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Fertility Treatment Add-Ons: Do They Add Up?

Progress Educational Trust
Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent's Park, London NW1 4RG
29 March 2017
This public event was organised by the Progress Educational Trust (PET), was sponsored by the British Fertility Society (BFS), and was held at the Royal College of Obstetricians and Gynaecologists.
Fertility treatment 'add-ons' are procedures and treatments offered alongside IVF - sometimes at considerable expense to the patient - which may not be supported by robust evidence. The benefits, harms and appropriateness of add-ons are often open to question, and the role of add-ons in fertility treatment has become a matter of heated debate among professionals and a source of confusion for patients.
A recent episode of the BBC1 programme Panorama, entitled Inside Britain's Fertility Business, led to controversy when it questioned the way UK fertility clinics offer add-ons to patients. The programme was accompanied by two British Medical Journal (BMJ) studies, arguing that there is little or no evidence to support most add-ons offered in the UK and that the websites of UK fertility clinics are unclear on the subject of add-ons. A number of fertility professionals have responded by criticising the approach and the findings of Panorama and of the two BMJ studies.
Another review of the way UK fertility clinic websites discuss add-ons has been undertaken by the fertility regulator, the Human Fertilisation and Embryology Authority (HFEA). The HFEA has reported concerns about add-ons among fertility patients and other stakeholders, and its 2017-2020 Strategy includes the objective to 'publish clear information so that patients understand treatments and treatment add-ons and feel prepared'.
This public event explored questions raised by these developments, including:
What counts as an add-on? The BMJ studies list 27 'add-on interventions', distinguishing these from other categories of treatment including 'alternatives to IVF' and 'treatments for preservation of fertility'. Fertility professionals argue that the BMJ approach has led to some 'necessary' and 'essential' fertility treatments being wrongly categorised as add-ons.
Meanwhile, a recent study of add-ons in the journal Human Reproduction focuses on six 'adjunct IVF laboratory treatments and tests that are currently being offered globally', and an earlier study in the journal Facts, Views and Visions in ObGyn assesses various 'interventions which are being practised with little justifiable evidence to support their use within the realm of IVF/ICSI programmes'.
Who is best placed to judge the evidence for add-ons? What is the ideal standard of evidence? Is it for example a Cochrane Review, or is this unrealistic?
Alongside its recent study of add-ons, the journal Human Reproduction published an editorial entitled 'Do we need a randomised clinical trial for everything?' which concluded that the answer to this question was no.
How much evidence is it reasonable to expect, before a treatment is offered to patients? IVF itself was not subject to randomised controlled trials when it was first introduced into medical practice, and the pioneers of IVF had to develop and refine the technique with little support from the medical research establishment.
But should patients be expected to pay for a novel treatment, if they are effectively part of a clinic's research? If patients do not pay, then how else should such research be funded and by whom?
What is the role of the HFEA, the National Institute for Health and Care Excellence (NICE) and professional bodies such as the BFS in helping patients navigate add-ons, given that online information can often fall short of established standards?
Does equipping the patient with a thorough grasp of evidence (or the lack of it) effectively amount to a recommendation for or against each add-on?
Finally, what is the duty of the medical professional and what is the role of patient choice?
If a professional mentions the availability of a novel or unconventional treatment on their website, or during a consultation, is this tantamount to endorsing that same treatment?
If a patient is informed of the lack of evidence for a treatment, and is still prepared to pay for it, should they be able to do so?

Professor Adam Balen
Chair of the British Fertility Society, and Consultant in Reproductive Medicine and Surgery at the Leeds Centre for Reproductive Medicine
Sally Cheshire
Chair of the Human Fertilisation and Embryology Authority, and Chair of Health Education North West
Dr Simon Fishel
Founder and President of CARE Fertility and the Rachel Foundation
Dr Raj Mathur
Consultant Gynaecologist and Lead for Reproductive Medicine at St Mary's Hospital and Consultant Gynaecologist at Manchester Fertility

Fiona Fox
Chair of Trustees at PET, and Founder and Chief Executive of the Science Media Centre

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