the NEED for quality care in the FERTILITY sector
in the past year, Femtech has become a buzzword and women’s health is increasingly being noticed — but is it really?
AUGUST 2022
by Caterina Calisti & Yahel Halamish
Femtech is a relatively young industry. The broad term refers to technological solutions to address women’s health issues, including menstrual health, reproductive health, sexual health, maternal health, and menopause. Though the topic recently gained more awareness, women’s health needs remain widely underserved. Investments in Healthcare solutions have substantially grown, with $44B raised in 2021; yet, according to Pitchbook estimation, only 4% of companies’ R&D spending is addressing the needs of women — demonstrating a huge disconnect between opportunity and reality.
We recently published a Medium blog about The Lowdown, a portfolio company that is solving one of the earliest needs in a woman’s life cycle: the need for contraception. In this post, we focus on (in)fertility as an area of needs, and provide some guidelines for how health technology innovators can address it in order to maximize their chances of success.
the FERTILITY market and the growing use of ART
The treatment for infertility using Assisted Reproductive Technologies (ART) is relatively young: the first in-vitro fertilization (IVF) pregnancy was reported in 1973. Since then, the treatment of infertility has become a large business across the world as infertility became a global health issue affecting millions of people of reproductive age worldwide. Available data suggests that 15% of reproductive-age couples suffer from difficulty conceiving globally. Growing infertility issues are expected to further increase the demand for fertility services.
Infertility can be caused by different factors affecting women and men alike. Though women often bear the bulk of the treatment, a third of the infertility cases are reported to be caused by male reproductive issues, and another third by unknown factors or both women and men. The treatment for infertility often includes medications and the use of ART, with the most commonly known method being IVF. In Europe, however, over 70% of procedures nowadays use the method of IntraCytoplasmic Sperm Injection (ICSI),. ART procedures are not only used as a treatment for infertility but also enables individuals and LGBTQ couples to have children.
Financial coverage for fertility treatments is often inadequate. Payment is widely out-of-pocket. Medical costs of a single ART cycle are estimated at $30,000. Three cycles are generally needed to increase the chance of successful pregnancy to ~50%. The probability that the first ART cycle will result in a pregnancy is merely ~30%.
The extent of out-of-pocket expenses and the lack of a clear definition of infertility as a disease are making infertility a health issue structurally different from most others. Though different, it is still operating in a multi-stakeholders environment, including patients, clinicians, private and public clinics, and labs.
We at Nina Capital have screened over 4000 companies in the last three years. Of these, 4.5% are focused on childbirth and fertility. An additional 1.4% are focused on different women’s health needs. About 91% of the companies in the fertility space have combined software and hardware innovations, while only 9% are pure computing solutions (algorithms). Most innovations we evaluated come out from the United Kingdom (19.3%), followed by the United States (15%), Spain (12.3%), Germany (8.6%), and Israel (8.6%).
As we dive deeper into this market, based on the knowledge we’ve accrued studying and speaking with many founders, we are most preoccupied with looking to assess the incentives that make its different stakeholders tick, focusing on the two stakeholders that we consider key: patients and providers.
drivers for Patient-Centeredness: the PATIENTS' perspective
Patient-centered care is defined by the Institute of Medicine as care that is respectful and responsive to individual patient preferences and needs, and that is guided by patient values. Universally desirable, patient-centeredness is especially so when studying needs in the fertility space. Fertility journeys often bear heavy psychological and physical distress on the patients. Unsurprisingly, a study including more than 200 infertile couples and investigating the strengths and weaknesses of fertility treatments highlighted patient-centeredness as an essential dimension of quality of care.
We break down here relevant desirable outcomes in fertility from a patient-centric perspective. They represent key drivers or, put differently, criteria for acceptance of any solution. For innovation in this sector to be successful, we believe entrepreneurs should consider each of these outcomes before entering the space: their solutions will be judged or decided based on these merits. They are: easy access, (no) pain, transparency, and a high success rate.
easy access.
Fundamental need-criteria related to access to care include waiting time to be enrolled in treatment, duration of treatment, geographical proximity, ease of scheduling, and financing costs. When innovation in fertility treatments fails to adequately address these criteria, patients find barriers to access. In our research, we found the two main barriers today to be time, both spent in waiting and in treatment, and financial costs.
