Kate is one of tens of thousands of patients whose fertility treatments have been disrupted by the coronavirus pandemic. These treatments can be emotionally fraught at the best of times: a triangulation of risks and probabilities, girded by hope and desperation. The stakes are inherently high: thousands if not tens of thousands of dollars in costs, and invasive hormone treatments with potentially severe side effects, all for the hope of a much-wanted baby.
The pandemic confronts patients and health-care providers with new ethical dilemmas. Is it too risky to pursue a fertility procedure when there’s a deadly virus going around? And might it divert medical resources from urgent covid-19 care? In a fast-growing and increasingly lucrative industry, those questions are now creating a schism that could last long after the crisis is over.
Covid-19 arrived as the fertility industry was undergoing a rapid expansion and change in structure. More and more people are attempting to have children later in life. In 1972, the average age of a first-time mother was 21. By 2016, it was 26. And women with college degrees—who tend to have higher incomes—don’t have a child, on average, until they are over 30. The ASRM lifted the “experimental” label on egg freezing in 2012. Two years later, Apple and Facebook were among the first large firms to announce that their insurance plans would cover the procedure. In 2018, American fertility clinics carried out nearly 18,000 egg-freezing or embryo-freezing procedures for the purposes of “fertility preservation,” according to the Society for Assisted Reproductive Technology (SART), a subsidiary organization of the ASRM.
“You have no margin if you’re not seeing new patients.”
David Sable, former fertility doctor
Before egg retrieval a woman must inject hormones, typically over the course of one to three weeks. These hormones stimulate her ovaries to grow more eggs to maturity than the usual one per month. Besides taking hormones, she visits a clinic every other day for blood tests and ultrasounds to track the eggs’ growth. Once the eggs are extracted, they can be frozen unfertilized, or they can be fertilized with sperm in an incubator to make embryos, which can then be either frozen or transferred to the uterus straight away. Fewer than half of IVF embryo transfers are successful—and under 10% for women older 40 using their own, fresh embryos. That is why a growing number of women are “banking” eggs or embryos before they intend to get pregnant, in order to accumulate a surplus of younger, healthier eggs.
Private equity and venture capital investors anticipate that the confluence of these two trends—increased insurance coverage and older parents—will cause demand for egg freezing, IVF (in vitro fertilization), and other fertility services to keep increasing. Until recently, most fertility clinics in the United States operated as independent entities, but they are now being acquired by investors who are turning them into outposts of national and global chains. McDermott, Will, and Emery, a prominent law firm, estimates that the global market for fertility services will reach about $31 billion annually by 2023, nearly doubling from $16.8 billion in 2016.
Fertility clinics are very profitable and have high margins, says David Sable, a former fertility doctor who now oversees a fund investing in innovative fertility technology. “But,” he adds, “you have no margin if you’re not seeing new patients.”
As the US went into lockdown in mid-March, it seemed logical that fertility patients would be asked to hold off on having treatment.