THE SEEMINGLY UNSTOPPABLE CORPORATIZATION OF OUR REPRODUCTIVE MEDICINE
By Norbert Gleicher, MD, Medical Director and Chief Scientist, at The Center for Human Reproduction in New York City. He can be contacted directly at ngleicher@thechr.com.
Norbert Gleicher, MD, is the Medical Director and Chief Scientist of the Center for Human Reproduction (CHR) in NYC. As one of only very few remaining still actively practicing first generation IVF researchers and clinical practitioners in the US, he in this article describes how he views the massive changes the field of IVF has—especially over the last two decades—undergone worldwide.
This publication is the edited version of an article that appeared in the September-October issue of the CHR VOICE.
In the August 8 issue of The New England Journal of Medicine, Nancy Tomes, PhD, a Distinguished Professor of History at the Department of History at Stony Brook University in New York state, wrote an interesting Perspective article in a series of articles on the corporatization of the US health care The Journal recently announced. It deserves attention.
Based on a prominent pharma executive’s comment at a recent health care conference organized by J.P. Morgan, the article was titled, “A Gilded Age for Patients? The Broken Promise of Profit Driven Medicine.”¹ The executive’s comment was: “It is clear the industry is at a pivotal moment—a golden age for patients marked by unprecedented innovation,” suggesting substantial opportunities for investments in gene and cell therapies, artificial intelligence (AI)—driven digital health solutions, and medical robotics.”
As the title of Tone’s article already indicates, while not contradicting the executive’s investment conclusions, she considers his comments just as further evidence that the concept of a profit-driven US health care system has failed.
Considering The Journal’s general and historical political orientation to the left of center—when has The Journal, indeed, ever in recent memory published an Opinion article at or to the right of center? Choice of author and of her conclusions cannot surprise. But that, of course, does not mean that this author may not be correct in her conclusions!
Some historical background
As a historian she offered in her article a very helpful background when noting that between the 1920s and 1960s medicine in the US developed a physician-controlled business model. This model, however incentivized outside corporate interests in investing in health care over the next two decades, with the result being that, by the 1980s, physicians had largely lost control of the business model they had devised, a development she astutely described as “the tail of financialization wagging the dog of medical practice.”
Investors, moreover, co-opted in the process “the language of consumerism,” claiming the takeover to be in the best interest of patients, when patients as well as their physicians—in reality—completely lost economic control over their health care choices to administrators, of course primarily representing the investors’ interests.
She also noted in her article that—interestingly—the American Medical Association (AMA) and American Hospital Association fully supported these developments, claiming that “prudent consumer-patients could afford innovative, technology-driven care by giving up luxury items and saving for medical crises.” Medical entrepreneurs, moreover, based their investments on the believe that applying standard market discipline to healthcare proven effective in other businesses, would be equally effective in health care if the right combinations of innovation, efficiency and cost-benefit considerations could be achieved and would in the process improve health care for patients, while, still, allowing investors to appropriately profit.
Remarkably, this kind of thinking not only controlled the for-profit health care market but also not-for-profit institutions which, often, basically followed the same investment strategies, including the purchasing of physician practices, often in competition with private equity investors.
Another major development affecting U.S. health care happened in parallel. Starting around 1970, proponents of a market-driven medical economy—quite paradoxically—presented themselves as patient representatives and defendants of consumerism, demanding improving medical care on behalf of consumers. One of the demands was better information, fostering strong political pressure for previously to the public prohibited advertisement in medicine by pharma, hospitals, as well as physicians. Small physician offices however, of course, did not have the means to pursue such advertisements; but pharma, insurance, and hospital industries, by spending heavily in direct-to-consumer advertisement, gained enormous market power. Their final winning argument made was a right to “free speech” (that could not be withheld from pharma, insurance, and hospital industries).
Results, however, ended up quite different from expectations: One of the most consequential results was what Tomes called a “merger movement” in hospital services and medical practices that in many markets significantly reduced competition and allowed ever more dominant industrial players to arise, which, for lack of competition, were able to gain efficiency of size without having to pass on those gains to consumers. Moreover, as a consequence, over 70% of U.S. physicians are now employed by these commercial entities (i.e., by industry).
