IVF clinics are selling ‘add-ons’ with little evidence they work

There is no high-quality evidence proving that IVF ‘add-on’ treatments offered by British fertility clinics increase the chance of a pregnancy, according to a study by Oxford University’s Centre for Evidence-Based Medicine.

The research, commissioned by the BBC’s Panorama and published in the British Medical Journal, found that just one in four IVF cycles resulted in a live birth. It concluded that 26 out of the 27 available ‘add-on’ treatments available in the UK were not backed up by ‘good scientific evidence’.

The treatments (which include drug and blood tests, genetic screening tests and embryo housings) range in price from £100 to £3,500, in addition to the cost of IVF.

The only treatment found to be supported by ‘moderate quality evidence’ is the endometrial scratch, which involves scratching the womb lining to increase the chances of an embryo successfully attaching.

The study’s lead author, Carl Heneghan, told Panorama: ‘It was one of the worst examples I’ve ever seen in healthcare. The first thing you would expect to happen is that anything that makes a claim for an intervention would be backed up by some evidence. Some of these treatments are of no benefit to you whatsoever and some of them are harmful.’

Evidence for these interventions can be found at websites such as the Cochrane Library and NHS Evidence.

Instant analysis
This paper sought to find what additional services and interventions were offered in the private sector for IVF which were claimed to improve fertility outcomes. A list of 38 fertility interventions were identified; 27 of these were classed as add-ons.

For 27 out of the 38 interventions, systematic reviews existed, from which five of the interventions were shown to raise the chance of a healthy pregnancy. There was incomplete data on 13 interventions, and in seven where the intervention was seen not to improve live birth outcomes. Ultimately, evidence was patchy or poor for many of the interventions. In some cases, evidence of harms also existed, although this was more difficult to find.

The suggestion was that the fertility companies were not being upfront about the justification for these interventions. Patients were not able to make an informed choice, it was argued, and instead the extras were presented as something that could be deleterious to the pregnancy if omitted.

The crux of the report was over what information was given to a patient in order for her to provide informed consent — whether the whole picture was being given as opposed to a ‘sell’.

My impression has long been that some hormonal interventions and even investigative tests are being pushed on to patients with a poor or non-existent evidence base and without much explanation. Often it is presented as a sort of barman’s prerogative, varying from bar to bar, or clinic to clinic. Some clinics use it as an advertising tool to suggest their methods yield better results.

Often a lot of things offered to supplement the fertility schedule actually increase anxiety in the patient, for example ultrasound checks on the progress of the pregnancy at incredibly early gestational ages. What the fertility centres may not explain is that they are powerless to do anything — that there is not much in the way of ‘abnormality’ that they can do anything about.

The problems that private sector IVF clinics create for the NHS are also significant. Patients often go back to the NHS to request ‘observational’ blood tests and hormonal prescriptions for free, as the charge for these can snowball in the private sector. But they are by no means within the budget of an NHS surgery and many doctors aren’t really qualified to prescribe them.

The thrust of the Panorama report is that patients should ask fertility clinics to provide evidence for their extra interventions.

Unfortunately, there is also a grey area over who is meant to bring the clinics to book.
RM