Who Really Needs IVF—and Who Doesn’t
The couple that didn’t need IVF. Not everyone does.
A young couple came to see me, both in their early thirties, anxious after a year of trying to conceive. They had already looked up IVF clinics online and were convinced something must be “wrong.” A standard work-up had shown that his sperm analysis was normal, her ovulation was regular every 27 days, hormone tests were normal, her fallopian tubes were open and the uterus was fine. Their weights were both within the normal range, and their diet was OK. Nothing suggested a major obstacle.
Instead of rushing them toward IVF, I gave a simpler prescription: have regular intercourse, particularly during the fertile window (which they needed to be taught), and pay attention to timing. I also encouraged them to lower stress—take walks together, try meditation, and keep sex about intimacy, not just a task. Three months later they returned—pregnant, relieved, and grateful. 9 months later I delivered a healthy baby girl, and 16 months after that another one.
Their story is not unusual. It reminds us that while IVF is a life-changing technology for many, it is not the first step for everyone.
Understanding how fertility works
For pregnancy to occur naturally, several systems must work together.
The woman must ovulate, usually releasing one egg each month.
Sperm from the man must reach the egg through the cervix and uterus into the fallopian tubes.
The egg and sperm must meet and fertilize in the tube.
The resulting embryo must travel into the uterus and implant.
This chain is delicate but surprisingly efficient when all parts are working. Age plays a role, but so do lifestyle factors like smoking, stress, and especially weight. Too much or too little body fat can disrupt hormones and ovulation.
The basic fertility evaluation
Before considering high-tech treatments, doctors usually begin with simple, evidence-based tests:
Semen analysis: Are there enough sperm, are they moving well, and do they look normal?
Ovulation testing: Do hormone levels and cycles confirm regular release of eggs?
Uterine cavity and fallopian tube check: Are the tubes open and the uterus healthy?
Egg quantity and quality testing: Blood tests such as AMH (anti-Müllerian hormone) and FSH (follicle-stimulating hormone), sometimes combined with an ultrasound of the ovaries, give a picture of ovarian reserve. Age is the single biggest factor—after 35, egg quality and number decline more sharply.
Weight and metabolic health: Women who are significantly overweight or underweight may not ovulate regularly. Obesity also increases miscarriage risk and lowers IVF success rates. Doctors often encourage optimizing weight before treatment.
Often these tests come back normal. In such cases, time, patience, and timed intercourse are still the best “treatment” for many couples, at least in the short term.
I am going to tell you a (not so) secret: IVF or in-vitro fertilization is not for everyone.
What IVF really is
In vitro fertilization (IVF) means “fertilization outside the body.” Instead of egg and sperm meeting in the fallopian tube, they are brought together in the laboratory:
Ovarian stimulation – The woman takes hormone injections to make several eggs mature at once.
Egg retrieval – A short procedure under sedation collects the eggs from the ovaries.
Fertilization in the lab – Eggs are combined with sperm in a dish; sometimes a single sperm is injected directly into the egg (ICSI).
Embryo culture – Fertilized eggs develop for a few days under careful monitoring.
Embryo transfer – One or more embryos are placed into the uterus, where they can hopefully implant and grow into a pregnancy.
IVF bypasses major obstacles such as blocked fallopian tubes or severely abnormal sperm. It is powerful, but it is also demanding—physically, emotionally, and financially.
Sex and timing: how often is enough?
One of the most common misconceptions is that sex needs to be daily, or even multiple times a day, to conceive. In fact, sperm survive inside the female reproductive tract for up to five days, waiting for the egg to be released. That means couples don’t need to exhaust themselves.
The fertile window is about six days: the five days before ovulation and the day of ovulation itself.
The best advice is to have sex every two to three days throughout the cycle. This ensures sperm are always available without making sex mechanical or stressful.
For couples who want to be more precise, timing intercourse to the two days before ovulation and the day of ovulation gives the highest chance of success.
In other words, “regular” sex doesn’t mean an exhausting schedule. It means steady, consistent closeness during the month—with a little extra attention to the middle of the cycle.
