Wednesday 30 September 2020

big egg

The egg race

Money is flowing in the world of IVF and fertility clinics. But where are the investors going?

By Emma Hartley

The event that started it all happened in Oldham general hospital on 25 July 1978 when Louise Joy Brown was born, and with her, an entire industry devoted to the treatment of infertility.

She was the first human baby to have been successfully brought to term using in vitro fertilisation. It later emerged that despite becoming known as a “test tube baby” she had initially been grown in a jar, before being implanted as an embryo in her mother’s womb. And even though her parents were never made aware that the procedure they were undergoing had not yet produced a living baby – raising ethical questions about informed consent – Louise’s middle name said it all. After nine years of trying to become pregnant and being thwarted by blocked fallopian tubes, Lesley and John Brown were ecstatic to have become parents.

Louise Brown is now 42 years old, and since her birth and that of her younger sister, Natalie, through the same procedure, both women have gone on to conceive naturally themselves. Similarly, the fertility industry has developed a life of its own. Since 1978, more than 8 million IVF children have been born and what was once extraordinary is now mundane; 2.5 million cycles are being performed internationally every year, resulting in over 500,000 annual deliveries. In 2017, 50,000 patients in the UK underwent 70,000 fertility treatments, 93 per cent of which were IVF; the remaining seven percent involved donor insemination.

Louise Brown in 2018, following a press conference to mark her approaching 40th birthday

It is big business. Data Bridge, a research firm, predicts that by 2026 the global fertility industry will be worth $41bn in sales, up from $25bn in 2019. This demand is being driven by women waiting longer before starting a family, a drop in sperm counts, sometimes attributed to plastics in the environment, and increasing numbers of LGBT couples attempting the procedure.

However, in terms of research and development funding in the global healthcare industry, fertility is not even in the top 15 recipient sectors. Cardiovascular disease, cancer, diabetes and dementia get a much larger share of venture capital.

Yet the desire of millions of individuals – with money to spend – for a child of their own is a powerful force that probably isn’t going to become any less powerful as world population growth continues to decline. So where is the investment going?

The smart money in the fertility sector is investing in artificial intelligence, or AI, according to Dr Declan Keane. And in this analysis he is far from alone. The advent of machine learning – in which computers are able to incorporate the outcomes of previous calculations into new calculations without further human input – is transforming the world we live in. In the fertility sector, machine learning involves using data about known outcomes – successful live births, or otherwise – to improve future outcomes. Each round of calculations should refine the resulting algorithm – a mathematical definition of the ideal conditions in which to create a baby – with the dream of 100 per cent success rates. There is a very long way to go, though.

In 2016, Dr Keane sold a 51 per cent stake in his Irish chain of IVF and fertility clinics, ReproMed, to FutureLife, owned by Hartenberg Holdings in Prague. Since then FutureLife, which is among the three biggest owners of fertility clinics in Europe, has expanded its Irish business through other purchases and Dr Keane remains hands on.

He makes a compelling case that the biggest problem to solve in the fertility industry is the high financial and psychological cost paid by many would-be parents for what would be seen in any other sector as extremely poor service. But as the IVF success rate increases, producing more live births, those costs will logically diminish. Any given round of IVF had only an average of a 22 per cent chance of resulting in a live birth in 2017 (up from 18 per cent in 2012), according to the UK Human Fertilisation and Embryo Authority’s (HFEA). At a cost of as much as £5,000 per round, most of which is funded privately in the UK, the process can create more stress than it is intending to solve, a particularly terrible irony given that stress is believed to be antithetical to pregnancy.

Dr Keane is not alone in pointing to Apricity, an online fertility startup based in London and Paris, as offering one of the brightest hopes at the moment for dramatic improvement in IVF success rates.

Founded by serial entrepreneur Caroline Noublanche, Apricity recently raised €6m from AXA’s Kamet Ventures, and, at around the same time, purchased Altrui, an egg-donation service. Keane said: “They are using AI to analyse data collected about IVF rounds, both successful and unsuccessful, and then using the results to build an algorithm predicting the conditions that maximise the chance of a successful live birth. It’s about collecting as many data points for each round of IVF as possible – genetics, metabolites, you name it – and then analysing each embryo before implantation.” It’s a living, breathing exemplification of the idea that success comes from failure.

