Freshman Philosophy, NIAW, and the Democratization of IVF

David Sable
4 min readApr 25, 2023

For National Infertility Awareness Week

I understand the IVF marketplace with the help of the stars of my University of Pennsylvania freshman syllabus, Pareto and Maslow. Vilfredo Pareto, best known for the 80/20 rule, also described an economic equilibrium state where, regardless of who starts with what and how equitably or inequitably all the stuff in the world is distributed and owned, left to free trade among themselves with each transaction making both parties better off until the members of a group reach an equilibrium state where make on better off without making the counterparty worse off. The betterment of the group as a whole will stop.

Abraham Maslow and the hierarchy of needs, taught and invoked in any discussion of human behavior and motivation, stratified human needs into categories from the most urgent (physiologic and safety) to the less urgent (the need for love, self-esteem, and comfort), and theorized that people triage their attention and energy to meeting the less pressing needs only once the more urgent needs are satisfied.

A medical version of the Maslow hierarchy demonstration is ongoing in the emergency department of any hospital where a highly trained (and patient) triage person, usually a nurse, enforces a “this is not first come, first served zone” state. Exsanguination, precipitous birth, and trauma are seen before chest pain, which is seen before headache (unless accompanied by signs of stroke); acute conditions are seen before the chronic, and some people are directed down the hall to make an appointment at ongoing care clinic, after determining that none of the rapidly progressive conditions are present (acute appendicitis, for example.)

We take care of physical pain, hunger, thirst, and fatigue daily before attending to loneliness, melancholy, aesthetics, and curiosity. It’s tempting to apply terms like more essential and less important as you travel up the pyramid from losing consciousness from internal bleeding to a gradually worsening blurry vision to feelings of unease and disassociation.

When Maslow and Pareto meet to describe the stagnant IVF marketplace of the first thirty years, Maslow first points out, for most of us, that the drive to start and have a family is physiologic, and the inability to do so creates hunger and pain closer to starvation in its command of attention and search for a solution. For many of us, the inability to conceive a child, successfully carry a child to viability, or nurture young children safely through childhood, becomes that primary preoccupation of life and creates a void that cannot be willed away, wished away, or “Just be strong-ed” away.
In business school, they taught us in marketing that fear sells. But pain sells more. Seen through the univocal lens of the marketplace, starting a family without the cooperation of physiology and nature is the melancholy in the morning, the drag on the work day, the tamping of the joy when encountering beauty or creativity or when called upon to express love, the cause of insomnia and the subject of bad dreams. We lack the right word to describe this particular void, to invoke the urgency that “starving” or “exhausted” describes. We’ve all felt famished, parched, and exhausted; we’ve jumped up and down, desperately needing to go to the bathroom while stuck in the elevator. Until these temporary conditions are relieved, nothing else in our lives matters. Thankfully, relief is usually nearby and coming soon.

That’s not the case for the pain of infertility. Helping is not so easy.
Handing half of your sandwich to a hungry neighbor is one thing. Its quite another to design and build thousands of square feet of sterile laboratory space, staff and equip it with scientists, technicians, incubators, microscopes with micromanipulators and vitrification units, and maintain an inventory of glassware, media, and liquid nitrogen, then attach a clinical unit filled with doctors and nurses and genetic counselors and financial and administrative staff, and to implement a system to meet the reinvestment and working capital needs to pay for the facility.

For the first thirty years, this was done by doctors following the private practice model, and the number of labs grew steadily, reaching a peak of about 500. At that point, with just about all of the doctors employed and busy and making a good living, and since having an adequately trained reproductive endocrinologist is a gating go/no-go decision point in the Can I Start an IVF Program decision tree, Pareto stepped in and said that we had reached equilibrium and that a stable number — not necessarily adequate or correct — the amount of IVF availability (and therefore access and therefore the aggregate ability to solve infertility) had been reached.
And in a Pareto optimal equilibrium state, no one does better without someone else doing worse.

And no one volunteers to be the one to do worse.

So we either have to wait for the world to change in a way that reignites trade or to make it easier or more desirable to meet one group’s needs in a way that matches the conditions that another group is equipped to take off and want to take care of.

In this case, we have an enormous group of people, perhaps 10% of the reproductive-aged population, a group in the tens of millions worldwide, with empty rooms and unoccupied picture frames, with photo sleeves in wallets and planned education savings accounts desperate for the opportunity to purchase the services of another group that holds the knowledge and capacity to elevate each of those people to the next rung on the Maslow hierarchy.

Next: technology + Maslow conquer Pareto.



David Sable

bio fund manager, Columbia prof, ex-reproductive endocrinologist, roadie for @PriyaMayadas. I post first drafts.