When IVF is the right choice
IVF (in vitro fertilization) is a remarkable procedure, but it is not magic—it is a targeted solution for specific problems. Couples should consider IVF right away when tests show conditions that make natural conception highly unlikely or impossible:
Blocked or absent fallopian tubes – If both tubes are closed or damaged, the egg and sperm cannot meet naturally. IVF bypasses the tubes.
Severe male factor infertility – Very low sperm count or poor movement/shape often cannot be overcome with timing alone. With IVF, sperm can be directly injected into the egg (ICSI).
Severe endometriosis – When pelvic anatomy is distorted and eggs or sperm cannot meet, IVF may be necessary.
Premature ovarian insufficiency or very low ovarian reserve (ie “bad eggs”) – When egg supply is critically low or the egg quality is “bad”, IVF (sometimes with donor eggs) may be the only realistic option.
Genetic concerns – Couples who carry serious hereditary conditions may use IVF with preimplantation genetic testing to avoid passing them on.
Failed less invasive treatments – If simpler methods like ovulation induction or intrauterine insemination (IUI) repeatedly fail, IVF may be the next logical step.
The hidden risks of IVF
IVF can bypass major fertility barriers, but it also carries medical risks. Studies consistently show:
Multiple pregnancies are more common, especially when multiple embryos are transferred. Twins and triplets increase the risk of preterm birth, low birth weight, and complications for the mother.
Pregnancy complications are higher with IVF. Women who conceive with IVF have increased risks of preeclampsia, gestational diabetes, and cesarean delivery.
Stillbirth and perinatal mortality are modestly higher compared to spontaneous conceptions, even after adjusting for maternal age.
Birth defects are slightly more common in IVF pregnancies, though the absolute risk remains low.
These risks don’t mean IVF is unsafe—it means it must be used thoughtfully, with full awareness of potential complications.
The financial reality
Another barrier is cost. In the United States, a single IVF cycle costs between $12,000 and $20,000, not including medications, genetic testing, or storage fees. Many couples require more than one cycle. Insurance coverage varies, and for many, IVF represents a major financial strain.
Stress, the invisible barrier
Stress alone does not cause infertility, but it can make the journey harder. High stress can disrupt ovulation, lower sperm quality, and make intimacy feel like a chore rather than a joy. The anxiety of “trying” every month often becomes a vicious cycle—stress feeds infertility fears, and infertility fears feed stress.
Evidence suggests that stress reduction, mindfulness, and meditation can improve quality of life for couples trying to conceive, and may even improve pregnancy rates. Simple practices—deep breathing, yoga, guided meditation, or just daily walks—help shift the focus from performance to connection.
Fertility is not only about biology; it is also about the mental and emotional space in which conception takes place.
Who does not need IVF right away
The opposite is equally important. Many couples undergo IVF prematurely, with little chance of added benefit:
Couples with normal tests, under age 35, who have tried for less than two years.
Women with regular ovulation, good ovarian reserve, and open tubes.
Men with normal sperm counts and function.
Couples whose main challenge is timing, stress, or lifestyle—not biology.
In these cases, reassurance, counseling, and lifestyle adjustments—including stress reduction—are often more effective than immediately turning to IVF.
Practical lessons for couples and clinicians
Test first, treat later. A thorough fertility evaluation often points the way forward.
IVF is not a shortcut. It is a powerful solution for defined problems, not a cure-all.
Natural conception is still possible. Many couples with normal tests will conceive with time and proper guidance.
Sex and stress both matter. Regular, well-timed intercourse—and reducing stress—remain the most natural “treatments” when everything else checks out.
Individualize care. Every couple’s path is different. The art of medicine is knowing when technology is needed and when patience is wiser.
IVF is one of the great triumphs of modern medicine. It has created millions of families who otherwise could not exist. But it should be used thoughtfully, not reflexively.
The ethical question we must ask is simple: Are we using IVF because it is the right treatment for a proven barrier—or because we are impatient, anxious, or pressured by the marketplace of fertility medicine?
Sometimes the most advanced medical advice is also the most ancient: wait, trust the body, and let nature take its course—until evidence tells us otherwise.