Private equity and reproductive medicine: “Fertile breeding ground” – a physician’s perspective”

Abstract

The growing influence of private equity (PE) in reproductive medicine makes it increasingly important to examine its impact from the perspectives of physicians, patients, and investors. As PE firms increasingly acquire fertility clinics and related healthcare services, they bring promises of operational efficiency, expanded access, and innovation. At the same time, these developments have come under growing scrutiny, raising critical concerns about the commercialization of care, equity of access, and the long-term impact on clinical outcomes. From the physician’s viewpoint, PE involvement presents both opportunities and challenges—shaping medical autonomy, clinical decision-making, and the ability to prioritize patient-centered care. The article critically assesses these dynamics, weighing the potential benefits of investment against concerns over profit-driven models, regulatory scrutiny, and the shifting role of healthcare professionals in an increasingly corporatized landscape.

Introduction

In early 2024, the Financial Times published a leading article,"Private equity has made fertility roll-ups its latest baby,"underscoring the increasing interest of private equity (PE) firms in the fertility sector [1]. Around the same time, a review titled "Is private equity Ruining health care? It’s Complicated" examined PE’s impact on healthcare, concluding that its effects are complex and resist simple classification [2].

The fact that the Financial Times took interest in the issue, reflects that professional and academic scrutiny of PE in reproductive medicine has been growing for some time. Studies in healthcare economics, law, and bioethics have raised concerns about the implications of profit-driven ownership on clinical quality, medical autonomy, and equitable access [3–6].

Editorials and opinion pieces in Fertility and Sterility, New England Journal of Medicine, and other major publications reflect a growing chorus of voices—clinicians, researchers, and policymakers—calling for a more critical examination of the PE model in fertility care [6–8].

Regulatory bodies such as HFEA and professional societies like ESHRE have also weighed in on the commercial influences shaping patient care, further reinforcing that the debate extends well beyond individual case studies [9–11].

Assessing whether private equity (PE) involvement in reproductive healthcare is beneficial or detrimental requires a nuanced perspective, because its impact is neither uniformly positive nor wholly negative. While PE can bring much-needed capital, infrastructure, and business expertise that improve access and operational efficiency, it can also introduce financial pressures that undermine clinical independence, prioritize profit over patient outcomes, and shift decision-making away from physicians. This paper offers a physician’s insights, on the basis of firsthand experience with four consecutive PE acquisitions.

Founded in 1998 in Barcelona as a physician-led fertility clinic, Eugin underwent four ownership changes over 13 years. It was first acquired by Spanish private equity firm ProA Capital in 2010, then sold to UAE-based NMC Health in 2015, followed by German- based Fresenius Helios in 2021, and most recently after only two years to IVI RMA and GED Capital in 2023.

Supporters and opponents

There is ample evidence that chain ownership can improve productivity and quality in the retail and service sectors [12, 13]. However, in healthcare, its application raises numerous concerns about prioritizing profits over patient well-being [14–16].

Supporters argue that chain ownership positively impacts the fertility sector by increasing productivity, typically measured through higher IVF cycle volumes, streamlined operations, and greater revenue per clinic. Chain ownership refers to the consolidation of multiple fertility clinics under a single corporate entity, often managed centrally and backed by private equity or other institutional investors. Research by scholars from Haas and Copenhagen business schools that analyzed data from the U.S. revealed that IVF cycles rose by 27.2% and that live birth rates increased by 13.6% after acquisition via fertility chains [17].

However, these findings must be interpreted with caution. The situation in the U.S. cannot be extrapolated to other countries because the market is highly fragmented. Therefore, the improved outcomes observed in this study appear to be attributed to smaller clinics being acquired by higher-quality chains rather than chain ownership itself.

There are no other published data indicating higher live birth rates following PE acquisition. In fact, with or without PE, available data and other publications indicate plateauing or declining pregnancy rates worldwide [18].

Furthermore, this increase in cycles and live birth rates does not align with our ‘real world’ experience across four consecutive PE ownerships. While the total number of treatment cycles increased with every PE buyout due to the acquisition and centralization of additional clinics within the group, this did not translate into improved clinical outcomes at the individual clinic level.

In our clinical practice, success rates remained stable or, in some periods, declined slightly. This observation is consistent with data from the Spanish national register [19].

Other published studies also indicate a plateau—and in some regions, a decline—in IVF success rates in recent years [20–23].

