Per reporter: Chen Xing, Lin Zichen
"Don't say this, it's too painful".
Like Zhao Li (pseudonym), many mothers who have successfully given birth to children through IVF technology rarely mention their experiences to others, which is a hidden pain for a small number of people. But in fact, the population that needs to use manual intervention to give birth is no longer a niche group, and the data cited in the prospectuses of many listed companies show that the number of infertility patients in China exceeds 50 million.
Assisted reproductive technology has been used in clinical practice for many years. Among them, IVF technology is also known as the "last hope" of many infertile couples.
On the mainland, about 300,000 IVF babies are born every year, and behind each IVF baby is the effort of energy and money. According to the "Clinical Practice Guidelines for Assisted Reproduction for Elderly Infertile Women in China", when women are 35 years old and below, they need an average of 3 treatment cycles to successfully give a live birth, and the price of a single egg retrieval cycle is about 33,000 yuan to 42,000 yuan. This means that women of childbearing age need to spend at least 100,000 yuan or more to have a successful live birth.
With the introduction of a series of policies to encourage fertility, it is clear that the price of assisted reproduction should not be a reason to restrict births. Recently, 16 assisted reproductive technology projects such as artificial insemination and embryo transfer have been included in the Beijing Medical Insurance Class A directory, and after the official implementation on March 26, the Beijing "Qiuwa" group can reduce the cost of diagnosis and treatment by an average of 10,000 yuan.
Patients are relieved and the market is encouraging. On the day of the announcement of the policy, Jinxin Fertility (01951. HK), Daga Vikon (301126. SZ) and other related companies have seen their share prices rise sharply. However, the overall cost is high, the diagnosis and treatment position is relatively low, and the scarcity of professional licenses are still the three major obstacles to assisted reproductive technology to benefit infertility people. The first inclusion of medical insurance can be called "ice-breaking", some people in the industry said bluntly, but compared to the problem of how to distribute the cake, it is more important to think about how to make the cake bigger at this stage.
It was finally successful after three transplants:
Don't actively say your child is IVF
In the Spring Festival of 2020, Zhao Li (pseudonym) spent in the hospital's delivery room. For this moment, 41-year-old Zhao Li has been working hard for 5 years. Hearing the child's loud crying, Zhao Li also cried, half of the tears were joy, half of them were relief after years of bitterness and hard work.
Although friends and relatives know that the child was born in the form of IVF, few people will bring up this topic. At the child's full moon feast, curious people inquired about Zhao Li's experience in doing test tubes, and Zhao Li also waved her hand, "Don't say this, it's too painful."
"I wouldn't take the initiative to say that the child was born in a test tube. While more and more people are now aware of this technology, I myself am a beneficiary of IVF technology. But I can't say what the reason is, I may be worried that people wear colored glasses for children on the one hand, and on the other hand, I am afraid that some people will inevitably speculate behind our couple's problems before they can't have children. Zhao Li said.
In fact, the population that needs to use manual intervention to give birth is no longer a niche group. Multiple factors such as environmental pollution, delayed childbearing age, life stress, and poor living habits are still driving this number to continue to grow.
In order to meet the fertility needs of infertile people, drug treatment, surgical treatment and assisted reproductive treatment have been carried out in clinical practice for many years. Compared to the first two methods, assisted reproduction has a higher pregnancy rate, and IVF technology is also known as the "last hope" for many infertile couples.
The results of the latest national reproductive health epidemiological survey and analysis by the team of academician Qiao Jie of Peking University show that in the mainland, about 300,000 IVF babies are born every year, and the total number of cycles in various technical categories of assisted reproductive treatment has exceeded 1 million cycles/year.
Atlas of Treatment Methods for Infertility Patients Data source: Kaiyuan Securities, Jiufang Financial Research Institute
But IVF technology is just as painful and risky.
Before choosing to do test tubes, Zhao Li and her husband tried folk earth remedies, traditional Chinese medicine diet therapy, and improved lifestyle, but to no avail. After going to the hospital for a systematic examination, it was concluded that only IVF could be tried. At first, the doctor selected the second-generation (intra-plasma sperm injection, ICSI) technology for Zhao Li, but after two attempts, the implantation failed, and the doctor suggested that Zhao Li change to a third-generation IVF.
