Your humble columnist, a retired reproductive endocrinologist, suggests the following seven trends that will define in vitro fertilization (IVF) in the coming decade:
1) IVF for the prevention of disease: The combination of 1) inexpensive human genome sequencing, 2) a vast increase in the number of known identifiable genetic diseases and 3) the wide availability of cheap 23andMe type genetic screening will result in an explosion of demand for IVF from fertile couples who wish to prevent the transmission of genetic diseases to their children. This trend, which started in the 1990’s, will more than double the demand for IVF worldwide.
These new IVF indications should and will result in routine insurance coverage for IVF. This will in turn lead to:
2) Much greater cost pressure on the IVF procedure. Competitive cost pressure has already moderated the rise in IVF pricing, but more widespread IVF coverage will accelerate this trend, as patients expect the same limits on out-of-pocket expenditure as they see with other medically-necessary procedures. Patient and insurance pressure will lead to:
3) Standardization of procedures, including increased automation. Note the graph showing Moore’s Law (drop in computing costs) and the extremely rapid drop in genome sequencing costs. Why have IVF laboratory costs stayed relatively constant (actually increased) since IVF was introduced decades ago while the no-less-complex sequencing costs plummeted in a much shorter time frame? We will examine the reasons in a future column, but market dynamics will inevitably reverse the increase in the costs of performing an IVF cycle.
4) IVF Mega-Clinics. I have seen countless business plans over the past couple of years describing various combinations of IVF centers in different parts of the country merging, gaining economies of scale, trying to maintain pricing power and protecting quality branding. This trend, very successfully pioneered by my ex-partner Richard Scott, the founder of Reproductive Medicine Associates (RMA) (disclosure: no business relationship) will accelerate as the market expands and consumer decisions are made less by individual patients and more by a combination of large insurers assembling networks and Uber/Open Table/Zoc Doc aggregators efficiently helping patients find an appropriate clinic. As has occurred in many areas of medicine, business will move to big purchaser (insurer/payor/patient purchasing service) buying from big provider (hospital/mega clinic.)
Trends numbers 1-4 arise from macro demand and supply trends. They will be matched by evolution in the clinics themselves, including:
5) A quantum leap in IVF technology. IVF was 1980’s technology and cured many cases of anatomic and unexplained infertility. Intracytoplasmic sperm injection (ICSI) and pre-implantation genetic diagnosis (PGD) were 1990’s technologies aimed at male factor and genetic-related infertility. The years since have seen incremental improvements in IVF techniques, but nothing revolutionary. Now, novel techniques aimed at oocyte (egg) factor infertility are in development. Ovascience (OVAS) (disc: I serve on their clinical advisory board, and OVAS is a public company in which my fund can invest), for example, is investigating oocyte precursor cells as a means to rejuvenate the eggs of patients that consistently result in poorly formed embryos. Another example: the technique known as “Three-Parent IVF,” originally invented by my colleague Jacques Cohen at Saint Barnabas Medical Center, has been resurrected in England as a treatment for inherited mitochondrial disease, and may – in theory -- also return as an infertility treatment.
For now, Ovascience’s Augment program is only available outside the United States, and only England has (just) approved Three-Parent IVF (a terrible and somewhat misleading name actually, but we’ll use it for now because it is the standard terminology.) This ex-US trend, which will likely continue given the high US regulatory barriers to commercialization, will lead to:
6) Widespread IVF medical tourism. In my last years at Saint Barnabas, few of my patients were New Jersey residents. The combination of our embryologists’ expertise and Dr. Cohen’s innovative laboratory techniques drew patients from all over the world. A routine day saw new patients from California, Canada, Russia, Japan, Italy and Brazil, attracted by high pregnancy rates and techniques they could not take advantage of closer to home.
If new treatments are only available outside of the United States, this trend will revers, and United States patients and couples will travel wherever necessary to maximize the likelihood of a good outcome.
7) Finally, the new treatments described above and others aimed at what we call “the egg factor,” one of the most vexing challenges in reproductive medicine, will result in the gradual disappearance of egg donation as a treatment for infertility.
Of course there are trends of which I am unaware and ideas that others far smarter than me are working on right now. Hopefully all of the trends in IVF will lead to safer, more efficient, and less costly care. Our patients, our friends and our families deserve nothing less.
