The High Price of Hope

On any given morning, the clinic’s waiting room was so packed that patients had to sit on the floor, tucking jackets and tote bags beneath chairs to make space. Some flipped through their paperwork or scrolled on their phones; others silently reviewed their list of questions or geared up to walk yet another doctor through their medical history. Several of the patients were already worn out from their long drives into the city. More of them were trying to map out how much additional time off they could swing, or how much room was left on their line of credit.

For many of the people in the waiting room, all this was perfectly normal. Patients often pursue fertility treatment for years, and in the thick of it, appointments occur daily. The chaotic rhythm, the stops and starts, the gaps in communication, the need to step over others, literally, to see your nurse or doctor—it barely fazed them anymore. For Sarah Attia, however, it was all new.

An only child, Attia always wanted kids. She and her husband started trying in 2016, when she was 30 and he was 32. A year in, they still weren’t pregnant, and they decided it was time to get help. After a battery of bloodwork and diagnostic tests, they arrived at their first appointment with a fertility specialist. Attia was nervous but optimistic. She worked in crisis communications, after all—she was an expert at identifying problems and figuring out how to fix them. Then the doctor gave them the news: they had “unexplained infertility,” a catch-all term used when standard testing fails to reveal a specific cause. It affects between 15 and 30 per cent of patients.

Related: How I learned the horrifying truth about my biological father

Attia was devastated—how can anything be unexplained?—but their doctor was matter-of-fact. The couple was healthy and young. In vitro fertilization, he assured them, would be the answer. On her way out, Attia was handed a sheet of paper with a list of procedures and prices on it. Some, like egg retrieval and embryo transfers, she expected to see, and others, like acupuncture, she didn’t. Then there were the ones she couldn’t make sense of: pre-implantation genetic testing and a series of lab tools with names like Embryoscope and Spindleview and Matris. It was overwhelming. No one explained which interventions were necessary and which were not, why one test cost $300 and another more than $2,000. All Attia knew was that she would do anything to get pregnant.

She and her husband immediately applied to the Ontario Fertility Program, which covers one round of IVF for patients under 43. When the approval finally came through a year later, they kicked off the process with an egg retrieval and fertilization. Here’s how IVF works: the patient is given hormone injections, which prompt the ovaries to produce a crop of eggs instead of the usual one. A thin needle snakes through the vaginal canal, pierces the vaginal wall and then gently sucks up mature eggs directly from the ovary. Meanwhile, a sperm sample is collected and “washed” of debris and dead cells to boost its potency. In the lab, the sperm and eggs meet in a Petri dish, where, under the right conditions—temperature, oxygen levels, carefully calibered nutrients and luck—fertilization can occur. The resulting embryos are then coaxed along in an incubator. If any make it to the blastocyst stage, around day five, they can be transferred into a uterus. That’s where, fingers crossed, the embryo will burrow into the endometrial lining and set up shop.

Related: “At 31, I discovered that my parents had been keeping a shocking secret—and the surprises just kept coming”

When Attia’s IVF yielded seven viable embryos, the doctor was optimistic. But the first embryo transfer, in November of 2018, failed. So did the next one, a few months later. The crush of disappointment was difficult to bear, and the rest of the process—the rushed appointments, the feeling of being just another file at a clinic stretched beyond capacity—was no easier. Attia had a gnawing sense that something wasn’t right. The doctor encouraged them to push on, reluctant to change anything in Attia’s protocol. It happens, he said. Then the third embryo transfer, in late 2019, ended in an early miscarriage.

Exhausted and fed up, Attia convinced her doctor to transfer two embryos at once—something clinics are hesitant to do in younger patients because it increases the chance of twins, which is considered a higher-risk pregnancy. In February of 2020, the couple’s fourth and fifth embryos were transferred together. Tests tracked the rise of pregnancy hormones in Attia’s blood. They were low at first but detectable, and then they doubled, then doubled again. In early March, Attia went in for an ultrasound alone, as the clinic had started instituting Covid restrictions. The technician moved the probe over her belly slowly. Silently. Something was wrong. After a long while came the terrible confirmation: no heartbeat. Hollowed out by the sudden rush of grief, Attia fought to stifle her sobs as she moved through the clinic’s waiting room—still so crowded, even in the early days of the pandemic—to find her husband and tell him she’d miscarried again.

