Private equity in: Fertility services

In 2015, Sheryl Sandberg sat down with a Bloomberg TV host to explain a new benefit Facebook had begun to offer its employees. She offered a story about a young Facebook employee who wished to freeze her eggs before undergoing cancer treatment.

As Sandberg explained, “I talked about it with our head of HR, and said, ‘God we should cover this.’ And then we looked at each other and said, ‘Why would we only cover this for women with cancer, why wouldn’t we cover this more broadly?'”

As with most things Sheryl Sandberg, observers viewed the addition of egg freezing to employee benefits as a forward step but simultaneously suspected her tightly packaged anecdote wasn’t the whole story. As Vice noted, the “emphasis on feminist messaging from all sides helps obscure another force at play: capitalism.” Egg freezing has the distinct upside of keeping employees at their desks, potentially postponing childbearing until after they’ve given their twenties and thirties to the company.

But the twisted incentives—driven by the rise of private equity in the fertility space—run deeper than keeping women employees working. As STAT News notes, “[p]rivate equity’s goal is to profit, and to profit quickly — acquisitions are typically sold within three to seven years. This may be a good business model for investors, but it can conflict with the goal of providing women with safe, accessible, and high-quality health care.”

Private equity has leveraged corporate feminist marketing to promote egg freezing, or oocyte cryopreservation, a treatment formerly used only for women reaching the end of their fertile years or about to undergo cancer treatment, to increasingly younger women. The science of fertility and egg freezing is remarkably spotty, especially for women in their twenties. But that hasn’t stopped financiers from encouraging women and their employers to bankroll treatments that cost tens of thousands of dollars.

A changing market

Egg freezing was declared non-experimental by the American Society for Reproductive Medicine in 2012, just a few years before Facebook began including the procedure in its employee benefits. With the announcement, so-called “social egg freezing” (freezing one’s eggs to delay pregnancy for social reasons) exploded. In 2015, approximately 6,200 women froze their eggs. In 2017, the number had risen to 11,000, and the market is expected to continue to grow at a rate of around 25% year over year.

Drawn by the increasing popularity of egg freezing—and likely the fact that most fertility clinics exist outside the insurance space, accepting cash payments only—private equity flocked to the space. The industry, formerly a smattering of no more than 500 individual clinics across the U.S., is consolidating. Private equity firms are trying to roll up the once-independent “artisanal kitchens” into standardized egg freezing services.

But as private equity owners rush to roll up the space, they’re running into a bit of a problem. The market for egg freezing remains relatively small—most women who want to get pregnant do so the old-fashioned way. Making stakeholders happy, then, requires marketing to an ever-younger population of women, convincing them to freeze their eggs.

Pink = explicitly targets millennials

The graph above is not conclusive; IntegraMed Fertility especially has hundreds of clinics in the US. Notably, the clinics really aren’t located in the Midwest; instead, they’re located in wealthier coastal cities.

Source: https://www.integramed.com/locate-a-practice/

Exploitation of cultural fears

In the most generous telling, oocyte cryopreservation cuts the Gordian knot of women seeking to maximize their career potential while still becoming mothers. As the American Society for Reproductive Medicine wrote in updated recommendations in 2018, “Planned OC [oocyte cryopreservation] may also promote social justice by reducing the obstacles women currently face because their reproductive window is smaller than men’s. By extending the time when women may start a family, planned OC can lessen the effects of educational and workplace constraints that disparately burden one sex; thus, oocyte cryopreservation can contribute to equality of men and women.”

But while this social justice framework makes sense—and is true for some women—it fails to take into account surveys suggesting that the majority of women undergoing social egg freezing are doing it because they don’t yet have partners with whom they would like to bear a child.

Setting aside the cultural factors that have led to a dearth of suitable male partners for upwardly mobile women, this factor makes the marketing of private equity-owned fertility clinics…very strange. How does a 25-year-old woman with an average of, say, at least 10 more years of fertility know if she’ll have a suitable partner in those next 10 years? Is the uncertainty worth dumping tens of thousands of dollars into an uncertain treatment?

Under the guise of allowing women to make more flexible career choices, private equity fertility marketing exploits modern working women’s fears that they won’t find a life partner. And it starts to exploit that fear shortly after women graduate college.

