Introduction
The medically assisted reproduction (MAR) industry is a rapidly expanding sector of the economy, driven by rising global infertility rates, which affect approximately 48 million couples and 186 million individuals worldwide. More than 10 million children have been born using MAR techniques (WHO, 2021), and the demand for these services continues to increase, now accounting for up to 7.9% of all births in Europe (Wyns et al., 2022). On a global scale, Spain is one of the leading countries in terms of the number of clinics and total MAR cycles performed and is one of the main European destinations for reproductive tourism (Lafuente-Funes et al., 2023). According to the Spanish Fertility Society (SEF) registry, 165,453 IVF cycles and 33,818 artificial inseminations were performed in 2021, representing an 11.7% increase compared to 2019 (SEF, 2021). The MAR industry has experienced significant growth, with the global in vitro fertilisation market reaching a valuation of USD 25 billion in 2022. Forecasts suggest that it will exceed USD 59.45 billion by 2032. In Europe, the MAR market reached USD 7.75 billion in 2022 and is predicted to be worth over USD 13.05 billion by 2032, as a result of increasing medical tourism and legal reforms related to MAR techniques (Precedence Research, 2023). The internet has transformed how patients access MAR information. While patients once relied on doctors, they now have the ability to conduct online research on clinics in advance (Zhu et al., 2024). However, this shift has not eliminated the information gap between patients and providers, often leading to marketing strategies that prioritise client acquisition over transparent communication of clinical outcomes. Major (2019) emphasises that patients typically possess less information than providers, including knowledge about alternative treatments and their effectiveness.
Many fertility clinics present success rates using a wide range of inconsistent measures, making it difficult for patients to make informed choices (Wilkinson et al., 2017). The efficiency of the treatment in achieving its intended outcome is a central consideration. In the case of fertility treatment, the objective is the birth of a healthy child. Success in MAR should be understood as a multidimensional concept that includes not only live birth rates but also patient satisfaction, cost-effectiveness, and time to pregnancy (Rienzi et al., 2021). As we shall see, however, information about success rates is presented by clinics in a variety of ways—sometimes as live births, sometimes in terms of pregnancies per attempt. This information is essential for making an informed decision and should therefore be presented with maximum clarity and accuracy. One of the most critical factors for informed decision-making is treatment success rates. However, these rates are often presented in different ways, including pregnancy rates instead of live birth rates. In this paper, we present a systematic analysis of the information provided about success rates on the websites of the five most representative clinics in Spain. To our knowledge, this is the first systematic study focusing on this issue.
Methods
Patient and Public Involvement: Patients or the public were not involved in the design, conduct, reporting, or dissemination plans of this research.
To identify the most frequently consulted MAR clinics in Spain, we conducted internet searches using the five most common Google search keywords related to fertility treatment: ‘fertilisation’,‘insemination‘, ‘infertility’, ‘pregnancy IVF’ (in vitro fertilisation), and ‘ICSI’ (intracytoplasmic sperm injection). We chose this selection method to identify the most frequently visited and consulted clinics in Spain, ensuring that their online information is the most visible to the general public. Search results for each keyword were selected in order of appearance, excluding magazine articles, blogs, and clinics without their own laboratory. The selected clinics were Ginefiv, Instituto Bernabeu, Institut Marqués, FIV Valencia, and IVI-RMA. The selection process took place between July and August 2021. All chosen clinics operate in the private sector, which provides the majority of fertility treatments in Spain. These clinics are the most visible to the general public and offer first-hand information about techniques and success rates. Due to their strong online presence and high visibility in search results, they play a significant role in shaping how the public perceives MAR, particularly in terms of its effectiveness, accessibility, and potential outcomes. Once selected, the websites of these five clinics were thoroughly examined to determine the information available in the local language. Data collection followed a systematic approach using specially designed templates categorised by theme, incorporating both textual and graphical content. Success rates were among the key themes analysed. The collected information was analysed in July and August 2023, and the clinic websites were reviewed again in March 2025 to verify any changes. The analysis focused on the terminology used to define treatment success rates (live birth, clinical pregnancy, or chemical pregnancy), certification and auditing by external bodies, reference to data sources, differentiation of success rates by age and technique (Artificial insemination, IVF/ICSI, with or without gamete donation), and generalised quantitative descriptions of treatment effectiveness.
This research has been conducted under the European Project “B2-InF: Be Better Informed About Fertility”. The B2-InF Project was approved by the Research Ethics Committee of the University of Navarra (Project no. 2021.004, approved 29/01/2021). Data and materials related to this research are publicly available in the B2-InF project repository on Zenodo (Carrasco et al., 2023).