After four failed transfers, their doctor announced that it was time for another approach. He proposed sending the remaining embryos for PGT-A, the pre-­implantation genetic testing Attia had seen on the list of procedures. A contentious test—and at $2,500 for the two embryos, the most expensive add-on ­available—PGT-A would shape what happened over the next four years.

---

“Fertility treatment felt like an addiction,” says Attia. “If I just keep going, eventually I’ll hit the jackpot, right?”

---

IVF has never been simple, but the treatment pathway used to at least be straightforward. Today, the process has become an endlessly branching set of decisions about genetic assays, hormone adjustments, receptivity tests and AI-powered lab tools. Each option is presented as a way to maybe improve the odds, and each generates revenue for the private clinics that order the tests and the companies that own the labs. Patients are handed literal menus with little guidance—just the implication that, if they really want a baby, they’ll pick something on the list.

These add-ons are a major factor in the spiking valuation of the global fertility market, which was estimated at almost $50 billion in 2023 and is projected to nearly double in the next decade. In 2024, more than 30,000 Canadians sought fertility care, an increase of nearly 50 per cent in 10 years. No central agency tracks total expenditures, but in 2023, more than 7,700 privately funded IVF cycles were performed in Ontario. At an average of $20,000 apiece, that’s more than $150 million spent in this province alone. And with birth rates plummeting to historic lows—1.2 births per woman in Ontario, well under the 2.1 needed for a population to replace itself—the demand for assisted reproduction keeps climbing. Fertility is now one of the fastest-growing health care sectors, and one of the least regulated.

Related: On the front lines of Toronto’s booming, semi-legal surrogacy market

In Ontario, there’s no consistent standard of care across clinics, no consumer protection, no public reporting of outcomes, no licensing for the lab staff who handle eggs and embryos, and virtually no recourse when things go wrong. All but one of the province’s 43 clinics are privately owned. And as the industry has grown, investors have moved in, consolidating physician-owned clinics into large networks where there is risk that profit, not clinical judgment, often calls the shots—and patients like Attia are left to deal with the fallout.

When Louise Joy Brown, the world’s first “test-tube baby,” was born in 1978, she was both a scientific marvel and a catalyst of moral panic. Her birth, the result of an embryo cultured in a Petri dish (not a test tube, it turns out), prompted tabloid headlines warning of an onslaught of “Frankenbabies.” Clergy in Rome worried that doctors might not know, or be able to contain, what they had wrought in creating life outside the body. On the flip side, scientists and doctors were fascinated and keen to build up the field.

The first Canadian IVF clinic opened at Université Laval, in Quebec City, in 1980, followed by one at the University of British Columbia in 1982. A year later, the Life Program at Toronto East General Hospital (now Michael Garron) recorded the country’s first confirmed IVF pregnancy. It would have held the distinction of the first Canadian IVF birth, too, had a UBC patient not delivered prematurely on Christmas Day in 1983. Considered highly experimental, IVF was administered through a few hospital-based programs, funded by research grants and closely audited by university ethics boards. As the science improved, demand grew. And for almost a decade, Ontario covered IVF for patients—the first province to do so. Then, in April of 1994, the treatment was de-listed from public health insurance except for patients with blocked tubes. Overnight, fertility care became largely pay-to-play.

Related: After 10 rounds of fertility treatment and four miscarriages, we became parents in the last way we expected

A handful of physician-owned clinics already existed, but after the de-listing, they proliferated. Today, there are roughly 70 full-service clinics and satellite sites across the country. Nearly all of them are for-profit, and they range wildly in outcomes. Overall, one in three transfers results in a live birth, but that average doesn’t hold at every facility—despite what the clinics themselves may suggest. “You go on the internet, and every clinic in Toronto claims to be the best in the country,” says Arthur Leader, one of Canada’s pioneers in reproductive medicine. Now retired, he spent 12 years inspecting facilities on behalf of the College of Physicians and Surgeons of Ontario. He’s seen every single one in the province. And while some are above average, he says, some are decidedly not.