The impact on the infertility field
All of this, of course, also applied to infertility practice. One, indeed, can even argue that only a small minority of medical specialties were as significantly affected by all of these changes as the infertility field, with private physician-owned practice—which once constituted over 80% of IVF practice in the country—largely gone and private equity owning an ever-increasing bulk of IVF clinics not only in the U.S. but worldwide. One, therefore, can actually argue that the infertility field can—very well—be considered a barometer for where Private Equity ownership in medicine may be going.
According to the 2018 CDC Fertility Clinic Success Rates Report, Private Equity already in the year 2018 “owned” almost a third of all U.S. IVF cycles (29.3% to be accurate). Considering the growth Private Equity ownership of IVF clinics in the country over the last seven years, one must assume that this percentage has significantly grown and, likely, by now exceeds 50%. If one, furthermore, assumes that large hospital networks and academic institutions, combined, probably represent approximately one-quarter of all IVF cycles, the conclusion that private physician-owned medical practice in the IVF field is disappearing appears—at least for the moment—indisputable.
This impression is further enhanced by the marketing dominance of large clinic networks which not only extends to marketing efforts to potential patient populations, but also includes the ability to recruit specialty staff, including nurses, embryologists and physicians. Considering the considerable and quickly increasing shortage in all of these professions within fertility medicine, it is important to note that some of the major equity-owned clinic chains—through ownership of university and other hospital-affiliated IVF clinics (in NYC, for example, the NYU and Mount Sinai programs, in the Washington, DC, area the Shady Grove program, etc)—now are also benefitting from direct priority access to new trainees in those programs. That means they have priority access to the only 50-60 REI fellows graduating fellowships every year and, of course, to the nurse graduates at affiliated nursing schools.
But their competitive advantages with still privately-owned clinics do not only extend to better marketing opportunities and staff recruitment. Private equity and other non-medical ownership structures have also become disproportionally important within professional organizations by placing their staff into elected administrative positions in professional organizations (i.e., for example the ASRM/SART) and—far more importantly—by becoming, together with other non-physician owned support industries—often also owned by Private Equity, cross-ownership, and/or other investment structures – the principal financial supporters of professional organizations (i.e., again, for example ASRM/SART but also ESHRE, etc).
Besides membership fees, income from the rent of commercial space in the exhibition hall of the ASRM’s Annual Scientific Congress & Expo are—together with donations and sponsorships from industry—the major income sources of the ASRM. It is not accidental that the annual ASRM “Congress” in 2024 was renamed “Congress and Expo” (while ESHRE, interestingly, still calls its annual meeting “Annual Meeting”). And it is also, for example, not coincidental that the ASRM (in collaboration with its internal sister society, the Society for Reproductive Biologists and Technologists, in October of 2024 announced the so-called Clinical Embryology Learning Program (CELL), “a tuition-based initiative designed to address the critical need for standardized training in human IVF laboratories across the United States” which opened in January of this year, offering a 10-months-long course that ends up with certification, with the first class just having started in July.²
And who is the commercial partner in this endeavor providing facilities and (only) “in part support,” as the ASRM announcement noticed?” CooperSurgical (see above), a wholly-owned subsidiary of CooperCompanies, a Nasdaq listed company and among the biggest suppliers to the infertility field and, likely, only coincidentally among the biggest suppliers of instrumentations and supplies to embryology laboratories as well as one of the largest—if not the largest—suppliers of genetic testing services to the IVF field worldwide which, of course, includes preimplantation genetic testing for aneuploidy (PGT-A).
One can only wonder who the graduates of the CELL will choose as their supplier organization and how they will feel about the use of PGT-A in IVF, which even the ASRM—after years of delays—finally last year concluded does not offer any outcome advantages of proven significance to IVF.³
In short, the impact of the corporatization of the infertility field has not only been substantial, - but to a significant degree has at so many different levels been substantially negative. And this can be considered a conservative assessment because the degrees of deterioration in especially IVF practice could be easily described as tragic, considering the likely most significant adverse consequence, IVF cycle outcomes, which, since 2010, not only no longer have been improving, but, in fresh cycles with reference point cycle, start have steadily declined. In other words, the infertility patient who starts a fresh IVF cycle in 2025 has significantly lower (and the difference is by no means marginal) live birth chances than the same patient would have had in 2010.
