What’s missing in the IVF story: paying attention to needs beyond the medical

Fertility medicine moves fast. Every year brings a new technique, a new technology, a new reason for hope. But after years of seeing couples through this process, I’ve stopped getting excited every time something new lands in our lab. The medical hurdles are only one part of what my patients are actually dealing with. The rest is family pressure, money, and the long, drawn-out stress of waiting to find out whether a cycle worked. India has caught up impressively on the technology side with AI in the lab, vitrification and better stimulation protocols. We have not, however, kept to the same pace when it comes to access to fertility treatment or the emotional part of this work.

The emotional weight

Infertility is a medical condition that is often treated by society as a moral failing. Couples walk in to clinics, already worn down by questions at weddings, advice from in-laws, and comparisons with cousins who got pregnant without trying. In a culture where having children is tied so tightly to identity, the pressure can be suffocating. A cycle that doesn’t take adds a specific kind of grief that most patients aren’t prepared for, and frankly, that we as clinicians don’t always handle well either. Counselling and psychological support are not add-ons in fertility care. They belong in the protocol. Patients who feel emotionally supported tend to do better on the medical side too.

Another important factor is costs. Costs are the part nobody likes to talk about. IVF in India is mostly paid out of pocket. I’ve sat across from couples who had to choose between a second cycle and their savings, sometimes more than once. Insurance coverage is patchy, and we badly need IVF models priced for middle-income families. Treatment should not depend on what someone can put on a card.

What medicine still can’t do

Science has come a long way, but success rates aren’t what patients expect when they walk in. Implantation failure, egg quality, and the steady decline with age, are real limits we run into every week. Women who delay parenthood, often for very good reasons, face a smaller ovarian reserve by the time they get to us. Sperm parameters have been declining globally for decades for reasons that aren’t fully understood. The work being done on genetics and the uterine microbiome is promising, but the embryo-endometrium relationship is still partly a black box.

New tools bring new questions. Gene editing and embryo selection are running ahead of the ethical frameworks meant to govern them. Surrogacy law in India has changed several times over the last decade. Donor anonymity rules are inconsistent across clinics. There is no settled framework for long-term embryo storage. As clinicians, we have to keep asking what we should be doing, not just what we can.

What is working

There are real reasons for optimism despite the many challenges and unknowns. AI tools in the lab are getting better at picking embryos with a high chance of implantation, and we have seen the difference in our success rates. Egg, sperm, and embryo freezing give younger patients a way to plan around their lives instead of against them. Combining medical treatment with attention to sleep, diet, and stress genuinely improves outcomes, not just patient comfort. Personalised protocols tuned to a couple’s specific history are slowly replacing the one-protocol-for-everyone approach most of us were trained on.

What’s needed now

Science has to keep advancing, but it has to be priced so families can actually afford it. Care has to be compassionate without losing clinical rigor. Parenthood should not depend on a family’s income or on what society believes a family should look like.

Fertility treatment is technical work, but it is not really about the technology. It is about people who want children and the long, often painful road they walk to get there. The tools are improving. Access is improving, but more slowly. The emotional and ethical sides are where I think we have the most ground to cover.

(Dr. Richika Sahay Shukla is co-founder and medical director, India IVF Fertility. rshukla@indiaivf.in)