IVF add-ons are optional extras sold on top of a standard cycle, such as embryo glue, time-lapse incubation, endometrial scratching, receptivity tests, immune treatments and platelet-rich plasma. They can add a lot to a quote. Two of the most careful reviews available, from the UK regulator and from Europe's fertility society, find that none of the common ones has high-quality evidence that it improves your chance of a baby.
This guide sets out the current HFEA ratings and ESHRE's 2023 recommendations side by side. It then covers the few situations where specific add-ons do have a recognized role, how bundled "premium" packages inflate quotes abroad, and what to ask before you pay.
Sources: HFEA treatment add-ons page1 and ESHRE good practice recommendations.2
How the HFEA rates IVF add-ons
The Human Fertilisation and Embryology Authority regulates UK fertility clinics. It rates add-ons with a color system based on whether they improve the chance of having a baby for most patients. Its expert advisory committee reviews the ratings, and the HFEA says it updates them when new evidence emerges or at least every five years.13 The current ratings were published in October 2023, and the page was last reviewed on 28 September 2026.1
| Rating | Meaning |
|---|---|
| Green | On balance, high-quality evidence shows the add-on is effective |
| Yellow | Unclear whether it is effective, because moderate or high-quality studies conflict |
| Grey | Cannot be rated, because there is not enough moderate or high-quality evidence |
| Black | On balance, moderate or high-quality evidence shows it has no effect on the outcome |
| Red | Potential safety concerns, and/or the evidence suggests it may reduce the chance of success |
Two details matter. The ratings are for most patients, so a specific group may still benefit. And the HFEA says a red rating does not automatically mean an add-on is unsafe or unsuitable for you. Its individual add-on pages explain the safety detail and sometimes rate other outcomes, such as miscarriage or OHSS.1
Common add-ons and their current HFEA ratings
These are the ratings shown on the HFEA's add-ons page as of its September 2026 review. Each is rated for its effect on the chance of a live birth for most patients.1
| Add-on | What it is | HFEA rating |
|---|---|---|
| Endometrial scratching | Deliberately irritating the womb lining before a cycle | Yellow |
| Embryo glue (hyaluronate-enriched transfer medium) | A culture medium used at transfer, meant to help implantation | Yellow |
| Elective freeze-all | Freezing all embryos and transferring in a later cycle | Yellow |
| Assisted hatching | Thinning or opening the embryo's outer shell before transfer | Grey |
| Time-lapse imaging and incubation | Incubators with cameras that photograph embryos as they develop | Black |
| Endometrial receptivity testing (such as ERA) | A biopsy to time transfer to a supposed implantation window | Red |
| Intralipid infusions | An immune treatment given by drip | Grey |
| IVIG (intravenous immunoglobulin) | An immune treatment made from donated blood plasma | Red |
| Steroids (glucocorticoids) | Immune-suppressing drugs such as prednisolone | Red |
| Platelet-rich plasma (PRP) | Concentrated blood platelets injected into the ovary or womb | Red |
| PGT-A | Testing embryos for chromosome number before transfer | Red |
| Androgen supplementation (DHEA, testosterone) | Hormone supplements before stimulation | Grey |
| IMSI | High-magnification sperm selection for ICSI | Grey |
| PICSI (for male factor) | Selecting sperm that bind to hyaluronan | Black |
| Sperm DNA fragmentation testing | A test of sperm DNA damage | Grey |
| Intrauterine culture | Placing early embryos in the womb in a device before transfer | Grey |
| Microbiome testing | Testing the bacteria of the womb or vagina | Grey |
The HFEA removed artificial egg activation with calcium ionophore from this rated list in October 2023.1 If a clinic abroad describes any of these as "proven" or "recommended for everyone", that does not match the UK regulator's reading of the evidence. For PGT-A specifically, see our guide on what to verify before paying for PGT-A abroad.
What ESHRE's 2023 add-ons recommendations say
In 2023 the European Society of Human Reproduction and Embryology published good practice recommendations on add-ons in Human Reproduction.24 The paper's stated goal was to make sure patients are fully informed about their options. It also notes that add-ons usually come at extra cost, and that the evidence behind them is limited.2 Coverage at the time summed up the message as insufficient evidence that most add-ons improve fertility.5 The recommendations are also listed on ESHRE's own guidelines site.6
Here are the positions we checked in the full paper:2
| Add-on | ESHRE position |
|---|---|
| Endometrial receptivity tests | Currently available tests are not recommended |
| Immune blood tests and uterine NK-cell testing | Not recommended |
| Immunomodulating treatments (Intralipid, IVIG, rh-LIF, PBMCs, anti-TNF) | Not recommended |
| Assisted hatching | Not recommended |
| PGT-A | Not recommended for routine clinical use |
| Growth factor-supplemented culture medium (GM-CSF) | Not recommended |
| IMSI, PICSI and MACS sperm selection | Not recommended for routine clinical use |
| Sperm DNA damage testing | Not recommended for routine clinical use |
| Screening hysteroscopy | Not recommended routinely; can be considered after recurrent implantation failure |
| Artificial oocyte activation | Not for routine use; recommended for specific fertilization failure situations |
| In vitro activation and mitochondrial replacement to improve egg quality | Not recommended |
We could not check every section of the ESHRE paper for this guide, including its positions on endometrial scratching, embryo glue, time-lapse, PRP and steroids, so those are not in the table. If a clinic offers you one of them, ask it to show you the relevant ESHRE recommendation alongside the HFEA rating above.
