in-vitro fertilisation in canada · in-vitro fertilisation in canada cost structure analysis...

IN-VITRO FERTILISATION IN CANADA

C O S T S T R U C T U R E A N A L Y S I S

Prepared for

Canadian Fertility and Andrology Society

By OVO CONSULTING 8000 Boul Decarie

Montreal, QC H4P 2S4

October 2009

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Executive Summary Provincial governments in Canada will start studying and looking at the prospects of funding Assisted Reproductive Technologies (ART), as they do in many European countries. In assessing the level of state participation, these governments will quickly come to the realisation that there is a net economic benefit to funding IVF, but before they do so – it is vital to understand what the Canadian-based clinics go through in terms of associated direct and indirect costs in delivering ART. This study focuses on two main aspects of the costs; One is pricing, what the clinics charge patients for various treatments, and the second is the actual cost associated with the delivery of this vital medical service.

The Canadian In-Vitro Fertilisation (IVF) market consists of 26 clinics spread out over 8 provinces. These clinics operate year-round and offer various ART procedures to infertile Canadian couples. The IVF system in Canada is almost entirely private and thus limited to those who can afford the treatment.

All clinics in Canada spend over 50% of the costs on three fundamental services; Laboratory, Nursing and Doctors honorariums. While some clinics can spend more than others, all carry a similar cost structure.

The costs associated with IVF can vary depending on what part of the country you are being treated. With the most common Canadian ART treatment being the stimulated In-Vitro Fertilisation (sIVF), infertile couples can expect to pay between $4,600 and $8,000, with an average of $5,660. These clinics incur costs to deliver sIVF between $5,026 and $5,450 with an average of $5,254.

Clinic net margins average at less than 7% per cycle, while other procedures render a larger margin for the whole of the clinic. This study will reveal that some clinics across Canada will need to increase prices across the board to accommodate for the increases in human resources costs, supplies and technology.

IVF treatment will continue to grow in Canada as the demand increases. Once governments fund the process, the treatments will be available to a wider span of society and allow many more couples to get access to ARTs.

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Note to the reader This report, while detailed, is by no means exhaustive. The data used to analyse the cost structure was primarily gathered through an on-site visit with a practicing clinic, online sources and a national survey of all Canadian clinics. For the most part, clinics offered a window into their own cost structures, but with the exception of one, conducted an in-depth in-house cost-accounting analysis to determine their actual clinical costs.

All figures, numbers, analysis and opinions are the sole responsibility of the authors and might not necessarily represent those of the CFAS.

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Acknowledgements OVO Consulting acknowledges the significant contribution of all the participating clinics across Canada. Many of the clinic owners and directors offered very valuable data and input that clarified the cost structure in their own clinical practices. We also thank Ms. Agneta Hollander, the staff and its members at the CFAS for their continuous help and support during the drafting of this report.

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Methodology The methodology used in this report is a mix between primary and secondary research. We initially mapped out the entire process of an IVF treatment for both the medical staff and the patient. This map allowed us to allocate direct and indirect costs to every step of the process. The final result culminated in a detailed outline of the cost drivers in an IVF process in Canada.

In analysing these cost drivers, we undertook a full on-field study and a step-by-step approach to dissecting costs and revenues. We also undertook a full national survey with all 26 fertility clinics in Canada, of which half responded directly.

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Objectives of the report To identify the prices of ART across Canada.

To assess the overall cost structure of an IVF cycle.

To identify direct and indirect costs per treatment cycle.

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TABLE OF CONTENT A S S I S T E D R E P R O D U C T I V E T E C H N O L O G I E S : C O S T S T R U C T U R E I N C A N A D A

Executive Summary .......................................................................................................... ii

Note to the reader .............................................................................................................iii

Acknowledgements .......................................................................................................... iv

Methodology...................................................................................................................... v

Objectives of the report .................................................................................................... vi

1 Introduction ................................................................................................................1

2 Background................................................................................................................3

2.1 Context and political drivers................................................................................3

2.1.1 Decline in national Birth rate........................................................................3

2.1.2 Population replacement and fertility ............................................................3

2.1.3 Political supervision .....................................................................................3

2.1.4 Rising need for Assisted Reproductive Technologies .................................4

3 The A.R.T. Process....................................................................................................5

3.1 Infertility diagnosis ..............................................................................................5

3.1.1 What is Infertility? ........................................................................................5

3.1.2 Infertility Disorders in Canada .....................................................................5

3.1.3 Economic Drivers ........................................................................................5

3.2 Assisted Reproductive Technology – Treatments ..............................................7

3.2.1 Intrauterine insemination (IUI) .....................................................................7

3.2.2 In Vitro Fertilization (IVF).............................................................................7

3.2.3 Intra-Cytoplasmic Sperm Injection (ICSI) ....................................................7

3.2.4 Assisted Hatching (AH) ...............................................................................7

3.2.5 Superovulation.............................................................................................7

3.2.6 Frozen Embryo Transfer (FET) ...................................................................8

3.3 Standards of quality and results in Canada ........................................................8

4 Price of ART.............................................................................................................10

4.1 Prices in Canada ..............................................................................................10

4.2 Prices in Québec ..............................................................................................11

4.3 Prices in Ontario ...............................................................................................12

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4.4 Prices in Western Canada ................................................................................13

