The Promise and Perils of the New Fertility Entrepreneurs

By | Published May 19, 2021 | The New Yorker
The Promise and Perils of the New Fertility Entrepreneurs

France Brunel, who is thirty-six, first considered freezing her eggs after ending a two-year relationship, in 2018. She’s not sure she wants children, especially if she remains single, and she knows egg-freezing does not guarantee her a baby. But she felt it was the best chance she had to preserve the option. “I don’t want to regret it at thirty-nine—if I meet someone, and want kids at that time, to say, ‘Shit, I should have frozen my eggs,’ ” she told me.

Brunel lives in New York, where she runs an innovation-strategy firm while studying to be an Ayurvedic-medicine practitioner. About two years ago, she started seeing ads for Kindbody, the fertility-services franchise, on her Instagram feed. While attending a health-care conference, she spotted a Kindbody van parked outside; inside the van, she received a basic fertility screening, free of charge. Later, she visited Kindbody’s street-level studio in the Flatiron District, a loft-like space that used to house a high-end Mexican restaurant. There, she submitted to a suite of blood tests and a count of her follicles. (Each follicle has an egg that has the potential to mature, with the help of hormonal stimulation.)

The Flatiron flagship, on the same block as a lingerie shop and an athleisure store, can almost pass for a downtown boutique. There are displays of chia face oil and roll-on perfume vials in the sun-filled waiting room, which has lots of blond wood and pops of color. “It feels like you’re stepping into the Wing when you go there. It’s all pink and yellow,” Brunel said. She noted the “cool matcha-turmeric latte powders” and “millennial brands that retail at all the millennial places,” such as the spa chain the Well. “It’s very cheesy, Instagrammable, but it’s all about owning your future and you having control,” Brunel told me. “It’s—it’s empowering.”

Kindbody’s appealing environment and upbeat message compare favorably with any notion of a traditional fertility clinic, which might conjure a sad beige waiting room full of deflated couples. By giving infertility a breezy, stylish backdrop, Kindbody and its peers aim to destigmatize the sector, much as Thinx underwear did for periods, with its ubiquitous New York City subway ads. The aesthetic extends beyond the clinic space. Mosie Baby, a maker of D.I.Y. insemination kits, swathes its products in a familiar bouquet of saturated pastels. The Legacy at-home sperm-freezing kit comes in packaging that looks suited to a hand-poured soy candle.

In the U.S., where the average age at marriage and first birth continues to increase—especially in coastal cities such as San Francisco and New York, where women have their first child at thirty-two and thirty-one, respectively—an estimated eight to fifteen per cent of heterosexual couples will experience infertility. When you add queer couples and single patients who hope to become parents, as well as people with heritable genetic conditions or cancer, demand could be as high as 1.1 million cycles per year, according to an estimate by David Sable. (Sable, a former reproductive endocrinologist, is now a portfolio manager overseeing “a reproductive medicine focused venture fund.”)

Today’s fertility entrepreneurs represent a new, proactive attitude toward reproduction, centered on preëmptive treatments during one’s most fertile years. This shift opens up a potentially limitless market, as Lucy van de Wiel, a research associate at the Reproductive Sociology Research Group at the University of Cambridge, and the author of “Freezing Fertility,” told me. “You don’t have to wait for people to become infertile and then they look for a solution,” she said. Instead, “you can basically tell women that they need to manage their fertility, and they need your services to do that.” Anticipating regret—Brunel’s “Shit, I should have frozen my eggs” moment—is essential to the business model. If the old goal was to make a baby, accounting for lost time, the new goal is to make fertility, starting at any age.

With multiple locations across the U.S., Kindbody is perhaps best known for parking its bright yellow van on high-traffic corners and offering free fertility tests to passersby. Gina Bartasi, the founder and C.E.O., points to the van as symbolic of the future of health care: convenient, easily accessible, and built around the customer, who can stop by for a fertility checkup on her lunch hour. Bartasi has cited SoulCycle and Drybar, with their strong, recognizable branding, as inspirations for Kindbody.

“When I go into Soulcycle, I can be tired and cold, and I walk in and inevitably there are three people in yellow behind the counter who greet me, and they are cheery and bubbly, and they don’t have a care in the world,” Bartasi said. “You have to build that consistency of culture, of cheeriness, of customer service.” Bartasi’s last company, the fertility-benefits provider Progyny, managed fertility coverage on behalf of employers, acting as a middleman; at Kindbody, Bartasi sells fertility treatments directly to consumers and employers. (Progyny went public in October, 2019, and is currently valued at over four billion dollars.)

