/*Accordion Page Settings*/

International Care

224 The Best of Fertility Network C-Suite

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, nor does the Advertiser's sponsorship constitute an endorsement of the guest or their organization. The guest's appearance is not an endorsement of the Advertiser.


Since 2019, Inside Reproductive Health has conducted over 220 interviews, featuring prominent physicians and executives from numerous fertility companies.

Among them, nine CEOs continue to lead their respective Fertility Clinic Networks or chair their network’s board.

Together, their networks have overseen an estimated 1.6 million IVF cycles and other reproductive treatments that have resulted in over 2 million pregnancies,

This is an episode you don’t want to miss as we showcase:

  • Gina Bartasi and the only three things she believes matter in healthcare

  • Dave Burford sharing his battle-tested sales advice

  • TJ Farnsworth’s entrepreneurial journey and his perspective on the necessities of field wide collaboration.

  • Dr. Kshitiz Murdia’s reasoning on why doctors make good CEOs

  • Marc Segal’s perspective on private equity and its place in Fertility’s future

  • Francisco Lobbosco’s first 100 days as CEO and the power of listening

  • David Stern’s steps to finding the right financial partner (Hint: It’s like a marriage)

  • Lisa Van Dolah’s philosophy of transitioning nurses into executive leadership roles

  • Andrew Meikle discussing the power of perspective (Both patient & entrepreneur)


Dave Burford, CARE Fertility
Website

Gina Bartasi, Kindbody
Website | LinkedIn | Facebook | Instagram

Dr. Kshitiz Murdia, Indira IVF
Website | LinkedIn | Facebook | Instagram

TJ Farnsworth, Inception Fertility
Website | LinkedIn | Facebook

Francisco Lobbosco, FutureLife
Website | LinkedIn

Marc Segal, US Fertility
Website | LinkedIn | Instagram

Lisa Van Dolah, Ivy Fertility
Website | LinkedIn

David Stern, Boston IVF
Website | LinkedIn | Facebook | Instagram

Andrew Meikle, Fertility Partners
Website


Transcript

[00:00:00] Griffin Jones: Since 2019, Inside Reproductive Health has conducted roughly 230 interviews and counting featuring prominent physicians and executives from numerous fertility companies across the world. Among them, nine CEOs continue to lead their respective fertility clinic networks or chair their networks board.

Together, their networks have overseen an estimated 1. 6 million IVF cycles and other reproductive treatments that have resulted in over 2 million estimated pregnancies. 

Sponsor: This episode was brought to you by Organon, Organon is committed to championing care equity in fertility. By elevating education, expanding resources, and investing in innovative solutions, Organon stands with aspiring parents on their unique journeys. Learn more at FertilityJourney.com.

Announcer: Today’s Advertiser helped make the production and delivery of this episode possible. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, nor does the Advertiser's sponsorship constitute an endorsement of the guest or their organization. The guest's appearance is not an endorsement of the Advertiser.

[00:00:28] Kevin Ali: Hi, I'm Kevin Ali, CEO of Organon, and at Organon, we're committed to engaging with leaders across reproductive medicine. I'm proud to help introduce the best of Fertility Network's C Suite.

For the Inside Reproductive Health podcast. 

[00:00:43] Griffin Jones: Thank you, Kevin. Our best of reel begins with the CEO of Inception Fertility and the Prelude Network, TJ Farnsworth's vision emphasizes the power of collaboration among networks and clinics to advance the fertility field. 

[01:00:00]Now you're at the head of one of the largest fertility networks in the Western world, and it didn't exist five years ago, and so talk about that speed. 

[00:01:07] TJ Farnsworth: Yeah, so I think that, you know, we opened our very first practice from scratch. We didn't want to inherit, you know, ideas, not that ideas from established practices are bad. We've got some fantastic practices as part of our network that have been around for 20, 25, 30 plus years that bring a ton to the table.

But we wanted the opportunity to be able to experiment with things and ask the questions of why are things being done the way they are? And the answer being that's just the way they're done is always a bad answer. There may be a lot of great answers, but that's just the way it's always been done is never a good one.

So That allowed us to challenge what we can do and experiment. And then we also have the, we look at it as the best of both worlds. And then we have practices as part of Zora Network that have been around for, you know, with Eastern Fertility Specialists in Houston, which was our first acquisition practice.

They've been around for 25 plus years, you know, to the President's Network with RBA and TSC and NYU, bring a ton to the table. And the idea that we can bring the knowledge base From all of these places, people that are challenging the norm and saying, why can't we do things differently with de novo development from scratch operations to establish practices that have been doing it in such a way that really does work and those work for a really great reason.

And that way we can take the best of all worlds and combine them together. It's sort of been a unique approach. To how we grow the business, it's allowed us to grow into, you pointed out, you know, one of the largest networks in the world, and we're very proud of that. And mostly we're very proud of the fact that the way it came together, because it came together in such a way that lots of different people bring a lot of really great talents, really great experiences and really great processes to the table that we can blend to create the best of all worlds.

I'd love to see a whole lot more collaboration with our industry. You know, I think that coming out of a different specialty, I am surprised at all a return at how the lack of collaboration that exists between all of the big national networks and the independent practices in terms of sharing best practices, what can we be doing to make them successful?

You know, to the extent that the other national networks are successful to the extent that other independent practices are successful. That's good for me. That's good for inception. That's good for all of us as an industry. We want to see people be successful. And you know, we need to focus less on our competition amongst ourselves and more on our customer as our patient.

And that can be done through greater collaboration. 

[00:03:39] Griffin Jones: Rather than dictating from the top, our next guest engaged with staff across all levels, gathering insights to guide future life's growth. Hear how Francisco Lobbosco spent his first 100 days as CEO of FutureLife. 

So that leads you after your 100 days to recommend changes, and you said that they accepted all of the changes you proposed. What were they? 

[00:04:01] Francisco Lobbosco: So listen, so I went on by having, let's say, Um, one strong mandate, which was not imposed by anyone, but I could read it through my first a hundred days. Future life from a medical perspective is very well positioned and our medical outcomes are it. Fantastic. Francisco. Now you know that don't touch that.

Right? So let's, let's make sure that whatever you do, you don't mess up with the medical excellence that we're having in the business because that is what describes us. But then I went on and said, okay, so one of the things I'm asking is why are you here? And I'm getting different, different views, all great views, all great answers.

Um, and especially when I go around clinics, the purpose is there. What I was missing was this little trick on asking the same question around support center and saying, why are you guys here? And perhaps we were missing that, you know, to verbalize the, the purpose, the mission, the vision, the values of importantly, the values of future life.

So I went on and asked, why are we here? And then I went on and asked, what are we, uh, what are we setting ourselves to achieve? I, what our strategy is going to be in the next five years. And then finally, how are we going to. You know, just go through that strategy. So the why, the what, and the how. Um, so quite simply after my 100 days, the first thing I did is to grab, um, collect a number of associates across clinics, different roles, support center, different roles.

And we set ourselves with support of a, um, of an agency to define the future life purpose. Why is future life here? What's our vision of the world? What's our mission? And most importantly, what are our values? Um, and obviously we have clinics, as I said to you, that were quite independent and they are still independent for many years, very successfully.

And some of those clinics have strong statements in place. And my purpose is not to, my mission is not to change those statements. But to have a united voice on future life and why is future life here to, to, to drive that core identity. So we've done that. And actually, I'm not sure when, when this podcast is going to go live, but I'm flying to Barcelona tomorrow to the first global leadership summit, where we're going to introduce those.

Those statements to everyone, to all our leaders in clinics. And then obviously we're going to introduce the strategy. And the strategy, as you can imagine, is something that together with my management team, tapping into the medical advisory board, tapping into some key opinion leaders from country, we developed and we put on a paper.

And that strategy went through my supervisory board, of course, in June, and that was approved. And now we're going to introduce you, introduce a strategy into, into the FutureLife Society again at the end of this week. Um, and that is how we're going to go through that strategy and what is important for us to achieve.

And this question of why do we have a group? What is group going to do different than the clinics we're doing until now independently? That's a very important question that needs answering quite fast. Um, the synergies that we'll have a group. Those roles and responsibilities between, okay, clinics are doing this, fantastic.

How can groups support the clinics on, on being better at that, you know, at that quality of care? How can we help the clinicians in particular, the, the EMTs, the embryologists, the nurses to have more time with patients? Instead of having, you know, non value added activities or non value added time. So that's the purpose of group.

And that's what we're setting here to, to, uh, to achieve through the how. And finally, and with this I finish, um, it's all about, as I said earlier, to keeping that medical excellence in place. And therefore we introduced. Literally two months ago, our medical advisory board to the CEO, uh, which are 10 of our 10 of our great, uh, associates, you know, medical doctors, embryologists.

Um, and we'll get together once a month, um, and they have three different topics in the agenda that they need to help us, um, drive just as a final thought from my end, which is something I said to my team quite often. Um, I know that people like you Griffin, most of your listeners, if not all have been, have been in this sector in this space for, for quite some time.

And you're very familiar with it. Um, but sometimes it's good to have someone external timing, uh, reminding On how powerful it is to work that you guys do on a daily basis. And I'm talking about everyone working in clinics, right? So um, this goes for everyone working in a clinic, MDs, embryologists, nurses, receptionists, coordinators.

It's just fascinating what you guys do on a daily basis. I mean, your job is to put smiles on people's faces. Um, so my last words would be encouraging you to continue going. Um, I think what you're doing helps the sector in particular Griffin, uh, and for everyone else out there, just, just keep going. I think, um, we, or you in particular, uh, are changing the world one baby at a time.

So big thank you from my end. 

[00:09:16] Griffin Jones: Boston IVF says that in order to take good care of patients, you have to have a business model that takes good care of their providers and staff. Listen to David Stern discuss the vital steps to finding the right long term financial partner. 

[00:09:28] David Stern: And you know, one of the important things, it sounds a little corny, um, but the Boston IVF, our model is we want to do what's right for the patient first and foremost.

So we believe, and this is instilled because the physicians founded the practice and I'm not a physician, I'm an MBA, but I can tell you, I don't mess with the lab and I don't mess with the physicians. because those are the two most important assets that we have in our company. And I'm never going to tell an embryologist if they want to use a certain media and they want to use a certain microscope or an incubator because they get better success rates.

It's in my interest as a business person to make sure we get the best success rates that we can because our patients are going to be happy. Our referring physicians are going to be happy. Everybody's going to be happy. So I'm not going to cut corners and say, Hey, I got a great deal on this media. From A, B, C media factory, and it's not the same quality as Irvine or Cooper, but you gotta use it because we're saving money.

Same thing with catheters. We have physicians that choose different catheters. We don't have one catheter. We let the physician who's doing the transfer use the catheter they feel comfortable with. It costs us more, but the physician feels like they're doing a better transfer and they're more comfortable doing it.

So who am I as a business person to tell a physician how to practice or an embryologist how to practice? When you're dating someone, your first date is not about getting married. You have to date someone, see if it's a right fit and then get married. And I think we approach it the same way. We want to date our practices that we're going to partner with, see if it's a good fit, see if the culture is right.

See if we have, you know, commonality and an IVF center that's being approached by anybody, a strategic, a private equity, venture capital, whoever. Should be doing the same kind of due diligence. Is there a cultural fit? Do you agree on what the midterm and long term goals should be? Where do you see yourselves in five years?

And having a very open discussion about what that looks like and, and talking about who makes the decision. Does business trump medicine or does medicine trump business? And those are important discussions to have before, you know, on those dates, um, before you get married. I was, you know, with COVID, we've gone out and it's very important.

We go out and we do site visits. We want to look at the IVF center. We want to talk to the physicians. We sit down with them. I can't tell you the number of deals that we haven't won, where the other party that wins has never set foot in an IVF center that they're buying. They've never met the physician face to face.

It's all been on Zoom and they do a video tour. And if I'm spending that kind of money, Now, granted when private equity is doing it, it's not their money. It's someone else's money, but it's kind of like going in to buy a house and doing it on a Zoom video and never walking in that house. That's kind of scary.

Um, and so if a physician, if I'm a physician selling my practice and I never get to meet the person and they never come to see what my practice looks like, I would think long and hard about, are they the right partner for me?

Sponsor: Organon is dedicated to delivering impactful medicines and solutions for a healthier tomorrow. Guided by its mission of being here for her health, Organon proudly recognizes fertility providers around the world focusing on care equity. 

We believe everyone should have access to fertility education and treatment. By collaborating with providers, advocates, and communities, Organon is working to elevate fertility awareness, expand resources, and invest in innovative products that help more aspiring parents access the care they deserve. 

Every journey to parenthood is unique. Organon stands with you. Learn more about Organon’s resources at FertilityJourney.com

[00:12:39] Griffin Jones: Here, Chairman of U. S. Fertility, Mark Segal, delve into the enduring presence of private equity in the fertility sector, emphasizing the significance of aligning business goals with a genuine passion for solving critical issues in the fertility field.

[00:12:52] Marc Segal: Private equity is no question. Private equity is here to stay, right? It's not going anywhere. Um, and it will, there will [00:13:00] always be this need for capital and equity. Um, and I also, I also believe, you know, These innovative, uh, in physicians want to be something part of something larger than than themselves, right?

Um, and so finding the right fit. Yeah, is is, of course, paramount. Um, I would say that I've seen in my career again, uh, private equity. make very poor decisions and very poor business decisions and in some cases, you know, destroy practices, um, and, and, and the culture that they may have created. Uh, but I've also been very fortunate to be part of a group, be part of groups that I think have driven real value and innovation that's benefited both just both physicians and patients.

I believe, you know, the group that we are affiliated today called Amulet Capital is exactly that. I've been very, very impressed. And as I said, I've been involved with many different private equity groups. Um, I think there's this misconception about, uh, uh, that private equity, you know, what the does is.

drive down, drive costs and it's, uh, and therefore that impacts quality of medicine. I think that's a, that's actually a false. narrative. I think it's a false assumption. 

[00:14:34] Griffin Jones: You think it's false that it drives them up or because they're seeking profits or, or drives them down for efficiency? Which one of those do you think is a fallacy?

I think it's, I think 

[00:14:43] Marc Segal: it's a false narrative that, that driving down costs, driving down costs drives down quality of medicine. Um, Where I think private equity and again, maybe larger groups succeed is in the ability to drive to drive costs in an efficient through efficiency. Right. And, and, uh, and to me, driving down costs, which hopefully at the end of the day implies driving down price to patients or driving or driving access through increased payer contracts, etc.

Leads to better access to patients. And in fact, if you look at the larger groups, you look at, you look at the, you know, pregnancy rate outcomes, it completely validates the point that the larger groups are driving, driving innovation, driving pregnancy rates, doing different things that I think others are taking note of and trying to learn from.

Um, so, um, I, I do think it's, you know, at the end of the day, yes, you should do your homework and you should pick your right partner. Um, because not everyone's the same, not every private equity is the same. Um, but I, I, you know, I am a believer they're here to stay. I'm a believer, I'm a firm believer that they will, That they will continue to add value and make change in a positive way, not a negative way.

What is it that I need to do to kind of grow my, my practice? in order so I can maximize the valuation, uh, or potentially exit that type of thing. And, um, and what I think, and I would say this is actually all businesses in general, this is not specific to physicians or even healthcare, but, but, you know, when you've got, uh, when you've got a founder and entrepreneur that has started a business, it may be a family owned business,

If they are, if they start or have started having the conversation, you know, if they, if they're thinking about, I want to sell my business in a year's time, or even two years time, it's probably too late to have that to start thinking what I need to do. To maximize value, the conversation or the thought process about maximizing value has to occur much earlier on because it's part of a strategy.

It's part of a mindset, you know, of this is what I'm after. This is where I think I can build it. This is what I and so it's really to maximize value. It's a five year process. Now again, here's the calculus. Do I, do I spend, uh, do I spend the next five years building, hopefully, you know, doubling the size, tripling the size of the business that I have today and will valuations remain where they are today, right?

That's the big question. Because no one knows what tomorrow brings. No one knows what, what valuation, what interest rates and valuation and how much it's private equity will want to participate five years from now. Um, and so I think the calculus you have to make in all of this is, I'm either in it for the long term, if I'm only focused on, I want to figure out what the exit and how to maximize value so I can exit at some point, I actually think it's the wrong conversation to be having with yourself, right?

If I'm that entrepreneur, I think you've got to be driven by, you What are you trying? What problem are you trying to solve? What? What motivates you? What gets you to get up? You know, um, out of bed every morning. I want to do the kinds of things that you do. And you've got to love it. You've got to have a passion for it.

I mean, I know that I wouldn't be doing this for 25 years. If I didn't feel excited and passionate about it. 

[00:18:43] Griffin Jones: Our next leader, CEO of Care Fertility, Dave Burford, sheds light on the imperative of enhancing business processes to improve the patient experience. One of the biggest criticisms about so much external finance entering this field of medicine is the that there is a financial pressure and sometimes an oversight on operational quality.

There's operational improvements to be made for days in this field. There's, there's no shortage of those, but there is also the reality that there. It's a way of looking at things where it can be just looked at from a spreadsheet without the consideration of actually making the operational improvements.

And you had to at least experience some of the other sides. So what were a few of the surprises that awaited you? 

[00:19:37] Dave Burford: I think first and foremost, um, finance is very good on spreadsheets. Operations is very bad on PowerPoints and spreadsheets. Operations is about people and it's about process. And you only really can deal with one when you understand the other.

And so if I take us back to cares challenges at the time, it was very much around, um, a business that was geared up to, um, serve the clinic rather than the patients. And that's okay. When you've got a lot of demand and not much supply, but when, when that dynamic changes slightly and you've got more competition in town and you've got other people that are doing things in a more dynamic way, and actually.

The challenge is bringing in, um, supply or patients, then you've got to change your processes to adapt to that. And you've got to be more patient friendly and you've got to be more, um, Uh, adaptive and fluid in the way that you deal with things. And so, yeah, you can only really do that by talking to the people on the ground, talking to the staff, understanding what their challenges are, and then adapting the processes to meet the demands of patients and the needs of staff.

Um, So it was, for me, it was nice to get away from the, the laptop and the, and the, and the, and the PC and to actually talk to people and understand what is it that is the challenge here and that's best supported by a bit of data, if I'm honest as well, because sometimes anecdotal conversations only take you so far and you need to have a bit of skepticism about what you hear and then you need to look at the data and say, well, actually, look, we've got a thousand people calling us at The seven o'clock at night, you're telling me that patients don't have a demand for late night calls.

But why have I got a thousand, why have I got a thousand people ringing me when the lines are closed and it's just tweaking then some of those operational processes to meet those needs. Um, generally not that challenging, but, um, involved, yeah. Sales side device is critical and these advisors do an amazing job, but it's when it's a very fast six week process and highest bid wins kind of thing.

It might be perfect for some sellers, but in my experience, what you'll find is that there's sometimes a misalignment after the sale because you didn't really get chance to talk about what it is that you want and what it is that they want and how can you, it was a very quick, it was a very quick process.

And so this is. Quite often somebody's lifetimes work, right? They spent 20 years building this business. Why not spend a little bit longer just getting to know who it is that you're going to be partnering with after the, after the deal would be my main advice, really, to, to people. And then, as I say, my passion and, and cares passion, having done lots and lots of these acquisitions over the years is to really understand what it is that people want, uh, and then to try and tailor that deal to suit them.

[00:22:38] Griffin Jones: Dr. Kshitiz Murdia, CEO of Indira IVF's CLIPS, revolve around the importance of standardizing protocols across the entire network of doctors, emphasizing the need for consistency and quality. 

[00:22:50] Dr. Kshitiz Murdia: I think that brings me to another important point, Griffin, is around the doctor recruitment, as to how we have done it.

Because. Ours is a B2C brand and patients are coming to Indira IVF and not to a particular doctor. I mean, patients don't come with a mindset that I have to go and meet such and such doctor or get treated by such and such doctor. They just see Indira IVF, they would come to Indira IVF, and then they would get to know who is the doctor treating them.

And every other day we have a roaster, so somebody is consulting today. Their pickup might be done by a separate doctor. Their embryo transfer might be done by a separate doctor. It's as per the schedule or the roster in the clinic. Uh, so it was our responsibility to ensure that we have similar protocols, similar outcomes across all the doctors because that's what we were doing.

One patient could be meeting two or three doctors in the clinic at different points of time during the same cycle and the protocols should not differ. The language that they speak should not differ. And that's why we started this Indira Fertility Academy back in 2016, which is one of the world class setups in training in fertility.

Our training center has been recognized by, recently by British Fertility Society. Our training center is recognized by Merck Foundation in Egypt. They regularly send, uh, uh, African and Indonesian and Malaysian, Vietnam, all the Asia Pacific doctors for training. We run a fellowship program with them for three months.

And 99 percent of the doctors who are working with us, I've been trained through our own fertility academy and same with the embryologist also. And once we got a hang of it, uh, we understood that, you know, IVF is not so difficult. It's not a rocket science. You know, every gynecologist and a life science, uh, a postgraduate could be trained into either being a IVF doctor or an embryologist.

Uh, either ways. Uh, we developed a structured program and we understood that there are 15 or 20 steps during the whole IVF cycle. Once you have an SOP around each and every step, you just hammer in the training that you just need to follow the SOP. Don't bother about the final outcomes. Final outcomes are bound to come.

And we've been very successful. I think the average age of our doctors is 35 or 36 in spite of, you know, a few doctors being with us for almost 10 years now. Uh, so that gave us a very good handle on expansion because. See, expansion, the major limiting factor for any clinical enterprise or an organization to expand rapidly is not funds, it's not infrastructure.

You, everybody has deep pockets, everybody has private equity money. You can fund a hundred centers in one year. You have the infrastructure available. You can buy spaces, you can rent them, you can do. I think the critical bottleneck for any organization could be having skilled manpower, you know, and then there's always shortage of manpower in whichever field you go.

And we decided that we would not struggle with this part. Let us create our own skilled manpower and let us not depend on the market, uh, uh, to get skilled manpower. The idea was to select somebody working with the company for, for, for last few years, because. You know, when DA invested, we were only at 50 center, we were the largest in the country in terms of number of centers, in terms of doctors being trained, in terms of business and, and the overall top line.

I think the idea from DA's side was, uh, nobody has done, uh, good work in the country in India in the IVF suite apart from Indira IVF. Let us have somebody from the group internally, uh, and promote them to the, to be the CEO. And I think because of, uh, uh, some of the diligence is being done on the company before DA invested.

Uh, so there were a couple of private equities, uh, looking at us and in all the big force coming and doing diligence. So I got exposed to many more financial aspects, many more HR and marketing aspects as well. And, uh, so I think, I think it was. Because everybody, all these shareholders thought that I had a very broad based idea about the business and not just the medical function.

Uh, and, and, and obviously we are very strong believers that a medical organization should always be headed by a doctor because that gives you much more leverage. In terms of talking to the doctors, because ultimately all these, uh, businesses are built on the ground in the clinics and not sitting in the corporate office in your air conditioned chambers and working on excels or laptops or you can't build a business.

Their business is actually being done at the clinical level by the clinicians, by the nurses, by the embryologist. So you would need somebody who could have that wavelength of talking to these doctors who the doctors would also respond to and respect. Uh, and it's not just about number, number, number that you need to clock certain revenue.

You need to clock certain number of patients being treated. It's always more to do with the medical outcomes and how do you treat and how do you excel in, in the overall outcome. So I, I, I strongly still feel, uh, that a non medical person, uh, one sounds very commercial to the doctors. Uh, doctors would not give that much of respect because.

Again, they feel the other person has no knowledge about medicine and is just come here and just telling us all the numbers on Excel. And we feel it's not like that. And, you know, Patients are different. The actual clinical life is different. So I think a good balance, uh, uh, between the medical and the financial work is required when you want to control the doctors.

And when I say control, because ours is a very different culture and DNA, it's not doctors independently practicing in their own. world and they have a different protocol and they have a different business mindset. All of us, uh, all the two 50 plus doctors run on a single platform, run on a single protocol.

Everybody, uh, is, is, is in very. Close touch, I would say, and everybody's using the similar protocol.

[00:29:13] Griffin Jones: How many nurses, what percentage that you've worked with over the course of your career, which is a lot, do you think have it in them to be an executive? And do not say a hundred percent, do not say all of them. I don't want it. I want any kind of fluffy millennial feel good answer. I mean, if you work with a ton of people, ballpark, what are the percentage, uh, that you feel like really have it within them that they could be not manager, not director, but top C-suite?

[00:29:47] Lisa Van Dolah: Anybody that sets their mind out to do it can do it, but you have to be willing to, to learn, um, and step out of, uh, Kind of a comfort of a clinical based mindset. And I think, um, many nurses don't want to have anything to do with that. They went into the profession, um, to be a clinical focused expert and they should, that's amazing.

Um, and they should continue to explore that, how they can continue to contribute there. Um, you know, there's only so many individuals that went into nursing originally that then look at organizational, um, Uh, you know, goals and organizational, you know, success as being something that are even interested in, in being responsible for.

So, you know, we all can contribute at every level of nursing, um, to that organization success, whether or not you want to be the one that's. that's thinking about that 100 percent of the time is, you know, it's only an interest of certain, certain individuals. And, you know, but I don't think any nurse should limit themselves, um, to that possibility if that's something they're interested in doing.

If this is a role that you want to learn, we'll be here to support you. And so if it's something that you want As a nurse to step into something that maybe is outside of what you perceive to be your training. I think you need to seek that opportunity, um, and ask for those around you to support you, um, in learning things that maybe you don't have any experience in yet.

Um, and I think nursing, um, has tremendous foundation to offer you the skill set. Uh, in a variety of roles, whether it's administrative management, leadership, um, or, you know, like you said, project management, sales, marketing, business development, all of those things are, are, are ways training, teaching, um, for nurses to, to advance their career.

And so it's not just one path, but I think nursing has tremendous foundational, um, value that, that you can build on if you're interested in. 

[00:31:58] Griffin Jones: The three things that matter in healthcare are patient experience, patient outcome, and cost, according to our next leader, Chair of KindBody, Gina Bartasi. Here, Gina stressed the value of team collaboration and employee well being in delivering exceptional patient care.

[00:32:11] Gina Bartasi: Really? Only three things matter in healthcare? Any kind of health care, but specifically fertility, um, patient experience, patient outcome and cost. It's the only thing that matters to the patient, patient experience, patient outcome and cost. And by the way, it's the only thing that matters to the employer.

And what I have found after building and running the largest care navigation firm as a care navigation or middleman or an insurance company, um, Um, you cannot effectuate change in those three areas. An insurance company or care navigation firm cannot affect member experience. They cannot affect outcomes and they cannot affect costs.

Only the doctor's going to set his reimbursement rate. He's only going to decide how many embryos to transfer. Only he can decide how to give that patient bad news, whether that's, um, uh, diminished ovarian reserve diagnosis or a failed IVF cycle. But in order to really effectuate change. And really change kind of how patients go through the process.

You have to be in the doctor business. So today the employers are issuing RFPs. Um, I think in the beginning, uh, large tech companies on both coasts are really in the Valley kind of started this fertility benefit. But today you see requests coming in from very, very large employers in retail and manufacturing and automotive.

Like again, it's moved from kind of a nice to have to a must have benefit. Employees always come first. They have to because the employees will take care. If you take care of your employees first, they will take care of your customer. They will take care of your patients. And that's when we're talking to doctors, you know, and doctors say, well, I used to do that.

You know, we want the doctors to know that we can train and teach. nurses and front desk managers and practice managers to be just as kind and just as empathetic to that patient that the doctor can. So again, employees always come first as it relates to the lab. 

[00:34:11] Griffin Jones: Talk a bit about how you use the brand for culture.

[00:34:15] Gina Bartasi: Yeah, I think, um, a lot of it starts with humility, right? The brand is humble. It's not anybody's last name. It's not, you know, um, and our culture really starts with this humility, right? So those two things are ingrained. I think, um, it's not just humility to, it's a vulnerability to it. Um, you know, uh, It's also our brand and our culture.

We do embrace risk. You know, we tell our doctors, we're like, embrace risk, do something crazy on TikTok. Can you tell a doctor to, or a scientist embrace risk? They're like, whoa, whoa, whoa, whoa, whoa. I'm a doctor. I don't embrace risk, except that if you teach them, we're not talking about embracing risk when it comes to, a prognosis of an onco patient.

We're talking about taking risk as it relates to the brand, as it relates to culture, allow yourself to have fun, allow yourself to smile, giving devastating news. Another failed pregnancy test is hard. It's hard. And we're so glad you're empathetic to your patient. But outside of that, how can we make you smile?

How can you be cheery and yellow and optimistic? And so we believe that there's a lot of similarities that brand and culture do go together. And I don't think our brand would be as successful if our culture wasn't so strong. And I don't think our culture would be so strong if our brand wasn't so strong.

And there's a, I think the other thing that I would say about culture and brand is team. Right. Um, I think too often, you know, healthcare people and doctors in particular may think solo first, like I'm a doctor and hierarchical and solo. And those are not things that belong in our brand or our culture. We don't do anything singularly.

Not any of us. And, and Dr. Beltsos would say the same thing. And Beth Eschbach, Greg Poulos, none of us do anything by ourselves. And that's intentional. We make group collaborative decisions and same thing with our brand. It's, it's, it's, we invite feedback. We invite constructive feedback, constructive criticism, because we want to get better every day.

And again, that goes back to our brand and our culture. 

[00:36:25] Griffin Jones: Andrew Meikle, Executive Chairman at The Fertility Partners, challenges traditional paradigms as he advocates for financial awareness and entrepreneurship in clinic management. 

[00:36:33] Andrew Meikle: I think that, um, you know, the typical practice owner is not an entrepreneur, and they're not typically very business savvy.

Some are, and they're doing exceptionally well. This space has grown 10 percent compounded forever. And, and, you know, No disrespect, but almost anyone can do well in that sort of a setting, especially when supply is not meeting demand. So everyone's doing well. Um, almost everyone's doing well. I think there's another level.

It's not just about revenue and EBITDA, you know, our mission and, you know, I'm a healthcare provider at heart is to drive clinical outcomes to use science, collaborate with stakeholders and our group to, to drive clinical outcomes, to be more successful for our patients. And as well to improve, dramatically improve the patient experience, the patient journey.

So it's pretty simple. All of our decisions are made, um, You know, based on those two things. And I think there's a tremendous opportunity to professionalize some of the areas in the space. Um, when you look at, at management, for example, I think there are a lot of people doing a lot of great things, but it's, it's sort of doctor first, it's not patient first.

So we're flipping this, um, profession on its head and looking at the management and the operational efficiency and effectiveness of, of clinics. We're looking at Uh, you know, lean processing from a patient perspective. We're looking at, um, sort of value innovation from a customer perspective. It's gotta be driven by, um, by the patient.

We have to serve the patient. Um, and I, and I think it's largely the other way today. So we, we have a completely different lens and I think most groups, um, we're investing for the longterm. Um, we can get into private equity if you want. I am now. Back. We are now backed by private equity. You got to be careful who you choose, who you partner with.

You got to be careful who you marry. You got to spend time. You got to do your diligence. You got to go on dates. Um, and you have to be, um, ruthless in your due diligence because it is a life sentence. I don't know how to turn a physician into an entrepreneur per se. I think you have to have the fortitude for it.

You have to be able to delegate tremendously because you need to see everything from 60, 000 feet and not be too in the weeds. Um, I think an absolutely critical element and some Something that I see as a weakness generally in the space is a lack of, um, financial, um, awareness, a lot, a lack of operating the business, uh, with financial metrics.

Um, people in the space seem to look at it in the rear view mirror rather than in real time. You know, our organization, we provide a full P and L every month. Month by the eighth day of the next month. So our partners can see what they've done in their business and and uh, How it relates to the strap plan that we've worked on them for going forward.

Um, so I think you know We don't have enough time, but I you know, I mean a start would be Definitely start reading some, some books, you know, um, there's a ton of great information on entrepreneurship out there. Gerber has a whole series. Uh, uh, you know, those things are very helpful, but, but you really have to take yourself out of the day to day equation, be able to see it from 60, 000 feet, have the best, most independent.

You know, brightest people you can working for you, um, actually, you know, executing on things. And I think that's a big first step. There are tremendous opportunities out there to, um, to partner with various organizations if it, if it suits you. And I think it's just really important to, you know, Have your house in order before entering into that do your due diligence find the right fit um, and look this this profession right now, is it incredibly, um, is that an inflection point it is changing and If you want to change, you might, you might look to join an organization that, um, aligns with your values and they can help you.

They could support you, um, to implement changes in your clinic, to drive patient flow, to, um, to make your life easier so you can provide the best possible medicine. 

[00:40:56] Kevin Ali: In today's episode, we learned how various leaders are working to evolve the landscape of reproductive medicine. Working together, we can drive innovation to help improve the aspiring parent's experience.

I'm Kevin Ali, CEO of Organon. Thank you for listening to the Inside Reproductive Health podcast. 

Sponsor: This episode was brought to you by Organon, Organon is committed to championing care equity in fertility. By elevating education, expanding resources, and investing in innovative solutions, Organon stands with aspiring parents on their unique journeys. Learn more at FertilityJourney.com.

Announcer: Today’s Advertiser helped make the production and delivery of this episode possible. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, nor does the Advertiser's sponsorship constitute an endorsement of the guest or their organization. The guest's appearance is not an endorsement of the Advertiser.

216 One Fertility CEO's Plans After 100 Days of Listening with Francisco Lobbosco, CEO of FutureLife

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


The first 100 days are often the litmus test of leadership, and this week’s guest rose to the occasion.

Francisco Lobbosco, CEO of FutureLife, spent the first 100 days of his tenure hopping country to country, clinic to clinic, clinician to clinician while asking one set of questions. What he learned from his listening has created the blueprint for the future of FutureLife.

Tune in to hear Francisco reveal:

  • The questions he used to create his growth strategy.

  • How his first 100 days inspired FutureLife’s current mandate.

  • FutureLife’s 4-Pillars driving the company forward.

  • A clinic’s sweet spot for FutureLife acquisition [And the KPI’s they look for]

  • His philosophy on Quartile Growth

  • Some of the solutions FutureLife is implementing [Including a new CRM]

  • FutureLife’s growth trajectory [And if they’re expanding beyond the European continent in 2024]


Francisco Lobbosco
LinkedIn

FutureLife
Website
LinkedIn

Transcript

[00:00:00] Francisco Lobbosco: I took my first a hundred days to just go around and listen. But after that, I went through probably the key opinion, all the key opinion leaders that we have in the business in all 10 countries, and I started proposing changes. And to my surprise, they said yes to all of it. I think it's a matter of communication.

I think it's a matter of explaining what would happen if we were to do things differently. And most importantly, it's a matter of making sure that you don't mess up with the medical freedom that they have. 

[00:00:32]Sponsor: This episode was brought to you by AIVF. Maximize your clinic's potential with EMA by AIVF. Slash end to end embryo evaluation time by a staggering 97.8 percent. Freeing your staff to focus on what truly matters. Curious how this reduction in evaluation time could affect your bottom line? Visit aivf.co/precalc and use our free calculator to uncover the cost saving benefits of EMA by AIVF.

Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health nor of the advertiser. The advertiser does not have editorial control over the content of this episode and the guest's appearance is not an endorsement of the advertiser.

[00:01:32] Griffin Jones: 45 clinics, 1500 employees, 450 physicians, according to their website, and he may have said 250 FTE docs, 55, 000 IVF cycles amounting to the second largest fertility clinic network on the continent of Europe. At least with regard to number of locations. That's according to our guest, the person that has found himself at the helm of this network.

The organization is Future Life. The CEO is Francisco Lobbosco. At time of recording, Francisco has been in his post for the last six months. He spent the first three and a half. Going from team to team, doc to doc, country to country, office to office, asking one set of questions. He tells us what those questions were.

He tells us the mandate that future life has come up with since those 100 days. He says he didn't propose any changes within those first 100 days, and since, all the changes that he proposed have been accepted. tried to dig into what those were and he tells us about future life's four strategic pillars.

Medical excellence, patients, associates, who we on this side of the pond would not just consider associate physicians, but associate physicians, partner physicians, embryologists, lab directors, all staff. All employees. Finally, growth. Francisco shares what puts a clinic in the sweet spot for future life to want to acquire.

He talks about which KPIs they're measuring, including but not limited to, take home baby rate, net promoter score, employee net promoter score. Francisco says that he's systems agnostic, but coding obsessed. I said, I don't know, man, we'll see how long that goes. They have seven EMRs. So I press him a little bit on that.

Are you really going to be able to keep seven EMRs? You're going to go down to one. What's that going to be like? What's your philosophy on that? And he shares his response. He shares his philosophy on quartile growth, which clinics and providers you focus on the bell curve. Francisco shares some of the solutions they're implementing now, including a new CRM, who that is and who they vetted from 17 options.

Will this be the promised child CRM? I don't know. I've been hurt before. And then I asked Francisco to conclude on trajectory of growth for future life. Are we going to see future life expand beyond. the European continent in 2024. Please enjoy all of these answers and more with Francisco Lobbosco, CEO of FutureLife.

Mr. Lobbosco, Francisco, welcome to the Inside Reproductive Health podcast. 

[00:03:46] Francisco Lobbosco: Thank you, Griffin. It's a pleasure to be here today. 

[00:03:48] Griffin Jones: It took me 200 some episodes, but I finally have the CEO of a European network. We've had Canada. India, the United States, the UK, but never mainland Europe. And you are our first, thank you for obliging us as we continue to grow the global audience.

[00:04:07] Francisco Lobbosco: My pleasure. I'll try to represent Europe in the best possible way. 

[00:04:10] Griffin Jones: I hope so. You're the CEO of Future Life. That's been your job for the last six months as of this recording. And tell us a little bit about Future Life. Is it, in the, as far as the. network sizes of Europe, where do you all rank in terms of volume, in terms of doctor size, and maybe just a little bit of, background and I'll cover the rest of the background in the intro.

[00:04:35] Francisco Lobbosco: Yeah, sure. So we have 45 clinics, we're present in 10 countries. We are ranking number two in Europe in terms of locations. We do 55, 000 cycles a year, 2, 300 associates from which 350 are MDs, medical doctors, that's head count. 250 full time equivalents that could be, and we are very, proud to say that we are part of, helping this world, receiving a new baby every 45 minutes.

So that is probably our, best stat yet. 

[00:05:08] Griffin Jones: You came from outside of the field. Tell us about how you found yourself in this post. 

[00:05:15] Francisco Lobbosco: So yes, so before, before coming here, I was in veterinary health and I was approached by a headhunter and I, do have a personal past connection with IBF and when, they call me and they started sharing this material, read material about the industry and the company, we at home together with Margot, my wife, we felt so passionate about it and they share, I think in total 500 pages.

And, we went through it, I think it took us two night and it became a topic of discussion on my wife is a marketeer and the journey and how many touch points do we have and is this a place where you would harmonize or not having 10 countries, it was a very good interview process and the funny thing about that interview process is that it was slightly different.

Because one of the shareholders invited me here to Prague, where I am today, where we have the head office, and instead of coming straight to the office, we stop up the Prague castle, which if you've never been in Prague, it's a beautiful, it's a beautiful scene, and we start walking towards the office, and that's a good 40, 45 minutes walk.

Through the, old Prague is fascinating. So I was already, fascinated about the scenery and then I arrived to the clinic and this is my first clinic visit ever. And, I go into the lab and I make a million questions around the way, but when I got into the laboratory, that's where I saw magic happening.

And I was just in time to see on the big screen an X ray process being carried out by one of our great embryologists. And I look at him as a. I, this is fascinating. What you guys are creating here, life is just fascinating. So I felt quite strong already in my first interview. And after, I think it was in total of nine interviews, I was lucky enough to be offered the job and I'm very pleased where I am today.

[00:07:13] Griffin Jones: What was in those 500 pages? Was it a sales pitch to you to come and be recruited? Was it their pro forma? Was it a mix of things? What was in those contents? It 

[00:07:26] Francisco Lobbosco: was the BBs from past acquisitions. So Future Life is owned by main two shareholders, Hartenberg and CBC Capital Partners. And CBC entered last year or at the end of 2020, but I think they finalized the transaction in 22.

And therefore there was a lot of quite recent data for me to go through. And it was quite good really. 

[00:07:49] Griffin Jones: What made it attractive as a business person, as a business leader that. said you could have gone to a few different companies and maybe been in the one, two or three spot, but you had this offer and you're looking at their history.

What made it attractive to you to where, what did you look at specifically and say, this is something that I can really be a part of? 

[00:08:14] Francisco Lobbosco: A couple of things, but I will start with the most important one. as you just said, I had the opportunity working across. Different businesses, different industries, great companies, great experiences.

But none of them have the strong sense of purpose that future life has. And of course, this is not just exclusive to us here in future life. Of course, this is across every single clinic within the fertility space and every single person working at an IVF clinic. And I'm probably, you've been quite a long time in this space.

But Hey, let me remind you and everyone who've been part of this for a longer period of time. We are so lucky to be working where we are already. We are able to spend our days working on something that is truly amazing. Something that makes a huge difference to the world, really. And our job is to bring smiles to people's faces, to make their dreams come true.

And there is nothing more powerful than that. 

[00:09:13] Griffin Jones: How about from a business perspective in terms of what growth potential did you see? What role, what did you see yourself being able to add? 

[00:09:24] Francisco Lobbosco: it's a very good question. So here at Future Life we're quite lucky because the clinics that Hartenberg at the beginning and then CVC together with Hartenberg have been acquiring over the past years are very good clinics.

And I'm sure you will come to, what challenges do you face? this is one of them. The clinics are quite good. the medical outcomes are very strong. Financially, they are very successful. Wherever I went before, you always had a car crash, right? Something to turn around. In this particular case, when my 45, the worst thing I had is a single bidget.

it's fantastic financially speaking, so it's very difficult to come with new ideas when something's been working for such a long time, right? And let's not forget that you have the founders of the clinics, which are still present in most cases in our clinics, 99 percent of the cases. So engaging with them on saying, listen, I know what, brought you here over the last 20, 25 years is being great.

But what if we were to do things slightly different so as to maintain that medical side of the business, which, I believe in medical firm, but to give it a different tone to professionalize certain areas of the business, of the support centers, of the functions that are supporting you guys to deliver that highest quality of care possible, and there is, there are opportunities.

Outside Griffin, there are opportunities in the marketing area. There are opportunities on how we connect with our patients. we have, and we still have incredibly good, very strong, isolated clinics. we started last year to generate a community of clinics within FutureLive, but we are far away from where we want to be in the future.

And I think the synergies that 45 clinics can create, that's the goal in here. And from a business perspective. That's where really you can quantify the possibilities. 

[00:11:17] Griffin Jones: It's interesting that sometimes the fact that it isn't a car crash on the PNL in many cases, in my view, is part of the reason why parts of the field haven't advanced that much because I said, why would I, our patients are getting pregnant or at least enough of them are, and we're doing great.

And lousiest social media presence or office space, or even if we are. Using paper and EMRs, we still have people coming out of the woodwork, offering us X multiple of EBITDA. We're still taking plenty of money home. We still have lots of people telling us that they love us. and I feel that's been the reason why the venture capital.

Was probably 10 years later than it would have been like 10 years ago, there was no venture capital. There was private equity. I don't want to say there was none. There was very little venture capital. I've really only started to see venture capital in the fertility space, three, four years. And I feel like we would have seen that 10, 12 years ago, if there was just more of a.

of, impetus to scale. Do, what's your view having been in here six months? Are you starting to see, is there any external force that you see starting to cause people to change more or is that external force still going to take some time to build? 

[00:12:41] Francisco Lobbosco: I think you just described it really well.

And I think partially the drivers about having a very strong financial performance are there in terms of stopping development. However, I must say that I was personally very surprised. After my learning process, I took my first a hundred days to just go around and listen. But after that, I went through probably the key opinion, all the key opinion leaders that we have in the business in all 10 countries.

And I started proposing changes. And to my surprise, They said yes to all of it. I think it's a matter of communication. I think it's a matter of explaining what would happen if we were to do things differently and most importantly, it's a matter of making sure that you don't mess up with the medical freedom that they have.

And I'm very respectful of that. But when it comes to how can we improve at supporting the business from a finance, from a marketing, from an IT, from an HR perspective, I think there's a lot to improve there. Before we even get to the medical area from, a medical perspective, I have great advisor, so I don't need to get into that terrain.

[00:13:54] Griffin Jones: Did you propose any changes in those first 100 days? 

[00:13:58] Francisco Lobbosco: Not in the first ones. no. So I am very respectful of. Coming into a new sector and so what I've done is I just went around, I visited every single clinic, I spent loads of hours talking to all our associates, not just the key opinion leaders in each of the clinics or the founders or the GMs, but I just, just wander around talking to.

Our embryologists, that's where I really enjoy spending my time if I visit a clinic in the lab. so talking to embryologists, learning, how they do things, talking to nurses, talking to the onboarding coordinators, even in the call center, I enjoy spending time because they want to know why they are calling us.

so I have a million questions on what I've done, which is something I always do. If I go around with my defined questionnaire and I just ask the question, the same question to different people within the same clinic. within different clinics, and then I go back and I ask the same question to the same person in different moments in time.

And what usually tend to happen is you get different answers and that helps you to make up your mind on assessing where the business is today and what do we think we need to do to improve the business and bring it to the next level. 

[00:15:11] Sponsor: Boost your IVF clinic success with EMA by AIVF with our suite of AI modules.

Analyze embryo viability with precision, considering visual quality, morphokinetics, and genetic integrity. Enjoy seamless clinic management with advanced IVF analytics, integrated EMR connectivity, and a centralized communication hub. Ensure 24 7 access from any device and connect to multiple time lapse systems simultaneously.

Using our platform, our partners have experienced a 10 percent rise in implantation rates and a 30 percent increase in capacity. Don't just take our word for it, see the actual impact on your bottom line. Visit aivf.co/precalc, input your clinic's data, and get a personalized report on how EMA by AIVF can revolutionize your operations and financial performance. That's aivf.co/precalc.

[00:16:16] Griffin Jones: I was hoping you were going to say you went in with a disguise like undercover boss with the glasses and the big fake plastic nose and the mustache underneath it. And see, you didn't undercover boss them. You went in and you had a questionnaire. What was on that questionnaire? 

[00:16:32] Francisco Lobbosco: Why are you here? So that's my first question that I always ask when I go into a new place.

Why are you working here? So you usually start with, what's your name? What do you do? For how long have you been doing that? And why? Why are you with us for the last 10 years? Tell me what's different in this clinic versus the clinic next door. And to my surprise, our attrition rate is very, low. And people have, quite a lengthy period of time with us.

And therefore I'm fascinated to know, why do they stay? so that, that's my first question always, and you have so many different reasons. And that makes our job as a newly, my job as a new leader of a business slightly more difficult because you want to make sure you attach to the reasons that are keeping people happy and engaged and motivated.

But at the same time, you want to improve certain processes and SOPs and ways of working with an athlete. And therefore it's quite interesting when you ask the why are you here? It's never in this sector in particular, different to the prior businesses I worked for, perhaps. It's never about money, I'm still to get the answer saying they pay really well, which I think we do by the way, markets market rate.

But the point being is no one's here because of the money they're all here because of the patients and what they get to deliver for them, which is fascinating. 

[00:17:54] Griffin Jones: Are you using that question to find out what processes can be changed or what you need to know before you change a process? So if you're finding out that, a number of people really like a specific person or, a really specific way of doing things that you take that into consideration when you're making a process change, or is that just to, is that for rapport building?

And then you start to get into more granular questions after that. 

[00:18:23] Francisco Lobbosco: Yeah, but I don't take that question as the only question, to make up my mind. Of course, if someone tells me within a coordinator or the call center, right? So if I go into a call center and they have six people and I ask why you're here and everybody tells me my boss or the environment here is great.

I take that as a very good positive. So I try to learn what is that person doing to keep these people motivated and engaged and so on. But yes, the team, they usually gimme the team. The team is great. the team is great. and, then is, I get to help people and we are very, respectful about the quality of the service, the quality of the care that we provide.

So those are usually the two or three answers that I get. Within the very different versions of that. 

[00:19:07] Griffin Jones: So that leads you after you 100 days to recommend changes and you said that they accepted all of the changes you proposed. What were they? So 

[00:19:17] Francisco Lobbosco: listen, so I went on by having, let's say, one strong mandate.

Which was not imposed by anyone, but I could read it through my first a hundred days, future life from a medical perspective is very well positioned and our medical outcomes are it fantastic Francisco. Now, that don't touch that, right? So let's, make sure that whatever you don't mess up with the medical excellence that we're having in the business, because that is what describes us.

But then I went on and said, okay, so one of the things I'm asking is why are you here? And I'm getting different, views, all great views, all great answers. And especially when I go around clinics, the purpose is there. What I was missing was this little trick on asking the same question around support center and saying, why are you guys here?

And perhaps we were missing that, to verbalize the purpose, the mission, the vision, the values of importantly, the values of future life. So I went on and asked, why are we here? And then I went on and asked. What are we, setting ourselves to achieve? I, what our strategy is going to be in the next five years.

And then finally, how are we going to, just go through that strategy. So the why, the what and the how. So yeah. Quite simply after my a hundred days, the first thing I did is to grab, collect a number of associates across clinics, different roles, support center, different roles, and we set ourselves with support of a, of an agency to define the future life purpose.

Why is future life here? What's our vision of the world? What's our mission? And most importantly, what are our values? And obviously, we have clinics, as I said to you, that were quite independent, and they are still independent for many years, very successfully. And some of those clinics have strong statements in place.

And my purpose is not to, my mission is not to change those statements. But to have a united voice on future life and why is future life here to drive that core identity. So we've done that. And actually, I'm not sure when this podcast is going to go live, but I'm flying to Barcelona tomorrow to the first global leadership summit, where we're going to introduce those.

Those statements to everyone and to all our leaders in clinics and then obviously we're going to introduce the strategy and the strategy as you can imagine is something that together with my management team tapping into the medical advisory board tapping into some key opinion leaders from country we developed and we put on a paper and that strategy went through my supervisory board of course in june and that was approved and now we're going to introduce you introduce the strategy into the future life society again at the end of this week And then it's how we're going to go through that strategy and what is important for us to achieve.

And this question of why do we have a group? What is group going to do different than the clinics were doing until now independently? That's a very important question that needs answering quite fast. The synergies that we will have a group, those roles and responsibilities between, okay, clinics are doing this.

Fantastic. How can groups support the clinics on, being better at that, at that quality of care? How can we help the clinicians in particular, the EMTs, the embryologists, the nurses to have more time with patients instead of having, non value added activities or non value added time.

So that's the purpose of group. And that's what we're setting here to achieve through the how. And finally, would you say a finish? It's all about, as I said earlier, to keeping that medical excellence in place. And therefore we introduced literally two months ago, our medical advisory board to the CEO, which are 10 of our 10 of our great associates, medical doctors, embryologists.

And we get together once a month and they have three different topics in the agenda that they need to help us drive. so yeah, so I'll pause here for a minute because I think I gave you a lot there. 

[00:23:19] Griffin Jones: Was there no medical advisory before, board before? Was every clinic just operating with their own medical director?

[00:23:28] Francisco Lobbosco: So there was a scientific advisory board before, which was great, but I think we were missing parts of what I'm expecting the medical advisory board to do. So when in the medical advisory board, you have three areas that we predefined. So scientific research, now it's part of the medical advisory board.

We have education that it was perhaps not tackled before. And then the third one is what I call the business drivers. And that could be procurement, could be total reward strategy for the business, could be M& A, could be no thanks, right? 

[00:23:59] Griffin Jones: So you're involving them in the comprehensive growth strategy of the company.

Tell us what about what, does that strategy look like? You talked about some of the questions and I want to start asking those questions is to see what answers are in place thus far here. By the time this podcast episode comes out, you will have already shared that strategy with, you will have already released that strategy.

So it won't be news, but for the sake of. context of the conversation, tell us about what it, what is this strategy for the next year? 

[00:24:33] Francisco Lobbosco: Yeah. So we have four main strategic pillars. So we have medical excellence, we have our associates, we have our patients and we have growth. So those are our four pillars. In addition to the four pillars, if you were to think about a house, the typical house that you see in business.

You'll have the foundations and for me, the foundations are to make sure that we have the right reporting timely and accurate, and let's make sure we go through to have the right digital tools in place, right? I think there was an episode a few weeks ago that you guys, published it was fantastic.

I certainly enjoy it, but for us is to start the journey on this digital transformation, what are the basic initiatives that we want to land across the whole of future life? So those are the foundations. From a financial reporting and from our digital infrastructure. And at the end of it, as an outcome of it, we'll have our financial performance.

Okay. So we want to make sure that we have a strong and predictable results over the years up to 2027, but that's the outcome. And I'm convinced, as I always say to my team, that if we were to have strong success rates or medical outcomes, as we currently have on a strong patient satisfaction, the financials will come.

That's a matter of time, but I've seen places where actually financials are really good and patient satisfaction is poor or the medical outcomes are poor and that in the long term will take a toll. So for me, it's incredibly important that we stick with those medical outcomes being very high and patient satisfaction being very high.

I gave you the four pillars. So again, medical excellence, patients, associates, and growth. And within each of the pillars, what you have is a strategy. So medical excellence, our strategy is quite simple. Enable a quality and patient safety culture focusing on improved outcomes. Every strategy has a goal and a way to measure the goal, and then we'll have building blocks within those strategy pillars, right?

So again, medical excellence, for example, you have quality leadership, transparency, learning, and safety culture, advanced data usage, and clinical standard and outcomes. And then at the end of it, what is going to be our 2024 corporate objective? Because we wanna set this five year roadmap, but with milestones that we are set to achieve over the upcoming, midterm, short term, midterm and long term.

so that's how we set the strategy. 

[00:27:01] Griffin Jones: This might just be my own ignorance. Why is medical excellence its own pillar as opposed to it just being the. It being the result of the providers and patients pillars, I 

[00:27:14] Francisco Lobbosco: think it needs attention by itself. I think obviously when we talk about associates, we're talking in general about our, I think this is where you're going.

So we talk about associates. We're talking about clinical associates in general. When we talk about patients, it's the outcome, it's how happy they are is by the outcome of the medical excellence. When we're talking about growth is organic growth and inorganic growth. And there are cross.

But one of the things that perhaps. We did not have Griffin and I think we were very lucky on the way we've been acquiring over the last couple of years is this minimum medical and minimum lab standards across future life. But whilst we go on and on in this journey of, inviting more clinics to be part of the future life family, we need to make sure we have those minimum standards ready because, high quality clinics.

It's great, but are we going to have the same number of high quality clinics in five times across Europe that we're going to, go on and pursue to join us? Maybe not. So let's make sure we set the minimum standards right now. And I want the medical pillar to be a reminder for us of what we're trying to achieve all day long, doesn't matter the size, it doesn't matter the financial outcomes that is a pillar, the medical outcomes are a pillar for us.

[00:28:31] Griffin Jones: And when you say associates, I want to make sure we're using the words correctly, because in the U. S., associate would mean an employed physician. It typically would not mean an embryologist or a lab director. It also would be different from a partner physician. in Europe, does associate refer to all clinicians and all scientists?

[00:28:52] Francisco Lobbosco: All employees, from a receptionist to, the chief medical officer, everyone is an associate, but it's just terminology. 

[00:29:01] Griffin Jones: So then on the growth side, what do you plan to implement for the growth pillar? So you have a couple of things, right? 

[00:29:09] Francisco Lobbosco: So you have. Organic growth and inorganic growth, and obviously from developments that we've seen lately, inorganic growth is very important.

So perhaps I should start there. We have a great team, a great MNA team that they go out and source and talk to the best clinics in Europe about future life. With my arrival, the first thing we did is we put minimum requirements of clinics that we want to pursue, right? We want to have a conversation with.

And those minimum requirements could be as simple as, size of the total clinic, number of medical doctors, the size of the lab and potential capacity for, number of cycles, success rates. So by setting the minimum requirements, then our M& A team actually had what we call clinics within the sweet spot.

and then we go on and proceed the discussion with them. So inorganic is incredibly important. And then of course you have organic, we have organic coming from, a couple of building blocks. Productivity, you'll have synergies and you'll have advanced data usage, which is linked to probably productivity.

so productivity for us is not to push more work to our doctors or our nurses or our embryologists, but to understand how can we help them to have more air time with our patients. What is it that they are doing that perhaps these non valued activities, can we reduce them? Can we help them to reduce them?

I think you were pointing out into paperless before, I think you were referring to that, that, that's one of the drivers, right? So how much time are you spending on daily basis on printing forms and filling them out and in that are not required by law because every country is Understanding how we can help our clinicians and productivity is incredibly important.

And then understanding how we can leverage the group synergies across all our clinics is also very important. And then data, when, I came here in April, we, didn't have a very automated way of getting data, frankly speaking. And I think the team have, done a great effort over the last six months.

And now we have daily. Insights that are reporting for every single clinic that we have operational marketing and medical data coming, in an automated way, accurate way to us that then we share back because that's the intention. So every member of clinic leadership teams will be able to see not only their numbers, their dashboards in ways that they haven't done until now, but also they will be able to see what the others are doing.

Because the intention here is to share best practice. So if I'm struggling in an area of my business and I see that clinic A is doing fantastically well, we are actually pushing clinic B to call clinic A to see what they are doing. So data, has been incredibly important, but also we have. One of the most modern in, in, in house, lab facilities here in Proud, and we want to benefit from it.

We have one of the strongest marketing teams that we are building as we are speaking. So we want to make sure that we provide support to the clinics from a marketing point of view. Education, I talked about it before. We have a meat bank, right? So we want to make sure that we, prioritize our future life clinics when it comes to the donor material and so on.

[00:32:27] Griffin Jones: I want to dig into a bunch of these. I'm deciding which one to go first into. Let's talk about the insights because you're getting operational marketing, medical data every day. What are some of those KPIs that you're looking at every day? 

[00:32:40] Francisco Lobbosco: Yeah, very good question. So we started getting the data only a couple of weeks ago, and again, if you were to ask me about the challenges that I'm facing, these are challenges that I faced also in my prior positions where I went from having not much visibility and just reports that were manual into automated, and accurate reports.

And the risk with that, Griffin, is that you are overflowing the organization with data and KPIs and reports and so on. So it's just at the kick of a button distance for us to have loads of KPIs. So answering your question, I am a big fan, not us, us from many years ago to have a maximum of five things we really want to push.

So if you're a part of a leadership team, probably you're looking at the many, KPIs, which is great, but up to five is what you should push and reward for. and as you can imagine, deciding which five we're going to publish is quite an interesting discussion. And I'm quite open about the discussion and I want my executive team to have a say about it.

So we're actually looking into it, but of course, I'm not going to lie to you. So coming back to that strategy, right? So I talked to you about the four pillars and I talked about our digital journey, so most probably we will end up with at least one KPI for each of the pillars to be consistent with what we're saying that we want to achieve.

Now, if you want to dive into a particular pillar, of course, you will have loads of data, right? So I guess the first KPIs that come to mind, and again, with the caveat of this hasn't been decided yet with between me and my management team, NPS, patient related, take home baby rate, medical excellence related, EMPs, Associates related.

And then I had two more, one related to demand creation and one related to operational excellence. But those are still under discussion. 

[00:34:42] Griffin Jones: So those acronyms for those listening, NPS is net promoter score. EMPS I'm guessing is employment engagement score. what does that stand for? 

[00:34:53] Francisco Lobbosco: Yeah. 

[00:34:54] Griffin Jones: Employee net Promoter score.

Oh, okay. Oh, ENP. Okay. Yeah. So you got your NPS for patients and your ENPS Got it. Correct. And, then you talked to, you told us that initially this data wasn't being gathered and, or at least wasn't automated. Maybe it was being gathered, maybe it was here or there, and Correct. It was gathered.

[00:35:12] Francisco Lobbosco: But in a manual basis. So now it's a lot easier to access that data and to make decisions based on the data. But as something new, you may get overwhelmed. but that's where we are today. And we're incredibly happy with what the team, as I said, have achieved over the last six months. And now is what we're going to do with that.

And, this is the fun part of it. 

[00:35:32] Griffin Jones: What did you do to automate that data intake? 

[00:35:38] Francisco Lobbosco: We made it a topic, we made it a recurrent daily topic. Of course, we hire an external consultant to help us with it. So we have a number of EMRs in this, in the business. We don't have a single EMR. We have a number of them.

[00:35:52] Griffin Jones: and, that sounds horrible. I've never met one person that likes their EMR. Yeah. I've met people that like their EMR better than other ones. And they like the people that make the EMR and because they do their best, but I've never met. someone that's this is 100 percent my favorite thing to use ever, and you have multiple EMRs.

is that going to be something that, stays over time? Or how do you get, how do you get multiple EMRs to equate into one source of truth? 

[00:36:25] Francisco Lobbosco: Yeah, great timing for a great question because I just came this morning out of a management team meeting where we allocated 60 minutes to that discussion.

and listen, so one thing I learned years ago is that I am system agnostic. But I am coding obsessed. So if I can take the data in the right way out of an EMR and my medical doctors, nurses, embryologists, coordinators are happy with the system, but we can tap into it and generate these definitions, equal definitions in the cloud, and then just, spread the insights across.

I'm happy with that. But obviously as we expand the question is how many do you want to have? Because every new clinic most probably will come with their own EMR. So there's a decision to be made there. But so far we are okay with the seven EMRs we're having. and especially because as I said, this, this third party consultant company help us to tap into every single one of them.

And now we have access to the insights that again, it's not just for us at management here at group level, but we're cascading that down for, the clinics to make decisions as well. 

[00:37:41] Griffin Jones: So I've seen all three approaches with regard to when you acquire a number of clinics and then you adopt different EMRs, or they have different EMRs, I've seen the approach of everybody, you can keep your EMR, decide for yourself, we're going to make a recommendation of what EMR we should use, and here's our SOP, but you decide if you're going to implement it or not, and then I've also seen, and probably even more recently, we're going to all go to this EMR.

This is the way it is for everybody in the network. This is what we're doing. It sounds like right now you're choosing the approach of one of the first two. why not make everybody, you said your system's agnostic. I get that. But even from a coding obsessed perspective, doesn't it? I feel like I would, I just know there's going to be some pain in your.

In the future of this isn't coding the right way because they're not actually coding equivalents in these systems. And, especially when you see one group having a low NPS because of their EMR and another group having a higher NPS because they really like their EMR. So why are you not going with the third option now?

Not the right time for sure. 

[00:38:51] Francisco Lobbosco: I think we have other priorities. I think the current DMR systems that we have in place give us what we need today. And again, for every decision, every initiative that we implement and we create a group level, most probably it will have repercussions at the clinical level.

And what I do not like to do is to overwhelm the clinics with projects that then will have an impact on the way we treat our patients. And changing EMRs, as or developing EMRs, you need to tap into that, you need to work with clinical associates. And I think today is not the right time for it, but I'm not saying no for the future, but I think today is not the right time.

[00:39:33] Griffin Jones: So you're getting these insights and not just the KPIs in the form of insights, but you're getting wisdom in the sense of asking the questions, what can be. Removed in order to add more value, what non value added activities can go? What can we do to give more time back to our associates? You're a smart guy.

You've been asking these questions for a hundred days. I assume you have a couple of, answers by this point. what are a couple of those things that you can do to remove non value added activities for associates? 

[00:40:09] Francisco Lobbosco: Yeah. And I think every clinic is different and every, the starting point for every single clinic is very different, right?

So with data now we can see, volumes going through productivity metrics going through, and as I said, you can sit on daily basis or intraday if you wanted to. And if you see a clinic that is, I'm a big fan of quartile and everything, right? So you have in a regular bell curve, you'll have Q1 two, three, and four.

So if you think about the quartile one and two, they are below average. So you wanna bring them to average, right? So you'll probably get a better impact from doing the, a bigger impact from doing that than pushing Q4 into, the 98 to the 99%. And as I said, every clinic is different. But there's one thing that I learned, which is my MDs, our MDs, our nurses, our embryologists are flat out is they're not playing Tetris in their consultation rooms.

And therefore, if they're delivering a lower productivity levels than the clinic next door within future life, that means that they're probably doing something else that the other clinic is not doing. And in most ca, in 99.9% of the cases. The MDs are looking at us saying, help me because I want to see more patients, but I have to do all these things that are stopping from, they are stopping me from seeing more patients.

And I think that's, the area that is very different clinic by clinic. So if you ask me for an answer now, I don't have an answer. I have many answers and they're very particular to the countries, to the clinics. There's some legislation in some places where everything has to be paper based. So it's quite different clinic by clinic.

[00:41:50] Griffin Jones: That brings me to, it's jumping ahead to a question about the EU in terms of, I'm sure there's some things that are, standard across the board, but then I imagine that there are many differences country to country. And, what's it like navigating those differences? What stood out to you in terms of particularities between different governance?

[00:42:12] Francisco Lobbosco: yeah, it is different, but one of the things I experienced here that I didn't experience in my past experiences is fertility tourism, and therefore patients are willing to actually move to the next clinic in the next country to access whatever they cannot access at home. And that is one of the biggest things that here at Future Life we need to start leveraging.

And, that referral within our own family is something that is missing. It's something that is going to drive growth as we were talking about growth earlier, definitely. But most importantly, something that our patients are asking for, because if in clinic A, I come to clinic A because I heard great things about clinic A.

But you cannot treat me because I'm a single man, for example, where can I go? Or, a homosexual cop, where can I go? we can definitely help you here and here and here and here, and we'll, make it happen for you. So that is one of the biggest benefits from having this community of Canine Excel across 10 countries that we think, I think we need to leverage a 

[00:43:15] Griffin Jones: And that's helpful in having a lot of this data aggregated and having the, teams working together too, because then you can build that infrastructure of, it's not just, Oh, I think our clinic over here does that.

It's, we have, let's take you over to the portfolio and let's see where. Where you're going to be able to be helped on the solution side of the elements, 

[00:43:41] Francisco Lobbosco: sorry to jump in, but one of the elements I think is close to your heart as well as we're implementing a common CRM system across every single clinic.

And that actually will help us as well with that transition and to offer, the right treatment for, all patients across independently on the borders. 

[00:43:59] Griffin Jones: Is it a CRM we would know like a HubSpot or a Salesforce, or is it a different kind of CRM? Creation. 

[00:44:04] Francisco Lobbosco: I'm not sure if you heard about it. I'm not familiar with them.

[00:44:08] Griffin Jones: And how did you vet them? They're based out of London. The CRM topic is, interesting to me because the reason why. I don't advise most small clinics to do it is because it's just too much work. The bigger groups have found a way to make Salesforce work and the big networks, but it's still not what I would want.

If I had my druthers, I would want a CRM that fully integrates within EMR because otherwise there's just too much duplicate work. So how did you vet this solution? 

[00:44:40] Francisco Lobbosco: So we obviously have lots of requirements at the moment of selection. We worked very collaboratively between the digital team, the operations team and the marketing team, because everybody has a say on what, what conditions we want to drive out of a CRM.

and we started with, I think it was 17 potential options. We went through meeting each of them, making sure that they could. Cope with our requirements, different to what it may sound. Our requirements are, is it going to be simple to use? Am I going to get just, what I need? I don't need a Ferrari to drive through the streets of Prague.

I need something that would take me from A to B. Is that going to take me from A to B? But potentially having the potential to go to C if I wanted to go to C after. So we were quite picky on our requirements. And, some of the names you mentioned there were. Definitely within the top five of our consideration, but in the end, we decide for creation, which I think they are based out of London.

[00:45:41] Griffin Jones: Do you plan to use it just for patients, new patient sourcing? Do you also plan to use it for referral providers? Because I've seen CRMs used both ways, where you use it as like the digital CRM, the marketing CRM, but also as the sales CRM for referring providers. How do you plan to use it? 

[00:46:00] Francisco Lobbosco: there's a phase one for sure on phase one is to make sure that we use it for marketing purposes, but we have the, what I was saying, let's go from A to B and then potentially let's go for C.

can you take me to C? these guys can take us to C and C is precisely what you're saying. I think eventually there are some functionality sitting in the EMR that potentially can go to the CRM. It's becoming a bit technical. Definitely it's a second phase of the project. 

[00:46:27] Griffin Jones: Maybe we stick with the growth theme For the last couple minutes of our conversation, you mentioned you've identified a sweet spot.

Some of those clinics might in this, in your sweet spot, might be listening and maybe future life is a good partner for them. Tell us a little bit. More about who's your sweet spot of clinic to come into your portfolio. 

[00:46:52] Francisco Lobbosco: first of all, we are very keen on having reputable clinics, right? So we're not in the business of turning around clinics from a medical point of view, we just trust our medical community in every clinic that we acquire, and we believe that they're up to the quality that we want to be proud of offering.

Answering your question, it will depend. And the reason why it will depend is because if we're talking about a new country, probably you want to go with a clinic that is slightly larger, that if you want to go into a country where we already have presence and we have a half clinic, as we call it, because from a half clinic, you can provide certain services as a great marketing team, as a great IT team, and so on, which is what we do, Again, it depends on the country, but if we were to enter a new country, we'll be looking into a clinic that, does around, as a minimum 600 pickups a year. We'll be looking into is there succession planning? I, do I have four or five at least FTEs in place? I'm talking about medical doctors.

What about the founder? How important is the figure of the founder? Is there succession for the founder? How is it being managed from a support perspective? can we utilize those great resources coming from the support functions in that clinic that we are acquiring to potentially expanding within that country, relying on the marketing individual that sits in that particular clinic or the finance individual that sits in that particular clinic.

We're looking for certain minimum square footage or square meters. Obviously we're looking into. EVDA as a consideration, because based on turnover EVDA, if the clinic has opportunities or not financially speaking, but that is usually the last consideration for us is all about success rates, which are in general here in Europe, they are published.

