Feeling unsure about IVF add-ons and which ones might truly help? During this event, Dr Elena Santiago, Gynaecologist and Fertility Specialist at Vida Fertility in Spain, explored a wide range of IVF add-ons, including: Ovarian and Endometrial PRGF; MACS, PICSI, SpermSlow, Zymot, IMSI techniques; EmbryoScope; PGT; as well as AI tools for ovarian stimulation and follicular monitoring.
Dr Santiago broke it all down: what’s evidence-based, what’s optional, and what might actually improve your chances, tailored to your individual fertility needs. In recent years, IVF treatment has evolved rapidly, with a growing number of additional techniques – commonly referred to as IVF “add-ons” – becoming available. During her presentation, Dr Elena Santiago, Gynaecologist and Fertility Specialist at Vida Fertility in Madrid, explained how these add-ons can support different stages of IVF treatment and why careful, individualised decision-making is essential.
Dr Santiago emphasised that while many add-ons may improve outcomes in selected cases, not every option is appropriate for every patient. The key message throughout her talk was clear: IVF add-ons should always be tailored to a patient’s medical history, diagnosis, and personal circumstances.
IVF is a multi-step process, and add-ons can be applied at different points along the treatment pathway. Dr Santiago explained that these additional techniques may be used during ovarian stimulation, sperm selection, fertilisation, embryo culture, or endometrial preparation before embryo transfer.
Some add-ons are widely used and considered beneficial for many patients, while others are recommended only in specific situations, such as repeated implantation failure, recurrent miscarriage, low ovarian reserve, or male-factor infertility. According to Dr Santiago, understanding when and why an add-on is suggested is crucial for patients making informed decisions.
One of the first add-ons discussed was ovarian platelet-rich plasma (PRP) treatment. Dr Santiago explained that this technique aims to activate follicles that are present in the ovaries but remain “silent” and do not normally respond to ovarian stimulation.
During routine ultrasound scans, doctors assess antral follicles to estimate ovarian reserve. However, smaller follicles may exist in earlier developmental stages and lack the receptors needed to respond to gonadotropins. Dr Santiago explained that PRP may help activate these follicles, allowing them to become responsive to stimulation.
Ovarian PRP is typically considered for women with very low ovarian reserve, particularly when AMH levels are below 0.5 ng/mL or when the antral follicle count is fewer than two or three follicles across both ovaries. It may also be considered for women under 45 years of age, and in selected younger women with premature ovarian insufficiency.
The procedure involves a simple blood draw one to two hours before treatment. Growth factors are extracted from the patient’s plasma, and the PRP is infused into each ovary using an ultrasound-guided vaginal approach, similar to egg retrieval. The procedure is short and usually performed under sedation. Dr Santiago noted that ovarian stimulation typically begins one or two cycles later.
Dr Santiago then discussed sperm selection add-ons, which are chosen based on semen analysis results and the couple’s reproductive history. In cases of recurrent miscarriage or repeated implantation failure, she often recommends assessing sperm DNA fragmentation.
DNA fragmentation testing can identify single-strand and double-strand DNA damage in sperm. If high levels of fragmentation are detected, specialised sperm selection techniques may be used to select sperm with better DNA integrity before ICSI.
Mechanical selection methods, such as microfluidic devices, can help isolate sperm without DNA strand breaks, potentially improving fertilisation rates, embryo development, and pregnancy outcomes. For higher single-strand DNA fragmentation, chemical selection techniques may be used, while severe sperm morphology abnormalities may require high-magnification sperm selection using specialised microscopes.
Once fertilisation has taken place, embryo development in the laboratory becomes the focus. Dr Santiago highlighted the importance of maintaining stable conditions that closely mimic the natural environment of the fallopian tubes and uterus, including temperature and gas composition.
Modern incubators equipped with time-lapse imaging systems allow continuous monitoring of embryo development without disturbing the embryos. Each embryo is recorded on video, enabling embryologists to assess not only morphology but also the timing and pattern of cell divisions.
Dr Santiago explained that abnormal division patterns, particularly in early stages, may indicate reduced developmental potential. Time-lapse technology provides valuable additional information and, in her experience, has been associated with a higher number of good-quality blastocysts compared to traditional incubators. However, she noted that while this add-on has no disadvantages, it may increase treatment costs and is not mandatory in all cases.
