/*Accordion Page Settings*/

Private Equity and Venture Capital

217 A Cold VC Climate, an IVF Start Up Incubator, and 15 new fertility companies with Dr. Santiago Munné

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


You have an idea for a start-up that will completely revolutionize the fertility space and need seed money, how do you attract investors to believe in your idea?

Dr. Santiago Munné, Co-Founder of Homu Health Ventures, offers up the investor side of that question as he gives an honest look at the venture capital landscape in the fertility space.

Tune in as Dr. Munné:

  • Introduces us to a different kind of venture capital in the fertility space

  • Tells us the start-up must-haves for his company to invest

  • Discusses AI: Tool or complete business solution?

  • Reveals Homu Health’s target ROI multiple (And their ROI timeline)

  • Speaks on the current climate of the VC Market (Hint: Winter is coming)


Dr. Santiago Munné
LinkedIn

Homu Health Services
Website
LinkedIn
Facebook
Instagram
Twitter

Transcript

[00:00:00] Dr. Santiago Munné: The funds have dried out completely. The ones that were lucky that, had investment, before. so now they had to preserve it, significantly. for instance, a company that were, was developing a couple of products will have to focus only on a single one, things like that. 

[00:00:20] Sponsor: This episode was brought to you by Mind360, where psychological evaluations become effortless. As an exclusive offer, all IRH subscribers will receive their first evaluation free. Visit www.mind360.us/irh to sign up and reserve your spot on our list. Elevate care, reduce wait times. Mind360 is psychology made simple.

Sponsor: This episode was brought to you by Family Inceptions. Join the Family Inceptions surrogate referral list at familyinceptions.com/irh. Connect with intended parents by using our exclusive surrogacy roadmap and elevate your practice today.

Announcer: Today's advertisers helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertisers. The advertisers do not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertisers.

[00:01:40] Griffin Jones: You have an idea for a startup that will completely revolutionize the fertility space. You need money. You might want some guidance. You might want some collaboration. How much of your company would you give up in order to get those? My guest talks about the average percentage of equity that his firm takes in startups, and he introduces us to a different kind of venture capital in the fertility space.

Dr. Santiago Munné, HOMU Ventures, is an incubator. They currently have 15 companies in their portfolio, all in the reproductive health space. They're developing companies at different parts of the fertility treatment chain. Dr. Munay talks about the ecosystem that they all fit into. You might know Santi as the founder of Recombine, the founder of Reprogenetics.

I believe he sold both of those companies to Cooper, where he was the chief scientific officer for a couple years. He's co founded a number of other companies and operated some of them. He was on the other side as the investee. Now he's the investor. We go through what is their target return on investment multiple?

What's their target return on investment timeframe? What do these companies have to have and have to prove before Dr. Munay's team will invest in them? Why don't they invest in AI companies? Is Santi right about AI solutions being more tools than complete business solutions? Or is he missing the bigger picture?

We go into more detail about the automation that needs to happen in the IVF lab, beyond storage and witnessing to automating ICSI, automating egg freezing and others. I asked Dr. Monet, what's the appropriate level of proof of concept for companies in these stages? They haven't sold anything yet. How do you know anybody wants it?

And Santi shares what it's like out there in the current venture capital market. I don't know Dr. Monet too well beyond this interview, but one thing that I think you're going to like about him is that he's not a pitch man. He gives very straightforward answers. And as far as I can tell, it doesn't sugarcoat anything.

Enjoy the episode. Dr. Munné, Santi, welcome to the Inside Reproductive Health podcast. 

[00:03:24] Dr. Santiago Munné: Thank you. 

[00:03:26] Griffin Jones: Nice to be here. I've gotten to know you a bit from your involvement in different companies. I've gotten to know a little bit of some of the companies that you've invested in, and I'm not here to necessarily talk Too much about those individual companies, but I am interested in how you invest in them and how you've chosen to invest in them.

I want to get to all of that, but your background is first a scientific training. You, your PhD is in genetics. I believe that you also have a degree in biology. And so when did business come into play? When did investing come into play? Did that come in very early? on in your career as you were studying genetics and biology or did it come much later?

[00:04:14] Dr. Santiago Munné: No, actually, so I, I, developed the first genetic test to, screen embryos for chromosome normalities and accidentally that became, it became a company and then it was, one after another. we created our companies or I got involved in, investing and so on. And at the end it was, I had a little bit too many at the same time.

So we decided to create an incubator and with some help, then, now we have this incubator among health ventures, in which we have about 15 companies, all in reproductive medicine. 

[00:04:55] Griffin Jones: So you said you had a couple too many. How many companies did you have before you formed the incubator? 

[00:05:02] Dr. Santiago Munné: one thing is to, to be the CEO.

I've been only the CEO of, ReproGenetics. and then I, helped found, several other companies. and yes, between The day to day of these companies, so it was getting too complicated. So we decided to, that we needed more help basically after, I sold a couple of them to, to Cooper, surgical, I funded, two, three more companies and as we have thought of ideas of potential companies, but it became, too complicated to manage all those.

So with a friend, we decided to get some more help and create an incubator where we put all these ideas and emerging companies, mostly on proceed stage. and this is come how these incubators started up. 

[00:06:06] Griffin Jones: In the beginning, were you involved as an operator in all of those businesses you said you sold two or three companies and were you either CEO or chief scientific officer or chief operating officer of all of them?

Were you deeply involved in the operations of all of those companies? 

[00:06:24] Dr. Santiago Munné: yeah, I've been reprogenetics where I was the CEO, then I've been CEO and chief scientific officer of a couple more, including overture. The last one. 

[00:06:35] Griffin Jones: So there's a difference between being an operator and the investor. And I guess we'll get to that.

But when you had those, companies with reprogenetic or, any of the other companies, did you have a venture capital funding for any of those companies? 

[00:06:58] Dr. Santiago Munné: yes. Yes. represent no repression ethics. But we had, that was all organic. But all the others have been funded by private equity. Sorry, right by VC.

[00:07:13] Griffin Jones: so you did have experience working with venture capitalists with private equity, right? with investors before you became one yourself, was there a process that you went through, while you were still at, the operator level of those two or three companies that was like a transition to an investor.

So you were like a part investor in your own companies. Did you become an accredited investor during that time? Talk to us about what that process was like. 

[00:07:44] Dr. Santiago Munné: No, that happened afterwards. so first We got funding in, several of these companies, Recombine, Phosphorus, Overture, and after that, we funded these incubator and started investing in it.

[00:08:03] Griffin Jones: What year did the incubator start? 

[00:08:05] Dr. Santiago Munné: That was only, three years ago. 

[00:08:08] Griffin Jones: So you've had success in building the businesses. You get some capital to do it. You have some. the experience with venture capital. but tell us more about how the incubator came to be. 

[00:08:26] Dr. Santiago Munné: Basically, we think that when you are starting a company, the investors, or the market will push you to develop a single product.

and you're lucky you will develop this product and you may be successful. And if you're successful, you may create other products after that. But usually you have to focus on a single product and In order to change reproductive medicine as we know it to make it more affordable and more efficient, you really need to change a lot of things.

You need a whole ecosystem of companies that are synergetic between themselves. And this is really very difficult to do with from a single company. I don't think any of the ones that are there. or that we have invested, they can do it by themselves. The idea or the leitmotif of, the incubator is, to create this ecosystem of companies that are synergetic and together, they may be able to, change and improve the, field of reproductive medicine.

[00:09:31] Griffin Jones: How do they work together in that ecosystem? 

[00:09:35] Dr. Santiago Munné: so for instance, we have, a company, that's called Sama that it's, developing, basically monitors patients remotely. But then we have another one, Genome embryonics that develops a genetic test to screen embryos, for the no mutations doing whole genome sequencing.

So we put them together, and gene embryonics will develop a test that. will be a companion, test for hormone stimulation. So that will help some, better monitor patients, for instance. Or, for instance, we'll have another company butterfly, that is developing a system to retrieve X, from by flushing, the, uterine cavity.

the need of surgery or an anesthesia. And on the other side, there is Overture that has developed egg freezing, in a very small, device. So if you combine them, you could put them, both systems in an OB GYN office. you wouldn't need an OR. and the idea is that, then Fertility preservation would be much easier, would be done in an RBGY office instead of having to go to an IBS center. we're looking for companies that, that, combine, can change the, the field. 

[00:11:02] Griffin Jones: So are you keeping all of this in a sort of hub? is there a hub for this ecosystem? Or you're connecting these companies together and are they just connecting with each other so they can learn from each other a little bit?

Or are you viewing this like a map? And here's where each of these different players. plug in and you have some sort of centralized way that they are all working in towards the same manifestation of the ecosystem. Yeah, 

[00:11:30] Dr. Santiago Munné: no, it's, more like a map. Yeah. And we're, trying to find, actively find sometimes, companies that feed some gaps in these ecosystem, but yeah, it's not a physical, place.

[00:11:47] Griffin Jones: Did you start with that map three or four years ago when you started the incubator? How differently does that, how differently or how diff, similarly does that map look today than it did four years ago? 

[00:12:04] Dr. Santiago Munné: it looks much better. I think at the beginning, we thought it would be easier. and it's not gonna be so easy.

It takes much more funding. And yeah, there are a lot of things that you don't predict. but yeah, I think it looks better. but also more complicated. so I think we're, getting closer, but we were not expecting, to be so difficult. 

[00:12:32] Griffin Jones: What specifically did you think would be easier? 

[00:12:38] Dr. Santiago Munné: we thought, that, things will happen much sooner and then you get the dynamics of, small companies, investors, funding and so on that derails, a bunch of these products and companies.

[00:12:52] Griffin Jones: When you say, things would happen much sooner, do you mean, fundraising would happen much, certain fundraising rounds? Yeah, 

[00:13:00] Dr. Santiago Munné: absolutely. We had very difficult two years for funding. So all the companies basically had to, to be much more conservative, with the money that they raised previously. because it's, very difficult right now still to, to raise funds. 

[00:13:19] Griffin Jones: How do you as an incubator, work with other venture firms? 

[00:13:26] Dr. Santiago Munné: Basically, we, try to, co invest sometimes, but mostly we, are trying to, yeah, to sell the companies or to, basically. Advertise that these companies are doing this work and that they need funding, more than coinvest.

Usually we, we find the companies that we like and then we try to, find people that would coinvest, but, not, at the contrary. 

[00:14:01] Griffin Jones: So I'm probably a little bit ignorant as to how incubators work. I think I assumed that incubators will do some angel or some maybe seed round investing in all of the companies in the incubator.

Is that the case? have you invested at the angel level at each of them? Have you invested beyond the angel round for any of them in the series a or 

[00:14:23] Dr. Santiago Munné: yes. So we did the angel proceed and seed. and some are at the level of, a, but yeah, we, try to, to invest at the very early stage and, get about 10 percent of the company.

[00:14:43] Griffin Jones: And so what in your estimate, why has it been difficult in, your view to this fundraising environment in the last two years, because the last year, while we've seen interest rates skyrocket relative to what they had been, the, the capital that was just floating around for two years is started to, To not flow like that.

But, the prior to that there was a lot of money going around. And so in your view, what has been the challenge in fundraising for these companies? 

[00:15:20] Dr. Santiago Munné: Yes, no, that, the funds have dried out completely. And the ones that were lucky that, had investment, before, so now they had to preserve it, significantly.

for instance, a company that were, was developing a couple of products will have to focus only on a single one, things like that. 

[00:15:46] Griffin Jones: That was going to be my question in terms of what does this do to their commercialization? Does it, does it delay it or does it make it happen sooner because they have to start selling?

[00:15:59] Dr. Santiago Munné: in a way it makes you, to be more, agile that, so far all, most of them have survived that process and are still, at it. but yes, it has delayed. going to market, and make things more difficult. 

[00:16:19] Griffin Jones: Are all of these companies in similar stages? Did they all start with you four years ago or some started four years ago?

Some started two years ago and maybe in the last couple of months you have somebody else tell us about that. 

[00:16:34] Dr. Santiago Munné: Yeah, most of them are at similar stages. So either they are all past proof of concept so that they are working on products that, they will reach the market in maybe a year, two years. a couple are have products already in the market, just starting selling them very early.

[00:16:59] Griffin Jones: So tell us, how do you, decide which companies are worth taking on? 

[00:17:05] Dr. Santiago Munné: Yeah, so we want companies that have IP or that they are developing IP, so not very interested in marketplaces and things like that. And that will, that they could return, let's say, 20 X, Roy in 6 to 8 years, and in, in which we can really contribute ourselves also.

So we like to be very involved in these companies. So we have to understand it. and also we want to contribute. That's, the fun part to, to be involved with them. not just Silly money. 

[00:17:46] Sponsor: Are you tired of the complex, time consuming psychological evaluation process that takes around six weeks?

Mind360 is here to change that. We specialize in making psychological assessments for third party infertility cycles seamless and stress free. With our platform, you'll get assessments done by PhD professionals, streamlined through telehealth, directly into your clinic's portal, ensuring compliance with ASRM and FDA guidelines without the hassle.

But here's the best part. Sign up today and your clinic will receive the first patient evaluation absolutely free. Experience first hand how Mind360 can transform the way your clinic's third party program operates, improving both efficiency and patient care. Don't let cumbersome evaluations slow you down.

Visit www.mind360.us/irh and let mind360 take the burden off your shoulders, making psychological evaluations a breeze.

[00:18:50] Griffin Jones: How do you determine what degree of intellectual property is worth it or, do they even have the intellectual property? Like you might look at something and you might say, that's not really.

That's not IP. how do you, determine that? 

[00:19:07] Dr. Santiago Munné: Oh, it's, they should, develop patents. They should file for patents. And for instance, it's very difficult to get patents in AI. So it's one of the areas in which we're we haven't done anything because I think, you just need big data.

if you're a network, have the, data organized, and any network can create their own AI to select embryos, do an algorithm for hormone stimulation and so on. That's why we haven't touched that. Also, it's very difficult to protect it, algorithms.

[00:19:44] Griffin Jones: I want to talk about that. I want to get into, to what that actually might entail.

network being able to create their own AI algorithms. But first on the on the patent side for IPS, are you looking at folks that already have technology under patent? Is patent pending sufficient to you? How do you look at that? 

[00:20:07] Dr. Santiago Munné: No, patent pending will be sufficient, provided that we understand the patent and we think that it may go somewhere.

[00:20:14] Griffin Jones: As you're building out this, map, tell us more just at a high level, what do you think is, missing most in the fertility space? You've been in the field for a long time now. You've gotten to see both incumbent fertility companies and fertility clinic networks. You've gotten to work in it.

You've gotten to build and sell a few companies and now you have these new young companies and you're, mapping together the needs that. that are missing. What are those needs in your view? How would you categorize the biggest two or three needs that are currently missing or are big challenges in the fertility space?

[00:20:53] Dr. Santiago Munne: Definitely. it's a big focus on automation. so the whole IVF lab should be automated. not because we're going to get rid of the people that were there. there is a lot of steps that are manual, just pipetting, in which the only thing that you could do is, make a mistake. It's not very rewarding to do it.

initially embryologists were scientists, now are becoming technicians. so if, the routine part that's where you can make mistakes, can be, automated, that will be great because it's great variability between clinics, and between. people working on the same clinic, from, for instance, I have a paper on, genetic abnormalities in embryos, in egg donors.

In theory, all egg donors are young. So you have, you should have a similar rate of, from some abnormalities in those embryos, but we had from 20 to 60 percent unemployed rates depending on the clinic. So obviously this means that there is too much variability. The problem with variability is that then when you launch a product, let's say when we launch PGD, for instance, some people would say, it doesn't work because they don't do it.

and it's very difficult then that a new technique catches on because everybody does it differently. And the results are not consistent. If you have, let's say you launch it in a platform, then it's much easier to see if it works or it doesn't work on. If it works, then you can innovate far faster and faster.

So these platforms, it's what we really need to innovate much faster. So yes, one thing is, Automation. I would say that's the, key. then there haven't been any, new developments in, drugs, for a long time or how those drugs are, delivered. We are not investing in that because it's a lot of money.

So for us at our level, we cannot invest in, in drugs. But there is a, it's a, it's an area where, there is not much innovation lately. and how the drugs are delivered also. Why do you suspect that is? The patents, from those drugs expire and it seems that the, those companies are, not interested in developing new ones.

I really don't know. but, yeah, there is, not much, innovation there or. People developing new drugs and deliveries of those drugs. 

[00:23:47] Griffin Jones: So you're not aware of too much innovation happening on the drug side for pharmaceuticals. so then we'll go back to where you are more familiar with the innovation happening that you're trying to do, the automation in the IVF lab.

I want to describe to you how I understand the IVF lab and you tell me what. is being automated or can be automated. And this is what I understand as someone who does not have any clinical training or any scientific background. So that, the egg is retrieved, and goes into the lab through a window, typically in the OR, the embryologists then put the oocytes in media, and, and then think, I don't know if, there's something else that happens to it.

They grow it to day five blastocysts. they need to label, everything up where all of the specimens come from the, sperm, the oocytes, the donor trails. I don't know exactly where it's stored during that time. And then once embryos are created, the Most viable embryo is transferred back to the uterus and the other embryos are stored.

And those embryos can be stored on site or they can be stored off site. some may need to go to deposition and be discarded and, and there needs to be labeling and monitoring across that chain. but that's the extent. To, which I understand our audience understand this a lot more deeply, than I do.

But tell me in that chain, what isn't automated now? What needs to be automated? 

[00:25:32] Dr. Santiago Munné: So right now there is very little that it's automated. The, we have probably two or three products. So for instance, you have the embryoscopes or incubators. with some time lapse that can capture images continuously. So you don't have to take the embers from the incubator to check them.

that's been a great events. And this really has as a platform that became probably the first platform that we had. And thanks to that, now we have, we can develop AI to select embryos. so that was a great. invention and, it's one of the few things that it's basically automated before we had to take the embers out of the incubator every, day to check them, that created changes in temperature and pH and so on.

so it was, a little bit detrimental for the embryos. and then we have, yeah, there are some machines that, that, can track where the eggs are frozen. so that's like tomorrow, for instance, and then you have a witnesses. So before, you had to have two people, watching each other, so you don't lose track of all these dishes, because mistakes were done and are done very commonly.

So you needed a witness system. now with, with these tags, you can, it's called a window system. And, by tagging all the dishes, you know where they are and it doesn't let you make mistakes when you are handling a bunch of dishes. but these are essentially small things. you still have to, for instance, do, ICSI.

So inject the sperm inside the egg. That's, is a company overture working on that. It's not commercialized. freeze eggs. Also there's no commercialized yet, but are people developing that overture? you could, for instance, when you do the transfer of the embryos, about 10 to 20%, it's thought that, those transfers don't go well.

because of, basically you are doing the transfer blindly with an ultrasound, but it's blindly. So now there is this company, Butterfly, that has put a lens on the catheter at the end. So we'll be able to see exactly where you put the, the embryos when you do the transfer. and. So once you start automating each one of these steps, then you can think about putting all these steps together in a machine that does the whole thing together.

But first, or at least how some of these companies are working is just, having technological blocks. that solved one problem first, and then you, once you solve it, then you put them together. 

[00:28:40] Griffin Jones: That brings me back to your original thesis of having the incubator because there's all of these different problems and it's hard for one company to to solve for all of the individual challenges and this way you have an ecosystem of people that, can come together and fill in that map.

What about someone that would say, why not create just one massive company and have this one massive company do all of that from start to finish? What's the argument against that? 

[00:29:20] Dr. Santiago Munne: No, there is no argument against that. It's that, you need a lot of financing and then your vision may not be the right one, right?

You may have a way to do it, but it may not work. So if you have, let's say, a competition of ideas on how it should work, I think it will be more successful at the end. 

[00:29:46] Griffin Jones: So it either way you need a lot of financing, so that seem yeah, you'll need a lot of financing. either, whether it's a, number of different companies solving different problems or one aspiring mega lift company trying to, solve, it all themselves.

Seems like either way you need a lot of financing, and you could have errors in the vision one way or the other. But are you saying with. with having multiple smaller company or not necessarily even smaller, but starting smaller in scope, we're starting more focused in scope. Are you saying that it allows for more iteration?

[00:30:25] Dr. Santiago Munné: Because I think it would allow for, yeah, if let's say this big company tries to solve everything, but it fails in one point and doesn't know how to solve it or financing finishes or. Then the whole project goes to meanwhile, if you have a bunch of companies competing in each one of the technological models, some of them will succeed.

And then at the end, you'll have the whole pipeline. 

[00:30:52] Sponsor: IVF specialists and REI clinics, it's time to share the step by step guidance of surrogacy experts with your independent IPs. Our roadmap is where intended parents start their journey. Sign up to be on our surrogacy referral list. Joining means you're part of their first step towards parenthood.

This isn't just about being listed. It's about being a preferred choice for those who seek the best in fertility care. We provide a comprehensive resource for everyone involved in the process. Join the Family Inceptions Referral Network by visiting familyinceptions.com/irh. Be more than a clinic.

Be a cornerstone in the path to family.

[00:31:40] Griffin Jones: So you talked about these areas for automation that you see is important and part of the reason that it fits with your investment thesis is because they've And Got patent pending. That sounds like that's one of the reasons why you haven't invested in a I companies because there's not a patent to be filed for their, and so I want to explore that a little bit more because you said if your networks could be able to create their own a I create their own algorithms and.

I'm wondering how accurate or how easy that is. people said the same thing about software for years, right? It's not until people said Oh, we could, we can create our own workflow software, we can create our own CRM and it's like in. The vast majority of cases, it's a lot better to use somebody else's software.

And so tell us about how this analogy either applies or doesn't apply with AI. right now, 

[00:32:43] Dr. Santiago Munné: AI has been used mostly for MBU selection. And really, it seems that there is like a plateau around 70 percent or under the curve about. distinguishing which embryos will implant. and there are like probably 10 companies or more working on the same.

basically all of them had access to some network of centers where they got the data. so it, it seems that there is very little differentiation between one product and another. and to us, as I said, I think that if you have enough data, and a team of five or six people experts in that, you can do the same.

[00:33:34] Griffin Jones: So who do you think will win that race? 

[00:33:40] Dr. Santiago Munné: I, think that, it's what they had to develop. It's been developed. As I said, we wouldn't invest on it right now, because there is not enough differentiation. and I think it's very easy to enter that market, right? That you have enough data. 

[00:33:56] Griffin Jones: So it sounds like then they're missing something because in one of the things that's missing sounds like patents and it And you know a particular differentiator, but it's almost there It seems like it would be almost certain to me maybe I'm wrong that many of the technologies that you're incubating today will will be powered by A.

I. In some ways in the future. what would certain A. I. Companies need to evolve to the next? Would they need to incorporate with some kind of hardware or just something that requires a patent as you all start to incorporate? AI more, what do they need to do on their side? 

[00:34:42] Dr. Santiago Munné: No, I, see AI as a tool, so it could be mathematics, physics, AI.

for instance, in Overture, so we develop, an automated XE device that, that uses AI. we have a couple of developers and that was enough to, for, the device to find where the sperm was, where the needles were, and injected perfectly. but it was a tool. It was not, it was just. Part of the, toolbox that we had to, develop the device.

So it's, I see it more as, as a tool, more, than a company or an entity itself. 

[00:35:28] Griffin Jones: you talk about, the involvement from the incubator in the companies that you're selecting. What type of involvement do you have with them? 

[00:35:40] Dr. Santiago Munné: for instance, I am, sorry, in addition of, other duties, but basically I'm, in the board of, three of the 15 companies that we have in incubator.

and I'm in contact every week with them meetings, introduction to investors, to clients, networks, going through, through the business plan, the whole thing. 

[00:36:10] Griffin Jones: And so what type of advice are you giving them, let's say when it comes to forming the business plan, that this is a, company that's, in your incubator, they have something that you've liked.

How are you typically coaching them? 

[00:36:27] Dr. Santiago Munne: Usually we're looking for either, products that fit the story. And sometimes they come from scientists that, that are, they have a very good idea. they know how to develop the idea, but they are not very good. Executors. And in those cases, what we've done in a couple of, instances was to then to put A-A-C-E-O, that, that was more executive than, a scientist.

It, the, combination of being a scientist and, a good, CEO, it's quite difficult. there are not too many examples. So usually either we find, these people or if not, then sometimes we had, help, we put CEOs, sometimes for a limited time, to just to help them. 

[00:37:28] Griffin Jones: How often is it the case that people are seeking you out because they want that help with?

different business leadership. I'm of the bias that most founders want to remain in control of their company, but I guess it could be the case that there are some scientists out there that say, listen, I want to be a co founder. I want to be the chief scientific officer and I want to have a huge role in this, but I know that I'm not going to be the one to build out the company.

How often is it the case where people are pursuing new leadership and looking for your help with that versus you really have to. To encourage them to do it, I would say, 

[00:38:07] Dr. Santiago Munné: all the starts up wanting to be the CEO and manage the company. But then they realize that I'm a scientist. What I enjoy is to developing products, discovering new things on the day to day.

It's a killer. And I don't like that. so I some of them rather better. Become want to be become a justice chief scientific officer and not have to deal with all the other things. 

[00:38:37] Griffin Jones: And so you talked about, patents is one of the things that you're looking for in companies and if they don't have that differentiator, that's one of the things that maybe isn't a good fit for your incubator, but what else is a no go for you if you're looking at a, a new company that it's like, if it's like this, then probably not something we want to get involved with.

[00:39:01] Dr. Santiago Munne: One, it has to, by itself, it, needs to, be big enough the idea that it could sustain a company. So we don't want little things that, that we don't think, by itself would be, a viable company or a large company. Individuals are very important. so we need, to have a good, and I, guess it's more a feeling that person, has the vision, the right vision, to take it to, to the next level.

and yes, it, it, needs also to, to feed the, vision as I said, that we have. 

[00:39:46] Griffin Jones: How about the appropriate level of proof of concept for your incubator? One of the things that I feel like I wouldn't necessarily be a great VC at is, I think I typically want to see more proof of concept from just about anything.

I want to see sales. And in many cases, that, you're dealing with technologies that aren't ready for that. That's why they're pursuing VC. That's why they're Pursuing being in an incubator, but my bias is to want to see something that says the only way that I know that the market wants this is because the market has paid for it.

People in the marketplace have parted ways with their dollars and that's what proves concept. My threshold is probably too high for, venture capital, but what is the appropriate level of proof of concept for companies in this stage in your view? 

[00:40:42] Dr. Santiago Munné: Yeah, right now, I think we would be satisfied, with looking for companies that can solve a problem.

we know if they solve that problem, eventually they will sell. We know the whole market. we know all the other networks. we can help them to sell to these networks. and so if we think that the solution will be good, then we think That, then we would invest, we don't need to see sales.

[00:41:20] Griffin Jones: I guess that's why people like you exist, and then if you win big, and, and maybe I don't have a high enough risk tolerance yet to be a venture capital myself, and, but that's, also why I probably wouldn't be getting a 20x ROI either. that's why certain companies get. 20 XR wise, because they're investing at an earlier stage.

And, you've seen the, the venture capital, marketplace change a lot in the last two years with regards to funds. What do you see on the horizon now? Is it getting worse? Is it, staying steady? Is it, starting to improve? What do you think is going to happen in the next six months? 

[00:42:12] Dr. Santiago Munné: it seems that, there was still some investment in, early stage and, now it seems that it started to, to change, and that's what I read because I haven't seen the change yet, but it's, it seems that, later stages will start to get, funded again.

But, right now at this stage that we are, it's still, difficult to get funding. so the, this change hasn't occurred yet.

[00:42:50] Griffin Jones: What are you doing to your strategy? Just hoping the market changes? Are you approaching new people, going to new different geographic markets? maybe if you were Looking at VCs in, in London or New York or Silicon Valley.

Now you're looking more at Singapore or New Delhi. I don't know, but, how, has your strategy changed? 

[00:43:12] Dr. Santiago Munné: yes. so we, because I was, Living in, in Europe, we focus mostly on raising funds in Europe and it's much more difficult even to raise funds in Europe than in the U. S. So we are opening a chapter in the U.

S., to facilitate, more funding from the U. S. I know that the U. S. it's easy right now, but we hope to, to get a wider network of potential investors. 

[00:43:46] Griffin Jones: you've given us a very honest look at the, the venture capital landscape in the fertility space at what it's like to incubate companies in that stage, the need in the marketplace that they're filling.

How would you like to conclude with our audience? 

[00:44:08] Dr. Santiago Munné: yes, I think that most of the innovation in this field is gonna happen in the startups. Basically, there is little funding from government to invest in. Infertility and reproductive medicine. And now with, traditionally, most of the innovation happen in, in the clinics themselves, a lots of my ready doctors, innovating, scientists, but now with the consolidation in all these networks, all these be funded networks, I think that one of the first thing that it will go will be research and development in these networks.

So really, all the innovation it's going to happen probably, in these startups. 

[00:44:58] Griffin Jones: Dr. Santiago Munné, thank you so much for coming on the Inside Reproductive Health podcast. 

[00:45:03] Dr. Santiago Munné: Thank you. It was a pleasure. 

[00:45:05] Sponsor: This episode was brought to you by Mind360, where psychological evaluations become effortless. As an exclusive offer, all IRH subscribers will receive their first evaluation free. Visit www.mind360.us/irh to sign up and reserve your spot on our list. Elevate care, reduce wait times. Mind360 is psychology made simple.

This episode was brought to you by Family Inceptions. Join the family inception surrogate referral list at familyinceptions.com/irh. Connect with intended parents by using our exclusive surrogacy roadmap and elevate your practice today.

Announcer: Today's advertisers helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertisers. The advertisers do not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertisers. Thank you for listening to Inside Reproductive Health.

216 One Fertility CEO's Plans After 100 Days of Listening with Francisco Lobbosco, CEO of FutureLife

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


The first 100 days are often the litmus test of leadership, and this week’s guest rose to the occasion.

Francisco Lobbosco, CEO of FutureLife, spent the first 100 days of his tenure hopping country to country, clinic to clinic, clinician to clinician while asking one set of questions. What he learned from his listening has created the blueprint for the future of FutureLife.

Tune in to hear Francisco reveal:

  • The questions he used to create his growth strategy.

  • How his first 100 days inspired FutureLife’s current mandate.

  • FutureLife’s 4-Pillars driving the company forward.

  • A clinic’s sweet spot for FutureLife acquisition [And the KPI’s they look for]

  • His philosophy on Quartile Growth

  • Some of the solutions FutureLife is implementing [Including a new CRM]

  • FutureLife’s growth trajectory [And if they’re expanding beyond the European continent in 2024]


Francisco Lobbosco
LinkedIn

FutureLife
Website
LinkedIn

Transcript

[00:00:00] Francisco Lobbosco: I took my first a hundred days to just go around and listen. But after that, I went through probably the key opinion, all the key opinion leaders that we have in the business in all 10 countries, and I started proposing changes. And to my surprise, they said yes to all of it. I think it's a matter of communication.

I think it's a matter of explaining what would happen if we were to do things differently. And most importantly, it's a matter of making sure that you don't mess up with the medical freedom that they have. 

[00:00:32]Sponsor: This episode was brought to you by AIVF. Maximize your clinic's potential with EMA by AIVF. Slash end to end embryo evaluation time by a staggering 97.8 percent. Freeing your staff to focus on what truly matters. Curious how this reduction in evaluation time could affect your bottom line? Visit aivf.co/precalc and use our free calculator to uncover the cost saving benefits of EMA by AIVF.

Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health nor of the advertiser. The advertiser does not have editorial control over the content of this episode and the guest's appearance is not an endorsement of the advertiser.

[00:01:32] Griffin Jones: 45 clinics, 1500 employees, 450 physicians, according to their website, and he may have said 250 FTE docs, 55, 000 IVF cycles amounting to the second largest fertility clinic network on the continent of Europe. At least with regard to number of locations. That's according to our guest, the person that has found himself at the helm of this network.

The organization is Future Life. The CEO is Francisco Lobbosco. At time of recording, Francisco has been in his post for the last six months. He spent the first three and a half. Going from team to team, doc to doc, country to country, office to office, asking one set of questions. He tells us what those questions were.

He tells us the mandate that future life has come up with since those 100 days. He says he didn't propose any changes within those first 100 days, and since, all the changes that he proposed have been accepted. tried to dig into what those were and he tells us about future life's four strategic pillars.

Medical excellence, patients, associates, who we on this side of the pond would not just consider associate physicians, but associate physicians, partner physicians, embryologists, lab directors, all staff. All employees. Finally, growth. Francisco shares what puts a clinic in the sweet spot for future life to want to acquire.

He talks about which KPIs they're measuring, including but not limited to, take home baby rate, net promoter score, employee net promoter score. Francisco says that he's systems agnostic, but coding obsessed. I said, I don't know, man, we'll see how long that goes. They have seven EMRs. So I press him a little bit on that.

Are you really going to be able to keep seven EMRs? You're going to go down to one. What's that going to be like? What's your philosophy on that? And he shares his response. He shares his philosophy on quartile growth, which clinics and providers you focus on the bell curve. Francisco shares some of the solutions they're implementing now, including a new CRM, who that is and who they vetted from 17 options.

Will this be the promised child CRM? I don't know. I've been hurt before. And then I asked Francisco to conclude on trajectory of growth for future life. Are we going to see future life expand beyond. the European continent in 2024. Please enjoy all of these answers and more with Francisco Lobbosco, CEO of FutureLife.

Mr. Lobbosco, Francisco, welcome to the Inside Reproductive Health podcast. 

[00:03:46] Francisco Lobbosco: Thank you, Griffin. It's a pleasure to be here today. 

[00:03:48] Griffin Jones: It took me 200 some episodes, but I finally have the CEO of a European network. We've had Canada. India, the United States, the UK, but never mainland Europe. And you are our first, thank you for obliging us as we continue to grow the global audience.

[00:04:07] Francisco Lobbosco: My pleasure. I'll try to represent Europe in the best possible way. 

[00:04:10] Griffin Jones: I hope so. You're the CEO of Future Life. That's been your job for the last six months as of this recording. And tell us a little bit about Future Life. Is it, in the, as far as the. network sizes of Europe, where do you all rank in terms of volume, in terms of doctor size, and maybe just a little bit of, background and I'll cover the rest of the background in the intro.

[00:04:35] Francisco Lobbosco: Yeah, sure. So we have 45 clinics, we're present in 10 countries. We are ranking number two in Europe in terms of locations. We do 55, 000 cycles a year, 2, 300 associates from which 350 are MDs, medical doctors, that's head count. 250 full time equivalents that could be, and we are very, proud to say that we are part of, helping this world, receiving a new baby every 45 minutes.

So that is probably our, best stat yet. 

[00:05:08] Griffin Jones: You came from outside of the field. Tell us about how you found yourself in this post. 

[00:05:15] Francisco Lobbosco: So yes, so before, before coming here, I was in veterinary health and I was approached by a headhunter and I, do have a personal past connection with IBF and when, they call me and they started sharing this material, read material about the industry and the company, we at home together with Margot, my wife, we felt so passionate about it and they share, I think in total 500 pages.

And, we went through it, I think it took us two night and it became a topic of discussion on my wife is a marketeer and the journey and how many touch points do we have and is this a place where you would harmonize or not having 10 countries, it was a very good interview process and the funny thing about that interview process is that it was slightly different.

Because one of the shareholders invited me here to Prague, where I am today, where we have the head office, and instead of coming straight to the office, we stop up the Prague castle, which if you've never been in Prague, it's a beautiful, it's a beautiful scene, and we start walking towards the office, and that's a good 40, 45 minutes walk.

Through the, old Prague is fascinating. So I was already, fascinated about the scenery and then I arrived to the clinic and this is my first clinic visit ever. And, I go into the lab and I make a million questions around the way, but when I got into the laboratory, that's where I saw magic happening.

And I was just in time to see on the big screen an X ray process being carried out by one of our great embryologists. And I look at him as a. I, this is fascinating. What you guys are creating here, life is just fascinating. So I felt quite strong already in my first interview. And after, I think it was in total of nine interviews, I was lucky enough to be offered the job and I'm very pleased where I am today.

[00:07:13] Griffin Jones: What was in those 500 pages? Was it a sales pitch to you to come and be recruited? Was it their pro forma? Was it a mix of things? What was in those contents? It 

[00:07:26] Francisco Lobbosco: was the BBs from past acquisitions. So Future Life is owned by main two shareholders, Hartenberg and CBC Capital Partners. And CBC entered last year or at the end of 2020, but I think they finalized the transaction in 22.

And therefore there was a lot of quite recent data for me to go through. And it was quite good really. 

[00:07:49] Griffin Jones: What made it attractive as a business person, as a business leader that. said you could have gone to a few different companies and maybe been in the one, two or three spot, but you had this offer and you're looking at their history.

What made it attractive to you to where, what did you look at specifically and say, this is something that I can really be a part of? 

[00:08:14] Francisco Lobbosco: A couple of things, but I will start with the most important one. as you just said, I had the opportunity working across. Different businesses, different industries, great companies, great experiences.

But none of them have the strong sense of purpose that future life has. And of course, this is not just exclusive to us here in future life. Of course, this is across every single clinic within the fertility space and every single person working at an IVF clinic. And I'm probably, you've been quite a long time in this space.

But Hey, let me remind you and everyone who've been part of this for a longer period of time. We are so lucky to be working where we are already. We are able to spend our days working on something that is truly amazing. Something that makes a huge difference to the world, really. And our job is to bring smiles to people's faces, to make their dreams come true.

And there is nothing more powerful than that. 

[00:09:13] Griffin Jones: How about from a business perspective in terms of what growth potential did you see? What role, what did you see yourself being able to add? 

[00:09:24] Francisco Lobbosco: it's a very good question. So here at Future Life we're quite lucky because the clinics that Hartenberg at the beginning and then CVC together with Hartenberg have been acquiring over the past years are very good clinics.

And I'm sure you will come to, what challenges do you face? this is one of them. The clinics are quite good. the medical outcomes are very strong. Financially, they are very successful. Wherever I went before, you always had a car crash, right? Something to turn around. In this particular case, when my 45, the worst thing I had is a single bidget.

it's fantastic financially speaking, so it's very difficult to come with new ideas when something's been working for such a long time, right? And let's not forget that you have the founders of the clinics, which are still present in most cases in our clinics, 99 percent of the cases. So engaging with them on saying, listen, I know what, brought you here over the last 20, 25 years is being great.

But what if we were to do things slightly different so as to maintain that medical side of the business, which, I believe in medical firm, but to give it a different tone to professionalize certain areas of the business, of the support centers, of the functions that are supporting you guys to deliver that highest quality of care possible, and there is, there are opportunities.

Outside Griffin, there are opportunities in the marketing area. There are opportunities on how we connect with our patients. we have, and we still have incredibly good, very strong, isolated clinics. we started last year to generate a community of clinics within FutureLive, but we are far away from where we want to be in the future.

And I think the synergies that 45 clinics can create, that's the goal in here. And from a business perspective. That's where really you can quantify the possibilities. 

[00:11:17] Griffin Jones: It's interesting that sometimes the fact that it isn't a car crash on the PNL in many cases, in my view, is part of the reason why parts of the field haven't advanced that much because I said, why would I, our patients are getting pregnant or at least enough of them are, and we're doing great.

And lousiest social media presence or office space, or even if we are. Using paper and EMRs, we still have people coming out of the woodwork, offering us X multiple of EBITDA. We're still taking plenty of money home. We still have lots of people telling us that they love us. and I feel that's been the reason why the venture capital.

Was probably 10 years later than it would have been like 10 years ago, there was no venture capital. There was private equity. I don't want to say there was none. There was very little venture capital. I've really only started to see venture capital in the fertility space, three, four years. And I feel like we would have seen that 10, 12 years ago, if there was just more of a.

of, impetus to scale. Do, what's your view having been in here six months? Are you starting to see, is there any external force that you see starting to cause people to change more or is that external force still going to take some time to build? 

[00:12:41] Francisco Lobbosco: I think you just described it really well.

And I think partially the drivers about having a very strong financial performance are there in terms of stopping development. However, I must say that I was personally very surprised. After my learning process, I took my first a hundred days to just go around and listen. But after that, I went through probably the key opinion, all the key opinion leaders that we have in the business in all 10 countries.

And I started proposing changes. And to my surprise, They said yes to all of it. I think it's a matter of communication. I think it's a matter of explaining what would happen if we were to do things differently and most importantly, it's a matter of making sure that you don't mess up with the medical freedom that they have.

And I'm very respectful of that. But when it comes to how can we improve at supporting the business from a finance, from a marketing, from an IT, from an HR perspective, I think there's a lot to improve there. Before we even get to the medical area from, a medical perspective, I have great advisor, so I don't need to get into that terrain.

[00:13:54] Griffin Jones: Did you propose any changes in those first 100 days? 

[00:13:58] Francisco Lobbosco: Not in the first ones. no. So I am very respectful of. Coming into a new sector and so what I've done is I just went around, I visited every single clinic, I spent loads of hours talking to all our associates, not just the key opinion leaders in each of the clinics or the founders or the GMs, but I just, just wander around talking to.

Our embryologists, that's where I really enjoy spending my time if I visit a clinic in the lab. so talking to embryologists, learning, how they do things, talking to nurses, talking to the onboarding coordinators, even in the call center, I enjoy spending time because they want to know why they are calling us.

so I have a million questions on what I've done, which is something I always do. If I go around with my defined questionnaire and I just ask the question, the same question to different people within the same clinic. within different clinics, and then I go back and I ask the same question to the same person in different moments in time.

And what usually tend to happen is you get different answers and that helps you to make up your mind on assessing where the business is today and what do we think we need to do to improve the business and bring it to the next level. 

[00:15:11] Sponsor: Boost your IVF clinic success with EMA by AIVF with our suite of AI modules.

Analyze embryo viability with precision, considering visual quality, morphokinetics, and genetic integrity. Enjoy seamless clinic management with advanced IVF analytics, integrated EMR connectivity, and a centralized communication hub. Ensure 24 7 access from any device and connect to multiple time lapse systems simultaneously.

Using our platform, our partners have experienced a 10 percent rise in implantation rates and a 30 percent increase in capacity. Don't just take our word for it, see the actual impact on your bottom line. Visit aivf.co/precalc, input your clinic's data, and get a personalized report on how EMA by AIVF can revolutionize your operations and financial performance. That's aivf.co/precalc.

[00:16:16] Griffin Jones: I was hoping you were going to say you went in with a disguise like undercover boss with the glasses and the big fake plastic nose and the mustache underneath it. And see, you didn't undercover boss them. You went in and you had a questionnaire. What was on that questionnaire? 

[00:16:32] Francisco Lobbosco: Why are you here? So that's my first question that I always ask when I go into a new place.

Why are you working here? So you usually start with, what's your name? What do you do? For how long have you been doing that? And why? Why are you with us for the last 10 years? Tell me what's different in this clinic versus the clinic next door. And to my surprise, our attrition rate is very, low. And people have, quite a lengthy period of time with us.

And therefore I'm fascinated to know, why do they stay? so that, that's my first question always, and you have so many different reasons. And that makes our job as a newly, my job as a new leader of a business slightly more difficult because you want to make sure you attach to the reasons that are keeping people happy and engaged and motivated.

But at the same time, you want to improve certain processes and SOPs and ways of working with an athlete. And therefore it's quite interesting when you ask the why are you here? It's never in this sector in particular, different to the prior businesses I worked for, perhaps. It's never about money, I'm still to get the answer saying they pay really well, which I think we do by the way, markets market rate.