Results
Criteria, clarification and definition of success rate
Table 1 shows the criteria used to define success rates on the websites of the clinics surveyed. In particular, we analysed whether the success rate is defined as live birth, clinical pregnancy, or chemical pregnancy, and whether these criteria are explicitly stated and explained.
Table 1. Criteria on which the success rate is based.
| Live birth | Clinical pregnancya
| Biochemicalb
| Explanation*
| Definition** |
|---|
| Ginefiv1 | No | No | Yes | No | No |
| Instituto Bernabeu2
| No | Yes | Yes | No | No |
| Institut Marquès3
| Yes | Yes | Yes | Clinical pregnancy/ “Born” | No |
| FIV Valencia4
| No | No | Yes | No | No |
| IVI-RMA5
| No | No | Yes | biochemical pregnancy tests | Yes |
• Of the five clinics surveyed, all provided information about success rates in terms of chemical pregnancy. For three clinics, this is the only success rate information provided, while the other two also report clinical pregnancy rates.
• Only one clinic provides data on live birth rates. Additionally, only two of the clinics explicitly refer to 'chemical pregnancy' and 'clinical pregnancy' using those terms. None of the clinics clearly explains the meaning of the terms 'chemical pregnancy' or 'clinical pregnancy'.
Online information on success rate and age
A woman’s age is the most important prognostic factor from a fertility perspective. A woman’s chances of becoming pregnant remain relatively stable up to the age of 30 and begin to decline rapidly from the age of 37 onwards. For this reason, it is critical to provide information about success rates in relation to the woman’s age. Treatment uptake data indeed show that age is a determining factor. SEF data indicate that about 50% of women attending clinics are over 40 years old, and approximately 75% of the total number of cycles and transfers involving egg donation are for women over 40.
In the clinics surveyed (see Table 2), we analysed the information provided about success rates in relation to age. We found that all of the clinics surveyed present success rates by age group, although these groupings vary from clinic to clinic.
Table 2. Success rates according to age range.
| AI | IVF/ICSI | Egg donation |
|---|
| Ginefiv6
| No range | <30, 30- 34, 35-39, 40-45, >45 | 35-39, 40-45, >45 |
| Instituto Bernabeu7
| No range | <35, 35-39, >40 | No range |
| Institut Marques8
| <35, 35-39, >40 | <35, 35-39, >40 | No range |
| FIV Valencia9
| No range | <35, 35-39, >40 | No range |
| IVI-RMA10
| No range | <29, 30-34, 35-39, 40-44 | No range |
• Four clinics do not provide age-related success rates for donor oocytes, and only one of these also does provide age-related success rates for artificial insemination.
• Only one clinic provides information for an age range over 45.
Success rates and MAR techniques
We also analysed the information on success rates according to the different techniques and procedures offered (see Table 3).
Table 3. Distinction of success rates by MAR techniques.
| IVF/ICSI | Egg donation |
|---|
| Ginefiv11
| No | Yes |
| Instituto Bernabeu12
| No | Yes |
| Institut Marquez13
| No | Yes |
| FIV Valencia14
| Yes | Yes |
| IVI-RMA15
| No | Yes |
• All of the websites consulted differentiate between success rates for patients with and without egg donation.
• Only one of the five clinics make a distinction between the success rates for those who undergo IVF and those who undergo ICSI.
Also, because success rates vary according to the techniques used, this information needs to be clearly differentiated. We find, however, that the four clinics consulted give a combined success rate for IVF and ICSI, and it is not clear whether this is an average of the two. In fact, based on the data provided by the French government, the success rate of ICSI is only slightly higher than that of IVF, and not always. Studies indicate that when the cause of infertility is not of paternal origin, the success rates of IVF are better than those of ICSI, although it is debatable which technique is more beneficial in other cases (Bantel-Finet et al., 2022). In light of this evidence, and given the different costs associated with using one or the other, information about success rates should enable patients to take these factors into consideration. With regard to gamete donation, all the clinics differentiate success rates according to whether or not gamete donors are used, with the peculiarity that four of the clinics interviewed give a single percentage success rate for all ages when donating eggs.
Generalised quantitative descriptions of effectiveness
For each clinic website, in addition to examining systematic presentations of success rates, we also looked for other quantitative descriptions of overall success rates or expected results—for example, those found in the general narrative of the clinic (see Table 4). In four of the five clinics, we found at least one general quantitative description of success rates, i.e., quantitative information that does not specify any relation to age, technique, or the use of gamete donation.
