When is enough enough? Deciding to end fertility treatment

“One more time. Then we stop.”

The first time they said it was two years ago, in the car park outside the hospital, with the test results in the glove compartment. The second time was last year, driving home in silence after a failed embryo transfer. The third time was last week. And both of them knew what neither said out loud: that “one more time” was no longer a plan, but a way of avoiding the question nobody wants to ask. When is enough enough?

This post isn’t about when you should stop. Nobody on the outside can tell you that — not a doctor, not a therapist, not your mum telling you “you mustn’t give up”. It is about why this decision is so hard, everything that ends with it, and how you can approach it in a way that won’t tear you apart — neither you nor your relationship.

Why there’s no right moment

Most treatments have a natural end. You take antibiotics for ten days, a wound heals, physiotherapy runs its course. Assisted reproduction has no natural end. There is always another attempt, another option, another test that might reveal what went wrong. Medicine keeps moving forward, and every advance is both a source of hope and one more reason not to stop.

That’s why people often don’t decide to end treatment so much as have it happen to them: the money runs out, the body says no, a doctor says there are no more options, or they simply can’t carry on. A study by Christina Olivius and colleagues in Sweden followed couples whose public health system covered three cycles of IVF. Many couples stopped before they had used all the funded attempts — and the most common reason wasn’t money or a poor prognosis, but the psychological burden of treatment. A later systematic review by Sofia Gameiro and colleagues found a similar picture: psychological and relational strain is among the most common reasons people stop.

This matters for two reasons. First: if you feel you can’t go on, you aren’t weak — you are in very large company. Second: when the decision makes itself, out of exhaustion, it is often harder to come to terms with later than one you take with your eyes open. I wrote about everything treatment asks of body and mind in Assisted reproduction and its emotional cost.

Everything that ends when treatment ends

When people talk about ending treatment, it sounds as though it’s only the treatment that ends. In reality, much more does.

• Hope in a particular form. Not necessarily hope for a child, but hope that this particular path would lead to one.
• The structure of your life. Years divided into cycles, appointments and waiting for results suddenly lose their rhythm.
• The plan. A picture of the future you may have carried since the early years of your relationship.
• The relationship with the clinical team. People who knew you in your most vulnerable moments are no longer part of your life.
• A role. You were a couple who was fighting. Who are you now?

Pauline Boss coined the term ambiguous loss for losses without a clear ending. Infertility is a typical example: you aren’t grieving someone who has died, but someone who never was. Ending treatment gives this loss a shape — which is both a relief and a new kind of pain. I have also written about how it hurts when life doesn’t unfold the way you imagined in The loss of a plan.

The fear of regret

When I ask people what keeps them in treatment long after they feel they can’t go on, the answer is often the same: “What if the next one is the one that works?” The thought is understandable. But it has a trap: because another attempt is always possible, regret is always possible too. Carrying on can’t remove it — it can only postpone it.

Regret is an emotion we fear more than we actually experience it. Daniel Gilbert and colleagues showed in a series of experiments that we tend to overestimate how bad it will be and underestimate how well we can come to terms with an outcome. That doesn’t mean there will be no regret. It does mean it won’t necessarily look the way you picture it today, in the middle of exhaustion.

Research on how people live in the years after unsuccessful treatment is fairly reassuring, with one important caveat. In a meta-analysis, Gameiro and Finnigan found that most people who remain without children adjust well in the long term, although on average they fare somewhat worse than those who became parents. A Dutch study that followed women for more than a decade after treatment showed something I think is crucial: poorer mental health was linked less to whether they had a child than to whether the wish for a child remained open. Women who managed to let go of the wish and set themselves other goals were better off.

So the end of treatment is not necessarily the end of a good life. It is harder when treatment ends but the wish is left with nowhere to go.

When partners aren’t in the same place

Rarely do both partners feel at the same time that it’s enough. Often one has been worn out for months while the other would try once more. One is thinking about adoption, the other doesn’t want to hear about it. The woman often carries the physical side of treatment, while the man may feel he has no right to say he can’t go on — after all, “he’s not the one getting the injections”.

Here is how a conversation might sound when these differences first come to the surface (composite, not a real person):

“We said this one would be the last.”
“I know. But the doctor said we still have one more option.”
“You want to try again?”
“I don’t know if I want to. I’m afraid that in ten years I’ll think we gave up too soon.”
“And I’m afraid that in ten years I won’t know you any more if we carry on like this.”
A long silence. “You’ve never told me that.”

Nobody in this short exchange is wrong. Both are talking about fear — just each about a different one. And only once the second fear is spoken can the conversation shift from “once more or not” to the question of what each of them is really protecting.

When partners grieve differently, it is often a source of misunderstanding rather than a sign that they don’t understand each other. I wrote more about this in Grieving as a couple.

A decision isn’t a single moment

Many people wait for a clear moment when they’ll just know. Often it doesn’t come. Instead there are months when one day you feel it’s enough and the next that stopping now would be a betrayal. That isn’t indecisiveness. It’s ambivalence: you want two opposite things at once, and both are real.

It helps to break the decision into smaller steps that aren’t final:

• A pause with a deadline. “We won’t do anything until spring. Then we’ll talk again.” A pause isn’t an ending, but it creates space in which you can see what life without treatment feels like.
• A limit set in advance. A number of attempts, an amount of money or a date you agree on before starting the next round — not in the middle of disappointment.
• A change of path. For some couples, the end of treatment is the beginning of thinking about adoption or a different kind of family; for others, the beginning of life without children.

