Thanos Papathanasiou: Are We Preparing Patients for the IVF Cycle, or for the IVF Journey?

Thanos Papathanasiou, CEO and Medical Director at Bourn Hall Fertility Clinic UK, shared on LinkedIn:

“I have been reflecting recently on how we discuss IVF success rates during our medical consultations, and whether we sometimes place too much emphasis on the first treatment cycle.

We explain the treatment, what to expect from egg collection and embryo development, and naturally, the chances of having a baby.

We may even provide a personalised prediction of success, based on the patient’s age and medical history.

There is nothing wrong with this. In fact, it is an important part of good counselling.

But I wonder whether we sometimes miss the bigger picture.

A woman might leave her consultation knowing that she has a 35% chance of having a baby from her first complete IVF cycle.

She understands that success is far from guaranteed.

But does this mean that she is genuinely prepared for the possibility of an unsuccessful attempt, or for what might come afterwards?

I don’t think these are necessarily the same thing.

There are understandable reasons why doctors tend to concentrate on the first cycle.

It is the treatment we are about to provide, and its outcome will often give us valuable information about ovarian response and embryo development.

We also want patients to remain positive, rather than overwhelm them with the possibility of repeated treatment before they have even started.

This is not just my impression.

A study published in Human Reproduction in 2022 by Harrison and colleagues found that planning IVF one cycle at a time was considered normal practice among the fertility professionals interviewed.

One of the concerns was that discussing the possibility of several cycles might undermine patients’ optimism.

I understand that concern, but I am not entirely convinced by it.

In my experience, patients can be remarkably optimistic about their first IVF attempt, even when they understand that the statistical chance of success is relatively modest. We should not necessarily discourage that optimism. But perhaps we should help patients place it within a more realistic expectation of the overall treatment journey.

And I think this becomes particularly important as women get older.

1. Consider a woman in her early thirties with a favourable prognosis.

She may have a reasonable chance of having a baby from one egg collection, including any subsequent frozen embryo transfers.

2. Now consider a woman in her early forties using her own eggs.

Her chances may be considerably lower, and she may need to contemplate more than one egg collection, recognising that even repeated attempts may not lead to a baby.

In both situations, we can quote an accurate success rate. But I would argue that the more important task is to help these women develop realistic, and quite different, expectations about what treatment may involve.

For the younger woman, one egg collection may well be sufficient. For the older woman, the possibility of repeated treatment, the implications of time, and the limitations of further attempts may need to be discussed much more explicitly.

Of course, age alone does not determine prognosis.

The principle is that counselling should reflect the likely treatment journey, rather than simply provide a different percentage.

There is another aspect of this which I find particularly interesting.

By concentrating so much on the first cycle, could we actually be making an unsuccessful outcome more difficult for patients to process?

If all the discussion, planning and optimism have centred on the first attempt, its failure may feel like the failure of the entire treatment plan.

Yet clinically, that is not necessarily the case.

There may be frozen embryos available, we may have learnt valuable information, or another attempt may still offer a reasonable prospect of success. Equally, the first cycle may reveal that we should reconsider the treatment strategy.

I am not suggesting that better preparation necessarily reduces the disappointment of an unsuccessful cycle. We do not have sufficient evidence to claim that. But I do wonder whether we could help patients approach treatment with expectations that are more realistic and perhaps more resilient.

Research by McLernon and colleagues, published in the BMJ in 2016, demonstrated the importance of considering cumulative live-birth chances across complete IVF cycles.

We already recognise scientifically that IVF success cannot always be meaningfully understood through a single attempt.

Perhaps our consultations should reflect this more consistently.

This does not mean encouraging patients to commit to several cycles from the outset. We must reassess prognosis after each attempt, and sometimes the right advice will be not to continue.

Nor does it mean abandoning success rates. I believe they are useful, particularly when comparing treatment options. But I am less convinced that spending time explaining increasingly precise percentages necessarily improves a patient’s understanding.

I would rather that a patient leaves knowing whether one egg collection is reasonably likely to be enough, whether further treatment might be necessary, what that might achieve, and what the alternatives are.

And perhaps there is a more fundamental reason why we tend to concentrate on individual cycles.

As clinics, we organise almost everything around them. We schedule cycles, measure outcomes per cycle, and usually charge per cycle. It is therefore quite natural that we have come to organise much of our counselling around the same unit.

But this is how we deliver treatment, not necessarily how patients experience it.

Our patients are not primarily interested in having an IVF cycle.

They want to have a baby, and they need to understand what trying to achieve that may realistically involve.

For me, this is the important distinction.

We should continue to make clinical decisions one cycle at a time. But we should prepare our patients for the journey from the very beginning.”

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