Ava x SanitasA PROPOSED SOLUTION FOR MITIGATING THE

HIGH COST OF CONCEPTION-RELATED HEALTHCARE

W H I T E PA PE R

AVA AG | MARCH 2020 | PAGE 2

Ava

Sanitas

A digital women’s health company with offices in Zurich, San Francisco, Makati and Belgrade, Ava is advancing women’s health by bringing together artificial intelligence and clinical research.

Its flagship product, the Ava Fertility Tracker, was launched in 2016, and is now sold in more than 30 countries worldwide. Worn at night, it provides women with real-time, personalised information about their fertility, pregnancy, and general health.

Sanitas is one of the largest health insurers in Switzerland with more than 840,000 customers and a premium volume of nearly CHF 3 billion.

The company offers appropriate products and optimum insurance solutions for all stages of life and develops services tailored to customer requirements, which includes finding more efficient and differentiated ways of managing the cost of claims.

Overview

The struggle to conceive a child is a burden faced increasingly by couples worldwide. The resulting growth in demand for assisted reproductive technologies is taking a financial toll on the healthcare system, insurers, and household incomes. This case outlines how a partnership between femtech firm Ava and Swiss

health insurer Sanitas is seeking to ease the burden through early intervention. It outlines how similar collaboration models could help reduce the overall cost of reproductive healthcare while shortening time-to-pregnancy and the frustrations faced by couples struggling to conceive.

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Properly timing intercourse can double the chances of conception in fertile couples.1

This knowledge gap leads to stress, frustration and, in many cases, the mistaken assumption that biological factors are causing fertility issues. What’s more, women are starting their families later in life, at an age when their fertility may already be in decline.

29: The European mean age of women at first birth 2016.3

In 1975, the mean age was 25.7.4

But there remains a disconnect between statistical reality and real-world behaviour.

Modern fertility’s costly disconnect

The partnership enables women who are insured under the Sanitas Planning a Family plan to take control of their reproductive journey by covering the cost of the Ava Fertility Tracker. This advanced cycle-tracking tool identifies the user’s unique fertile window in real time,

helping to optimize her chances of conceiving naturally before the need for costlier or more invasive assistive reproductive technologies arises. The benefits of early intervention are best explained by examining the challenges faced by couples trying to conceive today.

Almost 75% of women do not know the best time in their cycle to have conceptive intercourse.2

One in eight women will seek fertility intervention.10

29 Prior research has shown that a woman’s fertility decreases with age, with the most rapid decrease happening after the age of 35.5–9 By 40, a woman’s chance of getting pregnant naturally each cycle is just 5%.5,6

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Medical intervention for conception often results in assisted reproductive technology such as in-vitro fertilization (IVF). Around the world, IVF is expensive; a single cycle can cost couples thousands of dollars out of pocket.11-13 $20,00011

€3,00012

CHF8,50013

DE

US

But women often require multiple cycles to achieve a viable pregnancy.

Average cost of a single IVF treatment

Which does not account for the expenditures of those who have failed or given up. And the health-care related cost of fertility intervention doesn’t end with conception.

Singleton: $30,115 €27,076 / CHF 28,836

Twins: $147,124 €132,277 / CHF 140,876

Triplets or more: $571,480 / €513,811 CHF 547,115

Successful IVF patients require an average of up to three rounds of fertilization.11

US $60,000 DE €9,000 CH CHF 25,500

Up to 30% of IVF pregnancies result in multi-fetal pregnancies.14

CH

30

Infants of multiple gestations are more likely to stay in a neonatal intensive care unit than singletons.14 Delivery costs (from a US study, calculated based on a Personal Health Care index) on average are15:

These costs, together with the stress and anxiety that failed conception attempts bring to relationships, can be significantly mitigated by addressing one of the root causes of presumed infertility: improper timing of intercourse. Modern fertility’s costly disconnect doesn’t have to exist.

Cost per delivery

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Ava: A simple, effective solution

How Ava works

Starting at under $300 / CHF 300 / €300, the Ava Fertility Tracker is an affordable first step for women with no pre-existing fertility conditions who may be having difficulty conceiving.*

Ava has three components: a sensor bracelet, an app, and a set of algorithms. The bracelet is worn at night. While the wearer sleeps, sensors measure multiple physiological parameters associated with the opening and closing of the fertile window.

Collected data is communicated to a back-end database and interpreted by Ava’s algorithms. The user’s real-time cycle-phase information is then relayed back within minutes via an in-app dashboard, allowing couples to properly time conceptive intercourse to the fertile window for the highest chances of success.

