The Landscape of Fertility Clinic Ownership: Evolution, Profit, and Patient-Centered Progress

I read Joe O’Connor’s recent article in the Financial Post about the shifting ownership dynamics in Canadian fertility clinics with great interest (“The business of fertility is booming in Canada — and big money is buying in”). As the CEO of Markham Fertility Centre, I’ve witnessed this transformation firsthand over the past two and a half decades. While O’Connor highlights the trend toward consolidation and private equity involvement, the story is more nuanced – one of necessary evolution that, despite challenges, holds potential benefits for patients if guided by transparency and accountability. Let me trace the key phases and offer a balanced perspective.

The Evolution of Clinic Ownership: From Public Roots to Private Consolidation

In the early 2000s, many fertility services in Canada were embedded within public institutions – hospitals and universities like Mount Sinai or the Ottawa Civic Hospital. These programs focused on research, training, and subsidized care, often prioritizing access over scalability. However, funding constraints and growing demand led to a wave of “extrication” starting around 2005–2010. Clinics began spinning off into independent, physician-owned entities to gain operational flexibility and meet patient needs more efficiently. This era saw a proliferation of private IVF centres, with physician-owners driving about 70–80% of practices by the mid-2010s. It was an age of innovation, as doctors could invest directly in cutting-edge technologies without bureaucratic hurdles. I was fortunate enough to be part of this first wave when Ottawa Fertility Centre emerged from the Ottawa Civic Hospital.

By the late 2010s, maturity set in. Many independent clinics reached peak efficiency but faced rising costs for equipment, staffing, and compliance. Enter private equity (PE): Starting around 2018–2020, firms like The Fertility Partners and Prelude Fertility began acquiring practices, consolidating the market. This evolved further in 2021–2023 with foreign entities entering Canada. In 2021, US-based Eugin Group acquired Trio Fertility which was subsequently acquired again by Spain’s IVI RMA in 2024. Another US-based conglomerate called Inception (Prelude Network) entered Canada through Vancouver with its acquisition of PCRM and later Calgary’s Regional Fertility Program and a new IVF clinic in Edmonton. These weren’t the first foreign acquisitions. IntegraMed acquired clinics in Quebec in the 2010s, but later was forced to sell it’s US and Canadian clinics.

Today, physician-owned clinics represent only ~30% of the landscape, down from 70–80%, with over 60% controlled by PE, partnerships, or larger conglomerates. Hospital based programs like McGill and Mount Sinai have dwindled to around 5% but still serve an important role in academic research and education. This shift reflects a global trend: In the US, similar consolidations (e.g., IntegraMed’s rise and fall) have created networks like US Fertility, emphasizing scale for bargaining power with insurers and suppliers.

Profit Isn’t the Enemy – It’s Fuel for Innovation

O’Connor rightly notes the profit-driven nature of this consolidation, but profit itself isn’t inherently bad. In fact, it’s essential for sustaining and advancing fertility care. Clinics need margins to invest in clinical innovations, scientific research, and operational improvements (such as EMR systems for better patient tracking). Physician-owned practices often reinvest profits directly into patient care, but PE brings sophisticated capital that raises the bar for the entire ecosystem. In the end, these innovations should reduce costs and improve outcomes for patients. Outcomes are improving marginally – about 1% a year over the last decade, but costs continue to rise. At Markham Fertility Centre, we have tried hard to keep prices in line and are among the lower cost IVF providers in Ontario, even with added benefits like anaesthesiology-assisted egg retrievals (the only clinic in Canada to provide this service for every retrieval at no additional cost) and genetic counselling, also provided at no additional cost. I predict prices will come down eventually. However, more investment is needed to ensure clinics evolve with technology; technology that will help ensure provision of the best, safest, and most patient-centred care while also valuing and retaining employees.

That said, I acknowledge the tension: PE’s primary goal is to build value for an eventual exit (7 to 9 years), which can intensify profit-mindedness. This is evident in pricing—Ontario’s most expensive clinics are PE-backed while hospital-based programs and physician-owned ones like Markham Fertility Centre offer more accessible and affordable pricing (see chart below). Unfortunately, many privately held clinics still do not post their prices on their websites. This needs to change. Also, despite O’Connor’s assertion, some of the best outcomes come from physician-owned centres. There is no evidence that quality and outcomes are correlated with ownership type. In fact, in an annual review of national IVF statistics, Markham Fertility Centre has regularly achieved among the highest pregnancy rates in the country in certain categories. While many clinics claim to have the best pregnancy rates, it is a claim they should not be making without full disclosure across all clinics. For the most part, patients can rely on Canadian clinics for respectable outcomes. The standard of care is high in most clinics across Canada, whether hospital-based, PE-based, or independently owned by physicians. The real difference is in cost and how care is delivered.