Chains have the potential to enhance clinical performance by providing capital, managerial support (e.g., marketing, revenue cycle management), and quality improvements through best practices and research collaboration [3].

Patient choice appears to expand in a commercialized and corporatized fertility sector, as patients are presented with a broader range of options [6]. 

At face value, they can select from various clinics and opt for additional products or services beyond standard fertility care [24]. They choose tailored payment structures or make more informed and active decisions regarding whether to continue or discontinue treatment [5].

Opponents argue that while corporatization and commercialization in ART can impact patient choice, the effects may not be entirely positive [25].

The notion “what’s good for patients is good for business” is an oversimplification. Skepticism toward such claims is justified. The concept of patient or consumer autonomy is frequently claimed to justify clinics’ practices. While patients are ultimately responsible for their own treatment choices, this holds true only if they are fully and accurately informed by their physicians [25].

Corporatization may also negatively impact patient care and limit the meaningfulness of patient choices in less direct ways.

An important example is the frequent loss of continuity of care due to mergers and acquisitions. Frequent staff turnover, as well as diminished attention and personalization caused by the reliance on ancillary staff and standardized protocols, are almost inevitable and frequent after PE takeovers [10, 25]. Cutting corners to gain a competitive advantage is inherent in the PE strategy because of its short timelines. This ultimately raises the question of whether quantity is compatible with quality.

What makes ART appealing to investors

Over the past two decades, demographic shifts and sociocultural changes have fueled growing investor interest in women’s health [26]. Reproductive healthcare has become a focal point for PE and corporate investment [17]. This fragmented yet resilient industry combines steady revenue streams with significant growth potential [27]. PE firms invest in companies primarily to generate high financial returns within a set timeframe [4]. Corporate investors invest for strategic reasons, such as expanding their market, acquiring new technology, or integrating a supply chain [4]. Profit matters, but their primary goal is often long-term business synergy [4]. 

PE firms drive consolidation by acquiring clinics from retiring physicians or small chains and leveraging scale, marketing, and shared expertise to expand their footprint [3, 17]. The sector’s growth is further supported by trends such as delayed family planning, high self-pay rates, increasing demand from LGBTQ + individuals, and the profitability of advanced reproductive technologies such as in vitro fertilization (IVF) and genetic testing [3, 24, 26].

The fertility services sector also benefits from a strong private pay component, ensuring an attractive reimbursement profile [27, 28]. Additionally, its recession-resistant nature supports consistent demand regardless of economic conditions [27, 29].

Half a century after the birth of the first “test tube baby”, IVF-assisted pregnancies constitute 2.5% of all births in the U.S. [30, 31]. 

More than 2% of babies born in European countries are now the result of assisted reproductive technology (ART). The proportion varies significantly by country. Northern and Western European countries tend to report higher ART usage due to greater access to care, strong public health systems, and broader social acceptance [20]. In France, for example, 3.7% of children born in 2019 were conceived through ART, with 2.9% conceived via in vitro fertilization (IVF) and 0.8% via artificial insemination [32]. Denmark has one of the highest proportions of births resulting from ART [33].

Market volume, players and projection

In 2018, private equity (PE) firms owned 14.7% of U.S. fertility practices, and these clinics were responsible for 29.3% of all assisted reproductive technology (ART) cycles in the U.S. [17, 34]. Specific data on PE investments in reproductive medicine by region are limited. However, it is estimated that 30 to 35 private equity firms have invested in the global fertility and IVF sector [35, 36]. In the U.S., notable PE firms include InTandem Capital Partners, which was previously involved with Boston IVF before its acquisition by IVI RMA; and KKR, which acquired Boston IVF from Fresenius and is a key investor in IVI RMA [37]. In Europe/EMEA, leading firms include CVC Capital Partners, which co-controls FutureLife; Hartenberg Holding, also invested in FutureLife; Nordic Capital, which owns CARE Fertility in the UK; and KKR, which owns GeneraLife and, together with GED Capital, acquired the Eugin Group [35–38].

In 2023, PE firms invested approximately $2.9 billion across 30 global fertility sector buyouts.39 The global fertility services market is projected to grow from $30 billion in 2021 to $73 billion by 2027.40 To remain competitive, providers are increasingly seeking partnerships that offer scale, geographic reach, and diversified services.41 This growth continues to attract new investors and intensify competition among existing sponsors, with sustained activity expected through new investments, secondary buyouts, and add-on acquisitions [35].