Unfortunately, it’s nearly impossible for patients to tell the difference. There’s no public data that allows patients or even clinicians to see how one facility stacks up against another. Clinics collect all kinds of information—on patient ages, how many get pregnant, how many deliver healthy babies, and more—and submit it, on a voluntary basis, to a national database. Then it’s all anonymized, and only national averages are reported, making it impossible to know where the data is coming from. To properly analyze the spread, Leader filed Freedom of Information requests with the Better Outcomes Registry and Network, a provincial agency that collects data on pregnancy, birth and childhood, including live birth rates from Ontario’s fertility clinics. The anonymized data from 2019 showed that cumulative live birth rates—the percentage of patients who took home a baby from one egg retrieval cycle—ranged from roughly 10 per cent to 46 per cent. In other words, where one clinic was making roughly one out of every two families very happy, another’s average was just one in 10.

A clinic’s success rate depends almost entirely on what happens behind its lab’s air-locked, pressure-controlled doors. An infinitesimal shift in temperature can introduce mutations into an egg. Despite the high-stakes nature of their work, the embryologists and lab staff who handle the storage, freezing and thawing of sperm, eggs and embryos in Ontario don’t need a licence and don’t answer to a professional regulator. The College of Physicians and Surgeons of Ontario can inspect clinics, but its mandate is limited to emergency preparedness and infection control, not lab quality or treatment protocols. In 2015, the Ontario Liberals asked the CPSO to develop stronger oversight: training standards, clinical guidelines, inspections and mandatory data reporting. The proposed changes were approved two years later but abandoned when Doug Ford was elected premier.

Nearly half a century after Brown’s birth, IVF still largely feels, if not quite like a miracle, then at least like impressively executed science. But each of those steps incurs a cost, and many of those costs aren’t clearly delineated. An “IVF cycle” is typically listed between $9,000 and $14,600 on clinic websites, but that often doesn’t include embryo freezing and storage (which can be as much as $1,850 for the first year) or transfers (another $2,300 to $3,950). Then there are the medications, which can easily run as high as $10,000. Myriad other fees pop up along the way: for cycle coordination and monitoring, for consultations, for counselling sessions, for transferring embryos and eggs to other clinics.

It’s not unusual for patients to spend $20,000 to $30,000 by the time they’ve used all embryos from a single retrieval. The province can offset the cost, but that help is limited. Since 2015, the Ontario Fertility Program has covered one round of IVF—essentially the egg retrieval and the transfer of any resulting embryos—for patients under 43, like Attia. Almost everything else is paid out of pocket. Last fall, the province announced a $250-million expansion to the program in addition to a new tax credit covering 25 per cent of eligible fertility expenses. This investment is expected to triple the number of families who can access publicly funded fertility treatments. And with the government stepping in as a big player, some in the industry see it as a chance to implement long-needed oversight. “Right now, there are some regulations in place, but not enough people are looking over our shoulder,” says Tom Hannam, a reproductive endocrinologist and the owner of Hannam Fertility Centre at Church and Bloor. The Ministry of Health, he says, is already sitting on a rock-solid database that could be used for accountability or quality control.

Until oversight exists, prospective parents are left, with little guidance, to face an ever-expanding menu of add-on treatments and tests. The grab-bag of procedures includes assisted hatching (using a laser to poke a hole in the embryo’s outer shell), endometrial scratching (roughing up the lining of the uterus with a catheter), embryo “glue,” and a roster of immune and receptivity tests. According to a 2025 review of Canadian fertility clinic websites, nearly 98 per cent mention at least one add-on, priced between a couple of hundred dollars and more than $5,000 per cycle. The evidence behind these add-ons is mixed at best and non-existent at worst, but they’re all profitable.

Financial incentives exist throughout medicine—fee-for-service physicians in the public system also earn more when they do more. But, in fertility, where patients pay out of pocket for almost everything, each step in the journey is a potential revenue generator. Clinics can perform procedures, sell medications and run labs; lab companies can market tests for routine use that haven’t been shown to work for certain groups; and there’s no regulatory body setting prices or monitoring ­treatment patterns. Most ­fertility clinics and care providers are driven by a genuine desire to help would-be parents build their families. But the treatments they offer exist in a fragile decision-making space where emotions are high and hormones can be too. Time feels like a vise grip, and the bills just keep climbing. Patients are drained but somehow still hopeful, grasping at random statistics. The system is built to make them feel like success is inevitable if they just keep going.

