In August of this year, The Economist proclaimed in a headline, “The fertility business is booming,” and indeed, the statistics cited in the accompanying article support this proclamation. Today, the industry brings in $25 billion in sales, for example, and this number is projected to nearly double to $41 billion by 2026. Meanwhile, investors poured $624 million dollars into fertility businesses in 2018, up from under $200 million less than a decade ago. Baby-making, from IVF to egg freezing to fertility testing and way, way beyond is indeed big business.

David Sable, MD, a former fertility doctor who now runs the Special Situations Life Sciences Fund, which invests in fertility-centric businesses, says that currently, assisted reproduction is the most underutilized area of health care in the U.S. economy. But that’s set to change, thanks in part to an explosion of startups as well as employers and states aiming to expand insurance coverage of these pricey services. (For reference, one round of IVF costs at least $12,000, and often is higher thanks to separate medication costs). He predicts that thanks to these changes, an additional 1.129 million Americans per year will be able to access fertility treatments.

Plus, adds Norbert Gleicher, MD, medical director and chief scientist at the Center for Human Reproduction, demographic shifts are going to increase demand as well. “Patient populations are aging and women are having fewer and fewer children and so as a consequence, there are more and more fertility services needed,” he says.

But with an influx of cash comes a massive proliferation of similar startups, making it hard to know what is what. Consider this your extensive guide inside the lucrative world of fertility startups so you can navigate the space like a pro.

Predicting future fertility

The major players: Modern Fertility, Everlywell, Egg-Q, and Let’s Get Checked

Fertility hinges on so many variables, including age, partner’s age, sperm quality, egg quality, disease—so there is currently no way to know if you will be able to get pregnant today or at any time in the future. Still, some startups are hoping to empower women with what data can exist around their fertility.

Notable among these is Modern Fertility, which offers a suite of at-home finger prick blood tests which are analyzed in a lab and then digested by professionals into accessible, customized tidbits meant to inform women of where they stand on their fertility and hormonal health. “We felt like the entire conversation about fertility was very reactive as opposed to proactive,” says co-founder Afton Vechery. “We knew there were these better predictors of future fertility than just age alone, and we set out to make those as easy-to-access as possible.” Those predictors include fertility-affecting hormones like anti-Mullerian hormone (AMH) which tell you about how many eggs you have, testosterone, which in excess can impact fertility, and luteinizing hormone, which regulates ovarian function.

The idea beyond Modern Fertility is not for customers to get a one-time read on their hormones, but rather to start testing early and continue testing each year so as to get a sense of how their numbers are changing over time—and thus make informed decisions about family planning. The tests they run can, of course, be run at fertility clinics, but at a higher cost. Modern Fertility’s test currently costs $159; a comparable blood panel at a clinic may cost more like $1200.

Not all experts are convinced by the merits of this kind of testing (also offered by Everlywell, Egg-Q, and Let’s Get Checked). “I think most people are really unnerved by the idea of selling women tests for their AMH and FSH and implying that will foreshadow their natural fertility,” says Fertility IQ founder Jake Anderson-Bialis. He worries that people will take this imperfect data and make rash decisions like shelling out thousands of dollars on egg freezing. Dr. Sable, meanwhile, says that while these tests might be able to point to problems like PCOS or hormonal imbalances, the tests don’t otherwise offer much concrete assurance.

Vechery argues in response that fertility hormones are not determinative, but they do offer some clues if followed over time. She says one of the company’s goals is to create better predictive models, however, and customers can opt to share their data with in-house studies built around that aim.

Egg freezing

The major players: Ova and Extend Fertility

Egg freezing used to only be offered to people who were at risk of losing their fertility due to disease like cancer—the fertility preservation service gave such people a chance at having biological children post-treatment. Then in 2012, the American Society for Reproductive Medicine (ASRM) declared the procedure to be no longer experimental. Enter the explosion of stand-alone egg freezing clinics.

For the most part, these centers have peeled egg freezing away from other infertility services (e.g. IVF) with the aim of decreasing stigma and improving accessibility via reduced costs. (Extend, it should be noted, recently expanded its offerings to include IVF services.) Many have also begun marketing this opt-in procedure as a sexy and empowering choice to proactively preserve a person’s fertility.

