Assisted Reproduction: Methods and When It Is Needed

This term describes all the methods that have been developed to help a couple have a child. However, the term is also often used for specialized treatment methods, such as in vitro fertilization (IVF). These treatment interventions include:

• in vitro fertilization (IVF): Eggs are retrieved from the woman’s ovaries and placed together with the partner’s sperm in a special dish (a shallow plate) in the lab. Then the embryos formed by the union of egg and sperm are transferred into the uterus.
• intracytoplasmic sperm injection (ICSI): This procedure is similar to IVF, but instead of letting egg and sperm join on their own, a single sperm is injected directly into the egg, and the resulting embryo is then transferred into the uterus.
• the use of donor eggs or sperm: In artificial insemination, donor sperm can be used when the partner has a low sperm count or produces no sperm at all. In some cases where the woman cannot produce eggs, an egg from another woman is used, which is fertilized with sperm from the partner of the woman who wants to have a child, and the resulting embryo is transferred into the uterus.
• surrogacy: In this case, another woman carries a couple’s embryo (created with the couple’s egg and sperm or with a donor’s) until delivery, and the newborn is then handed over to the couple.

Success rates vary greatly from couple to couple. They depend mainly on the woman’s age and the cause of infertility, and younger women have better chances overall. That is why a general average says little about your own case: ask the clinic for live birth rates per embryo transfer for your age group.

When assisted reproduction is needed

The general rule is simple. If you are under 35 and have been trying for a year without success, it is time to get tested. After 35 the interval drops to six months, while after 40 it is worth talking to a specialist from the start. The evaluation always involves both partners, since infertility is due almost as often to the man as to the woman.

The testing that comes first

• Hormone testing and anti-Mullerian hormone (AMH), to assess ovarian reserve.
• Transvaginal ultrasound with follicle count.
• Hysterosalpingography (HSG), to check whether the fallopian tubes are open.
• Semen analysis, the basic test for male infertility.

From the simplest to the most complex method

Treatment does not necessarily start with IVF. When the picture allows it, milder options come first:

• Ovulation induction with timed intercourse, mainly in women with disorders of ovulation.
• Intrauterine insemination (IUI), for a mild male factor or unexplained infertility with open fallopian tubes.
• In vitro fertilization (IVF/ICSI), when the previous options are not enough or are not suitable.
• Mini IVF, with milder medication stimulation in selected cases.
• Preimplantation genetic testing (PGT), when there is a genetic indication.
• Egg freezing, to preserve fertility.

For couples who need donated genetic material, there are egg donation and surrogacy, always within the framework set by Greek law.

What determines the chances of success

The woman’s age is the strongest factor. Next come ovarian reserve, sperm quality, the cause of infertility and the quality of the embryology lab. Weight, smoking and alcohol matter more than most people think. Published rates are averages. Your own estimate comes only after complete testing.

Ovulation induction: the simplest form of assisted reproduction

For many women with irregular cycles, the problem is that ovulation does not happen or happens only sporadically. Here treatment can be simple: pills for a few days at the start of the cycle, aiming for one or two mature follicles to develop.

• Medications: letrozole and clomiphene are the most common options. In women with polycystic ovaries, letrozole is now often considered the first choice.
• Follow-up: an ultrasound in the middle of the cycle to see how many follicles have developed and when the right time for intercourse is.
• Duration: usually a few cycles are tried. If pregnancy is not achieved, treatment is stepped up.
• Risk: the development of many follicles increases the chance of a twin or triplet pregnancy. That is why ultrasound monitoring should not be skipped.

Ovulation induction makes sense only when the fallopian tubes are open and sperm quality is adequate. Otherwise, precious time is lost.

Assisted reproduction and age: what changes after 35 and after 40

Age does not affect only the number of eggs. It mainly affects their quality. Over the years the proportion of eggs with the wrong number of chromosomes rises, which explains why the chances of implantation drop and miscarriages increase.

From 35 to 39

• Evaluation starts after six months of unsuccessful trying.
• Simpler methods are tried for a shorter time before stepping up.
• Freezing embryos for a possible second child in the future is discussed from the start.

40 and over

• IVF is usually recommended early, because every month counts.
• Preimplantation chromosome testing can be discussed, with realistic information about its limits.
• When ovarian reserve is very low or attempts with your own eggs are not working, egg donation offers significantly higher chances.

Conditions that change the treatment plan

Some gynecological conditions need special handling before or during treatment:

• Endometriosis: depending on severity and age, the decision lies between surgical treatment and going straight to IVF. See more about endometriosis and fertility.
• Hydrosalpinx: a fallopian tube filled with fluid lowers the chances of implantation. Removing or tying off the tube by laparoscopy is often recommended before embryo transfer.
• Fibroids: those that distort the uterine cavity are usually removed before treatment. More about uterine fibroids.
• Endometrial polyps: they are removed by hysteroscopy, a short procedure without incisions.
• Recurrent miscarriages: they require separate testing, including karyotyping of the couple and evaluation of the uterus and for thrombophilia. Read about recurrent miscarriage.

The risks of treatment and how they are prevented

Assisted reproduction methods are safe when applied correctly. There are, however, specific risks you should know about:

• Multiple pregnancy: the most important risk for the mother and the newborns. It is prevented with careful monitoring in the milder methods and by transferring a single embryo in IVF.
• Ectopic pregnancy: it can also happen after IVF, mainly in women with fallopian tube disease. That is why every positive test is followed by an early ultrasound.
• Egg retrieval complications: bleeding or infection are rare. Get in touch right away if you develop fever or severe pain in the days afterward.
• Psychological burden: it is often underestimated. Support from a mental health professional helps many couples keep going.

