What UK Data on IVF “Add-Ons” Reveal About US Utilization
While the UK curbs unnecessary IVF ‘add-ons,’ US clinics continue to embrace them—often at patients’ expense.
Historically, the UK has been much more disciplined than the US in regard to “add-ons” (a term originally coined by British colleagues) to IVF. The country, for example, still uses much less preimplantation genetic testing for aneuploidy (PGT-A) than the US. Yet a recent survey revealed that almost three out of four British IVF patients in 2024 utilized at least one supposedly useless “add-on” in their last IVF cycle.
As Ron Shinkman in an August 21, 2025, mailing of Inside Reproductive Health noted,¹ his report was based on data collected by the local government-linked authority supervising IVF practice in the UK, the Human Fertilisation and Embryology Authority (HFEA), as part of its annual survey of fertility patients, which interviewed 1,500 patients and their partners. HFEA is, in general, much more active in its supervisory activities than the CDC and FDA in the US, and, indeed, going back to 2017, has been very actively discouraging “add-ons.” More specifically, as the heading of Shinkman’s article noted, “73% of UK IVF patients in 2024 paid for unproven ‘add-ons.’”
The report, however, must be consumed with caution because HFEA considers some treatments to be unvalidated “add-ons,” which others may consider validated to at least acceptable degrees in some patients, including, for example, androgen and growth hormone supplementations, acupuncture, and so-called EmbryoGlue. Remarkably, only 13.5% of UK patients used PGT-A (in the US, recent usage likely exceeded 50% of all IVF cycles, including donor egg cycles. Accurate data for 2024 will not be available until 2026 at the earliest. Yet even these 13.5% represented almost a doubling in rate from 2021, when the rate used to be only 7%.
Interestingly, the utilization of one “add-on,” endometrial scratching, significantly declined from 24% in 2018 to only 10.3% in 2024, even though at least one recent meta-analysis, to everybody’s surprise, actually supported the use of scratching.² HFEA rated scratching “amber,” suggesting that “on balance it is not clear whether this ‘add-on’ improves IVF outcome.”
The survey also revealed that roughly 60% of patients believed that what HFEA calls unproven “add-ons” would improve IVF outcomes and chose to use them because their IVF clinics often recommended them with the assurance that the “add-on” would improve their IVF cycle outcome chances.
“Add-ons” have, of course, been a common theme in the VOICE for many years, but – considering all of these data were generated by HFEA, it is important to restate how the CHR views the use of so-called “add-ons:” (i) The CHR, of course, in principle fully agrees that any diagnostic test and any treatment recommended to a patient should have a clearly outline purpose and should be able to favorably withstand a risk benefit analysis. The CHR, however, also realizes that—like in any medical specialty—only roughly 10% clinical practice is based on clearly established high-quality evidence³ (and, as a general principle of medicine, even that evidence can be expected to change over time).
Moreover, what is one person’s “evidence” may be another person’s “garbage science.” As a recently published Review article on the subject noted,⁴ evidence can be stratified into six levels (see below). So, one must ask which level(s) of evidence HFEA, therefore, was using in determining its grading system?
Level IA evidence is obtained from a meta-analysis of multiple well-conducted and well-designed randomized trials. Randomized trials provide some of the strongest clinical evidence, and if these are repeated and the results are combined in a meta-analysis, then the overall results are assumed to be even stronger.
Level IB evidence is obtained from a single well-conducted and well-designed randomized controlled trial. When well-designed and well-conducted, the randomized controlled study is a gold standard for clinical medicine.
Level IIA evidence is from at least one well-designed, executed, non-randomized controlled study. When randomization does not occur, there may be more bias introduced into the study.
Level IIB evidence is from at least one well-designed case-control or cohort study. A randomized controlled study cannot effectively or ethically study all clinical questions.
Level III evidence is from at least one non-experimental study. Typically, it would include case series, not well-designed case-control or cohort studies.