There are six days a cycle when it’s possible to conceive. Ava is clinically tested to recognise five of them.

1. WORN AT NIGHT 2. SYNCED IN THE MORNING 3. FERTILE WINDOW

DISPLAYED

* Ava is right for women whose cycles occur regularly between 24 to 35 days. It has not been tested for conditions that interrupt ovulation such as PCOS or hypothalamic amenorrhea, but such patients may still find Ava useful in tracking their cycles and gaining a better understanding of their bodies.

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Ava is clinically proven

Ava’s clinical study of more than 200 women and over 1,000 menstrual cycles measured changes to five physiological parameters (see graph at right) that, taken together, identified the fertile window with 89% accuracy.16 These results are publicly available and were published in the peer-reviewed Journal of Medical Internet Research.

Ava’s bracelet and algorithms were the first—and still only—wearable sensor technology to identify both the opening and closing of the fertile window, providing couples with 5.3 days each cycle during which intercourse is optimal for conception.17

The findings on the algorithm’s performance were presented at the Annual Meeting of the American Society of Reproductive Medicine (ASRM)18, the Swiss Society of Gynecology and Obstetrics (SGGG)17, the German Society of Gynecology and Obstetrics (DGGG)19, the European Society of Human Reproduction and Embryology (ESHRE)20, and the International Federation of Fertility Societies (IFFS)21.

SKIN TEMPERATURE

Decreases by about 0.2°C after menstruation before rising 0.4°C after ovulation, remaining elevated until the next period begins. RESTING PULSE RATE

Drops by about 1.5 beats during the follicular (pre-ovulation) phase, before increasing through the fertile window and peaking in the luteal (post-ovulation) phase. HEART RATE VARIABILITY RATIO

Typically rises in the follicular phase and falls in the luteal phase. It’s an indicator of physiological stress, with a higher ratio suggesting the body is under greater duress. PERFUSION

Is the passage of blood through the circulatory system. It’s lowest at the start of the fertile window and highest in the luteal phase and during menstruation. BREATHING RATE

Measures lower at the start of the fertile window and higher in the late luteal phase.

Ava abides by the highest security standards both in the EU and the United States, and has region-specific servers for storing data. User data is stored anonymously with ID and registration info separately stored.

Data and Security

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Ava compared to other fertility-tracking methods

Unlike period-tracker apps that are frequently inaccurate22, LH tests that predict one or two days of fertility, or the temperature method that relies on retrospective measurements, Ava identifies a woman’s 5.3 most fertile days in real time.17 It is the only wearable sensor technology clinically tested to identify both the opening and closing of the fertile window.

When women purchase an Ava bracelet, they receive an invitation to private, user-only Facebook communities, where they can connect with Ava experts and almost 40,000 members globally. As many as five community sub-groups (each with a version in English, German, French, and Spanish) cover topics ranging from cycle tracking to miscarriage, and share an average engagement rate of 86%.* These communities are part of Ava’s vision to be not just a product, but an ecosystem of women’s health support.

* Data on file

The Ava Communities

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Reduced time to conception

Ava’s research team performed a retrospective analysis of data from 19,838 American and European real-world women who conceived using the Ava Fertility Tracker to determine if women who cycle tracked using Ava prior to trying to conceive became pregnant faster than women who did not cycle track first.

Evaluating results using a technique called the Bootstrap Method, the study found that early adoption of Ava for cycle-tracking purposes was associated with a significantly shorter time to conception (mean Δ in time to conception = 20.42 days, SD = 2.29; 95% CI: 17.59, 26.58, p<.001).

Robust linear regression also revealed no significant difference in time to conception for women 35 years or older compared to their younger peers, with prior experience using the Ava Fertility Tracker constituting the only significant predictor in the model.

In this study of real-world users of the Ava Fertility Tracker, it appears that the technology may enable women, regardless of their age, to better identify their fertile window and increase their odds of conceiving sooner, overcoming common obstacles that would otherwise lead them to seek out IVF.

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Sanitas’ Planning a Family supplementary insurance plan

Summary of benefits

Sanitas is working to change the outdated idea that health insurers only intervene once something has gone wrong in a customer’s life. Instead, it takes a “prevention is better than cure” approach, focusing on the individual’s well-being at every life stage.

