Why IVF isn't always the first step in infertility treatment

Infertility affects an estimated one in six people globally during their reproductive years. In men, infertility is commonly linked to problems with sperm production, movement or ejaculation, while in women it may result from disorders affecting the ovaries, uterus, fallopian tubes or the endocrine system, according to the World Health Organization.

In India, too, infertility remains an important public health concern, with recent research highlighting the need for better access to timely diagnosis and treatment. 

A recent systematic review and meta-analysis of studies conducted across India between 1997 and 2023 estimated that the pooled prevalence of overall infertility among women of reproductive age was 8%, with primary infertility at 5% and secondary infertility at 2%. The researchers analysed data from 25,778 women across multiple states and concluded that "infertility urgently requires a comprehensive policy emphasising a strategic plan of action", adding that accessible and equitable reproductive healthcare services are needed for "early identification and management of infertility."

On the occasion of World IVF Day, we spoke to Dr Akanksha Goel, Fertility Specialist, Nova IVF Fertility, Kolkata, to understand why IVF is not always the first step in fertility treatment, when couples should seek medical evaluation, and how doctors decide the most appropriate treatment based on an individual's underlying condition.

Infertility does not always mean IVF

Dr Akanksha Goel said one of the biggest misconceptions surrounding infertility is that difficulty conceiving automatically means a couple needs IVF. She emphasised that while assisted reproductive technologies have transformed fertility care, they are not always the first or only treatment option.

"Fertility care is not about offering the highest technology as early as possible. It is about identifying the underlying cause of infertility and treating it with the least invasive approach that offers the best chance of success," she said.

According to Dr Goel, many fertility problems can be identified through evaluation and managed with lifestyle modifications, medications or simple procedures, without immediately resorting to assisted reproduction.

Evaluation and lifestyle changes often come first

Dr Goel said couples should generally seek medical evaluation after one year of trying to conceive if the woman is under 35 years of age, or after six months if she is older than 35. However, women with irregular periods, endometriosis, recurrent miscarriages, a history of pelvic infections or suspected male-factor infertility should seek medical advice sooner.

She explained that the initial fertility work-up is relatively straightforward and includes assessing ovulation, ovarian reserve, sperm quality, fallopian tube patency, uterine health, hormone levels, thyroid function and lifestyle factors.

"Current lifestyle habits such as obesity, smoking, excessive alcohol intake, chronic stress, poor sleep, lack of exercise and diets high in processed foods can all affect fertility in both men and women. Addressing these factors and correcting conditions such as diabetes, hormonal imbalances and nutritional deficiencies can significantly improve the chances of natural conception," she said.

Many fertility problems respond to simpler treatments

According to Dr Goel, irregular or absent ovulation is among the most common causes of female infertility and is often linked to conditions such as Polyendocrine metabolic ovarian syndrome (PMOS), thyroid disorders, elevated prolactin levels or other hormonal imbalances.

"Many of these conditions respond well to fertility medications or treatment of the underlying hormonal disorder. For some couples, timed intercourse or intrauterine insemination (IUI) after ovulation induction is sufficient, and IVF is not required immediately," she said.

She added that certain structural abnormalities, including uterine polyps, adhesions, fibroids, uterine septum and some cases of endometriosis, can often be treated with minimally invasive procedures such as hysteroscopy or laparoscopy before considering assisted reproductive techniques.

IVF is recommended only in specific situations

Dr Goel stressed that male infertility should receive equal attention during evaluation, noting that male factors contribute to nearly half of infertility cases. She said semen analysis can help identify treatable causes such as infections, hormonal disorders, varicoceles, obesity, smoking, poorly controlled diabetes, medication use and nutritional deficiencies.

While describing IVF as one of the most effective fertility treatments, she said it is generally reserved for situations where less invasive options are unlikely to succeed or have already failed.

"Couples with blocked fallopian tubes, diminished ovarian reserve, advanced maternal age, severe male-factor infertility, recurrent implantation failure or certain genetic conditions may benefit most from IVF. However, beginning IVF without a comprehensive fertility assessment or without addressing treatable causes may not always be the most appropriate approach," she said.

She concluded that fertility treatment should always be individualised.

"No two fertility journeys are the same. The goal is not to recommend the most advanced treatment first, but to provide the right treatment at the right time for each couple based on their specific diagnosis and reproductive needs," she said.

This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS