The Amboy Street Ventures’ Industry Insights series features a collection of pieces authored by experts in the women’s health and sexual health space.
Introduction to the author – Leslie Schrock
Leslie Schrock is an author and angel investor working at the convergence of health and technology. Her breakout hit book, Bumpin’: The Modern Guide to Pregnancy mixes the latest clinical research with practical advice for working families. Her second book, Fertility Rules, takes the same approach to male and female fertility. Leslie is an advisor to Maven, Alife, Origin, and Reverence and an investor in Caribou, Conceivable Life Sciences, Roon, Perchwell, Legacy, and Kinfield. She is also on Gameto’s bioethics board and the board of advisors at the Moody School of Communication at her alma mater, The University of Texas at Austin.
She was named one of Fast Company’s Most Creative People in Business, and her work has been featured on CNBC, NPR, Time, GQ, Fortune, Entrepreneur, Wired, The Economist, and The New York Times. Connect with Leslie at LeslieSchrock.com, on Instagram, or read her Substack. medications/devices has driven her success in gaining commercial and Medicaid access for numerous products, ensuring that they reach the hands of patients.
Three predictions for the future of fertility
The first IVF baby was born 45 years ago. Since then, treatments have improved, but not enough to reduce the average number of cycles required to achieve a live birth below three. Today’s fertility treatments are still very bespoke and invasive, and the labs are crude and prone to human error too. Unless you can pay out of pocket, access to infertility care is only granted if you have the right employer or qualify for spotty, state-by-state coverage. Infertility was deemed a disease by the WHO over a decade ago, but there is still debate over whether or not particular subtypes of infertility are worthy of Medicaid or insurance coverage, leaving low-income and LGBTQ+ patients out in the cold.
Even with all of the progress made in other areas of health care, when it comes to fertility, an area all of us should care about, we have a lot of work to do—good news for those interested in starting companies or investing in this space. Here are a few ways that fertility care will change:
AI and robotics will create a standard of care and transform embryology
The rumor of the AI doctor and robots dispensing precise healthcare services has been floating around for well over a decade. As an enthusiastic fan of sci-fi, I look forward to the day when broken humans can simply be plugged into machines, diagnosed, and treated flawlessly. But that is unlikely to happen in our lifetimes. Humans are imperfect diagnosers, biases creep in and shade treatments, and we require rest to be accurate. But healthcare is personal. Vanishing the human touch entirely isn’t a future I want, and I’m pretty sure no one else does either.
That said, there are many places we should replace flawed human work with automation. A prime example is the fertility industry, which is far too expensive and short too many providers to serve all of the people who need it. Alife is using AI and ML to customize infertility protocols and optimize processes like embryo selection, ultimately reducing the number of cycles required to achieve a live birth. With enough data, they could also create a true, evidence-backed standard of care, from personalized shot protocols to a deeper understanding of embryo quality.
A major risk to fertility treatments is the person who handles those precious gametes in the lab. If your embryologist shows up to work with a hangover, it doesn’t matter how precise your shot protocol was. Like other areas of fertility medicine, there is also a shortage of embryologists, so some labs are staffed by people without the proper education. The quality and storage at embryology labs differ wildly from clinic to clinic, and no matter how great they are, the process is too manual, prone to human error, and expensive for new providers to open new clinics. Embryology is also the most expensive, difficult barrier to scaling the provider space to include ob-gyns, making them frontline infertility providers and leaving reproductive endocrinologists for more complex cases.
Conceivable Life Sciences is creating automated embryology labs, utilizing AI and robotics to more precisely handle gametes and reduce labor requirements and overall costs. Speaking of that fragile egg, AI and better equipment, especially microscopy, could also reveal the truth of an egg’s quality pre-freeze or fertilization, which cannot be determined today without destroying it since it’s a single cell.
Male testing and treatment will reduce the number of cycles required
One in six people globally will struggle with infertility. Even though they aren’t tested or treated at the same rates as women, half of those people are men. Yet, in 25% of infertility investigations, men aren’t examined, even though sperm quality has plummeted by over 50% in the past 50 years for reasons unknown. The invention of intracytoplasmic sperm injection (ICSI), a procedure done during IVF that requires only one viable sperm, has led providers to care far less about male factor. Ironically, ICSI is now used during the majority of IVF cycles regardless of the underlying cause, even though it doesn’t raise the live birth rate unless the problem is, in fact, male factor.
There are around 1300 reproductive endocrinologists to test and treat infertility, which is not enough to fill the need. But there is a fertility provider shortage even more acute: reproductive urology. They are urologists who pursue a fertility fellowship and test and treat problems of the male reproductive system, from varicocele to low semen parameters. Knowing that infertility prevalence is split equally between men and women, you’d expect there to be more than 200 people trained to treat it. But that’s where we are. We don’t have enough open fellowships to train new physicians, and many are retiring too. Urologists can handle some basic issues, but more complex cases need a specialist. And in most geographies, there simply isn’t anyone available for in-person care or a months-long waiting list. As a result, these issues often go untreated and undiagnosed even though they can indicate other health conditions for men like cancer and tumors.
Posterity Health is partnering with clinics and benefits providers to scale access to reproductive urology with telemedicine consultations and standardized treatment plans. Because, unlike women and eggs, sperm health can often be improved by simple lifestyle hacks like changing diet, stopping smoking, avoiding saunas, hot tubs, and cycling, and reducing exposure to endocrine-disrupting chemicals, all of which ultimately could result in fewer cycles and invasive treatments for women.
Care will move from the clinic to the home
1 in 5 couples who undergo IVF go on to have a “miracle” pregnancy later. Theories range from a shift in lifestyle factors to the imprecise diagnosis “they got lucky”, but clearly, some patients are overtreated. Theories range from a shift in lifestyle factors to undiagnosed male factor infertility that resolves but in most cases, the underlying cause is never determined.
Couples that have difficulty getting pregnant have a few choices: do nothing, try the internet for questionable solutions, or visit a fertility clinic for invasive treatments. It’s rare to go straight to IVF, but if it’s early days during an exploration, there aren’t many simple, cheap solutions beyond medication and timed intercourse. Intrauterine insemination (IUI) is often the first line of defense when a couple seeks care, as it’s cheaper and less invasive than IVF. But there’s just one problem: for those with unexplained fertility, the per cycle IUI success rate is only 7-10%, even when combined with drugs. With male factor, it jumps to 17%, but even then, it nearly takes an average of between 3 and 4 cycles if it works at all.
Intracervical insemination (ICI) is the at-home version and is used mostly by lesbian couples and single women with a sperm donor, for couples that can’t physically have sex or who have painful sex, or for those who have just been at it for a long time and are tired of timed sex. Béa Fertility launched a clinical-grade ICI system, and over 100,000 Mosie Baby intravaginal insemination (IVI, a close cousin of ICI) kits have been sold, with thousands of families reporting reported successful pregnancies via their patented syringe. The biggest difference outside of cost and doing it from the comfort of home is the washing of the sperm and insertion directly into the uterus that is performed in IUI. But as one literature review put it, there was not sufficient evidence (or enough high-quality research) to indicate any difference in outcome between ICI and IUI, making it a much cheaper, simpler place for couples who are struggling to start.
We look forward to bringing you more from women’s health and sexual health experts in this Industry Insights series. Stay tuned!
