In Venture Capital fertilization
Multi-million dollar private equity firms offer fertility practices an ultimatum: sell part of their practice, or have their market-share siphoned away.
Major firms spend hundreds of millions of dollars nationwide because they are in a race to consolidate as much of the fragmented IVF market as they can. This is only to speak of companies who own and operate networks of fertility clinics. In parallel, in 2017, PitchBook tallied more than $178 million invested into startups developing fertility products. In our series about fertility practices’ tectonic shift from small clinic to entrepreneurial venture, we’ve detailed the challenges that independent fertility practices face that their big new competitors don’t. So who are these new titans, and what are they up to?
Important disclaimer: Neither I, nor Fertility Bridge have a direct commercial relationship with these companies at time of writing, though we certainly may in the future. We work or have worked with clinics in some of their networks. This profile is not a revelation of insider knowledge. Rather, it is a curated synopsis of public information. My observations and opinions are exactly those, based on information that has been publicly released by these companies or covered in the press.
compete with or join them. just don't pretend they don't exist
I have good friends that work for these companies or have affiliated their practices with them. Some might be very happy with their corporate partners and some might not be. It could be an excellent decision for your practice to sell equity to one of these firms or engage in a different level of strategic partnership with them. For some practice owners, a relationship with one of these firms is the answer to a lot of headaches. The stress of operations is shared with someone else, so providers can focus on practicing medicine.
Other practice principals feel they would lose control over the way they treat patients. They have their own vision for their culture and operations. If you’ve been struggling with this decision, I suggest reading part 2 of our series on vision and strategy, to see where you stand. This might be a long conversation, or several, with your business partner, spouse, clergyman, or bartender. You have to make the decision that’s right for you, your family, and your practice. There’s no right or wrong answer in a vacuum. Whether you decide to fight ‘em or join ‘em, however, we just can’t pretend these major new players don’t exist.
Second important disclaimer: It can be very fashionable to say these companies are more interested in their quarterly profits than the best interest of the patient. There may be cases when business pressures affect personal care. But I would be just as quick to point out that these companies might better serve patients in certain areas because they are better suited to face the challenges that we talked about throughtout this series. Their bankrolls may come from Wall Street, but the people that I know that work for these fertility networks are just as passionate about serving patients as those in private practice. Nevertheless, neither you, nor I, nor they get to pass final judgement on the quality of their output. The patient market decides.
The (Relatively) New Kids on the block
If we covered all newer companies in non-direct competition with fertility practices, this blog post would be longer than Don Quixote. In this article, we profile those networks who directly compete with other fertility centers. We also learn about the private equity firms behind them. Once again we ask ourselves, what is the plan?
Now let’s meet the people who want to buy you out or blow you over.
1). PRELUDE FERTILITY
Prelude Fertility splashed into reproductive headlines in the fall of 2016 when Forbes magazine reported on The 200 Million Dollar Startup That Wants to Stop the Biological Clock. Where does a startup get $200 million and how have they acquired market-share so quickly? Meet the war chest and strategic acquisitions behind Prelude’s rapid market entry.
- Lee Equity Partners. If Prelude’s coffers total $200 million, and Lee Equity’s buy-in was in line with their disclosed portfolio, then one might speculate that 25 to 50% of Prelude’s initial funding came from Lee Equity Partners. Massive capital from Lee Equity Partners has allowed Prelude to accelerate their acquisition of existing companies, and have they ever.
- RBA. In October 2016, Prelude reported that it had acquired Reproductive Biology Associates (RBA) of Atlanta. RBA is the largest IVF practice group in the state of Georgia. Perhaps more importantly, RBA came with their sister company, My Egg Bank.
- MyEggBank was created by RBA in 2010. According to their corporate timeline, their affiliate network grew from 22 clinics in 2012 to 109 in 2017. They report that over 4,400 babies have been born from MyEggBank donor eggs.
