Fertility and Andrology
Canadian Fertility and Andrology Society
Last updated: March 2025
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Preimplantation genetic testing for aneuploidy (PGT-A) was developed to help select the best embryos for transfer in an in vitro fertilization (IVF) cycle by screening out aneuploidy. However, there is no improvement in live birth rate per cycle started compared with IVF alone. PGT-A adds extra cost, carries a risk of misdiagnosis, and there is no long-term data reported on childhood outcomes. Patients should be counselled on the risks and limitations of testing.
Sources:
Chan C et al. Preimplantation genetic testing for aneuploidy: A Canadian Fertility and Andrology Society Guideline. Reproductive Biomedicine Online. 2021;
42(1): 105-116. PMID: 33303366.Munne S. et al. Preimplantation genetic testing for aneuploidy versus morphology as selection criteria for single frozen-thawed embryo transfer in good
prognosis patients: a multicenter randomized clinical trial. Fertility and Sterility 2019; 112: 1071–1079. PMID: 31551155.Yan et al. Live Birth with or without Preimplantation Genetic Testing for Aneuploidy. N Engl J Med 2021;385:2047-58. PMID: 34818479.
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Several studies demonstrate that the use of high doses of gonadotropins does not result in an increased number of
dominant follicles recruited, mature oocytes retrieved, nor good quality embryos produced compared with lower dosing regimens. Given that there is a greater cost to the patient, with no evidence of an improved outcome, avoidance of high doses of gonadotropins is recommended.Sources:
Friedler S, et al. An upper limit of gonadotropin dose in patients undergoing ART should be advocated. Gynecol Endocrinol 2016 Dec;32(12):965-969.
PMID: 27345589.Haas J, et al. Do poor-responder patients benefit from increasing the daily gonadotropin dose during controlled ovarian hyperstimulation for IVF? Gynecol
Endocrinol 2015 Jan;31(1):79-82. PMID: 25223892.Lensen et al. Individualised gonadotropin dose selection using markers of ovarian reserve for women undergoing in vitro fertilisation plus intracytoplasmic
sperm injection (IVF/ICSI). Cochrane Database of Systematic Reviews 2018, Issue 2. Art. No.: CD012693. PMID: 29388198. -
Assisted hatching (AH) is a technique where the zona pellucida is disrupted to improve implantation and therefore live birth rates from embryos created through IVF. Although there may be a benefit to performing AH in certain patient populations, the routine use of AH for all patients undergoing a fresh embryo transfer has not been shown to improve live birth rates.
Sources:
Lacey et al. Assisted hatching on assisted conception (in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI). Cochrane Database of
Systematic Reviews 2021, Issue 3. Art. No.: CD001894. PMID: 33730422.American Society for Reproductive Medicine. The role of assisted hatching in in vitro fertilization: a guideline. Fertil Steril. 2022 Jun;117(6):1177-1182.
PMID: 35618358. -
There is no improvement in live birth rate or clinical pregnancy rate with lymphocyte immunization therapy and it has potential for harm.
Sources:
Achilli C, et al. The role of immunotherapy in in vitro fertilization and recurrent pregnancy loss: a systematic review and meta-analysis. Fertil Steril 2018;
110(6):1089-1100. PMID: 30396553.Ober C et al. Mononuclear-cell immunisation in prevention of recurrent miscarriages: a randomised trial. Lancet 1999; 354: 365–69. PMID: 10437864.
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High-grade evidence to support the routine use of sperm DNA fragmentation testing as part of initial screening
investigations for infertility is lacking.Sources:
Pfeifer S, et al. The clinical utility of sperm DNA integrity testing: a guideline. Fertil Steril. 2013;99(3):673–7. PMID: 23391408.
Schlegel PN et al. Diagnosis and treatment of infertility in men: AUA/ASRM guideline part I. Fertil Steril. 2021 Jan;115(1):54-61. doi: 10.1016/j.
fertnstert.2020.11.015. Epub 2020 Dec 9. PMID: 33309062.Zhang Z, et al. Sperm DNA fragmentation index and pregnancy outcome after IVF or ICSI: a meta-analysis. J Assist Reprod Genet. 2015;32:17–26.
PMID: 25392073. -
Hysteroscopy before IVF in a person with a normal uterus on transvaginal ultrasound does not improve the live birth rate.
Sources:
El-Toukhy T, Campo R, Khalaf Y et al. Hysteroscopy in recurrent in-vitro fertilisation failure (TROPHY): a multicentre, randomised controlled trial. Lancet. 2016 Jun 25;387(10038):2614-2621. Epub 2016 Apr 27. PMID: 27132053.
