Europe: Rising Infertility in a Fragmented Market

In this article, we want to talk about how we've identified Europe as a prime example of cross border fertility care. In Europe, fertility treatment regulations and pricing vary by country and international travel is made easier by shared physical borders. Across Europe, the fertility market is ~$7.6B equating to ~500,000 cycles, with an estimated 10% CAGR. Of that, approximately 5% of all European fertility care likely involves cross-border travel, which would equate to ~25k cycles a year attributed to medical tourism.

As is the case globally, infertility is rising and demand for fertility services in Europe continues to grow.  A healthy replacement rate for a stable population is considered to be a total fertility rate of 2.1 births per woman, yet, in 2022, the total fertility rate in Europe was estimated to be 1.49 births per woman compared with 2.7 in 1950. Several macro factors we have already discussed are contributing to this trend; for example, in 2001, the most prevalent age of pregnancy was between 25-29 years old whereas in 2020, the fertility rate of women aged 30-34 became the highest, leading to a greater need for assisted reproductive technologies including egg freezing and IVF as women choose to delay family planning.

Across Europe, prices can range for egg freezing and IVF cycles. For example, an IVF cycle can cost between $6-10k in the UK,  $4-8k in Spain, and $3-6k in Portugal, with additional costs for donor eggs. In those same countries, an egg freezing cycle averages around $3-4k (UK), $2-3k (Spain), and $1.5-2.5k (Portugal). Some countries such as the Czech Republic and Poland can generally offer even reduced pricing. However, though pricing variations may be helpful, a more powerful motivating factor for cross border care in Europe is based on regulatory arbitrage and quality of care.

In many countries, access to treatment can be restricted. A recent survey on fertility treatment policies across Europe found a clear bias towards heterosexual couples at the expense of single people and LGBT couples with 41 countries providing donor insemination to heterosexual couples but only 19 to female couples and 30 to single women.  For example, in some countries such as Italy or France, access to fertility treatments are limited to heterosexual couples with a demonstrated case of medical infertility and even if the government partially funds or reimburses treatment, many cases would be better served seeking care abroad. Further, social egg freezing, or the practice of a presumably fertile woman freezing eggs for use later in life, is not allowed in several EU member states including Austria, France, Hungary, Lithuania, Malta, Norway, Serbia and Slovenia.

Two countries in particular have both high standards of care and progressive regulations in relation to fertility treatments: Spain and Portugal. Spain was the first EU country to allow fertility treatment for all women, and opened the first sperm bank, quickly becoming a foremost destination for IVF in Europe.

Portugal more recently followed to allow all women access, and passed one of the most progressive legislations in Europe in 2019 when it dropped the requirement for donor anonymity. Portugal offers clear regulations supporting access to IVF for non traditional couples and high availability of donor material due to supportive donor regulation. Currently, Portugal does ~9k cycles annually, and has the potential to reach ~32k with greater support for clinic infrastructure, equating to a €128M market with expectations to grow by ~€16-20M per year as people flock to Portugal for its high quality of care, low waiting lists, and favorable regulations.

Portugal’s emerging and fast growing market is largely fragmented to date, presenting an inflection point for investment and consolidation of independent clinics- making it a region to keep an eye on!

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