Colleen Wagner Coughlin, Ova’s founder and laboratory director, says that Ova stands out from other freezing boutiques because of the quality of their lab. “The most critical factor that sets Ova apart is our proven, extensive track record of turning frozen eggs into babies,” she says. On their site, they say that 80 percent of their egg freezing patients ultimately have a baby using their frozen eggs. Meanwhile in 2016 (the most recent year data is available), 21 to 35 percent of frozen egg transfers led to live, healthy births, depending on the age of the patient.

Others in the fertility field worry that none of the promises made around egg freezing can be kept, no matter how experienced the lab. “I personally find that the way how much of that is being marketed at times quite distasteful,” says Dr. Gleicher. “The facts that are presented to those young women are not always correct.” He says that egg freezing is still primarily meant for people who are about to lose their ovarian function (such as cancer patients), and he doesn’t think there is enough data to accurately predict outcomes for people who want to extend their fertility window to justify the cost and potential risks.

Regardless, egg freezing is on the rise, and both Dr. Sable and Dr. Geicher tell me that as investment money floods the space, an explosion in boutique clinics is—for better or worse, depending on your perspective—likely to follow.

Pregnancy planning

The major players: Mira, Natalist, Ava

Fertility startups are also flooding the market with technology aimed at assisting people in getting pregnant the old-fashioned way, but expediently. Mostly, this technology takes the shape of fertility trackers—software (read: apps) and hardware (read: devices, wearable and otherwise) which aim to help people pinpoint their most fertile days so they can time intercourse accordingly.

Specifics vary. Mira, for example, upgrades the traditional pee stick with hardware that analyzes a sample’s content not just for the telltale sign of ovulation—a surge in luteinizing hormone (LH)—but also for specific measurements of that hormone’s concentration. “By combining hormonal concentration and menstrual pattern tracking with machine learning algorithms powered by artificial intelligence, Mira Fertility has the capability to personalize cycle prediction, health data interpretation, and behavior guidance to each woman based on the individual’s hormone concentration analysis,” says co-founder Sylvia M. Kang. Early next year, Mira will launch additional test wands, which will work with the existing hardware to measure estrogen and progesterone in addition to LH.

Newbie startup Natalist also relies on urine tests, though the company’s given them a makeover and packaged them with a host of other road-to-conception products in order to facilitate pregnancy. The subscription service delivers monthly bundles containing ovulation and pregnancy test kits, proprietary prenatal vitamins and omega-3 supplements, and a magazine-like “textbook” to explain the complicated business of conception. “A huge part of getting pregnant is being your healthiest self, and so why can’t the products that you use make you feel good?” asks founder Halle Tecco. “We spent a lot of time making our instructions very millennial woman-friendly, just dead simple to use, and the actual test itself is a little bit slimmer and sleeker and more compact [than store-bought models].”

More established brand Ava utilizes a wearable watch-like device to track a different set of fertility metrics overnight, including skin temperature, resting pulse rate, heart rate variability ratio, and breathing rate. Each can tell you different information about where you are in your cycle. “For many women, tracking fertility can become like a full-time job—women have to wake up early to take their temperature, pee on sticks all throughout the month, and check cervical mucus daily,” says co-founder Lea von Bidder. “Ava is more convenient than other methods… when you wake up, the data you need is right there.”

There are several other fertility trackers on the market, but some professionals aren’t sold on technology’s value add to pregnancy planning. “There are a tremendous amount of wearables and things of that sort that are interesting, but things that try to precisely identify the fertile window are not really needle movers,” says Dr. Sable. Los Angeles-based OB/GYN Candice Daneshvar, MD, likewise dismisses the tech, adding that good old-fashioned drugstore pee tests do just fine when it comes to tracking ovulation.

Education and community

The major players: Fertility IQ and Opionato

Most people don’t know much about fertility treatments until they become patients, at which point their limited knowledge base expands slightly via Google, a too-busy fertility doctor, and their friends. Some fertility-focused startups are hoping to eliminate these knowledge gaps in order to empower women to make the best decisions for themselves.

