Table 5.

Professional quotes

Theme	Participant	Illustrative quotations
Professional theme 1: ‘treating desperation’	Australia embryologist 12	‘I think having add-ons gives them that slight feeling that they have opened all the doors. They have explored all the avenues. And then maybe they will be able to, you know, complete their IVF journey at least with the satisfaction that they know they have tried everything. They have given it all.’
Professional theme 2: ‘the patient shopper’	UK embryologist 9	‘But I think patients as well are becoming a lot more informed and a lot more are aware of what is available. And certainly I, I think a proportion of patients, you know, if they are not able to have certain add-ons at a particular clinic they can probably take their business elsewhere as well.’
Professional theme 3: ‘tensions within evidence-based practice’	Australia clinician 6	‘Everyone talks about how expensive IVF is and, you know, that it’s $10 000 a cycle. And many people say it has a low success rate, which is not true. So, if a patient has a certain amount of money, there is no question that the greatest likelihood of getting pregnant is the more IVF they have, the more cycles they have, the more eggs that are collected, the more embryos that are made. So, when patients are wasting their money on totally charlatan, unethical treatments, they are using their pool of money towards something that is not making them pregnant. For example, something like embryo biopsy that might double the cost of the cycle. Where, in fact, they would have been better off having two cycles.’
	Australia clinician 8	‘To have a proper randomised trial that can prove efficacy, let’s say improving the chances from 2% to 3%, that’s a 50% increase, but to actually have that show significance in a randomised control trial would be impossible to do. It’s not a trial that you can do because it requires thousands and thousands of patients. Nobody can run such a trial. So, uh, our ability to prove efficacy of any add-on is very limited.’
	Australia embryologist 8	‘And all the scientific journal papers are skewed, as well, depending on the clinic, depending on who’s studying it, and depending on who’s, who’s publishing it. I think the results vary too much at this stage with a lot of different add-ons.’
Professional theme 4: ‘potential for harm’	UK clinician 1	‘…there will be the case where you will damage some embryos in the process of biopsying them for example. And you will, you’ll have some abnormal, you’ll, you may be damaging the occasional normal embryo. And I always say to patients about mosaicism, just because the results are abnormal doesn’t mean to say that that baby’s abnormal. So, you may be causing harm, but that’s a discussion we have with them.’
Professional theme 5: ‘success not profits’	Australia clinician 10	‘I can't begin to tell you the anger that I see in my rooms when for whatever reason I say to them, well, natural killer cells are elevated, or you have tissue compatibly, or you have a balance translocation of your chromosomes which is why you're not getting pregnant. But nobody has done these tests and they've had IVF treatments without success. And they’re very angry that they've wasted all this money on previous cycles.’
	Australia embryologist 9	‘I actually feel quite angry sometimes when you hear of patients that have gone to other clinics and been sold all this stuff that’s really, you do wonder if it’s doing more harm than good. And you just think if, your problem is, is quite simple, cut away all of that and just focus on the basic science that we know is working, save your money. I think, I, I do think that there is a bit of exploitation going on.’
	UK embryologist 10	‘But there’s other add-ons that, they don’t cost any money to the clinic, like assisted hatching. That, the cost for the lab is zero. Obviously, you can always factor in the knowledge of the embryologist, the equipment calibrations, blah, blah, blah. But the cost is essentially to buy anything. So, for that one, for example, there shouldn’t be a charge at all.’

IVF, in vitro fertilisation.