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In other words, if clinics face a cap on how much they can charge for each fertility procedure, it is in their economic interest to treat as many patients as efficiently as they can. [74] Essentially, they are in a volume business. The availability of insurance expands the pool of potential patients but limits the amount of revenue that each one can generate. [75] In states like New York and California, by contrast, less generous insurance coverage changes the financial incentives of fertility treatment. [76] Here, clinics tend to be less interested in how many patients they treat, concentrating instead on the upper end of the market—on the patients who are wealthy enough to dispense with insurance mandates and pay whatever it takes (see table 2-3).

In the fertility trade, therefore, as in sperm and hormones, specialization and consolidation have already proceeded apace. The most successful clinics are either very high volume or very high tech, whereas the others—smaller, less sophisticated, less commercial—increasingly are being squeezed by declining profit margins and an increased pressure to merge.

All the clinics, moreover, are affected by the constraints laid out in chapter 1. They are, first of all, racing to keep up with a science that, for the past twenty years, has been progressing by leaps and bounds. This means that they are constantly forced to invest in this new science: in the most newly minted doctors, the best-trained technicians, the most sophisticated laboratory equipment, all of which raises their costs. At the same time, though, they must reckon with the reality that their customer base is sharply limited by these same costs and, ironically, by the success that science has brought. In other words, because fees for IVF remain so high, demand is lower than it otherwise would be. And because IVF procedures are increasingly successful—leading to a greater percentage of pregnancies in a shorter time—the pool of patients is actually shrinking. As one doctor wryly remarked, “Most infertility practices today have a hard time replacing the patients we ‘lose’ to pregnancy.” [77]

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