But the point being is no one's here because of the money they're all here because of the patients and what they get to deliver for them, which is fascinating. 

[00:17:54] Griffin Jones: Are you using that question to find out what processes can be changed or what you need to know before you change a process? So if you're finding out that, a number of people really like a specific person or, a really specific way of doing things that you take that into consideration when you're making a process change, or is that just to, is that for rapport building?

And then you start to get into more granular questions after that. 

[00:18:23] Francisco Lobbosco: Yeah, but I don't take that question as the only question, to make up my mind. Of course, if someone tells me within a coordinator or the call center, right? So if I go into a call center and they have six people and I ask why you're here and everybody tells me my boss or the environment here is great.

I take that as a very good positive. So I try to learn what is that person doing to keep these people motivated and engaged and so on. But yes, the team, they usually gimme the team. The team is great. the team is great. and, then is, I get to help people and we are very, respectful about the quality of the service, the quality of the care that we provide.

So those are usually the two or three answers that I get. Within the very different versions of that. 

[00:19:07] Griffin Jones: So that leads you after you 100 days to recommend changes and you said that they accepted all of the changes you proposed. What were they? So 

[00:19:17] Francisco Lobbosco: listen, so I went on by having, let's say, one strong mandate.

Which was not imposed by anyone, but I could read it through my first a hundred days, future life from a medical perspective is very well positioned and our medical outcomes are it fantastic Francisco. Now, that don't touch that, right? So let's, make sure that whatever you don't mess up with the medical excellence that we're having in the business, because that is what describes us.

But then I went on and said, okay, so one of the things I'm asking is why are you here? And I'm getting different, views, all great views, all great answers. And especially when I go around clinics, the purpose is there. What I was missing was this little trick on asking the same question around support center and saying, why are you guys here?

And perhaps we were missing that, to verbalize the purpose, the mission, the vision, the values of importantly, the values of future life. So I went on and asked, why are we here? And then I went on and asked. What are we, setting ourselves to achieve? I, what our strategy is going to be in the next five years.

And then finally, how are we going to, just go through that strategy. So the why, the what and the how. So yeah. Quite simply after my a hundred days, the first thing I did is to grab, collect a number of associates across clinics, different roles, support center, different roles, and we set ourselves with support of a, of an agency to define the future life purpose.

Why is future life here? What's our vision of the world? What's our mission? And most importantly, what are our values? And obviously, we have clinics, as I said to you, that were quite independent, and they are still independent for many years, very successfully. And some of those clinics have strong statements in place.

And my purpose is not to, my mission is not to change those statements. But to have a united voice on future life and why is future life here to drive that core identity. So we've done that. And actually, I'm not sure when this podcast is going to go live, but I'm flying to Barcelona tomorrow to the first global leadership summit, where we're going to introduce those.

Those statements to everyone and to all our leaders in clinics and then obviously we're going to introduce the strategy and the strategy as you can imagine is something that together with my management team tapping into the medical advisory board tapping into some key opinion leaders from country we developed and we put on a paper and that strategy went through my supervisory board of course in june and that was approved and now we're going to introduce you introduce the strategy into the future life society again at the end of this week And then it's how we're going to go through that strategy and what is important for us to achieve.

And this question of why do we have a group? What is group going to do different than the clinics were doing until now independently? That's a very important question that needs answering quite fast. The synergies that we will have a group, those roles and responsibilities between, okay, clinics are doing this.

Fantastic. How can groups support the clinics on, being better at that, at that quality of care? How can we help the clinicians in particular, the EMTs, the embryologists, the nurses to have more time with patients instead of having, non value added activities or non value added time.

So that's the purpose of group. And that's what we're setting here to achieve through the how. And finally, would you say a finish? It's all about, as I said earlier, to keeping that medical excellence in place. And therefore we introduced literally two months ago, our medical advisory board to the CEO, which are 10 of our 10 of our great associates, medical doctors, embryologists.

And we get together once a month and they have three different topics in the agenda that they need to help us drive. so yeah, so I'll pause here for a minute because I think I gave you a lot there. 

[00:23:19] Griffin Jones: Was there no medical advisory before, board before? Was every clinic just operating with their own medical director?

[00:23:28] Francisco Lobbosco: So there was a scientific advisory board before, which was great, but I think we were missing parts of what I'm expecting the medical advisory board to do. So when in the medical advisory board, you have three areas that we predefined. So scientific research, now it's part of the medical advisory board.

We have education that it was perhaps not tackled before. And then the third one is what I call the business drivers. And that could be procurement, could be total reward strategy for the business, could be M& A, could be no thanks, right? 

[00:23:59] Griffin Jones: So you're involving them in the comprehensive growth strategy of the company.

Tell us what about what, does that strategy look like? You talked about some of the questions and I want to start asking those questions is to see what answers are in place thus far here. By the time this podcast episode comes out, you will have already shared that strategy with, you will have already released that strategy.

So it won't be news, but for the sake of. context of the conversation, tell us about what it, what is this strategy for the next year? 

[00:24:33] Francisco Lobbosco: Yeah. So we have four main strategic pillars. So we have medical excellence, we have our associates, we have our patients and we have growth. So those are our four pillars. In addition to the four pillars, if you were to think about a house, the typical house that you see in business.

You'll have the foundations and for me, the foundations are to make sure that we have the right reporting timely and accurate, and let's make sure we go through to have the right digital tools in place, right? I think there was an episode a few weeks ago that you guys, published it was fantastic.

I certainly enjoy it, but for us is to start the journey on this digital transformation, what are the basic initiatives that we want to land across the whole of future life? So those are the foundations. From a financial reporting and from our digital infrastructure. And at the end of it, as an outcome of it, we'll have our financial performance.

Okay. So we want to make sure that we have a strong and predictable results over the years up to 2027, but that's the outcome. And I'm convinced, as I always say to my team, that if we were to have strong success rates or medical outcomes, as we currently have on a strong patient satisfaction, the financials will come.

That's a matter of time, but I've seen places where actually financials are really good and patient satisfaction is poor or the medical outcomes are poor and that in the long term will take a toll. So for me, it's incredibly important that we stick with those medical outcomes being very high and patient satisfaction being very high.

I gave you the four pillars. So again, medical excellence, patients, associates, and growth. And within each of the pillars, what you have is a strategy. So medical excellence, our strategy is quite simple. Enable a quality and patient safety culture focusing on improved outcomes. Every strategy has a goal and a way to measure the goal, and then we'll have building blocks within those strategy pillars, right?

So again, medical excellence, for example, you have quality leadership, transparency, learning, and safety culture, advanced data usage, and clinical standard and outcomes. And then at the end of it, what is going to be our 2024 corporate objective? Because we wanna set this five year roadmap, but with milestones that we are set to achieve over the upcoming, midterm, short term, midterm and long term.

so that's how we set the strategy. 

[00:27:01] Griffin Jones: This might just be my own ignorance. Why is medical excellence its own pillar as opposed to it just being the. It being the result of the providers and patients pillars, I 

[00:27:14] Francisco Lobbosco: think it needs attention by itself. I think obviously when we talk about associates, we're talking in general about our, I think this is where you're going.

So we talk about associates. We're talking about clinical associates in general. When we talk about patients, it's the outcome, it's how happy they are is by the outcome of the medical excellence. When we're talking about growth is organic growth and inorganic growth. And there are cross.

But one of the things that perhaps. We did not have Griffin and I think we were very lucky on the way we've been acquiring over the last couple of years is this minimum medical and minimum lab standards across future life. But whilst we go on and on in this journey of, inviting more clinics to be part of the future life family, we need to make sure we have those minimum standards ready because, high quality clinics.

It's great, but are we going to have the same number of high quality clinics in five times across Europe that we're going to, go on and pursue to join us? Maybe not. So let's make sure we set the minimum standards right now. And I want the medical pillar to be a reminder for us of what we're trying to achieve all day long, doesn't matter the size, it doesn't matter the financial outcomes that is a pillar, the medical outcomes are a pillar for us.

[00:28:31] Griffin Jones: And when you say associates, I want to make sure we're using the words correctly, because in the U. S., associate would mean an employed physician. It typically would not mean an embryologist or a lab director. It also would be different from a partner physician. in Europe, does associate refer to all clinicians and all scientists?

[00:28:52] Francisco Lobbosco: All employees, from a receptionist to, the chief medical officer, everyone is an associate, but it's just terminology. 

[00:29:01] Griffin Jones: So then on the growth side, what do you plan to implement for the growth pillar? So you have a couple of things, right? 

[00:29:09] Francisco Lobbosco: So you have. Organic growth and inorganic growth, and obviously from developments that we've seen lately, inorganic growth is very important.

So perhaps I should start there. We have a great team, a great MNA team that they go out and source and talk to the best clinics in Europe about future life. With my arrival, the first thing we did is we put minimum requirements of clinics that we want to pursue, right? We want to have a conversation with.

And those minimum requirements could be as simple as, size of the total clinic, number of medical doctors, the size of the lab and potential capacity for, number of cycles, success rates. So by setting the minimum requirements, then our M& A team actually had what we call clinics within the sweet spot.

and then we go on and proceed the discussion with them. So inorganic is incredibly important. And then of course you have organic, we have organic coming from, a couple of building blocks. Productivity, you'll have synergies and you'll have advanced data usage, which is linked to probably productivity.

so productivity for us is not to push more work to our doctors or our nurses or our embryologists, but to understand how can we help them to have more air time with our patients. What is it that they are doing that perhaps these non valued activities, can we reduce them? Can we help them to reduce them?

I think you were pointing out into paperless before, I think you were referring to that, that, that's one of the drivers, right? So how much time are you spending on daily basis on printing forms and filling them out and in that are not required by law because every country is Understanding how we can help our clinicians and productivity is incredibly important.

And then understanding how we can leverage the group synergies across all our clinics is also very important. And then data, when, I came here in April, we, didn't have a very automated way of getting data, frankly speaking. And I think the team have, done a great effort over the last six months.

And now we have daily. Insights that are reporting for every single clinic that we have operational marketing and medical data coming, in an automated way, accurate way to us that then we share back because that's the intention. So every member of clinic leadership teams will be able to see not only their numbers, their dashboards in ways that they haven't done until now, but also they will be able to see what the others are doing.

Because the intention here is to share best practice. So if I'm struggling in an area of my business and I see that clinic A is doing fantastically well, we are actually pushing clinic B to call clinic A to see what they are doing. So data, has been incredibly important, but also we have. One of the most modern in, in, in house, lab facilities here in Proud, and we want to benefit from it.

We have one of the strongest marketing teams that we are building as we are speaking. So we want to make sure that we provide support to the clinics from a marketing point of view. Education, I talked about it before. We have a meat bank, right? So we want to make sure that we, prioritize our future life clinics when it comes to the donor material and so on.

[00:32:27] Griffin Jones: I want to dig into a bunch of these. I'm deciding which one to go first into. Let's talk about the insights because you're getting operational marketing, medical data every day. What are some of those KPIs that you're looking at every day? 

[00:32:40] Francisco Lobbosco: Yeah, very good question. So we started getting the data only a couple of weeks ago, and again, if you were to ask me about the challenges that I'm facing, these are challenges that I faced also in my prior positions where I went from having not much visibility and just reports that were manual into automated, and accurate reports.

And the risk with that, Griffin, is that you are overflowing the organization with data and KPIs and reports and so on. So it's just at the kick of a button distance for us to have loads of KPIs. So answering your question, I am a big fan, not us, us from many years ago to have a maximum of five things we really want to push.

So if you're a part of a leadership team, probably you're looking at the many, KPIs, which is great, but up to five is what you should push and reward for. and as you can imagine, deciding which five we're going to publish is quite an interesting discussion. And I'm quite open about the discussion and I want my executive team to have a say about it.

So we're actually looking into it, but of course, I'm not going to lie to you. So coming back to that strategy, right? So I talked to you about the four pillars and I talked about our digital journey, so most probably we will end up with at least one KPI for each of the pillars to be consistent with what we're saying that we want to achieve.

Now, if you want to dive into a particular pillar, of course, you will have loads of data, right? So I guess the first KPIs that come to mind, and again, with the caveat of this hasn't been decided yet with between me and my management team, NPS, patient related, take home baby rate, medical excellence related, EMPs, Associates related.

And then I had two more, one related to demand creation and one related to operational excellence. But those are still under discussion. 

[00:34:42] Griffin Jones: So those acronyms for those listening, NPS is net promoter score. EMPS I'm guessing is employment engagement score. what does that stand for? 

[00:34:53] Francisco Lobbosco: Yeah. 

[00:34:54] Griffin Jones: Employee net Promoter score.

Oh, okay. Oh, ENP. Okay. Yeah. So you got your NPS for patients and your ENPS Got it. Correct. And, then you talked to, you told us that initially this data wasn't being gathered and, or at least wasn't automated. Maybe it was being gathered, maybe it was here or there, and Correct. It was gathered.

[00:35:12] Francisco Lobbosco: But in a manual basis. So now it's a lot easier to access that data and to make decisions based on the data. But as something new, you may get overwhelmed. but that's where we are today. And we're incredibly happy with what the team, as I said, have achieved over the last six months. And now is what we're going to do with that.

And, this is the fun part of it. 

[00:35:32] Griffin Jones: What did you do to automate that data intake? 

[00:35:38] Francisco Lobbosco: We made it a topic, we made it a recurrent daily topic. Of course, we hire an external consultant to help us with it. So we have a number of EMRs in this, in the business. We don't have a single EMR. We have a number of them.

[00:35:52] Griffin Jones: and, that sounds horrible. I've never met one person that likes their EMR. Yeah. I've met people that like their EMR better than other ones. And they like the people that make the EMR and because they do their best, but I've never met. someone that's this is 100 percent my favorite thing to use ever, and you have multiple EMRs.

is that going to be something that, stays over time? Or how do you get, how do you get multiple EMRs to equate into one source of truth? 

[00:36:25] Francisco Lobbosco: Yeah, great timing for a great question because I just came this morning out of a management team meeting where we allocated 60 minutes to that discussion.

and listen, so one thing I learned years ago is that I am system agnostic. But I am coding obsessed. So if I can take the data in the right way out of an EMR and my medical doctors, nurses, embryologists, coordinators are happy with the system, but we can tap into it and generate these definitions, equal definitions in the cloud, and then just, spread the insights across.

I'm happy with that. But obviously as we expand the question is how many do you want to have? Because every new clinic most probably will come with their own EMR. So there's a decision to be made there. But so far we are okay with the seven EMRs we're having. and especially because as I said, this, this third party consultant company help us to tap into every single one of them.

And now we have access to the insights that again, it's not just for us at management here at group level, but we're cascading that down for, the clinics to make decisions as well. 

[00:37:41] Griffin Jones: So I've seen all three approaches with regard to when you acquire a number of clinics and then you adopt different EMRs, or they have different EMRs, I've seen the approach of everybody, you can keep your EMR, decide for yourself, we're going to make a recommendation of what EMR we should use, and here's our SOP, but you decide if you're going to implement it or not, and then I've also seen, and probably even more recently, we're going to all go to this EMR.

This is the way it is for everybody in the network. This is what we're doing. It sounds like right now you're choosing the approach of one of the first two. why not make everybody, you said your system's agnostic. I get that. But even from a coding obsessed perspective, doesn't it? I feel like I would, I just know there's going to be some pain in your.

In the future of this isn't coding the right way because they're not actually coding equivalents in these systems. And, especially when you see one group having a low NPS because of their EMR and another group having a higher NPS because they really like their EMR. So why are you not going with the third option now?

Not the right time for sure. 

[00:38:51] Francisco Lobbosco: I think we have other priorities. I think the current DMR systems that we have in place give us what we need today. And again, for every decision, every initiative that we implement and we create a group level, most probably it will have repercussions at the clinical level.

And what I do not like to do is to overwhelm the clinics with projects that then will have an impact on the way we treat our patients. And changing EMRs, as or developing EMRs, you need to tap into that, you need to work with clinical associates. And I think today is not the right time for it, but I'm not saying no for the future, but I think today is not the right time.

[00:39:33] Griffin Jones: So you're getting these insights and not just the KPIs in the form of insights, but you're getting wisdom in the sense of asking the questions, what can be. Removed in order to add more value, what non value added activities can go? What can we do to give more time back to our associates? You're a smart guy.

You've been asking these questions for a hundred days. I assume you have a couple of, answers by this point. what are a couple of those things that you can do to remove non value added activities for associates? 

[00:40:09] Francisco Lobbosco: Yeah. And I think every clinic is different and every, the starting point for every single clinic is very different, right?

So with data now we can see, volumes going through productivity metrics going through, and as I said, you can sit on daily basis or intraday if you wanted to. And if you see a clinic that is, I'm a big fan of quartile and everything, right? So you have in a regular bell curve, you'll have Q1 two, three, and four.

So if you think about the quartile one and two, they are below average. So you wanna bring them to average, right? So you'll probably get a better impact from doing the, a bigger impact from doing that than pushing Q4 into, the 98 to the 99%. And as I said, every clinic is different. But there's one thing that I learned, which is my MDs, our MDs, our nurses, our embryologists are flat out is they're not playing Tetris in their consultation rooms.

And therefore, if they're delivering a lower productivity levels than the clinic next door within future life, that means that they're probably doing something else that the other clinic is not doing. And in most ca, in 99.9% of the cases. The MDs are looking at us saying, help me because I want to see more patients, but I have to do all these things that are stopping from, they are stopping me from seeing more patients.

And I think that's, the area that is very different clinic by clinic. So if you ask me for an answer now, I don't have an answer. I have many answers and they're very particular to the countries, to the clinics. There's some legislation in some places where everything has to be paper based. So it's quite different clinic by clinic.

[00:41:50] Griffin Jones: That brings me to, it's jumping ahead to a question about the EU in terms of, I'm sure there's some things that are, standard across the board, but then I imagine that there are many differences country to country. And, what's it like navigating those differences? What stood out to you in terms of particularities between different governance?

[00:42:12] Francisco Lobbosco: yeah, it is different, but one of the things I experienced here that I didn't experience in my past experiences is fertility tourism, and therefore patients are willing to actually move to the next clinic in the next country to access whatever they cannot access at home. And that is one of the biggest things that here at Future Life we need to start leveraging.

And, that referral within our own family is something that is missing. It's something that is going to drive growth as we were talking about growth earlier, definitely. But most importantly, something that our patients are asking for, because if in clinic A, I come to clinic A because I heard great things about clinic A.

But you cannot treat me because I'm a single man, for example, where can I go? Or, a homosexual cop, where can I go? we can definitely help you here and here and here and here, and we'll, make it happen for you. So that is one of the biggest benefits from having this community of Canine Excel across 10 countries that we think, I think we need to leverage a 

[00:43:15] Griffin Jones: And that's helpful in having a lot of this data aggregated and having the, teams working together too, because then you can build that infrastructure of, it's not just, Oh, I think our clinic over here does that.

It's, we have, let's take you over to the portfolio and let's see where. Where you're going to be able to be helped on the solution side of the elements, 

[00:43:41] Francisco Lobbosco: sorry to jump in, but one of the elements I think is close to your heart as well as we're implementing a common CRM system across every single clinic.

And that actually will help us as well with that transition and to offer, the right treatment for, all patients across independently on the borders. 

[00:43:59] Griffin Jones: Is it a CRM we would know like a HubSpot or a Salesforce, or is it a different kind of CRM? Creation. 

[00:44:04] Francisco Lobbosco: I'm not sure if you heard about it. I'm not familiar with them.

[00:44:08] Griffin Jones: And how did you vet them? They're based out of London. The CRM topic is, interesting to me because the reason why. I don't advise most small clinics to do it is because it's just too much work. The bigger groups have found a way to make Salesforce work and the big networks, but it's still not what I would want.

If I had my druthers, I would want a CRM that fully integrates within EMR because otherwise there's just too much duplicate work. So how did you vet this solution? 

[00:44:40] Francisco Lobbosco: So we obviously have lots of requirements at the moment of selection. We worked very collaboratively between the digital team, the operations team and the marketing team, because everybody has a say on what, what conditions we want to drive out of a CRM.

and we started with, I think it was 17 potential options. We went through meeting each of them, making sure that they could. Cope with our requirements, different to what it may sound. Our requirements are, is it going to be simple to use? Am I going to get just, what I need? I don't need a Ferrari to drive through the streets of Prague.

I need something that would take me from A to B. Is that going to take me from A to B? But potentially having the potential to go to C if I wanted to go to C after. So we were quite picky on our requirements. And, some of the names you mentioned there were. Definitely within the top five of our consideration, but in the end, we decide for creation, which I think they are based out of London.

[00:45:41] Griffin Jones: Do you plan to use it just for patients, new patient sourcing? Do you also plan to use it for referral providers? Because I've seen CRMs used both ways, where you use it as like the digital CRM, the marketing CRM, but also as the sales CRM for referring providers. How do you plan to use it? 

[00:46:00] Francisco Lobbosco: there's a phase one for sure on phase one is to make sure that we use it for marketing purposes, but we have the, what I was saying, let's go from A to B and then potentially let's go for C.

can you take me to C? these guys can take us to C and C is precisely what you're saying. I think eventually there are some functionality sitting in the EMR that potentially can go to the CRM. It's becoming a bit technical. Definitely it's a second phase of the project. 

[00:46:27] Griffin Jones: Maybe we stick with the growth theme For the last couple minutes of our conversation, you mentioned you've identified a sweet spot.

Some of those clinics might in this, in your sweet spot, might be listening and maybe future life is a good partner for them. Tell us a little bit. More about who's your sweet spot of clinic to come into your portfolio. 

[00:46:52] Francisco Lobbosco: first of all, we are very keen on having reputable clinics, right? So we're not in the business of turning around clinics from a medical point of view, we just trust our medical community in every clinic that we acquire, and we believe that they're up to the quality that we want to be proud of offering.

Answering your question, it will depend. And the reason why it will depend is because if we're talking about a new country, probably you want to go with a clinic that is slightly larger, that if you want to go into a country where we already have presence and we have a half clinic, as we call it, because from a half clinic, you can provide certain services as a great marketing team, as a great IT team, and so on, which is what we do, Again, it depends on the country, but if we were to enter a new country, we'll be looking into a clinic that, does around, as a minimum 600 pickups a year. We'll be looking into is there succession planning? I, do I have four or five at least FTEs in place? I'm talking about medical doctors.

What about the founder? How important is the figure of the founder? Is there succession for the founder? How is it being managed from a support perspective? can we utilize those great resources coming from the support functions in that clinic that we are acquiring to potentially expanding within that country, relying on the marketing individual that sits in that particular clinic or the finance individual that sits in that particular clinic.

We're looking for certain minimum square footage or square meters. Obviously we're looking into. EVDA as a consideration, because based on turnover EVDA, if the clinic has opportunities or not financially speaking, but that is usually the last consideration for us is all about success rates, which are in general here in Europe, they are published.

And therefore you can see the medical excellence or the medical quality that clinic has to offer. And then we send our teams out there. We send our operators, we send our chief medical officer. So we have one in West New York, one in Central Europe. They go and see the clinic and they come with a report.

And usually I'm also going out, seeing the clinic meeting, meeting the people that will potentially partner with us. Oh, in most cases, we don't acquire a hundred percent because we like them to have skin in the game and to continue with us partnering and so on. So therefore that partnership and the quality of the partnership is incredibly important for us.

[00:49:18] Griffin Jones: all right, so you're not taking 100 percent stake in, are you taking a majority stake in most of the clinics? 

[00:49:24] Francisco Lobbosco: Yes. Yes, definitely. and again, we're open for, a hundred percents, but in general, people are very proud. Founders are really proud of what they built and they want to keep going, which is great for us.

They want to keep going, but we better support from a digital perspective, but support from a finance perspective, from a marketing perspective, and that's what we can offer. 

[00:49:45] Griffin Jones: The pick, when you said 600 pickups, I wasn't familiar with that term. Does that refer to ag retrievals? Is that referred to? Yes. Okay.

So at a minimum, you're talking about not the smallest. I would say the, where it starts to become a mid sized practice as opposed to a small practice. Do you have the opportunity in the year to place docs in, to have docs go from some countries to other countries? Like in the U S one of the biggest challenges for single doc.

groups is that it's hard to get other docs to come to that area if they're in a small market. There's at least one group in the U. S. that I know of that has been taking advantage of it. They have bought a couple of these single doc groups because they can take some of their docs and fly them out there for a week or two at a time and batch cycles.

Do you have the opportunity to do that in the year or does the regulation between countries prohibit that? 

[00:50:41] Francisco Lobbosco: It depends on the country, we do have examples, we, have Hans who was working in Spain now, he's the chief medical officer for, reprimanding Ireland. we have Tomas in Slovakia coming from Czechia.

So we do have examples, it's just, it is a bit more complicated to, to have that freedom of movement when it comes to doctors, but definitely it's an area that we need to explore a little bit better, especially when it comes to embryologists. 

[00:51:08] Griffin Jones: That could be its whole episode in of its own talking about being able to use a bank of embryologists, and there's a lot of questions that I haven't asked you that I will be happy to ask you bringing you back onto the show.

With Growth is international. In your near horizon, now that we're seeing, we, saw the East Asian cohort by Indira and IVF, we see ginseng fertility own HRC in California. We saw care in the UK for the first time, make an acquisition in the United States. And in the end of 22, are we, should we expect to see future life moving beyond the continent in 2024, 

[00:51:52] Francisco Lobbosco: so we see many opportunities in Europe for us to continue looking at.

Also, we need to remind ourselves, especially that ourselves here at future life, that we're a new team with loads of initiatives being carried out as we speak. So focusing on the 45 plus the ones that will come from Europe next year, probably is the right thing. With that being said, we're always looking at what the market has to offer.

And, definitely the U S is a, is a market that, is attractive from different considerations, definitely other parts of the world as well. So I'm not saying no to it. I'm just conscious that we are incredibly busy at this precise moment. Delivering what we have to deliver here in Europe.

We also see opportunities for expanding here in Europe as well. 

[00:52:45] Griffin Jones: Francisco, it's been a pleasure talking with you. I want to give you the floor to conclude with your vision for growth, your vision for why, what we need to do to help the people of, why we're here. The floor is yours. 

[00:53:00] Francisco Lobbosco: thank you. I think I really enjoyed the conversation, perhaps just as a final thought from my end, which is something I said to my team quite often, I know that people like you, Griffin, most of your listeners, if not all, have been in this sector in this space for quite some time.

And you're very familiar with it. Sometimes it's good to have someone external coming, reminding us. On how powerful it is to work that you guys do on a daily basis. And I'm talking about everyone working in clinics, right? So this goes for everyone working in a clinic, MDs, embryologists, nurses, receptionists, coordinators.

It's just fascinating what you guys do on a daily basis. your job is to put smiles on people's faces. So my last words would be encouraging you to continue going. I think what you're doing helps the sector in particular, for everyone else out there, just keep going. I think we, or you in particular, are changing the world one way at a time.

So big thank you from my end. 

[00:54:02] Griffin Jones: you have helped with the impetus for more international content because I think it was earlier this year, maybe end of 22 when you first messaged me and said, I'm coming into the space and I'm, using your media to, to learn more about it. I said, Oh, maybe we should start creating more international content.

So you're among. among the reasons why we're expanding coverage for the global audience. and I'm thankful to those people that, that send me notes like that. And I echo your sentiments for people, because I'm not a clinician. I've, barely passed high school biology and, I often forget to, to sometimes stand back and say the same things that you just have.

So Francisco Lobbosco, thank you for saying it. Thank you for saying it on the Inside Reproductive Health Podcast. Thank you, Griffin. 

[00:54:52] Sponsor: This episode was brought to you by AIVF. Maximize your clinic's potential with EMA by AIVF slash end-to-end embryo evaluation time by a staggering 97.8%, freeing your staff to focus on what truly matters.

Curious how this reduction in evaluation time could affect your bottom line? Visit aivf.co/precalc and use our free calculator to uncover the cost saving benefits of EMA by AIVF. 

Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you, but the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser. The advertiser does not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertiser. Thank you for listening to Inside Reproductive health.

205 Vertical Integration of the Fertility Field: What Lies Ahead with Louis Villalba

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


Is vertical integration inevitable?

That’s the question we explore this week with Louis Villalba, CEO of TMRW Life Sciences, as he dives into the consolidation and current business climate within the fertility space.

Tune in to learn about:

  • The 5 ancillary services of the fertility space (And how they make the distinction between vertical and horizontal integration)

  • The argument against concentrating these services (Like risking new buckets of liability)

  • The argument for concentrating these services (The sweet spot to acquiring a related service)

  • Backward integration vs Forward integration (Move closer to raw materials or toward end patient consumers?)

  • A breakdown of the recent major lawsuits in fertility (And what those would look like in a vertically integrated fertility space)

  • Speculation on when we could expect to see antitrust regulation in the field


Louis Villalba
LinkedIn

TMRW Life Sciences
LinkedIn
Facebook
Instagram
Twitter: @TMRWLifeSci

Transcript

[00:00:00] Louis Villalba: What this does is it shows you, as we have obviously a lot of natural, you know, you know, kind of consolidation in our space that's occurring with private equity, as the buyers become more sophisticated, what you see is actually a lot of focus on how do we continue to control more of the patient, you know, experience, if you will, and then how do we monetize, you know, those, you know, those efforts in terms of providing other services that we outsource.

[00:00:24] Sponsor: This episode was brought to you by Surrogacy Roadmap, a self led educational course created by Family Inceptions. How many social media surrogacy matches have you come across? Get your free lesson from surrogacyroadmap.com/for-professionals. That's surrogacyroadmap.com/for-professionals.

Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you. 

But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser. The advertiser does not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertiser.

[00:01:14] Griffin Jones: Can you just be a fertility clinic anymore? And I don't even mean, can you just be an independently owned fertility clinic anymore? I mean, like, even if you're a large group, a network of fertility clinics, multi state, multi lab even. Will you be able to get away with providing lab and clinical services only, or will you have to integrate into other verticals?

Vertical integration is happening in the fertility field. It's not just kind body. It's not just recharged capital in Southeast Asia. I suspect with these massive capital firms like KKR and Blackrock entering the fertility field that we are going to see a lot more vertical integration. And so that's why I brought in my guest, Luis Villalba.

Lou has recently been promoted to CEO of Tomorrow. He was the CEO of Geneo Biomedics, and he's led commercial divisions for a number of different companies in the space. To make the distinction between vertical [00:02:00] integration and horizontal integration, Lou lays out. The five main ancillary services in the fertility space.

This is from the point of view of the fertility clinic, safety and technology, storage, lab, egg banks, which I'm guessing you would just say gamete banks and surrogacy services. He talks about the buyers like KKR bringing a new level of sophistication to their approach to controlling the value chain. Lou makes the argument against concentrating ancillary services.

And he makes the argument for it. In the argument against, he talks about the risk of a headcount and new buckets of liability. I push him a little bit about what the strength of a balance sheet means. How relative is it in the time that we're in now where capital is starting to tighten up versus five years ago when seemingly anyone could get a loan for a low amount of money, for a low amount of interest.

We talk a little bit about major lawsuits that have been recent like The chart ink lawsuit from the Pacific Fertility Center failure five years ago. What that would look like in a vertically integrated fertility field. With regard to the healthiness of the balance sheet, Lou talks about the healthiness of gross margins for fertility networks.

What's the good end of the range? What's a poor end of the range? In the argument for Lou talks about the sweet spot for where it makes sense for a fertility company to acquire a related service. I asked him about backward integration moving closer toward the raw material versus forward integration moving closer towards the end.

patient consumer. I ask him about what tomorrow is up to. Lou gives his opinion on if it's a five horse race among the largest fertility clinic networks, what will happen next in that dynamic, like consolidation between horses two through five. I named some companies and I asked Lou to tell me who he thinks are the front runners right now.

And then finally, I asked Lou to speculate on when we might start to see some antitrust regulation happening. in the field. We've seen a little bit. There's more integration happening. Politically, there might be an appetite for trust busting on the populist waves of both the left and the right, according to my amateur political analysis.

And Lou gives his thoughts. Enjoy this episode about the inevitability of vertical integration in the fertility space with Lou Villalba. Mr. Villalba, Lou, welcome to the Inside Reproductive Health podcast. 

[00:04:02] Louis Villalba: Thank you, Griffin. Happy to be here with you. 

[00:04:04] Griffin Jones: I'm happy to have you on because you and I have gotten to know each other over the past few months.

But recently we were at a meeting and when you and I were just having a side conversation about vertical integration, I was like, stop, this needs to be, I need to be recording this. It needs, I got to get this into a podcast episode. And I want to ask you all sorts of things about vertical integration, about specifically what's happening in the field of how necessary it is, when it backfires, how, how people go forward and backward.

But let's maybe start with just how you would describe vertical integration and ancillary services and introduce the theme for us. 

[00:04:43] Louis Villalba: Sure. Sounds great. And I appreciate it and appreciate the, uh, the discussion. So if we look today in terms of ancillary services, and let's say, for example, we focus on some of the larger IVF networks in the U S a lot of these groups have taken a look at, you know, kind of You know, bringing on into their operations, what I'll [00:05:00] call five different components.

One is safety and technology. So anything they can do to automate their existing platform on a day to day basis. Second would be storage. Obviously as storage, you know, is some people outsource. Some people have actually started to manage directly on their own. Then obviously you have genetic labs, which is a very big, you know, important part of the day to day business.

As we see networks starting to own their own labs and integrate and actually acquire some of the labs and services they were using, then you obviously you have egg banks and you have surrogacy services. So these are generally the five major components of ancillary services that most networks are concentrated on.

And not only networks, but if the single providers are large enough in terms of scale, they would also benefit from, you know, concentrating on these types of components. 

[00:05:45] Griffin Jones: So, are some of these, would some of these be examples of horizontal integration? Like, I guess it depends on where you are in the journey, right?

Like, because if you're a, if you, if, if it's third party IVF, then I suppose [00:06:00] that having the egg bank and the surrogacy services as a part of the chain would be vertical. But how do you distinguish horizontal versus vertical in this case? 

[00:06:12] Louis Villalba: Yeah, it's an important question, and we'll just take a quick step back.

So if you look, for example, at like innovation fertility, it's prior to their, you know, merging with U. S. fertility, and you look, you look at the services they were offering, I think they were, you know, a lab focused, you know, network, right? That, you know, basically took on, you know, a lot of different aspects.

They had storage, they hired actually a sales team. led by some, you know, highly qualified, you know, talent to go out and sell their genetic lab services, their storage services and amongst and amongst other things. And they were looking to expand that as they went into their merger. So time will tell with us fertility, what they choose to do.

So if you compare that to vertical or horizontal. you know, integration, you can make the case that if it's their own existing, you know, kind of physicians [00:07:00] that they support, that would be more of a horizontal. If they take it out to other, you know, entities, we could, you know, we can talk about virtual integration in terms of, you know, those types of services.

But I think first and foremost, what this does is it shows you As we have, obviously a lot of natural, you know, you know, kind of consolidation in our space that's occurring with private equity. As the buyers become more sophisticated, what you see is actually a lot of focus on how do we continue to control more of the patient, you know, experience if you will.

And then how do we monetize, you know, those, you know, those efforts in terms of providing other services that we outsource. Now, there's obviously like all good things in life. There's a lot of execution as you continue to offer more services that's required from a network perspective. And if you think of day to day care versus bringing on additional services, it brings on a different set of circumstances that you have to execute to provide that patient experience.

[00:07:56] Griffin Jones: So when you say buyers are becoming more sophisticated, you're not talking about the fertility patient and consumer, you're talking about the business to business buyer, the buyers purchasing clinics, clinic networks, and fertility companies? 

[00:08:11] Louis Villalba: So I would say we have, we have sophistication increasing on both sides, okay?

And I would say that obviously the buyers are becoming more sophisticated. You look at KKR's acquisition paying two and a half billion dollars for, you know, for Evie RMA, that is, you know, that's a major player. There's no larger private equity group in the world. That's probably going to get into private equity or excuse me, into IVF outside of a BlackRock, let's say something of that nature.

So what does, you know, a purchaser. of that, you know, kind of bandwidth bring. It brings a level of sophistication that is different than, you know, in terms of how the business has actually grown. I always love to point out we're 44 years old in the world in terms of the oldest IVF baby, right? And so this business was, you know, this industry was built on the backs of a lot of great healthcare providers that, you know, established IVF to where it is today.

And that attention continues to multiple or multiply. in terms of the buyers that are coming in to the space now. So we see progenies of the world going directly to the patients, right? They go to employers, they offer benefits that creates a, you know, a level of sophistication that, you know, takes them, you know, a middleman out of the equation.

And now you see these types of, you know, providers starting to influence patient treatment patterns, right. In terms of where they go, what types of services are offered, what things are covered. You know, we see obviously a lot of. You know, you know, if you look in my opinion, if you look at a Massachusetts or an Illinois and you look at the mandates that have been approved in those states for some time, that's the future of IVF in the United States to a certain extent, okay?

We're going to see that type of coverage continuing to expand as it should and provide more coverage to, you know, to patients because we know that, you know, currently right now there's nowhere near enough treatment for the amount of demand that's in the market today. 

[00:09:56] Griffin Jones: So do you think a lot of the drive towards vertical integration is coming from the investor side?

Is this part of the investor thesis now? Is this, how much is it coming from operators that feel like, well, I just simply need to do this in order to complete the rest of our business plan versus investors coming in with is part of their thesis. And it is, is it, is it part of almost every investor's thesis now?

[00:10:22] Louis Villalba: Think that, you know, every investor is going to look to obviously maximize their investment, right? And how do you do that? Do you do that by controlling more ancillary services, you know, and increased profit? through providing, you know, or controlling that type of the business. And there's, you know, there's a great debate that goes on.

There are some networks CEOs that, you know, would, would, you know, argue that concentrated on ancillary services is not the right way to increase profitability. And, you know, in an IVF network, actually seeing more patients as a way to actually increase profitability is, is what some would say. Others would argue and say, look, this is the best way for me to control quality.

This is the best way for me to control safety. And yes, for controlling those things, I probably will realize a better profit. Okay. And I, you know, in terms of, you know, where they will call the sweet spot from a risk and profitability equation. I think it's a lot of that depends on scale. So once you reach a certain size and you're obviously, you know, your volumes obviously support these types of investment.

These make it natural sense for some businesses to, you know, to take on this type of service, but it doesn't come without risk. Right. And anytime you actually perform an additional service for, you know, for patients that comes with an execution, you know, responsibility that's on the back end. And let's look at, for example, at genetic labs.

All right. So genetic labs obviously have grown tremendously in the last, let's say seven to 10 years. Okay. You look at where things started with PGS and you just follow the natural equation, you know, to where we are today with PGTA, et cetera. And what you'll see is a lot of, you know, networks now, once they reach a certain size, taking on their own genetic labs.

Okay. So in terms of, you know, the responsibility that comes with providing, [00:12:00] let's say, a genetic test, the results. There is an enormous professional liability that you don't have as a care provider, but you do as a genetic lab operator. And so these are the types of considerations that I think people go through and they have to look at, you know, what type of, you know, professional liability insurance do I need to carry outside of my malpractice insurance to perform these types of services.

[00:12:22] Griffin Jones: Okay, so there's a couple different ways, I want to, I want to, I'm making some notes because I want to dive back into risk. I want to talk about controlling the value chain to best ensure the patient experience. I want to, to first start on asking you to steel man the argument that concentrating And on ancillary services, not the best way to increase profit, but that to just focus on patient volume is, whether that's your position or not, I'm just asking you to steel man it.

What's the argument there? 

[00:12:54] Louis Villalba: So one of the most expensive parts of, you know, of any services business is headcount. And the amount of headcount required to provide additional services actually increases your expense level, right? So on the, on one end of the equation, you're going to argue that my top line revenue is going to increase, right?

Because I'm now going to bill out and enjoy the profit that I was outsourcing to a genetic lab, you know, previously. If I manage that responsibility on my own. So the other part is going to be, you know, when you look at any IVF clinic in terms of a network or a well run business, the, you know, the general P and L statements of an IVF clinic are going to range.

And if, you know, unfortunately the low 20 percent when things aren't going well to probably low 40 percent when they're run close to perfectly. Okay. So if that is your range, 20 to 40 percent in terms of your profit, and you're going to reinvest that back into. offering additional services to your patients, you don't have a lot of runway for margin of error.

So if you take on a responsibility, for example, like storage, and you actually go out, you acquire a facility, you make the investment, you actually are bringing on additional risk now because you have an outsourced facility where you're storing some of your most you know, precious, you know, kind of resources of any IVF, you know, network.

And then you are going to manage that on a day to day basis with additional headcount. Okay. On, you know, in terms of managing that responsibility. So those types of risks you manage, obviously in your clinic, one way, when you outsource to a different facility that you're running, okay, that you're eliminating risk, you're actually bringing on additional risk to yourself, but more importantly, you're actually increasing your expense level.

And so that relationship between risk and reward is an important equation. When ancillary services comes up for clinics to consider, because if we said, for example, you know, your revenue per patient's going to increase. If you concentrate, you know, just on the patient experience within your own clinic versus, you know, managing outside services.

I think that's an important distinction any CEO would want to think through as they make a decision on, you know, managing things directly versus outsourcing. 

[00:15:00] Griffin Jones: If the trend of vertical integration really continues and the number of fertility clinic groups that remain unintegrated gets smaller, do they have to have a really strong consumer brand in order to...

Maintain that niche and not be in all of the other verticals. 

[00:15:26] Louis Villalba: Yeah, it's important to think about this. All right. So your, your patient experience is obviously, you know, in the journey is created by so many different interactions, right? It's the interaction from when you walk into when you sit down with, let's say, you know, nurse before you get to the MD.

Or in some cases where embryologists do speak with patients that, you know, they have those types of interactions. You bring in ancillary services and let's say, God forbid, you have a bad experience with a genetic lab. Okay. Where does that brand reputation get hit? Does it get hit on the, on the clinic or does it get hit?

for the genetic lab. If it's an outside service, it's going to go on to the clinic, you know, generally, because that's where the direct patient experiences. And so I think that, you know, the, you know, the, the ability to build a, you know, a strong brand in this space is, you know, encompasses all of those points of interaction.

And so the more that you're obviously, you know, focused on the things that you can do to increase your brand awareness and create a good experience, the better off, you know, your interactions with. Patients are going to be, and that's going to be the strength of your brand. The quality of the people that you partner with is going to be the strength of your brand.

Okay. And I think that's, you know, what will eventually, you know, rise to the surface in this, in this equation, as people, you know, look like in all types of, you know, of businesses. You know, the more points of execution you have in any equation, the higher risk you have, right? And so if you want to bring on, you know, additional, you know, points of execution into your care model, you have to realize that you're going to need the management involved and the expertise involved to execute against, you know, those responsibilities. 

And I think that the attraction of the profit is one part of the equation. The execution of the quality is, is extremely important because that involves safety, which at the end of the day, we're all most focused on. 

[00:17:14] Griffin Jones: Well, let's go to a different industry for a second where safety is less of the concern and it isn't as serious as what.

People do in this field, but we were just in California recently, and I don't eat fast food normally, but every time I'm in California, Lou, I just want In N Out Burger. And, uh, so last time we were at PCRS, and I'm getting In N Out Burger, and I start, I'm really curious about the company, and it's a three billion dollar company, Lou, no franchises.