Virtual IVF clinics

Commercialization and corporatization of ART have created a marketplace of clinics, products, and services [4, 39]. The growing commercialization of fertility care has reshaped industry relationships. Rising costs have driven the emergence of third-party fertility lenders and virtual clinics, which act as intermediaries—merely "patient brokers"—linking patients, especially international ones, with partner clinics for services such as initial consultations and cycle monitoring [24, 40]. Among others, examples include Apricity, Now Fertility, and Fertilly—platform-based companies seeking to capitalize on the expanding fertility market [40]. Their promises of increased patient volume resonate with the objectives of PE-backed clinics focused on rapid profit maximization [3]. The recent bankruptcy of Apricity, a virtual clinic, highlights the instability of this model [41, 42]. Acting primarily as brokers and offering only online concierge services, they lack the depth of comprehensive patient care. While these platforms promote greater access to information and broader patient options, they bypass the responsibilities of a traditional clinic [43]. As a result, patients risk being left adrift in cyberspace when real-world issues arise [41, 44].

Time to exit

PE investors seek to generate short-term returns by buying and selling fertility companies within a 3- to 7-year timeframe [5]. Their strategy often involves reducing operational costs. Decisions between acquisition and exit are largely driven by cost-cutting measures within a tight timeframe. During this period, they implement structural changes to the operational and business models of acquired companies to increase revenue potential, extract value, and engineer a higher sale price [42]. This shift has led to a decline in independent, physician-run fertility clinics and the rise of larger, multibranch fertility networks managed by business-oriented boards [45]. In 2022, PE investment in the fertility sector peaked at 41 buyouts worth $8.4 billion, including the industry's largest buyout to date, KKR’s $3 + billion acquisition of IVI-RMA Global [35]. Many of these acquisitions rely on leveraged buyouts, where borrowed capital is used to finance purchases. While this approach offers the potential for high returns, it also carries significant risks [46]. In some cases, financial pressures force firms to sell much earlier than planned. A notable example is Fresenius, which, after just two years, sold the Barcelona-based Eugin Group to KKR’s IVI-RMA and GED Capital in November 2023 for reportedly $534 million. Since 2015, approximately 10 organizations have transitioned to their second private equity partner, reflecting the sector’s dynamic growth and investor interest [47]. The average holding period for PE investments has been increasing. In 2023, the average holding period for buyouts among U.S. and Canadian PE funds reached 7.1 years, the longest period since at least 2000 [48]. Historically, holding periods have averaged between 3 and 5 years; they remain short, but recent trends indicate a lengthening duration [49]. The short investment horizon of the PE strategy creates a dilemma. Like the often-criticized consulting industry, both prioritize short-term gains over deep engagement and long-term accountability. Consultants without field expertise "helicopter in" to solve problems but lack the time for meaningful learning or responsibility for long-term outcomes. By the time the consequences unfold, they are long gone. The PE playbook remains consistent: cut costs, restructure, and position the company for resale at a higher valuation—a model that continues to shape the fertility industry [42].

Commercialization of the IVF + conflict of interest

Fertility has long been described as a business [50, 51]. In recent decades, the global marketplace for assisted reproductive technology (ART) has grown significantly. Commercialization and corporatization of ART have created a “surge” of clinics, products, and services. While this has arguably increased choice for patients, this “choice”, shaped by commercial and corporate imperatives, may not automatically mean better-quality care [52].

With the internationalization and commercialization of IVF, there is a global debate regarding its impact. What are reproductive specialists' responsibilities in regard to balancing the viability of a private or corporate practice with a high standard of care for their patients?

Few studies have been published to examine the potential "conflict of interest" (COI) between IVF clinics operating as commercial businesses. However, similar ethical concerns have been raised in other fields where private, elective, and largely self-funded care models dominate—such as cosmetic surgery, dentistry, and certain outpatient procedures—highlighting a broader tension between patient-centered care and profit-driven decision-making [10, 53–57].

More research is needed to explore how potential conflicts impact the way clinics offer and deliver treatment [9]. If processes of corporatization increase patient choice, they may not do so in entirely unproblematic ways. Patient interests and business interests are not automatically aligned [52, 58].