Smit JG, Kasius JC, Eijkemans MJC et al. Hysteroscopy before in-vitro fertilisation (inSIGHT): a multicentre, randomised controlled trial. Lancet. 2016 Jun 25;387(10038):2622-2629. Epub 2016 Apr 27. Erratum in: Lancet. 2019 Jun 15;393(10189):2394. PMID: 27132052.
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Current available endometrial receptivity testing with personalized embryo transfer causes patient discomfort, additional costs, with no improvement in pregnancy rate.
Sources:
Doyle N, Jahandideh S, Hill MJ et al. Effect of Timing by Endometrial Receptivity Testing vs Standard Timing of Frozen Embryo Transfer on Live Birth in Patients Undergoing In Vitro Fertilization: A Randomized Clinical Trial. JAMA. 2022 Dec 6;328(21):2117-2125. PMID: 36472596.
K Lundin, J G Bentzen, G Bozdag et al. Good practice recommendations on add-ons in reproductive medicine. Hum Reprod. 2023 Nov 2;38(11):2062-2104. PMID: 37747409.
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Repetitive hormone blood tests (FSH, LH, estradiol and progesterone) and ultrasounds during a menstrual cycle to advise infertile patients on when to time intercourse are not necessary. Optimal timing of intercourse to achieve pregnancy can be easily performed through at home urinary ovulation predictor kits or the use of a fertility application with high fecundability rates. Additionally, these tests create patient discomfort, require travel to the clinic, and use of plastic blood tubes and reagents, contributing to the growing negative impact of emissions and healthcare waste on the environment.
Sources:
Favaro C, Pearson JT, Rowland SP et al. Time to Pregnancy for Women Using a Fertility Awareness Based Mobile Application to Plan a Pregnancy. J Womens Health (Larchmt). 2021 Nov;30(11):1538-1545. Epub 2021 Sep 8. PMID: 34495761.
Practice Committee of the American Society for Reproductive Medicine. Fertility evaluation of infertile women: a committee opinion. Fertil Steril 2021;116:1255-1265. Epub 2021 Oct 2. PMID: 34607703.
Silverstein WK, Weinerman AS, Born K et al. Reducing routine inpatient blood testing. BMJ. 2022 Oct 26;379:e070698. PMID: 36288811.
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Travelling long distances to access treatment for infertility is not uncommon. Most fertility consultations and follow-up visits can be safely performed remotely. CO2 emissions from transportation contribute to greenhouse gas emissions and climate change, which can be significantly reduced by providing virtual visits instead of in-person visits. Virtual care can also reduce time away from work and costs to patients.
Sources:
Flodgren G, Rachas A, Farmer AJ et al. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015 Sep 7;2015(9):CD002098. PMID: 26343551.
Mikhael S, Gaidis A, Gavrilova-Jordan L. Regional disparities in access to assisted reproductive technology: assessment of patient satisfaction when employing modern technology to close the gap. J Assist Reprod Genet. 2021 Apr;38(4):889-894. Epub 2021 Jan 14. PMID: 33447948.
Tennison I, Roschnik S, Ashby B et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health. 2021 Feb;5(2):e84-e92. PMID: 33581070.
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The Canadian Fertility and Andrology Society (CFAS) Choosing Wisely National Working Group used a modified Delphi consensus approach, consisting of 5 rounds, to generate item ideas, review supporting evidence, assess clinical relevance, estimate recommendation impact and narrow the items. The Working Group was comprised of 11 diverse clinicians with experience in the field. Round 4 of the Delphi process consisted of a National CFAS Membership Survey to rank the remaining 13 items. The top 5 items were selected based on 4 qualities: prevalence, cost, potential for harm and impact on clinical practice (round 5). The CFAS Board of Directors provided feedback which was incorporated into the composition of the final list approved by the Board.
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Choosing Wisely Canada’s climate-conscious recommendations are developed by clinician societies to improve planetary health without compromising patient care. These recommendations highlight everyday practices we can reduce or eliminate to minimize environmental harm. Visit our climate page to explore all the recommendations and learn more.
Sources:
Chan C et al. Preimplantation genetic testing for aneuploidy: A Canadian Fertility and Andrology Society Guideline. Reproductive Biomedicine Online. 2021;
42(1): 105-116. PMID: 33303366.
Munne S. et al. Preimplantation genetic testing for aneuploidy versus morphology as selection criteria for single frozen-thawed embryo transfer in good
prognosis patients: a multicenter randomized clinical trial. Fertility and Sterility 2019; 112: 1071–1079. PMID: 31551155.
Yan et al. Live Birth with or without Preimplantation Genetic Testing for Aneuploidy. N Engl J Med 2021;385:2047-58. PMID: 34818479.
