FERTILITY AND STERILITY威

VOL. 75, NO. 5, MAY 2001

Copyright ©2001 American Society for Reproductive Medicine
Published by Elsevier Science Inc.
REPRODUCTIVE ENDOCRINOLOGY
Printed on acid-free paper in U.S.A.

How do patients choose private in vitro

fertilization treatment? A customer
survey in a tertiary fertility center in
the United Kingdom
Amir Lass, M.D., and Peter Brinsden, F.R.C.O.G.
Bourn Hall Clinic, Bourn, Cambridge, United Kingdom

Objective: To assess the relevant factors affecting patients’ decision when choosing a clinic for private,
self-funded IVF treatment.
Design: Prospective anonymous closed questionnaires.
Setting: Single tertiary-care private IVF center.
Patient(s): New patients attending primary consultation in a period of 7 months from September 1999 to
March 2000.
Intervention(s): None.
Main Outcome Measure(s): Primary knowledge about the clinic, source of referral, knowledge of, avail-
ability of information pack, and familiarity with the clinic’s success rates and treatment’s price. The last
question assessed the relative importance of each factor in the decision-making process according to the
SERVQUAL model, modified version. All items were measured as perceptions on a 5-point Likert scale. 1 ⫽
not important, 3 ⫽ neutral, and 5 ⫽ very important.
Result(s): One hundred seventy-five patients completed the questionnaire. They were well informed and
investigated the market before making their final choice. Patients collect information from many sources,
including new channels such as the Internet. Up to one third of patients do not consult their doctor before
treatment. By far the most relevant factor in decision making is the success rate (i.e., delivery rates) of the
clinic, followed by recommendation by general practitioner (GP) or consultant (respectively, Likert scale
score, 4.6; 95% confidence interval [CI], 4.5– 4.7; and Likert scale score, 4.0; 95% CI, 3.9 – 4.2; P⬍.01). Other
factors, such as cost of the treatment, friends and relatives’ opinions, and distance from home were not
relevant.
Conclusion(s): Units that wish to thrive and increase their market share should deliver high-quality service
and concentrate their efforts on excelling in performance. (Fertil Steril威 2001;75:893–7. ©2001 by American
Society for Reproductive Medicine.)
Key Words: Customers, IVF, pregnancy rate, purchasing decision

Received August 25, 2000;
revised and accepted
December 1, 2000.
Present address for reprint
requests: Amir Lass, M.D.,
Serono International SA,
Stanwell Road, Feltham,
Middx, TW14 8NX, UK
(FAX: ⫹44 208-8187267;
E-mail:
amir.lass@serono.com).
0015-0282/01/$20.00
PII S0015-0282(01)01751-4
In the United Kingdom, most medical treat-
ments are provided by the National Health Ser-
vice (NHS) free of charge. The private medical
market is relatively small and operates in par-
allel with the NHS, usually in private hospitals.
Recent figures show that about 11% of the
population have a private medical insurance
scheme, mostly as employee benefits through
collective workplace agreement (1). This rate is
much lower than in the United States.
The market for advanced reproductive tech-
nology (ART) treatments in the United King-
dom is substantially different from the above
model. The decision to fund this treatment is
the prerogative of the regional health authority
and differs from region to region (post-code
lottery). Currently, most couples who require
IVF treatment are not funded, and they are
never funded if they are older than 38 years or
have living children. In addition, private health
insurers do not cover the cost of IVF cycles (in
some cases, they cover consultations and diag-
nostic tests). The majority of treatments are
performed therefore in private units or in pri-
vate wings of public hospitals, fully paid for by
the patients themselves.

