What counselling should be provided after repeated IVF failures?

[Tier B] Begin with the arithmetic rather than the investigation list. Establish what the cumulative expected probability actually was across the cycles attempted, given her age, oocyte yield and embryo quality. A substantial proportion of couples described as having repeated failure have simply not yet had enough good-quality embryos transferred for success to have been likely. Structure of the conversation: Review each cycle in detail — oocyte yield, maturity, fertilisation, embryo development trajectory, and endometrial response. Patients are frequently unaware they can request this, and it is usually more informative than new tests. Distinguish failure to produce embryos from failure to implant. These are different problems with different responses, and conflating them leads to unnecessary implantation-focused investigation. Be explicit about which add-ons lack evidence. Endometrial receptivity testing is HFEA red-rated. Immunological testing and therapy, inherited thrombophilia screening, endometrial scratch, intralipid and IVIG are not supported. Couples at this stage are highly motivated to try anything, which makes candour more important rather than less. Name the alternatives properly — donor oocytes, donor sperm, donation of embryos, surrogacy where legally available, adoption, and stopping treatment. Stopping is a legitimate outcome and is rarely presented as one. Offer counselling support. The psychological burden at this point is substantial and specialist fertility counselling exists for it. Reviewer: this answer previously cited a non-existent "ESHRE 2024", removed in migration 045. It is now uncited, which is accurate. If a source exists for structured post-failure counselling, add it.