Who owns and controls the means of reproduction? Assisted fertility and pregnancy as a multi-billion dollar market

In a recent conversation about commodification, one of us brought up the topic of fertility and pregnancy. I was immediately interrupted. My male conversational counterpart felt the urge to teach me that surely, I must have misunderstood my research area, because “children are not sold.” Similarly, when talking about fertility in a workshop on economic analysis, we were told that the issue at stake was economics, not feminism.

This blog post aims to break it to all of us who need to hear it: fertility and pregnancy (which exist prior to the children our conversational partner referred to) are indeed not only commodified, but also commercialised and financialised. Reproductive bodies have long been entangled with violence, propertization, profit-generation —not least during slavery. Today, the rise of assisted reproductive technologies (ART) opens up new possibilities of integrating fertility into markets. To address these developments, we’re taking you onto a blog-sized deep-dive into the fertillity industry which blooms around ART and moves billions of dollars.

ART refers to technologies, such as hormones, medical equipment and preservation freezers, which enable the retrieval, storage, transport, treatment and insertion of reproductive material, including egg cells, embryos and sperm. Here, we focus on the case of eggs. Egg transfers (commonly known as ‘egg donations’)—which are illegal in Germany—refer to the processes in which people who hope to become pregnant receive egg cells from another person. Reasons on the receiving end vary, including infertility, genetic diseases, and preferences (e.g. the ROPA method). So-called ‘social freezing’ concerns the retrieval and preservation of one’s own egg cells for later use. Due to cryopreservation (a special cooling method to preserve cells), eggs and embryos can now be stored for decades—just recently, embryos which were conceived in the same year as one of the authors, were born—and shipped around the world. Accordingly, egg banks and fertility clinics are popping up all around the world. Now that assisted reproductive technologies are sharply increasing—in Germany fertility treatments have increased by about 25% wihtin merely four years (2017 – 2021)—an urgent question comes up: who owns these technologies and clinics? And who controls them and profits from them? Let’s remember that fertility clinics, just like hospitals, may be run by public, non-profit or private actors. While lots of information and heated debates exist when it comes to the privatisation and commercialisation of hospitals, the way fertility is structured remains little understood or discussed.

So, who owns the medical equipment and facilities which are needed to retrieve, store, ship and insert eggs? The answer is: it’s not that easy to say. While a simple Google search will tell you the share of private, public and “freigemeinnützigen” (charitable) hospitals in all its details, it requires a deeper dig to get a grasp on the fertility landscape. Here, we want to share some results of our digging.

To start with, we see an increasing privatisation and commercialisation of fertility clinics. Privatisation means that something passes from public ownership into private hands. Commercialisation refers to the managing or running of a business or institution with the aim of generating financial gain (‘profit’ or ‘surplus value’). For example, in Spain and England, fertility centres which were previously run by the public health sector are increasingly sold off to private actors who are aiming to create profit. Oftentimes, big business takes over. Here, a typical example is the clinic Luarmia, which was founded in 1998 by two doctors in Barcelona. In 2010, it was bought by ProA Capital (a Spanish private equity company) for 75€ million. In Germany, we witness a similar trend: A minority of fertility clinics are run by public actors such as universities, while the majority of clinics were built up by doctors as small-scale businesses. Currently, a handful of international companies are starting to change the scene. Fuelled by international investments, they are buying these clinics and restructuring them into chains which are oftentimes run by international investment banks and managers like Goldman Sachs.

The question that arises: what profit are businesses making by selling egg cells? The truth is: we don’t know. The people selling their egg cells don’t know. And the people buying eggs don’t know. To our knowledge, private fertility clinics do not provide this kind of information concerning egg sales. But we can make some estimates: looking at Spain (the European country with the most egg transfers), donors receive around 800€ for one cycle, while we estimate that clinics pocket around 12,800€. Furthermore, we know that the sales volume of the global fertility market is estimated to be $27.5 billion in 2023, with annual growth rates of 10%.

The story doesn’t end with commercialisation, but rather continues with financialisation. More and more money—globally, but also with regards to the fertility industry—is generated and circulated not through the production and trade of goods, but through financial transactions. To capture this trend of making money by moving money—e.g. through shares, bonds, rents, investments with private debt, purchases and resales, etc.—economists like Rudolf Hilferding and others have proposed understanding the era we live in as one of “financialized capitalism.”

