Unveiling the shifting landscape of infertility care: Diagnostics, treatments, and private equity’s growing influence

Abstract

Over the past two decades, fertility services have experienced significant shifts in ownership structures worldwide, transitioning from predominantly public or physician-owned clinics to a market increasingly influenced by private equity. These changes raise debates about treatment efficacy, cost transparency, and the ethical implications of profit-driven health care. This review provides an evidence-based overview of trends in fertility clinic ownership (public, physician-owned, and private equity-backed), along with reported success rates and implications for treatment quality, cost transparency, and patient well-being. A narrative synthesis was conducted using peer-reviewed literature, registry data, and industry reports published between 2000 and 2025 (projected). Ownership distribution, reported live birth rates, and financial transparency were examined. Regional studies, market analyses, and professional guidelines were used to infer trends when global data were unavailable. Ownership trends show a decline in public- and physician-owned clinics, with private equity projected to control up to 50% of fertility centers in some regions by 2025. Treatment efficacy improved across all clinic types, with live birth rate per in vitro fertilization cycle rising from ~25 - 30% in 2000 to ~35 - 45% by 2020 in younger cohorts; higher rates in private equity clinics may reflect patient selection and reporting variability. Cost transparency remains inconsistent, particularly in private equity networks where bundled pricing and aggressive marketing may obscure true costs and incentivize unnecessary add-ons. The consolidation of fertility centers under corporate ownership has reshaped reproductive health care. Ongoing concerns include pricing opacity, the clinical value of “add-on” treatments, and the ethical positioning of clinicians in profit-driven settings.

Keywords

Infertility clinics / Private equity / Public health care / Conflict of interest / Cost transparency / Patient-centered care / Healthcare commercialization / Evidence-based practice

Funding

None.

Conflict of interest

The authors declare that they have no competing interests.

References

[1] Agenda Digitale. (n.d.). Il Boom Delle Università Telematiche in Italia: L’impatto Sull’istruzione Superiore. Available from: https://www.agendadigitale.eu/scuola-digitale/il-boom-delle-universita-telematiche-in-italia-limpatto-sullistruzione-superiore [Last accessed on 2025 Jun 12].

[2] American College of Obstetricians and Gynecologists. (2019). Committee opinion No. 781: Tubal factor infertility. Obstetrics and Gynecology, 133(6):e249-e256.

[3] American Medical Association. (2021). Code of Medical Ethics Overview. AMA Press: Chicago.

[4] American Society for Reproductive Medicine. (2020a). Ethics Committee guidelines for advertising and marketing in reproductive medicine. Fertility and Sterility, 114(6):1157-1162.

[5] American Society for Reproductive Medicine. (2020b). Diagnostic evaluation of the infertile female: A committee opinion. Fertility and Sterility, 113(6):1197-1202.

[6] Athey, S., & Garthwaite, C. (2017). Private equity investment in healthcare: An analysis of efficiency and outcomes. Health Affairs, 36(3):495-502.

[7] Avest, E., & Lazarus, J. (2021). Consolidation in the fertility industry: Evaluating patient outcomes and clinic performance. Healthcare Finance Review, 10(4):333-347.

[8] Beauchamp, T.L., & Childress, J.F. (2013). Principles of Biomedical Ethics. 8^th ed. Oxford: Oxford University Press.

[9] Bhattacharya, S., & Porter, M. (2008). Reproductive health and ethical controversies in IVF. BMJ, 336(7647):619-620.

[10] Boitrelle, F., Shah, R., Saleh, R., Henkel, R., Kandil, H., Chung, E., et al. (2021). The sixth edition of the WHO manual for human semen analysis: A critical review and SWOT analysis. Life (Basel), 11(12):1368. https://doi.org/10.3390/life11121368

[11] Boulet, S.L., Mehta, A., Kissin, D.M., Warner, L., Kawwass, J.F., & Jamieson, D.J. (2015). Trends in use of and reproductive outcomes associated with intracytoplasmic sperm injection. JAMA, 313(3):255-263. https://doi.org/10.1001/jama.2014.17985

[12] Broer, S.L., Broekmans, F.J., Laven, J.S., & Fauser, B.C. (2014). Anti-Müllerian hormone: Ovarian reserve testing and its potential clinical implications. Human Reproduction Update, 20(5):688-701. https://doi.org/10.1093/humupd/dmu020

[13] Bulletti, F.M., & Bulletti, C. (2025). Infertility treatment models: Progress or profit? Examining public, private, and hybrid approaches. EC Gynecology, 14(1):1-17.

