I would like to answer these two questions together and talk about why couples could get unsuccessful assisted fertility results. The reasons for unsuccessful results should be examined under two headings. The first is the absence of pregnancy despite the transfer of good quality embryos and the second is the absence of pregnancy, however, with the transfer of poor quality embryos.

For those in the group where the quality of the embryo is poor unfortunately there is not much that can be done. These couples should be investigated for the presence of chromosomal abnormalities. In couples with balanced translocations up to 80% of the embryos can be abnormal. If the women is a good responder, in other words if she produces many eggs after stimulation of the ovaries one could select normal embryos using Preimplantation Genetic Diagnosis (PGD). In couples who repeatedly yield poor quality embryos but who have a normal genetic make-up various adjunctive treatments have been tried but their effectiveness and/or safety have not been proven. Among these methods there is cytoplasmic transfer, co-cultures, use of aspirin and heparin, sequential transfer, and many others.

The reason for repeated bad quality embryo is usually related to eggs. It could very rarely be related to the quality of spermatozoa. Especially in the cases of men with asospermia, if the fertilization is affected with spermatozoa that have not matured (spermatid) the quality of the embryo is bad and there is no chance of getting pregnant with the transfer of these embryos. If the results of the genetic examination are normal, there could be a genetic problem at ovarian level and this cannot be treated. Pregnancy will result only with the use of donor eggs.

For couples that do not get pregnant after the transfer of good quality embryos other tests should be conducted. Hysteroscopy to determine whether there is an abnormality in the uterus is the first one of these. During this procedure myomas, polyps etc. that have been missed before could be detected. In most cases such pathology can be treated by hysteroscopy. Bad embryo transfer technique or difficult embryo transfers will also lower the chances of getting pregnant. For cases where embryo transfers are repeatedly difficult, the cervix can be dilated or shaved by hysteroscopy .

For women with blocked fallopian tubes if there is water in the fallopian tubes (hydrosalpinks) these should be removed before starting a new round of treatment. The presence of such fallopian tubes will lower the chances of getting pregnant by 50%. If all the embryo transfers were done in the 2nd or 3rd days a delayed embryo transfer (blastocyst transfer) could be useful. Apart from these, such tests and treatments as antiphospholipid antibody measurements, trombophilia assessment, or administration of blood diluting agents were not shown to have any positive effects. Although it could provide some information preimplantation genetic diagnosis will not have any positive effects on the pregnancy rates.