How Dr Vani decides, in her own words.

Under 35 with good reserve: 3 to 4 IUI cycles. 35 to 37: 2 to 3. 38 and over: 1 to 2 if reserve is satisfactory. Sooner to IVF if reserve is low or endometriosis is advanced.

We usually move from IUI to IVF after 3 to 4 well-timed IUI cycles, but the decision is never based on cycle number alone. The woman's age, ovarian reserve, duration of infertility and underlying diagnosis are equally important. In women younger than 35 with a good ovarian reserve, we generally offer 3 to 4 consecutive IUI cycles. Performing them back-to-back helps maximise the cumulative chance of pregnancy.

Extremely low reserve over 40, repeatedly poor eggs, failed fertilisation, consistently poor embryos, repeated embryo arrest, no viable sperm. We also do not proceed where pregnancy poses a serious risk to the woman's life or where ART law does not permit it.

In these situations, I explain the prognosis clearly and discuss whether stopping treatment or considering alternatives such as egg donation may offer a more realistic chance of success. Some couples, even after understanding the very low probability, may still wish to attempt one final cycle before considering alternatives. Religious and personal choices regarding treatment are always respected.

Egg accumulation and individualised stimulation, including dual stimulation, rather than simply higher doses.

In women with low ovarian reserve, our aim is often to maximise the number of eggs collected rather than relying on a single stimulation cycle. Dual stimulation involves performing one ovarian stimulation from the beginning of the menstrual cycle, followed by a second stimulation a few days after the first egg retrieval. This allows us to collect more eggs within a shorter period of time.

More than 90% of our embryo transfers are frozen.

We generally favour FET because it allows us to prepare the endometrium under more controlled conditions. During ovarian stimulation, gonadotropin injections can cause estrogen and sometimes progesterone levels to rise well above physiological levels. A freeze-all approach is particularly important in women at risk of ovarian hyperstimulation syndrome, such as some women with PCOS. Frozen transfer is also necessary when embryos undergo PGT-A, because the embryos are biopsied and frozen while genetic testing is completed.

ICSI should not simply be viewed as automatically better IVF.

ICSI is particularly useful in cases of severe male-factor infertility: very low sperm counts, poor motility or a high proportion of abnormal sperm. It is also indicated when sperm must be surgically retrieved from the testes, when there has been previous complete fertilisation failure with conventional IVF, and when frozen eggs are being fertilised. At Jananam we tend to favour ICSI because it can reduce the risk of unexpected fertilisation failure and improve the proportion of eggs that fertilise in appropriate patients. However, the decision should still be individualised.

We offer add-ons selectively rather than routinely.

The principle is simple: we recommend an add-on only when we believe there is a reasonable clinical justification for that individual patient. We commonly recommend PGT-A for women aged 38 years and above, and may also consider it for repeated IVF failure or recurrent pregnancy loss. Couples with specific genetic conditions may require PGT-M, while chromosomal rearrangements may require PGT-SR. For selected women with repeated implantation failure or recurrent pregnancy loss, we may recommend EMMA/ALICE testing. Immune testing is reserved for a specific subgroup of patients with repeated implantation failure or recurrent miscarriage. We also perform assisted hatching for day-three frozen embryos.

Couples wait too long to resume treatment after a failed cycle.

Understandably, they feel disappointed, anxious and lose confidence in treatment, but a long gap can sometimes reduce their future chances further. After a failed IVF cycle, it is important to understand the likely reason for failure and to have a clear backup plan. If embryos are remaining, they may still be transferred after suitable investigations and lifestyle improvement. What happens next depends mainly on the woman's age, ovarian reserve and sperm quality.

Lifestyle, led by a healthy weight. Then smoking, alcohol, about seven hours of sleep, stress, folic acid, and correcting thyroid, diabetes, blood pressure and vitamin D.

There is strong evidence that achieving an ideal weight can positively affect egg quality, sperm quality, embryo quality and implantation, while also reducing the risk of miscarriage. Smoking and alcohol should ideally be stopped, as both can adversely affect fertility in men and women. Adequate sleep is another important but often ignored factor. These are practical steps that can genuinely improve factors affecting IVF outcome.

We do not transfer more than two embryos under any circumstance. Single embryo transfer is preferred for tested euploid embryos at any age, and usually under 38 with a good blastocyst.

Our policy is to transfer the smallest number of embryos needed to give a good chance of pregnancy while avoiding the risks of multiple pregnancy. In women aged 38 and above, we may discuss transfer of two blastocysts depending on the individual situation. In donor egg cycles, we usually prefer a single blastocyst transfer.

Treatment is certainly possible, but she may need more than one cycle of ovarian stimulation and egg collection to have a reasonable chance of success.

I discuss the prognosis honestly and compassionately. At 41 she is considered to be of advanced maternal age, which usually means both reduced ovarian reserve and a higher proportion of chromosomally abnormal eggs. These two factors together lower the chance of pregnancy and increase the risk of miscarriage. We also discuss the possible role of PGT-A, which may help identify euploid embryos before transfer. At the same time, I always explain the alternative of donor egg IVF. If she chooses to proceed with her own eggs, we fully support her with individualised treatment and realistic expectations.