That’s what worries experts like Leader. If a person wants nothing more than to have a baby, and they’re told that a certain procedure may not necessarily help but that it could—what’s that person going to do? What’s another few thousand dollars when they’ve already spent $12,000? Among those treatment add-ons, none has taken off like PGT-A—the priciest test and the most aggressively marketed.

After almost three years in the system, and with just two embryos from her funded cycle left, Attia was desperate to try something new. So when her doctor suggested sending those embryos for PGT-A, she handed over the $2,500 for testing. PGT-A offers a snapshot of an embryo’s chromosomal composition at a single moment in development. A small number of cells are extracted from the embryo’s outer shell and analyzed to see which have the expected number of chromosomes (46, making them what is called “euploid”) and which don’t (making them “aneuploid”). The theory: chromosomally abnormal embryos—the aneuploids—are less likely to implant or result in a healthy pregnancy. Identifying them would hopefully keep Attia from another failed transfer or miscarriage.

One of the embryos came back abnormal, and the clinic wouldn’t transfer it—most clinics won’t. The other was found to be “low-level mosaic,” meaning most of its cells appeared normal. But some carried a third copy of chromosome 18, which causes a severe and often deadly genetic disorder. After talking it over, Attia and her husband made the only decision they could live with: they transferred the mosaic embryo anyway. It didn’t take.

So they started all over again, with a second retrieval at the same clinic, this time on their own dime. It yielded another five embryos. For $5,000, they tested all of them. Two were mosaics, and three came back chromosomally normal. Her doctor told her that women with three chromosomally normal embryos have a 95 per cent chance of delivering a healthy baby. Over the next year, they transferred all five embryos. Each one failed. All those euploids, Attia thought in disbelief, and it still didn’t work.

Some patients believe, wrongly, that “euploidy” is a shorthand for certainty. When they don’t get pregnant, they go searching for explanations the test can’t provide, swapping results on fertility forums and asking the same questions over and over: Why would a euploid miscarry? How can a euploid transfer fail? How can I get my body to produce more chromosomally normal embryos? How many should I aim for to get one to stick? With a chromosomally normal embryo, what are my odds—really?

Many of them see doctors who tell them some version of the 95 per cent figure Attia was given. The problem is that the statistic comes from a 2019 study at just one centre—RMA New Jersey—that tracked 4,515 women who transferred up to three chromosomally normal embryos. The embryos were tested by the Foundation for Embryonic Competence, a non-profit lab co-founded by RMA’s clinical and scientific director, which also funded the study. And while the study found that 95 per cent of those women achieved a pregnancy by their third transfer, it’s a result that doesn’t predict what will happen for any given patient—plus it measures pregnancies, not live births. When I asked, RMA did not provide clarity on how the study was funded or its findings.

The 95 per cent figure isn’t the only point of confusion about what PGT-A can and can’t do. While the test screens for embryos with the wrong number of chromosomes (a common cause of miscarriage), it cannot tell you whether an embryo will implant or lead to a pregnancy, says Claire Jones, a reproductive endocrinologist with Mount Sinai Fertility. According to Jones, PGT-A can be beneficial to older patients, who produce a much higher ratio of chromosomally abnormal embryos, and for people who have had previous pregnancy losses. By isolating chromosomally abnormal embryos, the test can reduce the risk of miscarriage.

Where the test hasn’t been proven is with younger patients, who typically produce a much higher proportion of chromosomally normal embryos—meaning there’s little for the test to filter out. Ultimately, those same chromosomally normal embryos would have been transferred with or without PGT-A. Some research even suggests that routine PGT-A use in younger patients may slightly reduce overall pregnancy rates, which is the opposite of what patients are paying for, because embryos flagged as abnormal are sometimes viable. To encourage critical thinking around fertility procedures, Jones spearheaded a project with the Canadian Fertility and Andrology Society and an organization called Choosing Wisely Canada. Revised each year, it’s a list that “identifies tests and treatments commonly used in specialties that are not supported by evidence and could expose patients to harm.” The goal isn’t to ban any of the included interventions, says Jones, but to motivate doctors to pinpoint when and for whom they are actually useful and to encourage conversations with patients. PGT-A is number one on the list of questionable fertility and andrology interventions.