893
 The market for ART in the United Kingdom is a highly
sophisticated, fragmented, and specialized-niche service in-
dustry. Centers performing ART are all licensed and regu-
lated by the Human Fertilization and Embryology Authority
(HFEA) according to Parliament Act 1990. Britain is one of
the most regulated countries in the world. Many other units
offer first-line infertility treatments that do not require reg-
istration with the HFEA, such as ovulation induction and
IUI. Since 1995, the HFEA has published an annual report
that lists all the licensed clinics and their delivery rates; this
is known to the public as the league table, although this list
might be skewed (2). This public document has become very
popular with patients and clinicians as it enables them to
assess performance of each clinic.
The market is very competitive, dense, and expanding. In
the last 4 years, there has been an increase of 50% in the
number of patients treated nationally, with a parallel increase
of 33% in the number of ART units. Currently, 73 centers
perform more than 30,000 IVF cycles a year in the United
Kingdom (3). There is no market leader: the largest unit has
only 5.5% of market share, and the six largest units, which
perform more than 1,000 cycles per year, have 23% of the
market share (4). The cost of one complete cycle ranging
from £965 to £2,500 (mean, £1,715; in US dollars, $1,450 to
$3,750; mean, $2,570), not including medications (4).
The decision to embark on such a physically, emotionally,
and financially demanding treatment as IVF is not taken
easily by the patients. It is a nonemergency, private, elective
medical treatment, and the mechanism of this decision is not
clear. The aim of this study was to understand and analyze
factors affecting customers‘ purchasing decision at a single
private, tertiary fertility center in the United Kingdom.
MATERIAL AND METHODS
The study was prospective, assessor blinded, and based
on patient questionnaires voluntarily and anonymously com-
pleted (Appendix). In a period of 7 months from September
1999 to March 2000, all new potential private patients at
Bourn Hall Clinic (BHC) were asked to fill in a question-
naire designed specifically for this study by one author
(A.L.). Patients who had had treatment previously in this
clinic or those who were funded by local health authorities
via contracts between the NHS and the clinic (i.e., local
health authorities purchase the treatment from the clinic and
supply it to patients free of charge) were excluded from the
study and did not receive the questionnaire. The question-
naires were completed and handed in before the patients’
initial consultation at the clinic to eliminate the possible
effect of personal impressions from the clinic and its per-
sonnel on the answers. To maintain strict anonymity, identity
of patients handing in the form was not recorded; therefore,
no attempt was made to correlate between demographic data
and answers to the questions. Patients who booked a primary
894 Lass and Brinsden How do patients choose private IVF treatment?
consultation received by post an information package from
the clinic that included recent delivery rates and a price list
of the different treatments available.
In the questionnaire, patients were asked how they first
heard of the clinic, who referred them to it, and whether they
knew its success rates and price of the IVF cycle.
The last question aimed to analyze the relative weight of
each factor in the purchasing behavior of infertility treat-
ment. This question was planned according the SERVQUAL
model, modified version, proposed by Parasuraman et al. (5).
All items were measured as perceptions on a 5-point Likert
scale: 1 ⫽ not important, 3 ⫽ neutral, and 5 ⫽ very impor-
tant.
Statistical analysis was performed using the Student t-
test, ␹2 test, and Mann-Whitney U-test for nonparametric
data when appropriate, using the Medcalc statistical software
package (Mariakerke, Belgium).
RESULTS
From September 1999 to March 2000, 370 new patients
resident in the United Kingdom, mostly from southeast An-
glia (328 patients, 88.6%), came for primary consultation. Of
them, 175 (47.3%) completed the questionnaires. One hun-
dred and six (60.0%) couples had the first knowledge about
the clinic from their GP and/or consultant, whereas 53
(30.3%) patients were informed by friends or relatives. Other
sources of information were significantly less frequent, and
none of the patients acquired their initial data from national
or local newspapers and magazines (Fig. 1).
Referrals to the clinic were distributed equally between
GPs (32.6%), consultant gynecologists (34.9%), and self-
referrals (32.6%). Patients were well informed about the
clinic before their first visit. Nearly all patients (97.3%)
received an information package, 92.6% knew the price of
the cycle, and 87.4% were familiar with the recent delivery
rate of BHC.
The most important factor for patients in choosing the
clinic was its success rate (mean rating of 4.6; 95% CI,
4.5– 4.7), significantly more so than the recommendation of
their GP or consultant (4.0; 95% CI: 3.9 – 4.2, P⬍.01).
Delivery rates and doctor’s recommendation were statisti-
cally more important than price, distance from home,
friends‘ opinion, and information pack from the clinic,
which were neutral factors (⬍4, Fig. 2).
GPs’ and consultants’ opinions were more important to
patients who were referred for treatment by them than to
patients who were self-referred (4.2 vs. 3.7, P⫽.018), but for
both groups, the success rate was equally the most relevant
factor, at the high rank of 4.6.
DISCUSSION
IVF treatment is a complicated, demanding, and, in many
cases, a physically, emotionally, and financially draining
Vol. 75, No. 5, May 2001