Extended embryo culture to the blastocyst stage is now standard practice in many private clinics, particularly in Spain. Dr Santiago explained that culturing embryos to day five allows for better embryo selection and avoids transferring embryos that may arrest development at an earlier stage.
Blastocyst culture also supports the practice of single embryo transfer. Dr Santiago emphasised that transferring one good-quality blastocyst often achieves pregnancy rates similar to transferring two embryos, while significantly reducing the risks associated with multiple pregnancies.
Multiple pregnancies carry higher risks for both the mother and babies, including gestational diabetes, hypertension, pre-eclampsia, and premature delivery. Although identical twins can still occur after a single embryo transfer, this remains rare. For these reasons, Dr Santiago stressed that single embryo transfer is preferred whenever possible.
Preimplantation genetic testing for aneuploidy (PGT-A) is another commonly used add-on, typically performed at the blastocyst stage. Dr Santiago explained that a small biopsy is taken from the trophectoderm, which later forms the placenta, allowing assessment of the embryo’s chromosomal status with high reliability.
PGT-A is often recommended for women over 38, as well as for patients with recurrent miscarriage or repeated implantation failure. Additional forms of genetic testing include PGT-M, used to screen for known single-gene disorders when both parents carry the same mutation, and PGT-SR, which screens for chromosomal rearrangements such as translocations or inversions.
In cases of chromosomal rearrangements, patients may be healthy themselves but face difficulties achieving or maintaining a pregnancy. IVF with appropriate genetic testing allows selection of chromosomally balanced embryos, improving the chances of a healthy pregnancy.
Endometrial PRP was discussed as another important add-on, particularly for women with thin endometrium, repeated implantation failure, or conditions such as Asherman’s syndrome. The preparation process is similar to ovarian PRP, involving a blood draw and extraction of growth factors.
The PRP is infused into the uterus in a short, outpatient procedure, usually performed three times before embryo transfer. These infusions are spaced over several days, with embryo transfer taking place shortly afterwards.
Dr Santiago explained that endometrial PRP aims to improve endometrial thickness, enhance receptivity, and increase pregnancy rates in selected patients.
Dr Santiago also briefly addressed the growing role of artificial intelligence in IVF. AI-based tools are increasingly used to support decision-making in areas such as embryo selection, ovarian stimulation protocols, and fertility preservation strategies.
For example, AI algorithms may analyse images of eggs or embryos to predict pregnancy outcomes, helping patients decide whether to proceed with additional cycles or embryo accumulation. While not all clinics offer the same tools, these technologies can provide valuable support to clinicians and embryologists.
In closing, Dr Santiago highlighted that IVF add-ons can offer meaningful benefits, but they should never be applied automatically. Some techniques, such as blastocyst culture and time-lapse incubators, may be useful for many patients, while others, including PRP treatments, advanced sperm selection, or genetic testing, are appropriate only in specific clinical scenarios.
Her central message was the importance of individualised care.
Not everything needs to be applied to every case.
She explained, emphasising that expert guidance and personalised treatment planning are essential to achieving the best possible outcomes.
By understanding the purpose, indications, and limitations of IVF add-ons, patients can feel more confident and informed as they navigate their fertility treatment journey.
Yes. PGT-M is not allowed for every genetic disease that we know. It needs to be a known, common genetic disease, as you correctly said, but also severe, meaning that the life of the baby or child could be really affected or at risk. So, not all diseases can be diagnosed.
If that’s the case, it’s true that you need to go through this national commission. Unfortunately, it takes time. Normally, we need to wait for the case to be resolved, which can take from 6 to 12 months. Not all the cases are accepted.
It’s true that you have quite a good response in terms of the number of follicles, which is very good considering your age. The problem with the PRP treatment is that it doesn’t increase the quality of the eggs. We are only able to increase the response slightly, maybe 1 or 2 more follicles in the ovarian stimulation after PRP. Therefore, I don’t think in your particular case it is going to help much. That’s why we have this age limitation of 45 years.
Obviously, if you’ve just turned 46, we can still use it, but I’m not sure it will be helpful. In the majority of women over 45, even if the ovarian reserve is good, the egg quality is very low, and as a result, pregnancy rates are very low.
In these cases, you have to suspect that maybe we could have high DNA fragmentation. This is one of the scenarios where maybe it’s because of the egg, but we never know. We can’t test the egg, but we are able to test the sperm. So let’s see — if we do have high DNA fragmentation, then we can use extra sperm selection techniques before the ICSI and see if we can improve embryo development and get more blastocysts.
