests and treatments with limited evidence

After failed transfers, you may come across tests and treatments that promise to fix implantation. ESHRE recommends limiting investigations and treatments to those with a clear rationale and data showing they are likely to help (ESHRE). Two examples from the UK regulator's ratings:

Endometrial receptivity testing is rated red for most patients, because moderate- to high-quality evidence suggests it may reduce treatment effectiveness (HFEA).
Steroids used as an immune treatment are rated red for most patients, partly because of potential safety concerns (HFEA).

This does not mean no one benefits from any extra test. It means it is worth asking what a test will change about your plan before paying for it.

Looking after yourself

Repeated failed cycles can bring grief, anxiety, and exhaustion. Counseling with a qualified fertility counselor and social support can help (SART). Taking a break between cycles is a valid choice.

Questions to ask your clinician

Given my age and the embryos transferred, what was my expected chance of success, and does my history meet the threshold for further testing?
Do you think embryo, egg, sperm, or uterine factors are most likely here?
Which tests do you recommend now, and how would each result change our plan?
Is any add-on you are suggesting supported by good evidence for someone like me?
Would a different stimulation protocol, ICSI, or donor eggs or sperm be worth discussing?
What support is available if we decide to pause or change direction?

This article is general education, not medical advice. A reproductive endocrinologist who knows your full history is the right person to guide next steps.