"It was almost desperate during that time. The test tube is simple to say, and the steps are drawn as a picture, but only when you start do you know how difficult it is. Zhao Li said, "Before doing the test tube, I was worried about how many injections I needed, whether there was a risk in egg retrieval, and whether the transplant was unsafe, and then I only cared about one problem, that is, whether the embryo could implant."
After the failure of the first embryo transfer implantation, Zhao Li began to take progesterone to improve the implantation rate, "each time to take fifty to eighty injections, at the beginning I also counted the number of needles, countdown when it will end." Later, I became numb, and there were needle holes on my ass and stomach, and too many needles caused my ass to be hard. When it hurts the most, you can't sit, you can't lie down."
Physical torture is still secondary, more testing is the frustration and powerlessness caused by failure, Zhao Li said, waiting for the results of the two weeks can be called the longest 14 days in life, the most terrible is not to know how many such 14 days to go through. With the idea of trying one last time, Zhao Li and her husband rushed to a hospital in Beijing that was quite prestigious for IVF. In the hospital hall, Zhao Li saw many patients with the same troubles who came from all over the world.
In order to save money, Zhao Li lived in a family hotel two kilometers away from the hospital, and she did not expect that the people who temporarily lived in this hotel were all couples like them. The innkeeper said that because of the hospital, it supported nearly a hundred family hotels within a few kilometers of the neighborhood.
In the months that followed, Zhao Li traveled back and forth between her hometown and Beijing, saving up a bunch of tickets and finally exchanging them for a B-ultrasound map showing a small life. Now, Zhao Li's WeChat avatar and circle of friends are full of photos and videos of children. This year's Spring Festival, Zhao Li let the child record a video, in the video, the child can already say "Happy New Year".
"When I saw the child, I thought it was all worth it, but it was still a little uncomfortable for me to reminisce about the days when I did the test tube." Zhao Li said.
"Impossible" becomes "possible":
Assisted reproductive technology completes health care "ice-breaking"
For Zhao Li, assisted reproduction ignites the hope of pregnancy. And the same crowd as Zhao Li ignited a hundred billion assisted reproduction track.
According to the journal Reproductive Biology and Endocrinology, about 20% of infertile couples worldwide choose assisted reproduction services, creating a market demand of 434.1 billion yuan. From the perspective of composition, IVF accounted for 97%, with a scale of 421.2 billion yuan, becoming the leading demand in the assisted reproduction market.
Total number of domestic ATR service cycles Source: Pacific Securities
In this field, there have been a number of listed companies layouts, such as Lizhu Group, which lays out upstream drugs, Becon Medical, which has high-value consumables, and Jinxin Reproductive, Dajia Weikang, and Kangzhi Pharmaceutical (300086. SZ) and so on.
Capital with a keen sense of smell has also long been aimed at the assisted reproduction track. Around 2015, established investment companies such as Sequoia Capital, Warburg Pincus Investment, Aobo Capital, and Hillhouse Capital entered the market. In 2021, 30 investment institutions such as Jue capital investment and Jinsheng Capital will come down. Relevant data show that from the beginning of last year to November, the scale of investment and financing in China's assisted reproduction industry exceeded 3.6 billion yuan, and at least 9 companies have been financed or acquired.
At the beginning of 2022, a piece of news ignited the mood of the assisted reproduction market. On February 21, the Beijing Municipal Medical Insurance Bureau, the Health Commission and the Human Resources and Social Security Bureau issued the Notice on Regulating and Adjusting the Price Items of Some Medical Services, which uniformly priced 53 assisted reproductive technology projects such as in vitro fertilization embryo culture, and 16 of them were included in Class A medical insurance (outpatient only), which was implemented from March 26 and applied to 15 public assisted reproductive medical institutions designated by basic medical insurance in Beijing.
The reporter learned that this policy basically covers the commonly used technologies used by public medical institutions in Beijing to carry out assisted reproduction, and the 16 assisted reproductive technologies included in Class A medical insurance cover about 8,000-10,000 yuan of treatment costs (excluding three generations of technology), with a single cycle treatment cost of about 35,000-45,000 yuan (excluding three generations of technology) as the technical basis, according to the median calculation, medical insurance reimbursement costs account for about 23% of single-cycle treatment costs. Data from Huachuang Securities also shows that the projects included in Beijing medical insurance this time reduce the price of first-generation technology and second-generation technology by about 10,000 yuan, and if the follow-up rules follow up smoothly, each IVF (IVF generation technology) cycle can be reduced by 25%-30%.