Also, the time-lapse incubator is going to help you maybe achieve more embryos, as we are not needing to take embryos outside of the incubator at all times to see them under the microscope. Therefore, environmental conditions are going to be much more stable, and we do see more blastocysts growing in some patients.
Normally yes, it’s an extra cost. But it’s affordable in the majority of cases. In my opinion, it’s definitely worth it because it doesn’t mean any disadvantage. It gives you more information, better environmental conditions — so why not use it? Most patients actually go for it. They accept it and want it included.
When we do PGT-A testing, which is very common nowadays, it’s also better for embryologists to see for each embryo when is the best time to do the biopsy. It’s not always the blastocyst on day five that’s perfect for the biopsy. Sometimes we need to wait for a particular expansion, maybe until day six, or maybe on day five in the afternoon. It gives us more information to decide when is the best time for each embryo to be biopsied.
All the studies going on now with these new techniques try to see if the morphology, the divisions of the embryos, and many other tools, like metabolism, are related to chromosomal disorders.
We need more time to see if this is the case. But I believe that in the future, we might be able to get rid of the biopsy and have other tools to detect healthy embryos.
Not until now. We haven’t done it. We’ve seen several discussions about it, but it’s true that it’s still a little bit experimental. We believe that when you have a good team doing those biopsies, not harming the embryo, they are used to doing it, and we don’t get bad results. Doing PGT-A testing does not harm embryos or decrease pregnancy rates.
Nowadays, we do have better results with PGT-A testing, and that’s why we continue with it. As I mentioned, non-invasive testing is still experimental. We need to wait longer to prove that it works and gives results. It gives you a lot of information, and it’s very good. In the future, there’s going to be more viability with these techniques. But for now, PGTA still provides better results and helps us decide which are the best embryos.
There are many questions here. First of all, fertilization rate was quite good, and afterwards the number of embryos was maybe a little bit lower than expected. On average, we normally get around 50% blastocysts from the initial number of fertilized eggs. With egg donation treatments, it’s not only important to see how many good quality embryos we achieve, because each embryo is already going to have very good quality. Therefore, pregnancy rates should be quite high with each embryo, and sometimes we don’t need so many.
Let’s try with those embryos and see if you can achieve a pregnancy. Don’t worry too much about the number — this is biology. We talk about averages, but each cycle can be different. Sometimes with six eggs from a donor, you achieve six blastocysts. Sometimes, you don’t achieve any with twelve eggs. Even with the same donor, you may have different results across cycles.
It’s not always related to the sperm. If you’ve done a selection technique like ZyMot, I wouldn’t consider it such a bad result. Three blastocysts seems to me a good result and offer very good chances for pregnancy.
Regarding supplements, it depends on the type of fragmentation that was high. If you used ZyMot, I believe it was the double-strand fragmentation. Therefore, we need antioxidants such as zinc, CoQ10, DHA (omega-3 fats), and curcumin. So far, we’ve seen that curcumin helps to lower double DNA fragmentation.
It’s also very important to maintain good lifestyle habits , not just avoiding smoking or drinking, but also limiting coffee to a maximum of one per day, avoiding sugary drinks like cola or other soft drinks. Try to eat as healthy as possible, not just lettuce, but plenty of fruits and vegetables. Cooking at home is usually healthier than eating fast food. That’s it.
This is the key question. I wish I had tools to improve this. We’re trying to find something, but it’s really difficult. The same goes for sperm. Having good life habits and taking antioxidants and vitamins in a controlled way can improve quality a little. In some patients with high inflammation, whether from life habits, endometriosis, or another condition reducing inflammation may help improve egg quality.
But it’s really hard to say, “Take this and egg quality will be better.” There’s nothing definitive we can recommend that we know works for sure.
PRP does sometimes increase implantation rates and may help improve endometrial lining, although not always. It can help regenerate the tissue, maybe improve vascularization, and thus increase endometrial thickness and receptivity. Some patients, if the first PRP doesn’t work, may benefit from subendometrial PRP — not just infusing PRP inside the uterus, but injecting it with a small needle throughout the endometrial lining under hysteroscopic guidance.
But I insist, in your case, 6.7 mm seems to me quite a good thickness. So maybe that’s not necessary for you. Still, if you can afford another PRP treatment, I believe it’s a good idea. It’s a bit more complicated as you need to go several times for those infusions, but there are no disadvantages. It can only offer benefits. So yes, try it, I think it’s good.