Owned almost entirely by one woman. Now, granted, she's an heiress, it was her grand grandfather, I think, and then her father and her uncle, and her uncle didn't have heirs, if I remember the story correctly. But, this is a three billion dollar company. No franchises. Highly profitable. I haven't really dug in, but I don't, I don't think a ton of vertical integration.

I think, I think they mostly occupy their spot. Contrast that with McDonald's, let's say. And you know, I think McDonald's might, their parent company owns a bunch of shares of Coke and, you know, and, and, you know, they probably own the distributors or at least some. Parts of the distributors that for their suppliers and they own the potato farms in some cases and, or at least independent contract them like they do.

And, and so who would you, would you rather, would you rather be, would you rather own In N Out burger in that situation, or would you rather be the equivalent level shareholder in terms of capital at McDonald's and why? 

[00:18:44] Louis Villalba: Yeah. Yeah. It's great. It's a great scenario. And I love the in and out story. You know, a long time, California, it's a, it's, it's just a fantastic, I think, you know, example of, but one family that controlled the entire, you know, evolution of that brand starting out, you know, obviously it was a Southern California based business.

They knew they had a high quality product. They have been enticed along the way. You know, you can imagine every year with their growth of someone to come in from a private equity side, acquire this, scale it, you know, nationalize it. And, you know, from that, create it into a worldwide brand. But what they, you know, what they figured out early on was, you know, obviously there's, you know, there's always more than one route to success, right.

And their route to success was going to be about staying as a high quality brand. And so not to say that other brands aren't. High quality, but they definitely have stayed a higher quality brand, which is why they have such a cold following. And whenever they, you know, their distribution centers in terms of where their products go out to the different stores, those have been very geographically selected.

Right? So there're only a certain number of hours on a truck, you know, from the distribution point to actually the point of, you know, service and I. I believe that model in healthcare has some, some similarities, right? So we, first and foremost, we have, you know, we want safety and we want success, right? And success in my mind is quality in this.

And so what we want to continue to do is we want to build obviously points of care that deliver the highest success and the highest safety and the best patient experience possible, right? Everything encompasses into that patient experience. That's why. The patient referral in our business is still by far the most effective referral, no matter how much money, technology, artificial intelligence we spend in trying to control, you know, patient pathway, you know, patient referrals still drive, you know, a majority of a lot of our business.

And we know in terms of the number of diagnosis, you know, versus the number of treatable patients, we've got a lot of room, you know, for continued growth in this, in this business. Quality is, I still, in my opinion, going to be one of the most important things for us to build IVF worldwide in terms of its reputation.

We need to continue to support high quality providers and high quality standards. 

[00:20:54] Sponsor: Why are some third party IVF programs thriving while others are barely getting by? How do fertility centers convert more patients that need third party IVF? Fertility centers face increased competition, making patient retention in third party IVF a challenge.

Issues arise as cycles do not come to fruition. Insufficient review of gestational carriers medical records. Overlooking mental health and legal expertise, causing chaos. Limited staffing, pulling nurses and coordinators away for extra attention. Family Inceptions, with 15 plus years of experience, introduces the Surrogacy Roadmap.

This solution empowers intended parents to review and qualify surrogates, seamlessly prepare for clinic screening, address costs up front, covering compensations, escrow, and insurances, navigate contingencies at every trimester, engage with reproductive professionals and attorneys, prepare comprehensively for pregnancy and postpartum care.

Intended parents pay for Surrogacy Roadmaps. Clinics simply refer their nightmare IVF surrogacy cases to Surrogacy Roadmap. Get your free lesson from surrogacyroadmap.com/for-professionals.
That's surrogacyroadmap.com/for-professionals.

[00:22:22] Griffin Jones: You give very tangible examples of what In N Out does, but also what other people do.

So I think if people do want to maintain that route, that thinking of what those, what those indicators of quality are and truly investing them as necessary, as opposed to just saying, Oh, you know, we've got a good reputation. I don't think, I don't think that's going to come. I think quality has to be a measurable strategy and in that situation, at least I suspect it does.

I want to have you. Dealman, the, the, the case for controlling the, the value chain, but before we do that, is there also a strategy that can be applied if you don't control the value chain that you can pit vendors against each other? Like, I'm thinking of what happened in, what seems to me to have happened in genetics.

Like, you, you have the fertility networks and they're driving down the price, having all the genetics companies compete with each other. And so that seems to me like a cost saving strategy that might, that might not be duplicable If you also own that vertical, or am I missing something? 

[00:23:32] Louis Villalba: No, you're not missing anything.

So, look, there are only, you know, when a patient walks through the, you know, the entrance of a clinic and actually, and arrives for care, you know, call it whatever. There are 30 unique events for you, for example, to drive, you know, revenue on a patient, right? There's a, you know, so there's screening on the front end.

There's, you know, there's diagnosis, there's obviously pharmaceutical treatment, and then you actually get into, you know, obviously, you know, trying to, you know, produce eggs, right? Those sites or, or do a sperm analysis. So then you get into your laboratory process, right? And within your, what we'll call your case rate, all of the, all of the fees that are associated at case rate are, are to cover.

everything to let's say a blastocyst production, and then a transfer, right? A retrieval and a transfer. And so when you take, you know, in terms of the number of steps that are in a case rate, and you say the value that's been assigned, you know, to that, you know, to that case rate, then the only thing you can do on the back end of that is sell additional screening, additional storage, you know, additional services, you know, you know, to patients.

And that in terms of what, you know, the ability for them to kind of increase the revenue per patient, that's where people are, are, are evaluating, evaluating, obviously, where are the options there and under our current, you know, care paradigm today, it's a pretty strict protocol in terms of how you can actually increase revenue in a, within an IVF clinic.

Other people are trying to expand that, you know, let's say that, you know, kind of. care, you know, option, meaning that they're not just going to do reproductive health. They're going to do gynecological services, right? So that gets into well, woman visits that gets into more of a general maintenance of, you know, of, you know, of a female health life.

And that is where they're trying to say, look, we built this infrastructure. We want to drive more, you know, patient volume through this infrastructure. You know, women's health services actually can encompass not just reproductive care. They can also, you know, encompass, you know, gynecologic care. And so that's where I think.

You'll see, you know, in terms of the, the focus continue to evolve. We'll see this now. It hasn't succeeded. People have tried it in the past. Was it too early? Was it not the right design? Was it, you know, and let's say for example, you know, geographically, you know, not, you know, not, you know, kind of aligned in terms of, you know, with patient mindsets.

There's a lot of factors that go into expanding, obviously, you know, patient care. But I think with the level of sophistication that is now coming into IVF, we're going to see some successful models that expand the, you know, the care continuum. 

[00:26:01] Griffin Jones: Is there something to be said about the timing right now that impacts the risk that you started to talk about?

You talked about both legal liability, which we want to talk some more about, but you talked a bit about financial risk. Is there a risk, especially now, of being over leveraged if you're acquiring other companies and other verticals and maybe three years ago it would have been fine because if you started to stretch out your runway you'd just borrow some extra capital at a very low interest rate and now that Interest rates are higher.

It appears that lenders are getting a bit tighter. A couple of the big lenders like Silicon Valley Bank and Signature have gone under. And I suspect that we're going, there's rumors of, of, of a couple, you know, of a bankruptcy or two or a mass layoff or two in the pipeline. When it, when it happens, we'll report on it.

Right now, they're just rumors, but I, I think that some of them will happen because of the climate that we're in. What is, What is the timing that we're in right now due to vertical integration that might otherwise happen in the fertility field? 

[00:27:07] Louis Villalba: Right. So the businesses that, you know, have weaker balance sheets obviously are not in a position to go out and acquire ancillary services or invest in ancillary services because they're obviously, you know, They're financing their current levels, you know, of debt if they, if they have them.

And so that puts them obviously in a more conservative position in terms of looking at, you know, building these types of, you know, of care, this type of service, you know, for their, for their patients. What that does though, is it means the independent providers that obviously specialize in these types of ancillary services, the strength of their business, obviously.

starts to rise to the surface. And then what you'll see in competition, as we've seen, obviously in the genetic screening world, and you'll see in the storage world, you'll see in, you know, and obviously the surrogacy services, not to the same extent, but definitely at some level and egg banks, you'll see, you know, obviously the force of competition, people will negotiate.

You know, the strength and the size of some of these organizations will mean that they're going to pay, you know, they're going to actually save money in terms of, you know, providing these types of services through a third party. And they'll leverage that, you know, to increase their profitability on a per patient basis by not carrying all the expense of actually hiring headcount, investing in technology, all the things that are required to, you know, to deliver these types of ancillary services.

They'll approach it, you know, in the, what I'll say, the good old fashioned way, which is their core competencies is what they'll focus on. They'll outsource the things that aren't, you know, important to their, you know, are central to their core competencies and rely on high quality partners to deliver that level of care.

[00:28:39] Griffin Jones: Our business is trying to improve their cash position right now so that they could, they can still continue a vertical integration strategy, even if capital tightens up. 

[00:28:50] Louis Villalba: Yeah, I would say, you know, you have obviously a lot of private equity buyers that are coming to space and everyone in the private equity world has a, you know, a longer, you can say a shorter or a longer term, you know, strategy, and that's to monetize the assets that they've required.

Right? So the way that you monetize, obviously, is you have the balance sheet. You know, be as strong as possible. And then you're either going to go to the public equity markets or you're going to roll them up and sell them and a bigger, you know, to a bigger consortium that has a longer term vision. I think some of the big players in this space that have come in have a longer term view.

Okay. I think a lot of the initial private equity that we attracted and that the reproductive health actually is experienced in the last, you know, we'll call it three years is a shorter term view. It's something in that three to five year time horizon. I think the bigger players actually look at things in a 10 year time horizon.

They're not as, you know, reactive to market conditions like we see today, where some of the, you know, the, we'll say the smaller players, you know, they have to return on the funds that they've committed and they actually have to show, you know, obviously returns to the shareholders that they're providing for.

So this will benefit us, I think over time as we mature and we get in longer term, you know, relationships with bigger providers that have long, you know, longer term views. 

[00:30:03] Griffin Jones: Whether the strategy and the outlook is long term or short term, the strength of a balance sheet is still somewhat relative, isn't it?

Relative to if, if, if there's money that can be easily borrowed or, or. Received some other way versus it looks like things are tight. Not only are capital markets tight, but also our AR is starting to age out more. It was at 45 and now it's at 60 or now it's closer to 90. And so, so what is like, what is the strength of a balance sheet have to look like nowadays?

[00:30:38] Louis Villalba: Yeah. So I think, you know, in a, in a services model where you see, again, these, you know, these kind of general, you know, returns, you know, in a high quality, you know, IVF clinic, you'll see, you know, you know, close to kind of a, a low forties in terms of gross margin. Okay. And then let's say in an underperformer, you can see something as low as, you know, as 20%.

So if you think in terms of that's your gross margin and what you have to invest in and what type of investment you're going to attract into a business like that. People are going to want to see, obviously, they're going to want to see that your balance sheet is improving over time, that you have growth in terms of, you know, the services that you're providing.

So we, you know, we have a lot of what I'll call the central, you know, checkpoints that can, you know, acquire and attract investors into the space. What a lot of it kind of comes down to is now what is the management skill set to execute and show improvement in terms of the profitability of these businesses over time.

And so that strength actually has to come through and, and, you know, what we'll call higher quality, you know, performance and that performance now is, is, is starting to be looked at, you know, under a different lens because you have seasoned investors that actually. you know, hold these, you know, groups, obviously accountable to the, you know, to delivering the results that they expect.

Now, that's not always an attractive, you know, comment within healthcare. And I completely understand the reality is, you know, medicine is a business. Okay. Our, of course, our job is to provide the highest quality of care. And one would argue if we provide high quality care, the business will sort itself out.

And I think that's very accurate because if we're doing the, you know, the right thing in terms for the patient, we're going to this market. And there's plenty of growth. Plenty of greenfield in front of this space for everyone to appreciate, you know, in the years, in the years to come.

[00:32:20] Griffin Jones: So you talked a bit about the risk liability and one example that you gave was, well, if you're in just in the clinical vertical, for example, you have your malpractice liability, but then if you go into a lab vertical, a storage vertical, there's other liability that you have.

What other examples are there in terms of legal? risks that people need to consider when they're moving into other verticals. 

[00:32:48] Louis Villalba: Yeah. So, so kind of the two categories fall between professional liability. Okay. And personal liability. Right. And so professional liability, you're an MD or an embryologist, you have a, you know, you have your normal set of standards that you perform, you know, on a, or steps you perform on a day to day basis.

So those are covered generally your malpractice policies. And because, you know, that that's what's designed to cover. that part of your day to day job. When you start to, you know, expand the types of services that you offer, for example, something in genetics, you start to actually take on, you know, providing a result, right?

And a result that people are going to continue to, you know, make clinical evaluations against and make more importantly care decisions against, right? And so when you look, for example, at the accuracy of the test results that you provide, obviously, you know, if they're the lower the, you know, the accuracy, the more risk there is in terms of the type of guidance you provide.

You obviously include all types of fair balance statements saying something's 97, 98 percent successful or predictable, but guess what? That still leaves you a little bit of a window, you know, of risk there. All right. And so that isn't risk that if you are outsourcing, you carry, you carry it from a malpractice standpoint.

Okay. But you don't carry it, you know, directly as a professional liability perspective. And those are the types of, you know, important, you know, considerations that. Any network or any clinic needs to think through if they want to expand, you know, into ancillary services, you know, for example, in storage, you know, if you actually have, you know, let's say, for example, you know, 10, 000 patients on one site that you're storing from a legacy inventory, and you have some type of tank failure, which unfortunately happens from time to time, where does that risk fall?

If it's in, you know, if you're providing. That service on your own versus outsource. The answer is it falls everywhere, but it's going to fall to one side more. Okay. If you're actually, you know, so to speak, holding the bag on that, you know, directly, and that is, you know, that's an important consideration, I think, as people get into this and some of the sophisticated buyers now are obviously forcing, you know, some of these networks to actually look outside, you know, to use third party services, you know, for these, you know, these ancillary steps that are involved in the business.

[00:34:59] Griffin Jones: You're making me think of the recent Chart, Inc. settlements. So, Chart, Inc. was, I believe, the manufacturer of the tanks at Pacific Fertility Center. I don't know if they also were for the Cleveland Clinic as well, but, you know, so, I think patients sued Pacific Fertility Center, Pacific Fertility Center sued Chart, I think patients sued Chart directly, then Chart.

Went and I believe one of their suppliers was Extron and so they're, they're suing Extron. So either that doesn't get to happen if you're vertically integrated because you're just being sued at all of those points. Or, or is it like the McDonald's example where it's like that one little vendor that, because they're not, no one's vertically integrated and absolutely.

Everything, right? Like even Amazon still buys some things from other people. And so does that, if you're in that type of situation, does that put someone in a position where it's like, okay, this is how the, you know, it was 90 percent through our different verticals and maybe 10 percent through this supplier that we have, but we're going to squash this supplier in a legal battle and make it seem like it was 50 percent their liability.

Is that something we might expect to see? 

[00:36:10] Louis Villalba: I think, you know, the trial lawyers are always, you know, you know, very focused on going towards the deepest pockets wherever they're, they're positioned. So if there is a path to, you know, get into that party in the equation, they will find it and they'll, they'll naturally end up there.

You know, you bring up a good example in terms of the equation that's involved, like for any finished product, there are, you know, generally a consortium of, you know, of, you know, just different providers that, you know, all, you know, have their contributions to a finished product. The quality piece that comes out in the back end of that in terms of who is responsible for checking that, managing that, those are always a central point of where most of the liability is probably going to, you know, fall on the shoulders of, but that's, you know, that in terms of a physician's office or an IVF clinic is, you know, is why it's, there's so much risk for them in this type of ancillary service.

And so I think what, you know, for example, what we learned in the Pacific fertility case is that, you know, not only did we, you know, we have, you know, a long list of people that are, are going to be, you know, kind of subpoenaed in this, we also learned another important thing that the technology that's involved today.

They're that was involved in at that point was completely inadequate in terms of identifying the problem, right? The alarm systems that set up now are set up to be reactive. They're not set up to be predictive and where we need to shift in these types of ancillary services where I think most of the providers are currently doing this.

is they actually have things that predict, they monitor things like LN2 consumption, they monitor oxygen, they monitor temperature, they remote access into these systems because they watch them 24 7. And that's the type of focus that we need to improve the quality within reproductive health because that's the trust that patients are putting in us in terms of building, you know, this, you know, uh, obviously service into something that's extremely, you know, high quality.

[00:37:59] Griffin Jones: Well then let's shift to that quality argument about controlling the value chain. So we've gone through the cons of integration and the potential risks and the pros to perhaps just focusing on patient volume or focusing on one piece of the vertical as opposed to integrating. Now let's talk about the pros and steelman that argument.

If controlling the value chain ends up appearing to be totally necessary in the next five to ten years, why might that be? 

[00:38:26] Louis Villalba: So I think, you know, there's every business has what we'll call a sweet spot, just in terms of the, you know, the amount of, let's say, kind of strategy, technology, headcount investment that you have into a business, that investment's actually going to help you, let's say, for example, maximize your quality, maximize your return on investment.

Figuring out where that intersection is in every business is, you know, is a critical part. And I think that, you know, if you look in terms of the healthcare services model that we're involved in, you think of the number of headcount that's involved within an IVF clinic, you can think about, you know, the administration side, think about the lab, you know, in terms of embryologists, technicians, et cetera, think on the MD side.

And then as you add different ancillary services, They're going to have to add headcount to manage those responsibilities. So, you know, there's a volume that at a certain point, it's going to make sense. Right. And then there's an argument that says until you reach that volume, or if you have to increase your headcount to a point because the volume is so large, then, you know, you have to ask yourself.

I have buying power. Am I better off doing this and managing this internally under my own roof? Or am I better off negotiating a very competitive deal with a high quality provider? And that's the trend that's in front of us. And that's what I think we'll see, you know, in the next two to five years, we'll see this.

And we see the negotiations right now. There's, you know, discussions underway at this point for all the networks to actually band together. to have, you know, competitive purchasing agreements with some of the major providers of this space. So it's naturally occurring. I think it's just part of the maturity of reproductive health.

And we'll continue to see this evolve. I believe strongly over the next few years. 

[00:40:00] Griffin Jones: What about those vertical integrators that seem to have no sweet spot? You said there's a sweet spot that makes sense because it has got, but then you look at like Tesla and it's like, man, he's buying. Everything. You look at Amazon, it's okay.

Now they got the cloud services. Oh, and they have Whole Foods. They've got that distri distribution. Now they're in content creation so that their products are everywhere. So that you're not leaving Amazon, you're, or you're not going to Netflix, you're not leaving Amazon. You're staying, you're watching your videos in Prime, buying your products in Prime.

Oh. by the Washington Post, too, just because, you know, it can't hurt to, it can't hurt to be in D. C. when you're playing at this level. And so it seems so I know those are like the top of the top examples. But do you how likely is it that we'll see someone in the fertility field that doesn't seem to have that sweet spot?

They're like, we're going to be in absolutely everything that touches the patient. 

[00:40:58] Louis Villalba: So, you know, I, you know, there's so much execution, right. And the examples that you just provided. So for example, on Amazon, we look at where Amazon started and, you know, the argument was, it's never going to be a profitable company.

You can remember that, you know, for many, many years. Right. But what, what did they do? They continued to grow their top line and they can. Tended to consolidate, you know, against their original foundation in a step-by-step fashion, right? They didn't grow into the company. They are today, just overnight to several years and several years of high quality acquisitions, several years of high quality management of a business.

And it built a brand, a brand that people trust. And so, you know, how do they control the American, you know, the worldwide consumers buying behavior. Now they're seen as a high quality provider and they have a trusted brand, right? So I think same thing applies to Tesla in a big way, right? They were, you know.

You know, pioneers in the EV market, but they also had a premium brand to begin with, right? Who didn't aspire to have a Tesla, you know, let's say back in like the 2007 to 2010 range, when they were more scarce right now, that's a common brand. People see it around, they see it everywhere and it, you know, and they've created different price points to bring different levels of the market in.

And what are we continuing to see in terms of reproductive healthcare? Some will argue that obviously like, for example, in the U S we have, you know, we, in terms of cost of treatment, we've created a market that only, you know, treats a certain segment of the market. And so we have other entities that have come in, for example, like a kind body that say, our mission is to create, you know, is to improve access to care.

We want to do things at a lower price point. We have these efforts now to go directly to the employers, to the progenies of the world, right. to manage the cost associated, you know, with treatment. So we can encourage, you know, companies to invest more in reproductive, you know, reproductive healthcare and treatment.

And so all of these things I think are, are growing, you know, our industry right in front of our eyes in terms of who's going to consolidate them and who's going to maximize. I think you look to some of, you know, the recent acquisitions that have, you know, have taken place when you attract the names of like a KKR, their longterm view.

Obviously has a long term strategy. And if you look at the brands that they're buying, I would, you know, I think one could argue there are some higher, high quality brands. So I would look, you know, at those types of buyers to see who's going to kind of set the, you know, the strategy for what pieces are going to be rolled up and at what time, because.

there's, there's a lot of consolidation still in front of us, but you know, the foundation in terms of the number of clinics that we have that are available today to treat patients, I believe that number is going to continue to increase over the next few years. 

[00:43:28] Griffin Jones: So we might see it from the behemoths that are coming in like KKR and maybe BlackRock will too and some others are who, who, who do you suspect is in the lead right now?

So, you know, you mentioned us fertility, we'll see what, what. They, they end up doing, it's, I might guess kind body, you know, from just what I can see in terms of they got clinics. I don't know if they still do the mobile testing, but they had that. They've got the employer benefit carve out. They've since gone into a third party.

I believe they acquired a gestational carrier agency. The one is escaping me right now, but so, and, and I think they expanded EOS when they bought VIO. So they're, they're more in a third party. So I might guess them who's, who's. Charging ahead. And who are the front runners right now? 

[00:44:14] Louis Villalba: Well, if you look in terms of volume size cycles and who has control right now, it's, you know, us fertility control is obviously a majority of the market from that perspective.

You start to go down the list from there. And I think there's some arguments that if it's a five horse race and you have one that's in the lead right now. Horses between number two and number five, if they consolidate together, you're going to have more of an equal parity in terms of volume and size.

And I expect that those are the next moves that we'll see in front of us. Okay. I mean, you look at groups like Pentacle that, you know, have been high growth in terms of the number of acquisitions that they've made over the last few years now with valuations actually coming down to a more respectable level and a more competitive level.

I think that the ones with the strong balance sheets, we're going to see them continue to accelerate their acquisition strategies. Over the next 12 to 18 months, because prices are more competitive than they were, you know, just 12 months ago. And in terms of, you know, what shifts in the business strategies for some of these networks, I think that there's a tremendous amount of evaluation going on right now about what is the next natural extension for their care paradigm.

to add, you know, to offer to this patient group. And I think that, you know, we have success rates, obviously, that are, you know, continuing to improve year over year. Some might argue that our live birth rates aren't, you know, accelerating. This is a complicated field to succeed in. I think everyone knows that, but I think in terms of like the number of blastocyst embryos that we're producing on a day to day basis, I, you know, those percentages, you cannot argue it.

They've improved dramatically. Okay. There's a lot that goes into that, but you know, starting with the blastocyst embryo is obviously a great place to start in terms of long term success for reproductive healthcare. So I think we'll, we'll continue to see, you know, that the trust and the quality of the market improves year over year, which will be a natural, you know, extension to bring in more people in for treatment.

[00:46:05] Griffin Jones: Is this integration necessary in order to actually be able to implement a lot of the innovations that are happening because I see all these solutions coming in and some of them are probably they're not going to win their duds and they maybe just be features but some of them seem it's like oh I can really tell I can see the value in that but they're still having a hard time gaining adoption for whatever reason, and often it just has to do with the variance of workflow.

So even if you have an MSO, you've often pasted those different clinics together. They've got different workflows and often it's, it's just not the same as like I, I had the CEO of Indira IVF from India and he said, I hired 250 Uh, OBGYN physicians, I train them on fertility, meaning my company does, and I make sure they're all younger than me.

So they all do the same thing. And so it's a lot easier to implement a lot of some of these scale innovations and the workflow, the variance and workflow is one of the things that, that seems to hamper is, is this vertical integration necessary in order to be able to, to get things in? Because there's a lot of.

things. It's like, man, you really do automate. You really do reduce that level of work that people have. But in order to implement it, it's an add on for, for where people don't have capacity. So is, is this necessary in order to be able to implement the rest of the innovations? 

[00:47:31] Louis Villalba: Yeah. So, you know, I think that if we think in terms of the, you know, the meeting that we attended out in Napa together, the, one of the great debates is around, you know, I practice evidence based medicine.

Okay. And so everyone's looking for evidence in terms of how they make decisions. And then I think what's equally there for a lot of people are people who are looking at the cost of, you know, the different decisions that they make. Okay. And so in terms of looking at AI technologies and where they are today, if you went to someone and said, I'm going to give you higher quality information.

Do you think you're going to be able to have a better chance of success? Okay. I did. Short answer is going to be yes. Right. Because people are qualified and you know, part of the decisions that they make are based on the information they have. So you know, this whole, you know, great debate on what, how much data you need to obviously, you know, kind of make, let's say a clinical decision.

I think kids is a very important part of this equation and the value of that data that you provide is what people are obviously thirsty for and they're thirsty, you know, for an advantage. Right. Right. So you'll see. you know, some people obviously get on the front end of the equation in terms of, you know, of, of acquiring, let's say a technology before the middle of the market will adopt something.

Right. And so the early adopters, like if you look at an AI, you look at time lapse imaging, you look at single step media. I mean, you know, there are a lot of markers that you can look at, but the, you know, I think one of the more interesting things that, you know, from a behavior standpoint. is, you know, you are not going to get what's called a standard of care where you're treating 51 percent of the addressable market with anything in a short period of time.

It's just, there are so many, you know, and factors involved with changing people's behavior around different things. And they can be business related. They can be behavior related. They can be control related in terms of you're on a network and your protocols get set and you're going to follow those.

Which, you know, in the Indira equation, you know, they're doing a great job of setting a standard that they want their, you know, their groups to follow. I think the hardest thing to do in medicine is change behavior in terms of if you want to try and do it fast, because the faster, you know, you push. the harder that they resist.

And that's just the natural, you know, kind of ebb and flow of our market. I do think, you know, um, from a society standpoint, we're continuing to set practice guidelines around very, you know, very important things with innovation and how you present and offer those early innovations to patients. If people see things as an advantage, you know, certain groups are always going to, you know, obviously maximize that they'll take advantage of it.

Then certain patients are going to be attracted to it. Okay. And if it's gone through [00:50:00] a regulatory process, which in most, you know, aspects it has, because if people are making clinical decisions, they've had to take it through an FDA clearance, they've had to take it through, you know, some type of, you know, it has to adhere to CLIA lab regulations, something of that nature where things get.

you know, unfortunately inconsistent is if they don't have to follow those types of controls, then one could have an argument about, Hey, how did you, you know, get to offer this to patients? Right. Because if we look, you know, in terms of today's, so let's say for example, you know, of the 450 plus clinics we have in the U S Most of them, you know, probably are doing things, you know, that don't have a lot of FDA clearance because they weren't required to do that.

Right. They have CLIA lab regulations, but, you know, on a day to day basis, they've created their own SOPs, their fine running labs, and they adhere to those types of controls. 

[00:50:48] Griffin Jones: If this happens and someone is kind of driving it at the vertical level, I'm just picking on KineBody, I'm not saying it's them, but Gino has of course said that vertical integration is part of their thesis and touching all the parts of the value chain is part of their thesis, and so let's just say it's them and they, you know, And.

own EMR, own pharmacy, own everything for those that don't, does that force them to, even though they're not integrating as businesses, they have to have more in integrative features that so that does it force the pharmacies that are left, the EMRs that are left, the scheduling softwares, et cetera, that are left to have to communicate with each other in order to, and have more interoperative functionality because otherwise it would, it seems to me like it would be a cheetah against a.

[00:51:43] Louis Villalba: Yeah. Right. So there was definitely a, um, a level of efficiency with automation, right. And offering a complete, let's say, you know, offering in terms of, you know, from pharmaceutical through, you know, let's say delivery of a, you know, of a healthy, happy baby. And so if that is in terms of your longer term, you know, care strategy, the pressure on the business is to.

Did you know, is to demonstrate that they can manage that at a, in a cost effective way, right? So there's a rush to control all these different steps. What we haven't seen yet is the importance, you know, kind of, you know, output on the back end, is it more cost effective or your outcomes better, you know, all of the things that are generally going to drive, you know, longer term investment, longer term strategy.

I think it's a natural maturity cycle that we're going through, you know, as an industry, and I think it's the right normal thing to do. I think the question will become, all right, so what are the most important, you know, steps in my business? What steps do I need to control to provide the best experience for my patients, meaning, you know, and hopefully delivering healthy, happy babies and what's really rolled up into that.

Okay. And, you know, and that's, you know, that is, I think left to be determined just in, you know, in terms of where we are, you know, as an industry, but I think that it will be highly competitive for the next several years as the great race, you know, kind of continues for that, that type of control. 

[00:53:03] Griffin Jones: Do you think that we'll start to see more backward integration, so forward integration, meaning I'm, I'm a fertility clinic and then maybe I acquire, you know, an OBGYN or, or some sort of referral source, I'm getting closer to the end patient and backward being go, go back to the raw material, you could go all the way as far back to the raw materials, but just in that direction, whether you go that far back or not.

Will we see more backward integration? 

[00:53:35] Louis Villalba: I definitely think we will. There will be some groups that will look, you know, in terms of the, of the backward review lens mirror, and they'll, they'll go, they'll probably be ones that I think. As we naturally go through this process and we see where success is on the front end, they'll look at, you know, what can the back end of the equation be?

And does that give me any, you know, strategic advantage over those that are offering, you know, things on the front end? If you can contract with the patient up front, Then you control the pathway in terms that they follow, right? And that's what some of the benefit providers have done a masterful job of, okay?

They, they have, you know, in terms of the patient, their points of care, if they're going to be established to their network, then from a competitive standpoint, you're then, you know, you've plugged them into your equation, right? You have to naturally manage them through the process, but you have control at that point.

[00:54:25] Griffin Jones: Will we see tomorrow buying a fertility clinic network, will we see tomorrow buying a Hamilton Thorne or... 

[00:54:31] Louis Villalba: No. So at this stage, you know, I think, and I, you know, if anything, I've learned in 30 years of business, you know, try to do, you know, do one thing, do it well. Okay. And be the best at it. Right. And that sounds, you know, cavalier, but it's the honest to God truth.

It's, you know, we obviously built a technology platform or the only company that wrote It's own, you know, operating program. I'd be F. O. S. It's proprietary to tomorrow. The first step was to automate, obviously the storage component of the business and bring as much digital, you know, kind of chain of custody, you know, protection to that side of the business as possible.

We're obviously in the midst of. You know, of launching this in the U. S. Now, and what's quite interesting is normally when you launch new technology networks aren't generally the first adopters, they have bigger operations and they're generally you succeed with them later in an equation. But for tomorrow, it's been the it's it's inverse.

It's the opposite. And so the obvious question is why? And I think that there's more of a strategy to manage the risk side of this business from a higher level. And they see obviously also from their buyer standpoint that they need better digital chains of custody and better you. You know, trace traceability more importantly in this side of the equation and who's got the best platform to do that.

Obviously, tomorrow's got, you know, very established FDA cleared system. And so that's been the natural pathway that we'll follow. And I think that automation in the, you know, in the lab, it's definitely a path that will continue to go upstream with. We think that there's a lot of ways to, you know, to obviously improve, you know, the day to day lives of, of laboratories.

And we're. Concentrated on going upstream to deliver that we have our partner and conceivable. Obviously our founders from tomorrow, they're creating another lab automated company that will probably, you know, be a nice, you know, development house for tomorrow, you know, based services and products in the future as they continue to innovate on that side.

[00:56:17] Griffin Jones: Do you think it's inevitable for those behemoths that we were talking about before, like if you're KKR and you're picking up your EVRMA for three and a half billion or whatever, I don't remember how much it was at that time, but, and you see it working, it seems like if you really believe in assisted reproductive technology as part of your thesis and that company is profitable in your portfolio to me, then it seems like, yeah, let's go out and get a storage company.

Let's go out and get, let's get progeny. Well, it would be hard to take progeny off of the market, but let's, let's buy a, if not Hamilton Thorne, at least try to get them to sell us one of their brands. Is it, is it inevitable to see backward integration with the behemoths coming in? 

[00:57:01] Louis Villalba: Yeah. So consolidation is, you know, is obviously part of the world.

I think, you know, to run a medical device company versus to run a healthcare services company are very different, you know, kind of management skills. And it's obviously they fit under the same therapeutic area, but they have very different business models and there's usually very different skill sets that succeed in managing those types of businesses.

I think that, you know, what we see in a lot of other industries and within medicine is you see people, you know, consolidate where it naturally fits. And then you see them obviously partner where it doesn't naturally fit. And I think the naturally fit part is where our space is still going through the evaluation of what really fits under, let's say, a healthcare services model and what really fits under a medical device or a pharmaceutical model.

And that's where, you know, that's just, you know, kind of the natural growth that we see in terms of reproductive health. I think it's the right focus. And more importantly, I think what it will do is it'll help deliver high quality care. And we'll continue to attract, you know, obviously the trust of more people based on the higher quality of care that we'll provide.

I think that, you know, for example, the, you know, the Hamilton Thorns of the world, they, you know, there's continued demand for them to innovate, bring more technology to the market. I think the partnerships between industry and healthcare services. You'll see, for example, innovation funds of a lot of the large networks now, like U.

S. Fertility, Pentacle, for example, they're all going to have their own types of innovation funds, and they're going to make investments into the technologies in the early stages that they see will benefit their day to day care, you know, management. And so that, that's, I think, what's been lacking in the past, and we'll see that as a very, you know, important component of the future, you know, of care and IVF.

[00:58:41] Griffin Jones: You're not a lawyer, but I want you to speculate a bit because all of this begs the question of when we might start to see antitrust regulators come in. Do you know of, can you speak to any red flags of when, when they would come in and how likely it might be? 

[00:58:56] Louis Villalba: Yeah. So look, I think that we saw our first signal of antitrust in this space when Cooper, you know, was focused on acquiring the assets of Cook for the women's health business.

And antitrust, you know, obviously, as they mentioned in their, in their public disclosures, they had some reviews that they had to, you know, they had to go through. They just made an announcement in their last quarterly hearings that they're no longer pursuing that, you know, that acquisition. So I think that that is the first signal in terms of we have the attention of the regulators in this space.

All right. And ones would argue that now, you know, over 50 percent of IVF cycles are now controlled by IVF networks. Okay. So we reached, let's say a milestone that, you know, people are going to start to pay attention in terms of the consolidation of clinics. You know, there, it does seem that there's general momentum in those directions.

So you know, I'm not going to, you know, speculate that I know anything more than that. I could point to Australia as an example. So Australia actually. As a competition authority got involved, I think close to seven years ago when they reached a 50 percent kind of milestone in their market comparably. And they basically, you know, have not allowed, let's say the big three to consolidate any more of the market to protect, you know, some independent, you know, offerings.

So I think it's, you know, we are starting as again, as young industry, we're starting to lobby a lot more. And I think we're starting to help, you know, a lot of edgy, you know, kind of. You know, different government officials understand the importance of reproductive health care. We obviously have declining fertility rates in this country and every major G7 country for that matter.

So the, you know, the importance of actually supporting reproductive health care can probably never be more important. All right. So what do we do with that as an industry and as a specialty in terms of how we, you know, utilize that momentum within Washington to support, you know, the continued expansion of this service.

[01:00:37] Griffin Jones: Lou, I didn't, I deliberately didn't even go too deeply into the, the five core pillars of the ancillary services, the safety and technology stores, own labs, the egg banks, the surrogacy services, because I want to have you back on. I wanted to use this episode as painting the picture of, of what's going on in vertical integration.

I would love to have you back on in the fall to go more deeply into these. And unlike the director of the hangover movies, my sequels are always better. Lou, Lou Villalba, current CEO of Tomorrow, and congratulations on that new post, by the way. Thank you so much for coming on the Inside Reproductive Health podcast.

[01:01:16] Louis Villalba: Thank you, Griffin. It's a joy to be with you and appreciate the kind remarks. Thanks very much. 

[01:01:22] Sponsor: This episode was brought to you by Surrogacy Roadmap, a self led educational course created by Family Inceptions. Guide your patients to Surrogacy Roadmap for all independent journeys. Get your free lesson from surrogacyroadmap.com/for-professionals. That's surrogacyroadmap.com/for-professionals. Today's advertiser helped make the production and delivery of this episode possible for free to you, but the themes expressed by the guests do not necessarily reflect the fuse of inside reproductive health, nor of the advertiser.

Announcer: The advertiser does not have editorial control over the content of this episode, and the guest appearance is not an endorsement of the advertiser. Thank you for listening to Inside Reproductive Health.

190 Letter of Intent: How to build the foundation for selling and buying a fertility clinic. Richard Groberg and Jay Stucki

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


Gain expert insights and invaluable advice on navigating the sale of your fertility practice with special emphasis on that crucial document - the Letter of Intent. Richard Groberg, a seasoned financial expert and Jay Stucki, an experienced corporate attorney, share insights from the sell side perspective and zoom in on the details that matter most.

  • Discover the major points addressed in the Letter of Intent that serves as the foundation for buying or selling a company.

  • Delve into comprehensive coverage of key elements in the LOI including:

    • Insurance

    • Non-competes

    • Governance

    • Equity

    • Evaluation multiples (based on adjusted EBITDA)

    • Profitability conversion

  • Acquire valuable knowledge into the process and timeline of finalizing the LOI and next steps to completing the transaction.


Jay Stucki:
Stucki Legal, PLLC
LinkedIn

Richard Groberg:
LinkedIn

Transcript

Jay Stucki  00:00

I think one to start with, they don't understand the 30,000 foot view of how important the loi, or the letter of intent can be. That is the roadmap. And unless you know where you're going, and you've been there, is it hard for generic LOI?


Sponsor  00:18

This episode was brought to you by bundle, you may be able to receive a free list of financially qualified IVF patients across the US and Canada. Email Courtney at cbarrett@bundlefertility.com. That's cbarrett@bundlfertility.com. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of inside reproductive health. Nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guests appearance is not an endorsement of the advertiser.

Griffin Jones  00:59

Are you serious? Are you serious about buying my fertility practice? We'll find out from the letter of intent. That's the topic that I zoom in with my experts today. Richard Groberg and J. Stucki, Richard, you know, because he's a financial expert who's been on the show multiple times, and he's given plenty of advice on what you need to consider when selling your fertility company. Jay Stucki has also represented fertility companies on both the buy side and the sell side, or at least he's represented companies on both side perhaps fertility was just sell so I didn't get into that specific but today we talk from the sell side perspective. She's a corporate attorney whose careers focused on estate planning, asset protection, real estate transactions acquisitions, in medical and in software for decades. And today with Richard and Jay, I decided to get very specific on the letter of intent. The loi is what they call the roadmap or the foundation for buying or selling and company. They talk about the major points of an LOI, what happens to your malpractice insurance, the noncompetes post closing governance, rollover equity, equity and apparent company working capital like how much cash and accounts receivable you need to leave in the business for how long controlling documents like medical direction assignment of membership interest, joint operating agreements, irrevocable proxies, employment agreements MSA agreements, your valuation multiple based on adjusted EBITDA converting your profitability if it's based on cash, accounting, or cruel accounting, what needs to be talked about in the three to six meetings that happened before signing an LOI? What happens in the very early stages signing your NDA what happens between them and how the letter of intent is finalized? Any one of those subtopics could be its own topic on the show. I'm sure I'll have them back on to discuss because of so many of you are at this stage and you want to get this right. Enjoy this conversation with Richard Groberg and Jay Stucki about constructing your letter of intent. Oh, and I probably have to give you a disclaimer. This is not legal advice. I'm not an attorney, adjacent attorney, but it's not legal advice, simply insights for your informational use only. Mr. Groberg. Richard, Welcome back to Inside Reproductive Health yet again. Mr. Stucki. Jay, welcome to Inside Reproductive Health.



Jay Stucki  00:59

Thank you, glad to be participating today.



Griffin Jones  00:59

Richard, the audience is a little bit familiar with you at this point. You have been on the show a couple of times. And you're also quoted from our journalists when they are doing articles about some of the business dealings happening in the field. Jay, you are a corporate attorney? Are you mostly Is it mostly sell side that you represent? Are you sell side and buy side equally?


Jay Stucki  03:40

No, I wouldn't say equally, probably mostly sell side. But I've been on both sides of the table. So I've got a depth of knowledge level from each perspective. And I've also worked for practice management companies. So I get the physician side, I've had to represent many physicians and getting them out of bad contracts. So I think I kind of bring up a bit of expertise to the layers that most attorneys won't see.



Griffin Jones  04:14

One sub topic that was popular that we covered with Richard was talking about mistakes that Fertility Centers often make when they're selling with regard to accounting, things that are categorized as business expenses that shouldn't be and that impacts their EBITDA. What are some of the common mistakes that you're seeing from a legal perspective when people are going to sell their fertility company?



Jay Stucki  04:38

I think one to start with, they don't understand the 30,000 foot view of how important the LOI or the letter of intent can be. That is the roadmap and unless you know where you're going and you've been there is a bit hard for generic LOI. I you know, I like in the the legal side of things, you know, if you, if you're a couple and you want to get pregnant, you're not going to rely solely on your GP or internal medicine, you're going to want to go to a reproductive endocrinologist, you need that specialty. And it's the same thing in law, you need someone who knows both sides of the table to really hone in, I think Richard could probably give you a couple examples of allies that were vague from the start, because they didn't understand the full process of where this needed to go at the end of the day, how to protect the physicians, and yet make it a deal that works for both the acquiring entity and the seller.



Griffin Jones  05:44

What are a couple of those examples? Richard, do you have any LOIs being too vague from the start?


Richard Groberg  05:52

Yes, I've seen a couple recently that were negotiated by people other than me, when a couple of examples, most of these transactions talk about the fact that the valuation will be a multiple of what's called an adjusted EBITDA, which adds back and subtracts for certain adjustments. But if the language is unclear that that includes converting the sellers profitability from a cash basis accounting to an accrual basis accounting, they can wake up a month or two months down the road. And their adjusted EBITDA is significantly different than what they thought it was. And it can cause problems. The other issue I've seen recently, is where the seller also owns real estate that's used by the practice. And if it's not clarified, that the post closing lease rate will be based on some combination of the current rate and an independent appraisal, then, and that's that final number could affect the EBITDA and the valuation and the purchase price. It can cause problems later on down the road. Jay will talk about other issues in terms of duration of non competes, and the various different non competes. And what happens to rollover equity in the practice or in the corporate group acquiring if a doctor leaves early or is fired for cause. But those kinds of things, especially when Jay and I are working together representing a seller, we work very hard to make sure that the major issues have very clearly negotiated will define so that we don't get down the road and then have problems a month, two months later, when everyone spent a lot of money on accountants and lawyers and other advisers.



