Balancing innovation and efficiency in a private-equity-changed world of IVF: the case for sustainable scale.

The scale of IVF centres currently ranges from small, stand-alone units to large networked organizations operating across multiple regions or countries. This diversity in organizational models may influence clinical outcomes, patient experience, professional practice, innovation and long-term sustainability. In parallel with broader healthcare trends, the fertility sector has undergone rapid consolidation over the last decade, prompting renewed debate regarding the relationship between centre size, governance structures, quality of care and efficiency. This opinion paper critically examines the strengths and limitations of both small and large IVF centres, with particular attention to the concepts of critical mass, technology adoption, human resources, quality management and professional autonomy. Beyond size alone, the discussion also covers how evolving governance models, particularly the growing influence of managerial and financial decision making, may reshape scientific leadership and clinical practice within fertility centres. Importantly, the authors acknowledge the scarcity of high-quality comparative evidence linking organizational scale to live birth outcomes or patient-reported measures. Rather than advocating for a single optimal size, they propose the concept of a 'sustainable or balanced scale', defined as an organizational equilibrium where operational robustness, leadership, science and innovation coexist with uncompromising personalized, patient-centred care.