[14] Chen, E.M., Cox, J.T., Begaj, T., Armstrong, G.W., Khurana, R.N., Parikh, R. (2021). Prevalence and performance of private-equity-affiliated fertility practices. Fertility and Sterility, 115(3):664-671. https://doi.org/10.1016/j.fertnstert.2020.10.040

[15] College of American Pathologists. (2021). Reproductive Laboratory Accreditation Program. Available from: https://newsroom.cap.org/cap-in-the-news/the-college-of-american-pathologists-hosts-2021-annual-meeting- -sept.-25-28- -2021/s/ddd40e42-232a-48ba-810b-c2da7ec091f0 [Last accessed on 2025 Jun 12].

[16] Cookson, R., Doran, T., Asaria, M., Gupta, I., & Mujica, F.P. (2021). The inverse care law re-examined: A global perspective. Lancet, 397(10276):828-838. https://doi.org/10.1016/S0140-6736(21)00243-9

[17] De Geyter, C., Wyns, C., Calhaz-Jorge, C., Kupka, M.S., Mocanu, E., Motrenko, T., et al. (2020). ART in Europe, 2016: Results generated from European registries by ESHRE. Human Reproduction Open, 2020(1):hoz038. https://doi.org/10.1093/hropen/hoz038

[18] Epstein, A.M. (2018). How private equity affects innovation in healthcare: A mixed blessing. New England Journal of Medicine, 378(4):403-405.

[19] Ethics Committee of the American Society for Reproductive Medicine. (2018). Financial aspects of assisted reproductive technology: An ethics committee opinion. Fertility and Sterility, 109(3):453-457. https://doi.org/10.1016/j.fertnstert.2018.01.023

[20] European Society of Human Reproduction and Embryology. (2021a). ART Fact Sheet. ESHRE Guidelines.

[21] European Society of Human Reproduction and Embryology. (2021b). Infertility Prevalence Estimates, 1990-2030. ESHRE Reports.

[22] Garcia-Velasco, J.A., Alper, M., Capalbo, A., Casper, R., Fatemi, H., Molinaro, T., et al. (2025). Private versus funded infertility care: Not a challenge but a call for cooperation. Reproductive Biomedicine Online, 50(1):104694. https://doi.org/10.1016/j.rbmo.2024.104694

[23] Gleicher, N., Kushnir, V.A., & Barad, D.H. (2019). Worldwide decline of IVF birth rates and its probable causes. Human Reproduction Open, 3:hoz017. https://doi.org/10.1093/hropen/hoz017

[24] Gleicher, N., Kushnir, V.A., & Barad, D.H. (2020). New trends in reproductive endocrinology: The role of advanced diagnostics. Reproductive Biology and Endocrinology, 18(1):119. https://doi.org/10.1186/s12958-020-00665-2

[25] Hinton, L., Kurinczuk, J.J., & Ziebland, S. (2019). Infertility, isolation and the internet: The role of online support. Human Reproduction, 34(2):220-226.

[26] Hotaling, J.M., & Harris, I. (2019). The economics of fertility care: Rising costs and changing landscapes. Current Opinion in Obstetrics and Gynecology, 31(3):193-198.

[27] Jain, T., Harlow, B.L., & Hornstein, M.D. (2022). The corporatization of fertility care: Trends, implications, and the future of reproductive medicine. Fertility and Sterility, 117(3):457-465. https://doi.org/10.1016/j.fertnstert.2021.12.020

[28] Kushnir, V.A., & Barad, D.H. (2021). Corporate consolidation of fertility services in the United States: A review of market trends, ethical concerns, and practice implications. Fertility and Sterility Reports, 2(4):512-518. https://doi.org/10.1016/j.xfrr.2021.08.004

[29] Maheshwari, A., McLernon, D., & Bhattacharya, S. (2016). Cumulative live birth rate: Time for a consensus definition. Fertility and Sterility, 106(6):1432-1437.

