Recurrent implantation failure (RIF) is one of the most-cited yet least-defined entities in reproductive medicine. The literature contains hundreds of distinct definitions, and a substantial proportion of patients labelled as RIF may represent statistical artefacts rather than a persistent endometrial pathology. The lecture offers a critical re-examination.
Reviews of the field have identified more than 600 distinct RIF definitions across publications. Without a unified definition there can be no comparable trials, no clean clinical recommendations and no consistent prescribing. The widely-cited «three failed transfers» rule ignores age and ploidy — the dominant predictors of implantation success.
Data from large cohorts of serial euploid embryo transfers consistently show cumulative success rates approaching 95–98% across three to four transfers. A persistent endometrial factor is incompatible with this pattern. True biological RIF is therefore likely to occur in less than 5%, and probably less than 2%, of well-counselled couples.
Two complementary consensuses appeared in 2023: ESHRE focuses on clinical practice (60% cumulative-chance threshold), Lugano focuses on research (95% threshold). Both converge on the same conclusion: routine add-ons (anticoagulants, corticoids, antibiotics, endometrial scratch) lack proven efficacy and should not be applied indiscriminately.
Patient drop-out from ART is driven by misaligned expectations more than financial barriers. Counselling patients with cumulative-probability tables, performing diagnostic work-up before the first cycle (not after a setback), and treating failure as data rather than as defeat are the most impactful clinical interventions available today.
Is recurrent implantation failure a distinct clinical entity — or a statistical artefact created by the absence of a unified definition? Data on cumulative pregnancy and live birth rates across serial euploid embryo transfers, plus consensus algorithms (ESHRE 2023, Lugano 2023) for diagnosis, work-up and management.
Is recurrent implantation failure a distinct clinical entity — or a statistical artefact created by the absence of a unified definition? Data on cumulative pregnancy and live birth rates across serial euploid embryo transfers, plus consensus algorithms (ESHRE 2023, Lugano 2023) for diagnosis, work-up and management.
Replace single-cycle odds with age-adjusted cumulative success tables tailored to PGT-A status.
Use age-adjusted euploid transfer failure counts per current consensus, not the legacy 3-transfer rule.
Complete hysteroscopy and other investigations at intake, not after a setback, to protect the doctor-patient relationship.
Recognise that anticoagulants, corticoids, antibiotics and endometrial scratch lack proven efficacy.
Human reproduction specialist in Obstetrics and Gynaecology at Hôpital Foch (Paris), where he is clinical coordinator of the ART division. Certified in obstetrics, gynaecology and reproductive medicine, with a fellowship at IVIRMA (New Jersey). Associate Editor of Fertility and Sterility and author of more than 90 publications.
Author of the lecture "Recurrent implantation failure, reality or a statistical mirage?"
