From Lab to Life: How Boston IVF is Reshaping Fertility

THL’s Healthcare in Action, Episode 1

[00:00:00] David Stern We’re doing so much better than Mother Nature now because of these new techniques and these technologies that have improved our efficiency and our ability to select healthy embryos. So it’s a huge success story, and we’re able to help thousands and thousands of people in the United States. 

[00:00:19] Josh Nelson That’s David Stern, CEO of Boston IVF. And I’m Josh Nelson, Head of Healthcare at THL Partners. And this is Health Care in Action, a podcast that explores the latest developments and innovations transforming the U.S. health care sector from cutting edge technology to thoughtful approaches to patient care. I’m here today with my colleague Jon Lange, who’s going to be leading us in a conversation about in vitro fertilization, the challenges of it’s early days and how technology and thoughtful management are helping improve patient experience and outcomes for IVF in the U.S. and around the world. Jon, take it away. 

[00:00:57] Jon Lange Thanks, Josh. According to the Department of Health and Human Services, approximately 90,000 babies born in the U.S. in 2022 were conceived through the use of in vitro fertilization or IVF. That accounts for more than 2 percent of all births. So IVF has helped a significant number of people in the U.S. and across the world. And, of course, it can be life changing for all the people who rely on it to start families. We know from the National Survey of Family Growth that approximately 10 percent of men and women under 50 will experience some form of infertility. Before IVF, the available options are much more limited. IVF has totally changed the landscape of what’s possible for families. In Boston, IVF has been at the forefront of patient care and innovation all along the way. Established in 1986, Boston IVF was the first private IVF center in New England and one of the first in the U.S.. The mission, then, as it remains today, was to offer patients fertility care catered to their needs, improving the odds of a successful birth. Today, Boston IVF is one of the largest providers of IVF in the U.S., with over nine centers, 30 offices and 31 physicians across ten states. They’ve also helped bring over 125,000 babies into the world. A big part of this success is due to Boston IVF commitment to investing in new technologies and working closely with top partners in educational institutions like Harvard Medical School. On today’s episode, I’ll speak with David Stern about the current state of IVF and what’s on the horizon. It’s a topic with broad importance and one that’s getting increasing attention in the U.S. and globally. David has been a thought leader and a champion for reproductive health for more than 30 years, and so pleased to be able to talk with him about such an important and topical issue for families across the U.S. and around the world. So let’s get into it. David, thank you so much for joining us. It’s great to have you. 

[00:02:52] David Stern Jon, thanks for having me on. I’m very excited about this discussion we’re going to have today. 

[00:02:57] Jon Lange So, David, for those who don’t know Boston IVF, would you just give a bit of background, a bit of history? How did Boston IVF start and take us on the journey to where you are today? 

[00:03:09] David Stern IVF is a young field in the United States and in the world. The first IVF baby in the United States was born in 1981, and the first IVF baby was born in the U.K. in 1978. So it’s a very young field. Boston IVF is one of the oldest IVF centers in the United States. It’s a private practice, and it was founded in 1986 when physicians that were working at the Beth Israel Deaconess Medical Center left the hospital and felt that doing a private practice would provide better patient care in a nicer setting for their patients who were going through infertility treatment. And it started in one office in Brookline, Massachusetts, with four doctors. And we’ve now expanded to 12 IVF labs, 20 offices, about 40 physicians. And we’re in nine states. So we’ve grown considerably since then. 

[00:04:05] Jon Lange You mentioned this choice or this alternative between being a private IVF provider and then also perhaps directly affiliated or employed by a hospital. Why did Boston IVF decide at the beginning to become a private practice? 

[00:04:20] David Stern When IVF started in the mid 80s, it was very difficult to sync up a woman’s schedule. And so you didn’t know when she was ovulating. You had to constantly monitor her and then go into the operating room. So it could be at two in the morning and the operating rooms in a hospital are busy. At that time, it was also a laparoscopy, so you had to go in through the abdomen and collect the eggs from the ovaries. It wasn’t a priority for the hospital. So the offices of the physicians were not in a nice part of the hospital. They might have been in the basement and patients going in had to run through the hospital to all these different places as opposed to going into a very nice private practice where you’re going into the waiting room and the offices are nice and then you can go to the surgical center. At that time, it was actually in the same building on a different floor, but very easy for patients and much more of a patient friendly experience. 