Despite concerns from specialists like Jones, PGT-A use keeps climbing. In Canada, it was used in nearly 38 per cent of IVF cycles in 2024, up from 21 per cent in 2019, according to data from the Canadian Assisted Reproductive Technologies Register. One clinician I spoke to said that PGT-A was presented as the preferred option to every patient at the private equity–backed clinic where she used to work—they had to opt out or it would be used by default. But the surge isn’t coming from clinics alone. If they don’t have an in-house testing lab (and most don’t), clinics aren’t the ones collecting the bulk of the add-on fees. The bigger push comes from the genetics testing labs themselves.

Demanding more accountability from genetics testing companies, a series of class-action lawsuits have been filed in the US and Canada since 2024. Jan Marin, a Toronto lawyer who specializes in medical negligence cases, represents fertility patients in the Canadian suit filed this year. She thinks the official estimate of 38 per cent on PGT-A use is low—at least 80 per cent of her clients have sent their embryos for testing. “The vast majority of cycles use PGT-A at this point,” she says. And that’s because, the US suit alleges, genetics testing companies—including Cooper Genomics, the lab used by Attia’s clinics—have oversold the test’s accuracy, minimized its limitations and pushed promotional materials that treat PGT-A as a must-have rather than an option. This despite the fact that no randomized controlled trial has demonstrated that PGT-A testing increases the success of IVF, decreases the chance of miscarriage or increases live birth rates across all age groups.

In court filings, Cooper Genomics has denied the allegations and moved to dismiss the lawsuit. The company argues that the tests work as advertised, in that they accurately identify ­chromosomal status. It states that patients “received the benefit of the bargain”—meaning they got what they paid for, a genetic test that would tell them with more than 97 per cent accuracy which embryos were chromosomally normal. In its answer to the complaint, Cooper Genomics also flips the responsibility back onto the fertility doctors and their clinics. “PGT-A tests are not off-the-shelf consumer products, but are accessible only through physicians who provide individualized care to their patients,” the company says. The physicians, it continues, are the ones with the duty to warn patients of the risks—including misdiagnosis, embryo damage during biopsy, the destruction of viable embryos and harm to patients with limited embryos.

---

The trade show was a bazaar of modern reproductive care: medicine and maybe-medicine, hard science and hard sell

---

The legal question at the heart of the lawsuits is basic but has major implications, says Marin. Is PGT-A health care or is it a product? That distinction matters because consumer-protection law doesn’t always apply neatly to medical services. Here, she argues, it should. The issue isn’t clinical judgment—it’s how a commercial product was marketed and sold to doctors and patients. On paper, PGT-A results can look almost bulletproof. But, in the lawsuits, Marin and her colleagues claim that the test was never properly validated before being offered to patients, never put through the kind of rigorous clinical trials required to demonstrate that its results are as reliable as advertised.

And misdiagnoses do happen. One 2018 study found that nearly seven per cent of embryos that developed into healthy babies would have been discarded if doctors had seen genetic test results first. According to another, from 2024, one in 10 chromosomally abnormal embryos and one in five mosaics (those with a mix of normal and abnormal cells) are misdiagnosed. In other words, the embryos most likely to be written off are also the ones about which the test is most likely to be wrong. And yet, the belief that PGT-A can offer clarity has been enormously profitable for the companies behind it. In 2021, Swedish fertility firm VitroLife bought Igenomix—one of the companies named in the lawsuits and a lab widely used in Ontario—for roughly $2.8 billion. (Neither VitroLife nor Igenomix responded to requests for comment.) That deal was just one piece of a larger boom: globally, the annual revenue generated by pre-implantation genetic testing is projected to nearly double to roughly $1.6 billion by 2030.

Because patients have been told that PGT-A is more than 97 per cent accurate, the results of the test can become the fulcrum of a whole treatment plan, as plaintiffs in the class actions contend. It’s the vulnerability that concerns Marin most—how exposed fertility patients are. By the time someone is sitting across from a clinician considering genetic testing, or watching a lab-provided webinar that promises to take the guesswork out of IVF, they’ve been told that it will increase their chances of having a baby. According to the lawsuits, testing companies exploit exactly this dynamic.