And therefore you can see the medical excellence or the medical quality that clinic has to offer. And then we send our teams out there. We send our operators, we send our chief medical officer. So we have one in West New York, one in Central Europe. They go and see the clinic and they come with a report.

And usually I'm also going out, seeing the clinic meeting, meeting the people that will potentially partner with us. Oh, in most cases, we don't acquire a hundred percent because we like them to have skin in the game and to continue with us partnering and so on. So therefore that partnership and the quality of the partnership is incredibly important for us.

[00:49:18] Griffin Jones: all right, so you're not taking 100 percent stake in, are you taking a majority stake in most of the clinics? 

[00:49:24] Francisco Lobbosco: Yes. Yes, definitely. and again, we're open for, a hundred percents, but in general, people are very proud. Founders are really proud of what they built and they want to keep going, which is great for us.

They want to keep going, but we better support from a digital perspective, but support from a finance perspective, from a marketing perspective, and that's what we can offer. 

[00:49:45] Griffin Jones: The pick, when you said 600 pickups, I wasn't familiar with that term. Does that refer to ag retrievals? Is that referred to? Yes. Okay.

So at a minimum, you're talking about not the smallest. I would say the, where it starts to become a mid sized practice as opposed to a small practice. Do you have the opportunity in the year to place docs in, to have docs go from some countries to other countries? Like in the U S one of the biggest challenges for single doc.

groups is that it's hard to get other docs to come to that area if they're in a small market. There's at least one group in the U. S. that I know of that has been taking advantage of it. They have bought a couple of these single doc groups because they can take some of their docs and fly them out there for a week or two at a time and batch cycles.

Do you have the opportunity to do that in the year or does the regulation between countries prohibit that? 

[00:50:41] Francisco Lobbosco: It depends on the country, we do have examples, we, have Hans who was working in Spain now, he's the chief medical officer for, reprimanding Ireland. we have Tomas in Slovakia coming from Czechia.

So we do have examples, it's just, it is a bit more complicated to, to have that freedom of movement when it comes to doctors, but definitely it's an area that we need to explore a little bit better, especially when it comes to embryologists. 

[00:51:08] Griffin Jones: That could be its whole episode in of its own talking about being able to use a bank of embryologists, and there's a lot of questions that I haven't asked you that I will be happy to ask you bringing you back onto the show.

With Growth is international. In your near horizon, now that we're seeing, we, saw the East Asian cohort by Indira and IVF, we see ginseng fertility own HRC in California. We saw care in the UK for the first time, make an acquisition in the United States. And in the end of 22, are we, should we expect to see future life moving beyond the continent in 2024, 

[00:51:52] Francisco Lobbosco: so we see many opportunities in Europe for us to continue looking at.

Also, we need to remind ourselves, especially that ourselves here at future life, that we're a new team with loads of initiatives being carried out as we speak. So focusing on the 45 plus the ones that will come from Europe next year, probably is the right thing. With that being said, we're always looking at what the market has to offer.

And, definitely the U S is a, is a market that, is attractive from different considerations, definitely other parts of the world as well. So I'm not saying no to it. I'm just conscious that we are incredibly busy at this precise moment. Delivering what we have to deliver here in Europe.

We also see opportunities for expanding here in Europe as well. 

[00:52:45] Griffin Jones: Francisco, it's been a pleasure talking with you. I want to give you the floor to conclude with your vision for growth, your vision for why, what we need to do to help the people of, why we're here. The floor is yours. 

[00:53:00] Francisco Lobbosco: thank you. I think I really enjoyed the conversation, perhaps just as a final thought from my end, which is something I said to my team quite often, I know that people like you, Griffin, most of your listeners, if not all, have been in this sector in this space for quite some time.

And you're very familiar with it. Sometimes it's good to have someone external coming, reminding us. On how powerful it is to work that you guys do on a daily basis. And I'm talking about everyone working in clinics, right? So this goes for everyone working in a clinic, MDs, embryologists, nurses, receptionists, coordinators.

It's just fascinating what you guys do on a daily basis. your job is to put smiles on people's faces. So my last words would be encouraging you to continue going. I think what you're doing helps the sector in particular, for everyone else out there, just keep going. I think we, or you in particular, are changing the world one way at a time.

So big thank you from my end. 

[00:54:02] Griffin Jones: you have helped with the impetus for more international content because I think it was earlier this year, maybe end of 22 when you first messaged me and said, I'm coming into the space and I'm, using your media to, to learn more about it. I said, Oh, maybe we should start creating more international content.

So you're among. among the reasons why we're expanding coverage for the global audience. and I'm thankful to those people that, that send me notes like that. And I echo your sentiments for people, because I'm not a clinician. I've, barely passed high school biology and, I often forget to, to sometimes stand back and say the same things that you just have.

So Francisco Lobbosco, thank you for saying it. Thank you for saying it on the Inside Reproductive Health Podcast. Thank you, Griffin. 

[00:54:52] Sponsor: This episode was brought to you by AIVF. Maximize your clinic's potential with EMA by AIVF slash end-to-end embryo evaluation time by a staggering 97.8%, freeing your staff to focus on what truly matters.

Curious how this reduction in evaluation time could affect your bottom line? Visit aivf.co/precalc and use our free calculator to uncover the cost saving benefits of EMA by AIVF. 

Announcer: Today's advertiser helped make the production and delivery of this episode possible for free to you, but the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser. The advertiser does not have editorial control over the content of this episode, and the guest's appearance is not an endorsement of the advertiser. Thank you for listening to Inside Reproductive health.

196 Your Intro to The IVF Market in Latin America with Daniel Madero

DISCLAIMER: Today’s Advertiser helped make the production and delivery of this episode possible, for free, to you! But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the Advertiser. The Advertiser does not have editorial control over the content of this episode, and the guest’s appearance is not an endorsement of the Advertiser.


Daniel Madero, VP of Partnerships at LEVY Health, gives an inside look at the fertility industry throughout Latin America, breaking down the market from major players to major growth potential throughout the region.

Tune in to hear Daniel discuss:

  • The growth of the Latin American Fertility Market in the last 20 years [Revealing the countries that are major players by market shares]

  • Regional Regulations [And their impact on everything from taxes to gestational carriers for same-sex couples]

  • How Post-Covid Inflation is affecting the IVF-space throughout the region.

  • Why it costs 40% more to set-up the IVF lab in Latin America [As compared to the US and even the same country 10 years ago]


Dan Madero, LEVY Health LinkedIn

Transcript

Daniel Madero  00:00

It's a Greenfield, the amount of things that can be done in Latin America overall, just pick the country. You know, you have countries with populations of 20 million that are doing 2000 cycles, 3000 cycles, 50,000,000, 4,000 cycles, right? The conversation, I think should be, how can we get into Latin America. Straying away from the traditional model that we see in the US and Europe.

Sponsor  00:30

This episode was brought to you by BUNDL. To learn more about the BUNDL with Medications℠ program, and how they can optimize treatments for your practice and patients, please visit www.bundlfertility.com/medications-cost. That's bundlfertility.com/medications-cost. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser, the advertiser does not have editorial control over the content of this episode. And the guests appearance is not an endorsement of the advertiser.

Griffin Jones  01:21

This IVF market just keeps getting bigger, the number of people in the world that need IVF services is much greater than the number of people that are getting it now, that is much greater than any one given country. That's part of the reason why we've been covering so many different regions and players in different regions on Inside Reproductive Health recently, because you didn't see many national players 10 or 20 years ago, now you see plenty, and now we're starting to see those national players from different nations become global players. The region we zoomed in on today is Latin America, because from Mexico to the bottom of the South American continent lives in a population about double that of the United States. Yes, this is for the execs and doc's that aren't the most familiar with the Latin American market yet, but you practice owners, lab directors and executives in Latin America, I want your feedback. And I want you to share this with your audience. Because whenever I delve into a new region or new topic, I start broadly the more you ping me with you should have mentioned this dataset, you left out this player you left out this development, the more specific we make our content, the better it gets. If you want to see more content about Latin America, give me your feedback about this episode, and give it to my guest, Daniel Madero. Because I approached this topic broadly, I needed someone that seen a lot of different areas of both the industry and the clinic side in Latin America and globally, for some context as to how it compares. Daniel was the chief financial officer of a clinic in Colombia before it was acquired by Eugin than his general manager after the acquisition. He's been a consultant. He's led bizdev corporate partnerships, third party services in different areas of the quote industry side, and he takes us through the countries that have the biggest market share, starting with the top three, what their market share is how many IVF cycles they're doing, how many IVF cycles they're doing per million people how that compares to a country like the US or a really advanced IVF country like Israel. He talks to us about regulation, like same sex gestational carriers, or gestational carriers for same sex couples going through IVF. Now being allowed. And Daniel, welcome to Inside Reproductive Health.

Daniel Madero  03:22

Thank you, Griffin, it's a pleasure to be here with you.

Griffin Jones  03:25

You're going to take on a new geography today, one I haven't covered on the show before. So you're swimming into new waters, we've started to cover more of Europe, more of the UK, some of India, some of East Asia and Southeast Asia really have not even had one topic on Latin America. That is until today. And I think that it is beyond due time and want to delve into it partly because I think that we're going to see more of this consolidation, as you and I speak, there's a number of fertility networks that are for sale that are already cross continental, that may likely be purchased by other cross continental buyers, I suspect that we're going to see more of that. And so I just don't think it's going to be this backyard or that backyard in the future, even if globalization slows down for a while. So let's maybe start broadly with just what's going on in the IVF market and Latin America right now.

Daniel Madero  04:27

You know, say you had other Latin Americans in your podcast.

Griffin Jones  04:31

I have Latin Americans on the podcast, but I've never talked about that in America. No, no.

Daniel Madero  04:41

So overall Latin America is it's a special place. Because we have twice the population of the US are about 350 million, but only a fraction of IVF cycles. Within the space you're going to see that there are major players, we'll talk about it today, but the the rest of the continent is lagging behind. So we have Brazil, Argentina and Mexico, leading the way in that order. And then the rest of the continent is smaller on it. So in total, we're doing about 107,000 cycles, including egg freezing transfers, like fresh and frozen transfers, egg donation. So, you know, in total, and this is projected, so about 85% of IVF centers report into REDLARA, which is, you know, the equivalent of ASRM or x rayed for Latin America. And this 106,000 represent the the potential total, with those extra 50%.

Griffin Jones  05:57

So 100, so about 100,000, you're saying from all the way from Mexico, down to Chile and Argentina, we're talking about Mexico, Central America, South America got 100,000 cycles, maybe a little bit more coming from all of those countries? 

Daniel Madero  06:14

Correct

Griffin Jones  06:14

And that total population, you said is twice the the US so from all the way from Mexico down to the tip of South America, we're talking about 600 or so million?

Daniel Madero  06:24

Yeah. So we doubled the population, and we only do 1/3 of the cycles.

Griffin Jones  06:29

So are we seeing a really unequal distribution, you already said there is an unequal distribution, in that Brazil, Argentina, Mexico leading the way? And then and then it's a distant fourth from there is, is Brazil? Like, is their market? What's the market share chunks of those countries do you know?

Daniel Madero  06:48

So Brazil is gonna represent about 43% of cycles, followed by Argentina at 20% of cycles, and then Mexico at 15% of cycles. Everything else, you know, the fourth one is Peru at seven and a half percent. And Chile at 5%.

Griffin Jones  07:10

I'm not surprised by Brazil leading the way I am a little bit surprised that Mexico is a little bit further behind, because we're talking about I think, what is it 110 million? Are we talking about somewhere around 100 million in population, Mexico? And it seems to me like with the explosion of new tech industry, and a lot of reshoring, that's coming back to the US a lot of that manufacturing, coming to Mexico, is that part of the reason why you're seeing Texas just explode, you're in Austin, you part of the reason why you're seeing that area blow up is because you have the tech sphere in Austin, then you have the semi skilled manufacturing in Mexico with regard to that. That's how it's called in the channel. And so I would have thought that given what I perceived to be an explosion in their economy, that they would have been further ahead, are they? Are they catching up real fast? Is this 15% been stagnant? What what's it like if we zoom in on Mexico?


Daniel Madero  08:14

So we want to talk about Mexico, I think let's talk about now more challenges within like each one of these countries. And one of the things that is going to be ubiquitous across Latin America is the price of IVF cycles. They're extremely expensive compared to what a regular person will make. So what we end up with is that IVF cycle represents a higher percentage of their total income, thus becomes harder to attain, the prices tend to be on the higher end. So and, you know, bear in mind that there is a difference, a major difference between pricing the US and the rest of the world overall. So in Latin America, you could say that, for multiple cycles that are three cycles, you're going to end up spending $10,000 $11,000, depending on where you are, and that represents a really high percentage of the total income of the patient.

Griffin Jones  09:27

So if we're talking about three cycles going to add about 10, or 11,000, is that just to the clinic, or does that include meds? Typically, an estimate?

Daniel Madero  09:38

I'm gonna say that this depends on the country, but yes, it this will be meds included.

Griffin Jones  09:43

Okay. So all in we're talking about maybe 10 or 11,000, where that could be 50,000 in the US, but it's still we're still looking at something that is proportionate to income, out of a lot of people's range. Correct? What other challenges are Are our countries facing? So are they are they seeing from as far as you can tell the same shortage in embryologist and fertility specialists that we've seen in the US and Canada.

Daniel Madero  10:13

On the one hand, in Mexico, that is not a challenge just because all OB/GYNs in Mexico are trained with reproductive endocrinology as well. So any OB/GYN in Mexico can perform ART services. So in Mexico, doctors are not a challenge. What I have seen though, is that, embryologist, if they have good English, will often get exported. So they will be hired for by outside clinics. So from personal experience, I have a friend that after being in Colombia, he went to Dubai did a short stint there, and then came back to Colombia and is now in Cairo. perfect English, highly skilled. And of course, the salaries are gonna be a lot higher in dollars than they are in Colombian pesos or insert the currency

Griffin Jones  11:21

so lesson to all the lab directors listening don't teach your embryologist English, you're gonna lose them. So then are there operational challenges that you're seeing that are different than in the EU, I suspect it varies country to country, but are we typically seeing the same workflow where it's, you call you maybe get a referral, you come for your new patient visit, typically you do your testing between your new patient visit in your follow up some clinics, of course, do testing before new patient, but most I think are still doing it in between the patient and follow up, what's the operational system look like?

Daniel Madero  12:01

It will look very similar. You know, I'll give you a very specific example, in Colombia, a lot of the patients come from referrals. So a lot of the times the clinic's name will be very closely tied to the doctor's name. So the patients will come to the doctor referred to by a gynecologist. In other cases, you will have something that happens in Mexico, given that they can do their own cycles, instead of sending them to a clinic, they would rather keep them get them pregnant, and then keep that patient all the way through to delivery. So you're gonna see, you know, different dynamics, but for the most part, there is a referral system, it functions in the same way than in the US. So you have lower cycles per per doctor, you know, so we're not talking about doctors or clinics that are doing your 800 cycles per doctor. But on the, you know, on the 150, 200 cycles, 250 cycles per doctor, which is on the lower end.

Griffin Jones  13:15

Yeah, I would say it's on the lower end. And so you're saying that some clinics are practicing obstetrics that they're keeping those patients because that would change the referral pattern?

Daniel Madero  13:25

Yes, in Mexico, it does. And in Colombia used to be that case, and it's changed over time. I cannot speak to Brazil. And I know in Argentina, and you know, here we can talk more specifically about about dynamics in Argentina, IVF cycles are covered by, you know, healthcare. So that's one of the other reasons why you see such a high percentage of cycles being performed in Argentina, because they're just covered, unlike in Colombia, where we have a socialized health care system. So on average, when you go to the hospital here in Colombia, you'll pay maybe a couple bucks, when you're when you leave. But when you have to pay out of pocket, you just don't like to pay out of pocket, right? Like you don't pay out of pocket, because you're not used to it. So when you see a bill that's for, I was gonna say pesos, because it would be millions of pesos. You're not used to it, and you're a little more careful of your money in those cases, right? Healthcare is healthcare. So if you're used to going to a hospital not paying any money, when you get to a fertility clinic and you're charged, you know, $5,000, $10,000 then you're like, wait, wait, wait. I don't know if I if I want to do this. I don't know if they have the money to do this.

Griffin Jones  14:50

I want to come back to this question of coverage in a second. But on the on the obstetrics part I could see that disrupting, I could see that limiting some new patient growth because if, I'm going to go on an assumption is that the reason why they want to keep the patients for obstetrics is for volume and revenue, they don't have enough IVF volume, they make more revenue if they keep them from obstetrics. But that by definition means that there's some type of valuable revenue happening in obstetrics, which means that in a situation wouldn't want to lose that revenue. And so yeah, if you have a gynecologist, it's also practicing obstetrics, are the partners in their practice? Are we less likely to refer to that group? And I, that could be part of the reason why you see fertility clinics getting less referrals in Mexico, if in fact, that's happening?

Daniel Madero  15:44

Yeah, I would agree. I don't want to say that's the case. But I can see that definitely happening. I know that that was a dynamic here in Colombia, that has changed.

Griffin Jones  15:55

Why did it change in Colombia?

Daniel Madero  15:57

Because doctors stuck to just doing fertility. So the other doctors, their friends, would know, hey, this patient that can't get pregnant, instead of me trying to do you know, my seventh IUI, you're going to send it to Dr. X, Dr. Madero, and my dad, and my dad would return a pregnant patient. So it made more sense to just ship out everything that they couldn't do, and then get back a presentation, which is where the, which is the revenue they're looking for. Now, here's the other thing in Mexico, you have, you have doctors taking patients to labs. So that's another model that is common in Mexico, there is a clinic. And instead of having, you know, a set of doctors that are affiliated to that clinic, there are different doctors that bring their cases to the clinic. So say, you know, the clinic has Dr. X, and that Dr. X is doing 30% of all cycles that are being done at the lab, yet 70% of the cycles come from outside doctors that can bring their own patients. So that's another dynamic that you see in Mexico as well.

Sponsor  17:14

Medication costs are a huge stressor for patients working through IVF and IUI treatments, they can be costly. And the variability of when they're needed means an even more difficult process. But it doesn't have to be this way. And that's why BUNDL has streamlined the process with their new BUNDL with Medications℠ program. BUNDL with Medications℠ is a multi cycle offering that includes all the patient's medications for one upfront cost. To learn about BUNDL's exclusive virtual pharmacy program, and how this can optimize treatments for your practice and patients, please visit www.bundlfertility.com/medications-cost. That's bundlfertility.com/medications-cost.

Griffin Jones  18:02

So I wonder if it's a question of like just where the development phase in the market place is. And Columbia has reached that level of maturity and development where they now can have fertility specialists that only do fertility cases and, and so they don't, they're not practicing obstetrics. Is that on the, I know I'm asking you to speculate so maybe you can't, but is that on the horizon? From what you can tell in Mexico? Or do you think fertility specialists are gonna be practicing obstetrics for a while?

Daniel Madero  18:36

That is a really good question, but I cannot speculate on that, to be honest, I would get I would try to ask Paco, for example. He might, he might have a better idea on it.

Griffin Jones  18:46

And this is how I approach all of these topics. They start really broadly. And then the more I do, the more I'm able to zoom in and ask better questions in any one of these countries, particularly the top three could be there could be their own topic, and then you could have certain players in each of those three, that could be their own topic. So you mentioned my assumption would have been, and this is why we don't assume, but my assumption would have been I didn't conclude it that the entire Latin American IVF market was cash pay or almost 100%. But you said in Argentina, the government pays for cycles?

Daniel Madero  19:27

Yep. So I was reading the law this morning, actually. And I think it's if you're a woman that is looking to do IVF it will be covered with your own eggs up to 44. 

Griffin Jones  19:41

Two cycles, one cycle?

Daniel Madero  19:43

I don't have specific numbers to be honest.

Griffin Jones  19:45

So that would, because it did kind of surprise me, to see Argentina almost double what Mexico is in terms of their their share of the Latin American IVF market. Argentina is a smaller country by population, probably a higher per capita wealth, but it's still,

Daniel Madero  20:05

 In Mexico?

Griffin Jones  20:06

I mean, like the total, the total like so if you took the averages of, of Buenos Aires, but I would imagine, again now I'm really, I'm really be sticking my foot in my mouth and talking about what I what I don't know. Um, so it's just a guess but I would suspect that Mexico has a higher GDP total, but but in the per capita wealth is is higher in in Argentina would would be my guess. But so so they're they're paying for cycles on there. Are there other countries in Latin America where they're paying for IVF besides Argentina?

Daniel Madero  20:44

Yep Peru, oh well no, actually that IVF is covered you mean? 

Griffin Jones  20:48

Yes. 


Daniel Madero  20:50

I don't know, I don't know to what degree I know that here in Colombia there is a there's a push to try to get covered. Given that, you know, most of healthcare is socialized, why not IVF? Right? It's still a disease. Right. So there has been a push to try to get that through. And it's been really difficult. I don't know how it works in Brazil. I don't think it's covered. I think it's cash pay. The one that I'm sure of is Argentina. I would I would like to say Chile, but like looking at the numbers, maybe, maybe not, because Chile's is very small country anyways. So I wouldn't really know.

Griffin Jones  21:34

So what's happening with regard to people trying to scale IVF in these markets. So in the US, it's all about let's get from 250,000 into at least 2 million cycles. We need to be automating the lab, we need to be practicing at top of license, we need to be training more specialists and advanced practice providers. We need artificial intelligence for case management. And you have a lot of players and by players I mean, on the vendor side, these are the people that we see in booths at ESHRE and ASRM that are trying to break into the US market some with more success than others, are people trying to break into the Latin American market in the same way, like do they see it as an opportunity where well, if we can really drive the cost down, then then the markets even bigger or is the US the place where people generally want to try to do that because the margins are greater up front? And then then then if they can scale in the US that they'll be able to take some of those economies of scale to, to higher population, lower per capita income regions like the Indian subcontinent, Latin America.

Daniel Madero  22:51

So I'm gonna go on a small tangent that I think it's related to this. But if you think about all the different technology that we have in IVF, it's the same across the board, be it in India, China, Colombia, the US, what we have is same incubators, the same laminar flow cabins, you have, you know, state of the art labs, all of those are very expensive. And if you have a weak currency, setting up one of those labs, he's going to be way more expensive. So to give you an idea, when I set up a lab here, like a clinic here in Colombia, the price of all the equipment was put here in my lab, about 30% to 40%, more expensive than what it would have been in Spain, or in Europe or in the US. So that right there, it's an indication that there's something that's happening within that it's the media is more expensive. The petri dishes are more expensive, though, XYZ just put it in there, because most of it is made in dollars. So without these technologies that you're talking about, if they're going to be charging $500 a patient, then in a country like Argentina, that is now going to represent about, you know, 25% of the total cost of the cycle. So I don't think we're doing the same. I think that we've been looking at how things are being done in the US and Europe and basing it on that. And when you just transpose whatever it's being done elsewhere here, the prices are not going to change much. The other part is medication. Medications are extremely expensive. Nevertheless, they're not as expensive as in the US, right? Like, for example, this is a conversation I bumped into the other day with someone in the US and Menopur was considered the low cost option. Here in Colombia verses a Gonal-F, or Follistim. So when you think about that, now, you bring a completely new dimension into the equation, right medication ends up being a higher percentage of the total cost of the full cycle than what it would be elsewhere. All of that, because, you know, things are being brought in, in dollars. And when the dollar goes up, and the pestle goes down, that means that, you know, intrinsically IVF is going to get more expensive.

Griffin Jones  25:35

Has that happened in the last three years with inflation? So I, the only Latin American currency that I follow is the boliviano. And it hasn't changed it is, it's hooked to the US dollar, it's always around 6.9, sometimes you'll see it 6.8, something you might see it six point, it's always around 6.9, somewhere around there. And an even with the inflation that we've had post 2020 through 2022. And maybe even in now, it hasn't gone, it hasn't gone up, it hasn't changed. It's always hooked to whatever the US dollar does. Now, you can get a ton of variance in Latin America, especially in Argentina, where when I was living in Latin America, Argentina had 40% inflation year over year. And that wasn't like a COVID stimulus. That was like that was like the status quo. And so, so did did we see like an extra did this come into play more with the inflation that has happened globally, post COVID.

Daniel Madero  26:40

So I'll give you the the Colombian peso example. Before COVID, it was sitting at, let's call it, you know, $3.5 to $1, $3.5,000 to $1. By the end of last year, we were sitting at five, to $1. And now we are at four, for $1. So it's like playing jump rope 10 years ago, it used it was 1.82. So that has a huge incidence in, in the result, right? Because what ends up happening is when I set up the lab, 10 years ago, 12 years ago, the all the equipment costs have avoided what it would cost today to set up a ladder, because everything has to be imported. And now you want to talk about local regulation. Brazil is a complicated country, in terms of bringing in external technology, media, that it's a completely different story, when you want to bring in, for example, gametes, and all of these are going to be at a premium, if you will, just because of the currency exchange. So the challenges of bringing new technology in, for example, here in Colombia, you're going to pay? I think it's depends depending on the on the type of equipment between 20 and 40% taxes on the equipment.


Griffin Jones  28:11

And you're saying taxes as in like an as an import tax and tax not, you're not talking about the the lowercase t tax of inflation, you're talking about actual government taxes, 

Daniel Madero  28:24

Government taxes, correct,

Daniel Madero  28:26

Yes. It will depend on the country and it will vary. I know that Brazil is very, there tends to be heavy on on taxes for importing things. And it tends to favor locally made things here in Colombia it goes up and up and down. But it depends on the type of technology. I would say it's similar in Argentina. Also, you want to talk about politics, which I really don't want to talk about, but overall Latin America is leaning left at this stage. And when you have governments like leftist governments taking over, then there is a higher price on specific types of products and services as well. So you see those taxes going up. And as a company, if you're buying something that sales tax, you know, so you have the input tax plus the sales tax. So it just balloons to the point that you're going to be paying 40% more than what you would pay in the US.

Griffin Jones  28:26

in that 20 to 40%. I want to I want to talk about taxes, I want to talk about regulation, I should mention that what you're saying on the on the side of the jump rope of the Colombian peso, that that's just currency rate exchange, I'm not and when so when I say that the boliviano is attached to the dollar I should be making the caveat that that doesn't mean that there isn't inflation in Bolivia, there is, because the you know, the the purchase power of of a boliviano and the dollar has gone down. And so that's just currency rate exchange. So you can be getting it on multiple set you can be getting on the currency side, you can get it on the purchase power side. And then And then you mentioned taxes are due those really vary from country to country. Is that 20 to 40% pretty standard? Are there some that have really high taxes and then like Mexico being a NAFTA does that change? 

Griffin Jones  30:23

So before we talk about regulation, I want to see so it seems like just from a cost perspective of materials, media technology, at least hardware technology, I, I'm thinking HSGs, and things like that, it's it's going to be far more expensive because of the currency rate because of the taxes. What about these AI companies that are really trying to break into the US and Europe? Are they trying to break into Latin America? Or not really yet? They're trying to figure the US out first, and then and then they'll come to Latin America?


Daniel Madero  31:02

So I know that, you know, IVF 2.0, is based out of Mexico. So I'm guessing and hoping that they have partnerships in Mexico and are willing to spread that technology down into Latin America. I know that which one is it, Life Whisperer, is already available in a few countries in Latin America as well. And I don't know how the pricing structure works, but I'm guessing it's going to be a different pricing tier for a clinic in the US than a clinic or a patient in the US and a patient in Latin America. But to be honest, I don't know of other ones that are trying to get into the market. Now, if you think about the reasons why I'm gonna play, I'm gonna try to, you know, put myself in their shoes, you have 106,000 cycles, that are distributed to a pretty small, total percentage of the population with a high price sensitivity in very difficult, it's not like you get one certification, like CE mark in Europe, and you're everywhere. It's you have to go to Colombia, you have to go to Mexico and learn how to deal with Mexican system with the Colombian system with the Brazilian system, you know, insert Portuguese here, Argentina, Peru, Ecuador. And when you're talking about, you know, a couple of 1000, few 1000 cycles, the legwork might not justify coming into these markets.

Griffin Jones  32:42

So it could be a while before we start to see some major innovation happening, let's say in Bolivia, I don't know, there has to be a fertility clinic with an IVF lab and in Santa Cruz, Bolivia, I suspect that there, there's I suspect that there's one in Santa Cruz and there might be a one in the Paz and Cochabamba there's probably at least one in Santa Cruz.

Daniel Madero  33:05

There are three, there's three, they're doing in total 1000 cycles. 

Griffin Jones  33:09

Okay. So you got three clinics doing 1000,  look at you with the data. I asked Daniel to do some some homework, because I know he's good with this stuff. But I wanted him to be able to pull up a couple of those numbers that I don't know. Thank you for that. So three clinics doing 1000 cycles. So because of the reasons that you just mentioned, the variance in regulation, the variance, it's not like, it's not like you're you just get that CE sticker good for the whole EU, you get the FDA approval, you're good for 330 million people in the US, you you're going from country to country, and some of those countries are so small market, it could be a while before we really see, like a scale and innovation in a place like Bolivia?

Daniel Madero  33:49

I would say so, right? I think the focus is going to be on those markets that are bigger. Argentina, Brazil, Mexico to start with, and then trickle down into other ones. There are some ways to do homologation of certifications here in, in Colombia. So like, I know that the regulatory entity is a little more lax with devices that have gone through FDA approval already. So if you have FDA, it's easier to get into one of these markets. I don't know for other countries, but in the end, that could be the case if you have gotten through FTA then getting into one of these countries is going to be easier. I'm gonna guess on this, I'm not gonna guess anything actually. Rather not.

Griffin Jones  34:41

Well, then then talk to me about what's happening in Brazil as in as in what ways is Brazil an outlier to the rest of the region? Because it's one it's a larger country. It's got a higher GDP, higher per capita income and While none of not not a highest GDP, not a highest population, not as high as per capita income, anywhere close to the US, I could still see it having a lot of what these companies are attracted to in the US. And and that also might be more cash paid in the US is right now could be attractive to different people coming in tell me but in what ways is Brazil an outlier?

Daniel Madero  35:26

Let's start with your average middle class yearly salary. In Brazil, it's about $9,000. As I said, a year the average cost of an IVF cycle is $5,400. That's about 60%. It's pretty high. But if you look at the population of Brazil, there are a lot of people with a lot of money, I'm also going to guess that financial institutions are a little more advanced, does access to capital comes easier. It's also a country, the sheer size of the country. It's a market that big. It's, you know, a big opportunity, however you see it. And now we're talking about Brazil doing 50%, sorry, 50,000 cycles, how much does that represent? Like the total potential amount of cycles that could be done, it's just a fraction, right? With with a, with a population that big, we're seeing a very low penetration overall. So Brazil, to give you an idea, it's doing about 230 cycles, for every 1 million people in the country. In the USA, we're doing 800 for every 1 million people. And you know, the ideal, right, like, the place we want to get to is an Israel at 4300 cycles for every 1 million people. So I think there's still a lot of potential of growth. And like I mentioned before, just doing an IVF cycle is going to be 60% of your yearly salary. So just bringing those costs down, is going to really open up a big opportunity in any one of these countries that we're talking about. Now, what I know is that in big population areas, like Sao Paulo, you have mega clinics, by clinics that are doing 5000 cycles in you know, per year, which you know, challenges or like it goes head to head to those big mega centers that we have in the US, like big centers. So, we have those in Latin America, but there's still so much room for growth Majan, if you took that number of 230 cycles for every 1 million people in Brazil, and we're able to get to the 800 in that they have, we're talking now about 150,000 cycles being done in Brazil, unlike where they are today, which is like 50,000. So one of the major challenges and I think you know, you're talking about technology, one of the major challenges that we have here in Colombia, in Brazil and Argentina in Latin America overall, is how do we stop looking at the rest of the world? And how they are doing things? And how can we figure out a model that works for our own economies for our own populations, frameworks, like legal frameworks, how do we get to that? To give you an idea, Colombia is a country that has now regulation, it's great area regulation, but it's legal to do surrogacy, and same sex surrogacy as well. And it's become a destination now. There are there are clinics now they're just focusing on surrogacy here in Colombia. And that's a great thing, right? We are increasing the number of cycles we're doing. The caveat though, is that we are not offering services to our own population. So the need is still going on map. And if we find a way to change the way the process is being done, say like a Paco and positive, then now we are we're getting into the meaty, the good of how can we grow the market in Latin America. So I don't think that the opportunity lies in the traditional ROLAP which has been tried before. With IVI like either IVI came to Mexico. There's a history with IVI and Latin America. I don't personally know it. But it would be for example, a great thing to to research you But IVI, Eugin, so you know, the same group that's going up for sale that you put an article up on a few weeks ago, they are here. I was I was part of the first acquisition of Eugin outside of the nuclear clinic here in Colombia. And, you know, I'm not gonna say it's not going great. But it's still not growing the market significantly, like we should be doing. So I think the the key to success in Latin America is in how can we change process? Or how we can help? Can we create technology or develop technology that suits the needs of our populations? And I know that, by the way, like, I want to give thanks to, I'm advising a company here in Colombia, and they were the ones that provided a lot of the information that I'm giving to you right now. But they're working on increasing access, here in Colombia, right? Like, how can we take what we have here today, and we improve it, we change it, and we get to more people, instead of going to from sort of doing a recycle recycles for 100 million people in Colombia? How can we do 800 cycles for every one 1 million people in Colombia?

Griffin Jones  41:19

And so is when you're going through this, you can't make legislative changes, you can't remove taxes, but you might see some things as you're visiting clinics in these different countries that that you think, but they could do this? They could do this? What is what's the lowest hanging fruit that you see that if you if you ran? If you were the CEO of that clinic group, that that would be one way that you're able to do more volume?

Daniel Madero  41:50

That is such a good question. I would think it's the doctors, you know, REs, for the most part, doing most of the cycle. And they're the ones that have to do it all. I'm generalizing. I don't know if this is the case in most clinics, in all clinics, but I think there's an opportunity there to offload a lot of the work to the different parts of the of the clinic. On the other hand, it's precisely that right, if you're talking about going to a public hospital is how do you create a good referral flow for those patients in need of fertility treatments? Because sometimes, and I remember this from my conversations with OB/GYN here in Colombia, they would, you know, try time relations for eight months to a year with a 39, 40 year old woman. And at that stage, it's like, wait, you need more education, right? That's not That's not how it's supposed to be done. Or earlier at the eighth, ninth IUI, the patient would come to us and be like, well, I've done nine IUIs, what do I do now? Like, well, there are other options out there. So general education, both to doctors, patients, but also those creating those flows with her hospitals overall, or OB GYN groups, you know, insert however the country works to get those referrals earlier and faster.

Griffin Jones  43:32

You talked about some of the key players who are you talked about, you know, Eugin, which is a Spanish company and owns Boston IVF and they own Trio in Canada, and they're owned by Fresenius Helios right now, you talked about IVI which is merged with RMA to become IVI-RMA. IVI started in Spain and that RMA started in New Jersey, but who are like the who are the big networks there that, you know, like who's their equivalent to the inceptions preludes us fertility panic calls. And I guess I'm the like, maybe there's not as much of a difference between the MSO name and the clinic name. But like the Shady Grove Fertility, the Boston IV of the HRC, like, who are the really big groups that are in Latin America, and where are they?