[00:05:17] Jon Lange What was IVF like 40, 50 years ago? 

[00:05:21] David Stern It’s a great question. When IVF started, we didn’t have enough technology to be able to grow eggs and sperm and fertilized eggs outside of the body. And so back in those early days of IVF, we wanted to get the embryos back into the body as quick as possible because the woman’s uterus was the best incubator for that embryo to grow and to implant and to become a baby. Over time, we’ve actually made improvements to the media that the fertilized eggs grow in to become embryos. One huge improvement was for many, many years. If a man didn’t have enough sperm or it wasn’t motile, it didn’t swim properly. They needed a donor sperm. They couldn’t use their own sperm. And in the 1990s mid-nineties, a new technology was created where you can take a single sperm and inject it into an egg, and that egg fertilizes normally. And for men that didn’t have the ability to use their sperm, which is male factor in fertility, is about a third of infertility cases. So it’s a significant number of men that had problems were able to utilize their genetic sperm instead of getting a third party donor. And it made a huge change to the field and being able to treat these men. Another big improvement in technology is growing the embryos longer. So we used to put three or four embryos back. It was almost like throwing spaghetti against the wall to see if it stuck. You put a bunch of embryos back. You didn’t know if they were good or bad and you hoped that one of them would implant. The result of that was, we had very high twin rates. Over 30 percent of babies born through IVF were twins. And we had a high triplet rate about 5 to 10 percent of triplets. And that’s not a good obstetrical outcome. 

[00:07:14] Jon Lange As you think about your patients and maybe patients who are just beginning to consider IVF or maybe people who are younger who think they might want to have kids but aren’t even really thinking seriously about IVF yet. What advice would you give them with the benefit of all your experience and all your insight into the journey and patient care? 

[00:07:36] David Stern So many people say, you know, I’m putting my career first and I want to get to a point in my career where I can take maternity leave and paternity leave, and that’s going to be another ten years. But ten years go and 15 years go. And now you’re 39 years old and you’re like, okay, I have a baby, let’s go. And it’s not that easy. Human nature. We weren’t designed biologically to have babies at 39 because in the Middle Ages, people lived to 40. Now you’re living to 80. You can’t wait until 40 to have a kid. You know, biologically, we’re still the same humans that we were. 

[00:08:12] Jon Lange And one thing you mentioned to me a while back, which I thought was really fascinating, is OB-GYNs often expect their patients to ask if they think there’s a problem in the patients are expecting the OB-GYN to ask all the relevant questions to see if there might be infertility, and that that’s just a really difficult dynamic to get to a good outcome. 

[00:08:31] David Stern We did research with OBs and with patients and that was the biggest disconnect that we found was there wasn’t a good communication and a lot of it I think was because of the pressure of reimbursement and how quickly and how many people you have to see. The doctor didn’t want to force this idea of, you know, I’m asking you and your parents are asking you and your grandparents are asking you, when are you going to have a kid? And they didn’t want to add this pressure. And the patient basically felt like, well, if there was a medical concern, surely they would raise it. And so, yeah, it’s a disconnect, unfortunately, that we don’t have better education about this age related infertility. 

[00:09:11] Jon Lange Boston IVF has been a market leader for a long time. And so what do you think originally differentiated Boston IVF from its competitors? And then how do you think about sustaining that and advancing that going forward? 

[00:09:23] David Stern We always like to think that we are number one in the market because of our affiliation with Harvard Medical School or because of our very high success rates. We have a very industry leading pregnancy rate and live birth rate for patients. But in actuality, when we ask patients about why they come, there are a couple different reasons why. One reason is patient referrals. A lot of our patients are coming from either OB-GYNs or from a friend or a family who have gotten pregnant with us. And so that third party recommendation is actually very important and we see a higher likelihood of going into treatment. When those patients come referred to us from a trusted individual. It could be their physician, it could be a friend or family. So that’s one component. The other component is convenience. So we talked about the patient experience. Boston IVF was very forward thinking in setting up a hub and spoke model. And what I mean by that is our main lab is in Waltham, Massachusetts. All the patients come in for their egg retrieval procedure and their embryo transfer procedure in Waltham. But IVF involves ultrasound monitoring and blood monitoring. And Boston IVF has set up offices around the Boston area, ringing the Boston area. So we have a North Shore office. We have a downtown office. We have a chest and hill office. We have a South Shore office. We go out now as far as Springfield, Massachusetts, where we have physicians who will see patients as well as do their daily monitoring. And so nobody has to come just into Waltham, but they can have that monitoring either where they live or where they work, which is much easier for them from an experience standpoint. 