4.5 Prices in Eastern Canada .................................................................................14

4.6 Supplementary charges: medication ................................................................14

5 Cost structure of fertility treatments in Canada........................................................16

5.1 Cost structure of sIVF process .........................................................................16

5.1.1 Cost Structure in Western Canada............................................................17

5.1.2 Cost Structure in Ontario ...........................................................................18

5.1.3 Cost Structure in Québec ..........................................................................20

5.1.4 Cost Structure in Eastern Canada.............................................................20

5.2 Cost Structure of IVF-ICSI process ..................................................................21

6 Conclusion ...............................................................................................................23

Appendix A: Generic IVF Process Map...........................................................................24

Bibliography ....................................................................................................................26

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1 Introduction In analysing a cost structure, we dissected the actual process in an IVF treatment, from the moment a patient gets a medical consultation, to the moment of the procedure and then the follow-up. We also looked at all the perspectives of clinical operations. A cost structure exercise allows a clinic to better understand its processes and gives an insight into profitability of overall operations. While there are standards that every clinic follows, every clinic establishes their own internal policies, protocols, benchmarks and quality control measure.

In our analysis we looked at how a laboratory operates, from the staff duties to the equipment used, manufacturers’ brands purchased, maintenance records and finally to training and research. The laboratory is the central point to an IVF clinic and dominates the clinic budget by representing 20% of total overall costs. Laboratory managers and embryologist staff also contribute to the overall fertility success rate of a clinic, but for the purpose of this study, we analysed the laboratory costs as an accounting exercise and did not look at other human factors that can greatly determine the fertility success rates. As in clinics, laboratories are also not all built the same, but all clinics surveyed in Canada adopt a similar cost structure.

The economic conditions have also played a factor in cost structures in Canadian-based IVF clinics. While the demand for IVF treatment has not slowed down due to the onset of a global recession, pricing for materials, equipment and even employees have given an adverse effect. For the most part, clinics have maintained the price they charge patients stable. General labour, during a recession, is cheaper but skilled and specialised workers are harder to find and more expensive. Equipment and supply costs increase year-over-year, yet the increases have simply been absorbed by the clinic owners, even though our research indicated any increases to be at the rate of inflation or higher.

Physician costs are also contentious, as the Canadian norm that Québec-based medics are paid at a lower rate than other counterparts in the rest of Canada, has also appeared in this study. Yet, the medical doctors practicing IVF tend to be the proprietors of their establishment; they make up the difference in their net margins from other services. This business model is not consistent with efficient clinical management from a financial perspective. Pricing strategies have also given a negative effect on some clinics based in Western Canada, as the net margins of a stimulated IVF (sIVF) are amongst the lowest in the country.

Understanding the cost structure of an IVF treatment will not necessarily increase fertility rates in Canada, but it will allow doctors to better manage their processes and allow their medical clinics to adopt better standards to

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increase the supply of IVF treatment to an ever increasing demand for the service.

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2 Background

2.1 Context and political drivers

2.1.1 Decline in national Birth rate

Canada has experienced a constant decline in national birth rate for many years. Statistics Canada (2009)1 released new numbers showing Canada's birth rate has fallen to its lowest level ever recorded. In 2008, the rate dropped to 10.29 live births for every 1,000 population. At the same time, infertility among Canadian couples has risen and now affects 10 to 20% of the population. In other words, it is estimated that up to one in six Canadian couples experience infertility. Increasingly, Canadians experiencing infertility are turning to Assisted Reproductive Technologies (ART) to help achieve their parental project.

2.1.2 Population replacement and fertility

To keep a stable population (replacement fertility rate RFR), there is a need for 2.1 children per couple. In 2003, the RFR in Canada was down to 1.53 in Canada. Increasing immigration, while it may counter the decrease in population, will not solve the infertility problem.

Encouraging Childbearing, by making ART treatments accessible to the whole population, without financial discrimination, can increase fertility rates considerably. In countries in Western Europe, the governments cover the couples’ costs associated to IVF treatments.

2.1.3 Political supervision

Since the Royal Commission on New Reproductive Technologies tabled its report in 1993, the federal government has been working to develop a legislative framework to protect the health and safety, rights and dignity of Canadians who use these technologies. Actions taken by Health Canada have included the introduction of a voluntary moratorium on nine problematic Assisted Human Reproduction (AHR) activities in 1995, and passage of the Processing and Distribution of Semen for Assisted Conception Regulations under the Food and Drugs Act in 1996. The Act provided for the development of a federal regulatory agency responsible for licensing, inspection and enforcement activities controlled under the Act.

1 Statistics Canada (2008). Report on the Demographic Situation in Canada. Catalogue 91-209-XIE. Viewed online [04/04/2009] http://www.statcan.gc.ca/bsolc/olc-cel/olc-cel?catno=91-209-x&lang=eng

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Assisted Human Reproduction Canada2 was established by the Government in 2006. The first set of regulations of the Act to come into effect was the prohibiting use of human reproductive material for the purpose of creating an embryo, and the use of in vitro embryos for any purpose, unless written consent is provided by the donor.