Caroline Noublanche

Apricity’s chief scientific officer, Dr Christina Hickman, recently made an appearance before the UK’s HFEA to give a summary of the opportunities that AI offers in the field of fertility. US startups working on the same problem include Mojo, Life Whisperer and Ivy.

The approach means that the hundreds of thousands of sets of data for historical IVF pregnancies that have been collected and stored unused by clinics over the years have suddenly developed a usefulness (and financial value) that could only have been guessed at before. There is an analogy to be made with the leap forward in law enforcement that accompanied advances in forensic DNA use. “You could usefully sink hundreds of millions into developing this – buying up as much of this historical data as possible, as well as gathering new data – because crunching it has got to be the way forwards,” said Dr Keane.

The most clearly visible part of the fertility industry is the cohort of gleaming IVF clinics where hard cash is spent in the precarious pursuit of a successful pregnancy through medical technology. In March and April 2019, the two largest chains of fertility clinics in the UK – The Fertility Partnership and CARE Fertility – were both bought by venture capital as part of an inevitable process of consolidation in this growth market.

CARE Fertility was bought by Silverfleet Capital from Bowmark Capital, two London-based outfits, in a leveraged buyout for an unspecified amount. Since then Silverfleet has continued to purchase UK fertility practices, increasing the number of facilities in the CARE group.

Meanwhile The Fertility Partnership, out of Oxford, was bought by Impilo, which is Nordic venture capital, and which shortly afterwards also purchased VivaNeo GmBH, a northern European chain of fertility clinics, from Waterland Private Equity, which is Dutch. Impilo specialises in pharmaceutical, medical and healthcare investments, which it does in order to “increase productivity, improve preventative care and postpone the need for hospital care”. It advertises itself as a financial engine for improving global health.

Further afield, the advent of Covid-19 did not prevent an announcement this month that Trifork, a technology company with a history of strategic investment headquartered in Copenhagen, had been awarded two contracts to build a pregnancy app for the Danish government. This is interesting because Trifork is also an early stage investor for Exseed – a technology company improving men’s access to information about their own sperm count and providing tailored lifestyle advice on how to increase it.

Joern Larson, Trifork’s CEO, explained that both investments arose as a result of considering his own and his friends’ experience in having children. “I have friends who have tried to become pregnant many times, sometimes involving more than 10 cycles of IVF. It drains you of everything because it’s a very tough medical treatment psychologically. You have very embarrassing checkups and it’s very costly: for some people it is the thing that they spend the most money on in their life,” he said.

Exceed home testing fertility kit for men

Larson said that the main challenge for Exseed “is that male fertility is a taboo. Women mind less going to the doctor, getting checked and getting advice. Whereas men don’t go to doctors: I am the same in this regard. So I think it’s a challenging market – it’s a lot about education – but it’s growing all the time.

“When I first heard of Exseed it was just an idea. A medical professional from the hospital in Copenhagen came up with it. He said he thought he could develop a better, cheaper test, to replace the very expensive lab procedure that is still done today. And then we were developing the whole technology. You need to magnify the sample, analyse the video. So there were a lot of challenges. But after a while we had a prototype and invested some more.”

In a more oestrogen-centric development, Bjorn Von Sivers is an investment manager at VNV Global in Stockholm, which was the lead investor last year in a $2.4m seed round for Grace Health, an AI chatbot devoted to women’s fertility and sexual health issues. Unusually, of the eight investors mentioned on Crunchbase, a business information platform, half of them are women. This is because lack of investment for female-led companies, of which Grace Health is one, is often attributed to the lack of understanding by male investors of the problems that female-led startups are intended to solve. In the UK only 1 per cent of venture funding goes to all-female teams.

But for VNV, the investment is a part of a different pattern. VNV Global has a range of interests in emerging markets as well as owning 10 per cent of the UK-based AI chatbot startup Babylon Health. Von Sivers says that Grace Health has 700,000 users in Ghana and Rwanda, capitalising on the new ubiquity of smartphones, in the context of poor health infrastructure. “But it’s still very early on their journey. We’re not expecting to monetise any time soon. One day, though, I think the first monetisation will be partnerships with clinics for consultations with nurses, midwives and doctors, as well as the opportunity to partner with the pharmaceutical industry. It’s quite a simple product – the computer is able to figure out what info you’re looking for and send it to you – but if you can get users involved you can launch a more formal service on top of that.”

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