Jay Stucki  07:45

And let me just add to that, that, you know, you're you're trying to look at the entire structure, I can't tell you how many LOIs, I've been handed, and it was going to be a stock purchase agreement or an asset purchase agreement. And because of the structure because of rollover and contribution, tax considerations, it ends up getting flipped, and we end up with a completely different structure. So it it's more than just, you know, understanding noncompete or the quality of earnings. It's the LOI really has to look deeper into how the sellers were organized formed tax consequences, how long they've had ownership, short term, capital gains versus long term capital gains, estate planning issues, especially if there's a rollover component.


Griffin Jones  08:38

Why is this those and maybe it'll just enlighten my own ignorance. But to me, that the LOI was simply the the letter that says, you know, we're going to do our due diligence, we're going to explore a deal, but it sounds like more of the terms of the deal need to be established in the loi, where I would have thought, well, you know, if the if the valuation multiple needs to be adjusted in a better based on adjusted EBITDA and that might change, that that would just happen in the deal doesn't necessarily happen. And in the LOI, why does this stuff need to happen in the LOI?



Jay Stucki  09:16

Well, the LOI can't be as detailed as the definitive documents, obviously. And as the saying goes, the devils in the details. And so when you get into negotiations, and you're trying to explain the pros and cons of certain language or certain concepts, it seems to always harken back to well, that's not what we were told when we were being courted. And so it's very helpful that even though the LOI is probably only going to be a few pages long to be able to go back and use that as a tool for refreshing the memory of what was being said during the courting and, and I've watched effect I've used Richard to be able to go back and say, Richard, you were involved in this LOI and negotiating upfront, what was the understanding? And then you get all the parties together. And you walk through, yes, that's what was said, oh, shoot, okay. And just because the buyer said something, it doesn't mean it translated over to the attorneys. So you kind of have to get the attorneys back on track to be in line with what was negotiated under the LOI.



Richard Groberg  10:32

If and if I can amplify that, Griffin. At least in the transactions, I've worked in the sellers, this is a one time thing, they've built their practice, they've operated for a number of years, for various reasons, they're ready to sell it a partner with a PD back group, they vet two or three, or perhaps more potential sellers, they've made a decision, it's like, This is who I'm gonna marry. Because it's not like selling a piece of real estate where you sell and walk away. And when the LOI is signed, both sides start spending a lot of money. It's a time consuming, painful process. And you want to, again, there's a balancing act, if you negotiate every possible thing, you have a 200 page document in the loi, which you can't do, but you want to lock down enough of the major points, some of which are very subtle. I'll give you another example. If one of the buyers has their own malpractice carrier, and everybody has to switch, and they're requiring the seller to have to make the switch and by a tail policy. Well, that affects the economics of the deal. And if one of the sellers is ready for retirement, that could affect the structure. So as much of that, that says very significant could be at least buttoned down enough that when we get down the road, the lawyers could say, hey, Richard, while you were there, what Jay said, what was it that the parties discussed and agreed to? It helps lock in the major points.



Griffin Jones  12:04

Let's talk about those major points. You mentioned malpractice and the potential for needing tail policy. You talked about the valuation multiple and adjusted EBITDA or the potential for converting sellers profitability based on cash basis accounting or accrual based accounting. What are the major points that need to go in to a letter of intent?



Richard Groberg  12:28

I'll give a quick answer. And then Jay will come in too, the noncompetes are very important. post closing governance is important. Not all the groups are the same, and not all the sellers are the same. Some sellers don't need a lot of help from the corporate group, and how much interference there's going to be becomes important issue some need more help. So discussion about governance, to the extent they're getting rollover equity in the practice, what fees the corporate group charges or doesn't charge and how it affects profit participations. To the extent the sellers are getting equity in the parent, how that's viewed and what happens and get what happens if somebody leaves early. How whether working cow working capital is calculated, most of the buyers require the seller to keep enough cash or accounts receivable in the business to cover bills for a period of time. Others allow the seller to keep the accounts receivable wanna J's favorite issues to battle is? Okay, what are the reps and warranties and indemnifications? And what is the seller responsible for post closing but may have occurred? Pre closing? So, Jay, have I missed any major ones?



Jay Stucki  13:47

No, I've just say that there's so many different subsets. So for example, if you're talking about could controlling documents, you're going to have a whole different set of considerations under an employment agreement that you're going to have if there's rollover contribution, and now you become an equity holder in the parent company, versus when restrictions and covenants that you're going to have in the asset purchase or stock purchase agreement. And all of those will carry a whole different slew of requirements. And so it's, you will see some of that addressed as to what the expectations are between the parties in the LOI, but it's not just oh, hey, a traditional non compete because having equity in the parent. And if the parent would say is a limited liability company, you're talking about now coming in as an equity owner, do you have a say, what's your vote? Are you just a financial interest? I'm sure there's going to be power of attorney considerations. So you're going to have contribution tagalong, drag along, right I mean, there's all sorts of things that now come into play is that owner that in the parent, and of course, the parent doesn't want a minority owner controlling. So a lot of times you'll see those levels shake out in the LOI as well. 



Richard Groberg  15:14

There are two transactions recently where the seller selected Jay to represent them. And in both cases, there were issues that came up on some of the things that Jay just talked about, where the buyer said, nobody's ever asked for that before. And why is that an issue. And by the time we got done, the buyers were changing their documents to reflect going forward, things that Jay brought up that no one had addressed. And some of the prior sellers were saying, Why didn't I get that and we need to change our documents. So there really is a level of detail and the interaction between purchase agreements, employment agreements, noncompetes equity, the parent, that if you're not watching careful and won't be synced, that can cause problems later on.


Sponsor  16:05

Different Fertility Centers across the United States have started to see new patient volumes decrease to counter the decrease in new patient revenue. Fertility Centers are turning to partners who have IVF ready financially qualified patients, but who don't yet have a fertility clinic coordinator from bundle has a list of treatment ready patients in each city, there is no fee, but the offer is for the US and Canada only. Email Courtney for your free list of financially qualified IVF patients at cbarrett@bundlfertility.com. That's cbarrett@bundlfertility.com.

Griffin Jones  16:44

Jay, I was gonna have you define controlling documents at risk of me sounding stupid. That's my job as the podcast host. Hopefully there's at least one other person in the audience that was wondering that, but please define controlling documents for us. 

Jay Stucki  17:03

Yeah, absolutely. I mean, first of all, you have to understand the there's the concept of the corporate practice of medicine. And many states have certain laws, summer force, different levels of enforcement. And so everybody kind of approaches buyers, from the corporate side approach things from what if the law changes. So that's kind of always in the backdrop that brings forward management service agreements, because usually there's going to be an management service organization or an MSO involved. You're going to have a medical directors somewhere, sometimes it's the seller, sometimes the management company wants their own medical director. And there's a level of control there. You have different mechanisms, such as succession agreements, assignment of membership interests, the revocable proxies, you can do control through loan agreements, and of course, through your employment agreement. And then there's the whole level of control, if you're going to say, Hey, I'm going to become a member. Now you're talking about, you know, joinder, to an operating agreement, LLC agreements, you know, so those are kind of the core documents, that you have to understand all of them, and know which tool the buyers are going to bring forth. And usually it's a multiple of the tools. For example, I just did a deal where we use irrevocable proxies employment agreements, and an MSA agreement. Another deal that we did back in now, I'm going to say, April, we use an management service agreement, succession agreements, an assignment of membership interests, it all those are all documents that are done on the front end. So for me, it's making sure that the physician understands how they're controlled by these documents. Because when it comes right down to it, right, the physician is responsible for the patient care. And the competing interest or concept here is, how do if I'm a physician, how do I do my job and give the quality of patient care I want if somebody else is controlling the organization, and you get into what is a clinical asset versus a non clinical asset, right, the physician, the Medical Director controls the clinical assets, which is really the patient care patient records. And then you have the non clinical assets which are owned by the company. You get into a situation where it's not a, let's say, a good, a good company, or they have a bad reputation, and I've had to help doctors get out of these situations. They can make your life miserable, right, they're gonna put in there on staff, you just lost somebody that was with you for a long time, but they want their own person there, or they're not going to buy you the equipment that you need or that you feel you need. And so, you know, sure, if you're the doctor, you say, wait a minute, you're affecting my ability to practice. In fact, for those who, whom some of you might already know, this is a big issue in the Northern District of California right now, it's federal court, where the Association of Emergency Medicine anyways, the group brought a lawsuit claiming that all of these controlling ancillary agreements that companies use to effectively control the doctor is being challenged as it is, in fact, the corporate practice of medicine because you've tied the physicians hands. Now, I think there's a delicate balance here that if you have people who understand the industry, such as you know, Richard, myself, then there's, there's a fair trade off being made. To see it another way. If I want to sell my practice, you know, I certainly can't take millions of dollars from my practice, and then expect to still control it and run it and do everything that I want.

Griffin Jones  21:14

Some people still do expect that, whether they realize that that's what their they'll say, they don't expect that, but they're expecting that, you know, when somebody is telling them what supplies they can order after and who what EMR they're going to use and who they can hire. Yeah, that's when they realize it, but when it's happening, they don't seem to, to always realize that,

Jay Stucki  21:37

Right. And my goal is not to try to tell the physician that it's gonna be, you know, this great rosy relationship and the honeymoons gonna go on forever, but rather makes sure that the physician or the sellers, are fully aware of these restrictive covenants of these controlling documents. Because at the end of the day, I assure you, the buyer, the practice management company, is going to control the practice, you know, if you're a physician, you know, gotta do depositions. And the other side always says, you know, almost right out of the gate, okay, Doctor, tell me, you know, what have we done that's affected your ability to treat a patient. And the doctor is not going to sit there and say, Oh, I can't treat my patients, because, of course not, they'd be committing malpractice. So it's, it's really about understanding a balance here, and making sure everybody's aware of what their arrangement is, and what they've negotiated, what they've sold, what they bought, and what their responsibilities are post closing.

Richard Groberg  22:47

And then lawyers like Jay, make sure that the documents accurately reflect what's been agreed to, in addition to the doctors understanding what they're getting into.

Jay Stucki  22:57

Sure. Let me give you an example of that. Thank you, Richard. You have some situations where they want the physicians held accountable for any losses. And my view on that is, if you're going to be held accountable for losses, or it could affect your compensation pool, because most of these agreements have some form of compensation pool, then the physician should have a level of say, in the expenditures under the MSO. If you're not responsible for losses, and it's not going to affect your compensation, then there should be a much less expectation of any say, as it relates to expenditures or how the MSO, you know, allocates costs to the clinic. So you there's that balance, where you really have to read the documents and see how much responsibility versus how much say you have, you know, they play off of each other.

Richard Groberg  23:57

That's a great example where the language in the LOI is important. If a doctor's post closing bonus is based on growth of earnings, then they need more visibility and say, into what's expensive practice. But if their bonus is based on how many retrievals do you do over a threshold, as an example, well, then it's not as important.

Griffin Jones  24:23

Am I correct in understanding Jay that the controlling documents themselves are not going in the LOI? It's simply refers to what controlling documents are going to be negotiated in the deal.

Jay Stucki  24:36

I mean, there's more than likely a reference to the MSA reference to an employment agreement, reference to maybe some of the high level restrictive covenants such as a non compete that you'd expect in the employment agreement. But usually the LOI is not going to get into P back or drag along rights that you would see under say the parent comp any equity ownership? So now it's more of a reference to the MSA and what falls out under the MSA. And I think that's critical where people like Richard come in. Because in the initial stages, the physicians look for someone to be able to say, Hey, can you explain the MSA to me? How does you know? How does the management services organization work? And am I really still going to be able to run my practice? Right? And, and, look, there are situations where the doctor sell their practice, and they run it just as they always did. And there's no or little interference. There's also situations where the doctor say, Oh, hold on, I don't like somebody telling me what to do. And we're going to put a stop to this right now. And the relationship deteriorates. So,

Griffin Jones  25:53

Richard, from your vantage point, does the multiple effect that so in other words, if if someone pays a lower multiple, are they more likely to let the physician Coast then if they pay a higher multiple times, because I'm just thinking if if I pay 15x, for something, I need to make sure that there is something different happening in their operations that or their their marketing that makes more patients come in, and they make more money? Because I need to earn that money back is from your vantage point is there does difference when people buy at a higher lower multiple how involved they are in dictating the operation? 

Richard Groberg  26:37

No pun intended, but that that question is pregnant with with the complexity of reasons why multiples are what they are, you know, multiples are typically higher, if there's a strategic reason for the buyer, or there's there's factors that make the practice, you know, the doctors younger, they're in a new building, they're at a high growth curve for multiple years. multiples are also dependent on, you know, working with one group that got an offer from a group that puts much less cash down upfront, and there's much more equity in the parrot, their trade off is okay, we'll pay a higher multiple, not necessarily paying a higher multiple, because we're going to do more to your practice post closing your different styles, Jay and I have worked with sellers who don't need a lot of help leave me alone. And that's okay. They're probably not a good fit for some buyers, but are for others. We've also worked with a couple of practices, businesses in the fertility industry, that were dynamic businesses growing, but reached a point where they absolutely needed management help. And the seller understood that in one case, it worked very well post closing and another case, the seller couldn't adjust to someone telling them what to do. But that didn't necessarily mean there was a higher multiple, because we're going to be more involved with

Griffin Jones  28:04

I want to go into some of these different major points and and try to find out how detailed they have to be in the LOI, let's go back to malpractice for a second does it have to be established in the LOI of if we're going to have a tail policy on the doctor, if the docs gonna be responsible for their tail, but how much of malpractice needs to be established in the LOI? 

Richard Groberg  28:29

Well, I think things like that. It's it's the eye of the beholder, whether it's material, my view, if it's material in terms of changing the nature of the practice, or an expense to the seller, or changes the essence of the practice. It should not be a surprise later on down the road. I mean, if, for example, if I've got practice with a seller getting ready to retire soon, and the buyer is requiring the change of malpractice carrier to tail, the doctor retiring pre closing, getting a free tail from their existing policy and not having to buy it so he'll say could save hundreds of 1000s of dollars. So were they a bit upset that they didn't find that out until a month before closing? Yes. But again, it's it's hard to know upfront what's material and whatnot material. But when you've got people like Jay, and hopefully myself, we've done a lot of things. We know the questions to ask so that anything that's likely to be material to the seller buyer is brought to the forefront in the LOI and not oh, by the way, somewhere down the road.

Jay Stucki  29:48

Now, let me add to that that Well, typically when you're talking about the traditional things, non non compete covenants or restrictions on territories Tell coverage, those tend to be pretty well understood and easy to negotiate with, as long as you have that expectation upfront, and you know, that it needs to be dealt with. I would say that, you know, we spend more time on, really the contribution and rollover or time as it relates to the role of the physicians when they become partners, how you bring in an associate physician, who participates in the compensation pool, what say you have an expenses, how the MSO is going to interact? Who's going to be the medical director? Those tend to be the more complicated negotiated issues than your traditional Oh, yeah, there's there's an expected now to compete, you know.

Griffin Jones  30:48

What, what level of detail, are you negotiating those things in the LOI?

Jay Stucki  30:54

Only, from the standpoint that it's a concern for either the buyer or the seller. And I think that's where Richard sits down. And he talks with this sellers and says, Okay, you know, let's talk about the warts. Let's talk about the problems, let's talk about your goals. And once you know, those, it's not that you have to necessarily expose them. But it allows you then to know what to work with, and what's important and what needs to go in the LOI and the you, you know, we're also concerned I know, Richard is, and I am, I don't want to start down a process where I know there's a problem. And then at the end, say, oh, save, by the way, no, you address it upfront. And, again, if you know the war, you know how to address it, and you don't catch anybody off guard. It is developing trust in my negotiations with opposing counsel, that we're all on the same page, we're all trying to get to the same goal. So it's not about hiding the ball. It's about vetting this upfront. And if it's important, as Richard says, we then included in the loi, if it doesn't look like it's important, then we back off. But the LOI is usually a compilation of five, six meetings between the parties through these discussions to make sure that everybody understands if there's an issue, let's get it in the LOI. And then, you know, the standard things, like I said, about the non compete, those tend to just be an expectation that everybody already knows how to deal with.

Richard Groberg  32:32

Yeah, Griffin, people who've never been through this before, the expression I use is you don't know what you don't know about the process. And when you've been through this, as many times as I have, as buyer seller, being sold to a group representing private equity, and now representing sellers, and with Jays experience, if we at least are aware of these issues up fraud, talk about it with the seller, make sure that the major ones are addressed, then we avoid the surprises and problems down the road. When people spend a lot of time and money that could blow up deals, create Hill will delay things, it's just it works better to try to address the major issues up front, having awareness having been through it a bunch of times of what the pitfalls could be.

Jay Stucki  33:24

The other thing too, is that you don't want to be I can't tell you how many times opposing counsel so well, that standard language that we use. And if you don't know that and have the level of experience than the variety of different deals that you've done in the fertility industry, you are in a very difficult position to be able to come back and tell them even though they know, be able to tell them why it's not standard language or why you're gonna reject their standard language. So yeah, you really need that detail, because that's a, I think, a tool that opposing counsel uses often. Oh, that's just standard, though it isn't standard.

Griffin Jones  34:07

I want to come back to standard language. It sounds like for your discovery of how material important these different major points for the LOI are, whether it's malpractice, non competes, post closing governance, rollover equity, equity and parent company working capital and controlling documents. It sounds like that is being discovered in a process which, you said Jay, might be five or six meetings. What does the first of those meetings look like? Actually, let's go prior to the first of those meetings. What needs to happen before the first meeting?

Richard Groberg  34:42

Every representative of seller does it differently. But in my scenarios, by the time the seller is ready to move forward and negotiate to conclusion and LOI, they've shared financial information they've had calls, they've discussed the buyer strategy and philosophy. They discussed what the seller is looking for in a partner to transaction, and then the buyer proffers that LOI, which then starts the negotiating process. That process itself a little bit like a marriage prenup helps define whether they're going to be major issues or not major issues and what the working relationships like. You know, again, if you've got a buyer that is more hands on, they're going to push some issues to make sure it's a good partner, the seller does it at the appropriate time, Jay gets involved to make sure that the non-lawyers aren't missing any things and significance. Again, by the time an LOI is ready for signature, as Jay said, besides all the pre LOI processes, there's 3, 4, 5, 6 meetings and discussions and back and forth. That gets hopefully gets everybody comfortable that yes, this is this is a good mutual relationship. And, and we've got enough documented that hopefully, the lawyers won't screw it up.

Jay Stucki  36:11

Now, but there's also an initial kind of, you eyeball a situation, are the sellers really ready to sell? I mean, that's a big question. And a lot of times, it's no guys, you need to get this in order, get this corrected. Or if you sell now, you're going to run into this kind of tax issue. So maybe you want to wait or maybe we get you a high enough multiple, that it's, it's worth that tax issue trade off.

Griffin Jones  36:39

So these 3, 4, 5, 6 meetings are we talking about? These are meetings that happen after we've decided, hey, there's probably a fit here where we're going to move towards proffering an LOI, or these are these meetings are just anything that happens before the LOI is proffered. 

Richard Groberg  37:00

The way I was defining it. There's a bunch of meetings, discussions, probably at least one person before the buyer says, I really want to buy you, I'm going to send you an LOI. They have an understanding of what the seller is looking for. When that LOI comes in there then are a series of calls, Zoom meetings, team meetings, discussions, that hopefully gets to a mutually acceptable ready to sign LOI.

Griffin Jones  37:31

So before we're even at that point of saying, Yeah, we're we're ready to receive an LOI from you. We're ready to proffer you, an LOI there, you that's when you're looking at financial information, talking about the buyers strategy and philosophy. That's that's when that stuff's generally happening. Richard, even before you decide that, yeah, we're, we're ready to move to LOI?

Richard Groberg  37:58

Yes. And every buyer is different in terms of the level of due diligence they do. All of them will visit in person and make sure there's good chemistry that want to see the facilities. They'll look at financial data, operating data, pregnancy statistics, valuate, the lab try to understand the nature of the doctors who's leaving, who's staying who were the driving forces. I mean, it's a big decision for the buyer. It's not just buying for the sake of buying, and who cares what the practice looks like, people want to look good. 

Jay Stucki  38:31

But I mean, you have ownership of the lab, that's a possibility comes into play as well. But the what Richard just covered, but keep in mind, there's a nondisclosure agreement in place. That's the first step.

Griffin Jones  38:47

So the the NDA happens prior to the financial statements being, 

Jay Stucki  38:52

Right out of the chute so that you can exchange information and not have to worry about any improper disclosures.

Griffin Jones  39:00

Okay, so that kind of starts you down the road of the, of where you might be going towards the LOI and Richard, is do sellers ask for buyers financial information as well like, show me Integra Med, how, how overleveraged Are you? Are people doing that? Can they do that?

Richard Groberg  39:21

Yeah, so that's that's an interesting dance. Typically, the buyer will make a presentation and share some financial information about the practices they have and their revenue and their their earnings. Pitch, typically, not until post LOI if the sellers are taking equity in the parent, where they give detailed financial information. Because if I'm the seller, and I'm taking 20 or 30% of my proceeds and stock and the parent, I clearly have to understand the economics of the parent. You know, what's their valuation, what are their earnings, what's their corporate overhead? What are the What are the limitations on just the CEO paying huge salaries? They're not being profitability? How much debt do they have? So, but that level of detail invariably happens post LOI somewhere down the road. Now pre LOI, but especially post Integra Med, all the sellers want to understand, hey, if I'm getting stock in you, I want to understand your story and what your plans are, and what's my stock, going to be worth someday

Jay Stucki  40:30

well, not only what the stock is going to be worse, but is there even a market to sell it, you have yet to remember, these are most likely privately held companies with some kind of VC backing. And it's not like you can just turn around and say, Hey, I'm going to sell my shares to anybody, you're going to have very harsh restrictions on your ability to sell those shares. And that's where we get into the estate planning component, right? If these, if this is a long time hold, or a long time play, I think that a seller needs to the ability to be able to put their equity into some kind of estate plan, you know, trust for their children, whatever, because it's not, like there's a quick turn, we're going to sell my 20%, you know, next year.

Richard Groberg  41:20

Jay does a lot of work with the sellers on that, because the reality is, to the extent they're rolling into the parent, yeah, they're deferring their taxes on that part of the sale proceeds. But they're, they're minority equity in a private company, that hopefully someday, somewhere in the future, will sell to another private equity firm or another one of the roll up groups or maybe go public. And if they go public, you're probably going to be restricted and not get to sell anyway. So people have to understand they're going to take that stock, and they're going to stick it in the drawer somewhere and hope, in the state or trust, and hope that someday, they merge it to somebody else or sell to somebody else.

Griffin Jones  42:03

So we've signed our NDA, we've looked at each other's financial information, we've assessed some culture vet, we maybe have done a visit and well, hopefully we've done a visit by that point. And we have done some a little bit of due diligence enough to say that we want to move forward with an LOI. What is that? Maybe? And maybe there's three meetings after that. Maybe there's six meetings after that. But what is the first or the earliest meetings typically look like? 

Richard Groberg  42:31

Post LOI? 

Griffin Jones  42:32

No, this is pre LOI, but after, after some of that earliest due diligence has been done. So it's after we we've looked at the buyers philosophy, we've heard their pitch, we've, they've seen our financials, we've determined there's a fit, we want to move forward, then when we start to build and negotiate the LOI, what does that first meeting typically look like?

Richard Groberg  42:55

They sent in an LOI typically, either to me or to the sellers and me. And often it's to me first so I could push back on things that I know from the seller's perspective, date to be modified changed, are going to be acceptable, I try to keep the sellers free of getting sucked into what I call the transaction vortex as much as possible. And at the appropriate point, we may have to get back on the phone with the sellers and buyers to discuss sort of issues that can't seem to get resolved. Sometimes it's not necessary. Sometimes it is,

Jay Stucki  43:34

The LOI is a negotiated document between the partners. It's not as if they send it over and say take it or leave it.

Griffin Jones  43:41

And so those we talked a little bit about though, is that often you're not in the, you're not having the buyer, or excuse me, the seller, look at the LOI until you've had a chance to take a look at it yourself. Why keep them out of the transactional vortex?

Richard Groberg  44:05

Well, sometimes they are they do get a copy. Sometimes they don't do my job and other sellers, representatives job is to represent them know what the sellers want, don't want and try, you know, they're seeing patients all day long. They've got their lives. And so to the extent I know what they're going to accept or not accept, I never make decisions without their input, nor does Jay. But my job is to go back to this buyer. And I've never had an LOI that was like, oh, this is perfect, we're accepting it. To go back and say, can you please explain this or we need to tweak this or you've got something from a prior document you forgot to take out or we've got these issues to discuss. It's always with the direction of my sellers, Jay is the same way but what I don't want to do and part of my job is to keep the sellers from getting so caught up in that process, that it distracts them from their, their business, distracts them from patient care and taking care of their staff. And then, I mean, most of my calls with my sellers are very early in the morning or the evening, or weekends, because they're busy with patient care and, and their staff.

Jay Stucki  45:24

Well, and the physicians want to stay busy with their patient care, because they're, you know, the the multiple is going to be used, you don't want that last month to drop off, because I assure you, they are going to make sure that their calculation is a rolling, usually a rolling 12 months. And they're going to take that up to the very last minute, any data they can have. So if there's a drop off at the end, because the physicians taken away from patient care, that's a drop off in revenues, that's going to affect the, what's used in calculating the multiple.

Richard Groberg  46:03

I've seen lots of transactions, Griffin, where sellers in lots of different industries didn't have a lawyer or an advisor working with them. And they got so caught up in the in the business of the transaction that their practice suffered, there started to be staff issues in affected their business, sometimes in hostile negotiations, that's a tactic. And then it affects the ultimate purchase price. Because the buyer comes in and says, hey, the last three months, your business has deteriorated 20%, it's not worth as much.

Griffin Jones  46:43

So you're talking about part of part of it is convenience, part of it is so that the physician is able to remain productive, but is there also a component of it so that they don't get too invested early on it. So if they start to invest so much of their time they start to be in every meeting, if they that they start to become too invested into the sale, and that gives the buyer more leverage. Is that is that it play at all?

Jay Stucki  47:09

I would say no, just from the standpoint that, you know, if if I don't think this is a deal that can be done at the end, I would have be upfront with the physician from the get go. And, you know, good advisors not going to get you to the point of an LOI if he doesn't believe that it's a good fit. And that's not only from the Richard perspective as a consultant, but from the attorney perspective. The last thing we want

Richard Groberg  47:36

 That continues all the way through to the closing

Jay Stucki  47:40

Right, the last thing you want is, you know, legal, your client telling their attorney, you know, what, what the heck did you get me into? And so, you know, I love it at the end of the day, when my clients come back to me and say, Jay, not only did you do a great job, but you benefited all the other physicians are in the group, because you saw things that they didn't it that the MSO recognize, they need to adjust that now benefits the hall. Boy, we wish they could pay your bill. But great job. And that's the goal. That's that satisfaction, what I look for at the end of the day, but that's in the forefront of my mind from the get go.


Richard Groberg  48:21

Yeah, Griffin from from an analogous situation an RE, who runs his practice has people in the practice who do their jobs better than they can that that facilitate or leverage their ability to holistically run the practice. When it comes to these transactions, with the hundreds of hours that Jay and other lawyers invest that I work on. They're trusting the experts to do what they need to do on behalf of the sellers. And but to make sure they never get surprised. You know, Jay Jay, invest hundreds of hours going back and forth with the lawyers. And it's his job to make sure that he knows what the seller will and won't do. And when there were major issues, explain it and make sure the seller knows what they're getting into on all these subtle, subjective issues. But if the seller had to do all that in his or herself, first of all, they might not have the expertise to do it, even if they think they do, but their practice would suffer. 

Griffin Jones  49:23

Jay, it might be unethical to enter into an LOI with more than one buyer. Is it illegal?

Jay Stucki  49:31

No. But typically, you're, you will not see an LOI that doesn't have an exclusivity clause. In other words, nobody wants to, you know, it's very expensive, very time consuming. I mean, you're talking about hundreds of 1000s of dollars on any significant transaction. And nobody wants to say hey, what do you mean? I'm one of three horses in the race. Right? So that's where the importance of the upfront work. comes in to make sure that that's the horse, you want to hitch your wagon to, to make sure. And of course, if you're the buyer, you want the exclusivity because you're not going to go down the road and have the carpet pulled out from under you at the last minute.

Griffin Jones  50:14

From your vantage point, having done a number of these deals, what percentage would you say of LOIs do not result in a deal between that buyer and seller?


Jay Stucki  50:24

I think it depends on the industry. In the fertility industry, I've never had one not go through. But I think that's because I try to team up with people like Richard, who we set the table before, hey, we know what we're getting into. And we're not trying to take somebody down the path of an unknown. And let's hope for the best. Like I said earlier, if I don't think I can get this deal closed, I'm going to tell you that upfront, when I get an LOI that's already been signed, as opposed to draft or, yeah, I study it very closely. I'll call Richard, I'll call the client. And I'll good drill down and go through the questions to make sure that I understand what was behind it. And there are representations that I've declined. So, you know, to the extent maybe that LOI didn't go through, yeah, that's a real possibility. But I wasn't involved at that point, because I never took the assign.


Griffin Jones  51:23

So that wasn't necessarily my understanding. You know, I wasn't in the RMA, New Jersey, Shady Grove deal that didn't happen, what it was, what was it seven years ago, or something like that. But there was almost certainly an LOI in place there. And I don't have specific details I'm inferring a lot. But something didn't happen there. So my understanding was that it was more common. Jay, it seems like it's it's not so common for, for parties once once the LOI is in place for for them not to do the deal

Jay Stucki  51:53

I'm sure there's a lot of LOIs that collapse I, I represent a different group of entities in a different industry that run into the same issues of licensing corporate practice of medicine type analogy. And yeah, there's LOIs there that collapse all the time. So I'm sure they're out there. What I'm trying to distinguish is that, you know, if you can separate the wheat from the chaff, you can pick and choose. And I've been fortunate that I'm able to pick and choose those deals that I believe are workable that will produce that I'm not wasting my clients time. And so I maybe I can't really answer your question globally. But from the standpoint of those deals that I I'm selected for, and that I want to participate in, in the fertility industry, I'm batting nearly 100%.

Griffin Jones  52:51

So we've negotiated the LOI at this point what needs to happen before it's finalized. So, you know, Richard has torn it apart, Jay has torn it apart. Now are all the parties brought back in to review the document together? Are you reviewing it with the seller separately? And then buyer's counsel is reviewing with them separately? How, what how is the how is the LOI finalized before everybody signs it?

Richard Groberg  53:17

Well, I'm in the negotiations go back and forth. And both parties at some point, reach a point where they go, okay, there are no more open issues. And then everyone gets final changes or reviews that make sure that everything that was supposed to be changed, got changed the way it should, and then everybody signs.


Griffin Jones  53:34

Do you all review that together, though? You know, in the same Zoom meeting, or the same boardroom, or that can just happen, as each line

Richard Groberg  53:42

Modern technology, DocuSign, or whatever your poison is.


Jay Stucki  53:46

And let me tell you, there's also an underlying thing that we look for, in these back and forth meetings on the LOI, and that's the sense of cooperation, is everybody looking for the same goal? Because inevitably, there's going to be some clarification that's going to come up under the LOI that needs to be vetted when you get into the due diligence and the definitive documents. And if you don't have that sense of cooperation when you're negotiating the LOI, that's kind of a red flag from the start.


Griffin Jones  54:21

I'm glad we zoomed in on the topic of LOI so today we could have gone a lot broader but I like as I have experts on more frequently to dig deeper in particular topics. And we spent an entire episode talking about the letter of intent, which I think is really useful for folks. And it also gives me about 90 different ideas for follow up episodes that we could have you each back on because any one of those major points for LOI could be its own episode topic, but I will let each of you conclude, what does our audience need to know about letters of intent before they sign one to sell their practice?

Jay Stucki  55:02

I think you have to be upfront with your counsel or your advisor as to what your real goals are, you've got to drop your guard, you know, if you are really wanting to retire sooner than later, that's absolutely critical if you have health issues, and you know, you kind of kept it kind of behind the scenes or private, you need to disclose that. And so, you know, with attorneys, you get attorney client privilege that attaches right away with advisors, they have their own separate agreements. But it really is important to understand the client, and what their goals are, what their concerns are, what the warts are. And if I have that upfront, I can get you a good LOI. Absolutely. And it may not be with the the buyer that you wanted. But take the fertility industry, you know, there's four or five, companies always looking for a good acquisition. And so you're able to shop and see who might be the best bet.

Richard Groberg  56:09

And I think some my perspective, Griffin, like I've said before, it's not the final document, but there should be enough specificity detail based on the buyer and sellers goals, that it's an important governing framework. So all the work that has to be done after, and it needs to be taken very seriously, it's a lot like getting engaged. People are going to spend a lot of time and money soon as that document's signed. And you don't want surprises down the road. You don't want major problems down the road. And as Jay said, hopefully by the time that LOI is fully negotiated, the parties have a good working relationship. There's still going to be issues, there's still going to be some battles fought, hopefully between the lawyers, but it's an important stepping stone to the rest of what will happen. And I'm still seeing problems in some deals that haven't closed yet, because the LOI was unclear on some things.

Griffin Jones  57:13

Jay Stuki, Richard Groberg. Thank you both very much for coming on to the inside reproductive health podcast.

Jay Stucki  57:19

Glad to be here.

Richard Groberg  57:21

Thank you, Griffin. Appreciate what you're doing to the industry.

Sponsor  57:24

This episode was brought to you by bundle, you may be able to receive a free list of financially qualified IVF patients across the US and Canada. Email Courtney cbarrett@bundlfertility.com. That's cbarrett@bundlfertility.com. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of inside reproductive health. Nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guests appearance is not an endorsement of the advertiser. You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertilitybridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health.

177 More Than 1 New IVF Center Per Week: India’s 0-40% Fertility Network Market Share Growth



This week’s guest, Vinesh Ghadia, CEO and co-founder of BlackCap Equity’s fertility vertical in India, talks about the exponential growth and consolidation happening right now in India in the fertility space. How is it possible to have 60 to 70 new fertility centers per year opening, with no shortage of fertility doctors? Tune in to the the latest episode of Inside Reproductive Health to find out.

Listen to hear:

  • About the five to six biggest fertility chains in India, and the four to five that are on their way up now.

  • How India is averaging more than one new fertility clinic per week in the country.

  • What the US can learn from India in terms of consolidation, comparatively, where a network with 35-40 clinics is considered a midsize chain.

  • Why Mr. Ghada believes India will be the biggest market for growth in the ART space in the next decade.

  • What Indian fertility companies did to solve their fertility doctor shortage problem, and what they may do regarding the embryologist shortage.

  • What Vinesh thinks is causing the falling price of PGT-A.

Vinesh Gadhia’s Info: 

Website: Black Cap Equity Management
Website: Star Fertility Prive Ltd

LinkedIn: https://www.linkedin.com/in/vinesh-gadhia-56a00890/

Twitter: https://twitter.com/gadhiavinesh?lang=en

Transcript

Vinesh Gadhia  00:00

Nice Jean. But 30% of IVF cycles were done in the organized ci 16% clinic 3% in ownership 30% in cycles, at present as we speak 35 to 40% of India's IVF cycles are part of organized chain and the rest 60 person is still fragmented and organized. So starting from zero to 40, it only took one decade.


Griffin Jones  00:32

60 years 70 New Fertility Centers per year, no problem getting doctors imagine that that's according to our guests, Dinesh Gadea, who is the CEO of the IVF vertical in India and the emerging markets for black cap equity. He had been the CEO of RT fertility clinics. He had been the ce o of Nova, part of the Evie network or partner of the Evie network. And he makes that clarification finesse started in the IVF world in India in the early 90s, at the ripe age of 21. At a time when there were only four or five fertility clinics in the entire country. We talk about the five or six biggest chains and fertility clinics in India and the four or five that are coming now we talk about how more than one new fertility clinic a week on average is coming to be in the country. We talk about what the United States can learn in terms of consolidation because this is a marketplace where roughly a decade or so ago 0% of market share was under fertility clinic chains. And now 40% is in India and network with 35 to 40. Clinics is a mid sized chain, Vanessa is looking at buying some of those mid sized chains and consolidating them into a larger group. He talks about that and then I make him put in demographics in numbers and in figures why he believes that India is the biggest market for growth in the assisted reproductive technology space in the next decade. He talks about the scaling opportunities for companies growing into the fertility space in India and their internal rate of returns or expected IRR. Anyway, he talks about what Indian fertility companies did to solve their fertility doctor shortage what they're doing and might be doing to solve their embryologist shortage. And we talk a bit about career tracks for young fertility doctors, which I think is probably the biggest difference, at least that I heard in a short conversation between the United States and Canada. And what seems to be happening in India, according to at least this account in a very small conversation. And if we didn't talk about enough, he talked about the falling price a PG TA and why he believes that that is going to make the total percentage of cycles that use PG ta go up from five to 6% to about 25% of all cycles that are done. This little bit of coverage that we've done on the assisted reproductive technology space in India is only the tip of the iceberg for covering what's happening in that country. We plan to do a lot more of it. So I hope you enjoy this conversation with Dinesh Gardea, Mr. Gowda, the Nash, welcome to the Inside reproductive health podcast.


Vinesh Gadhia  02:52

Thank you very much Griffin for having me. It's an absolute pleasure and my privilege to be speaking and talking to you on your podcast. It's very interesting space. For me and us. I think it's becoming interesting space for millions of couples in India and globally. Thank you for having me here.


Griffin Jones  03:09

I think it's becoming an interesting space for people that worked in the fertility field all over the globe. And I said to one of our recent guests Dr. GHOSH dusty Dyer, that 5% of our subscriber base comes from India, people that work in the IVF field in India. And previously to that episode, I had never created any content specific to the marketplace in India and I look forward to covering more this year with Dr. GHOSH dasa, we laid the groundwork of the history of IVF. In India, how some practices are set up there, you have a lot of experience at the home of some larger groups. And so I'd like to talk to you about the history of some of the large clinic groups of the business landscape and then what you see as some of the unique scaling opportunities and challenges. Let's start with the clinic side, can you walk us through the history of the large fertility groups in India, who are they and how did they come to be


Vinesh Gadhia  04:10

when we talk about fertility groups is more about organized change of IVF clinics in India, but to just to understand my narration in in detail, I would take a little bit historical background on how our as a country we have evolved. I have started working in this space in early 90s. This is my 30th year in IVs space from Day Zero Day One of my professional career at the tender age of 21. I fell in love with this space because it's something that helps to create more happiness and I'm the author in the universe in early 90s. In India, fertility infertility or fertility was considered as personal shortcoming and it was considered as destiny it was neither accepted as medical treatment or Medicaid disease. And and most doctors I would say now 85% of gynecologist who are treating infertility did not have a chapter of infertility in their final year of master's in gynecology. So that was the state and I come from that background where I've seen this industry growing from ground zero. So, very few IVF clinics in early 90s, maybe four or five, and then it started growing towards the end of the decade, early 2000 is where infertility treatments started becoming a little popular amongst the patients and also wants the doctor I have been on pharma side for 16 years kneading and launching large IVF business from the pharmaceutical companies and I crossed the bridge in 2011. When I came towards the service side, I was one of the founding member of India's first organized IVF chain backed by a private equity company. So, it was only in 2010 Later, large fertility groups started coming into existence. It was a group of venture capitalists and private equity in healthcare business. And they thought that possibly IVF is complementing to the naked healthcare model. It was it was group of venture capitalists and backed by one large private equity. They reached out to one senior doctor in India, Dr. MANISH banker, and Dr. banker and me used to be very good friends because I was from pharma side and he was my key account. He reached out to me, we went and did a presentation to the board about business case and scientific case. And we started we worked three months on the strategy board on the ground zero business plants and also in business model. And then started our first step is India's possibly the first ambitious plan for a large fertility Qi. What did


Griffin Jones  06:47

you have to prove at that time? Dinesh, what did you as you're building the business plan? This is something that is pretty new to the venture capitalists and private equity partners and you're working three months on this business plan, what did you really have to focus on to prove in that business plan?


Vinesh Gadhia  07:05

Very interesting me nobody in during that time in India believed that this fragmented Doctor owned IVF clinics, this market can be organized, the biggest challenge was to present the business model to the private equity and the board. And one of the interesting fact which I was driving and and there were not many takers in the boardroom also, is that we will launch a PRK IVF business first time in India, where in the IVF clinic we will not have any neighbor room. No guyhnic practice no obstetric practice, because what investors were thinking is that if we if and once we grow IVF business, we have readymade pregnancies from our IVF business. So we will do delivery business also, let's birding business, where I was very sure in the model that it has to be pure plain I had my logic ended. Second from where to bring patients in India. So the belief system was that it's word of mouth. And I was very, very sure that because infertility is not talked about, there are meats and taboos, there is stigma around it, people take very few people first come forward for treatment. And people who get positive results don't speak about IVF amongst their friends and family. So word of mouth is extremely slow. It takes very long time to develop business on word of mouth. So I had why business plan which was based on a very new concept of meeting 1000s of gynecologist convincing them to refer a patient to us and the business model. So there were a lot of challenges. There were too many no naysayers that did not work. I think in deep in my heart and along with the Medical Director Dr. MANISH banker and his partner, Ravi Patel, we were convinced that this will work. It took heart time to convince the board. But the first step was defining I think in business model.


Griffin Jones  08:58

You had your reasons for wanting to go the pureplay IVF route when other traditionalists may have also wanted to include obstetrics, what were your reasons that you felt strongly this has to be purely fertility treatment.


Vinesh Gadhia  09:14

So Griffin it's very interesting if you if you analyze the full funnel approach, millions of couples in India suffering from infertility majority I'm talking about 2010 majority believes that their treat they can be treated by astrologers by cracks and they would of course, I'm a God believing person so they would go to church mosque temple. My belief was that if you are a God believing person suffering from infertility, which is a who classified medical disease, you have to fight God in a doctor an immunologist, and not in the temple because you will not get a cell there. Out of that few million couples who would not even come for medical treatment, the large segment of the funnel, who accept Did and understood in and largely in urban area that it's a medical issue. Sadly in India it is still considered woman's problem medical it's a couples problem. So, so out of these millions of couples many are most of them accepting it medical disease but woman's problem will go to gynecologist so 70 80% of infertile patient in India even today will first go to gynecologist medically right or show because GYN they can treat majority of infertility and not everybody requires IVF so, why in gynecology see 10 patient of infertility two or three will require IVF but they will not refer because the standard on IVF clinics in India are also doing obstetrician birthday. So basically it was not referring but it was losing patient to a competitor or your colleague right to get my point. So this ref net ne identify identifying patients requiring IVF we're never referring to another IVF specialist because the patient will never come back to the doctor because they themselves are competiting to the birthing and upsetting business. Now it took very long time, a long time for me to convince my board and my investors that the majority of untapped potential in India is live with gynecologist so we did a small Deep State study, meeting 500 gynecologist 500 is small in India and asking them do you see infertile patient? Do you see patients who require IVF? If yes, whether you refer or not. 100% doctor said that they get infected patient 90% of doctors said they have patients who need IVF. All 90% said we don't refer when we should why. So when we refer a patient, we lose our patient. Second, we don't believe IVF is great results. Third, we believe IVF is expensive. I had presented the study to the to the management and saying that this is where they can work. And we can explore untapped potential, get patient for our need, not from other IVF center because that's very small. But from the market, which is not, which is not tapped so far. So we were we were getting into an untapped potential of the IVF business. It took six months one year for me to prove that this is the model which will work for that business to come in from referral network or from gynecologist referring to IVF specialist, we cannot compete with them. So we cannot have no neighbor whom in our clinics we cannot do badly.


