Baby-booming: the business of IVF

Big-city investors have been moving into the IVF business. Will their demand for profits lead to the exploitation of women’s desire for children? 

The IVF baby boom is big business in Australia, a multimillion dollar industry built on the hopes of would-be parents and propped up by one of the world's most generous government subsidy schemes.

A recent economics report declared that IVF was moving away from a "specialist medical service to a lucrative business for potential investors".

Over the past 18 months, two IVF companies have made rock-star entrances onto the Australian stock exchange. First, Virtus debuted with a market value of $600 million in June 2013, followed in 2014 by Monash IVF, valued at $430 million.

But as so often happens when corporate dollars flutter around medical interventions, the ethical debate has begun.

For IVF, the questions are basic. Does the interest of the shareholders override the interests of the patients? How will the IVF industry manage access to medical innovation and monied investors without exploiting their customers' often desperate desire for children?

"IVF is being marketed as a great investment opportunity, underwritten by the Medicare safety net," says former Howard Government advisor Terry Barnes.

"If you look at the major provider's marketing material for investors, the success rate is not referring to live births. The emphasis is on throughput. It is on volume, the number of cycles. That's where the return on investment is for shareholders."

Mr Barnes - it is worth stressing - is the policy guru who lit the fuse on the Coalition's plans for a GP co-payment. But his interest in Medicare has meant he has also set his sights on IVF, last year calling for a parliamentary inquiry into the industry and for the introduction of new restrictions to Medicare support for assisted reproduction services.

He's not happy with the cost of IVF to taxpayers, which is currently in excess of $230 million a year and growing.

Medicare, he says, unlike most other public funding systems around the globe, places no restrictions on the number of cycles, no restrictions on a woman's age, marital status, weight, or smoking status.

"Given that Medicare and private health insurance are subsidising a highly commercialised and lucrative industry, the Abbott Government can and should ask some fresh policy questions about the appropriateness and ethics of [assisted reproductive technology] business models," Mr Barnes says.

IVF's business model is not predicated on treatment success, Mr Barnes argues.

Profits are not contingent on the delivery of the end product, a baby, meaning repeatedly unsuccessful customers drive profits.

Fertility specialists are among the major shareholders in IVF companies who are reaping the financial rewards of the corporatisation of the industry, he says.

"While clinicians' instinct is to help patients to the maximum extent possible, there is also a commercial interest," he says.

Doctors as shareholders
There has been a flurry of media reports suggesting that some IVF doctors own up to $20 million worth of IVF company shares.

The ABC claimed last year that at the time when Virtus and Monash IVF were listed, their doctors and fertility specialists owned around 20% of the shares in each company. The financial sums are not small.

But Dr Lyndon Hale, co-director of Virtus Health and medical director of its Melbourne IVF clinic, is sceptical about the alleged distortion of care as a result of the search from profit.

"We have protocols in place in terms of who is appropriate to treat and in terms of treatment review," he says.

"If I don't think my patient is in a good position to do IVF, then I don't recommend IVF. If IVF is not working, I recommend they stop doing IVF.

"Everyone who does IVF wants a baby, and all the people who work in IVF -- doctors, nurses, counsellors -- are in the business to make it happen, and they tend to be optimistic people.

"Do they lead people on? I don't believe so."

And the suggestion by Mr Barnes that the IVF industry does not hinge on optimising successful treatment but on pandering to repeatedly unsuccessful customers was "incomprehensible", Dr Hale adds.


" It's a competitive industry. I can't for one moment believe that we are not trying 100% each time to get the patient pregnant."

"Following that logic, it implies that I would do a sloppy job so that patient comes back for another transfer. It's incomprehensible that I would even think that," Dr Hale says.

Bulk-billing IVF?
Heat has been added to these debates with the arrival towards the end of 2014 of low-cost IVF suppliers who want to carve out a slice of the market for themselves with the financial support of Medicare subsidies.

The GP corporate Primary Health Care opened its first IVF clinic in Sydney, Primary IVF in July last year, pledging the first IVF babies as a result of bulk-billing. The company said that 1200 patients made bookings with the clinic within its first 10 days.