2.1.4 Rising need for Assisted Reproductive Technologies

The uptake per capita of IVF in Canada is fairly low compared to other countries (Collins, 2002)3. At the time of the Collins study, less than 190 IVF cycles were performed per million populations per annum.

In 2009, after a rising awareness and falling misconceptions about ART treatments, the situation has changed. According to the Assisted Human Reproduction Canada (2009)4, over the past three decades, more than 1.5 million people have been born as a result of these innovative methods of conceiving children all over the world. In Canada, some 3,500 live births have been made possible by ART each year. Numerous treatments are available to couples with difficulties to conceive. Among all the ARTs available, IVF is the most effective (IAAC, 2009)5.

In Canada, the need of IVF far exceeds its accessibility, and the treatment remains financially out of reach for many infertile couples. Due to lack of funding, patients tend to choose cheaper but less effective alternatives such as ovarian stimulation, with or without intro-uterine insemination (IUI).

It is in the best intention for Canadian couples trying to conceive to have access to the best ART treatments without financial struggles.

2 Assisted Human Reproduction Canada (2009). 2008 annual report. Viewed online [04/04/2009] http://www.ahrc-pac.gc.ca/aux_bin.php?auxid=33 3 Collins, J.A. (2002). An international survey of the health economics of IVF and ICSI. Human Reproduction Update. 8(3), 265-277. European Society of Human Reproduction and Embryology. 4 Assisted Human Reproduction Canada (2009). 2008 annual report. Viewed online [04/04/2009] http://www.ahrc-pac.gc.ca/aux_bin.php?auxid=33 5 Infertility Awareness Association of Canada. (2009) A Follow Up On IVF Children Viewed online [04/04/2009] http://www.iaac.ca/en/library/medical/ivf-children---starr-revised

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3 The A.R.T. Process

3.1 Infertility diagnosis

3.1.1 What is Infertility?

After 12 consecutive months of attempting to have a child without success, couples are said to be infertile. This does not imply the inability to have children, but rather a difficulty to conceive (Government of Canada, 2009)6. A potential mother over 35 is often advised to seek help from a fertility specialist if she is having trouble conceiving after 6 months. Mothers who repeatedly get pregnant, but are unable to carry a child full term are also considered infertile.

Although it is not always the case, infertility is commonly seen as a woman's problem. This has been determined to be untrue, as men can equally be the cause of the infertility. The only way to know the appropriate course of action is for both partners to be tested through a full diagnosis. While fully 10 percent of couples never find out the cause of their infertility, it is possible that infertile couples both have conditions contributing to their difficulties in conceiving. ART provides diverse treatments to assist infertile couples with male, female and male/female conditions so as to give birth to a child.

3.1.2 Infertility Disorders in Canada

One of every 6 Canadian couple experiences fertility problems. Sexually transmitted diseases and delayed childbearing have been identified as two of the most important risk factors of infertility. Twenty percent of infertility among couples can be traced to damage to the women's fallopian tubes resulting from pelvic inflammatory disease.

3.1.3 Economic Drivers

According to Boivin et al (2007)7, approximately 9 percent of couples worldwide are infertile and only 56% of these couples seek treatment. Yet, only 22% of these couples receive adequate medical care. Factors associated to this low number, are related to the economic costs associated to fertility treatment. Couples seeking treatments would increase if they knew that the financial costs were covered by the state.

6 Government of Canada (2009). What is infertility? Viewed online [04/04/2009] http://www.bioportal.gc.ca/English/View.asp?x=767 7 Jacky Boivin, Laura Bunting, John A. Collins and Karl G. Nygren, “International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care” Human Reproduction, Vol. 22, No. 6 pp. 1506-1512, 2007

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According to research by Fiddelers8, society benefits from an IVF child in the sum of $370,000 net benefit in the child’s lifetime. An IVF child will contribute over $2.87million to the Gross National Product (GNP) over its lifetime in taxes (both direct and indirect), while costing the state to educate, train, offer social welfare, health benefits and retirement income of $2.5million.

8 Fiddelers, A.A.A., J.L Severens, C.D. Dirksen, J.C.M. Dumoulin, J.A. Land and J.L.H. Evers, “Economic evaluations of single-versus double-embryo transfer in IVF”, Human Reproduction Update 2007 13(1):5-13 , 10 November 2006

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3.2 Assisted Reproductive Technology9 – Treatments

ART is usually used for patients who experience conditions such as blocked fallopian tubes, widespread endometriosis, male conditions and unexplained infertility. The most common ART techniques include:

3.2.1 Intrauterine insemination (IUI)

Intrauterine insemination is used to overcome male difficulties in conception by directly introducing seminal fluid into the uterus. This is also used in cases of mild endometriosis or cervical mucus of poor quality or hostile to sperm.

3.2.2 In Vitro Fertilization (IVF)

In Vitro Fertilization is a process in which the egg and the sperm are placed together into a dish outside the body. The actual fertilisation occurs spontaneously and the embryo is transferred into the uterus. This technique is used, for example, in cases of blocked fallopian tubes.

3.2.3 Intra-Cytoplasmic Sperm Injection (ICSI)

ICSI is a procedure in which a single sperm is injected directly into an egg. This procedure is most commonly used to overcome male infertility problems.

