IVF Add-Ons: What the Randomized Trials Actually Found

For most people, mostly not. The UK fertility regulator, the HFEA, rates none of the common add-ons green for improving the chance of having a baby, and it rates several — PGT-A, endometrial receptivity testing, steroids and IVIG — red, meaning they may lower your chances or carry safety concerns.

The one add-on with moderate-quality evidence of a real, if small, benefit is hyaluronan transfer medium, often sold as embryo glue — and it raises the chance of twins when more than one embryo is transferred. The HFEA's own advice to people paying for treatment is to consider whether the money would do more as another cycle of proven treatment than as extras on one cycle.

After a failed cycle, "anything that might help" is a hard offer to turn down. That is exactly why it is worth knowing what each extra has actually been shown to do before you pay for it.

The HFEA's Scientific and Clinical Advances Advisory Committee rates each add-on on the published evidence, and reviews a rating when new evidence appears or at least every five years. Five colours are used:

• Green — high-quality evidence that it works.
• Amber — conflicting moderate or high-quality evidence; some trials positive, some not.
• Grey — not enough moderate or high-quality evidence to rate it.
• Black — moderate or high-quality evidence that it makes no difference.
• Red — safety concerns, or evidence that it may reduce the chance of success.

A UK rating is useful in India because the trials behind it are international and the biology is the same. We have not found an Indian body that grades add-ons this way. What Indian law does do is require every clinic to tell you the advantages, disadvantages, cost, side effects and risks of each procedure, including the risk of multiple pregnancy (ART Act 2021, section 21(c)) — so you are entitled to ask for this in writing.

PGT-A (embryo chromosome screening). Rated red for the chance of a baby for most patients, because it often leaves fewer embryos to transfer and can lengthen the time to a birth. In the largest trial, 1,212 women aged 20 to 37 with at least three good blastocysts had a cumulative live birth rate of 77.2% with PGT-A against 81.8% without it. ASRM's 2024 committee opinion says its value as a routine screening test "has not been demonstrated". More on this in our PGT-A article and on the PGT-A treatment page.

Two caveats keep this honest. The HFEA rates PGT-A green for reducing miscarriage — in that trial pregnancy loss was 8.7% against 12.6% — but notes that fewer miscarriages need not mean more babies; ASRM calls the miscarriage benefit unclear. And for older women the HFEA rating is grey: there is not enough good evidence either way. In India, section 25 of the ART Act also says pre-implantation genetic testing "shall be used to screen the human embryo for known, pre-existing, heritable or genetic diseases only" — ask any clinic offering PGT-A how it applies that in your case.

Endometrial receptivity testing (ERA). Rated red. A double-blind trial of 767 patients transferring a single tested embryo found live birth in 58.5% of transfers timed by the test against 61.9% with standard timing. It also needs a womb-lining biopsy and a freeze-all cycle. ESHRE's 2023 recommendations: the available tests are not recommended.

Steroids and IVIG for the immune system. Both rated red because of safety concerns, and ESHRE does not recommend them. The HFEA notes that blood NK-cell tests measure cells in the blood, not the womb, and "offer no useful information" about pregnancy. This does not apply to anyone with a diagnosed immune disease, whose treatment should continue under their own specialist.

Time-lapse imaging. Rated black. The TILT trial randomised 1,575 patients: live birth was 33.7% with time-lapse imaging and 33.0% with standard care. It appears to be safe; it is simply not shown to add babies. Details in our review of TILT.

PICSI (hyaluronan-selected sperm). Rated black for couples having ICSI for male-factor infertility. In a trial of 2,752 couples, term live birth was 27.4% with PICSI and 25.2% with ICSI (odds ratio 1.12, 95% CI 0.95 to 1.34). A 2026 Cochrane review found it probably reduces miscarriage; the HFEA rates that benefit grey — too little evidence — for women over 35.

Embryo glue (hyaluronan-enriched transfer medium). The add-on most often dismissed alongside the others, and the one that does not belong with them. The 2020 Cochrane review pooled 10 trials of 4,066 participants and found it probably increases live birth (RR 1.21, 95% CI 1.10 to 1.31; moderate-quality evidence): if 33 in 100 would have a baby without it, between 37 and 44 would with it. ESHRE 2023 recommends it, while noting the effect was seen after fresh transfers and not frozen ones. The HFEA rates it amber.

The catch is twins. The same review found multiple pregnancy rose too (RR 1.45, 1.24 to 1.70), probably because many trials transferred more than one embryo. ESHRE's advice is to pair it with single-embryo transfer.

Endometrial scratching. Rated amber for IVF and ICSI, and grey for recurrent implantation failure. The largest trial, 1,364 women, found live birth of 26.1% in both groups. ESHRE does not recommend it routinely; it can be painful and carries a small infection risk. See our review of that trial.

Grey does not mean harmless or useless. It means nobody can yet say, which is different from the confidence with which these are usually offered.

• Assisted hatching, including laser hatching. Cochrane 2021: live birth OR 1.09 (0.92 to 1.29) across 14 trials, low-quality evidence, with a possible rise in multiple pregnancy. ESHRE does not recommend it. See the laser-assisted hatching page.
• IMSI (high-magnification sperm selection). Cochrane 2020: live birth RR 1.11 (0.89 to 1.39) across 929 couples, very low-quality evidence. ESHRE: not for routine use.
• Intralipids. Two trials of 244 patients gave an uncertain result; ESHRE does not recommend them and lists serious reported side effects.
• Sperm DNA fragmentation testing. ESHRE does not recommend routine testing. The HFEA notes there is no agreed method or cut-off, and rates the treatments that usually follow a high result — antioxidants, sperm sorting — grey, and switching to testicular sperm red. More in our DNA fragmentation article.

Ask, in writing, before you agree. The ART Act already obliges the clinic to explain advantages, disadvantages, cost and risks, so these are not awkward questions:

1. Why is this recommended for me specifically, and what is the HFEA rating for it?
2. What did the largest randomised trial find for live birth — not pregnancy tests or implantation?
3. What does it cost, and is it itemised separately on my quote?
4. What would change if I declined it?

Then weigh the money. An ICMR study of 148 couples at five tertiary hospitals found an average out-of-pocket spend of ₹2,30,668 per IVF cycle in private hospitals and ₹1,10,104 in public ones, with drugs the largest share. Add-ons sit on top of that. The HFEA and other UK bodies agreed in October 2023 that unproven treatments should be offered only within research, without an extra charge.

Sometimes the honest answer is that nothing extra is needed — or that the question is about testing, timing or a simpler treatment rather than more technology. Our guides to IVF costs in India and choosing a clinic cover the rest of the quote.

A disclosure: IVF Pulse runs fertility clinics in Bangalore and publishes treatment pages for PGT-A and assisted hatching. The ratings and trial results above apply to those as much as to anyone else's.