This low-cost IVF "product", according to an IBIS World report, has the potential to "significantly shake up the fertility services market, given the size of the entity involved".

Primary IVF says it is simply about levelling the field for all Australians, who should not be denied their chance for parenthood by prohibitive costs.

Working on the business model of providing 30 in-vitro fertilisation cycles per month, Primary IVF says patients will pay roughly $500 per cycle including pathology and non-Medicare rebatable expenses. This is a fraction of the average out-of-pocket cost of $4000 offered by Australia's current IVF market leaders.

Both Virtus and Monash IVF have their own forays into the low-cost IVF sector: Virtus with branded Primary clinics, and Monash IVF's new offshoot clinic BUMP.

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BUMP's general manager Dr Kylie de Boer says the clinic is able to keep costs down by restricting patient intake to candidates with the best chances of success and few complications. So its patients must be under 45, have a BMI less than 35, and are not likely to need a general anaesthetic for egg collection.

Hope vs facts
But does the growing marketing around IVF - particularly to a generation of older women who are delaying motherhood -  mean patients are being sold false hope? Are those endless IVF media stories about "miracle babies" smothering a harder, colder truth?

"Nobody wants to run stories about the people who go through IVF for nothing", said Lisa Jardine, the outgoing head of the UK's Human Fertilisation and Embryology Authority in a high-profile interview as she fought, successfully, to stop the UK Government dismantling the country's IVF watchdog.

Dr Karin Hammarberg (PhD), senior research fellow at Monash University's School of Public Health and Preventive Medicine, agrees to a large extent.

"I don't think the message has penetrated that IVF has its limits," she says, suggesting potential patients need to be watchful for the ways reporting of IVF success rates can be manipulated.

"It is a lot about how you present percentages."

For example, at first glance, claims of a one-in-four IVF success rate measured by pregnancy per cycle sounds promising, but it's not the full picture.

"You haven't counted anyone who doesn't get a transfer or those who lose a pregnancy," she says.

Live births are the outcome that counts. Of the 70,082 IVF cycles initiated in 2012 for women of all ages, 17.9% resulted in a live birth.

"It's a grim figure," Dr Hammarberg says.

She also says that partly as a result of the marketing, the public belief that IVF can overcome age-related infertility has become rusted-on.

One in four of the women who underwent an autologous ART cycle in 2012 was aged 40 or older, according to the Australian and New Zealand Reproductive Database.

Yet despite the abundance of women over 40 promoting IVF in the media, the live birth rate in 40-44 year olds was 8% , dropping to 1.8% for women 45 and older according to ANZARD's lastest report (2012).

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Running alongside this issue, there have also been concerns that the IVF industry is overservicing patients by offering ART to would-be parents who are likely to conceive naturally.

For instance, a 2014 report from an international consortium of IVF experts claimed that IVF was being overused for couples with unexplained infertility.

The Evidence Based IVF Group warned that only "weak" evidence underpinned the explosion of IVF for unexplained fertility, which now accounts for as many as one in four Australian couples undergoing IVF.

In response, Professor Peter Illingworth, medical director of Virtus' group of clinics branded as IVF Australia, criticises the group for ignoring the importance of IVF for older women with unexplained infertility.

"The wait-and-see approach is fine for women who are 31 or 32 years old, but if you're 38 and trying to have a family, IVF is a very important consideration," Professor Illingworth says.

"Doctors need to explain to all patients with unexplained infertility that IVF may not be their only chance of conception, but it could speed it up."

NHMRC review
The growth of the IVF industry is prompting action to ensure patients are not exploited.

Over the past few months, the NHMRC's ART review committee has investigated the corporatisation of IVF and the potential perils of patients caught in the middle of commercial transactions as part of a review of its ART guidelines.

Chair of the review committee, Professor Ian Olver, says the main focus of the guidelines would be ensuring patients were given a complete picture of the risks and benefits of IVF.

"There is a lot of emotion involved in deciding whether to undergo IVF, which makes it more important that you give very accurate information."

The revised guidelines are due in the coming months. They will be read with interest.

Whether they can make decisions for women considering IVF any less fraught, will remain to be seen.