Daniel Madero  44:20

Brazil? And okay, let's talk about groups because I don't think there is, or there are like big networks here. Other than the ones that are coming in from outside. So Eugin owns the biggest if not one of the biggest clinics in Brazil, Huntington's. you have the ones in Argentina, same. They own one of those in Argentina. So they've been buying the big ones, right, because that's where the profits will be.

Griffin Jones  44:49

You talked about networks coming in like IVI and Eugin, and those would be like the US Fertility's and the Inceptions, and the Pinnacles, and then who are they, who are they buying? Like who are the Shady Groves, the Boston IVFs, the HRCs, the the really, the Vios, the big groups that are in different areas that people are buying, like who are those big clinic names in different countries, or at least a couple of them?

Daniel Madero  45:20

In Argentina, we have CEGYR. And I know that they also have a lab of their own. So CEGYR, Huntington's in Brazil is a major one as well. So here being CEGYR, Dr. Sergio Papier, being the medical director there, you have Huntington's in Brazil, in Brazil, there are more than one, I'm just gonna give you one Brazil, Huntington's owned by Eugin. Now in Mexico, you have a group that's in finance, and I know they have more than one clinic across Mexico. There's one in in Peru, and they're the biggest by a good chunk by a margin called Concebir. They're in Lima, but they also have like clinics in Aliquippa and in other places. Here in Colombia, you have two big ones now one called Inser ,of the other one ReproTech written the same way as the cryo storage in the US, ReproTech, those would be the ones that I would focus on. Because the rest, I don't know that many clinics in other parts that are going to be as big, you know, on that scale. It's a Greenfield, the amount of things that can be done in Latin America overall, just pick the country. You know, you have countries with populations of 20 million that are doing 2000 cycles, 3000 cycles, 50,000,000, 4,000 cycles. Right, the conversation, I think should be how can we get into Latin America, straying away from the traditional model that we see in the US and Europe. And insert, Africa, any country in Africa, it's going to be very similar. You're seeing the sheer size of India makes it that it's an incredible market. But you're seeing it in India, you had a great series on it. But yeah, I think the opportunity in Latin America with 660 million people, or 650 million people projected to be like 750 by 2050. It's a massive opportunity that we shouldn't be overlooking.

Griffin Jones  47:45

And we'll be getting into more specific topics about Latin America and IVF market as it progresses. But I needed somebody to walk me through the one on one. So sorry, that didn't go too deep into any of the the the particular verticals that we could have, I will want to and want to have you back. And for some it may have been too elementary, but I think you got to start somewhere. And my questions that is we're we're too elementary for your scope. But I think that this market is going to be one of the ones that you see a lot of big growth in, whether it's whether it's next month or in a few years, I don't have a crystal ball, but it's time to get the one on one, one on one out of the way because you're gonna see more of it. And you are the guy to come on and do it. Daniel Madero, my friend, thank you very much for coming on Inside Reproductive Health podcast.

Daniel Madero  48:39

Thank you. It's a pleasure. It's all it's awesome to be on this side of the mic, and I can't wait to see what else you put out there.

Sponsor  48:47

This episode was brought to you by BUNDL. To learn more about the BUNDL with Medications℠ program, and how they can optimize treatments for your practice and patients, Please visit www.bundlfertility.com/medications-cost. That's bundlfertility.com/medications-cost. Today's advertiser helped make the production and delivery of this episode possible for free to you. But the themes expressed by the guests do not necessarily reflect the views of Inside Reproductive Health, nor of the advertiser. The advertiser does not have editorial control over the content of this episode, and the guests appearance is not an endorsement of the advertiser. You've been listening to the Inside Reproductive Health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society, visit fertilitybridge.com to begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to Inside Reproductive Health.

183 One Set Of Protocols For 250 Fertility Doctors; Featuring Dr. Kshitiz Murdia, CEO of Indira IVF



Some practices can’t get two fertility doctors to agree on a set of protocols.  How about >250 physicians?

Dr. Kshitiz Murdia, CEO of Indira IVF discusses the enormous growth of the Indira network in India, how their approach to IVF practice management differs from the US’, and how they tackled massive obstacles (such as patient education)  along the way.

Listen to hear:

  • Indira’s massive marketing and awareness programs.

  • How to transition out of your clinical role, to a director role, and finally, CEO.

  • The due diligence regarding private equity groups that took place before the majority stake sale of the company.

  • How Dr. Murdia got out of the ‘conributor seat’ and into the seats of integrator and visionary.

  • About the standard operating procedures Dr. Murdia and his team built, and the training and management system that backs them up.

  • Griffin press if standardization in protocols is antithetical to individualized care.

Indira IVF Hospital Pvt Ltd Website: www.Indiraivf.com

Transcript

Kshitiz Murdia  00:00

it was our responsibility to ensure that we have similar protocols similar outcomes across all the doctors because one patient could be meeting two or three doctors in the clinic and different points of time during the same cycle and the protocols should not differ the language that they speak should not differ.


Griffin Jones  00:24

250 fertility doctors 50 IVF labs 60 to 70 satellite offices 27 to 20,000 employees did I get that right? These are my notes from my conversation with the CEO of Indira IVF, one of the largest fertility clinic networks in India. His name is Dr. Kshitiz Murdia.  He joined Indira IVF as the second physician in 2010 2011. By 2014, they had 50 locations. We talked about that process first starting with a massive marketing machine doing awareness camps across the country to generate awareness for infertility and fertility solutions. And then for their practice, we'll talk about how after three to four years, Dr. Murdia has stepped out of his clinical role and then transition to CEO first as medical director and then when they sold part of their company, or maybe a majority stake of their company, to ta associates becoming CEO, and the due diligence process with private equity groups before that, that gave him that financial and HR and marketing ops background education. I think this is a really good example. For those of you Doc's that I've talked about when I've pointed the accountability chart before and lots of articles that I've written, I talked about the entrepreneur operating system, and how many of you practice owners are in multiple seats. In the visionary seat, you're in the integrator seat, you're in different seats as contributors in physicians, you're in different management seats as medical directors seems to me that Dr. Murdia has done this, as well as anyone has of getting out of those contributor seats and moving into if not the visionary and integrator seat, the visionary seat, I think really behooves you to pay attention to how he did that in terms of building standard operating procedures, his process for building standard operating procedures in different areas and the training management system that backs up those SOPs, we spend a lot of time talking about creating one way of doing things proven way of doing things, having a training system, hiring management, and not just building the airplane as you're flying it and do IVF is apparently done this so much so that with 250, fertility doctors in counting, they have one set of protocols. There's one protocol for each patient type. I tried to play devil's advocate for you because I could see that driving some of you crazy, but I think the variance in protocols is an issue of scalability in fertility clinic operations, I can't vet whether that's necessary or how necessary it is, but Dr. Murdia responds to it. This is a very large operation that in 2019 ended up selling to ta associates the private equity firm that had owned CCRM and they have a massive HR and operational infrastructure behind them. Dr. Maria details that in this episode, so I hope you enjoy it. Dr. Murdia, Kshitiz Welcome to Inside reproductive health.


Kshitiz Murdia  03:19

Thank you Griffin. Thank you for having me on this show.


Griffin Jones  03:22

I promised my audience that I was going to cover more of the IVF market in India this year, we have you know, the third guests that we've had in 2023 to talk about the Indian IVF market because it seems to be expanding like no other market right now. At least I see. It seems everyone that's quote unquote, industry side, if you look in their LinkedIn profile, there's a picture of them visiting India, there's a picture that I'm talking about their company expanding in India, whether it's a genetics company, or a software company, or one of the pharmaceutical companies and, and so there seems to be a lot of activity, and we'd like to talk about that activity. I'd like to talk more about the present in the future. But in order to talk about the present in the future, I'd like to just talk a little bit about your enterprise in dira IVF. And, and how that got started. And can you give us a little brief history and where you are today?


Kshitiz Murdia  04:18

Yeah. So Griffin in Dr. We have started the routes are started in 1970s 1980. When our chairman Dr. Jim odia, he published his first paper on male infertility, which was published in The Lancet incidentally, in the same issue when the first test tube baby was reported by step two and Edwards back in August 1978. Since then, he has been very active, but particularly on the male side of infertility, because that time it was a big social stigma and a taboo, that males also could be responsible for fertility and everybody would put forward the female for checkups for investigation and the other things. So to bring that concept back in nine Getting a deal and especially in a country like India, it was a big, big problem statement, I would say, to talk about male infertility to ask the male partners to come forward for investigation. So he took this great step, I would say back then, and he's been practicing from 1980s. And then he started his own clinic in 1988, primarily focused on male infertility made diagnostics. You established his one of the first sperm banks in the country in India, where Neil's suffering from a zero sperm count could benefit. I am a gynecologist. I joined him in 2010 2011. That's when we revamped the whole setup, started doing IVF for the first time, in one small town in western part of the country, which is the poor, it's a very beautiful city, I would say I mean, a lot of tourists. So we revamped the setup, we started doing fertility surgeries, we started doing IVF for the first time, back in 2010, my brother, he joined me as an embryologist. And then we used to be home combined jointly, all three of us used to practice from 2010 to 2014, we were pretty much limited one center that we started back in the bowl with the western part of the country. And then we soon realized that there is a lot of awareness gap in the country that people are not aware about the scientific practices. So we should go out to people, we should organize these pre patient awareness camps, run a campaign in the country, educate more and more people about what fertility issues are, what is the medical scientific treatment, how much it could cost, how much days of treatment it might take. And we started taking these awareness camps. And then I think I think in the last one decade, we must have taken more than 2500 camps educated more than 70,000 couples about infertility. And that's what set up the route for our brand, I would say because we now proudly say that we are the we are the only b2c brand of IVF in the country, which is directly to consumers. And it's all started because of these awareness camps that we established long back, I think the second biggest challenge in front of us was around affordability. Because all said and done IVF might be cheaper, in some sense in the country in India compared to the Western world. But if you compare the disposable income of of the people here, for for an average middle class income, it could be, you know, a year or two years of their salary that they would have to spend, and it's all out of pocket, nothing is covered by insurance. So I think the second major challenge for us, apart from increasing awareness was around affordability, how can we make the whole treatment very much affordable. And then the third challenge in the country was around accessibility, because majority of these IVF centers were situated in the metro cities or the bigger towns, and then, you know, people would have to travel all the way stay there. It's a longest treatment, two or three visits, spanning over three months. So again, it was a big, big challenge. So we started opening out clinics in other parts of the country. So the idea from our side was you go to the patients and explain them open a good quality clinic with a better outcomes near to their locality. And that's how we started expanding. So 2014 was our first center outside the base location with paper, which was in Pune, which is in Maharashtra. After that from 2014 to 2018. We were at 50 centers 2018 to 22. We were at 100 centers. And we quickly adopted the hub and spoke model where we said we can't go to the smaller towns and villages with the whole stack of the bigger fertility hospital, let us do something which is a smaller capex a smaller model, which we can also go into the smaller towns and villages are lesser investment I would say. But at the same time ensuring that 70 to 80% of the IVF treatment is being carried out at that one sector and that smaller spool and then only for the critical operative procedures for a day or two days or three days maximum. The patient would have to travel all the way to the hub are the main center. So I think accessibility was a key thing that we quickly addressed back in 2015 16. And then we started having these folks also in the smaller cities


Griffin Jones  09:41

was it retrievals and transfers that were done at the hub and everything else was done at the spoke all the testing the monitoring the console that was all done at the the satellite offices,


Kshitiz Murdia  09:55

so we would have a full time gynecologist working at the spokes also and all week. interpretations, the stimulations, the ultrasounds, the monitorings, everything would happen in this book, only the retrieval and transfer was done at the end that reduced the number of visits at the hub for a patient.


Griffin Jones  10:13

And so you've got three days it sounds like awareness, affordability, accessibility, it sounds like awareness came first that you laid the groundwork of doing some marketing of getting people familiar with what the challenges they were facing, and then what you did and sounds like you did that before you built some of your your spokes. Now, what is involved in those patient awareness camps? Is that something that is it is that an event that they attend,


Kshitiz Murdia  10:44

we organized kind of an event where all the patients are called, we do marketing in the newspaper, digital and other ways of marketing that this kind of doctor is coming for a consultation. And any patient who requires this type of fertility consultation can come there. And at Indy cap, it's a free awareness camp, we take a one hour video session through a PowerPoint presentation explaining the normal fertility process, where could be the problems in the male part and the female pot, and how IUI and IVF and exist can overcome these certain problems. Which patient category should go for conservative for medical management for IUI than for IVF. So at least they are aware, and they are on the scientific path of the journey for treating their their fertility problems. Do you still do the awareness camps? Yes, we still continue to do that. How have they changed


Griffin Jones  11:38

over time. So if you started doing them in 2010, or whatever, this is kind of pretty socialist as as people are getting on social media. Now today, they have all kinds of information in social media. So in 2010, I suspect that that information may have been now to them. Contrast that with 2023 where they've got recordings that you have done, they've got recordings that your Doc's have done and and probably they can watch old camps that awareness camps they can watch on. So how is the awareness camps evolved as social media and digital info is increased?


Kshitiz Murdia  12:15

Pretty good question, Griffin. I think because we've also seen a lot of change in the last 10 years earlier, I think when we used to organize this camp used to have 200 plus couples in all the bigger cities attending the camp because information was not freely available. So those were mega camps, we used to register a lot of people and they used to come forward for treatment. And our our our contribution also from the camps and the print media, which is a newspaper was much much higher, before COVID, I would say, which was around 50% or 50%. Plus, after COVID. What happened in the country, it accelerated the digital adoption of everything, whether it is its digital payments, or consuming the news articles, or seeing all the Facebook's Instagrams and Google and all those things. At present, I think our digital media contributes to almost 56 to 60% of our footfalls that are happening to the center. And now we have slightly changed the format of the camp where we don't go to the places and invite people to marketing. It's very focused with some local doctor there in the community who was famous with the Kinect, and then they would have some patients. So we our doctor would travel to their their center in advance will let them know that we are coming on this date so they can gather all the fertility patients so it's more of a I would say a doctor clinic that way where we would use those camps to be organized. But yes, yeah, I think it's it's dramatically changed from what we used to do. But earlier I think two or three people from from our family were doing these camps and now we have 20 plus doctors and India at one time. So that has added too much of power to the entire organization.


Griffin Jones  13:59

And I want to talk about what went into that growth the operational logistics behind the growth I do have a side question about involving the local doctors because one debate in the US is how much obg lands that are not Rei what certified they're not Rei fellowship trained how much OBGYN is can and should be upskilled or trained to do things up to an including IVF retrievals. And, and so there's there's debate on how much they should be used. But there's definitely a camp of folks that do want to involve OBGYN more and some of them have had challenges I believe with recruiting OBGYN to be part of their network because when you have someone who's businesses also who is also to do obstetrics, do gynecology, then they feel like their patients are being taken away if if if you're using another OB GYN so how did you navigate that when you were when you're leveraging these local doctors So how did you avoid the rivalry that they might have with other doctors in that area?


Kshitiz Murdia  15:08

So first of all, Griffin, I think there's no concept called reproductive endocrinologist in the country. It's OB GYN only, which would be doing obstetrics and also IVF after a certain amount of training that is required by law. Secondly, our volumes of these kinds of b2b interventions, so called I would say b2b Now, because b2c is direct to consumer b2b. So these beta channels is still in the range of 10 to 15%. The good part is we don't do obstetrics. And we don't do deliveries of our own patients also. So you know, when the patient comes to me for IVF, they would go back for the obstetric work or or the routine antenatal follow up to that particular note. So we don't have a rivalry in in that sense it's a symbiotic relationship.


Griffin Jones  15:55

Well now with neither but if you're if you're using these doctors for your awareness camps in your involving the local OBGYN then how would you not tick off the other OBGYN in that area that say well wire? Oh, well, if Indira is using Dr. So and so then I'm not using Indira


Kshitiz Murdia  16:11

No. So we have a list of top 20 or 30 gynecologist in the in the city who are actively involved into fertility work and we keep rotating between all the doctors we have tie up with all the doctors, we do send delivery patients the obstetric work of our own conceived IVF cycles to all these doctors. So there's a symbiotic relationship. And then we are always there as a as a service provider to help them in their procurement to help them their pathology labs or any audits, any trainings, any any software upgrades, anything that we as a platform can add value to their practice, we are more than willing. And I think that brings me to another important point Griffin is is around the doctor recruitment as to how we have done it because ours is a b2c brand and patients are coming to Indore IVF and not to a particular doctor. I mean, patients don't come with a mindset that I have to go and meet such an such doctor or get treated by such and such a doctor. They just see in the eye we they would come to in HR IVF. And then they would get to know who's the doctor treating them. And every other day we have a roaster. So somebody is consulting today, their pickup might be done by a separate doctor, they impertinence or might be done by a separate doctor. It's as per the these Can you hold the roaster in the clinic. So it was our responsibility to ensure that we have similar protocols similar outcomes across all the doctors because one patient could be meeting two or three doctors in the clinic and different points of time. During the same cycle and the protocols should not differ, the language that they speak should not differ. And that's why we started this in the RAF fertility Academy back in 2016, which is one of the world class adopts in training in fertility. Our training center has been recognized my recently while British fertility society. Our training center is recognized by Merck foundation in Egypt. They regularly send Africa and Indonesia and Malaysia and Vietnam War the Asia Pacific doctors for training we run a fellowship program with them for three months. And 99% of the doctors who are working with us have been trained to our own fertility Academy. And same with the embryologist also. And once we got a hang of it, we understood that you know, IVF is not so difficult. It's not rocket science. You know, every gynecologist and life science postgraduate could be trained into either being a IVF doctor or an embryologist either ways, we developed a structured program and we understood that there are 15 or 20 steps during the whole IVF cycle. Once you have an SOP around each and every step, you just hammer in the training that you just need to follow the SOP don't bother about the final outcomes, final outcomes are bound to come. And we've been very successful. I think the average age of our doctors is 35 or 36, in spite of, you know, a few doctors being with us for almost 10 years now. So that gave us a very good handle on expansion because the expansion the major limiting factor for any clinical enterprise or an organization to expand rapidly is not funds, it's not infrastructure, you everybody has deep pockets everybody has private equity money, you can fund 100 centers in one year, you have the infrastructure available, you can buy a spaces you can rent them you can do I think the critical bottleneck for any organization could be having skilled manpower, you know, and then there's always shortage of skilled manpower in whichever field you go. And we decided that we would not struggle with this part. Let us create our own skilled manpower let us not depend on the market to get skilled manpower or to by practicing from doctor that you know, some such dope some work done or having good practices in it. Nigeria, you just go and acquire them? We said, No, let's have a b2c brand being built up, let's fuel the pipeline for recruiting young talent for for training them adequately ensuring that outcomes are as good as senior doctors. And now we regularly plot the outcomes of every doctor who's working with us, whether it is their one year experience, or six months experience versus their 10 years experience. And we see most of our doctors fall within a very narrow range of success or outcomes or embryo transfer outcomes. And that's all because of the structured training process, I would say and the strict SOP that every doctor has to follow with the team. So I think the overall strategy went to well, when we started expanding is one on a b2c brand, recruiting a very young talent pool, adequate training men, ensuring that they follow the SOPs, and then the outcomes are good, and then the word of outspread. And then again, b2c. So the entire circle went well, with the overall strategy that we wanted to explore.


Griffin Jones  21:02

And finally, it's interesting, because I've been thinking about this from my own business recently, that a shortage of skilled manpower, however you want to phrase skilled talent, or, and skill can be a relative term means meaning the talent that you need in order to fulfill your delivery obligations. But I have been thinking about this a lot for my own company recently, and how that's more important than getting the funding at that particular time, or at least in some instances it is. Now tell me a bit about that. Because many people would say, Well, no, we dive in more do we need the venture capital money in order to be able to build the SOPs, in order to be able to hire the manpower, we need this private equity, we need this debt. So tell me about how it can be more important to to fulfill that need of a shortage of talent and have the training processes the SOPs for them, then then the funding itself.


Kshitiz Murdia  22:05

By the way, I think carefully, it is a it is a multi stage process, you can't achieve everything on day one. And then you need to decide as per your business, the the line or the field or the vertical that you're in, what is the most critical thing. So, you know, whatever we are today, we were not even 10%, I would say five years back, or 10 years back. So 10 years back, the most critical part, the most shocking part of the bottleneck for us was training, right? So we focus first on training, we never had Oracle or the best ERP systems or the best tech platforms that we would have today. But I think I think that was the need of the hour. So as as a business as a company, you need to decide there could be 10 things that you want to achieve in life, but then it has to be staged in a five to 10 year horizon, that these are the two critical things or one critical thing that I need to achieve immediately in the first year. And that's what we did. I think the first part was force force training. And obviously, we focused very hard very heavily on training demand. But I stepped back within, I would say, three or four years of my medical practice that having done more than 10,000 cases, I had to step back from the active clinical practice. And I used to only and only do training of the new recruits and focus my 90% of the time, ensuring that they follow the right protocols have been trained, they follow the right clinical procedure, their skills are to that level. And fortunately for us, IVF is not a very skilled procedure, I would say normal delivery is much more technically skilled or riskier than doing an IVF cycle. So I think I stepped back from active clinical work from all that thing. And then ensured that, you know, I would provide training to all my new recruits for joining in my brother step back from the active embryology working but involved in training. So I think I think both of us dedicated too much time into the training part, having those SOPs, our SOPs might not be in the form that are there today, like you have a booklet and SOP written by this person, reviewed by this person at this didn't change and that date, but they were very primitive shape. But that's fine. I mean, you know, you need to have some SOP in place that this is how you would work. Maybe it's not in the best of the forms of formats that you would require. But I think that's that's what we did. And then then started the journey of having quality auditors, you know, somebody external parties could come in validate whatever you're doing whatever work. I think the third important thing that we took up is building a solid management team, which got completed three or four years back at we have senior people of experts working in their domain like finance it HR or medical or tech, having worked for a decade or two in various other multinational companies and get all of these people together and showed that there is a chemistry between the entire senior management team, they understand healthcare, they understand IBM, set up the goals with them as to what we need to achieve in the next two or three years. And then once everything is fine, then you look after, I mean, for us, Tech was important, but we consciously delayed it for some time till we had the proper team in place, because you need good quality people to to develop those IT platforms that you would want. And once we've developed the ID platforms in the last two or three years, two years, mostly, then is the is the hard work of ensuring that everybody does a shift in the practice from the pen and paper system to a fully integrated digital end to end system. So I think I think we, we very consciously understood that these are the challenges, but what is critical for the business has to go first, what is good to have could take, you know, little later timelines and that's how we went up. And I'm starting


Griffin Jones  26:00

to feel validated today as you're validating some of what I'm working on for my own business. Right now I've owned fertility bridge as a client services from doing clinic marketing for many years now. But in the last year or so I've been building inside reproductive health, not even really focusing on building inside reproductive health as a trade media company. So the inside of reproductive health is the Wall Street Journal is the Financial Times that everyone director level and above in the fertility industry worldwide, reads every morning listens to every morning. And so in building that my natural tendency is sell, sell and then deliver. And I've realized at some point that way, okay, I don't need to do crazy selling right now I've got enough money, I can figure out a way to do some of this other stuff. And every time I sell, I'm increasing my delivery obligation, meaning what I Griffin have to do in order to fulfill that order that I just sold. And then my bet is that if I sell to an advertiser that could mean 20 hours of my time for that one advertiser. And am I better off selling right now just to get more money in or whatever? And, and then having to use 20 of my hours to fulfill the order for that client? Or am I better off with those 20 hours working on the operational systems, the training systems, so that we have the people in place to be able to fulfill and the answers, obviously, the ladders, like, Okay, now, I'm really just selling a couple people here and there to continue to validate the concept to make sure that the systems we are building are actually applied to real people that they're not just hypothetical, but there's way more emphasis on operations and delivery. And you're the first person I think that I've heard talked about that on the show, I think most of the time, people are very much building delivery while they're building the operations, because they have, you know, they've sold the private equity, or they have so many financial obligations, and they need to meet them right now. Why do you suppose it is that high growth, companies overlook that, that period of really building the SOPs and the training and the hiring of the people and not trying to build the airplane while they fly it?


Kshitiz Murdia  28:25

I think that's one of the very critical things is building a good foundation. And I mean, good foundation, you might not be able to build right from day one, after you progressed a little while and you got success in some area. And that's where you, you start building the solid foundation for a sustainable growth. And I think for us, that insight came from our private equity investment team associates, Boston based private equity firm invested with us in April 2019. And their their philosophy or, or their way of looking at business is always to have a strong management team have a good corporate governance, you know, in order to have a sustainable growth, I would say. So I think a lot of interventions that we did on building or correcting the foundation, which is which is currently now a very rock solid foundation that you know, business is not dependent on one critical function or one critical person. It's an ecosystem that is running on its own that has a great solid foundation. And even if one vertical or one function or one person is not performing well or certainly go out of business, you know, you certainly don't flatter and then your business continuity there. And obviously ensuring that you you are true to your patients you are not, you know, over promising or doing false promises or doing something short term that would help you. It's all about that mindset of having a long term view, having a sustainable view, having good corporate governance, because it's all about wealth creation. and not earning money every day, which is which is much more important for for private equity or even for the shareholders. Once you get to that mindset, you will start thinking your all your actions would start getting pointed towards wealth creation or value creation rather than earning certain dollars every day or every month are looking at the p&l everyday.


Griffin Jones  30:20

So there's two routes that I want to go with this conversation one has to do with your background and the other has to do with the SOP and and building that structure for SOP. So let's do the second one. First, let's talk about how you built the structure for SOPs. Because as I'm building more standard operating procedures, I'm also realizing Okay, I need an umbrella governance for how SOPs are created. Because if you have sales team creating sales SOPs, and you have operations, folks creating operations, SOPs, and HR people creating EHR SOPs, they could start to look different from each other. And then they have to be Jigsaw together later. And so it's better to have a certain governance where you have a master process for how processes were made. How did you approach that?


Kshitiz Murdia  31:09

So I think my personal view, Griffin is start from the very basic things that you could achieve very quickly, rather than waiting for the entire structure to fall through from the top because you know, that will involve a lot of skilled manpower, we might or many companies are not at that stage, when they start on middle of their journey. I would say even if you're able to achieve 60%, up 70% of what you want to achieve tomorrow, let's do that, rather than waiting for one year to achieve 80 90% 100%. And that's the philosophy that we followed in all the tech developments. Also, you would want a certain page to look like in a particular way you need 10 fields, here are five fields there are the critical are they showstoppers yes or no? If it is, yes, otherwise, even with that 50% of the period, if I'm good to go, whatever I'm doing today, I'm able to do 80% of that on a digital platform or an SOP or any other thing, we would just go ahead do it. Because there are multiple challenges once you put it to the user, there are bound to have all these questions and debates that would come up that they need certain changes that they need this, they need that, you know, and it will be a continuous process of development. So don't wait for the final end stage of how a corporate governance structure should look like and ditching trying to stitch it on the very first day, it is very difficult to achieve to that level. So I mean, all of us are very fragile in the leadership team at Indore IVF that we very quickly adopt the process let us start knowing fully well that we need to reach to this stage 100% But not to be or tomorrow, maybe after three months or six months or depending one year. But this is what we want to start today. And let's go ahead and build it up.


Griffin Jones  32:56

Did you have the embryology team making their own processes? Did you have the nursing team making nursing processes and physicians making the metal starting with the Medical Director presumably making protocols? How did how did individual process areas come to be?


Kshitiz Murdia  33:16

So we had different different verticals, making their different policies and processes and then, you know, problems are bound to happen whenever problems come all of us would assimilate as a group and see what changes we need to make in the various processes, but certain of the medical and the medical excellence so we have one medical department who's responsible for all the clinical and embryology processes, we have a separate medical excellence department who looks after all the medical protocols, whether they are safe for the patient, whether they are done rightly, in our patient identification, facility management, all the we screen our centers across 498 points spread across 12 different chapters of a credentialing program, and then everybody has to match that program and and the medical excellence runs very independently of the medical core function. So they would very closely interact as in when if there are problems, so I left it we have 70% Correct. But you know, all these issues would keep coming up every now and then in you sit together as a group and align the overall strategy. What is the culture? What is the DNA of the organization? How should in the IVF react in a particular situation? Is is what would govern the changes in the SOPs if required?


Griffin Jones  34:32

Did you put this all into one master document or didn't live All in One Drive? Where does that does each SOP area live with its own department?


Kshitiz Murdia  34:46

So it's mostly in the HR we have a learning management system. So all the policies procedures, everything has been feeding into the learning management system, and different people based their job roles and their category or We create, they keep receiving periodic emails of certain courses that they need to complete. And also we have a very active learning environment. So every week or every 10 days, there's a separate team learning team separate over take care of all the new join is the new recruits, take them to the entire mission vision values, to the basic trainings, the clinical aspects and other things. When did vision


Griffin Jones  35:23

mission and values come in as a central part of the training did that come after you had been building some SOPs? And and then you needed to start gluing all of the different areas together? Or did it come from the beginning?


Kshitiz Murdia  35:41

No, you it came in? I think I would say three, three and a half years back and not 10 years back? Yeah. feverishly add some SOP some I will also not say a full fledged SOP document, it's a way of working could be some verbal trainings or other things or some PPTs that we would have. It all eventually came in the last five years, I would say one by one.


Griffin Jones  36:06

And so your training management system? Is that proprietary Training Management System that it for India? IVF? Or do you use something like train you will or loom or any of those softwares?


Kshitiz Murdia  36:19

Yeah, we have a software from adrenaline, which is an HR software, which is our HRMS, which has the learning modules when we have all the videos being uploaded on the learning module, and then it periodically keep sending reminders to all these.


Griffin Jones  36:34

How involved were you in selecting that solution? Did you have your HR folks do it? Or were you personally involved in choosing that solution?


Kshitiz Murdia  36:43

Yeah, I got involved in most of these softwares selection. And obviously, then the implementation and the customization, we involve more the business side rather than the IT side. So all our our, our eh is the EMR the medical function has developed, it has supported our ERP implementation the finance team has done it has supported similar to the HR system. So we had this very different approach that let the business drive the implementation of software's rather than it doing it and then they send it to business and business will have 10 things to circle back to the it. So we thought let's involve the business on the very first day, and it will be like a support function of converting the thoughts into the ID language. That's it.


Griffin Jones  37:31

So that makes sense of why business would be involved in choosing the talent management or the resuming the Training Management System. But why you personally what is it that you were looking for?


Kshitiz Murdia  37:44

So because we, me and my brother, we had seen various systems in the last 10 years, we tried implementing EMRs, we failed on three attempts, I think. And that was to do because one, it was not thoroughly evaluated. Second, when we were growing very rapidly, from five centers to 25, to 50, to 100, your requirements kept changing every six months. So by the time you evaluate the software, you feel happy, they come back, they start implementation customizations, your requirements have gone, then x of what they were six months back. And that's why we were not able to you know, properly implement it. Secondly, we never had a good management team or leadership team. Because you require enough bandwidth to implement all the IT processes. It's not just implementation or customizations, you require good change management that should happen at every level, every person was using the software. So I think I think that because of all those things, we could not implement great it or tech platforms five, six years back when we tried and we failed twice or thrice. But once we have a good leadership team good management below us, we are also grown to 80 or 90 100 centers, pretty much our requirements was fixed, I would still not say we were 100% clear on what we were now also as you go, and then you know, business would require 10 More things. So anyways, if you're 80% there, just go in and implement it. These things would keep coming in people would want the moon and the stars. And then you can keep building on it in the next phase. Yeah, they'll


Griffin Jones  39:19

always want something more. So they always will be in a next phase. How did you go on this journey to CEO? What were the milestones as you look back now because your training is as a physician, right? So you started off seeing patients and you're trained as an OB GYN. And then how did you become a CEO? What do you look back and see as the most significant milestones.


Kshitiz Murdia  39:45

So I think initial three or four years I was practicing as a as a gynecologist as a physician doing active clinical work while all the ultrasound pick up after surgery is everything. After three or four years when we started expanding In, I took a little back seat from the active work started working as the as the trainer, I would say for all the physicians and other things. But once we had five or six or seven centers, I started acting as the medical director, being responsible for all the protocols being responsible for all the trainings, being responsible for what medications they would use, what would be the doors, what would be the prescriptions like and all those things, after being the medical director for maybe two or three years, and then ta invested with us and T was wanting to put a proper governance and a corporate structure that any private equity would want. The idea was to select somebody working with the company for for last few years. Because you know, when T invested, we were already at 50 Center, we were the largest in the country, in terms of number of centers, in terms of doctors being trained in terms of business. And in the overall top line. I think the idea from the side was nobody has done good work in the country in India in the IVF suite apart from Indore IVF, let us have somebody from the group internally and promote them to the to be the CEO. And I think because of some of the diligence is being done on the company before they invested. So there were a couple of private equities, looking at us and in all the big force coming and doing diligence. So I got exposed to many more financial aspects, many more HR and marketing aspects as well. So I think I think it was because everybody, all the shareholders thought that I had a very broad based idea about the business and not just the medical function. And obviously, we are very strong believers that our medical organization should always be headed by a doctor, because that gives you much more leverage in terms of talking to the doctors, because ultimately, all these businesses are built on the ground in the clinics and not sitting in the corporate office in your air conditioned chambers and working on Excel or laptops or you can't build a business, their business is actually being done at the clinic level by the clinicians, by the nurses by the embryologist. So you will need somebody who could have that wavelength of talking to these doctors who the doctors will also respond to and respect. And it's not just about number number number that you need to clock certain revenue, you need to block certain number of patients being treated. It's always more to do with the medical outcomes, and how do you treat and how do you excel in, in the overall outcomes, I strongly still feel that a non medical person, no one sounds very commercial to the doctors, doctors would not give that much of respect. Because, again, they feel the other person has no knowledge about medicine, and is just come here and just telling us all the numbers on Excel. And we feel it's not like that. And you know, patients are different, the actual clinical life is different. So I think a good balance between the medical and the financial work is required when you want to control the doctors and when I say control because ours is a very different culture in DNA. It's not doctors independently practice in in their own world. And they have a different protocol. And they have a different business mindset. All of us all the 250 Plus doctors are run on a single platform, run on a single protocol, everybody is in very close touch, I would say everybody's using the similar protocol.


Griffin Jones  43:30

So you need a doc at the top in order to get that many Doc's to buy into similar protocols. I think I think that's hard enough for you even if you have a doctor at the top. And so that makes sense to have a physician as the CEO, but you said that it was doing some of the due diligence, with the private equity companies that you were talking to prior to ta associates that gave you more education and finance and HR, how much education, finance and HR did you have prior to those due diligence process?