Where specific add-ons do have a role
"Not for routine use" does not always mean "never". ESHRE's paper names a few situations where a technique is reasonable for a defined group:2
- Artificial oocyte activation is recommended after complete fertilization failure (no fertilized eggs), very low fertilization (under 30%), or globozoospermia, a rare sperm defect.
- Screening hysteroscopy can be considered for people with recurrent implantation failure.
- Artificial sperm activation is recommended for total asthenozoospermia (no moving sperm) not caused by structural tail defects.
- Microfluidic sperm selection can be considered.
Freeze-all is another case where the reason matters. For most patients the HFEA rates it yellow. But clinics also use freezing for medical reasons, such as lowering OHSS risk, and the HFEA notes that individual add-on pages may rate outcomes other than live birth.1 Our guide to fresh vs frozen embryo transfer abroad covers when freezing changes travel plans.
The test is whether the clinic can name your specific reason, from your history or test results, and explain what evidence applies to people like you.
Why add-ons need extra scrutiny abroad
The HFEA ratings and UK consumer-law guidance apply to UK clinics. The HFEA also points to a consensus statement from 19 October 2023: treatments without strong evidence of safety or effectiveness should only be offered in a research setting, and patients should not be charged extra to take part in research.1 The UK's Competition and Markets Authority has also published consumer-law guidance for clinics treating self-funded IVF patients.7
When you travel, those protections usually do not follow you. Rules on what clinics can sell, how they price it, and what they must disclose vary by country. Even in the UK, press coverage reported a watchdog finding that private IVF patients were not always getting all the facts they needed to make informed decisions, and the CMA has published findings on how well clinics comply with consumer law.89 Abroad, with language barriers and less time to think, it is easier still to agree to extras you would have questioned at home.
A practical approach is to use the HFEA ratings and ESHRE recommendations as your yardstick wherever you are treated. They are public, current and free to check. Our guide on how to vet an IVF clinic abroad covers the other checks.
How bundling inflates IVF quotes
Add-ons rarely appear as a single line. They are often folded into tiers with names like "premium", "advanced" or "maximum success" packages. A higher tier may include time-lapse incubation, embryo glue, assisted hatching and PGT-A, all priced together. That makes it hard to see what you are paying for each item, and hard to drop the ones you do not want.
A quote that hides add-ons
- One package price with a long list of "included technologies"
- Add-ons presented as standard practice
- No price for the package without them
- Success claims attached to the premium tier
A quote you can compare
- Base cycle priced on its own
- Each add-on as a separate line with its own price
- A clear statement of which add-ons are optional
- The clinic's reason for each add-on in your case
The HFEA's advice to self-funding patients is worth repeating: treatment without add-ons is effective for most people, and the money spent on unproven extras might be better used on another full cycle.1 When you compare destinations, compare base cycle prices first, then decide on each add-on one at a time.
Be cautious if a clinic says an add-on is required for all patients, quotes a success-rate boost without published evidence, will not price the cycle without it, or pressures you to decide on the day of the consultation.
Questions to ask before paying for an add-on
- Why me? What in my history or test results makes you recommend this add-on for me specifically?
- What evidence? Which published studies support it for people like me, and how does it fit the HFEA rating and the ESHRE 2023 recommendation?
- What outcome? Does it improve the chance of a live birth, or only something earlier, such as embryo grading?
- What risks? Are there safety concerns, side effects or delays to my cycle?
- What price alone? What does the cycle cost without it, and what does the add-on cost as a separate line?
- Is it research? If it is experimental, is it being offered within a registered study, and am I being charged for it?
- Can I decline? Will declining change anything else about my treatment or package?
Ask for the answers in writing. If you want help separating base costs from add-ons across several quotes, you can request a quote review.
None of this means every add-on is useless for everyone. It means the burden of proof sits with the clinic. Talk through any add-on with your own fertility specialist before you commit, especially immune treatments and anything injected into the ovary or womb.