IVF Add-Ons Evidence Scorecard
The IVF cycle itself follows a well-established protocol. What varies, sometimes dramatically, is the menu of add-on technologies offered on top of it. Some add-ons have robust evidence behind them. Others are biologically plausible but unproven. And some are marketed to patients at a time when they are most vulnerable to "anything that might help."
This scorecard evaluates each common add-on against the same standard: is there randomized controlled trial evidence showing an improvement in live birth rates?
The Scorecard
| Add-On | What It Does | Evidence Level | Typical Added Cost | Worth Considering? |
|---|---|---|---|---|
| ICSI | Injects single sperm into egg | Strong | $1,500 to $2,500 | Yes, for male factor or prior fertilization failure |
| PGT-A | Screens embryo chromosomes | Strong | $3,000 to $6,000 | Yes, for age 37+, recurrent loss, or prior failures |
| Endometrial scratch | Intentional uterine injury before transfer | Moderate (negative) | $200 to $500 | No. Large RCTs found no benefit; may worsen outcomes |
| EmbryoGlue | Hyaluronan-enriched transfer medium | Moderate | $200 to $400 | Low cost, modest evidence; reasonable |
| Time-lapse (EmbryoScope) | Continuous embryo monitoring | Moderate | $500 to $1,500 | Better data for embryo selection, not proven to improve LBR |
| Assisted hatching | Thins/breaches zona pellucida | Weak | $300 to $700 | Only with thick zona or advanced age; not routine |
| PICSI | Selects sperm by hyaluronan binding | Moderate | $300 to $600 | Some RCT evidence for reducing miscarriage; promising |
| Zymot | Microfluidic sperm selection | Emerging | $300 to $500 | Biologically plausible; limited clinical trial data |
| Intralipid infusion | Immune modulation | Insufficient | $400 to $800 | Not supported by current evidence; not recommended routinely |
| PRP (uterine) | Platelet-rich plasma into uterine cavity | Emerging | $500 to $1,500 | Thin lining cases only; evidence incomplete |
| Growth hormone | Adjunct during stimulation | Moderate | $500 to $2,000 | Limited to poor responders; not for routine use |
The Add-Ons with the Strongest Evidence
ICSI
Intracytoplasmic sperm injection is the most established "add-on," though it is so widely used that many clinics consider it standard. It was developed for severe male factor infertility and is clearly beneficial in that context. Its use has expanded to include all IVF cycles at many clinics, even with normal sperm parameters, though the evidence for universal ICSI is debated.
PGT-A
Preimplantation genetic testing for aneuploidy reduces the per-transfer miscarriage rate and improves the per-transfer live birth rate by selecting chromosomally normal embryos. The debate is about whether it improves cumulative live birth rate per retrieval cycle, since it removes embryos that might have self-corrected (mosaics) or been normal (biopsy error).
The Add-Ons to Be Cautious About
Endometrial Scratch
Once widely offered based on a promising initial study, endometrial scratching has not held up to rigorous testing. The largest RCT (over 1,300 patients) found no improvement in live birth rates, and a trend toward worse outcomes. Most guidelines now recommend against routine scratch.
Immune Treatments
Intralipid infusions, IVIG, steroids, and other immune-modulating treatments are offered by some clinics for patients with recurrent implantation failure. The rationale is that the immune system may be "rejecting" the embryo. The evidence for this hypothesis, and for the treatments based on it, is insufficient for routine clinical use.
How to Navigate the Menu
Three questions to ask about any proposed add-on:
- Is there a randomized controlled trial showing this improves live birth rates (not just clinical pregnancy rates)?
- Is this recommended for my specific situation, or is it offered to all patients at this clinic?
- What does it add to the cycle cost, and is there a cheaper alternative with the same evidence base?
A clinic that answers these questions openly and tailors add-ons to individual clinical needs, rather than offering a fixed package, is one that prioritizes evidence over revenue.
Frequently Asked Questions
What are IVF add-ons?
Add-ons are supplementary techniques or products offered alongside a standard IVF cycle. They range from well-studied interventions like ICSI and PGT-A to emerging technologies like time-lapse incubation and EmbryoGlue. They always add cost.
Does EmbryoGlue improve IVF success rates?
EmbryoGlue (hyaluronan-enriched transfer medium) has been studied in several trials. A Cochrane review found a modest improvement in clinical pregnancy rate, but the quality of evidence was rated low to moderate. It is relatively inexpensive, which shifts the cost-benefit calculation.
Is time-lapse incubation worth the extra cost?
Time-lapse (EmbryoScope) allows continuous monitoring without removing embryos from the incubator. While it provides more embryo development data, randomized trials have not consistently shown improved live birth rates compared to standard incubation with equivalent embryo selection.
What about assisted hatching?
Assisted hatching (thinning or breaching the embryo's outer shell before transfer) was originally developed for patients with thick zona pellucida. A Cochrane review found a possible small increase in clinical pregnancy rate but no significant difference in live birth rate. ASRM guidelines do not recommend routine use.
How do I decide which add-ons to accept?
Ask your clinic three questions about each: Is there a randomized controlled trial showing improved live birth rates? How much does it add to the cycle cost? And would you recommend this for my specific clinical situation, or is this offered to all patients?
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