Griffin Jones  12:35

So you finally are able to prove this concept to the capitalists behind the private equity that are investing and you and Dr. MANISH banker ostensibly get your business proposal accepted, then what happens?


Vinesh Gadhia  12:51

So we started with the first clinic of Dr. Banker acquiring the clinic. And we had a very, very ambitious plan of starting a chain of 25 clinics doing 10,000 cycles in a in a year. When I used to say this to industry experts in India, and also across the world. I used to attend global IVF conferences. Yeah. Most people used to not believe it that this is possible. Half of them used to laugh not in front of me but behind me.


Griffin Jones  13:20

How many cycles was it that you were a plan


Vinesh Gadhia  13:23

was to reach 10,000 cycles in a year.


Griffin Jones  13:26

And that was laughable at that time.


Vinesh Gadhia  13:28

Nobody could believe that there was no group doing 1000 cycle. So when we were presenting our plan, most people thought that it's on paper and cannot be executed or it's difficult to give life to this pen. So we did our first clinic in Ahmedabad which was a brownfield acquisition. Then we started creating Greenfield clinics, hiring young doctors hiring young embryologist, a very young business t, which is sales and marketing and the ops team. And we progressed when, in the first three years, we really ignited the market growth. There were five change slots, which are now changed which were launched after success of Nova. In 2015. There was an EY report white paper on IVF potential in India, which was published by Ernst and Young, which which shows Nova IVF as the leader in the industry with nine clinics doing highest number of IVF cycles and having best in class students. I think if you asked me that was the igniting point in India, where more groups started investing shattered and visualizing the plan and from from practically zero organized business in 2020. In India we have about 35 to 40% of IVF cycles which are with organized change and now there are several chains in India.


Griffin Jones  14:50

You live in Mumbai did your original financiers also come from Mumbai? Did they come from other parts of India? Did they come from Spain? Did they come from other parts of the world? world where were the original people that bought into your idea with their dollars come from


Vinesh Gadhia  15:06

the first seed investment came from an American venture capitalist GTI capital, global technologies investment. Second major investment came from a, again a venture capitalist from us, any new enterprise associates, third came from Middle East, which was born exist, it was submit a Middle East based venture capitalist. The turning point was when we launched our fifth clinic, Dr. Banker also realized that to run one clinic of excellence is a different ballgame. But to run a chain is very different in terms of having all the standard edition inishbofin protocols in place, so we got in touch with world's largest chains, which were based out of Australia and Europe. And we finally zero in partnered with Spain, which at that time was also needed in the world. So Evie spent came as our technology partner and after that, we got Goldman Sachs on board as our private equity investment leading investment was was from Goldman, which gave us a lot of confidence on our modern on our progress, which was made in in the first couple of years and gave us definitely a ability to invest in quantity and in infrastructure and standardization. So, we took off from from Ed coming in and Goldman coming in. So there were basically five investors put together it was also backed by one individual doctor from Bangalore as a promoter along with the CD and Misha Doctor nationality. So, we had good mix of venture capitalists and private and large private equity like Goldman Sachs.


Griffin Jones  16:48

It was so as Nova is growing and then eventually merges with Evie in Spain and is financed by Goldman what what other groups are merging? You said that five other chains came after Who are they and when did they come about?


Vinesh Gadhia  17:03

So I would just clarify that it was never a merger with TV Evos our technology partner we had a royalty agreement with them and a sweat equity diverse chatted for or whatever they were helping us and they were very valuable partner for our quality improvement in their IVF currently India's largest IVF Qi one of the largest in the world, there are more than 100 Plus clinics across the country. And they have they have done some very very I would say phenomenal execution of of plan entire to tie efficiently largely was next they started their journey from a very small town in India you know the poor which is in upper upper west western region. And after naoise initial success Indira started expanding when there was another health care healthcare group, which was Manipal health, which is again eat today also is number one number two health care group in India they folded into IVF with a chain called encore Manipal there was another encore player in India backed by private equity their company name is healthcare global at CG they forward into IVF chain called a teaching the lab the biggest healthcare group in India is Apollo Apollo forward into IVF shade or depo fertility at present as we speak, in last three years in spite of COVID time, there are four or five new chains which are launched in India and they all are expanding, expanding robust and doing investment of millions of dollar in north there is a new chain which has come up with 16 connection as to your CKB luck, there is a chain in southern region called 49 Do we have seven clinic there is a chain in southern most state in India and Kerala HRMC there is you name it and in India you will find find them mid level change chains. And it just took off. And as I said in 2016 17 16% of clinics were organized part of organized change. But 30% of IVF cycles were done in the organized change to 16% clinic 3% in ownership 30% in cycles at present as we speak 35 to 40% of India's IVF cycles are part of organized chain and the rest 60% is still fragmented unorganized. So starting from zero to 40. It only took one decade.


Griffin Jones  19:42

What do you think is going to happen in the next decade? And perhaps before I ask that you may have answered my question about consolidation but maybe not so 60% of the market is still being done by those clinics, not within a network. In the US and Canada networks are running out of clinics to buy and it's not because they've consolidated all of the clinics, there's still plenty of independent clinics, but there aren't so many 4567 etc Doctor clinics left in the US in Canada that are independently owned. Is that problem on the horizon yet in India? Or do we have a long way to go before we run into the problem of not having enough sizable clinics to buy


Vinesh Gadhia  20:28

very in cushion Griffin again, some demographic detail piece today across the world we talk about India being the growth engine of the world economy IVF is also very similar or even better. India has highest young population in the world. As of 2010, we had 247 million couples in reproductive age, as of 2010, can you imagine in 2020 are expected we still have to do our population census which we do once in 10 year because of COVID. This time, it was delayed in 2020 10 years later expected couples in reproductive ages 434 million from 230 to 47 to 430 4 million. It's a huge demographic shift. Even if you consider same infertile patient, which was recorded and published by Indian government in 2010, acknowledged by EY report in 2015, which is 9% infertility, it has increased in fertility in India, but even if you consider safe from 30 million infertile couple in 2010, we are now 62,000,050 2 million infertile. So, we have a huge demographic dividend ifcn population in the world highest one of the highest urge of parenthood in the world, which is not there in most developed countries in India. I would say 9.9 out of 10 people in their in their young age will get married and nine out of 10 people will opt for becoming parent. It's a societal cultural strength in India that we are very high urge of parenthood. Now, highest in population highest urge of parenthood, but ever changing lifestyle. There is a published study in fertility sharing dream it's an indoor Spanish study done by Nova AV Indian woman peaks fertility potential at the age of 25. Whereas in Caucasian woman, its fertility potential at the age of 31. There is an inherited genetic and difference of six years. Why concerning we used to marry early is because of this. Now, while we try and copy western lifestyle, our genes don't change. This brings very high burden of infertility in India because we are now marrying late in India, copying western lifestyle, whatever genes remain the same. This all put together even if we have 2000 plus IVF clinics now. We do 250,000 cycles in India now, which is number two, number three in the world. We are still under 10% of the real potential so far as the market which looks very big, but we are just taking off. answer to your question. Our cruising altitude or saturation is 1015 20 years away. So current growth in agribusiness is launching new clinics launching new chain every week. We add 60 to 70 IVF clinics every year, which is one clinical week. So consolidation in India as I would say, just from where I am seeing it is just beginning. So we have 1000s of clinic in India to vie shortage of IVF clinics to consolidate or IVF chains to get consolidated. That shortage is 10 years of at least 10 years away. Because we have a long runway in front of us too.


Griffin Jones  24:10

Is it more common to consolidate clinics? Or is it more common to start a clinic de novo if we're one of these six or seven chains? Are we more likely in the course of a year? Are we buying more independently on clinics and bring them into our group or are we creating more clinics de novo


Vinesh Gadhia  24:30

so all the chains today including Nova Indira Mila Apollo 14 Nine PRMC you name all the chains I would have missed a couple of names sir I'm sorry about that.


Griffin Jones  24:43

I do I always miss a couple of names initially I know that a couple people will curse me and and maybe your contemporaries will curse you for leaving them out too but welcome to The Club.


Vinesh Gadhia  24:55

So all of them today are are are launching in you Kleenex organic, because that's that that's enough market for everybody still to be tapped. I would I give you once very small I mean, not inside example. So I am at present working on an IVF platform story where I am in discussion with four or five mid, mid level organized chain to acquire them for the platform. And my strategy is to buy and built by four or five chain that is certify 40 clinics and wait maybe 3540 clinics in next seven a year and have an exit insight in 2030 or 2030 278 years to 10 years of business plan. I think even though I started looking at some assets is they want to add to their portfolio. Choi is Indira and other chain. This has just begun in last I would say sick since 2022. Largely because now there is an ARD regulation in place. So government has passed ARD Regulation Act. And because regulation is enforce many single doctor on clinics believe that it is better to be part of organized network where there is a bandwidth, there is management bandwidth, there is professional handling of all the department including quality departments and audit departments. So that when there is a regulation in place, there is better bandwidth to handle the larger business. Also, it's just last one or two year, most senior doctors are many successful IVF clinics, led by doctors have realized that organized chains are growing much faster compared to single doctor on clinic because of the management bandwidth and because of capability of investment. So they also started believing that joining hands with an organized chain. Current chain is basically a good idea. And it's Win Win partnership for both. So the word consolidation just started shortage 10 years away.


Griffin Jones  27:01

I'm catching my breath because this is a order of magnitude that we haven't totally seen. And when I'm seeing my colleagues, LinkedIn posts of them visiting Indiana I'm seeing this more than I've ever seen it before, partly because no one could travel for two years, but also partly because something's clearly happening in the country. And you're starting to give numbers to that story of what's happening there. How are you getting doctors in the US and Canada people are consolidating, but then they're running into challenges, staffing them with REI, as I talked with Dr. Bheeshma pushed us er in that episode, that's the REI fellowship doesn't exist in the same way in India that it does in the US, but how are you finding enough physicians to be able to staff these programs?


Vinesh Gadhia  27:50

So good. Again, anything you asked to me? I sound very ancient. It's very interesting possibly because I love to speak about IVF business in India. My first designation in an organized chi no IVF was Director Dr. empanelment. Because the my it was the same question. My private equity investor or my board believed that finding the doctor will be difficult. Recently I was working with the art fertility clinics again a Middle East based very high quality IVF chain again backed by a private equity capital. When I was sitting with the board before joining presenting my business plan, the only question was asked to me by the management team of Gulf capital is that from where would you find out? So all questions are similar my answer is very, very simple. In India, they have 40,000 gynecologist for zero 40,000 highest number of medical consultant across the world. We are blessed with talent in our country. Out of these 40,000 gynecologist 10,000 diagnosis actively practice infertility and all of them aspire to become a specialist. In India, we have plenty of organized chains who are doing fellowship course starting from three months to six months to one year to two years. Some very good fellowship course which are led by Milan Dr. Kamini route and led by Dr. Norma the shockcraft. Very very good fellowship course led by EV along with Dr. Banker in Nova. Fellowship courses are done in small chains with mid level change even in 49 Even in Oasis. Now to train a gynecologist who is already doing good level of surgery, incision injections and large endoscopic surgery, on skills for own pickup is if you ask me, I don't know if doctors will like listing this. It's not difficult. It's a three month training. A gynecologist who is already practicing Infertility can be trained to become a specialist. We have enough plenty of one year courses in India. So there there will be no challenge and I'm repeating no challenge in finding good is specialist key like a specialist. Absolute No. The challenge will be in finding right embryologist we never had any university in India who offers embryology nobody in India understood the potential of requirements of embryology which will come money fall. The Health Care Group which I referred before started IVF chain is one of the most reputed medical university they started embryology course, seven, eight, maybe nine years before but they were they were giving six embryos a year now, I think they are doing some 20 or 30. Now, in India, there are six or seven universities who have MS in clinical embryos, but it is thin skin shortage in India. Severe skill shortage is embryologist, not doctors. What can


Griffin Jones  30:54

be done to solve that embryology shortage Can the same solution that was done with the chains themselves starting these three month to two year training fellowships Can the same clinic networks also create the infrastructure for embryology training, because if you're creating at least one fertility clinic a week in the country, and it sounds like with six or seven embryology programs at the university, and maybe a couple others that you're not on pace to fill that clinic growth with embryologist staffing the labs behind them can the clinic networks offer the same training that they did to cover the DR solution.


Vinesh Gadhia  31:37

In 2013 14 we when we were on the journey of a very robust growth in Nova, we realized this challenged that we cannot depend on acquiring empanadas from market. First thing we did was we joined hand with the first university and we used to offer internship course to all the students of Manipal who are passing out MSc in embryology and we used to have the first look at them and do and pick up the best talent from that but that also not enough. The alongwith EV Kochi co curated 180 day course for a master's in life science student whichever which which you can find in plenty in India. And we had 180 days of logbook training program co curated supervised by embryologist from eenie so we created our own bench strength and we never face shortage because of these two things, join hands with universities and took all of them as our intern and absorbed most of them as trainee in our in our clinics and out of our say Soviet 19 clinics one and I when we divested to TPG 910 large clinic can have two embryologist anytime which can be trained in our logbook training program supervised by EB so we created our own band strength in there actually cracked it even better. They have a company training school in their headquarter for Dr. And Mr. Rajesh and they have a crash course of three months. Any ml Masters in Science student can be trained under simulators, excellent training ecosystem, very documented, they churn out their own embryologist and own doctors IV specialists. So two large chain wide Indira cracked it very well. The way forward is either all the chain have there is one clinic as their training training hub, take science students in India, which are available in plenty and trade create a training ecosystem. Second is I mean, I have this dream in my mind that we should have a school of embryology in India having 50 100 students every year of coming from science master's in science and we have best of the minds in the world who can be brought in as faculty and we can develop a very robust training ecosystem in India. I mean, we have students from Oxford University in India, many from Oxford doing MSC Ammirati that we have students from Monash University in India from Nottingham from ICL from UC and you name reputed universities offering MSc in embryology. We have students in India from the who are practicing embryology. So it's high time that in India, we create more infrastructure for embryology training program, which is very doable.


Griffin Jones  34:35

I would say it's high time as well, because there could be another vulnerability that there's already an embryologist shortages in India. But what if some richer countries namely the United States figure out their visa mass that they have been struggling with the last few years? What if they figure it out and say okay, we are going to start taking this seriously and get some more skilled people from the sciences. With embryology being a focus, then you would certainly want to make sure that you had enough embryologist, if something like that would happen.


Vinesh Gadhia  35:08

I think you are giving secret sauce for the US IVF industry. I was talking to one of colleague in IVs business in us about a month before. And I was saying that they keep seeing me that we have a shortage of embryologist in us. And I said if there is a special visa visa for embryologist in the US at least I know 100 People from India will apply. So I completely agree that if this happens, so there are many embroiders in India, who go to UK and to Canada but not in us because getting visa is not east,


Griffin Jones  35:42

our embryologists able to buy into the equity of clinic groups.


Vinesh Gadhia  35:50

Wow. Again, interesting point, which has a strong belief system in India. Now, with more it becoming organized with more shortage, the venue of employees have increased in the last five years recently. Not to the extent of what that they can buy equity or they are offered Aesop's in India still. But I strongly believe that it's not a very fact that this will happen in India, because it was largely a doctrine lead. And now I think, at least in organized ecosystem of IVF the value of embryos this is when understood, still not to the level of being a critic. But


Griffin Jones  36:34

how does the track look for young doctors? Are they buying in at the practice level that the local clinic level are they buying in at the network level are both happening neither happening? What does it look like for young fertility Doc's


Vinesh Gadhia  36:50

a young guy, Nick Norris, who is doing birthing practice does not have work life balance in India, it's a huge business, and potentially very high because we deliver the highest number of babies in the world. So I don't need to dive deep dive into the numbers. There is a current trend in India, which is changing that the young inequalities who are who are passing out, they want, they are the current generation, right. So they want work life balance. So they we have more and more doctors who want to be in IVF rather than going into birdie. and taught them if they want work life balance is a fixed time job. And there is an men management ecosystem. Well, well trained operation staff, well trained nurse so that once the name clinic, they don't have to keep bothering about anything. So the young talent, who doesn't want to be in birding practice, but in IVF, are more attracted towards organist because you have a better work life balance. And you can learn and you can grow in an organization, you can learn a lot of things.


Griffin Jones  37:58

So younger dogs might also not have the leverage or the focus, or there's other things we offer that they're not totally focused on buying in yet. What about those that are medical directors? How are those folks building their career, so you have a number of OB GYN who are just simply happy not to be practicing obstetrics, they're happy to have office hours, maybe make some more and be part of the growth, it's happening within their continued education as well as in the field. But then you're going to have some of those that are deeply entrepreneurial. And they say, I want to start a network, I want to become this chief medical officer of this network, what are their career tracks look like?


Vinesh Gadhia  38:39

So in an organized setup, there is a structure in place where if you're heading a clinic, so in clinic, the the org structure is that there is IV specialist, and there is a medical director, or the or the chief, the cdmos doctor in the clinic. And there are a large change which are shaping up in India. So there are regional directors who look after five, six clinics, they also practice in one of the clinic, and they look after as leader in in five, six clinics, around 10 to 15 doctors, and then there is a national medical director. So there is a career path for a doctor to grow. But at the same time, it's not very clear. It's not very visible. For a doctor to like any other employee visionary, there is a very visible career path. For a doctor. It's not very visible or not very easy to grow in the career. Most doctors in India tend recently believe that increasing that practice and increasing their commercial take home is that growth, not they never look at career growth of handing more clinics or being in leadership position. I would say in the last 10 years it has started evolving, but still it's not very established. So for a doctor if they're doing five cycles, 10 cycles a month, it grows to 25 a month, or it goes to 50 a month. So their professional growth is more work. And they take home more money, rather than growing up in the ladder, that desperation not many doctors have in India,


Griffin Jones  40:16

I can hear a lot of American doctors groaning and saying, Oh, don't worry, nice, you're gonna have to deal with this problem. 10 years down the line when they want all of it and the American doctors that grew up with the career path that you just talked about and worked really hard on it sometimes feel that some of the younger doctors now want to skip that path and move into where they are. So that'll be a barrel of monkeys that comes as part of the fruits of the labor of having a growing market. It's a it's a good problem to have, I guess, because that means that the companies and the marketplace has gotten to a certain point, I want to ask you about other growth challenges. But we've spent a lot of time talking about the clinics, I really wanted to have that understanding tell us what's going on elsewhere in the fertility industry. In India, we talked a lot about the network's coming up, how 10 years ago, they had almost no chair of the market today, they have 40% of the market, there's a lot more growth, there's a clinic happening at least once a week with 60 or 70 a year. But what's happening on the industry side genetic testing lab manufacturing pharmaceuticals, what artificial intelligence other things that I'm not even thinking to ask you what's what's happening on the industry side.


Vinesh Gadhia  41:37

So India, as a country is the to date in adopting new technologies. What has changed in the last five years is adoption of fitness systems by 234 chains in India, which is an onshore alarm systems. Genetic testing in India is a very interesting curve, it's going through a very interesting curve from nothing about five, seven years before. Today, it's about 5% of the cycle, genetic testing. Now, very quickly, I will I would, I would try to address this as a patient if you have for for good quality embryo slash blastocysts. And if you what, what is the dynamics in India, I'm not saying scientifically what is right or wrong. If I if I if I offer patient genetic testing that out of these four, which is the best embryo which I can transfer to you, so that you are time to pregnancy is reduced. And we identify the best genetically the most normal embryo where a patient believes that if you transfer two out of four, if I don't get pregnant, and the next cycle in frozen embryos transfer, you transfer the remaining two. So what is the advantage of going through genetic testing where I'm spending so much of money. So it's difficult in India because 95% patient pays out of pocket and the cost of genetic testing. When we launched the first genetic test India, which was Evie company launched through novice legal entity, it was as good as one IVF cycle, it was very difficult for a patient to spend four to IVF cycle for genetic testing other they will, they will, they will do more frozen embryo transfers. Now the genetic testing percentage is going up, the price of egta is going down once the surprise of PGT even match to the frozen embryo transfer price which is very close now. This will suddenly flip it's a tipping point from the current five 7% of cycles undergoing pcta It will go up to 25%. By next five years is what I believe. Now there are 10 companies who are offering genetic testing. There are good pgti models available in India. And the pricing is going down as the number of testing is going up. We are still about a year or two away from the tipping point is what I believe I keep advising to some large global companies that this is a great business opportunity in India. If you can burn money for one or two year or not earn much one or two year. This one's cake. This is a business of scale. about artificial intelligence. Two companies are launched in India to change they're adopted as a trial method one is embryonic another is nightmarish but I think it will grow it will start going well. Genetic testing artificial intelligence sickness system alarm system, standardized high quality lab protocol I think are now prevalent in most organized CI but it are these are at very different levels. If I can speak at fidelity in India as only six clinics, it is based out of Middle East backed by private equity is at a very different and noon, if you see any arts fertility clinic you will not feel any difference between the clinic in New York, London, Tokyo or India. Indira Noah up to the notch of international standards, other chains are following to that standard. So over on lap parameter quality parameter or standardization, IT infrastructure is being growing very fast in India but led primarily by organized cheats.


Griffin Jones  45:26

What's causing the price of PGA to drop?


Vinesh Gadhia  45:30

It's basically sequential know if you are if you are running more sample in one cycle, it will reduce the cost per sample. I'm not a genetic specialist, but I can in business sense I know I was one of the member who had developed the Strategy Board for first genetic company in India, which was EVs company, it was known Evie omics at that time. Now, it is very popular e genomics, why it's no money the company now show the more tests you do, your fixed cost remains the same. And your consumable costs remain the same. Because it is cycle of sequencing, it will reduce the cost of testing for that provider. So you can offer less cost to the IVF service droid. Are the


Griffin Jones  46:15

networks doing deals with the genetics testing companies to be their either exclusive or the preferred group. And so when you talk about scale, is there a risk that of not winning the scale game because I think of in vitae, closing their fertility division and some of for closing their fertility division. And they talked about lack of insurance reimbursements in the United States. But another thing that people talk about is that they're losing the game of profitability with the MSOs with the network's than the network's are negotiating deals that are ultimately not profitable for most and so they have to lose money, as you said for some time, but maybe they can't do that. Maybe it could could have been the case that in vitae couldn't do that, that semaphore couldn't do that. So is that is it a dangerous game to try to win. And I'm not just picking on PGT companies here, but really anybody that thinks about scaling in this way and thinks about having to lose money for a little time, that's always a risk is that risk greater in India that you you don't actually win and you just lose money and go out.


Vinesh Gadhia  47:32

So, you take example of numbers 250,000 cycles growing at 17 18% CAGR, we will be about half a million cycle in next five year expected to be million cycle by the end of this decade. From current 5% of genetic testing VG da it can go up to 20 25% which is largely still less less less compared to Japan or us or most of the country. The scale is is phenomenon in front of any genetic company now, where if your mix was launched in India, when it was an Eevee company not not invested by private equity after that, it was some private equity now, it is vitrolife company it broke even company level and second year most genetic company in India new companies are also making money even today. So, at 20% more cost per genetic testing compared to a frozen embryo transfer in India 20% More mostly genetic company and making money. What I'm trying to say is there if they bring down the cost and allow the market penetration to go up, and it crosses a tipping point of equivalent cost of frozen embryo transfer, this will boom it will go up phenomenon the company which can do this is Cooper fertility, they are a global company they have about close to a billion dollar revenue now highly profitable, they are still not launched their pgti model which they have launched in Europe and US in India now keep and keeps the question that if they can bring it x price and still either make very less money or no money, if not burn the skin and and tap into large groups who will ready to a pledge X number of testing. It's a good model it


Griffin Jones  49:27

Cooper's not in the business of losing money. So seems like they may not have figured it out yet. And I wonder is there a different model that these companies can do? So they you talked about the scale which is enormous and unprecedented anyplace else in the world? He talked about 243 million people of reproductive age, I believe it was over 50 million people who need assisted reproductive technology. Nine out of 10 of the young people are going to want to have children even at as their maternal age advances so that the scale is there, just the pricing model need to have these networks in place in order to be able to put forth a model that works for them to like, if we sell 100,000x, then the price is a if we sell 100, if we sell 1,000,000x, and the price is B, if we sell 10 million, then the price is C do that, is there a gradient model that they need to be able to work on in order to be successful? And do they need the networks to be able to do that?


Vinesh Gadhia  50:34

I think what you're seeing is is very right, at just let's take an example. Today, the one of the chain, which which say for an example, I'm reading a chain, it is doing 5000 cycles, IVF cycles, and we are doing genetic testing of two or 3% of patient at x price, I can go towards genetic service provider that at why price this to 3% Can I can pledge 10%. And there are five chains who can come together to work on the table, and pledge, all put together a huge number of genetic testing in one year, which is more than the total country which is doing a survey spread provider, a global service provider, it's a very good business model. It will help industry to do more testing, it will reduce time to pregnancy, it will reduce the current abortion, it will improve results. And it will help industry both the base and then I think there is no written it's a it's a it's a patch which will then go robust towards growth.


Griffin Jones  51:36

But as you've been a wealth of information during this conversation, you walked us through some of the history of consolidation in India, the formation of networks, the early days with private equity, the training of fertility doctors, and somewhat and soon to be more so embryologist, the expanse of the demographics the expanse of growth from clinics, you talk to us about the scaling potential that industry side companies have PGT just being one of those examples. How would you like to conclude with our audiences, mostly US based but it's increasingly global increasingly from India as well? How would you like to conclude about your prospects for the future of the marketplace?


Vinesh Gadhia  52:24

So Griffin I really strongly believe and I think everybody in the world that would have to have a great business. What is required is right market condition. Right capital, right people? Right? I don't think timing can be better than this in India. It is yeah and population one of the highest urge of parenthood changing lifestyle and increasing infertile patient in vignettes all want to become parrot timing is right. There is no shortage of global capital investment in India in sunsense sector like healthcare and IVF. We have enough talent in India accepting embryologist. I mean at 250,000 cycle number two number three in the world in India is on firm track to become fertility treatment capital in next two to three years.


Griffin Jones  53:12

I hope we get to have you back on a couple of times during those 10 years the nest Gadea thank you so much for coming on the inside reproductive health podcast.


53:22

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

163 An Integramed Autopsy & An REI’s Entrepreneurial Rebirth

This week, Dr. John Schnorr joins Griffin to break down what transpired when he and his colleagues found themself at the bottom of the Integramed fallout. What happened to his clinic and his patients through the unraveling, how did it influence his career path afterward, and what entrepreneurial venture did he undertake as a result- all on this week’s episode of Inside Reproductive Health. 

Listen to hear:

  • What happens when another company is the employer of your employees-and they close their doors overnight-without paying you-or anyone else.

  • What considerations you should make before you enter into an agreement with any company- especially when the rules for assignment change drastically under the umbrella of bankruptcy law. 

  • How Dr. Schnorr rose from this downturn, and continued down an entrepreneurial AI path which has the potential to significantly impact the industry down the line. 


Dr. Schnorr’s info:

LinkedIn: www.linkedin.com/in/john-schnorr-md

Twitter: @JohnSchnorr1

Company: www.cycleclarity.com


Transcript




Dr. John Schnorr  00:00

They ended up going chapter seven, which has gigantic implications for the patients and for the fertility practices, because now they're going to disappear. And part of the thing that really challenged us the most is they had captured all of our revenue. So they had taken all of our revenue, they had all of our patient deposits. We didn't have any of our patient deposits. Patients wrote checks to Costal Fertility, they didn't write them to IntegraMed, we're not going to be able to go back to the patient and say, No, you made the check to the wrong person. You know, you need to pay us again, we had to, you know, provide care for service for monies we never received.


Griffin Jones  00:41

RIP Integramed. We go through what happened with Integramed from one practice owner's point of view the rebirth from that my guest today is Dr. John Schnorr. Dr. Schnorr finished fellowship from the Jones Institute in 2001. He joined a group called southeastern Fertility Center at that time as an employed physician became a partner there split off with a partner of his to form his current practice coastal fertility. They were an integrated practice. Now they're not they're independently owned. We talked about what that was like when another company is the employer of your employees and they close the doors. Almost overnight. We talk about the rebirth from that we talk about the landscape of of what it might be like to go with another group versus staying independent. Dr. Schneider has been involved in different entrepreneurial ventures. Now he has a venture focusing on one of his own pain points with the time that it takes for snog furs and other clinicians and other staff to go through the ultrasound process. We talk about that venture and the idea of moving forward as an entrepreneur as an REI. So hopefully this gives some career path ideas for some of the physicians listening and hopefully it also makes some connections. Dr. Schnorr. John, welcome to Inside reproductive health.


Dr. John Schnorr  02:11

Thank you. I'm excited to be here with you today.


Griffin Jones  02:13

I'm interested in having you because you're an entrepreneurial document involved in different ventures, you've been a senior partner in your practice. And so I would like to explore that business route. But let's maybe start with your timeline. You were you. You've been independent. You've been corporate, you've been independent. Again, you've you've been involved in other ventures. So let's start. Maybe not from the beginning, beginning but let's start after fellowship. How do you find yourself in private practice?


Dr. John Schnorr  02:44

Well, I start I did when did fellowship at a place called the Jones Institute in Norfolk, Virginia, came out in 2001. And then I came straight to Charleston, South Carolina, where I am now I joined it at that time, a practice called southeastern Fertility Center, who at that time was run by a physician, Grant Patton and I became an employee and eventually a partner at Southeastern Fertility Center. And it's in Mount Pleasant, South Carolina, which is one of the suburbs of Charleston, South Carolina.


Griffin Jones  03:12

Were you the first employed doc?


Dr. John Schnorr  03:15

There? I was not. So there was another employee doc here at the same time, who actually I think, was even a partner by the time I got here. So there were two partners at the time, and then I was an employed physician.


Griffin Jones  03:26

And how did you choose them? I know that we're used to a time where there are job openings all across the country. Dr. Chen and Dr. Lee have talked about times earlier than when you exit fellowship. Where are you guys? We're, we're delivering babies because there wasn't any job. So what was the landscape like in 2001?


Dr. John Schnorr  03:47

It's a good question. When I was getting out of fellowship in 2001, there was not a lot of demand for reproductive endocrinologist. So there weren't a lot of job openings. I did have a couple of different offers. I had two young daughters at that time. They're now older daughters at that now, but at that time, they're younger daughters, and I wanted a wholesome place to raise kids that I thought would be a good environment to live. Were from the West Coast. I'm from Arizona, but we just felt that Charleston had the right feel to it. And importantly, I wanted an academic connection. And I joined the Medical University of South Carolina part time while I was also a private practice physician at Southeastern Fertility Center, and eventually became the Division Director of musc. And I've now been their division directors since 2003.


Griffin Jones  04:34

So did southeastern become the practice that you're a part of today or did you leave in form another?


Dr. John Schnorr  04:42

No, it melted down in a partnership dispute around 2012. At which time we then started our own practice called Costal Fertility specialist I'm in right now. And I have thought for other doctors that I work with at Costal Fertility specialist.


Griffin Jones  04:59

So Did some of those folks that went on to start coastal with you were they at Southwest southeastern at


Dr. John Schnorr  05:05

the time, one of them was one of them was. So he was with me at Southeastern Fertility Center. His name is Michael slowy. He's from RMA in New York and came actually over to join us in 2009. And then in 2012, we together work to join to make coastal fertility specialist.


Griffin Jones  05:24

Were you a partner at that time at Southeastern? What did you learn from the partnership dispute that you decided, Okay, I'm going to make sure that we're we run our group as we move forward this way, what were some of the important lesson? Yeah,


Dr. John Schnorr  05:39

that's a fair question. It was a partnership, which was run by a physician who was probably 65 years of age when I came to town. And he wanted to continue working. And I think there was some reasons to believe that maybe we should part ways. And so we and the new practice called coastal for coastal fertility, elected that if you're greater than 70 years of age, you need to sell your shares back to the to the company and the company will then employ you at will if they feel that's the right thing to do. So that was one of the core decisions made for the new practice and the new practice. Kosta, fertility is very kind of socialized in a way that we share probably 60% of the revenue, and 40% of the revenue is based upon productivity. And that makes it so you're not competing against your partners, and you kind of it's all All for one and one for all but you still get rewarded for some productivity.


Griffin Jones  06:33

How did you learn to make a model like this? Was it all trial and error?


Dr. John Schnorr  06:38

I kind of thought a little bit about what what did I want out of a practice and I wanted a partner who was a partner, not a competitor, I wanted a collaborative effort. I tend to be a little bit capitalist by nature, that entrepreneur spirit is a little bit capitalist. And that's not my nature to have a socialized kind of approach to things. But I thought it would make it more comfortable and easier. And I think for a successful practice, there's plenty of money to give around. And if you were to craft some crazy, wonderful agreement, so you make an extra million or $2 million in your life. My bet is that doesn't change who you are at the end. And it's the partnership. It's the friendship, it's the collaboration, it's the fun, that changes who you are. And that's the spirit that I wanted to create. So we created a buy in practice, which is fairly easy to buy in because we wanted the best physicians, and we want it to be attractive for them to join us. I've been very lucky with the doctors who have joined me over the years.


Griffin Jones  07:33

So that started with yourself and Dr. Silva in 2012 2012. Dr.


Dr. John Schnorr  07:38

Slowly came in 2009. We formed Coastal Fertility Specialists in 2012. Don't quote me on the exact numbers, but Dr. Heather Cook joined us, I think in 2014 2015, she is now a full partner. We have Dr. Jessica McLaughlin who joined us, I think in 2019. She's now a full partner. And we're lucky enough to have Dr. Carrie Riestenberg, who joined us about three or four months ago, and she certainly on our partnership tract also.


Griffin Jones  08:07

So at what point did Integramed come into the picture?


Dr. John Schnorr  08:13

So when I was a partner at Southeastern Fertility Center, we I think my partner and I, at that time, agreed that administratively we were weaker than we were clinically that we were clinically probably a B plus to a minus grade practice. But administratively, we didn't have some of the skill sets to really administer a practice like that. We thought we might be a C or a C minus administratively. And so our senior partner that time was very interested in Integra med. And in 2007, we became partners of Integra med. The partnership at that time was what's called an MSA or a medical service agreement. That time importantly, entanglement was a publicly owned company that was traded on the stock market. There were probably 30 Other practices who are partners with Integra med. They got a percent of our net revenue, I think that percent was 6% of our net revenue or gross revenue, actually, they got 6% of our gross revenue. And then in that deal, they got 15% of our net profit.


Griffin Jones  09:16

Can we clarify medical service agreement for the audience? Because I think some people think especially maybe some of the newer Doc's think that Integra mat always had an equity model, like many of the networks today do and they did have that model. They did take equity in some of the groups that they worked with, but sometimes they also just had a management verb service agreement, and you talked about medical service agreement. Can you tell us about what that is?


Dr. John Schnorr  09:45

So it was an agreement of medical services that we were going to provide they kind of let us be the doctors and they were the administrators, they actually employed all of our staff. So our staff were no longer really employees of southeastern Fertility Center. They were employees of Integra. permit which will become important later on down the road. They actually manage all of our revenue, meaning that when a check was written to southeastern Fertility Center that got handed to Integra Matic, I put it into an Integra mat account and tigerman within pay all of our bills, and then the the income would come back to the doctors at the end. So whatever profit was available at the end, was given to the doctors got 85% of the profit and Integra mat got 15% of the profit. So that's how that agreement worked. And, you know, honestly, for the first couple of years, they did make us better, you know, they did provide advertising and marketing ideas, they provided management for our Executive Director, they provided decent health care benefits for the staff a better 401 K for the staff. I mean, for the first couple of years, it was good. It wasn't perfect. I mean, they wanted us to kind of you know, not be southeastern fertility as much as they wanted us to be in Tiger match. So there was some kind of loss of identity. And we weren't totally comfortable with that. And they tried to push things that we didn't necessarily want. But I think it's probably pretty typical in a relationship to have some give and take. And for the most part, I think integrity had made us better. And a lot of my business ideas and concepts now probably came from a lot of their teachings along the way.


Griffin Jones  11:16

And so for the folks listening, what you described, part of what you described is a professional employment organization a PEO on the employee side, when Dr. Schneider says that the employees were employees of integrity said that's actually very common. It's very common for organizations between, let's say, five and 200 full time employees to join a PEO. The PEO then becomes the employer. And they're the ones cutting the paychecks they have, because that PEO has 1000s and 1000s of employees, they get better deals on 401 K and health insurance, they broker that type of thing. And that's so that's very common for medical practices, law practices, any type of business between five and 200 people that you said that was it South Eastern, so does that carry over as you went and formed?


Dr. John Schnorr  12:08

Right? So that's a good question. So southeastern kind of melted down around 2012. And at that time, we were forming coastal fertility and Tagore. Matt wanted to be part of coastal fertility, not the old southeastern. And so we crafted an agreement to be part of integrity and moving forward. And that was a very conscious decision showing at that time and temperament was very good for us. We thought it made us better to be part of integrity and and we consciously elected to continue to be part of integrity and in 2012.


Griffin Jones  12:37

So this is still part of the years where, where it's going well for being in that relationship, when and how did things start to change? Yeah.


Dr. John Schnorr  12:47

So you know, the first we got when that things were changing a little bit foreign Tiger men was when they got purchased by a private equity firm. So a private equity firm, called safeguard and September of 2012, purchased all of the public stock that was available, and took Integra mat private at the time. So guard at that time, was a private equity fund, out of Montreal, and actually was owned by a publicly held company called Power Corp, which was also out of Montreal. And I remember very vividly when that announcement happened. We were at SRM and San Diego and they announced this new kind of sale where this was all going to be taken private. And the goal was to get all these additional revenues because they're now private, and then responded back out into the public service for sector for more money. And so everybody was kind of make good money off of that. And we had a big meeting about all of it. And, you know, one of my questions to them was at that time, Warren Buffett was a very kind of leadership person in the field of investment. I simply said, Are you guys buy in long term hold or are you kind of a buy and flip, and they said, we are 100% Warren Buffett, we are going to be in it for the long run. We got you guys got good leadership. Nobody ever says buy and flip do they buy and flip wasn't a word that happened. New Leadership did get brought in some very wonderful people got brought in to Houston, a lot of really neat people who kind of really helped get entanglement up to a better footing. I do think that there was some improvement over the first couple of years. But we started to know that notice that leadership started to leave over time. And so I'd have to think just kind of rolling out numbers 2018 2019, we started to see a lot of turnover of staff. I think I later learned that there may have been a lot of debt put onto Integra mat that they were servicing a fair amount of debt. And so there was a little less profit leftover and maybe some more challenges, kind of keeping things moving forward. So we kept noticing the people we used to interact with weren't there anymore, or they had more roles than they had before. So We started to over time and you know, 2018 2019 got less benefit out of Integra mat. So there'll be less marketing activity, there'll be less insights and people come in to teach us how to do things better. And so I think at some point, we started seeing diminishing return out of entanglement.


Griffin Jones  15:17

Do you have any insights as to why companies do that when they purchase a company that's listed on the stock market, they take it private, I can only think of a handful of examples, cigar doing that with Integra mat. My first employer was clear channel, which is now I heart media, and they were a publicly traded company. And then I believe the Marx Brothers purchased them and took took them back private. Of course, everyone's talking about Elon Musk and Twitter right now. And so those are the examples that I think of why what's the strategy behind that? Do you know,


Dr. John Schnorr  15:50

I think, I don't know for sure. But I think the strategy was to bring revenue in from other sources where, you know, you now have 30 practices, and maybe all 30 practices, which use the same genetic testing lab and they use the same pharmacy, should you be able to pull all this money together so that the revenue could increase, you maybe you can make decisions a little bit quicker than a publicly held company, and then flip it back out into the market once you really amass more income. So it was about making more money. And, and again, this was a private equity firm, who I think was primarily interested in just that.


Griffin Jones  16:24

And so it gets to be 2018 2019. You're seeing changes, then what happens?


Dr. John Schnorr  16:31

So, you know, we started, you know, having some dissatisfaction within our practice about Integra mat, but didn't take any action on that. It's my understanding that eventually Integra mat decided to put themselves up for sale, that over time, the company that owned regard called Power Corp actually had been writing down in their annual financial reporting. Between 2017 2018 I think they were writing down the value of Integra Mattis, who saw the value declining, and they would make statements that they've had some unsuccessful acquisitions and the costs required to reinvest in the company has lowered profitability, and they kind of lowered the value over time. And actually, they put themselves up for sale, I'm guessing 2019, certainly by 2020. They were for sale. And it's my understanding, they had a bitter, we're pretty deep in negotiations, right around the time that COVID happened.


Griffin Jones  17:29

And so then COVID happens. And I know some stories from other folks where they found themselves without a payroll company overnight, they found themselves without HR overnight. And, and as you talked about your employees were at that point in, technically employees of integrity read, so COVID hits and how does it unfold? So it


Dr. John Schnorr  17:53

was really tough for us. I mean, COVID was tough for everybody. But you know, right. When this started going, there started to be national recommendations that the fertility practice has stopped practicing fertility for a while, or at least slow down and what they're doing. And a lot of really great practice chose to do that. And I respect that decision. I mean, I totally understand that decision. But entanglement made their money off of the practice of reproductive endocrinology. So if you stopped seeing patients, you stopped billing, if you stopped billing, you stopped getting collections, if you stopped getting collections, the revenue was kind of dry up for entanglement. And I think they, they frankly, saw that coming. We were one of the practices that didn't stop seeing patients, we continued, we continued at the same pace. We added a lot of security measures, we didn't have any patients get COVID We didn't have any doctors get COVID. We did it safely. And very importantly, we did it profitably. We were profitable every single month. But what we started noticing is COVID kind of really hit around March, around April, we had vendors calling us because they weren't getting paid for the invoices they had out. We had vendors actually starting to deny us services because our invoices weren't being paid. And, you know, we would call Integra mat and say, look, we've been profitable, you guys know, we've been profitable, why aren't you paying our bills, and they would say, well, we're gonna pay your bills. And then we got to the point where they weren't paying the doctors, they were paying the staff, but they weren't paying the doctors. And so by April or so the doctors were digging into their own pockets, to pay the vendors so that we could continue to provide services, and they weren't getting income. So it was a double hit. We weren't getting income, and we were going into savings to try to pay the vendors and that culminated in what became a bankruptcy filing by Integra Med, which was in May of 2020.


Griffin Jones  19:45

And so at this point, you're you've got you got vendors coming for you, you you have to I guess make changes. And for those listening the bankruptcy that was filed in May of 2020 was chapter seven. And for those that don't know chapter For 11 means that you can restructure, you go through bankruptcy court you, you build a plan and you, you put your debtors in positions and you come up with a plan to pay them off and eventually emerge from bankruptcy. Chapter Seven has closed the doors. And so you get so in April, you're already having to dig into your own savings, you're already not getting paid, and then made 20 of those. Yeah. And now we're, we're gone. So how did you begin to replace the infrastructure?