3.2.4 Assisted Hatching (AH)

This procedure is performed shortly before the embryo is transferred to the uterus. A small opening is made in the outer layer surrounding the egg, in order to help the embryo hatch out and aid in the implantation process of the growing embryo.

3.2.5 Superovulation

Up to 80% of women, whose difficulties in conceiving stem from physical disorders can be helped with assisted conception treatments that promote the growth and development of multiple ovarian follicles.

This treatment is essentially a part of other ART treatments as a technique to stimulate the production of follicles. 9 Assisted Conception Taskforce Canada ACT (2009). Media Backgrounder: Conception Difficulties and Assisted Conception. Viewed online [04/04/2009] http://www.assistedconception.ca/english/resources/Conception%20Difficulties%20Backgrounder.pdf

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3.2.6 Frozen Embryo Transfer (FET)

In IVF, embryos can be either "fresh" from fertilised egg cells of the same menstrual cycle, or "frozen", that is they have been generated in a preceding cycle, cryo-preserved and are thawed just prior to the transfer.

3.3 Standards of quality and results in Canada

The most recent statistics for IVF clinics in Canada10, stem from reported live birth rates of 8278 IVF treatment cycles (including intracytoplasmic sperm injection [ICSI]), undertaken in all IVF centres in Canada. There were 2314 IVF/ICSI treatment cycles performed in Western Canada, 4321 cycles in Ontario, 1446 cycles in Quebec, and 197 cycles in Atlantic Canada.

The overall live birth rate was 27% per cycle started:

• 70% of births were singletons. • 95% of the multiple births were twins.

The live birth rates by age of the mother were:

• for women under 35 years old, the live birth rate was 34% • for women aged 35-39 years, the live birth rate was 26% • for women 40 years old and over, the live birth rate was 11%.

The proportion of babies with congenital anomalies was not different from that seen in the population of women conceiving naturally.

The miscarriage rate was 15% per clinical intrauterine pregnancy, which is the same with the overall miscarriage rate for natural conceptions.

Preliminary results were reported for a combined total of 9019 IVF/ICSI treatment cycles undertaken in all IVF centres in Canada in 2007:

The overall pregnancy rate was 35% per cycle started, an increase of 9 percentage points since 1999 when data collection was first performed.

Complications occurred in fewer than 2% of treatment cycles:

• 68% of pregnancies were singletons. • 92% of multiple pregnancies were twins.

10 Canadian Fertility and Andrology Society (2009). Human Assisted Reproduction 2008 Live Birth Rates for Canada. Viewed online [04/04/2009]. http://www.cfasonline.ca/index.php?option=com_content&view=article&id=260&Itemid=460

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As expected, the woman’s age had a strong influence on pregnancy rate:

• for women under 35 years old, the pregnancy rate was 43% • for women aged 35-39 years, the pregnancy rate was 33% • for women 40 years old and over, the pregnancy rate was 18%.

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Other IUI nIUI nIVF Cycle sIVF cycle ICSI+ s cycle Hatching FET

Western Canada $650 $363 $4,717 $5,617 $6,983 $875

Ontario $4,200 $5,700 $6,914 $313 $1,179

Québec $500 $400 $4,000 $5,500 $7,000 $500 $1,125

Eastern Canada $1,225 $250 $4,950 $5,925 $7,425 $750

Average National Price 721 $ 350 $ 4,471 $ 5,660 $ 6,996 $ 406 $ 1,067 $

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

4 Price of ART The high cost of ART is an inherent problem that affects many countries and many different health systems11. Per capita use of IVF is higher in countries where IVF is covered either by public funding or health insurance. The costs and lack of insurance coverage put infertility treatments, particularly IVF, completely out of reach for many Canadian couples, and create financial hardship for many others.

While the Boivin et al12 study indicates an overall need of over 17,000 IVF cycles in Canada annually, the financial reality limits many infertile couples to seek only 8000 cycles a year. As a result, Canadian infertility services are used primarily by middle to high income households, even though the rates of infertility are equivalent, or greater, in other segments of the population.

4.1 Prices in Canada

11 PATRICIA KATZ, ROBERT NACHTIGALL & JONATHAN SHOWSTACK (2002). The economic impact of the assisted reproductive technologies, Institute for Health Policy Studies, University of California, San Francisco, CA94143-0936, 12 Boivin, J., Bunting, L., Collins, J.A. and Nygren, K.G. (2007). International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. Human Reproduction, 22(6), 1506-1512. DOI: 10.1093/humanrep/dem046. Oxford University Press

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$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

Other IUI nIUI nIVF Cycle sIVF cycle ICSI+ s cycle FETClinique A $4,000 $5,500 $7,000 $1,500

Clinique B $500 $400 $4,000 $5,500 $7,000 $1,000

Clinique C $5,500 $7,000 $1,000

Clinique D $5,500 $7,000 $1,000

Average Quebec $500 $400 $4,000 $5,500 $7,000 $1,125

Quebec Price Comparison

In a country-wide scan of pricing, prices for ART services are relatively the same with very few differences between clinics. Our survey revealed that the overall average pricing for an IVF in stimulated cycle (sIVF) is at $5,66013, with a range from $4,600 to $8,000 per cycle. This pricing is consistent with the Collins14 study where the cost per sIVF cycle is slated on average at $5700 in Canada.