Kshitiz Murdia  44:04

I think nothing I had no background about an ENT and other things. I think those diligence process exposed me to many more technical terms in the finance, what is revenue, what is collection and you know, EBIT da and all those things I started learning, of course, now having being the CEO and interacting with all these lovely professionals that report to me and are experts in their field. I have much more now control and handle and knowledge on the various marketing functions, the HR, the tech, the operations, the finance, the medical excellence, everything is, is pretty much there because they've they've they've taken the company to an extremely high level in terms of governance and compliance beat any field, whether it is HR or medical excellence or idea of finance. So I think I think that initial exposure helped me a lot.


Griffin Jones  44:54

How did you adapt to what it must have been drinking from a firehose with That level of information trying to keep up with those folks, what resources or education? Or how did you lose it just articles on the internet? How did you get up to speed?


Kshitiz Murdia  45:11

I think I was very open to all of them during the journey. If I don't understand anything, even being the CEO, I will be very open and upfront, and I don't understand this, pardon me, I'm a doctor. So I might not understand just explain me. And obviously the the you are running the business from day one. So you have that business sense. And you could catch up things which is in the interest of the business or not in the interests of the business. So they would say that I then simplify those films for me and explain me a you know, if I'm not able to understand, you must have


Griffin Jones  45:45

caught up and in you did so in a way that has really allowed you to scale and pretty darn quickly, it seems from especially starting around 2014. And then seems to have escalated quite a bit. You talked about having a one protocol, one set of protocols for all of the doctors and you said 52 Doctors was


Kshitiz Murdia  46:06

that goal goal? 52 plus 250 plus two. Okay,


Griffin Jones  46:09

so over 250 Doctors Wow. And everyone's using the same set of protocols. In the United States, it seems that people are resistant to do that. And I'm not clinically trained. And I come from a sales and marketing background. And I just kind of observe and it seems to me, like people are very reluctant to have any kind of uniform protocol. That's all we always let the doctor practice how they want to. And I think as a business person, I think what's pretty darn inefficient, it seems fine, but I'm not clinically trained. You you decided that that was the right way to go. What do you what do you what made you decide that? And what do you think the resistance to that idea is


Kshitiz Murdia  46:50

very interesting, when I think when I started practicing I was 29 or 30 years, when I recruited the first doctor, I was 33 or 34. And then purposefully, I would want to recruit a younger doctor who was little junior to me. So they would come and listen to what I'm saying, you know, and eventually it happened that we were recruiting all junior people, you know, 2830 31 and then ensuring that we train them efficiently. But later we realized, if I if I recruit a younger person who just graduated yesterday, from OB GYN, he or she is blank in his mind, or her mind about IVF, they don't know anything about IVF, right? Whatever files, you need to insert in their mind and block it, they will be stuck there. You know, somebody who's practice in IVF, for 1015 years might be a good clinician, but they come with their own baggage that this is what I think is right. You know, this is what I've been doing in my last decade or so. And this is what I swear by. And I will not change whether you tell me that this is good or this is bad, I have not changed my practice. And that's why, you know, if somebody would come for an application, or we can see application comes, somebody says I have 15 years of experience in IVF and wonderful clinician, good business, good outcomes, somebody comes and tells me I have just graduated yesterday with my OBGYN, we'll pick up the later one and not select the first one because you know, we are a rapidly changing organization is what I was doing as a clinician 10 years back, we have changed the complete protocol in today, if I see today, and what I was doing 10 years back is completely different. So one should have that flexibility in their mind to keep adapting to the newer protocols, evidence based medicine that comes in. And I feel this younger Lord, having gone through that process of working with us getting trained with us, following one single protocol. Every time a new protocol comes in, we do a pilot tested at one, report the outcomes to all the people and then say, Okay, let's go and change this protocol from tomorrow morning. You know, because this is better. This is the evidence based reports. This is the pilot that we've done. So the entire culture of the organization has said from day one, that it has to be young people moldable whatever we have taught them, I think I think most of our people would not know the various five or 10 different types of protocols that exist. And if they would just know, one protocol that they've been taught because they had no background about it. I think that's that's the plus point that we gain, recruiting younger people because we were not depending on experienced clinicians for getting patients, patients are being sourced by the marketing function. And we were very confident any clinician, we were trained to get similar outcomes, you know, so I think our work of a trained doctor was being handled by the marketing function and the training function to get more patients and ensure once you get those patients the outcomes have to be good.


Griffin Jones  49:44

There could be a couple of reasons why people don't have one protocol where it's because well, we need older docks in order to have them do their own marketing or we don't have the training infrastructure to bring everyone up to do this one protocol or it could simply be that There are dogs that are set in their ways that and they're not receptive to change. And that could be very difficult and having one universal protocol. What about someone that would say, That's too rigid? Dr. Marty, that's too it's that doesn't allow the clinician to be a clinician at that point. They're just a, they're just a cog in the machine. And it doesn't allow them to provide individualized care to the patient, how would you respond to that?


Kshitiz Murdia  50:31

So Griffin, we we're not saying one protocol, it could be multiple protocols, but one protocol for one type of patient. So we are individualized yet standardized, I would say, you know, for a different type of a patient, young patient, you would use a different protocol for the older patient, you would use a different protocol. But I would not have 10 protocols for my older patients or five protocols. For my younger patients, we do allow some kind of flexibility, but not to a very great extent, I would not say they can choose between three or four protocols, or three different types of medicine, we would maximum have one particular medicine being prescribed for a particular compound. At max very, very rarely, I would say two different types of brands are medicine. So everything is being systematically put in Europe, people, people are okay with it doctors because they are getting outcomes, you know, if something is wrong in my system, in my protocols in my SOP, you will not get outcomes. And then you know, I would also want to change if you're getting good outcomes. If everything is well, why would you want to change a particular protocol. And slowly, we are now getting to a point where we would now be enforcing it to our system to AI EMR, which would be much more intelligent. And we are feeding all our SOPs and protocols into the EMR. So it would keep assisting, keep alerting keep stopping the doctors at any point of time, if they are going in the wrong direction.


Griffin Jones  51:55

And so how would you respond to someone that says that ties my hands too much?


Kshitiz Murdia  51:59

I mean, it's okay. I mean, if there is any protocol that you think is better, let us know we'll do a pilot in your center with few patients and see if the outcomes are good, we are happy to change the entire country on that protocol. We are open to that. But it has to result in better outcomes or reduce the risk of complications to the patient, or reduce the expenses of the patient, then we are open to it.


Griffin Jones  52:22

Let's recap some of this meteoric growth that you've had. So that so you join in 2010. For at the time, there was one center in the western part of India, and from 2010 to 2014, you had that one location, and you're practicing as a as a clinician, there's no second location, second location opens up in 2014. And that's when you start with the awareness camps and starting to grow the marketing. And then by 2018, you had 50 centers, or at least 50 offices. So at this time, is there still one hub? And in the other 49 or so are spokes?


Kshitiz Murdia  53:04

No no majority of them, but hubs


Griffin Jones  53:07

is IVF labs? 


Kshitiz Murdia  53:09

Yes. 


Griffin Jones  53:10

Across the country? 


Kshitiz Murdia  53:11

Across the country. Yes. 


Griffin Jones  53:13

And so what is it today? How many IVF labs does Indira fertility have


Kshitiz Murdia  53:18

this for labs? Well, most 49 or 50, and rest 65 66? Whatever 67 number would be spokes.


Griffin Jones  53:27

Wow. So So somewhere around 50, IVF labs, and then somewhere between 60 and 70 offices in more remote areas where they do everything except retrieval and transfer. 


Kshitiz Murdia  53:40

Yeah. 


Griffin Jones  53:40

And 250 physicians about maybe a little more? 


Kshitiz Murdia  53:46

Yes. 


Griffin Jones  53:47

And how many employees


Kshitiz Murdia  53:49

Roughly 2700 2800 employees? 


Griffin Jones  53:49

Wow, so there was a there was a dramatic growth that that went from 2014 to 2019. It sounds like it was largely fueled by the awareness camps that you were doing that marketing, building the SOP and the training. And then at what point did you decide okay, we need a financier behind this and because it sounds like you were talking to some private equity folks before TA and that it sounds like ta happened in 2019. So, what year was it when you decided okay, we need a financier behind this.


Kshitiz Murdia  54:26

So, Griffin, I think the the requirement was not from the financing point of view because fortunately IVF is a good business to be in the margins are better and then you know, your own internal accruals could fund the the future growth of this interest. The requirement to have a private equity was more from a global exposure point of view, having good governance, good systems, good processes, attracting good talent to your company and then obviously building that solid foundation. You know, as a family as a promoter, we brought the company to one level. Now to go Further, we need some partner who can instill those values, though that culture in the company attract talent, build a solid foundation. And then obviously, we can take it to the next level. So I think that was one of the major requirements. So with the DA investment, nothing came in into the company, it was all secondary money being passed to the shareholders. But if we had a partner who could, you know, structure the whole organization for the future?


Griffin Jones  55:25

Why did you need their help for that? Why? Why couldn't you do that? On your own the culture that normally it seems that's what what comes from the organic side? What do you what do you think you needed their help with?


Kshitiz Murdia  55:37

I think as a as a family, as a promoter, you are not exposed to that global expertise. And, you know, once you have private equity people coming in, they you get to learn a lot on on corporate governance, on structure on sustainability of the business on building a platform, as a family as a promoter, you are very much involved into day to day operations. And I said, the difference between a value creation or a wealth creation versus difference between, you know, looking at your p&l every day, every month, every year on how many profits or much profits you make. So that's a basic mindset difference. And I mean, we've been exposed with deer for the last four years, and now the mindset has changed dramatically. If you were to talk to me five years back, my mindset would have been different. So today's


Griffin Jones  56:23

associate at that time was behind CCRM. Is that right?


Kshitiz Murdia  56:28

They used to want CCRM. till last year, I think last year, they sold it off somebody.


Griffin Jones  56:33

So when they came in, they had a good bit of experience in the fertility space. What things did you say, Okay, we want to do we want to learn from the CCRM way and what other things you say, no, we want to protect this and do this our way?


Kshitiz Murdia  56:49

I think I think there was no technical exchange of information that happened from the CCRM. I think it was the global expertise of tea associates, having worked on multiple businesses across different geographies, and also some experience on fertility business. But I think it's very difficult to replicate practices from one country to another country, and then you know, expect good outcome is the general know how of building a good foundation that helped us to a great extent, I would say if I look back at their partnership, the value and that they have created I think it's it's building out that solid foundation, then building out that leadership team, and developing that culture that DNA, the organization that is very future ready for any kind of growth, it kind of shocks that might come along our way.


Griffin Jones  57:35

There's so much more I could ask you, but we'll save that for a future episode. I'd love to have you back on the show. If you're open to that idea, at some point in the future have any summary of what you're talking about? Or maybe Indira has plans for the future putting thoughts?


Kshitiz Murdia  57:48

Well, we are open to some acquisitions in some parts of the country as well. We also looking at senses to our businesses, which is getting into genetics getting into pathology, we have Axos lot of pharma products, which are directly being manufactured for us from the cdmos. We are looking at adjacent businesses like mother and child as well. We have already started our expansion medicine countries, which is Nepal and Bangladesh and Southeast Asia being a very attractive market. We are very open to you know, having a partner who could take us or help us in that area. I think this is broadly the plan that we're looking at for the future growth. But


Griffin Jones  58:29

Kshitiz Murdia, thank you so much for coming on inside reproductive health.


Kshitiz Murdia  58:33

Pleasure, Griffin, I enjoyed the conversation. Thank you for inviting me.


Sponsor  58:38

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

177 More Than 1 New IVF Center Per Week: India’s 0-40% Fertility Network Market Share Growth



This week’s guest, Vinesh Ghadia, CEO and co-founder of BlackCap Equity’s fertility vertical in India, talks about the exponential growth and consolidation happening right now in India in the fertility space. How is it possible to have 60 to 70 new fertility centers per year opening, with no shortage of fertility doctors? Tune in to the the latest episode of Inside Reproductive Health to find out.

Listen to hear:

  • About the five to six biggest fertility chains in India, and the four to five that are on their way up now.

  • How India is averaging more than one new fertility clinic per week in the country.

  • What the US can learn from India in terms of consolidation, comparatively, where a network with 35-40 clinics is considered a midsize chain.

  • Why Mr. Ghada believes India will be the biggest market for growth in the ART space in the next decade.

  • What Indian fertility companies did to solve their fertility doctor shortage problem, and what they may do regarding the embryologist shortage.

  • What Vinesh thinks is causing the falling price of PGT-A.

Vinesh Gadhia’s Info: 

Website: Black Cap Equity Management
Website: Star Fertility Prive Ltd

LinkedIn: https://www.linkedin.com/in/vinesh-gadhia-56a00890/

Twitter: https://twitter.com/gadhiavinesh?lang=en

Transcript

Vinesh Gadhia  00:00

Nice Jean. But 30% of IVF cycles were done in the organized ci 16% clinic 3% in ownership 30% in cycles, at present as we speak 35 to 40% of India's IVF cycles are part of organized chain and the rest 60 person is still fragmented and organized. So starting from zero to 40, it only took one decade.


Griffin Jones  00:32

60 years 70 New Fertility Centers per year, no problem getting doctors imagine that that's according to our guests, Dinesh Gadea, who is the CEO of the IVF vertical in India and the emerging markets for black cap equity. He had been the CEO of RT fertility clinics. He had been the ce o of Nova, part of the Evie network or partner of the Evie network. And he makes that clarification finesse started in the IVF world in India in the early 90s, at the ripe age of 21. At a time when there were only four or five fertility clinics in the entire country. We talk about the five or six biggest chains and fertility clinics in India and the four or five that are coming now we talk about how more than one new fertility clinic a week on average is coming to be in the country. We talk about what the United States can learn in terms of consolidation because this is a marketplace where roughly a decade or so ago 0% of market share was under fertility clinic chains. And now 40% is in India and network with 35 to 40. Clinics is a mid sized chain, Vanessa is looking at buying some of those mid sized chains and consolidating them into a larger group. He talks about that and then I make him put in demographics in numbers and in figures why he believes that India is the biggest market for growth in the assisted reproductive technology space in the next decade. He talks about the scaling opportunities for companies growing into the fertility space in India and their internal rate of returns or expected IRR. Anyway, he talks about what Indian fertility companies did to solve their fertility doctor shortage what they're doing and might be doing to solve their embryologist shortage. And we talk a bit about career tracks for young fertility doctors, which I think is probably the biggest difference, at least that I heard in a short conversation between the United States and Canada. And what seems to be happening in India, according to at least this account in a very small conversation. And if we didn't talk about enough, he talked about the falling price a PG TA and why he believes that that is going to make the total percentage of cycles that use PG ta go up from five to 6% to about 25% of all cycles that are done. This little bit of coverage that we've done on the assisted reproductive technology space in India is only the tip of the iceberg for covering what's happening in that country. We plan to do a lot more of it. So I hope you enjoy this conversation with Dinesh Gardea, Mr. Gowda, the Nash, welcome to the Inside reproductive health podcast.


Vinesh Gadhia  02:52

Thank you very much Griffin for having me. It's an absolute pleasure and my privilege to be speaking and talking to you on your podcast. It's very interesting space. For me and us. I think it's becoming interesting space for millions of couples in India and globally. Thank you for having me here.


Griffin Jones  03:09

I think it's becoming an interesting space for people that worked in the fertility field all over the globe. And I said to one of our recent guests Dr. GHOSH dusty Dyer, that 5% of our subscriber base comes from India, people that work in the IVF field in India. And previously to that episode, I had never created any content specific to the marketplace in India and I look forward to covering more this year with Dr. GHOSH dasa, we laid the groundwork of the history of IVF. In India, how some practices are set up there, you have a lot of experience at the home of some larger groups. And so I'd like to talk to you about the history of some of the large clinic groups of the business landscape and then what you see as some of the unique scaling opportunities and challenges. Let's start with the clinic side, can you walk us through the history of the large fertility groups in India, who are they and how did they come to be


Vinesh Gadhia  04:10

when we talk about fertility groups is more about organized change of IVF clinics in India, but to just to understand my narration in in detail, I would take a little bit historical background on how our as a country we have evolved. I have started working in this space in early 90s. This is my 30th year in IVs space from Day Zero Day One of my professional career at the tender age of 21. I fell in love with this space because it's something that helps to create more happiness and I'm the author in the universe in early 90s. In India, fertility infertility or fertility was considered as personal shortcoming and it was considered as destiny it was neither accepted as medical treatment or Medicaid disease. And and most doctors I would say now 85% of gynecologist who are treating infertility did not have a chapter of infertility in their final year of master's in gynecology. So that was the state and I come from that background where I've seen this industry growing from ground zero. So, very few IVF clinics in early 90s, maybe four or five, and then it started growing towards the end of the decade, early 2000 is where infertility treatments started becoming a little popular amongst the patients and also wants the doctor I have been on pharma side for 16 years kneading and launching large IVF business from the pharmaceutical companies and I crossed the bridge in 2011. When I came towards the service side, I was one of the founding member of India's first organized IVF chain backed by a private equity company. So, it was only in 2010 Later, large fertility groups started coming into existence. It was a group of venture capitalists and private equity in healthcare business. And they thought that possibly IVF is complementing to the naked healthcare model. It was it was group of venture capitalists and backed by one large private equity. They reached out to one senior doctor in India, Dr. MANISH banker, and Dr. banker and me used to be very good friends because I was from pharma side and he was my key account. He reached out to me, we went and did a presentation to the board about business case and scientific case. And we started we worked three months on the strategy board on the ground zero business plants and also in business model. And then started our first step is India's possibly the first ambitious plan for a large fertility Qi. What did


Griffin Jones  06:47

you have to prove at that time? Dinesh, what did you as you're building the business plan? This is something that is pretty new to the venture capitalists and private equity partners and you're working three months on this business plan, what did you really have to focus on to prove in that business plan?


Vinesh Gadhia  07:05

Very interesting me nobody in during that time in India believed that this fragmented Doctor owned IVF clinics, this market can be organized, the biggest challenge was to present the business model to the private equity and the board. And one of the interesting fact which I was driving and and there were not many takers in the boardroom also, is that we will launch a PRK IVF business first time in India, where in the IVF clinic we will not have any neighbor room. No guyhnic practice no obstetric practice, because what investors were thinking is that if we if and once we grow IVF business, we have readymade pregnancies from our IVF business. So we will do delivery business also, let's birding business, where I was very sure in the model that it has to be pure plain I had my logic ended. Second from where to bring patients in India. So the belief system was that it's word of mouth. And I was very, very sure that because infertility is not talked about, there are meats and taboos, there is stigma around it, people take very few people first come forward for treatment. And people who get positive results don't speak about IVF amongst their friends and family. So word of mouth is extremely slow. It takes very long time to develop business on word of mouth. So I had why business plan which was based on a very new concept of meeting 1000s of gynecologist convincing them to refer a patient to us and the business model. So there were a lot of challenges. There were too many no naysayers that did not work. I think in deep in my heart and along with the Medical Director Dr. MANISH banker and his partner, Ravi Patel, we were convinced that this will work. It took heart time to convince the board. But the first step was defining I think in business model.


Griffin Jones  08:58

You had your reasons for wanting to go the pureplay IVF route when other traditionalists may have also wanted to include obstetrics, what were your reasons that you felt strongly this has to be purely fertility treatment.


Vinesh Gadhia  09:14

So Griffin it's very interesting if you if you analyze the full funnel approach, millions of couples in India suffering from infertility majority I'm talking about 2010 majority believes that their treat they can be treated by astrologers by cracks and they would of course, I'm a God believing person so they would go to church mosque temple. My belief was that if you are a God believing person suffering from infertility, which is a who classified medical disease, you have to fight God in a doctor an immunologist, and not in the temple because you will not get a cell there. Out of that few million couples who would not even come for medical treatment, the large segment of the funnel, who accept Did and understood in and largely in urban area that it's a medical issue. Sadly in India it is still considered woman's problem medical it's a couples problem. So, so out of these millions of couples many are most of them accepting it medical disease but woman's problem will go to gynecologist so 70 80% of infertile patient in India even today will first go to gynecologist medically right or show because GYN they can treat majority of infertility and not everybody requires IVF so, why in gynecology see 10 patient of infertility two or three will require IVF but they will not refer because the standard on IVF clinics in India are also doing obstetrician birthday. So basically it was not referring but it was losing patient to a competitor or your colleague right to get my point. So this ref net ne identify identifying patients requiring IVF we're never referring to another IVF specialist because the patient will never come back to the doctor because they themselves are competiting to the birthing and upsetting business. Now it took very long time, a long time for me to convince my board and my investors that the majority of untapped potential in India is live with gynecologist so we did a small Deep State study, meeting 500 gynecologist 500 is small in India and asking them do you see infertile patient? Do you see patients who require IVF? If yes, whether you refer or not. 100% doctor said that they get infected patient 90% of doctors said they have patients who need IVF. All 90% said we don't refer when we should why. So when we refer a patient, we lose our patient. Second, we don't believe IVF is great results. Third, we believe IVF is expensive. I had presented the study to the to the management and saying that this is where they can work. And we can explore untapped potential, get patient for our need, not from other IVF center because that's very small. But from the market, which is not, which is not tapped so far. So we were we were getting into an untapped potential of the IVF business. It took six months one year for me to prove that this is the model which will work for that business to come in from referral network or from gynecologist referring to IVF specialist, we cannot compete with them. So we cannot have no neighbor whom in our clinics we cannot do badly.


Griffin Jones  12:35

So you finally are able to prove this concept to the capitalists behind the private equity that are investing and you and Dr. MANISH banker ostensibly get your business proposal accepted, then what happens?


Vinesh Gadhia  12:51

So we started with the first clinic of Dr. Banker acquiring the clinic. And we had a very, very ambitious plan of starting a chain of 25 clinics doing 10,000 cycles in a in a year. When I used to say this to industry experts in India, and also across the world. I used to attend global IVF conferences. Yeah. Most people used to not believe it that this is possible. Half of them used to laugh not in front of me but behind me.


Griffin Jones  13:20

How many cycles was it that you were a plan


Vinesh Gadhia  13:23

was to reach 10,000 cycles in a year.


Griffin Jones  13:26

And that was laughable at that time.


Vinesh Gadhia  13:28

Nobody could believe that there was no group doing 1000 cycle. So when we were presenting our plan, most people thought that it's on paper and cannot be executed or it's difficult to give life to this pen. So we did our first clinic in Ahmedabad which was a brownfield acquisition. Then we started creating Greenfield clinics, hiring young doctors hiring young embryologist, a very young business t, which is sales and marketing and the ops team. And we progressed when, in the first three years, we really ignited the market growth. There were five change slots, which are now changed which were launched after success of Nova. In 2015. There was an EY report white paper on IVF potential in India, which was published by Ernst and Young, which which shows Nova IVF as the leader in the industry with nine clinics doing highest number of IVF cycles and having best in class students. I think if you asked me that was the igniting point in India, where more groups started investing shattered and visualizing the plan and from from practically zero organized business in 2020. In India we have about 35 to 40% of IVF cycles which are with organized change and now there are several chains in India.


Griffin Jones  14:50

You live in Mumbai did your original financiers also come from Mumbai? Did they come from other parts of India? Did they come from Spain? Did they come from other parts of the world? world where were the original people that bought into your idea with their dollars come from


Vinesh Gadhia  15:06

the first seed investment came from an American venture capitalist GTI capital, global technologies investment. Second major investment came from a, again a venture capitalist from us, any new enterprise associates, third came from Middle East, which was born exist, it was submit a Middle East based venture capitalist. The turning point was when we launched our fifth clinic, Dr. Banker also realized that to run one clinic of excellence is a different ballgame. But to run a chain is very different in terms of having all the standard edition inishbofin protocols in place, so we got in touch with world's largest chains, which were based out of Australia and Europe. And we finally zero in partnered with Spain, which at that time was also needed in the world. So Evie spent came as our technology partner and after that, we got Goldman Sachs on board as our private equity investment leading investment was was from Goldman, which gave us a lot of confidence on our modern on our progress, which was made in in the first couple of years and gave us definitely a ability to invest in quantity and in infrastructure and standardization. So, we took off from from Ed coming in and Goldman coming in. So there were basically five investors put together it was also backed by one individual doctor from Bangalore as a promoter along with the CD and Misha Doctor nationality. So, we had good mix of venture capitalists and private and large private equity like Goldman Sachs.


Griffin Jones  16:48

It was so as Nova is growing and then eventually merges with Evie in Spain and is financed by Goldman what what other groups are merging? You said that five other chains came after Who are they and when did they come about?


Vinesh Gadhia  17:03

So I would just clarify that it was never a merger with TV Evos our technology partner we had a royalty agreement with them and a sweat equity diverse chatted for or whatever they were helping us and they were very valuable partner for our quality improvement in their IVF currently India's largest IVF Qi one of the largest in the world, there are more than 100 Plus clinics across the country. And they have they have done some very very I would say phenomenal execution of of plan entire to tie efficiently largely was next they started their journey from a very small town in India you know the poor which is in upper upper west western region. And after naoise initial success Indira started expanding when there was another health care healthcare group, which was Manipal health, which is again eat today also is number one number two health care group in India they folded into IVF with a chain called encore Manipal there was another encore player in India backed by private equity their company name is healthcare global at CG they forward into IVF chain called a teaching the lab the biggest healthcare group in India is Apollo Apollo forward into IVF shade or depo fertility at present as we speak, in last three years in spite of COVID time, there are four or five new chains which are launched in India and they all are expanding, expanding robust and doing investment of millions of dollar in north there is a new chain which has come up with 16 connection as to your CKB luck, there is a chain in southern region called 49 Do we have seven clinic there is a chain in southern most state in India and Kerala HRMC there is you name it and in India you will find find them mid level change chains. And it just took off. And as I said in 2016 17 16% of clinics were organized part of organized change. But 30% of IVF cycles were done in the organized change to 16% clinic 3% in ownership 30% in cycles at present as we speak 35 to 40% of India's IVF cycles are part of organized chain and the rest 60% is still fragmented unorganized. So starting from zero to 40. It only took one decade.


Griffin Jones  19:42

What do you think is going to happen in the next decade? And perhaps before I ask that you may have answered my question about consolidation but maybe not so 60% of the market is still being done by those clinics, not within a network. In the US and Canada networks are running out of clinics to buy and it's not because they've consolidated all of the clinics, there's still plenty of independent clinics, but there aren't so many 4567 etc Doctor clinics left in the US in Canada that are independently owned. Is that problem on the horizon yet in India? Or do we have a long way to go before we run into the problem of not having enough sizable clinics to buy


Vinesh Gadhia  20:28

very in cushion Griffin again, some demographic detail piece today across the world we talk about India being the growth engine of the world economy IVF is also very similar or even better. India has highest young population in the world. As of 2010, we had 247 million couples in reproductive age, as of 2010, can you imagine in 2020 are expected we still have to do our population census which we do once in 10 year because of COVID. This time, it was delayed in 2020 10 years later expected couples in reproductive ages 434 million from 230 to 47 to 430 4 million. It's a huge demographic shift. Even if you consider same infertile patient, which was recorded and published by Indian government in 2010, acknowledged by EY report in 2015, which is 9% infertility, it has increased in fertility in India, but even if you consider safe from 30 million infertile couple in 2010, we are now 62,000,050 2 million infertile. So, we have a huge demographic dividend ifcn population in the world highest one of the highest urge of parenthood in the world, which is not there in most developed countries in India. I would say 9.9 out of 10 people in their in their young age will get married and nine out of 10 people will opt for becoming parent. It's a societal cultural strength in India that we are very high urge of parenthood. Now, highest in population highest urge of parenthood, but ever changing lifestyle. There is a published study in fertility sharing dream it's an indoor Spanish study done by Nova AV Indian woman peaks fertility potential at the age of 25. Whereas in Caucasian woman, its fertility potential at the age of 31. There is an inherited genetic and difference of six years. Why concerning we used to marry early is because of this. Now, while we try and copy western lifestyle, our genes don't change. This brings very high burden of infertility in India because we are now marrying late in India, copying western lifestyle, whatever genes remain the same. This all put together even if we have 2000 plus IVF clinics now. We do 250,000 cycles in India now, which is number two, number three in the world. We are still under 10% of the real potential so far as the market which looks very big, but we are just taking off. answer to your question. Our cruising altitude or saturation is 1015 20 years away. So current growth in agribusiness is launching new clinics launching new chain every week. We add 60 to 70 IVF clinics every year, which is one clinical week. So consolidation in India as I would say, just from where I am seeing it is just beginning. So we have 1000s of clinic in India to vie shortage of IVF clinics to consolidate or IVF chains to get consolidated. That shortage is 10 years of at least 10 years away. Because we have a long runway in front of us too.


Griffin Jones  24:10

Is it more common to consolidate clinics? Or is it more common to start a clinic de novo if we're one of these six or seven chains? Are we more likely in the course of a year? Are we buying more independently on clinics and bring them into our group or are we creating more clinics de novo


Vinesh Gadhia  24:30

so all the chains today including Nova Indira Mila Apollo 14 Nine PRMC you name all the chains I would have missed a couple of names sir I'm sorry about that.


Griffin Jones  24:43

I do I always miss a couple of names initially I know that a couple people will curse me and and maybe your contemporaries will curse you for leaving them out too but welcome to The Club.


Vinesh Gadhia  24:55

So all of them today are are are launching in you Kleenex organic, because that's that that's enough market for everybody still to be tapped. I would I give you once very small I mean, not inside example. So I am at present working on an IVF platform story where I am in discussion with four or five mid, mid level organized chain to acquire them for the platform. And my strategy is to buy and built by four or five chain that is certify 40 clinics and wait maybe 3540 clinics in next seven a year and have an exit insight in 2030 or 2030 278 years to 10 years of business plan. I think even though I started looking at some assets is they want to add to their portfolio. Choi is Indira and other chain. This has just begun in last I would say sick since 2022. Largely because now there is an ARD regulation in place. So government has passed ARD Regulation Act. And because regulation is enforce many single doctor on clinics believe that it is better to be part of organized network where there is a bandwidth, there is management bandwidth, there is professional handling of all the department including quality departments and audit departments. So that when there is a regulation in place, there is better bandwidth to handle the larger business. Also, it's just last one or two year, most senior doctors are many successful IVF clinics, led by doctors have realized that organized chains are growing much faster compared to single doctor on clinic because of the management bandwidth and because of capability of investment. So they also started believing that joining hands with an organized chain. Current chain is basically a good idea. And it's Win Win partnership for both. So the word consolidation just started shortage 10 years away.


Griffin Jones  27:01

I'm catching my breath because this is a order of magnitude that we haven't totally seen. And when I'm seeing my colleagues, LinkedIn posts of them visiting Indiana I'm seeing this more than I've ever seen it before, partly because no one could travel for two years, but also partly because something's clearly happening in the country. And you're starting to give numbers to that story of what's happening there. How are you getting doctors in the US and Canada people are consolidating, but then they're running into challenges, staffing them with REI, as I talked with Dr. Bheeshma pushed us er in that episode, that's the REI fellowship doesn't exist in the same way in India that it does in the US, but how are you finding enough physicians to be able to staff these programs?


Vinesh Gadhia  27:50

So good. Again, anything you asked to me? I sound very ancient. It's very interesting possibly because I love to speak about IVF business in India. My first designation in an organized chi no IVF was Director Dr. empanelment. Because the my it was the same question. My private equity investor or my board believed that finding the doctor will be difficult. Recently I was working with the art fertility clinics again a Middle East based very high quality IVF chain again backed by a private equity capital. When I was sitting with the board before joining presenting my business plan, the only question was asked to me by the management team of Gulf capital is that from where would you find out? So all questions are similar my answer is very, very simple. In India, they have 40,000 gynecologist for zero 40,000 highest number of medical consultant across the world. We are blessed with talent in our country. Out of these 40,000 gynecologist 10,000 diagnosis actively practice infertility and all of them aspire to become a specialist. In India, we have plenty of organized chains who are doing fellowship course starting from three months to six months to one year to two years. Some very good fellowship course which are led by Milan Dr. Kamini route and led by Dr. Norma the shockcraft. Very very good fellowship course led by EV along with Dr. Banker in Nova. Fellowship courses are done in small chains with mid level change even in 49 Even in Oasis. Now to train a gynecologist who is already doing good level of surgery, incision injections and large endoscopic surgery, on skills for own pickup is if you ask me, I don't know if doctors will like listing this. It's not difficult. It's a three month training. A gynecologist who is already practicing Infertility can be trained to become a specialist. We have enough plenty of one year courses in India. So there there will be no challenge and I'm repeating no challenge in finding good is specialist key like a specialist. Absolute No. The challenge will be in finding right embryologist we never had any university in India who offers embryology nobody in India understood the potential of requirements of embryology which will come money fall. The Health Care Group which I referred before started IVF chain is one of the most reputed medical university they started embryology course, seven, eight, maybe nine years before but they were they were giving six embryos a year now, I think they are doing some 20 or 30. Now, in India, there are six or seven universities who have MS in clinical embryos, but it is thin skin shortage in India. Severe skill shortage is embryologist, not doctors. What can


Griffin Jones  30:54

be done to solve that embryology shortage Can the same solution that was done with the chains themselves starting these three month to two year training fellowships Can the same clinic networks also create the infrastructure for embryology training, because if you're creating at least one fertility clinic a week in the country, and it sounds like with six or seven embryology programs at the university, and maybe a couple others that you're not on pace to fill that clinic growth with embryologist staffing the labs behind them can the clinic networks offer the same training that they did to cover the DR solution.


Vinesh Gadhia  31:37

In 2013 14 we when we were on the journey of a very robust growth in Nova, we realized this challenged that we cannot depend on acquiring empanadas from market. First thing we did was we joined hand with the first university and we used to offer internship course to all the students of Manipal who are passing out MSc in embryology and we used to have the first look at them and do and pick up the best talent from that but that also not enough. The alongwith EV Kochi co curated 180 day course for a master's in life science student whichever which which you can find in plenty in India. And we had 180 days of logbook training program co curated supervised by embryologist from eenie so we created our own bench strength and we never face shortage because of these two things, join hands with universities and took all of them as our intern and absorbed most of them as trainee in our in our clinics and out of our say Soviet 19 clinics one and I when we divested to TPG 910 large clinic can have two embryologist anytime which can be trained in our logbook training program supervised by EB so we created our own band strength in there actually cracked it even better. They have a company training school in their headquarter for Dr. And Mr. Rajesh and they have a crash course of three months. Any ml Masters in Science student can be trained under simulators, excellent training ecosystem, very documented, they churn out their own embryologist and own doctors IV specialists. So two large chain wide Indira cracked it very well. The way forward is either all the chain have there is one clinic as their training training hub, take science students in India, which are available in plenty and trade create a training ecosystem. Second is I mean, I have this dream in my mind that we should have a school of embryology in India having 50 100 students every year of coming from science master's in science and we have best of the minds in the world who can be brought in as faculty and we can develop a very robust training ecosystem in India. I mean, we have students from Oxford University in India, many from Oxford doing MSC Ammirati that we have students from Monash University in India from Nottingham from ICL from UC and you name reputed universities offering MSc in embryology. We have students in India from the who are practicing embryology. So it's high time that in India, we create more infrastructure for embryology training program, which is very doable.