Fertility remains an uncertain science

The social egg freezing phenomenon also elides the very vague science around women’s fertility. As a 2013 essay in the Atlantic eloquently pointed out, the widely cited statistic that one in three women aged 35-39 are unable to get pregnant after a year of trying is actually based on a survey of 17th and 18th century French birth records. This statistic, despite its origins in a pre-antibiotic era, has permeated American culture so as to be commonly accepted knowledge. As the author of the Atlantic piece writes,

When I mention this to friends and associates, by far the most common reaction is: “No … No way. Really?

Revolutionary-era French women aside, fertility seems to be a much more malleable thing than is commonly believed. As one scientist says to the Atlantic author, “[f]ertility is relatively stable until the late 30s, with the inflection point somewhere around 38 or 39.”

In lieu of any physical infertility problems, then, women trying to get pregnant probably won’t have too much of an issue until their late 30s. The risk of genetic disorders and miscarriage rises slightly with age, and pregnancy can be easier younger, but fertility does not seem to approach a cliff until a much later age than conventional wisdom would suggest.

The success rate of live births coming from once-frozen eggs is also a surprisingly challenging thing to measure. Statistics from the UK suggest it ranges from 3% to 18%, depending at least in part on the woman’s age. It’s unclear how egg freezing from increasingly younger women will change the statistics. The eggs might be healthier—or they might be frozen for so long as to be unviable. As one doctor noted to the New York Times, “[a]ssuming you have normal fertility and nothing unusual in your family history, there’s definitely a point where it’s too early, and we don’t know what the shelf life of these eggs are.”

In other words, even though private equity has a financial incentive to scare younger women into freezing their eggs, freezing eggs too early might lessen the chances of pregnancy from those eggs. In fact, one study that performed a cost-benefit analysis found that the most effective age to freeze eggs is 34, and the most cost-effective age is 37. This is partly because younger women have a high probability of finding a life partner with whom they want to bear children.

One Verge reporter, writing about a millennial-focused egg freezing startup, visited a hormone-checking pop-up. While she was there, an employee of the startup invited her to get her hormone levels checked. As the reporter wrote: “’I’m 24,’ I tell her. ‘So?’ she says.”

The ever-younger age of women funneled into fertility workshops and egg freezing appointments reflects the financial pressures of the industry. Although egg retrieval and freezing is expensive (and women or their employers pay in perpetuity to keep the eggs in frozen storage), and although the procedure is rising in popularity, less than 1% of women in the U.S. undergo egg freezing. The need for returns for private equity shareholders incentivizes clinics to keep convincing new populations of (wealthy, insured) women to freeze their eggs.

Under-regulated industry

Despite—or because of—the amount of capital floating around, the industry is poorly regulated. Some states require clinics to be accredited, but some don’t. Fertility clinics are required to report their pregnancy success rates to the Centers for Disease Control, which the CDC reports publicly—but this is more or less the extent of the regulation. (The reported success rates measure the rate of success from implantation of the egg, they do not include success rates from frozen egg to live birth.)

The pressures of getting returns for private equity investors have also led some clinics to offer clients add-ons that are scientifically unproven. In some cases, the add-ons can even increase the rate of miscarriage. As one woman told STAT News, the doctors did not explicitly tell her that the expensive add-ons would increase her chances of a live birth. “But there was an implicit message that it would improve my chances,” she said. “It didn’t really sink in, when the doctor described this as cutting-edge, that that meant experimental.”

Conclusion

One Jezebel author, writing about social egg freezing, noted that “life is full of disappointments, and most of them are monetizable.” But the problem with fertility clinics is that private equity pressures are leading many fertility clinics to manufacture a future disappointment—primarily exploiting young women’s fears of not finding a suitable partner—and monetizing that. And financial incentives can expand that monetization far beyond the bounds of current science.

All of this is not to say that social egg freezing is bad—several studies have found that, as mentioned above, the benefits start to outweigh the costs in a woman’s mid-thirties. But the procedure is nowhere near as easy (or cheap, frankly) as the marketing seems to suggest. And egg freezing, while it may provide some women a measure of mental security, should not be treated as a wellness product on the same plane as ordering a daily salad. The impact of private equity in the fertility space has made egg freezing more accessible (to a certain class of upwardly mobile, mostly white women) for the wrong reasons.