On the day of the news release, assisted reproduction concept stocks rose sharply. According to the Jinxin Reproductive Prospectus, as of September 30, 2018, the average cost per IVF treatment egg retrieval cycle was 48279 yuan. Each IVF case costs nearly $50,000. One of the important reasons for the positive response of the market is that the high price has always been an important factor in the low penetration rate of assisted reproduction in the mainland. According to the "Clinical Practice Guidelines for Assisted Reproduction for Elderly Infertility Women in China", when women are 35 years old and below, they need an average of 3 treatment cycles to successfully give births, and the price of a single egg retrieval cycle is about 33,000 yuan to 42,000 yuan, and women over 35 years old need a longer cycle. This means that women of childbearing age need to spend at least 100,000 yuan or more to have a successful live birth.
30% to 40% of these costs flow to the cost of medicine, 40% to 50% to the cost of surgery, 10% to 20% to the examination fee, throughout the ovulation induction, egg retrieval, in vitro fertilization, embryo transfer, pregnancy testing of all aspects, the ultimate goal is to promote the difficult "dating" of eggs and sperm with the help of technology. Generally speaking, in a treatment cycle that takes 2 to 3 months, the number of outpatient visits for patients is about 20 times, taking medicines, injections, and running hospitals, each of which has to pay a huge financial and time cost.
The industry generally believes that the inclusion of assisted reproductive services in medical insurance is conducive to improving the patient's ability to bear the price, thereby opening the "ceiling" of penetration. Judging from foreign data, in 2016, Japanese IVF accounted for 5.54% of the newborn population, and Australian IVF accounted for 4.37% of the newborn population, and the driving force behind it came from the national subsidy program or a high proportion of reimbursement. For example, the Czech Republic, France and Sweden provide 100 per cent reimbursement for IVF and IUI (intrauterine insemination) treatments for women of appropriate age within a limited number of cycles.
According to the Pacific Securities Research Report, the domestic IVF penetration rate in 2016 was 10.2%, far lower than the level of 56.1% in Japan in the same period, with the change of patient age structure, patient payment can be improved and patient awareness is improved, it is expected that the IVF penetration rate is expected to increase to 27% in 2030.
However, some voices pointed out that as an early attempt for assisted reproduction to be included in the medical insurance directory, the insurance of related technologies is relatively limited. According to Kaiyuan Securities, comparing the data in the Notice with the relevant medical service price catalogue publicly disclosed by a public tertiary hospital in Beijing, the two catalogues have a total of 25 identical assisted reproductive technology projects, of which 21 are comparable in price, 7 are price increases, 14 are price decreases, the price increase items change by 7% to 80%, the price reduction items change by 1% to 49%, and the price change of the price increase items is even greater; overall, the total price change of the 21 comparable projects is -4%, Little change overall.
Comparison of the price catalogue of a public tertiary hospital in Beijing and the price adjustment catalogue Data source: Kaiyuan Securities
In the view of practitioners, the possibility of medical institutions taking the initiative to reduce prices in the short term is also unlikely. Liu Jie (pseudonym), a doctor who has been working in the field of reproductive medicine for nearly 20 years, told reporters that many of the drugs currently used for IVF are imported, and they are also a big head in the total cost, but the 16 expenses that currently enter the Beijing medical insurance class A directory are basically the cost of (surgery) treatment.
Price of assisted reproduction-related drugs Source: Wall Street Academy
Li Ming (pseudonym), who is engaged in management work in a private assisted reproduction hospital, also told reporters that the cost of IVF treatment not only occurs in the operating room, but also accounts for medication and physical examination. The 16 techniques listed in the Category A catalogue are not suitable for all patients, such as "pre-transfer screening", which can only be done in patients with familial genetic diseases whose indicators meet the indications.