[30] Mastenbroek, S., Twisk, M., Van Echten-Arends, J., Sikkema- Raddatz, B., Korevaar, J.C., Verhoeve, H.R., et al. (2011). In vitro fertilization with preimplantation genetic screening. New England Journal of Medicine, 357(1):9-17. https://doi.org/10.1056/NEJMoa067744

[31] Mau-Holzmann, U.A. (2005). Somatic chromosomal abnormalities in infertile men and women. Cytogenetic and Genome Research, 111(3-4):317-336. https://doi.org/10.1159/000086906

[32] Mazza, E., De Santis, L., & Selman, H. (2022). Investigating the efficacy of add-on treatments in IVF: A systematic review of the literature. Reproductive BioMedicine Online, 45(3):499-507.

[33] Milstein, R. (2009). Conflicts of interest in medicine. JAMA, 302(12):1294-1295.

[34] Palermo, G., Joris, H., Devroey, P., & Van Steirteghem, A. (1992). Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet, 340(8810):17-18. https://doi.org/10.1016/0140-6736(92)92425-f

[35] Patrizio, P., Albertini, D.F., Gleicher, N., Caplan, A.L. The changing world of IVF: the pros and cons of new business models offering assisted reproductive technologies. Journal of Assisted Reproduction and Genetics. 2022; 39(2):305-313. https://doi.org/10.1007/s10815-022-02399-y

[36] Pines, J.M. (2019). Private equity and the corporatization of healthcare: Revisited. Health Affairs, 38(12):2105-2107.

[37] Saleh, F.L., Adashi, E.Y., Sable, D.B., Kushnir, V.A., & Taylor, H.S. (2023). Changes to reproductive endocrinology and infertility practice, research, and training as investor mergers increase. Fertil Steril Rep, 4(4):332-336. https://doi.org/10.1016/j.xfre.2023.08.001

[38] Society for Assisted Reproductive Technology. (2020). Clinic Summary Report, National Summary Data 2019-2020. Available from: https://www.sart.org [Last accessed on 2025 Jun 12].

[39] Steptoe, P.C., & Edwards, R.G. (1978). Birth after the reimplantation of a human embryo. Lancet, 312(8085):366. https://doi.org/10.1016/s0140-6736(78)92957-4

[40] The Financial Times. (2023). Fresenius sells Eugin Group to KKR. London: The Financial Times.

[41] The, Lancet. (2024). The fertility industry: Profiting from vulnerability. The Lancet, 404(10449):215. https://doi.org/10.1016/S0140-6736(24)01484-3

[42] Tradeoffs. (2024). Is private equity ruining health care? It’s complicated. Available from: https://tradeoffs.org/2024/05/16/private-equity-health-care/?utm_source=chatgpt.com [Last accessed on 2025 Jun 12].

[43] Van Dongen, S., Verhagen, T., & Manders, J. (2020). Online reputational influences in the fertility sector: Systematic review of digital marketing practices. Interactive Journal of Medical Research, 9(2):e17912.

[44] Van Loendersloot, L., Repping, S., Bossuyt, P., Van der Veen, F., & Van Wely, M. (2014). Prediction models in in vitro fertilization; where are we? A mini review. Journal of Advanced Research, 5(3):295-301. https://doi.org/10.1016/j.jare.2013.05.002

[45] World Health Organization. (2020). Infertility:A Tabulation of Available Data On Prevalence of Primary and Secondary Infertility. Geneva: WHO Press.

[46] Zegers-Hochschild, F., Adamson, G.D., Dyer, S., Racowsky, C., De Mouzon, J., Sokol, R., et al. (2017). The international glossary on infertility and fertility care, 2017. Fertility and Sterility, 108(3):393-406. https://doi.org/10.1016/j.fertnstert.2017.06.005

[47] Zorrilla, M., & Yatsenko, A.N. (2013). The genetics of infertility: Current status of the field. Current Genetic Medicine Reports, 1(4):247-260. https://doi.org/10.1007/s40142-013-0027-1