As social distancing becomes the norm and hospitals across the country are overwhelmed with coronavirus cases, a stark, anxious reality is sinking in for thousands of Americans hoping to have a family someday, as well as companies whose business models often rely on smart time management for aspiring parents.

The American Society for Reproductive Medicine issued recommendations last month essentially halting egg freezing, IVF, and other procedures considered to be elective. The industry organization reasserted the same guidelines as of March 30, noting, “It is unclear how long the COVID-19 pandemic will continue.”

The coronavirus pandemic is already upending the fertility services industry—estimated at $27 billion by CB Insights—and impacting a range of patients, clinics, and fertility services, including surrogate pregnancies, egg freezing, and IVF. Since a lot of fertility treatments are time-sensitive, it’s only going to get more taxing emotionally and financially with each passing month.

The number of unknowns about the virus, including its impact on pregnancies and financial fallout for both patients and clinics, is plunging the fertility industry into unchartered crisis mode that may exceed the 2008 financial fallout.

Since there is limited scientific evidence on what the pregnancy risk is from the coronavirus, no consensus has yet been reached in the global medical community on what the best practices are, and there isn’t an outright ban on pregnancies. For couples who can get pregnant naturally, the Centers for Disease Control (CDC) recommended following “usual preventive actions,” and some countries have categorized pregnant women as a vulnerable group based on the knowledge that “some viral infections are worse” in pregnant women.

Each clinic and industry segment face specific challenges depending on their funding model and traction, but everyone in reproductive medicine is likely to be impacted.

“There is a spectrum of impact, inconvenience, people putting their plans on hold who’ve tried to conceive for years, but also in terms of finances—if they need to restart at a later time, they may not have the financial resources,” said David Sable, who has invested in the fertility sector since the late 1990s. “In the best of times, there are going to be companies that don’t make it. We don’t have our arms around how big of a challenge it’s going to be. We don’t know the timetable for the worldwide recession or worse.”

Egg freezing, which has matured as a service only over the past few years, is particularly vulnerable.

“The recession will force employers and patients to be more price-sensitive than ever before, so the winners will be clinics who have priced their services in anticipation of the recession, which means on the lower end of the range,” said Gina Bartasi, founder and chief executive officer of Kindbody, a fertility startup that has raised $31.3 million so far looking to disrupt traditional clinic space with a more lifestyle approach to a range of services including fertility assessment, egg freezing, IVF, community events, and fertility supplements. “It really depends on your funding partner and burn rate. We're fortunate that we have some of the best partners in Perceptive Advisors, Google Ventures, and RRE Ventures.”

Since no one can predict how long the coronavirus outbreak will last, some fertility companies like Kindbody are already preparing for a disruption to their business of at least a year.

“Fertility has proven recession-resistant throughout time, and I think all fertility tech startups that have raised sufficient cash or are in cash conservation mode will thrive once we begin to return to the new normal,” said Bartasi. “I know ASRM is looking to reduce the restrictions as soon as plausible for the health of all patients.”

Extend Fertility, which has one of the largest egg freezing volumes in the country, is offering discounts for women considering freezing their eggs, which will require a deposit now, and patients can proceed with a cycle once the pause is lifted. The company has halted new cycles in line with ASRM’s guidelines.

“It’s a very hard time for the industry, to say the least,” said Joshua Klein, chief clinical officer at Extend Fertility. “We’re doing our best to buckle in and prepare for a prolonged interruption. We can’t imagine not doing business for 18 months and staying intact in the form in which we’re in. But I think a month or two or three is very realistic, and we’ll have to figure out how we manage that situation if it’s longer than that.”

Timing is everything

The central worry for the clinics and their patients is that a lot of fertility-related services are time-sensitive both in terms of the biological clock as well as the careful timing of the procedures themselves. The questions about the virus’s risks for pregnant patients add to the uncertainty and pressures faced by other types of businesses.

The longer this uneasy situation lasts, the bigger the financial strain on the clinics: How long can they keep the lights on, pay their staff, and continue operations until everything goes back to normal and their clients feel comfortable resuming treatments?

At Extend Fertility, it takes about 1.4 egg freeze cycles per patient to extract enough eggs to complete the treatment, depending on age; younger women typically require fewer cycles. In total, the company completed more than 1,900 egg freeze cycles in 2018 and 2019, and it is anticipating a “temporary dramatic drop” this year.

“If a very prolonged amount of time passes and [patients] can’t proceed with the plan that they had for themselves, that’s obviously a source of anxiety,” said Klein. “From a clinical perspective, we can reassure people that…for most women, the difference between freezing eggs today to two or three months from now is usually not something they need to be concerned about.”

The latest federal guidelines and death toll projections already include timelines through August, at least, although a lot of uncertainties remain about which businesses will be able to resume normal operations and how soon.

For patients around the world, a de facto moratorium on fertility procedures is already having an impact.

“We've been trying to conceive for six years,” said 30-year-old Kirsty Hampson, who lives in the U.K. “I'm with CARE Fertility in Bath, and I was told on the 20th that because I hadn't started the estrogen tablets, it didn't count as a started cycle and that it would be canceled. I now just have to wait until they are starting treatments again.”

Fertility treatments are often a multistep process. Patients who had the opportunity to complete some steps before the pandemic feel lucky, but they are now unsure about how long it will be before they can continue with the next steps.