"It seems that these dozen items add up to a lot of money, but specific to the head, we probably pre-evaluated it, and we may be able to reimburse about 10,000 or so." Li Ming said that if the patient does not see other diseases in the outpatient clinic throughout the year, the amount of outpatient treatment (reimbursement) is 20,000 yuan, and his total cost is about 10,000 yuan. There is also a part that requires 30% of the out-of-pocket expense.
Assisted reproductive institutions take over obstetrics?
First climb over the mountain of fees
Liu Jie told reporters that many years ago, IVF was still a relatively unfamiliar word, but with the general improvement of the socio-economic level, the patient's awareness of IVF has greatly improved. Currently, about 20 percent of the infertility patients she receives need to go to the IVF step.
At present, Liu Jie's public hospital has no qualifications to carry out IVF technology, and Liu Jie has a positive attitude towards the view that assisted reproductive technology has accelerated the pace of medical insurance, believing that this is a supporting tool to encourage fertility.
"The number of women has declined significantly in the past two years." Liu Jie said that after the introduction of the two-child policy in 2016, the number of pregnant women in her hospital peaked, but it began to decline slowly in the second year, and by 2018 it had recovered to the level of 2015, and then it has decreased year by year.
At the same time, the age distribution of women began to "go both ways", that is, the number of women with early pregnancies and late childbearing gradually increased, and the number of women of the right age decreased. This trend may continue to drive up infertility rates – the National Health Commission's "Core Information on Health Education on infertility Prevention and Control" issued last November shows that age is a key factor affecting fertility. Fertility declines after the age of 30 and declines rapidly after the age of 35; fertility begins to decline after the age of 40.
In 2019, Liu Jie's hospital cut down an obstetrics department, and today's delivery volume is only half of the original. Private maternity hospitals, which had expanded wildly in previous years, began to seek transformation.
Assisted reproductive institutions took the baton and ran. From 2016 to 2019, the number of medical institutions approved to carry out human assisted reproductive technology increased from 451 to 517, and the number of medical institutions approved to set up human sperm banks increased from 23 to 27, including many private hospitals, and also gave birth to a number of popular listed companies such as Jinxin Reproduction.
Infertility patients have more options, and the "success rate" they care about most is the core competitiveness of these institutions. Li Ming told reporters that in general, public tertiary hospitals are the first choice for patients after diagnosis, and then wait until they fail to do private institutions, so the average age of private institutions to accept patients is higher than that of tertiary hospitals, but the success rate does not depend on the private or public nature of the hospital, more importantly, the doctor's technology, laboratory equipment, embryologist experience, etc. Some private institutions may have a better sense of experience or team stability than public hospitals.
Therefore, even if the full cost of IVF in private institutions is nearly 30% higher than that of public hospitals, there are still many patients who rush to private hospitals without queuing, and the medical environment is private and the success rate in publicity is higher. In recent years, more and more assisted reproductive hospitals have gained a foothold in the local area, begun to cooperate with private gynecological hospitals, or independently carry out obstetric examinations, fetal safety, and production business, so as to provide "one-stop service" for successfully pregnant mothers of IVF.
When various fertility incentive policies were frequently introduced, the concept of assisted reproduction began to take off. The most typical is that after the official announcement of the three-child policy at the end of May last year and the inclusion of a number of assisted reproductive technologies in Beijing medical insurance, the stock prices of upstream and downstream companies of assisted reproduction soared. But then there was a continuous cooling.
It is worth mentioning that compared with the frenzy of the secondary market, the primary market is much more "calm".
After communicating with her peers, Liu Jie also found that the number of IVF cycles in the nearby reproductive center did not reach the market's expected surge, and even sometimes it was low.
For this gap, Liu Jie believes that it is the result of the combination of two forces: the decline in fertility desire and the increase in infertility rate. For example, she said, assuming that there is 1 infertility patient in the original 10 age-appropriate fertility populations, the number of infertility patients may increase to 1.5 to 2 after the popularization of bad living habits such as staying up late, but at the same time, the number of people with fertility intentions is also declining. The number of people in need of IVF under the influence of these two factors may not necessarily increase significantly or even increase.