The growing ART industry is receiving more public criticism and scrutiny. Much of this criticism centers on the concern that clinics are increasingly prioritizing profit and financial incentives at the expense of patient interests.

“Patient choice” is often positioned as the ultimate expression of autonomy. Clinics offer an expanding menu of treatments, add-ons, and financing models, presenting the fertility journey as customizable and consumer driven. However, this abundance of options can obscure important limitations: patients frequently make decisions under emotional distress, time pressure, and without full access to independent, evidence-based counseling [6, 25, 54]. Moreover, when success rates, pricing, and treatment risks are marketed aggressively, the line between informed choice and strategic persuasion begins to blur [3, 25]. Financial constraints further complicate decision-making, especially in self-pay markets where patients may opt for packages or add-ons that promise better outcomes—regardless of clinical necessity [5]. In this environment, the notion of “choice” risks becoming a rhetorical tool that justifies commercial expansion while masking power imbalances and structural limitations in patient agency [3, 59].

Reports suggesting that the growing business of ART generates COI for clinicians may be rhetorically compelling. Claims that ART practice is distorted by the COI should be supported by empirical evidence. This, of course, is quite difficult [9].

Patient/consumer autonomy is often invoked to justify clinics’ practices. Claiming the patient being ultimately responsible for their own treatment choices is a simplification since it presupposes that they have been well informed in the first place. Even if it was finally the case that corporatization and commercialization increased the degree of choice and that patients were able to freely decide, these choices are not equally accessible to all patients.

A common practice of corporate governance is to appoint physicians as senior managers or board directors, leveraging their medical expertise as a competitive advantage [60, 61]. The American Medical Association encourages doctor participation on boards [62]. In theory, this can enhance organizational performance, provide competitive insights, and improve clinical quality.

However, critics see it as a mere cosmetic measure that legitimizes healthcare businesses while leaving key decisions to business and marketing leaders.

A striking example is the excessive promotion of add-on treatments—often medically obsolete, lacking robust evidence of clinical benefit, yet highly profitable. Endometrial scratching, preimplantation genetic testing for aneuploidy (PGT-A), platelet-rich plasma (PRP) injections, and various immune therapies are just a few examples [50, 52, 53]. While the use of add-ons predates PE involvement and is not exclusive to corporate clinics, the scale and aggressiveness of their promotion have significantly increased under PE ownership [3, 6]. In these settings, commercial teams—rather than clinicians—often drive the inclusion of such treatments in the clinic’s portfolio [10]. Academic and independent clinics may also offer these interventions, but typically with more restrained messaging and under clearer research or informed consent frameworks [9, 10, 53, 54]. The controversy lies not in the existence of these add-ons, but in how they are marketed, incentivized, and presented to patients.

In practice, doctors selected for positions on boards often have little operational know-how, no business background, and no appetite for or intention to challenge medically questionable business decisions. They serve as figureheads, creating the impression that corporate decisions carry medical approval.

In the end, a practicing doctor on a board must face conflicts of interest. Given the inherent frictions between profit-driven motives and the commitment to best clinical practices, dilemmas and challenges are inevitable [3, 60].

These conflicts arise when physicians involved in governance roles are expected to endorse or remain silent about business strategies that may not align with clinical best practices. For example, they may face pressure to support the expansion of unproven add-ons, approve financial incentive schemes tied to cycle volume, or tolerate aggressive marketing that could mislead patients. Such dilemmas are inevitable when medical professionals are placed in dual roles. This tension can compromise patient trust, dilute clinical integrity, and shift focus away from individualized care toward revenue generation.

Attinger et al. argue that discussions about doctors on boards focus mainly on business benefits while overlooking potential conflicts with patient interests and the question of whether—or how—a “doctor–director should advocate for those interests at the board level” (if at all) [3].

Risk-sharing programs

Even under optimal conditions, there is a substantial risk that any assisted reproductive technology (ART) cycle may be unsuccessful. ART can be an emotionally, physically, and financially taxing experience for patients, often accompanied by anxiety, disappointment, and grief—especially after repeated unsuccessful cycles. It also places pressure on physicians, who must balance empathy, patient expectations, and clinical uncertainty [11, 63–66]. Faced with the risk of failure and the financial burden of ART, some patients may drop out of treatment, whereas others may turn to additional treatment options or seek the "security" of guarantee programs.