As the IVF-ICSI treatment requires a larger manpower of technical and expert staff, the average Canadian pricing is at $6,996 with a range of $5,600 to $9,500. Frozen Embryo Transfer (FET) average pricing is at $1067 with a range from $750 to $1,500. Natural cycle IVF (nIVF), while only practiced in a handful of clinics in British Columbia, Ontario, Québec and Nova Scotia, has an average pricing of $4,471 with a range of between $4,000 and $5,000.

4.2 Prices in Québec

The Québec market pricing is set evenly amongst the four clinics15 in the province. Prices for the most important treatment of nIVF, sIVF, and IVF-ICSI is all set at the same price, with nIVF at $4,000, sIVF $5,500 and IVF-ICSI at $7,000.

13 Pricing analysis is based on actual survey answers and published prices on websites and other printed public materials. 18 out of 26 clinics reported. 14 Collins, John A. “An International Survey of the Health Economics of IVF and ICSI” Human Reproduction Update, 2002 Vol 8, No.3 pp 265-277 15 In Quebec 4 on 4 clinics reporting data or publicly available.

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$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Clinic A Clinic B Clinic C Clinic D Clinic E Clinic F Clinic G Ontario average

nIVF Cycle $4,200 $4,200

sIVF cycle $5,700 $5,800 $6,000 $6,000 $4,500 $5,900 $6,000 $5,700

ICSI+ s cycle $6,850 $6,800 $7,500 $7,150 $5,500 $7,100 $7,500 $6,914

Hatching $300 $400 $250 $300 $313

FET $1,250 $1,000 $1,000 $1,500 $1,100 $1,200 $1,200 $1,179

Ontario Price Comparison

All three treatments are set along the Canadian averages, with the only variation coming from FET, where only one clinic charges 50% more than the other three clinics at $1,500. The other three clinics charge $1,000 for FET, bringing the Québec average to $1,125, which is slightly higher than the Canadian average. Prices in Ontario.

4.3 Prices in Ontario

Ontario, being the largest base of clinics in Canada, with 15 clinics16 in total, has a stable pricing scheme that hovers around the national average. In sIVF, average price in Ontario is at $5,700 with a range of prices from $4,500 to $6,000.

The IVF-ICSI treatment, the average is at $6,914 with a range of $5,500 to $7,500. FET in Ontario is priced at $1,179 on average with a range from $1,000 to $1,500. For the single clinic that conducts nIVF, the price is $4,200, which is below the Canadian average.

The Ontario pricing model is consistent with the national pricing for treatments. New entrants in the Ontario market tend to be medical doctors who practiced with an existing clinic and later decided to open their own practice. This trend is not affecting overall pricing, since these doctors tend

16 In Ontario 7 on 15 clinics reporting data or publicly available.

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$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000

$10,000

Clinic A Clinic B Clinic C Clinic D Clinic E Clinic F Western Canada Average

Other IUI $400 $700 $800 $700 $650

nIUI $300 $400 $350 $400 $363

nIVF Cycle $5,000 $4,150 $5,000 $4,717

sIVF cycle $5,300 $8,000 $5,000 $5,400 $4,600 $5,400 $5,617

ICSI+ s cycle $6,800 $9,500 $6,500 $6,900 $5,600 $6,600 $6,983

FET $1,000 $750 $1,000 $750 $875

Western Canada Price Comparison

to embrace the actual pricing schemes, by adopting similar structures as their former clinics.

4.4 Prices in Western Canada

Western Canada17 has seven clinics with five based in British Columbia. Price structure varies significantly18 where the largest spread in prices exists. sIVF in Western Canada averages at $5,617 with a range from $4,600 to $8,000. The average pricing is slightly lower than the national average of $5,660, but consistent with the rest of the country.

IVF-ICSI cycle is priced on average at $6,983 with a range from $5,600 to $9,500. While the pricing points reflect the Canadian average, the higher priced clinics could be basing their pricing on a supply/demand strategy.

FET in Western Canada is amongst the lowest priced in the country with an average of $875 and a price range of $750 to $1,000, yet not all clinics in this part of Canada offer the treatment. nIVF is only offered in 3 out of 5 British Columbia-based clinics, with an average price of $4,717, and a price range of $4,150 to $5,000.

17 Western Canada is British Columbia, Alberta, Saskatchewan and Manitoba 18 In Western Canada 6 of 8 clinics reporting data or publicly available.

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$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Other IUI nIUI nIVF Cycle sIVF cycle ICSI+ s cycle

FET

Clinic A $1,225 $250 $4,950 $5,925 $7,425 $750

Axis Title

Eastern Canada Price Comparison

4.5 Prices in Eastern Canada

Eastern Canada19 consists of two clinics20. Price structure is based on one reporting clinic for nIVF, sIVF, IVF-ICSI and FET. nIVF is set at $4,950 which is higher than the national average. sIVF is set at $5,925, which is 6% higher than the Canadian average, while IVF-ICSI is amongst the highest in the country at $7,425 and FET is set at $750.