Dr. John Schnorr  20:31

So and so you're exactly right, Griffin. I mean, when we started getting when that bankruptcy was a discussion, we went met with our local attorneys and told him what was happening and that this should be chapter seven. And I'm not kidding. They consistently laughed at us as a bunch of naive physicians, which we probably were that healthcare companies don't do chapter seven, they would do chapter 11. And then I was saying, honestly, I really think there's gonna be chapter seven, no, no, no, they're gonna do chapter 11. Here's how we're going to handle that. Well, they end up going chapter seven, which has gigantic implications for the patients and for the fertility practices, because now they're going to disappear. And part of the thing that really challenged us the most is they had captured all of our revenue. So they had taken all of our revenue, they had all of our patient deposits, we didn't have any of our patient deposits. Patients wrote checks to Costal Fertility, they didn't write them to IntegraMed, we're not going to be able to go back to the patient and say, No, you made the check to the wrong person, you know, you need to pay us again, we had to, you know, provide care for service for monies we never received. And adding insult to injury, they had a guarantee Money Back Guarantee program that they had sold to patients called IVF. Attain, in which the patient would receive a lump sum check, and be given up to three IVF cycles and your money back if you don't give birth. And those were contracts to Integra man, that we felt obligated as physicians running a practice to comply with. And so we ended up providing free care to a lot of patients who had paid us in advance, we never got any of the money and Tiger Man has the money, and we didn't receive any of it.


Griffin Jones  22:12

And how did you replace your your What did you have to replace in terms of the administration? How did you do that in


Dr. John Schnorr  22:20

everything, everything. So Griffin, within about two weeks, we had an EMR that was run by Integra men. We had all of our employees had to go over to coastal fertility, Costal Fertility had four employees at that time, they were the doctors, we had to absorb every employee, we had to actually get a payroll system put in place for all that we had to work our way out of that EMR into a new EMR along the way. And then we had a gigantic legal battle, which was on our doorstep, which we didn't see common either, which was something that became a formidable experience for us. So I have great partners, and everybody was divvied up with a task. One partners task was to find a new EMR and other partners task was to help onboard the new employees. And my task was to be part of this kind of upcoming litigation so that we could survive this.


Griffin Jones  23:13

And so you that that sounds like a great lesson and leadership, by the way of, hey, we've got five fires and four partners and associate or whatever, that or whatever it is, and and breaking that apart. And so as you're, you're you're coming through all of this, then I guess it starts to think about next steps. Were you thinking about how do we emerge from this at this point? How are we going to restructure or in these early months is it simply just keep the ship above water?


Dr. John Schnorr  23:50

Well, what I learned if I'm the first business, southeastern fertility is that when we were melting down, we believed at Coastal fertility, that the patient was going to get us through this, that the one who won the patients was going to win the revenue and was going to survive. And that was true for southeastern Fertility Center. And when we came to the bankruptcy meltdown, we decided we were always going to do what's right for the patient and provide the care that they paid for, even though we didn't receive the money. And so our vision was continued to provide great care, continue to take care of our staff who provide the great care, and along the way, figure out the rest of it. And so that's how we manage that. And there were some very down days and hard times getting through it. But we ended up frankly, as a better company than we were even while we were under entanglement.


Griffin Jones  24:39

So then you start to rise from the situation and people went in different ways. Some groups formed a new group together from entanglement. Some groups stayed independent. Some groups went all different kinds of ways. They sold to new networks that were coming they merged with the practice across time. And they sold to the dock that was in the other city and wanted to come to their city. And so how did you decide the route that you ended up taking?


Dr. John Schnorr  25:09

Right? So so that legal challenge that was presented to us is one that we didn't know anything about, which is that of course, and bankruptcy, the job is to sell the assets and then provide whatever money you get from that to the people who are owed money. And it was considered that an asset to the Integra man was our contract with integrity meant, meaning that in theory, our contract had value. And that value would go to the highest bidder, meaning that our contract would be put up for sale. And the challenge with that is that our contract have voting rights with it. So Integra mat got a full 50% vote at our meetings. So in theory, our contract could be sold to our competitor, who could then come into our boardroom and make whatever vote they wanted and force things to happen, because they outbid somebody else for our contract. And so that became uncomfortable for us. And we ended up working with some of the other practices who were part of Integra Med, in a legal effort to win our contract through court, unfortunately, is, you know, not by accident, bankruptcy was declared in Delaware, which is considered the state most favored for the bankrupt party. And so this all went down in the state of Delaware. And in Delaware, they appointed a trustee who was in charge of liquidating the assets. And the trustee, consistent with prior legal history, decided that our contract was an asset and our asset was going to be put up for sale. And we had to fight that and we had to fight that so that we could become close to fertility itself, not part of another person who could be our competitor or necessarily somebody that we didn't necessarily want to work with. And that became a formidable challenge for us and legal dispute that probably lasted upwards of six months.


Griffin Jones  27:03

I'm not a lawyer, but it sounds to me like the argument would be breach there. No, that's


Dr. John Schnorr  27:09

right. What and our contract it said that you couldn't assign our contract to somebody else. But in bankruptcy court, you can throw that out. So in bankruptcy, a lot of normal contractual agreements can be thrown out of the contract. And the way we want it is actually through a tennis star. So this is kind of an interesting story. It turns out that I think it was Andre Agassi. I'm not totally sure about this. But he had a contract in which he was going to do marketing for a sports apparel company. And that sports apparel company went bankrupt. And his contract with a sportswear company got sold to another company, for example, Danny's. So now Andre Agassi was going to have to mark it for Danny's, for example, and I kind of made up Danny's instead of the sports apparel company. And Andre Agassi argued that that's a personal service agreement. And appropriate personal service agreement is an agreement that involves a relationship of personal trust in which the character reputation skills and discretion are necessary to render that performance. So he's basically saying I agreed as a tennis star to work with a sports of our company, I didn't agree to work with this restaurant, and therefore you can't give this contract to the restaurant and in court. And that legal challenge, he won that. And so that was a precedent by which our attorneys argued that in some ways, the physicians are performers with specific skills and talents involving personal trust relationships with the patients, which require character reputation, skill and discretion, and therefore, assigning that to somebody else would be an appropriate plus, considering that who you're assigning it to would get 50% vote in your practice. Fortunately, the judge saw that favorably in our way, and agreement was crafted in which we got to get our own contract back, we essentially bought our own contract back. And we bought it by providing the free care to the patients and honoring the shared risk agreements that were already put in place by Integra med. So I think the judge wanted to be fair for the doctors, but also fair for the patients. And I realize I'm a biased person in this discussion, but it seems like it was fair, and that the patients did well, and the doctors got the contract back and got to run their own practice.


Griffin Jones  29:33

Listen to that doctors, you might never have thought that you could someday have a career parallel because of Andre Agassi. And yet, and here it is. That's fascinating. You could you've ever predicted something like that would have an impact. And maybe you read that years prior in the Wall Street Journal or something and thought, Oh, that's interesting. And you flip the page on to the next story and And lo and behold, it's Sunday, it has tremendous significance.


Dr. John Schnorr  30:03

I mean, what I was really impressed by the leeway bankruptcy judges have that they can take things you agree to in your contract and say, No, we're not gonna honor this, we're not honor that, like literally in our contract said you cannot assign this to somebody else. And bankruptcy court, they say now that doesn't exist, we're going to take that out. So the ability to rewrite agreements during bankruptcy, I'm sure there's good legal reason for that. But it's something that I didn't understand. And I didn't understand that our contract would become an asset that would be up for grabs. And so that was a little bit of a journey and stressful at times. And, you know, we kind of got through that and got our own contract back and to be able to function at Coastal fertility on our own and done very well with that.


Griffin Jones  30:45

That is fascinating. I wonder if there is ways of crafting language for bankruptcy courts or for that potential contingency? Oh, I have to bring a lawyer on the show to talk about that. But I wanted to ask you, what do you suppose the conventional wisdom was behind when when advisors and and lawyers said Ah, there's that they won't file for Chapter Seven everybody files for chapter 11? And health care? What do you suppose was the the logic behind them thinking that


Dr. John Schnorr  31:18

why they went chapter seven instead of 11?


Griffin Jones  31:20

No, not the not not entanglement, filing Chapter Seven, but rather wide? Why good counsel, that that Utah lawyers, advisors, people that know the business? Well, while they were almost certain that they would file for Chapter 11, thinking you're crazy for thinking that they would file for a Chapter? Well, I


Dr. John Schnorr  31:37

think it's because 98% of the time, they're right in chapter 11. So I think it was just based upon the statistics and how uncommon it was for a healthcare company to do chapter seven.


Griffin Jones  31:46

And is that simply because healthcare tends to be better pay, they tend to be able to get lines of credit more easily, or, or, or get revenue streams back online more easily. And let's say it's an entertainment company, it could be, it could theoretically be anything, it could maybe it's maybe it's a bust brand, maybe it's a,


Dr. John Schnorr  32:06

I'm guessing that the margins were thin enough that they didn't see profitability, and a new company realizing you can wipe away the debt, the margins were still thin enough, and they were challenged enough that they didn't think it was going to be a viable company, even after bankruptcy.


Griffin Jones  32:21

So then some people form a new group other people sell to other groups all over the place, some people merge. So far, you have remained independent, is that right? That's right. That's right. Is that for the foreseeable future? Or? Yeah, that's


Dr. John Schnorr  32:39

a good question. I and honestly, I have a lot of discussions with my current partners, that I think being part of a network can have a lot of positive effects. I mean, we know the negative stuff now after going through all that. But I think the positive is the collegiality, the meetings, where everybody kind of meets together the new freshing ideas about marketing and administrative support, and maybe negotiating on insurance contracts, I think there can be a lot of benefits. And so I still see those benefits, but we also see some of the dangers along the way. And, you know, I think that the important thing that I learned from this is that, you know, venture capital can be good private equity can be good, I'm not against them at all. I think there's some great examples of that being successful. But I think the most important thing is whatever you get into make sure that your interests are fully aligned, that sometimes they're not aligned. And if they're not aligned, if one person is about the money, and the other is about the patients. I think that's right for challengers. I also think it's important to control your own revenue. I think one of the challenges we had is we weren't capturing our own revenue. I think one of the things we did well is we maintained our brand identity, and our reputation and our brand loyalty. So when we did separate from Integra mat, they still knew who coaster fertility was. And I think having an out in your contract keeps it fair, I think it keeps it honest. The ability to have a divorce kind of keeps everybody interested in working together, knowing that somebody could leave if it wasn't working out. So you know, contracts that are quote, evergreen and go on forever without an out. I'm leery of those type of contracts. I think those are contracts that have challenges with them. And I do think all contracts should prohibit assignment. Now. We talked about that not being helpful in and bankruptcy core, but maybe at some level, it's nice to have that around so that they can't assign your contract to somebody else.


Griffin Jones  34:38

We've talked a little bit about that on the show before having an assignment or no assignment clause. Does that preclude some folks from from wanting to buy in to a fertility center though some companies from wanting to buy a fertility center if there's no assignment because hey, if my goal is I want to flip this and three and a half years, I have to be able to assign I have To be able to sell. So would would, could that potentially diminish the multiple that someone received on their EBIT? Da? I guess it makes sense. Well, that's one that that's a possibility. But for all the reasons that you brought up, it's something that you really want to think about. And especially because I'm, I'm completely speculating, but now we have how many networks 910 11, some, some, somewhere around that ballpark somewhere. But I attended 12. And a few years ago, we had a few, I don't think we're going to have 10 to 12. For a while, I don't think we're going to have 18 to 20. Even if we do get close to that number for a little bit, I suspect that these folks are going to be gobbling each other up pretty in the relatively near future, because eventually, there's just not enough practices to buy. And the only way that you're going to be able to acquire other practices is by acquiring the parent company. And in your case, I, I don't need to, to tap your phone calls, I know that you're getting I know that you're getting calls because you're a five Doctor group, and you're in a non mandated state and you've run it so profitably. And so what what is made you not say yes, up to this point?


Dr. John Schnorr  36:15

Well, and so we have received a lot of a lot of calls I know every practice has. And there are some that were interested in and some were not the ones we're more interested in, have a more collegial aspect, which will be kind of they present a toolbox of options, and you choose from the options you like. And if you don't like some of the options, you don't do it. And they give you a little bit more autonomy along the way, and you get to control your own revenue. And, you know, those are the models, we tend to like a little bit more. And so we're continuing those discussions. But we're still very early on in any of those discussions.


Griffin Jones  36:48

Well, let's talk about other entrepreneurial threads that a physician can pull, whether they own their own practice or not. But I have often thought that when you either work for a company or you own a company, you get to at least form a good hypothesis for what could be a market need based on your own challenges. And so you have done that in the in the cinematographer space and, and perhaps others, but I just like to hear about what you're delving into now and what got you into it.


Dr. John Schnorr  37:24

Right. So I've always kind of had a little entrepreneurial spirit, and I've always wanted to try to make the world a better place. I'm the guy who was always trying to think about what's the pain points now and how do we make those pain points better? And I've always found I remember back in my fellowship days, one of the pain points was doing ultrasounds of follicles. That when we were doing that I was the doctor considered measuring big. So whenever they looked at a measurement that snorted, they would say, well, it's you know, he measured 19 millimeters is probably 17. Or, you know, they would always kind of discount my measurements. But we'd have other fellows that they said, Well, he measures small, so we're going to add to him. So we're always kind of using these kind of fudge factors and kind of measuring follicles, and also thought it was a fairly tedious process measuring these follicles. And so around 2019 or so I was reading The Wall Street Journal one morning, and there was a big article that showed that artificial intelligence and this prospective study was able to identify breast cancers as well or better than radiologists looking at the same mammogram images. And those images that were put up honestly, I looked at I couldn't figure out where the breast cancer was right. I mean, a reproductive endocrinologist don't have a lot of training in that. But AI is seeing this breast cancer as well or better than radiologists. So I thought well, to me, that's fascinating, right, a second pair of eyes on a breast cancer very important. What could it do in the space of reproductive endocrinology. And it dawned on me that maybe we could use ultrasound and apply artificial intelligence to the ultrasound images, so that we can identify and measure the follicles within the ovary with the benefit, maybe we can do it faster. But also maybe we can standardize it. So there aren't people who measure big and small, they're just people who measure kind of that standard measurement. And so, you know, being the entrepreneur, I didn't want to put a lot of money into without seeing if it was, you know, patentable or already patented by somebody else. It was open space, we were awarded three patents and the ability of artificial intelligence to see follicles. We then went in search of an artificial intelligence company who could help us do this. And of all places in the Ukraine. There is an artificial intelligence group that was measuring with artificial intelligence when the football went across the line. So they're able to track a football going across the line. They're working with backup cameras from cars, they were doing a lot of really neat things. And they thought that they could help us with this project. So we started a pilot project where we just looked to see if we could do this and track a follicle. It turned out to be successful. And then with a whole team of annotators, literally, we annotated 19,000 Varian images, they had over 90,000 follicles where you're showing repetitively where a follicle is within the ovary so that artificial intelligence can learn what a follicle is and what a bladder is, and therefore more accurately read the ultrasound image of the ovary.


Griffin Jones  40:24

How did you find the team to work with in the Ukraine in Ukraine is at this point, are you are you googling artificial intelligence developer


Dr. John Schnorr  40:33

and started with Googling, and then have friends who are in the space who were using AI and maybe the legal field and other areas who would point me in directions and, you know, we would kind of interview each other to figure out what they've done in the past talk to their references can figure it out, and then put a small amount of money into it to figure out if they can actually get a private pilot off the ground and see if it's successful at an early level, it was very inaccurate, early on. But the proof of concept that we could track a follicle and see a follicle and discriminated from the bladder was what I needed to know. And when my belief was, as I annotated more and more and showed it more and more, it would get more and more accurate. And in fact, that happened to the point that our accuracy rate went to above 92%. With a dice score, which in artificial intelligence is the way you measure the accuracy. It's a combination of accuracy, precision, and recall, that gives you this dice score. And to get a dice score above 85% is good. We got up to 92% by annotating over 90,000 follicles now, that was a mind numbing process. And I reviewed every one of those annotations to make sure they were done accurately so that we had an accurate platform on the other end.


Griffin Jones  41:44

Are you bootstrapping at this point? Are you talking to VCs? So and and even now are when you said you've got patents, I immediately thought oh, they love patents on Shark Tank. Every time somebody uses the word patent on Shark Tank, the sharks get reengaged. And so that made me think of venture capital are you talking with with VC now? Are you hoping to continue to bootstrap?


Dr. John Schnorr  42:07

Yeah, certainly, we'll talk with anybody it's been bootstrap now. But we'll talk with anybody. The challenge that we didn't see common Griffin, was that the FDA considers software that reads a medical device or medical image, it considers that a medical device. So the FDA says that they have to regulate our software just as if it were a hip implant. So that was a challenge. We didn't see common. We ended up doing five clinical trials to prove to the FDA that we had an accurate safe product. And we received FDA clearance in January of 2021. So this is now a product that's available on the market called cycle clarity.


Griffin Jones  42:48

And so at now, you're beginning to to unroll the product did start with using it in your own practice was was getting your partner's to adopt a part of you. I mean, when you were when you were quality checking the AI, you were doing it yourself. But in terms of adoption, were your partners, the first people that you are trying to get on board.


Dr. John Schnorr  43:12

And so you're right. So the FDA is jurisdiction is you can you write your own software, you can use your own software, but you can't sell your software until you get FDA approval. And so we have been using this artificial intelligence application since kind of early 2021. And so it's now been functional at our office for a significant period of time. And I have great partners who I think probably were a little leery at first with what I was doing. And they kind of gave me a little leeway. And I think now they look at this is an indispensable resource within our practice that it allows us to do a variant ultrasounds that take 10 seconds per ovary, literally, you put the probe in, you push the button, it scans to the ovary, it feeds the results directly to the EMR, it does the same to the left ovary. And what an ultrasonographer will do is they'll come in the morning, they'll do maybe 20, back to back ultrasounds each taken a minute, two minutes, three minutes, around 10 o'clock. Once their morning's done, they're gonna review each of the images takes about a minute to review each image, and then it gets put directly into the EMR, what my partners will tell you the greatest value is or the second greatest value is that anytime any day they can review every one of you have any images from top to bottom to make sure as accurately read and try to correlate any differences between estrogen levels and progesterone levels. It gives a second look a second opinion. And I think they would tell you that's probably one of the greatest values.


Griffin Jones  44:44

Have you ever done a side venture like this before where the where it wasn't just the main business in your main business being the practice? Have you done ventures like this that aren't the main business in the past?


Dr. John Schnorr  44:58

I have I was fortunate to be part Part of donor egg bank USA, which I've learned a lot from Michael Levy, who is a great person and created a great company with Heidi Hayes. Prior to that, I had written some software for OB GYN training for their board examinations. And so there are many different times when I've kind of done things on the side that have been beneficial. And I've enjoyed that I enjoyed making things and building things, and watching it grow in a way that you're impacting millions of people, rather than that one person in front of you as a physician day in and day out.


Griffin Jones  45:29

What big differences do you perceive, if any, between starting a venture in a space that's relatively unexplored? It's it's, it's a new technology taking over for something that is analog and inefficient, versus starting a proven business model, like an REI practice? What differences do you notice it's the


Dr. John Schnorr  45:51

risk model and the lack of guarantee, and it's the capital investment. I mean, a lot of capital was invested in this artificial intelligence company, where probably somebody would have given us a 5% chance that we can even create a platform that works much less read it accurately. So I imagined going into this, it didn't look like this was going to work very well. But as it started to build, and we got more and more smart team members involved, who all had their own expertise, I mean, we have a chief technology officer who's amazing senior engineers that are amazing. We have a data scientist specialist, we got a Chief Operating Officer, we have medical device reps, who are integration specialists. We're now in seven different web contracts with all the large major networks except for one. And we're in seven different locations, we have 17 different offices. And right now we have over 45 different people doing ultrasounds. And importantly, they all offer Sam with the same degree of accuracy because there's AI doing it. So you know, the benefit becomes, you no longer need to be a physician working at the bottom of your license doing, you know, follicular ultrasounds, you can be a medical assistant working at the top of your license with cycle clarity, getting the same measurement accuracy as to reproductive endocrinologist, while the reproductive endocrinologist is now seeing patients. And our own studies show that we'll say four hours of physician time per day, four hours per day, for a clinic doing 1500 or more cycles per year, and IVF, allowing you to see more patients to maybe do more surgery, do more retrievals and let the medical assistants do or even the ultrasound ographers do the scans. And then if you have any questions about it, when you do STEM review, every one of those event images will be there for you to see from top to bottom.


Griffin Jones  47:39

I've recently had Dr. David sable back on the show. And the thesis behind his investing strategy is that we have to be able to expand the number of people that are served by art in the country and worldwide, and that the quality cannot decrease as cost decreases that the current standard for quality has to be the standard cost needs to be lowered from there. And technology lifecycle clarity has to be a part of that solution. It sounds like what you're working on has a piece of that really well thought of. But when I see challenges of models like that being adopted, it has to do with clinic workflow, and that there's just so much variance in clinic workflow, that there have been really good tech solutions, and some of them are still out there. And some of them are being adopted, but many of them not as fast as I think that they probably ought to be. And it's because there's so much variance in clinic workflow. How do you overcome that?


Dr. John Schnorr  48:45

Well, and I think you're I think you nailed it, I think our greatest challenge is synthesis change. And even though it's positive changes change, and change is hard. And change takes inertia. And it's got to be painful enough that you make that change. And so our job is to find clinics with good leadership from the physicians who say this is going to be a positive change moving forward. We're going to implement this we want to you to put effort into this ultrasound, ographers gnamaize, and physicians to make this work. And with effort we've been able to show it coastal fertility and now seven other centers that it works very, very well. And at Coastal fertility. What matters the most is the number of eggs retrieved. The maturity of the eggs retrieved the fertilization rate, all the embryology endpoints that matter the most were unaffected or improved by using artificial intelligence. So this application can help you forecast when to do the egg retrieval when the most number of embryos are going to be there and how to improve pregnancy rates. And importantly, it uses the center's specific own embryology data through our data science experts and artificial intelligence to figure out when the best time is for each particular clinic.


Griffin Jones  49:52

Do you see yourself moving into this type of entrepreneurial role full time and I didn't just I don't just mean like real clarity, I mean, you could probably sit down and write down all of the pain points, the analog pain points that you have, as a practice owner as a clinician, you maybe you already have written them off. And you could just start saying, well, now I can work with AI developers on this problem and on this one, and so do you see yourself doing this full time?


Dr. John Schnorr  50:21

It's it's a great question. I love being a physician. And I think ideas come because you're a physician, you're currently seeing patients and you're seeing the pain points, and you're able to evaluate your own product and your own clinic. So I never see a time in which I'm not a majority physician. But you know, could there be a time when I dedicate more time to kind of maybe cycle clarity other things? Yes, I mean, that's a possibility. But I always want to have a significant part of my time being take care, take care of patients. That's what I love.


Griffin Jones  50:49

You got to keep the sauce sharp. John, you've given us gold in this episode, I think a lot of the young doctors are really going to get a lot out. But I think a lot of your colleagues are also going to and I hope that there's somebody that you used to talk to a lot that you just haven't in a little while that says, you know, I want to reach out to John and say, I enjoyed it. I hope I hope somebody does that. That's my pious hope. The only difference between a sinner and a saint is a pious hope. But how would you like to conclude knowing that most of our audience is there are a lot I would say if there's 150 fellows that at some point, maybe 50 of them are listening, there are a lot of young Doc's, the biggest segment is is partners of practice. And then the next is is C suite. So you've walked us through an entrepreneurial path for Rei is how would you like to conclude,


Dr. John Schnorr  51:40

I would like to conclude that we're blessed to be featured in the field of reproductive endocrinology, I mean, what a special place where and to help couples have kids and families that they wouldn't otherwise have. And I just as an entrepreneur, always wanted to make the world a better place. Whether I'm making it a better place because I'm working on environmental concerns or method. Maybe I'm trying to invent a better speculum, or maybe a better way of doing ultrasounds. I think we should all just work on our own little niche of our world figure out what our talents are individually and how we can apply those to patient cares to make the world a better place.


Griffin Jones  52:14

Dr. John Schnorr, thank you for coming on inside reproductive health. Hope to have you back. Thank you.


52:21

You've been listening to the inside reproductive health podcast with Griffin Jones. If you're ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society, visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health



162 4 Principles For Abandoning The Travel Agent Model Of IVF Care: With David Sable and Abigail Sirus

Former practicing REI, David Sable, and venture capitalist, Abigail Sirus, deconstruct how democratization will change the face of the IVF field. Sable and Sirus break down the four principles of how this will be accomplished, perhaps sooner than anyone anticipated, on this week’s episode of Inside Reproductive Health, with Griffin Jones.

Listen to hear:

  • What Sable and Sirus believe will happen when the travel-agent model for IVF care is abandoned and patients are empowered to oversee their own care.

  • Griffin question what risks this evolution may introduce to both patients and practitioners.

  • What Sable and Sirus think may happen to incumbent REIs- whether or not they will  be phased out entirely.

  • Why Sable and Sirus believe, one day, patients will pay for IVF if - and only if- they have a baby.

Reference:

https://dbsable.medium.com/the-four-guiding-principles-for-democratizing-ivf-pre-asrm-2022-prep-notes-from-the-front-lines-of-2f2fd66e5d8d


Abigail’s info:

LinkedIn: https://www.linkedin.com/in/abigailsirus/

Company: AWM Investment Company Inc.

David’s info:

LinkedIn: https://www.linkedin.com/in/davidsable/

Company: Life Sciences


Transcript

Griffin Jones  00:26

Netflix? Or are you Blockbuster Video? Or are you HBO? Or are you some other analogy that should be applied to the fertility field as we talk about the massive change that is coming from venture capital to the field of reproductive health. My guests today are Dr. David Sable, who needs very little introduction to you all. This is his third time on the show former practicing REIi also teaches at Columbia University for classes on entrepreneurship also manages a fund for Life Sciences. Today, we bring on his colleague, Miss Abigail Sirus, who is a venture capitalist and investment associate for another life sciences Innovation Fund. She had at IBM for another number of years before that, today we talk about the four principles for democratizing IVF. We get so engrossed into these principles and the changes that might be happening in the marketplace and who might be executing upon them that we're going to have a part to where we go through some of the mapping where of the areas of biggest potential disruption for the fertility field, I felt that we needed this conversation to set up the next one, and I don't tire of having Dr. Sable back on the show, and you don't seem to either. So until you do, then these multi part series make sense today enjoy the four principles for democratizing IVF. With Dr. David Sable and Abigail service. Ms. Sirius, Abigail, welcome to Inside Reproductive Health. Dr. Sable. David, welcome back to Inside Reproductive Health.


Abigail Sirus  02:08

Thank you for having us.


Griffin Jones  02:11

I'm always happy to have Dr. Sable. Back on the show Abigail, this is the first time that you and I have met. And I want to talk about an article that David wrote recently based on work that the two of you have done together. But before we get into the article, just give me a little background. How did the two of you link up? Sure,


Abigail Sirus  02:29

I'd be happy to. So Griffin, David and I actually had the pleasure of meeting on a project at while I was at my previous company, IBM, I was a blockchain strategy consultant. And David was actually one of my clients. So we in that instance, we're trying to create a blockchain enabled system called IVF, open to really bring standards to the way that biospecimens are stored and tracked and traced along with chain of custody for in vitro. And I admit, you know, Griffin, I'm actually the product of IVF. So my twin brother and I were born via IVF. And it's it's truly a miracle that, you know, I really wouldn't be here without. And so it's always had a place in my heart and been special to me. But when I got to meet with David and several others across the industry now a few years ago, and do this project together, my eyes were really opened to the industry in a new way. And I'm a process minded person. And when I started to understand the inefficiencies across the space, it really started to inspire me and grow my passion for all of the opportunity that is here. And things that we can can kind of bring to light through innovation, which I know we'll talk about a little bit


Griffin Jones  03:42

later. But what came of IVF open?


Abigail Sirus  03:45

Absolutely. Well, I'll let David answer that question.


David Sable  03:49

Thanks, Griffin. Thanks for having us. having me back. And having Abigail on. Going back to the decision to bring Abigail on I try to endeavor to be the dumbest person in the room. Wherever I am.


Griffin Jones  04:00

It doesn't work when you and I are hanging out.


David Sable  04:04

Well, certainly when she's around, it's today. That happens. But now IVF open was we likened it to building drainage ditches for to let the IVF industry scale try to help you and I might have talked about it briefly trying to have one place that assigned identifiers for frozen eggs and embryos so that nobody ever was stuck someone's eggs and embryos for somebody else's. And nice thing is it kind of got it's been taken up by a lot of the private industry incumbents and made part of their kind of overall strategy. Training Group enforce these kind of rules by a nonprofit is a difficult thing to do. So having kind of the industry say yeah, this is a really good thing to avoid these problems. Let's go ahead and try and see if we can build into our her handling of specimens, a uniformity of labeling. And that'll evolve in a nice way kind of organically. within the industry, what we did is we tried to put all the incumbents together into a single, not a room and single single zoom screen. And, you know, it really it's it was great was that everybody got it. Everybody understood, and left the effort, which hats off actually to Risa Levine, who you know, who's a super patient advocate activist in this field for kind of getting the whole thing off the ground. And the other great thing that came out of it is I got to know Abigail, because IBM was a big partner of ours, in that. And then when I was looking for someone to join me, actually just having us if you know anybody, and she said, Well, how about me? I said, well, they knew you were available, I wouldn't be asking. So I brought her on as soon as I could. And that's been terrific. She's been with us for almost a year. Now.


Griffin Jones  05:57

Let's talk about the article that brings us here today, which is about the four principles for democratizing IVF, the four guiding principles for democratizing IVF. And this was an article that you published just before ASRM David. And there are four principles, I have a feeling that we're going to go into the third one disproportionately today, at least that's where my disproportionate interest lies. But the four principles for democratizing IVF are abandoned the truck travel agent model for IVF patient care, use the gravitational pole, foreign by incumbents making today's highest pregnancy rates, the floor of outcomes for the future. And fourth, using greater certainty uniformly higher outcomes and improve data collection analysis to actually quote, qualified data leading to better risk management, who will talk about the four of those principles? Let's start with the first one. What do you mean by abandoning the travel agent model of IVF? Patient care?


David Sable  07:05

Well, yeah, 30 years ago, if you wanted to take a grand tour of Europe, you call up a travel agent. And they would book your flights for you book, your hotel, book, your tours, make reservation restaurants for you add up the bill, put a big margin on top of it send you one bill, and he'd write one check. And it's a it was a way of getting things done. And it's a nice model, if you a can afford it, be have access to a great travel agent. And see they actually give you what it is that you want. For the IVF world. That's kind of what we have. Now you go to an IVF clinic, you say I'm having difficulty conceiving, and the incumbents in the clinic make all the decisions for you. And they charge you one amount. So your input really comes down to just choosing a clinic. And they make all the decisions for you from there. What the future of IVF as we foresee it, and the way things seem to be evolving, as we disassemble the cycle into different places, into geographies closer to where the patients live. Using our inputs more efficiently, not putting everything into a $2,500 a square foot laboratory is that the patient herself or the family themselves will be able to choose maybe being monitored one place, have their egg retrieval somewhere else, take the rigs store them somewhere else. In initiate contact with the laboratory, once the eggs are frozen, and maybe bring your reproductive endocrinologist into the process later on. Giving the patient the opportunity to choose to stay closer to home do some price comparison shopping. Really the way we purchase just about everything nowadays, there's no reason that IVF cannot evolve into that model, which will result in greater access, more price comparison we have more price choices, and an ability to kind of oversee one's own care the way you can do so many other choices now in the marketplace.


Griffin Jones  09:24

Maybe we'll bring this up a little bit when we get to the third point where we talked about dollars until baby and time until baby in life disruption to baby but is there a risk if you are abandoning the travel agent model the all in one model by choosing your clinic of having death by 1000 cuts like I don't think the airlines have added a lot of value the Spirit Airlines and the Frontier Airlines by having people choose if they want to bring a carry on if they want to pay more for that or if they want to pay more for not having a middle seat and maybe there's something to be said For the Southwest, and the jet blues and the Alaska's that have brought down cost without making people have to nickel and dime on an each individual micro choice. But what about that?


David Sable  10:14

Well, I think that if you're looking at people, yeah, if you're looking at the people who have access to air travel now, without a very, very low close budget airline, we have to pay for your seat choice and pay for each bag you bring on. And there's no food and there's no flight attendants, then it may not be very additive to them. But we have to ask ourselves, and you have to start every conversation the same way, what problem are we solving. And if we're solving for access for the next million, 5 million people per year that need IVF, that have no access to it now, then they may be more than willing to, at a price point in a geographic location that works for them suffer and endure some of those little cuts of inconvenience. Whereas if the choice is they have no access to IVF at all, then were you kind of opening that consumer choice up where it will matter, people don't want to buy an IVF cycle, they want to have a baby. And if I, you know, look at some of the inconvenience and the things that people endure now to go through an IVF cycle, including traveling 1000s of miles, and taking off at 40 hours of work, per cycle, in order to go back and forth to the clinic to be monitored things of that sort, then, you know, I don't want to make consumers and patients decisions for them. I think that as you expand the market, you know, our big goal is to go from 3 million cycles a year to 30 million cycles. We've got to give a lot of different patient experiences, put them into the market, and let the patients slash consumers themselves decide.


Griffin Jones  12:06

You brought up the point of I don't want to make the patient's decisions for them referring to the travel agent model, but I can hear a number of RBIs thinking I make patients decisions for them. That's what my job is. What decisions are patients qualified to make? And maybe perhaps they're not qualified to make? Like, are we talking about picking their own PGT? Provider? Are we talking about picking where they store their gametes and their embryos? Are we picking where they're pharmacy to? What are what are we talking about


David Sable  12:44

all of the above? It's so amazing again, when I met Abigail, who had not yet had another than professional reasons to learn about it. She was incredibly knowledgeable about the process, the science, the medicine, everything there was I remember thinking, what was your healthcare background in college, this is like somebody who's like a pre med that decided to go into data and analytics. Turns out years an accounting major, pretty good accounting major imagine my patients knew so much about what they were undergoing that, why not entrust them with the ability to comparison shop for the best IVF process that works for them. Rather than have us decide for them. You look at the range of pregnancy rates from one cycle from one program to the next. And through the United States and through the world. Here we're doing about 2.6 million cycles per year, worldwide, hitting about half a million babies, tells us that our efficiency is somewhere between 20 to 25% per cycle worldwide. We know we have clinics here in the US that are doing 65% per single embryo transfer, if that embryos genetically normal. So there's an enormous range. So to think that the de facto proper way to navigate your IVF cycle is to put all the decision making in someone else that may turn out to be the case. But why? Why do we assume that's the only case. And again, this is within the context of trying to expand the size of the marketplace, to people who really, really need IVF not to have a baby or to have a healthy baby or to get pregnant at all by a factor of five or 10x. So it's the putting different choices out there. It's we go back to our old metaphor of we have an IVF industry that's the hotel industry with just the four seasons Is the Ritz Carlton. But we got a heck of a lot more people that need a place to sleep. And essentially, their frame of reference may be give me a comfortable bed, and a clean bathroom at a price I can afford. And they'll get the same eight hours of good sleep that you'll get in the Ritz Carlton. If we keep people the same probability of having a baby. And we're transparent enough in the marketplace the same way all other consumer marketplaces are going, then why not interest this the patients, again, because a lot of these people would have choice would have no choice at all, it'd be out of the market. And so I think that the REI is have done a fabulous job of making these choices up to now. It's great, and they should Oh, this should always be a place for them. And high touch high hand holding, kind of decision making for you service is fabulous the same way. There's still great travel agents out there. But it shouldn't be the only choice.


Griffin Jones  16:02

Well, not to defer to anecdotes. But hopefully to give some context, Abigail, during your journey, were there. segments of the journey where you wish that you had decision making authority that you could have opted for the option that you wanted? Or did you choose any options that are now informing how you view this from a business perspective?


Abigail Sirus  16:26

Yeah, and just to be clear, I do not have an IVF baby. I was born via IVF. So I can't speak directly to the process itself from that intimate of a perspective. Although, you know, who knows, maybe I will, I will one day. And I'll come back. And you know, we can have another discussion. But what I can tell you is just from observing the industry today, as David said, not only about the hotel chain model of making sure that there are the Holiday Inn expresses as well as the Ritz Carlton's, really, for us as well. It's about geographic access, and making sure that, you know, a teacher in Des Moines has just as much of a chance as having the family that she so desperately wants as anyone who's right near our office in New York City. And it's only by increasing that optionality and bringing services to patients through you know, at home monitoring and other innovations that we're seeing that we'll be able to bring those models to bear, which is part of what I'm so excited about coming from IBM, where we were doing consulting projects with innovative technologies, like blockchain, and AI and quantum computing, and starting to see some of those models take shape in this industry as well, is just, it's just the tip of the iceberg.


Griffin Jones  17:35

You talk about that there should be a gravitational pull for incumbents. That's the second principle of democratizing IVF. But is there often an inherent conflict from incumbent, Dr. Harrington sent me a book by Clayton Christensen, who is the author of a theory of disruptive innovation, or at least one of the theories behind disruptive innovation where he charts out the corpse of blockbuster and other incumbents that were simply dis their disincentivized relative to their current model, their expenses, their profits, their current obligations, against someone that's coming into the marketplace that doesn't have nearly as many obligations, they don't need to make as much revenue. They don't have current infrastructure as expenses. So you talk about using a gravitational pole for and comments or at least ideally, there should be one. But isn't there not one very often almost by nature?


David Sable  18:41

The agreement? It's great question and when we mapped out the strategy for reengineering IVF. The second principle really came down to the best what knew in the best circumstances, this will be steered, managed and navigated by the income. It's the people that know it best. You know, the experienced Ori eyes the best embryologists, but recognizing that there is a natural, rational and perfectly reasonable, kind of, you know, inertia towards changing the way you do things like frankly, when I was running a busy IVF program, I was making a good living, I was employing a lot of people. And I was busy as all hell. So if you came to me and say, Okay, it's your job to, you know, open up the world. So that the next million, 5 million 10 million people have access to it. I'd say listen, it's a nice idea. But where am I supposed to fit that into my schedule? So going from anecdote to generalization. You know, Eduardo Harrington is as visionary as any young Rei out there. And you recognize that you can't really rely on incumbents. So To do all the heavy lifting for you. So the way we look at is we can do with them, we can do without them, we can do it with the existing Rei infrastructure. And we try to make it in their best interest by looking at their operational capacity, looking at the limitations of the inputs, where they're bottlenecks are in their process, and trying to come up with solutions that make them able to expand what they do in a less costly manner. And they can decide to triage that input any way they want, they may decide to expand their geographic reach. If we cut the IVF cycle to three parts, retrieval and freezing being one part, storage being a second, and then thaw fertilization, development and transfer. Third, they may decide to have retrieval stations all over the place. And they may take their existing satellite offices and use them there. They may do alliances with large OBGYN groups in rural areas. To do them there, they could do them. alliances with other programs, leveraging the real estate that they have, they can use decision making decision support software to put 10 times the number of people through stimulations. And so the army on duty Rei on duty only needs to look at four or 5% of the results each day because the computer will make the same decisions that they are, you're all different ways that we can facilitate their operations. So in that way, we like to think that the incumbents are going to be served by innovation. But if they choose to keep things the way they are, which is perfectly okay, if some of these programs are doing fabulous patient throughput, terrific care, great results, then we can use these technologies to reach patients that have otherwise no choices by bringing other people into the marketplace as suppliers. In a way that maintains the quality of care, because we're gonna be using a different engineering, different data analysis, and different process optimization, try to arrive at the well, the well run IVF kitchens that exist now. So we can do them with these people without a lot of what we do in IVF is repetitive things that over and over again, a lot of embryology will lend itself to automation, robotics, things of that sort. So that way we can build the kind of bigger parallel industry that can take that next 10 million people in that aren't being served. And the incumbents can choose to participate wherever they want to. We want to make it easy for them to do so without giving them absolute control over who gets to be treated worldwide. Because again, what are we solving for? We're solving for access. And the size of marketplace not being served is a lot bigger than the size of the market currently being served. To the incumbent people. We embrace them, we want them to do a fabulous job. But we don't want to be in a position. And if we're acting as advocates for the unserved we don't want to give them control over who gets to be treated who doesn't.


Griffin Jones  23:32

Incumbents can be served by the innovation or it can be done without them. It sounds like you had a I wasn't at your talk at SRI. But it sounds like you were a little bit more stern with that message at SRI, what are the consequence? What did you say their first second, what are the consequences if they if they choose not to be a part of the innovation?


David Sable  23:58

Oh, it's a it's a competitive marketplace. You know, the right now we've got a small number of suppliers, with a enormous reserve army of new patients that are trying to get in and more and more patients getting coverage as well. Their coverage from employers, state mandates, things of that sort. I guess the the downside to not participating is you're locking yourself into a model that we may or may not be able to replace that you go into, you know, what are the what does a patient look at when they're trying to make a decision to how to navigate their journey? And Abigail and I came up with three key performance indicators. It's using an MBA term, but it seems I just saw the patients silently make these decisions. For the 20 years I saw patients dollars per baby time until they have a baby and the life disrupt Should they have to endure to have a day, every patient is solving for those things. And those are our North Stars in trying to kind of navigate or map out how we reengineer, the IVF worlds. So if the clinic existing now is operating at capacity, and they have full control over the pricing, it's exactly what you want as a supplier in any industry, you want to operate, you want to be as busy as you want to be. And you want to be able to charge what you want to charge. And this is not a value judgment, every economic actor is kind of solving for that. But they're operating within an environment where there's a cost structure, there's an access structure. And if people have no choices, then they're the kind of a, you know, they're at your whim. They, you know, the there, they have to serve under the parameters that you set. Now the markets can change. And if we put out a, whether it's technology, whether it's using AI, whether it's finding alternative practitioners, whether it's opening of centers closer to them, we're suddenly those dollars per baby time to baby in life disruption are much more skewed in the patient's favor. and to hell with it, I'm no longer going to the ball of the ball to buy a bookstore, to buy a book, in a big bookstore, I'm going to do it online, I'm going to download a Kindle file, I'm going to have all these other ways of fulfilling my need for a text file called a book, I'm gonna have all these other ways of fulfilling my needs to build a family. And the incumbents if they don't fund either change their marketing strategy, change the way that they fulfill that or, you know, maybe they maybe they're still doing such a great job, that people that want that higher touch, higher cost, higher travel type IVF experience will continue to come to them, which is great. It's a really it just puts that competition into the marketplace. That, you know, it's all doctors always say, no, we want the free we want free market medicine. Well, this is free market medicine. But it's free market in a way that the patients have access. And the patients themselves have choice. Not were the providers can rely on monopoly power to keep their keep their practices the way that they are now,


Griffin Jones  27:32

Abigail, are there some segments of incumbents that you see more vulnerable as others going back to the blockbuster example, that's the example that's always used in every business course is used in mainstream everyone knows that example. huge corporation in blockbuster, within a few years being totally supplanted by now a titanic Corporation of Netflix. But I think the story that almost no one talks about I don't ever hear anybody talking about is no that was HBO. So HBO live to tell the tale. And as far as I know, they're still doing well, I haven't looked at looked at their performance or their stock prices or anything. But as far as I know, HBO is still doing just fine. But that Netflix space in the market was HBOs to take and somebody came out of nowhere. Netflix and did it. But HBO had the same considerations. They didn't suffer the same consequences as blockbuster but they lost the land grabs, are you seeing some incumbents that might be more vulnerable than others and, and in different ways than just you know, being being supplanted? Entirely?