Griffin Jones  34:35

I would say it's high time as well, because there could be another vulnerability that there's already an embryologist shortages in India. But what if some richer countries namely the United States figure out their visa mass that they have been struggling with the last few years? What if they figure it out and say okay, we are going to start taking this seriously and get some more skilled people from the sciences. With embryology being a focus, then you would certainly want to make sure that you had enough embryologist, if something like that would happen.


Vinesh Gadhia  35:08

I think you are giving secret sauce for the US IVF industry. I was talking to one of colleague in IVs business in us about a month before. And I was saying that they keep seeing me that we have a shortage of embryologist in us. And I said if there is a special visa visa for embryologist in the US at least I know 100 People from India will apply. So I completely agree that if this happens, so there are many embroiders in India, who go to UK and to Canada but not in us because getting visa is not east,


Griffin Jones  35:42

our embryologists able to buy into the equity of clinic groups.


Vinesh Gadhia  35:50

Wow. Again, interesting point, which has a strong belief system in India. Now, with more it becoming organized with more shortage, the venue of employees have increased in the last five years recently. Not to the extent of what that they can buy equity or they are offered Aesop's in India still. But I strongly believe that it's not a very fact that this will happen in India, because it was largely a doctrine lead. And now I think, at least in organized ecosystem of IVF the value of embryos this is when understood, still not to the level of being a critic. But


Griffin Jones  36:34

how does the track look for young doctors? Are they buying in at the practice level that the local clinic level are they buying in at the network level are both happening neither happening? What does it look like for young fertility Doc's


Vinesh Gadhia  36:50

a young guy, Nick Norris, who is doing birthing practice does not have work life balance in India, it's a huge business, and potentially very high because we deliver the highest number of babies in the world. So I don't need to dive deep dive into the numbers. There is a current trend in India, which is changing that the young inequalities who are who are passing out, they want, they are the current generation, right. So they want work life balance. So they we have more and more doctors who want to be in IVF rather than going into birdie. and taught them if they want work life balance is a fixed time job. And there is an men management ecosystem. Well, well trained operation staff, well trained nurse so that once the name clinic, they don't have to keep bothering about anything. So the young talent, who doesn't want to be in birding practice, but in IVF, are more attracted towards organist because you have a better work life balance. And you can learn and you can grow in an organization, you can learn a lot of things.


Griffin Jones  37:58

So younger dogs might also not have the leverage or the focus, or there's other things we offer that they're not totally focused on buying in yet. What about those that are medical directors? How are those folks building their career, so you have a number of OB GYN who are just simply happy not to be practicing obstetrics, they're happy to have office hours, maybe make some more and be part of the growth, it's happening within their continued education as well as in the field. But then you're going to have some of those that are deeply entrepreneurial. And they say, I want to start a network, I want to become this chief medical officer of this network, what are their career tracks look like?


Vinesh Gadhia  38:39

So in an organized setup, there is a structure in place where if you're heading a clinic, so in clinic, the the org structure is that there is IV specialist, and there is a medical director, or the or the chief, the cdmos doctor in the clinic. And there are a large change which are shaping up in India. So there are regional directors who look after five, six clinics, they also practice in one of the clinic, and they look after as leader in in five, six clinics, around 10 to 15 doctors, and then there is a national medical director. So there is a career path for a doctor to grow. But at the same time, it's not very clear. It's not very visible. For a doctor to like any other employee visionary, there is a very visible career path. For a doctor. It's not very visible or not very easy to grow in the career. Most doctors in India tend recently believe that increasing that practice and increasing their commercial take home is that growth, not they never look at career growth of handing more clinics or being in leadership position. I would say in the last 10 years it has started evolving, but still it's not very established. So for a doctor if they're doing five cycles, 10 cycles a month, it grows to 25 a month, or it goes to 50 a month. So their professional growth is more work. And they take home more money, rather than growing up in the ladder, that desperation not many doctors have in India,


Griffin Jones  40:16

I can hear a lot of American doctors groaning and saying, Oh, don't worry, nice, you're gonna have to deal with this problem. 10 years down the line when they want all of it and the American doctors that grew up with the career path that you just talked about and worked really hard on it sometimes feel that some of the younger doctors now want to skip that path and move into where they are. So that'll be a barrel of monkeys that comes as part of the fruits of the labor of having a growing market. It's a it's a good problem to have, I guess, because that means that the companies and the marketplace has gotten to a certain point, I want to ask you about other growth challenges. But we've spent a lot of time talking about the clinics, I really wanted to have that understanding tell us what's going on elsewhere in the fertility industry. In India, we talked a lot about the network's coming up, how 10 years ago, they had almost no chair of the market today, they have 40% of the market, there's a lot more growth, there's a clinic happening at least once a week with 60 or 70 a year. But what's happening on the industry side genetic testing lab manufacturing pharmaceuticals, what artificial intelligence other things that I'm not even thinking to ask you what's what's happening on the industry side.


Vinesh Gadhia  41:37

So India, as a country is the to date in adopting new technologies. What has changed in the last five years is adoption of fitness systems by 234 chains in India, which is an onshore alarm systems. Genetic testing in India is a very interesting curve, it's going through a very interesting curve from nothing about five, seven years before. Today, it's about 5% of the cycle, genetic testing. Now, very quickly, I will I would, I would try to address this as a patient if you have for for good quality embryo slash blastocysts. And if you what, what is the dynamics in India, I'm not saying scientifically what is right or wrong. If I if I if I offer patient genetic testing that out of these four, which is the best embryo which I can transfer to you, so that you are time to pregnancy is reduced. And we identify the best genetically the most normal embryo where a patient believes that if you transfer two out of four, if I don't get pregnant, and the next cycle in frozen embryos transfer, you transfer the remaining two. So what is the advantage of going through genetic testing where I'm spending so much of money. So it's difficult in India because 95% patient pays out of pocket and the cost of genetic testing. When we launched the first genetic test India, which was Evie company launched through novice legal entity, it was as good as one IVF cycle, it was very difficult for a patient to spend four to IVF cycle for genetic testing other they will, they will, they will do more frozen embryo transfers. Now the genetic testing percentage is going up, the price of egta is going down once the surprise of PGT even match to the frozen embryo transfer price which is very close now. This will suddenly flip it's a tipping point from the current five 7% of cycles undergoing pcta It will go up to 25%. By next five years is what I believe. Now there are 10 companies who are offering genetic testing. There are good pgti models available in India. And the pricing is going down as the number of testing is going up. We are still about a year or two away from the tipping point is what I believe I keep advising to some large global companies that this is a great business opportunity in India. If you can burn money for one or two year or not earn much one or two year. This one's cake. This is a business of scale. about artificial intelligence. Two companies are launched in India to change they're adopted as a trial method one is embryonic another is nightmarish but I think it will grow it will start going well. Genetic testing artificial intelligence sickness system alarm system, standardized high quality lab protocol I think are now prevalent in most organized CI but it are these are at very different levels. If I can speak at fidelity in India as only six clinics, it is based out of Middle East backed by private equity is at a very different and noon, if you see any arts fertility clinic you will not feel any difference between the clinic in New York, London, Tokyo or India. Indira Noah up to the notch of international standards, other chains are following to that standard. So over on lap parameter quality parameter or standardization, IT infrastructure is being growing very fast in India but led primarily by organized cheats.


Griffin Jones  45:26

What's causing the price of PGA to drop?


Vinesh Gadhia  45:30

It's basically sequential know if you are if you are running more sample in one cycle, it will reduce the cost per sample. I'm not a genetic specialist, but I can in business sense I know I was one of the member who had developed the Strategy Board for first genetic company in India, which was EVs company, it was known Evie omics at that time. Now, it is very popular e genomics, why it's no money the company now show the more tests you do, your fixed cost remains the same. And your consumable costs remain the same. Because it is cycle of sequencing, it will reduce the cost of testing for that provider. So you can offer less cost to the IVF service droid. Are the


Griffin Jones  46:15

networks doing deals with the genetics testing companies to be their either exclusive or the preferred group. And so when you talk about scale, is there a risk that of not winning the scale game because I think of in vitae, closing their fertility division and some of for closing their fertility division. And they talked about lack of insurance reimbursements in the United States. But another thing that people talk about is that they're losing the game of profitability with the MSOs with the network's than the network's are negotiating deals that are ultimately not profitable for most and so they have to lose money, as you said for some time, but maybe they can't do that. Maybe it could could have been the case that in vitae couldn't do that, that semaphore couldn't do that. So is that is it a dangerous game to try to win. And I'm not just picking on PGT companies here, but really anybody that thinks about scaling in this way and thinks about having to lose money for a little time, that's always a risk is that risk greater in India that you you don't actually win and you just lose money and go out.


Vinesh Gadhia  47:32

So, you take example of numbers 250,000 cycles growing at 17 18% CAGR, we will be about half a million cycle in next five year expected to be million cycle by the end of this decade. From current 5% of genetic testing VG da it can go up to 20 25% which is largely still less less less compared to Japan or us or most of the country. The scale is is phenomenon in front of any genetic company now, where if your mix was launched in India, when it was an Eevee company not not invested by private equity after that, it was some private equity now, it is vitrolife company it broke even company level and second year most genetic company in India new companies are also making money even today. So, at 20% more cost per genetic testing compared to a frozen embryo transfer in India 20% More mostly genetic company and making money. What I'm trying to say is there if they bring down the cost and allow the market penetration to go up, and it crosses a tipping point of equivalent cost of frozen embryo transfer, this will boom it will go up phenomenon the company which can do this is Cooper fertility, they are a global company they have about close to a billion dollar revenue now highly profitable, they are still not launched their pgti model which they have launched in Europe and US in India now keep and keeps the question that if they can bring it x price and still either make very less money or no money, if not burn the skin and and tap into large groups who will ready to a pledge X number of testing. It's a good model it


Griffin Jones  49:27

Cooper's not in the business of losing money. So seems like they may not have figured it out yet. And I wonder is there a different model that these companies can do? So they you talked about the scale which is enormous and unprecedented anyplace else in the world? He talked about 243 million people of reproductive age, I believe it was over 50 million people who need assisted reproductive technology. Nine out of 10 of the young people are going to want to have children even at as their maternal age advances so that the scale is there, just the pricing model need to have these networks in place in order to be able to put forth a model that works for them to like, if we sell 100,000x, then the price is a if we sell 100, if we sell 1,000,000x, and the price is B, if we sell 10 million, then the price is C do that, is there a gradient model that they need to be able to work on in order to be successful? And do they need the networks to be able to do that?


Vinesh Gadhia  50:34

I think what you're seeing is is very right, at just let's take an example. Today, the one of the chain, which which say for an example, I'm reading a chain, it is doing 5000 cycles, IVF cycles, and we are doing genetic testing of two or 3% of patient at x price, I can go towards genetic service provider that at why price this to 3% Can I can pledge 10%. And there are five chains who can come together to work on the table, and pledge, all put together a huge number of genetic testing in one year, which is more than the total country which is doing a survey spread provider, a global service provider, it's a very good business model. It will help industry to do more testing, it will reduce time to pregnancy, it will reduce the current abortion, it will improve results. And it will help industry both the base and then I think there is no written it's a it's a it's a patch which will then go robust towards growth.


Griffin Jones  51:36

But as you've been a wealth of information during this conversation, you walked us through some of the history of consolidation in India, the formation of networks, the early days with private equity, the training of fertility doctors, and somewhat and soon to be more so embryologist, the expanse of the demographics the expanse of growth from clinics, you talk to us about the scaling potential that industry side companies have PGT just being one of those examples. How would you like to conclude with our audiences, mostly US based but it's increasingly global increasingly from India as well? How would you like to conclude about your prospects for the future of the marketplace?


Vinesh Gadhia  52:24

So Griffin I really strongly believe and I think everybody in the world that would have to have a great business. What is required is right market condition. Right capital, right people? Right? I don't think timing can be better than this in India. It is yeah and population one of the highest urge of parenthood changing lifestyle and increasing infertile patient in vignettes all want to become parrot timing is right. There is no shortage of global capital investment in India in sunsense sector like healthcare and IVF. We have enough talent in India accepting embryologist. I mean at 250,000 cycle number two number three in the world in India is on firm track to become fertility treatment capital in next two to three years.


Griffin Jones  53:12

I hope we get to have you back on a couple of times during those 10 years the nest Gadea thank you so much for coming on the inside reproductive health podcast.


53:22

You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health

169 When Embryologists Own Equity. With CARE Fertility’s Chief Scientific Officer, Dr. Alison Campbell

It’s uncommon for an embryologist to own equity in a clinic-lab company, at least here in the US. This week, Griffin hosts Alison Campbell to discuss where her career started, and how she earned her current role as  equity stakeholder and business influencer as the Chief Scientifc Officer of the UK’s largest fertility care provider, CARE Fertility.

Listen to hear:

  • What it is like when an embryologist becomes an equity partner of their group or practice.

  • The unique advantages a lab director can bring to the practice.

  • The potential for fertility clinic networks to become early stage investors in fertility startups 

  • The differences in opportunities for embryologist education opportunities between the US and UK

  • Dr. Campbell’s viability test for companies that want to sell to CARE Fertility. What the 3-4 who advance to demo do to get there.


Dr. Campbell’s info:

LinkedIn: https://www.linkedin.com/in/alison-campbell-85669831/

Website: https://www.carefertility.com/


Transcript


Griffin Jones  00:03

What perspective are lab directors able to bring to a partnership that might not be there otherwise?


Dr. Alison Campbell  00:19

Well, the lab director role is critical in terms of the quality of the embryology practice. The services offered the standards in the laboratory and also the efficiencies of for laboratory. And I think as a an international profession, embryologists are quite collaborative. So I think we're important in that we can set up collaborations and there are examples of us doing that. And on an international scale. So I think that brings a lot of synergies across the world. And it brings better standards and treatments for our patients.


Griffin Jones  00:57

That folks, you too can own a piece of a company we almost never talk about that on this show. We talk about partnership for physicians, what they have to do in order to be able to own equity in their practice groups. We talk about entrepreneurs and the importance of owning equity. We almost ever talk about that in the lab context. I have had Bill van Juran from Fertility Center of San Diego, who owns part of that group. But we have almost never explored this option that changes today with my guest, Allison Campbell. She's the Chief Scientific Officer for CARE Fertility. It's the largest fertility group in the UK, Dr. Campbell got her master's in medical science in art back in the 90s from the University of Nottingham, and a few years back, she got her PhD in developmental biology and embryology from the University of Kent. She started off from the inception of care fertility in 1997. And now is their chief scientific officer, as they are a much larger group financed by private equity through Nordic capital making their first acquisition into the US. We talk a little bit about that we talk about the what it's like for an embryologist to become an equity owner in their company. Whether it's the practice group or the lab or the umbrella company that joins the two, we talk about the advantages and ideas that a lab equity owner might be able to bring to the practice. In the case of Dr. Campbell, it was time lapse imaging all the way to the artificial intelligence program that Kara fertility is using now to automate their workflow reduce time, and ostensively improve outcomes. For you folks that are on the startup side, we talked about what it's like for companies like care to actually be investors in the early stages of these IVF lab startups. And I suggest a possible infrastructure for that, like how US fertility has and I ask Alison, her perspective, as someone who is called on by many of you companies trying to sell to her to her peers, both at her company and other places, she suspects she gets about 20 requests for demoing their product or service over the course of a year. And then she might actually demo three or four of them. We're not even talking implementation. We're just talking demoing, maybe three or four out of 20. I asked her what those other 16 or 17 don't have, and hope you're interested in her answer and that you're interested overall, in this interview with Dr. Allison Campbell, Dr. Campbell. Allison, welcome to Inside reproductive health.


Dr. Alison Campbell  03:26

Thank you. Thanks, Griffin. Nice to be here.


Griffin Jones  03:30

I explained just before we started that you're one of only a handful of guests that I've had on from the UK, and I hope to have more. You are the chief scientific officer at Care Fertility, which, if I understand correctly, is the largest fertility provider group in the UK. And can we maybe start with just how did you get to that position, give us a little bit of background on how you came to where you currently are. And then I want to ask you some questions about the future of the lab and the marketplace on the other side of the Atlantic.


Dr. Alison Campbell  04:06

Great. So yeah, well, I was a very ambitious young scientist, passionate about embryology and fertility. And back in the early 90s. When this when I was in my early 20s. There weren't really many opportunities. There certainly weren't many degree courses that specialized in embryology or clinical embryology and IVF. So I managed to muscle my way in to a small IVF clinic in Nottingham, with Professor Simon Fishel and then I did the master's degree in assisted reproduction technology. So that was the first the worldspace master's degree. So from there, a few of us broke away and set up CARE Fertility. So that was 1997. And we've just grown since then. So I was a regular embryologist became a lab director and then group lead as we got more clinics, and then I was appointed Chief Scientific Officer last year.


Griffin Jones  05:07

It was the world's first master's degree in embryology at that time, was it specific to assisted reproductive technology? Was it in more general embryology what type of master's degree was it at the time?


Dr. Alison Campbell  05:22

Yeah, it was a master of Medical Sciences in assisted reproductive reproduction technology. So very specific, very human focused, of course, we stood animal models and, and the practicals often included animal models, but it was focused on human embryology and assisted reproduction. So it was perfect for me.


Griffin Jones  05:44

So you were part of the group that formed CARE in 1997, you were named Chief Scientific Officer last year, it sounds like a lot of growth in the last two and a half decades. Tell us a little bit about that.


Dr. Alison Campbell  05:58

Yeah, and lots of growth. So we had a bit of a growth spurt early on and say in the first five years, we, we had four or five clinics across the UK. And then we sat tight for a while, and then private equity got involved, and that was silver fleet. And we started to expand get more clinics in the UK and into Dublin, Ireland, then we sold on to Epson, it's for silver fleet, when and Bo Mark capital. That's right. And then last year, Nordic capital took over. So now with Nordic behind us, we have plans for internationalization. And we have recently merged with IDF life in Spain, so three clinics in Spain, and also in North Carolina, USA.


Griffin Jones  06:55

Part of the reason that you and I became connected was because my company covered a story on care fertility is acquisition of rich fertility in North Carolina. And so the biggest group in the UK coming to the US, I didn't write the article, but I read it. And that's part of how you and I became connected. But even before that, someone told me to speak to you. And it was someone from the UK. And they mentioned to me that lab personnel lab directors tend to be more involved in the business of the fertility groups in the UK than is the case in the US. And there are a few exceptions. In the US, there are a few lab directors that are part owners are partners in the clinic in the entire or the parent company that owns both the clinic and the lab. But I can only think of a handful. And so is it the case that there are more lab directors that are partners in their firms in the UK? And was that the case for you?


Dr. Alison Campbell  08:07

Yeah, it was certainly the case for me right from the beginning. And I negotiated my way in, I felt I had a lot of value to add. And and I'd say it's not especially common, but there are a few examples. In Europe. We've got Laura, for example, at Janiero life. So she is a stakeholder shareholder. And so there are a few examples. And I think it's really important I think we have we can earn you and that's we've demonstrated, and also in the UK, which doesn't seem to be the case, in the US at least. embryologist can have a significant professional status we we can qualify to be comparable with our medical colleagues. So I'm a consultant embryologist. So it's a membership of the Royal College of pathologists, which gives us parity with our medical colleagues, which is not possible in in many places. And I don't think that's possible in the US. So I think that helps


Griffin Jones  09:07

parody, in what sense


Dr. Alison Campbell  09:10

in terms of qualifications and consultant status. So it's, the Royal Colleges were traditionally established in the UK for medics, but we got into the Royal College of pathologists as a profession some years ago. So it's quite rigorous assessments and portfolios and then to be used. But if you get to that, then we are of equivalent standing in the eyes of the utility in the UK at least.


Griffin Jones  09:41

You talked about it being valuable to have lab directors as partners in the business. What perspective are lab directors able to bring? To what perspective are they have directors able to bring to a partnership that might not be there otherwise?


Dr. Alison Campbell  10:04

Well, the lab director role is critical in terms of the quality of the embryology practice, the services offered the standards in the laboratory and also the efficiencies of for laboratory. And I think as a, as an international profession, embryologist are quite collaborative. So I think we're important in that we can set up collaborations and there are examples of of us doing that. And on an international scale, so I think that brings a lot of synergies across the world, and it brings better standards and treatments for our patients.


Griffin Jones  10:43

It's funny to think of embryologist, lab directors not being a part of the business ownership, because it's half of the process. It as you when you ventured into this partnership, how did you undertake that. So the common I don't want to say, I'm thinking of a particular word that I'm gonna have the editor edit out my, my fumbling here, Alison. But there's a common axiom among physicians that we weren't taught business in medical school, and that we had to figure this out, all on our own after. And as I might make the assumption that that was the case, in a master's degree in human reproduction, that you weren't learning about income statements and bit and Mark sales and marketing and human resources and every other thing that is required in owning and managing a business. How did you decide to take you said that you negotiated in early on? What made you feel that you could do that? And what did you do to start to go through the learning curve?


Dr. Alison Campbell  12:07

Yeah, that well, it's a great question. And and I think we've got to say that successful businesses and management teams need all different skills coming to the table. So not every clinical embryologist has the same skills that I have. And I don't have all that business acumen necessarily that has been taught. So some of it comes naturally. And I, I had, I felt I could bring innovation and ideas. And I had a track record of doing that. So that clearly answer value. So I think that it's, it doesn't have to be to have to be an equity and stakeholder to, to bring that to the table. But I felt that I could and I should be rewarded for that. And I think it's really important for our profession to have people at that level to champion that what we're doing as a as a discipline, because the work is really demanding, we know that there's a lot of stress in healthcare generally, and particularly in the IDF lab. The work that we do is very intensive and it's very valuable. We've got to be focused all the time to give our patients the best outcomes and and we need to be rewarded for that.


Griffin Jones  13:27

I want to plant some ideas in younger embryologist said right now that this is a possible career track for them. It is clearly possible in the UK and even though it's not common in the US it does happen there know about every country for every audience member listening, but I want to plant a little seed in young embryologist mind that this is a potential career path for them. What did you find to be the steepest part of the learning curve of being a partner?


Dr. Alison Campbell  14:00

What it is, is talking the language of business I find didn't come especially naturally. So just being put in front of a board or when we were going through the sales to be in those management review those meetings were you talking to potential buyers and, and private equity to get involved with that was challenging, I would say for me personally, and because of my background, but I was there for a purpose, which was to be able to explain some of the great work that we're doing and some of the ideas we've got and the value that we can add to the business. So as long as I've got the right content beside me together, that that's not a problem.


Griffin Jones  14:40

Did you seek out any particular mentors? Did you take any courses? What did you find most helpful in getting up to speed?


Dr. Alison Campbell  14:51

I have quite honestly I'm quite an independent person. And I've read a few books blackbox thinking and so what's your view Few TV shows. So it's more of seeking out information that would I felt would benefit me personally in that arena and and talking to colleagues. But there aren't that many that I could liaise with that sort of directly relate to my position. So, in terms of clinical embryology, so I was talking to my business colleagues, the finance team, and and just learning from each other as I've gone along, I don't forget much. So I, I collect information and experience as I go along. And I have done all my career, which is more than 25 years now.


Griffin Jones  15:33

Well, now lab directors that are looking to take an equity in their company young embryologist are considering partnership in their practice lab companies as an option now they have you to consult with they have someone that has, has gone through this before. So they do have a colleague to liaise with Now you talked about some of the ideas that you had in the beginning that as a, as a senior embryologist to lab director that you had some ideas to bring to this new venture? What were some of those earlier ideas?


Dr. Alison Campbell  16:11

Well, probably one of the best examples would be 2011, when I started to see time lapse imaging, arriving on the scene, and it's not, it makes it easier. If you're in my position and you have a big group of clinics, then you don't have to be as active to seek out possibilities and collaborations because people will come to us, which which makes things a little bit easier. So in terms of horizon scanning, a lot of that words done because people are seeking us out before we sometimes have seen what's what's coming. So time lapse was one of those examples. So I have knock on the door. And straightaway, I could see the potential. And there were lots of cynics, even my seniors at the time, well, is this is this really just pretty pictures? Or can we do something useful with it. So I had to fight really hard in the early days to get that established. But we did and we introduced it across our clinics. With military operation, I would say it was so an rigorous the way we implemented it, because I could see the benefit of analyzing these time lapse videos, which are taken of every embryo every 10 minutes or so throughout the whole culture period. So the distinction between that practice and standard embryology which is still in place in many labs across the world, it's the normal waited to do IVF. The difference was dramatic. So you can either have a couple of snapshot images or records of your embryos developing, or you can have a continuous live feed of the embryo development, which at that time in 20 lavena, we didn't really understand. But if we approached it like we did, and we annotated very particularly what we were seeing, and we would collate an extensive database, and be able to use that data to develop algorithms to predict outcomes. So where we are now fast forward to 2023 is a live birth prediction algorithm based on all of that data. And that was about half a billion single images of embryos. So 10s of 1000s of embryos and half a billion images, we have put into this machine learning system and developed an algorithm to automatically annotate those embryos now, so that's a massive time savings for us, and to predict live births, so we can select embryos more reliably. So it's it's been a huge success story.


Griffin Jones  18:53

I want to talk more about that predictive algorithm. You don't have to do all of the horizon seeking because being a large group, people are coming to you. And I'm assuming that that means the folks that are in the booth set the entries and the ASRM that the folks that are selling their services, they're of course, calling on you and they're calling on you pretty aggressively. And so you have lots of solutions being pitched to you at different times. And you saw the value in time lapse imaging early on. You mentioned that some of the seniors were skeptical at the time. And I think this is germane to the conversation for embryologist that might become partners that might become equity owners in their parent companies. Because especially if they're the first they are going to be seeing things that perhaps the clinicians aren't seeing and they're going to have to be persuasive. So what were they cynical or skeptical about? And talk us through how you persuaded them


Dr. Alison Campbell  20:00

Yeah, that well, the cynicism came around, it's a new device, it's really expensive. And we know how much she loves embryos, Allison, you just want to watch them all day and all night. So that was the challenge. And, and they weren't the only people saying that. And a lot of people were saying, well irregular incubator costs five to 10,000 pounds. And this device costs 5060 70,000 pounds. So really, it's how can we justify that. So we had to have the foresight to say, Well, if we have these devices, and we develop algorithms, we'll be able to sell the spaces in this time up device to our patients, and improve their outcomes and give them videos of their developing embryos. So they can start their baby album much earlier. So all these different benefits. And there's the theoretical benefit that even without the algorithms and the data, this device will be a better incubation environment, because we don't need to disturb the dishes with the embryos. So they really say and that the environment is discontinuous and maintained. So I had to be really tenacious, when I'd never really done a business plan before. So I had to rely on the company who wanted to sell a device to support me with that, and negotiate getting some free devices in for a period whilst we evaluate to make sure it does what we expect it will do. So and then we did that relatively quickly. The the chief financial officer actually said, over my dead body Campbell, will you have one of these in your lab? So that made me grit my teeth and say, Alright, I'll show you. So yeah, we did. And now we've got more than 20 of the devices that come solo on laboratories and every day of the week, we're using them to select embryos more confidently, and you didn't you


Griffin Jones  22:01

didn't have to kill the chief financial officer to prove the point.


Dr. Alison Campbell  22:05

Exactly. Then we stayed friends.


Griffin Jones  22:09

At You talked a bit about a trial period for evaluation. And that might be part of the question that I have of, you're seeing the value of time lapse imaging on the horizon, you and then at some point, we get to a military operation in terms of how rigorous the implementation was. Talk to us a little bit about the the trial period in that it very often doesn't go from salesmen come to us, they've got the device, they've got the solution, and boom, it's in the network, just like that. What was it tell us a little bit about how you prove the concept that it could be implemented at scale? Yeah,


Dr. Alison Campbell  22:55

so we got the device probably on the scene or return arrangement and the three months and then I pushed, pushed it to six months. And I thought, well, the quickest way to get some data would probably be through the PG, PG PG ta cycles, because we've got outcome euploid, or our new quota, that binary outcome, if we wait for clinical practice or live births, that's going to take us too long, and the clock's ticking and a need to show the benefit soon. So with only 100 embryos, we'd started to build a an aneuploidy risk classification model, which we then validated on some different data, and it seemed to be effective. So I published that quite quickly. And so already, we could show that we could distinguish embryos that were euploid or aneuploid. Based on them. Morpho kinetics are based on the time they reach different cell stages. So that that was the strategy and and it worked, because we could demonstrate that quite quickly. And so based on that, we invested in more devices and built the datasets. And recently, we're Nordic capital. I've been amazing last year and invested a lot of money in machine learning technology so that we can automatically annotate these embryos rather than sitting like we have done for almost 10 years, annotating the videos.


Griffin Jones  24:22

And all the while the company care fertility is growing in the United States, and probably everywhere else. There's great variance to how much certain partners are involved. I've worked with practice groups where all of the partners are involved in every decision. I've worked with large practice groups where they break up their partners into different committees to be responsible for I've worked with practices where really the managing partner is calling all of the shots and the other partners don't care. And I shouldn't say they don't care, but they're not involved in a lot of the different verticals of decision making in the business, be it HR marketing or purchases or anything else. And I suspect that variance would be the case as we start to see if and when we start to see more embryologist becoming equity owners. For you. How involved were you in the growth of the company geographically in terms of we should go into this market? This we should consider taking on this group? Was that something that you were focused on? Or were you focused almost solely on building out the lab capacity?


Dr. Alison Campbell  25:45

I was I was involved in terms of being aware of the conversations being aware of the work that was going on by external parties to to understand the markets across the world and where our best opportunities might be. And I could contribute in a way that okay, I know that lab, I know those people and in that clinic, and I've heard is quite anecdotal, and just just general industry in Tao was quite useful in in some occasions, so about the rules and regulations in different countries will make a difference if we've got these products, and we're big on donation. Well, in this country, donation isn't legal. So if those sorts of bits of information that I could contribute.


Griffin Jones  26:31

So at the time, were you under, at the time, in 2011, perhaps was there different rules in Ireland, with perhaps EU guidance than there was in the UK? Or at the time was the UK under the same EU guidance? What was the variance going from country to country in the beginning?


Dr. Alison Campbell  26:56

Well, with Ireland and the UK, we were both were under the EU tissues and cells directive. But that was quite differently interpreted by the UK regular regulator, the hfpa. And the Irish regulate to the Irish medicines board as it was then. So the focus, at least in the UK was more about patient consent and, and quality of treatment and information provision. It's much broader than that. But basically, whereas in Ireland, it's all about the safety of the tissues and cells. So there was quite a different emphasis, even though the overarching rules and regs were similar. But we managed to navigate our way through that, and it's worked out really well.


Griffin Jones  27:41

Do you now have to do the same thing with Spain and the United States?


Dr. Alison Campbell  27:47

Yeah, we have to understand that. Yeah. The backdrop the regulatory backdrop, and the treatments that are permitted to be offered. And we need to understand how how they do business in Spain and how they do business in the US and and try and find synergies and yeah, so it's an exciting time.


Griffin Jones  28:07

What differences are noteworthy, in your view


Dr. Alison Campbell  28:10

noteworthy differences? Well, one, one is with Spain and the UK, in Spain, surrogacy is illegal. So that's a big difference. And donation of gannets is anonymous, in the UK and not in Spain. So they are quite different. So there may be synergies there. There are UK patients, many UK patients go overseas for treatments for various reasons. One being that they don't want to donor anonymity. So there's a possibility of synergies there. So it's all of those sorts of things that we need to get our heads around. And we do that as part of the due diligence. But now we're really early days into the integration. So we're, we're looking at all of those things now.


Griffin Jones  28:58

So that could be one difference. The word Anonymous is all but void from the nomenclature in the United States. In fact, I think if you say anonymous donor at SRM Summit, someone from the legal professional group will jump you. It has been ingrained in us the last two years that we no longer use the word anonymous to describe donors that the realities of genetic testing of consumer genetic testing of ancestry.com and 23andme and the combination of that with the prevalence of social media has all but completely wiped out the concept of anonymity. So is that still part? Is it still in the legal and common nomenclature in reproductive health in the UK to talk about anonymous donors?


Dr. Alison Campbell  29:58

It is yeah, on We probably use non identifiable as more commonly in our, in our patient communications and our documentation. But it's a it's an interesting year this year is now the first year that children from donation 18 years ago, they're becoming 18 years of age and they can now go and find out some information about their, their donor that was used to create them. So it's not entirely non identical, but at least at the time of treatment, it currently it has how it is it's not identifiable. But once the child gets to 18 years old, they can find out identifying information on the top 10.


Griffin Jones  30:44

So that's a difference been in the United States and one that you'll share. see plenty of now that care fertility is in North Carolina in the United States. And I read in the article that one of the reasons talked about the generals shortage of embryologists and I saw that you all have an academy for embryologist and I thought that might be part of the solution. But I wondered, does the UK not have the same shortage of embryologist that that everywhere else does, it seems to me like they had. And so do you have the same shortage of embryologist as other parts of the world have seen? And tell us a bit about what you're trying to do to solve it?


Dr. Alison Campbell  31:32

Well, yeah, there is considered to be a shortage of clinical embryologist. But there are several training routes that in the UK that embryologist can follow. So in terms of the government, the national training scheme that the scientist training program, the places are quite limited. And so and that's a three year master's degree part time with a clinic with an accredited laboratory and all on the arteries of our accredited for this STP training. But there are limited places so we can also train embryologist slowly through a six year route to get state registered. It's so there are structured training schemes. So I am not personally concerned about a shortage of the workforce going forward. And we've also established a master's degree ourselves. Last year it was launched. And in the year actually, by coincidence that the world's first master's that we talked about that I did start. So when that was good timing ready, so we can continue to offer a master's degree training. So I don't think we've got a big problem in the UK, it just seemed that in the US, there is a big shortage, probably because that first generation of embryologist that stayed with the in the field. And there hasn't been a great transfer of information and responsibility. And there hasn't been any false structured training programs that have brought the next generation on at the pace they need it to be brought on.


Griffin Jones  33:05

So are you bringing some of the folks from the US over to your program in the UK?


Dr. Alison Campbell  33:11

Well, that's that's a distinct possibility. Yes, that's what I would like to do bring them over to our masters and chair training facility, and they can neither have just personalized training. It depends what they need. So I'm looking into different opportunities to bring people over from the US to answer and also to send our guys over to them. Because as long as I can demonstrate their qualifications and competency, which I can, then they could work under a lab director, we know IUs lab.


Griffin Jones  33:44

Are you looking at the possibility of doing that with embryologists that come from groups that are not care owned?


Dr. Alison Campbell  33:53

Well, yeah, our training courses are open to anybody really around the world. So that's absolutely a possibility. It's more difficult for us to send our trained embryologist into other US branches to work unless they're part of our company. So we're exploring the visa situation, which is a bit of a minefield at the moment. So we're exploring what what that might mean, but I don't envisage we will be able to send trained scientists all over the place. It's just into our sister clinics.


