Sperm Counts Are Falling. Does a New Wave of Tech Start-Ups Hold the Answers?

Sperm Counts Are Falling. Does a New Wave of Tech Start-Ups Hold the Answers?

Ciaran and Jenn had never questioned the fact that they wanted a family. But they knew, given Jenn’s history of polycystic ovary syndrome, that they might need some help. They had been trying to conceive for nearly a year and were well along the road to IVF when, at the end of an appointment – almost as an afterthought – a doctor suggested that they check Ciaran’s sperm.

A few weeks later, the couple returned to meet with a consultant. As usual, the focus was on Jenn. The consultant went over her latest test results, then turned to her husband. ‘There’s not much we can do for you, Ciaran,’ he said.

His tone suggested this would come as no surprise – but, seeing Ciaran’s confusion, his expression changed. ‘He realised that I had no idea about my infertility,’ Ciaran says.

The atmosphere in the room seemed to contract; Ciaran felt himself having ‘a weird, out-of-body experience’, like he’d learned of the death of a loved one. His analysis had returned, showing a sperm count of 1,500, with less than 1% deemed viable. According to the World Health Organization (WHO), the range for a ‘normal’ sperm count begins at 15m and reaches up to 250m.

Since the first IVF baby was born in 1978, infertility has been a growing concern. Last year, a report by the WHO found that it now affects roughly one in six of the adult population.

Like all other issues of family planning and reproductive health, infertility has largely been treated as a women’s problem. But mounting evidence is highlighting what should have always been obvious: we’ve been neglecting half of the issue.

A 2017 meta-analysis by Shanna Swan, professor of public health at Icahn School of Medicine at Mount Sinai in New York, found that sperm counts in Europe, North America, Australia and New Zealand have plummeted by nearly 60% since 1973, prompting ‘Spermageddon’ headlines that warn of the end of the human race.

While other researchers have questioned Professor Swan’s findings, seven years later, the science continues to point to a troubling trend of falling sperm counts. Even more concerningly: the reasons for this aren’t clear.

A study last year linked lower concentration of sperm with exposure to insecticides; another pointed to mobile phones. Pollution, stress, plastics, steroids and even skinny jeans have also been implicated alongside the usual factors such as weight, smoking status and alcohol consumption.

Declining male fertility has been compounded by the cultural shift (at least in high-income countries) towards delaying children until later in life. In 2022, the number of babies born in England and Wales dropped to the lowest level in 20 years; in Scotland, deaths are outstripping births. Similar trends are being observed around the world, from China and Andorra to Spain and Puerto Rico.

‘There’s sufficient data now to indicate that there is a challenge that we need to rise to,’ says Christopher Barratt, head of reproductive medicine at the University of Dundee and a world-renowned expert in male infertility. ‘If we’d started 20 years ago, we’d have the answers – but because we’ve buried our heads in the sand, we haven’t made progress.’

As a result of widespread government inaction, start-ups are stepping in to sound the alarm and equip men with the tools to take charge of their fertility.

ExSeed, a Danish company, offers ‘accurate and discreet’ home sperm tests with results in just 15 minutes. Mojo conducts analyses remotely with ‘novel AI’. Oxford-based newcomer Jack Fertility hopes its postal kits will ‘remove barriers’. In the US, companies such as Legacy are offering sperm testing and freezing, to better ‘secure your most valuable assets’.

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While women are made abundantly aware of their ‘biological clock’ and the fertility ‘cliff’, men see a similar decline from age 40 – it’s just not as widely publicised, or discussed.

All Ciaran remembers ever being taught about fertility was how not to get a girl pregnant, and ‘putting a condom on a banana’ at school, he laughs. Now 37, and a Yorkshire-based schoolteacher, Ciaran was 26 at the time of his devastating diagnosis. He played rugby and lifted weights, and was generally healthy.

For a long time, Ciaran says, he was in a state of shock, prolonged by a move from Sussex to Bedfordshire for Jenn’s work. The change in catchment area meant that they had to wait a year before continuing with infertility treatment on the NHS. While

Jenn was counting down the days until they could recommence IVF, Ciaran oscillated between denying his diagnosis and turning over the same sparse details. In that year of purgatory, his mental health began to deteriorate. He couldn’t shake the dreadful thought: ‘We’re doing this because of me.’