Kindbody has several competitors that focus on egg-freezing, including the New York-based Extend Fertility and Prelude Fertility, one of whose founders, Martín Varsavsky, is an evangelist for a universal fertility market. Varsavsky, who is based in Madrid and Miami, is the chairman of Inception, the parent corporation of Prelude. Nine years ago, he and his wife, Nina, were struggling to conceive. Varsavsky, who was then fifty-one, knew that his age could present challenges, but he was surprised to learn that even women in their early thirties, such as Nina, could have diminished ovarian reserve—a low number of eggs.

“Because I am a tech entrepreneur, when I’m in a waiting room, I’m always imagining how things could be,” Varsavsky told me. He envisioned a new norm for reproduction, one that would anticipate infertility rather than simply react to it. Young people in their reproductive prime could freeze their sperm or eggs in their twenties, live their lives, pursue careers, and then, when they finally met the right person, thaw their frozen gametes.

Varsavsky called his vision the Prelude Method. It consists of four steps: freeze eggs or sperm at a young age; combine them, at the right time, to yield embryos; test each embryo for genetic abnormalities; and transfer one embryo at a time to the uterus, to avoid multiple births. He looked to the U.S. both for investors and as Prelude’s first, and biggest, market. “If you want to raise money for crazy ideas, you have to come to America,” he said, as we sat in an empty office at the N.Y.U. Langone Fertility Center. “If you say, ‘Sex is great, but not to make babies; give me one hundred million dollars’—in Europe, you don’t get it. In America, investors are intrigued.”

The idea, he told potential investors, was not to compete for the infertility patients already being served by existing clinics. About seventy-seven thousand children are born through I.V.F. each year, he explained, but some three million are born after being conceived without medical intervention. Why not go after that much larger market, and turn babies who might otherwise be spontaneously conceived into Prelude babies? “When they meet,” Varsavsky said, picturing a Prelude couple, “and they want to have children—which now tends to be in the late thirties—they say, ‘Ah, I have frozen sperm and I have frozen eggs!’ They say, ‘Hey, why don’t we have sex for fun, but make a baby in the serious way.’ ” In other words, through I.V.F.

Making a baby in the serious way would include the use of technology such as pre-implantation genetic testing (P.G.T.), which is performed on cells removed from embryos. P.G.T., Varsavsky said, would prevent needless suffering, create a healthier population, and spare people the painful decision of whether to abort a fetus with genetic abnormalities. In a 2016 LinkedIn post, Varsavsky argued that investment in embryo testing is one way to bring U.S. health-care spending under control, alongside more commonplace suggestions like reducing smoking and encouraging exercise. “The best way to lower health care costs is for people not to get sick,” he wrote, “and preventing severe congenital illness helps wellbeing and to lower the health care system cost as a whole.”

Varsavsky’s rhetoric seemed to complete the severing of sex from reproduction that began with the invention of modern contraception. He acknowledges that some observers may detect a whiff of eugenics in his enthusiasm for universal P.G.T., but, he noted, as a parent of seven himself, “You’re only as happy as your saddest child.” He continued, “People say, ‘Oh, I want to have a baby, I want to have a baby’—but they really want to have a healthy baby, right?”

By 2016, Varsavsky had raised a hundred million dollars from Lee Equity Partners, a New York-based private-equity firm whose track record includes creating and selling a nationwide chain of eating-disorder clinics. He started building the Prelude Network by bringing in Reproductive Biology Associates, a group of clinics in Georgia, and its affiliated donor-egg bank, MyEggBank. Mehmet Oz, known as Dr. Oz, joined Prelude’s board. At the same time, T.J. Farnsworth, a health-care entrepreneur, was building a similar chain of practices, Inception Fertility Ventures, in Texas and Georgia. (In 2018, Farnsworth’s previous company SightLine Health LLC, a network of radiation-therapy centers, agreed to pay up to $11.5 million to settle a government lawsuit alleging it paid kickbacks to referring physicians. There was no determination of liability.) In March, 2019, the two fertility chains merged into the Prelude Network, which has forty-five clinics in twenty-two markets, including the N.Y.U. Langone Fertility Center.

Varsavsky described Prelude’s target clientele as ambitious, highly educated young professional women who populate large U.S. cities. “American women are very organized in their thinking,” he said. “They are realizing that, if they want to have control of their lives, having control of their reproduction is a key element.”

Varsavsky’s next big idea is to automate the fertility lab, through the NaturaLife machine, which he calls “an embryology lab in a box.” Using robotics, biochips, and A.I. technology, the machine would perform the same functions as a human embryologist—select sperm and eggs to create embryos and then genetically test them—with greater accuracy and at a fraction of the cost. The machine, now in prototype, has backing from some of Silicon Valley’s biggest names, including Marc Benioff, Khosla Ventures, Anne Wojcicki, and Susan Wojcicki.

