IVF add-ons: are they supported by evidence?
Research Fellow, University of Melbourne, Australia
Progress Educational Trust09 August 2021
IVF add-ons are procedures, techniques or medicines which can be used in addition to standard IVF protocols. They are usually offered by IVF clinics, and used by patients, with the hope that they will improve the chance of IVF success.
Many different IVF add-ons are available, each proposed to somehow improve the fertility of the patients or the IVF process itself. Examples include: endometrial scratching (disrupting the endometrium prior to embryo transfer, hoping this might improve the chance of embryo implantation), EmbryoGlue (a special solution the embryo is dipped into before embryo transfer), and pre-implantation genetic testing for aneuploidy (screening of embryos for those with the wrong number of chromosomes). IVF add-ons may also be considered to include complementary therapies such as acupuncture and Chinese herbal medicine, and even nutritional supplements, such as vitamins or smoothies that are suggested to boost fertility.
The problem is, most of these IVF add-ons probably don't work. At least, we don't have any good evidence that they do. In a recent review, of 21 different add-ons available in Australia none was supported by 'high-quality evidence' of benefit i.e., that they improve the chance of getting pregnant and having a baby from IVF; three had moderate-quality evidence and two had low-quality evidence. For the remainder, the evidence was either very low quality, conflicting, or so imprecise that it was not possible to know whether the add-on is beneficial, harmful, or has no effect.
Despite a lack of good evidence, use of IVF add-ons is thought to be widespread – although there is little data on their availability and use. Most IVF registers around the world don't collect and report on IVF add-on use. We can learn a little about add-on availability from IVF clinic websites – what add-ons are offered and what they cost. Reviews of IVF clinic websites conducted by ourselves and others have shown that 80 percent of IVF clinics in the UK and Australasia offer IVF add-ons, and that these usually cost patients extra. However, this doesn't tell us whether add-ons are actually being used – just that they are available. We wanted information about the prevalence of add-on use, including those that might be accessed outside the IVF clinic. Therefore, we conducted an online survey to ask IVF patients in Australia about whether they had used add-ons. IVF is commonplace here, with Australia having one of the highest rates per capita in the world, and is mostly provided by large companies. We were predominantly interested in the prevalence and nature of IVF add-on use, the role of the clinician and patient in the decision-making, the sources of information used to support these decisions, and the importance of scientific evidence, all from the perspective of the IVF patient.
Our survey targeted women who had undergone IVF in Australia in the last three years. A total of 1590 responses were received. The headline result is that IVF add-on use is the norm: 82 percent of women had used at least one add-on during their IVF treatment in the last three years. The most commonly used add-on was acupuncture, accessed by a massive 45 percent of IVF patients specifically for the purposes of helping them with IVF. Another complementary therapy, Chinese herbal medicine, was also common – reported to have been used by 26 percent of women.
Women reported that usually they heard about IVF add-ons first from their treating fertility specialist, and that the specialist had been the one to raise the idea of using add-ons at their consultation. However, patients also tended to believe that the final decision to use the add-on was shared equally between themselves and their doctor. Women did not appear to suffer from particularly high levels of regret about the decision to use add-ons; however, regret was higher among those who did not conceive, or who thought their doctor had the biggest role in the decision to use add-ons.
Our survey found that add-ons cost patients extra 72 percent of the time. IVF add-ons can also be expensive, costing anywhere between a few dollars and a few thousand. PGT-A, testing embryos for the wrong number of chromosomes, costs approximately AU$700 per embryo, and the Endometrial Receptivity Analysis is a new test which costs approximately AU$3000. Some add-ons were often free, such as time-lapse imaging of embryos or EmbryoGlue. This is probably because these add-ons are used routinely at some IVF centres for all patients, and the costs may be absorbed by the clinic or built into the cost of IVF.
Patients reported to place high importance on scientific evidence that add-ons are effective and safe. However, we know that most add-ons are not supported by good evidence. Therefore, the fact that women view evidence as important, yet used many add-ons which are not supported by evidence, might suggest that they were not adequately informed about the evidence base before using the add-on. Initiatives are underway in many settings to help ensure patients are making informed decisions in the IVF clinic. The Human Fertilisation and Embryology Authority and the Fertility Society of Australia and New Zealand have both released guidance requesting for patients to be provided with adequate information about the benefits and risks of add-ons, and to provide written informed consent, to better ensure patients are making good decisions.
Reproduced with permission from BioNews, an email and online sources of news, information and comment on assisted reproduction and genetics.