Fertility add-ons under scrutiny – what patients are asking
Both NHS and private fertility clinics are being urged to stop offering treatments that are not proven to help people conceive, according to new draft guidance from the National Institute for Health and Care Excellence (NICE).
The recommendations, currently open for consultation (I’ll be back to report on the outcome in a few weeks), highlight several well-known fertility “add-ons” that research suggests do not improve outcomes. They also propose widening access to fertility preservation services, such as egg freezing, for people whose fertility may be at risk due to medical conditions.
While the consultation rolls, let’s break down what’s in the new guidelines, and answer some of the most common patient questions around fertility add-ons, costs, and risks.
What are fertility add-ons?
The Human Fertilisation and Embryology Authority (HFEA) defines add-ons as additional procedures, tests or medicines offered on top of standard fertility treatment, usually at extra cost.
A recent HFEA survey found almost three-quarters of patients had used at least one add-on, but only 37% said the risks had been explained to them. The BBC reports that NICE is now advising clinics to stop offering several of these treatments outside of research settings.
Under the spotlight in the draft guidance from NICE are:
- intracytoplasmic sperm injection (ICSI) – read up on the difference between ICSI, IVF and IUI
- endometrial scratch – we discuss this add-on in more depth in our donor egg miscarriage guide
- hysteroscopy – catch this interview covering IVF success rates for specific situations, for more notes
- endometrial receptivity testing (ERA) – we’ve clarified the difference between ERA and ReceptivaDx testing, for in-depth info
All caught up? Let’s do the specifics.
What is ICSI treatment?
Intracytoplasmic sperm injection (ICSI) involves injecting a single sperm directly into an egg in the laboratory. It is usually recommended for male factor infertility, such as very low sperm count.
ICSI treatment cost
Costs vary between clinics, but ICSI is typically charged as an additional procedure (add-on), on top of IVF fees. This additional cost can typically increase your IVF bill by around £800-£1,500 in the UK, in 2025.
ICSI risks
While widely used and effective for certain causes of infertility, ICSI also carries risks. Studies have raised questions about the long-term health implications for offspring, though findings remain under investigation. NICE’s draft guidelines specifically advise against using ICSI in men with healthy semen, where standard IVF is usually sufficient.
Why do eggs not fertilise with ICSI?
Even with ICSI, fertilisation is not guaranteed. Factors such as egg quality, sperm quality and underlying medical conditions can all affect the outcome.
What is endometrial scratching?
Endometrial scratch is a procedure where the womb lining is gently “scratched” with a small sterile tube, usually ahead of embryo transfer. It has been thought to improve implantation rates.
NICE’s latest draft guidance advises against offering this as an add-on, due to a lack of evidence that it improves IVF outcomes.
What is hysteroscopy?
A hysteroscopy is a procedure that allows doctors to look inside the womb using a fine telescope-like instrument called a hysteroscope. It can be used to check for problems such as polyps, fibroids or scarring, and may also be carried out to investigate heavy periods or repeated miscarriage.
In fertility care, some clinics have offered hysteroscopy as a pre-treatment add-on, in the hope that examining or clearing the womb lining might improve IVF outcomes. However, in its updated draft guidance, NICE advises against using hysteroscopy solely as an add-on procedure, as there is no clear evidence that it increases the chances of pregnancy.
Hysteroscopy cost
Costs can differ significantly depending on whether it is carried out within the NHS (when clinically necessary) or privately as part of fertility treatment.
How painful is a hysteroscopy without anaesthesia?
In terms of experience, pain levels vary. Some people report mild discomfort, while others find it painful, particularly without anaesthesia.
What is the ERA test?
The endometrial receptivity analysis (ERA) test looks at gene expression in a sample of womb lining, aiming to identify the best time for embryo transfer.
But is it worth it? NICE’s draft guidance advises against using the ERA test as a routine add-on. The evidence so far suggests it does not consistently improve IVF outcomes.
For further detail on ERA testing, and how it compares to other tests such as ReceptivaDx (and yes, they do test for different things), see our in-depth guide.
NICE updates – fertility preservation recommendations
Beyond add-ons, NICE is recommending wider access to fertility preservation. Currently offered mostly to cancer patients, services like egg, embryo and sperm freezing could in future be extended to people with conditions that affect fertility, such as severe recurrent endometriosis. We’re fans – watch this space.
IVF access and cycles
NICE also reviewed evidence around the number of IVF cycles that should be offered. It now recommends:
- Up to three full cycles of IVF for women under 40 who meet certain criteria
- One full cycle for women aged 40 and 41, under specific criteria
While NICE sets out the guidance, decisions on funding remain with local NHS integrated care boards.
What happens next?
The draft guidelines cover England, Wales and Northern Ireland. They are open for consultation until 21 October 2025, with final recommendations due in 2026.
Dr Fergus Macbeth, chair of NICE’s fertility guideline committee, said:
“People going through fertility treatment are often willing to try anything that might help them conceive. This makes them vulnerable to being offered treatments that sound promising but haven’t been properly tested.”
We’ll be back as soon as the recommendations update, with all the info and further reading.