We pointed this fact out for the first time in 2019,⁴ and things have since then continued to deteriorate in the U.S. (and likely elsewhere as well, though other regions do not report outcomes as detailed as the U.S.) in a straight line from year to year, leaving only one explanation: Many, if not most, new treatments introduced to IVF under the proclaimed intent to improve IVF outcomes have not only failed, but have actually adversely affected outcomes.
And the main culprits are easy to identify: Routine extended embryo culture, routine elective single embryo transfer (yes, eSET has greatly reduced twin pregnancy rates, but why doesn’t anybody talk about at what price?). And then, there is, of course, PGT-A, now in the U.S. likely used in already over half of all IVF cycles, including, in donor-egg cycles without any evidence of any outcome benefit, as already above noted according to ASRM/SART.²
But this ASRM/SART opinion has not gone far enough because it failed to acknowledge at least two major consequences that must follow the document’s conclusion that PGT-A does in general populations not improve IVF outcomes in any way:
It is indisputable that PGT-A not only does not improve IVF outcomes, but actually reduces pregnancy chances. One, indeed, does not have to go into any detailed discussion on this subject (the CHR has contributed published papers on this subject for almost 20 years and there are multiple reasons why PGT-A in selected patient populations, indeed, reduces pregnancy and live birth chances) because even proponents of PGT-A by now have no option but to acknowledge that huge numbers of allegedly chromosomal “abnormal” embryos have been withheld from transfers—and in most IVF clinics in the U.S. are still being withheld—even though they still may have pregnancy and normal live birth chances, whether one calls them “mosaic” or “aneuploid.” In practical terms this means that their withholding from transfer reduced, and is still reducing, cumulative pregnancy chances for so-affected patients.
If a medical test does not offer any benefits whatsoever and, in addition, adds at least $5,000 to the costs of an already very expensive IVF cycle, why should this test continue in use?
The timidity of the ASRM (and ESHRE) in regard to PGT-A is, therefore, difficult to understand, unless one is willing to accept the notion that financial considerations are in play. The same questions, however, also arise when one asks why IVF clinics still routinely recommend PGT-A to their patients, when even ASRM now has officially concluded that, when used unselectively, the procedure does not help?²
That financial motives may be here at play as well, is suggested by a preliminary study we recently published which investigated PGT-A utilization based on clinic ownership. In comparing ownership by private physician, hospital/medical school, and outside investors—unsurprisingly—the highest utilization of PGT-A was found by investor-owned clinics.⁵ And, on a side note, higher utilization, of course, also did not improve IVF cycle outcomes.
Overall, all this, of course, should not surprise, since the published data demonstrating that Private Equity investments in medicine in general increase costs (and often lower quality of services, resulting in increasing patient dissatisfaction) now have become overwhelming.6-8 The state of Massachusetts, therefore,⁶⁻⁸ as the first state in the union, recently passed a new law (House Bill 5159) which regulated Private Equity investments in health care in quite significant ways after a major privately owned health care system went bankrupt. The New England Journal of Medicine described the law as the perhaps most “far-reaching state legislation in the U.S. aimed at curtailing the influence of private equity in health care.”⁹ The question, therefore, now arises where will all of this lead in the infertility field?
The future of infertility practice
As we, of course, live in rather volatile political as well as economic times, predictions are probably more risky than usual. I will nevertheless try and may do so with, maybe, surprising optimism, considering that this article, at least to this point, can, certainly, not be described as painting an optimistic picture.
But my optimism regarding the future of fertility practice in the U.S. is, paradoxically, exactly based on what I consider the current tragic condition of the field, which makes me believe that we already are witnessing the beginning of what I can only call the “crash” of the current system. And this crash will have a variety of reasons: Since everything, of course, starts and ends with money and since most of so-far discussed changes in Us fertility practice occurred because of billions of investor dollars flowing into the fertility field, lest start with those investors.
They, frankly speaking, mostly don’t give a damn; their concern is to make their money (i.e., their investments) work by earning more money. For Private Equity investors that means that they expect their investment to double or even triple in five to seven years. Practically this means, that they are planning to sell a company they bought—often to another equity investor—with substantial profit within this time frame because they need the money to satisfy their own investors’ demand for profit and for future investments.
