IVF add-ons: what the evidence really says

This is a sensitive subject for someone who works with clinics. I’m addressing it anyway, because every year I see patients exhaust their budget on add-ons, only to run out of money for an additional embryo transfer – one that would actually have improved their chances.

How to assess an add-on

The only question that matters is: does it increase the live birth rate, in randomised trials, for patients like you? Not the ‘positive test’ rate, not the ‘perceived embryo quality’, not the doctor’s impression. Two European references summarise the evidence:

• the ESHRE, which published good practice guidelines in 2023 covering more than forty options;
• the HFEA, the UK regulator, which classifies each option by colour: green (effective), yellow (conflicting evidence), grey (insufficient evidence), black (no effect), red (possible risk or negative effect).

To date, no option has been classified as green by the HFEA.

The table, option by option

• Time-lapse (incubator with camera): an excellent laboratory tool, but with no proven increase in live births. HFEA: black. ESHRE: not recommended as routine practice.
• Embryo glue (hyaluronic acid-enriched medium): some meta-analyses suggest a small benefit, whilst others do not. HFEA: yellow. As it is inexpensive, its use may be considered.
• Endometrial scratching: the large New Zealand trial published in the New England Journal of Medicine in 2019 found no benefit. HFEA: yellow. ESHRE: not recommended.
• Endometrial receptivity test (ERA): the highest-quality studies have shown no benefit. HFEA: red. ESHRE: not recommended.
• PGT-A: does not increase the number of births per egg retrieval and may result in viable embryos being discarded; it is mainly considered for women aged 38–40 and over. HFEA: red. See the detailed article.
• Assisted hatching: no demonstrated benefit in terms of births. HFEA: grey.
• IMSI, PICSI: sperm selection, with no demonstrated benefit in routine use. See ICSI or conventional IVF.
• Immunotherapies (intralipids, immunoglobulins, corticosteroids): not recommended by the ESHRE, with possible adverse effects. HFEA: red for immunoglobulins and corticosteroids.
• Ovarian or endometrial PRP: restricted to research according to ESHRE. See the article on PRP.
• Growth hormone, DHEA in poor responders: not routinely recommended.
• Systematic ‘freeze-all’: no overall benefit, but useful where there is a risk of hyperstimulation. HFEA: yellow.

The rare situations in which an add-on is justified

Certain techniques have a genuine, specific indication: artificial egg activation following a complete failure of fertilisation, hysteroscopy in cases of repeated implantation failure, and PGT-M for a known genetic disorder. The difference is simple: we are addressing a specific problem identified in your case history, not a general concern.

Why are these options so widespread?

Because they meet a real need: to do everything possible. Because they are profitable. And because a clinic that does not offer them fears appearing less modern than its neighbour. None of this makes them treatments.

The right questions to ask

1. What specific problem in my medical history is this option supposed to resolve?
2. What is its effect on the birth rate, and where does this figure come from?
3. How much does it cost, and is it optional?
4. Would my budget be better spent on a transfer or an additional cycle?

A doctor who answers these questions clearly – including by saying ‘this option isn’t useful for you’ – is a doctor you can trust. This is, in fact, one of the criteria I recommend when choosing a clinic.

Frequently asked questions