Financial"risk-sharing"programs provide patients with a payment structure in which they pay a higher upfront fee for a package of multiple IVF cycles. These programs usually offer a partial or full refund if the patient does not achieve pregnancy or delivers a baby. The rise of these programs is closely tied to the commercialization of ART, reflecting a shift toward financially structured treatment models in fertility care. Such programs have been criticized as exploitative, misleading, and contrary to long-standing professional norms against charging contingency fees for medical services [11].

Proponents, however, argue that these payment models provide a legitimate response to the lack of health insurance coverage for IVF in certain countries and address patient concerns about the high financial burden and substantial risk of IVF failure. The situation in Europe and the U.S. is very different.

In the U.S., only 20 states currently mandate insurance coverage for fertility care, and only 14 states require coverage that includes IVF [65]. Additionally, in Europe, funding is lacking across the continent. Only 12 countries offer up to six funded cycles of intrauterine insemination (IUI). Only three countries offer up to six fully funded cycles of IVF/ICSI, and 35 offer it partial funding [22, 67]. 

In an opinion paper exclusively dedicated to risk sharing programs, the American Society for Reproductive Medicine (ASRM) stated that"they may be ethically acceptable when practiced under certain carefully limited guidelines: With advancements in IVF laboratory techniques and improved live birth rates (LBRs), these programs were first introduced for oocyte donation and later expanded to autologous IVF in good-prognosis patients. While some critics dismiss them outright, a more nuanced and balanced perspective is warranted. ASRM rightfully states that "ethical acceptability … must be judged by their impact on patients and not by the profit motive or entrepreneurial impulse that may also have motivated their emergence [11].

However, current practices show that clinics often fail to clearly explain key details, leaving crucial aspects of financial agreements unclear or ambiguous. This lack of clarity may not be intentional, but marketing is prone to oversimplification—especially in settings driven by commercial priorities. It often results from rushed or business-oriented processes, particularly when the focus is on preparing clinics for rapid resale rather than ensuring long-term transparency. Based on personal experience and direct clinical observation, physicians are then left to manage the consequences of marketing materials and contractual language they did not create and cannot fully control.

The concern that financial "risk-sharing" programs may be misleading is therefore not unfounded. Some authors even describe them as "exploitative", potentially pressing patients into opting for a more expensive IVF package than necessary [11, 24]. Critics argue that these programs are little more than "misleading marketing," that often overpromises and underdelivers [24, 68].

This paper does not examine treatment packages that guarantee only a specific number of embryo transfers or clinical pregnancies, as such models are inherently vulnerable to misleading marketing. The ultimate goal of reproductive medicine is a live birth, not a specific number of transfers or a positive pregnancy test. The term"guarantee"can easily lead patients to confuse the number of transfers with the number of cycles. Patients must receive clear and transparent information about success rates, as the distinction between pregnancy rates per transfer and cumulative pregnancy rates per cycle is often misunderstood, poorly explained, or deliberately obscured [11].

Predicting a live birth with certainty is impossible. While population-level data exist—such as the European IVF-Monitoring Consortium’s (EIM) reported cumulative delivery rate of 32.3% per IVF cycle [69] and studies showing that up to 63% of couples achieve a live birth after three IVF or ICSI cycles [70]—these figures do not translate directly to individual outcomes. The ability to apply population-level statistics to predict live birth for any one patient is inherently limited due to individual variability in treatment response, age and other clinical factors. Thus, while robust outcome data exist, certainty at the individual level remains out of reach.

ASRM explicitly states that "criteria for program inclusion and termination must be specified clearly on marketing materials" and "as early in the evaluation process as possible" [11]. However, this is often not the case. First, in a corporate environment, doctors are no longer the final decision-makers. Doctors still carry out the medical decision-making and ensure informed consent, but they do not decide whether a guarantee program or add-on is implemented in the first place or how it is marketed. Second, in an increasingly competitive market, aggressive marketing often trumps quality counseling.

This is an observation based on clinical experience across multiple PE transitions, but it is also supported by literature documenting how business and marketing teams—rather than physicians—increasingly shape patient-facing strategies in PE-owned fertility clinics [3, 4, 6, 8].