[00:11:13] Jon Lange It sounds like you guys are really thoughtful about where to set up spokes, where to set up locations, how to expand the business. And so can you walk me through that a little bit? 

[00:11:22] David Stern It’s a great question. We actually have worked with companies that help us heatmap. One example is we work with Salesforce.com for customer relationship management and we’re able to utilize the software program to see when a call comes into our call center, where are they coming from, where are they, where do they live? And we can do a heatmap of the different communities around our main location. Perfect point to that is we’re opening a new office in Concord, Massachusetts. And one of the reasons that we chose Concord was we saw based on our heat map and based on where other IVF centers have offices, that more people are moving west of the Boston area. And the 495 ring is becoming very populated, especially with younger people trying to build families so people in their late 20s and early 30s. And when we look at where our patients are coming from and what locations we have, we have an office, for example, in Westborough, Massachusetts. We have an office in Worcester. Those offices we see have gotten very busy. And Concord was an area where there wasn’t any other monitoring facilities. There were no other IVF center offices and Emerson hospitals in Concord. And there are two very large OB-GYN practices. So we saw that as a great opportunity for us to expand and build an office there. And we’re opening in September with a brand new office in Concord, Massachusetts, because that area was able to give us a further reach into some of those communities on that 495 belt kind of west of our location in Waltham. 

[00:12:55] Jon Lange Can you talk a bit more about the opportunities in automation? And then also in AI? 

[00:12:59] David Stern There are two aspects of AI and automation that I think can really change some of the way that we treat patients today. One of the things that we do and large IVF centers typically do this is we look at our key performance indicators across our business, but also on our clinical side. Every technologist, every embryologist that’s doing the ICSI Inner Cytoplasmic Sperm Injection procedure we track, are they successful and does that egg fertilize? And we look at every operator across all of our labs and we put a report out and we have a standard deviation and we look for people that are above and below the standard deviation. And for people that are above, we use them to train people that are below. We do the same thing for physicians. When we do an embryo transfer, they take the embryo, they place it into the uterus with a catheter, and we track the pregnancy rate by which physician did that transfer. And we do the same thing above the standard deviation below. We do retraining. And by doing this on a regular basis, we’re able to try to retrain as needed. We also have this assessment by visualization, and there are companies that now use time lapse imaging and artificial intelligence to see things that are human eye can’t see as an embryo is growing and dividing. And are there cells that are fragmented within that larger embryo of multi cells that the computer can pick up that the human eye can’t? And we’re working with some startup companies to be able to identify how artificial intelligence and machine learning can give us a much more objective metric of selecting these good embryos versus the human eye that we’re using today. The other interesting thing that we’re using AI for is in patient prediction, based on a very large dataset of all of our patients. We’re able to collect data on a couple the sperm quality, the endocrine parameters of the women, their blood levels, their age, their smoking history. So both clinical as well as lifestyle. And then the artificial intelligence can find patients that have those similar characteristics and see what’s the best protocol for them to start with, what their outcome is. And so we’re now able to give almost this personalized picture to a patient and say, based on all of these parameters, this is the likelihood of you having a baby, oh you’re a smoker, oh you don’t exercise, if you cut your smoking and stop it for three months, if you start exercising, if you change your diet, maybe lose some weight, we can take you from this likelihood of a baby to this likelihood of a baby. And we know that because we see this improvement in other patients and the artificial intelligence data set and the algorithms are able to show us taking a couple different lifestyle changes might make a difference in your successful outcome or not. Another interesting area is when you’re dosing a patient with the drug. We’re working with an artificial intelligence company that can give us more. Give the doctor a decision support tool of when to increase the dose or decrease the dose based on the optimum number of follicles that is developing. So you have the most eggs when you’re collecting the eggs. What timing do you do for the ovulation to cause ovulation and that helps us from an operating room standpoint to normalize the procedures on a daily basis. So all of this is really exciting in the next five years of working with these AI and machine learning companies to help us identify better dosing, better normalization for our workload and better selection criteria. 

