At a time when one in five married American couples experience infertility, and one in three American men have a low sperm count, concerns around fertility and conception have led millions to seek solutions. But family building is rarely a linear process, and for every individual or couple able to successfully conceive on the first try, there are just as many who may seem to be doing everything right without success. Assisted reproductive technologies like in vitro fertilization (IVF) have rightly gained significant positive attention for their ability to deliver successful outcomes for tens of millions of families around the world, but the reality is that IVF is just one point in a stepwise approach for families. Far from being the first tool a reproductive endocrinologist reaches for in their toolkit, it is more akin to a solution of last resort, a break-in-case-of-emergency option tried only when other options have been exhausted. To understand how IVF fits into the full reproductive picture, let us take a step back and look at the continuum of fertility care.
Comprehensive fertility evaluation
Fertility topics are widely discussed on social media and in pop culture, so some patients will seek out a reproductive endocrinologist directly. Others will rely on their trusted OBGYN to advise if/when they should meet with one. Regardless of how the connection is made, the first step in assessing potential fertility problems is a comprehensive evaluation which will lay the foundation for a personalized treatment plan. Understanding why conception has not occurred is critical to developing that plan and, in many cases, can identify opportunities for successful pregnancy without the need for advanced assisted reproductive technologies. Fertility care is not one-size-fits-all, it is tailored to every individual’s unique situation. Female fertility evaluations typically include assessments of ovulatory function, ovarian reserve, fallopian tube patency, and uterine structure. Testing often includes anti-Müllerian hormone (AMH) levels, ultrasound-based antral follicle counts, hormonal testing, and imaging studies such as hysterosalpingography. Male factor infertility, which contributes to approximately 50 percent of infertility cases, is evaluated through semen analysis, hormonal testing, and, when appropriate, genetic screening or structural assessment. Only by looking at the male and female side, can a full reproductive picture be sketched out.
Cycle optimization and ovulation support
In many cases, identifying and treating the root causes of infertility can improve natural conception outcomes, but for patients with ovulatory or hormonal irregularities, reproductive endocrinologists will focus on restoring cycle function. Restoring or optimizing ovulation is often a key early step in fertility care. Conditions such as polycystic ovary syndrome (PCOS), thyroid dysfunction, or hyperprolactinemia can disrupt ovulation but frequently respond well to medical therapy. Ovulatory disorders account for approximately 25 percent of female infertility cases, according to the American Society for Reproductive Medicine (ASRM), and data consistently show that identifying and treating underlying causes of infertility can meaningfully improve pregnancy outcomes. For many couples, cycle monitoring and timed intercourse alone can significantly improve pregnancy rates by optimizing the fertile window.
Surgical interventions to address structural issues
Anatomical abnormalities within the uterus or pelvis can also impair fertility. Surgical interventions can often restore reproductive potential and improve both natural conception and assisted reproduction outcomes. Research evaluating fibroids and fertility outcomes has shown that removal of submucosal fibroids can improve reproductive success. ASRM guidance on uterine septum and reproductive outcomes also supports surgical correction in patients with recurrent pregnancy loss. According to a review published in the New England Journal of Medicine, endometriosis affects an estimated 10 percent of reproductive-age women and up to 50 percent of infertile patients. Surgery can help improve fertility by removing obstructions in cases where hormonal medications are not effective. These interventions highlight the importance of optimizing the reproductive environment before escalating to more complex treatments.
Lifestyle and whole-patient health optimization
Fertility care recognizes the importance of overall health in reproductive success, and doctors will discuss body weight, metabolic health, smoking, alcohol use, environmental exposures, and stress with patients as factors that all play measurable roles in fertility outcomes. ASRM guidance on obesity and reproduction notes that even modest weight reduction can improve ovulation and pregnancy outcomes, and the U.S. Surgeon General’s report on smoking and health notes that smoking has been associated with reduced ovarian reserve and poorer reproductive outcomes. These conversations are a staple for every patient and inform their personalized treatment plan. Whole-patient interventions not only improve natural fertility outcomes but support assisted ones as well. Research conducted by IVI RMA shows that IVF patients who also underwent registered dietician and nutritionist (RDN) counseling gained roughly one more mature oocyte per retrieval than patients without nutritional counseling which resulted in a significantly higher number of normal embryos.
Intermediate assisted reproductive options
After assessing lifestyle factors, for some patients, physicians may recommend intrauterine insemination (IUI) as a step between natural conception and IVF. IUI is often used for mild male factor infertility, unexplained infertility, or ovulatory disorders following induction therapy. IUI can be helpful if the cervix has scarring that prevents sperm from entering the uterus and also enables doctors to assess and select the healthiest and strongest sperm to use.
When IVF becomes the most effective next step
IVF comes into play when less invasive therapies are unlikely to succeed or when specific medical conditions significantly reduce the probability of pregnancy through other approaches. These include tubal factor infertility, severe male factor infertility, genetic conditions requiring embryo testing, recurrent pregnancy loss, and age-related fertility decline. For these patients, IVF offers a path to parenthood, and the opportunity to bypass obstacles that might prevent natural conception. Advances in embryo culture, genetic testing, and laboratory technology have also contributed to improved outcomes and reduced multiple pregnancy risk through single embryo transfer strategies. The Center for Disease Control (CDC) gathers data from fertility clinics across the United States each year as part of the National Assisted Reproductive Technology Surveillance System. These data inform its IVF Success Estimator tool which can help patients understand their chance of having a live birth using IVF. Results can vary widely by clinic, so patients should closely evaluate each clinic they consider for treatment. IVF also expands family-building opportunities for patients who otherwise could not conceive, including individuals requiring donor gametes, fertility preservation prior to medical treatment, and LGBTQ+ individuals.
A continuum, not a competition
Modern fertility care is most effective when it is flexible, collaborative, and individualized. Some patients conceive through ovulation induction or surgical treatment. Others move from lower-intensity therapies to IVF after unsuccessful attempts. Still others may utilize IVF for one pregnancy and then pursue alternative pathways for future family-building. Fertility care should be thought of as a continuum that is centered on clinical reality and personalized, patient-centered care, rather than a choice between competing approaches. IVF is not the starting point for every patient, nor is it the final step for every family. It is one component of a thoughtful, evidence-based progression designed to help patients build families in the safest and most effective way possible.
Scott Morin is a reproductive endocrinologist.