FIGURE 1
Source of primary knowledge of BHC.
Lass. How do patients choose private IVF treatment? Fertil Steril 2001.
process. Regretfully, most of patients in the United Kingdom
do not receive any financial assistance from their local health
authorities and need to raise the funds themselves. IVF
treatment is therefore a service offered to potential custom-
ers in a dense market, with strong competition between the
numerous providers of this service. Patients are required to
make a consent decision when choosing the clinic in which
they try to achieve their target of becoming parents. As with
any other service, healthcare organizations share the features
and problems of a service industry (6):
● Intangibility: the service cannot be seen or examined
before consuming.
● Inseparability: the service is produced and consumed at
the same time and cannot be separated from the pro-
viders (i.e., doctors, nurses), so the consumer must be
integrated into the production process.
● Variability: quality may vary greatly, depending on who
provides services and when, where, and how service is
provided.
● Perishability: the service cannot be stored for later sale
or use, so empty consultation slots or idle time are a loss
of revenue.
● Lack of ownership: customers have access for limited
time, and they “own” it only when they use the service,
not in later stages, in contrast to the case with product
consumption.
FERTILITY & STERILITY威
This is, to our knowledge, the first study that attempts to
understand the mechanism involved in customers’ decision
to have an advanced fertility treatment on a private basis.
Bennett (7) argues that fundamental understanding of buy-
ers’ needs and wants, through the eyes of the buyer, will help
to generate a stronger and more strategic focus on the
achievement of the service provider’s objectives. The pur-
chasing process is quite complicated and comprises a few
stages and influences (8). The process is considerably dif-
ferent in health care purchasing because the referral doctor,
who is not the customer, has significant weight on the buyer
(the patient), much more than in consuming any other prod-
uct or service (9). Whereas patients are the purchasers of the
service, GPs and consultants are the “opinion formers” (10).
Our results show that GP and/or consultant recommenda-
tions are very important to the patients. The high rank of a
doctor’s opinion for patients who have been referred by them
is not surprising, and it is probable that patients who received
a negative opinion from their GP about BHC would not have
come to our clinic. Moreover, quality and depth of informa-
tion and strength of recommendation are likely to range
significantly from one GP to another, as well as level of
relationship between different patients and physicians. These
factors naturally could not be assessed in this study.
A third of our patients did not even bother to consult their
doctor before approaching the clinic, a surprisingly large
number for the British medical system. However, recent
publications from the United States have presented an
emerging trend that customers are relying less on doctors
today than in the past to choose the “right” hospital (11, 12).
This is partly a result of the intangibility of the health care
services that leads even professional purchasers like GPs to
act more like inexperienced consumers (13) and partly a
result of the spread of medical data through the media, as
well as through open publications like the HFEA Annual
Report.
It is important to note that despite the expanding use of
the Internet and the wealth of medical information available
on it, only 5.7% of patients in this survey learned about the
clinic from this source. Although most of the IVF units in the
United Kingdom have websites, they are not a major source
for information, but this reality will probably change in the
future. In this study, the importance of data retrieved from
the Internet was not assessed; however, it is probably of
similar importance as the information package from the
clinic because the data is basically similar, albeit more
detailed.
It is clear from the data that for all patients, success rate
(i.e., delivery rate) is the most important determining factor
in the decision process. However, this factor should be
interpreted cautiously; BHC was located only in the 20th
place in terms of success rate, with a rate similar to the
national average rate (17.7% vs. 17.8%, respectively), ac-
cording to the latest HFEA report available in that period.
895
 FIGURE 2
Factors affecting purchasing decision for BHC’s customers. Values are mean ⫾ 95% confidence interval.
Lass. How do patients choose private IVF treatment? Fertil Steril 2001.
There is thus a discrepancy between declared importance of
excellency and the position of BHC in the United Kingdom
league table. However, BHC has a unique, good “brand”: it