Table 4. Non-specific quantitative information.
| Ginefiv16
|
“The pregnancy rate per cycle is 75%, and the cumulative pregnancy rate after three cycles exceeds 90%.”
|
| Instituto Bernabeu17
|
“Our statistics are certified and audited: after three treatments 96% of our patients achieve pregnancy”.
|
| Institut Marquès18
|
“Thus, our success rates, audited by the government of Catalonia, are among the highest in Europe. 9 out of 10 patients who come to us achieve pregnancy in one or more attempts”.
|
| FIV Valencia19
|
“FIV Valencia has impressive success rates in egg donation treatments, with a cumulative pregnancy rate of 95%, making it one of the leading clinics in Europe.“
|
| IVI-RMA20
|
“ IVI has the best pregnancy rates, 9 out of 10 couples who trust us achieve their goal of becoming parents”.
|
Concerning “non-specific quantitative information,” in all of the clinics consulted, we found claims regarding the high effectiveness of MAR, but without specifying techniques, procedures, or age. On three clinics' websites, the same message is repeated: 9 out of 10 achieve pregnancy. Two clinic websites present this information in connection with “achieving the expected results” and “the goal of becoming parents,” which strongly implies that 90% of patients achieve a live birth. Such statements violate Spanish and European consumer protection laws on truthful advertising, which prohibit any advertising that, through false or misleading information—or the omission of essential details—leads consumers to make misinformed decisions.
Limited certification and transparency of success rate data
Only two clinics state that the data from which they derive success rates has been certified. One clinic states that its data has been certified by a relevant authority. Although access to a copy of the certificate is provided, this signed document is not sufficient for purposes of substantiation. It does not provide access to evidence-based data to corroborate the figures provided. On the other hand, it should be noted that the certificate does provide a detailed description of the process by which the certifying agency verified the data. Another clinic only claims that its data on success rates have been certified by a public body, but without providing access to this certificate or any further description of the certification process.
Discussion
We found few studies focusing on how success rates are advertised in assisted human reproduction clinics. One such study was conducted by the Human Fertilisation and Embryology Authority (HFEA) in the United Kingdom (Committee of Advertising Practice, 2021). After analysing the information promoted within the sector, the HFEA warned of a lack of transparency in the presentation of success rate statistics. Specifically, they expressed concern that results are often reported only for patients under 35 years of age and that the terminology used is unclear. The HFEA also recommended that percentages be presented as “live birth rate per embryo transfer.” Another study (Sauerbrun-Cutler et al., 2021) examined information provided by over 90% of U.S. clinics through their websites. According to the American Society for Reproductive Technology (SART) guidelines on advertising, live birth rates per cycle start (intended retrieval) must be prominently displayed first, followed by rates per egg retrieval and per embryo transfer, with success rates reported for each SART-defined age category. Omitting live birth data per cycle start is not permitted. SART categorises maternal age as follows: <35, 35–37, 38–40, 41–42, and >42 years. The study analysed information from 361 U.S. clinics and found that only 10.5% reported success rates in terms of live births per transfer, retrieval, and cycle.
The primary expectation of people seeking fertility treatment is to become the parent of a healthy child—the main reason they seek the services of a clinic. Only one clinic complies with this requirement. Even in that case, information about the live birth rate is presented alongside data on clinical and chemical pregnancies, offering a misleading picture of effectiveness. The remaining four clinics report success rates only in terms of pregnancy: Two clinics report both clinical and chemical pregnancies, and three report only chemical pregnancy. However, only one of these clinics clearly states the type of pregnancy for which information is provided. None of the five clinics consulted provides clear definitions of their terminology.
Given this expectation, clinics cannot comply with consumer law unless they provide success rate information explicitly defined in terms of live births. Faced with this ambiguity and lack of clarity, some governments (e.g., France) have set up a public website where citizens can find success rates presented exclusively in terms of birth (Agence de la Biomédicine, 2025), and have prohibited clinics from provid-ing their own criteria and results. Similarly, Australia and New Zealand Assisted Reproduction Database (FSANZ), Society for Assisted Reproductive Technology (SART), and Center for Disease Control and Prevention (CDC), have created websites that must be accessible from the websites of all clinics, where potential customers can enter data and receive a success rate defined exclusively in terms of live birth.
In relation to this issue, it is worthwhile to point out a deficiency in the way information about success rates is managed by the Spanish Fertility Society (SEF). The SEF publishes a yearly report (“Registro Nacional de Actividad – Registro SEF”) that presents official national statistics based on data collected from all clinics, covering all the MAR techniques performed in Spain in a given year. In this document, information is presented as an average over just three age groups: <35, 35–39, and ≥40. We consider this information to be insufficient for making an informed decision about fertility treatment and indicative of a lack of involvement and oversight on the part of the Ministry of Health, which is responsible for establishing standards for data transparency in the fertility industry.
