The individual assessment of each patient prior to a decision regarding treatment is essential

Each patient’s clinical history will show whether more complex investigations are required and whether more complicated or specific reproduction techniques would be useful. A woman with hormonal abnormalities due to polycystic ovaries will require a more gentle treatment to prevent hyperstimulation, and if estradiol levels are high it will be better to delay embryo transfer to a time when these levels are not detrimental to implantation.

If there is low ovarian response, the use of androgens is the best way to obtain a better response when trying to achieve development of embryos or blastocytes for transfer or for genetic tests, or when simply waiting for the best cycle for the ovaries to develop.

When a couple has a long history of repeated disappointment and unsuccessful treatment cycles which have included the transfer of good embryos, we need to investigate the reason for implantation failure. This involves evaluation of endometrial receptivity (including array) and consideration of possible genetic abnormalities, possible haematological or immunological abnormalities or chronic endometriosis (evaluated using hysteroscopy). We then turn to implantation of more developed embryos, blastocytes, which can increase the couple’s chances, changing the time of implantation based on changes in the implantation window or in the case of hydrosalpynx, deferring transfer until this is resolved also increase the likelihood of implantation, there are several possibilities.

When a couple produce a “normal” semen sample but with a low or no fertilisation rate, when poor quality embryos are produced or even if there is a good fertilisation rate with good embryos but pregnancy still cannot be achieved, assessment techniques such as sperm DNA fragmentation or FISH analysis are required to provide us with more genetic information.