The 'Male Part' of the Equation

It shouldn’t come as a surprise to learn that, across all cases of infertility, between 40% and 50% have to do with ‘male factor’ infertility. And yet a 2020 paper found that in roughly 25% of cases of couples presenting with infertility, the man is not even evaluated.

For decades, assisted reproductive technology has been overwhelmingly focused on ‘the female part of the equation’, says Morten Ulsted, chief executive and co-founder of ExSeed. ‘It places an unfair emotional burden on women; it sidelines a lot of men who want to actively participate… and it leads to suboptimal treatment outcomes.’

The challenge here is shifting the responsibility. For men, it’s not enough just to raise awareness, Ulsted suggests. ‘We’re not that good at talking about health-related issues – certainly worse than women, I think,’ he says. ‘It’s also about providing tools: I think men like to take action.’

ExSeed aims to alleviate the stigma that prevents many men from seeking a sperm analysis, by making the process as frictionless as possible. ExSeed’s home tests claim to measure sperm count, motility, concentration and volume to lab-grade accuracy.

In practice, it’s like an over-the-counter science experiment. Using a pipette, you drop a little semen on to the provided slide, then insert it into a device resembling an at-home Covid test. This illuminates and magnifies the sperm present, permitting you to film them using your smartphone camera, then submit the footage through the ExSeed app for analysis.

Within 15 minutes, users are sent their total motile sperm count and personalised recommendations for how to improve or maintain their sperm health. Both are generated by algorithms, but each test includes an optional consultation with a fertility specialist. From buying the kit (starting at £84.99 for two tests) to receiving the results, the entire process is carried out in the comfort of your own home.

ExSeed’s platform also allows users to share their results with their doctor, making it ‘complementary to the great work already being done in the public system’, says Ulsted – not a replacement.

Andrologists – sperm researchers – are alert to the possibilities. ‘I think the time is ripe for a bit of innovation… and I don’t really see it coming out of universities,’ says Allan Pacey, a professor of andrology at the University of Manchester. ‘Quite honestly, I think they’re largely disinterested.’

Professor Pacey is a leading expert on male reproductive health and (along with Professor Barratt) co-author of a recent report* calling for ‘urgent, global action’ on the sperm crisis. He has served as an adviser to ExSeed and Legacy in the past, drawn by the fact that they’re not just proactive, but also well-resourced.

Research into male infertility is often overlooked by academic funding bodies because it’s wrongly assumed to be covered by the work being done for the IVF industry. Meanwhile, advances in reproductive healthcare have historically been led by organisations such as the Royal College of Obstetricians and Gynaecologists – which are, ‘by definition, not really very interested in men’, says Professor Pacey.

Professor Pacey has been studying sperm for 30 years and says the field has been stalling for closer to 70. ‘We have no radical treatments for male infertility. We can’t stimulate a man to make new sperm or more sperm… We’ve got no changes in diagnostic methods, no magic pill – and a lack of basic knowledge.’

After decades of inaction, the wave of ‘sperm-tech’ start-ups in the past five years is promising, says Professor Pacey. Though it’s too early to say whether it will lead to revolutionary treatments, ‘I want to see change – and I think this is the way it’s going to happen.’

At the least, he continues, ExSeed is helping to raise awareness and engage men in the subject of their fertility. When he speaks at events such as The Fertility Show in London, he’s crowded by people wanting to learn more. ‘There’s a myth out there that men aren’t interested – but it’s just that they’re not getting the opportunities.’

Steven Blake, 32, from Bedfordshire, stumbled upon ExSeed when he and his partner were trying for their second baby. Because they had conceived naturally once, when they sought help from their GP, the assumption was that Steven ‘must be fine’, he says. But the more he thought about it, the more counter-intuitive it seemed. ‘It’s half and half, isn’t it?’

Steven was nervous to take the ExSeed test, he says – ‘just because we’d been trying for so long’. But within minutes, the result had returned an average sperm count. The relief was instantaneous, says Steven. He recalls running down to show his partner the result – and the video of his magnified sperm. ‘You can literally see them swimming around… it’s just incredible.’ A few months after Steven took the ExSeed test, his partner fell pregnant naturally. Steven credits the knowledge with helping them over the line. ‘It took the pressure off both of us.’