Medical investor Wang Qiang (pseudonym) told the "Daily Economic News" reporter that the assisted reproduction industry is a strong policy attribute industry, which is closely related to policy attitudes and strength. "It can be seen that when the 'two-child policy' and other policies to encourage fertility were introduced, both the industry and capital set off a lot of heat." Because everyone clearly sees that the policy is encouraging, they all have high hopes for the size of the market. However, this enthusiasm is often intermittent, and the stock prices of some listed targets are flat because the strength of the policy is not strong enough, the price of services and the issuance of licenses limit the volume of the market, and capital is hoped to be realized."
In Wang Qiang's view, Beijing took the lead in incorporating 16 assisted reproductive technologies into medical insurance, releasing the signal of the state encouraging fertility, but in the process of practice, it is necessary to further observe the effect and the feasibility of rolling out. "The positioning of medical insurance is still 'basic', the medical insurance funds in various places are not the same, and the scope and extent of assisted reproduction into medical insurance are still debatable."
According to media reports, just the day after the Beijing Municipal Medical Insurance Bureau issued the new medical insurance policy, the Shanghai Municipal Medical Insurance Bureau held a research meeting to discuss related issues such as the inclusion of assisted reproductive technology projects in medical insurance. But in fact, in addition to economically developed areas, there are still many places where there is considerable pressure on medical insurance funds, and it is obviously quite difficult to incorporate expensive assisted reproductive services into medical insurance. Previously, for example, the Henan Provincial Medical Insurance Bureau replied on the people's network leadership message board: At present, Henan does not have the ability to expand the scope of medical insurance payment to assisted reproduction, and only focuses on meeting basic medical needs; the medical insurance fund of the Henan Provincial Medical Insurance Bureau is only "slightly surplus".
"The phenomenon of off-site medical treatment in assisted reproduction is more prominent, the proportion of patients in first-tier cities and medical institutions is higher, and the direct settlement of outpatient expenses in domestic off-site medical treatment is still being piloted, and a single or a small number of cities take the lead in incorporating assisted reproduction into medical insurance will not directly lead to rapid growth in the industry in a short period of time." Wang Qiang added.
It's more important to make the cake bigger
Head hospitals are in short supply, and second- and third-tier institutions are "not enough to eat"
On the other hand, in the eyes of industry insiders, the price of services is only one of the factors restricting the take-off of the assisted reproduction industry.
According to the Health Commission, as of December 31, 2020, there were 536 medical institutions approved to carry out human assisted reproductive technology in the mainland, of which 411 medical institutions were approved to carry out first- and second-generation technologies; A total of 78 medical institutions have been approved to carry out three generations of technology.
According to the "Human Assisted Reproductive Technology Application Plan (2021-2025)" released in January 2021, the number of assisted reproductive institutions requiring the provision of "artificial insemination of husband sperm, artificial insemination for fertilization, in vitro fertilization - embryo child transplantation, and intracytoplasmic sperm microinjection technology" shall not exceed 15% of the total number of institutions by the end of 2020, and in principle, 1 assisted reproductive institution can be set up for every 2.3 million to 3 million people according to the number of permanent residents The human sperm bank setting does not exceed 1 per province (autonomous region, city) in principle.
This means that by 2025, no more than 80 new assisted reproductive institutions will be added to the mainland. To be one in eighty luck, you also need to cross the threshold of license approval. The relevant research report of Tianfeng Securities has pointed out that the application conditions for assisted reproduction licenses are strict and the cycle is long, and it takes about 10.5 years to collect artificial insemination and IVF first, second and third generation licenses.
In February 2021, when the National Health Commission replied to the "Proposal on Increasing the Number of Assisted Reproductive Technology Institutions and Relaxing the Access to Assisted Reproductive Technologies", it clearly stated that "in recent years, with the continuous decline in the number of women of childbearing age, the amount of assisted reproductive technology services in the country has been basically stable, and the service volume in some areas has shown a downward trend.
The scarcity of licenses makes it difficult for service providers to expand rapidly through their own chains. In recent years, whether it is a new entrant in the industry or a senior participant, most of them have cut into the track or expanded their scale through acquisitions. "But the real problem is that 90% of the assisted reproductive institutions in China are reproductive departments of public hospitals, and these departments or hospitals are not acquired by private institutions if they want to." Wang Qiang said.
