Fertility
Rise of chain clinics supporting better IVF outcomes – study
A new study has suggested that the rise of fertility clinic chains – as opposed to independent facilities – is helping to improve IVF outcomes.
In the US, where the study is focused, demand for in IVF increased almost 140 per cent between 2004 and 2018. In that period, the market share of for-profit chain clinics grew from five to 20 per cent, with chains now performing over 40 per cent of IVF treatment cycles nationwide.
The paper suggests that chain ownership has improved results, since clinics acquired by a chain serve more patients, increasing IVF treatment cycles by 27 per cent. They ultimately increase live birth rates by nearly 14 per cent, the researchers say.
The study, published in the journal Management Science, was compiled by Ambar La Forgia, of Haas School of Business, UC Berkeley, and coauthored by Julia Bodner of Copenhagen Business School.
La Forgia says: “Chain organisations are very common in hotels and restaurants. But when it comes to healthcare, because it hasn’t traditionally been delivered in this way, it seems to be making a lot of people uneasy. Policymakers are particularly concerned that chains will chase profit at the expense of patient outcomes.”
But the findings provide more optimistic reading.
To compare the performance of chain and independent clinics, La Forgia and Bodner collated a novel set of clinic and patient data that drew from the Centers for Disease Control, and the National Center for Health Statistics.
They also manually checked the ownership of every fertility clinic in the US. From this effort, they were able to look at two main outcomes between the years 2004 and 2018: How many IVF cycles does each clinic perform? And what is the success rate, measured by live births per transfer?
The researchers found that after a fertility chain acquires a clinic, IVF cycles increase dramatically and live birth rates increase by 13.6 per cent.
“This means that these chain clinics are doing more cycles of IVF and converting more of those cycles into live births,” La Forgia says. “They are actually improving the quality of care in a meaningful way.”
Chain clinics are not doing this by simply transferring a lot more embryos, either. La Forgia and Bodner find that they are actually producing more “singleton” births—that is, the birth of one baby—than their independent clinic peers, which implicitly suggests a better embryo selection process.
But what if these results are driven by a more stringent patient screening process, or by chains being more selective about the markets in which they operate?
La Forgia and Bodner investigated these possibilities and found no supporting evidence. There is no appreciable change in the patient population after a chain takes over an independent clinic. In fact, the largest improvement in live births is among patients who are 38 years old and older—the population that typically has the lowest success rates. Nor are their significant differences in the broader demographics of neighbuorhoods in which chain clinics operate, the researchers found.
Instead, it appears that chains improve outcomes through two mechanisms: the availability of more resources and a heavier focus on sharing best practices.
The researchers make this case through several analyses. For instance, chains tend to introduce new processes and procedures known to improve birth rates. In fact, the lowest-performing clinics see the largest improvements when taken over by a chain, and clinics acquired by the highest-performing chains experience the greatest improvements.
Most notably, the researchers found that affiliated IVF clinics, which pay chains for select management support and financing options but retain managerial independence, witness an increase in patient volume and number of IVF cycles, but unlike fully acquired clinics, they don’t demonstrate an improvement in birth rates.
“Basically, in affiliated clinics the number of live births is going up as an absolute value, but they’re not getting better at achieving live births,” La Forgia says. “Our hypothesis is that a chain is willing to share its resources widely, but it may not want to share specific knowledge with an organization it doesn’t own, so we’ll only see this knowledge transfer in acquired clinics.”
The authors demonstrated a final benefit of chains, which is that they increase access to IVF by expanding the market—performing more IVF cycles—rather than stealing business from competitors.
Some of the findings may be explained by the fact that compared with many other parts of the healthcare system, fertility clinics share some characteristics with retail stores and chain restaurants. It’s a relatively more competitive market and patients typically pay up front and out-of-pocket for care. Clinics are also legally required to send their data to the government.
Other sectors like dialysis and nursing care are more opaque and dependent on insurance, so chains may have fewer incentives to improve quality of care. But the researchers point out that plenty of health care is shifting toward a retail model, including dermatology providers, urgent care clinics, and physical therapists.
“Very little research speaks to the ways in which chains are good or bad for patients,” La Forgia says. “We ought to start paying attention to what kinds of markets might lend themselves well to this business model.”
Softening ageing ovaries could help women remain fertile for longer, early animal research suggests.
Fertility declines with age for several reasons, including poorer egg quality, fewer ovarian follicles and the gradual stiffening of ovarian tissue.
Existing fertility treatments, including hormone therapy and in vitro fertilisation, mainly address hormonal imbalances or help eggs mature or become fertilised.
Scientists are now examining whether changing the physical structure of the ovaries could provide another route for future fertility treatments.
Stuart A. Cook, of the Cardiovascular and Metabolic Disorders Programme at Duke-National University of Singapore Medical School, published an accompanying commentary on the research.
Researchers led by Shixuan Wang at Huazhong University of Science and Technology in Wuhan, China, collected healthy ovarian tissue from younger, middle-aged and older women.
They also examined samples from patients with polycystic ovary syndrome, known as PCOS, premature ovarian insufficiency, or POI, and endometriosis.
PCOS is a hormonal condition that can disrupt ovulation. POI occurs when the ovaries stop working normally before the age of 40, while endometriosis causes tissue similar to the womb lining to grow elsewhere in the body.
Tests of protein levels and gene activity found higher levels of the inflammatory protein interleukin-11, or IL-11, in ageing and diseased ovaries.
In laboratory experiments, the researchers exposed ovarian fibroblasts to IL-11. Fibroblasts are cells that produce connective tissue.
The protein caused the cells to produce excess collagen, a structural material that can build up during scarring and make tissue stiffer.