[00:16:43] Jon Lange How do you define success and where is that trending over time? Where do you see that evolving to in the next five, ten years? 

[00:16:51] David Stern It used to be in the early days that a success was a live birth, and that was maybe 15 percent in any given month. Mother Nature is actually very inefficient as well. And so a healthy couple, only 8 to 10 percent of them will have a baby in any given month. But over the course of a year, that all adds up and becomes cumulative. So about 85 percent over that year will have a baby. Infertility is a reduction in that natural fecundity rate. And what we’ve been able to do is improve that single monthly success to now a woman under 35 is over 50 percent likely to have a baby from one IVF cycle. And cumulatively, because you have those embryos could potentially have two babies, 30 percent will have two babies. But each month that they are using another embryo that’s been frozen, the cumulative rate could become more like 60 percent. So we’re doing so much better than Mother Nature now because of these new techniques and these technologies that have improved our efficiency and our ability to select healthy embryos. So it’s a huge success story, and we’re able to help thousands and thousands of people in the United States. And in fact, of the 3 million babies born a year in the United States, I think 3 or 4 percent are now coming from IVF. 

[00:18:20] Jon Lange It’s not only so fascinating, but also just such a great success story in health care technology, in health care, access, in patient experience. It’s just great to hear. 

[00:18:31] David Stern One of the things I think, Jon, that a lot of times private equity gets a bad rap for is looking at the data and basically saying, well, productivity is important. Of course productivity is important, but this is a great example of having that ability to think about how can it be beneficial to outcomes, how can improve outcomes? Are there ways that you can look at this across a network and basically increase everybody’s success by utilizing this? And IVF centers have evolved very similar to Boston IVF in that they are private practice doctors offices and they’re still a majority of them in United States that are two or three doctors operating one office. And they don’t have the ability to look at the data. They don’t have the insights to look at it, and they don’t, quite frankly, have the time. You know, some people see it as, well, you know, it’s big brother, but there are definitely advantages of doing it and improving outcomes and improving patient care at the end of the day. 

[00:19:35] Jon Lange Where do you see growth coming from for the industry and then for Boston IVF in particular, is it more people getting care or are there additional services or additional locations or additional levels of success that you see being provided in the next ten, 20 years? How do you see the industry playing out? 

[00:19:54] David Stern All of the above? I’m very bullish on the growth opportunities in the field for a couple of reasons. The first is access to care is a problem in the United States. When you look at the United States compared to other Western countries, especially Europe, where socialized medicine is involved, we are the lowest per capita access of fertility treatment in the United States compared to Europe, compared to even China, Japan is higher. In the United States, depending on what state you live in, you will either have coverage for IVF or you won’t have coverage for IVF. It’s a state determined insurance coverage and it’s based on commercial insurance. There is no federal mandate that says that all insurance companies need to cover IVF. So if you work in that state and you have a commercial insurance plan like a blue cross and it varies by state, but if you work for an employer that has 50 or more employees or 100 or more employees, you have IVF covered if you are infertile. We see a much higher utilization in those states. So the difference in access to care is a state that doesn’t have an IVF mandate. 3.3 women per 1000 get care, get treatment in an IVF mandate state. 8.8 women per thousand get treatment. So almost three times more women have access to treatment in an IVF mandated state than they do in a non managed state because the cost is so much higher when you’re paying out of pocket. So being able to reduce the cost will increase access and technology that’s coming down the pike, automation is one thing that I think will improve access by bringing the cost down. 

[00:21:41] Jon Lange Even for states that don’t have a mandate. What are the relative economics for an employer covering IVF versus not covering IVF? And I imagine it’s not a simple calculation because there may be complications down the road for a couple or a patient trying to conceive without using the best technology upfront. 