After spending six years and undergoing two egg retrievals at the same clinic, Attia needed a fresh start. In the fall of 2023, she underwent her third retrieval at a new clinic and ended up with five embryos. Her doctor wanted to send them for PGT-A, but Attia was hesitant. It hadn’t made a difference in the past. Still, she and her husband had switched to this clinic for its expertise in immunotherapy, and her new doctor wanted to understand whether the obstacle was in the embryos or in Attia’s body. So they forked over another $5,000. The results were mixed: one chromosomally normal embryo along with two abnormal ones, one mosaic and one that returned no result at all.

With just one chromosomally normal embryo, Attia threw everything she had at preparing for the transfer. Analysis hadn’t turned up any glaring immune issues, but her doctor put her on immunotherapy anyway. “You never know,” she told Attia. For six months, Attia cycled through a battery of treatments: intralipid infusions, steroids, blood thinners. She even tried a controversial therapy, suspended by the FDA in the US, which involved slowly injecting vials of her husband’s white blood cells under her skin. The burning sensation was almost ­unbearable—but, a few months later, she did it all over again. “I was willing to try anything,” she says. “It felt like an addiction. If I just keep going, eventually I’ll hit the jackpot, right?”

On the day she went in for the transfer, Attia felt the weight of every decision she and her husband had made: the money they’d spent—more than $100,000—all the doctors and clinics, the years of treatment. “I remember looking at this embryo like it was our last chance,” she says. The transfer failed.

At the Canadian Fertility Show, the line between health care and consumer culture has all but disappeared. Held on a Saturday last October in a convention room at the Westin Harbour Castle, the expo brought together two dozen exhibitors. Clinics, sperm banks, surrogacy agencies, testing companies and other fertility vendors filled the space, jockeying to introduce the 250 attendees to all they had to offer.

The strap from the branded tote I’d been handed on arrival that morning dug sharply into my shoulder. As I did a lap of the room, the bag heaved with freebies—vitamin samples, a motivational calendar, ovarian reserve screening tests, pamphlets. At one table, an Irish nutritionist touted supplements “based entirely on his own research.” Across the aisle, a Greek clinic promised to rejuvenate aging ovaries with platelet-rich plasma injections. At the other end of the room, an attendee was stretched out on a massage table while a practitioner waved a tuning fork above her abdomen, drawing invisible circles in the air.

There were clinics with solid reputations for nuanced, evidence-based care and others known for steering patients toward pricier, more questionable package deals. Near the entrance, a national advocacy group that has spent decades pushing for accessible, research-driven care was positioned across from a major event sponsor promoting the same painful, banned-in-the-US procedure Attia had undergone. It was a bazaar of modern reproduction: medicine and maybe-medicine, hard science and hard sell, all under the same fluorescent lights.

At the Igenomix booth, the company’s scientific adviser described a new test called Embrace, designed to bring more clarity to embryo selection without the need for a biopsy. Instead, she explained, Embrace analyzed the DNA the embryo naturally releases into the fluid surrounding it in a Petri dish. When I asked whom the test was intended for, she said Embrace was best suited to patients who don’t meet the usual criteria for PGT-A, including situations involving donor eggs or sperm. “Or patients that are younger and have a good prognosis,” she added. If they don’t need PGT-A, the thinking seems to be, maybe they’ll buy Embrace—at a minimum cost in Ontario of $1,800 for the lab fee and $400 for each embryo tested.

The test’s concordance rate with traditional PGT-A is also only about 78 per cent, meaning it disagrees more than one in five times, a significant gap when the result dictates which embryos are to be transferred. Studies in the peer-reviewed medical journals Human Reproduction and Scientific Reports found that non-invasive PGT-A, the approach used by Embrace, misclassified nearly half of chromosomally normal embryos as abnormal. When I asked Tom Hannam about Embrace’s viability, he hedged. “I’m not saying it’s definitely exploitative,” he said. “But, if I was interested in taking advantage, that’s what I’d do. I’d charge a lot of money for a test with limited evidence.” Where innovation ends and where something more opportunistic begins is “a question of trust,” he added, “between patients willing to try something unproven and clinicians tasked with separating the cutting edge from the under-studied.” He, for instance, is a defender of PGT-A when used for the appropriate patients. There’s a solid body of research for patients to weigh when deciding whether it’s right for them, he reasoned. “It doesn’t meet the definition of exploitative,” he said.