- Waiting time. Couples often feel a sense of urgency that “time is running low,” especially if the infertile partner starts the treatment at a relatively old reproductive age. In these cases, long waiting times can negatively affect the chances of a positive outcome.
- Duration of treatment. Time not only impacts the effectiveness of the treatment, but the process itself is time-consuming. An average IVF treatment can take up to 4 months (including pre-cycle procedures). While undergoing fertility treatments, patients are required to frequently attend the clinic for checkups, including bloodwork, ultrasounds, and consultations with a nurse: such a demanding schedule may be difficult to integrate with an already busy work routine. Moreover, in many cases, a patient will need to undergo more than one ART cycle. The duration of the treatment might impact the patient’s decision to proceed to another cycle.
- Financial costs. The majority of people undergoing ART treatments in the US pay out of pocket. Considering the median annual family income in the US was $79,900 for 2021, a single ART cycle represents more than 35% of the average household’s income. The lack of public funds accounts for a lower rate of births using ART in the US (1.5%) compared to Denmark, Belgium, and Sweden, where average percentages are 5.9%, 4.0%, and 3.5%, respectively. Not only public funding, but other factors such as geography, race, ethnicity, sexual orientation, gender identity, and marital status can be causes of disparities in (financial) access to reproductive treatments. When the price for treatment in the home country is too high or the national criteria for public funding are not met (e.g for the NHS in the UK), infertile patients are likely to consider other countries offering the treatment for a cheaper price, where the level of safety and standard of care is not guaranteed, endangering the health of the patient.
(no) pain.
Infertility takes a toll on both the physical and emotional levels. When addressing needs in infertility, entrepreneurs should be mindful not to add, and desirably to reduce, the pain inflicted by infertility to the body and mind.
- Physical level: women undergoing fertility treatments often describe them as grueling; for example, they have to inject themselves with hormones. The fertility journey is also accompanied by medication that often carries side effects such as breast tenderness, bloating, hot flashes, and headaches.
- Emotional level: many couples struggle with depression while undergoing fertility treatments, especially after several failed attempts to become parents. Their state of anxiety can influence their decision to drop out of treatment, even if they still have a good chance of eventually succeeding.
transparency.
The process of selecting a fertility clinic is often tedious, time-consuming, and opaque. Clinics vary by reputation, treatment specialization, location, and more. Public reports and reviews about the clinics are a useful source of information for the patients, especially since these factors are some of the key motivations for cross-border travel in the global medical tourism sector. However, potential patients looking to compare different clinics often find it difficult to source credible information.
Once the clinic is chosen, patients also desire accurate information about the available treatment alternatives to driving informed and personalized decisions. In case of doubt, fertility experts should help the patients to correctly understand and interpret the available information, for example about the possible effect of a failed ART cycle on the subsequent ones. Moreover, when suggesting a type of fertility treatment, the physician should take into account the patient’s values and preferences, which may change over time: at the beginning of treatment, a couple may prefer less invasive options such as hormonal therapies; later, the same couple may consider ART if the previous approach was not successful. Patients’ preferences extremely vary on the topic of genetic parentage, also: some people may refuse medical treatments that involve third-party genetic material, while others may be open to accepting donor sperm or eggs — especially if treatments with their own genetic material previously failed. The journey of fertility treatments holds many forks in the road, each one requiring a decision. To promote an informed decision patients need access to accurate and unbiased information.
high success rates.
According to the Human Fertilization and Embryology Authority (HFEA), birth rates from IVF in the UK tripled from 1991 (7%) to 2018 (24%) for patients younger than 35. This steady increase mirrors the progress in ART that has been made so far, giving hope to young infertile individuals and couples worldwide.
However, success rates for higher patient age bands (40–50) remain low. Several individual factors other than age such as infertility diagnosis, history of previous births, or miscarriages impact the chances of success per ART cycle as well.
Even for patients under 40 years old, The National Institute for Health and Care Excellence (NICE) recommends three IVF cycles to have chances of successful pregnancies of 45–53% compared to 20–35% success rates per cycle. Data shows that there is still room for improvement in ART success rates to alleviate the burden of infertility associated with multiple cycles of treatment.