Reasoning for a higher pricing point can be attributed to higher fixed costs and a limited number of patients. With a smaller pool of demand, clinics will not necessarily be able to benefit from economies of scale, when incurring the large costs associated with building a laboratory.

4.6 Supplementary charges: medication

It is important to note that IVF procedures are not standard. Every patient has different conditions and experiences various personal health situations. As a consequence, physicians rarely prescribe the same IVF protocol twice.

19 Eastern Canada is New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland & Labrador 20 In Eastern Canada 1 of 2 clinics reporting data or publicly available.

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This is the same for the type and amount of drugs used through the different ARTs. From natural to stimulated cycles, assisted hatching to IVF-ICSIs, the overall price of drugs at the charge of patients can vary from $2500 to $7000.

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sIVF TOTAL costs %

Direct Costs drivers General Admin 445.37 $ 7.93%Physicians 968.02 $ 17.25%Other health specialists 286.45 $ 5.10%Lab 1,154.63 $ 20.57%Nursing department 934.48 $ 16.65%Coordination 103.22 $ 1.84%

Total Direct 3,892.16 $ 69.34%

Indirect cost driversQuality Control 198.50 $ 3.54%Trainning 198.50 $ 3.54%R&D 286.42 $ 5.10%

Total indirect 683.42 $ 12.18%

Total Overhead per cycle 678.48 $ 12.09%

Total Average Cost (Canada) 5,254.07 $ 93.61%

Average Canadian Price 5,613.00 $

Average cost structure of a stimulated IVF cycle in Canada

5 Cost structure of fertility treatments in Canada

5.1 Cost structure of sIVF process

In our study, we analysed a cost chain model (see Appendix A) by taking every step in the process phase of treatment, from the first consultation through to screening, virology and then through the IVF coordination and into the procedure. During this exhaustive mapping, we tagged on specific costs associated with every process.

In setting up a cost-chain structure, we split the task between direct and indirect costs associated to any given treatment. While our chain model analysed the costs of sIVF, and ICSI, we focused our cross-country analysis on the sIVF cycle.

The direct costs to any treatment are those associated with labour, equipment, disposables that are related to the actual treatment, whether it is in the lab, with nursing and/or the medical staff. The indirect costs are sub-split into operational overhead and indirect cost drivers, of which we find quality controls, training and research & development. The laboratory cost analysis was based on an embryo transfer of two to three days and did not

analyse the blastocyst method of transfer on day five. The blastocyst

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method would incur approximately 10% to 15% higher costs, since it includes higher incubation, more materials and a longer embryologist intervention.

Overall, the sIVF procedure incurred 69.34% in direct costs, with 12.18% in indirect costs and 12.09% in overhead charges. Consistent with all clinics in Canada and resembling clinics in other countries, the three most important direct costs are related to laboratory, nursing and the intervention of a medical doctor, which account for 54.47% of the total cost per cycle.

Indirect cost drivers at 12.18%, consist of quality control, training and research and development. Every clinic establishes their own internal cost policies to spend on these indirect costs, yet our survey revealed that some clinics do not differentiate such costs, and might be included in direct costs or overhead. Overall results might be skewed, yet we believe that spending on quality control, training and R&D, sets the right principles in managing a quality fertility clinic.

Total overhead costs consist of office equipment, depreciation and other non-essential expenses related to running the overall clinic. This is different than the administration costs associated directly with an ART procedure. In the direct costs section, we took into consideration the booking of appointments and overall patient management to be an essential direct cost, while other vertical services offered in any given clinic is not related to the ART procedure but rather to the overall clinic profitability. Thus we segregated both categories in the overall cost structure. Canadian clinics spend 12.09% on average in total overhead costs per sIVF procedure.

Finally our research revealed that clinics, for the most part, can expect to generate a net margin of less than 7% in delivering a typical sIVF procedure.

5.1.1 Cost Structure in Western Canada

The western provinces, which are dominated by British Columbia-based clinics, are operating with the lowest net margins in the country. With less than 5% in net margins, the western clinics operate below the national average, indicating their pricing might be too low to accommodate their cost structures. Long-term, these clinics will not be sustainable without adjusting their pricing. These clinics might also be making up the difference with other ART procedures and/or through sales of other services.

Western clinics operate with 64.20% direct costs in delivering sIVF. In accordance with the national trend, the three highest areas of direct spending are the lab, nursing and doctor fees. Our survey indicated that doctors in Western Canada typically receive a $1,000 flat fee for each cycle, which corresponds to the national average. Flat fee honorariums are not uncommon and are dependant on the individual clinic. In a completely

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sIVF TOTAL costs %

Direct Costs drivers General Admin 406.58 $ 7.24%Physicians 1,000.00 $ 17.80%Other health specialists ‐ $ 0.00%Lab 1,140.82 $ 20.31%Nursing department 923.30 $ 16.44%Coordination 135.44 $ 2.41%

Total Direct 3,606.13 $ 64.20%




Total Cost 5,347.08 $ 95.19%

Average Western Canada Price 5,617.00 $

Western Canada Average Cost Strucutre of sIVF cycle

private system, each clinic establishes its own internal cost policies, while in a public system, doctor honorariums are typically controlled.

Laboratory costs and nursing follows the national average, suggesting these clinics are following the general salary standards for these professions.

