Recurrent implantation failure refers to failure to achieve a clinical pregnancy after transfer of at least four good-quality embryos in a minimum of three fresh or frozen cycles in a woman under the age of 40 years. The failure to implant may be a consequence of embryo or uterine factors. Thorough investigations should be carried out to ascertain whether there is any underlying cause of the condition. Ovarian function should be assessed by measurement of antral follicle count, FSH and anti-Mu¨llerian hormone. Increased sperm DNA fragmentation may be a contributory cause. Various uterine pathology including fibroids, endometrial polyps, congenital anomalies and intrauterine adhesions should be excluded by ultrasonography and hysteroscopy. Hydrosalpinges are a recognized cause of implantation failure and should be excluded by hysterosalpingogram; if necessary, laparoscopy should be performed to confirm or refute the diagnosis. Treatment offered should be evidence based, aimed at improving embryo quality or endometrial receptivity. Gamete donation or surrogacy may be necessary if there is no realistic chance of success with further IVF attempts.

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Obesity can affect ovulation and the chances of pregnancy. In this prospective study, a weight loss programme was assessed to determine whether it could help infertile overweight anovulatory women to establish ovulation and assist in achieving pregnancy, ideally without further medical intervention. The subjects acted as their own historical controls. They underwent a weekly programme of behavioural change in relation to exercise and diet over 6 months; those who did not complete the 6 months were treated as the comparison group. Women in the study group lost an average of 6.3 kg, with 12 of the 13 subjects resuming ovulation and 11 becoming pregnant, five of these spontaneously. Fitness, diet and psychometric measurements all improved. Fasting insulin and testosterone concentrations dropped significantly, while sex hormone binding globulin concentrations rose. None of these changes occurred in the comparison group. Thus, weight loss with a resultant improvement in ovulation, pregnancy outcome, self-esteem and endocrine parameters is the first therapeutic option for women who are infertile and overweight.

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