is the first purposely designed IVF unit founded by IVF
pioneers Dr. Steptoe and Professor Edwards immediately
after the delivery of the first “test tube” baby in the world,
Louise Brown in 1978. It is possible that the clinic is re-
garded as excellent by patients and clinicians regardless of
its position in a league table of any kind. The importance of
brand name in service market is well recognized (14 –16).
Two different perceived qualities in high-level service
like health care exist: technical and functional (17). Techni-
cal quality measures what is delivered: for example, the
quality and effectiveness of diagnosis and medical proce-
dures of a hospital. Functional quality measures how the
service is delivered—the care and manners of the delivery
personnel. Each quality affects satisfaction and loyalty in a
different manner. Mittal and Lassar (18) recently showed in
a survey of 123 customers in the health care services that
satisfaction is a result of functional quality, whereas loyalty
is determined on technical quality. Satisfaction is a “must
requirement” for loyalty but does not guarantee it. Even at
the satisfaction rating of 5 (excellent), as many as 19.5% of
consumers of health care services are willing to switch. In
the IVF market, the technical quality is much more trans-
896 Lass and Brinsden How do patients choose private IVF treatment?
parent to customers because of the publication of the league
table, in contrast to the case of any other discipline in
medicine. The functional quality can be assessed only during
and after consumption of the service. The functional quality
is reflected partially in friends and relatives’ opinions or by
word of mouth. A few authors have advocated the impor-
tance of this method in healthcare marketing (19, 20). How-
ever, our results show that although 30% heard about the
clinic initially from friends, word of mouth was not an
important factor in their decision (value of 3.2).
Price of the treatment, a major issue in any purchasing
process, had neutral importance in this study, in spite of
BHC being in the top 10% of the price list in the United
Kingdom. It is possible that for other customers, the price
was a crucial factor and they avoided the clinic on that
ground. We recognize the limitation in drawing conclusions
from study based on a survey in a single IVF center in the
United Kingdom, which does not necessarily reflect the
situation in other parts and units of the United Kingdom and
abroad. It will be interesting to compare these trends with
surveys from other units or preferably from national data.
In summary, we found that patients who require private
IVF treatment are well informed and investigate the market
before making their final choice. They collect information
Vol. 75, No. 5, May 2001
from many sources, including new channels such as the
Internet. Although GPs’ and consultants’ opinions are still a
very important source of advice and referral, up to a third of
patients do not consult them before their treatment. By far
the most relevant factor in the decision making is the success
rate of the clinic. Success rate data is currently widely
available since the publication of the league table. Units that
wish to thrive and increase their market share should con-
centrate their efforts on excelling in their performance.
Acknowledgments: The first author thanks Mrs. Carol Blackman, Marketing
Department, University of Westminster Business School, London, United
Kingdom, for her invaluable supervision. This study was A.L.’s part of a
final project in fulfillment of the requirements for the degree of Master of
Business Administration (MBA).
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APPENDIX:

Patients questionnaire.

1. How did you know about Bourn Hall Clinic?

• From friends or relatives Y/N
• Through your GP/consultant Y/N
• Daily/weekly newspapers articles Y/N
• Women’s magazines Y/N
• Radio/television programs Y/N
• Internet Y/N
• Others (please specify)
2. Have you been referred to Bourn Hall by:
• Your GP
• Your consultant gynecologist
• Self-referral
3. Do you know the success rate of the Clinic? Yes/No
4. Do you know the price of the treatment? Yes/No
5. Did you receive any information pack from Bourn Hall Clinic? Yes/No
6. How important is each of these factors in deciding whether to
have a treatment at Bourn Hall Clinic?
• (N/A-not applicable, 1-not important, 5-very important)
• Friends/relatives recommendations N/A 1 2 3 4 5
• GP/consultant recommendations N/A 1 2 3 4 5
• The price of the treatment N/A 1 2 3 4 5
• Success rate of the treatment N/A 1 2 3 4 5
• Information package from the clinic N/A 1 2 3 4 5
• Distance from your home N/A 1 2 3 4 5
• Information on the Internet N/A 1 2 3 4 5

Lass. How do patients choose private IVF treatment? Fertil Steril 2001.

FERTILITY & STERILITY威 897