Only few people think of the fertility industry in the context of financialisation. Yet, the financialisation of the fertility industry is in full swing, with potential far-reaching consequences for the way reproduction will occur in the future. To begin with, serial entrepreneurs, alongside private equity companies, have shown strong interest in the sector. For example, when Martin Varsavsky, a US-American entrepreneur specialised in real estate and cloud computing, decided to enter the fertility industry, he was able to secure $200 million in investments from Lee Equity, a private equity firm. This means that private equity managers have a say in the ways fertility clinics operate. Furthermore, such money is put to use (to make more money) in several ways: we see acquisitions, mergers and sellings. For instance, the above-mentioned company Luarmia, which was bought by ProA Capital for 75€ million in 2010, was sold just four years later for 143€ million to NMC, a stock-listed health-corporate based in the United Arab Emirates.

We are also witnessing an increasing entanglement of fertility clinics and physicians with debt accruement institutions. For example, Van de Wiel shows how in the UK, Access Fertility and Fertility Finance offer “multicycle and guarantee packages” to 33 major UK clinics, and clinicians from US clinics hold majority shares in these companies. This means, as Van de Wiel points out: “while fertility lenders’ websites typically emphasize the intention to help or understand intended parents’ financial stress, fertility loans offered through clinics also regularly double as investment opportunities for physicians, as is the case for major lenders.”

Is all of this just happening in the US and the UK? The short answer is: no. Let’s turn to Germany: in 2005, the German hospital corporation Fresenius buys the Helios clinics for 1.5€ billion and becomes Europe’s leading hospital operator. In 2017, they acquire Quironsalud—which includes clinics in Spain and Latin America—for 5.76€ billion. In 2020, the Eugin Group, a fertility service provider which includes the above-mentioned Luarmia and Boston IVF, is acquired, and in 2022, further acquisitions in the fertility sector are made in the US. In Germany, the hospital-fertility-clinics conglomerate not only owns several fertility clinics, but also owns fertility information channels, including a 24-hour hotline for intended parents and PineApp Fertility, which provides information on fertility clinics and treatments .

Tendencies of financialisation are further coupled with developments towards monopolisation and transnationalisation. Monopolisation is mainly realised through mergers and acquisitions. For example, the above-mentioned Martin Varsavsky used parts of the $200 million in private equity cash to buy up fertility clinics. As a consequence, within its first year, Prelude Fertility became the second largest fertility company in the US.

Transnationalisation refers to corporations operating across state boundaries, oftentimes circumventing state regulations and taxes as well as exploiting currency differences and cheap labour power. The reproductive sector is no different—a development which is captured by the concept of Global Fertility Chains: eggs from South African donors may be handled by US American agencies, gestated by surrogates in Mexico, and the child may live with intended parents in Europe. Furthermore, many of the fertility corporates are active across countries and sectors. An example is the above-mentioned German hospital chain Fresenius Helios, which is present in 10 countries and three continents. As an international corporation, they attract German patients travelling to Spanish clinics to carry out egg transfers which are illegal in Germany. In keeping with this, the German Eugin Clinics website offers Skype meetings with Spanish medical professionals who speak Italian, French, English, German, Chinese and Japanese.

What does it mean when fertility treatments are increasingly  in the hands of commercial and financial actors?

While possible consequences of the privatisation of fertility treatments will be discussed elsewhere, it is worth mentioning that corporate actors are not only in for the long game. They are also in to change the game: the fertility sector attracts those billions of dollars because of a vision. In Prelude Fertility’s words, “Reinventing Fertility.”  While this slogan merely gives us a vague foreboding of changes on the horizon, it is clear that economic incentive structures are changing towards medicalised fertility.

To conclude, fertility and pregnancy cannot be understood as occuring outside of the economy, as we hear in workshops and conversations. Rather, we urgently need discussions about the political economy of biological reproduction, including the possible consequences of privatisation and commercialisation of fertility treatments. It is high-time to take pregnancy seriously in every realm of political discussion, including economics—and to learn from those who continously struggle for reproductive autonomy and justice.