In the preceding analysis of information provided by Spanish clinics, our focus has been on the clarity and accuracy of information related to success rates. We believe that this analysis shows that the clinics analysed do not comply with national and European legal standards for advertising and publicity (Art. 3 of the Law 34/1988; ICC Code, 2018). Potential patients should not be misled into believing that the success rate of a procedure is significantly higher than it actually is. Even if clinics change their information policies so that success rates are clearly and accurately presented, however, another issue needs to be confronted. According to Spanish legal regulations on MAR in the public sector (Art. 3.1, Law 14/2006): “Assisted reproduction techniques shall be performed only where there are reasonable chances of success, they do not pose a serious risk to the health, physical or mental health of the woman or the possible offspring, and after free and conscious acceptance of the application by the woman, who must have been earlier and duly informed of her chances of success, as well as of her risks and the conditions of that application.” The phrase “reasonable chances of success” serves as a legal threshold that limits access to fertility treatment in the public sector to women up to the age of 40. It is worth noting the disparity between the public and private sectors with respect to this issue.
Conclusion
The primary expectation of people seeking fertility treatment—and their main reason for using the services of a clinic—is to have a child at home. Therefore, success rates should be defined clearly and exclusively in terms of live birth. To ensure the validity of the success rates presented, clinics should provide access to evidence-based data sources that allow for independent verification. However, none of the clinics consulted provide access to sources that would substantiate the origin or accuracy of their data. Substantiation is not merely a matter of good practice; it is a legal requirement. The 2018 Code of Advertising and Marketing Communication of the International Chamber of Commerce (ICC) states: “Descriptions, claims or illustrations relating to verifiable facts in marketing communications should be capable of substantiation. Claims that state or imply that a particular level or type of substantiation exists must have at least the level of substantiation advertised. Substantiation should be available so that evidence can be produced without delay and upon request to the self-regulatory organisations responsible for the implementation of the Code” (Article 6).
Furthermore, the information provided on success rates should be based on the best available evidence, and clinics should offer access to the underlying data for verification purposes. Success rates must also be disaggregated by age group, as general success rates are misleading and should be avoided. These recommendations are not only consistent with existing laws on consumer protection and advertising (e.g., Article 7.1 of Law 3/1991; Art. 3 of the Law 34/1988; ICC Code, 2018; Directive 2006 / 114 / EC), but also align with universal standards of medical ethics and informed consent. Yet, none of the clinics surveyed adhere to these principles. Success rate data should be monitored and controlled by external, independent authorities to prevent clinics from publishing unverified or misleading statistics. To avoid conflicts of interest, we see no alternative but to establish a centralised public authority responsible for collecting, verifying, and managing clinic data to protect the rights and interests of citizens. We advocate for the standardisation of success rate reporting to emphasise that these figures should not be used as a basis for competition among clinics. Success rates are not universal indicators of quality, as outcomes depend heavily on each patient's individual health condition. Patients should be informed that success rates serve as contextual information rather than a definitive measure of a clinic’s competence. In our view, more robust regulation of the information provided by the fertility industry in Spain is urgently needed.
Ethics approval
This project (no. 2021.004) received ethical approval on 29/01/2021 by the Research Ethics Committee of the University of Navarra.
Data availability statement
Underlying data
The data underlying the results cannot be shared for confidentiality reasons. The data has been restricted due to the sensitive nature of the information provided. There is a concern that the fertility industry might exploit this information for commercial purposes. Therefore, in the Grant Agreement nr. 872706 — B2-InF, signed by the Research Executive Agency of European Commission and all B2InF project partners, was established that the dissemination level of the interviews, as well as the dissemination level of the reports and thematic analyses of the interviews, is "confidential", explicitly defined as "only for members of the consortium (including the Commission Services)". (see Annex 1, p. 6/27 of the Grant Agreement nr. 872706).
To request access, please email the corresponding author. Access will be granted once is confirmed that the data will be used solely for scientific research purposes and that all researchers involved in the study have no conflicts of interest. For the evaluation of the request, the Principal Investigator (PI) should submit:
1. A draft that includes, at a minimum, the hypothesis, the objectives of the research project, and the methodological framework.
2. A CV of the last 15 years for each researcher who will participate in the research and/or will have access to the data.
3. A personal statement from each researcher addressing the following points separately:
In my last 15 years, neither my institution nor I, personally, have received salary, funding, grants, or personal fees from entities funded by the fertility industry (including clinics, laboratories or biopharma companies).
In my last 15 years, neither my institution nor I, personally, have currently or previously collaborated with advocacy groups or civil associations related directly or indirectly to fertility issues.