- Vivere Health. Why buy one IVF lab at a time when you could acquire several at once? In a parallel running story, Prelude reported acquiring Vivere Health in October 2017. Vivere Health, LLC was founded in 2010 in partnership with Houston Fertility Institute. After an impressive acquisition journey of its own, Vivere Health had owned and operated IVF clinics and labs in
- New Orleans
In April 2016, Vivere was listed in Fortune Magazine as one of the fastest growing female-owned companies in the United States.
Prelude says that their strategic goal is national scale. With a few more acquisitions of this pattern and magnitude, they will have achieved that end.
2). IVI RMA Global
- IVI was founded in Valencia, Spain in 1990. They own subsidiaries in genetic testing, IVF lab consulting, research and development, and stem sell banking, to name a few. In 2016, IVI owned and operated 60 clinic locations in 11 countries and treated over 60,000 patients.
- Nova IVI. Major fertility networks aren’t relegated to the United States. They come from all over the globe and their expansion is international. In April 2012, IVI acquired Nova Pulse IVF and now owns and operates one of the largest fertility networks in India. Nova IVI reports over 19,000 IVF pregnancies in India alone.
- RMA. According to their own PR announcement, RMA of New Jersey grew 70% in new patient volume from 2012 to 2017. I am unclear on RMA of New Jersey’s exact relationship with other RMA network clinics in the United States. Clinics under the RMA name operate in
- New Jersey
- New York
In February 2017, IVI announced that their merger with RMA of New Jersey would make them the largest fertility network in the world. In a horridly translated press release, IVI reports that they own 70% of the new company while RMA of New Jersey owns 30%. They mention their combined 2,400 employees, including 200 physicians and 300 research scientists across 70 clinics in 13 countries.
Integramed Fertility’s model is different from many fertility networks. Private equity is only one of three relationship models for Integramed. They also sell services for marketing and practice management that do not involve taking equity in the practice.
- Integramed Fertility is a division of Integramed America and they report to be the largest fertility network in North America. With 2,200 employees and affiliate employees, the network is comprised of 39 centers at 153 locations across 32 states and the District of Columbia.
- Attain Fertility. Integramed owns Attain Fertility, a patient-facing IVF finance program. They offer multi cycle programs, multi cycle programs with refunds, and bundling with additional services such as PGS and third party services. Subsequently, Attain functions as a lead generation company. Patients can search for Attain Fertility member clinics by doctor or by geographic area and Attain funnels those new patient leads to the clinic. Their business model is similar to that of ARC Fertility.
- Sagard Holdings. Similar to how Prelude Fertility acquires practices through the funding of Lee Equity Partners, Integramed’s capital comes from Sagard Holdings. Integramed had been a publicly traded company, but Sagard reportedly took them off of the Stock Market in 2012 for just under $170 million.
4). OVATION FERTILITY
Ovation Fertility was founded in 2015 by physicians at Texas Fertility Center after a “major private equity investment to form a national network of assisted reproductive technology (ART) labratories”. At time of writing, Ovation Fertility owns and operates six IVF labs in five U.S. states.
The private equity manager behind Ovation's capital is MTS Health Services.
The Colorado Center for Reproductive Medicine, CCRM as you fondly know them, enters new markets by acquisition like everyone else. Perhaps more than the other groups, however, CCRM enters new market areas through De Novo clinics. This means they help develop new labs and clinics in strong markets. In recent years, CCRM has opened or acquired IVF labs and practices in
- New York
- Northern Virginia
- Southern California
- San Francisco Bay Area
CCRM markets their lab advantages in every one of their markets. Since 2015, the private equity behind CCRM’s expansion comes at least partly from TA Associates in Boston. TA reports having raised over $18 billion in capital across their portfolio.