Griffin Jones  34:27

Yeah, but that's a barrel of monkeys. So I want to talk about how you decide to implement some of the solutions that you see on the horizon. I'm hoping that I can get an answer out of you that is a lot more specific than what we look at the solutions that are out there and we choose what is ultimately going to be best for outcomes. I would like to get an idea of your vetting process because there's gonna be a lot of people listening to this episode from genetics companies from lab equipment company is from people that want to sell to us specifically, and that want to sell to your peers. And I would love to give them a little bit of insight into how your vetting process works. Because I walk the booth section, the exhibit, section it all of the conferences that we go to, and I see a lot of great solutions or seemingly great solutions. And I see a lot of them struggle with getting adoption and with being able to sell into groups. And so part of the reason is because you have a system in place, you're you have plans, and perhaps not everybody can add the value needed to be added at scale. Talk to us a bit in the level of detail that you can about how you that new solutions that are coming on the marketplace.


Dr. Alison Campbell  35:57

Yeah, and there are so many, so many new solutions, so many startups, so many AI products, lots of different automation products, the cloud. And so how would you bet them? Well, ideally, I want to get my hands on it. So I want to demonstrate that it works in our own hands in our own laboratories. So it depends how far developed it is. If it's sort of still a prototype, then I have to use my gut most often and think, right? W this has potential, would we get a return on investment if we invest time, and potentially money and resource into this, this new device or whatever it might be? So lots of questions, depending on the stage the product might be at, but certainly want to demonstrate in our own hands wants some evidence that it's reassuring that that is going to work. And then we'll have a play with it. So we can either do that in terms of just an evaluation quite rough and ready, just yet some user feedback, is it saving your time? Is the protocol easier to follow them? Do we like the suppliers? Are they supportive? Or else we could get involved in a clinical trial? Which is also interesting, but what's in it for us short term, medium term long term, if we get involved? Is there an equity stake possible it's a startup? Do they really want us to put effort into it and and support them beyond their scientific training board. There are lots of different ways that we think about it. But at the end of the day, we need to make sure that these potential new products or services that we're buying, are going to add value. And we're going to get the return on our investment, it's going to save time, it's going to make life sweeter or simpler in the laboratories. And most importantly, it's going to improve outcomes. Even if we're talking about marginal gains, any improvement, we want it. So that's been in a nutshell, what I would be thinking


Griffin Jones  38:05

do you can you possibly quantify even in the ballpark? How many requests you get in a given year for you or your team to demo a product?


Dr. Alison Campbell  38:19

Probably 20.


Griffin Jones  38:23

So that's plenty of those 20 How many? Do you think that you actually go on to demo not even implemented scale, but just demo?


Dr. Alison Campbell  38:32

Probably three or four?


Griffin Jones  38:36

What did those three or four have that the other 17 or 16? Don't.


Dr. Alison Campbell  38:44

They? They have either phenomenal testimonials from people that I would trust. And they potential to save a lot of time, their potential to improve outcomes, or the potential to reduce costs.


Griffin Jones  39:10

They all say that they have all of those things settle down. I'll say we will save you so much time it will save you so much I've got and we're going to improve outcomes. What is it about those that are and we're not even at the implementation phase yet? What is it about those 16 or 17 that they they might fail to convince you that they have the ability to save time and cost and improve outcomes?


Dr. Alison Campbell  39:42

Yet well there's absolutely lots of smoke and mirrors and you see when you walk around ashtray often these big banners Oh, this is the best new thing. It's great. And when you dig deep, there is nothing to see it's just somebody's idea. And it's it's very premature. So a lot of them I find all Perimetry law. And so I decide whether to stay in touch. Tell me where you are in 12 months time or go away? I'm sorry, we don't have time to spend on this at the moment. So very polite, but some. Yeah, it is difficult. There's a lot of, there's not a lot of substance behind many of the products that are offered to us to evaluate, they may not even be physically ready. So it's is we have to do it as efficiently as possible, because it does take time. We need information. We need quick meeting facts, figures, and, and timelines and take it from there.


Griffin Jones  40:39

It sounds like how far advanced the concept is, is a predictor of how likely they are to to be taken seriously and be demoed. For those that are still very premature. What is it that they're trying to get you to do? Or they're trying to get you to be their guinea pig in some way? What is it that they're trying to get a group your size involved in? If they're not ready to? To provide the solution? What is it that they want you to do?


Dr. Alison Campbell  41:14

Well, often they want guidance. I think they want markets in towel they want they just want to test the water. Are we heading in the right direction? Is this a good idea? There's sort of free market research, I think is often what they're trying to get


Griffin Jones  41:31

it Yeah, that makes sense. A little bit of free consulting and some of your intelligence. Tell us a bit about when it makes sense to to take equity, because I think that could be a useful solution for some of the groups and of course, any entrepreneur has to decide, is this something that we actually want? Are we going to do a fundraise anyway, and it could make sense to have one of our potential customers be our one of our investors? They have to make that calculation on their end, on your end are that not not speaking and you personally don't even care fertility, but more broadly on the fertility companies that fertility clinic network with fertility lab network? side? When does it makes sense to take equity in a potential lab startup?


Dr. Alison Campbell  42:30

Yeah, well, it's a good question. And I've spoken about it like it's something we do every day of the week. And we really do not, there are not many examples of us doing this. But I think it I imagine it isn't now hooked. But I think there's, I think there's something really, that this has potential. And I think, as we get bigger, there will be more opportunities to work like that. And, and more synergies. So I think cam in the one example that I can talk about, without naming too many names, is, yeah, it's a new technology. And we're involved, it was a small local company that I thought had a great idea wasn't gonna cost us very much. The equity wasn't free, which I think in some cases had been negotiated because of how much we could bring to the table, the know how, and the expertise and the trials and all of those things. So I think that's something where we could explore it with you potential partners. But in this case, and we made a small investment, got a small bit of equity, just to show our commitment, and to support this, this small startup in getting what they needed to get, and keep going. So yeah, I think there are many different ways that we could approach this. And it's about what you bring to the table and what you're prepared to dedicate to a new potential product. We have. There are owned products, a few of them, and it could in this automated annotation. And we have been talking about potential commercialization and potential partnerships. Because we've got the product we've invested in it, we've we've used a lot of scientific knowledge and data. And that's our contribution. And it, it's our IP, that if we were to commercialize it, then I could see advantages in finding a partner with the know how to, to do that to not just to sell it and to distribute it worldwide foot to certify to regulate it to get it accredited as a medical device, which is effectively what it is.


Griffin Jones  44:39

In that particular case. Did you find it interesting that they were pitching you their product? And you all found it interesting enough that you wanted to invest a little in it or did they approach you to invest in take some equity in the company?


Dr. Alison Campbell  44:57

Well, the the first approach was not we didn't discuss equity, it was just getting to know each other looking at the product thinking of the potential. And then it was probably my idea to say, right, well, why don't we talk about us being a shareholder in your company, because we were prepared to put a bit of time and effort into this and, and show that we should be your exclusive partner had the time being so it was that it was a bit opportunistic, I'm honest.


Griffin Jones  45:26

I wonder if that opportunism is going to be something that we see a lot more of from fertility networks, from management service organizations, and maybe even something that you end up leading for care fertility in, in the United States, you're now contemporary us fertility has an innovation fund. My friend, Dr. Eduardo Harrington, is the director of that fund. And I don't know if it's just Angel seed money, rounds, but they they have a fun for this type of thing. And I could see that being adopted from a lot of different networks. So we are an early stage company, and you're looking for us to bring your market to scale. Oh, you're trying to get some free market research for us? Well, maybe in exchange for this, and they have an ecosystem for this care fertility have that E N any of that ecosystem? Now? Is there any plans to to build it? Or is this a seed being planted that maybe we have a very different conversation here from now?


Dr. Alison Campbell  46:36

Well, we have a Research and Innovation Board, which discusses all potential opportunities. So it's quite a senior, he's very senior board and with the director of clinical governance, and


Griffin Jones  46:49

but do they have a fund of here's how many millions of dollars we have to be able to take equity in different companies that and a term structure for here's the rounds that we buy in, under what terms? Does that ecosystem exist yet?


Dr. Alison Campbell  47:04

Not yet. No, that's not not that sophisticated, yet.


Griffin Jones  47:09

You're welcome care of fertility, even though you've probably there's probably been lots of discussion of it at some level or not. I'm gonna pretend to take credit for it here from from a single podcast episode, whether anyone believes that or not is is up to them. I want to talk a bit about the solutions that you're now implementing, which have to do with the predictive algorithms for live live birth. Tell us more about that. And how did it come to be and what's coming next.


Dr. Alison Campbell  47:46

So we've we're on version six of our predicted algorithms, we call it care maps are they the maps stands for morphic genetic algorithms to predict success. And it's built on 1000s of embryo transfers, where we know the live birth outcome positive or negative. So it's very predictive of life birth, so it ranks embryos, it gives them a score of one to 10. If you get a score of 10, your chance of live birth is approaching 60%. And then the scale goes down to a score of one you like birth chances less than 5%. And remembering that lots of embryos generally look very similar. So we've got these scores that absolutely helpless, choose the best one first time. So it's an amazing tool is sophisticated, and it's automatically generated now, so takes seconds to get this information on each embryo. So going forward, we've automated the annotation element, we're still using a statistical prospected me validated algorithm to generate the score go forward, we are likely to make this more accurate and sophisticated, maybe implementing more artificial intelligence to give us this accuracy and speed, because we've got the data. So it is an exciting time, everybody's talking about AI. And then I'm really proud that we've got our own tool that is AI based. And we now need to try and see whether it's effective outside of our group, or our UK group that trained this model. So we can get take it to reach we can take it to Spain, and we can start to understand whether it's transferable or if we need to calibrate it, which is it's possible, calibrate it for different clinics. So loads of work still to do on that. But yeah, we're ahead of the curve, I would say.


Griffin Jones  49:43

Whether it's this tool or whether it's other technology in the lab, I often ask people, What do you see as the biggest changes happening in the next five to 10 years in the lab? I don't want to ask you that. I want to ask you shorter term. What do you see as the biggest change? judges in the next 18 to 24 months in the lab,


Dr. Alison Campbell  50:07

that I will, it will be artificial intelligence, directing what we do directing our choices, directing which gametes should be used, are going to give us the best chance how we should time, everything. So, all of that data, it's all about the big data we've been collecting over the last 20 years, and some more rigorously than others, but that data will inform exactly how we do what we do and when we do it. So the time intervals between each of the procedures could be optimized, based on this data based on the evidence we've collected with this data. So I think there's gonna be a lot of that coming out in the next year or two. And, and it's all good because it's going to make things much more automated, and efficient and effective. Everything checks a lot of boxes.


Griffin Jones  51:02

As it does as it makes the workflow more automated, as it makes decision making more efficient as it improves the time intervals required to devote to the embryology process, as and after it does those things. What does the role of the embryologist evolve into?


Dr. Alison Campbell  51:27

Well, lots of embryologist saw getting a little bit nervous about robots taking over. But I don't I'm not concerned about that. I think we're always going to need embryologist we need the scientific inputs, we need the personal communication to some extent with the patients. And that's not going to go away. I think the embryologist lines should get simpler and easier with these new tools and algorithms and automation systems. So I'm not worried about that, like some people aren't. And I think we just got to embrace it. Because we want this continuous improvement. We need the efficiencies. And we need the results.


Griffin Jones  52:08

Dr. Campbell, you've given us so much in this episode, I wanted to even unpack more. But there's so much that we could happily invite you back for a second episode for you talk to us about partnership track or embryologist and lab directors, which is something after 170 Odd episodes, whatever it is that never talked about. We've talked to us about technologies emerging in the lab from time lapsing more than a decade ago to artificial intelligence. Now you've given great coaching for those folks that are trying to sell into the lab. And you've given us something to think about in terms of different geographies and regulations as groups expand, and how we steal and use embryologist in different places. I'm going to let you decide which of those threads or anyone that you want to use as an umbrella for all of them of how you'd like to conclude today.


Dr. Alison Campbell  53:18

Well, I think I'd like to compared by by just saying that the future of assisted reproduction technology is bright. I think the internationalization that we're seeing is a really positive thing, that we can all come together with our expertise and experience and drive things forward at a faster rate. So I think businesses will benefit employees will benefit and patients will benefit from this. This forward. Dr.


Griffin Jones  53:52

Dr. Allison Campbell, thank you very much for coming on inside reproductive health.


Dr. Alison Campbell  53:57

Thank you. Thanks for having me.


54:00

You've been listening to the inside reproductive health podcast with Griffin Jones. If you're ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health






168 The Checklist For Truth In Fertility News



This week, Griffin shares five points on how to report- and listen to-  the news. What should you be looking for in reliable journalism? Do you understand the message being delivered, and is it verifiable? What to look for, what to look past, and what to think twice about, on this week’s episode of Inside Reproductive Health with Griffin Jones.


Transcript

Griffin Jones  00:00

If you have a friend who is he or she that you argue with a lot, and they present to you information from new sources, media sources that they follow that you're thinking, How the heck can you not see the bias that they're leading to you. And here is how you are going to get that person to at least see a little more clearly, you're going to be able to do this a lot more effectively than winning any kind of argument against them. And hopefully, you apply it to yourself to. So instead of telling someone the bias in whatever information that they're absorbing, give them this checklist. I'm going to give you this checklist, I apply it to myself as a news viewer, I hope you apply it to yourself before you check anyone else's bias.


 This is an ode to a journalism professor that I had 20 years ago, this is long before I ever thought about doing any kind of journalistic endeavor. I only took one broadcasting course in college, I think, and the this course taught me how to report the news, it was teaching students how to report even though I knew that wasn't going to be my career, I used it on how to view the news. And I contacted my professor Ron grave after 15 plus years of having taken one class within one semester, sure that he didn't remember me in retirement, and contacted him. I think two years ago, even before we started positioning inside reproductive health as a media company, before we started doing anything with news coverage for inside reproductive health, I just wanted to use it to have as the viewer and to be able to immortalize his lessons in some way. So the checklist that I came up with is inspired by the teaching lessons that Professor graves taught us on how to report the news, I think is very valuable for how to watch the news. He called his teaching lessons on the one hand, and he would also say, on the other hand, and I think the other hand, is actually the reason for the one hand the other hand, is that perhaps there's no such thing as pure objectivity. But the one hand gives us some rules that we can get a lot closer than we otherwise would. This is part of inside reproductive health editorial style guide, but you should use it for watching any kind of news that you normally watch local news, political news, maybe not sports and entertainment, because I don't think that's real news. 


There are five items on our checklist. The first two are fairly self explanatory. The first is that it answers six basic questions who, what, where, why, when how? The second is that it has a clear point, what's the main message that the story is getting across the other three, I think can use a bit more explanation. The third is that it's clearly attributed exactly what source a piece of information came from. Example, according to a February 16 study in the New England Journal of Medicine, or the governor said on Tuesday, I remember in Professor graves class when we would report on something the city would say the city budget is going to be passed on Thursday, and he would say who says the budget is going to be passed on Thursday. How do you know that it's going to be passed on Thursday. Councilman Smith said it'd be passed on Thursday. Then say Councilman Smith says the city budget will be passed on Thursday. Fourth is that it fits into context of a bigger picture. It reports on trends, not anecdotes. We see a ton of anecdote reporting and contemporary media reports on trends and then it compares trends. It uses facts and figures, not man on the street interviews. Fifth is that it's free of flowery language and editorial judgments. There's no adverbs. Like chillingly alarmingly, tragically, there's no superlatives. It was the best it was the worst. There's no promotional items. It uses exact numbers or best estimates, we would say if there was a lot of people at the event, and Professor grave would say a lot. Like 40,000 was a no like 60. And he would say, then, say 60. And it's free of comments on how good or how bad something is. It lets the viewer the reader decide. I don't watch cable news, I don't consume most popular news sources. But at the gym, there's two different cable news channels on each one that reports how the other one only reports Bs and the tickers below them talk about one group of people's lies or this dastardly plan or this horrible event. The best of news reporting lets the viewer Have the reader designed for him or herself. So those are the five main points answer six basic questions has a clear point, it's clearly attributed fits into the context of the bigger picture. And it's free of flowery language and editorial judgments. 


And while it's not in this checklist, Professor Greg would often talk about the other hand, what's left out from the basic answers to our six basic questions. Why was this the main point? What's the limiting principle for what's a given for a certain citation? We could say Abraham Lincoln was the 16th, President of the United States. According to the Smithsonian, there are some things that I read, as we're putting out, say, I don't think that that needs a citation. I I think that that is well established. But I don't know exactly what that limiting principle is. And I suspect that it varies. I don't know that there is one limiting principle for the context of how it fits into the bigger picture. Did we give Opposing Viewpoints? Sometimes there's not an opposing viewpoint of a postal worker shoots up is co workers. There's not an opposing viewpoint, for it's good to shoot up your co workers. But there is context that might be unanswered, if we're reporting on postal workers shooting up offices. How common is that? Actually, among postal workers? How common is that, among other professions? Is there a reason we're focusing on postal workers as opposed to others? There's a lot of questions about the context into which certain stories can fit with regard to being free of flowery language, we can eliminate adverbs or adjectives, we can do that pretty empirically. There's no adjectives here. There's no adverbs here, we try to all but eliminate them. So that makes that part easy. But you still have to have nouns and verbs. 


What are that if I say this investment bank is a giant investment bank, they're a banking giant, that's still a little bit of a value judgment. They're one of the biggest in the world that's probably not too far of a reach or if someone's under investigation, do use the word probe do use the word targeted, when you're not sure if they're guilty or innocent. Scientists, many of you are scientists are meant to prioritize the unknown over the known you're meant to prioritize what you don't know over what you do know, journalists should do the same thing. They should prioritize what they don't know over what they do know. And some verbs might exonerate someone will be bending more in the direction of exonerating someone while some verbs might be bending more in the direction of condemning someone. And journalists aren't meant to do that.


 And whatever the limiting principles are, for those types of noun and those types of verbs, I suspect isn't a categorical law, either that there's that there's some subjectivity that can't be avoided. Now that you have your checklist now that you know the limitations to the checklist, there's different rules for different types of media, not all forums or news media, the podcast isn't news reporting, our podcast isn't news reporting, I'm in a position right now that I think is ultimately a good one. I'm in both the editor seat and the sales seat right now. And it can be awkward when you're in the sales seat, having conversation about how you're going to help the advertiser reach our audience, increase their leads, and you're talking about sales and marketing. 


And then in another seat in the editor, see, you might have to launch something that isn't the most flattering about them. Most of the time, it's neutral ish. A lot of times people don't like it when it's not in their marketing or PR control. But most of the time, it's just pretty neutral. At some point, it could be something that's pretty bad. And for that reason, I think it's good that I'm in the sales seat and the editor seat right now, because if I can build the media company to the standards of these editorial standards, while I'm still physically in both seats, having both of these different interactions with sometimes the same relationships, and that's a really good foundation for when they are different people in different departments that these folks are responsible for editing and programming.


 These folks are responsible for sales and the media company is built on the values that the editorial standards cannot be compromised. I'm guardedly optimistic about that. It's a pious hope the only difference between a sinner and a saint is a pious hope but let me remark with regard to the same rules for certain forum like my podcast are different from news media. I said most things are neutral but if you and I both live long enough, something bad will happen in our field something real bad if you and I are both blessed enough to live long enough and inside reproductive health we'll have to report on it even if it's a very dear friend of mine, a dear friendship can't escape the obligation of the news but a dear friendship might benefit from the other media that we have example Dr. Trixie Bambino gets in huge trouble for a whole bunch of sexual allegations does Oh, A bunch of bad stuff. CEO Rocco McGillicutty embezzled from the company frauds, insurance, to frauds, shareholders steals patient money. Instead, reproductive health will have to report stories like that. But I will also have Dr. Bambino or Mr. McGillicuddy. On my show afterwards to give their perspective, I'd be hard on them if the facts are there, and they're on my show, but I will let people come on my show. So I'm letting you know that right now, there are standards for the news. And there's different standards for other types of news media, I'm letting you know where I'm at so that you can see my transparency. 


I don't hold my own commentary. I don't hold the podcast. I don't hold articles that I write myself that aren't news articles to the same standard that I hold our journalists to our news reporting editorial standards, too. And when something like this happens not if you and I are both blessed to live long enough, and people say how could you do this? I'm going to point to this episode right here and say I give people platforms to speak. I'm Griffin Jones. Good night, and good luck.


11:04

You've been listening to the inside reproductive health podcast with Griffin Jones. If you're ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health


167 IVF In India: The Walking Giant of The Fertility Field

What’s happening in the business side of the fertility field in what’s soon to be the most populous country on the planet? Dr. Biswanath Ghosh Dastidar shares the origin of IVF and the fertility business model in India, as well as the challenges and coming trends for reproductive medicine in the country. 

Who was India’s contemporary to Patrick Steptoe? Did you ever hear of his tragic end?

Listen to hear:

  • The tragedy behind the Patrick Steptoe and Howard Jones of India.

  • About Dr. Dastidar’s connections to the pioneers of the fertility field in India.

  • What models look like in India, how they differ from the US and Europe.

  • About the new trend of large companies consolidating and forming new companies.

  • About the future potential of the IVF industry growth in India




Dr. Dastidar’s info:

LinkedIn: https://www.linkedin.com/in/biswanath-ghosh-dastidar-51428b178/

Website: www.gdifr.in


Transcript


Dr. Baswanath Ghosh Dastidar  00:04

You just cannot ignore India in the global context because such a huge population, if you leave everything else apart is to such a huge population a burgeoning population of reproductive, of you know reproductive age group couples. India is what is known as in the demographic sweet spot in global terms right now. So we are going to have a young growing population over the next 30 years, say up to 2000 2000 42,050. And the needs of this population, the requirements for reproductive healthcare the requirements for fertility for IVF. It just makes it a very exciting space to work in, in this field.


Griffin Jones:

1.4 billion people, and almost 100% self pay patients. Those two figures alone are probably why you're going to hear a lot more about the fertility field in India, particularly the IVF business market in India, a lot in the coming decade. Almost 5% of my audience comes from India, and I've never created any content for the Indian market, you've noticed that we're creating a lot more content recently. And as we create more, we'll give you options to segment I want this kind of content. You don't have to deliver as much of this. While we get to that you might listen to this episode, whether you live in the United States or Canada or elsewhere in the world. Because the Indian market, as far as I can tell, is going to get a larger and larger share of attention both from your side the clinical lab, scientific, peer reviewed side but especially from the business side, the genetics companies, the pharmaceutical companies are going to be spending a lot of their attention on India in the coming decade. They already are so I bring on a guest Dr. Biswanath Ghosh Dastidar, he is part of the center that is one of the pioneer centers in India, they are in Kolkata, India. So he talks about his connection to that practice group to the Pioneer history in India. He talks to us about the Patrick Steptoe and Howard Jones of India and what happened to that person, then we move on to what models are like in India, what we're used to seeing in the United States and Canada in the UK with large health systems, large research, hospital University IVF is not really the case in India, it's almost entirely private practice. Private Partnerships, partnerships between physicians sharing ownership is relatively new, according to Dr. Dastidar. And now really large companies are both consolidating in India as well as forming new companies in the subcontinent. Dr. Dastidar was trained at Cambridge University and Oxford University in embryology and I hope you really enjoy his perspective on what may become the world's largest IVF market. Dr. Dastidar, Dr. Bish, welcome to Inside reproductive health. 



Dr. Biswanath Ghosh Dastidar:

Hi, Griffin. It's great to be here. And I'm sure it's morning in America. So good morning to all your viewers. And yeah, it's nice to be here. It's just after my practice here in Indian local time. It's evening and nice to be here.


Griffin Jones:  I look forward to asking you questions about the partner associate model in India. But before I do that, you and I met at ASRM and we met at the business of mines talk at SRM. And we got to have a little small talk after the panel discussion. And I was telling you about how 5% of my audience comes from India, even though I've created exactly 0.0% of our content about the Indian market. And you told me if you start to cover the Indian market, the


Griffin Jones  04:10

folks that work in reproductive health and India are going to be really engaged and really interested in and you said you you will develop a following or you said something like that. What did you mean by that?


Dr. Biswanath Ghosh Dastidar:  You see Griffin firstly, I completely remember our meeting at the SRM and it was a great session, I thought it was very different session to what I've been used to it past as RMS. And then we had our follow up conversation and what I meant was that both in terms of reproductive medicine and fertility or infertility or IVF as well as in terms of general reproductive health and women's health. You just cannot ignore India in the global context because it's such a huge population. If you leave everything else apart


Dr. Baswanath Ghosh Dastidar  05:00

Is this such a huge population a burgeoning population of reproductive, of you know, reproductive age group couples, India is what is known as in the demographic sweet spot in global terms right now. So we are going to have a young growing population over the next 30 years, say up to 2000 2000 42,050. And the needs of this population, the requirements for a reproductive health care the requirements for fertility for IVF. It just makes it a very exciting space to work in, in this field in India. And there's a lot of there's a lot of scope for engagement for discussion for brainstorming. And for podcasts like yours. I think there's a lot of scope for engaging with issues in India right now, requirements for IVF Tell me about that, do you mean unique considerations for in India around IVF. So, you know, India in terms of the IVF industry, though India was a pioneer country, as long as as as far as starting IVF is concerned or early development and research in IBM is concerned, India started really early. I mean, India was contemporary to the UK to the US, in terms of, you know, getting off the board with IBM Research. And I'm fortunate enough to be associated with one of those pioneer centers. So, the center that I am associated with in Calcutta, this center has been associated with the birth of India's third IVF, baby in 1986. And with the birth of India's second xe baby, which is intracytoplasmic, sperm injection, or xe, which is specifically indicated for severe male factor infertility where you know, the sperm count is really low or the sperm are not more tied and other reasons. So this center was associated within this third IVF, baby and secondary qcbs, back as far back as the 1980s and 1990s. So, so in the did get off the blocks early, but the problem is the field of infertility IVF is still underserved. There's still a lot of patients who don't have access to treatment. There's still a large nascent, vacant space available for IVF centers and IVF services. So yeah, it's it's a big market and a lot of it is still untapped. In the United States, the name is Howard Jones in the UK, it's Patrick step toe. So India's contemporary to the US and UK at that time, who was the big name in India at that who's the Patrick Steptoe or Howard Jones, of Indian IVF? So, that's a very, very interesting question, Griffin. And you have to hear me out for around, you know, a couple of minutes or five minutes here because it's an interesting and it's a slightly complex story, because the first IVF pregnancy in India and the first delivery of an IVF baby in India happened can temporary Believe me or not, happened contemporary to the first IVF baby born in the world in the UK, in Cambridge, in 1978. And the doctor Professor Robert Edwards and Dr. Patrick Steptoe as early as that contemporary in the same year, which is not what India can say about a lot of different, you know, arenas of scientific endeavor. In IVF. The first Indian IVF baby was born in the same year as the first IVF baby in the world. It was done by Professor Subash Mukherjee, by Professor Subash Mukherjee, who was based in the very city in which I'm sitting right now speaking to Calcutta. The name of the baby is is Durga. And the problem was that his contemporary Medical Society, the Society of gynaecologists, and other people with vested interests, just did not believe his work and just is not they raise doubts and questions over over his work. He was ostracized, he was hounded by politicians, by bureaucrats, and he was led to such a state of mental disarray that he committed suicide. Okay. So this is how India's IVF story begins. After this, one of his students, one of his early students, got together collaborated with a very eminent senior gynecologist in Calcutta. And they started what is possibly India's second IVF program, again here in the city that I'm working in in Calcutta. Those two names are Professor bn Chakravarthy, who was the gynecologist and Dr. Sudarshan ghost, dusty Dar, who was the IVF embryologist and the guy in the lab, they got together and started the program in Calcutta. And the second program started in Mumbai or as you might probably know it as Bombay, were a collaboration between Dr. Indira Hinduja and Professor Anand Kumar took place so there were these two Two centers and these two programs, which started simultaneously after the death of Dr. Sue Bosch Mukherjee. And these two centers both delivered IVF babies in 1986. So I belong to one of these two programs. So the program in which I am a part of right now and where I'm sitting right now speaking to you. This is Dr. Sudarshan. Ghost, the Steelers program IVF center. So this is a pioneer center and that's how early it was, you know, so the names are really Professor Subash Mukherjee to start with. And then Professor bn Chakravarthy. Dr. Sudarshan goes dusted our Dr. Indira Kumar and Dr. Hahn and Dr. Indira Hinduja and Dr. Anand Kumar. These will be the early pioneers. So, what did these two new pioneers after Dr. Mukherjee his death if part of the reason that brought him to that demise was either ridicule or lack of acceptance, then how did these two programs form in that aftermath? So you know, that story is also very interesting and it's not very, it's not very similar to each other, these are two different stories. So the the program, which developed in Mumbai or Bombay under Dr. Anand Kumar and train the Rahim Bucha was a nationally funded nationally supported program. So, it was you know, it had the support of the Indian Council of Medical Research and a big hospital. So, was very structured, very organized program. And the program which simultaneously started in Calcutta, under Professor Bian Chakravarthy and dot Sudharshan course, this data, this was a private initiative. This was a private initiative just between these two very enterprising, very courageous individuals. And they collaborated, they pulled in their own resources, their own earnings, and they started in IVF lab, and they started program in Calcutta. And those guys in Mumbai who were funded and supported by a very, very prominent Indian research agency, they started their program in Bombay. And yeah, they both lead to pregnancies again, you know, as strange as it may sound, they both lead to deliveries of IVF babies in the same year again, in 1986. Were they affiliated with research universities with academic hospital systems? Were they completely independent? These were both both were independent programs. But the Bombay program was supported by one of the prominent Indian research agencies research but not but not part of a teaching hospital, not part of a large hospital system. It was funded by a reason. The Bombay program had close links to a large hospital, but not the calculator program. It was completely privately started and privately funded program. And this is in the mid 1980s, in Kolkata. So this started off in the early 1980s. This started off in 1979 1980. And it I mean, you know, you'll you'll be interested to know that they had their first IVF pregnancies which delivered which led to a successful delivery of a baby in 1986. But the Calcutta program, interestingly, reported the first IVF pregnancy in India to be reported in an international scientific Congress in the World Congress on IVF in Helsinki, in Finland in 1984. Unfortunately, that pregnancy did not go up to term so that pregnancy resulted in a miscarriage a few months later. But yeah, the work started in 1979 1980 81. And both the center's had delivery, successful deliveries in 86. I'm wondering if this is setting us up for a different model in India than what we saw in the United States generally, what we saw in the United States after Dr. Jones throughout the 1980s, most IVF, virtually all of it was happening within research hospitals, systems, and then started to leave a little bit in the 1980s to have independent IVF centers like I think Boston IVF was among the first a lot more in the mid 1990s And then through the early 2000s. But if if there were two programs, essentially starting simultaneously in India, it sounds like Kolkata was completely independent, then what routes are there to the then then how did the model for Indian IVF develop after that? So you know, you know, Griffin, I must congratulate you because this point you just raised it's such a prescient observation on your part because you've hit the proverbial nail right on the head because that is exactly what happened. Owing to the fact of you know how these two early initial pioneer program started off. From there if we trace the history of IVF in India from then onwards, right up to today, you will find that the print dominant players in the IVF market has always been private centers. So that's the way it started off. And that's the way it continued. And that's the way it still is today. Majority of the IVF market in India is dominated by private players. It started off that way from the 1980s 1990s. It's persisted today. Yes, there are different models as well. So there are big hospitals, big free standing individual private hospitals, which have developed IVF units. There are large, freestanding government funded teaching institutions teaching hospitals, which also have IVF units do have very few ID number, let me tell you very few in number. And the very recent development, which is as recent as the last decade or so is the emergence of the IVF chain, you know, like a corporate group, which is putting in its money to set up IVF centers all over the country. So you have all these models, but it really started off with individual enterprising private individuals and doctors who set up private IVF centers. And it's the root of that could be traced back, in fact, to the way that the pioneering IVF work started in India, as you so correctly pointed out, I must tell you, I never thought of it this way.


Griffin Jones  16:16

So did the private IVF practice in India take did replicate the general practice model at first, you have other independently own general practices or maybe other specialties and subspecialties did the first RBIs in the first fertility specialist in India just say, Okay, we're just going to do that. But with an IVF. Lab, how did it differ? I'm not very sure that's the case, you know, reference. So what what really happened was, if you go back to the 1980s, and


Dr. Baswanath Ghosh Dastidar  16:50

early 1990s, health care, generally in India, has always been sought. I don't have the exact numbers of the exact data with me, but it's always been reasonably fairly divided between the private sector and the government sector, you know, between individually run private hospitals and private clinics, as well as large hospitals, chains, government hospitals, teaching hospitals. So that balance has always been there in medical practice in India, right from the beginning. It's interesting, why? And you raise a very interesting question, to be honest, you know, this is something I haven't bonded on much in the past. But I guess the reason why IVF really took off in the private sector is because of the inherent nature of the subject. IVF is such a multifactorial subject, it needs so much of quality control, it needs so much of oversight. There are so many different aspects which are going on, you know, there's the laboratory, there's the operating room, there's ultrasounds happening, there's reproductive endocrinology. So it's really different fields of expertise, which have to collaborate in a very close and well synced manner. You have the RSI, you have somebody who's doing the ultrasounds, you have a surgeon, you have a gynecologist, you have an embryologist in the laboratory, and and ologists apart from just the science part of it IVF right from the beginning, was also, you know, it's an institution, it's not just one man sitting in a clinic, seeing patients and writing prescriptions. It's a business, it's a, it's a company as well, or every IVF centers is essentially a small company as well. Right? So I think because it needed so much of collaboration and looking at so many different aspects. And we had to be perfectly attuned to each other perfectly working together, which with each other. I think that was very, very difficult to achieve in a large setup in a large government hospital where, you know, it was very watertight compartments, you know, people didn't really collaborate so much didn't really it was very difficult to get different people have different specialities to, to always work together in a coordinated manner. So it was easier to just break away from that model and start off a small center. So we have two different origins in Kolkata and Mumbai. And then do we almost instantly start to see private IVF centers opening in Bangalore and New Delhi and other parts of the country? Or did it continue to be fairly unknown in those two cities before it spread to the rest of the subcontinent? A bit of both. So you know, initially in the 1980s, particularly, there was a lot of monopoly in the IVF business, if you will, because so these these two centers were there, in Calcutta and in Mumbai, and of course, there were other centers, which were coming up other leading doctors who took charge and who, you know, set up institutes in different states in different cities of the country. But I think it is, the population largely remained underserved in terms of fertility meds, Sit in terms of Reproductive Medicine IVF services. I think it's really the last, you know, it's really the last 15 years, it's the last 15 years, which has seen burgeoning booming interest in the field all over the country and setting up of many, many new centers. And so how did the first fertility specialists in India sub specialized did they train abroad? Did they develop a fellowship program or some kind of training licensures cert to certification in India? Tell us about how they subspecialized again, you know, that's another very interesting question. So, right, in the beginning, the early pioneers I spoke to you about, they were pretty much self trained, you know. So they were self trained individuals who traveled the world, they went to conferences, they went to the European meetings in the American Society meetings at that time, you didn't have an SRM at that time, you had something which was known as the American fertility society or the AFS. Right? And the ASHRAE in Europe wasn't even formed at that time. What is now the ASHRAE, those same group of leaders, were just organizing conferences in Europe, which we're going by the name of World Congress on in vitro fertilization, stuff like that. So these early pioneers traveled to those, those early centers in Europe and the USA, they observed, they found mentors and they learned and then they really spread this education and they spread the training to the rest of the country to the rest of the doctors, these early pioneers, which we spoke about. And then gradually you find that in the organized sector, some courses and some training programs on Rei on embryology started in different hospitals, in some nodal centers, for example, the All India Institute of Medical Sciences or the Ames in Delhi, that started a very robust IVF program. But training in clinical embryology and I would like to stress on this because this is a this is a very unique phenomenon, the training, structured formal university training in clinical embryology, both theoretical as well as hands on, didn't happen until much later. So that's really an issue of the last 1015 years before that. All clinical embryologists were people who had learned by working under one of these early pioneers, or by working with somebody who had learned from these early pioneers. So the training in clinical embryology became structured only much later, training in Rei started to get structured before that. But to be honest, to this day, even now, we have very limited training available in a structured University setup format, both whether for clinical embryology or for Rei. It's available, yes, but not widely available. It's very few places which offer SAS training. And so then how did the first independent practices develop in terms of businesses was it like in the United States where you have one or two or three Doc's coming together, and then they form a partnership together? In those days, it was usually equal partnerships. But if it was, if it was a single founder, they would often retain a controlling majority partnership, if not majority plurality controlling partnership as they brought on additional partners, what was it like in India? So you know, now now, we're really getting into the meat of the matter into the core of what I'm assuming your podcast is about and what we also discussed it SRF the models, so you have to understand that the early models was exceedingly exceedingly dominated by single expert led centers, right. So the early IVF centers in the 1980s in the 1990s, even up to the early 2000s. Every leading IVF center was by and large, headed by one specialist by one specialist who was trained, either self trained or had trained themselves by visiting these other programs I spoke about in Rei, Obstetricians and Gynaecologists who wanted to sub specialize in Rei. And they established these centers, almost almost like a private limited enterprise, like a private limited company. When they hired other doctors to work with them. They hired clinical embryologist, but it was really individual single Rei specialists who were setting up these early centers, partnerships and collaborations between groups of doctors is a much more recent phenomenon. It's it's been happening maybe for the last 15 years, and, of course, the corporate entry into it.