The researchers then genetically modified mice so they could not respond to IL-11. The animals developed less ovarian stiffening and maintained better ovarian function as they aged.
Similar results were seen in mouse models of PCOS and POI caused by chemotherapy.
In the final part of the experiment, older mice and rats were injected with a nanoparticle treatment containing small interfering RNA, or siRNA, designed to switch off IL-11.
The treatment made the animals’ ovaries less stiff and improved fertility.
Pregnancy rates among older mice rose from 25 per cent to 50 per cent, while average litter sizes also increased.
More rats treated with the therapy became pregnant and produced larger litters.
The approach remains highly speculative and will require considerably more research before its safety or effectiveness in women can be established.
However, the researchers said blocking the inflammatory pathway could eventually form the basis of new fertility treatments.
They said: “We propose that anti-IL-11 therapy represents a promising translational strategy for delaying ovarian ageing.”
W Group has opened applications for W Accelerate with Merck KGaA and M Ventures, inviting reproductive and maternal health startups, scaleups and spinouts to pitch for direct access to global pharma partnership and strategic investment.
Selected companies will pitch on 5th October, competing for the chance to accelerate their growth through commercial partnerships, investment, or both.
This is the third time Merck KGaA, a global leader in reproductive health, has partnered with W Group on the programme, which exists to close the innovation and investment gap in women’s health by connecting the sector’s most promising startups directly with the corporates and investors positioned to scale them.
What Merck KGaA and M Ventures are looking for
This year’s call is focused on breakthrough solutions in female infertility, fertility preservation, adenomyosis, endometriosis, polyendocrine metabolic ovarian syndrome (PMOS), ovarian insufficiency, preeclampsia and pregnancy comorbidities.
New for this round, applicants choose between three pathways depending on what they need from the programme:
- The Partnership Lane, for companies seeking commercial collaborations and strategic relationships
- The Investment Lane, for founders looking to connect with investors and secure funding to scale
- The Dual Lane, for innovators pursuing both partnership and investment opportunities
How the Accelerate event works
Selected companies get a 1:1 pitch practice session ahead of time, then a private 30-minute session with Merck KGaA and M Ventures leadership on the day itself, small-group sessions with regulatory and investment strategy experts, an “Ask Merck Anything” roundtable, and a VIP networking reception.
Key dates
- Open call launches: 8th July
- Open call closes: 2nd September
- Notification of successful companies: 11th September
- Pitch day: 5th October
Applications are open now at wplatform.typeform.com/to/KGzviBQM.
Fertility
Older women face lower chance of fertility treatment working, even with donor eggs, study finds
IVF success declines with age even when women use young donor eggs, with a marked fall from around 49, research suggests.
The findings challenge the idea that donor eggs can fully “reset” the reproductive clock, although researchers said they should not discourage older couples from trying.
Dr Beatrice Crestani, from an assisted reproduction medical institute in Italy, said reproductive ageing had traditionally been seen mainly as an issue involving the ovaries.
She said replacing older eggs with younger donor eggs was often believed to “reset” the reproductive clock.
Dr Crestani added: “Our findings suggest the picture is more complex.”
The study followed 1,774 women undergoing in vitro fertilisation, or IVF, using donated eggs. IVF involves fertilising an egg in a laboratory before transferring an embryo to the womb.
Women in their mid to late 30s had a 54 per cent chance of becoming pregnant after treatment, compared with around 43 per cent among those aged 49 or older.
Live birth rates fell from 46 per cent to 32 per cent, while miscarriage rates rose from 24 per cent to 38 per cent.
Women aged 49 and older had twice the risk of miscarriage compared with those aged 35 to 40.
Researchers believe changes to the endometrium with age may help explain the difference. The endometrium is the lining of the womb where a fertilised egg or embryo implants and grows.
Although the thickness of the womb lining was similar across the age groups, its condition declined with age.
Researchers said future work might find ways to predict, prevent or improve uterine ageing.
Dr Crestani said: “These findings should not discourage women from pursuing donor-egg treatment, because success rates remain meaningful even at advanced ages.
“However, patients should be counselled that donor eggs cannot completely eliminate the effects of reproductive ageing, particularly beyond 49 years.”
Among women who transferred all their available embryos, the live birth rate was around 80 per cent for those aged 35 to 40 and 62.5 per cent for those aged 49 or older.
Experts stressed that the health of the womb and ovaries differs between women.
There is no legal upper age limit for IVF in the UK, unlike some European countries. Greece has an upper limit of 54.
Women in the UK can donate or share their eggs up to the age of 36.
Regulators ask private UK clinics to assess the welfare of any resulting child and whether the recipient can safely carry a pregnancy.
NHS guidelines recommend offering three IVF cycles to women up to the age of 40 and one cycle to women up to the age of 42.
Patients using donor eggs usually have to fund that part of the treatment themselves.
People conceived using sperm, eggs or embryos from donors registered after 1 April 2005 can request identifying information about their biological donor parent once they turn 18.
The findings are being presented at the European Society of Human Reproduction and Embryology.
Professor Borut Kovacic, chair-elect of the society, said researchers were trying to better understand the “cross-talk” between an implanting embryo and the womb lining. This refers to the biological signals exchanged during implantation.
He said the age threshold associated with the beginning of a loss of uterine function was unlikely to be absolute.
Professor Kovacic added: “It provides important information for patients and offers a valuable foundation for future research aimed at identifying novel biomarkers of uterine ageing.”
Dr Ippokratis Sarris, chair-elect of the British Fertility Society, called for more research.
He said pregnancies could carry greater risks for older women and recommended thorough health checks and counselling for couples beginning fertility treatment.
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