As Varsavsky was building Prelude, he engaged the branding agency West (whose founder Allison Johnson helped to launch the iPhone). West’s focus groups revealed that women associated the need for fertility care with a body’s failure to do what is supposed to come naturally. Prelude had to strip away any stigma that still clung to fertility treatment, and persuade women that “this is a positive thing, this is about empowerment, this isn’t about failure,” Joanna Rees, the managing partner at West, said. In landing on Prelude’s bright, clean aesthetic—a color palette dominated by a gender-neutral mustard yellow—West was careful to avoid colors that people associate with actual babies. “Everything wasn’t light pink and light blue,” Rees said. Prelude’s tagline is “Options Preserved.” (Legacy, the at-home sperm-banking service, relies on a similar language of empowerment—“Own your fertility/From your own home”—but on a somewhat more masculine palette of dark forest green.)

“We go to college and we get graduate degrees and then we’re just on that growth curve in our professional life that is exciting and motivating for us, and all of a sudden this dilemma comes in, of, ‘Uh-oh, now I want to have a family,’ ” Rees said. “What we’re doing at Prelude is letting people know that they have choice.”

The sociologist Kylie Baldwin, who is the author of a book on egg-freezing, writes that patients’ experience of the procedure “reflected a strong subscription to neoliberal values of individual accountability, self-actualisation and self-determined action.” She describes preëmptive fertility treatments in language that feels lifted from a mutual fund’s investor prospectus: they are “a contemporary tool of risk management which enables users to guard their reproductive ambitions and assets from the risks seemingly posed by their ageing bodies.” Women who are able to take advantage of egg-freezing might be thought of as “reproductive entrepreneurs, or ‘repropreneurs,’ ” to borrow terms from scholars who write about transnational surrogacy. “It fits in very much with the neoliberal idea that you are the entrepreneur, the manager, the managing director of your own life,” she told me.

This form of risk management, however, carries its own set of perils. Because egg-freezing is still a relatively new technology, and because the vast majority of eggs that have undergone the process have not yet been thawed, success rates are hard to pinpoint. A 2015 study from Spain concluded that women age thirty-six and older who freeze ten eggs have less than a thirty-per-cent chance of having a baby. Yet reproductive endocrinologists also warn against freezing one’s eggs too early. Julie Lamb, a reproductive endocrinologist and infertility specialist at Pacific Northwest Fertility, in Washington, told me that, for most women in their twenties, she doesn’t recommend doing it, “because they’re so young—they have such a low chance of needing them.”

By leveraging our own biological material, Baldwin suggests, we have completed the shift from a commodity economy to “the asset economy,” which doubles as the title of a recent book by Lisa Adkins, Melinda Cooper, and Martijn Konings. The authors define the asset economy as a system in which “value” is inherently speculative. Having a baby, long a hyper-consumerist endeavor, has been thoroughly financialized; much like saving for retirement, one can start planning for, and paying for, a baby years or even decades in advance of the event.

Owing to a mix of spotty insurance coverage, high up-front costs, and stigma, the U.S. has one of the lowest rates of I.V.F. utilization among the richest countries. (In Japan, there is one I.V.F.-treatment cycle for every two hundred and twenty-nine people; in the U.S., that figure is one per sixteen hundred and fifteen.) To address cost barriers, fertility entrepreneurs are expanding into financial products. Farnsworth’s new company, Bundl, promises patients a baby or their money back. “You don’t have to have somebody that has thirty thousand dollars in savings,” Farnsworth said. “Kind of like a car payment, you say, ‘Look, it’s four hundred dollars a month, or whatever it ends up being, for four or five years.’ ” Like providers of other insurance products, Bundl relies on actuarial calculations (as well as the expertise of an automotive-finance executive who came to Bundl from BMW). The final price tag depends on patients’ health data and odds of success.

The covid-19 crisis caused an estimated eight-per-cent decline in births in the U.S., or about three hundred thousand fewer babies. It did not, however, lead to a commensurate drop in demand for fertility services. Amid the uncertainty and anxiety of the pandemic, and the dating drought that it precipitated, many of those who could afford it—or who still worked for employers that pay for it—invested in egg- and sperm-freezing when clinics reopened after initial shutdowns. Legacy reported a tenfold increase in sales volume in 2020 compared with 2019, and has served over five thousand men since its founding, in 2018. Its competitor Dadi reported a threefold rise in 2021 over 2020. James Grifo, the head of the N.Y.U. Langone Fertility Center, told Yahoo Finance, in October, that egg-freezing was up forty-one per cent between June and September of 2020 compared with the same period the previous year. Farnsworth said that the growth in Prelude’s number of I.V.F. cycles has been five to ten per cent higher than expected, and fifteen per cent higher for egg-freezing cycles. The number of egg-freezing cycles performed at Kindbody’s locations more than tripled in 2020. By the end of this year, the company will have fourteen clinics, with another twelve scheduled to open in 2022; it also plans to dispatch mobile clinics directly to employer campuses.