The insurer developed the Planning a Family plan in 2019 to offer couples a preventative course of action should they have difficulty conceiving. This plan is the first of its kind in Switzerland to address fertility, building on the benefits available under mandatory basic Swiss health insurance. If the customer does not fall pregnant using the resources available under basic insurance, the Planning a Family coverage (outlined in the table below) takes effect.

“Women should be able to take out insurance for fertility treatments as naturally as they do for dental treatments. But if the possibility of fertility problems is not discussed openly and transparently, many are not even aware of the option.”

– Franziska König, Head of Product Development

Artificial insemination in the womb

75% of costs for 2 additional rounds, up to CHF 2,000* Up to 3 rounds

Ava fertility tracker 100% of cost ***

Artificial insemination outside the womb (e.g. IVF)

75% of costs up to CHF 12,000*

Genetic embryo screening 75% of costs up to CHF 5,000*

Prenatal testing 75% of costs up to CHF 500** Only in high-risk cases

BENEFITSSWISS MANDATORY BASIC

INSURANCE PLAN

SANITAS’ PLANNING A FAMILY

SUPPLEMENTARY INSURANCE

* Benefits can be claimed 24 months after the insurance contract starts.** Benefits can be claimed 9 months after the insurance contract starts.*** No waiting period.

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The Ava-Sanitas partnership

Sanitas covers the cost of the Ava Fertility Tracker for all women insured under the Planning a Family plan. In addition, Ava and Sanitas jointly provide significant discounts to Sanitas customers and employees.

1) Full cost of the Ava Fertility Tracker reimbursed

under the Planning a Family plan

Planning a Family customers order the bracelet through Ava’s website using a specially designed storefront and the costs are covered by Sanitas.

2) Discount on the Ava Fertility Tracker for Sanitas

customers

As a sign-up perk, subscribers to Sanitas’ free Maternity Services Programme are rewarded with a discount code to use when making a purchase through the Ava website.

3) Discount on the Ava Fertility Tracker for Sanitas

employees

Through internal channels, Sanitas employees are also provided with an Ava discount code to use at time of purchase.

“Sanitas takes the perspective of the insured. By looking at the entire reproductive journey, our aim is to support and accompany our clients from the earliest stage. When we began looking into providing the most comprehensive fertility tracking method to our customers, Ava met our objective in several ways.

First, it is a certified medical device and the only women’s wearable to track the five most important physiological markers of fertility (it is considerably more precise than, for example, the conventional ‘temperature method’). In clinical trials, the Ava bracelet was proven to identify a woman’s five most fertile days in real time with 89% accuracy.

Ensuring our clients’ data privacy was also extremely important to us. We were put entirely at ease by Ava’s back-end security, in which the user’s cycle data is fully anonymised, stored separately from her login information, and never shared with third parties.

As a further benefit, Ava supports women through online communities that cover topics such as fertility, conception, motherhood, and even loss. This demonstrates a customer-centered approach that fits perfectly with the Sanitas mission to support customers throughout every life stage and therefore be a real health partner. For these and many other reasons, our choice naturally fell on Ava.”

Why partner with Ava?

– Franziska König, Head of Product Development

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Conclusion

Get in touch

There is strong evidence to suggest that providing couples with the Ava Fertility Tracker as part of basic or supplementary insurance plans:

1. provides actionable insights to help clients achieve their pregnancy goals sooner.

2. has the potential to avoid the risk of multiple pregnancies associated with medical fertility intervention.

3. may decrease the stress and uncertainty associated with conception.

4. may increase satisfaction from the insurer and employer providing Ava as a benefit.

5. may decrease insurer and out-of-pocket healthcare costs.

For more information regarding the Ava Fertility Tracker or this white paper, contact

Niels van der Valk, Commercial Director Healthcare, Ava niels.vandervalk@avawomen.com +41 78 220 51 00 avawomen.com

For more information about the Sanitas Planning a Family supplementary insurance plan, contact

Sanitas,+41 800 22 88 44sanitas.com/planning-a-family

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References

1. Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse in relation to ovulation: Effects on the probability of conception, survival of the pregnancy, and sex of the baby. N Engl J Med. 1995;333(23):1517-1521.

2. Johnson SR, Pion C. Multinational survey of women’s knowledge and attitudes towards fertility and pregnancy. In: RCOG World Conference. Liverpool, UK; 2013:194.

3. Eurostat. Births and fertility in 2016: Women in EU have first child on average at 29.https://ec.europa.eu/eurostat/documents/2995521/8774296/3-28032018-AP-EN.pdf/fdf8ebdf-a6a4-4153-9ee9-2f05652d8ee0. Published March 28, 2018.