“Going through the process is pretty emotionally and physically intensive. To think that you couldn’t have completed that would have been devastating,” said Julia Kramer, 35, who completed an egg freezing cycle a year ago in New York. She had plans to try to get pregnant naturally before using the frozen eggs, but she is now putting the next steps on hold. “I don’t know if I’ll be thinking about it until the end of the year.”

While most clinics are currently closed, not all fertility clinics are following the industry guidelines. Some states, including Virginia, Arizona, and Florida, have issued executive orders to halt elective surgeries, but there are no direct consequences for simply not following the ASRM’s guidelines.

"ASRM is an educational body, not a regulatory one,” said Sean Tipton, a spokesman for ASRM, in an email. “Our job is to provide our members and their patients with the best possible information so they can make sound medical decisions."

Opportunity for reinvention

Assisted reproduction is still a fairly new industry that has grown in popularity over the past five years, with new businesses popping up, and now the sector has been largely on hold because of a global pandemic. The more established companies that have already gained traction with clients, proven their product-market fit, and offer affordable services are likely to weather the storm, industry experts estimate.

“I imagine that will lead to disruption and maybe permanent change in the landscape of the different players in the fertility space,” Klein noted. “I can’t speak for my competition, but certainly newer startups that are more in their growth phase and spend a lot of money on their marketing phase without the clinical volume behind them, they are probably a little more anxious than we are.”

Some investors see this crisis as an opportunity for the industry to reinvent itself, potentially opening the door to more affordable solutions and automated technologies.

“For investors, the fertility sector is a very interesting, growing one, and the fact that clinics are having trouble might make it even more interesting, depending on solutions created by the startups,” said Benjamin Joffe, a Paris-based partner at HAX, an accelerator that focuses on hardware startups. “Anything that is consumer-oriented will be more and more relevant, and anything that can lower the costs for clinics is also more relevant.”

In the U.S., some see the current crisis as a chance to address some of the systemic challenges like the high price point, obstacles preventing access, lack of fertility education, ethics in marketing, or lack of storage space. This could lead to expediting projected industry trends and redefining the future of the industry as well as specific segments like IVF.

“The current crisis is going to magnify the need for much more efficient throughput of the IVF segment in the U.S. and the rest of the world,” Sable said, noting there’s been more demand for services than the industry has been able to offer. “We’ve been incredibly underserving this population for decades, worldwide, and the degree of being underserved is much higher in the United States. You can’t rectify that overnight just by making it cheaper.”

Compared to other countries, many fertility treatments in the United States remain costly: An average IVF cycle costs more than $23,000, while an egg freezing cycle clocks in at an average of about $17,000, according to FertilityIQ. Medication costs, storage costs, and the number of cycles required varies by patient, but the average IVF patient completes multiple cycles. While some insurance plans are starting to cover parts of assisted reproduction, most of these costs are often paid out of pocket.

Companies like TMRW, a New York–based startup set to launch in August focusing on specimen management systems for IVF, see breakthroughs in fertility technology expanding demand for clinics to handle “billions of embryos in their care,” which today's labs can’t accommodate. The number of U.S. patients storing eggs or embryos jumped from 17,000 in 2005 to nearly 700,000 in 2017, according to TMRW’s estimates.

The pandemic has created immediate pressure for industry players to generate revenue and support their existing clients.

Companies like Modern Fertility and Kindbody are looking to sustain and engage their existing and potential clients online.

Kindbody hosted a virtual retreat on April 4, which featured “fertility facts, financial wellness, healthy eating, and meditation.” Almost 900 participants tuned in, the kind of virtual engagement the company described as “unlike anything” it has seen before.

The company is also making its clinical space and medical professionals available to tackle the coronavirus outbreak while the industry moratorium is in place, the CEO said.

The crisis is also not deterring new entrants that see opportunity and demand in the fertility industry.

Kegg, a fertility-tracking Kegel device, is going to market amid the coronavirus outbreak—its fertility tracking devices based on cervical fluid are pending FDA approval. The company is still planning to ship its first order this month.

Kegg began sourcing all of its components in Taiwan to reduce delays when the outbreak hit China, and the company is seeing an opportunity in the fact that while traditional clinics are closed, their clients still need support.

“COVID-19 accelerated the process of transitioning all services and products online. Fortunately, wearable devices and digital health companies have been built to serve users from the comfort of their homes,” said Kristina Cahojova, founder and CEO of Kegg. “We are better prepared than some newcomers. Also, 700,000 IVF patients are anxiously browsing the Internet on what to do when their fertility clinics are shutting down.”

The long-term impact on the fertility industry as a whole will ultimately depend on how long the pandemic and existing ASRM guidelines will last.

“Even if coronavirus is not a thing of the past completely three months from now, this is a time-sensitive topic by its nature,” noted Klein of Extend Fertility. “Fertility treatments are not the first thing that need to be open, but it’s not the last thing either. I don’t think we have to wait until the last case of coronavirus.”

Many fertility patients would agree: There is already a lot of uncertainty with assisted reproduction, and your chances of success diminish as time goes by. For many, it takes time to decide on the right treatment and then go through the process itself, which can be strict.

Since both the timing of the procedure and the process itself are time-sensitive and have to be done exactly right, Kramer described her egg freezing cycle as buying fertility insurance.

“With the guidelines now taking that away, it’s just devastating,” she said.