[00:22:04] David Stern It’s a great question. And there is a fantastic case study by a company called Progyny. Progyny is a fertility benefit carve out and they typically target self-insured companies who don’t have to offer fertility benefit because of a risk. There’s a loophole, and they don’t need to follow a state mandate. And they did a case study with AbbVie. I believe AbbVie is based in Illinois. So because they’re self-insured, they don’t have to follow the Illinois state mandate. And their case study was looking at in one year, AbbVie is a giant company that has over 10,000 employees. In one year, they had over 200 twins and triplets, which cost the organization something like 17 million dollars in NICU costs. They use Progyny to align the benefits, offer IVF treatment, offer single embryo transfer and reduce the multiple births for the company to, I think, two in the following year from over 200 and reduce their NICU costs from 17 million dollars to virtually 500,000 or something. It was a huge economic win and exactly as you’re suggesting, a way for the company to end up saving money by offering this benefit because patients aren’t doing things that may be more risky because they want to have a child that ends up leading to higher health care costs for society or for the company in general. 

[00:23:35] Jon Lange Got it. It’s fascinating and may be just one of many examples of some of the complexities in health care. You mentioned private equity, as you say. People have lots of different views on private equity. At this point, you’ve worked with a variety of different companies with a variety of different ownership structures and capital structures. How would you describe a partnership with a private equity firm? The pros, the cons, how to get the most out of it? 

[00:24:02] David Stern I’m new to a private equity ownership structure, but I think the most important thing in any relationship is communication is setting expectations, understanding what those expectations are. And first and foremost, physicians are not cogs in a wheel. You’re a physician and you’re treating a patient and your outcomes and overall patient care has to be paramount. And we’re very lucky in our partner today that that’s the number one priority, is making sure that the medical care being delivered is the most important thing. We’re in health care. You can’t lose sight of that. It’s great to be able to have these other parameters and improve business. There are a lot of learnings that you can bring from other industries to improve that overall patient experience. But at the end of the day, we’re all health care providers and the physician has to feel that they have the flexibility to treat patients in the best way possible. 

[00:25:01] Jon Lange As you think about physicians, the one thing we think about a lot is how to recruit and retain the best ones. How do you go to market and make sure that you are getting the best ones, that you’re retaining the best ones, that you’re creating an environment where people want to come and stay? 

[00:25:17] David Stern It’s a great question. It’s not an easy question. One of the things I think there is a sense of safety in being in a large practice and IVF is economically impacted in economic downturns. But being in a practice that has a financial sponsor, you can maybe weather the storm better. Another big differentiator is partnership. A lot of times when you’re in a bigger network, we have a very clear pathway to partnership and we talk about it when we’re recruiting doctors to say, look, this is the time frame that you should expect it, and here’s what it looks like. It’s a very objective component based on these different ABCD. When you’re in a smaller practice I’ve heard of physicians that were promised partnership after three, four or five years and it doesn’t happen. So there are advantages from a recruitment standpoint of doing it. Another advantage is because you’re in a big practice. We have marketing. When a new doctor starts with us. We’re able to fill their schedule. We’re able to help them go out and market themselves. We have social media, Facebook, Instagram, all these different vehicles that when a new doctor comes on, we can get them right out to OB-GYN referrals, market them on social media. When you’re in a smaller practice. You don’t have that ability to do that. And we’ve been lucky that we have successfully recruited doctors. We have three new doctors starting this fall. We hired at last year, we had six new doctors. And so we’ve been successful in being able to attract and retain our physician base. 

[00:26:56] Jon Lange I am such an optimist about IVF and the impact it can continue to have on the world. What makes you most excited? What makes you most passionate about your job? About the industry? About the road ahead? 

[00:27:10] David Stern This field has just been such an amazing ride for me over 30 years in this area because there’s constantly been evolution and improvements in technology, you know, human genome sequencing and these things where I see the field going is areas that we talked about automation being able to scale this at a much higher level. It’s amazing. And I think as now a parent with older kids where I see huge opportunities is there is genetic diseases that we can eradicate, but there are also other diseases and we can screen out potential genetic diseases that we have in our family. It’s not a guarantee, but you can reduce the relative risk by transferring a healthy embryo and having a healthy grandchild. And so when I think about that, that’s what really excites me, is not just infertility to treat the couples that can have babies, but to treat couples that want to have healthy babies. What’s most important as we do it in a very thoughtful way and we do it in a way that you’re not creating, you know, a eugenics like, we want to have, you know, six foot five, you know, blond haired, blue eyed Adonis is an Olympic athletes. And we’re not talking about that. We’re talking about healthy, healthy babies. 

