What is driving demand for IVF in the Middle East?

 

Childbirth is a very important part of Middle Eastern culture and seen as a government priority to help expand citizen population. As such, some wealthy states fund IVF for their citizens.  Whilst not ubiquitous, it does create pockets of large markets in the region, which are, or could be, targeted by operators and investors. 

IVF ‘oil rush’

Candesic reviewed IVF markets in the region and found significant increases in IVF volumes in the majority of them. Underlying growth rates in the Middle East range from -3.4% in Kuwait to 24.9% in Oman, and 33.6% in Abu Dhabi, compared to growth of 3.2% in the UK and 2.8% in Germany. There are several drivers driving demand for IVF; infertility is twice as prevalent in the UAE (33%) than in the UK (14%). 

Keeping it in the family

Consanguinity, marrying close relatives, is common in the region.  Hassan Abu Saad’s study shows a clear link between consanguineous marriage and children with intellectual and developmental disability (IDD). The biological explanation is the presence of autosomal recessive disorder. Essentially, if both parents carry the same autosomal recessive gene, there is a higher chance of their child inheriting two abnormal genes and, therefore, suffering from disease. 

Many Middle Eastern countries have deep-rooted cultural customs normalising consanguineous marriage. Studies suggest that between 30% and 40% of marriages in Oman and the UAE are consanguineous, with even higher rates (over 50%) in Saudi Arabia and Kuwait, compared to less than 1% in the UK. 

Therefore, the risk of IDD is higher and IVF allows for embryos to be tested for specific genetic diseases prior to being implanted: this is known as Preimplantation Genetic Screening or Diagnosis (PGS/PGD). Embryos are left to develop in-vitro for around five days, after which some cells are collected and tested, allowing parents to determine whether or not the embryo is free of genetic problems before starting the pregnancy. Couples concerned about how their consanguineous relationship might affect their children often elect to have PGD testing. Given the high consanguinity rates in the Middle East, this is a significant demand driver for IVF services and is unlikely to change in the foreseeable future. 

Disease of affluence

Obesity is another key driver of IVF demand in the Middle East, with known causal links to low sperm count in males and to hormonal imbalances and polycystic ovary syndrome in females. Obesity in either parent can cause fertility issues. It is associated with reduced ovulation rates, increased miscarriage rates, and poor response to ovarian stimulation during assisted conception. These factors result in increased time to conception, and lower implantation and pregnancy rates following both spontaneous and assisted conception. 

According to the WHO, Kuwait is the 11th most obese country in the world, with an obesity rate of 37.9%, just above the US (ranked 12th) and followed by Jordan, Saudi Arabia, Qatar, Lebanon, and the UAE. Obesity reduces the probability of couples achieving pregnancy both naturally and through fertility treatments. 

Lack of sun in the Middle East?

Vitamin D deficiency is another potential driver. Approximately 90% of Emirate females have vitamin D deficiency, caused by lack of sun exposure, as women often cover themselves for cultural and religious reasons wearing the burka or hijab and stay indoors due to intense climatic heat.  Chu et al. found that live births are more likely to occur in women who had sufficient vitamin D compared to those who did not.

The unmentionable hits social media

Improved awareness and social acceptance of fertility treatments is another demand driver. Increasing awareness of treatment options (partly due to better information dissemination via the Internet) is also contributing to more couples seeking treatment, although word-of-mouth remains the most common channel for couples when deciding on clinics in the UAE.

Brave new world

Technological and scientific progress has supported improving success rates over the last decade, which also drives demand. Middle Eastern clinics often practise the ‘freeze-all’ strategy: by freezing all embryos at the blastocyst stage, they can then select only the best embryos for cultivation after day five. This leads to a success rate above 54% for most major clinics, which favourably compares with the average success rates for US and UK players of 46% and 22%, respectively. Customers view these results as better ‘value for money’ and are more likely to try the treatment.

Using IVF for gender selection (so called ‘family balancing’) is also legal in some GCC countries and is sought even by couples with no fertility issues.  Of note, Oman does not allow gender selection, meaning some couples travel and seek treatment in the UAE. 

Overall, the growing complexity of treatments (e.g., PGS/PGD and ICSI) is a market value driver, as complex treatments tend to be more expensive. 

IVF and public funding

The availability of public funding varies significantly between countries, and even between Emirates within the UAE. The number of publicly funded IVF cycles varies. There is generous funding to encourage people to have children in Abu Dhabi, with treatments available for married couples in both private and public hospitals. Some countries, such as Kuwait, fund IVF only for certain types of treatment or under certain conditions. In Oman, funding is only available to Ministry of Health and Armed Forces employees, who are reimbursed for IVF treatments. Government funding for IVF was scrapped in 2017 and is not expected to be reinstated. 

Similar to Dubai, Oman, Kuwait, and the Saudi Arabia are mostly cash markets and dependent on the number of wealthy people in the population. Even those who are eligible for public funding in these countries might have to wait months for an appointment. Thus, those with available funds are more likely to pay for private IVF treatment, especially if older and with decreasing chances of successful conception. 

Patients’ perception of the value for money provided by private fertility treatments has been improving, despite the relatively high treatment costs. Given the challenging patient population in the Middle East, the treatment price for IVF ranges from US$6,750 - US$9,990 without medication, with three cycles usually being necessary. This is nearly double the price of equivalent treatment in the UK. With further payments for add-ons, such as PGS/PGD, the overall treatment may exceed US$50,000 in some complex cases. 

New approaches are employed to achieve better success rates among Middle Eastern populations. These are important for not only achieving better outcomes given the local challenges, especially consanguinity, but also attracting patients to clinics. The growth in ‘word-of-mouth’ referrals is contributing to increased confidence and acceptance of privately funded fertility treatments.  The internet is another valuable channel for sourcing patients, especially those coming to the UAE from surrounding GCC countries for treatment. Candesic estimates that medical tourism in the UAE accounts for 10%, with potential for future growth given increasing numbers of patients coming from Africa and India. 

A longer version of this article, including additional market statistics and analysis of investor opportunities, is published in the Dec/Jan issue of the LaingBuisson journal, Healthcare Markets.  

References 

  • Abu Saad, H., Elbedour, S., Hallaq, E., Merrick, J. and Tenenbaum, A. (2014). Consanguineous Marriage and Intellectual and Developmental Disabilities among Arab Bedouins Children of the Negev Region in Southern Israel: A Pilot Study. PubMed – NCBI. [online] www.ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3904202/ [Accessed 21 Oct. 2019].
  • Chu, J., Gallos, I., Tobias, A., Tan, B., Eapen, A. and Coomarasamy, A. (2018). Vitamin D and assisted reproductive treatment outcome: a systematic review and meta-analysis. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29149263 [Accessed 21 Oct. 2019]. 

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