This has to be seen as a direct consequence of the shift away from independent, doctor-run clinics toward larger fertility companies focused on financial performance rather than patient care [6, 7]. Physicians face a significant increase in workload due to a constant influx of poorly defined and explained marketing materials with short “shelf life”. This creates a high risk for misunderstandings and patient complaints, potentially damaging the important doctor–patient dyad [64, 65, 71]. This "disconnection" between medical decision-making and marketing lies at the heart of the commercialization of IVF and corporate ART clinics.

Obviously, not all patients can be eligible for these programs. A normal uterine cavity and acceptable sperm parameters are, among other, essential inclusion criteria. In autologous IVF cycles, only a small, highly selective group—primarily young, healthy women under 35 years without previous IVF failure—can be considered “candidates”. This creates a paradox: patients most likely to benefit are already good responders, while those who need support the most are often excluded [11, 24, 63].

Given the importance of oocyte quality in IVF success, risk-sharing programs should be limited primarily to oocyte donation, where key prognostic factors can be controlled. Oocyte donation consistently results in cumulative live birth rates exceeding 90% across all age groups [72]. While the likelihood of not achieving a live birth with oocyte donation is low, the number of transfers or cycles needed remains unpredictable.

Limited to oocyte donation and transparently explained, these programs can offer patients meaningful reassurance and help relieve the psychological and financial burden of potential reproductive failure. In fact, they can serve as a powerful tool to protect patients, regardless of ownership model.

Risk-sharing programs for autologous IVF should be implemented with caution for the abovementioned reasons. Programs that guarantee only a set number of transfers or a positive pregnancy test can be labeled misleading marketing tools and can only create confusion.

In assisted reproduction, the patient–physician relationship must balance trust, guidance, and autonomy. ART patients are increasingly well-informed and tend to “shop around” for services [6, 73, 74], making the traditional paternalistic model less viable. Instead, a shared decision-making approach—where treatment decisions reflect clinical indications, patient values, and economic imperatives—is essential [75, 76].

This differs from both maternalism, where physicians act in patients’ best interests, and purely autonomy-based models that present neutral information without professional input [75]. In practice, a hybrid approach is often needed, especially given the emotional and financial pressures of ART [76, 77].

This becomes particularly relevant when explaining financial guarantee programs or add-ons. Patients may misinterpret success rate metrics or struggle with complex options, requiring careful, evidence-based counseling [69, 77].

Maintaining this balance is increasingly difficult in corporatized settings, where marketing pressures, limited consultation time, and the proliferation of treatment options challenge the depth and integrity of patient-centered counseling [78]. There is no one-size-fits-all solution.

Add-On´s

The proliferation of “add-on” treatments in IVF is closely tied to industry commercialization, driven by increasingly aggressive marketing strategies [10, 25]. In this competitive landscape, the pressure to increase patient numbers and meet profit targets encourages clinics to offer a broad range of often unproven treatments [68]. The rationale is to attract or retain patients at any cost, knowing that evidence-based counseling may lead to their loss to a competing clinic [10].

A common and justified concern is that PEs might pressure clinicians—implicitly or explicitly—to recommend treatments or diagnostic tests lacking evidence, suggest more invasive procedures, or advise a greater number of cycles than medically necessary [3, 5].

The rationale is to attract or retain patients at any cost, knowing that evidence-based counseling may lead to their loss to a competing clinic.

However, it should be noted that the use of add-ons is not exclusive to PE-backed clinics. Patients themselves often pressure clinics and physicians into adopting tests, techniques, and treatments they would typically avoid owing to a lack of supporting evidence. The fear of losing patients to competing clinics is a powerful driver in this context.

This creates significant tension for physicians, particularly in PE-owned clinics. Informed consent remains the physician’s responsibility. However, at the heart of the problem is the disconnect between marketing and medicine in PE-owned versus doctor-owned clinics. In PE-owned settings, physicians often have no control over what is promoted or how it is presented. These decisions are made by business or marketing leads. As a result, physicians are placed in the difficult position of upholding informed consent within a framework they did not create. That means having to contradict promotional messages by advising patients against certain add-ons or financial packages. The counseling process and informed consent become more difficult. This creates friction and confusion, as patients may question why their physician’s guidance conflicts with information found on the clinic’s website.

Currently, patient demand—not clinical evidence—often drives the adoption of new technologies. A textbook example is the introduction of time-lapse systems. While they streamline embryologists’ work and support blastulation, they have not been shown to significantly improve pregnancy success rates [79, 80].