Friedler S, et al. An upper limit of gonadotropin dose in patients undergoing ART should be advocated. Gynecol Endocrinol 2016 Dec;32(12):965-969.
PMID: 27345589.
Haas J, et al. Do poor-responder patients benefit from increasing the daily gonadotropin dose during controlled ovarian hyperstimulation for IVF? Gynecol
Endocrinol 2015 Jan;31(1):79-82. PMID: 25223892.
Lensen et al. Individualised gonadotropin dose selection using markers of ovarian reserve for women undergoing in vitro fertilisation plus intracytoplasmic
sperm injection (IVF/ICSI). Cochrane Database of Systematic Reviews 2018, Issue 2. Art. No.: CD012693. PMID: 29388198.
Lacey et al. Assisted hatching on assisted conception (in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI). Cochrane Database of
Systematic Reviews 2021, Issue 3. Art. No.: CD001894. PMID: 33730422.
American Society for Reproductive Medicine. The role of assisted hatching in in vitro fertilization: a guideline. Fertil Steril. 2022 Jun;117(6):1177-1182.
PMID: 35618358.
Achilli C, et al. The role of immunotherapy in in vitro fertilization and recurrent pregnancy loss: a systematic review and meta-analysis. Fertil Steril 2018;
110(6):1089-1100. PMID: 30396553.
Ober C et al. Mononuclear-cell immunisation in prevention of recurrent miscarriages: a randomised trial. Lancet 1999; 354: 365–69. PMID: 10437864.
Pfeifer S, et al. The clinical utility of sperm DNA integrity testing: a guideline. Fertil Steril. 2013;99(3):673–7. PMID: 23391408.
Schlegel PN et al. Diagnosis and treatment of infertility in men: AUA/ASRM guideline part I. Fertil Steril. 2021 Jan;115(1):54-61. doi: 10.1016/j.
fertnstert.2020.11.015. Epub 2020 Dec 9. PMID: 33309062.
Zhang Z, et al. Sperm DNA fragmentation index and pregnancy outcome after IVF or ICSI: a meta-analysis. J Assist Reprod Genet. 2015;32:17–26.
PMID: 25392073.
El-Toukhy T, Campo R, Khalaf Y et al. Hysteroscopy in recurrent in-vitro fertilisation failure (TROPHY): a multicentre, randomised controlled trial. Lancet. 2016 Jun 25;387(10038):2614-2621. Epub 2016 Apr 27. PMID: 27132053.
Smit JG, Kasius JC, Eijkemans MJC et al. Hysteroscopy before in-vitro fertilisation (inSIGHT): a multicentre, randomised controlled trial. Lancet. 2016 Jun 25;387(10038):2622-2629. Epub 2016 Apr 27. Erratum in: Lancet. 2019 Jun 15;393(10189):2394. PMID: 27132052.
Doyle N, Jahandideh S, Hill MJ et al. Effect of Timing by Endometrial Receptivity Testing vs Standard Timing of Frozen Embryo Transfer on Live Birth in Patients Undergoing In Vitro Fertilization: A Randomized Clinical Trial. JAMA. 2022 Dec 6;328(21):2117-2125. PMID: 36472596.
K Lundin, J G Bentzen, G Bozdag et al. Good practice recommendations on add-ons in reproductive medicine. Hum Reprod. 2023 Nov 2;38(11):2062-2104. PMID: 37747409.
Favaro C, Pearson JT, Rowland SP et al. Time to Pregnancy for Women Using a Fertility Awareness Based Mobile Application to Plan a Pregnancy. J Womens Health (Larchmt). 2021 Nov;30(11):1538-1545. Epub 2021 Sep 8. PMID: 34495761.
Practice Committee of the American Society for Reproductive Medicine. Fertility evaluation of infertile women: a committee opinion. Fertil Steril 2021;116:1255-1265. Epub 2021 Oct 2. PMID: 34607703.
Silverstein WK, Weinerman AS, Born K et al. Reducing routine inpatient blood testing. BMJ. 2022 Oct 26;379:e070698. PMID: 36288811.
Flodgren G, Rachas A, Farmer AJ et al. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015 Sep 7;2015(9):CD002098. PMID: 26343551.
Mikhael S, Gaidis A, Gavrilova-Jordan L. Regional disparities in access to assisted reproductive technology: assessment of patient satisfaction when employing modern technology to close the gap. J Assist Reprod Genet. 2021 Apr;38(4):889-894. Epub 2021 Jan 14. PMID: 33447948.
Tennison I, Roschnik S, Ashby B et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health. 2021 Feb;5(2):e84-e92. PMID: 33581070.
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
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