Level IV includes expert opinions from respected authorities on the subject based on their clinical experience.
Moreover, the evidence discussion as currently held in the medical literature, in the CHR’s opinion, overlooks one very important issue, and that is cost.
As levels of evidence are currently used (including, we assume, by HFEA), they apply whatever the costs of the “add-on.” So, for example, the costs of an acupuncture treatment are only a small fraction of the costs of utilizing PGT-A in an IVF cycle or utilizing an all-freeze policy that mandates an additional IVF cycle. Both of these treatment choices add significant costs to already too expensive IVF cycles (not even considering the additional costs from automatically having to culture all embryos to blastocyst-stage, cryopreservation and storage costs, etc.)
Or—as another example demonstrates well—supplementation with dehydroepiandrosterone (DHEA) for hypo-androgenism costs pennies in comparison to supplementing with human growth hormone, both by HFEA, however, judged equally in their assessment of appropriateness. In the US, some of the most aggressive deniers of, for example, androgen supplementation in hypo-androgenic women and/or immunological treatments in women with hyperactive immune systems, are among the most aggressive proponents of PGT-A utilization. Androgen supplementation and most immune treatments, indeed, cost pennies in comparison to PGT-A.
Obviously, at least in the CHR’s opinion, a more expensive remedy, assuming everything else being equal, receiving more scrutiny makes sense (i.e., having to offer a better level of evidence before clinical utilization than a cheaper medication). The use of HGH, therefore, should receive more scrutiny than supplementation with DHEA.
In other words, if a remedy or a test is dirt-cheap and creates no risk for the patient, offering it to a patient under more questionable circumstances (of course, with full transparency and disclosure) may, therefore, at times appear appropriate, even if the beneficial effects of the treatment are more questionable. But if the same treatment carries with it significant additional costs, such use in the CHR’s opinion would likely be inappropriate (patients, of course, do often have a right to receive treatments “against medical advice” if full disclosure is documented).
But why some “add-ons” remain so popular, even if significantly adding to IVF cycle costs, has remained largely unexplained. PGT-A demonstrates this fact better than likely any other “add-on” because researchers—among them several at the CHR—have so convincingly accumulated extremely convincing evidence of PGT-A not fulfilling any of many promised and still widely advertised alleged outcome benefits for IVF that even ASRM and SART finally dismissed (after over 20 years of PGT-A use) by stating in formal Practice Committee Opinions that not a single outcome benefit has really been established for PGT-A⁵ (see in that regard also the following commentary).
Which brings us back to the HFEA report and what we actually consider its likely most telling finding: As already noted above, ca. 60% of UK women who resorted to the utilization of “add-ons” did so in part because their IVF clinic recommended it, as it would increase their chance of having a baby.”¹
It, therefore, seems reasonable to assume that the reason why PGT-A utilization in US IVF clinics is so much higher than in the UK and is still increasing despite so much accumulating hard evidence against its use is primarily driven by what patients hear from providers in their IVF clinics. And that, of course, raises the even bigger question: What motivates IVF clinics in continuing to push for more and more PGT-A utilization (in the US, even donor egg cycles using young healthy egg donors often utilize PGT-A).
And the answer appears obvious! Don’t you think so?
References
Shinkman R. Inside Reproductive Health. August 21, 2025. https://www.fertilitybridge.com/news-articles/ivf-unproven-add-ons-uk-hfea-patient-survey
Chrysoula Iakovidou et al., Reprod Biol Endocrinol 2023;21:89
Howick J. Science Alert. September 3, 2020. https://www.sciencealert.com/around-90-percent-of-your-medical-treatments-isn-t-backed-by-high-quality-evidence
Tenny S, Varacallo MA. National Center for Biotechnology Information. Updated September 10, 2024. https://www.ncbi.nlm.nih.gov/books/NBK470182/
Practice Committees of ASRM & SART. Fertil Steril 2024;122(3):421-434