Fertility IQ was founded by husband-and-wife team Jake and Deboarah Anderson-Bialis after struggling with their own fertility issues. “When we had just had our second miscarriage and we were done with our second clinic, we really felt like we just didn’t have enough information on the doctors, the clinics, the treatments, the costs, the risks, the alternatives—all the stuff that you would need to navigate this process successfully whether you’re trying to build a family or you’re preserving your fertility,” Jake Bialis says.

The company creates educational materials divided into courses, which run a wide gamut in terms of topics, and doctor/clinic reviews (32,000 and counting) provided by mostly verified patients—with a focus on the diversity of fertility patients. “It’s really important that you hear from people with whom you have a lot in common about their experience, because a 40 year-old woman using donor eggs for IVF doesn’t necessarily want to hear from woman who’s 28 and trying IUI for the first time… a gay couple doing surrogacy blazes a completely different path than a heterosexual couple,” Bialis says.

Insurance

The major players: Progyny, WIN fertility, Carrot Fertility

It’s no secret to anyone who’s been through fertility treatments that typical insurance coverage is abysmal; however, a new fertility-specific insurance market is emerging thanks to an uptick in interest from employers who see fertility benefits as a huge incentive for employment retainment. “The whole human resources industry has figured out that the best benefit you can offer high cost of acquisition and high cost of retention employees is IVF and egg freezing coverage,” Dr. Sable says. Indeed,68 percent of respondents in a 2015 survey conducted by the Reproductive Medicine Associates of New Jersey indicated they were willing to change jobs to ensure fertility coverage.

According to George Patounakis, MD, a fertility specialist in the Progyny Provider Network, there are vast differences between what these fertility-specific insurers provide to the employees of their clients and what regular insurers provide. Typically with the latter, there’s a limited lifetime benefit, for example, which rarely covers even one full IVF cycle. Many also include rules which limit treatment options (especially for same sex couples or single mothers by choice), too, and often don’t cover top fertility specialists.

Meanwhile, Dr. Patounakis says Progyny approves full cycles rather than dollar amounts, so patients can go into the process knowing the entire thing will be covered, including add-ons which are rarely covered by other insurers. “[With Progyny], you know how many cycles you get with your with your infertility benefit—it’s not going to be some mysterious dollar amount that can get chewed up by barely even one cycle,” he says. Plus, you can split up your cycle so that it makes sense for your timeline—utilize a portion of your benefits now to freeze your eggs and then later, when you’re ready to have a kid, the duration of your IVF cycle will be covered, too.

Closed-loop care

The major player:Kindbody

Fertility treatments are typically siloed in specialty centers which touch on no other aspects of a woman’s health, but Kindbody—which launched in 2018 as a full-service fertility clinic—is looking to disrupt this model with its new brick-and-mortar locations in New York, San Francisco, and Los Angeles and its direct-to-employer benefits solution. “We want to bring everything you need under one roof,” says co-founder and head of product Joanne Schneider. “Yes, we are fertility focused, but we think it’s a mistake to look at fertility in a vacuum so we offer OB/GYN services, mental health services, nutrition [counseling], and we even rolled out a supplement line recently.”

Technically, Kindbody patients could begin as routine gynecology patients and evolve into fertility patients, meaning the earliest stages of the fertility conversation won’t be brushed over or missed altogether. “Hormone imbalances can be a reason why people struggle to get pregnant, and that’s something that you should be addressing pretty early on,” Schneider says as an example. They also offer online booking, a digital patient portal for easy access to lab results, and telemedicine to accommodate their busy customers’ schedules.

Given that Dr. Sable tells me he and his investment peers have identified the patient transition from OB/GYNs to reproductive endocrinologists as a major pain point in the fertility industry, Kindbody is unlikely to be the only player in this one-stop-fertility-shop space for long.

Still not sure what’s what? Here are 10 fertility myths doctors want you to stop believing stat. Plus, a newsflash: Your fertility is important even if you don’t want kids.