If you notice you’ve been discussing the decision for a year and are still in the same place, it may no longer be deliberation but a way of avoiding the decision. I wrote about this in Decision paralysis: when thinking it over becomes a way of avoiding.

Questions for your doctor — not for me

Part of the decision is medical, and no conversation with a therapist can replace it. Talk to your gynaecologist or fertility clinic about your realistic chances, what another attempt would mean for your body, and what other medical routes exist.

It helps to go into that conversation prepared. Write your questions down beforehand, because in the consulting room they often slip your mind. For example: given everything we know, how do you rate my chances with the next attempt? Is there anything we could still change? What would you advise if you were in my place, and why? And if your partner can, they should come too — so that afterwards you don’t have two different memories of the same conversation.

The European Society of Human Reproduction and Embryology (ESHRE) guideline on psychosocial care in infertility recommends that clinical teams support people at every stage of treatment, including when it ends. If you need to talk about this, don’t hesitate to ask.

Exercise: two letters from the future

This exercise is meant for couples, but you can also do it on your own. Set aside an hour when nothing is rushing you.

1. Each of you picks a point in the future — say, five years from today. Write separately, without conferring.
2. Write the first letter from a future in which you carried on with treatment — whatever the outcome. What were those years like? How were you? What do you feel when you look back?
3. Write the second letter from a future in which you ended treatment now. What did you do instead? What do you miss? What were you spared?
4. In both letters, underline the sentences that hurt and the ones that brought you calm. Don’t think about why — just underline.
5. Read only the underlined sentences to each other. Don’t try to persuade or correct each other. At the end, each of you says only what you heard and what surprised you.

The exercise won’t make the decision for you. But it often shows where you are closer than you thought — and where each of you stands on your own bank, in ways you haven’t yet told each other.

After the end: grief others can’t see

When treatment ends, the people around you often expect things to get easier. “At least there are no more injections.” “Now you can focus on yourselves again.” There is some truth in that: many people feel relief after deciding. And then they feel ashamed of the relief — as if feeling it betrayed the child who never was.

Relief and sadness aren’t opposites. You can feel both on the same day, even in the same hour. Grief after the end of treatment often goes unacknowledged — because there is no one to grieve for in a way others would recognise. More on this in The grief nobody acknowledges.

Nor does grief move through neat, consecutive stages. It comes in waves that return with dates, news and gatherings. I explained why the idea of stages of grief doesn’t hold in The stages of grief are a myth.

One of the things that helps most during this time is giving the grief a shape. Some couples create a small ritual: a letter to the child who never was, a tree in the garden, a trip to a place that matters to them. Others throw away or pack up the box of medication and test results. A ritual doesn’t end the grief, but it gives it somewhere to go.

When a decision isn’t the answer

So far I’ve written as if the decision to end treatment is something to be made consciously and as soon as possible. That isn’t always so.

First: if you feel you have to stop now, this very moment, it’s worth checking whether exhaustion or depression is doing the talking. Decisions made in the depths of distress are sometimes right — and sometimes they are an escape from pain that would be better lived through first. In that case, a pause is better than a final decision. If you notice that you aren’t sleeping, that nothing gives you pleasure, or that thoughts are appearing that it would be better if you weren’t here, talk to your doctor or see a psychiatrist. If the thoughts are serious, in Slovenia you can call the crisis line Klic v duševni stiski on 01 520 99 00 (from 7 pm to 7 am), the Samaritans helpline in Slovenia on 116 123 (24 hours), or in an emergency 112.

Second: sometimes the decision isn’t yours. Medical reasons can end treatment before you are ready. Then the question isn’t “is it enough”, but how to live with a decision you didn’t choose. That is a different and often harder path.

Third: some people never feel ready. That isn’t a failure. Enough can also be quiet, without any sense of certainty — simply the fact that you reached a point where you could say “this is where we stop”.

And fourth: not every couple needs therapy to get through this. Many manage with each other’s help, with friends, with support groups. Therapy is one option, not a precondition.

How therapy can help

In relational family therapy, in which I am training, we never see decisions about children as decisions of two people alone. Each one also carries the voices of parents and grandparents, messages about what it means to be a woman, a man, a family. Sometimes it turns out that “we mustn’t give up” is not so much your own voice as the voice of someone you have carried with you since childhood. Once you recognise it, the decision often becomes easier — not because it gets simpler, but because it becomes more your own.

A longer session with a genogram, such as A Look into the Past, can also help: together we look at how your family has spoken, across generations, about children, losses and when enough is enough. I also work with English-speaking clients, in person in Ljubljana.

If you have already made the decision and are wondering how to go on, there is a post on Life without children: chosen and unchosen. And you’ll find a short explanation of why infertility weighs so heavily in the knowledge base under infertility and distress.

What to remember

• Fertility treatment has no natural end, which makes deciding to stop harder than with most other treatments.
• Psychological burden is among the most common reasons people end treatment — if you can’t go on, you are not alone.
• Carrying on can’t remove regret, only postpone it. In the long run, whether the wish finds a place matters more than whether treatment continues.
• A decision isn’t a single moment: a pause with a deadline, a limit set in advance and talking about both partners’ fears all help.
• After the end, relief and sadness can coexist — and both are fine.