In this article, we’ve only talked about your direct competitors. There are more companies from China and elsewhere that are buying fertility practices at high multiples that I don’t know very much about. There are large practice groups without private equity that acquire other clinics into their group. We didn’t even mention the new competitors that siphon market-share by offering new solutions or focusing on particular services. Here are just a few:
Boston IVF merged with Reproductive Science Center of New England in 2014. Boston IVF operates 29 office locations in
- New York
- New Hampshire
- Rhode Island
You don’t need to find Indiana and Arizona on a map to see that Boston IVF has interest in expanding beyond the northeast. Boston IVF is the “preferred provider of fertility services” for 15 different major health insurance plans. Boston IVF is the clinical affiliate of the Beth Israel Deaconess Medical Center and Harvard Medical School REI fellowship program. How would you like that advantage for recruiting new physicians? If there is a private equity firm associated with Boston IVF, I didn’t find it.
- Extend Fertility. How will you be able to compete against Extend Fertility when social egg freezing is a secondary service for you, when it is their bread and butter? The venture capital firm behind Extend Fertility is North Peak Capital.
- INVO BioScience works with IVF centers, they also work with OB/GYNs who do not perform IVF. Sure, their success rates can’t touch IVF. Do you think they won’t get better? INVO BioScience has been a publicly traded company since 2008. Genetics companies, device manufacturers, and financial entities are expanding in the marketplace as we speak.
WHAT DOES IT all MEAN FOR YOU?
What’s a good ol' independently owned fertility practice group to do? Is there an opportunity for you to compete and thrive in this radically different world? You might look at regional banks or craft breweries. A century ago, every city in North America boasted their own local brewery, likely several. Beer became commoditized, and the corporations with the best distribution, market share, and financial leverage acquired or vanquished their competitors. By the 1990s, we were left with Anheuser-Busch, Miller, and Coors. South African Breweries purchased Miller and Molson-Coors (another merged mega conglomerate) in 2008 to become SABMiller-Coors, and finally merged with Anheuser-Busch/InBev (another merged mega conglomerate) in 2016 .
The past twenty years should have been a terrible period to start a brewery. Yet, quite to the contrary, independent breweries opened all over the country and took marketshare from the big players, now at 23% . Middle market companies like Sam Adams and Yuengling grew their own sales and grew by acquiring small breweries. The cycle continues. We see the same pattern among regional banks, and I believe we are seeing it in our field as well.
Small practices join together to become mid-size practices, and large companies acquire both small and mid-size groups. Then, physicians leave big practice groups and academic institutions to start the cycle anew. (I’ve got my eye on you, Vios Fertility). I don’t believe that all independent practices will be acquired or wiped out. The current and coming landscapes are just exceedingly difficult for unintentional REI entrepreneurs.
if you can't beat 'em, join 'em
What will happen if you're unprepared for these competitors when the next economic recession starts? What will you do if 30-40% of the money in the marketplace goes away, seemingly over night? What would that do to your IVF volume? To your new patient visits?
Entrepreneurial competition isn't the only answer. It might make sense to sell equity in your practice or control of your lab. It could be the answer to a lot of your problems. One of the companies profiled in this article might be a great fit for your office. If we want to sell our practice, and want to go into the negotiation with “strong upside”, plenty of options, and not as a “distressed asset”, what is the plan?
if you can't join 'em, beat 'em
On the other hand, the idea of giving up control and direction of your practice might eat you alive. Only you can make that decision. By taking market-share from big competitors now, as opposed to letting them take ours, we can prepare for an economic downturn in which we will not only survive, but thrive. If we are going to defend and grow market share against majorly funded competitors, what is the plan?
We’ll conclude our series on IVF centers’ tectonic shift from small healthcare practice to entrepreneurial venture with perhaps their greatest challenge of all. Yet, it’s also their greatest opportunity and their chance to beat their giant new competitors where they lag.
In Part 4, we discuss the biggest change ever to occur in human communication and technology.
The one that dwarfs the revolution of the printing press.
The one we're living through right now.
What is the plan?