To summarize, from a patient’s perspective, we consider important that entrepreneurs are mindful of the following desirable outcomes when setting out to address needs in infertility:
drivers for efficiency and effectiveness in care: the PROVIDERS perspective
Fertility clinics usually offer most, if not all, the services required for infertility treatment including any necessary lab work. Laboratories are often owned by Fertility clinics. They can also sell additional wellness products and supplements to patients, generating multiple revenue streams.
Fertility Clinics, as businesses, need to build a strong name and reputation; to do so, they are incentivized to provide a high quality of care. From a provider’s perspective, the drivers or criteria for successful adoption of new solutions in this space are:
improved communication.
Clinics view patient communication as important to drive patient satisfaction. Currently, many clinics are using outdated methods to monitor the patients progress with no ability to triage the patients’ needs. Today most patients require more than one ART cycle for a successful birth, yet numerous will not continue the process at all after the first failed attempt, and might even approach a different clinic. Patient communication enables the clinics to strengthen their connection to the patients, reducing the probability they will prematurely abandon the treatment while increasing the potential number of ART cycles performed at the clinic at a minimal cost.
high success rates.
The fertility clinic market is predominantly operated by private providers. In Europe, a market that is highly supported by public funding, over 70% of the clinics are private. The private nature of the market is driving competition between clinics and a need for differentiation. In many countries legislation and guidelines are in place, requiring clinics operating ART procedures to report, amongst others, their success rates. This data is used by clinics as a marketing tool, driving higher demand to clinics that show a better track record. Clinics are actively looking for ways to improve success rates. Incidentally, absent solutions that actually work, untrustworthy clinics may resort to short-sighted behaviors:
- they may refuse to accept patients with a low probability of success
- they may intentionally fail to comply with reporting requirements
protection from liability.
Regulation on ART procedures is sometimes lacking and generally lagging behind regulations surrounding other health procedures. To compound the issue, patients are often not equipped to insure themselves against bad outcomes. Many of negligence events are caused by errors in diagnosing, labeling, and handling samples and embryos for implantation.
The use of ART methods is becoming more common. In the US alone, the number of ART cycles performed doubled from 2010 to 2019. As the frequency of ART cycles grows and patients are becoming more aware and knowledgeable, regulators are putting a larger emphasis on Fertility clinics and the risk of liability claims grows, generating a need for fertility clinics to integrate technologies and procedures offering protection against potential claims.
high operational efficiency.
Clinics’ employees, mainly embryologists and clinicians, report high levels of stress and workload in their day-to-day operations. In part, this is due to a critical shortage of experienced clinical embryologists. Embryologists are highly trained professionals, holding a Master’s or a PhD, and are crucially important to the success of an ART treatment. The job of an embryologist is often stressful, time-consuming and time-sensitive in the following ways:
- No rest. Embryos can be left out for only a set amount of days ranging between 3–5 days. Keeping the embryos in the right environment is key
- Tedious. time-consuming manual work. The selection process of the egg, sperm, or embryo is tedious, time-consuming, and requires the utmost attention to increase the probability of success
- High pressure. Shortage in embryologists and heavy demand can potentially lead to human errors when selecting egg, sperm or embryo.
Increasingly, we’ve seen entrepreneurs promising automation of some of the steps in an embryologist’s workflow, which in turn increases a clinic’s efficiency by reducing (while potentially driving higher accuracy in the selection process!).
To summarize, from a provider’s perspective, we consider important that entrepreneurs are mindful of the following desirable outcomes when setting out to address needs in infertility:
the intersection of Patients and Providers needs as a driver for better QUALITY OF CARE
According to the WHO, Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes. It is based on evidence-based professional knowledge and is critical for achieving universal health coverage. Improving the quality of care and promoting patient-centeredness requires a true partnership between patients and providers.
Our belief is that the opportunity for innovation that sustainably improves the Quality of Care lies at the intersection between the patients’ and the payers’ incentives for its adoption. We found that there is a compelling area of overlap between patients’ and the providers’ desirable outcomes: innovators addressing needs in fertility will find themselves with strong foundations for meaningful impact on the overall quality of care if they are mindful to address all. Of course, any additional value delivered to patients or clinics at both sides of this intersection can only help adoption even further.
this is a call to action!
If you are a founder working on building something that alleviates any of these needs please reach out to us at Nina Capital. We are looking forward to meeting you.
Caterina & Yahel