I have never held a position on boards of scientific, social or commercial entities funded by the fertility industry (including clinics, laboratories, or biopharma companies).
Faculty Opinions recommendedReferences
- Agence de la biomédecine: Principaux chiffres de l’activité. [Access 1 Oct 2024].
Reference Source
- Carrasco MJ, et al.:
B2-InF project repository.
Zenodo.
2023. Reference Source
- Centers for Disease Control and Prevention (CDC): IVF success estimator. [Accessed 14 Jan 2024].
Reference Source
- Committee of Advertising Practice:
Enforcement notice: advertising of fertility treatments. Advertising standards authority,
2021. Reference Source
- de Bantel-Finet A, Arbo E, Colombani M, et al.:
Does intracytoplasmic sperm injection improve live birth rate when compared with conventional in vitro fertilization in non-male factor infertility? A systematic review and meta-analysis.
F&S Rev.
2022; 3(1): 57–68. Reference Source
- European Union: Directive 2006/114/EC of the European Parliament and of the council of 12 December 2006 concerning misleading and comparative advertising.
Official Journal of the European Union (OJ).
L376, 27 December 2006. Art. 3. Reference Source
- Fertility Society of Australia and New Zealand (FSANZ): ANZARD: Assisted Reproductive Technology in Australia and New Zealand. Fertility Society of Australia and New Zealand. Reference Source
- International Chamber of Commerce (ICC): Code of advertising and marketing communication practice. Paris: ICC, 2018. Reference Source
- Lafuente-Funes S, Weis C, Hudson N, et al.:
Egg donation in the age of vitrification: a study of egg providers’ perceptions and experiences in the UK, Belgium and Spain.
Sociol Health Illn.
2023; 45(2): 259–278. PubMed Abstract
| Publisher Full Text
| Free Full Text
- Major I:
Two-sided information asymmetry in the healthcare industry.
International Advances in Economic Research.
2019; 25(2): 177–193. Publisher Full Text
- Precedence Research: Fertility market size, growth, trends and report, 2023 to 2032. Precedence Research, [Accessed 12 Oct 2023]. Reference Source
- Rienzi L, Cimadomo D, Vaiarelli A, et al.:
Measuring success in IVF is a complex multidisciplinary task: time for a consensus?
Reprod Biomed Online.
2021; 43(5): 775–778. PubMed Abstract
| Publisher Full Text
- Sauerbrun-Cutler MT, Brown EC, Huber WJ, et al.:
Society for Assisted Reproductive Technology advertising guidelines: how are member clinics doing?
Fertil Steril.
2021; 115(1): 104–109. PubMed Abstract
| Publisher Full Text
- Society for Assisted Reproductive Technology (SART): IVF success estimator. [Accessed 3 Feb 2025]. Reference Source
- Sociedad Española de Fertilidad (SEF):
Registro nacional de Actividad - Registro SEF. 2021. Reference Source
- Sociedad Española de Fertilidad (SEF):
Registro nacional de actividad 2021. Registro Informe SEF: informe estadístico de técnicas de reproducción asistida. SEF, [Accessed 14 Jan 2024]. Reference Source
- Spain: Law 34/1988, of 11 November, General Advertising – updated on 1 March 2023. Boletín Oficial del Estado (BOE), No. 274, 15 November 1988. Art. 3. Reference Source
- Spain: Law 3/1991, of 10 January, on unfair competition. Boletín Oficial del Estado (BOE), No. 10, 11 January 1991. Art. 7.1. Reference Source
- Spain: Law 14/2006, of 26 May: on techniques of human reproduction. Boletín Oficial del Estado (BOE), No. 126, 27 May, 2006; Art. 3.1. Reference Source
- Wilkinson J, Vail A, Roberts SA:
Direct-to-consumer advertising of success rates for medically assisted reproduction: a review of national clinic websites.
BMJ Open.
2017; 7(1): e012218. PubMed Abstract
| Publisher Full Text
| Free Full Text
- World Health Organization:
WHO fact sheet on infertility.
Glob Reprod Health.
Spring,
2021; 6(1): e52. Publisher Full Text
- Wyns C, De Geyter C, Calhaz Jorge C, et al.:
Art in Europe, 2018: results generated from European registries by ESHRE.
Hum Reprod Open.
2022; 2022(3): hoac022. PubMed Abstract
| Publisher Full Text
| Free Full Text
- Zhu J, Shi Y, Cui Y, et al.:
The heterogeneous influences of online health information seeking on aspirin use for cardiovascular disease prevention.
Health Policy Technol.
2024; 13(2): 100842. Publisher Full Text
