OBJECTIVE: What factors do assisted reproductive terchnology (ART) providers take into account when they make decisions about offering \'add-ons\'?
METHODS: A qualitative analysis of interviews with 31 ART professionals, focusing on their views and experiences in relation to add-ons, including the factors that are considered when doctors make decisions about their use.
RESULTS: The participants reported that a range of considerations are taken into account when it comes to justifying the use of a particular add-on in a given circumstance, including the likelihood of benefit and harm, patients\' perceived psychological needs and preferences, and organizational expectations. Importantly, patient preferences, psychological factors and low risk of harm appear to be stronger motivations than increasing the likelihood of a live birth or the desire to innovate.
CONCLUSIONS: These findings suggest that it cannot be taken for granted that add-ons and innovation are closely linked. One possible response to this would be regulatory reform; for example, only allowing \'unproven\' add-ons to be used in the context of formal scientific evaluation. Alternatively, it could be made clear that add-ons that are not undergoing formal evaluation have more in common with other therapies lacking a clear evidence base, such as complementary and alternative medicines, than with conventional medical practice. Practices in relation to add-ons may also require a focus on the responsibilities of corporations, and the standards applying to purveyors of consumer goods and services.

IVF is the backbone of infertility treatment, but due to its costs, it is not affordable for everyone. The cost of IVF is further escalated by interventions added to the routine treatment, which are claimed to boost pregnancy rates, so-called add-ons. Consequently, it is critical to offset the increased costs of an intervention against a potentially higher benefit. Here, we propose using a simplified framework considering the cost of a standard IVF procedure to create one live-born baby as a benchmark for the cost-effectiveness of other fertility treatments, add-ons inclusive. This framework is a simplified approach to a formal economic evaluation, enabling a rapid assessment of cost effectiveness in clinical settings. For a 30-year-old woman, assuming a 44.6% cumulative live birth rate and a cost of $12 000 per complete cycle, the cost to create one live-born baby would be ∼$27 000 (i.e. willingness to pay). Under this concept, the decision whether to accept or reject a new treatment depends from an economic perspective on the incremental cost per additional live birth from the new treatment/add-on, with the $27 000 per live-born baby as a reference threshold. This threshold can vary with women\'s age, and other factors such as the economic perspective and risk of side effects can play a role. If a new add-on or treatment costs >$27 000 per live birth, it might be more rational to invest in a new IVF cycle rather than spending on the add-on. With the increasing number of novel technologies in IVF and the lack of a rapid approach to evaluate their cost-effectiveness, this simplified framework will help with a more objective assessment of the cost-effectiveness of infertility treatments, including add-ons.

This article reports the annals of a national consensus meeting on add-ons and social networks in Assisted Reproduction Techniques (ART). The panel of experts has developed a set of consensus points and this document is intended to be referenced as a national consensus to allow social networks and add-ons to be used in ART, following the standards of the Code of Medical Ethics and the Federal Council of Medicine, in a safe ethical and responsible way.

OBJECTIVE: In anticipation of the future development of assisted reproductive technology (ART) and to smoothly introduce new technology, it is necessary to understand the current staffing status of the medical system and the current state of treatment, as well as the status of in vitro fertilization add-ons, where the need for insurance coverage is currently a matter of debate.
METHODS: ART facilities in Japan were surveyed (437 valid responses, response rate: 71%). Current staffing status of the medical system, implementation rates of ART, add-on treatments, and medical supplies were investigated.
RESULTS: Despite the abundance of embryologists, nurses, and obstetricians and gynecologists in facilities, the majority of facilities lacked counselors, anesthesiologists, and other essential medical professionals. Conventional ovarian stimulation was widely adopted (median 120 [interquartile range 60-300] cycles), followed by mild ovarian simulation (60 [30-200]). Additionally, freeze-thaw embryo transfer cycles (300 [120-750]) were performed more frequently than fresh embryo transfer cycles (30 [30-60]). Among the add-ons, assisted hatching (85.1%), chronic endometritis examination (77.2%) and treatment (76.9%), artificial oocyte activation (67.3%), endometrial receptivity analysis (64.2%), and endometrial microbiome analysis (58.9%) were relatively widely employed.
CONCLUSIONS: The implementation of frozen-thawed embryo transfer cycles, freeze-all strategies, and add-on treatments have become popular and widely accepted despite the lack of robust evidence regarding their safety and efficacy.

The inability to quantitatively integrate scattered data regarding potential threats posed by the increasing total amount and diversity of chemical substances in our environment limits our ability to understand whether existing regulations and management actions sufficiently protect wildlife. Systematic literature reviews and meta-analyses are great scientific tools to build upon the current push for accessibility under the Open Science and FAIR movements. Despite the potential of such integrative analyses, the emergence of innovative findings in wildlife ecology and ecotoxicology is still too rare relative to the potential that is hidden within the entirety of the available scattered data. To promote the reuse of wildlife ecotoxicology data, we propose the ATTAC workflow which comprises five key steps (Access, Transparency, Transferability, Add-ons, and Conservation sensitivity) along the chain of collecting, homogenizing, and integrating data for subsequent meta-analyses. The ATTAC workflow brings together guidelines supporting both the data prime movers and re-users. As such, the ATTAC workflow could promote an open and collaborative wildlife ecotoxicology able to reach a major objective in this applied field, namely, providing strong scientific support for regulations and management actions to protect and preserve wildlife species.