These days, Steven runs marathons and follows a vegan diet – but before educating himself with ExSeed, he’d had no idea that drinking and smoking in his youth could have affected his fertility. ‘You don’t think about it until you’re at that point in your life,’ he says. Many of Steven’s friends have suffered miscarriages or tried IVF without success – but the subject of sperm rarely comes up. It’s not something that gets discussed at the pub, says Steven. ‘People will take the mickey out of you, like “firing blanks” – it’s that manly thing.’

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Now he makes a point of asking, have they thought about their sperm health? Do they know how to improve their chances? ‘It needs to be out there more,’ he says. ‘It’s just made me more aware of what’s happening in my body.’

Self-Optimising Our Sperm

Having been told his chances of conception were close to zero, Ciaran was given guidance on how to improve them. After his and Jenn’s third cycle of IVF failed in early 2014, Ciaran had a ‘complete breakdown’, he says. He stopped socialising and struggled to function. At times he was suicidal.

In the end, Jenn got him to seek help. In counselling, Ciaran began unpacking his feelings of failure and guilt. In his fourth session, he cried for most of the hour. He left the room feeling like a weight had been lifted.

With the burden alleviated, Ciaran moved from grief to clarity and began researching what he could do to improve his sperm count. He quit drinking, started having cooler showers and lost some weight. Meanwhile, Jenn took a break from IVF.

By the time they returned for another round, in July 2015, Ciaran was feeling the benefits of his lifestyle changes – and his sperm analysis reflected them. Over an 18-month period, he had gone from producing about 1,500 sperm to just over 4m – ‘which is phenomenal’, he says proudly. Their quality had also improved from below 1% to above 4%.

With his results still well below normal parameters, Ciaran had to have fertility treatment – but it was enough. His son Sebastian was born in March 2016; Ciaran and Jenn later went on to have a daughter, Enya, who’s now three. Ciaran recalls holding his newborn son and feeling the past half-decade of struggle just melt away. ‘All that pain was worth it.’ But he wonders now what one of these sperm start-ups could have done for him. ‘I may not have found myself in the hole that I did,’ he says.

According to Jack Fertility’s consumer research, most men ‘don’t know anything about their sperm’, says chief executive Lily Elsner – nor what they can do to improve it. Rather than necessarily targeting couples struggling to conceive, Elsner says Jack Fertility aims to educate men about their fertility and give them the tools to ‘optimise their sperm count’.

Elsner and her co-founder Nick Shipley set up the company in 2022, having been inspired by the take-up of mail-in coronavirus tests through the pandemic. They are currently in the process of fundraising, with a waiting list of 1,000 customers.

‘There are so many barriers to getting tested: mental and emotional, financial, geographic,’ Elsner says. Even the NHS will only treat infertility after couples have been trying for a year – often forcing them down the route of assisted reproductive technology.

With people often waiting until their thirties to start thinking about children, ‘every month matters’, she says. But sperm regenerates on average every 74 days, meaning positive lifestyle changes can be reflected in three months. Elsner’s long-term ambition is to get to a point where fertility monitoring is standard practice, ‘something you’d do on an annual, if not quarterly basis, just to stay on top of your health’.

But Professor Barratt is more circumspect about the role of the private sector in tackling ‘Spermageddon’. Though he too has consulted for ExSeed in the past, his research is primarily funded by the Gates Foundation, which pays about £1.1m a year to study sperm biology for the development of male contraceptives: far beyond a start-up’s budget. Moreover, their interests are typically narrow and specific to their product, Professor Barratt says. ‘They don’t fill the gaps in research.’ Nor should they be expected to, he adds.

What’s needed is public investment into the crisis of male fertility and collaboration between researchers worldwide. ‘We’ve got to get a pill that improves men’s fertility – that’s the key part,’ says Professor Barratt. ‘Everything else is tinkering around the edges.’

But presently, less than 1% of UK research councils’ funding goes towards male reproductive research – ‘which is not reflective of the size of the problem’, Professor Barratt says. An education campaign is ‘desperately needed’ to raise awareness of the current problem, targeting men from their teens. Many, for instance, won’t know that steroid use – which is rising among men in their early twenties – can affect fertility.

‘It’s not about putting one poster on a wall; it’s got to be much more intelligent than that,’ says Professor Barratt. It’s the responsibility of governments and bodies such as the British Fertility Society, he adds – not the private sector.