Embrace is just one of several recently introduced tests with soft, soothing names. One woman I spoke with for this piece had a doctor at a Scarborough fertility clinic recommend two Igenomix tests—EMMA and ALICE—costing a total of $1,800, despite more than one study questioning their efficacy. The woman had gone to the clinic to request a basic OHIP-covered biopsy to screen for endometritis, a uterine infection that can interfere with implantation. “They were happy to do a test,” she says, “but not the one that’s covered.”

The upsell isn’t reserved for lab tests, and the commercialization of care isn’t product-specific. It shows up in smaller, subtler ways too. In June of 2024, a 31-year-old lawyer from Barrie and her partner visited Generation Fertility, a clinic in Vaughan, for the first time. At that initial appointment, her doctor prescribed a mild ovulation-inducing drug and told them to start taking fertility supplements. The clinic followed up with an email containing information on how to buy the recommended supplements, either at the clinic or via a direct-purchase link. (The email also listed an alternative option that could be ordered through Amazon.)

She bought the supplements through the direct-purchase link, which she says sent her to Bird and Be, a popular Toronto fertility-wellness brand. The couple’s subscription cost roughly $140 a month. They shelled out for about a year, until one day the link broke. When she inspected the URL, it became clear that the link was routed to an affiliate marketing platform, making her wonder whether the clinic or someone associated with it may have received a referral fee when patients purchased Bird and Be products. At first, she was confused. Are doctors allowed to make money off the supplements they recommend? Then she got mad—Bird and Be supplements are pricey, among the most expensive options out there. If doctors are profiting off them, she thought, they should disclose that.

There may have been more than one party profiting every time the Barrie lawyer clicked that link. Generation Fertility isn’t a stand-alone clinic—it’s part of the Fertility Partners, a private equity–backed Canadian network launched in 2021 that now operates 36 locations across Canada and the US, making it one of the largest fertility operators in North America. The company’s medical director, Dan Nayot, also serves as chief medical adviser for Bird and Be. And he co-founded HaloHealth, a physician-led investment network that has put money into Bird and Be. In other words, the person overseeing her clinic was simultaneously advising the supplement company her clinic was recommending and profiting from an investment fund that had a stake in that same company. Further blurring the lines, Nayot also co-founded Future Fertility, the company that developed the AI-enabled tools Magenta (for assessing egg quality) and Violet (for egg ­freezing)—which are available at several Fertility Partners clinics.

When I reached out to the Fertility Partners for comment about affiliate links, a spokesperson said the network has no commercial relationship with Bird and Be and is not aware of any affiliate links being used within its clinics. They said clinicians may recommend that brand based on formulation, dosage and availability, and they emphasized that supplements are optional and not part of any treatment protocol. They also described Bird and Be as relatively affordable, though they acknowledged that such assessments can be subjective. Asked about potential conflicts of interest arising from overlapping roles between clinic leadership and fertility-related companies whose products or services are recommended to patients, the spokesperson said those relationships weren’t considered material enough to require disclosure given the small size of the fertility industry.

Even if that’s all true, private equity plugs fertility care into a much larger commercial ecosystem—one with growth targets and bottom-line pressures. The Fertility Partners was founded by Andrew Meikle, a dentist, with $90 million in private equity backing from Toronto-based Peloton Capital Management and Australia’s Heal Partners. This wasn’t Meikle’s first foray into health care consolidation. In 2011, he co-founded Dentalcorp, which grew to become Canada’s largest dental network, acquiring more than 550 practices nationwide, often at prices well above industry standard. The playbook was clear: consolidate fragmented markets, centralize operations and drive revenue growth. Peloton and Heal backed him then too. In late September, Dentalcorp was sold to an American private equity firm for $2.2 billion.