Since more patients inquire about and some even request these technologies during their first counseling session, many clinics have adopted time-lapse systems—not necessarily because of strong clinical data, but to avoid losing patients and to maintain a competitive edge [9, 50, 81].

This is based on personal clinical experience, but the trend has been noted in both qualitative studies and regulatory reports, which suggest that time-lapse imaging is often promoted for its commercial appeal despite limited evidence of improved clinical outcomes [9, 81].

The increasing use of add-ons in ART led the ESHRE to issue guidelines in late 2023. Similarly, the UK's HFEA (Human Fertilization and Embryology Authority) produced a joint statement in October 2023 [9, 10]. The HFEA states on their website: “It is important to keep in mind that for most patients, having routine cycles of proven fertility treatment are effective without using any treatment add-ons. If you are paying for your own treatment, … it might be better to pay for multiple cycles of IVF or IUI rather than spending large sums of money on a single treatment cycle with treatment add-ons that haven’t been proven to be effective” [8]. 

HFEA designed a very “user-friendly” traffic light rating system (green, amber, or red) to add-on procedures on the basis of the level of currently available evidence of clinical effectiveness. ⁸ No one has yet received a green light, indicating strong evidence for both effectiveness and safety.

Nevertheless, ART clinics and physicians worldwide continue to offer a wide range of add-ons, extending far beyond PGT-a, assisted hatching or sperm selection systems. The latest heavily marketed addition is platelet-rich plasma (PRP) treatment for ovarian rejuvenation. PRP is derived from the patient’s own blood and processed to concentrate platelets rich in growth factors such as IGF-1, FGF, and TGF-β, which are thought to promote tissue regeneration. PRP is injected into the ovaries with the aim of improving ovarian function, particularly in women with poor ovarian reserve or premature ovarian insufficiency. Although PRP has gained popularity in some fertility clinics, its clinical effectiveness remains speculative and unproven in high-quality studies [82, 83].

Preimplantation genetic testing for aneuploidy (PGT-a) is undoubtedly the most widely used add-on in IVF. While this topic warrants an entire article, a few key points are worth noting.

Class action lawsuits have been filed against multiple genetic testing companies, including CooperGenomics, CooperSurgical, Reproductive Genetic Innovations, Progenesis, and Natera. The lawsuits allege that these companies engaged in false and deceptive marketing, misleading patients about the benefits and capabilities of PGT-a.

According to the complaints, patients were told that PGT-a increases IVF success rates, improves the chances of a healthy pregnancy, reduces miscarriage risks, and shortens the time to pregnancy. Plaintiffs argue that these claims were exaggerated for financial gain, amounting to consumer fraud, breach of warranty, and other legal violations.

This highlights the dilemma and the fine line between marketing and evidence-based counseling. The use of PGT-a in the U.S. has increased in recent years, from 17% of IVF procedures in 2014 to nearly 45% in 2018. Current projections suggest that PGT-a may now be used in 60% or more of IVF cycles in the U.S. Although its prevalence remains significantly lower in Europe, concerns persist regarding the ethics and effectiveness of its widespread adoption [84, 85].

Artificial Intelligence

Artificial Intelligence (AI) tools used in ART received a lot of attention in the past years. Simultaneously the increasing involvement of PE is accelerating the integration of AI technologies, particularly in areas like embryo selection and predictive analytics [86]. But machine learning (ML) tools are also used beyond that e.g. in optimizing stimulation protocols [87].

At the center of PE strategies is to sell acquired businesses in a short time frame, aiming for a substantial profit. To achieve this, they must increase revenues and decrease operating costs [5, 46]. AI promises standardization and automation – a precondition for “scaling up and branching out” in the fertility industry [88]. This is inherently interesting to PE strategies by helping streamline processes and reducing costs before flipping an investment. AI systems integrate into the IVF workflow offering end-to-end optimization and cost savings, balanced with the promise of personalization of treatment [88]. While these advancements hold promises for enhancing clinical outcomes, they also introduce ethical, regulatory, and equity challenges that must be carefully navigated to ensure patient-centered care [89–92]. PE investment can significantly impact patient access to AI technologies, both positively and negatively. PE-backed clinic groups typically have greater capital and scalability than standalone clinics. This allows them to invest in AI-driven tools, rapidly deploy these technologies across clinic networks and implement centralized data systems that improve AI performance via larger datasets [90]. PE groups often push for standardization of clinical protocols. Using AI could help to reduce variation across clinics and improve efficiency. This may lower the costs of services, improve treatment outcomes through data-driven decision-making and potentially offer AI access to a broader base of patients within their networks [5, 90]. While this can enhance clinical efficiency and standardize care, it also raises concerns regarding equitable patient access [86]. AI-enhanced services are often marketed as premium services, potentially limiting their availability to patients in lower-income brackets or geographically underserved regions [3, 93]. Furthermore, proprietary AI tools developed within corporate structures may lack transparency and clinical validation, reducing patient trust and potentially skewing treatment decisions toward profitability rather than individualized care [86, 90, 94, 95]. 

