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In Australia and the UK, commercialization and corporatization of assisted reproductive technologies have created a marketplace of clinics, products, and services. While this has arguably increased choice for patients, 'choice', shaped by commercial imperatives may not mean better-quality care. At present, regulation of clinics (including clinic-corporations) and clinicians focuses on the doctor-patient dyad and the clinic-consumer dyad. Scant attention has been paid to the conflicts between the clinic-corporation's duty to its shareholders and investors, the medical profession's duty to the corporations within which they practice, and the obligations of both clinicians and corporations to patients and to health systems. Frameworks of regulation based in corporate governance and business ethics, such as stakeholder models and 'corporate social responsibility', have well-recognized limits and may not translate well into healthcare settings. This means that existing governance frameworks may not meet the needs of patients or health systems. We argue for the development of novel regulatory approaches that more explicitly characterize the obligations that both corporations and clinicians in corporate environments have to patients and to society, and that promote fulfilment of these obligations. We consider mechanisms for application in the multi-jurisdictional setting of Australia, and the single jurisdictional settings of the UK.

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RESEARCH QUESTION: What are the views of the medical directors of fertility clinics on IVF add-ons? DESIGN: A total of 93 UK clinics were emailed with an invitation for their medical director to participate. Ten IVF clinic medical directors were interviewed to discuss their views on the use of IVF add-ons. Some of the interviewees were medical directors of an IVF clinic with multiple branches across the UK, meaning the total number of clinics accounted for in this study was 35 out of the 93 contacted. Thematic analysis was used to analyse the data. RESULTS: The participants consisted of seven males and three females, with six from solely private clinics and four with NHS and private patients. Four themes were identified: clinical decision-making and the patient-doctor relationship; regulations and the add-on traffic light system; research and evidence; and commercialization and financialization of the IVF sector. CONCLUSIONS: UK IVF medical directors had a wide variety of views and experienced different pressures to offer IVF add-ons. The add-on discussion touches on core aspects of professional identity and the meaning of medical practice. The add-on debate points to broader changes in the organization of the IVF sector, which affect key aspects of practising (reproductive) medicine, including the patient-doctor relationship and responsibility for clinical decision-making, and the relationship between regulator and IVF clinic and between scientific evidence and clinical practice.

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In the last decade, the in-vitro fertilization (IVF) sector has witnessed a shift from so-called 'reactive IVF' to a new model of proactive fertility care. Whereas IVF was traditionally developed to treat people who found they were unable to conceive, the indication for IVF has broadened significantly to include a much wider group of potential patients through a new focus on proactive treatment of future (in)fertilities. This shift combines a number of new trends pertaining to preservation, prediction, private equity and platformization, all of which have gained influence in contemporary assisted reproduction. This article focuses on the emergence of company-sponsored fertility benefits, which combines each of these trends. Whereas fertility benefits - especially egg freezing insurance - have primarily been discussed in terms of women's empowerment or disenfranchisement, this article instead calls attention to the discursive, clinical and infrastructural shifts in contemporary assisted reproduction that have emerged with the rising popularity of these benefits. The analysis addresses these underdiscussed aspects of fertility benefits by focusing on the dynamics of demand; the shifts in the rationalization of intensified treatment pathways in the face of new reimbursement practices; and the online, platform-based infrastructures that are built to provide these treatments. In doing so, it analyses how this remaking of fertility towards an ethos of proactive fertility management reflects broader capitalist tailwinds.

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We invite systematic consideration of the metaphors of cycles and circulation as a long-term theme in the history of the life and environmental sciences and medicine. Ubiquitous in ancient religious and philosophical traditions, especially in representing the seasons and the motions of celestial bodies, circles once symbolized perfection. Over the centuries cyclic images in western medicine, natural philosophy, natural history and eventually biology gained independence from cosmology and theology and came to depend less on strictly circular forms. As potent 'canonical icons', cycles also interacted with representations of linear and irreversible change, including arrows, arcs, scales, series and trees, as in theories of the Earth and of evolution. In modern times life cycles and reproductive cycles have often been held to characterize life, in some cases especially female life, while human efforts selectively to foster and disrupt these cycles have harnessed their productivity in medicine and agriculture. But strong cyclic metaphors have continued to link physiology and climatology, medicine and economics, and biology and manufacturing, notably through the relations between land, food and population. From the grand nineteenth-century transformations of matter to systems ecology, the circulation of molecules through organic and inorganic compartments has posed the problem of maintaining identity in the face of flux and highlights the seductive ability of cyclic schemes to imply closure where no original state was in fact restored. More concerted attention to cycles and circulation will enrich analyses of the power of metaphors to naturalize understandings of life and their shaping by practical interests and political imaginations.

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RESEARCH QUESTION: How are IVF clinic websites advertising three common IVF add-ons: assisted hatching, time-lapse embryo imaging and preimplantation genetic testing for aneuploidies (PGT-A)? DESIGN: The Human Fertilisation and Embryology Authority 'Choose a fertility clinic' website service was used to identify IVF clinics and their websites. Assisted hatching, time-lapse embryo imaging and PGT-A were examined to determine which websites advertised them, what price they charged and what claims they made in relation to the add-ons. RESULTS: Eighty-seven eligible clinics were identified, with 72 unique websites; 37 (43%) clinics were part of one of nine groups of IVF clinics, of sizes ranging from two to eight clinics in the UK. Time-lapse imaging (TLI) was the most frequently advertised of the three add-ons (67% of clinics), followed by PGT-A (47%) and assisted hatching (28%). Very few websites stated that the effectiveness of the add-on was in doubt or unclear (four, two and one websites for TLI, PGT-A and assisted hatching, respectively), and none raised the possibility that an add-on might have negative effects. Claims of efficacy were often based on upstream outcomes (e.g. implantation, pregnancy). Some claims that PGT-A and TLI improved live birth rates were found. There was substantial variation in pricing. CONCLUSIONS: IVF clinic websites provide valuable information for patients seeking fertility treatment so it is key that the information is accurate and complete. There is a need for transparent information on interventions, including uncertainties and risks, to be made available by IVF clinics to support well-informed treatment decisions. The selected add-ons are widely advertised, and there is wide variation in pricing.

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The 21st century has witnessed the emergence of in silico reproduction alongside the familiar in vitro reproduction (e.g. IVF), as increasingly large and automatically-generated data sets have come to play an instrumental role in assisted reproduction. The article addresses this datafication of reproduction by analysing time-lapse embryo imaging, a key data-driven technology for embryo selection in IVF cycles. It discusses the new forms of knowledge and value creation enabled by data-driven embryo selection and positions this technology as a harbinger of a wider datafication of (reproductive) health. By analysing the new ways of seeing embryos with 'in silico vision,' the 'data generativity' of developing embryos and the patenting of embryo selection algorithms, I argue that this datafied method of embryo selection may not just result in more or less 'IVF success,' but also affects the conceptualisation and commercialisation of the assisted reproductive process. In doing so, I highlight how the datafication of reproduction both reflects and reinforces a consolidating trend in the fertility sector-characterised by mergers resulting in larger fertility chains, online platforms organising fertility care and expanded portfolios of companies aiming to cover each step of the IVF cycle.

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