Procedures used during in vitro fertilisation (IVF)

1.40 Pre-treatment

For recommendations on pre-treatment, see part B on pre-treatment therapies in the European Society of Human Reproduction and Embryology (ESHRE) guideline on ovarian stimulation for IVF/ICSI (update 2025).

1.40.1

Do not offer endometrial scratch as a pre-treatment means of improving the outcome of IVF. [2026]

1.40.2

Do not offer hysteroscopy as a pre-treatment means of improving the outcome of IVF. If uterine or endometrial abnormalities are suspected, see recommendation 1.18.16 in the section on investigation of suspected tubal and uterine abnormalities. [2026]

For a short explanation of why the committee made the 2026 recommendations and how they might affect practice, see the rationale and impact section on pre-treatment.

Full details of the evidence and the committee's discussion are in:

1.41 Endometrial receptivity testing

1.41.1

Do not offer endometrial receptivity testing as a treatment add-on for embryo transfer. This includes both gene expression analysis (for example, endometrial receptivity array) and microbiological analysis (for example, endometrial microbiome metagenomic analysis, analysis of infectious chronic endometritis). [2026]

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on endometrial receptivity testing.

Full details of the evidence and the committee's discussion are in evidence review D: endometrial receptivity testing.

1.42 Immunological treatments

1.42.1

Do not use immunological agents, including intralipids, intravenous immunoglobulins or steroids (glucocorticoids), as part of fertility treatment. [2026]

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on immunological treatments.

Full details of the evidence and the committee's discussion are in evidence review Q: immune therapies as a treatment add-on.

1.46.1

Clinics providing ovarian stimulation with gonadotrophins should have protocols in place for preventing, diagnosing and managing OHSS. [2004]

1.47 Oocyte retrieval

1.47.1

Offer conscious sedation for transvaginal retrieval of oocytes because it is a safe and acceptable method of providing analgesia. [2004]

1.47.2

Do not offer follicle flushing before oocyte retrieval if there are at least 3 follicles, because this procedure does not increase the number of oocytes retrieved or pregnancy rates, and it increases the duration of oocyte retrieval and associated pain. [2004]

For recommendations on surgical sperm retrieval, see the section on management of male factor fertility problems.

1.48 Embryo selection strategies

1.48.1

Do not offer pre-implantation genetic testing for aneuploidy (PGT‑A) as part of fertility treatment to improve live birth rates. [2026]

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on embryo selection strategies.

Full details of the evidence and the committee's discussion are in:

1.49 Embryo transfer strategies

1.49.1

Do not offer assisted hatching, because it has not been shown to improve pregnancy rates. [2004]

1.49.2

Offer ultrasound-guided embryo transfer during IVF because this improves pregnancy rates. [2004]

1.49.3

Replacement of embryos into a uterine cavity with an endometrium of less than 5 mm thickness is unlikely to result in a pregnancy and is therefore not recommended. [2004]

1.49.4

Provide information that bed rest of more than 20 minutes' duration following embryo transfer does not improve the outcome of IVF treatment. [2004]

1.49.5

Evaluate embryo quality, at both cleavage and blastocyst stages, according to the Association of Reproductive and Clinical Scientists (ARCS) and UK National External Quality Assessment Service (UK NEQAS) Embryo Grading Scheme. [2013, amended 2026]

1.49.6

When considering the number of fresh or frozen embryos to transfer in IVF treatment:

maternal age under 37 years:
- in the first full IVF cycle, use single embryo transfer
- in the second full IVF cycle, use single embryo transfer if 1 or more top-quality embryos are available; consider using 2 embryos if no top-quality embryos are available
- in the third full IVF cycle, transfer no more than 2 embryos
maternal age 37 to 39 years:
- in the first and second full IVF cycles, use single embryo transfer if there are 1 or more top-quality embryos; consider double embryo transfer if there are no top-quality embryos
- in the third full IVF cycle, transfer no more than 2 embryos
maternal age 40 to 41 years, consider double embryo transfer. [2013, amended 2026]

1.49.7

If IVF treatment is with donor eggs, use an embryo transfer strategy that is based on the age of the donor. [2013]

1.49.8

Do not transfer more than 2 embryos during any 1 cycle of IVF treatment. [2013]

1.49.9

Where a top-quality blastocyst is available, use single embryo transfer. [2013]

1.49.10

When considering double embryo transfer, discuss the risks of multiple pregnancy associated with this strategy. [2013]

1.49.11

Offer cryopreservation to store any remaining good-quality embryos after embryo transfer. [2013]

1.49.12

Advise women, and trans men and non-binary people with female reproductive organs who have regular ovulatory cycles that the likelihood of a live birth after replacement of frozen–thawed embryos is similar for embryos replaced during natural cycles and hormone-supplemented cycles. [2013]

Fertility problems: assessment and treatment