The indirect costs are amongst the highest in the country, with 7% of total cost being earmarked for research and development. Such a high percentage can suggest either a university-based clinic, where the practitioners are also involved at the academic level, or a set internal policy to encourage research.

Overhead, which includes depreciation of capital equipment is at 13.88% of

total costs per sIVF cycle, suggesting a high operating structure.

Our survey revealed that Western-based clinics will not use other physicians for anaesthesia and urology, which provides significant cost savings, considering that the average clinic in Canada spends 5.1% of their total costs per cycle on other medical specialists. Instead, most of these clinics keep these departments in house and let the medical doctors handle anaesthesia and urology. Taken into consideration, the overall medical honorariums for Western-based clinics is amongst the lowest, given the extra task they undertake and the amount of pay.

What is striking with the Western Canadian clinics is the small net margin of 4.81%. While these clinics place much emphasis on R&D, they do so at a sacrifice to net benefits. This practice will not be sustainable, since new market entrants will adjust their pricing to better reflect the market demands and thus force the competitors to increase pricing. We estimate that overall pricing in Western Canada is between 5% and 7% lower than other clinics across Canada. These clinics will have to adjust their pricing or lower their indirect costs to remain competitive in the marketplace.

5.1.2 Cost Structure in Ontario

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sIVF TOTAL costs %

Direct Costs drivers General Admin 542.02 $ 9.51%Physicians 1,233.33 $ 21.64%Other health specialists 375.87 $ 6.59%Lab 1,140.82 $ 20.01%Nursing department 923.30 $ 16.20%Coordination ‐ $ 0.00%

Total Direct 4,215.34 $ 73.95%




Total Cost 5,127.34 $ 89.95%

Average Ontario Price 5,700.00 $

Ontario Average Cost Strucutre of sIVF cycle

The Ontario market represents the largest base of clinical practice of IVF in Canada with 15 clinics in the province. Total direct costs per sIVF cycle in this province are the highest in Canada with an average of 73.95%. Laboratory, nursing and doctor honorariums represent 57.85% of total direct costs.

Doctor honorariums are the highest in Canada with an average of $1,233. These Ontario-based doctors typically receive higher premiums than other provinces, and thus reflect in the overall fertility clinics operation costs. Nursing and Laboratory costs resemble the national average and are proportionate with other clinics in our survey.

The higher general administration in direct costs is attributed to the fact that most Ontario-based clinics group up the coordination costs with general admin, or with the nursing, thus artificially inflating the overall general administration costs.

Indirect costs in Ontario although low in dollar figures, remain relative to other regions in the country. Our national survey revealed that as a matter of internal policy, most clinics spend 5% in R&D on a per cycle basis.

What stands out from the Ontario model – is the overall business model for a fertility clinic. The survey respondents indicated their model to operate on a “hub-and-spoke” model, where individual physicians pay into a general clinic outlay through “rents”, and pay a base fee per cycle, thus creating a “pay-as-you-go” system.

This business model allows for the clinical managers to imbed a large part of the overhead

into the direct cost drivers and reduce their overall overhead charges. The Pay-as-you-go model is designed to maximise rents and limit overall fixed costs, while improving net margins. As this model demonstrates, it is an effective commercial model.

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sIVF TOTAL costs %


Total Direct 3,671.38 $ 68.30%




Total Cost 5,026.15 $ 93.51%

Average Quebec Price 5,375.00 $

Québec Average Cost Strucutre of sIVF cycle

While we believe the hub-and-spoke business model to be a positive example in clinic operations, the Ontario analysis suggests a poor distribution of actual costs. This could possibly lead to poor management decision based on finances and not on quality and the pursuit of excellence.

5.1.3 Cost Structure in Québec

With four private clinics in Québec, overall direct costs are under the national average. In Québec, clinics can expect 68.3% in direct costs in a sIVF cycle. Laboratory, nursing and doctor honorariums account for 51.69% of overall costing, which is the lowest of the three essentials in our survey. Québec-based doctors receive the least amount in honorariums in Canada, and their net margin per cycle of 6.49% is amongst the lowest in the country.

In our survey, Québec-based clinics follow closely the national average in placing 5% R&D, and 3% each in quality control and training. While this is an internal policy, other clinics in Quebec could adopt a different mix, especially those that are located in public hospitals. One Quebec-based clinic, while private in practice, is located within the confines of a public hospital21, and can adopt a different combination of indirect costs, or simply be absorbed by the hospital administration.

While overhead costs are higher than the national average, they remain amongst the lowest in Canada compared to other regions, which is in line with the lower cost-of-living in Quebec. These lower costs would also account for a

larger net margin than other locations in the country.

5.1.4 Cost Structure in Eastern Canada

With only two clinics in Eastern Canada, supply of IVF clinics is fairly low for the level of demand in this part of the country. Eastern-based clinics

21 The only Québec-based IVF Centre hosted in a public hospital did not answer the survey, but our analysis centres on conversations with people at these clinics and through literature review.