Abigail Sirus  28:48

Yeah. And it's funny, you bring up the Netflix and blockbuster example, because that's one of the first cases I ever read in college. But I think about it informed two ways, in terms of incumbents first, who are not going to be willing to innovate, and bring in new practices or new processes or see things in a different way, which I think of as blockbuster. They're the ones who are sitting there streaming was coming to a head, we were seeing, you know, it becoming less and less expensive, with the compute power becoming more optimized, and they decided not to change their business. And because of that, they were usurped by Netflix. But then we have also the incumbents who do a specific part of the process or have their specific niche, just like HBO does, and creating their own content and being extremely good at that, and creating a name for themselves in that way, who will continue to have their corner of the market based on what they do well. And so I think that for the incumbents who are choosing not to innovate, they potentially might be at the most risk. Because, you know, I think it's good to see businesses growing and changing and adopting new modalities in ways that might be better than they ever were before. But then there will also be the HBO models who are very good at doing so. specific things, maybe they have a specific capacity where they have a number of genetic counselors on staff, or they can focus on specific, you know, more complicated journeys than others can like an HBO model, and they will be able to survive as well. But generally, you know, I think we keep focusing, you know, we've we've got Thanksgiving coming up this week on kind of this pie. And speaking about these incumbents who have really in the scheme of things, just a small sliver of the pumpkin or pecan pie, but the the pie is quite large. And so I think that there's vast opportunity for incumbents and new players to come into the industry together, and to create innovation that can improve the patient experience and make it more accessible for all.


Griffin Jones  30:39

Let's talk about the third principle then of what needs to happen in your view, in order for that to still be successful. That which is that today's highest pregnancy rates should be the floor of outcomes for the future, that it's not about delivering a lower quality product at a lower cost. It's keeping the main metrics of dollars until baby time until baby and life disruption to baby at the forefront at the forefront, excuse me. But aren't those three principles very often in conflict with one another that if you reduce the time to maybe you might have to increase the cost of AV or vice versa.


David Sable  31:28

One of the things that we learned when we started examining the IVF industry, as an industry that eight years ago, is that it's really characterized by outstanding science and really mediocre engineering. It's, you know, the you look at you in my career that pregnancy rates when I came out were middle single digits by putting back three and four embryos at a time. And we didn't touch the egg. So the idea of sticking a needle into the egg to do insemination with the sperm was just beyond us, much less doing things like genetic analysis. So the progress has been just remarkable. And the fact we have anybody that can have a baby, that can create a baby, more than half the time with one embryo routinely, on average, is that seemed like a million years in the future, back when I started being exposed to this in the 1980s. But that being said, that means that someone has cracked the code to get that high. And what is engineering engineering is just getting everybody on board to these best practices to do is to do things as well as everybody else. And if our goal is which we think it should be that anybody that needs IVF, to have a baby has access to IVF, say to a baby, then we've got to proliferate these best practices. Now, there are some people who are more talented than other people for manual procedures. And if we look elsewhere in cell biology, and we look elsewhere, in manufacturing and engineering, we see that these things can be standardized, to using robotics, using machine learning, two way that everybody can operate at the highest level, we will migrate to that it's unavoidable. Every industry that's tech based does that. And the sheer size, the sheer enormity of the demand for IVF services is going to migrate the best clinics to higher and higher pregnancy rates, they're much higher here in the US than they are in the world average, you're very high in areas of Western Europe and parts of Asia. And that will it's just a matter of time, get up there, we will collapse the pregnancy rates always upward finish. Now that said that means as we engineer and as you do more and more process optimization, those rates will be even higher. And that leads us to probably the biggest innovation, which is really going to disrupt this industry and I also think is inevitable, unavoidable and an unequivocal good. Is that shows you how bad I am at writing articles because I completely buried the lede. But I wrote that because the real big point that I was trying to make is that we're gonna get to a point where the expectation for outcome is very standard, no matter where you go. And is high enough that we can risk manage in a way using very simple principles of finance. And we turn things around and nobody ever pays for an IVF cycle where they don't. That is the ultimate democratization of the process. That's where we really change the way we deliver it. And it's very, very, it's very doable. Just a question of how much time in there indeed We do see a conflict turns real choice as to how you want to run your practice how you want to deliver this. And, you know, in the interim, we will see a splintering, of which clinics do suck, do certain things, well, which ones adopt a more convenient model? Which ones adopt a highest possible pregnancy outcome with a super high price point model. And this is all fine. This is the market working the way the market should, you know, if you notice, we're not talking about forcing the insurance industry to cover things that the basic insurance model doesn't say that they should cover. We're not talking about convincing governments to provide price support, or provide supplementation for patients. This is really trying to go through a free market model. These things may be accelerated by governments getting involved maybe because they're concerned about population shrinkage and things of that sort. But ultimately, the to the individual choices that the existing clinics are not going to stop the movement towards a much bigger marketplace marketplace with lots of choice. And that choice will ultimately include completely shielding, the patients were having to mortgage their houses two or three times in order to do that next cycle, are people draining the life savings, and never ending up with the baby. And you know, what's the big motive, the big driving factor, there is just this enormous, enormous market of people that really want to spend money, want to dedicate their time and effort towards building and all of us your grip, and certainly you included who interact with IVF patients, that you can't underestimate the size of that motivation. This is not consumer discretionary. This is not choosing to buy a book at a bookstore on Amazon or downloading video text file from HBO or Hulu, or going to your closet and having VHS tapes. This is one of the prime motivators in life. So there's this enormous, enormous marketplace out there that's going to find out oh, by people creating we means of fulfilling these needs.


Griffin Jones  37:37

Does that mean that we should expect one of the factors to to improve before the others? For example, should we expect dollars until baby to reduce before we see time until baby to be reduced? Or both of those to happen before we see life? disruption to baby? Are we? Is it more realistic to expect one of those dropping? And then that setting the standard where the value add becomes in the other two segments? Or are we looking at technologies that could possibly reduce the concern of all three at once?


David Sable  38:15

Yeah, I think it's a Venn diagram where the three circles overlap a lot. It's like dollars to baby if a patient has to travel 25 miles to the clinic every two days to be monitored or needs to travel to another state to have the cycle done needs to stay in that state, then that's a dollars per baby and time to baby and definitely a life disruption to the you know, when we develop new medications that can be given orally instead of by shots. Well, those shots are real life disruption to baby. They're also very, very expensive. And there's only two companies that make those sets of dollars per day. The fourth thing is well, so it's I think that as you as you move one, it tends to drag the other two along. And it's not so much a conscious choice because implicit in these are specific things you're doing. You're moving your retrievals from the big, unbelievably expensive lab to a procedure room, because the engineering system is closed up. So the for the egg never sees the ambient air or light before it's frozen. Or you move the retrieval to your satellite clinics 10s or hundreds or maybe even 1000s of miles away so that you can better leverage the enormous lab that you built. And you can kind of defacto increase the capacity of your laboratory without building out without spending another 2500 for another square foot of space. You may be moving your storage somewhere else. All of these things are going to improve your operational capacity, improve your ability to grow By the service you're giving now, in ways that can turn into translating into offering your patient a better experience that's more affordable, or more risk managed, or closer to where they live. I think it's just kind of a virtuous ecosystem, where you start attacking these things one at a time. And they show up at all of these parameters, both for the clinic themselves, and for the patients, as well as being a motivation for kind of ambitious entrepreneurs outside the fields that say, Hey, you got all these people newly insured, all these people who state mandates, all these people that may be in other countries now need the service. Look, Japan is doing everything they can to make IVF more accessible. Let's build it and they will come because right now they have nowhere else to go. It's kind of it's kind of like virtuous ecosystem, because


Griffin Jones  40:53

it seems like it should be a virtuous ecosystem. But there are clearly challenges to integration. If that's the case. And Abigail, I want to get your experience if you see if you've seen these challenges with integration in other areas, because it seems like there shouldn't be a Venn diagram that someone that can come in and improve the time until baby would also help be helping reduce the costs until baby and, and limiting the life disruption to baby. And there's all kinds of companies at ASRM that are trying to sell into clinics, and I see them struggling selling into clinics or a number of different reasons that can be an a whole podcast episode. And I've probably done one or two, but they are struggling, even though I see the value that they bring they they reduce nursing workflow, they reduce the the legality and other workflow, not all of the workflow much of the workflow involved in third party cycles. They reduce what Texans did ographers and other support staff have to do, I think of these companies, and I see the value that they bring, and there have having a hard time selling in two clinics, partly because of its it's seen as an added expense. But also because it is really hard to integrate given the variability of clinic workflow. So it seems like it should be a virtuous ecosystem. But there's some roadblocks, and I'm wondering what you've seen in other sectors that might be comparable.


Abigail Sirus  42:39

Yeah. And for me, it goes back to my background and emerging technology and how tech gets adopted, really, I mean, when we think about it, I started doing blockchain back in 2016, which feels like a long time and blockchain years are in any emerging tech where, yes, of course, in the beginning, when you're changing the status quo and introducing something new, there is that friction in that hesitancy, especially when the incumbent clinics have a great formula, they know what they're doing, they know how to do it well, and they know how to bring in an optimized value for it. So adding anything to that or changing anything, can be, can be met with a little bit of, of that friction that I mentioned before. But as we see with kind of all the traditional tech curves going into, you know, any business school case, yes, there's that friction in the beginning, and you kind of go up into the curve where over time, as the technology begins to be more widely adopted, it becomes status quo, and it becomes kind of bundled along and become standard of care in this case. And so I think that we're just in kind of the beginning of that cycle of seeing some of these new technologies starting to take shape. And as the value becomes more proven, and as it becomes, you know, these are some of the best educated patients, I think it throughout all of health care. And they know exactly, you know, what's going on and where their money's going. And if they hear that this clinic over here is doing something that might have better outcomes than a clinic down the street, I don't think they'll hesitate to, to make decisions based off of that, and to also encourage that kind of innovation. So I think it's going to happen organically and naturally at first, and then quickly and kind of more all at once once things start to become status quo. But as for integration, integration is always difficult. But what I think is important is, is patterns do start to emerge. And so once some of these early stage startups, you know, I had the pleasure of walking through the SRM booth just like you did, and getting to speak with a lot of them. Once they start becoming adopted, you know, a couple clinics at the time, and start being integrated into their workflow, they'll be that much better positioned to integrate into the next one. And you know, as well as we do in this industry, there is some pretty significant consolidation. So just winning over a couple of those larger chains could mean that a lot of innovation is adopted at a faster rate.


Griffin Jones  44:53

Well, I see that but I also see a lot of steps back and I see it being I see it also taking several years. So I think of one company that's been around for many years that probably has half of the market share and does very well. And, you know, they and so there's probably okay, we get a few of the early adopters on board that will try anything. And then that provides the case studies for us to increase the market share. And then, and then they've got some rapid growth for a little bit. But then either it just, it just stalls because whoever isn't adopting, still isn't adopting, and and they don't see the improvements as dramatic enough to to make the investment. Maybe they're just incremental, or the consolidation does happen, Abigail, and then they they go back, it regresses because the the new partners coming in are cutting costs and say, you know, what, we just don't see this as dramatic enough. So is, is incremental one year after another possible? If so, it doesn't seem revolutionary, it seems like it's taking a really long time for many of these companies, or does it have to be so dramatic and so obvious to that? This is now the standard. And if that's the case, what's necessary to do that be given the variability of clinic workflows, if something is really going to be that dramatic of an improvement, that means it has to affect a lot of the areas of the clinic and lab, presumably. And in order to do that, there's a lot of things that need to be integrated. So, David, you've said on the show before, that the entrepreneurs job is to solve the chicken and the egg. But what about this challenge of of improving incrementally? When? If, if the adoption, the catalyst for adoption, is seeing dramatic improvement?


David Sable  46:49

You Yeah, well, like, like a lot of things successful only be in retrospect. Yeah, and we're going to look back at one point and find that it's gonna be an awful lot of overnight successes after 15 years work. The kind of cul de sac that everybody drives into intellectually, when they envision, you know, this kind of a sweeping statement, but I often see, when I discuss innovation with an IVF, is it's always done within the context of the existing clinic structure as it is now. And it's always okay, how do we go into these existing clinics convinced them to do something different. And I think that we may find that the innovation really reaches critical mass. And you see those revolutionary steps, when we start building that industry alongside the one that's there now. Now, this may be one of the large consolidated chains, and these are terrific doctors, terrific administrators, they may decide, you know, we've really reached a limit of kind of the limit of growth of what we're doing under brand name of what we've got. So we've got the four seasons there, let's build a nother system for a different marketplace. Let's take a critical mass of these innovations. 4567 have put them together in a way that really adds up to a substantial change in cost of development delivering the service, yet with the same outcome probability, you know, take this, the, the old thought that lower cost or more convenient, has to be a trade off between lower probability of the baby that's unacceptable, you've got to have at least as good a chance of having a child at the end of the whole process. But you know, there is an enormous industry to address that doesn't exist, right. And trying to kind of force feed incremental innovation into the existing infrastructure, the existing clinics as they are, or as they are consolidating. Maybe too difficult a way to get these innovations into play. However, like I've been, I've been talking to founders now going on seven years. And watching them as they evolve their business plans. And it doesn't seem like it's been all that long. We've seen some really great changes the way people look at these things. Like if you're looking at you, and I've talked about AI. And if you're talking engineering in the 21st century, you're talking AI, which What does AI it's math, but it's a digitalization, of which previously were just kind of our teas and all processes. But the all the Ag companies a few years ago had the same business model. We're going to go We ended, we're going to optimize one part of the process one part of the IVF cycle. And we're going to charge $1,000 per click to do, or $2,000, a click to do it. Absolutely unsustainable business, great engineering, great concept, you are making the process work better. But the whole idea of building a business around, when really what we're trying to do is drive costs down, it was very difficult to demonstrate the value proposition. But if you take those same capabilities, and you say, Okay, we're going to talk to intact the entire process. This is just bringing the data collection, feed into the computers have computers tell us those things that really make the process work better, make it work more efficiently, and really feed into dollars per baby time to baby life disruption. And let's reengineer the system itself, let's offer IVF places where it's not available to people that have no access to it that really want it that can afford it at a lower price point. And let's build that places where it doesn't exist. And we're gonna start filling in a lot of the holes around the existing infrastructure around the existing clinics and the clinic networks. After that, we've got the existing clinics looking and suddenly, wow, there's someone else doing this. And it turns out that some of our people, some of our market, maybe want to do that instead, maybe it's closer to where they are, maybe there's they could do the same get, they get the same probability of an outcome. And they're willing to do the trade offs of not having quite the same experience that we've been offering. And that way, that kind of parallel industry is going to flow into the existing industry. This is what I'm not smart enough to be able to predict it. What are you already know, that incrementally looking at people with no access at all. And we're trying to one after another build systems that can deliver that access to them. And actually can do it in a way that we can measure and we can process optimize, iterate in a way that the current kind of artisanal system doesn't let us do that I think you're gonna see in retrospect, that these things had really revolutionary effects. But you just can't map it out. It's going to happen organically. And when you look at the proliferation of technology over the past 100 years, how did airplanes go from the Wright brothers to the first jet for two years later, to what we have now, which essentially the democratization of air travel, including airlines that charge you to pick your seat, and have no food on board, you have to pay for every single bag you bring. These are things that evolve, because the technology was built in let it evolve into that. And turns out there was a market segment, looking for the first eyeglasses were invented in the 1300s took about 300 years before everybody over 40 could see. And, you know, it's it's a very, very long time to put these innovations into a marketplace. it up if you can see it a lot faster. Because there's an extremely fast proliferation of knowledge. Consumers know where to go for the information. And given the information of the the way information travels over the internet, things of that sort. This a very, very savvy group of patients is waiting for access to the waiting for access. And again, we go back to the desire to have a family. He is one of those incredible, you just can't. It's just this is not consumer discretionary. This is not something you could like people give this out.


Griffin Jones  53:56

So it could be the case that the disruptive model coming from venture capital becomes not one that says we're gonna create something that sells to all of these people or even sells this to the patients as a as as a direct to consumer base, but rather all of these booths that are ASRM are at SRM trying to sell to the clinics to improve these envision they themselves are now the model we create a model running alongside the the current model. That's how I see the 15 year hard work the 30 year 40 year hard work potentially being an overnight success based on your insight.


Abigail Sirus  54:42

And I mean to me Griffin a great analogy and one that's obviously used quite often now is electric cars like Ford and GM. Chrysler everyone knew electric was coming but decisions were made not to pursue it until they were forced to buy a new entrant coming and doing things differently inspiring change and having customers or in our case, patients demanding that new kind of experience proliferate in other areas. So I think we're seeing this in other places, it will be modeled here, as David said, hopefully faster. And so we can get to more patients as fast as we can. But I think that


Griffin Jones  55:17

that's a good point. That's a, you just made me think of something, Abigail, which is that I suspect that that part of the reason why Tesla was able to come in as the entrant there were is from all of the different vendors and companies trying to sell to GM and Ford and Honda and Toyota over the years to develop certain technologies. And that made it possible for Tesla to come in faster possibly to acquire some of those to, to, to integrate some of those that weren't happening and build a whole new model, which could be the case of venture capital coming into


Abigail Sirus  55:49

exactly. And we're seeing, you know, new clinic models emerging where they're bringing in these technologies, almost as if they're within the clinic's DNA itself, they're getting off the ground while thinking about re engineering processes that still have yet to be optimized that kind of some of the larger the larger chains as well. And so they're starting off on that front foot of the innovation as they go, which I think is going to be really exciting to see how they can grow and progress and continue to innovate, since they're starting in that place already.


David Sable  56:21

In the kind of unspoken on talked about part of this, as well as there's an entire industry of cell biology, feeding into biopharmaceuticals, for example, and all sorts of new types of fluid engineering, that is not operating in a vacuum, like IVF is just one more area of cell biology. And a lot of these technologies are mature, they're in place elsewhere. And we just have to cart them or put them in the lab, plug them in. And it can really radically rattled radically change the way a lot of the IVF cycles performed in ways that can benefit the providers themselves in ways that can provide new founders who want to build different delivery systems of IVF. And all follow them benefit the patients, their mortgage, they're better engineered, so they're easier to scale. Since they're better engineer, they're easy to measure the benefit from these are things that are gonna go into bringing that IVF pregnancy rates higher and higher, towards the towards emerging of kind of the emergence of a best practices, and then give us a springboard to keep iterating to keep reengineering, to keep finding the thing that's working the least. So we can inch that pregnancy rate higher and higher. Then we bring in our actuarial and financial principles, we risk manage the whole thing. And we build an entire different IVF industry, where you pay for baby instead of buying IVF cycles. That's what you want to you want to get people's attention, you start totally risk managing the process. You will see the floodgates. So


Griffin Jones  58:09

that's your fourth, that's your fourth principle that you talk about in your article and talk about burying the lead David, I buried the lead as I read this again, and think oh, this, this will get people's attention. So the fourth principle recaps what you just said greater certainty uniformly higher outcomes and improved data collection and analysis leads to actually actuarial quality data, which leads to better risk management, which leads to pain and getting paid for outcomes, not cycles, you pay when the procedure works, you really believe that that's not only possible but inevitable.


David Sable  58:49

Yep, absolutely. It's too important. It's to the people that are consuming. People are also very yet it's the the optionality right now. It's just unacceptable for most the idea that someone talked to me for that five, six years ago, they say, Well, what's an IVF cycle costs like the cost of a small Toyota. What's the big deal of this? Well, you go into a Toyota dealer with 15 or $17,000, you drive out with a car, you walk into an IVF clinic with 15 or $17,000. And you walk out with a possibility of having a baby or a 35 to 65%, possibly of having nothing other than endured a lot of inconvenience, a lot of heartbreak and set your financial stability back quite a ways. Now, that is a a need in a marketplace that screams for someone to open up that market. So this is something you're talking about with incumbents or without incumbents. This is something that really plays right into the The underwriting insurance playbook. If the traditional insurers want to assume that, so far they have not. So we've seen the emergence of a secondary market, people doing IVF and fertility only underwriting insurance, which I'm thrilled about, we're seeing some of the practitioners start to re explore using risk management. And these kind of risk sharing strategies. This goes back to the late 1990s. But it was done very poorly. And as the numbers get better and better, frankly, it's an easy thing to do. If no one else does it, Griffin Newman, Abigail and I all started our own insurance company. It's just taking actuarial data, crunching the numbers using some very basic insurance principles, sticking the margin on top, making everybody else pay a little bit more. So the nobody pays to get enough. And it's really kind of trying to


Griffin Jones  1:00:59

think of where the precedent is for that, David, I see the actuarial principle. But I think of if we have a tumor removed, and we undergo chemo, if the if the cancer comes back, we'd still pay for that procedure. If we pay a landscaper to install drainage and and level our backyard and the flooding returns, we still pay that landscaper, we might write a bad review. But this happens all of the time, in other segments where people are paying to have a problem solved, but for whatever reason it it still happens. So what makes this possible in IVF? In a way that doesn't seem to have been possible yet. And oncology?


David Sable  1:01:45

Well, I don't know if we want to trade anecdotes. But why. But I practice that I did surgery, it's like until the problem was solved. You paid your surgical fee, and that was it. You know, follow up problems, things that complications that things have brought you back or part of what you're paying for upfront. Yeah, it's it's certainly there may be, you know, co pays and things of that sort along the way. But we really, you know, we're talking about risk managing in a way to make something affordable and acceptable, can take away the big optionality with whether there's some small, you know, it's like administrative fee that goes into paying for IVF. And certainly, let's say there's a late pregnancy loss in the third trimester, tragically, how does that get, you know, internal internalizing for the system, these are sort of details, what we're talking about is the, you set up a pricing system for your for your based on your outcomes, and you define the outcome, however you want. The same way, you know, it's maybe it's like a warranty. Maybe, as we've mapped out for the disease prevention, part of IVF, which is a enormous another enormous industry, when to be developed. Maybe the pricing marketing structure is essentially a gym membership for the family. You freeze your eggs early, you go on birth control, all of your pregnancies occur, using IVF and PGT. Him. And you have a zero risk of having a baby that dies of sickle cell disease, as 9% of babies born with a do have childhood. That you pay a certain amount for unlimited access to the service. And since we know what the service costs to produce, and we know the likelihood, and we build our business over selling your lifetime of access to disease prevention. Pricing is really just it's just taking the cost of production, looking at the enormous size of the marketplace, bringing some creativity, and a little bit of fearlessness into addressing a new market, rather than trying to just make a little bit of a change with the IBM ecosystem is one that most people are not served with really. We're really trying to build an industry that doesn't exist. And a big part of that is that this whole part of what was offered the possibility of having a child or family to people that don't have access to and making it affordable. And we're not going to make it affordable by just doing what we're doing now. And putting a lower price tag on although that's one one way of doing that. Wherever you address another 1015 or 20 million people worldwide, for a million to 2 million more people who in the US is by tackling price and the patient's own risk. We attack that with engineering, we attack it with certainty and attack it with numbers. And it's a, it's very antithetical to the idea of this produce now. And yeah, this is a big idea. But if you talk to all the people that don't have access to having families, you know, they're very open to big ideas. And there's not a room in this industry, both for the people that are doing such a good job. As well as people are going to cover and address those people in our research.


Griffin Jones  1:05:45

We spend so much time talking about the four principles behind democratizing IVF, that we didn't even really get a chance to go into the map, it could be its own topic. And I would love to have both of you back on the show to talk about how you mapped engineering solutions to IVF success because there is so much in the lab in the clinic. And you really give some of the main problems with labor, with embryology, with medication, with lab space and complexity, that I think it merits its own topic. So I'm inviting you back in front of everyone. David, your invitation is constantly standing. But Abigail, I'm explicitly inviting you back with Dr. Sable. To go over just the map in a sequel part to this episode, if you would oblige us in the new year.


Abigail Sirus  1:06:44

I'd love to absolutely looking forward to


Griffin Jones  1:06:47

it. I'd like to give both of you the floor to conclude and in a way that either summarizes what you talked about today, or what you want people to pay attention to, either within relation to the article or other things that they should be studying up on.


Abigail Sirus  1:07:08

So to summarize, Griffin, my perspective is is simple. We continue to talk about the small slice of the pie and how to cram as much innovation and new thinking and bring integration into that sliver. But I think that there's such a broad opportunity beyond that. And that innovation will come from all areas. And we're going to see different kinds of businesses entering the market, challenging incumbents learning from incumbents. And hopefully our goal is that over time, what it will do is increase access to anyone who needs IVF that they can happen and have the best outcomes of anywhere in the world. So that's how I would conclude.


David Sable  1:07:49

Yeah, just reiterate to what Abigail just, you know, this is a if there's a entrepreneurially healthcare entrepreneurial playground that's more interesting than this one. I haven't found it. You've got an enormous enormous life moving need, with a huge population of people. We've got a confluence of terrific engineering, information technology and great science. That is this this is yet having been the I look back at the last 30 years when we've done it IVF is breathtaking. It's absolutely spectacular. What we can do to scale that is, you know, it's it is just such an opportunity to take fearlessness, creativity, and just a lot of heart, your heart knows brain and is looking looking for comparisons. Don't look at healthcare. Don't look at the IVF industry. Look at what we've done. You know, my first computer, I love putting a picture of it one of my one of my talks, my 1988 Commodore PC 30, which was a fabulous $2,500 computer with 10 megabytes of RAM, and one male, half a megabyte of RAM, 10 megabyte hard drive, and a 286 chip. And it was a great computer wasn't connected to anything else. And to think what that computer does, what you can do with $2,500, the computing world now. That's where we are in IVF. Now where that computer was, which was about 40 years ago. Look at the IT industry, look at the transportation industry, look at communications. That's the kind of growth we're going to see to helping people get pregnant and families which argue is just as important. And the need there'd be the desire to suck that entrepreneurial effort up into an enormous industry is there and that's the opportunity. And that's the kind of growth that you're really looking for in the next 1015 20 years. And I'll leave it at that. In Griffin I will say this again. You are the only person that provides this kind of forum to talk about this. So I always like whenever I'm on your show, I always want to back it up by reinforcing what you're doing. Because this is not a insignificant part of. So, you know, I could stick myself in there and just a plug for what you're doing, which is really, really necessary, really important.


Griffin Jones  1:10:23

I'm grateful for the plug, I hope to be able to provide a lot more coverage in 2023, as inside reproductive health expands its scope. And there's certainly no shortage of material to cover based on what we talked about today based on what else is happening in the field. And I look forward to having both of you back on the show. To explore this more. Thank you both very much for coming on inside reproductive health.


1:10:52

You've been listening to the inside reproductive health podcast with Griffin Jones. If you're ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health



156 6 Of The Biggest Fertility News Stories You Should Know Before ASRM

Just in time for the ASRM conference, we share insights on the hottest fertility field news stories you can take with you to the Networking Lounge.


Listen to hear:

  • About the acquisition that took place, which was not reported in the US or Canada.

  • US Fertility’s recent change of CEO.

  • KKR’s debt for the IVIRMA deal.

  • The recent celebrity embryo lawsuit that has now turned against the clinic


With this roundup, Griffin offers a sneak peek into the future of Inside Reproductive Health and news coverage of the business of the fertility field.





Transcript


Griffin Jones  00:04

The biggest Fertility Center in Canada being sold to an overseas company and it not being reported on in North America KKR the global investment firm be behind the EV RMA deal. And the banks behind them selling off their debt, getting rid of their debt to private lenders. CCRM expanding into New Jersey with an acquisition, kind body expanding into Houston and getting the Walmart deal, a major lawsuit happening with that you knew about but now being directed towards the fertility clinic. The this is the news that I'm going to try to give you some insights on today. This is the type of news that inside reproductive health wants to report on in the future. This news content that I'm giving you today is not reported on by us. I'm giving you kind of a preview of the direction that inside reproductive health is going on. Many of you are coming back from SRM. Many of you talking about these things, at SRM. So I wanted to give you some water cooler topics to think about and reflect on catch you up a bit. By the time this episode airs. I'm sure there's probably a big announcement or two that happened today. That didn't make it to this episode. But inside reproductive health is moving in the direction of news media outlet of being able to cover more of these stories, we're still going to do the podcast where we go more in depth. But we also want to cover new stories like these. And many of you listening may have had a meeting about sponsorship with me at ASRM because we are starting to close those sponsorships and only a few companies are able to get in now. And for you, the listening audience, the docs, the CEOs that listen in to reproductive health and read, it's for the aim of getting you more content, some of which is is like this. So I'm gonna go through these stories today, I'm going to try to give my insights. As always, if I get something wrong, please email me and tell me and we can correct on a future episode or you can come on to give more insights or just complain about it quietly to a friend, whichever you prefer. First story is an older one I'm gonna go from older to more recent. And the reason I still want to talk about a story from over a year ago with the Yujun deal of TRIO fertility is because it was never reported on in North America. If you Google Eugin, TRIO, fertility, there's no story that I can find from the Toronto Star from the from Bloomberg from any US or Canadian media outlets. Eugin. If that name sounds familiar to you, is the health system out of Spain that bought Boston IVF. Some years back, they're owned by a another company that's a public traded company. And I think this is significant for two reasons. One is that I think that trio was the largest center in Canada, if you recall, there was a merger some years ago, between five and 10 years, probably seven, eight years ago, something like that, where there was a merger that made trio fertility between life quest and T carts. And then they became true, I believe there were the largest center in Toronto, according to this Spanish media outlet lab on guardia the they did 2700 cycles a year. And so I think that's significant. But I also think it's significant of parent companies that are buying centers, when some of their subsidiaries are large enough to also have done this acquisition. So just just like by you, just by numbers and speculation, Boston IVF could have done this deal. I don't know, I have no idea if they wanted to go to Canada or not. But I think about this when Shady Grove buys CRM and Houston that it's like well, did somebody else in US fertility want to do it? Do it will will these parent companies opened de novo clinics as part of the bigger brand or or will one of their subsidiaries. So I think that's significant. And I also think that it's significant that none of us knew about that. And it shows that there is a lot of strategy happening not just from Wall Street private equity, but European health systems and, and health systems and large networks in other countries that are still TGT coming to different markets in North America as far as I can tell, this is the their first acquisition in Canada, but with their, with their, all their acquisition of Boston IVF, or at least partial acquisition of Boston IVF as well. This media outlet plus mundo se is reporting that Eujin covers more than 37,000 IVF cycles in 2019. So you might infer how much they're doing. Now. Next story also a little bit older, but there's been an update in the last month or so is the what's behind the KKR deal of edrms. So many of you know that there was RMA of New Jersey, and then there was there were armies that are not affiliated with RMA of New Jersey, and there are their armies that were and then they merged with EV of Spain to be to form their global company, EV RMA a few years back. And then the company, the global investment firm KKR made an acquisition of e vrma. Global back in early 2020. To deal that is reported by Axios to have been $3 billion euros at the time, that would have been 3.2 million US, but they're probably paid in euros, at least according to that report. And but the latest development is that the banks that helped to finance that deal the some of them like Morgan Stanley, and Credit Suisse AG, according to this report by Bloomberg, have decided to sell off that debt to private credit firms. So instead of them getting the interest from that, that loan, there, they'd sold it, according to what Bloomberg says, for 96 and a half cents on the euro. So these banks took a little bit of a loss on it. And in order to sell it to the private lenders, they're not going to be getting that interest, the private credit firms will be and they sold what they had for a little bit because KKR they're using some of that some of what they're buying, you know, some of what they paid for is going to be from their limited partners. The pension funds, the the high net worth individuals, the these these big funds that they used to purchase, make a 3 billion euro purchase, according to this article, 800 million of that came from debt. And so that's been sold, what the greater applications are beyond that. That's beyond my paygrade right now, but if you know you can come on in, we could do an analysis of that. Next door is ecrm made a big acquisition of IRM s in New Jersey and I rms used to be part of the St. Barnabas health system there they were a private center on probably one of the largest independently owned private centers on the East Coast, they have 11 rd eyes. And that acquisition was officially announced at the end of August. And so this is going to add to CRMs footprint in the northeast, it may give them more leverage with insurance companies because they have CCRM, New York they also just added a doctor there. And so they may be able to have more leverage with insurance companies there may be more efficiencies in marketing and some of the services that they're offering that allows them to expand but this is a group that a lot of people wanted and was independent for a long time. And it's it's really big. There's not so many of these size groups anymore. There's there's very few and and CCRM got one of the last ones of that size. Next story. There's a big CEO change at one of the largest fertility companies in North America. That's us fertility. You of course know them from Shady Grove fertility Mark Segal, having been the CEO there then going on to be the CEO of the newly formed parent company that was formed in 2022. With the backing of the private equity firm amulet capital they took. They took one of the groups in Florida fertility Fertility Center of Illinois and RSC of the Bay Area to form us fertility at that time. Mark Segal, who had been the CEO for 25 Five years at Shady Grove, went on to become the CEO of that company. And it will be stepping down come the New Year, the new CEO is Richard Jennings. Jennings was the CEO of California cryo bank and then went on to be the CEO of generate life sciences, Derek lifesciences was acquired by Cooper in 2021. What this could mean is I wonder if this means companies like us fertility will be looking to expand more in the third party space, acquiring companies that are either surrogacy agencies or donor agencies or both. I think a lot of networks are creating their own. And it might make sense to do some acquisitions, it probably does make sense to do some acquisition. So I wonder if this would if Jennings being CEO of us fertility will help with something like that, if that's part of their vision. And I also wonder what this means for Shady Grove, because I don't know who the shady the CEO of Shady Grove is right now. I probably should. I don't know if Mark Segal held that position as he became the CEO of us fertility, according to his LinkedIn profile. He didn't I don't know what that means, if you just marked it, as you know, through that time through 2020. Or if if he was concurrently serving in that position, if they filled that with someone else, or if they decided not to feel that because they then had a parent company and US fertility and didn't feel that they needed that role, but perhaps a different type of President role. I don't know that somebody's probably going to get a bunch of texts saying how do you not know who this is and update me and you are absolutely free to do that. A big story on the fertility benefits coverage front is Walmart signing with kind body for a number of years, I thought that it was a one horse race with progeny, maybe it would become a two horse race with carrot, and then kind body started adding employer benefits as they grew into the company that they're building. And now maybe it's a two horse race, maybe it's a three horse race. Walmart's a pretty big deal. Insider reports that the benefits include financial support of up to $20,000 lifetime for eligible surrogacy and adoption costs that they are rolling this out company wide. And this is a company with 1.7 million associates but insider doesn't report how many of them will have access to that benefit or what the vesting terms are in other kind body news channel too. And Houston reports that came about he is opening and clinic there is that big news. I think it's big news because of what Houston is. Houston is sort of the anti Phoenix in terms of consolidation of clinics. Houston was a market that consolidated relatively early relative to the rest of the country. Of course, you had HFI Houston fertility Institute, which had sold their lab or at least part of their lab to Vera that was in the early days, sometimes in the mid 2000s. And then we've seen a lot more acquisitions since a spire had acquired Houston fertility specialists to have a spire Houston. They later went on to buy after they merged with Prelude and who had already acquired the Vera at that point merger acquired with Vera at that point they had, they had HFR as part of their portfolio, but then went on to buy the rest of the practice. The center of reproductive medicine was the last sizable independent practice in Houston. And then last year, they were acquired by Shady Grove fertility. So Houston has been a very consolidated market, there still are a few, much smaller independent practices there. Maybe they'll grow. But now there's more competition coming into that marketplace. Finally, the media outlets suggest reports on a update to a story that you've probably known about for some time, but this is the first time I've heard about this. And it sounds like they're now going after the clinic. So you've probably heard about the Sofia Vergara lawsuits that have been happening for the last decade or so with her ex fiance, Nick Loeb, if I'm understanding that correctly, where he was suing her to prevent her from taking the embryos from destroying the embryos. And he did not win that lawsuit over several years of litigation suggests now reports that the clinic itself is being sued. that art reproductive services, which I believe is our Reproductive Center in Beverly Hills, is now being named by Nick Loeb in the latest suit. This is reported as of October 9 22. I can't give you too many more legal insights here. I'm happy to have one of the reproductive attorneys that we've had on in the past, come back on and talk about more protection for you doctors and covered entities. But what I can see happening here is that the plaintiff, the ex fiance, didn't win against his ex fiance, who was probably well lawyered up. And so now he's going after another target. He didn't go after the fertility center at first went after his ex fiance he lost. And now for whatever reason, perhaps for this further say I have no idea is now going after the clinic. So I think it's something to think about for Fertility Centers that even if you might feel that, okay, this clearly isn't between us, you may need some extra legal protection, simply because you might be the easier target to go after in terms of arsenal of legal defense. That's a bit of my speculation. But that's the latest on that case that's being reported in the news. These are the insights that I have for you. Hopefully, you're talking about them at ASRM and sharing this episode and talking about these headlines, because we want to create a lot more news for you. In the future. We're working with journalists to bring original news stories for you. I've given you the stories that are currently in the news. We will expand the podcast coverage, we'll expand the news coverage. It's for you, the doctors and the nursing managers, the practice managers, the executives working in the fertility field, so that you have this news firsthand, into your mailbox. And thanks to the sponsors, that will be a part of it. And thanks to you all for listening. And if you've enjoyed this direction, please let me know please send me an email because it helps us to decide what content to cover next. Hope I got to see you at SRM and hope you have a safe journey back.


17:23

You've been listening to the inside reproductive health podcast with Griffin Jones. If you're ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health


152 Pinnacle Fertility: Where’d They Come From?!

Inside Reproductive Health guest, Andrew Mintz, shares the evolution of Pinnacle Fertility on this week’s podcast episode with Griffin Jones. The fertility network which now owns ORM (Oregon Reproductive Medicine), SRM (Seattle Reproductive Medicine) and others, seemingly came out of nowhere. Is their model scalable? Will it stand the test of time?

Tune in to hear:

  • Andrew Mintz detail the Pinnacle Fertility model, including how they constructed their Medical Director and Lab Director Councils, and how they contribute to the overarching success and development of their network.

  • Griffin press Andrew on the efficacy of Pinnacle Fertility’s physician buy-in program, and how it could potentially implode.

  • Griffin question whether or not Pinnacle Fertility’s private equity backing equally beneficial to physicians across the board, or only those stepping into retirement.

  • Griffin ask how Andrew Mintz and his team approached the selection of the ever-challenging EMR system, and how they decided on just one. 

Andrew’s information:

LinkedIn: https://www.linkedin.com/in/andrew-mintz-712a999/

Instagram: https://www.instagram.com/pinnaclefertility

Facebook: https://www.facebook.com/PinnacleFertility

Website: https://www.pinnaclefertility.com/


Transcript



Griffin Jones  00:04

Nobody says we put the patient last, Andrew, and nobody says we're a bunch of dishonest dirtbags that are going to stab you later. So how were you able to actually demonstrate that almost every Fertility Center in North America is going to be owned by one of two companies in the coming years. It's one of the things that I talk about with our guest, Andrew Mintz. He's the CEO of Pinnacle fertility. If you're like me, you didn't know about Pinnacle fertility last year until he was ASRM last year, maybe even PSP CRS this year that that name really took off, they acquired six groups at the end of 2021. They have acquired more since including Seattle reproductive medicine. So they're quickly becoming a big group. And we talk about their model for making protocols uniform, raising the standard of care in their view, including having a council of lab directors, a council of medical directors, which I think that concept is interesting for you to listen to. I push Andrew on the criticisms that people have of private equity is it really just for the benefit of the retiring Doc's? I asked him that question of do we think that this is going to become a two horse race in the future? I talked about brands, that Kindbody style of brand versus this network style of brand and tell him which side I think is better, and ask him for his opinion. I also asked him to talk about choosing an EMR what goes into that process and should go into any that process and why they chose the EMR that they did. I asked about the model of doctors buying into the parent company and not into not not the equity coming from the at the practice local level. So we get some good answers in there. If you feel that I can go deeper on a specific set of questions, email me, let me know and our next guest will be the victim for that. In the meantime, enjoy this interview with the CEO of Pinnacle fertility, Andrew Mintz. Mr. Mintz, Andrew, welcome to Inside reproductive health.

Andrew Mintz  02:21

Thank you, nice to finally meet you in person.

Griffin Jones  02:25

I had never heard of Pinnacle fertility before the winter of 2022. And then by the time I got to PCRs, it was all the buzz, it was blue Pinnacle liquid pinnacle is doing now. And it's and so here's a company that, as far as I know, didn't exist a year ago, or a year and a half ago, maybe you'll correct me on the timeline. But then, in short order, started making a splash in the field. So why don't we start with the timeline of Pinnacle. And the the opening or need that you all saw in the marketplace to to state your own existence?

Andrew Mintz  03:05

Sure. So we actually started in December of 2019, with the acquisition of Santa Monica, fertility out in California, and then you know, COVID, hit kind of right away, and there wasn't a lot done for the year 2020. But come 2021 We started to reengage in the market. And we closed six practices in 2021. In the second half of 2021. We didn't actually create our name of Pinnacle fertility until like October, which is why no one's ever heard of Pinnacle before. But we brought on first RGA of Ohio, which is out of Akron and Westerville. And brought on a Dominion fertility and Virginia ihr. In Chicago. We brought on advanced Fertility Centers in Arizona, California fertility partners in in California, and ORM in Portland, so a really good group. And I think, you know, there were a couple of things that we saw as an opportunity to partner with groups, and that was that I had this conversation with Richard Morris, who runs our medical director Council, which I'll tell you about in a minute. But years ago, the way the fertility industry used to work is that doctors were very collaborative with each other not competitive. So they would go to their meetings, and they'd really start sharing all kinds of information about what they did in the lab, what their clinical protocols were, what they were seeing in terms of outcomes, how they're trying to improve outcomes. It was a very collaborative approach. I think that over time, as more clinics were created, especially as those that were created in the same markets, it became more competitive and The willingness to share the secret sauce started to whittle away. And so I think we had lots of people who were doing their own thing, and seeing what their outcomes were and, you know, comparing themselves against national benchmarks, as they saw in SART or the CDC database, we really wanted to bring back the concept of doctors working together, sharing what they're doing in the lab, reducing the variation in care, and to really improve the outcome. And we saw that as an opportunity that we didn't see happening in this marketplace as much as it could have.

Griffin Jones  05:42

Well, what do you feel that you can do to facilitate that happening that many of the existing networks aren't or can't?

Andrew Mintz  05:50

Yeah, so I mean, we've done a several things. So one, we started a couple of councils, which have real teeth behind them. So we have a medical director, Council and a lab director Council. And those councils have a representative from each one of our clinics. And more as we brought in this year, we brought on another few practices this year. And what we do is we talk about in the lab, for example, we talk about making sure embryologist are using same techniques and protocols, the media that we're using in the lab are the same, that the equipment that we're using are the same. And really just starting to compare the outcomes and talking about what people are doing. So we actually have lab directors that are going from one lab to the other, to look at what others are doing and then sharing that in in a forum under which they're making decisions about how to reduce that variation and improve the outcome. And I don't know that we see that in a lot of other clinics, I think there's a lot of talk about it. But we've done a lot of that and, and the other piece that we've had to do is come out of the lab director councils, the fact that as we continue to expand, some of the problems that we're facing in the lab have to do with just what you can fit through the lab from a volume perspective. And there just aren't enough embryologist. And so our lab director console, for example, started our own embryology school. We're looking now at a certification for the students in terms of how they become certified which doesn't really exist outside of ASHRAE. And really trying to get a lot more embryologist out into the marketplace. So we can they started the school, we do it in two places. One in Arizona, one in Ohio. We have four students at any one time, we get them trained in about 100 days. And we can train about 30 embryologists a year. And so we're really dedicated to one being able to have more embryologists available for the industry, and also specifically about making sure that we are teaching them the kinds of processes that we think lead to the best outcomes, and to ensure that in fact, we see that across our network.