In contemporary ART, the use of \"add-ons\" during ovarian stimulation has increased, especially in poor responders. Growth Hormone (GH) is an adjunctive therapy that has been studied extensively in the translational and clinical setting, with an ongoing scientific debate over its effectiveness and optimal use. In this review, we aim to provide an overview of the physiologic basis for the use of GH in ART, and to summarize the latest evidence regarding its clinical use, primarily as an adjunct to ovarian stimulation, but also in the IVF lab and with regards to its effects on the endometrium.

Purpose: There is a lack of available evidence regarding the treatment pattern of switches and add-ons for individuals aged 65 years or older with epilepsy during the first years from the time they received their first anti-seizure medication because of the lack of valid methods. Therefore, this study aimed to develop an algorithm for identifying switches and add-ons using secondary data sources for anti-seizure medication users. Methods: Danish nationwide databases were used as data sources. Residents in Denmark between 1996 and 2018 who were diagnosed with epilepsy and redeemed their first prescription for anti-seizure medication after epilepsy diagnosis were followed up for 730 days until the end of the follow-up period, death, or emigration to assess switches and add-ons occurred during the follow-up period. The study outcomes were the overall accuracy of the classification of switch or add-on of the newly developed algorithm. Results: In total, 15870 individuals were included in the study population with a median age of 72.9 years, of whom 52.0% were male and 48.0% were female. A total of 988 of the 15879 patients from the study population were present during the 730-day follow-up period, and 988 individuals (6.2%) underwent a total of 1485 medication events with co-exposure to two or more anti-seizure medications. The newly developed algorithmic method correctly identified 9 out of 10 add-ons (overall accuracy 92%) and 9 out of 10 switches (overall accuracy 88%). Conclusion: The majority of switches and add-ons occurred early during the first 2 years of disease and according to clinical recommendations. The newly developed algorithm correctly identified 9 out of 10 switches/add-ons.

Add-ons at the time of in vitro fertilisation (IVF) have become commonplace, despite a general lack of evidence that they are effective and safe. The \'Colorado Protocol\' is a commonly used add-on consisting of aspirin, steroid and an antibiotic. Before commencing planning for a clinical trial evaluating the Colorado Protocol, researchers and funders need evidence that the Colorado Protocol is being prescribed, and to be assured that sufficient numbers of participants can be recruited for a clinical trial.
To survey fertility clinicians and patients on attitudes toward use of add-ons during IVF, willingness of patients to be randomly assigned to an add-on trial treatment or placebo, and what would be the clinically meaningful outcomes, using the Colorado Protocol as a test case.
Two online surveys were conducted: clinicians from fertility clinics across the United Kingdom, Australia, and New Zealand; and patients from Auckland-based clinics and NZ patient support groups.
Of 58 clinicians, 44 (75%) had recommended an add-on within the preceding year. Thirty-nine (67%) clinicians were aware of the Colorado Protocol, with 17 (29%) having recommended it within the preceding year. Of the 289 patients, 80% indicated willingness to take trial medications during IVF, and 68% were willing to be randomly assigned to the placebo arm of a trial. The median perceived minimum clinically important difference in live births in both samples was 5%.
A future trial of this add-on in IVF would be supported by patients in the context of the New Zealand fertility healthcare system.

What are the views of the medical directors of fertility clinics on IVF add-ons?
A total of 93 UK clinics were emailed with an invitation for their medical director to participate. Ten IVF clinic medical directors were interviewed to discuss their views on the use of IVF add-ons. Some of the interviewees were medical directors of an IVF clinic with multiple branches across the UK, meaning the total number of clinics accounted for in this study was 35 out of the 93 contacted. Thematic analysis was used to analyse the data.
The participants consisted of seven males and three females, with six from solely private clinics and four with NHS and private patients. Four themes were identified: clinical decision-making and the patient-doctor relationship; regulations and the add-on traffic light system; research and evidence; and commercialization and financialization of the IVF sector.
UK IVF medical directors had a wide variety of views and experienced different pressures to offer IVF add-ons. The add-on discussion touches on core aspects of professional identity and the meaning of medical practice. The add-on debate points to broader changes in the organization of the IVF sector, which affect key aspects of practising (reproductive) medicine, including the patient-doctor relationship and responsibility for clinical decision-making, and the relationship between regulator and IVF clinic and between scientific evidence and clinical practice.

In the last decade, the in-vitro fertilization (IVF) sector has witnessed a shift from so-called \'reactive IVF\' to a new model of proactive fertility care. Whereas IVF was traditionally developed to treat people who found they were unable to conceive, the indication for IVF has broadened significantly to include a much wider group of potential patients through a new focus on proactive treatment of future (in)fertilities. This shift combines a number of new trends pertaining to preservation, prediction, private equity and platformization, all of which have gained influence in contemporary assisted reproduction. This article focuses on the emergence of company-sponsored fertility benefits, which combines each of these trends. Whereas fertility benefits - especially egg freezing insurance - have primarily been discussed in terms of women\'s empowerment or disenfranchisement, this article instead calls attention to the discursive, clinical and infrastructural shifts in contemporary assisted reproduction that have emerged with the rising popularity of these benefits. The analysis addresses these underdiscussed aspects of fertility benefits by focusing on the dynamics of demand; the shifts in the rationalization of intensified treatment pathways in the face of new reimbursement practices; and the online, platform-based infrastructures that are built to provide these treatments. In doing so, it analyses how this remaking of fertility towards an ethos of proactive fertility management reflects broader capitalist tailwinds.