[00:28:29] Jon Lange David, thank you so much. It is always fascinating to talk to you. I am just so excited about the future for IVF and everything that you and Boston IVF are doing to push it forward. It’s always a pleasure and I look forward to continuing the conversation soon. 

[00:28:43] David Stern Thanks very much, Jon. It’s been a ton of fun. I appreciate it. 

[00:28:48] Jon Lange As we wrap this episode, I’m joined by my colleague Megan Preiner, Head of Healthcare services at THL. Megan, I always find the IVF space so fascinating and I thought David did a nice job laying out the history and the opportunities ahead. From your vantage point, leading health care services. Can you put IVF in a bit of context for us? How does it stand out across the healthcare services landscape? 

[00:29:09] Megan Jon, you’re right that IVF is so fascinating and there’s so much opportunity ahead. It’s easy to forget that IVF is still such a relatively new field. The industry has made incredible strides in the past 40 years, but there’s still so much innovation happening every day, not only in technology and outcomes, but also in patient access and experience. And from the standpoint of an investor, there’s a really exciting backdrop, in THL we’re always partners, our portfolio companies, to help drive innovation and navigate through changing technology, regulatory and market landscapes. And IVF is certainly one area where there’s plenty of opportunity for all of that. 

[00:29:42] Jon Lange It’s such an important point in something that’s often lost in the conversation about private equity in healthcare. Can you tell us a bit more about that? What are some of the ways private equity firms partner with providers? In some of the ways we can use our experience to help drive healthcare services businesses forward? 

[00:29:57] Megan It’s a great question and something I think isn’t talked about nearly enough. I thought David did a nice job laying out some of the ways that providers and private equity firms can partner to help advance growth, patient care and patient experience. One great example that we see over and over again with our portfolio companies is leveraging data and KPIs to get alignment around the most important metrics and then use those metrics as a North Star quality outcomes of patient experience, which ultimately leads to great commercial outcomes. In some sense, that seems like an obvious step, but it’s not always easy to gather and track and manage those key metrics. And it’s a way we can leverage THL decades of experience to help make an impact across a wide range of healthcare services companies. Another way we’re able to help drive value across providers is by helping them navigate the trend towards the consumerization of healthcare. As technology and consumer preferences have evolved, health care providers increasingly need to meet consumers where they are and provide a differentiated patient experience. David did a great job highlighting this trend. It touches everything from choosing where to build new locations to how to use technology to make the patient experience seamless. The trend toward consumerization is powerful and accelerating, and one of the many ways THL has been successful in partnering with our portfolio companies to drive value. 

[00:31:07] Jon Lange One point David mentioned, was the potential for automation and AI to have a significant impact in IVF. Is that consistent with what you’re seeing more broadly across healthcare services? 

[00:31:17] Megan Absolutely. Of course, there’s been a lot of talk about automation and AI over the past couple of years, and I know people may not immediately think about the impact of AI on healthcare services. David, though, pointed out some of the impacts that automation and AI can have not only on technology and outcomes, but also on identifying trends in the data to drive consumer behavior. We’re seeing that across the healthcare services landscape and it’s something we think about a lot with all of our investments. 

[00:31:41] Jon Lange David also mentioned a bit about the regulatory and reimbursement landscape. How do you think about that for investment perspective in IVF and beyond? 

[00:31:49] Megan The regulatory and reimbursement landscape is such an important aspect of investing across healthcare services. While it’s always difficult to pin down timing when politics and policy are involved. One element that’s really exciting about IVF is the prospect of expanding access over time. Other countries have given us a roadmap that suggests a significantly higher level of IVF access is possible. Whether that’s driven by technology advancements or policy or combination of both, the potential for expanded access IVF makes it an exciting area and holds a lot of promise for prospective parents in the US and around the world. 

[00:32:19] Jon Lange Megan, thanks so much for joining me. I’m really excited about the future of IVF, and I’m looking forward to continuing the conversation with you and David as the industry advances even further in the coming years. 

[00:32:32] Josh Nelson Thank you for listening to Healthcare in Action brought to you by THL. To help Healthcare in Action reach more listeners like you, either share this episode with a colleague, subscribe to the show or rate and review us on Apple Podcasts. For more information on THL Health Care franchise visit to THL.com/Verticals/HealthCare. 

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