There is proven money to be made in fertility—which creates significant pressure to make more money. The global market’s exponential growth has already attracted private equity and venture capital, and no other medical specialty has a larger share of corporate ownership. In Ontario, almost a third of the province’s 43 fertility clinics are now tied to investor-backed networks.

In 2023, Vancouver-based venture capital firm Rhino Venture poured $8 million into Twig Fertility, a Toronto clinic launched the year before to introduce “tech-driven” care to the fertility industry. That same year, Osmington Inc., a company owned by David Thomson—chair of Thomson Reuters and Canada’s second-richest man—invested $20 million in Pollin Fertility, a new clinic that would leverage proprietary AI algorithms paired with evidence-based medicine to enhance both fertility outcomes and the doctor-patient experience. In 2024, the first clinic Attia went to was acquired, along with 10 other Ontario clinics and more than 30 in Boston, by IVI-RMA—the same RMA behind the influential study often used to justify PGT-A—as part of a $535-million deal. IVI-RMA is owned by KKR, one of the biggest private equity firms in the world.

Investor backing can affect patient care. A 2023 American study found that patients at private equity–affiliated practices were 11 per cent more likely to use pre-implantation genetic testing before embryo transfer. Chloé Roumain, a reproductive endocrinologist who runs a clinic in North York, worked at a private equity–backed facility after her training. Some meetings, she recalled, were led not by medical staff but by business development, where the focus was on goals, like a certain ­number of cycles, that needed to be met. “It was understood that, if you were not meeting those targets, you needed to prescribe more IVF,” says Roumain. “But that’s a medical decision, and it may not be what the patient needs.”

Nearly every patient I spoke with for this piece believes that their doctors and clinics—whether they were public, physician-owned or backed by private equity—were acting in good faith and with their best interests in mind. What they didn’t trust was the system around them: the lack of transparency, the uneven standards that define fertility care in Canada and, crucially, the communication gaps. Hannam believes that a single moment is pivotal to a patient’s experience: after they receive a diagnosis and before they begin a treatment plan. “That’s the whole banana,” he says. Getting bad news is stressful and disorienting; studies show that patients retain only a fraction of what’s said to them in that moment. They’re rarely in the right headspace to define their broader goals, which are more nuanced than most people realize. Is it essential to have a child that’s genetically their own? Are they open to using donor eggs or sperm? Do they want to take their time—exploring less expensive, less invasive options—or do they not have time to take their time? In fertility treatment, even a few months’ delay means older eggs and fewer live births. That’s where the real work lies: not in pushing, or even pushing back against, another add-on but in setting expectations and goals early and revisiting the conversation often.

Attia’s husband was ready to stop when their last chromosomally normal embryo failed. But she couldn’t. Transferring their last two embryos felt to her like a necessary step toward closure, whatever came next. One day in October of 2023, her doctor transferred both—one with a high proportion of abnormal cells and another the test hadn’t been able to analyze. Attia wasn’t nervous: she was expecting the worst but hoping for the best. A few weeks later, on her birthday, she took a pregnancy test and saw a faint line. Then her in-clinic blood draw showed hormone levels higher than ever before. She and her husband booked an ultrasound, and together they saw the fetal heartbeat for the first time. Their daughter was born the following summer. “One of those embryos no one had any hope for,” says Attia. Ultimately, the $12,500 they had spent on PGT-A hadn’t really helped at all. The winning embryo was either one the test had mostly dismissed or one it had failed to interpret at all.

Stories like Attia’s reveal the limits of certainty in a field that relies on patients’ hopes and dreams. They show how much these patients are asked to shoulder. They show how much of the process is dictated by tests and how much by trust—and how fragile that trust is when the incentives shaping care are complex, commercial and largely invisible. The rise of add-ons has demonstrated that patients will spend money on tests for even the faintest suggestion that they might improve their odds of bringing home a baby. They are trying to navigate a system where marketing and medicine co-exist, a space that is populated by brilliant clinicians and world-class labs but also private equity and minimal regulation. For patients, that makes the experience both more hopeful and more fraught than ever. There are more options and better science but a lot more noise too. As the paths to possible parenthood multiply, so do the ways of getting lost along them.

This story appears in the March 2026 issue of Toronto Life magazine. To subscribe, click here. To purchase single issues, click here.