Misconceptions already abound about fertility. A sperm count doesn’t give a complete picture, says Professor Barratt. ‘You can have lots of sperm, but they’re not functional; you can have not a lot of sperm, and they’re highly functional… It’s no good just giving someone their result.’

Similarly, while factors including smoking and obesity have been shown to negatively affect fertility, the evidence for lifestyle interventions (such as getting more sleep) to improve it is poor, says Professor Barratt. He himself is sceptical that any of the home tests presently on the market give as accurate and high-quality an analysis as one carried out in a lab. The Human Fertilisation and Embryology Authority has likewise urged against taking home tests’ results as fact.

While aligned with Professor Barratt on the need for greater investment and education, Professor Pacey is more sanguine about the part played by sperm-tech. ‘If it triggers more men to engage with healthcare and to make earlier fertility decisions – it will all have been worth it,’ he says.

Australia’s government, having invested about £3.6m into funding for male infertility research and awareness, is a possible model for the UK to follow, says Professor Pacey – but ‘I don’t think we’ve really started that journey yet.’

The Next Generation

From where Khaled Kteily is sitting, it’s not only inevitable that the UK’s male-fertility market will grow – it’s also for the good of humanity.

Kteily founded Legacy in 2018 after a wake-up call about his own fertility. A tray of scalding-hot coffee was spilled on his lap, giving him secondary burns. ‘I was faced with the possibility of having to tell a partner, “I can’t give you kids,”’ he says. ‘So I went through the process of getting tested – and it was terrible: awkward, weird, expensive, clinical.’

Born out of the Harvard Innovation Lab, Legacy is now the largest male fertility clinic in North America, offering sperm testing, freezing and even supplements. The expanded service, relative to those presently offered in the UK, reflects both the US’s different regulatory environment and culture, says Kteily. ‘There’s just more comfort with stigmatised topics.’

It was Professor Swan’s 2017 ‘Spermageddon’ study that gave Kteily the confidence to start his business. ‘I knew that it was going to create a market… It would be the beginning of social awareness around male fertility.’

Indeed, within months of founding Legacy, Kteily had been featured in The New York Times – prompting his friends to dub him the ‘Sperm King’. (Kteily ran with it, purchasing the URL spermking.com; it continues to redirect to his LinkedIn profile.) In 2021, the company publicised investment from Orlando Bloom, Justin Bieber, The Weeknd and DJ Khaled as part of its move to ‘destigmatise male fertility’.

But it wasn’t until last year, Kteily says, that ‘sperm entered the zeitgeist’ – at least in the US, with men’s health guru Andrew Huberman, longevity specialist Peter Attia, productivity podcaster Tim Ferriss and biohacker Bryan Johnson all discussing the subject.

Legacy’s services are not accessible to everyone, with sperm storage costing about £950 for five years and £3,100 for life (though there are discounts for members of the military). The option of add-ons also underscore Legacy’s corporate interests. But Kteily also points to its investment in research through partnerships with Harvard and the American Society for Reproductive Medicine. ‘We’re putting money into growing the market, because male fertility is under-studied… You need that foundation of knowledge.’

In the future, Kteily hopes to collaborate with companies such as Jack Fertility in growing the UK market. At present, he puts it at about five years behind the US, but rapidly gaining momentum. ‘It’s inevitable,’ Kteily says. ‘The statistics are just too stark for this not to be constituting a public health emergency.’

Ever since Ciaran became a father, he has seen the cultural tide turn towards recognising ‘the male factor’ of infertility. He’s also doing his bit to shift it.

Last year, Ciaran and his friend Shaun Greenaway started The Male Fertility Podcast, sharing their own experiences and the latest science (with sponsorship from ExSeed). Both of them also work part-time as fertility coaches, supporting men to boost their sperm count – or come to terms with irreversible results. Ciaran is also a personal trainer.

‘I don’t want other men to feel like I did,’ says Ciaran, who now brands himself as The Male Fertility PT. Ciaran tried an ExSeed test for the podcastand says that it ‘would have been an amazing thing to have’ as a scared, stressed twentysomething.

In the future, Ciaran suggests, young men might be routinely checked the way that young women have regular smear tests. But hi-tech, instant solutions don’t remove the hurdles to seeking help. ‘You’ve got to break many generations of stigma down.’

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