Griffin Jones  08:18

Are you doing the same thing on the clinic side with a council of medical directors or practice directors?

Andrew Mintz  08:26

We are so we do have a medical director console as well. They making decisions in terms of you know, what kinds of genetic testing are we doing? Where do we send it? Who do we do it on? What kind of Mosaic embryos are we going to transfer? Which ones are we not? They're looking at safety protocols. They're looking at recruitment and retention issues. So there's a whole set of initiatives that our medical directors looking at as well, including clinical stimulation. So, you know, what are we doing to, you know, really reduce that variation, make sure that, in fact, we're doing the right thing for the patients and being able to maximize the, you know, their outcomes. And so there's a lot of sort of deep dive data that we pull and start sharing and discussing in those consults about the ways under which we're going to be practicing medicine within within pinnacle.

Griffin Jones  09:25

Is each practice represented by one medical director in the council?

Andrew Mintz  09:31

Yes. So we have one medical director regardless of size, so we brought on Seattle reproductive medicine just a few weeks ago. They have 14 rei physicians, but they only have one representative on the council, and then we've got Dominion fertility, which only has two physicians. And so they have one representative as well. It's a little bit like the Senate having two representative from each state. But But yeah, I mean, because the reality is, is that regardless of whether they're just talking to one other doctor or 12, they really need to make sure that that information is brought forward. It's discussed locally, and they are able to provide feedback in terms of what those what those protocols are.

Griffin Jones  10:12

Do they offer an equal vote and how the protocol comes to be?

Andrew Mintz  10:16

Yeah, so I think it's more of, you know, I think it's more of a discussion. And they come to consensus as opposed to voting things up or down. So you know, everyone recognizes that you can adopt a guideline that you think is going to be best for the organization, and then look at those outcomes. And if those outcomes aren't what you want, then you need to adapt your, your guidelines. So I'm not sure that we've actually taken a vote as much as there's been conversation and debate about the right thing to do. And, but everyone is dedicated to following the guidelines as they're created within the organization. So I don't think it's a majority rules type of, of atmosphere.

Griffin Jones  10:59

So that's my second question is, is how is the council governed, then, who makes the final decision who who releases the document, who drafts the document after, after the consensus is reached?

Andrew Mintz  11:16

Yeah, so we have the head of our medical director Council is Richard Mars, out of CFP. And he's the one that helps set the agenda. Um, he's collecting information from the clinics, and then coming up with recommendations to be discussed at the meetings. And so he is really kind of the driving force behind helping us prioritize what's important to the outcome, and the kinds of things that we're going to be addressing first, and how we're going to get there. So that's really how that's kind of organized, it's, it's a very, it's a free flowing set of conversation. So there's not a it's not a I wouldn't call it real formal, but they do come to decisions. And they do decide, you know which direction they want to go to. And we're just starting to scratch the surface. I mean, we're a new organizations, so they're addressing a handful of items, and they've got a handful or a long list of items that they really want to address going forward as well. You are

Griffin Jones  12:15

just scratching the surface, because now you've got a couple you your congratulations on that SRM acquisition, by the way, now you have a couple of dozen doctors across the, the the group thus far across the organization. Now, and, and, and people can come to consensus, but inevitably, people do not come to consensus every time in any organization. And we work with five Doctor clinics, and Dr. Nixon and I, I hear them not on the same page as each other. And very often, one doctor will be practicing a protocol in in office a and Dr. B is practicing a different protocol in office B. And and so when you inevitably run into, okay, there isn't a there isn't a complete consensus, maybe 70 or 80% are really on board and really feel strongly inevitably there's going to be a couple of people that feel strongly the other way. What do you do when you have established that protocol based on what the majority of the council sees it as best given the evidence? But there are a couple of people involved that don't want to practice that way.

Andrew Mintz  13:27

Yeah, so I mean, the first step is to create the protocol, the second step is to measure who's following it and who's not. And that's what we're in the process. So one of the things that we've also done is we've converted everybody to the same electronic record. So it makes it easier for us to be able to set things up within the system and for us to measure whether people are following the process as it's been decided. And so, you know, those are conversations, doctor to doctor, look, it's not a matter of whether they follow the protocol 100% of the time, there's no such thing as someone following the protocol 100% of the time, the issue is, are they documenting why they are not following the protocol, and there's going to be good reasons for it. So if there's a specific way under which we want to be stimulating a patient with a certain condition, and a doctor does not follow that protocol and does something else, if they're documenting why they're doing it, that allows us to be looking at that to understand how we need to expand our protocols to take care of different variables. So, again, being new, we have not yet I mean, we've created a handful of protocols and working on more. But really, these are long term studies for us to really determine whether in fact, they're giving us the outcomes we need, and who's following them. But we're really at the first step here of just making sure we create those protocols and and then we're going to start looking at who's following them and who's not and why.

Griffin Jones  14:50

And he talked about getting that measuring that as part of the EMR. You got everyone on the same EMR which is also not easy to do, which EMR did you choose? Did you make your own

Andrew Mintz  15:00

No, I mean, we don't start from scratch. So I mean, you know, there are, you know, everyone talks about using evidence based medicine. But the reality is that there's more than one protocol that's considered evidence based medicine. So I think there's not a lot of variation to begin with. And so I think

Griffin Jones  15:17

we're now referring to the protocol referring to the EMR that you chose your own proprietary, did you create your own proprietary EMR you chose another,

Andrew Mintz  15:26

we did not know, we, we moved to an assistant called Enable. And so we put everyone on enable, which we felt was has, right now the best capabilities to help us really connected with other technologies. So we've been really working hard on trying to use all the components of that system, to allow us to automate processes, and to really enhance the patient experience. So I've been talking a lot about, you know, creating and improving the clinical outcome. But the other piece of this is that we also really need to focus on the patient experience. And I think by having everyone on that same system and using technology to help us and the patient get through the process, I think that we're going to we're laser focused on that piece as well. So we need to make sure that patients are able to communicate to us effectively on time, we can be responsive to them, and there are the right people available to them. And the technologies are there to be able to interact with them appropriately get the information together and be able to present that to the patient, as well as recommendations and next steps. So we have not, at this point create our own electronic health record.

Griffin Jones  16:45

Well, let's talk about that shopping process. Because I think it'll be interesting to people. I'm not plugging one EMR over another. I am not I'm not qualified to do that we our clients use a number of them some of our clients use enable. But I think some people will be interested in to how you made that decision. I imagine there was a bit of a shopping or vetting process.

Andrew Mintz  17:06

Talk to us about that. Yeah, so we did that through all the IVF specific EHR systems out there. So we eliminated the ones that are more general electronic health records are used in the healthcare industry. And so there's a handful of ones in there. And we've actually done a review last year, and we recently did another one and just felt like it would meet our needs the best, especially in the way again, that it can integrate with technology, how some of the security issues that are, I think, available to it. And so really, we have a specific operational model that we have been employing in our practices. And we felt that this was just the best fit for that. And it's so far, it's, you know, it's worked for us because we're able to really collect the data. So at the end of the day, it's about how you use the electronic record system, as opposed to necessarily which ones you pick, this had features that we liked better that we think worked for us. And so that's how we made that decision. And that's what we're have moved are moving everyone onto that platform, what were those features that you liked? Oh, again, it was, you know, they have like two way texting with patients that gets embedded in the medical record and interfaces with the phone system, certainly in the way that it is built for the cloud. So it's not a server based system that was put in the cloud. It's a true cloud based system. So it has, we think some good security pieces in there. We felt that it was able to interface with vendors and and equipment more easily, giving us some good information, allowing us to bring it in and present it to the patient or want to, we'd like the patient portal, and the way that we could communicate to the patient. So there's just a bunch of things in there that sort of check the boxes for us. And, again, for the kind of operational model we use, I think that it just was a better fit. And so you know, the other ones have their I'm sure it have their advantages. We just felt like all the ability to use technology, all the think all of the capabilities that are built into the system that we are trying to take advantage of. We're just, you know, slightly ahead of, of where I think the other sports are there.

Griffin Jones  19:41

You mentioned wanting to improve the patient experience at a process level. What are some of the points in the process that you see is in need of fundamental repair?

Andrew Mintz  19:57

So there's there's a A fair amount, I think one is, you know, a number one has access. So, you know, being able to get patients in and get them through a IVF cycle that's efficient, that can make it efficient for the providers as well as the staff, I think is, is keep. So the biggest, I think hurdle in this industry for any practice is the fact that we still have a significant greater demand for services and supply of physicians and other providers to provide those services to them. And I believe that there is a room for innovation within practices that can allow for us to be able to service more patients in a very friendly way to get them through the system. And we can really sort of maximize the ability for patients to get in. So we still have clinics that have appointment, wait times that are three and four months out. It's too long, it's really unacceptable. And we need to solve that problem. So we think that the system will help us with automating processes and communicating to patients in a way that will make them more efficient. And so that's the first thing that I think needs to happen. The second thing is, is that I think we also need to meet the patients to where they are. So, you know, obviously, since COVID, you know, telemedicine has really caught on and it's here to stay. And I think patients like the convenience, I think a lot of them like the convenience, I think that they want to be communicated in a way other than a phone call, especially for the patients that we serve and the age group they're in. And so having the technologist that's allowed that we can text them to weigh that we can make sure that they're getting the information they need, we can embed the, the the videos that we have the educational materials that we have, and make sure they're getting through the process without someone having to call them and check in and we can sort of look at electronically will also help with that. So a lot of patients get lost through the process, they get lost at the beginning, because it's so overwhelming. And then they get lost through the process. And so to the extent that we can create processes, and have technologies that support getting these patients to understand what they're entering, and to help them get through the system efficiently, without being confused without being you know, without anyone falling through the cracks without missing something. Those are the things that I think are really key. And there's you know, story after story that I have seen where you know, patients, they get, you know, they get lost in this and they end up dropping out when they really need to continue through their IVF process or whatever fertility process. And

Griffin Jones  22:59

I have to say that I have to disclose that they're a sponsor before I ask the question, so it doesn't sound like a shameless plug, what are you using EngagedMD and all of your centers?

Andrew Mintz  23:10

Yeah. So I mean, we are rolling all these out and all of our practices. So they will all B have, they will have similar ways under which they are going to be processing patients. Obviously, there are differences from clinic to clinic, but we will be you know, we are continuing to roll out and refine our processes to make this efficient.

Griffin Jones  23:35

For those clients that are there, excuse me, those clinics that are three, four month out booking waitlist, and it's usually it's a couple physicians that are booking, it's often not the whole clinic unless it's a really small clinic in a really busy place. But for those that are booking out 12 plus weeks, is making that process more efficient include bringing some some of the testing that normally would happen after the first visit, and between the first visit and the follow up before the first visit.

Andrew Mintz  24:08

Yeah, so we are looking at the total process of care. And some of that is also, you know, some of the testing that we maybe can do in house to make that efficient as well. But we are looking at, you know, what's involved in a new patient visit what's involved in a follow up consult. And what information do they get between the first and the second and then before they start their cycle? What information do they get? And when do they get their medications and, and on and on. So we are looking at the whole process of care. We have mapped this out. And so we have a sort of a very specific philosophy about what should be happening at each step through the process. And the more consistent we can make that the better job we're going to do, of making sure that the patients aren't getting caught in the middle, you know, or Last,

Griffin Jones  25:00

can that also include some places the nurse does the follow up visit and the Ri does the initial visit, sometimes the REI does both. But some places the nurse does the first visit. And and so is that also part of this solution is a we? Well, maybe we used to do testing after the first visit. But now with this, with with booking this far out, that would mean that people can't get into the care system until that point. So we can we can do our testing before they come in for their visit we can we we can maybe have them meet with a nurse earlier so that that 12 week isn't isn't the first time they're seen. But it's the follow up with the RBI does does having either a nurse or an AP do the first visit is that in the playbook?

Andrew Mintz  25:50

Yeah. So I mean, we are invoking a type of license model. So we do not want physicians doing things that really only physicians can do we want advanced practice nurses to be able to do the things that they can do, we want RNs to do the things that they can do. And so we do have a general, a core set of services that we want each level to be to be doing. It depends on each mark, and, you know, each clinic. So in some clinics, we employ OB GYN who are doing some of that work as well. Some are have a really used nurse practitioners a lot others less so. But we do have a, a top a license philosophy. And so as we continue to integrate the practices, we will continue to be working on making sure that, you know, we're able to get doctors to do what doctors can do, which will help with the access issue. So if they're doing for example, you know, every single ultrasound, you know, that's not necessarily the most efficient use of physicians time.

Griffin Jones  26:57

I want to ask about the the inherent financing models of private equity, I'll let you know, Andrew, that I've been chewed out more than once by each side of being accused of being shill for private equity, that, you know, I'm in bed with these new private equity companies coming in and just using them to help buy clinics, which I'm not. And I've also been accused of being anti private equity and that, you know, I'm anti network and which I'm also not, I just I'm not qualified to evaluate the business models at that level, yet, I'm not strong enough in the finance piece of business in order to be able to say that maybe 510 plus years from now we'll be but right now, I'm very strong in the sales and marketing side. And I still feel like I have some pieces to shore up on that. And I and we are as a firm and so that's what I feel comfortable evaluating people on and I just ask people questions and I try to get them to respond to the counterpoints and, and so but I do hear a lot of the the model is inherently flawed, partly because of the debt that they have to service. And partly because I was stacked in favor of retiring doctors, and one of these folks that that mentioned, these boys is Dr. Ben White, he's a radiologist. And he's not in in Rei, but he writes about this a lot. And he says that the only doctors who can reliably benefit in private equity, are those senior partners close to retirement who can take their money and retire. So I'd like you to respond to that point.

Andrew Mintz  28:36

Yeah, I mean, to toe the truth grip, and I think it depends on who the private equity sponsor is, and what they are, you know, what are they trying to achieve? And what are they allowing the company to do? And so, so on one hand, I think there's two pieces to this one is, you know, and we see the stories is private equity, you know, destroying healthcare. And I can say that, in my experience working with Webster, which is the private equity, that company that controls, Pinnacle, is that they are very supportive of the strategies that that have been created. And that have been, you know, rolled out to the practices. And so we find a very, we have a board that is really pushing towards the successes of clinical outcomes, and patient experience, and caught and trying to find cost efficiencies for the patient. And I think that it creates a company that is sustainable strategy that's sustainable, that goes beyond who the private equity firm is. And so depending upon who it is, and I've worked with some that I think are very geared towards what's my return And I've quickly come to get it. And there are some that are really geared towards how can we build a great company? And what is it that we need to do to make that happen? I think we're gonna see more advances in healthcare is in fertility, particular, because of the investments being made. So I actually am very much in favor of allowing for investment in the industry, which I think it needs, when it comes to who does it benefit. I think it depends on how you define the benefit. But if you're talking about creating a company with with longevity, that is going to be competitive in the marketplace that has, you know, the latest technologies and equipment and provide the best outcome to the patient, I think that's a benefit to all physicians, whether they are near retirement age or not. And, in fact, those people who are younger will benefit from the investments that are being made now, that others may not in terms of the buyout that's going it goes out, you know, the buy up those towards the partners who own the clinic at the time. And so there is a one time, you know, financial gain to those positions. But I think if it's structured, right, you ensure that there, everyone's incentives are aligned. And that really, everyone's going to benefit from that. So we give, for example, we give equity to physicians that are, that did not own the practice, at the time of the sale, who have either we're either employed at the time or even employed after the transaction, we actually grant equity towards those associates. So they're tied into the whole value and, and the strategy, because the more successful the company, we want them to benefit from that as well. So

Griffin Jones  31:49

I think Woody in the private industry, me equity in the practice, or in the parent company, the parent company, for every associate or just for some associates that look like those are the ones that you want to stay on,

Andrew Mintz  32:02

for every Rei. So we give it to every REI has, is either been granted or is in the process of being granted equity in the parent company. And so they will own, you know, shares in the company, as does the private equity firm, as does the physicians who, you know, who bought who sold, you know, we're partnered with Pinnacle on that. So we find that an important aspect of tying everyone in. And for us, I think it helps with some of the some of the issues with turnover. So you know, the last thing that clinics can stand in this industry is to have physicians who are coming and going, it's disruptive, they're hard to find, access is already at a premium. So the better you can tie them into the success of the company, I think, the better chance you have of them staying and, and if you also create processes, and given technologies that make it easy for them to do their job, and they enjoy that and you create a culture of collaboration. And then they get to create a peer network of other physicians within pinnacle in this in this instance, I think it creates a winning strategy for doctors,

Griffin Jones  33:19

the investments that you talked about making it even if they all work, at the end of the day, it's about those investments are in service of getting our eyes to see more patients to be able to do more procedures. How much is there left to squeeze? Do you suppose before you're actually just squeezing?

Andrew Mintz  33:45

Yeah, it's not necessarily about the doctors working harder. Remember, we really want to move to a top a license model. So we really want them doing things that only physicians can do. So if they're working a 10 hour day, and, you know, they're doing, you know, consults for a few hours and and ultrasounds for another couple hours and then procedures for another couple of hours. The question is, what's the best use of their day? And how can that work? As opposed to how can we make you work harder, so that our support systems, more staff, more nurse practitioners, they may be able to assist and alleviate the work that are done by the doctors. And so the problem is still this imbalance between supply and demand. So the more that we can get people through the system, and the smarter we can work, the better we're going to be servicing the patient population.

Griffin Jones  34:41

I know a lot of doctors are seeing by 30 new patients a month it depends on how many partners they have and what kind of systems they have. But if we weren't to add hours into their week, and we were to do it with efficient processes, investment what What do you do? What do we suspect that that number is? Is it 50 new patients per month? Is it 60 new patients per month that we can, that we can get them to with pure efficiency and not hitting them with a, with a stick and dangling a carrot in front of their face?

Andrew Mintz  35:17

Yeah. First of all, I think that differs by doctor. So you know, they each process, you know, differently. I think we also need to be thinking about, you know, other ways to bring patients into the system. So, we talk about top of license, but the question is, can we train OBGYN is to do things that we aren't allowing OBGYN to generally do? Can we train nurse practitioners to do things like new patient intake, or to handle patients for cryopreservation, or for egg banking or some of those other things? So, again, I think we need to continue to innovate to make sure that people who want the service that they need can get it. But I'm not sure that that necessarily means that doctors have to see more patients in their day in order for us to significantly increase the ability for people to access and get through the process.

Griffin Jones  36:13

I want to shift gears for a second. Because I've had two different guests on with with different views on this. And I think it was back in episode 100. I had Mark Segal asked about he was asking about my opinion on what do I think about a network brand or partnership brand versus individual practice brands? And then I also had Gina bar tz on from kind body to talk about her brand, the global brand, that kind bodies building? In my opinion, Andrew is that I think that you all meaning that groups that have different brands from the parents organization and individual markets SRM in Seattle, or, or I'm in, in Portland. And I think that that I think that you all are at a disadvantage. It's like the IGA true value model where it's hard to scale brand to become a consumer brand. That is the pretty green lady from Starbucks that I think kind body has that advantage. Some people disagree with me, they think that it's better to have the local identity. Ultimately, I don't I don't think so in the in the longer run, I think you still have local reputation. Reputation is different from brand. But the whole point of brand is, is to be able to scale and identify. So you might think differently than I do. So I'd love to hear your side.

Andrew Mintz  37:44

Yeah, I mean, I think the branding strategy is to us not necessarily top of mind, in terms of some of the things that we're trying to accomplish. The reality is that these practices have local reputations, and the doctors themselves have local reputation. So there are some of our doctors who I think are known more so than for the name of the practice that they're in, let alone the national network that they're part of, I think that we will see over time that we'll be putting in some kind of tagline to our practices, such as, you know, a member of the pinnacle family, or something along those lines and create that, but I don't see the need for you know, the Starbucks of fertility, I just don't know that, that we need to create that kind of patient experience where they feel they can get the same thing when they go one to the other. If they're in Seattle, and they're going to go to LA and they want to go to Starbucks, they want they want to, they want to know that they're getting the same coffee made the same way. With the same process. I don't think that that's necessarily holds true in fertility, that what we do in Chicago, and what we do in Phoenix has to be exactly the same because we're not really servicing the same patient population, I think we will eliminate variations, but I'm not sure that that's going to be important to patients who are going to be accessing those services.

Griffin Jones  39:03

That's a good point from the repeat, you know, from the the repeat visitor, the repeat patient or in other fields, repeat customer side, it's not as necessary, which is part of what you want in a brand. You want people to just know what they're going to expect next, and they and they keep coming back. But in some areas like social media, especially, lots of people have lots of friends and they follow people in different markets. So to just being able to say I went to this place in New York, it was great. I went to this place in Chicago, and oh, there is one by me here in LA that that is useful. But also I think one thing that's just tremendously underused on the clinic side in our field is influencer marketing. We've seen the tip of it, but part of the reason why we haven't seen more is because up until very recently, there hasn't been somebody with one name that justifies a there a big price tag or a big Campaign for, you know these influencers to say, Yeah, we use x company.

Andrew Mintz  40:08

I just think that if we can provide the patient with the best possible outcome better than our competitors, and we can provide them with a good experience, I don't think that name is going to make a difference. And I think we're just going to stay focused on really those two aspects of the business and worry about the branding as time goes on. But at the end of the day, I'm on a much more sort of focused in on, how can we improve our outcomes? How can we improve our live birth rates? How can we make sure that patients are feeling like they were cared for through the process? And if that feels the same from clinic to clinic over time? That's great. If they're not called the same thing? I it, frankly, not that important to us.

Griffin Jones  40:51

You're doing something right, because you move very quickly, you said October of 2021 is I think, is when you decided on the pinnacle name, and it was in the second half of the 2021 that you closed on? Is it six practices. And and some of those are are ones that all of the other groups would have loved to have closed down. And so talk to us about your courtship process. Why was it successful in that short amount of time?

Andrew Mintz  41:22

I think that they buy into our strategy and our value. So our core values that we have around, you know, putting the patient first collaboration, integrity. These are I think, what speak to them. So we have

Griffin Jones  41:38

nobody says we put the patient last Andrew and nobody says we're a bunch of dishonest dirtbags that are gonna stab you later. So how were you able to actually demonstrate that?

Andrew Mintz  41:47

Yeah, I think that when we talk about not just that we have values, but that we live our values. So the creation of our lab director Council, and our medical director Council, for example, is a tangible thing that they can see that we're actually living our values. And so I think that's important when we go and have conversations with them about, we have these values, and this is how we live them. Here's our strategy, here's specifically how we are achieving these goals that we set up for themselves in terms of outcomes in terms of, you know, patient care, in terms of, you know, the patient experience in terms of all kinds of things. So we have some very specific goals for ourself. And, and we tell them specifically how we're going to get there, and what their and what their role is. And I think they get excited about it. Frankly, there's a there's more than one several practices that we had conversations that either we didn't think that they would fit well into our strategy in terms of them really participating it or they didn't like our strategy. And so from our perspective, that's okay, too. In that we think that we are partnering with those that are really dedicated to making that happen. And they have to take actions to make that happen. So the fact that they are participating on these committees, that they're adopting our protocols that they are, you know, we announced a partnership with genomics for our, our PGT testing, and everyone's now going to be sending to a genomic so that we can get consistency in terms of results. I mean, these are things that we are doing tangibly to make sure that we're getting the best outcomes. And I think that they see in the early days, they saw the vision and they bought into the vision. In the more recent days, they're seeing that we're actually executing on our strategy. And I think that speaking to who are partners in?

Griffin Jones  43:41

Yeah, so how did you how did you paint the vision? Because you, you did it before you even had a company name in many cases? So did you did you like bring a handful of people with you? Did you have Did you have some kind of storyboard? How did you you're successful in bringing some pretty big groups in before you even had like a cohesive exterior identity. So how did you How were you able to articulate the vision without that,

Andrew Mintz  44:12

so we set our we set a strategy and our strategy has some very specific goals. And so we were able to bring that out with us in terms of what we were going to do and how we were going to get there. Some of it is definitely leap of faith. So they looked at this and maybe they just saw something different than what others were doing. I can't speak to what the other networks are doing or what their strategies are other than what they share on your podcast or or on LinkedIn or something else. But I think that they really liked the concept and you know, selling the, you know, the whole collaboration piece you're going to work with other clinics are going to have peers, you're going to be sharing information and you're going to be making changes and making improvements and those be Pull to recognize that, in fact, that needs to happen. Even though some of our clinics have some of the best outcomes, I think in the country, the reality is that they all know that they can do better. And so the those that are more entrepreneurial, and spirit, those that are really understanding that, you know, change is not going to be avoided, that they have to embrace it. I think those are the ones that are really sort of gravitated to our strategy and our and our values, our mission, in terms of, you know, the thing that the steps that we're going to do to take to make some change now, you know, some of that is also, you know, comes with changes in process and changes and in partnerships and those kinds of things. And everyone recognizes that all that has to be reevaluated. So I think the clinics that we've been able to partner with have that same mindset, and those that have decided that we're not the best partner, maybe just have a different view or, or buying into, you know, the, you know, the mission of, you know, a competing platform, which is fine, too, there's plenty of that to go.

Griffin Jones  46:14

So you mentioned sometimes that it isn't a good fit, either. They don't think you're good for you don't think they're a good fit, what are some of the things that that tell you fairly early on or not even early on, at some point in the process, that it's not going to be a good fit.

Andrew Mintz  46:31

So two things are real red flags for us. One is, when they're only discussing money, then we know what the motivation is. And I'm not saying that money is not an important part of the conversation, but when they're fixated on the money and only the money, then then we know that they're really in it for the money. And that's not really the partner that we're looking for. The second thing is that we have a specific business model, you know, we when we ask them to roll equity, they roll it into the parent, not into the local. And so when they start when they start having conversations with you about changing the way and your philosophy about how you're approaching your partnership, then we recognize that maybe that's not there, too. And then, you know, we also do our own reviews of that as well. So, you know, we are looking at operations in the lab before we, you know, before we sign, you know, our definitive agreements, and we really need to make sure that, you know, they have a basis that we can build from, and not all clinics that we saw necessarily.

Griffin Jones  47:43

So they're getting equity in the new so part of you taking equity in their group is that they are doing that in exchange for equity, some partly, your cash is involved, too, but equity in the in the parent company, is that what you're

Andrew Mintz  47:59

talking about? Correct? That's correct.

Griffin Jones  48:03

What's the advantage of doing it that way?

Andrew Mintz  48:06

I think, you know, it allows them to buy into the full strategy of the organization. So if we are going to be building their own egg bank, for example, then they're going to be interested in figuring out how to make that as good as possible. And for them to be participating in the building and the use of an egg bank, as opposed to well, that's a separate financial, it doesn't really hit me. And therefore I'm sort of less invested in the outcome of how some of these, you know ventures are doing. So from our perspective, we like them to be supporting the strategy as a whole and them to be, again, part of that collaboration is that for all on the same page, so if it's good for, you know, if it's good for the organization, it's good for them, as well, as opposed to maybe advantage, one group over another for whatever reason. And, you know, we certainly don't want there to be competition within the organization, regarding who's getting more profits, we really want that ball to come into pinnacle. And for them to be incentivized to the pinnacle level.

Griffin Jones  49:19

I can see the upside of that. And sometimes there's a downside if people don't buy into the parent organization, and then it's just, it's just flipping the current. It's just flipping that the current practice, it's like, well, how much efficiency was really added and how much did we miss out on by not being a part of the network? So I can see the advantage of that does that put them at more of a risk for an Integra mat situation if my equity is here in this parent company now and then this parent company just took? Yeah, just bit the dust and, and now I don't have anything over there.

Andrew Mintz  49:53

Well, I think there's a lot of learnings from Integra med that I think everyone has taken with them Whether they were part of that network or not work, I mean, I think that because we have so many physicians involved at so many levels in the organization. So it's not just the medical director and the lab director concept, but we got someone who, you know, one of our physicians acts as a part time cmo for us. One of our physicians is leading a, our, our efforts on research and clinical trials, we have a physician who's leading our efforts on international marketing and other kinds of activities that sort of get them engaged and how it's going to work for the network as a whole, the more they participate in that, the more excited they are for it, and the more they're sort of willing to, to make it work. You know, I can see on the downside, which is, you know, what I do individually doesn't have as big of an impact to the whole organization as if it was just my clinic, but really don't have people thinking that way, at this time, at least. And so for us, it's been nothing but exciting to see the growth and the engagement that we're getting from our physicians and our practices to help Pinnacle be successful. And, and there were, they're starting to refer themselves as Pinnacle clinics, you know, over the name of their local brand. And, and, you know, internally, I mean, we don't clinical is not a patient facing brand, but it certainly is speaking to them in terms of what we're trying to do. So we're just loving the engagement that we're getting. And we're finding new ways to engage more and more physicians in the process.

Griffin Jones  51:45

For the audience that doesn't know Al Ries and Jack trout were two of the the like marketing thinkers of probably 80s, early 90s. I think Donny Deutsch, David Ogilvy, nowadays, Gary Vaynerchuk, they have that many books, they have a book called The 22 Immutable Laws of marketing, which I don't think is as relevant, I don't, I don't think they're I no longer think they're immutable, or at least many of them. I think some of them are mutable, but one of the rules that they have is the law of the category. And, and in that if you can't be the leader of a category, you create a new category of think of, well, you know, I'm not going to be the top personal injury attorney in my marketplace, but I can be the top personal injury attorney maybe for workplace accidents, and I'm going to own that category. And so, as long as we're speaking of just IVF centers, Fertility Centers is one category that hasn't fragmented in that way. Another one of their laws is that every in the end, every category becomes a two horse race. There's no RC Cola anymore. It's Coke and Pepsi. And, and I think there's, I don't know that that's true in every category. But do is that what we're going to see in the fertility field, is it so we've got pinnacle, we've got inception, Prelude we have. We've got us fertility, we've got the fertility partners, we've got IV somebody's gonna be really pissed at me for forgetting, you know, first facility, Boston, IVF, you know, somebody's gonna be mad at me. I'm going to forget somebody. But we have, you know, 678 network groups now. And is it inevitable that there's two of them and a number of years?

Andrew Mintz  53:33

Yeah, I mean, I think we'll see that we saw that with EDR. Ma. Right. So that was there an international play, and more so than, than local, but I would think that over time. The network's you know, there's only there's only 450 Some clinics in the United States. And, you know, some of them just are, you know, maybe investable. And so I think at some time, there will be conversations, if they're not already happening among the platforms to be combining their efforts into, you know, a single play, it would really, really have to show the advantages to making that happen. And I think that there, there is an could be. And so I would expect over the next few years, we may see that we may see platforms starting to come together. So if that's

Griffin Jones  54:25

the case, then it seems to me like some platforms would be incentivized to get gobbled up rather quickly. They they acquire a number of clinics, all of a sudden they are a company with a healthy balance sheets, they can get a multiple of the multiple that they purchased on which returns what their obligation to their limited partners. And so I could see some companies that may be where they were in business as a network partnership for a year or two. Become acquired by another one and And if that's the case, our practice owners not missing out on something because it's like, well, should, I should I could have just tried to build that multiple, that we ended up selling for more by myself.

Andrew Mintz  55:18

Welcoming, hindsight. 2020 So the reality is though, the woulda, coulda conversations I'm sure people have with themselves all the time, I think that we are going to see that. I think that in this industry, what we're going to find is that strategy, and and I think culture are going to win out. You know, we're, we're working in a very niche healthcare environment, right. And so certain, there are certain things that we don't see in fertility that you see in many other areas like, like burnout. Burnout is not nearly as prevalent in fertility as it is, let's say, an OB GYN. And so I think that we're going to find that people will continue to engage and stay engaged. And I think that these as these platforms come together, you'll find that you'll find a lot of interest from the partners to make it that much more successful. So if they have rolled equity or granted equity, I think that they will continue to want to have a stake in the game, and make sure that the kinds of collaboration and strategic initiatives that need to happen will happen. And I think we're going to continue to see that, at least in my lifetime.

Griffin Jones  56:46

I've, I've grilled Jaya, and you've been a great sport and and showed people what what they can consider with Pinnacle the our audiences, almost all practice owners, fertility execs, peers of yours, how would you want to younger Doc's? How would you want to conclude with them? Andrew?

Andrew Mintz  57:06

Well, I think what we really want is we want physicians to step up. So we are plagued infertility with a whole set of physicians that are called in or close to retirement. And what we need is we need future leaders. And I think the time is better now than ever. And so being able to go into a platform, such as pinnacle, or any of the others that you mentioned, and and be able to create opportunity for themselves in terms of leadership is never been stronger. And so I would really encourage physicians who are already in or about to enter the rd by field to really think about how to make it better. What can they do that their predecessors haven't? Haven't done? What kinds of ways can they take advantage of new technologies and investment that can take it to a whole different level, and I'm eager to see what some of these new strategies and some of these new adopters are going to come forward with and, and then see what happens. So I'm excited for the future and I can't wait for you know, seeing what's next, what new competitor comes in and what our existing competitors are doing to raise the bar.

Griffin Jones  58:33

We will link to Pentacles website in the show notes and as well to your LinkedIn profile for those that want to get in touch with you. Andrew Mintz, CEO of Pinnacle fertility, thank you very much for coming on inside reproductive health.

Andrew Mintz  58:48

Thank you, Griffin. Appreciate it.

58:50

You've been listening to the inside reproductive health podcast with Griffin Jones. If you're ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

147 The Fertility Private Equity Playbook: The Players And The Payors. As Analyzed by David Stern, CEO of Boston IVF

Boston IVF CEO David Stern describes some of the challenges of private equity backed businesses. Griffin grills David on the models of Boston IVF and their parent companies.

Listen to the latest episode of Inside Reproductive Health to hear

  • David Stern talk about how little of their own money private equity firms typically use

  • Griffin press David Stern on whether business decisions and clinical decisions are always separated

  • David Stern and Griffin discuss the meaning of “trapped equity”

  • What happens when Private Equity doesn’t flip at the right time, who pays for claw back provisions, and what about those hidden fees?

  • David Stern talk about Boston IVF’s model for partnership

145 Two Founders Trying to Flip The Script in The Challenging Fertility Start-up Space: Abby Mercado and Kristyn Hodgdon

On Inside Reproductive Health this week, Griffin Jones chats with Rescripted founders, Abby Mercado and Kristyn Hodgdon about their business model, how it came to be, and what risks they have in this space. How has Rescripted’s capital been invested? How do they keep content fresh? Will they survive and thrive in this space, even though so many others before them have failed- despite having massive capital? Listen now and join the conversation, with Griffin Jones on Inside Reproductive Health.

Listen to hear:

  • Griffin point out that pharmacies missed the boat- they could’ve seized the direct to consumer route, but did not.

  • Abby and Kristyn break down their business model, why it works, and what they won’t allow in their space.

  • Griffin discuss raisers of capital who had the cash, but ultimately failed, and question whether or not Rescripted has what it takes to beat the odds.

  • Abby and Kristyn explain why, and how, Rescripted was founded, and where it hopes to go in the future.

103 - Supply vs Demand and Artificial Intelligence in the Fertility Field with Dr. Robert Stillman

Understanding the past can often help create clarity for the future. Many industries are changing rapidly these days and Fertility practices are not immune. Changes from scientific advancements, culture, and consumers all play a role in the landscape shift of the industry. When you add technology to the mix, advancements start snowballing rapidly.

This week on Inside Reproductive Health I interviewed Dr. Robert Stillman, a Board Certified Reproductive Endocrinology and Fertility subspecialist with over 40 years of experience. We recount his experience from beginning to the present and what he deems will be important in the future. He has direct experience with the integration of private equity capital into fertility practice and has led trends in practice financing, technology (e.g. AI, genetic testing, egg freezing), physician and staff recruitment, retainment, compensation, partnership tract, and retirement paradigms.

In this episode, we talk about Dr. Stillman’s insight into the industry and big trends we are seeing including how Artificial Intelligence is and will continue to shift the industry. We also talk about:

  • How Private Equity effects Fertility Practice

  • What changes have happened in the Fertility field over the last 20 years

  • How has consolidation and expansion has affected the REI landscape

  • How Bob was able to successfully work with the academic centers


To learn more about our Goal and Competitive Diagnostic, visit us at FertilityBridge.com.

100 - An Inside Look at Merging and Consolidating Fertility Groups, an interview with Mark Segal

We’ve seen it happen all over the country and you’ve probably seen it in your backyard--clinics are merging and consolidating, absorbing the market share. But with the fall of Integramed in the spring of 2020 and dozens of clinics left in the lurch, mergers and consolidations started to appear more risky.

On this episode of Inside Reproductive Health, Griffin talks to Mark Segal, CEO of Shady Grove Fertility and CEO of the newly-formed US Fertility, a fertility group made up of Shady Grove Fertility, IVF Florida, RSC of the Bay Area, and FCI in Chicago. Despite forming in a pandemic and after the Integramed news, US Fertility’s partnerships thrive--and are geared to keep growing, especially in the next 18 months. So what does that mean for the hundreds of smaller clinics that continue to remain in the field?

99 - Entrepreneurship, Practice Valuation, and Working with Private Equity, an interview with Dr. Andrew Meikle

Are all clinic owners entrepreneurs? Do all physician-owners really have what it takes to successfully run and grow a private practice?

We’ve talked about joining networks, understanding private equity, and entrepreneurship a lot on this podcast, but usually we are talking about high-level practices to get patients in the door and help them convert to treatment. On this episode of Inside Reproductive Health, we get a new perspective, one that focuses on entrepreneurship, best business practices, and what it really takes to grow in our field.

Dr. Andrew Meikle is the Founder and CEO of The Fertility Partners, a company based in Canada that aims to empower and enable fertility clinics by providing collaboration and strategic expertise. Through his experience in other healthcare fields and his current work in the fertility field, Dr. Meikle shares his thoughts on clinic ownership and entrepreneurship, what fertility networks are looking for, and important things to keep in mind when considering joining private equity.

94 - How Modern Fertility is Changing the Patient Journey, an interview with Afton Vechery

After her own experience with fertility testing, Afton Vechery set out to make the testing process easier for millions of women across the country looking for a better understanding of their reproductive health. From day one, Modern Fertility aimed to provide quality, peer-reviewed information to empower young women to have the knowledge they need to make more informed decisions about her fertility.

On this episode of Inside Reproductive Health, Afton shares the Modern Fertility story. She shares how she brought her vision to life, including how she has been able to raise funds from Venture Capital companies. Griffin and Afton also discuss how Modern Fertility hopes to work with fertility clinics to improve the patient experience across the board.

90 - The Best of 2020

As we head into a new (and hopefully better) year, we wanted to take a look back on all the wonderful, inspiring guests we had on Inside Reproductive Health throughout the year. We talked about affordable care, mentoring new staff in the clinic and the lab. We learned about independent clinics and how they thrive despite heavy network competition, networks and how they continue to provide personalized care even after becoming publicly-owned. We talked about reducing physician burnout and increasing patient communication. And so much more.

On this episode of Inside Reproductive Health, we highlighted your favorite episodes and compiled the best clips into one episode for you to enjoy as 2020 wraps up.

85 - Venture Capital and Its Interests in the Fertility Field, an interview with Dr. David Sable

Venture Capital has been slowly making its way into the field over the last several years. But just what is it looking to improve?

On this episode of Inside Reproductive Health, Griffin talks to Dr. David Sable, a retired REI and current serial investor in biotechnology and other companies that aim to make the field more efficient and accessible by the patients we aim to treat. They discuss what it is going to take to scale to a million cycles in the US and 15 million around the world. From lessons from oncology to bottlenecks holding us back, Dr. Sable shares his biggest hopes for the fertility field and what entrepreneurs need to do to get it to the next level.

Dr. David Sable co-founded and served as director of the Institute for Reproductive Medicine and Science at Saint Barnabas Medical Center in New Jersey, was founder of Assisted Reproductive Medical Technologies, and was co-founder of Reprogenetics. In addition to serving as a reproductive endocrinologist, Dr. Sable also sought to help the field as a whole by finding investors to create new technology to increase the amount of people served by the field. Today, Dr. Sable is a life sciences portfolio manager, an adjunct at Columbia University, and serves as director, advisor, and board member for a wide range of biotech and advocacy organizations.

Learn more about Dr. David Sable at www.dbsable.com or find him on Twitter @dbsable.

83 - Growing an Independent Practice in the World’s Most Private Equity Dominated Market, an interview with Dr. John Crochet

On this episode of Inside Reproductive Health, Griffin talks to Dr. John Crochet of the Center of Reproductive Medicine. CoRM is an independently-owned clinic based in Houston, Texas, one of the largest markets in the field. In recent years, PE-owned and PE-backed clinics have started to take over the city, making the independent clinic almost obsolete… or have they?

Together, we discuss how the Center of Reproductive Medicine continues to thrive despite the money being funneled into their competitors in the market. From how they hire new docs to their philosophy on patient experience, we hear it all.

Dr. John Crochet trained in Reproductive Endocrinology and Infertility at Duke University and Obstetrics and Gynecology at the University of Texas. Originally from Texas, Dr. Crochet went back to his roots, joining the Center of Reproductive Medicine in 2012. As an REI, Dr. Crochet has a goal of providing personalized care and an evidence-based approach to each family hoping to expand.

81 - Ethical Implications of Physician Investment in Fertility-Related Businesses, an interview with Dr. Kevin Doody

Despite busy schedules taking care of patients and often running clinics themselves, it’s not uncommon to see doctors getting involved in ventures outside of their clinic’s four walls. From investing in pharmacies to serving as medical directors for new ART companies to starting software companies, REIs can be found doing a lot. No matter what the venture is, there is always the potential for creating a conflict of interest. So how do doctors draw the line? How are they able to ensure they are keeping the patient’s best interest at heart, and not just making decisions that are beneficial to the physician?

On this episode of Inside Reproductive Health, Griffin talks to Dr. Kevin Doody. Dr. Doody founded Care Fertility in Fort Worth, Texas with his wife, Kathy, in 1989. He is also co-creator of Effortless IVF, which is a new ART technology treatment that uses INVOcells. He is also the Chief Scientist of Global Fertility and Genetics.

Together, Griffin and Dr. Doody talk about entrepreneurship in the fertility field and then, we dig into conflicts of interest in the field: what is acceptable and what isn’t.

78 - Is Private Equity Putting Money Ahead of Patient Care? An Interview with Dr. Francisco Arredondo

Wall Street has been moving into healthcare for several years and it has been making its mark in the fertility field. Some practices have taken advantage of the influx of money in the field, but several haven’t. But several docs have some concerns, specifically when it comes to decision making.


Do private equity firms or people who invest in fertility clinics and businesses really have the best patient care in mind?


On this episode of Inside Reproductive Health, Griffin talks to Dr. Francisco Arredondo, founder of RMA of Texas and author of his upcoming book, MedikalPreneur. Together, we dive into the pros and cons of money entering our field in the form of private equity.