Varsavsky’s last business sold for $1.6 billion. The question of whether Prelude can repeat that success depends on scale and volume. (According to van de Wiel, at the publicly traded Australian chain Virtus Health, doctors receive bonuses for performing three hundred or more cycles per year, in recognition of “the value they generate for shareholders.”) Across the network, Prelude clinics are performing between twenty-five thousand and twenty-seven thousand cycles of I.V.F. and egg-freezing a year. But they are running up against capacity constraints. Clinics “don’t have the number of incubators they need to treat the number of patients they have,” Farnsworth told me. “We’re having to invest in additional equipment.”

A busy clinic is a mixed blessing. Nicole Noyes, a fertility specialist who co-founded N.Y.U.’s egg-freezing program, credits private equity and venture-backed firms with spreading the word about egg-freezing and other fertility care, both in the media and in the employer market. But Noyes, who oversees reproductive endocrinology and infertility at the nonprofit health-care network Northwell Health, worries that investors peering over physicians’ shoulders doesn’t serve the patient. “It’s good that private equity is saying, ‘Oh, by the way, you should have a baby and therefore you should freeze because your eggs are better when you’re younger,’ ” Noyes told me. But when the profit model is “volume-driven,” she said, “It’s like driving a car faster and faster. Okay, you’re going ten, you can go twenty, you can go thirty, you can go forty—but when is it not safe?”

Other doctors are concerned that, in their rush to open clinics, entrepreneurs underestimate the difficulty and precision of the egg-freezing process, and the level of expertise that it demands. “Egg-freezing is the hardest thing we do,” Peter Klatsky, a San Francisco-based reproductive endocrinologist and co-founder of Spring Fertility, which has several locations on the West Coast, said. “It’s a single cell.” Klatsky worries that many of the clinics offering egg-freezing do not have clinicians with the experience to perform this delicate procedure well. Eggs are the largest cell in the human body, and have the lowest surface-to-volume ratio. When they are flash frozen using the process called vitrification, they must be placed in cryoprotectants for just the right amount of time. Too long, and the cryoprotectant will itself be toxic to the cell; too short, and the cell’s liquid will form ice crystals, which will damage the egg and can render it unusable. “When women come back for their eggs, it’s going to be a nightmare,” Klatsky said. “It’s going to be really bad for our whole field. It could make people say, ‘Well, egg-freezing doesn’t work,’ because there’s massive variability” in outcomes between clinics. Spring Fertility offers a full refund to women who freeze at least twenty eggs before they turn thirty-five if they do not achieve a healthy pregnancy when they return to use them.

“My fear, in the egg-freezing space specifically, is that a patient doesn’t know the quality of care that they’re getting until five or ten years later,” Klatsky said. “That’s why I think that we need to provide a guarantee.”

Brunel’s experience of Kindbody was largely positive. The physical premises were small enough that she often saw familiar faces—nurses, doctors, front-desk staff; even if a doctor was working at a computer, Brunel would get a smile and a wave as she passed by. When she went in for the egg retrieval, which took place at a traditional fertility clinic, she was struck by its sterile atmosphere. “If Kindbody didn’t do it so casually, I don’t even know if I would have signed up in the first place. To get me over the hurdle, maybe they did well to actually look like the Wing,” she said. “If I had to step into the clinic right away, I would have probably felt like, Shit, it’s gonna be super expensive, I’m gonna have to deal with insurance, it’s gonna be a total mess. There, it felt like the Zipcar of egg-freezing.”

As Brunel told me later, the same qualities that had made Kindbody so inviting and approachable also distracted her from what she was there to do: inject enormous quantities of hormones into her body to stimulate egg maturation, then undergo a surgical procedure to have those eggs removed. “It’s a little too casual,” she said—a retail experience that left her on bed rest for a month. “How do you actually make it approachable and inviting, but not so casual that women forget that it’s a serious thing that they’re actually buying into?” she asked. “Until I actually dropped my pants and went onto the bed to have my things checked, I forgot I was there for that.”

Top Illustration by Virginia Gabrielli

This reporting was supported by the McGraw Center for Business Journalism at the City University of New York.

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