What to Know Before IVF: Counselling, Timing and Realistic Expectations

In vitro fertilisation (IVF) is an assisted reproductive technique in which an egg and sperm are fertilised outside the body and the resulting embryo is transferred to the womb (uterus). Many couples experiencing infertility (in everyday terms, difficulty having a baby) have heard this word before their first consultation; yet current guidelines describe IVF in many cases not as the first step but as a later one ^1,2. If a cause has been diagnosed and other treatments are not suitable, IVF is recommended directly ¹. This article brings together what you need to know before IVF is discussed, focusing on timing, counselling and realistic expectations.

In Türkiye, assisted reproductive treatment (ÜYTE) is carried out in centres licensed by the Sağlık Bakanlığı (Ministry of Health) — in units within hospitals or in independent centres; the application begins with an informed consent form completed jointly by the married couple ³. An obstetrics and gynaecology practice is not an IVF centre; the practice’s role is to carry out the couple’s basic assessment, decide together which step is appropriate and, when needed, refer them to a licensed centre and provide medical information and follow-up throughout the process.

The right timing: when to assess, when to treat?

The American Society for Reproductive Medicine (ASRM) states that assessment should begin if pregnancy has not occurred after 12 months of regular unprotected intercourse when the woman is under 35, or after 6 months when she is 35 or over, and that earlier action may be taken over the age of 40 ⁴. NICE (National Institute for Health and Care Excellence, 2026), England’s guideline body, takes 1 year as the basis; if the woman is 36 or over, or if either partner has a known cause, it recommends specialist assessment without waiting ¹. If there are irregular periods, known tubal or uterine disease, suspected endometriosis or a known problem in the male partner, there is no need to wait ⁴.

There is a scientific reason for waiting: among couples in which the woman is under 40 and who have regular unprotected intercourse, more than 80% conceive within 1 year; about half of the remainder conceive in the second year, and the overall rate exceeds 90% ¹. When assessment begins, both partners are assessed at the same time; the male partner’s history and at least one semen analysis are requested at the start of the process, because a contributing male factor is common ⁴. Completing this basic assessment before IVF is discussed prevents unnecessary or premature treatment.

A step-by-step approach to unexplained infertility

“Unexplained infertility” means that pregnancy has not occurred within 12 months even though ovulation, the tubes, the womb and the semen analysis have been found to be normal; the European Society of Human Reproduction and Embryology (ESHRE) uses this definition for women aged 40 and under, and reports that it is seen in up to 30% of infertile couples ². The guideline recommends basing the decision to start active treatment on the prognosis (the likely outlook); age, duration of infertility, previous treatments and previous pregnancies are the main factors that determine this outlook, and prediction models and the couple’s preference can help with the decision ².

For active treatment, ESHRE’s first-step recommendation is insemination combined with ovarian stimulation (intrauterine insemination, IUI); using injected ovulation hormones (gonadotrophins) at a low dose and with close monitoring reduces the risk of multiple pregnancy and of ovarian overstimulation (ovarian hyperstimulation syndrome, OHSS) ². The same guideline states that IVF has not been shown to be better than stimulated insemination for these couples ². NICE, on the other hand, recommends trying for a total of 2 years, then discussing the options of up to 4 cycles of gonadotrophin-stimulated insemination before IVF, or going straight to IVF; it does not recommend offering ovulation stimulation as a treatment on its own ¹.

Counselling: the right to information and the emotional burden

NICE asks that couples with fertility problems are seen together, that decisions are evidence-based and supported by written information, and that treatment options are discussed together with their benefit–risk balance ¹. Long-term safety is also part of the information given: no direct link has been shown between ovulation stimulation and invasive cancer, and the absolute risk of long-term adverse outcomes in children born after IVF is low; however, a small increase in borderline ovarian tumours cannot be ruled out, and it is noted that data on long-term health outcomes are still awaited ¹.

The emotional burden is not ignored. The guideline notes that stress in one or both partners can affect the relationship, sexual desire and frequency of intercourse, and recommends that counselling for emotional support is offered before, during and after investigations and treatment — whatever the outcome — and that it is provided by a professional independent of the team delivering the treatment ¹. ESHRE also recommends psychological support when needed ². In practice, this means that gynaecological follow-up is carried out, when needed, in collaboration with mental health professionals.

Realistic expectations: age, ovarian reserve and a “full cycle”

When IVF is discussed, ovarian reserve (an indicator of the remaining egg supply in the ovaries) is taken into account ¹. For England’s public health service (NHS), NICE recommends offering IVF up to the woman’s 42nd birthday; for women under 40, the initial plan is 3 full cycles, and if pregnancy does not occur, up to 3 further cycles are considered after the chances are discussed again; at 40–41, 1 full cycle is recommended if IVF has not been done before ¹. The arrangements in Türkiye can be obtained from the relevant centre. A “full cycle” includes one round of ovarian stimulation and all transfers of the fresh and frozen embryos obtained from it; one attempt is not just one transfer ¹.

Multiple pregnancy is a risk in IVF that can be reduced through the number of embryos transferred; for this reason NICE recommends that women under 37 have only one embryo transferred in the first cycle, that no more than two embryos are transferred in any cycle, and that if two embryos are being considered, the risks of multiple pregnancy are discussed separately; freezing and storing any remaining good-quality embryos is also recommended ¹. Contrary to a common belief, bed rest of more than 20 minutes after transfer has been shown not to improve the outcome ¹.

Add-ons: hope or evidence?

An add-on is any test, medicine, device, laboratory method or complementary treatment offered in addition to the standard IVF procedure ⁵. ESHRE’s 2023 good practice recommendations produced 42 recommendations in this area; none of them could be based on high-quality evidence, and only four could be supported by moderate-quality evidence ⁵. The guideline’s message is clear: patients should be fully informed about how likely each additional test or treatment is to increase the chance of a live birth, and the decision should be made with realistic expectations ⁵.

NICE 2026 is specific: the following are not recommended for improving IVF outcomes: endometrial scratching, screening hysteroscopy, endometrial receptivity tests, immune treatments such as intravenous fat (lipid) emulsion, intravenous immunoglobulin or cortisone-type (glucocorticoid) medicines, genetic screening of embryos (PGT-A) to increase live births, and assisted hatching ¹. ESHRE also reports that antioxidant supplements, acupuncture and inositol are probably not recommended in unexplained infertility ². If a treatment is suggested to you, you have the right to ask about its evidence and the reason it applies to you.

What is in your hands: lifestyle

Smoking — including passive smoking — is likely to reduce a woman’s chance of conceiving; in men, it is associated with lower semen quality ¹. If the body mass index (weight divided by the square of height) is 30 or above, it may take longer to conceive, and if ovulation is not taking place, losing weight is likely to improve the chances; if it is below 18.5 and periods are irregular, gaining weight may increase the chance of pregnancy ¹. No consistent link has been shown between caffeine and infertility; the effectiveness of complementary therapies has not been adequately evaluated ¹. Healthy eating and regular exercise are recommended ².

The Sağlık Bakanlığı (Ministry of Health) guideline recommends that women planning a pregnancy take 400–800 micrograms of folic acid a day, starting at least 1 month before pregnancy ⁶. Timing intercourse does not require a complicated calendar: regular intercourse every 2–3 days is enough ¹; sexual position, orgasm or lying on your back afterwards have not been shown to affect the chance of pregnancy ⁷. In summary, the IVF journey begins with a preliminary assessment, the right timing and evidence-based steps; when faced with add-ons and promises of hope, the question is always the same: “Has this step been shown to increase the chance of a live birth in my situation?” If you have symptoms, please consult an obstetrics and gynaecology specialist.