Just because you get a license doesn't mean patients will flock to you. Xu Wanpeng, the head of OnePlus Health, who has been engaged in overseas assisted reproduction business for many years, said in an interview with reporters that from the data point of view, the current number of domestic institutions and market demand are balanced, but the actual situation is "in short supply". What he calls "short supply" refers to the influx of a large number of patient resources to head hospitals and institutions, while second- and third-tier institutions are facing an imbalance of insufficient cycles.
"The annual outpatient volume of the Reproductive Medicine Center of the Third Hospital of Beijing Medical University is hundreds of thousands of people, while the reproductive department of non-head hospitals in some non-central cities such as Zhongshan and Huizhou in Guangdong Province can only do a few hundred a year." Coupled with the particularity of the assisted reproduction industry - the more cycles done, the higher the proficiency, the higher the success rate, the stronger the attraction to the patient population, the lower the success rate of institutions with insufficient cycles, the decline in word of mouth, and the further reduction in the number of patients. As a result, the demand for head hospitals is determined, and it is difficult to divert new or non-head institutions. Xu Wanpeng said.
In the eyes of the industry, it is not the time to think about how to distribute the cake, and "how to make the cake bigger" is the problem at hand. Xu Wanpeng believes that the inclusion of medical insurance is a shot in the arm, but it is not a panacea. He believes that the demand for assisted reproduction market has a tendency to expand, but this is a phase, and the expected duration should be around 5-8 years.
The assisted reproduction industry has a higher net interest rate than other industries Data sources: Open Source Securities, Jiufang Financial Research Institute
He further said that most of the current market increment is after 70 and 80, after the national encouragement policy such as medical insurance began, this part of the group that used to want to give birth but could not have children will now have a birth plan, due to age and physical reasons and the need to use assisted reproductive technology, but in 5-8 years, this group of increments is basically consumed, where the follow-up increment is, has not yet been seen. After the short-term outbreak of the domestic assisted reproduction market, it will occupy a stable market level of lower middle.
Data show that from 2017 to 2020, IVF treatment accounted for 1.03%, 1.19%, 1.21% and 1.36% of infertile couples, respectively. That is to say, the penetration rate of IVF is not high, and the rate of improvement is less than 0.2 percentage points per year. An important reason for this result is that IVF is still a "last-line treatment" for infertility. Whether from the perspective of patient mentality or cost, IVF technology is the last "trick", but it is not used until the critical moment.
The National Health Commission has also publicly spoken out, saying that "at present, scholars are more recognized by scholars as having a combined prevalence of infertility in mainland China of 7%-10%." The treatment of infertility is diverse, and through lifestyle changes, psychotherapy, drugs, surgery, etc., most patients can achieve a successful pregnancy, and less than 20% of patients need to receive assisted reproductive technology treatment."
After the epidemic began, Xu Wanpeng has changed careers, and except for one or two of his former peers who were "lucky" to get financing and licenses, and turned around to open private assisted reproductive institutions in China, the others have all changed careers. "In the past, many people chose to go abroad because they didn't want people to know that they were doing test tubes. At present, the technology of assisted reproduction in China is very mature, but the demand for increasing the willingness to have children may be stronger than changing the fertility conditions."
Reporter's Note丨The price is only a "big mountain" of assisted reproduction
Where there is demand, there is a market, and the same is true for assisted reproduction. The huge infertility group has forced the advancement of assisted reproductive technology and also bred a market worth hundreds of billions of assisted reproduction. With the introduction of policies to encourage fertility, especially Beijing took the lead in including 16 assisted reproductive technologies in medical insurance, many practitioners rejoiced.
Once the scope of services included in medical insurance is expanded, or the number of places where assisted reproduction is included in medical insurance, the "high-priced" problem that has been considered to plague assisted reproduction may usher in a solution, which is also conducive to reducing the medical burden of people in need. However, on the other hand, assisted reproduction does not belong to the category of "basic insurance", and the medical insurance fund situation in different places is not the same, and it is difficult to include the package of assisted reproduction services.
What cannot be ignored is that in addition to price, fertility willingness, scale replicability and consumer mentality are the eve that needs to be spent before assisted reproduction is to be "exploded".
Reporter: Chen Xing, Lin Zichen
Editor: Chen Junjie
Vision: Chen Guanyu
Typesetting: Chen Junjie Wang Shujie
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