But there have been problems recently in turning over Private Equity investments, and not only in the infertility arena. Private equity, in general, has been experiencing exit problems. Estimates suggest that between 4,000 and 6,500 exit transactions have already been delayed, representing up to half of the annual volume in the US.¹⁰ Whether the draught in exits already affects the fertility field is unclear but there are signs that at least some major investments in the infertility field are under water and—from what I have been hearing—the principal problem appears to be profitability.
In order to double or triple the value of a company, the company’s profit has to double or triple, and from what I am hearing practically none of the major fertility clinic networks has been able to accomplish that. While successful in increasing IVF cycle numbers, the assumption that this would lead to improvements in profitability has been proven wrong because IVF is, of course, very work intensive.
It, therefore, is not surprising that everybody is talking about automatization of embryology laboratories (a phantasy probably still years away), started using physician extenders to lower staffing costs, and made it clear to their physicians that they had to produce more IVF cycles or face the alternative. Executive and other staff turnover in many of these chain clinic organizations has been substantial, often involving staff from entry level to CEOs. A local NYC clinic of one of the largest IVF clinic networks for example just fired its excellent and very well-known embryology laboratory director. In short, we hear it rumbling at almost all of the major clinic networks.
All of this, of course, also means that nobody is happy. If staff is unhappy, work slows down, patients feel it, overcrowding becomes more severe, even if cycle numbers don’t increase, and patients don’t like it if they never see their REIs because most of the work is done by physician extenders, like physician assistants and/or nurse practitioners.
It appears to me that Private Equity finally recognized all of these problems, for many quite late in above noted five-to-seven-year turn-around cycle. These companies appear to have entered a very crucial last-chance scenario because Private Equity is merciless, once it recognizes that an investment failed. Who does not remember the widely loved French bakery chain Maison Kayser in NYC which practically overnight shut down all of its 16 locations across the city in the summer of 2020 because of the COVID pandemic. Its investors preferred to take the loss, rather than continue trying to recover because they would not have met their investment strategy even if a recovery had been possible.
So, what does all of this mean for the infertility field?
I believe we need to get ready for significant change. I would not be surprised if, at least some of the clinic chains broke up. At a minimum their numbers will decline. The field will have to choose between more automatization for standardization of treatments and individualization of patient care because both will not be possible in the same IVF clinic.
I, therefore, see over the next few years a radical reorganization of the infertility market into two distinct provider levels: Young and good prognosis patients will be taken care of in highly automated high-volume set-ups by mostly physician extenders, following strictly defined protocols. Clinics like that will be the large majority among all IVF clinics serving approximately 80-85% of IVF cycles in young and uncomplicated infertility cases and social fertility preservation. Older and more complex patients with poorer prognosis will attend more “old-fashioned” IVF clinics—more along what the CHR currently does—which, of course, cannot be high-volume clinics and requires much more physician and senior embryology involvement to individualize care.
These changes will, however, crystallize only after significant pain and after Private Equity finally starts to understand that medicine, while certainly a business, is very different from any other business. The infertility business demonstrates this better than many other fields of medicine because of what we do and where we do it. And—not to be forgotten—we, after all, are also the only field in medicine that does not only preserves, but creates life!
References
Tomes N. N Engl J Med 2025;393(6):521-524
ASRM. https://www.asrm.org/asrm-academy/professional-engagement/cell-program/
Practice Committees of ASRM and SART. Fertil Steril 2024;122(3). 421-433
Gleicher et al., Hum Reprod Open 2019(3):hoz017
Patrizio et al., J Assist Reprod Genet 2025; 42:81-84
Brownstein M. Harvard T.H. Chan School of Public Health. December 16, 2024. https://hsph.harvard.edu/news/private-equitys-appetite-for-hospitals-may-put-patients-at-risk/
Zhu et al., JAMA Intern Med 2024;184(5):579-58
Borsa et al. BMJ 2023; 382:e075244
Tai et al., N Engl J Med 2025;393(8):731-733
PWC. https://www.pwc.com/us/en/services/consulting/deals/library/capital-considerations-private-equity-exit-drought.html