Griffin Jones  25:00

is even more recent. So these private limited companies were often founded by fertility doctors, but they were not bringing on other fertility doctors as partners to own in their company. They were hiring them as employees and expanding their companies. And already are fertility specialists working together to form they're to partner together to own their practices. That's more recent to the last 15 years. Absolutely, absolutely. That's right. Yes. Where did you come in, in this model?


Dr. Baswanath Ghosh Dastidar  25:35

So after I, after I finished my studies and my you know, I finished my medical degree, I finished my training in OB GYN. I traveled to the UK. So I was based in the UK for a few years, my entire training in IVF, clinical embryology, in the laboratory aspects of it, so I'm a trained, I should have introduced myself, perhaps earlier. So I'm a trained Rei as well as I'm a trained clinical embryologist. So, my training in Rei and an OBGYN is mostly based in India, but my core training in the laboratory aspects of it and clinical embryology was in the UK. So I joined the University of Oxford, in the UK in 2012. I owe all my training in IVF, embryology to Oxford, then I came back to India, I super specialized in for the sub specialize in area and OBGYN. I also trained in OB GYN, again in the UK, where I headed in 2019. So I was in the University of Cambridge at Addenbrooke's Hospital, which is Cambridge University Hospital. So I finished all of that I returned to India, and then I started getting in touch with, with the leading practitioners with whom I'd had some experience working in my junior days, you know, as a research associate as a associate, clinician, and that's how I picked my field. And that's how I joined and I started working, and it's been, it's been okay so far. And are you yourself? Are you what we would call on associates and employee? Have you mentioned one of these private limited companies? Or are you a partner with with other physicians in the ownership of your practice group? So it's very interesting. So you know, when I mentioned, I should have perhaps mentioned this earlier, but I thought, let's keep this strictly professional and strictly accurate to the, to the history. But when I mentioned about these early groups of pioneers who set up these two first IVF programs in in Calcutta and in Mumbai, what I should have also told you is that one of the two pioneers who set up the first IVF program in Calcutta, Dr. Sudarshan, goes str, he's my dad. So, you know, I have grown up with IVF, from when I was really young, from when I was in high school from when I was in medical school. I've been growing up in IVF. So, so I just came back from the UK, and I joined him. And I've been working with him. I'm also associated with other hospitals now. I'm involved in this practice right now as as a consultant as a research consultant. And I consulted in the in the program, but it's just, it's a, it's a mostly academic and a research role, because I have other primary medical jobs, which I do. But yeah, that's how I'm involved right now. I thought about asking you if you were connected to that doctor, Coach Tassadar. Because, well, I had no idea how common or uncommon of a name that could be. So So you've you've you've grown up in this field, and then so I suppose that you've been able to see


Griffin Jones  28:51

things change. You talked a little bit you said, Okay, partnerships is relatively new in the last 10 to 15 years.


Dr. Baswanath Ghosh Dastidar  28:59

But But when did you start to see consolidation happen in the Indian fertility field? I would say that's, that's as recent as you know, the last the last couple of decades. It has recently in the last couple of decades, it's really been a fragmented field. Till then, it's really been the domain of small private players and small, private, privately established institutions. But in the last couple of decades, we've seen both the models you know, we've we've seen, specialists come together to join hands to form partnerships and work together. And we've also seen the entry of large chains which have funded and backed the setting up of multiple different IVF centers that's relatively recent last couple of decades. So is it the entry of large chains like you know, Evie coming in and forming new companies or is is that happening? More than the cars I'm buying this part? act like these six practices in New Delhi and merging them together and consolidating. Are we seeing one more than the other? It's a bit of both. It's a bit of both. So you mentioned Evie. So yes, Evie made its entry into India, you know, fairly recently the last couple of decades. And the model that we followed was a we approached, already established and prominent IVF centers with a leading area with the leading man who was already working in the field. And they joined hands with these private centers in these private practitioners. So they remodeled and rebranded the center as an Eevee. Center. And that's how he started to grow. But following Eevee, there have been others who have just, you know, it's just been a corporate group, which has been a business House, who don't necessarily have any experience in the medical field or don't necessarily have any experience in the IVF field, who have just financially backed the setting up of, of IVF chains. They have hired people with experience, they've hired doctors and embryologists and they form those teams, and they've set up those chains. So so both these models have had been apparent. Is there more opportunity in India, because of the way the training structure is set up for these large companies to come in to consolidate? And then to expand? I mean, it could be you could say there's less because there's no fellowship program that are funneling new fertility specialists in but is the lack of a fellowship structure, the lack of a training structure, the opportunity for these companies to come and say, Hey, we got a country 1.5 billion people, they don't have a training


Griffin Jones  31:50

a universal training system for fertility specialists, we'll set it up and we'll we'll do all the training and and then we don't have the same bottleneck problem of fertility specialists that other countries do, can that be the case? Or am I missing something? I think it's a little different reference. So I think


Dr. Baswanath Ghosh Dastidar  32:10

the issue here is that there's still a lot of scope for you know, for for setting an IVF footprint in India, for sure. There is scope to to establish a new IVF footprint in India. The problem is the training, you mentioned the REI training, you mentioned that is rather a hurdle, because you know, because there is no robust structured supply chain of adequately trained Rei is or clinical embryologist. Whenever a new entity is going to try and set up a new chain or new centers in India, there's always going to be the problem of adequately and appropriately trained manpower. Unless and until you use the model of Eevee, you know, where you already engage and incorporate RBIs and embryologist who are already working in the centers which are available. What's to stop them, though, from large companies like that we're talking to companies with hundreds of millions of dollars to say, we're going to set up either our own internal Academy, maybe we'll also will, it won't just be our academy, maybe we'll train other fertility specialists that end up working for different practices, or it will be internal. And we'll just say, Hey, if you're coming out of medical school, and you're starting to train an OB GYN come work for us what's to stop that? Oh, that would be great. I think that will be great for all of us. Because if if a big group with deep cash reserves and deep pockets and you know, requisite knowledge and requisite technical expertise, was interested in the field in India in order to set up a big, big Training Institute, that would be great for patients, it would be great for the field in general. And of course, they would have enough business. I think the only issue is that because training certification and accreditation is a very complex issue in India. You know, it's it's partly regulated, it's partly controlled by central nodal agencies, which are government agencies. So you have those loops to go through. But if, if those hurdles can be crossed, if you can start off this conversation with the national regulatory bodies, which which regulate medical education, which regulate scientific education, get the necessary clearances permits, then yeah, it would be great for the free I would be very open to actually partner with with anybody who's interested to do such a thing, because you know, so, of course, you must be aware that the IVF unit in Oxford is one of the leading and one of the most cutting edge units in the world and we've actually been in conversation with them to start off something like you just mentioned, like A really robust training program here in India. But it's just so complicated with the different legal and administrative hurdles, that, you know, it's still not happened. But that's a very exciting prospect. And yeah, there's a lot of scope for that I personally would be very, very interested with something like so there's so different government agencies regulates


Griffin Jones  35:23

ostensibly broader fields of medicine, but but reproductive medicine, but they don't, they don't have a training body for it is that is my understanding. Correct? Right. Right. I mean, there are there are specific training programs available in very small handful of hospitals and centers all over the country. But it's not very widespread. You're absolutely correct. But yes, the field is regulated, very closely. Do private IVF practices, private fertility practices run the gamut in size in India, like they do in the United States? Do you? Is it common to see single fertility specialist practices? Or is it more common to see larger groups that have maybe 10? Or 20, fertility specialists? Or Or there's there's groups where there's three or four? Does it run the whole gamut? Or is one size more common? No, I think, you know, with, with the increasing with increasing awareness about IVF, and how it is a very viable and a very exciting option to have a child.


Dr. Baswanath Ghosh Dastidar  36:24

The demand for IVF has been rising steadily over the last few decades. So it's been very difficult for a private center just to be running with one leading Rei or one leading man. So every center now will have multiple doctors will have multiple specialists areas who are part of that center. But However, having said that, the most common model is still going to be where each center is really run by one leading Rei man. And then there are others who are there associated with the center, but not in terms of equal partnerships between you know, equally shared between different areas, that is also there, that model is also there, but not as common. Talk to us then about how these models differ from


Griffin Jones  37:14

how they do in in other countries, what what you saw at Oxford, and what you saw at Cambridge? How is that different from what you see across India? Yeah, you know, so there are, there are two primary differences. I think the first one is, like I said,


Dr. Baswanath Ghosh Dastidar  37:32

in the UK, and I've, I've been closely associated with the Oxford fertility unit to the wefew. I've had some experience visiting the Cambridge IVF setup. And apart from that, I've also, you know, been part of the leading IVF unit in Glasgow, in Scotland and the gcrf on the Glasgow Center for Reproductive Medicine. And from these experiences, the differences are actually quite clear that the platelet site, all these centers, really have going, what they've got going is the concept of group practice, which you mentioned, like a partnership between two three or more different RBIs. In the UK, this particular person is, is designated as a PR or a person responsible by the hfpa, which is the human fertilization and embryology authority in the UK. So every every IVF unit needs to have one Rei designated as the person responsible. So that's just one person. But apart from that, doctor, there will always be 234 or more others who are working together as partners, you know. So what that does is that link that opens up a lot of collaborations, brainstorming, you know, academic exchanges, that says the academic side of it, if you look at the practical aspects of running the center, it eases your workload, it's easier to schedule your work, it's easier to schedule your time away from work. You have someone to share in the different aspects of both administrative administration as well as clinical work in India, because you just have really one main guy who's in charge of an IVF unit, although he might have multiple doctors working with him, it becomes more of a hassle because the smallness of the structure of a lot of these IVF units means that the same guy has to be focusing on the clinical aspects of it, the business promotion, aspect, Marketing Administration, everything really comes down to the main guy who's leading the IVF center. So you know, it's not as it's not as efficient. Of course, it has its advantages as well. There's more autonomy, there's more freedom to choose which direction you want to take and what you want to do, but it really hinders. It hinders growth. because, you know, you're just dividing your time into so many different disparate avenues. The other difference in the model, I think, is that the UK, and I think if you remember the discussion at SRM, Griffin, we were speaking about four different models of IVF. Here, it's in the UK, in the EU in the US. And one of those was the collaboration between an academic teaching based institution and a private IVF center how you know, these two entities work in very close ties with each other. And that is also the model which I experienced in the UK, both at Oxford and Cambridge. So, both the RFU as well as the Cambridge unit, they are essentially private, Li run IVF units led by, you know, a few small handful of doctors, but with very close academic research ties with the University of Oxford with the University of Cambridge. So, you know, you get the best of both worlds you have, you have the stringent quality control and the professionalism, and the SOPs, which are associated with a small, tightly run unit, but you also have the supply chain of medical students and residents and trainees and the research collaborations, the collaborations with research labs of non clinicians. So you get best of both worlds both in terms of supply chain in terms of academics research, as well as the business part of it and the day to day management part of it. So I think that is what we need more of in India, we definitely need closer ties, we need to actually establish the model where a privately run IVF center is associated with a teaching, research academic institution close ties, so that both patient care, academics, research, development, training of junior doctors can all run together.


Griffin Jones  41:54

The four models for those in the audience that were not at that S or M talk are academic someone that's purely academic, like a UC San Diego, right, an independently owned practice someone that isn't a part of any type of network such as Dallas, Fort Worth fertility associates, Dr. Ravi gota. Was their representative there, or someone that is part of a network that is it's a corporately owned, it's a corporate network, or sometimes called the corporate partnership. And that takes typically a controlling equity stake in what had been an independent practice. And they're part of a larger corporate network that's at least partly owned by private equity. And what the model that Dr. Ducharme is referring to private and make an example of that would be Boston IVF with Harvard and Brigham Women's or RMA of New York with Mount Sinai, though this what model does your center follow? So yeah, it's it's, you know, the model, which you mentioned, the private partnership that Dr. Garda clinic was following in the US, and


Dr. Baswanath Ghosh Dastidar  43:04

that's what we really are a private unit. But it's interesting that you came to this question, Griffin, because there has been a, there's been a bit of change in the last couple of years. And this needs to be addressed because although we have been a private partnership, a private IVF unit, from the time that this this institute was set up. Very recently, as recent as in the last two years, we have entered into an academic partnership with one of the leading Apex multi speciality tertiary teaching hospitals in the state of West Bengal in Calcutta. In fact, if you look it up, you'll find it is the leading and the apex referral hospital. With a glorious history of hundreds of years, it was one of the first multi speciality teaching hospitals set up in the British era before India got its independence. And this is as recent as the last one year. So we've entered into a private public partnership and it's called a PPP model, where our EU Institute has been tasked with the very exciting but also very challenging job of setting up Eastern India's first government owned government housed free funded IVF center for the poor population within the IPG MBR SSK hospital. So I PGM ER or Institute of postgraduate medical education and research is one of India's premier and oldest government sector, multi speciality tertiary referral hospitals. And they have tasked us based on you know, our history of innovation and research over the last four decades. We are setting up an IVF unit within that hospital so it's an a partnership model where we will be running this center, we will be providing the technical know how or when the trainings with the knowledge partner, and ibtm Er is going to act as you know, the the infrastructure, they are going to be helping with the infrastructure, the utilities, setting the costs of setting up the lab and the unit, and so on and so forth. It's very interesting development, very exciting development, I hope that this actually paves the way for new initiatives and ventures like this throughout the country. So that's to serve the poor population that you said, that's to serve the folks that currently don't have access to IVF. Is that my No, it's very interesting, let's yes and no, Griffin, you know, because in terms of who are the patients who are eligible to get treated at that new and upcoming IVF unit, in terms of who are eligible, there are no strict cutoff criteria as yet. I mean, the government might decide that it is going to enforce criteria for selection into that program. But it hasn't till now, unlike in the UK, so in the, in the UK, you have very strict criteria in terms of how many cycles of IVF can be NHS funded in which part of the UK depending on your address, depending on various different factors. So those things haven't yet been decided. So anybody is eligible to avail of this free treatment. But it just so happens, you know, that we don't foresee a lot of patients who are able to bear the costs of an IVF cycle are flocking to that center immediately, because you know, it's going to be rushed, we already have a we already have a waiting list of patients, which is running in 2000. And over 1000, not even in the hundreds, you know, so. So I still foresee that most patients who can afford IVF will still go to privately owned IVF units, but it's really going to be the poor population who need the subsidized treatment, who need the government funding for their treatment in the welfare country, you must be knowing that healthcare is free of cost for all who can't afford it. It's only IVF, which was not under the purview of that free government funded health care so far. So that's the attempt on the part of the government of West Bengal now to get IVF under the purview of free health care as well. So it's a bit under, it's a bit similar to the Canadian model, where you have Health Canada, you have universal health care across Canada, but in in most provinces, IVF is not funded, and even the ones that it is, to varying degrees. And I remember when the province of Ontario, this probably six or seven years ago, released their, their funding program, it was an awkward start, because you had such a need, because you had a population that was used to receiving free health care. They're not used to paying for it outside of a few few specialized things. And, and so they they you know, they did a lottery system. And I don't know if they still do that lottery system, but it was like, Oh, should I pay for my IVF cycle now and go through treatment? Or should I wait to see if I qualify in this lottery, it was I, I would love an update for those of our listeners from Ontario to give me an update, and maybe I'll even bring you on the show. And we can talk about it. But it was a that a lot to figure out in the beginning. How do you think they're going to try to do this? If you have a country of almost one and a half billion people, you have huge rates of poverty. And you we think that the number of people that can't afford IVF in the United States is high and it is it's dwarfed in India. And so how are they going? How are they going to roll this out? Well, for sure, it's going to be challenging, you know, it's going to be challenging and before you know before I come to your question, answer your question directly, if I can just touch upon the the four different models that we discussed today, SRM Griffin. So you know, the first model that we discussed was the large teaching hospital IVF unit right, which is a rarity, which is an absolute rarity in India, it is few and far in between, I think the most prominent one would be the one at the All India Institute of Medical Science raves in Delhi. There are a few here and there, but its rarity. Another model which we spoke about at ASRM was the corporate owned IVF chain where a big corporate houses a big company with deep pockets is funding setting up different IVF centers or or acquiring different currently functional IVF centers. So that is something which has been happening in India like I told you before, as well for the last couple of decades or so. By By and large, the vast majority of IVF centers in India still follow the privately owned privately run IVF unit model, which was the Dr. Goddess model, who was there at SRM. And I think it's very, very, very few private Demick IVF units, like we mentioned, the SRN are the fourth model where you have a private IVF unit with close ties linked to an established large academic research Medical Teaching Center. So I think that's really rare as well. And that's what we are trying to achieve here in Calcutta, with our partnership with IBM, er, the government investment goal. So hopefully this will lead to more such initiatives. And to answer your question, I'm not really sure you know, I don't have a clear answer for you. It's, it's just something that we have to wait, we have to wait and see how this, how this really rolls out.


Griffin Jones  51:00

We talked a little bit about models and how they're paid for mostly its teams, private payer, is it almost up? And this is the question I was fighting to remember to ask you earlier in the show. Is it almost 100% self pay in India right now? Is there any other any insurance companies that cover IVF? Are there any companies like progeny, carrot and kind body that work with employers to broker it as a benefit? Are we talking virtually all self pay for IVF patients?


Dr. Baswanath Ghosh Dastidar  51:39

Listen, if you were able to act as a facilitator, to get these guys into India, then I cannot tell you what a massive market they would come in to India to encounter because, you know, we are in dire need of that. We don't really have that. In any large scale throughout the country. There are a few schemes, there are a few healthcare schemes and insurance schemes which do have IVF under their purview. For example, some of the central government health schemes are CGH s, as we call them in India, they offer insurance and funding for a certain number of IVF cycles for their employees. There might be few schemes here and there. But by and large healthcare for IVF. In India, the vast majority of it is paid out of pocket by the patients. And apart from those few the small handful of government funded centers, where it's of course free of cost, which is also what we are trying to achieve in this new year, and that's coming up at IBM er,


Griffin Jones  52:44

how many IVF cycles does the typical fertility doctor do in India?


Dr. Baswanath Ghosh Dastidar  52:50

Oh, it varies. You know, it varies widely. So I think, are you talking about a particular Fertility Center, like one particular IVF unit?


Griffin Jones  53:00

I would say one day, I'd say so I would say in the United States, if you're doing less than 150, retrievals a year, there's either it's either it's not your full time job, or maybe you maybe you're at a private center that it's in trouble, I would usually don't see fertility specialists doing less than 150. Probably 180 is probably the average and then it's quite common to see in the two hundreds, but then you have a couple there's a couple Doc's in, in California that are doing 800 retrievals a year. And there's one fertility specialist in Chicago, Dr. Reed Jelani, who's podcast episode will have aired before yours, told me she did 1300 in 2022. Wow. And so are so what kind of range is typical for?


Dr. Baswanath Ghosh Dastidar  53:49

I think it's pretty similar here in India, Griffin. So if you find an IVF unit that's doing less than 100. And it's exactly the same numbers I was quoted to you as well, who's doing less than 150 cycles a year or maybe less than 100 cycles a year, that's really low. That's that's not possibly a very prominent IVF center. Whereas the really, really busy IVF centers would be doing around maybe 505 600 cycles a year. We in our center in our unit here, we are typically doing around in the in the four hundreds, around 404 30 cycles a year. But yeah, it would be around at least 150 cycles for most centers, which are doing well. At the very least,


Griffin Jones  54:35

you've given us such an interesting intro into the Indian IVF market into the history of Reproductive Medicine in India into how the model works. Our audience is almost entirely practice owners Doc's execs in lots of different companies in the fertility field. They are starting to pay attention to India. How would you You like to, and some of them, of course have been paying I don't I mean, as a as an aggregate they're starting to some of them, of course, have been paying much deeper attention than I for a long time. But how would you like to conclude with them?


Dr. Baswanath Ghosh Dastidar  55:14

You know, I would just like to say that there is a lot of scope in India, in the IDF field, the problem is that there are also a lot of hurdles to get across a lot of hoops that you have to get through. But there is no doubt about the fact that I think, really to two points to conclude is that, on the one hand, we need a more structured and robust supply chain in terms of training and education. That's a, b, we need more private Demick models of IVF units in India, where you have a private center, you have academics research going on and see yes, if if we could actually arrange insurance, wide coverage, and bring IVF under the purview of insurance, that would really be a game changer.


Griffin Jones  56:14

We will put your social media profiles, and that of the organizations that you work with as well in the shownotes will tag it. And I won't put your email address in any of those. But if people email me, and they say they want to talk to you, Do I have your permission to connect them with you? Oh,


Dr. Baswanath Ghosh Dastidar  56:33

yeah, absolutely. Absolutely. For starters, yeah. You can put up my social media information. And then yeah, I'll be happy to, to respond to emails, if they are channeled through you. Why not for sure. I'd love to help.


Griffin Jones  56:46

Dr. Business Coach does it are you are the first guest to talk about the Indian IVF market, I do not believe that you will be the last and you will not be the last. So I hope to have many more. Thank you so much for bringing this topic into our arsenal. Thank you for coming on the show.


Dr. Baswanath Ghosh Dastidar  57:04

Thank you so much, Griffin. It's been a pleasure. It's been interesting. And I really wish that and I really hope that your show and your podcast gets more viewers and more people engage on these very important issues which are not very frequently discussed. And it's been great to be here. Thank you so much for inviting me.


57:25

You've been listening to the inside reproductive health podcast with Griffin Jones. If you're ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic




70 - How HRC Came to be an International Publicly-Traded Fertility Group, an interview with Dr. Bradford Kolb

HRC Fertility is one of the largest providers of Assisted Reproductive Care in the United States. Started in Southern California in 1988, the clinic has grown immensely, serving thousands of patients every year. In 2017, HRC took their success globally, joining forces with Jinxin Fertility and listing on the Hong Kong Exchange. Despite the booming expansion, HRC never forgot its roots: providing quality, personal care for its patients and giving physicians the opportunity to have full control of patient treatment.

On this episode of Inside Reproductive Health, Griffin spoke with Dr. Bradford Kolb, President of HRC Fertility. Dr. Kolb joined the practice in 2001 and worked through the IPO process with his partners, making HRC what it is today. Not only did we talk about the process of going public, but more importantly, we talked about how HRC was able to maintain their patient and physician culture in this rapid phase of growth. He shares the structure of the clinic and what they do to maintain a small practice feel for such a large organization. Plus, Dr. Kolb offers advice for young fellows and physicians entering the world of Reproductive Medicine and what they can do to be successful in the field from both a personal and professional standpoint.

54 - Improving Patient Experience by Building an Empowered Team, An Interview with Dr. Peter Klatsky

There’s a challenge in finding the balance between keeping both your staff and patients happy. On this episode of Inside Reproductive Health, Griffin gets Dr. Peter Klatsky’s take on managing everyone’s satisfaction while providing a new standard of care. Working with his partners at Spring Fertility in California, their goal is to provide their patients a level of service that isn’t seen anywhere else, all while keeping their employees happy and in for the long haul.

49 - Do the Psychological Effects of Infertility Dictate Patient Decisions? An Interview with Amira Posner

It’s easy to feel like the patient’s journey is confined to the four walls of your clinic, but their journeys extend deep into their lives. Because of this, providing support services, either in your clinic or outside of it, is so important to the mental health of the families you serve. On this episode of Inside Reproductive Health, Griffin talks to Amira Posner, founder of Healing Infertility and the Mind-Body Fertility Group in Toronto, Ontario. With her background in social work and her experience with secondary infertility, Amira set out on a mission to help women going through a similar experience and provide them with the mental health support they need. Together, Griffin and Amira discuss what she does to support her clients and offers advice to providers and support staff on how they can best provide mental health support in their clinics.

47 - Geographical Differences in 3rd Party Reproduction, An Interview with Liz Ellwood

With the introduction of the Assisted Human Reproduction Act in Canada, Canadian clinics and families have been struggling to find quality third-party reproduction partners while remaining in accordance with the law. After going through her own journey and learning the challenges of the process, Liz Ellwood decided to make a difference in the lives of hundreds of Canadian families struggling with infertility by co-founding Fertility Match, an agency that matches families with donors. On this episode of Inside Reproductive Health, Griffin talks to Liz about her story and what she is doing to make the third-party reproductive process easier on families in Canada.

To learn more about Liz Ellwood, Fertile Future, and how you can help, visit www.fertilefuture.ca.

Want to learn more about Fertility Match? Visit them at www.fertilitymatch.ca.

The details of the Canadian Assisted Human Reproduction Act can be found at https://laws-lois.justice.gc.ca/eng/act/a-13.4/

To get started on a marketing plan for your company, complete the Goal and Competitive Diagnostic at FertilityBridge.com.

42 - Insights from a Futurist: Genetic Engineering, An Interview with Jamie Metzl

Preimplantation genetic testing has opened up a world of helping families have successful pregnancies. But when does the testing and selection of embryos go too far? In this episode of Inside Reproductive Health, Griffin talks to Dr. Jamie Metzl, author of Hacking Darwin: Genetic Engineering and the Future of Humanity. They discuss the implications of advanced technologies such as the future of embryo screening and gene-editing. More importantly, Dr. Metzl discusses the significance of understanding the coming technologies and how those in the fertility field can help prepare their patients and the rest of the world for these changes.

39 - Can Geographic Location Have An Impact on Fertility Success? An Interview with Dr. Alex Quaas

But think of the differences across the world--it’s hard to fathom! On this episode of Inside Reproductive Health, Griffin Jones and Dr. Alex Quaas give us a glimpse into (literally) the world of fertility. Having practiced in numerous states and countries, Dr. Quaas shares his experiences, diving into the biggest differences in care he witnessed in Europe and here in the USA.

28 - Can IVF or Egg Freezing Vacations Abroad Reduce Stress or Financial Woes? An Interview with Joseph Davis, MD

In this episode, Griffin hosts Dr. Joseph Davis, a Reproductive Endocrinologist who saw the need for a fertility clinic in the Cayman Islands and brought his years of experience working in US clinics and his passion for global health policy to a country that never before had this field of medicine. Jones and Davis chat about the world of fertility past the borders of the United States, discussing not only the access to care issues in other countries, but also the traveling of patients from the US to other countries to seek more affordable options, find privacy, or simply relax during the process.

22 - Benefits and Barriers of International Fertility Care. An Interview with Lori Whalen, R.N.

In this episode, host Griffin Jones speaks to Lori Whalen, a RN who currently works at HRC in Southern California as the international IVF coordinator. Whalen speaks across the country about topics such as compassion fatigue, so Jones invited her to discuss the intricacies related to international IVF as well as the ways to combat the compassion fatigue that often accompanies this high-pressure field.

4 - How to Increase IVF Patient Retention: An Interview with Dr. Alice Domar

In this episode, Griffin talks to Dr. Alice Domar, a psychologist and the co-creator or Ferticalm and Fertistrong apps. After many studies, Dr. Domar concluded that the infertility practices needed to become more patient centered care in order to reduce the dropout rates of those patients who have insurance. The number one reason for infertility patient dropout is stress. Reducing that stress can help patients to stay in treatment and then in turn help practices to keep business up.

What Canadian Fertility Centres Need to Know About the Law and Digital Media

By Griffin Jones

A patient’s health information is sacred and a fertility practice’s community of adoring supporters is invaluable. In a world where social media and communication technology develop years ahead of the law, how do we safeguard both privacy and engagement without sacrifice to one or the other? I have interviewed several attorneys regarding the Health Information Portability and Accountability Act (HIPAA) and other regulatory schemes in the United States, but I’ve yet to investigate the law relevant to you, the leaders in reproductive health across Canada.

Dr. Alan West

Dr. Alan West

That is, until now. Dr. Alan West is a physician and a partner at the law firm of Gowling WLG in Toronto. He specializes in healthcare advertising law. Mr. Evan Atwood is a senior associate at the same office who specializes in consumer and healthcare privacy law. You should always consult an attorney for specific legal advice, which Dr. West and Mr. Atwood do not give here, but they offer us some education about how the law can pertain to a Canadian fertility clinic’s internet presence.

Federal and provincial regulations

“We don’t have HIPAA. My head spins when I have to deal with HIPAA.” West clarifies. “We have a mix of federal and provincial laws”. Canada’s PIPEDA (Personal Information Protection and Electronic Documents Act), applies to health information as well as consumer information and applies only in provinces that haven’t passed their own statutes with privacy protections equivalent to those contained in the federal statute. .

Several provinces, including British Columbia and Ontario, have their own health privacy laws. In Ontario, the law is called PHIPA (the Personal Health Information Protection Act).  Atwood explains, “Both fortunately and unfortunately, the law does not explicitly state what information is prohibited from being released without authorization.” Unlike HIPAA in the United States, which has a data set of 18 identifying factors (name, date of birth, license plate number, etc.) for Protected Health Information (PHI), there is no concept of a data set in Canadian privacy law. The principles are much more general.

HIPAA’s 2013 Omnibus rule, adds liability to “business associates”, those who receive and send PHI to “covered entities” (healthcare providers). The obligations of a business associate are explicit. Again, in Canada, the law is not as specific, but the health records custodian (you, the fertility centre) is obliged to see that its vendors only store that data on behalf of the health records custodian, with the same protections in place.  

“The law is always behind the actual practice of medicine.”

Mr. Evan Atwood

Mr. Evan Atwood

In some provinces, medical practices are prohibited from mentioning the brand names of pharmaceuticals and devices in their advertisements. The regulation of marketing falls more on the practices than on the drug companies. “Doctors are allowed to advertise their own services, but they are not supposed to identify or associate themselves with specific products or drugs. Although many do so.” West finds. West and Atwood point to the example of “physician locators”, search engines within pharmaceutical or manufacturer websites, that list nearby physician offices who administer their products. These websites may be impermissibly marketing directly to the consumer, but “I know of no prosecution for using brand names in advertising,” West says.

West offers some insight as to why there is a lack of enforcement of some laws in healthcare advertising. Provincial boards of medical examiners have limited resources, and they spend their attention on investigating serious cases of fraud and malpractice, not on the use of brand names in advertising, which in some instances, have found their way into the public vernacular. In some provinces, there is no obligation to investigate every complaint that is reported to the provincial board. In others, such as Ontario, the board is obliged to investigate every written complaint. They might not take an enforcement action, but the risk is higher because they have to at least open the file.

This is important to know, because what is permissible in one province, may be prohibited by another province’s advertising law. In Ontario for instance, under the Medicine Act, patient testimonials are not permissible. Nonetheless, some medical practices may include testimonials on their websites, including some fertility centres. Whether you use testimonials on your website or not, what about the content posted by a patient to your Facebook or Google Places profile? In that case, it might be advisable not to solicit reviews. “It might not be the intent of the law, but I would rather be the prosecuting attorney than the defendant in such a scenario,” West opines. “As the law is written, I think the doctor has an obligation to police the postings on his or her social media channel”.

“The law has not caught up to reality, to put it mildly”, Atwood adds. “Still, there’s never been a prosecution for what a patient has put on a provider’s social media channel”.

Digital Media and Privacy Law

This wisdom comes with regard to provinces with regulations prohibiting patient testimonials, not with regard to health privacy. Consent is implied when a patient posts his or her own information on a clinic’s blog or social media channel. The doctor can leave it on their site. “Doctors and practices are allowed to respond to reviews and comments because the patient waives his or her right to privacy when they post their own information” West says.

“Implied consent has limits,” Atwood cautions. “You can’t take that content and use it somewhere else”. Failing to obtain the proper consent is a mistake that Atwood and West commonly see. Though Canadian law does not specify six core elements for what is required in an authorization (as in HIPAA), expressed, written consent should be obtained whenever you use patient information outside of what is specified in the law.

West leaves us with a bit of caution. While provincial boards have not yet enforced certain regulations, such as those against the use of brand names in physician advertising, he believes punitive measures could be likely in the future. “Be forewarned of enforcement action. That may be something we see quite a bit more.”

Get specific legal advice

In every country, the technologies and media that people use to communicate develop much more rapidly than the laws that regulate them. We have to engage our online communities in a way that respects patient privacy and also complies with the law. In my opinion, Canada’s laws seem to follow common sense more so than the ambiguity of other regulatory schemes, but I’m not an attorney. I recommend you always consult an attorney about the federal, provincial, and local regulations specific to your area.

Dr. Alan West is a partner in Gowling WLG's Toronto office, practicing primarily in areas of law related to pharmaceuticals and health care.

Mr. Evan Atwood is a senior associate at Gowling WLG’s Toronto office, with experience in guiding clients with advertising compliance issues with Health Canada.