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sIVF TOTAL costs %


Total Direct 4,075.79 $ 68.79%




Total Cost 5,453.05 $ 92.03%

Average Eastern Canada Price 5,925.00 $

Eastern Canada Average Cost Strucutre of sIVF cycle

resemble the cost structure of Québec with slight variations. The three essentials of doctor honorariums, laboratory and nursing remains the cornerstone of any clinic including those in this part of the country, with a total of 52.13% of the total cost. The differences come from the fact that Eastern Canadian-based clinics pay more for other health professionals, such as anaesthesiologists and urologists, than other parts of the country on a per cycle basis. Combining both the doctors’ honorariums, and the other medical specialists, the total amounts to 21.48% of the total cost, second only to Ontario. The high numbers are attributed to the scarcity for specialised medical professionals in this part of the country

Indirect costs in quality control, training and R&D are set at 3% each, which is comparatively lower than other clinics in the country, but relatively acceptable to assure quality.

The total overhead costs are at $844 per cycle, which remains high due to the higher operating costs in Eastern Canada. This in turn bodes poorly for a low net margin of 7.97%.

In analysing the Eastern provinces, the price structure will change as more entrants into the market place change overall pricing. Cost structure will probably lower with the onset of increased competition and possibly state-funding might introduce hospital-based clinics, which will bring down costs and prices in the long-term.

5.2 Cost Structure of IVF-ICSI process

Cost structure for the IVF-ICSI process is similar to the sIVF process as most of the cost-base remains the same. Consistent costs are associated with medical honorariums, nursing and laboratory with 48.59% of the total cost per cycle. While the laboratory cost increases in dollar figures, the proportion the lab has on total costs, remains similar to the sIVF with 21.84% of total cost per cycle. This is consistent with the IVF-ICIS procedure where the bulk of the work remains in the lab with an increase in embryologist and

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sIVF + ICSI TOTAL costs %

Direct Costs drivers General Admin 445.37 $ 6.40%Physicians 968.02 $ 13.91%Other health specialists 286.45 $ 5.40%Lab 1,519.46 $ 21.84%Nursing Department 892.79 $ 12.83%Coordination 135.44 $ 1.95%

Total Direct per cycle 4,247.52 $ 62.34%


Total indirect 1,173.19 $ 16.86%


Total Cost 6,099.20 $ 87.67%

Average Canadian Price 6,957.00 $

Suggested cost structure of a stimulated IVF cycle with ICSI in Canada

technician intervention, as well as an increase in disposable lab materials. Our survey results indicate the IVF-ICSI generates a 37% increase in laboratory charges.

A further analysis reveals that the IVF-ICSI is more profitable than the sIVF, since the Canadian pricing is higher than the sIVF and thus accounts for an average net margin of 12.33%. Important to note that most lab technicians are not capable of performing an IVF-ICSI, since it takes a more senior and experienced embryologist to perform the procedure. Some clinics in Canada perform more IVF-ICSI than they do sIVF, while the success rates vary, the IVF-ICSI requires more experienced and well trained manpower. On average clinics across the country, spend more on training and quality control in the IVF-ICS procedure than they do in the sIVF. According to our survey, some clinics entrust only one highly skilled and trained embryologist to

conduct all the IVF-ICSIs.

With an average of 16.86% spent on indirect costs, the IVF-ICSI requires the most skilled of employees to conduct the procedure, and thus renders the process more expensive for the consumer. Yet, the average pricing for the procedure seems to be well priced for the market, given the comfortable net margin spread. These margins can easily be used to shift profits onto other less profitable procedure, which clinics must perform.

The practice of IVF-ICSI is not practiced uniformly across Canada. Some clinics practice more IVF-ICSI, than they do other forms of ART, yet these decisions are based on medical interpretation and patient conditions.

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6 Conclusion Analysing the clinics across Canada, we have concluded that while not all clinics are built the same, the three core cost centres are; Laboratory, Nursing and Doctor’s honorariums. These three costs represent 54.47% on average across the country. While some clinics spend more in one area over another, the general consensus on core costs remain the same.

Where clinics differentiate is in pricing. Clinics in Western Canada have a lower net margin per cycle in sIVF, suggesting that the market will need to bear additional increases to accommodate the differences. Québec and Eastern Canada also have lower net margins, while the Ontario market has 10% per cycle. The Ontario market is the largest in Canada and has had the opportunity to benefit from increased competition and economies of scale, thus allowing for a larger margin. The rest of the country, while not far behind, still needs the same stimulus in order to bring these economies to their respective patients. These clinics will still have room to increase their pricing, until increased competition settles in to stabilise the price per cycle.

Important to note that almost all clinics in Canada are private, yet some clinics are housed in public institutions. This is not a major problem, but affects how a cost analysis is conducted. Public institutions tend to have more equipment and better access to other professionals, while the private clinic must build from within. Our analysis revealed that these publicly-housed clinics can benefit from certain overheads to give them a better profit margin overall.

While the demand for ART in Canada will continue to rise, the trend for publicly financed procedures will move towards a single-embryo transfer. This will push the clinics to embrace a higher number of blastocyst procedures, which will increase their base laboratory costs and eventually the overall pricing. Overall, governments across the country will have to realise that IVF is a net benefit to society and that allowing greater access to it will lead to a more efficient and effective use of public funds, to deliver an essential medical service.

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Appendix A: Generic IVF Process Map

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