How Private Equity Influences the Fertility Ecosystem

PE fosters a growth mentality and competitiveness that spurs innovation. PE is fueled by deeper pockets while physician-owned clinics may lack such leverage. Nonetheless, this creates a healthy competitive environment, theoretically elevating standards across public, independent, and PE-owned providers. Theoretically, competition and consolidation should drive costs down over time, but in Canada, it hasn’t yet – likely due to limited public funding, a relatively small market, and the rapidly evolving technologies within the field. Ironically, the consolidation of clinics may actually stifle innovation as decisions become centralized and budgets compete. In a strange twist, clinics that left hospitals to avoid bureaucracy may now be faced with a new bureaucracy within the larger multi-centre practices. This is the freedom of being an independent physician-owned practice. We can choose when and where to invest and we only answer to ourselves, our staff, and our patients – not to investors. This is a pretty big deal. We may have less free capital, but we are responsive, focused, careful, and nimble. Soon, as opportunities for growth mature for PE investors, we may see PE exit from IVF clinic ownership; Alternatively, we may see further consolidation or even more vertical integration – like acquiring supply chains or bringing external lab services (such as genetic testing) in house – to cut costs in search of better margins; or being optimistic, to lower prices for patients.

Digging Deeper: Value in the Ecosystem for Patients

O’Connor’s analysis stops short of recognizing the ecosystem’s overall value. The mix of ownership models – public for subsidized access and academic research, independent for personalized care and responsiveness, and PE for scaled innovation – benefits patients in the long run. Medicine ultimately belongs to physicians, who ensure ethical, evidence-based practice, while risk-tolerant investors fuel tech advancements. For now, this blend serves a purpose, but to truly empower patients (not clinics), we must enforce greater transparency and accountability. Here’s how:

1. Make Clinical Outcomes Publicly Accessible: IVF clinics in Canada report outcomes to a national database (BORNOntario) linking birth outcomes to ART technology. This is an admirable achievement that has been in voluntarily been in place for two decades and has led to better outcomes across the country. For example, data collection led to a significant decline in multiple pregnancy rates from over a peak of 29.4% in 2009 to around an all time low of 3.2% in 2023. BUT, we can improve transparency and choice for patients through proper and informed public disclosure of clinical outcomes. The Canadian Fertility and Andrology Society initiated a ‘Compliance Seal‘, standardizing how outcomes are reported to patients (a project I proudly worked on when I was Executive Director of the Society in 2015-18 along with other CFAS Board Members like Dr Neal Mahutte of Montreal Fertility). Patients deserve to know the outcomes generated by their clinic and they need to know that info is presented in a way that is consistent for all clinics.
   
2. Implement a Grading System for Add-On Services: Adopt the UK’s HFEA model, where add-ons like PGT-A or embryo glue are graded using a traffic-light system based on evidence. Green for proven benefits, red for limited/no evidence. This curbs over-promising and helps patients avoid unnecessary costs, or at least make informed decisions. There is a fine ethical balance to be achieved between ‘patient autonomy‘ and ‘doing everything possible‘ to achieve a pregnancy. That balance is achieved through proper disclosure of information about add-ons along with informed consent.
   
3. Disclose Public Funding and Establish Award Parameters: Require transparency on provincial funding (e.g., Ontario Fertility Program). Tie funding to metrics like clinical outcomes, Accreditation Canada participation, fee transparency, service to underserved groups (e.g., LGBTQ+ communities, remote areas, or complex cases), capacity, and existing wait lists. Proper criteria for funding allocation ensures equitable distribution and incentivizes quality and access over volume. A better alternative would be to qualify clinics based on criteria above and empower patients by letting them choose where to use their funded cycle. One might want to ponder how public funds should be allocated between foreign-owned entities, PE owned entities, independent clinics, and public-owned institutions.

In conclusion, the evolution of fertility clinic ownership isn’t a zero-sum game – it’s an opportunity for progress if we prioritize patients. By embracing competition while demanding transparency, we can build a system where innovation thrives while augmenting, quality, access and service, without sacrificing ethics. The field of assisted reproductive medicine – where private and public sectors merge – should be examined for its benefits and its limitations. Perhaps, the public health system can also learn from this model.