4. Botev N. Is Europe trapped in/by low fertility? The “Low Fertility Trap.” Entre Nous Eur Mag Sex Reprod Heal. 2006;63:4-7.

5. American Society for Reproductive Medicine. Waiting to have a baby? Advancing age decreases your ability to have children. https://www.asrm.org/resources/patient-resources/google-adwords-landing-pages/waiting-to-have-a-baby. Published 2020. Accessed February 11, 2020.

6. Menken J, Trussell J, Larsen U. Age and Infertility. Science (80- ). 1986;233(4771):1389-1394.

7. te Velde ER, Pearson PL. The variability of female reproductive aging. Hum Reprod Update. 2002;8(2):141-154.

8. Dunson DB, Colombo B, Baird DD. Changes with age in the level and duration of fertility in the menstrual cycle. Hum Reprod. 2002;17(5):1399-1403. doi:10.1093/humrep/17.5.1399

9. Dunson DB, Baird DD, Colombo B. Increased infertility with age in men and women. Obstet Gynecol. 2004;103(1):51-56. doi:10.1097/01.AOG.0000100153.24061.45

10. National Center for Health Statistics. Key statistics from the National Survey of Family Growth - I Listing. https://www.cdc.gov/nchs/nsfg/key_statistics/i_2015-2017.htm#infertilityservices. Published 2019. Accessed February 11, 2020.

11. FertilityIQ. Costs of IVF: Is IVF Good Value? https://www.fertilityiq.com/ivf-in-vitro-fertilization/costs-of-ivf#is-ivf-good-value. Accessed February 11, 2020.

12. Trappe H. Assisted Reproductive Technologies in Germany: A Review of the Current Situation. In: Kreyenfeld M, Konietzka D, eds. Childlessness in Europe: Contexts, Causes, and Consequences. Cham: Springer International Publishing; 2017:269-288. doi:10.1007/978-3-319-44667-7_13

13. Fertility Medicine and Gynaecological Endocrinology. Medically assisted reproduction: Cost. https://www.chuv.ch/en/fertilite/umr-home/medically-assisted-reproduction/cost/. Published 2019. Accessed February 11, 2020.

14. The ESHRE Capri Workshop Group. Multiple gestation pregnancy. Hum Reprod. 2000;15(8):1856-1864. doi:10.1093/humrep/15.8.1856

15. Lemos E V., Zhang D, Van Voorhis BJ, Hu XH. Healthcare expenses associated with multiple vs singleton pregnancies in the United States. Am J Obstet Gynecol. 2013;209(6):586.e1-586.e11. doi:10.1016/j.ajog.2013.10.005

16. Goodale BM, Shilaih M, Falco L, Dammeier F, Hamvas G, Leeners B. Wearable sensors reveal menses-driven changes in physiology and enable prediction of the fertile window: an observational study. J Med Internet Res. 2019;21(4):e13404. doi:10.2196/13404

17. Leeners B, Stein P. Digital women’s health based on wearables and Big Data. In: Swiss Society of Gynecology and Obstetrics (SGGG). Interlaken, Switzerland; 2016.

18. Stein P, Falco L, Kuebler F, et al. Digital women’s health based on wearables and Big Data. In: American Society for Reproductive Medicine (ASRM). Salt Lake City, UT; 2016.

19. Stein P, Falco L, Kuebler F, et al. Digital women’s health based on wearables and Big Data: New findings in physiological changes throughout the menstrual cycle. In: German Society of Gynecology and Obstetrics (DGGG). Stuttgart, Germany; 2016.

20. Shilaih M, Goodale BM, Cronin M, et al. Wearable sensors reveal menses-driven changes in physiology and enable prediction of the fertile window: A prospective, observational study. In: European Society of Human Reproduction and Embryology. Vienna, Austria; 2019.

21. Shilaih M, Goodale BM, Falco L, et al. Digital health: Wearable sensors reveal menses-driven changes in physiology. In: International Federation of Fertility Societies. Shanghai, China; 2019.

22. Moglia ML, Nguyen H V, Chyjek K, Chen KT, Castano PM. Evaluation of Smartphone Menstrual Cycle Tracking Applications Using an Adapted APPLICATIONS Scoring System. Obstet Gynecol. 2016;127(6):1153-1160. doi:10.1097/AOG.0000000000001444