Conclusion

The patient‒physician relationship, professional values, and patient interests must remain priorities, ensuring that health care serves patients [6]. If the call for regulation can be the solution, it has to be seen with skepticism [3, 68, 96]. Regulation as in governmental regulatory oversight ideally would imply independent licensing of clinics and providers, transparent reporting of success rates, financial models, and use of add-ons and regulatory oversight free from industry influence.

Corporatization and commercialization of ART may not always benefit patient choice. Regulations should prioritize meaningful patient autonomy, but current frameworks often rely on outdated assumptions about doctor–patient relationships, failing to reflect the fast-evolving realities of ART provision [3, 96]. 

The notion that ‘what’s good for patients is good for business’ is an oversimplification. Such claims as a defense against regulatory oversight and/or to protect status quo self-regulation must be valued carefully. Patient interests and business interests are not automatically aligned [3, 68, 96]. The same applies to the concept of patient or consumer autonomy, which is often used to justify the commercialization of IVF. While patients are ultimately responsible for their treatment choices, this assumes that they have been properly informed by their physicians in the first place.

While much of the academic and policy discussion on PE in ART has focused on clinical outcomes, pricing, and industry structure, relatively little attention has been paid to how patients perceive these shifts. It is likely that many patients remain unaware of PE ownership, as corporate affiliations are often obscured by the continued use of legacy clinic names [68, 96]. The limited available research suggests that patient awareness of corporate or PE ownership varies widely. Some studies indicate that patients tend to prioritize clinical success rates, convenience, and personalized care over ownership structures. The effectiveness of treatment and the competence of medical staff are consistently cited as key concerns [63, 77]. At the same time, there is evidence that patient-centered care is “sufficiently important for some patients that they are willing to trade-off higher fertility success rates for a more patient-centered” approach [96]. Moreover, emerging studies point to growing patient concern over transparency, ethics, and trust in the delivery of ART services, with some users placing increasing value on how these services are structured and delivered [68, 78].

PE strategies such as increasing operational efficiency, competition consolidation, and revenue diversification have the goal of creating competitive advantages and “flipping” the investment in a rather short time frame. These profit-driven motives are prone to create pressures that conflict with high-quality, patient-centered care and threaten physician autonomy [6, 78].

Profit is not inherently bad—quality medical care comes at a cost, and clinics and hospitals must remain profitable. The real challenge lies in balancing quality and quantity within these short timelines.

Physicians remain responsible for upholding ethical standards and delivering high-quality care regardless of ownership structure. However, in PE-owned settings, structural and commercial pressures can constrain physicians’ ability to fully practice patient-centered medicine. The issue is not that good care becomes impossible, but that it becomes more difficult to maintain under conditions shaped by non-medical priorities and often creating persistent friction between physicians and commercial leadership.

The trend of concentration with ever larger fertility groups, with its inherent drop in personalized medicine and quality counseling, might eventually lead to a shift back to smaller enterprises with the operational principle “quality over quantity”. For the time being private equity has found reproductive medicine and is here to stay. If it is friend or foe, “the fairy godmother” or the “big bad wolf”, as the authors Souter and Bormann asked in an article for Fertility and Sterility in 2021, remains to be seen and should be subject to further investigation [6, 96]. All stakeholders in fertility and reproductive medicine, especially physicians, should continue to carefully vet implications for a growing part of the specialty to be managed by nonmedical financial groups and its impact on healthcare quality, access, and equity [34].

Authors’ contributions

Andreas Abraham Zadeh (A.A.) was solely responsible for the conception, research, analysis, and writing of this manuscript.

Funding

No funding has been received.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.