Before you start: how the couple prepares

The three months before treatment can be put to good use. Sperm production takes about two and a half months, so lifestyle changes in the man show up in the semen analysis after that period.

• Folic acid for the woman, starting from the planning stage.
• Both partners quitting smoking, and cutting down on alcohol.
• Weight loss when body mass index is high. Even a moderate reduction improves ovulation and the chances of pregnancy.
• Testing and management of thyroid, blood sugar and prolactin.
• Vaccination for rubella and chickenpox if you are not immune, with the necessary waiting period before pregnancy.
• Avoiding exposure of the testicles to high temperatures, and discussing with the doctor any medications or anabolic steroids that may affect sperm.

The legal framework for assisted reproduction in Greece

Medically assisted reproduction in Greece is regulated by specific legislation and supervised by the National Authority for Medically Assisted Reproduction. In general terms:

• Written consent is required before any treatment; for unmarried couples it is given through a notarized document.
• A woman without a partner can also undergo treatment, using donor sperm.
• There is an upper age limit for the woman undergoing treatment, as set by law.
• Gamete donation is, as a rule, anonymous and may not be commercial in nature.
• Surrogacy is allowed only with court authorization and under strict conditions.

The details have changed with newer regulations, so ask for information on the current legislation before you start.

How to read success rates correctly

A percentage without an explanation can be misleading. Before comparing numbers, ask what exactly they measure:

• Positive test or live birth? A positive pregnancy test is not the same as a birth. The most meaningful measure is a live birth.
• Per cycle started or per embryo transfer? Rates per transfer look higher, because they do not include cycles that were canceled or did not produce embryos.
• Cumulative rate: the chance of having a baby from all the embryos of one egg retrieval cycle, fresh and frozen, is perhaps the most useful measure for a couple.
• Age group: an average that combines women aged 30 and 43 says little about either of them.

The most useful question is not “what is the clinic’s success rate” but “what are the realistic chances for our age and diagnosis, and over how many attempts.”

Unexplained infertility: when all tests are normal

In a significant share of couples, basic testing shows no problem. The woman ovulates, the tubes are open, the semen analysis is normal. And yet pregnancy does not happen. This is called unexplained infertility, and it is frustrating, because there is nothing specific to “fix.”

What it means in practice:

• The chance of natural conception is not zero, especially in younger women who have been trying for a short time.
• For couples where the woman is under 35 and infertility is of short duration, intrauterine insemination (IUI) with mild stimulation may be suggested first.
• When age is higher or attempts have lasted for years, IVF also has diagnostic value: it shows how the eggs, fertilization and embryo development behave.
• Additional testing, such as hysteroscopy or looking for mild endometriosis, is considered case by case and not in all women.

An “unexplained” diagnosis does not mean treatment has lower chances. Results are often very good, especially when the woman is younger.

The emotional side of the journey

Infertility tests your relationship, your friendships and your resilience. Many couples describe treatment as a constant up and down between hope and disappointment. You are not alone.

• Agree in advance how many attempts you are willing to make and when you will stop and reconsider.
• Choose who you will tell that you are having treatment. Fewer questions often mean less pressure.
• Make time for activities that have nothing to do with fertility.
• If anxiety or sadness affect your sleep, work or relationship, seek support from a psychologist experienced in this area.

For a personalized assessment of your case, book an appointment with Dr. Panagiotis Polyzos at his office in Athens or Volos.

Frequently Asked Questions

What is the difference between assisted reproduction and IVF?

Assisted reproduction is the broader term and includes all methods that help with conception. IVF is one of them, the most specialized.

When should we see a fertility specialist?

After 12 months of trying without conceiving if the woman is under 35, after 6 months if she is over 35, and sooner when there is a known problem such as irregular cycles, endometriosis or an abnormal semen analysis.

Do we always start with IVF?

No. Depending on the cause and age, ovulation induction or intrauterine insemination (IUI) may come first. IVF is recommended directly when the fallopian tubes are blocked, the male factor is severe or time is short.

How many attempts are usually needed?

There is no single number for everyone. Many couples achieve pregnancy within the first two to three attempts, but the chances depend mainly on age and ovarian reserve.

Are the stimulation medications safe?

They have been used for decades with a good safety profile. The most important complication is ovarian hyperstimulation syndrome, which today is prevented in most cases with modern protocols.

Can a woman without a partner undergo assisted reproduction?

Yes. In Greece the law allows a woman without a partner to undergo treatment with donor sperm, as long as she meets the legal requirements and gives written consent. Depending on fertility testing, intrauterine insemination (IUI) or IVF may be used.

How long should we wait between two attempts?

After an unsuccessful IUI, the next one can usually be done in the very next cycle. After IVF with egg retrieval, most doctors recommend waiting at least one normal cycle so the ovaries can recover. If there are frozen embryos, their transfer can be scheduled sooner than a new stimulation.

Do fertility treatments increase the risk of cancer?

Large follow-up studies do not show a significant increase in the risk of breast or endometrial cancer from stimulation medications. For ovarian cancer the data are reassuring, with the small differences described attributed mainly to infertility itself. Regular gynecological checkups continue as usual.

Do I need to take time off work during treatment?

In most cases, not for long. Monitoring visits during stimulation are short and usually take place early in the morning. You need the day of egg retrieval off, because of the sedation, and ideally half a day for the embryo transfer.